Part 9

Non-tuberculous Tuberculous ======================= ======================= FIRST-BORN LAST-BORN FIRST-BORN LAST-BORN ========== ========= ========== ========= Paternal Family 33.9 37.2 40.6 49.9 Maternal Family 34.6 37.5 40.0 53.4

Comparison of the mortality of the First and Last-born, The mortality of the First-born = 100.

Non-tuberculous Tuberculous ======================= ======================= FIRST-BORN LAST-BORN FIRST-BORN LAST-BORN ========== ========= ========== ========= Paternal Family 100 108 100 128 Maternal Family 100 108 100 134

Figure C 56.]

[Sidenote: C 57]

Of a materially greater influence than the numerical position of birth or the number of children in each family is the length of interval between births. We point at first to Figure C 57--+interval between births and child mortality+, after Ansell and Westergaard, by Dr. A. Bluhm. She writes in reference to it: "Ansell has demonstrated, from the material of the National Life Assurance Society of London, that a child has an increasingly better chance to survive his first year, the greater the interval between his own birth and that of the child born before him. If this interval is less than a year, the infant mortality is double what it is when there is an interval of two years (15.75% against 7.33%). This influence makes itself felt beyond the age of infancy up to five years but not in so striking a manner. The proportion becomes modified to 20% against 12%. As the influence of the birth interval on child mortality is still very perceptible after the tenth or later children, it may be assumed that it is not caused exclusively by the exhaustion of the maternal organism produced by the rapid sequence of births. The varying length of breast-feeding of the children has probably also its influence. Though these statistics give no data about the mode of infant feeding, it is nevertheless probable that in those families in which there are longer intervals between consecutive births each child is suckled for a longer period.

[Sidenote: C 58]

+Birth interval and health of the offspring+, after Riffel--v. d. Velden.

[Sidenote: C 59]

+Influence of the length of the birth interval and the duration of breast-feeding on infant mortality+, exhibited by Weinberg. The author writes regarding the latter table "in proportion to the length of the interval between two births, the mortality of the children following decreases materially, but this relation only becomes clearly apparent in families in which several of the children have been suckled for more than six months."

[Sidenote: C 60, 61 62]

The intimate connection which exists between birth interval and suckling and the great importance which suckling has under the favourable influence of a long birth interval is shown in Dr. Agnes Bluhm's Figures C 60, C 61, and C 62--+infant nutrition (breast feeding), number of children and infant mortality+, after Dr. Marie Baum. "The material is taken from the towns of Gladbach, Rheydt, Odenkirchen and, Rheindalen, and comprises 1,495, mostly poor families, with 9,393 cases in which the mother survived childbirth and 9,487 children born alive. In this table only 7,983 children were counted, because the remainder had not reached the age of one year on the day of counting. Of these 7,983, there died before the completion of the first year 1,276, or 15.98%."

+Number of children and child mortality+: Bluhm adds:--"Figure 1 shows in Curve A the +influence of the duration of breast feeding+; in Curve B +influence of numerical position of birth on the mortality of the infant+. The very divergent course of the two curves expresses the very different influence of both these factors on mortality; the latter is almost exclusively dependent upon the length of suckling, and shows corresponding with its increase a continuous and steep decline down to 1.46% from a maximum number of 35%. The very slight increase of the mortality of children suckled for six weeks compared with those who have not been breast fed at all is immaterial (35.55% against 35.28%). These figures prove only that breast feeding up to six weeks does not give the child any protection against fatal diseases. The influence of the birth number hardly makes itself felt up to the seventh child, only from the eighth onwards the power of resistance decreases continuously but not nearly to the same degree in which it grows with the length of breast-feeding (greatest difference only 21%). Curve B shows a materially different course from that of similar curves by other authors, for instance--from Geissler's well-known curve, dealing with Saxon miners, in which not only the first born show up less favourably than the second and third born, but in which, from the fourth child on, the mortality increases rapidly. The economical condition of both groups being similar (85% of Baum's families had a maximum yearly income of £75), it is highly probable that the difference in the curves arises from different methods of infant feeding. In the Rhine provinces, as is also proved by Baum's figures, the feeding is good; in Saxony, however, it is notoriously bad. The co-relation of infant mortality with infant feeding is very clearly illustrated in Figures 2 and 3, the former shows the +influence of the length of suckling on the mortality of the children classed in order of birth+, the latter +the influence of the order of birth in connection with different lengthed periods of suckling+. The extraordinarily regular course of all the nine curves in Figure 2 and the extremely irregular course of the six top curves in Figure 3 are very striking. From these figures it is shown that the first, second and third born if breast-fed for a short time only, or not at all, are subjected to much greater risks than the eighth, ninth, tenth or later children, suckled for a sufficient length of time (maximum difference 1 to 42). In the curve showing the children who were breast fed for 39 weeks (Figure 3), the influence of the high birth number shows only to a very small degree."

