The Case For Birth Control

CHAPTER III POPULATION AND BIRTH RATE — BIRTH CONTROL — FROM “THE EMPIRE AND THE BIRTH-RATE” — VARIATIONS OF POPULATION, BIRTH-RATE, &c., IN THE BRITISH EMPIRE — OTHER COUNTRIES — CONCLUSION — DIAGRAMS OF INTERNATIONAL VITAL STATISTICS — VARIOUS COUNTRIES 1901–05. — VARIOUS COUNTRIES. CRUDE & CORRECTED DEATH-RATES. — LONDON 1905–1909. — PARIS 1906. — UNITED KINGDOM. Growth of Population. — UNITED KINGDOM. Birth and Death Rates. — GERMAN EMPIRE. Growth of Population. — GERMAN EMPIRE. Birth and Death Rates. — FRANCE POPULATION. — FRANCE. BIRTH & DEATH RATES. — VARIOUS DISEASES. — FRANCE. BIRTH & DEATH RATES. — ENGLAND & WALES. BIRTHS & DEATHS. MARRIAGE, FERTILITY, & ILLEGITIMACY. VARIOUS DISEASES. — THE NETHERLANDS. — NORWAY. — SWEDEN. — DENMARK. — BELGIUM. — ITALY. — SPAIN. — COUNTRIES WITH NEARLY STATIONARY BIRTH-RATE — COUNTRIES WITH RISING BIRTH-RATES — BRITISH COLONIES — BERLIN. — BERLIN. — EUROPE. — WESTERN EUROPE.

In this chapter it is demonstrated that a high birth rate invariably means a high death rate, particularly a high infant mortality. Where a knowledge of methods to prevent conception results in a lowering of the birth rate, proportionately more of those children born survive, and a healthier, sturdier population is the result.

It may be said that Nature has been seriously troubled with the problem of reproduction even from the first creation of life. Our own doubts and difficulties in that sphere are but a continuation of those experienced on the earth long before Man’s ancestors descended from the forest trees. Nature’s first insistent impulse was for reproduction, and so the lowlier organisms increase at an enormous rate, though by far the greater number of the creatures thus produced are doomed to early destruction by other creatures which prey upon them. Then sex arose and developed. And the object of sex may be said to act as a check on reproduction, and not, as we have sometimes too hastily assumed, to ensure reproduction, for that was already more than fully ensured by other methods already in existence. The device of sex rendered reproduction more difficult, but in decreasing the quantity of offspring it at the same time improved their quality. As the sexual process increased in complexity the individuals produced equally grew more complex and better equipped to resist the dangers they were subjected to. Fishes are spawned by the thousand, but only a few come to maturity. The higher mammals produce but few offspring and surround them with parental care until they are able to lead their own lives with a fair chance of surviving. Thus the sexual process in its finally developed form may be regarded as a mechanism for subordinating quantity to quality, and so promoting the evolution of life to ever higher stages.

This process, which is plain to see on the largest scale throughout living nature, may be more minutely studied, as it acts within a narrower range, in the human species. Here we statistically formulate it in the terms of birth-rate 44and death-rate; by the mutual relationship of the two courses of the birth-rate and the death-rate we are able to estimate the evolutionary rank of a nation, and the degree in which it has succeeded in subordinating the primitive standard of quantity to the higher and later standard of quality.

It is especially in Europe that we can investigate this relationship by the help of statistics which in some cases extend for nearly a century back. We can trace the various phases through which each nation passes, the effects of prosperity, the influence of education and sanitary improvement, the general complex development of civilisation, in each case moving forward, though not regularly and steadily, to higher stages by means of a falling birth-rate, which is to some extent compensated for by a falling death-rate, the two rates nearly always running parallel, so that a temporary rise in the birth-rate is usually accompanied by a rise in the death-rate,—by a return, that is to say, to the conditions which we find at the beginning of animal life,—and a steady fall in the birth-rate is always accompanied by a fall in the death-rate.

The modern phase of this movement, soon after which our precise knowledge begins, may be said to date from the industrial expansion, due to the introduction of machinery, which Professor Marshall places in England about the year 1760. That represents the beginning of an era in which all civilised and semi-civilised countries are still living. For the earlier centuries we lack precise data, but we are able to form certain probable conclusions. The population of a country in those ages seems to have grown very slowly and sometimes even to have retrograded. At the end of the sixteenth century the population of England and Wales is estimated at five millions and at the end of seventeenth at six millions,—only 20% increase during the century—although during the nineteenth century the population nearly quadrupled. This very gradual increase of the population seems to have been by no means due to a very low birth-rate, but to a very high death-rate. Throughout the Middle Ages a succession of virulent plagues and pestilences devastated Europe. Smallpox, which may be considered the latest of these, used to sweep off large masses of the youthful population in the eighteenth century. The result was a certain stability and a certain well-being in the population as a whole, these conditions being, however, maintained in a manner that was terribly wasteful and distressing.

The industrial revolution introduced a new era which began to show its features clearly in the early nineteenth century. On the one hand, a new motive had arisen to favor a more rapid increase of population. Small children could tend machinery and thereby earn wages to increase the family takings. This led to an immediate result in increased population and increased prosperity. But on the other hand, the rapid increase of population always tended to outrun the rapid increase of prosperity, and the more so since the rise of sanitary science began to drive back the invasions of the grosser and more destructive infectious diseases which had hitherto kept the population down. The result was that new forms of disease, distress, and 45destitution arose; the old stability was lost, and the new prosperity produced unrest in place of well-being. The social consciousness was still too immature to deal collectively with the difficulties and frictions which the industrial era introduced, and the individualism which under former conditions had operated wholesomely now acted perniciously to crush the souls and bodies of the workers, whether men, women or children.

As we know, the increase of knowledge and the growth of the social consciousness have slowly acted wholesomely during the past century to remedy the first evil results of the industrial revolution. The artificial and abnormal increase of the population has been checked because it is no longer permissible in most countries to stunt the minds and bodies of small children by placing them in factories. An elaborate system of factory legislation was devised, and is still ever drawing fresh groups of workers within its protective meshes. Sanitary science began to develop and to exert an enormous influence on the health of nations. At the same time the supreme importance of popular education was realised. The total result was that the nature of “prosperity” began to be transformed, instead of being, as it had been at the beginning of the industrial era, a direct appeal to the gratification of gross appetites and reckless lusts, it became an indirect stimulus to higher gratifications and more remote aspirations. Foresight became a dominating motive even in the general population, and a man’s anxiety for the welfare of his family was no longer forgotten in the pleasure of the moment. The social state again became more stable, and more “prosperity” was transformed into civilisation. This is the state of things now in progress in all industrial countries, though it has reached varying levels of development among different peoples.

It is thus clear that the birth-rate combined with the death-rate constitutes a delicate instrument for the measurement of civilisation, and that the record of these combined curves registers the upward or downward course of every nation. The curves, as we know, tend to be parallel, and when they are not parallel we are in the presence of a rare and abnormal state of things which is usually temporary or transitional.

It is instructive from this point of view to study the various nations of Europe, for here we find a large number of small nations, each with its own statistical system, confined within a small space and living under fairly uniform conditions. Let us take the very latest official figures (which are usually for 1913) and attempt to measure the civilisation of European countries on this basis. Beginning with the lowest birth-rate, and therefore in gradually descending rank of superiority, we find that the European countries stand in the following order: France, Belgium, Ireland, Sweden, the United Kingdom, Switzerland, Norway, Scotland, Denmark, Holland, the German Empire, Prussia, Finland, Spain, Austria, Italy, Hungary, Serbia, Bulgaria, Roumania, Russia. If we take the death-rate similarly, beginning with the lowest rate and gradually descending to the highest, we find the following 46order: Holland, Denmark, Norway, Sweden, Switzerland, the United Kingdom, Belgium, Scotland, Prussia, the German Empire, Finland, Ireland, France, Italy, Austria, Serbia, Spain, Bulgaria, Hungary, Roumania, Russia.

Now we cannot accept the birth-rates and death-rates of the various countries exactly at their face value. Temporary conditions, as well as the special composition of a population, not to mention peculiarities of registration, exert a disturbing effect. Roughly and on the whole, however, the figures are acceptable. It is instructive to find how closely the two rates agree. The agreement is, indeed, greater at the bottom than at the top; the eight countries which constitute the lowest group as regards birth-rate are the identical eight countries which furnish the heaviest death-rates. That was to be expected; a very high birth-rate seems fatally to involve a very high death-rate. But a very low birth-rate (as we see especially in the case of France) is not invariably associated with a very low death-rate though it is never associated with a high death-rate. This seems to indicate that those qualities in a highly civilised nation which restrain the production of offspring do not always or at once produce the eugenic racial qualities possessed by hardier peoples living under simpler conditions. But with these reservations it is not difficult to combine the two lists in a fairly concordant order of descending rank. Most readers will agree, that taking the European populations in bulk, without regard to the production of genius (for men of genius are always a very minute fraction of a nation), the European populations which they are accustomed to regard as standing at the head in the general diffusion of character, intelligence, education, and well-being, are all included in the first twelve or thirteen nations, which are the same in both lists though they do not follow the same order. These peoples, as peoples—that is, without regard to their size, their political importance, or their production of genius—represent the highest level of democratic civilisation in Europe.

It is scarcely necessary to add that various countries outside Europe equal or excel them; the death-rate of the United States, so far as statistics show, is the same as that of Sweden, that of Ontario, still better, is the same as Denmark, while the death-rate of the Australian Commonwealth with a medium birth-rate, is lower than that of any European country, and New Zealand holds the world’s championship in this field with the lowest death-rate of all. On the other hand, some extra-European countries compare less favorably with Europe: Japan, with a rather high birth-rate, has the same high death-rate as Spain, and Chili, with a still higher birth-rate, has a higher death-rate than Russia. So it is that among human peoples we find the same laws prevailing as among animals, and the higher nations of the world differ from those which are less highly evolved precisely as the elephant differs from the herring, though within a narrower range, that is to say, by producing fewer offspring and taking better care of them.

The whole of this evolutionary process, we have to remember, is a natural process. It has been going on from the beginning of the living world. But 47at a certain stage in the higher development of man without ceasing to be natural, it becomes conscious and deliberate. It is then that we have what may properly be termed Birth Control. That is to say that a process which had before been working slowly through the ages, attaining every new forward step with waste and pain, is henceforth carried out voluntarily, in the light of the high human qualities of reason and foresight and self-restraint. The rise of birth control may be said to correspond with the rise of social and sanitary science in the first half of the nineteenth century, and to be indeed an essential part of that movement. It is firmly established in all the most progressive and enlightened countries of Europe, notably in France and in England; in Germany, where formerly the birth-rate was very high, birth control has developed with extraordinary rapidity during the present century. In Holland its principle and practice are freely taught by physicians and nurses to the mothers of the people, with the result that there is in Holland no longer any necessity for unwanted babies, and this small country possesses the proud privilege of the lowest death-rate in Europe. In the free and enlightened democratic communities on the other side of the globe, in Australia and New Zealand, the same principles and practice are generally accepted, with the same beneficent results. On the other hand, in the more backward and ignorant countries of Europe, birth control is still little known, and death and disease flourish. This is the case in those eight countries which come at the bottom of both our lists.

Even in the more progressive countries, however, birth control has not been established without a struggle which has frequently ended in a hypocritical compromise, its principles being publicly ignored or denied and its practice privately accepted. For at the great and vitally important point in human progress which birth control represents, we really see the conflict of two moralities. The morality of the ancient world is here confronted by the morality of the new world. The old morality, knowing nothing of science and the process of Nature as worked out in the evolution of life, based itself on the early chapters of Genesis, in which the children of Noah are represented as entering an empty earth which it is their business to populate diligently. So it came about that for this morality, still innocent of eugenics, recklessness was almost a virtue. Children were given by God, if they died or were afflicted by congenital disease, it was the dispensation of God, and, whatever imprudence the parents might commit, the pathetic faith still ruled that “God will provide.” But in the new morality it is realised that in these matters Divine action can only be made manifest in human action, that is to say through the operation of our own enlightened reason and resolved will. Prudence, foresight, self-restraint—virtues which the old morality looked down on with benevolent contempt—assume a position of the first importance. In the eyes of the new morality the ideal woman is no longer the meek drudge condemned to endless and often ineffectual child-bearing, but the free and instructed woman, able to look before and after, trained in 48a sense of responsibility alike to herself and to the race, and determined to have no children but the best.

Such were the two moralities which came into conflict during the nineteenth century. They were irreconcilable and each firmly rooted, one in ancient religion and tradition, the other in progressive science and reason. Nothing was possible in such a clash of opposing ideas but a feeble and confused compromise such as we still find prevailing in various countries of old Europe. It was not a satisfactory solution, however inevitable, and especially unsatisfactory by the consequent obscurantism which placed difficulties in the way of spreading a knowledge of the methods of birth control among the masses of the population. For the result has been that while the more enlightened and educated have exercised a control over the size of their families, the poorer and more ignorant—who should have been offered every facility and encouragement to follow in the same path—have been left, through a conspiracy of secrecy, to carry on helplessly the bad customs of their forefathers. This social neglect has had the result that the superior family stocks have been hampered by the recklessness of the inferior stocks.

Such is the situation to-day when we find America entering this field. Up till now America had meekly accepted at Old Europe’s hands the traditional prescription of our Mediterranean book of Genesis, with its fascinating old-world fragrance of Mount Ararat. On the surface, the ancient morality had been complacently, almost unquestionably accepted in America, even to the extent of permitting a vast extension of abortion—a criminal practice which ever flourishes where birth-control is neglected. But to-day we suddenly see a new movement in the United States. In a flash, America awoke to the true significance of the issue. With that direct vision of hers, that swift practicality of action, and above all, that sense of the democratic nature of all social progress, we see her resolutely beginning to face this great problem. In her own vigorous native tongue we hear her demanding: “What in the thunder is all the secrecy about anyhow?” And we cannot doubt that America’s own answer to that demand will be of immense significance to the whole world.

BIRTH CONTROL. MARY ALDEN HOPKINS, in Harper’s Weekly, 1915.

No one knows what the birth rate of the United States is, or what it ever has been. Every European country knows its birth rate and its death rate, because every birth and every death is registered. Where the number of births, the number of deaths and the number of the population are all known, it is an easy matter to calculate the rates per thousand. But in the international tables of vital statistics our country’s figures are omitted.

