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Title: The Case for Birth Control - A Supplementary Brief and Statement of Facts
Author: Sanger, Margaret H.
Language: English
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                       The Case For Birth Control
              A Supplementary Brief and Statement of Facts

                            MARGARET H. SANGER

 To Aid the Court in its Consideration of the Statute designed to prevent
        the dissemination of information for Preventing Conception

                           PUBLISHED, MAY 1917

[Illustration]

 JONAH J. GOLDSTEIN
       COUNSEL



                              Copyright by
                           MARGARET H. SANGER
                                  1917



                                CONTENTS


 CHAPTER I. INTRODUCTORY                                               4
      Introductions to Birth Control by Margaret H. Sanger,
      Havelock Ellis, August Forel and G. F. Lydston.


 CHAPTER II. THE ORIGIN AND PRACTICE OF BIRTH CONTROL IN VARIOUS      23
   COUNTRIES
      Genesis of Movement,
      England,
      Holland,
      France,
      United States,
      Other Countries.


 CHAPTER III. POPULATION AND BIRTH RATE                               43
      Birth Control, by Havelock Ellis,
      Population Facts in United States,
      Birth Rate of British Empire,
      Birth Rate of Other Countries (With Tables).


 CHAPTER IV. INFANT MORTALITY                                         93
      General Statistics,
      Results of Children’s Bureau Survey at Johnstown, Pa., by Emma
        Duke,
      Manchester Report.


 CHAPTER V. MATERNAL MORTALITY AND DISEASES AFFECTED BY PREGNANCY    155
      Children’s Bureau Report, by Grace L. Meigs,
      Death Rates from Child Birth in Foreign Countries,
      A Municipal Birth Control Clinic,
      Tuberculosis,
      Kidney Diseases,
      Eclampsia,
      Diabetes,
      Pelvic Deformities,
      Heart Disease,
      Too Frequent Pregnancies,
      Pernicious Vomiting.


 CHAPTER VI. HARMFUL METHODS PRACTICED TO AVOID LARGE FAMILIES       185
      Coitus Interruptus,
      Continence,
      The Objects of Marriage, by Havelock Ellis,
      Abortion.


 CHAPTER VII. PROSTITUTION, FEEBLE-MINDEDNESS AND VENEREAL DISEASES  197
      The Social Evil,
      Feeble-mindedness,
      Syphilis,
      Gonorrhea.


 CHAPTER VIII. OTHER TRANSMISSIBLE DISEASES AND PAUPERISM            223
      Insanity,
      Epilepsy,
      Alcoholism,
      Pauperism,
      Child Labor.


 CHAPTER IX. CONCLUSION: EMINENT OPINIONS                            245
      The Progress of Holland,
      Eminent Opinions


 GLOSSARY                                                            250



                                FOREWORD


The purpose of the Appellant in presenting the various statistics and
medical and social facts incorporated in the supplementary brief,
entitled THE CASE FOR BIRTH CONTROL, is to give the Court a clear
conception of the meaning of birth control. The historical stages
through which this question has gone have been reviewed, its status in
foreign countries outlined. Finally, the effects upon the commonwealth
of the prohibition contained in the Section known as 1142 of the Penal
Law have been made clear. Said Section comprises in its prohibition the
very points of knowledge most necessary to human liberty, and has
resulted in extreme harm to the individual, to the family and to society
at large.

The idea of the social and racial value of knowledge to prevent
conception is new in the United States, and therefore it has been
difficult to get first-hand facts and comprehensive statistics with a
local bearing. Consequently, the Appellant has been obliged to lay
emphasis upon data from foreign countries where the subject has been
exhaustively studied, both theoretically and practically. However, the
American case for birth control, as presented in this compilation, is
the most complete possible in view of the records available.

                                                      MARGARET H. SANGER



                               CHAPTER I.
                              INTRODUCTORY


_The material in this general introduction to the question of the
prevention of conception comprises an article by Margaret H. Sanger and
extracts from the works of Havelock Ellis, August Forel and G. F.
Lydston, M.D. The last three are eminent authorities, whose opinions are
selected as being the clearest exposition of the social philosophy—Birth
Control._


    NOTE: All the notations of pages and tables refer to original
    documents and not to the present volume.


                               CHAPTER I
                      _THE CASE FOR BIRTH CONTROL_

                         BY MARGARET H. SANGER

(_The following is the case for birth control, as I found it during my
fourteen years’ experience as a trained nurse in New York City and
vicinity. It appeared as a special article in “Physical Culture,” April,
1917, and has been delivered by me as a lecture throughout the United
States. It is a brief summary of facts and conditions, as they exist in
this country._)

For centuries woman has gone forth with man to till the fields, to feed
and clothe the nations. She has sacrificed her life to populate the
earth. She has overdone her labors. She now steps forth and demands that
women shall cease producing in ignorance. To do this she must have
knowledge to control birth. This is the first immediate step she must
take toward the goal of her freedom.

Those who are opposed to this are simply those who do not know. Any one
who like myself has worked among the people and found on one hand an
ever-increasing population with its ever-increasing misery, poverty and
ignorance, and on the other hand a stationary or decreasing population
with its increasing wealth and higher standards of living, greater
freedom, joy and happiness, cannot doubt that birth control is the
livest issue of the day and one on which depends the future welfare of
the race.

Before I attempt to refute the arguments against birth control, I should
like to tell you something of the conditions I met with as a trained
nurse and of the experience that convinced me of its necessity and led
me to jeopardize my liberty in order to place this information in the
hands of the women who need it.

My first clear impression of life was that large families and poverty
went hand in hand. I was born and brought up in a glass factory town in
the western part of New York State. I was one of eleven children—so I
had some personal experience of the struggles and hardships a large
family endures.

When I was seventeen years old my mother died from overwork and the
strain of too frequent child bearing. I was left to care for the younger
children and share the burdens of all. When I was old enough I entered a
hospital to take up the profession of nursing.

In the hospital I found that seventy-five per cent. of the diseases of
men and women are the result of ignorance of their sex functions. I
found that every department of life was open to investigation and
discussion except that shaded valley of sex. The explorer, scientist,
inventor, may go forth in their various fields for investigation and
return to lay the fruits of their discoveries at the feet of society.
But woe to him who dares explore that forbidden realm of sex. No matter
how pure the motive, no matter what miseries he sought to remove,
slanders, persecutions and jail await him who dares bear the light of
knowledge into that cave of darkness.

So great was the ignorance of the women and girls I met concerning their
own bodies that I decided to specialize in woman’s diseases and took up
gynecological and obstetrical nursing.

A few years of this work brought me to a shocking discovery—that
knowledge of the methods of controlling birth was accessible to the
women of wealth while the working women were deliberately kept in
ignorance of this knowledge!

I found that the women of the working class were as anxious to obtain
this knowledge as their sisters of wealth, but that they were told that
there are laws on the statute books against imparting it to them. And
the medical profession was most religious in obeying these laws when the
patient was a poor woman.

I found that the women of the working class had emphatic views on the
crime of bringing children into the world to die of hunger. They would
rather risk their lives through abortion than give birth to little ones
they could not feed and care for.

For the laws against imparting this knowledge force these women into the
hands of the filthiest midwives and the quack abortionists—unless they
bear unwanted children—with the consequence that the deaths from
abortions are almost wholly among the working-class women.

No other country in the world has so large a number of abortions nor so
large a number of deaths of women resulting therefrom as the United
States of America. Our law makers close their virtuous eyes. A most
conservative estimate is that there are 250,000 abortions performed in
this country every year.

How often have I stood at the bedside of a woman in childbirth and seen
the tears flow in gladness and heard the sigh of “Thank God!” when told
that her child was born dead! What can man know of the fear and dread of
unwanted pregnancy? What can man know of the agony of carrying beneath
one’s heart a little life which tells the mother every instant that it
cannot survive? Even were it born alive the chances are that it would
perish within a year.

Do you know that three hundred thousand babies under one year of age die
in the United States every year from poverty and neglect, while six
hundred thousand parents remain in ignorance of how to prevent three
hundred thousand more babies from coming into the world the next year to
die of poverty and neglect?

I found from records concerning women of the underworld that eighty-five
per cent. of them come from parents averaging nine living children. And
that fifty per cent. of these are mentally defective.

We know, too, that among mentally defective parents the birth rate is
four times as great as that of the normal parent. Is this not cause for
alarm? Is it not time for our physicians, social workers and scientists
to face this array of facts and stop quibbling about woman’s morality? I
say this because it is these same people who raise objection to birth
control on the ground that it _may_ cause women to be immoral.

Solicitude for woman’s morals has ever been the cloak Authority has worn
in its age-long conspiracy to keep woman in bondage.

When I was in Spain a year ago, I found that the Spanish woman was far
behind her European sisters in readiness or even desire for modern
freedom. Upon investigation as to the cause of this I found that there
are over five thousand villages and towns in Spain with no means of
travel, transportation and communication save donkeys over bridle paths.
I was told that all attempts to build roads and railroads in Spain had
been met with the strongest opposition of the Clergy and the Government
on the ground that roads and railroads would make communication easier
and bring the women of the country into the cities _where they would
meet their downfall_.

Do we who have roads and railroads think our women are less moral than
the Spanish women? Certainly not. But we in this country are, after all,
just emerging from the fight for a higher education of women which met
with the same objection only a few years ago.

We know now that education has not done all the dreadful things to women
that its opponents predicted were certain to result. And so shall we
find that knowledge to control birth, which has been in the hands of the
women of wealth for the past twenty-five years, will not tend to lower
woman’s standard of morality.

Statistics show us that the birth-rate of any given quarter is in ratio
with and to its wealth. And further figures prove that in large cities
the rich districts yield a birth-rate of a third of that of the poor
districts. In Paris for every 1,000 women between the ages of 15 and 50
the poor districts yield 116 births and the rich districts 34 births. In
Berlin conditions are approximately the same. For every 1,000 women
between the ages of 15 and 50 the poor districts yield 157 births while
the rich yield 47. This applies also to all large cities the world over.

It can be inferred from these figures that the women of wealth use means
to control birth which is condemned when taught to the poor. But the
menace to our civilization, the problem of the day, is not the
stationary birth-rate among the upper classes so much as the tremendous
increase among the poor and diseased population of this country....

Is woman’s health not to be considered? Is she to remain a producing
machine? Is she to have time to think, to study, to care for herself?
Man cannot travel to his goal alone. And until woman has knowledge to
control birth she cannot get the time to think and develop. Until she
has the time to think, neither the suffrage question nor the social
question nor the labor question will interest her, and she will remain
the drudge that she is and her husband the slave that he is just as long
as they continue to supply the market with cheap labor.

Let me ask you: Has the State any more right to ravish a woman against
her will by keeping her in ignorance than a man has through brute force?
Has the State a better right to decide when she shall bear offspring?

Picture a woman with five or six little ones living on the average
working man’s wage of ten dollars a week. The mother is broken in health
and spirit, a worn out shadow of the woman she once was. Where is the
man or woman who would reproach me for trying to put into this woman’s
hands knowledge that will save her from giving birth to any more babies
doomed to certain poverty and misery and perhaps to disease and death.

Am I to be classed as immoral because I advocate small families for the
working class while Mr. Roosevelt can go up and down the length of the
land shouting and urging these women to have large families and is
neither arrested nor molested but considered by all society as highly
moral?

But I ask you which is the more moral—to urge this class of women to
have only those children she desires and can care for, or to delude her
into breeding thoughtlessly. Which is America’s definition of morality?

You will agree with me that a woman should be free.

Yet no adult woman who is ignorant of the means to prevent conception
can call herself free.

No woman can call herself free who cannot choose the time to be a mother
or not as she sees fit. This should be woman’s first demand.

Our present laws force woman into one of two ways: Celibacy, with its
nervous results, or abortion. All modern physicians testify that both
these conditions are harmful; that celibacy is the cause of many nervous
complaints, while abortion is a disgrace to a civilized community.
Physicians claim that early marriage with knowledge to control birth
would do away with both. For this would enable two young people to live
and work together until such time as they could care for a family. I
found that young people desire early marriage, and would marry early
were it not for the dread of a large family to support. Why will not
society countenance and advance this idea? Because it is still afraid of
the untried and the unknown.

I saw that fortunes were being spent in establishing baby nurseries,
where new babies are brought and cared for while the mothers toil in
sweatshops during the day. I saw that society with its well-intentioned
palliatives was in this respect like the quack, who cures a cancer by
burning off the top while the deadly disease continues to spread
underneath. I never felt this more strongly than I did three years ago,
after the death of the patient in my last nursing case.

This patient was the wife of a struggling working man—the mother of
three children—who was suffering from the results of a self-attempted
abortion. I found her in a very serious condition, and for three weeks
both the attending physician and myself labored night and day to bring
her out of the Valley of the Shadow of Death. We finally succeeded in
restoring her to her family.

I remember well the day I was leaving. The physician, too, was making
his last call. As the doctor put out his hand to say “Good-bye,” I saw
the patient had something to say to him, but was shy and timid about
saying it. I started to leave the room, but she called me back and said:

“Please don’t go. How can both of you leave me without telling me what I
can do to avoid another illness such as I have just passed through?”

I was interested to hear what the answer of the physician would be, and
I went back and sat down beside her in expectation of hearing a
sympathetic reply. To my amazement, he answered her with a joking sneer.
We came away.

Three months later, I was aroused from my sleep one midnight. A
telephone call from the husband of the same woman requested me to come
immediately as she was dangerously ill. I arrived to find her beyond
relief. Another conception had forced her into the hands of a cheap
abortionist, and she died at four o’clock the same morning, leaving
behind her three small children and a frantic husband.

I returned home as the sun was coming over the roofs of the Human
Bee-Hive, and I realized how futile my efforts and my work had been. I,
too, like the philanthropists and social workers, had been dealing with
the symptoms rather than the disease. I threw my nursing bag into the
corner and announced to my family that I would never take another case
until I had made it possible for working women in America to have
knowledge of birth control.

I found, to my utter surprise, that there was very little scientific
information on the question available in America. Although nearly every
country in Europe had this knowledge, we were the only civilized people
in the world whose postal laws forbade it.

The tyranny of the censorship of the post office is the greatest menace
to liberty in the United States to-day. The post office was never
intended to be a moral or ethical institution. It was intended to be
mechanically efficient; certainly not to pass upon the opinions in the
matter it conveys. If we concede this power to this institution, which
is only a public service, we might just as well give to the street car
companies and railroads the right to refuse to carry passengers whose
ideas they do not like.

I will not take up the story of the publication of “The Woman Rebel.”
You know how I began to publish it, how it was confiscated and
suppressed by the post office authorities, how I was indicted and
arrested for bringing it out, and how the case was postponed time and
time again and finally dismissed by Judge Clayton in the Federal Court.

These, and many more obstacles and difficulties were put in the path of
this philosophy and this work to suppress it if possible and discredit
it in any case.

My work has been to arouse interest in the subject of birth control in
America, and in this, I feel that I have been successful. The work now
before us is to crystallize and to organize this interest into action,
not only for the repeal of the laws but for the establishment of free
clinics in every large center of population in the country where
scientific, individual information may be given every adult person who
comes to ask it.

In Holland there are fifty-two clinics with nurses in charge, and the
medical profession has practically handed the work over to nurses. In
these clinics, which are mainly in the industrial and agricultural
districts, any woman who is married or old enough to be married, can
come for information and be instructed in the care and hygiene of her
body.

These clinics have been established for thirty years in Holland, and the
result has been that the general death-rate of Holland has fallen to the
lowest of any country in Europe. Also, the infant mortality of Amsterdam
and The Hague is found to be the lowest of any city in the world.
Holland proves that the practice of birth control leads to race
improvement; her increase of population has accelerated as the
death-rate has fallen.

In England, France, Scandinavia, and Germany, information regarding
birth control is also freely disseminated, but the establishment of
clinics in these countries is not so well organized as it is in Holland,
with the consequence that the upper and middle classes, as in this
country, have ready access to this knowledge, while the poor continue to
multiply because of their lack of it. This leads, especially in France,
to a high infant mortality, which, rather than a low birth-rate, is the
real cause of her decreasing population.

We in America should learn a lesson from this, and I would urge
immediate group action to form clinics at once. We have in this country
a splendid foundation in our hospital system and settlement work. The
American trained nurse is the best equipped and most capable in the
world, which enables us, if we begin work at once, to accomplish as much
in ten years’ time as the European countries have done in thirty years.

The clinic I established in the Brownsville district of Brooklyn
accomplished at least this: it showed the need and usefulness of such an
agency.

The free clinic is the solution for our problem. It will enable women to
help themselves, and will have much to do with disposing of this
soul-crushing charity which is at best a mere temporary relief.

Woman must be protected from incessant childbearing before she can
actively participate in the social life. She must triumph over Nature’s
and Man’s laws which have kept her in bondage. Just as man has triumphed
over Nature by the use of electricity, shipbuilding, bridges, etc., so
must woman triumph over the laws which have made her a childbearing
machine.


  _RACE REGENERATION. HAVELOCK ELLIS. New Tracts for the Times. Cassell
      & Co., Ltd., London, New York, Toronto and Melbourne. 1911._

HENRY HAVELOCK ELLIS: L.S.A. Hon. Member Medico-legal Society of New
York. Hon. Fellow of the Chicago Academy of Medicine; Foreign Associate
of the Societe Medico-Historique of Paris, etc.; General Editor of the
Contemporary Science Series (1889); born Croydon, Surrey, 2nd Feb.,
1859; belonging on both sides to families connected with the sea; spent
much of childhood on sea, (Pacific, etc.); educated, private schools;
St. Thomas’s Hospital; engaged in teaching in various parts of New South
Wales, 1875–79. Returned to England and qualified as medical man, but
only practiced for a short time, having become absorbed in scientific
and literary work. Edited the Mermaid Series of Old Dramatists, 1887–89.
Publications: The New Spirit, 1890; The Criminal, 1890 (4th edition
revised and enlarged 1910); Man and Woman, a Study of Human Secondary
Sexual Characters, 1894 (5th edition revised and enlarged 1914); Sexual
Inversion, being Vol. II of Studies in the Psychology of Sex, 1897 (3rd
edition revised and enlarged 1915); Affirmations, 1897; The Evolution of
Modesty, etc., being vol. I of the studies in Psychology of Sex, 1899
(3rd edition revised and enlarged, 1910); The 19th Century; A Dialogue
in Utopia, 1900; A Study of British Genius, 1904; Analysis of the Sexual
Impulse, 1903, (2nd edition revised and enlarged 1913); Sexual Selection
in Man, 1905; Erotic Symbolism, 1906; Sex in Relation to Society, being
vols. 3, 4, 5 and 6 of studies in psychology of sex; The Soul of Spain,
1908; The World of Dreams, 1911; The Task of Social Hygiene, 1912;
Impressions and Comments, 1914; Essays In War Time, 1916.

When we survey the movement of social reform which has been carried on
during the past one hundred years, we thus see that it is proceeding in
four stages. 1—The effort to clear away the gross filth of our cities,
to improve the dwellings, to introduce sanitation, and to combat
disease. 2—The attempt to attack the problem more thoroughly by
regulating conditions of work, and introducing the elaborate system of
factory legislation. 3—The still more fundamental step of taking in hand
the children who have not yet reached the age of work, nationalizing
education, and ultimately pushing back the care and over-sight of
infants to the moment of birth. 4—Finally, most fundamental step of all,
the effort, which is still only beginning to provide the conditions of
healthy life even before birth. It must be remembered that this movement
in all its four stages is still in active progress among us. It is not
mere ancient history. On the contrary, it is a movement that is
constantly spreading and at every point becoming more thorough, more
harmoniously organized. Before long it will involve a national medical
service, which will impose on doctors as their primary duty, not the
care of disease, but the preservation of health. We have to realize at
the same time that this movement has been exclusively concerned, not
with the improvement of the quality of human life, but exclusively with
the betterment of the conditions under which life is lived. It tacitly
assumed that we have no control over human life and no responsibility
for its production. It accepted human life—however numerous it might be
in quantity, however defective in quality—as a God given fact, which it
would be impious to question. It heroically set itself to the endless
task of cleansing the channels down which this muddy torrent swept. It
never went to the source. Only take care of the soil, these workers at
social reform said in effect, and the seed is no matter. That, as we can
now see, was a silly enough position to take up. P. 26.

Here we have been spending enormous enthusiasm, labor and money in
improving the conditions of life, with the notion in our heads that we
should thereby be improving life itself, and after 70 years we find no
convincing proof that the quality of our people is one whit better than
it was when for a large part they lived in filth, were ravaged by
disease, bred at random, soaked themselves in alcohol, and took no
thought for the morrow. Our boasted social reform has been a matter of
bricks and mortar—a piling up of hospitals, asylums, prisons and
workhouses—while our comparatively sober habits may be merely a sign of
the quietly valetudinarian way of life imposed on a race no longer
possessing the stamina to withstand excess.

One of the most obvious tests of our degree of success in social reform
directed to the betterment of social conditions is to be found in the
amount of our pauperism, and the condition of our paupers. If the
amelioration of the conditions of life can effect even a fraction of
what has been expected of it, the results ought to be seen in the
diminution of our pauperism, and the improvement of the condition of our
paupers. Yet so far as numbers are concerned, the vast army of our
paupers has remained fairly constant during the whole period of social
reform, if indeed it has not increased. As to the ineffectiveness of our
methods the Royal Commissioners, especially perhaps in their Minority
Report, have shed much light. It was to be expected that these muddled
methods should be most marked in all that concerns the beginnings of
life, for that is precisely where our whole treatment of social reform
has been most at fault. Children under 16 form nearly one-third of the
paupers relieved. In the United Kingdom the Poor Law authorities have on
their books as outdoor paupers, 50,000 infants under four years of age.
As regards the annual number of births in the Poor Law institutions of
the United Kingdom, there are not even definite statistics available,
but it is estimated in the Minority Report that the number is probably
over 15,000, 30% of these being legitimate children, and 70%
illegitimate. There is no system in the treatment of mothers; and often
not the most elementary care in the treatment of the infants. It is
scarcely surprising that though the general infant mortality is
excessively high, the infant mortality of the workhouse babies is two or
three times as high as that among the general population. And the Royal
Commissioners pathetically ask, “To what is this retrogression due? It
cannot be due to lack of expenditure, or to lack of costly and elaborate
machinery.” No, it certainly is not. It is in large part due, as we are
now just beginning to recognize, to the concentration of our activities
on the mere conditions of life, to our neglect of the betterment of life
itself. We have failed to realize that the whitening of our sepulchres
will not limit the number of corpses placed in those sepulchres. It is
the renewal of the spirit within that is needed, not alone the
improvement of material conditions, but the regeneration of life. If we
wish to realize more in detail the slight extent to which our efforts to
better the conditions of life have raised the quality of life itself, we
have but to turn to the problem of the feebleminded, which during recent
years has attracted so much attention. It is necessary to remember that
this feeblemindedness is largely handed on by heredity. Exact
investigation has now shown that feeblemindedness is inherited to an
enormous extent. Some years ago, Dr. Ashby, speaking from a large
experience, estimated that at least 75% of feebleminded children are
born with an inherited tendency to mental defect. More precise
investigation has shown since that this estimate was under the mark. Dr.
Tredgold, who in England has most carefully studied the heredity of the
feebleminded, found that in over 82% there is a bad nervous inheritance.
Heredity is the chief cause of feeblemindedness, and Tredgold has never
seen a normal child born of two feebleminded parents. The very thorough
investigation of the heredity of the feebleminded which is now being
carried on at the institution for their care at Vineland, N. J., shows
even more decisive results. By making careful pedigrees of the families
to which the inmates at Vineland belong it is seen that in a large
proportion of cases feeblemindedness is handed on from generation to
generation, and is transmissible through three generations, though it
sometimes skips a generation. Not only is feeblemindedness inherited,
and in a much greater degree than has been hitherto suspected, but the
feebleminded tend to have a much larger number of children than normal
people. The average number of children of feebleminded people seems to
be usually about one-third more than in normal families, and is
sometimes very much greater. Page 26–36.

And it is not only in themselves that the feebleminded are a burden on
the present generation and a menace to future generations. They are seen
to be often a more serious danger when we realize that in large measure
they form the reservoir from which the predatory classes are recruited.
This is for instance the case as regards the fallen. Feebleminded girls
of fairly high grade may often be said to be predestined to immorality
if left to themselves, not because they are vicious, but because they
are weak and have little power of resistance. They cannot properly weigh
their actions against the results of their actions, and even if they are
intelligent enough to do that, they are still too weak to regulate their
actions accordingly. Moreover, even when, as so often happens among the
high grade feebleminded, they are quite able and willing to work, after
they have lost their respectability by having a child, the opportunities
of work become more restricted and they drift into prostitution.
Criminality again is associated with feeblemindedness in the most
intimate way. Not only do criminals tend to belong to large families,
but the families that produce feebleminded offspring also produce
criminals. P. 40.

Closely related to the great feebleminded class, and from time to time
falling into crime are the inmates of workhouses, tramps and the
unemployable. The so-called able-bodied inmates of our workhouses are
frequently found on medical examination to be more than 50% cases of
mental defectives, equally so whether they are men or women. P. 42.

