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NEWSLETTER
 
medical humanities newsletter
The Bioethics Center, University Health Systems of Eastern Carolina
Department of Medical Humanities, The Brody School of Medicine at East Carolina University
 
 
 
The Social and Medical History of Crib Death
Todd L. Savitt Ph.D.

History is more than a compilation of dates and facts on a particular subject. This article will look at a condition which has existed since ancient times and has had a varied history owing to changes in societal attitudes and medical knowledge over the centuries—Sudden Infant Death Syndrome (SIDS), commonly known as crib death.

While the precise cause of SIDS is not clear, we can describe its usual manifestations and epidemiological patterns. The Second International Conference on Causes of Sudden Death in Infants (1969) defined SIDS as: “The sudden death of any infant or young child which is unexpected by history, and in which a thorough post-mortem examination fails to demonstrate an adequate cause for death.” This is still the most accepted definition. SIDS is an important cause of post-neonatal (28 days to one year) deaths in the United States (and world-wide), accounting for 0.77 deaths for every 1,000 live births. A few SIDS deaths occur during the first few weeks of life, gradually peaking between two and four months of age, and then declining over the next several months, until the age of 12 to 15 months. More deaths occur in the colder months of the year, and almost all deaths occur during sleep. SIDS strikes African Americans and Native Americans more frequently than Caucasians and people of Asian/Pacific Island and Hispanic origin, and occurs more often among families of low socio-economic status. In the last several years, SIDS deaths have declined dramatically, as parents have learned to put their young infants to sleep on their backs rather than on their bellies. The sequence of events in a typical case description of a crib death is:

An apparently thriving two-month-old boy is found dead face down in his crib. Except for a brief mild rhinorrhea during the previous week, the child has been in excellent health from birth. At a routine well-baby check by the family doctor a few days prior to the event, he appeared robust and free of problems. On the night of death, he took his formula eagerly and was put down in his crib about 10 p.m. His mother looked in before retiring; he was sleeping peacefully on his abdomen with his face to the side. When found at 6:30 a.m., he had obviously been dead for several hours.

In other cases, parents sleeping with an infant awaken to find the child dead and assume that, as one distraught mother wrote to a physician, “I had smothered her sometime during the night.” The response from community members has often been negative and accusatory: they assume the parents have been negligent and careless in managing the child, or worse, that they actually abused the infant.

Medical researchers did not recognize SIDS as a distinct entity until the mid-1940s; physicians and the public did not generally accept its existence until the 1970s. Because of this lack of recognition of SIDS until recently, parents or nurses of children dead of this disorder have been held responsible and punished or not depending on religious and societal attitudes of the period.

Is it possible for a historian to identify SIDS in earlier times? Using both descriptive and quantitative evidence, it can be shown that most infant deaths attributed to either accidental overlaying of the child by a parent or nurse while sleeping, or to accidental smothering of the child in its own bedclothes, pillows, or covers, were actually instances of SIDS. Descriptions of these phenomena from all periods bear a striking resemblance to modern case histories. For example, an overseer and a planter on a Virginia plantation wrote the following about the death of a slave infant:

I [Nathaniel Ryan, overseer] am sorry to inform you [Edmund Hubard, slave owner] that Matilda has lost her youngest child she over laid it, it was well and hearty when she went to bed and found it dead sometime in the night.

Last week [wrote Robert Hubard to his brother, Edmund] Tilla overlaid/when asleep/and killed her youngest child – a boy 6 or 7 months old. This was no doubt caused by her own want of care and attention. A 16th-century Florentine couple claimed to church authorities that they had smothered their child “accidentally while sleeping, and without any consciousness on their part of killing.” A 17th-century English diarist wrote: “It pleas’d God to take away my son Richard, being now a moneth old, yet without any sickness of danger perceivably, being to all appearance a most likely child; we suspected much (that) the nurse had overlayne him….” An official board of inquest in 17th-century Plymouth Colony decided of a 6-month-old child found dead in bed lying between its nurse and sister that “either it was stiffled by lying on its face or accidentally over layed in the bed.”