Our 1910 census announced that 23 states had “fairly complete” death 49registration. They recorded about 90% of their deaths. But the birth registration situation was shocking. The New England States, Pennsylvania and Michigan were the only acceptable states. The figures for the cities of Washington, D.C., and New York City passed muster also. The 1910 census birth rate is not yet published, but the 1900 census made shift to figure it out by means of the number of the population’s increase and the death rate. This would be surer if the death rate were not itself approximate. However, the calculated rates were, birth rate, 35.1 per 1000 population; death rate, 17.4 per 1000; excess of births over deaths 17.7 per 1000. Comparing these rates with the rates of the European countries for the same decade, we find ourselves near the head of the list for high birth rate, near the foot of the list for low death rate, and increasing faster than any other nation. These figures leave nothing to be desired from an emotional viewpoint. But they leave much to be desired in the way of accuracy. In addition to our lack of statistics we are confused by the effect of immigration.

The birth rate of every civilized country is falling. The following comparison of national birth rates is based on the ten largest countries of Europe. The less important ones show the same general characteristics. Asiatic countries must be excluded as they have no reliable vital statistics. The United States must be considered separately because both our mortality records and our birth registration are so defective that only approximate calculations can be made. The maximum birth rate preceding the present decline occurred in France 1811–20; in Norway, Sweden, Finland, Austria and Prussia 1821–30; Belgium 1831–40; Denmark 1851–60; Scotland and Spain 1861–70; England, Wales, Ireland, Hungary, Switzerland, Germany, Bavaria, Saxony, and the Netherlands 1871–80; Portugal, Italy, Serbia and Roumania, 1881–90.

The figures of the following table are taken from the Report of the Registrar General of Great Britain for 1910. Five year periods are used in place of single years to eliminate variations of exceptional years.

Seventy-third Annual Report of the Registrar-General of Births, Deaths and Marriages in England and Wales, 1910, London. Pub. by His Majesty’s Stationery Office. Printed by Darling and Sons, Ltd., Bacon St., E. London. 1912.

The countries are arranged in order of their 1906–10 rates.

By subtracting the figures in the second column from the first we obtain the fall in the rates between 1881–5 and 1906–10. Russia, in 1910, had the highest birth rate, and had suffered the slightest diminution, only 1.4 per thousand. Curiously Hungary, standing second in line, showed the greatest fall, 7.9. England and Wales, far down the scale, had a drop of 6.9 per thousand. Italy, The Netherlands, France, and Austria kept a fairly even pace with a fall of around 5. Belgium, Spain, and the German Empire lost only about 3 per thousand.

Much discussion has arisen concerning the cause of this decline. Two distinct stages occur in the fecundity of animal life. In the species below the human race it is checked by biological causes. In the human race it is checked by social and economic causes. As the scale of life rises, the number of offspring become fewer. The higher the animal, the fewer the offspring.

When we reach the human animal, we find in addition to pestilence, war, and “acts of God,” various forms of voluntary check. Semi-civilized countries manage the affair rather crudely; in India the Ganges is hardly yet free from infant corpses, and in China girl babies show an assisted mortality. More civilized countries limit the birth rate more felicitously, reducing the number of marriages and advancing the age of marriage, by imposing social, ethical, and financial obligations. This decreases the number of possible children. These indirect checks held back the increase of population so slightly, evenly and over so long a period as to be hardly perceptible. In the seventies appeared a phenomenon of spectacular novelty—the small family. Harmless methods of contraception had been perfected, the knowledge disseminated, and the means supplied. The birth rate, which had slowly declined through aeons, from eggs by the millions to yearly babies, dropped with dizzying rapidity.

As the birth rates of the nations fall, so fall the death rates. Here are the death rates for the same ten nations for the same years as the previous birth rate table.

A comparison of the two tables shows immediately that the countries having the highest birth rate have also the highest death rate. Russia, which heads the list in births, heads the list in deaths. Hungary comes second in both lists. Next come, in a slightly altered order, the four countries, German Empire, Spain, Austria and Italy. An exception occurs in France which has the unusual combination of a low birth rate and a medium death rate. Belgium, and England and Wales occupy the same position in both lists with low birth rates and low death rates. The Netherlands is the notable country with its medium birth rate and its low death rate. The Neo-Malthusians love to mention at this point that this country has governmental encouragement in teaching contraception.

The increase of a country is the difference between its birth rate and its death rate. The population of a country depends, not upon its birth rate, but upon its birth rate, minus its death rate. If the two are identical, the population is stationary. This happened in France in the 1891–5 period. The number of births per thousand inhabitants was exactly the number of deaths per thousand inhabitants. The rest of the world tolled the knell for France. But France instead of declining into the have-been nations showed that a controlled birth rate can be raised as well as lowered. Slowly and apparently intentionally she raised her rate during the succeeding years.

Decline and rise of French Birth rate: 1881–5, 2.5; 1886–90, 1.1; 1891–5, 0.0; 1896–1900, 1.2; 1901–5, 1.6; 1906–10, .7. Nor has France since those early nineties allowed her birth rate to fall below her death rate.

The populations of European nations are increasing, because the death rates are falling faster than the birth rates.

If we subtract the deaths per thousand inhabitants, given in the second table, from the births per thousand inhabitants given in the first table, we shall have the natural rate of increase. In every single case the number of 52births is greater than the number of deaths—so every country is increasing in population.

From the second column we find that Russia is increasing most rapidly. The Netherlands comes second in rate of increase—an honorable position to which the regulationists point triumphantly when they assert that control of the birth rate does not mean the ruin of the nation. The German Empire comes next, with Hungary following. England stands fifth in the rating of increase, and England takes the position with woeful lamentations. Italy, Austria, Belgium, and Spain are near the foot of the list, and France brings up the rear a long, long way behind. France is the only one that is anywhere in sight of a stationary population.

Excepting France and England, every one of these countries is increasing at a faster rate than formerly, because though the birth rate has fallen fast, the death rate has fallen faster. By comparing the second column showing the increase in the 1906–10 period with the first column showing the increase in the 1881–5 period, in the preceding table, we see how much each country is gaining in her rate of increase. This increase may or may not be considered desirable according to whether one wishes to conserve the food supply or increase the army. To every one it presents an interesting condition. It is unexpected to find with a falling birth rate an increasingly increasing population,—always excepting France and England.

When we are considering the growth of population it is not the births but the survivals that count; and it is a remarkable fact, of which illustrations will appear anon, that comparatively few of those who have made strong remarks on the birth-rate question seem to have realised this. The child that 53perishes before entering on a productive existence is not an asset to the numbers or efficiency of the community, but a drain upon it for which there is no compensating gain.

We shall now study the principal parts of our Empire seriatim, and it will suffice if we consider Great Britain and Ireland, Australasia, Canada, South Africa, and India.

England and Wales.—Special attention should be given to this diagram (Fig. 2), as, apart from England’s intrinsic Imperial importance, it exhibits changes typical of those taking place in the majority of civilised countries at the present time. Our Registrar-General’s Reports give us figures starting from the year 1853, and it will be seen that there was a fairly definite rise in the birth-rate till the year 1876, after which there set in that rapid and steady decline which we hear so much about to-day.

As to the cause of this remarkable decline, it is now pretty generally known that the chief factor is the voluntary reduction of the fertility rate (the average number of children to a marriage). Further, the decline has been largely a class one, affecting first the richer and more cultured classes, rapidly extending through the various grades of the middle classes until it has now reached the skilled artizans, but not the poorest and most unskilled laborers.

The evidence for these contentions is briefly (a) that just before the year 1876 an actuarial enquiry made by Mr. Ansell on behalf of the National Life Assurance Society revealed the fact that the average number of children to a family in the upper and professional classes at that time was somewhat over five, while the average for the whole population was 4.63 according to the Registrar-General’s Report; (b) that the birth-rate reckoned on the number of married women has since fallen from 304.1 per thousand in 1876 to 196.2 in 1911; (c) that families are now notoriously very small among the professional classes; and (d) that the birth-rate in some of the poorest districts of our large towns is still about as high as it was in 1876. We have not yet got the detailed returns of families for the census of 1911 in England and Wales; but for Scotland, where the variations in the birth-rate have been very similar, Dr. J. C. Dunlop, in a paper read before the Royal Statistical Society the other day, gave these details. The average number of children to a family among the poorest unskilled laborers is still about seven, while it is only 3.91 for medical practitioners, 4.33 for the clergy, and 3.76 for army officers.

Fig. 1.—POPULATION OF VARIOUS COUNTRIES.

VARIATIONS IN BIRTH RATE &c., IN ENGLAND & WALES

Fig. 2.—ENGLAND AND WALES.

Fig. 3.—IRELAND.

Turning at once, however, to the accompaniments of these changes in the birth-rate, we find that the death-rate has also shown very decided changes, although the temporary fluctuations prevent our locating them with the same precision. For between fifteen and twenty years after 1853 the general deathrate 54was approximately stationary, or perhaps slightly rising; but since then there has been a rapid and steady fall from about 22 per thousand to a little over 13. The infantile mortality, after various minor fluctuations, has fallen very rapidly since 1900. The net result of these changes is that the rate of 55natural increase of population (excess of birth-rate over death-rate) during the last five years has averaged 11 per thousand, which is nearly the same as in the first five years 1853–57, when it was 11.7 per thousand, although it temporarily increased to 14.3 per thousand in the quinquennium 1874–78. The cry of “depopulation” or of “race suicide” has little more justification to-day when our birth-rate is only 24 and the average family probably between three and four children than it had in 1855 with a birth-rate of 34 and an average of 5 births per marriage. In an article in the Daily Telegraph of January 17 last, a writer pointed out that mortality was very high among the large families of the seventeenth and eighteenth centuries, and asked: “If to lose half, or more than half, their children was common among well-to-do people, how did poor folks fare?”

The actual rise of the population, after allowing for migration, is, of course, given by the census returns. Fig. 1 shows the variation of the total population of the United Kingdom and of England and Wales, from 1850 onwards.

Many of you will have heard alarmist statements from various quarters to the effect that our population is rapidly becoming stationary owing to the combined results of a declining birth-rate and an accelerated emigration. In the Fortnightly Review for February last an article on “The Danger of Unrestricted Emigration,” by Mr. Archibald Hurd, contained a characteristic statement of this kind:—“The population of Ireland and Scotland is rapidly declining, and that of England and Wales is now practically stagnant, the natural increase only slightly exceeding the outflow due to emigration.”

We will deal with Ireland in a moment; but as regards both England and Wales and Scotland the statement appears entirely unwarranted. The actual increase of population in England and Wales between the censuses of 1901 and 1911 was 10.9 per cent., which is only a little below the “natural” increase (in Wales it reached the unprecedentedly high increase of 18.1 per cent.); while in Scotland the actual increase of population was 6.4 per cent. over the decade. Probably these alarms were due to consideration of emigration apart from immigration or from return of our own emigrants.^[7] The actual increase of population for the whole of the United Kingdom was 9.1 per cent.; and this has only been exceeded twice in the past six decades.

56We need not consider Scotland further, as its variations resemble those of England and Wales.

Fig. 4.—AUSTRALIA.

Fig. 5.—NEW ZEALAND.

Fig. 6.—ONTARIO, CANADA.

Fig. 7.—TORONTO.

Ireland.—Ireland’s statistics differ so much from those of most other countries that they merit special consideration. In Fig. 3 are shown the variations of its birth and death-rates. From these it appears that, for many years past, Ireland has had very low but practically steady birth-and death-rates. 57On further studying the matter, however, we find that Ireland’s low birth-rate is not due to small families, but to a low marriage rate (probably due to immigration of young people). The fertility rate of its women has remained high and steady, 283 per thousand in 1881, and 289 in 1901. The excess of births over deaths has averaged 6 per thousand recently, although it was much higher forty-five years ago. But the terrible poverty succeeding the famine produced the great tide of emigration which has reduced the population from eight to little over four millions. It should be observed, however, that it is late in the day to deplore the depopulation of Ireland, as it has now practically ceased. The fall of population was 11.8 per cent. between the censuses of 1851 and 1861, but only 1.7 per cent. between those of 1901 and 1911; while in the closing years of the decade, the Registrar-General’s returns gave the population as almost exactly stationary. It is highly probable that the next census will show an increase in the population of Ireland for the first time since 1846.

We may now turn to the various parts of our Empire overseas, and it will be sufficient if we consider the four principal divisions: Australasia, Canada, Union of South Africa, and India. The order is chosen as dealing with the populations of British origin first.

Australasia.—Australia and New Zealand both call for particular attention in this connection, as family limitation appears to be very general in them, and many authorities have spoken about it in strong terms. Mr. Roosevelt, for example, wrote as follows in 1911: “The rate of natural increase in New Zealand is actually lower than in Great Britain, and has tended steadily to decrease; while Australia increases so slowly that, even if the present rate were maintained, the population would not double itself in the next century.”

Again, the Bishop of London, last year appears to have told the North-West Australian Diocesan Association “that the birth-rate in Australia is going down even more rapidly than at home (United Kingdom), and that he did not know how we are going to keep Australia even British.”

In addition to these grave warnings, fears have been continually expressed concerning the danger of Australia from the Japanese or Chinese. We are told also that from the industrial point of view Australia is calling out for population; and a law giving a bonus of £5 for each child was passed a twelve-month ago. It would appear, therefore, that the birth-rate question is a very serious one in Australasia, especially when we are aware that determined attempts at checking the resources of family limitation have signally failed.

Let us now examine the actual figures for the variation of the birth-rate, etc., and compare them with the above statements. These are given in Figs. 4 and 5.

In both countries the birth-rate fifty years ago was remarkably high (well 58over 40 per thousand), and it has since fallen very rapidly to 26 or 27 per thousand. But in both of them the death-rate has fallen somewhat, and they now have the lowest death-rates in the world, that of New Zealand having been about 9.5 per thousand for many years past. So, instead of increasing slowly, their rate of natural increase by excess of births over deaths is actually the highest in the world (with the possible exception of Bulgaria). The natural increase of New Zealand during the last five years has been more than 50 per cent. greater than in Great Britain, instead of being less, as stated by Mr. Roosevelt; and instead of the birth-rate going on falling, it has, on the contrary, risen lately. The natural increase of Australia is 16 per thousand, which would cause the population to double in forty-four years, or to become five times as large in a century. The Australian birth-rate has been well maintained during the past seven years, and the death-rate has slightly declined; so the natural increase has slightly accelerated.