We have found that this movement for social reform, while it has been
inevitable and necessary, and is even yet by no means at an end, is not
fulfilling, and cannot fulfil the expectations of those who set it in
motion. It has even had the altogether undesigned and unexpected result
of increasing the burden it was intended to remove. Whatever the exact
action of natural selection may be, as soon as we begin to interfere
with it, and improve the conditions of life by caring for the unfit,
enabling them to survive and to propagate their like, as they will not
fail to do, insofar as they belong to the unfit stocks, then we are
certainly, without intending it, doing our best to lower the level of
life. We increase, or at best retain the unfit, while at the same time
we burden the fit with the task of providing for the unfit. In this way
we deteriorate the general quality of life in the next generation,
except insofar as our improvement of the environment may enable some to
remain fit, who under less favorable conditions would join the unfit. It
is now possible for us to realize how the way lies open to the next
great forward step in social reform. On the one hand the progressive
movement of improvement in the conditions of life, by proceeding
steadily back, as we have seen, to the conditions before birth, renders
the inevitable next step a deliberate controlled life itself. On the
other hand, the new social feeling which has been generated by the task
of improving the conditions of life, and of caring for those who are
unable to care for themselves, has made possible a new explanation of
responsibility to the race. We have realized practically and literally
that we are “our brother’s keepers.” We are beginning to realize that we
are the keepers of our children of the race that is to come after us.
Our sense of social responsibility is becoming a sense of racial
responsibility. It is that enlarged sense of responsibility which
renders possible what we call the regeneration of the race. We cannot
lay too much stress on this sense of responsibility for it is its growth
which alone renders possible any regeneration of the race. So far as
practical results are concerned, it is not enough for men of science to
investigate the facts and the principles of heredity and to attempt to
lay down the laws of eugenics, as the science which deals with the
improvement of the race is now called. It is not alone enough for
moralists to preach. The hope of the future lies in the slow development
of those habits, those social instincts arising inevitably out of the
actual facts of life, and deeper than science, deeper than morals. The
new sense of responsibility, not only for the human lives that now are,
but the new human lives that are to come, is a social instinct of this
fundamental nature. Therein lies its vitality and its promise. It is
only of recent years that it has been rendered possible. Until lately,
the methods of propagating the race continued to be the same as those of
savages thousands of years ago. Children “came” and their parents
disclaimed all responsibility for their coming; the children were sent
by God, and if they all turned out to be idiots, the responsibility was
God’s. That is all changed now. It is we who are more immediately the
creators of men. We generate the race; we alone can regenerate the race.
We have learned that in this, as in other matters, the Divine Force
works through us and that we are not entitled to cast the burden of our
evil actions on to any higher Power. The voluntary control of the number
of offspring which is now becoming the rule in all civilized countries
in every part of the world has been a matter of concern to some people,
who have realized that however desirable under the conditions, it may be
abused. But there are two points about it which they should do well
always to bear in mind. In the first place, it is the inevitable result
of the advance in civilization. Reckless abandonment to the impulse of
the moment, and careless indifference to the morrow, the selfish
gratification of individual desire at the expense of probable suffering
to lives that will come after, this may seem beautiful to some people,
but it is not civilization. All civilization involves an ever-increasing
forethought for others, even for others who are yet unborn. In the
second place, it is not only inevitable, but it furnishes us with the
one available lever for raising the level of our race. In classic days,
as in the East, it was possible to consider infanticide as a permissible
method for attaining this end. That is no longer possible to us. We must
go further back. We must control the beginnings of life. And that is a
better method, even a more civilized method, for it involves greater
forethought, and a finer sense of the value of life. To-day, all classes
in the community, save the lowest and most unfit, exercise some degree
of forethought and control in regulating the size of their families.
That it should be precisely the unfit who procreate in the most reckless
manner is a lamentable fact, but it is not a hopeless fact, and there is
no need for the desperate remedy of urging the fit to reduce themselves
in this matter to the level of the unfit. That would merely be a
backward movement of civilization. It is education, sobriety, and some
degree of well-being which lead to the control of the size of families,
and as it is social amelioration which brings this result about, it is a
result that we may view with equanimity. It used to be feared that a
falling birth rate was a national danger. We now know that this is not
the case, for not only does a falling birth rate lead to a falling death
rate, but in this matter no nation moves by itself. Civilization is
international, though one nation may be a little before or behind
another. Hitherto France has been ahead, but all other nations have
followed. In Germany, for instance, sometimes regarded as a rival of
England, the birth rate has fallen just as in England. Russia indeed is
an exception, but Russia is not only behind England, but behind Germany
in the march of civilization; its birth rate is high, its death rate is
high; a large proportion of its population live on the verge of famine.
We are not likely to take Russia as our guide in this matter; we have
gone through that stage long ago. But at the stage we have now reached
it is no longer a question of gaining control over the production of the
new generation, but of using that control, and of using it in such a way
that we may help to leave the world better than we found it. “What has
posterity done for me that I should do anything for posterity,” someone
is said to have asked? The answer is that to the human race that went
before him he owes everything, and that he can only repay the debt to
those who come after him. There is more than one way in which we can
repay our debt to the race, but there is no better way than by leaving
behind us those who are fit to carry on the tasks of life to higher ends
than we have ourselves perhaps been able to attain. Children have been
without value in the world because there have been too many of them;
they have been produced by a blind and helpless instinct, and have been
allowed to die by the hundred thousand. For more than half a century
after the era of social reform set in there was no decline at all in the
enormous infant mortality. It has only now begun, as the inevitable
accompaniment of the decline in the birth rate. Not the least service
done by the fall in the birth rate has been to teach us the worth of our
children. We possess the power, if we will, deliberately and consciously
to create a new race, to mold the world of the future. As we realize our
responsibility we see that our new power of control is not merely for
the end of limiting the quantity of human life, perhaps for a selfish
object, but for the high end of improving its quality. It is in our
power not only to generate life, but, if we will, to regenerate life. If
we realize that possibility, and if we understand how the course of
civilization has now brought it within our grasp, we have reached the
heart of our problem. Our greatest foe, apart from indifference, is
ignorance. Even science in this field is only beginning to feel its way,
while the mass have still to unlearn many prejudices of the past. P.
48–54.

Galton, during the last years of his life, believed that we are
approaching a time when eugenic considerations will become a factor of
religion, and when our existing religious conceptions will be
reinterpreted in the light of a sense of social needs, so enlarged as to
include the needs of the race which is to come. Certainly for those who
have been taught to believe that man was in the first place created by
God, it should not be difficult to realize the divine nature of the task
of human creation which has since been placed in the hands of man, to
recognize it as a practical part of religion, and to cherish a sense of
its responsibility. P. 63.


  _THE SEXUAL QUESTION. August Forel. A Scientific, Psychological,
      Hygienic and Sociological Study. Translated by C. F. Marshall,
      M.D., F.R.C.S. Late Assistant Surgeon to the Hospital for Diseases
      of the Skin. London._

AUGUST FOREL: Doctor of Philosophy honoris causa; Doctor of Laws honoris
causa. Born September 1848 at Morges, Switzerland. Educated at
University of Zurich and Vienna. In 1873 assistant physician at the
district insane asylum at Munich; 1877, Privat-dozent at the University;
1879, Privat-dozent and then Professor at Zurich, and until 1898
Director of the State Insane Asylum at Burgholzli near Zurich. Works:
Experience et remarques crit. sur les sensations des insectes (in 4 vol.
of Recueil Zoolog. suisse Genf. 1886–7) Giftapparat u. d. Analdrusen der
Ameisen, 1878; Les Fourmis de la Suisse, 1874; Errichtg. v.
Trinkerasylen, 1891; D. Hypnotismus; Gehirn und Seele; Hygiene der
Nerven und des Geistes; Die Sexuelle Frage; Verbrecher und Konstit.
Seelenabnormitat; Ges. Hirnanah. Abhandl; Sinnesleben d. Insekten;
Kulturstrebungen der Gegenwart.

He discovered in 1885 the seat of the auditory nerves in the brain;
researches into the psychology of ants.

We must not forget that among our brutal, yet human ancestors, the
struggle for life demanded the cruel and wanton exposure or slaughter of
all weak and decrepit individuals, and that epidemic diseases, plagues,
and pests ravaged the peoples without mercy. Of course our present
civilization has put up a barrier against all this. Yet for that very
reason, the blind and thoughtless propagation of degenerate, tainted and
enfeebled individuals is another atrocious danger to society. But then
the sexual appetite cannot be legislated out of existence, or killed by
repressive measures. We can but consider all legislation and all police
measures which are intended to regulate the sexual intercourse in the
human family as absolute failures, as inhuman, in fact as downright
detrimental to the race. Exacting laws have never improved the morals of
any race or nation, hypocrisy and secret evasion are the only results
obtained. It would be better by far if steps were taken to enlighten the
masses on the questions of sexual heredity and degeneration. Wisdom of
this kind does not corrupt.

The law of heredity winds like a red thread through the family history
of every criminal, of every epileptic, eccentric and insane person. And
we should sit still and watch our civilization go into decay and fall to
pieces without raising the cry of warning and applying the remedy?

The sexual appetite is very pronounced in tuberculous persons. They
marry and beget children in the most wanton fashion. The law cannot and
does not prevent them, and the carnal instinct is not to be killed. What
is to be done when law and religion forbid the application of preventive
measures and even prosecute the person that recommends them? Local
diseases and pathological conditions in the woman (at times in man also)
within wedlock, may render parturition and immediate danger to the life
of the mother or of the child, or of both together. Surely in such cases
it is the bounden duty of the physician to intervene and counsel
against, nay absolutely forbid impregnation. Well, how is it to be done?
Must husband and wife who love each other be separated? It would be
unnatural, in fact it is quite impossible. Or should they abandon sexual
intercourse altogether and live like brother and sister? Well, a few
exceptionally cold natures may have will power enough to carry into
effect such a pact. But in 99 out of 100 cases the interdict of the
sexual act sends the husband to satisfy his cravings elsewhere and
contract disease, or he falls in love with another woman and wrecks home
and family. Similar conditions may be brought about by other causes as
well. Take for instance, the poor working man, or mechanic, who has
already six or seven children, and whose wife is unusually fertile,
giving birth to children year after year. The wages of the father do not
suffice to properly support them all. The food that can be purchased
with the slender means is not at all adequate. Rent and other bills fall
behind and they get in debt. They are both young yet. What is to be
done? If they follow the natural law there will be an increase in the
family every year. Moreover, these ever-recurring labors weaken the
constitution of the mother and sap away her strength. Starvation? Sexual
continence in wedlock? It is curious indeed to hear rich men, well fed
clergymen, pious zealots and reformers, leaning back in comfortable
chairs discussing this burning question and bewailing the immorality of
the common people. Statistics prove that these very people who extol to
the poor all the blessings of a poor family never live up to their
teachings, either in theory or in practice. The majority of these
apostles of morality have no children at all or at the utmost two or
three. Why should that be so? What interesting reading it would make if
the sexual history of these persons were followed up and printed.

Many hygienic reasons and the most elemental laws of humanity demand
that the wife who is fertile above the average should have a rest of at
least 18 months between each succeeding pregnancy. But this cannot be
achieved in the natural course of events except in very rare cases
without wrecking the marriage. If we crystallize this sexual social
question we arrive at the following conclusions: There are a great many
cases, especially of a pathological character, but none the less, also,
in normal and sound individuals, in which procreation within wedlock or
without either definitely or temporarily either for the mother or the
child, or for both, and for that reason should be interdicted. Very few
men and a very small proportion of women—no matter how firmly they may
be resolved—are capable of suppressing their sexual needs. Even if they
succeed the consequences are generally of a disastrous nature, loss of
marital love, secret illicit relations with others, and subsequent
infidelity, nervous disorders, impotence, etc. In all these cases we are
confronted with the following dilemma: 1—In the unmarried person:
onanism or prostitution, or both. Is that morality? Such people must
either forever forego love, marriage, and normal lawful sexual
intercourse, or face sterility in wedded life. 2—Within marriage:
onanism, prostitution and infidelity, or the adoption of rational
preventive measures. I leave it to the reader, and to the law maker to
pick out the correct alternative and to arrive at the one possible
decent and ethical solution of these conflicting questions.

It seems almost incredible that in some countries medical men who are
not ashamed to throw young men into the arms of prostitution, blush when
mention is made of anti-conceptional measures. P. 427b.

A year, at least, should elapse between parturition and the next
conception; this gives approximately two years between the confinements.
In this way the wife keeps in good health and can bear healthy children
at pleasure. It is certainly better to procreate seven children, than to
procreate 14, of which seven die, to say nothing of the mother, who
rapidly becomes exhausted by uninterrupted confinements. P. 430.

It is quite certain that the sexual life of man can never raise above
its present state without being freed from the bonds of mysticism and
religious dogma, and based on a loyal and unequivocal human morality
which will recognize the normal wants of humanity, always having as its
principle object the welfare of posterity. P. 459.

The true task of a political economy which has the true happiness of man
at heart should be to encourage the procreation of happy, useful,
healthy and hard-working individuals. To build an ever increasing number
of hospitals, asylums for lunatics, idiots and incurables,
reformatories, etc., to provide them with every comfort and manage them
scientifically, is undoubtedly a very fine thing, and speaks well of the
progress and development of human sympathy. But what is forgotten is
that by concerning ourselves almost exclusively with human ruins, the
results of our social abuses, we gradually weaken the force of the
healthy portion of the population. By attacking the roots of the evil
and limiting the procreation of the unfit we shall be performing a work
which is much more humanitarian, if less striking in effect. Formerly,
our economists and politicians hardly have considered this question, and
even now very few are interested in it because it brings no honors, nor
money, as we do not ourselves see the fruits of such efforts. In short,
we amuse ourselves with repairing the ruins, but are afraid to attack
what makes these ruins. P. 465–6.

The anti-conceptional measures recommended have been often condemned,
sometimes as immoral, sometimes as contrary to aesthetics. To interfere
in this way with the action of nature is said to injure the poetry of
love and the moral feeling, and at the same time to disturb natural
selection. There are several replies to these objections. In the first
place, it is wrong to maintain that man cannot encroach on the life of
nature. If this were the case, the earth would now be a virgin forest,
and a great many plants and animals would not have been adapted to the
use of man. We have proved without deference, often with a brutal hand,
to the misfortune of art and poetry, that we are capable of successfully
meddling with the machinery of nature, even in what concerns our own
persons.

The aesthetic argument appears, at first sight, more valid. It is
unnecessary, however, to discuss matters of taste. From all points of
view, the details of coitus leave much to be desired from the aesthetic
point of view, and such a slight addition as a protective does not
appear to make any serious difference. P. 497–8.

She, (woman) ought to develop herself strongly and healthily by working
along with man in body and mind by procreating numerous children when
she is strong, robust and intelligent. But this does not nullify the
advantage that may accrue from limiting the number of conceptions when
the bodily and mental qualities are wanting in the procreators. P. 332.

One of the most difficult and important future tasks of social science
toward humanity is to set free sexual relations from the tyranny of
religious dogmas by placing them in harmony with the true and purely
human laws of natural science. P. 357.

In no animal do we find the abuses which man is permitted to practice
toward his wife and children. P. 368.

The law should abandon its useless and even harmful chicanery concerning
the questions of sexual relations and love, and regulate more carefully
the duties of parents toward their children, and thus protect future
generations against the abuses of the present generation. P. 377.

It is important to bear in mind that modern legislation on marriage
often favors the reproduction of criminals, lunatics and invalids, while
it hinders the production of healthy children by men who are
intelligent, honest and robust. When an abnormal, unhealthy man is
married his wife is obliged to submit to the conception of tainted
children. What we require is more personal liberty for healthy,
adaptable individuals and more restrictions for the abnormal, unhealthy
and dangerous. The civil law of the future will have to take these facts
into consideration if it wishes to keep level with scientific progress.
P. 393.


  _THE DISEASES OF SOCIETY AND DEGENERACY. THE VICE AND CRIME PROBLEM.
      G. F. Lydston, M.D., Professor of Genito-Urinary Surgery, State
      University of Illinois. Prof. of Criminal Anthropology, Chicago,
      Kent College of Law; Member of the American Medical Association,
      etc., etc. The Riverton Press, Chicago, 1912._

The responsibility of rearing a large number of useful and upright
citizens is a little too great for the poor family drudge who
manipulates the wash board with one hand, holding a squealing baby with
the other, and simultaneously attempts to keep in control a dozen other
demonstrative and lusty children. She has a difficult task before her,
even where her environment is favorable to the rearing of children, but
where the children are brought into contact with evil associates as they
are very likely to be when parental control is so lax as it necessarily
is under such circumstances, they are not likely to become either
ornamental or useful factors in our social system. If more attention
were paid to quality of both parentage and children, and less fretting
done as to the possible disasters to the nation incidental to small
numbers of children, it would be better for the race. At the present
day, when practically no attention is paid to stirpiculture in the human
species, it seems absurd to worry about diminution in size of the
American family. Is the function of the wife altogether that of a
breeding machine? Has she no personal rights? Should she be sacrificed
to posterity? Is it always her duty to rear a large family?
Unhesitatingly I answer no to each question. The perpetuation of the
race depends upon matrimony, it is true. It is not however woman’s
function merely to increase numbers at the expense of her own life and
comfort. This is a fallacy and an injustice to womanhood, and should be
contradicted from the house-tops. The woman who is merely a beast of
burden, a breeder of children, is a failure in modern life. Quality of
progeny is not conserved along such lines, and quality, not quantity,
makes for the elevation of the human race. Woman should not be
sacrificed to posterity. Something is due her as a social integer. She
is entitled to life, liberty and the pursuit of happiness. She, as well
as man, comes within the provisions of the constitution. Better a single
child properly reared by a happy contented mother than a dozen ill-fed,
unkempt, dirty, vicious and half-baked hoodlums. “Multiply and replenish
the earth” was once sound doctrine, but it does not uniformly fit modern
conditions. The scriptural injunction should be qualified. The
multiplication should not extend beyond the parents capacity to
comfortably rear and educate their children, nor beyond the number
consistent with the preservation of the mother’s health and happiness.



                              CHAPTER II.
       ORIGIN AND PRACTICE OF BIRTH CONTROL IN VARIOUS COUNTRIES


_In the countries covered by this chapter Birth Control has been
recognised as a legitimate science; leagues advocating the prevention of
conception have been formed; and the leading authorities have approved
the practice as being the foundation of a better social structure._


  _THE CONTROL OF BIRTHS. MARY ALDEN HOPKINS. Harper’s Weekly, April
      10th, 1915._

The European laws on this subject are in striking contrast to ours. They
treat contraception and abortion as two separate matters. The laws
against abortion are strict. The laws concerning contraception are
directed against distasteful advertising but not against private advice
or public propaganda. In England the applicant must state in writing
over his or her signature that he or she is married or about to be
married. In Holland formulas and methods may be supplied privately, but
must not be publicly advertised. In Germany there is no law on the
matter, but sentiment is strongly opposed to advertising. In Switzerland
it is forbidden to advertise or circularize. In Norway and Sweden
advertising is not expected. Italy and France have no law on the
subject. In Russia advertising in the newspapers is common. Everywhere
in Europe contraceptives are for sale at pharmacies.

The Birth Control Movement is antagonistic to the general practice of
abortion. The Hungarian senate, a few years ago, declared that the
limitation of families by prevention of conception was absolutely
necessary in order to check the wide-spread evil of attempted abortion.

Our present laws confuse the issue by classing—in a shockingly ignorant
fashion,—contraception, abortion, and pornography, in the same category.
The group is treated in the New York State Penal Code under the
astonishing title of “Indecent Articles.” The eye of the law
distinguishes no difference between the books of August Forel, a
scientist revered in laboratories all over the world, and the obscene
penny postcard sold by some slinking vendor.


  _THE MALTHUSIAN LEAGUE OF ENGLAND. The Origin and History of Birth
      Control in Great Britain. Reprinted from The Malthusian, April,
      1880._

Little improvement can be expected in morality until the production of
large families is regarded in the same light as drunkenness, or any
other physical excess.—John Stuart Mill, 1872.

In obedience to the request of the Nestor of political economists of
Europe, the distinguished editor of the _Journal des Economistes_ of
Paris, M. Joseph Garnier, we give a short account of the reasons which
led to the foundation of the Malthusian League, the latest product of
the nineteenth century’s ideas in the direction of social progress. It
gives us unfeigned pleasure to be the means of making the most thorough
of all French writers on the doctrines of our English latter-day
economists acquainted with the position which the great population
question has recently assumed in this country. It is not, we believe,
too much to allege that the most advanced thinkers of this country are
at this moment well aware of the existence of the new-Malthusian remedy
for the evils of society. How this has come to pass we proceed at once
to show.

It was not long after the publication of Mr. Malthus’ work that some
thoughtful men began to notice that in modern France the late marriage
customs of most European states were replaced to a certain extent by
prudence after marriage. Mr. Francis Place was one of the first to write
a work on population, in which he recommended the physical checks so
commonly made use of by the French parents for adoption in England. He
is said to have remonstrated with Mr. Malthus about an expression in the
first edition of his essay, in which he spoke of such checks under the
head of _Vice_, and the tradition is that Malthus left out the
expression in his subsequent edition: and, as he himself had two
children, Mr. Porter (of Nottingham) believes that Mr. Malthus was, like
Mr. Mill (the father of John Stuart Mill), himself a believer in the
_conjugal prudence_ practised by the better class of peasantry and
townspeople. Mr. Place is also said to have converted Mr. Robert Owen,
the socialist to his opinion, and it is believed that Mr. Owen owed the
success of his colony of New Lanark to a knowledge of this point, which
he communicated to his workmen. Mr. Robert Dale Owen, a son of Robert
Owen, emigrated in his youth to the United States of America, and became
before his death, in 1877, one of the foremost citizens of the western
republic. That gentleman, having doubtless heard the question discussed
by his father, Mr. Francis Place, and other friends in London, was
induced in 1830 to publish a now well-known treatise on the population
question, entitled _Moral Physiology_, a work written with the most
philanthropic design and couched in the most careful language consistent
with clearness and the attainment of its end, in which he gave a
description of the above-mentioned physical checks. This work was,
however, written subsequently to the publication of Mr. Richard
Carlile’s tract, entitled _Every Woman’s Book_, which was a most
outspoken work, written by one of those fearless thinkers who have done
so much to complete the reformation in England and secure freedom of
speech and of the press for this country. Had it not been for him and
his co-workers, England might at this day have been in as backward a
condition as modern Spain. Dr. Charles Knowlton, an able physician of
Boston, Massachusetts, U.S.A., was the next person who wrote upon this
question in his now famous little pamphlet, the _Fruits of Philosophy_,
wherein there was contained a good deal of popular information on
physiology, and a careful account of the checks spoken of by Mr. Dale
Owen and Mr. Carlile. This work was followed after a long interval by a
small pamphlet by Mr. Austin Holyoake, entitled _Large and Small
Families_, which, in company with the tracts by Carlile, Owen, and two
other works were sold for many years by booksellers of the ultra-liberal
party, latterly styled the _Secularists_.

In 1876 the _Fruits of Philosophy_, after circulating without notice for
forty years, was suddenly attacked as an obscene publication under an
Act of Parliament called “Lord Campbell’s Act,” and a bookseller in
Bristol, of the name of Cook, was sentenced to two years’ imprisonment
for selling it. The London publisher of the work, Mr. C. Watts, was also
prosecuted for selling it, but, on submission, was let off with merely
the payment of costs, or about two hundred pounds fine. The work would
have been suppressed had not Mr. C. Bradlaugh, the head of the
Secularist party and editor of the _National Reformer_, the most
advanced liberal journal in England, in company with a young but already
most distinguished lady, Mrs. Annie Besant, come forward and sold it
openly. In order to try the case, Mr. Bradlaugh and Mrs. Besant entered
into partnership in a publishing establishment in Stonecutter Street,
Farringdon Street, London, and sold the _Fruits of Philosophy_ quite
openly, sending copies of it to the city authorities. Mr. Bradlaugh had
for many years been an avowed Malthusian, and the lady also was quite
convinced of the importance of the question. Both were determined that
no bigoted society should put the work under the ban of the law without
a fight for it. The case was first tried at Guildhall, and was sent on
to the Court of Queen’s Bench, before the Lord Chief Justice Cockburn.
The trial began on the 18th of June, 1877, and lasted three days. The
jury contained, among other persons of wealth and position, the name of
Arthur Walter, Esq., the son of the proprietor of the _Times_ journal.
After a most powerful defence, in which Mrs. Besant and Mr. Bradlaugh
delivered speeches which told most powerfully upon the judge and all
present in the Court, the jury delivered the following verdict: “We are
unanimously of the opinion that the book in question (the _Fruits of
Philosophy_) is calculated to deprave public morals; but at the same
time we entirely exonerate the defendants from any corrupt motives in
publishing it.” The judge—who had charged quite in favor of the
defendants—would have let them off with a nominal fine, but, influenced
by the information that they intended carrying on the sale of the work,
strangely sentenced them to a heavy imprisonment and fine. Fortunately,
the higher Court of Appeal decided that there had been an error in the
indictment, and thus the defendants were set free. The prosecution has
not been repeated since that date.

The excitement caused by the trial led to the formation of a society
called The Malthusian League, which was set on foot as a means of
opposing both active and passive resistance to the attempts made to
stifle discussion on the population question. Mr. Bradlaugh had
commenced such a league many years previously, but the time was not ripe
for it. The first meeting of the League was held in the Minor Hall of
the Hall of Science, Old Street, on July 17th, 1877, for the election of
officers. That meeting elected Dr. C. R. Drysdale president, and Mrs.
Annie Besant honorary secretary, in company with Mr. Hember and Mr. R.
Shearer. The Council of the League consisted of Messrs. Bell, Brown,
Dray, Page, Mr. and Mrs. Parris, Mr. and Mrs. Rennick, Messrs. Rivers,
Seyler, G. Standing, Truelove, and Young. Mr. Swaagman was elected
treasurer to the League.

Very soon after the formation of the League, another prosecution of Mr.
Edward Truelove, bookseller, of High Holborn, took place in the Queen’s
Bench on February 1st, 1878. The works he was prosecuted for were quite
of the same character as Knowlton’s _Fruits of Philosophy_, and were
entitled: _More Physiology_, a most philanthropic pamphlet by Mr. Robert
Dale Owen, Senator of the United States, and another pamphlet entitled
_Individual, Family and National Poverty_. Mr. Truelove was most
effectually defended by Mr. William Hunter, and the case fell through,
as one of the jury considered the book quite moral and philanthropic in
its tendencies. The secretary for the “Society for the Suppression of
Vice,” Mr. Collette by name, followed up the prosecution, and Mr.
Truelove was tried in the Central Criminal Court on May 9th, 1878, and
condemned to a fine of fifty pounds and an imprisonment of four months
duration, which he underwent. An immense meeting was held in St. James
Hall, on the evening of June 6, 1878, to protest against this
disgraceful treatment of an honest man like Mr. Truelove, at which the
president of the League took the chair, and enthusiastic addresses were
delivered by Mrs. Besant and Mr. Bradlaugh.