The quantitative data are also convincing. Dr. Arnold Paltauf of Vienna presented tables, in an 1889 article on sudden unexplained infant deaths, showing that 59% of these children died between the ages of two and four months. A Surgeon of Police in Dundee, Scotland, reported in 1892 that of 258 instances of “overlaying” investigated between 1882 and 1891, 60% (154) were children two to four months old, and 62% (159) occurred between October and March, the cold months of the year. Two years later, the editors of the British Medical Journal complained about the high number of overlaying deaths during the winter.

Of interest historically is the attitude people had toward the overlaying and smothering of infants. Sudden unexpected and unexplained infant deaths were not matters in which police and the courts showed much interest until the 17th or 18th century. Before this, overlaying and smothering were matters dealt with by parents and church (rather than civil) officials. Until the early 19th century, these infant deaths were considered a social rather than a medical problem, and as such, were not the subject of anatomical or physiological scrutiny.

During medieval times overlaying was, according to historian R. H. Helmholz, “the principal means of infanticide and the major problem for the Church courts.” In ecclesiastical legislation, overlaying was associated with infanticide despite the usually recognized accidental nature of the incident. The law assumed that negligence or carelessness had to be involved in overlaying, and that despite parents’ lack of intent to kill, a church crime had been committed which required punishment. The degree of punishment could be lessened for such unintentional infanticide, but absolution was out of the question. Throughout the medieval period and on into the Renaissance, ecclesiastical rather than secular courts handled cases of infanticide, including accidental suffocation. The punishment meted out for both intentional and accidental infanticide was always far lighter than for murder of an adult. As early as about 700 A.D., the precedent for a lighter penance in cases of overlaying than of accidental adult murder had been established. The former required a penance of three years, one of them on bread and water, whereas the latter required similar punishment for five years, three of them on bread and water.

This apparently lax attitude toward infant life, as demonstrated both by the total absence of secular, criminal prosecutions in cases of infanticide, and lighter punishments for accidental deaths of infants compared to adults, is also expressed in a set of 14th century instructions for English parish priests. In these instructions, casually inserted along with failure to be a good Samaritan and quarreling with one’s wife, is the venial (pardonable) sin of overlaying one’s child. Still, overlaying – recognized as accidental– was regarded as a sin to which parish priests were alerted. That the Church was also interested in preserving the life of the child is indicated by the many injunctions in medieval Church legislation against parents taking infants into their beds upon pain of punishment should overlaying occur.

During the Renaissance, penance was still required, but harsher punishments were meted out in 16th century Florence to unwed mothers whose infants were suffocated and to old women accused of being witches who killed children and replaced them in parents’ beds. To protect infants from accidental smothering in bedclothes, Florentine craftsmen developed a device called an arcuccio (little arch), which fitted over the crib and prevented the blankets from lying directly on the child. It also contained cutouts on either side so that the mother or nurse could breast feed during the night without fear of rolling over and smothering the child. This device apparently gained some acceptance in England during the 18th century and was still in use in parts of Italy in the 1890s.

Slowly, a transition from prosecution for infanticide in ecclesiastical courts to secular courts occurred, paralleling the gradual movement away from Church authority during the Enlightenment, and the increasing ability of medical personnel to perform autopsies on infants and to determine the causes of death. By the early 19th century, civil and coroner’s courts were investigating cases of overlaying and smothering to determine cause of death.

As clinical-pathological correlations, popularized by publication in 1763 of Giovanni Morgagni’s On the Seats and Causes of Disease, and pathological anatomy, as taught at the French medical schools beginning in the 1790s, began to influence medical thought, a new concept of the cause of these infant deaths arose. Several physicians noted that the thymus glands of infants allegedly overlaid or smothered were quite large. They postulated that the gland (a) impinged on the trachea, cutting off the airway or the blood supply to the head, (b) somehow caused adverse stimulation of nerves controlling respiration, resulting in suffocation, or (c) grew so large as to reduce the size of the thoracic cavity, thereby affecting function of both heart and lungs. The condition became known as “thymic asthma” and gained some acceptance both in Europe and America.

Though further medical investigations by German physician Alexander Friedleben revealed in 1858 that the thymus could not cause the sudden death of an infant, the theory persisted. In 1889 a Viennese physician, Arnold Paltauf, elaborated on the thymic theory, claiming that a complex of bodily changes based on nutritional and constitutional deficiencies was the cause of sudden deaths of infants alone in cribs or in beds with parents. He called this diathesis status thymico-lymphaticus. Not until 1931 did a committee of pathologists study this condition and conclude that it had no “existence as a pathological entity.”