The foregoing statements are, of course, quite independent of immigration, and the following are the actual census figures for the increase of population.

It is worthy of note that in Australia, which is supposed to be needing population so much, the actual increase in the last two decades has been only slightly in excess of the natural increase. This means that the net immigration must have been very small, or that nearly as many people must have left Australia as entered it—a curious commentary on the alleged need for them.^[8] New Zealand, on the other hand, shows a phenomenally large increase by the combination of natural increase and immigration.

It will be well at this point to examine the justification for the yellow peril theory as regards Australia. Japan has certainly moved in the opposite direction to Australia in having increased its birth-rate from 26 to 33 per thousand between 1891 and 1910. But its general and infantile mortality have also increased. Thus its natural increase to-day is only 12.5 per thousand as against the 16 or 17 per thousand of Australia and New Zealand, while its actual rate of increase is far short of theirs. Although the population of Japan is about ten times that of the whole of Australasia, every year makes the proportionate disparity of numbers less instead of greater; while as regards health, physique and financial resources, the advantage, of course, lies heavily with our people. That Australasia will be well advised to look 59to her defences may be granted; but there seems no reason whatever to be dissatisfied with the increase of her population.

Canada.—Little can be said about this part of our Empire, owing to paucity of statistical information; but that little is most interesting and significant. As regards the total population, the census returns show a very rapid increase, that of 34 per cent. (from 5,371,315 in 1901 to 7,204,838 in 1911) being without parallel in modern times. When we come to consider the birth-rate, however, a remarkable phenomenon appears. The only part of the Dominion for which vital statistics appear to be available is the Province of Ontario. Fig. 6 shows that the birth-rate of Ontario was only 22 or 23 per thousand in the eighties, and actually dropped to 19 in 1895, since then it has recovered (owing to an increased marriage-rate) to about 25 per thousand. Its lowest birth-rate was equal to that of France to-day. But the death-rate had also fallen—namely, to 10 per thousand, so that the natural increase was 9 per thousand, or not much behind that of most civilised countries. This fact may be commended to the consideration of those who think that the slow rate of increase of the French population is due to its low birth-rate.

The remarkable phenomenon now appears. The increase of the birth-rate in Ontario to 25 per thousand has been accompanied, not by a corresponding rise in the natural increase, but by an increase of the death-rate to 14 per thousand! So the additional births appear to have populated the graveyards rather than the country. It has been suggested to me by Dr. Stevenson that the increase in the birth and death rates of Ontario may be exaggerated, in that due allowance has not been made by the Canadian authorities for the effect of immigration. But even making the fullest allowance for this, there can be no doubt that both the birth and death rates have risen, and by nearly the same amount. The city of Toronto (Fig. 7) is a most striking example of the same phenomenon.

There need be no great difficulty in understanding this result. We have continually heard in the papers recently of poverty and unemployment in most of the large towns of Canada. Although the resources of the country are no doubt enormous, they can only be brought relatively slowly into operation, owing to the shortness of the summer and the difficulties of transport. The frequently quoted statement that her food exports show signs of lessening indicates that the inability of food to keep pace with an unrestricted population will prove true here as elsewhere.

Canada offers excellent opportunities for sturdy efficient workers, and will be able to support an immense population some day. But any attempt to crowd it rapidly with children or inefficient town-bred immigrants will only raise the death-rate, unemployment and labor unrest. The lives of women settlers are generally exceedingly strenuous and trying; and this, in combination 60with the long distances from medical or other help, makes the bringing up of large families very precarious.

South Africa.—Beyond the fact that the population of the Union of South Africa increased from 5,175,824 in 1904 to 5,973,394 in 1911 (i.e., an increase of 15.4 per cent. in seven years) little information appears to be available. The white population seems to have increased from 1,116,806 to 1,276,242 (i.e., by 14.28 per cent.) in the interval, while the native population increased from 3,491,056 to 4,019,006 (i.e., by 15.12 per cent.). But since no figures as to birth-rates are available nothing can be said beyond the fact that the actual increase works out at about 20 per thousand per annum, which is fairly high.

India.—We now turn from colonies mainly occupied by our own race and exhibiting our modern characteristics to a most marked degree, and come to our great Eastern possession which has preserved the ancient traditions of rapid reproduction. Writer after writer has launched into panegyrics on “the glorious fertility of the East,” and the Bishop of Ripon a few years ago issued this impressive warning: “Learn from the East. If we could but bring ourselves to do so, perhaps at no very distant period the Yellow Peril might turn out to be the White Salvation.”

That India is a country of high birth-rate is of course notorious. The custom of almost universal child marriage, and the anxiety which prevails among some (apparently not all) of the religious sects for a large posterity would alone render this inherently probable. According to the Statesman’s Year Book for 1913 the average birth-rate for India in the three years 1908–10 was 37.7 per thousand. This, however, was “officially but imperfectly recorded,” and the census report for 1901 gave the probable birth-rate for India as 48.8 per thousand. This figure is not at all an unlikely one, for the same rate has prevailed in Russia and parts of Egypt; but such figures as have appeared in the 1911 census report seem to confirm the lower estimate. Here are the figures for three of the important provinces:—

It is possible that these figures are correct, even without any restraint upon births, as the census report of 1901 mentioned that premature and repeated maternity combined with chronic under-nutrition appeared to lead to exhaustion and loss of fertility. In any case, however, the birth-rate counts among the highest at the present day.

But when we turn to the death-rate and the natural and actual increase of population there seems little reason for congratulation. The death-rate, 61given by the Statesman’s Year Book, for the three years above quoted was no less than 34.3, leaving a natural increase of only 3.4 per thousand—the lowest in our Empire, and nearly as low as that of France. The figures for Bengal, etc., above only show a natural increase of 4.7 per thousand, half that of Ontario at its lowest birth-rate of 19 per thousand; those for the Punjab reveal, despite the high birth-rate, an actual diminution of population by excess of deaths over births.

The emigration from India appears to be so infinitesimal in comparison with its population that the actual increase represents the natural increase almost exactly. In Fig. 1 is shown the variation of population in the whole of India and in the British Provinces according to the census returns.

Thus the rate of increase of population has been exceedingly slow except as regards the totals for 1881 and 1891, and for the British Provinces in 1891. But the Census Commissioners themselves state that the first few enumerations rapidly increased in completeness, which probably accounted for a good deal of the two former increases; while as regards the British Provinces, there was an increase in area of no less than 25 per cent. between 1881 and 1901, which heavily discounts the increase of 11 per cent. in population in 1891. The average increase in the British Provinces comes out at only 4.3 per cent. per decade over the whole period from 1861 to 1911; so when the increase of area is taken into account it may be doubted whether there has been any great excess of births over deaths at all.

A more absolute contradiction to the theory that a “glorious fertility” produces numbers and vigor it would be difficult to conceive. India is a land of famine. We all know of the terrible holocausts of 1876–8 when over five million perished, and that of 1899–1901, which was held responsible for over a million deaths, besides numerous smaller ones. But as Mr. W. S. Lilly has written in India and its Problems, “We may truly say that in India, except in the irrigated tracts, famine is chronic—endemic. It always has been.” Sir Frederick Treves in his charming work, The Other Side of the Lantern, has expressed the same opinion, and he says:—“These are some of the great hordes who provide in their lean bodies victims for the yearly sacrifice to cholera, famine, and plague.” The average death-rate of 34.3 per thousand, which is probably underestimated, means, with a population of 315 millions, over ten million deaths annually. Were the Indian death-rate 10 per thousand as in Australasia, there would be only three million deaths. Hence, unless medical authorities can give good reason for postulating an inherent racial predisposition to premature death among the inhabitants of India, this means 62that at least seven millions of lives are wasted annually by starvation or the diseases to which it renders them an easy prey.

There can be no doubt in the mind of anyone who studies the figures, that India is a chronically, seriously over-populated country, despite the oft-quoted dictum of Sir William Hunter. That India might produce food enough to feed her present population need not be contested. But that any action on the part of the authorities will succeed in providing for an increase of ten millions annually is inconceivable. The whole Empire owes a tribute of gratitude and admiration to Sir A. Cotton whose magnificent irrigation schemes have so greatly increased the possibilities of agriculture. They have no doubt been the real cause of the 7 per cent. increase of population in the last decade. This, however, only means providing for two out of the seven millions to be saved; and irrigation like everything else has its limits.^[9] Nothing will remove starvation, pestilence, misery and unrest from India, except the adoption by her people of the parental prudence of western nations.

The idea has been constantly put forward that the religious prejudices of the Indian population make such a contingency impossible. Is it certain, however, that this is so? The Census Report of 1901 suggested that in Assam some restraints upon births had been in vogue. In 1911, again, the Vice-President of the Calcutta Municipality, Babu Nilambara Mukerji, M.A., called attention to the extreme poverty caused by over-population, and strongly advocated such restraints. His address seems to have been received with considerable favor, and I have been asked to write articles for prominent native papers on the subject.

The project of encouraging emigration from India has, of course, been put forward. But the recent experiences in South Africa and elsewhere hardly favor this proposition, and Mr. Archer in an interesting article on “India and Emigration,” in the Daily News of December 26, pointed out that the real difficulty of over-population could not be appreciably lessened in this way.

Ceylon.—In view of the foregoing, reference may be made to Ceylon which has published its birth and death rates continuously since 1881, though I do not know what reliance can be placed on them. Fig. 8 shows that the birth-rate has rapidly risen from 27 to 41 per thousand, but that the death-rate and infantile mortality have also greatly increased.

The Empire.—The top line in Fig. 1 shows the increase of the population of the whole of our Empire according to the Statistical Abstract just issued. The figures are as follows:—

63Of course the increase from 1891 to 1901 was swelled by the addition of the Union of South Africa, etc., but the addition in the second period probably fairly represents the natural increase. The countries which go to swell this increase are those in which small families are the rule, and have rates of increase varying from 11 to 17 per thousand. It is India with the highest birth-rate which pulls down the average.

The population of the world is now probably about 1,800,000,000, and increasing at the rate of 5 per cent. or 6 per cent. in a decade. So our Empire includes about a quarter of the world’s population and is increasing more rapidly than the remainder.

No consideration of this subject would be complete if comparison were not made with the more important nations outside our own Empire. If Imperialist security depends upon numbers, it is relative, not absolute, numbers which count, and our attitude towards the falling birth-rate must depend upon what is happening among our rivals.

France.—The case of France appears to be the chief cause of the fears concerning the declining birth-rate, and she is variously spoken of as “dying,” “becoming depopulated,” “decadent,” etc. In Fig. 9, I have collected the vital statistics for France over the whole period of her declining birth-rate, i.e. from before the Revolution. They show the following characteristics:—

1. France is not becoming depopulated. Her population has been slowly but steadily rising ever since the Franco-German war, both actually and by excess of births over deaths, although in some years the deaths have exceeded the births.

2. The excess of births over deaths in the last decade 1901–10, though small, is double that of the previous decade, notwithstanding that the birth-rate fell from 22.2 to 20.6. It averaged about 48,000 per annum.

3. In 1781–84, before the decline of the birth-rate set in, the birth-rate had the high value of 38.9 per thousand. But instead of this giving a high natural increase of population, the death-rate was no less than 37 per thousand, giving an excess of births over deaths of only 1.9 per thousand—little more than that (1.2) of the last decade.

4. The enormous fall of the birth-rate from 38.9 to 20.6 per thousand, has been accompanied by a fall in the death-rate from 37 to 19.4 per thousand. Thus a fall of 18.3 in the birth-rate has been accompanied by a fall of 17.6 in the death-rate, and only a drop of .7 per thousand in the rate of increase.

64

Fig. 8.—CEYLON.

Fig. 9.—FRANCE.

Fig. 10.—GERMANY.

Fig. 11.—BERLIN.

5. The present low rate of natural increase in France is not necessarily due to its low birth-rate, as Ontario in Canada, with a similar birth-rate, had a death-rate of 10 per thousand, or a natural increase of 9 per thousand—nearly as great as our own. The low increase of France is therefore due to 65its high death-rate, not to its low birth-rate, and an explanation or remedy should be found for the former before objection is made to the latter.

6. Possibly as a result of the present agitation in France in favor of large families, the births in the first half of last year increased by 8,000 over those of the corresponding period of 1912. Instead of producing a greater increase of population, the deaths increased by 12,000, so that the survivals actually diminished.

It appears from the foregoing that while it is true that France is increasing in population much more slowly than other countries, there is no justification for believing that an increased birth-rate would populate it more rapidly. Much more likely is it that the result would be the same as that shown in Ontario and other countries—a higher death-rate without any advantage as regards numbers.

Germany.—As France is held up as the awful example of a low birth-rate, so is Germany regarded as the good example of a high one. It is certainly fear of Germany that is responsible for so much of the anxiety concerning our birth-rate.

That the population of Germany is increasing very rapidly is quite true, and it certainly has also a relatively high birth-rate. (Fig. 10). But the birth-rate has fallen rapidly since 1876, and despite this the natural increase of population has actually accelerated, because the death-rate has fallen still more rapidly. As the German death-rate is still considerably above the 9 or 10 per thousand line, there is plenty of room for this process to continue. The curve of actual increase of population in Fig. 1, shows that it has become exceedingly high of late years, despite the great fall in the birth-rate.

Those, however, who still think that Germany’s high birth-rate is a source of advantage to her may be consoled to know it will not continue long. The fall in the last few years has been phenomenal; and the statement made in a German paper a few days ago that at the present rate the German birth-rate will be down to that of France in ten years’ time appears to be justified. The birth-rates of her large towns are already close to this point (Berlin 20.4, Hamburg 21.8, Dresden 20.2, Munich 21.9, while that of London is still about 24) and the country districts are sure to follow. But the example of Berlin is a most striking one as to the fallacy of regarding high birth-rates as conducive to rapid increase. Fig. 11 shows that the birth-rate of Berlin rose with great rapidity from 32 per thousand in 1841 to over 45 in 1876, since when it has fallen even more rapidly. But, neglecting sudden variations due to war and epidemics, the death-rate has risen and fallen in such close correspondence as to produce comparatively little change in the rate of natural increase. The variation of the infantile mortality is very similar. On all grounds, therefore, it seems difficult to see what advantage Germany has derived 66from her high birth-rate, and the disadvantages were so obvious that it is little wonder that the German people have decided in favor of a low one.