The trial of Mrs. Besant and Mr. Bradlaugh lasted several days, and
aroused a greater interest in the subject than had been known since the
days of Malthus. The English Press was full of the subject; scientific
congresses gave it their attention; many noted political economists
wrote about it; over a hundred petitions were presented to Parliament
requesting the freedom of open discussion; meetings of thousands of
persons were held in all the large cities; and as result, a strong
Neo-Malthusian League was formed in London.

                  *       *       *       *       *

From the small beginning described in the above article the English work
has spread over all the rest of the world. The following is a list of
the leagues having membership in the Federation Universelle de la
Regeneration Humaine, in which the English organization has always
played a leading part:


           FEDERATION UNIVERSELLE DE LA REGENERATION HUMAINE
                (Federation of Neo-Malthusian Leagues).


          _First President_: The late Dr. CHARLES R. DRYSDALE


                _President_: Dr. ALICE DRYSDALE VICKERY


                            VICE-PRESIDENTS

       Señor ALDECOA, Director of Government Charities, Madrid.
       Mr. G. ANDERSON, C.E.
       Major-General E. BEGBIE, _C.B._, D.S.O., Brighton.
       Dr. C. CALLAWAY, Cheltenham.
       M. VICTOR ERNEST, Belgium.
       M. G. GIROUD, Paris.
       Herr MAX HAUSMEISTER, Stuttgart.
       Mrs. HEATHERLEY.
       Mr. S. VAN HOUTEN, Deputé of the First Chamber, The Hague.
       Dr. ALETTA JACOBS, Amsterdam.
       Mr. JOSEPH MCCABE.
       Dr. MASCAUX, Courcelles, Belgium.
       Mr. ARTHUR B. MOSS.
       P. MURUGESA MUDALIAR, Madras.
       Mr. VIVIAN PHELIPS.
       Rt. Hon. J. M. ROBERTSON, M.P.
       Dr. J. RUTGERS, Verhulststraat, 9 Den Haag, Holland.
       Me. HOITSEMA RUTGERS, Verhulststraat, 9 Den Haag, Holland.
       Frau MARIE STRITT, Dresden.
       Dr. (Ph.) HELENE STOCKER, Berlin.
       Professor KNUT WICKSELL, Lund, Sweden.


                          CONSTITUENT BODIES.

  ENGLAND (1877).—The Malthusian League. Periodical, _The Malthusian_.

  HOLLAND (1885).—De Nieuw-Malthusiaansche Bond. Secretary, Dr. J.
      Rutgers, 9 Verhulststraat, Den Haag. Periodical, _Het Gellukkig
      Huisgezin_.

  GERMANY (1889).—Sozial Harmonische Verein. Secretary, Herr M.
      Hausmeister, Stuttgart. Periodical, _Die Sozial Harmonie_.

  FRANCE (1895).—_Génération Consciente._ 27 Rue de la Duée, Paris XX.

  SPAIN (1904).—Liga Española de Regeneración Humana. Secretary, Señor
      Luis Bulffi, Calle Provenza 177, Pral, la, Barcelona. Periodical,
      _Salud y Fuerza_.

  BELGIUM (1906).—Ligue Néo-Malthusienne. Secretary, Dr. Fernand
      Mascaux, Echevin, Courcelles. Periodical: _Génération Consciente_,
      27 Rue de la Duée, Paris XX.

  SWITZERLAND (1908).—Group Malthusien. Secretary, Valentin Grandjean,
      106 Rue des Eaux Vives, Geneva. Periodical, _La Vie Intime_.

  BOHEMIA-AUSTRIA (1901).—_Zadruhy._ Secretary, Michael Kacha, 1164
      Zizhov, Prague.

  PORTUGAL.—_Paz e Liberdade_, Revista Anti-Militarista e
      Neo-Malthusiana. E. Silva, junior, L. da Memória, 46 r/e, Lisbon.

  BRAZIL (1905).—Sección brasileña de propaganda. Secretaries: Manuel
      Moscosa, Rua de’Bento Pires 29, San Pablo; Antonio Dominiguez, Rua
      Vizcande de Moranguapez 25, Rio de Janeiro.

  CUBA (1907).—Sección de propaganda. Secretary, José Guardiola,
      Empedrado 14, Havana.

  SWEDEN (1911).—Sallskapet for Humanitar Barnalstring. President: Mr.
      Hinke Bergegren, Vanadisvagen 15, Stockholm, Va.

  FLEMISH BELGIUM (1912).—National Verbond ter Regeling van het
      Kindertal. President, M. L. van Brussel, Rue de Canal, 70,
      Louvain.

  ITALY (1913).—Lega Neomalthusiana Italiana. Secretary, Dr. Luigi
      Berta, Via Lamarmora 22, Turin. Periodical, _L’Educazione
      Sessuale_.

  AFRICA.—Ligue Néo-Malthusienne, Maison du Peuple, 10 Rampe Magenta,
      Alger.

The English organization, with headquarters in London, has for its
officers some of the most distinguished men and women in England:


                            FIRST PRESIDENT

     The late C. R. DRYSDALE, M.D., M.R.C.P., Lond., F.R.C.S., Eng.


                 PRESIDENT: Dr. ALICE DRYSDALE VICKERY.

                      47 Rotherwick Road, Hampstead Garden Suburb, N. W.


                            VICE-PRESIDENTS:

             Major-Gen. ELPHINSTONE BEGBIE, C.B., D.S.O.
             ARNOLD BENNETT, Esq.
             CHAS. CALLAWAY, Esq., M.A., D.Sc.
             Lieut.-Col. J. FALLON, L.R.C.P., R.A.M.C.
             E. S. P. HAYNES, Esq.
             DENNIS HIRD, Esq., M.A., J.P.
             Mrs. HEATHERLEY.
             Captain KELSO, R.N.
             JOSEPH MCCABE, Esq.
             C. KILLICK MILLARD, Esq., M.D., D.Sc., M.O.H.
             A. B. MOSS, Esq.
             VIVIAN PHELIPS, Esq.
             EDEN PHILLPOTTS, Esq.
             Right Hon. J. M. ROBERTSON, M.P.
             Lieut.-Colonel A. W. WARDEN, late Indian Army.
             H. G. WELLS, Esq.


                             HON. TREASURER:
                           W. V. OSBORNE, Esq.


                             HON. SECRETARY:
  BINNIE DUNLOP, Esq., M.B., Ch.B., Queen Anne’s Chambers, Westminster,
                                   S.W.
      (To whom all correspondence and subscriptions should be sent.)



                            GENERAL SECRETARY:
                         Miss O. M. JOHNSON, B.A.


                       EDITORS OF “THE MALTHUSIAN”:
                  DR. C. V. DRYSDALE; MRS. B. DRYSDALE.


                                 AUDITOR:
      Mrs. E. AYRES PURDIE, A.L.A.A., Hampden House, Kingsway, W.C.


                           LITERARY SECRETARY:
         Mr. GEORGE STANDRING, 7–9 Finsbury Street, London, E.C.
      (From whom Books on the Population Question can be obtained.)

The following are some extracts from the League’s rules:


                              II.—OBJECTS.

That the objects of this Society be:—

1. To spread among the people, by all practicable means, a knowledge of
the law of population, of its consequences, and of its bearing upon
human conduct and morals.

2. To urge upon the medical profession in general, and upon hospitals
and public medical authorities in particular, the duty of giving
instruction in hygienic contraceptive methods to all married people who
desire to limit their families, or who are in any way unfit for
parenthood; and to take any other steps which may be considered
desirable for the provision of such instruction.


                            III.—PRINCIPLES.

1. “That population (unless consciously and sufficiently controlled) has
a constant tendency to increase beyond the means of subsistence.”

2. That the checks which counteract this tendency are resolvable into
positive or life-destroying, and prudential or birth-restricting.

3. That the positive or life-destroying checks comprehend the premature
death of children and adults by disease, starvation, war, and
infanticide.

4. That the prudential or birth-restricting check consists in the
limitation of offspring (1) by abstention from or postponement of
marriage, or (2) by prudence after marriage.

5. That prolonged postponement of marriage—as advocated by Malthus—is
not only productive of much unhappiness, but is also a potent cause of
sexual vice and disease. Early marriage, on the contrary, tends to
ensure sexual purity, domestic comfort, social happiness and individual
health; but it is a grave social offence for men and women to bring into
the world more children than they can adequately house, feed, clothe,
and educate.

6. That over-population is the most fruitful source of pauperism,
ignorance, crime, and disease.

7. That it is of great importance that those afflicted with hereditary
disease, or who are otherwise plainly incapable of producing or rearing
physically, intellectually and morally satisfactory children, should not
become parents.

8. That the full and open discussion of the Population Question in all
its necessary aspects is a matter of vital moment to Society.

It has been the object of this organization during these years to carry
on the theoretical propaganda of Birth Control mainly among the
educators, consisting of clergymen, physicians, scientists,
sociologists, economists and others who in turn would form a strong,
reliable public opinion who would force the dissemination of practical
information among that element of society who are propagating the
diseased and unfit.

It is only within the last few years that this League has begun to
distribute information to prevent conception. Thousands of copies of
this leaflet have been distributed in nearly every country throughout
the civilized world except _The United States of America_ where laws
prevent its circulation.


                 PRACTICAL METHODS OF FAMILY LIMITATION

Notice.—The Council of the Malthusian League, while continuing to regard
this as a matter which is strictly within the province of the medical
profession, and which ought to be taken over by them, has compiled a
leaflet entitled “Hygienic Methods of Family Limitation,” for the
benefit of those desirous of limiting their families, but who are
ignorant of the means of doing so, and unable to get medical advice on
the subject. This leaflet can only be issued, however, to persons over
twenty-one years of age who are either married or about to be married,
and who declare their conscientious belief that family limitation is
justifiable on personal and national grounds. Anyone wishing to obtain a
copy of this leaflet must write his or her name and address clearly upon
both of the forms of declaration below, and send them to the Hon.
Secretary. The sealed leaflet will then be sent them. In order to
encourage family limitation among the poorest classes, _no charge will
be made either for the leaflet or postage_, but it is hoped that those
who can afford it will enclose stamps for postage or a small donation to
help the League in its work.

_Under no circumstances whatever can the practical leaflet be supplied
without a properly filled up declaration_, nor can more than one copy be
supplied to the same person. Those wishing to help others, may have
additional copies of the declaration form to hand on.

_The Malthusian League regrets that it is unable to comply with
applications for this leaflet from the United States._


               A BRIEF HISTORY OF THE MOVEMENT IN HOLLAND

Interest in the subject did not confine itself to England, for in 1878
at an International Medical Congress in Amsterdam the subject was
discussed with great enthusiasm. A paper prepared and read by Mr. S. Van
Houten (later Prime Minister) caused a wider interest in the matter and
a year later the Neo-Malthusian (or Birth Control) League of Holland was
organized. Charles R. Drysdale, then President of the English League,
attended the conference.

As is usual in such causes, many of the better educated and intelligent
classes adopted the practice at once, as did the better educated
workers; but the movement had as yet no interest among the poorest and
most ignorant. The League set to work at once to double its efforts in
these quarters. Dr. Aletta Jacobs, the first woman physician in Holland,
became a member of the League, and established a clinic where she gave
information on the means of prevention of conception free to all poor
women who applied for it.

All classes, especially the poor, welcomed the knowledge with open arms,
and requests came thick and fast for the League’s assistance to obtain
the necessary appliances free of charge. The consequence has been that
for the past twelve years the League has labored chiefly among the
people of the poorest districts. Dr. J. Rutgers and Madame Hoitsema
Rutgers, two ardent advocates of these principles, have devoted their
lives to this work. Dr. Rutgers says that where this knowledge is taught
there is a reciprocal action to be observed: “In families where children
are carefully procreated, they are reared carefully; and where they are
reared carefully, they are carefully procreated.”

The Neo-Malthusian (or Birth Control) League of Holland has over 7,000
men and women in its membership, and more than fifty nurses whom it
indorses.

These nurses are trained and instructed by Dr. Rutgers in the proper
means and hygienic principles of the methods of Birth Control. They are
established in practice in the various towns and cities throughout
Holland. They advise women as to the best method to employ to prevent
conception. They work mainly in the agricultural and industrial
districts, or are located near them; and their teachings include not
only the method of prevention of conception, but instruction in general
and sexual hygiene, cleanliness, the uselessness of drugs, and the
non-necessity of abortions. (The Council of the Neo-Malthusian or Birth
Control League calls attention to the fact that it has for its sole
object the Prevention of Conception, and not the causing of abortion.)

The clinic organized by Dr. Jacobs,—the first clinic in the world for
the organized dissemination of information on Birth Control,—proved so
efficient and beneficial to the standards of the community that others
were opened and established until there are now more than fifty in
operation.

There is no doubt that the establishment of these clinics is one of the
most important parts of the work of a Birth Control League. The written
word and written directions are very good, but the fact remains that
even the best educated women have very limited knowledge of the
construction of their generative organs or their physiology. What, then,
can be expected of the less educated women, who have had less advantages
and opportunities? It is consequently most desirable that there be
practical teaching of the methods to be recommended, and women taught
the physiology of their sex organs by those equipped with the knowledge
and capable of teaching it.

It stands to the credit of Holland that it is perhaps the only country
where the advocates of Birth Control have not been prosecuted or jailed;
because the laws regarding the liberty of the individual and the freedom
of the press uphold it, and protect its practise.


    THE DUTCH NEO-MALTHUSIAN (BIRTH CONTROL) LEAGUE REPORT FOR 1914

Despite the outbreak of war, the progress of the League has been most
satisfactory. The membership increased from 5,057 at the beginning of
1914 to 5,521 at the end; and branches now exist in twenty-eight towns
in Holland. The list of officers and correspondents alone now occupies
four pages of the Report, and comprises nearly two hundred names. As
these are of persons in every part in the country, it will be realised
how great are the facilities for everyone to obtain practical
information. Besides the great amount of advice given by the trained
workers, 7,200 copies of the League’s booklet giving practical advice on
methods of family limitation (birth control) were supplied. It is
instructive to see, in the reports from the various branches open
statements that Mrs. X (full name given) helped 149 women and supplied
seven gross of preventives, the kinds being clearly specified. The
branch reports give particulars of nearly 1,300 women personally
instructed in preventive methods by trained workers, but the war
prevented the returns from being anything like complete. And this in a
country of only six million inhabitants.—_The Malthusian_, London, July
15, 1915.


              RESULTS OF BIRTH CONTROL TEACHING IN HOLLAND

There is no doubt that the Neo-Malthusian (Birth Control) League of
Holland stands as the foremost in the world in organization, and also as
a practical example of the results to be obtained from the teaching of
the prevention of conception. Aside from the spreading influence of
these ideas in Belgium, Italy, and Germany, Holland presents to the
world a statistical record which proves unmistakably what the advocates
of Birth Control have claimed for it.

The infantile mortality of Amsterdam and The Hague is the lowest of any
cities in the world, while the general death rate and infantile
mortality of Holland has fallen to be the lowest of any country in
Europe. These statistics also refute the wild sayings of those who shout
against Birth Control and claim it means race suicide. On the contrary,
Holland proves that the practice of anti-conceptional methods leads to
race improvement, for the increase of population has accelerated as the
death rate has fallen. There has also been a rapid improvement in the
general physique and health of the Dutch people, while that of the high
birth rate countries, Russia and Germany, is said to be rapidly
deteriorating.

The following figures will suffice to show some of the improvements
which have been going on in Holland since 1881, the time the League
became actively engaged in the work:—


                 VITAL STATISTICS OF CHIEF DUTCH TOWNS

Taken from Annual Summary of Marriages, Births, and Deaths in England
and Wales, etc., for 1912.[1]


  Amsterdam (Malthusian (Birth Control) League started 1881; Dr. Aletta
                Jacobs gave advice to poor women, 1885.)

                         1881–85 1906–10  1912

 Birth Rate               37.1    24.7    23.3   per 1,000 of population

 Death Rate               25.1    13.1    11.2   per 1,000 of population

 Infantile Mortality:                            per thousand living
   (Deaths in first        203     90      64      births
   year)


    The Hague (now headquarters of the Neo-Malthusian (Birth Control)
                                 League)

                         1881–85 1906–10  1912

 Birth Rate               38.7    27.5    23.6   per 1,000 of population

 Death Rate               23.3    13.2    10.9   per 1,000 of population

 Infantile Mortality:                            per thousand living
   (Deaths in first        214     99      66      births
   year)


                              Rotterdam.[2]

                         1881–85 1906–10  1912

 Birth Rate               37.4    32.0    29.0   per 1,000 of population

 Death Rate               24.2    13.4    11.3   per 1,000 of population

 Infantile Mortality                             per thousand living
   (Deaths in first        209     105     79      births
   year)


                    Fertility and Illegitimacy Rates.

                         1880–2  1890–2  1900–2

                                                 Legitimate birth per
 Legitimate Fertility     306.4   296.5   252.7    1,000 Married Women
                                                   aged 15 to 45.

                                                 Illegitimate births per
 Illegitimate Fertility   16.1    16.3    11.3     1,000 Unmarried
                                                   Women, aged 15 to 45.


                               The Hague.

                         1880–2  1890–2  1900–2

 Legitimate Fertility     346.5   303.9   255.0

 Illegitimate Fertility   13.4    13.6     7.7


                               Rotterdam.

                         1880–2  1890–2  1900–2

 Legitimate Fertility     331.4   312.0   299.0

 Illegitimate Fertility   17.4    16.5    13.1

Footnote 1:

  These figures are the lowest in the whole list of death rates and
  infantile mortalities in the summary of births and deaths in cities in
  this Report.

Footnote 2:

  Lowest figure for the Continent.

There has been a marked improvement in the labor conditions in Holland
during these last ten years especially, wages having increased and hours
of labor decreased, with the cost of living taking a comparatively very
small rise.

There is no country in Europe where the educational advantages are so
great as in Holland.

That the Birth Control propaganda has been a success in Holland any one
travelling through that delightful, clean and cheerful country can
testify.

In that enlightened country, Holland, the teaching by the medical
profession of the most hygienic methods of birth limitation has enabled
the poor to have small families which they could raise to be physically
and morally better equipped than formerly, and what is most interesting
to observe is that, whether as a result of this or for some other
reason, the families among the well-to-do are not nearly as small as in
other countries.—_Dr. S. Adolphus Knopf, in The Survey for November,
1916._


                                GERMANY

Germany was the next to follow, in 1889, when Herr Max Hausmeister and
Herr Karl Lotter founded the Sozial Harmonische Verein, with its paper
_Die Sozial Harmonie_. Like the English League, this society has
confined its teachings to the theoretical and economic aspects of the
subject, in which it has especially distinguished itself. In Germany all
such doctrines are of course anathema, but the enormous decline in the
birth-rate in several towns testifies to the refusal of the German
people to be hectored into misery. All the signs point at present to an
extraordinary ferment of new ideas in Germany, and a large number of
other movements are more or less openly Neo-Malthusian.—From _The
Malthusian_ (London), January, 1909.

The German Sozial Harmonische Verein, founded in 1889, by Herr Max
Hausmeister, has continued its quiet, but effective, work, and its
periodical, _Die Sozial Harmonie_, has contained many articles of great
economic value. A remarkable feature in Germany, however, has been the
rapid rise of the Mutterschutz Society, under the able presidency of Dr.
Helene Stocker, a society which aims at obtaining greater security and
freedom for married and unmarried mothers, and at securing better
conditions for the rearing of their offspring. Neo-Malthusianism (Birth
Control) is becoming an important feature of this work, and is also
dealt with in the _Zeitschrift fur Sexual-wissenschaft_, a scientific
journal devoted to sex matters. The birth-rate of Prussia has seen one
of the most rapid declines, from 36.2 in 1901 to 33.7 in 1906, and 33.0
in 1907; while the death-rates for the same years have been 20.5, 17.9,
and 17.8, and the infantile mortalities 200, 177, and 168 respectively.
The birth-rate of Berlin in 1907 was 24.3, or below that of London,
26.8.—From _The Malthusian_ (London) for July 15th, 1909.


                                 FRANCE

France differs from all other countries in having realized the
individual advantages of the practice of birth control long before any
other country in Europe. It is said that the sale of the lands
(forfeited by the Emigrés or confiscated by the Commune after the
Revolution) to the people, together with the law of equal inheritance in
accordance with the principles of Liberty, Equality and Fraternity
adopted for their guidance formed the chief incentive to restriction of
the numbers of the family.

The birth-rate declined in an irregular manner from 1870 to the present
time, especially among the wealthy classes, while the poor and ignorant
continued to be burdened with large families. This led M. Paul Robin in
1896 to form the French Ligue de la Regeneration Humaine, and to employ
his enormous energy and enthusiasm towards the formation of leagues in
other countries. Bohemia, Spain, Brazil, Belgium, Cuba, Africa and
Switzerland formed leagues in succession, most of them circulating
periodicals dealing with Neo-Malthusian (Birth Control) theory and
practice. At the same time M. Robin formed a Federation Universelle de
la Regeneration Humaine, in which the various leagues have been
associated and which has held two international meetings—the first at
Paris in 1900 and the second at Liege in 1905.—From _The Malthusian_
(London) January, 1909.

Fifteen years after the founding of M. Robin’s work, the propaganda in
France is very complete and intense. Theoretical or practical, it
appears under many forms. It acts through books, pamphlets, leaflets,
journals, lectures, pictures, and even songs. Tens of thousands of
theoretical volumes and pamphlets are disseminated, hundreds of
thousands of leaflets are distributed. The practical pamphlets find
their success in rapidly disappearing editions. In every part of the
land—in town, and even country—lectures are given, and numerous militant
workers diffuse the good tidings in multitudes of papers. The centers of
our propaganda are too numerous to be fully quoted. In the first rank
are the societies exclusively Neo-Malthusian (Birth Control), which, in
fact, each carry on in their own manner the work undertaken by
_Regeneration_. The most active, the most enterprising, and the most
combative of these organizations, _Génération Consciente_, multiplies
its efforts, extends its action, and prospers unceasingly. Again there
exists a different class of propagandists—the individual—who, without
periodical, place or society, works by disseminating not only the
pamphlets, leaflets, and books, but also the means of prevention.—From
_The Malthusian_ (London) of September 15, 1910.

France has her population practically under control, and can increase or
diminish at will according to the prospects of good or bad times. (See
Page 37 for French Birth and Death Rate).—From _The Malthusian_ (London)
of April 15th, 1909.

France has set the example of real civilization and other nations are
following her more or less rapidly according to their advancement in
culture.

There has been a tendency to ascribe the low birth-rate in France to
infertility or degeneracy, although this is patently absurd to all those
who are acquainted with the French people. For the low birth-rate of
France is practically entirely due to prudential control of families
among married people who make no pretense to the avoidance of preventive
intercourse.

Dealing with the conditions of the people in France there is little that
does not compare favorably with all other old countries. The average
duration of life is about fifty years, which is nearly the highest in
Europe. The infantile mortality is the worst feature,[3] but it has been
declining for some years.

Footnote 3:

  Note: This is a problem of hygiene and infant welfare. If the same
  care were given the babies of France as is being given the infants of
  other advanced countries there is little doubt that the mortality rate
  would decline proportionately.—M. H. S.

There is no “too old at thirty-five” difficulty in France, elderly men
being employed where boys are (in other countries); there is no
unemployment worth speaking of; there is no land problem, and house
rents, instead of being forced up by excess of demand, are actually
lowered by excess of supply, so that the “unearned increment” is
frequently negative.—From _The Malthusian_ (London) for April 15th,
1909.

Writing of France in 1879, a few years after the close of the disastrous
Franco-Prussian War, Johannes Swaagman said:

“France, notwithstanding the heavy war indemnity of five milliards, and
perhaps an equal expenditure of her own war material, is now the only
country that has a surplus on its estimated budget, and can even dream
of reducing taxation. Besides this, large sums are being spent on
improvements, with a view of accelerating commerce and industry.

“France has still many things to learn, notably as regards hygiene, but
we have no hesitation in asserting that as regards the solution of the
most distressing problems which humanity has to face and as regards
general happiness and culture she is far ahead of all other countries
and she has simply led the way in the direction in which all other
nations are bound to follow, and in which they are already
hastening.”—From _The Malthusian_ (London) of April 15th, 1909.

Strong and vigorous movements exist in Switzerland, Belgium, Hungary,
Spain, Norway, Sweden, Denmark and Italy, while there are somewhat less
active ones in Russia, Japan, India, and even China. I will not take the
space to furnish the details of the movement in these countries because
they are mainly inspired in their activities from those well organized
Leagues already mentioned.


                     BIRTH AND DEATH RATE IN FRANCE

The actual facts as regards the French birth-rate are constantly
misrepresented. Taking the actual population, this appears to have been
24.8 millions in 1783, 28.9 millions in 1806, and to have gone on more
or less steadily increasing to 39.26 millions in 1907. Exceptions to
this increase have taken place six times since 1881, there being a
deficit or excess of deaths over births of 38,446 in 1890, of 10,505 in
1891, of 20,041 in 1892, of 17,813 in 1895, of 25,988 in 1900, and of
19,920 in 1907. Despite these deficits the natural increase, or excess
of births over deaths, was 1,232,744 in the twenty-five years from 1881
to 1905, while the total increase, including immigration, etc., was
1,690,000 during the same period. It is worthy of note also in view of
the suggestions that the deficit is about to become chronic, and that
France is therefore a “dying nation,” that in 1893 and 1894, after three
years of deficits, there were excesses of 7,000 and 39,000; in 1897 and
1898 of 93,700 and 108,000; and in 1901 of 72,000. There has been no
report since 1907, but Le Jour Officiel of Paris has given the figures
for the first six months of 1908, which show an _increase_ of 12,066,
partly due to a rise of 8,657 in the births and partly a decline of
8,416 in the deaths.—From _The Malthusian_ (London) of April 15th, 1909.