[Sidenote: C 61]

+Number of children and capacity for breast-feeding.+ Concerning this it is remarked: "The upper curve shows what percentage of children had to do without breast feeding, and the lower one how many enjoyed the sufficient period of 39 weeks of breast-feeding. Though Baum's figures are only intended to deal with the number of cases of breast feeding and not with its duration, and though no difference is made between exclusive and partial breast feeding, yet some conclusions may be drawn with regard to suckling capacity. In a district where breast feeding is as general as it is in the one examined into here, the number of women who voluntarily renounce every attempt at suckling must necessarily be small. The curve dealing with the children who had no breast feeding at all is therefore likely to give a fairly correct picture of the absolute or primary incapacity for suckling on the mother's part; absolute incapacity does not of course mean that the mother could not produce a single drop of milk, but that she does not produce enough to satisfy the child, and therefore must resort to artificial feeding. As a period of 39 weeks' feeding, even if only partial, points to a good capacity, the lower curve may also be taken as an expression of feeding ability. A comparison of both figures illustrates that the milk production after the first birth is smaller than after the following ones, and that beyond the eighth birth, it decreases materially and continuously, probably in consequence of the exhaustion of the maternal organism."

[Sidenote: C 62]

+The habit of breast-feeding as running in families and infant mortality.+ With this goes the following explanation: "The two figures illustrate the proportion of mortality of the infants in 143 bottle-feeding families and 376 breast-feeding families of the first order. As the line could not be drawn very sharply, and as in the bottle-feeding families there had to be included those in which as an exception one or other child was suckled for a few days or perhaps for a week, one can see in these groups only the expression of the habit, but not the power of suckling. Both figures illustrate the largely avoidable sacrifice in young lives which still goes on through a want of knowledge and of feeling of responsibility towards the coming race. With the absence of breast-feeding the unfavourable influence of a very large number of children becomes much more apparent; whereas in breast-feeding families the difference in the mortality between medium-sized families (four to six children) and very large families (above ten children) amounts to only 1.39%, it reaches 12.90% with the non-suckling families. Here, if the number of children surpasses ten, nearly every second child dies in the suckling age, and amongst thirteen families there is not a single one which has not lost a child in that period, whereas in breast-feeding families of the first order, with the same large number of children, only every thirteenth child died in infancy, and of sixteen families seven (= 43.75%) lost no infant." The same material is treated in a different way by Dr. Marie Baum, of Dusseldorf, in Figures C 63-66.

[Sidenote: C 63]

+As the length of the period of suckling of the preceding child increases, there is a constant and rapid decrease in the number of children who are born at intervals of less than one year.+ If the preceding child was not breast-fed a new birth occurred before the expiration of one year in 9.6 cases out of 100. With a suckling period of one-half to three-quarters of a year of the preceding child, this figure is reduced to 1.8 per cent., and after a still longer suckling period to 1 per cent. Out of one hundred mothers who have only partly or not at all suckled the preceding child, seventy must count on a fresh birth within a period of 1-3/4 years. If the preceding child was suckled for at least 39 weeks, only thirty-eight, and with a suckling period of more than a year only twenty mothers have to reckon on a fresh birth within 1-3/4 years.

Dependence of Infant Mortality on the Duration of Breast-Feeding and the Length of Time Intervening Between Successive Births.

[Sidenote: C 64]

Figure C 64 shows the +parallelism between+ the +average length of breast-feeding and the average time between births+ within the families. A half to three-quarters of the mothers who suckled either long enough or very long show an interval between births of from 1-1/4 to 3 years, whereas of those who did not suckle at all, or only did so insufficiently, only one-third belong to this group, and figure largely in the column of lower birth intervals.

Dependence of Infant Mortality on the Average Duration of Breast-Feeding and the Average Length of Time Intervening between the Successive Births of the Children in a Family.