Austria shows very similar variations to Germany.

Russia.—Russia has the largest population of any European nation, 120,588,000 in 1911. Its birth-rate for many years was the highest in the world, very nearly 50 per thousand. But its death-rate and infantile mortality have been the highest in Europe, so that its rate of increase of population, though rapid, has been less than that of New Zealand or Australia. Over two millions of unnecessary deaths have taken place annually, and one infant in every four (or over a million annually) dies in its first year. The war with Japan, a country of half its population and a much lower birth-rate, strikingly illustrated the inefficacy of mere numbers. In the Standard of March 6, it was stated that although the general recruiting standard in Russia is lower than in Austria, France, Germany, or Great Britain, the rejections in many localities reach the enormous figure of 70 per cent.

The Netherlands.—The foreign countries already dealt with are quite sufficient to give us a fair idea of our position among the great powers as regards the birth-rate question. No thoughtful person, however, can fail to see that this has another aspect which has generally been quite overlooked. It will therefore be of special interest to study the record of a nation in which this has been kept in view for many years. Holland is an intensely patriotic country, and its need for military efficiency is beyond dispute. It is inconceivable that her statesmen could contemplate a policy in any way detrimental to this. Yet it appears that in 1881 an organisation having as its direct object the reduction of the birth-rate, especially among the poor, was formed in Amsterdam, and that it received the warm support of Dr. van Houten, Minister of the Interior, and of Mynheer N. G. Pierson, the Finance Minister. It was thus enabled to conduct an energetic propaganda in favor of small families among the poorest classes, whose means or health did not permit them to do justice to large families. In 1895 its work had become so appreciated that it was approved by Royal Decree as one of the Societies of Public Utility. To-day it is a large and flourishing association with medical and other helpers in all the great centers. Thus in Holland the diminution of the birth-rate has been favored and directed on humanitarian and eugenic lines; and there has been a tendency for the State to become more individualistic in character, rather than to adopt that policy of State assistance which has been forced on most other nations by the gravity of their social problems, and which, by pressing on the educated classes, has led them seriously to restrict their numbers.

The results of their policy as regards the numbers and health of the population can be seen from Fig. 12. The birth-rate has fallen steadily and rapidly, especially in the last decade. The death-rate, however, has fallen so much more rapidly, that it has now reached 12.3 per thousand in 1912—the 67lowest figure in Europe; and the natural increase has reached 15.7 per thousand, the highest figure in Western Europe. The infantile mortality has also fallen more rapidly than in any other country. Indeed, Amsterdam and The Hague, the principal centres of the propaganda, had the lowest general and infantile mortality of all the great cities of the world, according to our Registrar-General’s Annual Summary for 1912.

Fig. 12.—THE NETHERLANDS.

When we turn from the question of numbers to the physical and social condition of the people, the results are even more gratifying. Those who have traveled in Holland will, I think, admit that the country looks prosperous, and the men, women and children robust and contented. Slums such as we have in our great cities seem practically non-existent; nor is there any sign of the stunting and anaemia so noticeable in our large towns, and even in our countryside. Dr. Soren Hansen in the Eugenics Congress of 1912 stated that the average stature of the Dutch people had increased by four inches in the last fifty years. The army records given in the official Year Book of the Netherlands are also most striking. The number of young men drawn annually for conscription by lot has increased from 27,559 in 1865 to 48,509 in 1911 (out of a population of 6,000,000); and of these the proportion over 5 ft. 7 in. in height has increased from 24.5 per cent. to 47.5 per cent., while that of those under 5 ft. 2½ in. has fallen from 25 per cent. to under 8 per cent. This is doubtless due to the fact that in Holland the poorest and least fit have been encouraged to be prudent, while in our country they have been having the largest families—the fitter classes having smaller families in 68consequence. Real wages which have fallen here and in Germany have apparently gone up in Holland, and her agriculture has rapidly improved. In every way that I have been able to test, her prosperity and progress has been most satisfactory. Moreover, Holland stands next to ourselves as a successful coloniser. Her possessions in the East and West Indies occupy an area of 783,000 square miles with a population of 38,000,000 (seven times her own population), 81,000 being Europeans. Germany, with a home population ten times greater, has colonies aggregating 1,029,000 square miles with a population of only 14,000,000 inhabitants, of whom but 25,000 are whites.

In view of all these records I cannot think that any unbiassed person will be able to avoid the conclusion that large numbers and national efficiency are not to be secured by a high birth-rate, especially in the lower strata of society. High birth-rates to-day invariably mean high general and infantile death-rates, and, when accompanied by humanitarian legislation, a serious process of reversed selection.

The explanation of this apparent paradox lies in the fact, which never seems to be properly understood, that the population of the world and of nearly all countries is constantly being kept in check by insufficiency of food. A French statistician, M. Hardy, has calculated (and his figures, though challenged by great authorities, have now been accepted) that if the total food production of the world were fairly distributed among its inhabitants, the ration of proteids available for each would only be two-thirds of that recognised as necessary for efficiency. Mr. Seebohm Rowntree has shown that large numbers of families in our own country—the richest in the world—have deficiencies of protein in their diet by amounts up to 40 per cent., and over 2,500,000 adult male workers have wages of 25s. a week or less, upon which with the present cost of living and rent in towns it is impossible to bring up more than three children properly. As a result, whenever families are large a considerable proportion of the children die, and of those who survive many grow up stunted and incapable of assimilating a good training. The over-crowding caused by large families with an ever decreasing margin for rent is also a potent cause of disease and of immorality—the latter evil being further greatly intensified by the economic difficulties in the way of marriage that are the chief bar to the prevention of those terrible diseases for which the Royal Commission, presided over by our Chairman, is investigating a remedy.

That the rate of increase of population of a country depends in almost every case upon its power of feeding its people by its own or imported food, and not upon its birth-rate, is a matter which statesmen will have to recognise; and those who are anxious for the increase of the population of our 69country and Empire, should turn their attention to the acceleration of food production instead of deploring the declining birth-rate. No intelligent person will claim that the food producing possibilities of the world are exhausted, but it does appear difficult to increase them at more than a very slow rate (probably at present not more than 6 per cent. or 7 per cent. in a decade); and the world’s population cannot increase faster than the food does. Irrigation in India has been followed by an increase in population far greater than before, and encouragement of agriculture or of the industries which bring food to this country is the only means by which our increase of population can be accelerated. No shuffling of the incidence of taxation, and no humanitarian schemes, will affect it—except prejudicially by favoring the increase of the inefficient rather than the efficient. Nor will emigration, the panacea of the orthodox Imperialist, solve the problem. We do not want effective producers to leave us, and these are the only people our colonies really desire. Our town-bred weaklings are frequently less fitted to succeed in the Colonies than at home, as the experience of Canada appears to testify. It has been said that “no Empire can survive which is rotten at the core”; and if we persist in the policy of encouraging the excessive reproduction of the poor, of taxing the capable for their support, of keeping about a third of our men and women unmarried, and of seeing many of our best emigrate for want of decent prospects at home, we need not be surprised if our Imperial efficiency diminishes.

On the other hand, if we consider the example of Holland we may be assured that a further fall in the birth-rate among the poorer classes will be accompanied by an immediate and progressive improvement in their conditions, by a checking of the output of physical and mental defectives, and by a gain in the national efficiency, and probably also in the rate of increase of our population. As the Bishop of Ripon said at the Church Congress of 1910: “If the diminution of the birth-rate could be shown to prevail among the unfit, we might view the phenomenon without apprehension, and we might even welcome the fact as evidence of the existence of noble and self-denying ideals.” There is no reason why the death-rate in any part of our Empire should be higher than the 9 per thousand of New Zealand, where poverty as we know it scarcely exists. The birth-rate of Great Britain can therefore fall to 20 per thousand before our normal natural increase of 11 per thousand is reduced. As this paper is being concluded, the Registrar-General’s figures for 1913 have come to hand, and show that the fall of the birth-rate in the last three years has been accompanied by a recovery in the natural increase to 10.8 per thousand.

In the accompanying diagrams white strips imply birth-rates, shaded strips death-rates, and black strips infantile mortality, or deaths of children under one year. The amount of the white strip visible above the shaded strip is, of course, the excess of birth over death-rate, or the rate of natural increase of population.

Fig. 1.—Shows the relation between birth and death-rates and infantile mortality in various countries in 1901–05.

Fig. 2.—Relation between birth-rate and corrected death-rates in various countries. (This shows that France is healthier than appears in Fig. 1.)

Fig. 3.—Shows relation between birth and death-rates from various causes in five districts of London.

Fig. 4.—Relation between the birth-rate and death-rate for various arrondissements of Paris in 1906. (Note that the increase in the Elysée quarter is as high as the average in the quarters of high birth-rate.)

Figs. 5 and 6.—Variations of the total population of birth- and death-rates in the United Kingdom and the German Empire. (Note that the fall in the death-rate corresponds fairly closely to that in the birth-rate.)

Fig. 7.—The same for France. (Note that the population is still increasing, although slowly.)

Fig. 8.—Birth and death-rates for France since 1781. (Note that the rate of increase of population in 1781 was no higher with a birth-rate of 39 per 1,000 than in 1901–6 with a birth-rate of only 21 per 1,000. A fall of 17.8 per 1,000 in the birth-rate has resulted in a fall of 17.5 per 1,000 in the death-rate.)

Fig. 9.—Birth and death-rates and infantile mortality for England and Wales. Also marriage rate, fertility of married women, illegitimacy, and variation of diseases. (Note that the illegitimate birth-rate has fallen to half since the fall of the birth-rate set in.)

Fig. 10.—Birth and death-rates and infantile mortality in the Netherlands. (Notice the rapid increase of population as the death-rate falls, and the great fall of infantile mortality, probably due to the practical work of the Dutch Neo-Malthusian Birth Control League among the poor.)

Figs. 11–13.—Protestant Countries. (Notice the correspondence between the birth and the death-rates and infantile mortality in all.)

Figs. 14–16.—Roman Catholic Countries. (Note that the fall of the 71birth-rate has taken place almost equally with that in the Protestant countries, and with the same result.)

Figs. 17–20.—The only four countries in which the birth-rate is approximately stationary. (Notice that the death-rate has not fallen—except perhaps in Russia—and that the infantile mortality has not fallen. Also that the highest birth-rate produces the highest death rate and infantile mortality, and the lowest birth-rate the lowest mortality.)

Figs. 21–24.—The only four countries with rising birth-rates. The death rate and infantile mortality have increased in every one.

Fig. 25.—Australia. The death-rate has fallen with the birth rate, and is now only about 10 per 1,000.

Fig. 26.—New Zealand. The only country in which the fall in the birth-rate has not produced a fall in the death-rate, and which is not therefore over populated. The infantile mortality is the lowest in the world, and the death-rate less than 10 per 1,000, which gives us an ideal which we can reach in all countries by lowering the birth-rate sufficiently.

Fig. 27.—The City of Toronto. The birth-rate has fallen and afterwards risen. The death-rate has fallen with the birth-rate, and afterwards risen, indicating that the improvements in sanitation have not been the cause of the falling death rate in other countries.

Fig. 28.—Berlin. The birth-rate rose rapidly from 1841 to 1876, and afterwards fell even more rapidly. The death-rate, except for epidemics and wars, rose and fell in almost precise correspondence with the birth-rate.

Fig. 29.—Berlin. The dotted area shows the fertility rate or births per 1,000 married women, and indicates the remarkably rapid fall since 1876. The correspondence of the infantile mortality with the birth-rate shown in Fig. 28 is very close.

Figs. 30 and 31.—Europe and Western Europe. These show that the total population of Europe is increasing faster the more the birth-rate falls, while in Western Europe the birth and death-rates correspond almost exactly. Calculations made from this show that about 25,000,000 fewer births and deaths have occurred in Europe since 1876, due to the fall in the birth-rate caused by the Knowlton Trial and the Neo-Malthusian movement. It should be noted that in the great majority of cases the decline of the birth-rate commenced in 1877, the year of the Knowlton Trial.

Fig. 1.

Fig. 2.

Fig. 3.

Fig. 4.

Fig. 5.

Fig. 5a

Fig. 6

Fig. 6a.

Fig. 7

Fig. 7a.

Fig. 7b.

Fig. 8.

Fig. 9

Fig. 10.

Fig. 11.

Fig. 12.

Fig. 13.

Fig. 14.

Fig. 15.

Fig. 16.

RUSSIA.

Fig. 17

ROUMANIA.

Fig. 18

JAMAICA.

Fig. 19

IRELAND.

Fig. 20

Figs. 21-23

CANADA (Ontario).

Fig. 24

AUSTRALIA (Commonwealth).

Fig. 25

NEW ZEALAND.

Fig. 26

Fig. 27

Fig. 28

Fig. 29

Fig. 30

Fig. 31

CHAPTER IV INFANT MORTALITY — INFANT MORTALITY: JOHNSTOWN, PA. — INTRODUCTION — RELATION OF INFANT MORTALITY TO ENVIRONMENT NEIGHBORHOOD INCIDENCE — SANITARY CONDITIONS—SEWERAGE, PAVEMENTS, GARBAGE COLLECTIONS — HOUSING — NATIONALITY — GENERAL NATIVITY — SERBO-CROATIAN — ITALIAN — SLOVAK, POLISH, ETC. — OTHER NATIONALITIES — STILLBIRTHS — ATTENDANT AT BIRTH — MOTHERS — LITERACY [22] — ABILITY TO SPEAK ENGLISH — YEARS IN THE UNITED STATES — AGE — BABY’S AGE AT DEATH AND CAUSE (DISEASE) OF DEATH — FEEDING — MOTHER’S HOUSEHOLD DUTIES, CESSATION AND RESUMPTION OF — ECONOMIC FACTORS — EARNINGS OF FATHER — GAINFUL WORK OF MOTHER — ILLEGITIMACY — REPRODUCTIVE HISTORIES — FOURTH ANNUAL REPORT OF THE CHIEF, CHILDREN’S BUREAU, U. S. DEPARTMENT OF LABOR, Washington, October 7, 1916 — INFANT MORTALITY—MANCHESTER

In the preceding pages it was stated that a high birth-rate is always accompanied by a high infant mortality. The material presented in this chapter demonstrates the fact that ignorance of methods to prevent conception forces the wives of ill-paid wage-workers to bear an excess of unwanted children. Figures are adduced to show an appalling death rate of infants under five years of age and the economic distress of the survivors in families unwanted and too large.