                          BIRTH RATE IN FRANCE

        Compiled from _The Malthusian_ (London), for April 15th,
                                  1909

       Year                                   Increase   Decrease
       1890                                                38,446
       1891                                                10,505
       1892                                                20,041
       1893                                      7,000
       1894                                     39,000
       1895                                                17,813
       1896                        No record available
       1897                                     93,700
       1898                                    108,000
       Total for 8 years                       247,700     86,800
                                                86,800
                                               ———————
       Total increase                          160,900
                                               ———————

       Rate of increase per year (approximately)           20,100
       Increase in total population from 1783 to 1907  15,000,000


                        UNITED STATES OF AMERICA

It is interesting to know that the present agitation for the
dissemination of knowledge to prevent conception, as expressed in the
various leagues throughout the world to-day had its greatest impetus and
inspiration from two books written by Americans in the United States.

The first of these was a pamphlet entitled “Moral Physiology,” written
by United States Senator Robert Dale Owen, son of Robert Owen, which was
published in New York City in 1830 and gave a description of the
physical checks made use of in France, where it was the custom to limit
the number of children to the means at the command of the family. This
book was much read and commented favorably upon in America.

So favorably did this publication appeal to the thinking minds of the
time, that Dr. Charles Knowlton, an able Boston physician, on reading
Owen’s pamphlet, was so struck by its importance as a contribution to
the science of hygiene that he brought out a similar work in 1833,
entitled “The Fruits of Philosophy.” His book was addressed to young
married people and gave a popular description of the anatomy of the
organs of reproduction, especially in the female, and a somewhat more
detailed account of the physical checks to prevent conception than had
been given in Owen’s pamphlet.

“The Fruits of Philosophy” circulated unchallenged for more than forty
years, and finally, in 1876, was attacked as an obscene publication
under the new act of Parliament called “Lord Campbell’s Act,” and a
bookseller of Bristol, England, was sentenced to two years’ imprisonment
for selling it.

This work would have been suppressed altogether had not Charles
Bradlaugh and Mrs. Annie Besant, two ardent defenders of British
liberty, come forward and volunteered to sell it in order to test the
case in the English courts. The trial, as has been described herein
under the title of “Birth Control League of England,” attracted great
attention to this philosophy throughout the world. It is a sad
commentary upon the legislative bodies of this country that up to the
present every attempt by advocates of this principle to discuss this
subject and awaken our people to its needs has been met with prosecution
and jail sentences.

During these last forty years the movement has made rapid progress in
all civilized countries except the United States. In this progressive
matter we find ourselves classed with Russia, Japan, India and China,
where national interest is concerned with quantity of human beings
rather than with quality.

But during the last five years the subject has come forcibly to the
front, mainly through prosecutions. Again a message has gained a hearing
from the dock which it could never have won from the platform.

The people of this country are now awakened to the need of knowledge to
prevent conception. Social workers, nurses, and members of the medical
profession find their work hampered and their activities nullified by
oppressive laws denying the individual the right of health, life and the
pursuit of happiness.

The most advanced thinkers in America are with us in this movement, the
sentiment being largely in favor of the establishment of clinics,
similar to those in Holland, where the poor and overburdened mothers may
come for advice to be given by doctors, nurses or others competent to
instruct.

Following are some of the names of men and women in the United States
who stand for the dissemination of such knowledge, have allied
themselves to this great humanitarian cause, and have come out in the
press for birth control as a national necessity:


               WELL KNOWN WOMEN WHO ENDORSE BIRTH CONTROL

                       Mrs. J. Borden Harriman
                       Mrs. Amos Pinchot
                       Mrs. Charles Tiffany
                       Mrs. Robert M. La Follete
                       Mrs. Herbert Croly
                       Mrs. Phillip Littell
                       Mrs. Raymond B. Stevens
                       Mrs. Simeon Ford
                       Mrs. Philip Lydig
                       Mrs. William I. Thomas
                       Mrs. Robert P. Bass
                       Mrs. Inez Haynes Irwin
                       Mrs. Paul Manship
                       Mrs. Frank Cothren
                       Mrs. George B. Hopkins
                       Mrs. J. Sargeant Cram
                       Mrs. William Leon Graves
                       Mrs. Gifford Pinchot
                       Mrs. J. G. Phelps Stokes
                       Mrs. Elsie Clews Parsons
                       Mrs. Amy Walker Field
                       Mrs. Mary Heaton Vorse
                       Mrs. Juliet Barrett Rublee
                       Mrs. Frances Hand
                       Mrs. Mabel Foster Spinney
                       Mrs. Belle I. Moskowitz
                       Miss Caroline Rutz-Rees
                       Miss Jessie Ashley
                       Miss Lillian D. Wald
                       Princess Troubetskoy


               NOTED PHYSICIANS WHO ENDORSE BIRTH CONTROL

  Dr. Abram Jacobi, ex-president, American Medical Association, New York
      City.

  Dr. Hermann M. Biggs, State Commissioner of Health, New York.

  Dr. John N. Hurty, secretary, State Board of Health, Indiana.

  Dr. Godfrey R. Pisek, professor of diseases of children, New York
      Post-Graduate Medical School and Hospital, New York City.

  Dr. J. W. Trask, United States Public Health Service, Washington, D.
      C.

  Dr. Ira S. Wile, editor, _American Medicine_, member Board of
      Education, New York City.

  Dr. John A. Wyeth, professor of surgery and president of the New York
      Polyclinic Medical School and Hospital, ex-president of the
      American Medical Assn., and New York Academy of Medicine, New York
      City.

  Dr. S. Adolphus Knopf, professor of medicine, department of
      Phthisio-therapy, at New York Post-Graduate Medical School and
      Hospital, New York City.

  Dr. Lydia Allen de Vilbiss, formerly of New York State Department of
      Health, now in charge of the division of Child Hygiene of the
      State Board of Health of Kansas.


          NOTED WRITERS AND TEACHERS WHO ENDORSE BIRTH CONTROL

                       Ernest Poole
                       Will Irwin
                       Walter Lippman
                       Paul Kellogg
                       Max Eastman
                       Winthrop D. Lane
                       John Reed
                       Prof. Warner Fite
                       Prof. William P. Montagu
                       Prof. Charles Zueblin
                       Prof. Durant Drake
                       Prof. Thomas Nixon Carver
                       Prof. Melvil Dewey
                       Prof. William H. Allen
                       Prof. Franklin H. Giddings
                       Prof. Irving Fisher
                       Hon. Homer Folks
                       Hon. William H. Wadhams
                       Dr. Henry Moskowitz
                       Hiram Myers
                       Dr. Scott Nearing
                       Eugene V. Debs


               NOTED MINISTERS WHO ENDORSE BIRTH CONTROL

  Rev. Dr. Frank Crane, formerly pastor of the Union Congregational
      Church, Worcester, Mass., now notable writer of editorial articles
      for New York _Globe_, etc.

  Rev. Dr. Percy Stickney Grant, rector, Protestant Episcopal Church of
      the Ascension, New York City.

  Rev. Dr. Frank Oliver Hall, minister, Church of the Divine Paternity,
      New York City.

  Rev. Dr. John Haynes Holmes, minister, Unitarian Church of the
      Messiah, New York City.

  Rev. Dr. Harvey Dee Brown, minister, Unitarian Church of the Messiah,
      New York City.

  Rev. Dr. Stephen S. Wise, rabbi of the Free Synagogue, New York City.

  Rev. Dr. Sidney E. Goldstein, rabbi of the Free Synagogue, New York
      City.

  Rev. Dr. Waldo Adams Amos, rector, Protestant Episcopal Church of St
      Paul, Hoboken, N. J.


    PROMINENT RESIDENTS OF CHICAGO, ILL., WHO ENDORSE BIRTH CONTROL

                    Dr. Isaac A. Abt
                    Rev. Myron E. Adams
                    Rev. Edward S. Ames
                    Dr. Charles S. Bacon
                    Mrs. E. W. Bemis
                    Mrs. I. S. Blackwelder
                    Mrs. Tiffany Blake
                    Dr. Anna E. Blount
                    Ralph E. Blount
                    Mrs. Joseph T. Bowen
                    Mr. and Mrs. Horace Bridges
                    Mr. and Mrs. Edward B. Burling
                    Mrs. Benjamin Carpenter
                    Dr. and Mrs. Frank Cary
                    Mr. and Mrs. William L. Chenery
                    Dr. Frank S. Churchill
                    Mr. and Mrs. Samuel Dauchy
                    Dr. J. B. De Lee
                    Mr. and Mrs. William F. Dummer
                    Mrs. Joseph N. Eisendrath
                    Mrs. Kellogg Fairbank
                    Dr. John Favill
                    Prof. and Mrs. James A. Field
                    Mrs. Walter L. Fisher
                    Mr. and Mrs. Jerome Frank
                    Rev. and Mrs. Charley W. Gilkey
                    Dr. and Mrs. Maurice L. Goodkind
                    Dr. Ethan A. Gray
                    Mr. and Mrs. E. T. Gundlach
                    Mrs. Alfred Hamburger
                    Dr. and Mrs. Ralph Hamill
                    Dr. Alice Hamilton
                    Mr. and Mrs. Charles F. Harding
                    Dr. N. Sproat Heaney
                    Mrs. Charles Henrotin
                    Dr. Rudolph W. Holmes
                    Mrs. Leila K. Hutchins
                    Dr. Karl K. Koessler
                    Mr. and Mrs. Herman Landauer
                    Dr. W. George Lee
                    Prof. and Mrs. Frank R. Lillie
                    Prof. and Mrs. J. Weber Linn
                    Mrs. Edwin L. Lobdell
                    Max Loeb
                    Judge and Mrs. Julian W. Mack
                    Prof. and Mrs. George H. Mead
                    Dr. James H. Mitchell
                    Mr. and Mrs. William S. Monroe
                    Prof. and Mrs. Addison W. Moore
                    Mrs. James W. Morrisson
                    Mr. and Mrs. George Packard
                    Mr. and Mrs. Benjamin Page
                    Mrs. Elia W. Peattie
                    Allen B. Pond
                    Mr. and Mrs. James F. Porter
                    Mrs. Julius Rosenwald
                    Mrs. Dunlap Smith
                    Mrs. Henry Solomon
                    Dr. Alexander F. Stevenson
                    Prof. Graham Taylor
                    Mrs. Harriet W. Walker
                    Mr. and Mrs. Willoughby Walling
                    Mrs. George Watkins
                    Mr. and Mrs. Payson Wild
                    Mrs. Wilmarth
                    Dr. Rachelle Yarros
                    Victor S. Yarros
                    Mr. and Mrs. Sigmund Zeisler

Physicians, scientists, economists, social workers and others interested
in the forward march of this country are simply marking time in progress
until it is decided whether or not the medical profession and its
assistants have the legal right to impart information to prevent
conception to those who need it. A favorable decision would permit men
and women to stem the incoming tide of feebleminded, unfit, degenerate
individuals who undermine our present social structure and place a
burden on generations yet unborn.



                              CHAPTER III
                       POPULATION AND BIRTH RATE


_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._


                             BIRTH CONTROL

                           BY HAVELOCK ELLIS

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 and 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 destitution 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 order: 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 at 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 a 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
registration. 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.


                    Yearly Number of Births per 1000
                              Inhabitants.

                                      1881–5 1906–10
                    Russia (European)   49.1 47.7[4]
                    Hungary             44.6    36.7
                    German Empire       37.0 34.3[4]
                    Spain               36.4    33.6
                    Austria             38.2    33.6
                    Italy               38.0    32.6
                    The Netherlands     34.8    29.6
                    Belgium             30.7 27.7[4]
                    England and Wales   33.5    26.6
                    France              24.7    19.7

Footnote 4:

  Figures for previous five years.

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.


                      Yearly Number of Deaths per
                           1,000 Inhabitants

                                      1881–5 1906–10
                    Russia (European)   35.4 30.9[5]
                    Hungary             33.1    25.0
                    Spain               32.6    24.3
                    Austria             30.1    22.3
                    Italy               27.3    21.0
                    German Empire       25.3 19.9[5]
                    France              22.2    19.2
                    Belgium             20.6 17.0[5]
                    England and Wales   19.4    14.7
                    The Netherlands     21.4    14.3

Footnote 5:

  Figures for previous five years.

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 births is greater than the number of deaths—so every
country is increasing in population.


                     Natural Increase in Population
                         per 1,000 Inhabitants

                                      1881–5 1906–10
                    Russia (European)   13.7 16.8[6]
                    The Netherlands     13.4    15.3
                    German Empire       11.7 14.4[6]
                    Hungary             11.5    11.7
                    England and Wales   14.1    11.5
                    Italy               10.7    11.4
                    Austria              8.1    11.3
                    Belgium             10.1 10.7[6]
                    Spain                3.8     9.3
                    France               2.5      .7

Footnote 6:

  Figures for previous five years.

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.


                  FROM “THE EMPIRE AND THE BIRTH-RATE”

                       BY C. V. DRYSDALE, _D.Sc._

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 perishes 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.


    VARIATIONS OF POPULATION, BIRTH-RATE, &c., IN THE BRITISH EMPIRE

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.

[Illustration: FIG. 1.—POPULATION OF VARIOUS COUNTRIES.]

_VARIATIONS IN BIRTH RATE &c., IN ENGLAND & WALES_

[Illustration: FIG. 2.—ENGLAND AND WALES.]

[Illustration: 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 was 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 natural 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.

Footnote 7:

  Further investigation appears to indicate that the official statistics
  concerning emigration and immigration are very unreliable. The
  Statistical Abstract for the United Kingdom for 1912 gives the total
  emigration in the ten years 1901–10 as 4,724,233, and the total
  immigration 2,409,490, leaving an outward balance of 2,314,723. In the
  same period there were 11,628,493 births and 6,780,266 deaths, giving
  a natural increase of 4,848,227; and since the actual increase by the
  census returns was 3,757,944, the net loss by emigration could only
  have been 1,091,283 or less than half of the officially recorded
  number. Thus it appears that little over one-fifth of our natural
  increase is lost by emigration. (Since writing this, I find the
  Registrar-General admits the returns prior to 1908 were defective.)

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

[Illustration: FIG. 4.—AUSTRALIA.]

[Illustration: FIG. 5.—NEW ZEALAND.]

[Illustration: FIG. 6.—ONTARIO, CANADA.]

[Illustration: 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. On 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 over 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.


                1860      1870      1880      1890      1900      1910

 Australia,   1,145,585 1,647,766 2,231,531 3,151,355 3,765,339 4,425,083
   population

 Per cent.
   increase               43.8      35.5      41.2      19.5      17.5
   in decade

 New Zealand,                                625,508   768,278  1,002,679
   population

 Per cent.
   increase                                             22.6      30.5
   in decade

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.

Footnote 8:

  In the five years 1901–05 there was an actual net loss of over 16,000
  persons by excess of emigration.

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 to 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 with 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:—


                   Total for decade    Percentage of  Excess    Actual
                        1901–11         Population   Births, – Increase
                                           1901       Deaths

                   Births     Deaths   Births Deaths

 Bengal, Behar   29,351,442 25,373,322  39.10  33.80 3,978,120 4,552,293
   and Orissa

 Punjab           8,286,261  8,843,708  40.8   43.5   –557,447   355,383

 Assam            1,883,545  1,564,022  35.70  29.65   319,523   489,892

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, given 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.


                 1872        1881        1891        1901        1911

 Total        206,162,360 263,896,330 287,314,671 294.361.056 315.001.099
   population

 Per cent.
   increase                  23.1        13.1         2.4         7.0
   in decade

 British      195,840,000 199,200,000 221,380,000 231,600,999 244,279,888
   Provinces

 Per cent.
   increase       .08         1.6        11.0         4.5         5.5
   in decade

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 that 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.

Footnote 9:

  In the article on India in the “Encyclopaedia Britannica” it is stated
  that the Irrigation Commission of 1901–03 emphatically asserted that
  irrigation alone could not cure famine.

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:—


               Census               1891        1901        1911
    Population                   345,356,000 385,572,000 417,268,000
    Per cent. increase in decade                11.6         8.3

Of 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.


                            OTHER COUNTRIES

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.

[Illustration: FIG. 8.—CEYLON.]

[Illustration: FIG. 9.—FRANCE.]

[Illustration: FIG. 10.—GERMANY.]

[Illustration: 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 its 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 from 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 lowest 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.

[Illustration: 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 consequence. 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.


                               CONCLUSION

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 country 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.


               DIAGRAMS OF INTERNATIONAL VITAL STATISTICS

              Prepared by Charles V. Drysdale, D.Sc., 1911

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
birth-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.

                                              CHARLES V. DRYSDALE, D.Sc.
                                                        1911.


                           _VARIOUS COUNTRIES
                               1901–05._

[Illustration: FIG. 1.]


                          _VARIOUS COUNTRIES.
                    CRUDE & CORRECTED DEATH-RATES._

[Illustration: FIG. 2.]


                                _LONDON
                              1905–1909._

[Illustration: FIG. 3.]


                                 _PARIS
                                 1906._

[Illustration: FIG. 4.]


                _UNITED KINGDOM. Growth of Population._

[Illustration: FIG. 5.]


                _UNITED KINGDOM. Birth and Death Rates._

[Illustration: FIG. 5A]


                 _GERMAN EMPIRE. Growth of Population._

[Illustration: FIG. 6]


                _GERMAN EMPIRE. Birth and Death Rates._

[Illustration: FIG. 6A.]


                          _FRANCE POPULATION._

[Illustration: FIG. 7]


                               _FRANCE._
                         _BIRTH & DEATH RATES._

[Illustration: FIG. 7A.]


                          _VARIOUS DISEASES._

[Illustration: FIG. 7B.]


                               _FRANCE._
                         _BIRTH & DEATH RATES._

[Illustration: FIG. 8.]


                           _ENGLAND & WALES._
                           _BIRTHS & DEATHS._
                 _MARRIAGE, FERTILITY, & ILLEGITIMACY._
                          _VARIOUS DISEASES._

[Illustration: FIG. 9]


                           _THE NETHERLANDS._

[Illustration: FIG. 10.]


                               _NORWAY._

[Illustration: FIG. 11.]


                               _SWEDEN._

[Illustration: FIG. 12.]


                               _DENMARK._

[Illustration: FIG. 13.]


                               _BELGIUM._

[Illustration: FIG. 14.]


                                _ITALY._

[Illustration: FIG. 15.]


                                _SPAIN._

[Illustration: FIG. 16.]


              COUNTRIES WITH NEARLY STATIONARY BIRTH-RATE


                               _RUSSIA._

[Illustration: FIG. 17]


                              _ROUMANIA._

[Illustration: FIG. 18]


                               _JAMAICA._

[Illustration: FIG. 19]


                               _IRELAND._

[Illustration: FIG. 20]


                   COUNTRIES WITH RISING BIRTH-RATES

[Illustration: FIGS. 21-23]


                            BRITISH COLONIES


                          _CANADA (Ontario)._

[Illustration: FIG. 24]


                      _AUSTRALIA (Commonwealth)._

[Illustration: FIG. 25]


                             _NEW ZEALAND._

[Illustration: FIG. 26]


                         _THE CITY OF TORONTO._

[Illustration: FIG. 27]


                               _BERLIN._

[Illustration: FIG. 28]


                               _BERLIN._

[Illustration: FIG. 29]


                               _EUROPE._

[Illustration: FIG. 30]


                           _WESTERN EUROPE._

[Illustration: FIG. 31]



                               CHAPTER IV
                            INFANT MORTALITY


_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 of 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 the 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).


                                 Deaths during first year
              1st born children            23%
              2nd born children            20%
              3rd born children            21%
              4th born children            23%
              5th born children            26%
              6th born children            29%
              7th born children            31%
              8th born children            33%
              9th born children            36%
              10th born children           41%
              11th born children           51%
              12th born children           60%


  _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.


             Infant Mortality Rate for all Children borne
                     by Married Mothers: Table 36

             Number of Pregnancies. Infant Mortality Rate.
             1 and 2                   108.5 per 1,000
             3 and 4                   126.0 per 1,000
             5 and 6                   152.8 per 1,000
             7 and 8                   176.4 per 1,000
             9 or more                 191.9 per 1,000
             Average                   149.9 per 1,000

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.


  Father’s earnings Live-births Deaths 1st year Infant mortality rate
  Under $625            384           82                        213.5
  $625 to $899          385           47                        122.1
  $900 or more          186           18                         96.8
  Ample                 476           40                         84.0

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.

According 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.


                    Order of Birth        Deaths per 1,000
              1st and 2nd born children        138.3
              3rd and 4th born children        143.2
              5th and 6th born children        177.0
              7th and 8th born children        181.5
              9th and later born children      201.1

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.


                Table 42.—Infant mortality rate for all
             children of married mothers included in this
              investigation, distributed according to the
                          father’s earnings.

            Father’s annual earnings  Infant mortality rate
            Under $521                        197.3
            $521 to $624                      193.1
            $625 to $779                      163.1
            $780 to $899                      168.4
            $900 to $1,199                    142.3
            $1,200 to $1,200 and over         102.2



              U. S. DEPARTMENT OF LABOR CHILDREN’S BUREAU

                        Julia C. Lathrop, Chief


                            INFANT MORTALITY

          RESULTS OF A FIELD STUDY IN JOHNSTOWN, PA., BASED ON
                      BIRTHS IN ONE CALENDAR YEAR

                              BY EMMA DUKE

                                  1915


                       (_Certain tables omitted_)



                    INFANT MORTALITY: JOHNSTOWN, PA.


                             _INTRODUCTION_

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:


    DEATHS OF CHILDREN UNDER 1 YEAR OF AGE PER 1,000 LIVE BIRTHS, BY
     QUINQUENNIAL PERIODS FROM 1901 TO 1910, AND ALSO FOR THE SINGLE
                    CALENDAR YEARS 1909 TO 1910.[10]

 ═══════════════════════╤═══════════╤═══════════╤═══════════╤═══════════
        COUNTRY.        │  1901 to  │  1906 to  │   1909    │   1910
                        │   1905    │   1910    │           │
 ───────────────────────┼───────────┼───────────┼───────────┼───────────
 Chile                  │        306│        315│        315│        313
 Russia (European)      │  ([11])   │           │           │
 Austria                │        215│           │           │
 Hungary                │        212│        204│        212│        194
 Prussia                │        190│        168│        164│        157
 Jamaica                │        174│        191│        174│        188
 Spain                  │        173│           │           │
 Ceylon                 │        171│        189│        202│        176
 Italy                  │        168│           │        155│
 Japan                  │        154│           │        166│
 Servia                 │        149│           │           │
 Belgium                │        148│           │        137│
 Bulgaria               │        148│           │           │
 France                 │        139│           │        120│
 England and Wales      │        138│        117│        109│        105
 The Netherlands        │        136│        114│         99│        108
 Switzerland            │        134│           │        115│
 Finland                │        131│        117│        111│        118
 Scotland               │        120│           │        108│
 Denmark                │        119│           │         98│
 Province of Ontario    │        114│        127│        131│        123
 Ireland                │         98│         94│         92│         96
 Australian Commonwealth│         97│         78│         72│         75
 Sweden                 │         91│           │         72│
 Norway                 │         81│           │         72│
 New Zealand            │         75│         70│         62│         68
 ───────────────────────┴───────────┴───────────┴───────────┴───────────

Footnote 10:

  From the Seventy-third Annual Report of the Registrar General of
  Births, Deaths, and Marriages in England and Wales (1910). London,
  1912.

Footnote 11:

  Available only for the period from 1896 to 1900, when it was 261.

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 were 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 means 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.


 ════════════╤═══════╤═══════╤═════════════╤═════════════
             │       │       │             │SEX OF BABY.
             ├───────┼───────┼─────────────┼─────┬───────
             │       │       │             │     │
 NATIONALITY │ Total │ Live  │             │     │
  OF MOTHER. │births.│births.│Still-births.│Male.│Female.
             │       │       │             │     │
             │       │       │             │     │
 ────────────┼───────┼───────┼─────────────┼─────┼───────
    Total    │    380│    350│           30│  227│    153
 ════════════╪═══════╪═══════╪═════════════╪═════╪═══════
     Native  │    134│    118│           16│   76│     58
     Foreign │    246│    232│           14│  151│     95
 ────────────┼───────┼───────┼─────────────┼─────┼───────
 Slovak,     │       │       │             │     │
   Polish,   │     43│     41│            2│   27│     16
   etc       │       │       │             │     │
 Croatian and│     13│     11│            2│   10│      3
   Servian   │       │       │             │     │
 Magyar      │      1│      1│             │    1│
 German      │      8│      8│             │    6│      2
 Italian     │     41│     39│            2│   26│     15
 Syrian and  │      7│      6│            1│    3│      4
   Greek     │       │       │             │     │
 British     │      7│      7│             │    3│      4
 Austrian    │       │       │             │     │
   (not      │    123│    116│            7│   73│     50
   otherwise │       │       │             │     │
   specified)│       │       │             │     │
 Not reported│      3│      3│             │    2│      1
 ────────────┴───────┴───────┴─────────────┴─────┴───────

 ════════════╤════════════════════════════╤═══════════
             │    ATTENDANT AT BIRTH.     │
 ────────────┼──────────┬────────┬────────┼───────────
             │          │        │        │Certificate
 NATIONALITY │          │        │        │  showing
  OF MOTHER. │Physician.│Midwife.│Unknown.│  deaths
             │          │        │        │  during
             │          │        │        │first year.
 ────────────┼──────────┼────────┼────────┼───────────
    Total    │       158│     180│      33│         47
 ════════════╪══════════╪════════╪════════╪═══════════
     Native  │       122│       5│       7│         12
     Foreign │        36│     184│      26│         35
 ────────────┼──────────┼────────┼────────┼───────────
 Slovak,     │          │        │        │
   Polish,   │         4│      37│       2│          3
   etc       │          │        │        │
 Croatian and│          │       7│       6│          5
   Servian   │          │        │        │
 Magyar      │          │       1│        │
 German      │         2│       5│       1│          2
 Italian     │         3│      36│       2│          4
 Syrian and  │         3│       4│        │          1
   Greek     │          │        │        │
 British     │         5│       2│        │
 Austrian    │          │        │        │
   (not      │        19│      89│      15│         20
   otherwise │          │        │        │
   specified)│          │        │        │
 Not reported│          │       3│        │
 ────────────┴──────────┴────────┴────────┴───────────


   RELATION OF INFANT MORTALITY TO ENVIRONMENT NEIGHBORHOOD INCIDENCE

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 21 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.