[Sidenote: C 65]

Figure C 65 enables us to examine into the +influence exercised by a longer or shorter interval after the preceding birth on the vitality of a child+, according as to whether the child was not breast-fed at all or only moderately or amply so. The black oblongs demonstrate that the average infant mortality falls regularly and decisively according to the length of time between the birth of the children considered and their predecessors. The average mortality of infants who are born in rapid succession--under one year, one to one and a quarter years, amounts to over 25 and to 22 per cent. respectively, whereas the average mortality of children with at least two years' interval amounts only to 11 per cent. "At the same time, however, it is observed that the influence of the length of suckling is still greater than that of the length of time elapsing between births. Even with an interval of three or more years, the mortality of children who were insufficiently or not at all breast-fed was above 20 per cent. The children who had been suckled for at least three-quarters of a year were only very slightly influenced by this factor in all groups, except that with a birth interval of less than one year, where the influence of short birth intervals is not counterbalanced even by long extended breast-feeding."

[Sidenote: C 66]

Figure C 66. "The +infant mortality within the families+ dealt with +falls materially and evenly as the average birth intervals lengthen+. With an average birth interval of less than one year, one-third of the children die in the first year, but only 7 per cent. where the average birth interval was over three years; but here also the influence is strongly modified by the mode of feeding. With the non-suckling families the mortality is almost 25 per cent., even with a birth interval of more than two years. On the other hand, when the duration of suckling is sufficient, short birth intervals almost disappear (see Table 2), and with an average birth interval of 1-1/4 to 2 years and a suckling duration of at least half a year the mortality remains on an extremely small scale."

[Sidenote: C 67-73]

Groth and Hahn have exhibited two large tables C 67 and C 68 and a similar one C 69, the results of their important investigations about +breast-feeding and mortality in the administrative districts of Bavaria+. Groth shows in Table C 70 "+mortality of sucklings in Bavaria+," and in Table C 71 "+breast-feeding and cancer+." In Tables C 72 and C 73 the Groth and Hahn statistics are treated by Dr. A. Bluhm from the point of view of the +influence of the habit of breast-feeding on the frequency of births+. In connection with Figure C 73 she remarks: "This diagram shows the number of bottle-fed babies in the various Bavarian districts counted at the time of vaccination. To give as correct a picture as possible of the probable influence which the habit of breast-feeding has on the birth-rate (annual number of births per 1,000 of the whole population) there are represented on this figure by green and yellow columns the average birth-rate for the five years, 1875 to 1879, because in that period a record birth-rate was established, so that it may be assumed that there was then no intentional restriction of births. We see within the four 'old Bavarian' districts, where on the average 64.1% of the babies were not breast-fed at all, the number of births is about 4 per 1,000 of the population higher than in the Palatinate and the three 'Frankish' districts, which together only show 18% of non-breast-fed children."

[Sidenote: C 72 & 73]

"These two figures deal with the +influence of the length of suckling on the birth-rate+, the longer the duration of the suckling period, _i.e._, the higher the number of children breast-fed for six months or more, the lower the birth-rate. This only holds good for the country (Curve B) not for towns (Curve A). This circumstance is explained by the fact that the voluntary restriction of births is much more frequent in towns than in the country, where consequently the influence of the length of the period of suckling on the birth frequency can find much stronger expression than in towns, where, as Curve A shows, it is entirely extinguished by artificial birth preventatives. From both tables it results that, to prevent the senseless waste of human life, the interval between every two births must be more than two years; further, that it is possible to increase it by breast-feeding; the number of births in a district is based in the main on the larger or smaller intervals at which the women of reproductive age have children, and it may, therefore, at the same time, be taken as an expression of these intervals. Keeping these two facts in view, and considering the influence of the mode of infant feeding on infant mortality, it appears to be in the interest of the race that by means of the long duration of breast-feeding, the birth intervals should be extended to at least two years. The facts established in these two tables have a considerable bearing on race-hygiene, especially in reference to the Neomalthusian contentions of the necessary inferiority of the later born, and as a confirmation of the utility of breast-feeding for the reduction of birth frequency. Extremely great appears the influence of breast-feeding on infant mortality."

[Sidenote: C 74-78]

This importance of breast-feeding is further illustrated by Figure C 74--+duration of breast-feeding and infant mortality+, after Dietrich; by Figure C 75--+average number of carious teeth+, after Bunge; and by the three figures, C 76, 77, and 78--"+average duration of breast-feeding and physical development, duration of breast-feeding and average school reports+, and +duration of breast-feeding and frequency of rachitic disturbances of development+," after the extensive and valuable researches by Röse.