MEDICAL GYNECOLOGY. Howard A. Kelly, A.B., M.D., LLD., Professor of Gynecological Surgery in Johns Hopkins University, and Gynecologist to the Johns Hopkins Hospital, etc. D. Appleton Co. New York and London, 1912.

As long as a community can rest content in the belief that a large infant mortality is the natural method of reducing the race of the unfit, the doctrine of laissez-faire can be accepted with complaisance. If, however, it seems probable that the influence of environment must be reckoned as a greater cause of infant mortality and of physical unfitness than the influence of heredity, it may be wiser for society, as it certainly will be easier, to preserve the lives and health of the children born, than to stimulate an increase in a birth rate now diminishing. As it is an open question whether the race as a whole suffers mental and physical deterioration from a diminished rate of production among the superior stocks, it is unquestionably a matter of public policy, as well as of common humanity, that conditions of living in communities should be made favorable to the preservation of the life and health of all infants and children. P. 41.

EUGENICS AND RACIAL POISONS. Prince A. Morrow, M.D. Pamphlet published by the Society of Sanitary and Moral Prophylaxis, N. Y., 1912.

Observation shows that the class known as degenerates is increasing much more rapidly than the general population and that their average duration of life has been lengthened. Diseases may be cured, but degeneracy, which is usually due to some inherited defect in the physical, mental or moral nature 94of the individual, is rarely amenable to curative treatment. It is only through applied eugenics that the vast volume of disease and degeneracy which flows through the channels of heredity can be prevented. Obviously this can be accomplished only through education and legislative restriction upon the procreation of the unfit.

In the making of the child, the mother not only contributes one half of the ancestral qualities which enter into its constitution, but furnishes all the nutrition and energy which serve to support its life. From this point of view the mother is the supreme parent of the child, she is the source of its life and from her blood is drawn the material which contributes to its growth and development. The welfare of the mother is the welfare of the child. We have thus come to recognize the dominant influence of the mother’s relation to the health, as well as the life of the race. A high standard of physical motherhood is the most favorable asset of a nation. Havelock Ellis, in his recent work, on the Psychology of Sex, says, “Nations have begun to recognize the desirability of education, but they have scarcely yet come to recognize that the nationalization of health is even more important than the nationalization of education. If it were necessary to choose between the task of getting children educated and the task of getting them well born and healthy, it would be better to abandon education. There have been many great people who never dreamed of national systems of education; there has been no great people without the art of producing healthy and vigorous children.”

Newman, the distinguished author of the work on “Infant Mortality” declares that the problem of infant mortality is not one of sanitation alone, or housing, or indeed of poverty as such, it is mainly a question of motherhood.

It is not probable that the scientific methods which have been successfully applied to plants and the selective breeding of animals will ever replace the haphazard methods of human reproduction.

There is no fact better established than that a man can transmit only that which he is. If his system is weakened by excess or tainted with disease he can beget only physical weakness, or beings tainted with disease. The syphilitic, the consumptive, the epileptic, the alcoholic, should not produce his kind.

NEO-MALTHUSIANISM AND RACE HYGIENE IN “PROBLEMS IN EUGENICS.” Vol. 2. London, 1913. Dr. Alfred Ploetz, President of the Int. Soc. for Race Hygiene.

Arthur Geissler concluded from a study of about 26,000 births of unselected marriages among miners that the mortality of children was least in 95the four first-born, and then increased to a very high rate. Following are Geissler’s figures, (marriages with only one or two children are omitted).

INFANT MORTALITY. Results of a Field Study in Johnstown, Pa., based on Births in one calendar year. By Emma Duke, Infant Mortality Series, No. 3. Bureau Publication No. 9. U. S. Department of Labor, Children’s Bureau.

The pamphlet embodies the result of a field study in Johnstown, Pa., based on one calendar year. The inspection was made in 1913, of the 1911 babies, so that even the last born baby included had reached its first birthday—or rather had had a chance to reach its first birthday; many of them were dead long before that day. Every mother of a 1911 baby was visited. She was questioned about the health of that child and all her other children. The report takes up the familiar factors—neighborhood environment, sanitary conditions, sewage, housing, nativity, attendance at birth, feeding, age of mother, and like matters. Full information is given on these points. Then the report considers infant mortality from a novel viewpoint—the relation of the death rate to the size of the family. The Johnstown statistics include families varying in number from one child to ten and over, and varying in health from none living to all living. The result of the study of infant mortality in relation to the size of the family is thus stated: “The statistics, based on the results of all her reportable pregnancies, show a generally higher infant mortality rate where the mother has had many pregnancies, but there is not always an increase from one pregnancy to the next.” The following table shows this tendency. It is based on the reproductive histories of 1,491 married mothers who had 5,617 births. Miscarriages are not included.

In contemplating these figures we think immediately of wage-earning mothers away from home, ignorant feeding, and lack of care. These are powerful factors in raising the death rate.

Of all the 1911 babies who died before they were a year old, 37% died in the first month of life. So much pain and misery and then no baby after all. All the skill in the world could not have saved those babies who lived only long enough to die.

The infant mortality rate for the babies whose fathers earn under $521 is almost twice as great as for those born into families in the most prosperous group. These figures strengthen the conclusion reached in the study of the babies born in 1911, namely that the economic factor is of far-reaching importance in determining the baby’s chance of life.

One of the tables showing the influence of the economic factor, is calculated on the basis of 1,434 live-born babies with fathers. 187 of these babies succumbed during the first year, giving a general mortality rate of 130.7 per 1,000. In these families a very few of the mothers worked outside the homes.

Expressed in words, this table asserts that when the family income is under $625 a year, the children born alive die before the first birthday at the rate of 213.5 to the 1,000. In striking contrast when the income is $900 or more, they die only 96.8 to the 1,000. “Ample” was the expression used when the investigator could not obtain exact information as to the amount, but saw no evidence of actual poverty. The same ratio held good when it was calculated for the native-born mothers alone and when it was calculated for the foreign-born mothers alone. Even where mothers are American-born women, staying at home to look after their children, the amount of money to be spent on the child strongly influences its chance of life and death.

97According to this table the superiority which children in indigent households show over children in well-to-do households is preeminent skill in dying. When father earns $12 a week the children die at the rate of 213 per 1,000; but when father earns $18 a week, only 96 children per 1,000 pass away the first year of their lives. The lower the father’s wages, the higher the babies’ death rate. Many a death certificate should read, “Died of poverty.”

The following table is compiled from the 5,617 children borne by 1,491 married mothers, in Johnstown, Pa.

Apparently the size of the family has much to do with the child’s chance of living, and apparently the earlier in the succession the child is born, the better chance of life it possesses. Death warrants await the coming of the youngest born.

The term infant mortality, used technically, applies to deaths of babies under 1 year of age. An infant mortality rate is a statement of the number of deaths of such infants in a given year per 1,000 births in the same year. Some countries include stillbirths in making the computations, but this method is not generally followed in this country nor has it been followed in this report.

Ordinary procedure is to compare the live births in a single calendar year with the deaths of babies under 12 months of age occurring in that same year, even though those who died may not have been born within the calendar year of their death. The infant mortality rates in this report, however, have not been computed on the usual basis, but for the purpose of securing greater accuracy in measuring the incidence of death this bureau has considered, in making the computation, only so many of the babies born in the year 1911 as could be located by its agents, and has compared with this number the number of deaths within this group of babies who died within one year of birth, even though some of these deaths may have occurred during the calendar year 1912.

Infant mortality can be accurately measured in no other way than by means of a system of completely registering all births as well as all deaths. In 1911 the United States Bureau of Census regarded the registration of deaths as being “fairly complete (at least 90 per cent. of the total)” in 23 States, but the same degree of completeness in the registration of births was found only in the New England States, Pennsylvania, and Michigan, and in New York City and Washington, D.C. An exact infant mortality rate for the United States as a whole cannot be computed owing to this generally incomplete registration. In the 1911 census report on mortality statistics, however, the infant mortality rate is estimated at 124 per 1,000 live births. How this estimated rate compared with the computed rates for other countries is shown in the following summary:

When it had been decided by the Children’s Bureau to make infant mortality the subject of its first field study and to include all babies born in a given calendar year, regardless of whether they lived or died during their first year, advice and cooperation were enlisted of mothers, physicians, nurses, and others experienced in the care of children, and also of trained investigators and statisticians, in the preparation of a schedule which was submitted to them for criticism.

With its limited force and funds it was not possible for the Children’s Bureau to extend its inquiries throughout the entire United States. It was therefore decided to make intensive studies of babies born in a single calendar year in each of a number of typical areas throughout the country that offered contrasts in climate and in economic and social conditions, the results to be eventually combined and correlated. It was necessary to restrict the choice of the first area to a place of such size as could be covered thoroughly within a reasonable time by the few agents available for the work.

Johnstown, Pa., was the first place selected. It is in a State where birth registration prevails, and hence a record of practically all babies could be secured; it is of such size that the work could be done by a small force within a reasonable period, and it seemed to present conditions that could with interest be contrasted with conditions typical of other communities. Moreover, the State commissioner of health and the State registrar of vital statistics 103were both working zealously to enforce birth-registration laws; both were actively interested in reducing infant mortality, and they welcomed a study of the subject in their State. In Johnstown the mayor, the president of the board of health, the health officer, and other local officials all showed the same spirit of hearty cooperation and interest.

Inasmuch as the study was confined to babies born in a single calendar year and work was begun in January, 1913, the latest year in which the babies could have been born and still have attained at least one full year of life was 1911.

Work was begun on January 15, 1913, with the transcription from the original records at Harrisburg of the names and other essential facts entered on the birth certificates of babies born in 1911, and, if the baby had died during its first year of life, items on the death certificate were also copied.

In the meantime the people of Johnstown through the press, and through the clergy in the foreign sections, had been informed of the purpose and plan of the investigation. Without the friendly spirit thus aroused and the interest manifested by the Civic Club and other organizations the work could not have been brought to a successful issue. The investigation was absolutely democratic; every mother of a baby born in 1911, rich or poor, native or foreign, was sought, and it is interesting to note refusals were met with in but two cases.

The original plan was to limit the investigation to those babies born in the calendar year selected whose births had been registered, the purpose being to secure facts concerning a definite group and not to measure the completeness of birth registration. Shortly after beginning the work, however, agents of this bureau were told that the Serbian women in Johnstown seldom had either a midwife or a physician at childbirth; that they called in a neighbor or depended upon their husbands for help at such times, or that they managed alone for themselves, and that therefore their babies usually escaped registration. The omission of these babies meant the exclusion of a number of mothers in a group that was too important racially to be omitted from an investigation embracing all races and classes. Accordingly a list of babies christened in the Serbian Church and born in the year 1911 was secured and an attempt made to locate them. In addition an agent called at each house in the principal Serbian quarter to inquire concerning births in 1911. A number of unregistered babies of Serbian mothers were thus found and included in the investigation.

The agents were sometimes approached by mothers of babies born in 1911 who resented being omitted from the investigation simply for the reason that their babies’ births had not been registered. The agents were therefore instructed to interview mothers thus accidentally encountered and to include their babies in the investigation. But no additional baptismal records were copied nor was a house-to-house canvass made of the city; in fact, no further 104means were resorted to to locate unregistered babies for the purpose of including them in the investigation.

There were 1,763 certificates copied at Harrisburg, and 1,383 of the babies named in them were reached by the agents. In addition, 168 babies for whom there were no birth certificates, but who were located in the ways just noted, were included, making a total of 1,551 completed schedules secured.

Of the 380 not included in the investigation there were 149 who could not be located at all; 220 others had moved out of reach—that is, into another city or State; 6 of the mothers had died; 3 could not be found at home after several calls, and 2 refused to be interviewed.

From the following summary of data recorded on the certificates of the 380 unlocated babies just referred to it appears that the infant mortality rate (134.3) among them is almost the same as that (134) shown in Table 1 for babies included in the investigation. In reality, however, it is perhaps a little higher, as some of these babies no doubt died outside of Johnstown and their deaths were recorded elsewhere.

The rate of infant mortality is regarded as a most reliable test of the sanitary condition of a district. (Sir Arthur Newsholme, Elements of Vital Statistics, p. 120. London, 1899.)

Johnstown is a hilly, somewhat Y-shaped area of about 5 square miles which spreads itself out into long, narrow, irregularly shaped strips, detached by rivers and runs and steep hills. In some places it is not over a quarter of a mile wide, but its extreme length is about 4 miles. The city is composed of 10521 wards and is an aggregation of what were formerly separate unrelated boroughs or towns. The names of these different sections, together with the numerical designations of the wards included in or comprising them, are shown in the following table. This table gives for each section not only the total population according to the Federal census of 1910, but also the number of live-born babies included in the investigation and the number and proportion of deaths among such babies during their first year.

To learn where the babies die is perhaps the first step in solving the infant mortality problem. The modern health officer recognizes this and generally has in his office a wall map upon which are indicated sections, wards, city blocks, and sometimes even houses. As infant deaths are reported, pins are stuck in the map in the proper places, a density of pins on any part of the map indicating, of course, where deaths are most numerous, although the percentage of infant deaths may not be the highest.

The highest infant mortality rate, 271, is found in the eleventh ward, known as Woodvale, although this is neither the most populous ward nor the one having the largest number of births. The infant mortality rate here, however, is double the rate for the city as a whole and more than five times as great as it is for the most favorable ward.

This is where the poorest, most lowly persons of the community live—families of men employed to do the unskilled work in the steel mills and the mines. They are for the most part foreigners, 78 per cent. of the mothers interviewed in this ward being foreign born.

106Through Woodvale runs the main line of the Pennsylvania Railroad. To the north of the tracks rises a steep hill, toward the top of which is Woodvale Avenue, the principal street north of the railroad. (See plate A.) Sewer connection is possible for the houses along this avenue, as a sewer main has recently been installed, but the people have not in all cases gone to the expense of having the connection made, and in other cases where they have done so sometimes only the sinks are connected with the sewer and the yard privy is retained.

On the streets above Woodvale Avenue dwellings are more scattered and the appearance is more rural. A few of the families still have to depend upon more or less distant springs for their water, although city water is quite generally available throughout Woodvale.