   TABLE 1.—DISTRIBUTION OF POPULATION, LIVE BIRTHS AND DEATHS DURING
      FIRST YEAR, AND INFANT MORTALITY RATE ACCORDING TO SECTION OF
       JOHNSTOWN, FOR ALL CHILDREN INCLUDED IN THIS INVESTIGATION.

 ════════════════════════════════╤═══════════╤═════════╤══════╤═════════
                                 │           │         │Deaths│
                                 │           │         │during│
                                 │           │         │first │
                                 │Population,│  Total  │ year │ Infant
    SECTION OF CITY AND WARD.    │ 1910.[12] │live-born│  of  │mortality
                                 │           │ babies. │babies│  rate.
                                 │           │         │ born │
                                 │           │         │  in  │
                                 │           │         │ 1911 │
 ────────────────────────────────┼───────────┼─────────┼──────┼─────────
          The whole city         │     55,482│    1,463│   196│    134.6
 ════════════════════════════════╪═══════════╪═════════╪══════╪═════════
 Down-town section (wards 1, 2,  │      5,944│       80│     4│     52.0
   3, 4)                         │           │         │      │
 Kernville (wards 5, 6)          │      6,070│      104│     6│     57.7
 Homerstown (ward 7)             │      4,476│      109│    17│    156.0
 Roxbury (ward 8)                │      2,862│       85│    19│    117.6
 Conemaugh Borough (wards 9, 10) │      5,282│      136│    16│    117.6
 Woodvale (ward 11)              │      3,945│      107│    20│    271.0
 Prospect (ward 12)              │      1,893│       55│    11│    200.9
 Peelorville (ward 13)           │      1,443│       13│     4│ ([13])
 Minersville (ward 14)           │      2,403│       72│     9│    125.0
 Cambria City (wards 15, 16)     │      8,706│      310│    55│    177.4
 Moxham (ward 17)                │      5,735│      157│    14│     39.2
 Morrellville (wards 18, 19, 20) │      5,757│      194│    15│     32.5
 Coopersdale (ward 21)           │        968│       36│     8│ ([13])
 ────────────────────────────────┴───────────┴─────────┴──────┴─────────

Footnote 12:

  Federal census of 1910.

Footnote 13:

  Total live births less than 50; base therefore considered too small to
  use in computing an infant mortality rate.

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.

Through 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. The 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 constantly 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, however, 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.)


      SANITARY CONDITIONS—SEWERAGE, PAVEMENTS, GARBAGE COLLECTIONS

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.

With 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, Dr. 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.


                                HOUSING

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 were 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.


  TABLE 3.—DISTRIBUTION OF LIVE BIRTHS AND OF DEATHS DURING FIRST YEAR,
       AND INFANT MORTALITY RATE, ACCORDING TO HOUSING CONDITIONS.

                                           Deaths during First Year
    HOUSING CONDITIONS     Live births   Number    Infant mortality rate

           Total                 1,463         196                 134.0
 Dry homes                         808          99                 122.5
 Moderately dry homes              336          47                 139.9
 Damp homes                        319          50                 156.7
 Bath                              496          36                  72.6
 No bath                           965         159                 164.8
 Not reported                        2           1        ([14])
 Water supply in house           1,173         138                 117.6
 Water supply outside              288          57                 197.9
 Not reported                        2           1        ([14])
 City water available            1,333         176                 132.0
 City water not available          128          19                 148.4
 Not reported                        2           1        ([14])
 Yard clean                        801          80                  99.9
 Yard not clean                    632         107                 169.3
 No yard                            28           8        ([14])
 Not reported                        2           1        ([14])
 Water-closet                      739          80                 108.3
 Yard privy                        722         115                 159.3
 Not reported                        2           1        ([14])

Footnote 14:

  Total live births less than 50; base therefore considered too small to
  use in computing an infant mortality rate.

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:


  TABLE 4.—DISTRIBUTION OF LIVE BIRTHS AND OF DEATHS DURING FIRST YEAR,
   AND INFANT MORTALITY, ACCORDING TO CLEANLINESS AND DRYNESS OF HOME.

                                          Deaths during First Year
   TYPE OF HOME       Live births         Number       Infant mortality
                                                             rate

     All types                 1,463               196             134.0
 Clean                           943               107             113.5
 Moderately clean                354                58             163.8
 Dirty                           166                31             186.7
 Dry                             807                99             122.7
 Damp                            656                97             147.9
 Clean:
     Dry                         581                61             105.0
     Damp                        362                46             127.1
 Moderately clean:
     Dry                         158                27             170.9
     Damp                        196                31             158.2
 Dirty:
     Dry                          68                11             161.8
     Damp                         98                20             204.1

Dirt 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:


              TABLE 5.—NUMBER OF BABIES LIVING IN HOMES OF
               EACH SPECIFIED SIZE, AND AVERAGE NUMBER OF
                PERSONS PER ROOM IN HOMES OF EACH SIZE.

             Size of home Live-born babies Persons per room

              All homes              1,463
             1 room                     33             4.42
             2 rooms                   165             2.27
             3 rooms                   147             1.83
             4 rooms                   526             1.58
             5 rooms                   222             1.22
             6 rooms                   233             1.07
             7 rooms                    38              .96
             8 rooms                    43             0.83
             9 rooms                    22              .93
             10 rooms                    4              .88
             11 rooms                    4              .64
             12 rooms                    1              .75
             13 rooms                    1              .69
             14 rooms                    2              .43
             Not reported               22

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.

The 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.


                              NATIONALITY


                            GENERAL NATIVITY

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.

Footnote 15:

  United States Immigration Commission Reports, Volume VIII.,
  “Immigrants in Industries: Part 2, Iron and Steel Manufacturing in the
  East,” p. 387. Reference is to Johnstown and is a very true picture of
  various immigrant institutions and of the comparative progress and
  assimilation of different races there. Although the immigration report
  was made five years before our investigation, conditions remain
  practically the same.

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 that 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.


                             SERBO-CROATIAN

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.

Footnote 16:

  A distinct and homogenous race, from a linguistic point of view, among
  Slavic peoples. They are divided into the groups “Croatian” and
  “Servian,” on political and religious grounds, the former being Roman
  Catholics and the latter Greek Orthodox. Their spoken language is the
  same but they can not read each other’s publications, for the
  Croatians use the Roman alphabet, or sometimes the strange old Slavic
  letters, while the Servians use the Russian characters fostered by the
  Greek Church.

  Three Krainers have also, for convenience, been included in this
  group. Krainers are Slovenians from the Austro-Hungarian Province of
  Carniola and are designated “close cousins of the Croatians but with a
  different though nearly related language” by Emily Greene Balch in her
  book entitled “Our Slavic Fellow Citizens.”

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, on 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.


                                ITALIAN

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.


                          SLOVAK, POLISH, ETC.

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, one 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.”

Footnote 17:

  Slovaks occupy practically all except the Ruthenian territory of
  northern Hungary; also found in great numbers in southeast Moravia.
  They are the Moravians conquered by Hungary. In physical type no
  dividing line can be drawn between Slovaks and Moravians. It is often
  claimed that Slovak is a Bohemian dialect.

Footnote 18:

  The west Slavic race native to the former Kingdom of Poland. For the
  most part they adhere to the Roman rather than the Greek Orthodox
  Catholic Church.

Footnote 19:

  The westernmost division or dialect of the Czech and the principal
  people or language of Bohemia. Czech is the westernmost race or
  linguistic division of the Slavic (except Wendish, in Germany), the
  race or people residing mainly in Bohemia and Moravia.

Footnote 20:

  Also known as Little Russians; live principally in southern Russia;
  also share Galicia with the Poles but greatly surpassed by Poles in
  number. In language and physical type resemble Slovaks. Generally
  Greek Orthodox, but a few are Greek Catholics of the Roman Catholic
  Church, whose priests marry, and are separated from other Roman
  Catholics by marked religious differences.

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.


                          OTHER NATIONALITIES

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.

Footnote 21:

  English, Irish, Scotch, and Welsh included in the term British.

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.


                              STILLBIRTHS

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.)


                           ATTENDANT AT BIRTH

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 quality 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.


                                MOTHERS


                              LITERACY[22]

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.

Footnote 22:

  By literacy is meant ability to read and write in any language and not
  simply in English.

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.


    TABLE 13.—DISTRIBUTION OF BIRTHS AND OF DEATHS DURING FIRST YEAR,
     INFANT MORTALITY RATE, AND NUMBER AND PER CENT OF STILLBIRTHS,
                ACCORDING TO LITERACY OF FOREIGN MOTHERS.

 ═══════════════════════╤═══════╤═══════╤═════════════╤═════════════════
   LITERACY OF FOREIGN  │ Total │ Live  │STILLBIRTHS. │  DEATHS DURING
        MOTHERS.        │births.│births.│             │   FIRST YEAR.
 ───────────────────────┼───────┼───────┼───────┬─────┼───────┬─────────
                        │       │       │       │ Per │       │ Infant
                        │       │       │Number.│cent.│Number.│mortality
                        │       │       │       │     │       │  rate.
 ───────────────────────┼───────┼───────┼───────┼─────┼───────┼─────────
     Foreign mothers    │    691│    648│     43│  6.2│    111│    171.3
 ═══════════════════════╪═══════╪═══════╪═══════╪═════╪═══════╪═════════
 Literate               │    445│    419│     26│  5.8│     62│    148.0
 Illiterate             │    246│    229│     17│  6.9│     49│    214.0
 ───────────────────────┴───────┴───────┴───────┴─────┴───────┴─────────


                        ABILITY TO SPEAK ENGLISH

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


    TABLE 14.—DISTRIBUTION OF BIRTHS AND OF DEATHS DURING FIRST YEAR,
     INFANT MORTALITY RATE, AND NUMBER AND PER CENT OF STILLBIRTHS,
        ACCORDING TO ABILITY OF FOREIGN MOTHER TO SPEAK ENGLISH.

 ═══════════════════════╤═══════╤═══════╤═════════════╤═════════════════
    ABILITY TO SPEAK    │ Total │ Live  │STILLBIRTHS. │  DEATHS DURING
        ENGLISH.        │births.│births.│             │   FIRST YEAR.
 ───────────────────────┼───────┼───────┼───────┬─────┼───────┬─────────
                        │       │       │       │ Per │       │ Infant
                        │       │       │Number.│cent.│Number.│mortality
                        │       │       │       │     │       │  rate.
 ───────────────────────┼───────┼───────┼───────┼─────┼───────┼─────────
     Foreign mothers    │    691│    648│     43│  6.2│    111│    171.3
 ═══════════════════════╪═══════╪═══════╪═══════╪═════╪═══════╪═════════
 Speak English          │    263│    247│     16│  6.1│     36│    145.7
 Can not speak English  │    428│    401│     27│  6.3│     75│    187.0
 ───────────────────────┴───────┴───────┴───────┴─────┴───────┴─────────


                       YEARS IN THE UNITED STATES

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.


                                  AGE

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.


    TABLE 16.—DISTRIBUTION OF BIRTHS AND OF DEATHS DURING FIRST YEAR,
     INFANT MORTALITY RATE, AND NUMBER AND PER CENT OF STILLBIRTHS,
                       ACCORDING TO AGE OF MOTHER.

 ════════════════╤════════╤════════╤═════════════════╤══════════════════
  AGE OF MOTHER. │ Total  │  Live  │  STILLBIRTHS.   │  DEATHS DURING
                 │births. │births. │                 │   FIRST YEAR.
 ────────────────┼────────┼────────┼────────┬────────┼────────┬─────────
                 │        │        │        │  Per   │        │ Infant
                 │        │        │Number. │ cent.  │Number. │mortality
                 │        │        │        │        │        │  rate.
 ────────────────┼────────┼────────┼────────┼────────┼────────┼─────────
   All mothers   │   1,551│   1,463│      88│     5.7│     196│    134.0
 ════════════════╪════════╪════════╪════════╪════════╪════════╪═════════
 Under 20        │     105│      95│      10│     9.5│      13│    136.8
 20 to 24        │     476│     454│      22│     4.6│      55│    121.1
 25 to 29        │     410│     391│      19│     4.6│      56│    143.2
 30 to 39        │     480│     449│      31│     6.5│      61│    135.9
 40 and over     │      80│      74│       6│     7.5│      11│    148.6
 ────────────────┴────────┴────────┴────────┴────────┴────────┴─────────

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.


            BABY’S AGE AT DEATH AND CAUSE (DISEASE) OF DEATH

_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.


 TABLE 17.—NUMBER AND PER CENT DISTRIBUTION OF DEATHS OF BABIES, BY AGE
                                AT DEATH.

 ═══════════════════════════════════╤═══════════════════════════════════
            AGE AT DEATH.           │ DEATHS OF BABIES OF ALL MOTHERS.
 ───────────────────────────────────┼─────────────────┬─────────────────
                                    │     Number.     │    Per cent.
                                    │                 │  distribution.
 ───────────────────────────────────┼─────────────────┼─────────────────
     Total deaths in first year     │              196│            100.0
 ═══════════════════════════════════╪═════════════════╪═════════════════
     First quarter                  │              108│             55.1
     First month                    │               74│             37.8
 ═══════════════════════════════════╪═════════════════╪═════════════════
 First week                         │               45│             23.0
 ───────────────────────────────────┼─────────────────┼─────────────────
   Less than 1 day and 1 day        │               30│             15.3
   2 days                           │                4│              2.0
   3 to 6 days                      │               11│              5.6
                                    │                 │
 Second week                        │               14│              7.1
 Third week                         │                7│              3.6
 Fourth week                        │                8│              4.1
                                    │                 │
 Second month                       │               18│              9.2
 Third month                        │               16│              8.2
                                    │                 │
 Second quarter                     │               42│             21.4
 Third quarter                      │               31│             15.8
 Fourth quarter                     │               15│              7.7
 ───────────────────────────────────┴─────────────────┴─────────────────

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.


 TABLE 18.—DISTRIBUTION OF DEATHS DURING FIRST YEAR AND INFANT MORTALITY
        RATE, ACCORDING TO CAUSE OF DEATH AND NATIVITY OF MOTHER.

 ═════════════════╤═════════════════════════════════════════════════════
  CAUSE OF DEATH. │       DEATHS DURING FIRST YEAR OF BABIES OF—
 ─────────────────┼─────────────────┬─────────────────┬─────────────────
                  │  All mothers.   │ Native mothers. │Foreign mothers.
 ─────────────────┼───────┬─────────┼───────┬─────────┼───────┬─────────
                  │       │ Infant  │       │ Infant  │       │ Infant
                  │Number.│mortality│Number.│mortality│Number.│mortality
                  │       │  rate.  │       │  rate.  │       │  rate.
 ─────────────────┼───────┼─────────┼───────┼─────────┼───────┼─────────
    All causes    │    196│    134.0│     85│    104.3│    111│    171.3
 ═════════════════╪═══════╪═════════╪═══════╪═════════╪═══════╪═════════
 Diarrhea and     │     52│     35.5│     17│     20.9│     35│     54.0
   enteritis      │       │         │       │         │       │
 Respiratory      │     50│     34.2│     19│     23.3│     31│     47.8
   diseases       │       │         │       │         │       │
 Premature births │     24│     16.4│     11│     13.5│     13│     20.1
 Congenital       │       │         │       │         │       │
   debility or    │     19│     12.9│      5│      6.1│     14│     21.6
   malformation   │       │         │       │         │       │
 Injuries at birth│      7│      4.8│      6│      7.4│      1│      1.5
 Other causes or  │     44│     30.1│     27│     33.1│     17│     26.2
   not reported   │       │         │       │         │       │
 ─────────────────┴───────┴─────────┴───────┴─────────┴───────┴─────────

The 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.

Footnote 23:

  The Diseases of Infancy and Childhood, by L. Emmett Holt. p. 345. New
  York, 1912.


    TABLE 19.—DISTRIBUTION OF DEATHS, ACCORDING TO CAUSE OF DEATH AND
            QUARTER OF CALENDAR YEAR IN WHICH DEATH OCCURRED.

 ═══════════════════════════════╤═══════╤═══════════════════════════════
         CAUSE OF DEATH.        │  All  │  QUARTER OF CALENDAR YEAR IN
                                │deaths.│     WHICH DEATH OCCURRED.
 ───────────────────────────────┼───────┼───────┬───────┬───────┬───────
                                │       │First. │Second.│Third. │Fourth.
 ───────────────────────────────┼───────┼───────┼───────┼───────┼───────
           All causes           │    196│     54│     29│     74│     39
 ═══════════════════════════════╪═══════╪═══════╪═══════╪═══════╪═══════
 Diarrhea and enteritis         │     52│      3│      5│     32│     12
 Respiratory diseases           │     50│     24│      8│      7│     11
 Premature births               │     24│      7│      5│      9│      3
 Congenital debility or         │     19│      5│      2│      8│      4
   malformation                 │       │       │       │       │
 Injuries at birth              │      7│      5│      1│       │      1
 Other causes or not reported   │     44│     10│      8│     18│      8
 ───────────────────────────────┴───────┴───────┴───────┴───────┴───────

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.

Footnote 24:

  Liefmann, H., and Lindemann, H., Die Lokalization der
  Sauglingsterblichkeit und ihre Beziehungen zur Wohnungsfrage. Med.
  Klinik 1912, pp. 8, 1074.

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.


                                FEEDING

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.

Footnote 25:

  Infantile Mortality and Infants’ Milk Depots. London.

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.


 TABLE 20.—DISTRIBUTION OF BABIES ALIVE AT 3, 6, AND 9 MONTHS OF AGE BY
 TYPE OF FEEDING AT EACH OF SAID AGES, ACCORDING TO ANNUAL EARNINGS OF
                     FATHER AND NATIVITY OF MOTHER.

 ══════════════╤═════════════════════════════════════════
     ANNUAL    │
  EARNINGS OF  │
   FATHER AND  │         BABIES LIVING AT AGE OF—
  NATIVITY OF  │
    MOTHER.    │
 ──────────────┼────────────────────┬────────────────────
               │     3 months.      │     6 months.
 ──────────────┼──────┬─────────────┼──────┬─────────────
               │      │ Completely  │      │ Completely
               │Total.│ weaned from │Total.│ weaned from
               │      │   breast.   │      │   breast.
 ──────────────┼──────┼───────┬─────┼──────┼───────┬─────
               │      │Number.│ Per │      │Number.│ Per
               │      │       │cent.│      │       │cent.
 ──────────────┼──────┼───────┼─────┼──────┼───────┼─────
     Total     │ 1,355│    193│ 14.2│ 1,313│    250│ 19.0
 ══════════════╪══════╪═══════╪═════╪══════╪═══════╪═════
   Under $624  │   341│     22│  6.5│   322│     32│  9.9
   $625 to $899│   358│     48│ 13.4│   351│     63│ 17.9
   $900 and    │   629│    114│ 18.1│   616│    146│ 23.7
   over[26]    │      │       │     │      │       │
   Not         │    27│      9│ 33.3│    24│      9│ 37.5
   reported[27]│      │       │     │      │       │
               │      │       │     │      │       │
     Mother    │   765│    155│ 20.3│   747│    195│ 26.1
   native      │      │       │     │      │       │
 ──────────────┼──────┼───────┼─────┼──────┼───────┼─────
 Under $624    │    69│     10│ 14.5│    66│     13│ 19.7
 $625 to $899  │   180│     36│ 20.0│   177│     46│ 26.0
 $900 and      │   491│    100│ 20.4│   482│    127│ 26.3
   over[26]    │      │       │     │      │       │
 Not           │    25│      9│ 36.0│    22│      9│ 40.9
   reported[27]│      │       │     │      │       │
               │      │       │     │      │       │
     Mother    │   590│     38│  6.4│   566│     55│  9.7
   foreign     │      │       │     │      │       │
 ──────────────┼──────┼───────┼─────┼──────┼───────┼─────
 Under $624    │   272│     12│  4.4│   256│     19│  7.4
 $625 to $899  │   178│     12│  6.7│   174│     17│  9.8
 $900 and      │   138│     14│ 10.1│   134│     19│ 14.2
   over[26]    │      │       │     │      │       │
 Not           │     2│       │     │     2│       │
   reported[27]│      │       │     │      │       │
 ──────────────┴──────┴───────┴─────┴──────┴───────┴─────

 ══════════════╤════════════════════
     ANNUAL    │
  EARNINGS OF  │
   FATHER AND  │BABIES LIVING AT AGE OF—
  NATIVITY OF  │
    MOTHER.    │
 ──────────────┼────────────────────
               │     9 months.
 ──────────────┼──────┬─────────────
               │      │ Completely
               │Total.│ weaned from
               │      │   breast.
 ──────────────┼──────┼───────┬─────
               │      │Number.│ Per
               │      │       │cent.
 ──────────────┼──────┼───────┼─────
     Total     │ 1,282│    358│ 27.5
 ══════════════╪══════╪═══════╪═════
   Under $624  │   309│     57│ 18.4
   $625 to $899│   342│     85│ 24.9
   $900 and    │   608│    201│ 33.1
   over[26]    │      │       │
   Not         │    23│     10│ 43.3
   reported[27]│      │       │
               │      │       │
     Mother    │   735│    251│ 34.1
   native      │      │       │
 ──────────────┼──────┼───────┼─────
 Under $624    │    65│     18│ 27.7
 $625 to $899  │   173│     55│ 31.8
 $900 and      │   476│    168│ 35.3
   over[26]    │      │       │
 Not           │    21│     10│ 47.6
   reported[27]│      │       │
               │      │       │
     Mother    │   547│    102│ 18.6
   foreign     │      │       │
 ──────────────┼──────┼───────┼─────
 Under $624    │   244│     39│ 16.0
 $625 to $899  │   169│     30│ 17.8
 $900 and      │   132│     33│ 25.0
   over[26]    │      │       │
 Not           │     2│       │
   reported[27]│      │       │
 ──────────────┴──────┴───────┴─────
Footnote 26:

  Includes those reported as earning “ample.” “Ample,” as used in this
  report has a somewhat technical meaning; when information concerning
  the father’s earnings was not available and the family showed no
  evidences of poverty, the word “ample” was used. When, however, the
  family was clearly in a state of abject poverty, it was included in
  the group “Under $521.”

Footnote 27:

  Unmarried mothers’ babies also included.

Breast 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.


 TABLE 25.—DISTRIBUTION OF ALL BIRTHS, LIVE BIRTHS, AND STILLBIRTHS AND
  OF DEATHS DURING FIRST YEAR, AND INFANT MORTALITY RATE, ACCORDING TO
                   SEX OF BABY AND NATIVITY OF MOTHER.

 ═══════════════════════╤═══════╤═══════╤══════════════╤════════════════
     SEX OF BABY AND    │  All  │ Live  │  STILLBIRTHS.│ DEATHS DURING
   NATIVITY OF MOTHER.  │births.│births.│              │  FIRST YEAR.
 ───────────────────────┼───────┼───────┼──────┬───────┼──────┬─────────
                        │       │       │      │ Rate  │      │ Infant
                        │       │       │Total.│  per  │Total.│mortality
                        │       │       │      │ 1,000 │      │  rate.
                        │       │       │      │births.│      │
 ───────────────────────┼───────┼───────┼──────┼───────┼──────┼─────────
    BABIES OF NATIVE    │       │       │      │       │      │
        MOTHERS.        │       │       │      │       │      │
                        │       │       │      │       │      │
      Total number      │    860│    815│    45│   52.3│    85│    104.3
 ═══════════════════════╪═══════╪═══════╪══════╪═══════╪══════╪═════════
 Male:                  │       │       │      │       │      │
     Number             │    433│    406│    27│   62.4│    46│    113.3
     Per cent.          │   50.3│   49.8│  60.0│       │  54.1│
 Female:                │       │       │      │       │      │
     Number             │    427│    409│    18│   42.2│    39│     95.4
     Per cent.          │   49.7│   50.2│  40.0│       │  45.9│
                        │       │       │      │       │      │
    BABIES OF FOREIGN   │       │       │      │       │      │
        MOTHERS.        │       │       │      │       │      │
                        │       │       │      │       │      │
      Total number      │    691│    648│    43│   62.2│   111│    171.3
 ═══════════════════════╪═══════╪═══════╪══════╪═══════╪══════╪═════════
 Male:                  │       │       │      │       │      │
     Number             │    380│    355│    25│   65.8│    59│    166.2
     Per cent.          │   55.0│   54.8│  58.1│       │  53.2│
 Female:                │       │       │      │       │      │
     Number             │    311│    293│    18│   57.9│    52│    177.5
     Per cent.          │   45.0│   45.2│  41.9│       │  46.8│
 ───────────────────────┴───────┴───────┴──────┴───────┴──────┴─────────


         MOTHER’S HOUSEHOLD DUTIES, CESSATION AND RESUMPTION OF

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:


   TABLE 26.—DISTRIBUTION OF BIRTHS ACCORDING TO TIME OF THE MOTHER’S
    RELINQUISHMENT OF PART OF HOUSEHOLD DUTIES BEFORE CONFINEMENT, BY
                           NATIVITY OF MOTHER.

 ════════════════════════════════════════════╤════════╤════════╤════════
 TIME OF RELINQUISHMENT OF PART OF HOUSEHOLD │  All   │   To   │   To
          DUTIES BEFORE CONFINEMENT.         │births. │ native │foreign
                                             │        │mothers.│mothers.
 ────────────────────────────────────────────┼────────┼────────┼────────
                 All mothers                 │   1,551│     860│     691
 ════════════════════════════════════════════╪════════╪════════╪════════
 No household duties relinquished to day of  │   1,350│     695│     655
   confinement                               │        │        │
 Part of duties relinquished:                │        │        │
     Less than 7 days before confinement     │       3│       1│       2
     7 to 13 days before confinement         │       7│       5│       2
     2 weeks to 1 month before confinement   │      16│      12│       4
     1 month or more before confinement      │     174│     146│      28
 Had no household duties                     │       1│       1│
 ────────────────────────────────────────────┴────────┴────────┴────────

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.