The thymic theory did, however, create a more humanitarian attitude toward nurses and mothers accused of negligence, as this German case from the 1880s illustrates:

A servant girl was entrusted with the care of an infant who was sleeping in its cradle near her. In the morning the previously healthy baby was found dead in the cradle. The girl was imprisoned, and the authorities ordered an autopsy, which was performed by Liman & Grawitz. Liman was unable to disprove Grawitz’ contention that death was attributable to a colossally enlarged thymus pressing on trachea, bronchi, and vessels. The magistrate released the woman….

Discussions of the cause of sudden unexplained infant deaths was quite confused toward the end of the 19th century. Contrast the above statement from Germany in the 1880s with this one by the Surgeon of Police of Dundee, Scotland, in 1892:

The principal causes producing this great mortality from overlaying are –
1. Ignorance and carelessness of mothers;
2. drunkenness; 3. overcrowding; and
4. according to some observers, illegitimacy
and the (life) insurance of infants.

He advocated passage of a law prohibiting parents from sleeping with their infants, and strenuous prosecution of parents whose children died under these conditions. Compare this attitude with that of two French writers in 1895 who claimed that nurses should not be blamed for smothering or overlaying infants. Their research showed that specific respiratory ailments were the true cause of death. Finally, to add to the uncertainty, the British Medical Journal published a letter in 1905 on sudden death and the thymus gland which closed with the following statement: In (Sir William) Osler’s (textbook of) Medicine, under “Diseases of the Thymus Gland,” it is stated that enlargement of the gland is a recognized cause of sudden infant death in infants, owing either to its direct pressure on the trachea or to its pressure on the pneumogastric (vagus nerve) causing spasm of the glottis. So confusion was rife as the new century began.In (Sir William) Osler’s (textbook of) Medicine, under “Diseases of the Thymus Gland,” it is stated that enlargement of the gland is a recognized cause of sudden infant death in infants, owing either to its direct pressure on the trachea or to its pressure on the pneumogastric (vagus nerve) causing spasm of the glottis. So confusion was rife as the new century began.

Research continued during the early 20th century as more physicians recognized that there were other possible explanations for these infant deaths. Parents and nurses were still often blamed for negligence in the care of their children who died of what people assumed was overlaying or suffocation in bedclothes, sheets, pillows, etc. For example, a New York physician, working under the auspices of the Special Committee on Infant Mortality, condemned, in a 1944 issue of the Journal of Pediatrics, the practice “of placing for feeding the unattended infant in its mother’s bed where death from overlaying may be caused by the mother who falls asleep.” He also noted that inattention to the style, weight, and fit of infant clothing, and the misuse of pillows, rubber sheets, easily untucked sheets and blankets, and unnecessary decorative articles for cribs and carriages were potential causes of infant suffocation.

During the early 1940s, researchers studied and challenged the concept of mechanical suffocation of infants. Doctors Jacob Werne and Irene Garrow of the Queens County, N.Y., Medical Examiner’s Office published a series of articles between 1942 and 1953 demonstrating that fulminating infection was the likely cause of alleged mechanical suffocations in infants. Their work drew widespread attention to the issue of sudden unexplained infant deaths. Dr. Paul V. Woolley, Jr., of Portland, Oregon, writing in 1945, noted that children invariably find an airway regardless of the position in which they are sleeping or the impediments (blankets, sheets, breast, bottle, mother’s body) put in their way, and so complemented the ideas of Werne and Garrow. His conclusion marked the start of a new era in thinking about sudden unexplained infant deaths by calling for a complete autopsy examination with full recourse to modern bacteriologic techniques: in every unexplained death of an infant. When this is done and still nothing is found, nor has incontrovertible evidence of suffocation been elicited, perhaps we should . . . admit that we are ignorant of the cause of death, thereby saving the family the stigma of having allowed their baby to smother in the bedclothes. Since then a growing knowledge of SIDS has helped reduce the guilt of parents and created an entirely different atmosphere in which to conduct research.

(This article is based on Savitt, T. “The Social and Medical History of Crib Death,” Journal of the Florida Medical Association 1979; 66, 8: 853-59. Complete references can be found therein.)