The streets near the bottom of the hill, as Plum Street, for example, are so much below the level of the sewer mains that they can not be properly drained into the sewer. Private drain pipes from houses are buried a few feet below the surface and protrude from the sides of the hills, dripping with house drainage which flows slowly into ditches and forms slimy pools. (See Plates B and C.)

None of the streets on the north side of the railroad track are paved; sidewalks and gutters are lacking. In cold weather the streets are icy and slippery and even dangerous on account of the grade. In warm weather they are frequently slippery and slimy with mud.

Maple Avenue is the principal street of that part of Woodvale lying to the south of the railroad tracks, and it is the only properly paved and graded street in Woodvale. The streets on this side of the tracks, however, are not in as bad a condition as those to the north, nor are the drainage and general sewerage conditions as offensive as north of the tracks, but many of the streets are nevertheless muddy and filthy. (See Plate D.)

Prospect ranks next to Woodvale in infant mortality, having a rate of 200. This section, lying along a steep hill and above one of the big plants of the steel company, has not a single properly graded, drained, and paved street. The sewers are of the open-ditch type, and the natural slope of the land toward the river is depended upon for carrying off the surface water that does not seep into the soil. The closets are generally in the yard and are either dry privies or they are situated over cesspools. Some of the people who live on the lower part of the slope have wells sunk directly in the course of the drainage from above. (See Plate E.)

Cambria City, which is composed of the two most populous wards of Johnstown, has the third highest infant mortality rate, 177.4. It has a large foreign element, as is evidenced by the fact that 90.6 per cent. of the mothers interviewed were foreign born. It is situated along the river, between the hills of Minersville and Morrellville, and somewhat to the north of Prospect. 107The sewage from other residential sections and from the steel mills above them empties into the river at this point. In warm, dry seasons the river is low, flows slowly, and forms foul-smelling pools.

Sewer connection is possible for most of the houses in Cambria City, although all are not connected. Some, on the streets bordering the river, have private drain pipes that empty out into the stream. Others have their kitchen sinks connected with the sewer but still retain yard privies, which, of course, are not sewer connected.

There is considerable crowding of houses on lots, rear houses being commonly built on lots intended for but one house. Density of population and house congestion are greater here than elsewhere in the city.

The streets of Cambria City are somewhat better graded and more generally paved than those of Woodvale, but muddy streets and unpaved sidewalks nevertheless exist here. Broad Street, however, which is the business thoroughfare and runs through the center of the section, is the widest and best constructed street in Johnstown. Bradley Alley, on the other hand, running the length of Cambria City and parallel to Broad Street, is the most conspicuous example in the city of a narrow lane or alley used as a residence street. A number of small dwellings, generally housing more than one family, have their frontage on this alley, which is 19 feet 10 inches in width and without sidewalks. It is unpaved and in bad condition, generally being either muddy or dusty and littered with bottles, cans, and other trash. (See Plates F. and G.)

Homerstown has an infant mortality rate of 156, ranking fourth among the several sections of Johnstown in this respect. It has a fairly prosperous and somewhat suburban appearance, but its comparatively high infant mortality rate can perhaps be partly accounted for by the bad street conditions and the fact that refuse of all sorts is dumped into the shallow river at this point.

Minersville is a district where a high rate would be expected from prevailing conditions. The rate is 125, or less than the average for the city but more than double that for the most favorable sections. This ward is built on a hill and so located that the rising clouds of grit-laden smoke from the steel mills envelop it much of the time. Only one street in this section is well paved, and this is seldom clean. Houses on some of the streets near the top of the hill are not sewer connected, and streams of waste water trickle down the hill and give rise to unpleasant odors. (See Plates H and I.)

Conemaugh Borough, with an infant mortality rate of 117.6, ranks sixth in this respect among the sections into which Johnstown has been divided. It comprises wards 9 and 10 and begins at the edge of the down-town section and spreads upward over the hills to the southwest. Some of the houses on streets near the top of the hill are not sewer connected, and streams of water 108constantly trickle down the numerous alleys and streets that descend the hill. (See Plate J.) This section makes a very unfavorable first impression because of the open drainage and of the many dirty, badly paved streets. (See Plate K.) Unlike some of the other wards, it has a rather evenly distributed population and is without the vast uninhabited areas and acutely congested spots found in some other sections. On the whole there is little crowding on the lots and there are many good-sized yards. One-third of the population is foreign born. Of these the Italians are the most numerous. Despite certain ugly spots this section has not the unwholesome atmosphere that characterizes Woodvale and to a lesser extent Prospect, Cambria City, and Minersville.

The infant mortality rate of 117.6 per thousand in Roxbury is the same as that of Conemaugh Borough. For reasons not plainly apparent the rate here is higher than in Moxham, Morrellville, Kernville, or the down-town section, although it appears to be as favorably conditioned as these sections are from a social, economic, and sanitary standpoint. Here, as in all these sections, however, are many conditions not conducive to health. For example, parts of Franklin Street are in bad repair. The roadway is full of ruts and holes; the street, which is seldom sprinkled, is dusty in dry weather and muddy in wet weather, and in front of good houses along one section of this street runs an open ditch that receives house drainage.

Moxham has the eighth highest infant mortality rate, it being 89.2. Conditions here are generally rather favorable, although there is some complaint that at “high water” the sewage received by one of the runs in this section backs into some of the houses and then the sinks and water-closets overflow. Some of the homes here, near the city limits, are not supplied with city water but are still dependent upon wells and springs.

One of the three wards constituting Morrellville (ward 18) has a rural appearance; there is little house crowding on lots, big yards are common, and the streets are not paved. It is, however, marred by an offensive open-ditch sewer. Ward 19 of Morrellville has a more finished, less rural appearance. One of its objectionable features is that house drainage and the bloody waste of slaughterhouses are emptied into a shallow stream that flows through it. Ward 20 adjoins ward 19, and although it spreads out into a suburb it appears for the most part to be a comfortable and busy little village. Strayer’s Run winds about here and receives sewage. The fact that it is without a guardrail in some places and that the railing is inadequate in others makes it a source of danger, and according to common report such accidents as children falling into the stream have occurred. The infant mortality rate for Morrellville is 82.5.

Kernville, a section with a considerable proportion of prosperous people, has a very favorable infant mortality rate, it being 57.7. Parts of this section, 109however, are on a hill stretching upward from Stony Creek, which is both unsightly and offensive in warm weather and when the water is low.

The down-town section, i.e., wards 1, 2, 3, and 4, where are to be found many of the best conditioned houses, the homes of many of the well-to-do people, has the lowest infant mortality rate in the city, it being but 50.

No infant mortality rate is presented in the tables for Coopersdale or for Peelorville. In the first-named section only 36 live-born infants were considered, and 8 of them died in their first year. But this high rate need not be considered as especially significant, as the base number is small for such a computation. Coopersdale, however, is a suburban-appearing community in which one would expect the infant mortality rate to be low.

Peelorville is that part of the thirteenth ward which adjoins Prospect. A number of company houses are located here in which sanitary conditions are fairly good. The ward seems to have good drainage and no sewage nuisances. It is a community of wage earners and not of prosperous homes. Only 18 babies are included in the report for this district, one of whom died. With such a small base the infant mortality rate is not significant. (See Plate L.)

The general inadequacy of the sewerage system which has been indicated for the city as a whole is due in part to the fact that the city is largely an aggregation of sections, formerly independent of Johnstown itself, which have been annexed at different periods. Some of these boroughs had sewer systems more or less developed when they were taken into Johnstown; others had none. Not only the sewerage of Johnstown but that of outlying boroughs pollutes the two shallow rivers, the Conemaugh and the Stony Creek, that flow through Johnstown. These are burdened with more waste than they can properly carry away, and the deposits which are left on the rocks in various sections of both rivers create nuisances that are the subject of much complaint, especially during the warm summer months. (See Plates M, N, O, and P.) At various times agitation has been started to improve the rivers which, as they flow through Johnstown, are, at the low-water stage, little better than swamps of reeking slime from the waste matter emptied into them from the hundreds of sewers along their banks. The pipes through which waste matter is emptied into the streams go only to the river edge, leaving their mouths uncovered and making the river beds at times pools of slowly flowing filth. These unsightly, malodorous conditions could be remedied if pipes were extended out into the middle of the streams, where the water is deeper.

110With the exception of sprinkling a few wagon loads of lime along the banks of the streams each year, the city has done nothing to abate the nuisances arising from the use of these rivers as sewers or to restrain the coal and steel companies from allowing the drainage from mines and mills to enter the streams.

The engineer’s records show that Johnstown had in 1911 a total of 41.1 miles of sewers and 36 sewer outlets, and 82 miles of streets, 52.7 miles being paved. The alleys in Johnstown are generally inhabited. They are narrow and without sidewalks. Their length is 52.88 miles and 47.35 miles are unpaved. The combined length of streets and alleys is 134.88 miles. A comparison of this combined length of streets and alleys with the 41.1 miles of sewers having 36 outlets shows the inadequacy of the sewer system.

Not only is there an absence of paving, but the roadways are in very bad condition. A protest by “A Citizen” in the Democrat of June 26, 1913, says that there are nine months in the year when it would be impossible for the proposed fire-department automobile engines to attend a fire in the seventh, eighth, eleventh, seventeenth, eighteenth, nineteenth, twentieth, and twenty-first wards owing to the condition of the streets.

The scavenger system is also very defective. Citizens are required to pay for the removal of their ashes, trash, and garbage. Garbage collections are not made by the municipality, but by private contractors, and any sort of receptacle, covered or uncovered, can or box, is pressed into service by householders. It is by no means uncommon to find streets and alleys littered with ashes, garbage, bottles, tin cans, beer cases, and small kegs. Dirty streets are by no means exceptional in Johnstown, even though the State of Pennsylvania has a law (act of Apr. 20, 1905) which provides for the punishment of any person who litters paved streets. It reads, in part, as follows (sec. 7 of Pamphlet Laws, 227):

“From and after the passage of this act, it shall be unlawful, and is hereby forbidden, for any person or persons to throw waste paper, sweepings, ashes, household waste, nails, or rubbish of any kind into any street in any city, borough, or township in this Commonwealth, or to interfere with, scatter, or disturb the contents of any receptacle or receptacles containing ashes, garbage, household waste, or rubbish which shall be placed upon any of said paved streets or sidewalks for the collection of the contents thereof.

“Any person or persons who shall violate any of the provisions of this act shall, upon conviction thereof before any magistrate, be sentenced to pay the cost of prosecution and to forfeit and pay a fine not exceeding $10 for each offense, and in default of the payment thereof shall be committed and imprisoned in the county jail of the proper county for a period not exceeding ten days.”

In a report on infant mortality to the registrar general of Ontario, 1910, 111Dr. Helen MacMurchy says: “Improve the water supply, the sewerage system, and the system of disposing of refuse; introduce better pavements, such as asphalt, and at once there is a decline in infantile mortality.” All these are sanitary features in need of great improvement in Johnstown, and unquestionably a lowered infant mortality rate would reward any efforts for their betterment.

In Johnstown the so-called “double” house predominates, usually frame. The double house is in reality two semidetached houses built upon a single lot. Rows of three or more houses of two, three, or four rooms each are common, and they are known locally as three-family, or six-family houses, as the case may be. Sometimes these are “rear houses,” that is, they are built behind other houses that face the street, on the same lots and in fact are approached by way of a narrow alley running alongside the house that has its frontage directly on the street. For this type of house water-closets or privies are often in rows in the yard or court that is used in common by all families. (See Plates Q and R.) In some places they are too few in number to permit each family to have the exclusive use of one.

Johnstown has three or four comparatively high-grade apartment houses, and in several office buildings rooms are rented to families for housekeeping. These are generally taken by native families.

In one of these office buildings the two lower floors are used for business purposes and the two upper floors are given over entirely to tenement purposes. From 40 to 50 families live here, many of whom have but one room. To serve the 20 or 25 families on each floor there is one bath and toilet room for men and another for women. Adjoining the toilet rooms is a small room containing garbage cans and trash receptacles for the use of the tenants.

The sanitary conditions in some of the best tenements or apartments, however, are not up to the standards of other cities, and in those occupied by the poorer people conditions are much worse than are usually permitted to exist in cities having large tenement houses in great numbers, where a tenement-house problem is recognized as such and active efforts are made by the municipality to improve conditions.

An absolute measure of the importance of each single housing defect in a high mortality rate can not be secured from this study. But it is not without interest to note that in homes where water is piped into the house the infant mortality rate was 117.6 per thousand, as compared with a rate of 197.9 in homes where the water had to be carried in from outdoors. Or that in the homes of 496 live-born babies where bathtubs were found the infant mortality rate was 72.6, while it was more than double, or 164.8, where there 112were no bathtubs. Desirable as a bathtub and bodily cleanliness may be, this does not prove that the lives of the babies were saved by the presence of the tub or the assumed cleanliness of the persons having them. In a city of Johnstown’s low housing standards, the tub is an index of a good home, a suitable house from a sanitary standpoint, a fairly comfortable income, and all the favorable conditions that go with such an income.

The same trend of a high infant mortality rate in connection with other housing defects is noted in the next table.

The following summary may be of interest in indicating some relation between infant mortality and cleanliness or uncleanliness combined with dryness or dampness of homes:

113Dirt is doubtless unhealthful, but the amount of ill health or the number of infant deaths caused by a home being dirty can hardly be measured, when, as is usually the case, the dirt is accompanied by so many other bad conditions arising from poverty. For example, a home in close proximity to railroad tracks or mills whose stacks send forth clouds of soot, smoke, and ashes is generally the poorly built home of those who have neither time nor means to secure and retain cleanliness under such difficulties.

Overcrowding in homes is another factor the relative importance of which can not be exactly determined, because of its close connection with other ills. But the degree of overcrowding is greatest in the small cheaper houses, those of one, two, three, or four rooms. The average number of persons per room in the homes of all live-born babies for whom the data were secured was found to be 1.38. Homes of four rooms were more numerous than those of any other size and they housed an average of 1.58 persons per room. The number of babies in homes of various sizes with the number of persons per room for homes of each size was as follows:

In homes of one, two, three, or four rooms or where the number of occupants ranged from 4.42 to 1.58 persons per room the infant mortality rate was 155, as compared with a rate of but 101.8 in larger homes, where the number ranged from 1.22 to 0.43 persons per room.