  TABLE 27.—DISTRIBUTION OF BIRTHS AND OF DEATHS DURING FIRST YEAR, AND
  INFANT MORTALITY RATE, ACCORDING TO TIME OF RELINQUISHMENT OF PART OF
             HOUSEHOLD DUTIES OF MOTHER BEFORE CONFINEMENT.

 ══════════════════════════════════╤════════╤════════╤════════╤═════════
 TIME OF RELINQUISHMENT OF PART OF │        │        │ Deaths │ Infant
      HOUSEHOLD DUTIES BEFORE      │  All   │  Live  │ during │mortality
            CONFINEMENT.           │births. │births. │ first  │  rate.
                                   │        │        │ year.  │
 ──────────────────────────────────┼────────┼────────┼────────┼─────────
            All mothers            │   1,551│   1,463│     196│    134.0
 ══════════════════════════════════╪════════╪════════╪════════╪═════════
 No cessation or less than 1 month │   1,376│   1,302│     178│    136.7
 1 month or more                   │     171│     160│      18│    112.5
 No housework                      │       1│       1│        │
 ──────────────────────────────────┴────────┴────────┴────────┴─────────

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.


 TABLE 28.—DISTRIBUTION OF LIVE BIRTHS AND OF DEATHS DURING FIRST YEAR,
 AND INFANT MORTALITY RATE, ACCORDING TO TIME OF MOTHER RESUMING PART OF
       HOUSEHOLD DUTIES AFTER CONFINEMENT, BY NATIVITY OF MOTHER.

 ═══════════════════════════╤══════════════════════════╤════════════════
  TIME OF RESUMING PART OF  │                          │ DEATHS DURING
   HOUSEHOLD DUTIES AFTER   │     LIVE BIRTHS TO—      │  FIRST YEAR.
        CONFINEMENT.        │                          │
 ───────────────────────────┼────────┬────────┬────────┼──────┬─────────
                            │  All   │ Native │Foreign │      │ Infant
                            │mothers.│mothers.│mothers.│Total.│mortality
                            │        │        │        │      │  rate.
 ───────────────────────────┼────────┼────────┼────────┼──────┼─────────
            Total           │   1,463│     815│     648│   196│    134.0
 ═══════════════════════════╪════════╪════════╪════════╪══════╪═════════
 8 days or less             │     467│      44│     423│    79│    169.2
 9 to 13 days               │     560│     446│     114│    70│    125.0
 14 days or more            │     427│     318│     109│    41│     96.0
 Mother died or not reported│       9│       7│       2│     6│ ([28])
 ───────────────────────────┴────────┴────────┴────────┴──────┴─────────

Footnote 28:

  Total number of live births less than 50; base therefore considered
  too small to use in computing an infant mortality rate.

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 cares 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.


 TABLE 29.—DISTRIBUTION OF LIVE BIRTHS AND OF DEATHS DURING FIRST YEAR,
   AND INFANT MORTALITY RATE, ACCORDING TO TIME OF MOTHER RESUMING ALL
       HOUSEHOLD DUTIES AFTER CONFINEMENT, BY NATIVITY OF MOTHER.

 ═══════════════════════════╤══════════════════════════╤════════════════
    TIME OF RESUMING ALL    │                          │ DEATHS DURING
   HOUSEHOLD DUTIES AFTER   │     LIVE BIRTHS TO—      │  FIRST YEAR.
        CONFINEMENT.        │                          │
 ───────────────────────────┼────────┬────────┬────────┼──────┬─────────
                            │  All   │ Native │Foreign │      │ Infant
                            │mothers.│mothers.│mothers.│Total.│mortality
                            │        │        │        │      │  rate.
 ───────────────────────────┼────────┼────────┼────────┼──────┼─────────
            Total           │   1,463│     815│     648│   196│    134.0
 ═══════════════════════════╪════════╪════════╪════════╪══════╪═════════
 8 days or less             │     219│      13│     206│    37│    168.9
 9 to 13 days               │     182│     132│      50│    30│    164.8
 14 days or more            │   1,053│     663│     390│   123│    116.8
 Mother died or not reported│       9│       7│       2│     6│ ([29])
 ───────────────────────────┴────────┴────────┴────────┴──────┴─────────

Footnote 29:

  Total live births less than 50; base therefore considered too small to
  use in computing an infant mortality rate.

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.


                            ECONOMIC FACTORS


                           EARNINGS OF FATHER

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 consecutive groups are combined an
invariable lowering of the infant mortality rate from one such combined
group to that next higher results.

Footnote 30:

  “Ample” as used in this report has a somewhat arbitrary meaning. When
  information concerning the father’s earnings was not available and the
  family showed no evidences of actual poverty, the word “ample” was
  used. If no information concerning earnings was available when, on the
  other hand, the family was clearly in a state of abject poverty, then
  the income was tabulated as “Under $521.”


 TABLE 30.—DISTRIBUTION OF LIVE BIRTHS AND OF DEATHS DURING FIRST YEAR,
  AND INFANT MORTALITY RATE, ACCORDING TO ANNUAL EARNINGS OF FATHER AND
          NATIVITY OF MOTHER, FOR LEGITIMATE LIVE-BORN BABIES.

 ═════════════════════════════════════════╤═════════╤═════════╤═════════
                                          │  Total  │ Deaths  │ Infant
  ANNUAL EARNINGS OF FATHER ACCORDING TO  │  live   │ during  │mortality
             NATIVITY OF WIFE.            │ births. │  first  │  rate.
                                          │         │  year.  │
 ─────────────────────────────────────────┼─────────┼─────────┼─────────
                   Total                  │    1,431│      187│    130.7
 ═════════════════════════════════════════╪═════════╪═════════╪═════════
   Under $625                             │      384│       82│    213.5
 ─────────────────────────────────────────┼─────────┼─────────┼─────────
     Under $521                           │      219│       56│    255.7
     $521 to $624                         │      165│       26│    157.6
                                          │         │         │
   $625 to $899                           │      385│       47│    122.1
 ─────────────────────────────────────────┼─────────┼─────────┼─────────
     $625 to $779                         │      224│       24│    107.1
     $780 to $899                         │      161│       23│    142.9
                                          │         │         │
   $900 or more                           │      186│       18│     96.8
 ─────────────────────────────────────────┼─────────┼─────────┼─────────
     $900 to $1,199                       │      138│       14│    101.4
     $1,200 or more                       │       48│        4│     83.3
                                          │         │         │
   Ample[1]                               │      476│       40│     84.0
                                          │         │         │
     Husbands with native wives           │      785│       76│     96.8
 ═════════════════════════════════════════╪═════════╪═════════╪═════════
 Under $625                               │       80│       16│    200.0
 ─────────────────────────────────────────┼─────────┼─────────┼─────────
   Under $521                             │       32│        9│ ([31])
   $521 to $624                           │       48│        7│    145.8
                                          │         │         │
 $625 to $899                             │      193│       20│    103.6
 ─────────────────────────────────────────┼─────────┼─────────┼─────────
   $625 to $779                           │       86│        6│     69.8
   $780 to $899                           │      107│       14│    130.8
                                          │         │         │
 $900 or more                             │      129│       10│     77.5
 ─────────────────────────────────────────┼─────────┼─────────┼─────────
   $900 to $1,199                         │       92│        7│     76.1
   $1,200 of more                         │       37│        3│ ([31])
                                          │         │         │
 Ample[1]                                 │      383│       30│     78.3
                                          │         │         │
     Husbands with foreign wives          │      646│      111│    171.8
 ═════════════════════════════════════════╪═════════╪═════════╪═════════
 Under $625                               │      304│       66│    217.1
 ─────────────────────────────────────────┼─────────┼─────────┼─────────
   Under $521                             │      187│       47│    251.3
   $521 to $624                           │      117│       19│    162.4
                                          │         │         │
 $625 to $899                             │      192│       27│    140.6
 ─────────────────────────────────────────┼─────────┼─────────┼─────────
   $625 to $779                           │      138│       18│    130.4
   $780 to $899                           │       54│        9│    166.7
                                          │         │         │
 $900 or more                             │       57│        8│    140.6
 ─────────────────────────────────────────┼─────────┼─────────┼─────────
   $900 to $1,199                         │       46│        7│    152.2
   $1,200 or more                         │       11│        1│ ([31])
                                          │         │         │
 Ample[32]                                │       93│       10│    107.5
 ─────────────────────────────────────────┴─────────┴─────────┴─────────

Footnote 31:

  Total live births less than 50; base therefore considered too small to
  use in computing an infant mortality rate.

Footnote 32:

  See note on page 45.

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.

The 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.


 TABLE 31.—NUMBER AND PER CENT OF MOTHERS BY NATIVITY, ACCORDING TO THE
                       ANNUAL EARNINGS OF HUSBAND.

 ═════════════════╤═════════════════╤═════════════════╤═════════════════
 ANNUAL EARNING OF│  ALL MOTHERS.   │ NATIVE MOTHERS. │FOREIGN MOTHERS.
     HUSBAND.     │                 │                 │
 ─────────────────┼────────┬────────┼────────┬────────┼────────┬────────
                  │Number. │  Per   │Number. │  Per   │Number. │  Per
                  │        │ cent.  │        │ cent.  │        │ cent.
 ─────────────────┼────────┼────────┼────────┼────────┼────────┼────────
       Total      │   1,491│   100.0│     816│   100.0│     675│   100.0
 ═════════════════╪════════╪════════╪════════╪════════╪════════╪════════
 Under $521       │     233│    15.6│      36│     4.4│     197│    29.2
 $521 to $624     │     174│    11.7│      50│     6.1│     124│    18.4
 $625 to $779     │     229│    15.4│      86│    10.5│     143│    21.2
 $780 to $899     │     166│    11.1│     108│    13.2│      58│     8.6
 $900 to $1,199   │     146│     9.8│      98│    12.0│      48│     7.1
 $1,200 and over  │      50│     3.4│      39│     4.8│      11│     1.6
 Ample[33]        │     493│    33.1│     399│    48.9│      94│    13.9
 ─────────────────┴────────┴────────┴────────┴────────┴────────┴────────

Footnote 33:

  See note on page 45.

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.


                         GAINFUL WORK OF MOTHER

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. of 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.


 TABLE 32.—NUMBER AND PER CENT OF HUSBANDS WITH WAGE-EARNING WIVES, BY
            NATIVITY OF WIFE AND ANNUAL EARNINGS OF HUSBAND.

 ═══════════════╤══════════════════════════╤══════════════════════════
                │     TOTAL HUSBANDS.      │  HUSBANDS HAVING NATIVE
                │                          │          WIVES.
 ───────────────┼────────┬─────────────────┼────────┬─────────────────
 ANNUAL EARNINGS│        │  Husbands with  │        │  Husbands with
   OF HUSBAND.  │Number. │  wage-earning   │Number. │  wage-earning
                │        │     wives.      │        │     wives.
 ───────────────┼────────┼────────┬────────┼────────┼────────┬────────
                │        │Number. │  Per   │        │Number. │  Per
                │        │        │ cent.  │        │        │ cent.
 ───────────────┼────────┼────────┼────────┼────────┼────────┼────────
      Total     │   1,491│     278│    18.6│     816│      26│     3.2
 ═══════════════╪════════╪════════╪════════╪════════╪════════╪════════
 Under $521     │     233│     111│    47.6│      36│       9│    25.0
 $521 to $624   │     174│      57│    32.8│      50│       3│     6.0
 $625 to $779   │     229│      51│    22.3│      86│       4│     4.7
 $780 to $899   │     166│      25│    15.1│     108│       6│     5.6
 $900 to $1,199 │     146│      13│     8.9│      98│       1│     1.0
 $1,200 and over│      50│       1│     2.0│      39│        │
 “Ample”[34]    │     493│      20│     4.1│     399│       3│      .8
 ───────────────┴────────┴────────┴────────┴────────┴────────┴────────

 ═══════════════╤══════════════════════════
                │ HUSBANDS HAVING FOREIGN
                │          WIVES.
 ───────────────┼────────┬─────────────────
 ANNUAL EARNINGS│        │  Husbands with
   OF HUSBAND.  │Number. │  wage-earning
                │        │     wives.
 ───────────────┼────────┼────────┬────────
                │        │Number. │  Per
                │        │        │ cent.
 ───────────────┼────────┼────────┼────────
      Total     │     675│     252│    37.3
 ═══════════════╪════════╪════════╪════════
 Under $521     │     197│     102│    51.8
 $521 to $624   │     124│      54│    43.5
 $625 to $779   │     143│      47│    32.9
 $780 to $899   │      58│      19│    32.8
 $900 to $1,199 │      48│      12│    25.0
 $1,200 and over│      11│       1│     9.1
 “Ample”[34]    │      94│      17│    18.1
 ───────────────┴────────┴────────┴────────
Footnote 34:

  See note on page 45.

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 among 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.


 TABLE 33.—DISTRIBUTION OF LIVE BIRTHS AND OF DEATHS DURING FIRST YEAR,
        AND INFANT MORTALITY RATE FOR BABIES OF WAGE-EARNING AND
    NONWAGE-EARNING MOTHERS, ACCORDING TO ANNUAL EARNINGS OF FATHER.

 ═════════════════╤═════════════════╤═════════════════╤═════════════════
  ANNUAL EARNINGS │  MOTHER A WAGE  │MOTHER NOT A WAGE│INFANT MORTALITY
    OF FATHER.    │     EARNER.     │     EARNER.     │      RATE.
 ─────────────────┼────────┬────────┼────────┬────────┼────────┬────────
                  │        │ Number │        │ Number │        │ Mother
                  │  Live  │   of   │  Live  │   of   │Mother a│ not a
                  │births. │ deaths │births. │ deaths │  wage  │  wage
                  │        │in first│        │in first│earner. │earner.
                  │        │ year.  │        │ year.  │        │
 ─────────────────┼────────┼────────┼────────┼────────┼────────┼────────
       Total      │     266│      50│   1,165│     137│   188.0│   117.6
 ═════════════════╪════════╪════════╪════════╪════════╪════════╪════════
 Under $521       │     105│      26│     114│      30│   247.6│   263.2
 $521 to $624     │      53│       8│     112│      18│   150.9│   160.7
 $625 to $779     │      48│       6│     176│      18│   127.1│   102.3
 $780 or over, or │      60│      10│     763│      71│   166.7│    93.1
   “ample”[35]    │        │        │        │        │        │
 ─────────────────┴────────┴────────┴────────┴────────┴────────┴────────

Footnote 35:

  See note on page 45.


                              ILLEGITIMACY

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.


  TABLE 34.—DISTRIBUTION OF BIRTHS AND OF DEATHS DURING FIRST YEAR, AND
             INFANT MORTALITY RATE, ACCORDING TO LEGITIMACY.

 ════════════════════════╤═════════╤═════════╤══════════════════════════
       LEGITIMACY.       │  Total  │  Live   │DEATHS DURING FIRST YEAR.
                         │ births. │ births. │
 ────────────────────────┼─────────┼─────────┼─────────┬────────────────
                         │         │         │ Number. │Infant mortality
                         │         │         │         │     rates.
 ────────────────────────┼─────────┼─────────┼─────────┼────────────────
 Illegitimate            │       34│       32│        9│           281.3
 Legitimate              │    1,517│    1,431│      187│           130.7
 ────────────────────────┴─────────┴─────────┴─────────┴────────────────

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.


                         REPRODUCTIVE HISTORIES

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.

Footnote 36:

  “Reportable” pregnancies are those terminating either in the birth of
  a live child or of a dead child when the period of gestation exceeds
  28 weeks; that is, when its registration or report is required by law.

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.


 TABLE 35.—DISTRIBUTION OF MOTHERS, OF LIVE BIRTHS, AND OF DEATHS DURING
 FIRST YEAR, AND INFANT MORTALITY RATE FOR BABIES OF NATIVE AND FOREIGN
   MARRIED MOTHERS, ACCORDING TO THE NUMBER OF REPORTABLE PREGNANCIES.

 ═════════════════╤════════╤═════════════════╤══════════════════════════
    REPORTABLE    │ Number │                 │
  PREGNANCIES FOR │   of   │NUMBER OF BABIES.│  INFANT MORTALITY RATE
 MARRIED MOTHERS. │married │                 │     AMONG BABIES OF—
                  │mothers.│                 │
 ─────────────────┼────────┼────────┬────────┼────────┬────────┬────────
                  │        │  Born  │Died in │  All   │ Native │Foreign
                  │        │ alive. │ first  │mothers.│mothers.│mothers.
                  │        │        │ year.  │        │        │
 ─────────────────┼────────┼────────┼────────┼────────┼────────┼────────
       Total      │   1,491│   5,363│     804│   149.9│   113.1│   184.6
 ═════════════════╪════════╪════════╪════════╪════════╪════════╪════════
 1                │     339│     322│      35│   108.7│    75.9│   183.7
 2                │     283│     544│      59│   108.5│    76.5│   156.7
 3                │     214│     626│      92│   147.0│   118.0│   177.6
 4                │     186│     723│      78│   107.9│    99.4│   116.3
 5                │     147│     704│     103│   146.3│    86.1│   191.5
 6                │      94│     546│      88│   161.2│   157.4│   163.6
 7                │      83│     555│      78│   140.5│   100.0│   173.8
 8                │      54│     426│      95│   223.0│   157.6│   272.7
 9                │      33│     283│      41│   144.9│   128.4│   155.2
 10  or more      │      58│     634│     135│   212.9│   164.5│   257.6
 ─────────────────┴────────┴────────┴────────┴────────┴────────┴────────

The statistics, based upon 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. This is more clearly shown when the
pregnancies are grouped as in the next table.


    TABLE 36.—INFANT MORTALITY RATE FOR ALL CHILDREN BORNE BY MARRIED
    MOTHERS, ACCORDING TO SPECIFIED NUMBER OF REPORTABLE PREGNANCIES.

 ════════════════════════════════════════════════╤══════════════════════
   REPORTABLE PREGNANCIES FOR MARRIED MOTHERS.   │Infant mortality rate.
 ────────────────────────────────────────────────┼──────────────────────
                      Total                      │                 149.9
 ════════════════════════════════════════════════╪══════════════════════
 1 and 2                                         │                 108.5
 3 and 4                                         │                 126.0
 5 and 6                                         │                 152.8
 7 and 8                                         │                 176.4
 9 or more                                       │                 191.9
 ────────────────────────────────────────────────┴──────────────────────

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.


    TABLE 37.—INFANT MORTALITY RATE FOR ALL CHILDREN BORNE BY MARRIED
  MOTHERS, ACCORDING TO SPECIFIED NUMBER OF REPORTABLE PREGNANCIES, BY
                                 GROUPS

 ════════════════════════════════════════════════╤══════════════════════
   REPORTABLE PREGNANCIES FOR MARRIED MOTHERS.   │Infant mortality rate.
 ────────────────────────────────────────────────┼──────────────────────
                                                 │
                     GROUP 1.                    │
                                                 │
 2 or less                                       │                 108.5
 3 or less                                       │                 124.7
 4 or less                                       │                 119.2
                                                 │
                     GROUP 2.                    │
                                                 │
 Over 4                                          │                 171.5
 Over 5                                          │                 178.8
 Over 6                                          │                 183.9
 ────────────────────────────────────────────────┴──────────────────────

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.


    TABLE 38.—INFANT MORTALITY RATE FOR ALL CHILDREN BORNE BY MARRIED
       MOTHERS, ACCORDING TO THE ORDER IN WHICH THE CHILD WAS BORN

 ════════════════════════════════════════════════╤══════════════════════
                 ORDER OF BIRTH.                 │Infant mortality rate.
 ────────────────────────────────────────────────┼──────────────────────
 First-born child                                │                 143.6
 Second-born child                               │                 131.2
 ────────────────────────────────────────────────┼──────────────────────
     First and second born children              │                 138.3
 ════════════════════════════════════════════════╪══════════════════════
 Third-born child                                │                 144.2
 Fourth-born child                               │                 142.0
 ────────────────────────────────────────────────┼──────────────────────
     Third and fourth born children              │                 143.2
 ════════════════════════════════════════════════╪══════════════════════
 Fifth-born child                                │                 178.1
 Sixth-born child                                │                 175.5
 ────────────────────────────────────────────────┼──────────────────────
     Fifth and sixth born children               │                 177.0
 ════════════════════════════════════════════════╪══════════════════════
 Seventh-born child                              │                 192.1
 Eighth-born child                               │                 165.4
 ────────────────────────────────────────────────┼──────────────────────
     Seventh and eighth born children.           │                 181.5
 ════════════════════════════════════════════════╪══════════════════════
 Ninth-born child                                │                 128.2
 Tenth or later born child                       │                 252.3
 ────────────────────────────────────────────────┼──────────────────────
     Ninth and later born children               │                 201.1
 ────────────────────────────────────────────────┴──────────────────────

The 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.


  TABLE 39.—LOWEST AND HIGHEST INFANT MORTALITY RATES, ACCORDING TO AGE
   OF MOTHER AT BIRTH OF CHILD AND THE ORDER IN WHICH CHILD WAS BORN.

 ═══════════════════════╤═══════════════════════════════════════════════
     ORDER OF BIRTH.    │ INFANT MORTALITY RATES, ACCORDING TO MOTHER’S
                        │                     AGE.
 ───────────────────────┼───────────────────────┬───────────────────────
                        │   Lowest mortality.   │  Highest mortality.
 ───────────────────────┼───────────┬───────────┼───────────┬───────────
                        │ Mother’s  │ Mortality │ Mother’s  │ Mortality
                        │   age.    │   rate.   │   age.    │   rate.
 ───────────────────────┼───────────┼───────────┼───────────┼───────────
      All children      │      20–24│      140.0│   Under 17│      367.3
 ═══════════════════════╪═══════════╪═══════════╪═══════════╪═══════════
 First child            │      25–29│       92.1│      17–19│      190.4
 Second child           │      25–29│      100.3│      17–19│      178.6
 Third child            │      30–39│      106.4│      25–29│      160.8
 Fourth child           │      30–39│      122.4│      20–24│      155.0
 Fifth child            │      30–39│      105.8│      25–29│      236.6
 Sixth child            │      30–39│      164.8│      25–29│      171.4
 ───────────────────────┴───────────┴───────────┴───────────┴───────────

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.


   TABLE 40.—TOTAL AND AVERAGE NUMBER OF LIVE-BORN CHILDREN BORNE BY
  MARRIED MOTHERS HAVING EITHER A LIVE BIRTH OR A STILLBIRTH IN 1911,
               CLASSIFIED BY NATIVITY AND AGE OF MOTHER.

 ══════════════════╤══════════════════════════╤══════════════════════════
                   │   ALL MARRIED MOTHERS.   │ NATIVE MARRIED MOTHERS.
 ──────────────────┼────────┬─────────────────┼────────┬─────────────────
  AGE OF MOTHER AT │        │    Live-born    │        │    Live-born
 BIRTH OF CHILD IN │ Total. │    children.    │ Total. │    children.
       1911.       │        │                 │        │
 ──────────────────┼────────┼────────┬────────┼────────┼────────┬────────
                   │        │Number. │Average.│        │Number. │Average.
 ──────────────────┼────────┼────────┼────────┼────────┼────────┼────────
      All ages     │   1,465│   5,363│     3.7│     801│   2,600│     3.2
 ══════════════════╪════════╪════════╪════════╪════════╪════════╪════════
 Under 20 years    │      81│      96│     1.2│      62│      70│     1.1
 20 to 24 years    │     456│     908│     2.0│     258│     483│     1.9
 25 to 29 years    │     389│   1,261│     3.2│     196│     536│     2.7
 30 to 39 years    │     459│   2,480│     5.4│     240│   1,188│     5.0
 40 years and over.│      80│     618│     7.7│      45│     323│     7.2
 ──────────────────┴────────┴────────┴────────┴────────┴────────┴────────

 ══════════════════╤══════════════════════════
                   │ FOREIGN MARRIED MOTHERS.
 ──────────────────┼────────┬─────────────────
  AGE OF MOTHER AT │        │    Live-born
 BIRTH OF CHILD IN │ Total. │    children.
       1911.       │        │
 ──────────────────┼────────┼────────┬────────
                   │        │Number. │Average.
 ──────────────────┼────────┼────────┼────────
      All ages     │     664│   2,763│     4.2
 ══════════════════╪════════╪════════╪════════
 Under 20 years    │      19│      26│     1.4
 20 to 24 years    │     198│     425│     2.1
 25 to 29 years    │     193│     725│     3.8
 30 to 39 years    │     219│   1,292│     5.9
 40 years and over.│      35│     295│     8.4
 ──────────────────┴────────┴────────┴────────

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,” as here used, means the sum of infant deaths (or deaths
in first year) and stillbirths.


   TABLE 41.—AGGREGATE NUMBER OF BIRTHS, LOSSES, AND RATE OF LOSS PER
         1,000 BIRTHS, ACCORDING TO NUMBER OF BIRTHS PER MOTHER.

 ══════════════════════════╤══════════════╤══════════════╤══════════════
    NUMBER OF BIRTHS PER   │  Aggregate   │  Aggregate   │ Rate of loss
          MOTHER.          │  number of   │  number of   │  per 1,000
                           │   births.    │   losses.    │   births.
 ──────────────────────────┼──────────────┼──────────────┼──────────────
           Total           │         5,617│         1,058│         188.4
 ══════════════════════════╪══════════════╪══════════════╪══════════════
 1                         │           335│            53│         158.6
 2                         │           554│            87│         157.0
 3                         │           648│           113│         174.4
 4                         │           748│           109│         145.7
 5                         │           740│           133│         179.7
 6                         │           576│           119│         206.6
 7                         │           574│           104│         181.2
 8                         │           432│           102│         236.1
 9                         │           324│            65│         200.6
 10 or more                │           686│           173│         252.2
 ──────────────────────────┴──────────────┴──────────────┴──────────────

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:


   TABLE 42.—INFANT MORTALITY RATE FOR ALL CHILDREN OF MARRIED MOTHERS
  INCLUDED IN THIS INVESTIGATION, DISTRIBUTED ACCORDING TO THE FATHER’S
                                EARNINGS.