It must be pointed out that a far more direct connection exists between breast-feeding, duration of suckling, infant mortality and physical development than through the mere provision of suitable nourishment for the child. A good suckling capacity is a symptom of a strong constitution which is transmitted from mother to child. Examination of Röse's table offers this suggestion.

[Sidenote: C 79-82]

+The importance of the hereditary constitution+ (which he considers is dependent on soil and climate) +as regards infant mortality+ v. Vogel expresses in four maps of Bavaria (Figures 79-82), so which he has furnished the following comments (contained in the pamphlet, "Der Örtliche Stand der Säuglingsterblichkeit in Bayern," Munich, Piloty and Loehle, 1911): "The district of the highest infant mortality in Bavaria is inhabited by a population of small height, small fitness for military service, and high tuberculous mortality. The reverse holds good on the whole for the district with a low mortality.

I cannot suppress another objection to the usual way of proving the--to my mind undoubted--influence of breast-feeding on the duration of life in infancy. Why is the mortality of those children who have not been suckled for a week so large? Is it because they have not been suckled, or because they have only lived altogether for less than a week? Or, again, to be able to be suckled for 40 or 50 weeks, one must have lived for 40 or 50 weeks, but a child who has lived for 40 or 50 weeks, whether it has been suckled or not, has passed over the worst period. It is well-known that the mortality in the first days of life is the highest in the second week, much higher than in the third week, and so on. In short, the mortality changes in such an extremely high degree in the course of the first year of life that this period is much too long for the comparison between mortality of suckled and non-suckled children. One ought to calculate how many of those who have been suckled for 0 weeks, one week, two weeks, one month, three months, six months, and so on, have survived the first week, the second week, the first month, and so on. Only in this manner can be established what is the share of the absence of breast-feeding and what is the share of the innate weakness and tendency to disease in the degree of infant mortality."

Exhibit C 81-82.

[Sidenote: C 83]

A striking peculiarity of cities, especially large cities, is, as pointed out before, the high mortality amongst men; for this general observation Figure C 83, +male and female mortality in town and country+, offers an example. Whereas the female mortality in Berlin, in the higher age groups, is even lower than in Mecklenburg with its preponderantly country population--which is evidence that in town life there are no inherent circumstances adversely affecting all persons in a high degree--the male mortality in all the age groups is higher, and in some much higher. The special adverse influence on men of town life is also apparent in the upper part of the figure (+comparison of male and female mortality)+. In Mecklenburg the mortality among men is at most 25% higher than among women, and during the period of most intense child production, as well as in the highest age group, it is even smaller, whereas in Berlin the differences are much more accentuated. It may be remarked that the higher male death-rate in Mecklenburg between the ages of 40 to 75 years can only to a small degree be explained by physiological reasons. This is shown for example by the fact that in the provinces of Schleswig-Holstein, Pomerania, Hanover, Hessen-Nassau, and the Rhein Provinces in the country, the expectation of life for men aged 25 years is about equal to that of women.

[Sidenote: C 84 & 85]

The higher male mortality in cities is only partially explained by the specific harmfulness peculiar to men's town occupations, though the mortality of peasants and agricultural labourers ranks amongst the lowest. A very important part in this connection may be played by syphilis. How terribly syphilis injures the body, though it is seldom directly fatal, is shown by the experiences of life insurance companies, of which examples are given in Tables C 84 and C 85. With the Gotha Life Insurance Bank, for instance, +the mortality of the syphilitic at the ages of 36 to 50 years+ was found to be nearly double as high (186%) as that of the non-syphilitic.

[Sidenote: C 85]

Table C 85 shows to what a high degree +the heart and vessels especially are harmed by syphilis+. At this point it is to be noted that it may now be considered as proved that the statement that general paralysis causes death in 2.9% cases among the non-syphilitic is erroneous, because general paralysis only occurs among persons who have been affected with syphilis. There is no doubt that the poison of syphilis is also most injurious to the germs and the progeny; the foetus is sometimes infected in the mother's womb, and sometimes suffers by the general debility of the maternal body. A large proportion also of those children who attain a higher age are either enfeebled or damaged in many ways, and this inferiority is often passed down to the grandchildren. The most recent Serum investigations (the Wasserman reaction) are the first to throw full light on this. In Germany syphilis occurs much more frequently in town than in the country; this no doubt dependent on prostitution and on a much greater degree of promiscuity of sexual intercourse in cities. In the country couples keep together with greater constancy, even in the case of cohabitation without marriage.

[Sidenote: C 86-88]