The 1910 census returns show that the greatest overcrowding was in ward 15, where the average number of persons per dwelling was 9.9. Wards 16, 11, and 14 came next with rates of 8.3, 7.7, and 7.2 respectively. The infant mortality rate for these four wards is 190.2, which is over one-third more than the rate for the whole city.

The mortality rate among infants who slept in a room with no other person than their parents was much lower than among those who slept in a room with more than two persons. The babies that slept in separate beds also had a much lower infant mortality rate than those who did not sleep alone, as shown in the next table. (Table omitted.)

In presenting statistics on sleeping and ventilation, only the babies who lived at least one month have been considered, for the reason that so many deaths during the first month of life were due to prenatal causes.

114The incidence shown in the foregoing table is significant, even though it can by no means be deduced therefrom that the health of a large proportion of babies was so impaired by sleeping with older and more or less unhealthy persons that death resulted. But irregular night feeding and overfeeding are undoubtedly harmful, and the mother is tempted to subject the baby to this when it sleeps with her and disturbs her rest.

Of the 1,389 babies who lived at least one month, 600, or 43.2 per cent., lived in homes where the baby slept in a room with not more than two other persons. The fact that the baby slept in a room with no more persons than its parents generally argues that the family’s means permitted them to have one or more additional rooms for other members of the family, but in other cases, of course, merely that there were no other persons in the family.

Almost every home visited had means for good ventilation of the baby’s room at night, yet but 604, or 43.5 per cent., of the 1,389 babies who lived at least a month slept at night in well-ventilated rooms—that is, in rooms where, according to the mother’s statement, a window was open all night. Some mothers opened windows when the weather was neither cold nor damp; or opened them in a hall or room adjoining that where the baby slept; others emphatically stated that at night the windows were “always shut tight.” The babies subjected to differences of ventilation show corresponding variations in infant mortality rates.

A high death rate in badly ventilated homes can not be charged wholly to bad air. The mother who did not, or could not, provide proper ventilation was generally the mother without the means or the knowledge necessary to enable her to care for her baby properly in other respects, and yet the marked differences suggest that ventilation is itself a very important ally of the baby in its first year of struggle for existence.

In many rooms that were poorly ventilated, windows were not opened for the reason that the room was not properly heated and the houses themselves were flimsy and drafty. The problem in such houses is to keep warm. If the windows were frequently or constantly opened, the houses would be too cold to live in. In some localities the outside air is so laden with soot, ashes, dirt, and smoke that every effort is made to keep it out of the house.

The foreigners, who generally have the most miserable homes, are not dirty people who select bad living conditions through innate poor judgment, low standards, and lack of taste. The squalid homes which housed the natives and later the Germans and the Irish until the present type of immigrants came to do the more poorly paid work were the only homes available within the purchasing power of their low wages. The new immigrants demanded practically nothing and the owners did practically nothing in the matter of improving these homes, which naturally became more and more squalid as time went on. An excessive infant mortality rate and insanitary homes in unhealthful sections were found to be coexistent.

The investigation embraced 860 babies of native mothers (of whom 6 were negroes) and 691 babies of foreign mothers, making a total of 1,551. The infant mortality rate for the entire group was 134 per 1,000 live births; for the babies of native mothers 104.3, and for those of foreign mothers 171.3. The stillbirth rate for native mothers having children in 1911 was less than that for foreign mothers, being 52.3, as compared with 62.2 per 1,000 total births.

The line between the natives and foreigners is very sharply drawn in Johnstown. The native population as a rule knows scarcely anything about the foreigners, except what appears in the newspapers about misdemeanors committed in foreign sections. The report of the Immigration Commission^[15] comments “on the attitude of the police department toward foreigners ... with regard to Sunday desecration,” and states that “the Croatians are accustomed to spend Sunday in singing, drinking, and noisy demonstrations. The police have been instructed to show no leniency on account of ignorance of the municipal regulations, and, without any attempt at explaining the laws, they arrest the offenders in large numbers.” Again, it states: “They are arrested more often for crimes that make them a nuisance to the native population than for mere infractions of the law.... Few arrests are made for immorality among foreigners.” “Sabbath desecration” is the crime foreigners are most frequently charged with.

Foreigners are employed largely in the less skilled occupations of the steel mills, which operate 24 hours a day, seven days a week. At the time the investigation was made some of the men in the steel mills worked for a period of two weeks on a night shift of 14 hours, then two weeks on a day shift of 10 hours, and back again to the night shift of 14 hours for another two weeks, and so on. When shifts were changed, one group of men was required to work throughout a period of 24 hours instead of for the usual 10 or 14 hour period and another group had 24 hours off duty. Some departments of the steel mills, however, shut down on Sundays, and in some departments for certain occupations an eight-hour day prevails, but these more favorable conditions do not prevail among the majority of the unskilled foreign workers whose homes were visited.

The foreigners who work on a 24-hour shift in a mill on one Sunday frequently “desecrate” their alternate free Sabbath by “singing, drinking, and noisy demonstrations,” in spite of the known danger of arrest for “crimes 116that make them a nuisance to the native population” or for “Sabbath desecration,” laws concerning which are strictly enforced in Johnstown; for example, children are not permitted to play in public playgrounds on Sunday and mercantile establishments are required to be closed on that day. Also, it is “unlawful for any person or persons to deliver ice cream, or to sell or deliver milk from wagon or by person carrying same, within the city on the Sabbath day, commonly called Sunday, after 12 o’clock m.” The ordinance from which the foregoing sentence was quoted became a law on January 25, 1914.

The foreign group having the highest infant mortality rate is the Serbo-Croatian^[16] where infant deaths numbered 263.9 per 1,000 live births.

The men of the Serbo-Croatian group are fine looking and powerful and are employed in the heavy unskilled work of the steel mills and the mines. They greatly outnumber the women of their race in Johnstown, and a man with a wife frequently becomes a “boarding boss”; that is, he fills his rooms with beds and rents out sleeping space to his fellow countrymen at from $2.50 to $3 a month each. The same bed and bedding is sometimes in service both night and day to accommodate men on the night and the day shifts of the steel mills.

The wife, without extra charge, makes up the beds, does the washing and ironing, and buys and prepares the food for all the lodgers. Usually she gets everything on credit and the lodgers pay their respective shares biweekly. These conditions exist to some extent among other foreigners, but are not as prevalent among other nationalities in Johnstown as among the Serbo-Croatians.

In a workingman’s family, it is sometimes said, the woman’s work-day is two hours longer than the man’s. But if this statement is correct in general, the augmentation stated is insufficient in these abnormal homes where the women are required to have many meals and dinner buckets ready at irregular hours to accommodate men working on different shifts.

The Serbo-Croatian women who, more than any of the others, do all this work are big, handsome, and graceful, proud and reckless of their strength. During the progress of the investigation, in the winter months, they were frequently seen walking about the yards and courts, in bare feet, 117on the snow and ice-covered ground, hanging up clothes or carrying water into the house from a yard hydrant.

Whether it harmed them to expend their force and vigor as they did could not be determined in individual cases, but their babies are the ones who died off with the greatest rapidity, their infant mortality rate being 263.9, as compared with the rates of 171.3 for all the foreign; 104.3 for the natives; and 134 for the entire group as shown in Table 18. Excluding babies of Serbo-Croatian mothers, the infant mortality rate for babies of foreign mothers is but 159.7.

The Italian mothers visited in Johnstown bore 75 children in 1911, 4 being stillborn. The infant mortality rate among the live born was 183.1, the highest of any racial group excepting the Serbo-Croatian, where it was 263.9.

The Italians have been in Johnstown somewhat longer than the Serbo-Croatians and they seem to have a little firmer grip on the community life there. Their homes are a shade better, a trifle cleaner, and somewhat less crowded than those of the Serbo-Croatians, although their hygienic standards seem little if any higher and they rank no better in literacy. The women do not perform the arduous duties that are the lot of so many of the Serbo-Croatian women; they have not the robust physique of the latter and the men are not found in those branches of the steel industry which require the extraordinary strength possessed by the Serbo-Croatians. The occupations of the Italian fathers were found to be more diversified than those of the Serbo-Croatians, some being fruit, grocery, or cheese merchants; steamship agents; bricklayers, carpenters, or workers at other skilled and semiskilled trades.

The infant mortality rate in the group designated “Slovak, Polish, etc.” is 177.1. In this group are included all the Slavic races represented in the investigation excepting the Serbo-Croatian. The babies of Slovak^[17] mothers were found to be most numerous, there being 276 of them. There were 108 babies of Polish,^[18] 2 of Bohemian,^[19] and 7 of Ruthenian^[20] mothers. In addition, 118one baby of a Scandinavian (Danish) mother was included, not because Scandinavians bear the least racial resemblance to the Slavic races, but because the few Scandinavians in Johnstown happened to be on about the same economic footing as the “Slovak, Polish, etc.”

The rate for this group is lower than that for either the Serbo-Croatians or the Italians, but it is nevertheless very high and one exceeded by only a few European countries, as shown by the table on page 12.

Some of the “Slovaks, Poles, etc.,” live in the same squalid sections as the Serbo-Croatians, and in the same type of inferior houses, but on the whole they have been in Johnstown longer, are more prosperous, and are therefore beginning to move from Cambria City and Woodvale, where formerly practically all lived, into more desirable sections. Those who have been in this country longest and intend to stay here are buying homes with large yards in the less crowded sections and are raising vegetables and flowers. Others, however, still remain in poor neighborhoods and sometimes buy houses there for from $300 to $600 each, built close together on rented ground.

Lodgers are by no means uncommon among the people in this group, but usually their homes are cleaner, less crowded, and possessed of more comforts than those of the Serbo-Croatians and Italians.

The British^[21] infant mortality rate in Johnstown is 129 and the German 127.7. The British and Germans in Johnstown are more prosperous than the Slavic, Magyar, Jewish, Italian, Syrian, and Greek peoples, and regard the others as “foreigners.” It was strange to hear a man, one who could speak English, say, “We are not foreigners; we are Germans.” The British and Germans occupy the same relative position economically that they occupy in the infant mortality scale with relation to other races.

In the Magyar group, of 38 babies born alive 4 died in their first year, making an infant mortality rate of 105.3, which is almost as low as that for babies of native mothers. The Magyars are little if any better off than the other “foreigners” among whom they live, but they possess somewhat higher standards of living. They live in poor neighborhoods and have inferior houses, but their homes are cleaner and they themselves somewhat more alert, personally cleaner, and less illiterate than the other foreigners.

There were but 10 babies of Hebrew mothers and 12 of Syrian and Greek mothers; among these there were no deaths. These groups are too small numerically to be significant in a comparative race study of infant mortality.

In all there were but 88 stillbirths included in the investigation. They were more numerous proportionately among the Germans than among the mothers of any of the other nationalities. No single nationality group, however, has a very large representation, and hence a comparison of the rate for one with that for another nationality is not as significant as the difference in rate between native and foreign mothers. Although a special study of the causes of stillbirths was not made in connection with a study of deaths of infants during their first year of life, nevertheless the incidence of these births among the different nationality groups is believed to be of some interest, and therefore shown in the next table. (Omitted.)

The native mother usually had a physician at childbirth; the foreign-born, a midwife. The more prosperous of the foreign mothers, however, departed from their traditions or customs and had physicians, while the American-born mothers, when very poor, resorted to midwives. The midwives usually charged $5, and sometimes only $3; they waited for payment or accepted it in installments, and they performed many little household services that no physician would think of rendering.

Two-thirds of those having no attendant were Serbo-Croatians. It was a Polish woman, however, who gave the following account of the birth of her last child:

At 5 o’clock Monday evening went to sister’s to return washboard, having just finished day’s washing. Baby born while there; sister too young to assist in any way; woman not accustomed to midwife anyway, so she cut cord herself; washed baby at sister’s house; walked home, cooked supper for boarders, and was in bed by 8 o’clock. Got up and ironed next day and day following; it tired her, so she then stayed in bed two days. She milked cows and sold milk day after baby’s birth, but being tired hired some one to do it later in week.

This woman keeps cows, chickens, and lodgers; also earns money doing laundry and char work. Husband deserts her at times; he makes $1.70 a day. A 15-year-old son makes $1.10 a day in coal mine. Mother thin and wiry; looks tired and worn. Frequent fights in home.

The infant mortality rate was lower for babies delivered by physicians than for those delivered by midwives or for those at whose birth no properly qualified attendant was present. This is not necessarily an indication of the 120quality of the care at birth, although in some cases the inefficiency of the midwife may have directly or indirectly caused deaths, just as in some instances a physician’s inefficiency may have caused them. The midwife, however, is resorted to by the poor, and in their homes are found other conditions that create a high infant mortality rate.

Frequently the Serbo-Croatian women dispense altogether with any assistance at childbirth; sometimes not even the husband or a neighbor assists. Over 30 per cent. of the births among the women of that race took place without a qualified attendant. More than one-half of those delivered by midwives, less than one-fifteenth of those delivered by physicians, and about one-fifth of those delivered without a qualified attendant had babies who died in their first year of life.

Fifteen of the 19 Serbo-Croatian women whose babies died under 1 year of age kept lodgers.

In Johnstown the midwife is resorted to principally by the poor. Recent laws that the State is now trying to enforce require that the standard for the practice of midwifery be raised. If this can be done midwives might become definitely helpful persons in the community. One or two of the intelligent graduate midwives in Johnstown have been an educational force among the foreign mothers for some years past. On the other hand there were others who were so dirty and so ignorant that they were a menace to the public health.

There are differences in the infant mortality rate between the babies of literate and the babies of illiterate mothers; between those with mothers who can speak English and those with mothers who can not; and between babies of the mothers who have been in this country for a considerable period and those of the newer arrivals. Comparisons of this nature are confined to the foreign mothers, as only three cases of illiteracy were found among native mothers, and the other comparisons would not, of course, be applicable in any case to native mothers.

The next table shows that the infant mortality rate among the children of illiterate foreign mothers was 214, or 66 per thousand greater than the rate among literate foreign mothers.

The next table shows that babies whose mothers can not speak English were characterized by a more unfavorable infant mortality rate than other babies.

In addition to a consideration of the babies according to their mothers’ ability to speak English, it is of interest to note the infant mortality rates among babies whose mothers have been in this country for different periods of time.

The high infant mortality rate for the children of newer immigrants, illiterates, and those who can not speak English is perhaps affected by the fact that they are at the same time generally of the poorest families and are housed in the most insanitary and unhealthful part of the city.