 ══════════════════════════════════════════╤════════════════════════════
         FATHER’S ANNUAL EARNINGS.         │   Infant mortality rate.
 ──────────────────────────────────────────┼────────────────────────────
 Under $521                                │                       197.3
 $521 to $624                              │                       193.1
 $625 to $779                              │                       163.1
 $780 to $899                              │                       168.4
 $900 to $1,199                            │                       142.2
 $1,200 and over                           │                       102.2
 ──────────────────────────────────────────┴────────────────────────────

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.


 TABLE V.—DISTRIBUTION OF LIVE BIRTHS AND OF DEATHS DURING FIRST YEAR,
     ACCORDING TO NUMBER OF PERSONS AND NUMBER OF ROOMS PER FAMILY.

 ═════════════════╤═════════════════════════════════════
                  │NUMBER OF BABIES WHO WERE BORN ALIVE
                  │AND NUMBER OF SUCH BABIES WHO DIED
                  │DURING FIRST YEAR IN HOMES HAVING—
 ─────────────────┼───────┬─────┬─────┬─────┬─────┬─────
    PERSONS PER   │  All  │     │     │     │     │
    FAMILY (NOT   │ live  │  1  │  2  │  3  │  4  │  5
 INCLUDING BABY). │ born  │room │rooms│rooms│rooms│rooms
                  │babies.│     │     │     │     │
 ─────────────────┼───────┼─────┼─────┼─────┼─────┼─────
           {Births│  1,463│   33│  165│  147│  526│  222
   Total   {Deaths│    196│    3│   29│   24│   79│   20
 ═════════════════╪═══════╪═════╪═════╪═════╪═════╪═════
           {Births│     24│    3│    7│    4│    6│    2
 2         {Deaths│     19│    1│    5│    4│    6│    1
                  │       │     │     │     │     │
           {Births│    275│   14│   46│   35│   96│   29
 3         {Deaths│     31│     │    5│    4│   12│    2
                  │       │     │     │     │     │
           {Births│    234│    7│   44│   20│   83│   40
 4         {Deaths│     30│    1│   12│    5│    9│    2
                  │       │     │     │     │     │
           {Births│    229│     │   27│   24│   88│   31
 5         {Deaths│     22│     │    1│    6│    9│    1
                  │       │     │     │     │     │
           {Births│    182│    2│   21│   17│   56│   37
 6         {Deaths│     18│     │    4│     │    8│    2
                  │       │     │     │     │     │
           {Births│    164│    2│   10│   20│   50│   32
 7         {Deaths│     15│     │    1│    2│    6│    1
                  │       │     │     │     │     │
           {Births│    107│    2│    5│   14│   37│   16
 8         {Deaths│     17│     │     │    2│    6│    3
                  │       │     │     │     │     │
           {Births│     79│    2│    2│    6│   27│   13
 9         {Deaths│      8│    1│     │     │    2│    2
                  │       │     │     │     │     │
           {Births│     58│    1│    1│    2│   26│    7
 10        {Deaths│     15│     │     │    1│   11│    2
                  │       │     │     │     │     │
           {Births│     36│     │    1│    1│   16│    3
 11        {Deaths│      4│     │    1│     │    1│    1
                  │       │     │     │     │     │
           {Births│     21│     │    1│    1│   10│    2
 12        {Deaths│      5│     │     │     │    2│    1
                  │       │     │     │     │     │
           {Births│     20│     │     │    1│   13│    4
 13        {Deaths│      4│     │     │     │    3│    1
                  │       │     │     │     │     │
           {Births│      8│     │     │    1│    5│    2
 14        {Deaths│      2│     │     │     │    1│    1
                  │       │     │     │     │     │
           {Births│      6│     │     │     │    3│    2
 15        {Deaths│      1│     │     │     │     │
                  │       │     │     │     │     │
           {Births│      4│     │     │     │    4│
 16        {Deaths│      2│     │     │     │    2│
                  │       │     │     │     │     │
           {Births│      3│     │     │     │    1│
 17        {Deaths│       │     │     │     │     │
                  │       │     │     │     │     │
           {Births│      5│     │     │    1│    1│
 18        {Deaths│      1│     │     │     │    1│
                  │       │     │     │     │     │
           {Births│      2│     │     │     │    2│
 19        {Deaths│       │     │     │     │     │
                  │       │     │     │     │     │
           {Births│      3│     │     │     │    1│    1
 20        {Deaths│      1│     │     │     │     │
                  │       │     │     │     │     │
           {Births│      1│     │     │     │     │
 22        {Deaths│      1│     │     │     │     │
                  │       │     │     │     │     │
           {Births│      1│     │     │     │    1│
 23        {Deaths│       │     │     │     │     │
                  │       │     │     │     │     │
 Not       {Births│      1│     │     │     │     │    1
 reported. {Deaths│       │     │     │     │     │
 ─────────────────┴───────┴─────┴─────┴─────┴─────┴─────

 ═════════════════╤═════════════════════════════════════
                  │NUMBER OF BABIES WHO WERE BORN ALIVE
                  │AND NUMBER OF SUCH BABIES WHO DIED
                  │DURING FIRST YEAR IN HOMES HAVING—
 ─────────────────┼─────┬─────┬─────┬─────┬─────┬───────
    PERSONS PER   │     │     │     │     │ 10  │Unknown
    FAMILY (NOT   │  6  │  7  │  8  │  9  │rooms│number
 INCLUDING BABY). │rooms│rooms│rooms│rooms│ and │  of
                  │     │     │     │     │over.│rooms.
 ─────────────────┼─────┼─────┼─────┼─────┼─────┼───────
           {Births│  233│   38│   43│   22│   12│     22
   Total   {Deaths│   20│    6│    6│    4│    2│      3
 ═════════════════╪═════╪═════╪═════╪═════╪═════╪═══════
           {Births│     │     │     │     │     │      2
 2         {Deaths│     │     │     │     │     │      2
                  │     │     │     │     │     │
           {Births│   37│    4│    6│    1│     │      7
 3         {Deaths│    3│    3│    2│     │     │
                  │     │     │     │     │     │
           {Births│   23│    4│    5│    2│    2│      4
 4         {Deaths│     │     │     │     │    1│
                  │     │     │     │     │     │
           {Births│   43│    4│    5│    1│    1│      5
 5         {Deaths│    4│     │    1│     │     │
                  │     │     │     │     │     │
           {Births│   34│    5│    7│    2│     │      1
 6         {Deaths│    3│     │    1│     │     │
                  │     │     │     │     │     │
           {Births│   30│    9│    6│    3│    1│      1
 7         {Deaths│    3│    1│     │    1│     │
                  │     │     │     │     │     │
           {Births│   18│    4│    6│    2│    3│
 8         {Deaths│    1│    2│    1│    1│    1│
                  │     │     │     │     │     │
           {Births│   13│    6│    2│    4│    4│
 9         {Deaths│    1│     │     │    2│     │
                  │     │     │     │     │     │
           {Births│   15│    1│    1│    3│     │      1
 10        {Deaths│    1│     │     │     │     │
                  │     │     │     │     │     │
           {Births│   10│     │    3│    2│     │
 11        {Deaths│    1│     │     │     │     │
                  │     │     │     │     │     │
           {Births│    6│     │    1│     │     │
 12        {Deaths│    1│     │    1│     │     │
                  │     │     │     │     │     │
           {Births│     │     │    1│    1│     │
 13        {Deaths│     │     │     │     │     │
                  │     │     │     │     │     │
           {Births│     │     │     │     │     │
 14        {Deaths│     │     │     │     │     │
                  │     │     │     │     │     │
           {Births│     │     │     │     │     │      1
 15        {Deaths│     │     │     │     │     │      1
                  │     │     │     │     │     │
           {Births│     │     │     │     │     │
 16        {Deaths│     │     │     │     │     │
                  │     │     │     │     │     │
           {Births│    1│     │    1│     │     │
 17        {Deaths│     │     │     │     │     │
                  │     │     │     │     │     │
           {Births│    1│    1│     │    1│     │
 18        {Deaths│     │     │     │     │     │
                  │     │     │     │     │     │
           {Births│     │     │     │     │     │
 19        {Deaths│     │     │     │     │     │
                  │     │     │     │     │     │
           {Births│    1│     │     │     │     │
 20        {Deaths│    1│     │     │     │     │
                  │     │     │     │     │     │
           {Births│    1│     │     │     │     │
 22        {Deaths│    1│     │     │     │     │
                  │     │     │     │     │     │
           {Births│     │     │     │     │     │
 23        {Deaths│     │     │     │     │     │
                  │     │     │     │     │     │
 Not       {Births│     │     │     │     │     │
 reported. {Deaths│     │     │     │     │     │
 ─────────────────┴─────┴─────┴─────┴─────┴─────┴───────


    TABLE VIII.—DISTRIBUTION OF DEATHS OF INFANTS AT SPECIFIED AGE,
     ACCORDING TO CAUSE OF DEATH OF INFANT AND NATIVITY OF MOTHER.

 ═══════════════╤══════╤═════════════════════════════════════════
                │      │               AGE AT DEATH.
 ───────────────┼──────┼───────────────────────────┬─────────────
                │Total │                           │
 CAUSE OF DEATH │deaths│                           │  1 week but
  OF INFANT AND │under │     Less than 1 week.     │ less than 1
   NATIVITY OF  │1 year│                           │    month.
     MOTHER.    │  of  │                           │
                │ age. │                           │
 ───────────────┼──────┼──────┬──────┬──────┬──────┼──────┬──────
                │      │      │      │      │      │      │1 week
                │      │      │1 day │      │      │      │ but
                │      │Total.│  or  │  2   │3 to 6│Total.│ less
                │      │      │less. │days. │days. │      │ than
                │      │      │      │      │      │      │  2.
                │      │      │      │      │      │      │
 ───────────────┼──────┼──────┼──────┼──────┼──────┼──────┼──────
   All causes   │   196│    45│    30│     4│    11│    29│    14
 ═══════════════╪══════╪══════╪══════╪══════╪══════╪══════╪══════
 Native mothers │    85│    25│    18│     3│     4│     9│     2
 Foreign mothers│   111│    20│    12│     1│     7│    20│    12
                │      │      │      │      │      │      │
   Diarrhea and │    52│     1│      │      │     1│     5│
   enteritis    │      │      │      │      │      │      │
 ───────────────┼──────┼──────┼──────┼──────┼──────┼──────┼──────
 Native mothers │    17│     1│      │      │     1│      │
 Foreign mothers│    35│      │      │      │      │     5│
                │      │      │      │      │      │      │
   Respiratory  │    50│      │      │      │      │     3│     3
   diseases     │      │      │      │      │      │      │
 ───────────────┼──────┼──────┼──────┼──────┼──────┼──────┼──────
 Native mothers │    19│      │      │      │      │      │
 Foreign mothers│    31│      │      │      │      │     3│     3
                │      │      │      │      │      │      │
   Premature    │    24│    21│    19│      │     2│     3│     3
   births       │      │      │      │      │      │      │
 ───────────────┼──────┼──────┼──────┼──────┼──────┼──────┼──────
 Native mothers │    11│    11│    11│      │      │      │
 Foreign mothers│    13│    10│     8│      │     2│     3│     3
                │      │      │      │      │      │      │
   Congenital   │      │      │      │      │      │      │
   debility or  │    19│    10│     7│     1│     2│     6│     2
   malformation │      │      │      │      │      │      │
 ───────────────┼──────┼──────┼──────┼──────┼──────┼──────┼──────
 Native mothers │     5│     4│     3│      │     1│     1│
 Foreign mothers│    14│     6│     4│     1│     1│     5│     2
                │      │      │      │      │      │      │
   Injuries at  │     7│     7│     3│     2│     2│      │
   birth        │      │      │      │      │      │      │
 ───────────────┼──────┼──────┼──────┼──────┼──────┼──────┼──────
 Native mothers │     6│     6│     3│     2│     1│      │
 Foreign mothers│     1│     1│      │      │     1│      │
                │      │      │      │      │      │      │
   Other or not │    44│     6│     1│     1│     4│    12│     6
   reported     │      │      │      │      │      │      │
 ───────────────┼──────┼──────┼──────┼──────┼──────┼──────┼──────
 Native mothers │    27│     3│     1│     1│     1│     8│     2
 Foreign mothers│    17│     3│      │      │     3│     4│     4
 ───────────────┴──────┴──────┴──────┴──────┴──────┴──────┴──────

 ═══════════════╤═══════════════════════════════════════════════════════
                │                     AGE AT DEATH.
 ───────────────┼─────────────┬─────────────────────────────────────────
 CAUSE OF DEATH │3 weeks but  │
  OF INFANT AND │less than 1  │      1 week but less than 1 month.
   NATIVITY OF  │month.       │
     MOTHER.    │             │
 ───────────────┼──────┬──────┼──────┬──────┬──────┬──────┬──────┬──────
                │  2   │  3   │      │  1   │  2   │  3   │  6   │
                │weeks │weeks │      │month │months│months│months│  9
                │ but  │ but  │Total.│ but  │ but  │ but  │ but  │months
                │ less │ less │      │ less │ less │ less │ less │ and
                │ than │than 1│      │ than │ than │ than │ than │over.
                │  3.  │month.│      │  2.  │  3.  │  6.  │  9.  │
 ───────────────┼──────┼──────┼──────┼──────┼──────┼──────┼──────┼──────
   All causes   │     7│     8│   122│    18│    16│    42│    31│    15
 ═══════════════╪══════╪══════╪══════╪══════╪══════╪══════╪══════╪══════
 Native mothers │     1│     6│    51│     9│     7│    18│    12│     5
 Foreign mothers│     6│     2│    71│     9│     9│    24│    19│    10
                │      │      │      │      │      │      │      │
   Diarrhea and │     3│     2│    46│     5│     4│    17│    15│     5
   enteritis    │      │      │      │      │      │      │      │
 ───────────────┼──────┼──────┼──────┼──────┼──────┼──────┼──────┼──────
 Native mothers │      │      │    16│     3│     1│     5│     5│     2
 Foreign mothers│     3│     2│    30│     2│     3│    12│    10│     3
                │      │      │      │      │      │      │      │
   Respiratory  │      │      │    47│     7│     4│    15│    13│     8
   diseases     │      │      │      │      │      │      │      │
 ───────────────┼──────┼──────┼──────┼──────┼──────┼──────┼──────┼──────
 Native mothers │      │      │    19│     2│     2│     8│     5│     2
 Foreign mothers│      │      │    28│     5│     2│     7│     8│     6
                │      │      │      │      │      │      │      │
   Premature    │      │      │      │      │      │      │      │
   births       │      │      │      │      │      │      │      │
 ───────────────┼──────┼──────┼──────┼──────┼──────┼──────┼──────┼──────
 Native mothers │      │      │      │      │      │      │      │
 Foreign mothers│      │      │      │      │      │      │      │
                │      │      │      │      │      │      │      │
   Congenital   │      │      │      │      │      │      │      │
   debility or  │     3│     1│     3│     1│     2│      │      │
   malformation │      │      │      │      │      │      │      │
 ───────────────┼──────┼──────┼──────┼──────┼──────┼──────┼──────┼──────
 Native mothers │      │     1│      │      │      │      │      │
 Foreign mothers│     3│      │     3│     1│     2│      │      │
                │      │      │      │      │      │      │      │
   Injuries at  │      │      │      │      │      │      │      │
   birth        │      │      │      │      │      │      │      │
 ───────────────┼──────┼──────┼──────┼──────┼──────┼──────┼──────┼──────
 Native mothers │      │      │      │      │      │      │      │
 Foreign mothers│      │      │      │      │      │      │      │
                │      │      │      │      │      │      │      │
   Other or not │     1│     5│    26│     5│     6│    10│     3│     2
   reported     │      │      │      │      │      │      │      │
 ───────────────┼──────┼──────┼──────┼──────┼──────┼──────┼──────┼──────
 Native mothers │     1│     5│    16│     4│     4│     5│     2│     1
 Foreign mothers│      │      │    10│     1│     2│     5│     1│     1
 ───────────────┴──────┴──────┴──────┴──────┴──────┴──────┴──────┴──────


    TABLE X.—DISTRIBUTION OF BIRTHS TO MARRIED WAGE-EARNING MOTHERS,
   ACCORDING TO HUSBAND’S ANNUAL EARNINGS AND NATIVITY AND EARNINGS OF
                                 MOTHER.

 ═════════════════╤═══════╤═════════════════════════════════════════════
   NATIVITY AND   │       │
  ANNUAL EARNINGS │ Total │ BIRTHS TO MARRIED WAGE-EARNING MOTHER WITH
    OF MARRIED    │births.│          HUSBAND EARNING ANNUALLY—
      MOTHER.     │       │
 ─────────────────┼───────┼─────┬─────┬─────┬─────┬───────┬──────┬──────
                  │       │Under│$521 │$625 │$780 │$900 to│$1,200│Ample.
                  │       │$521.│ to  │ to  │ to  │$1,199.│ and  │ [37]
                  │       │     │$624.│$779.│$899.│       │over. │
 ─────────────────┼───────┼─────┼─────┼─────┼─────┼───────┼──────┼──────
 All wage-earning │    281│  112│   57│   51│   25│     14│     1│    21
      mothers     │       │     │     │     │     │       │      │
 ═════════════════╪═══════╪═════╪═════╪═════╪═════╪═══════╪══════╪══════
  Under $53       │     20│    6│    5│    1│    4│      1│     —│     3
  $53 to $103     │     57│   23│   12│   11│    7│      3│     —│     1
  $104 to $207    │     89│   46│   16│   19│    3│      3│     —│     2
  $208 to $311    │     60│   23│   16│   12│    4│      3│     1│     1
  $312 and over   │     46│   14│    8│    8│    7│      2│     —│     7
  Not reported    │      9│    —│    —│    —│    —│      —│     2│     7
                  │       │     │     │     │     │       │      │
   Native         │       │     │     │     │     │       │      │
   wage-earning   │     26│    9│    3│    4│    6│      1│     —│     3
   mothers        │       │     │     │     │     │       │      │
 ─────────────────┼───────┼─────┼─────┼─────┼─────┼───────┼──────┼──────
 Under $53        │      6│    2│    1│    —│    2│      1│     —│     —
 $53 to $103      │      5│    2│    1│    2│    —│      —│     —│     —
 $104 to $207     │      5│    1│    1│    2│    1│      —│     —│     —
 $208 to $311     │      4│    3│    —│    —│    1│      —│     —│     —
 $312 and over    │      3│    1│    —│    —│    2│      —│     —│     —
 Not reported     │      3│    —│    —│    —│    —│      —│     —│     3
                  │       │     │     │     │     │       │      │
   Foreign        │       │     │     │     │     │       │      │
   wage-earning   │    255│  103│   54│   47│   19│     13│     1│    18
   mothers        │       │     │     │     │     │       │      │
 ─────────────────┼───────┼─────┼─────┼─────┼─────┼───────┼──────┼──────
 Under $53        │     14│    4│    4│    1│    2│      —│     —│     3
 $53 to $103      │     52│   21│   11│    9│    7│      3│     —│     1
 $104 to $207     │     84│   45│   15│   17│    2│      3│     —│     2
 $208 to $311     │     56│   20│   16│   12│    3│      3│     1│     1
 $312 and over    │     43│   13│    8│    8│    5│      2│     —│     7
 Not reported     │      6│    —│    —│    —│    —│      2│     —│     4
 ─────────────────┴───────┴─────┴─────┴─────┴─────┴───────┴──────┴──────

Footnote 37:

  See note on page 45.


 TABLE XI.—DISTRIBUTION OF RESULTS OF REPORTABLE PREGNANCIES (LIVE BIRTHS
  AND STILLBIRTHS) AND MISCARRIAGES, ACCORDING TO NUMBER PER MOTHER AND
                           NATIVITY OF MOTHER.

 ═══════════╤═════════════════════════════════════════════════════
            │   REPORTABLE PREGNANCIES AND RESULTS THEREOF.
            │
 ───────────┼────────────┬───────┬───────┬────────┬───────────────
            │            │       │       │        │
            │            │       │       │        │   Live births.
            │            │       │       │        │
 ───────────┼────────────┼───────┼───────┼────────┼───────┬───────
  NUMBER OF │            │       │       │        │       │
 REPORTABLE │            │       │       │        │       │
 PREGNANCIES│            │       │       │        │       │
 PER MOTHER │            │       │       │        │       │
     AND    │            │       │       │        │       │
 NATIVITY OF│            │       │       │        │       │
   MOTHER.  │            │       │       │        │       │
 ───────────┼────────────┼───────┼───────┼────────┼───────┼───────
            │            │       │       │        │       │Number
            │            │       │Excess │ Number │       │  of
            │   Total    │ Total │due to │   of   │Number.│mothers
            │pregnancies.│births.│plural │mothers.│       │having
            │            │       │births.│        │       │ live
            │            │       │       │        │       │births.
 ───────────┼────────────┼───────┼───────┼────────┼───────┼───────
 All married│       5,554│  5,617│     63│   1,491│  5,363│  1,465
   mothers  │            │       │       │        │       │
 ═══════════╪════════════╪═══════╪═══════╪════════╪═══════╪═══════
 1          │         339│    343│      4│     339│    322│    318
 2          │         566│    576│     10│     283│    544│    279
 3          │         642│    650│      8│     214│    626│    214
 4          │         744│    752│      8│     186│    723│    180
 5          │         735│    740│      5│     147│    704│    147
 6          │         564│    568│      4│      94│    546│     93
 7          │         581│    586│      5│      83│    555│     83
 8          │         432│    437│      5│      54│    426│     54
 9          │         297│    299│      2│      33│    283│     33
 10 or more │         654│    666│     12│      58│    634│     58
            │            │       │       │        │       │
     Native │       2,717│  2,744│     27│     816│  2,600│    801
 ───────────┼────────────┼───────┼───────┼────────┼───────┼───────
 1          │         234│    236│      2│     234│    224│    222
 2          │         346│    351│      5│     173│    327│    170
 3          │         333│    338│      5│     111│    322│    111
 4          │         376│    377│      1│      94│    362│     94
 5          │         325│    326│      1│      65│    302│     65
 6          │         222│    222│       │      37│    216│     37
 7          │         266│    267│      1│      38│    250│     38
 8          │         184│    187│      3│      23│    184│     23
 9          │         117│    118│      1│      13│    109│     13
 10 or more │         314│    322│      8│      28│    304│     28
            │            │       │       │        │       │
     Foreign│       2,837│  2,873│     36│     675│  2,763│    664
 ───────────┼────────────┼───────┼───────┼────────┼───────┼───────
 1          │         105│    107│      2│     105│     98│     96
 2          │         220│    225│      5│     110│    217│    109
 3          │         309│    312│      3│     103│    304│    103
 4          │         368│    375│      7│      92│    361│     92
 5          │         410│    414│      4│      82│    402│     82
 6          │         342│    346│      4│      57│    330│     56
 7          │         315│    319│      4│      45│    305│     45
 8          │         248│    250│      2│      31│    242│     31
 9          │         180│    181│      1│      20│    174│     20
 10 or more │         340│    344│      4│      30│    330│     30
 ───────────┴────────────┴───────┴───────┴────────┴───────┴───────

 ═══════════╤═════════════════════════════════════════════════════
            │     REPORTABLE PREGNANCIES AND RESULTS THEREOF.
            │
 ───────────┼─────────────────────────┬───────────────────────────
            │                         │
            │       Live births.      │        Stillbirths.
            │                         │
 ───────────┼─────────────────────────┼─────────────┬─────────────
  NUMBER OF │                         │             │
 REPORTABLE │                         │             │
 PREGNANCIES│                         │             │
 PER MOTHER │  Deaths in first year.  │             │
     AND    │                         │             │
 NATIVITY OF│                         │             │
   MOTHER.  │                         │             │
 ───────────┼───────┬───────┬─────────┼─────────────┼─────────────
            │       │Number │         │             │
            │       │  of   │ Infant  │             │  Number of
            │Number.│mothers│mortality│  Number of  │   mothers
            │       │having │  rate.  │still-births.│   having
            │       │babies │         │             │still-births.
            │       │ die.  │         │             │
 ───────────┼───────┼───────┼─────────┼─────────────┼─────────────
 All married│    804│    509│    149.9│          254│          194
   mothers  │       │       │         │             │
 ═══════════╪═══════╪═══════╪═════════╪═════════════╪═════════════
 1          │     35│     34│    108.7│           21│           21
 2          │     59│     54│    108.5│           32│           28
 3          │     92│     75│    147.0│           24│           23
 4          │     78│     64│    107.9│           29│           21
 5          │    103│     67│    146.3│           36│           31
 6          │     88│     60│    161.2│           22│           13
 7          │     78│     48│    140.5│           31│           22
 8          │     95│     42│    223.0│           11│            7
 9          │     41│     20│    144.9│           16│           11
 10 or more │    135│     45│    212.9│           32│           17
            │       │       │         │             │
     Native │    294│    206│    113.1│          144│          115
 ───────────┼───────┼───────┼─────────┼─────────────┼─────────────
 1          │     17│     17│     75.9│           12│           12
 2          │     25│     23│     76.5│           24│           21
 3          │     38│     31│    118.0│           16│           16
 4          │     36│     31│     99.4│           15│           13
 5          │     26│     21│     86.1│           24│           19
 6          │     34│     22│    157.4│            6│            5
 7          │     25│     18│    100.0│           17│           11
 8          │     29│     17│    157.6│            3│            2
 9          │     14│      7│    128.4│            9│            6
 10 or more │     50│     19│    164.5│           18│           10
            │       │       │         │             │
     Foreign│    510│    303│    184.6│          110│           79
 ───────────┼───────┼───────┼─────────┼─────────────┼─────────────
 1          │     18│     17│    183.7│            9│            9
 2          │     34│     31│    156.7│            8│            7
 3          │     54│     44│    177.6│            8│            7
 4          │     42│     33│    116.3│           14│            8
 5          │     77│     46│    191.5│           12│           12
 6          │     54│     38│    163.6│           16│            8
 7          │     53│     30│    173.8│           14│           11
 8          │     66│     25│    272.7│            8│            5
 9          │     27│     13│    155.2│            7│            5
 10 or more │     85│     26│    257.6│           14│            7
 ───────────┴───────┴───────┴─────────┴─────────────┴─────────────

 ═══════════════════╤══════════════════════════════
          REPORTABLE│ MISCARRIAGES IN ADDITION TO
     PREGNANCIES AND│   REPORTABLE PREGNANCIES.
    RESULTS THEREOF.│
 ───────────┬───────┼────────────┬─────────────────
            │Still- │            │Number of mothers
            │births.│            │    reporting
            │       │            │  miscarriages.
 ───────────┼───────┼────────────┼────────┬────────
  NUMBER OF │       │            │        │
 REPORTABLE │       │            │        │
 PREGNANCIES│       │            │        │
 PER MOTHER │       │            │        │
     AND    │       │            │        │
 NATIVITY OF│       │            │        │
   MOTHER.  │       │            │        │
 ───────────┼───────┼────────────┼────────┼────────
            │       │            │        │
            │  Per  │ Number of  │        │  Per
            │ cent. │miscarriages│ Total  │cent. of
            │of all │ reported.  │mothers.│  all
            │births.│            │        │mothers.
            │       │            │        │
 ───────────┼───────┼────────────┼────────┼────────
 All married│    4.5│         191│     130│     8.7
   mothers  │       │            │        │
 ═══════════╪═══════╪════════════╪════════╪════════
 1          │    6.1│           8│       8│     2.4
 2          │    5.6│          23│      16│     5.7
 3          │    3.7│          26│      18│     8.4
 4          │    3.9│          22│      18│     9.7
 5          │    4.9│          20│      14│     9.5
 6          │    3.9│          23│      14│    14.9
 7          │    5.3│          27│      15│    18.1
 8          │    2.5│          15│       9│    16.7
 9          │    5.4│          13│       8│ ([38])
 10 or more │    4.8│          14│      10│    17.2
            │       │            │        │
     Native │    5.2│         136│      92│    11.3
 ───────────┼───────┼────────────┼────────┼────────
 1          │    5.1│           7│       7│     3.0
 2          │    6.8│          18│      13│     7.5
 3          │    4.7│          21│      15│    13.5
 4          │    4.0│          13│      10│    10.6
 5          │    7.4│          13│      10│    15.4
 6          │    2.7│          17│       9│ ([38])
 7          │    6.4│          25│      13│ ([38])
 8          │    1.6│           8│       5│ ([38])
 9          │    7.6│           4│       3│ ([38])
 10 or more │    5.6│          10│       7│ ([38])
            │       │            │        │
     Foreign│    3.8│          55│      38│     5.6
 ───────────┼───────┼────────────┼────────┼────────
 1          │    8.4│           1│       1│     1.0
 2          │    3.6│           5│       3│     2.7
 3          │    2.6│           5│       3│     2.9
 4          │    3.7│           9│       8│     8.7
 5          │    2.9│           7│       4│     4.9
 6          │    4.6│           6│       5│     8.3
 7          │    4.4│           2│       2│ ([38])
 8          │    3.2│           7│       4│ ([38])
 9          │    3.9│           9│       5│ ([38])
 10 or more │    4.1│           4│       3│ ([38])
 ───────────┴───────┴────────────┴────────┴────────
Footnote 38:

  Not shown when base is less than 50.


