Maternal and Infant Mortality in Physicians’ Families in 1922

In 1922, Dr. Haven Emerson sent questionnaires to 1303 physicians, enclosing stamped return envelopes. He asked if their wives were alive (the addressees were all men), and if not, what had killed them. He asked how many children they had, whether any had been stillborn and whether any had died. In his cover letter, he wrote he was investigating whether such deaths were rarer in physicians’ families thanks to “the intimate knowledge of medicine upon which the saving of the lives of mothers and babies depends.”¹  He published his results in April 1924, as “Maternal and Infant Mortality in Physicians’ Families,” in the American Journal of Hygiene.^*

From the 1303 questionnaires, 751 sent back their forms, and 709 were married with children. He had data on the deaths of 49 wives, 9 related to pregnancy and childbirth (mainly sepsis and eclampsia). Doctors reported 64 stillbirths and 1910 live births within their families. Of those 1910 children 158 had died. More than half (83) died in the first year of life, and most (49) within the first week. Another 35 children died between their first and fifth birthday, and 40 after age 5.

A century later, Emerson’s painstaking tables are striking, listing one by one those 158 childhood deaths recorded by the 751 doctors. As a physician, you cannot help reading them through a lens that is at once mournful and most personal. Some of the many early deaths reflect the circumstances of delivery, whether prematurity (or “prolonged gestation”), cerebral hemorrhage, or “strangulated by cord.” Some are related to medical practice, as in “chloroform, excessive, of mother,” or “strangled by milk, nurse’s fault.” Most dramatic are the infections: the infants who died of “infection of navel, sepsis” or “staphylococcus empyema,” at 1 month, the pneumonia deaths (one, “post scurvy” at 9 months), the pertussis deaths at 2, 3, and 6 months, and the “streptococcus meningitis (post ear)” at 6 months. Among the children aged 1 to 5, infections account for 24 of the 35 deaths: tuberculous meningitis, pneumonia, measles, poliomyelitis, diphtheria, croup, influenza pneumonia, and scarlet fever.

It is a kind of sad reverse template of the childhood immunization schedule, and you cannot read those charts without reflecting on the limited powers of prevention and treatment a century ago, however educated and medically minded the parent. No antimicrobial agents were available to treat erysipelas or pneumonia. Physicians advised hygiene, but there are gastroenteritis deaths, and effective treatment still lay in the future. In 1922, physicians could not protect, or effectively treat, their patients, or their own families.

Emerson, however, did not see his charts as a tragic litany; his intention was actually to spotlight the benefits of medical training. He was a widely published researcher and a leader in public health in New York City in the early 20th century, serving from 1915 to 1918 as Health Commissioner, and later as a professor of public health at Cornell and Columbia.²  He felt his data showed that physicians’ families were comparatively protected. He calculated a crude infant mortality rate, deaths before the first birthday out of 1000 live births, of 43.46. Systematic tracking of births and deaths was relatively new in the United States and was limited to what was called the Death Registration Area, but in that area, for 1922, the infant mortality rate was 79.6. The “maternal risk rate,” the death rate of mothers from pregnancy or childbirth-related causes, was 45.5 per 10 000 pregnancies in his sample of physicians’ wives, while the comparable rate in the general population in 1920 was 81.4. Additionally, his physician data included deaths that had taken place over the previous 30 years or so when the general infant mortality rate had been higher. In fact, he argued, if the maternal and infant mortality rates in the general population could have been reduced to the rates in the physicians’ families, “there would have been saved 4000 lives of mothers and 11 000 lives of infants under 1 year of age, in the year 1922 alone.” He did not feel that the lower mortality rates he had calculated reflected socioeconomic status or nutrition, but rather knowledge of preventive medicine, including hygiene practices and proper care of newborns.

A century later, it is easy to quibble with Emerson’s methods, to criticize his choice of denominators and his willingness to juxtapose rates that are probably not comparable. Newer analyses suggest that his overall conclusion was likely flawed. In their 1991 book on the demographics of child mortality, Samuel Preston and Michael Haines concluded that early 20th century child mortality among children of US physicians and surgeons was only marginally better than the national average.³  But to focus on these deficiencies risks missing a longer-arcing point.

Moving back a century takes us into what historians might call a lost world of predictable, expected, child and maternal mortality, reminding us of how often death touched those who cared for children. Those doctors lived with certain realities which are as hard to imagine from the vantage point of 21st century pediatric primary care as they are from the vantage point of 21st century parenthood.

The long list of causes of death in physicians’ children over 5 (some extending into deaths in adulthood) is another inventory of what we would now consider completely treatable diseases: the 14-year-old who died of “streptococcus bacteremia (tonsillectomy),” the 15-year-old who died of “mastoid meningitis”, and the 9-year-old girl who died of “otitis meningitis.” There is a 6-year-old girl who died of scarlet fever, and an 8-year-old girl who died of pneumonia. At a moment when many physicians feel anxious and aware of the vulnerability of our patients (and our own children), these charts remind us of the deaths which most of us will never see in our practices, let alone in our families. Very specifically, we are reminded of the deaths prevented every day in pediatric primary care, by immunizations, by tuberculosis screening, and by antibiotics.

Emerson’s study underscores our own vulnerability as parents and as pediatricians, which we recognize during the coronavirus disease 19 pandemic. But his charts also remind us that we can offer parents and children forms of prevention and safety that would have seemed unthinkable a century ago; they underscore the daily miracles of vaccination, sanitation, and antimicrobial therapy. Those sad lists of deaths in the families of physicians who obediently filled in the surveys remind us that medical training does not in any way protect us from the vicissitudes of illness and the risk of loss. Our field grants us the privilege of helping to keep children safe, and we can look to the people we love most for a reminder of how precious, and recent, are the protections, preventions, and therapies that we have to offer.⁴