The age of the mother is frequently believed to be a factor in the health of the child. The highest infant mortality rate was found to be that for the group of babies with mothers over 40 years of age, and the lowest for babies of mothers from 20 to 24 years of age.

The youngest mothers have a higher stillbirth rate than other mothers, and the oldest group of mothers has the next highest rate. In this connection not only the foregoing table is of interest, but also Table XII, based upon the entire reproduction histories of the mothers included in this study. As all the children borne by these mothers are included, the base numbers in the latter table are larger and the figures therefore somewhat more significant.

A baby who comes into the world has less chance to live one week than an old man of 90, and less chance to live a year than one of 80.—Bergeron.

The most dangerous time of life is early infancy; even old age seldom has greater risk. Death strikes most often in infancy. The Johnstown babies died during their first year of life at the rate of 134 per 1,000 born alive, and they paid their heaviest toll in their very earliest days. If the total of 196 deaths had been distributed evenly throughout the 12 months, 8.3 per cent. of the babies would have died each month and 25 per cent. during each quarter. But instead of that 37.8 per cent. died in the first month; 9.2 per cent. in the second, and 8.2 per cent. in the third, or over 55 per cent. in the first quarter.

The large number of deaths in the first few hours or days of life indicates that many babies are born with some handicap and that in many instances the mother has been subjected to some condition which resulted in the birth of a child incapable of withstanding the ordinary strain of life. Of the 45 babies who died in Johnstown less than a week after birth, 38 died of prematurity, congenital debility or malformations, or injuries received at birth. In one other case the cause of death was given as “bowel trouble” and in six other cases it was not clearly defined. In addition to the 45 babies just referred to as having died in their first week, 12 died later either from prematurity or from congenital defects.

Of the deaths from causes arising after birth, 52 were attributed by the attending physicians to diarrhoea and enteritis, 50 to respiratory diseases; and 44 to some other or to some ill-defined cause.

124The latest census report on mortality statistics characterizes diarrhoea and enteritis as the “most important preventable cause of infant mortality” in the United States, and numerically at least it proves to be the most important cause of infant death in Johnstown.

Holt^[23] says that one of the most striking facts about diarrheal diseases in infants is their prevalence during the summer season. In Johnstown the infant diarrheal deaths were least prevalent in the first quarter of the year, next in the second, next prevalent in the fourth, and most prevalent in the third or summer quarter.

Our figures are too small to admit of broad generalizations or a very full discussion of infant deaths according to the period of the year.

This excess of infant deaths from diarrhea in the summer months has been established by statistics in many countries, and the cause of such an excess has been the subject of much discussion, but as yet there is no general agreement. Liefmann and Lindemann^[24] conclude, however, that in this field of controversy there are certain facts which are at present well established, these being the dependence of the high summer mortality on methods of feeding, on hot weather, and on the living and social condition of the parents. The last factor mentioned by these authors, including as it does housing conditions, economic status, and degree of intelligence, is becoming more and more the subject of study and investigation. It has been shown that the distinctly harmful effect of hot weather on the infant is increased when the housing conditions are bad; in overcrowded homes with bad ventilation the indoor temperature may be many degrees higher than the outdoor temperature. The ignorance and carelessness of mothers has also been shown to increase the bad effect of hot weather. With hygienic care, including cool baths, much fresh air, and careful feeding, many infants are able to pass through extremely hot weather without diarrheal disturbances.

Respiratory diseases were reported as a cause of death with almost as great frequency as diarrheal diseases. As shown by Table 19, these deaths occurred principally in the colder months of the first and fourth quarters of the calendar year.

Food is recognized as of such importance in relation to infant mortality that studies of this subject frequently resolve themselves into studies of feeding only. Invariably these demonstrate the truth of the statement of Dr. G. F. McCleary^[25] that “in human milk we have a unique and wonderful food for which the ingenuity of man may toil in vain to find a satisfactory substitute.” Many mothers, however, still fail to appreciate the risk their young babies face in being given any except the natural infant food, and consequently babies are in large numbers wholly or partly weaned from the breast in the earliest months of their lives.

Breast feeding is far more general, comparatively, among the poorer mothers than among the well to do, as shown by the following summary which gives the number and per cent. of babies of mothers with husbands earning varying incomes, who had been completely weaned from the breast when they were 3, 6, or 9 months of age, respectively. For each of the periods indicated the percentage completely weaned from the breast is much greater in the groups where earnings are highest.

126Breast feeding, wholly or in part, is continued for a longer period by foreign than by native mothers, as indicated in the preceding table, showing that 20.3, 26.1, and 34.1 per cent. of the native mothers’ babies as compared with 6.4, 9.7, and 18.6 per cent. of the foreign mothers’ babies had been weaned from the breast at the age of 3, 6, and 9 months, respectively.

The extent to which the native and foreign mothers in Johnstown relinquished a part of their household duties as the time for their confinement approached is shown below:

Among the 174 babies of mothers who relinquished part of their household duties a month before confinement, the infant mortality rate was 112.5, as compared with 136.7 for those of other mothers.

To what extent the relinquishment of household duties at a given time directly affected the health of the child can not be definitely shown. A relation may exist, but on the other hand the difference in the mortality rate may be due to the fact that the mothers could afford to give consideration to their condition and escape some of their heaviest tasks as their pregnancy approached its end, and were members of families who were thoughtful of them and relieved them of these tasks or employed extra household assistance at such times.

Another indication of intelligence and of comfortable surroundings is the care given a mother in the early days of her baby’s life, particularly if she is a nursing mother. The duration of her rest period before the resumption of part of her household duties is one measure of this. The foreign mothers, with less education, more numerous and arduous tasks, less opportunity for leisure, and smaller incomes, begin to resume their housework sooner than the native mothers with young babies.

The fact that a mother takes up her housework in the early days of her baby’s life does not necessarily increase the danger of its death. In some cases, however, mothers stated that the quantity of their breast milk was noticeably impaired when they got up and resumed their work too soon. Naturally this would affect the baby’s nutrition. In other cases a mother’s 128cares and duties may be so absorbing that she can not give the baby full attention. Whatever the exact explanation, attention should be called to the greater frequency of infant deaths when the mother resumed household duties very soon after childbirth.

A statement of the time of the mother’s resumption of household duties in full, like that giving the time of resumption in part, shows that the native mothers have the longer period of rest.

The infant mortality rates for all mothers in the group just referred to, according to the time of resuming housework in full after childbirth, show fewer infant deaths proportionately when the mother has had a longer rest; that is, a rest of two weeks or more.

A grouping of babies according to the income of the father shows the greatest incidence of infant deaths where wages are lowest, and the smallest incidence where they are highest, indicating clearly the relation between low wages and ill health and infant deaths.

For all live babies born in wedlock the infant mortality rate is 130.7. It rises to 255.7 when the father earns less than $521 a year or less than $10 a week, and falls to 84 when he earns $1,200 or more or if his earnings are “ample.”^[30] The variation in the infant mortality rate from one earnings group to another is not perfectly regular and consistent, but if any two or more 129consecutive groups are combined an invariable lowering of the infant mortality rate from one such combined group to that next higher results.

In considering the babies of native and of foreign mothers separately in the foregoing table, similar variations in mortality rates according to earnings of father are found, although the foreign infant death rate is higher in each group. The foreign are less numerous both actually and relatively in the higher wage groups.

130The foreigners of a given wage group almost always live in a poorer neighborhood than the natives earning the same amount. The foreigners go where they find their own countrymen, most of whom are poor, and hence even those who earn a fair wage find themselves, until they become Americanized, surrounded by poor conditions and an ignorant class of people.

It is of interest to note what per cent. of the native and what per cent. of the foreign are in the several earnings groups. The next table shows this for all married mothers and not simply for those of live-born babies as in the foregoing table.

The 1,491 married mothers included in the foregoing table bore 1,517 babies in 1911, the excess being due to plural births. The 33 unmarried mothers and their 34 babies (one mother had twins), although included in some of the general tables, are not included in those relative to the earnings of the husband.

In localities where large numbers of women are engaged in industrial work, comparisons are frequently made of the death rates among their babies with those of the babies of mothers not so engaged. In Johnstown, however, industrial occupations are not open to women, and but 3.1 per cent. of the mothers visited went outside their homes to earn money. All mothers who gained money by keeping lodgers or in any other way are, for convenience, designated “wage-earning” mothers, even though their earnings were not in the form of a definite wage at stated periods.

Although not industrially engaged, nearly one-fifth of the mothers did resort to some means of supplementing the earnings of their husbands. Usually they kept lodgers. This was done by the foreign mothers principally, exactly one-third of whom had lodgers, as compared with less than 1 per cent. 131of the native women. Usually work done outside the home consisted either of char work or of assisting husbands in their stores. Generally these stores were in the same building with the home.

When a mother of a young baby does not give her full time to her duties within the home but resorts to means of earning money, it generally indicates poverty. This is true to a greater degree in Johnstown than in places which have many inducements for women to work. In Johnstown, with its excess of males, especially in the foreign population, the woman’s services are particularly needed to make the home.

In the group where the husband earns $10 a week or less—that is, under $521 a year—many of the women are wage earners. In each group showing better earnings for the husband the number and percentage of wage-earning wives decline. Such a tabulation as the following almost automatically fixes the minimum wage on which a man, wife, and a child or two can live with any degree of comfort in Johnstown at about $780 a year. When the husband’s wage is less than $780 a year, it is shown that the wives, in considerable number, must be wage earners. As shown in the next table, in nearly half of the families where the husband earns $10 a week or less (less than $521 a year), the wife resorted to some means of earning money; when he earned as much as $900 a year, only 8.9 per cent. of the wives worked, and in the small group where the man earns as much as $1,200 a year, only 1 in 50.

It is impossible to judge from statistics alone whether or not the work done by an individual woman, either her own housework or work for money, is so excessive as to affect her during pregnancy or while nursing to the extent of reacting on the health of the baby; but the fact is that the infant mortality rate is higher among the babies of wage-earning mothers than 132among others, being 188 as compared with a rate of 117.6 among the babies of nonwage-earning mothers. Wage-earning mothers and low-wage fathers are in practically the same groups, and it is difficult to secure an exact measurement of the comparative weight of the two factors in the production of a high infant mortality rate.

Of the 1,551 birth included in this investigation 34, or 2.2 per cent., occurred out of wedlock. Nine of the 32 illegitimate babies who were born alive died during their first year. It is recognized that these figures are a very small base from which to draw conclusions concerning the effect of illegitimacy on the infant mortality rate. It is of interest, nevertheless, to note that the findings for this small group are similar to those of countries which compute an infant mortality rate for legitimate and illegitimate children separately, that is, a rate for illegitimates more than twice as high as for children born in wedlock.

Thirty-two, or 3.7 per cent., of the 860 native mothers, as compared with 2, or 0.3 per cent., of the 691 foreign mothers visited, had illegitimate children in 1911.

In addition to the data relating exclusively to babies born in 1911, a statement was secured from each mother as to the number and duration of each of her pregnancies and the result thereof; that is, the number of children she had borne, alive or dead, the number of miscarriages she had had, and the age at death of each live-born child who had died. Although this information was secured for all mothers, tabulations are presented of the data furnished by married mothers only. Comparatively few single mothers reported more than one child, and information from them on this point is not believed to be as reliable as that from married mothers.

The 1,491 married mothers of babies born in 1911 had had an aggregate of 5,554 pregnancies, resulting in 5,617 births, the excess of 63 births over pregnancies being due to plural births. Eight hundred and four of these children died under 1 year of age, making an infant mortality rate of 149.9 for all their babies, as compared with the rate of 134 for those born in 1911. The stillbirths of these women numbered 194, or 4.5 per cent. of the total number of births; miscarriages reported numbered 191, but these were not added to the total reportable^[36] pregnancies.

Details as to the infant mortality rates for all babies born to native and foreign mothers included in this study, not only in the year 1911 but at any other time, are presented in the next table, which classifies the babies according to the total number of reportable pregnancies that their mothers had had, to and including the pregnancy resulting in the 1911 birth.

The statistics, based upon the results of all her reportable pregnancies, show a generally higher infant mortality rate where the mother has had many 134pregnancies, but there is not always an increase from one pregnancy to the next. This is more clearly shown when the pregnancies are grouped as in the next table.

This tendency is shown in still another form of summary: Combinations of four or less pregnancies are, for convenience, considered as group 1, while the combinations of over four are designated group 2. The differences in rates in the two groups are notable. The infant mortality rate is much lower for the first than for the second group.

This influence of the size of the family upon the infant mortality rate is shown in the computations giving the relative infant mortality rate for the different children borne by married mothers. The rate is most favorable for the second-born child, being 131.2. Among first born it is 143.6; for tenth or later born children 252.3.

135The next table gives a further elaboration of the same data; that is, it shows the infant mortality rate where such rates are lowest and highest, respectively, according to the age of the mother at the child’s birth and the order in which the child was born. Attention is again directed to the fact that the statistics presented in this section on “Reproductive histories” are based upon the total number of reportable pregnancies; that is, in addition to the pregnancies resulting in births in 1911, all prior pregnancies of the women considered in the investigation have been included.

The difference in size of family for native and foreign mothers of different ages are indicated in the next table. The total and average number of live-born children, not reportable pregnancies, are given.

The next table shows all losses of pregnancy sustained by 628 mothers and the rate of loss per 1,000 births for mothers having different numbers of births or reportable pregnancies. For all mothers it was 188.4. “Loss,” 136as here used, means the sum of infant deaths (or deaths in first year) and stillbirths.

The influence of the economic factor on infant mortality among the babies born prior to 1911 can not be determined with exactness, as no inquiry was made concerning earnings of the father when the other children were born. But it is believed that his earnings during the year following the birth of the 1911 baby can be regarded as an index of the economic standing of the family for some time past. In individual cases, of course, revolutionary changes in the family’s income may have occurred, but for the great mass of people in the group considered it is not likely that within such a short space of time as that covered by the child-bearing period of the women considered—most of whom had not had numerous pregnancies—marked changes had taken place. If these known earnings are accepted as an index, the following variations are found to occur in the infant mortality rate for all the babies of whom a record was secured:

The infant mortality rate for the babies whose fathers earn under $521 is almost twice as great as for those born into families in the most prosperous group. These figures strengthen the conclusion reached in the study of the 137babies born in 1911, namely that the economic factor is of far-reaching importance in determining the baby’s chance of life.