    TABLE XII.—DISTRIBUTION OF RESULTS OF REPORTABLE PREGNANCIES (LIVE
 BIRTHS AND STILLBIRTHS) AND MISCARRIAGES, ACCORDING TO NUMBER PER MOTHER
                   AND AGE OF MOTHER AT EACH PREGNANCY.

 ═════════════╤════════════════════════════════════╤════════════════
   NUMBER OF  │                                    │
  REPORTABLE  │                                    │
  PREGNANCIES │                                    │
  AND AGE OF  │      REPORTABLE PREGNANCIES.       │  LIVE BIRTHS.
   MOTHER AT  │                                    │
 BIRTH OF BABY│                                    │
 BORN IN 1911.│                                    │
 ─────────────┼──────┬────────────────────┬────────┼───────┬────────
              │      │ Resulting births.  │        │       │
              │      │                    │        │       │
 ─────────────┼──────┼───────┬────────────┼────────┼───────┼────────
              │      │       │Excess over │ Number │       │ Number
              │Total.│Number.│pregnancies.│   of   │Number.│   of
              │      │       │    [39]    │mothers.│       │mothers.
              │      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
  All married │ 5,554│  5,617│          63│   1,491│  5,363│   1,465
    mothers   │      │       │            │        │       │
 ═════════════╪══════╪═══════╪════════════╪════════╪═══════╪════════
   Under 20   │   107│    108│           1│      89│     96│      81
   years      │      │       │            │        │       │
   20 to 24   │   933│    946│          13│     461│    908│     456
   years      │      │       │            │        │       │
   25 to 29   │ 1,316│  1,329│          13│     395│  1,261│     389
   years      │      │       │            │        │       │
   30 to 39   │ 2,570│  2,595│          25│     466│  2,480│     459
   years      │      │       │            │        │       │
   40 years   │   628│    639│          11│      80│    618│      80
   and over   │      │       │            │        │       │
 Average age: │      │       │            │        │       │
   28 years.  │      │       │            │        │       │
              │      │       │            │        │       │
 1 reportable │   339│    343│           4│     339│    322│     318
   pregnancy  │      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
 Under 20     │    74│     75│           1│      74│     67│      66
   years      │      │       │            │        │       │
 20 to 24     │   178│    179│           1│     178│    176│     175
   years      │      │       │            │        │       │
 25 to 29     │    57│     58│           1│      57│     54│      53
   years      │      │       │            │        │       │
 30 to 39     │    30│     31│           1│      30│     25│      24
   years      │      │       │            │        │       │
 Average age: │      │       │            │        │       │
   23 years.  │      │       │            │        │       │
              │      │       │            │        │       │
 2 reportable │   566│    576│          10│     283│    544│     279
   pregnancies│      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
 Under 20     │    24│     24│            │      12│     21│      12
   years      │      │       │            │        │       │
 20 to 24     │   312│    317│           5│     156│    302│     154
   years      │      │       │            │        │       │
 25 to 29     │   148│    151│           3│      74│    141│      73
   years      │      │       │            │        │       │
 30 to 39     │    78│     80│           2│      39│     76│      38
   years      │      │       │            │        │       │
 40 years and │     4│      4│            │       2│      4│       2
   over       │      │       │            │        │       │
 Average age: │      │       │            │        │       │
   25 years.  │      │       │            │        │       │
              │      │       │            │        │       │
 3 reportable │   642│    650│           8│     214│    626│     214
   pregnancies│      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
 Under 20     │     9│      9│            │       3│      8│       3
   years      │      │       │            │        │       │
 20 to 24     │   231│    234│           3│      77│    227│      77
   years      │      │       │            │        │       │
 25 to 29     │   285│    288│           3│      95│    277│      95
   years      │      │       │            │        │       │
 30 to 39     │   108│    110│           2│      36│    105│      36
   years      │      │       │            │        │       │
 40 years and │     9│      9│            │       3│      9│       3
   over       │      │       │            │        │       │
 Average age: │      │       │            │        │       │
   26 years.  │      │       │            │        │       │
              │      │       │            │        │       │
 4 reportable │   744│    752│           8│     186│    723│     186
   pregnancies│      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
 20 to 24     │   156│    160│           4│      39│    148│      39
   years      │      │       │            │        │       │
 25 to 29     │   300│    301│           1│      75│    290│      75
   years      │      │       │            │        │       │
 30 to 39     │   252│    255│           3│      63│    249│      63
   years      │      │       │            │        │       │
 40 years and │    36│     36│            │       9│     36│       9
   over       │      │       │            │        │       │
 Average age: │      │       │            │        │       │
   29 years.  │      │       │            │        │       │
              │      │       │            │        │       │
 5 reportable │   735│    740│           5│     147│    704│     147
   pregnancies│      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
 20 to 24     │    50│     50│            │      10│     49│      10
   years      │      │       │            │        │       │
 25 to 29     │   280│    283│           3│      56│    266│      56
   years      │      │       │            │        │       │
 30 to 39     │   375│    377│           2│      75│    361│      75
   years      │      │       │            │        │       │
 40 years and │    30│     30│            │       6│     28│       6
   over       │      │       │            │        │       │
 Average age: │      │       │            │        │       │
   30 years.  │      │       │            │        │       │
              │      │       │            │        │       │
 6 reportable │   564│    568│           4│      94│    546│      93
   pregnancies│      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
 20 to 24     │     6│      6│            │       1│      6│       1
   years      │      │       │            │        │       │
 25 to 29     │   132│    133│           1│      22│    127│      21
   years      │      │       │            │        │       │
 30 to 39     │   360│    362│           2│      60│    347│      60
   years      │      │       │            │        │       │
 40 years and │    66│     67│           1│      11│     66│      11
   over       │      │       │            │        │       │
 Average age: │      │       │            │        │       │
   33 years.  │      │       │            │        │       │
              │      │       │            │        │       │
 7 reportable │   581│    586│           5│      83│    555│      83
   pregnancies│      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
 25 to 29     │    98│     99│           1│      14│     90│      14
   years      │      │       │            │        │       │
 30 to 39     │   392│    395│           3│      56│    377│      56
   years      │      │       │            │        │       │
 40 years and │    91│     92│           1│      13│     88│      13
   over       │      │       │            │        │       │
 Average age: │      │       │            │        │       │
   34 years.  │      │       │            │        │       │
              │      │       │            │        │       │
 8 reportable │   432│    437│           5│      54│    426│      54
   pregnancies│      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
 25 to 29     │    16│     16│            │       2│     16│       2
   years      │      │       │            │        │       │
 30 to 39     │   408│    413│           5│      51│    403│      51
   years      │      │       │            │        │       │
 40 years and │     8│      8│            │       1│      7│       1
   over       │      │       │            │        │       │
 Average age: │      │       │            │        │       │
   35 years.  │      │       │            │        │       │
              │      │       │            │        │       │
 9 reportable │   297│    299│           2│      33│    283│      33
   pregnancies│      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
 30 to 39     │   207│    208│           1│      23│    195│      23
   years      │      │       │            │        │       │
 40 years and │    90│     91│           1│      10│     88│      10
   over       │      │       │            │        │       │
 Average age: │      │       │            │        │       │
   37 years.  │      │       │            │        │       │
              │      │       │            │        │       │
 10 or more   │   654│    666│          12│([41])58│    634│      58
   reportable │      │       │            │        │       │
   pregnancies│      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
 30 to 39     │   360│    364│           4│      33│    342│      33
   years      │      │       │            │        │       │
 40 years and │   294│    302│           8│      25│    292│      25
   over       │      │       │            │        │       │
 Average age: │      │       │            │        │       │
   39 years.  │      │       │            │        │       │
 ─────────────┴──────┴───────┴────────────┴────────┴───────┴────────

 ═════════════╤══════════════════════════╤══════════════════════════
   NUMBER OF  │                          │
  REPORTABLE  │                          │
  PREGNANCIES │  BABIES DYING IN FIRST   │
  AND AGE OF  │          YEAR.           │       STILLBIRTHS.
   MOTHER AT  │                          │
 BIRTH OF BABY│                          │
 BORN IN 1911.│                          │
 ─────────────┼───────┬────────┬─────────┼───────┬────────┬─────────
              │       │        │         │       │        │
              │       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
              │       │ Number │ Infant  │       │ Number │Per cent.
              │Number.│   of   │mortality│Number.│   of   │ of all
              │       │mothers.│  rate.  │       │mothers.│ births
              │       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
  All married │    804│     509│    149.9│    254│     194│      4.5
    mothers   │       │        │         │       │        │
 ═════════════╪═══════╪════════╪═════════╪═══════╪════════╪═════════
   Under 20   │     12│      11│    125.0│     12│      12│     11.1
   years      │       │        │         │       │        │
   20 to 24   │    140│     115│    154.2│     38│      29│      4.0
   years      │       │        │         │       │        │
   25 to 29   │    185│     132│    146.7│     68│      55│      5.1
   years      │       │        │         │       │        │
   30 to 39   │    382│     207│    154.0│    115│      84│      4.4
   years      │       │        │         │       │        │
   40 years   │     85│      44│    137.5│     21│      14│      3.3
   and over   │       │        │         │       │        │
 Average age: │       │        │         │       │        │
   28 years.  │       │        │         │       │        │
              │       │        │         │       │        │
 1 reportable │     35│      34│    108.7│     21│      21│      6.1
   pregnancy  │       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
 Under 20     │      8│       7│    119.4│      8│       8│     10.7
   years      │       │        │         │       │        │
 20 to 24     │     18│      18│    102.3│      3│       3│      1.7
   years      │       │        │         │       │        │
 25 to 29     │      4│       4│     74.1│      4│       4│      6.9
   years      │       │        │         │       │        │
 30 to 39     │      5│       5│ ([40])  │      6│       6│ ([40])
   years      │       │        │         │       │        │
 Average age: │       │        │         │       │        │
   23 years.  │       │        │         │       │        │
              │       │        │         │       │        │
 2 reportable │     59│      54│    108.5│      3│      28│      5.6
   pregnancies│       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
 Under 20     │      3│       3│ ([40])  │      3│       3│ ([40])
   years      │       │        │         │       │        │
 20 to 24     │     42│      37│    139.1│     15│      13│      4.7
   years      │       │        │         │       │        │
 25 to 29     │      9│       9│     63.8│     10│       9│      6.6
   years      │       │        │         │       │        │
 30 to 39     │      5│       5│     65.8│      4│       3│      5.0
   years      │       │        │         │       │        │
 40 years and │       │        │         │    ...│        │
   over       │       │        │         │       │        │
 Average age: │       │        │         │       │        │
   25 years.  │       │        │         │       │        │
              │       │        │         │       │        │
 3 reportable │     92│      75│    147.0│     24│      23│      3.7
   pregnancies│       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
 Under 20     │      1│       1│ ([40])  │      1│       1│ ([40])
   years      │       │        │         │       │        │
 20 to 24     │     40│      31│    176.2│      7│       6│      3.0
   years      │       │        │         │       │        │
 25 to 29     │     41│      33│    148.0│     11│      11│      3.8
   years      │       │        │         │       │        │
 30 to 39     │      8│       8│     76.2│      5│       5│      4.5
   years      │       │        │         │       │        │
 40 years and │      2│       2│ ([40])  │       │        │
   over       │       │        │         │       │        │
 Average age: │       │        │         │       │        │
   26 years.  │       │        │         │       │        │
              │       │        │         │       │        │
 4 reportable │     78│      64│    107.9│     29│      21│      3.9
   pregnancies│       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
 20 to 24     │     28│      21│    189.2│     12│       6│      7.5
   years      │       │        │         │       │        │
 25 to 29     │     26│      23│     89.7│     11│      10│      3.7
   years      │       │        │         │       │        │
 30 to 39     │     21│      17│     84.3│      6│       5│      2.4
   years      │       │        │         │       │        │
 40 years and │      3│       3│ ([40])  │       │        │
   over       │       │        │         │       │        │
 Average age: │       │        │         │       │        │
   29 years.  │       │        │         │       │        │
              │       │        │         │       │        │
 5 reportable │    103│      67│    146.3│     36│      31│      4.9
   pregnancies│       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
 20 to 24     │      9│       7│    183.7│      1│       1│      2.0
   years      │       │        │         │       │        │
 25 to 29     │     51│      31│    191.7│     17│      15│      6.0
   years      │       │        │         │       │        │
 30 to 39     │     40│      27│    110.8│     16│      14│      4.2
   years      │       │        │         │       │        │
 40 years and │      3│       2│ ([40])  │      2│       1│ ([40])
   over       │       │        │         │       │        │
 Average age: │       │        │         │       │        │
   30 years.  │       │        │         │       │        │
              │       │        │         │       │        │
 6 reportable │     88│      60│    161.2│     22│      13│      3.9
   pregnancies│       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
 20 to 24     │      3│       1│ ([40])  │       │        │
   years      │       │        │         │       │        │
 25 to 29     │     23│      17│    181.1│      6│       1│      4.5
   years      │       │        │         │       │        │
 30 to 39     │     54│      36│    155.6│     15│      11│      4.1
   years      │       │        │         │       │        │
 40 years and │      8│       6│    121.2│      1│       1│      1.5
   over       │       │        │         │       │        │
 Average age: │       │        │         │       │        │
   33 years.  │       │        │         │       │        │
              │       │        │         │       │        │
 7 reportable │     78│      48│    140.5│     31│      22│      5.3
   pregnancies│       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
 25 to 29     │     23│      13│    255.6│      9│       5│     10.0
   years      │       │        │         │       │        │
 30 to 39     │     45│      28│    119.4│     18│      15│      4.6
   years      │       │        │         │       │        │
 40 years and │     10│       7│    113.6│      4│       2│      4.3
   over       │       │        │         │       │        │
 Average age: │       │        │         │       │        │
   34 years.  │       │        │         │       │        │
              │       │        │         │       │        │
 8 reportable │     95│      42│    223.0│     11│       7│      2.5
   pregnancies│       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
 25 to 29     │      8│       2│ ([40])  │       │        │
   years      │       │        │         │       │        │
 30 to 39     │     87│      40│    215.9│     10│       6│      2.4
   years      │       │        │         │       │        │
 40 years and │       │        │         │      1│       1│ ([40])
   over       │       │        │         │       │        │
 Average age: │       │        │         │       │        │
   35 years.  │       │        │         │       │        │
              │       │        │         │       │        │
 9 reportable │     41│      20│    144.9│     16│      11│      5.4
   pregnancies│       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
 30 to 39     │     32│      15│    164.1│     13│       8│      6.3
   years      │       │        │         │       │        │
 40 years and │      9│       5│    102.3│      3│       3│      3.3
   over       │       │        │         │       │        │
 Average age: │       │        │         │       │        │
   37 years.  │       │        │         │       │        │
              │       │        │         │       │        │
 10 or more   │    135│      45│    212.9│     32│      17│      4.8
   reportable │       │        │         │       │        │
   pregnancies│       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
 30 to 39     │     85│      26│    248.5│     22│      11│      6.0
   years      │       │        │         │       │        │
 40 years and │     50│      19│    171.2│     10│       6│      3.3
   over       │       │        │         │       │        │
 Average age: │       │        │         │       │        │
   39 years.  │       │        │         │       │        │
 ─────────────┴───────┴────────┴─────────┴───────┴────────┴─────────

 ═════════════╤═══════════════════════════
   NUMBER OF  │
  REPORTABLE  │
  PREGNANCIES │
  AND AGE OF  │       MISCARRIAGES.
   MOTHER AT  │
 BIRTH OF BABY│
 BORN IN 1911.│
 ─────────────┼─────────┬─────────────────
              │         │     Mothers
              │         │   reporting.
 ─────────────┼─────────┼────────┬────────
              │         │        │  Per
              │ Number  │Number. │cent. of
              │reported.│        │  all
              │         │        │mothers.
 ─────────────┼─────────┼────────┼────────
  All married │      191│     130│     8.7
    mothers   │         │        │
 ═════════════╪═════════╪════════╪════════
   Under 20   │         │        │
   years      │         │        │
   20 to 24   │       19│      18│     3.9
   years      │         │        │
   25 to 29   │       46│      27│     6.8
   years      │         │        │
   30 to 39   │       95│      66│    14.2
   years      │         │        │
   40 years   │       31│      19│    23.8
   and over   │         │        │
 Average age: │         │        │
   28 years.  │         │        │
              │         │        │
 1 reportable │        8│       8│     2.4
   pregnancy  │         │        │
 ─────────────┼─────────┼────────┼────────
 Under 20     │         │        │
   years      │         │        │
 20 to 24     │        3│       3│     1.7
   years      │         │        │
 25 to 29     │        3│       3│     5.3
   years      │         │        │
 30 to 39     │        2│       2│ ([40])
   years      │         │        │
 Average age: │         │        │
   23 years.  │         │        │
              │         │        │
 2 reportable │       23│      16│     5.7
   pregnancies│         │        │
 ─────────────┼─────────┼────────┼────────
 Under 20     │         │        │
   years      │         │        │
 20 to 24     │        6│       6│     3.8
   years      │         │        │
 25 to 29     │        5│       3│     4.1
   years      │         │        │
 30 to 39     │       12│       7│ ([40])
   years      │         │        │
 40 years and │         │        │
   over       │         │        │
 Average age: │         │        │
   25 years.  │         │        │
              │         │        │
 3 reportable │       26│      18│     8.4
   pregnancies│         │        │
 ─────────────┼─────────┼────────┼────────
 Under 20     │         │        │
   years      │         │        │
 20 to 24     │        7│       6│     7.8
   years      │         │        │
 25 to 29     │       14│       7│     7.4
   years      │         │        │
 30 to 39     │        4│       4│ ([40])
   years      │         │        │
 40 years and │        1│       1│ ([40])
   over       │         │        │
 Average age: │         │        │
   26 years.  │         │        │
              │         │        │
 4 reportable │       22│      18│     9.7
   pregnancies│         │        │
 ─────────────┼─────────┼────────┼────────
 20 to 24     │        3│       3│ ([40])
   years      │         │        │
 25 to 29     │       10│       6│     8.0
   years      │         │        │
 30 to 39     │        6│       6│     9.5
   years      │         │        │
 40 years and │        3│       3│ ([40])
   over       │         │        │
 Average age: │         │        │
   29 years.  │         │        │
              │         │        │
 5 reportable │       20│      14│     9.5
   pregnancies│         │        │
 ─────────────┼─────────┼────────┼────────
 20 to 24     │         │        │
   years      │         │        │
 25 to 29     │        6│       4│     7.1
   years      │         │        │
 30 to 39     │       12│       8│    10.7
   years      │         │        │
 40 years and │        2│       2│ ([40])
   over       │         │        │
 Average age: │         │        │
   30 years.  │         │        │
              │         │        │
 6 reportable │       23│      14│    14.9
   pregnancies│         │        │
 ─────────────┼─────────┼────────┼────────
 20 to 24     │         │        │
   years      │         │        │
 25 to 29     │        6│       3│ ([40])
   years      │         │        │
 30 to 39     │       13│       9│    15.0
   years      │         │        │
 40 years and │        4│       2│ ([40])
   over       │         │        │
 Average age: │         │        │
   33 years.  │         │        │
              │         │        │
 7 reportable │       27│      15│    18.1
   pregnancies│         │        │
 ─────────────┼─────────┼────────┼────────
 25 to 29     │        2│       1│ ([40])
   years      │         │        │
 30 to 39     │       19│      11│    19.6
   years      │         │        │
 40 years and │        6│       3│ ([40])
   over       │         │        │
 Average age: │         │        │
   34 years.  │         │        │
              │         │        │
 8 reportable │       15│       9│    16.7
   pregnancies│         │        │
 ─────────────┼─────────┼────────┼────────
 25 to 29     │         │        │
   years      │         │        │
 30 to 39     │       15│       9│    17.6
   years      │         │        │
 40 years and │         │        │
   over       │         │        │
 Average age: │         │        │
   35 years.  │         │        │
              │         │        │
 9 reportable │       13│       8│    24.2
   pregnancies│         │        │
 ─────────────┼─────────┼────────┼────────
 30 to 39     │        5│       4│ ([40])
   years      │         │        │
 40 years and │        8│       4│ ([40])
   over       │         │        │
 Average age: │         │        │
   37 years.  │         │        │
              │         │        │
 10 or more   │       14│      10│    17.2
   reportable │         │        │
   pregnancies│         │        │
 ─────────────┼─────────┼────────┼────────
 30 to 39     │        7│       6│ ([40])
   years      │         │        │
 40 years and │        7│       4│ ([40])
   over       │         │        │
 Average age: │         │        │
   39 years.  │         │        │
 ─────────────┴─────────┴────────┴────────
Footnote 39:

  Excess of births over pregnancies due to plural births.

Footnote 40:

  Rate not computed because of small base.

Footnote 41:

  Includes 21 having 10 pregnancies; 16 having 11; 11 having 12; 6
  having 13; 3 having 14; 1 having 16.


   TABLE XIII.—DISTRIBUTION OF RESULTS OF REPORTABLE PREGNANCIES (LIVE
 BIRTHS AND STILLBIRTHS) AND MISCARRIAGES, ACCORDING TO NUMBER PER MOTHER
                         AND HUSBAND’S EARNINGS.

 ═════════════╤════════════════════════════════════╤════════════════
   SPECIFIED  │                                    │
   NUMBER OF  │                                    │
  PREGNANCIES │                                    │
    FOR ALL   │                                    │
    MARRIED   │      REPORTABLE PREGNANCIES.       │  LIVE BIRTHS.
  MOTHERS AND │                                    │
    ANNUAL    │                                    │
  EARNINGS OF │                                    │
   HUSBAND.   │                                    │
 ─────────────┼──────┬────────────────────┬────────┼───────┬────────
              │      │ Resulting births.  │        │       │
              │      │                    │        │       │
 ─────────────┼──────┼───────┬────────────┼────────┼───────┼────────
              │      │       │Excess over │ Number │       │ Number
              │Total.│Number.│pregnancies.│   of   │Number.│   of
              │      │       │    [42]    │mothers.│       │mothers.
              │      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
      All     │      │       │            │        │       │
  reportable  │ 5,554│  5,617│          63│   1,491│  5,363│   1,465
  pregnancies │      │       │            │        │       │
 ═════════════╪══════╪═══════╪════════════╪════════╪═══════╪════════
 Husband      │      │       │            │        │       │
   earns:     │      │       │            │        │       │
  Under $521  │   938│    946│           8│     233│    902│     227
  $521 to $624│   691│    700│           9│     174│    668│     173
  $625 to $779│   816│    826│          10│     229│    797│     227
  $780 to $899│   611│    616│           5│     166│    588│     163
  $900 to     │   574│    581│           7│     146│    548│     143
   $1,199     │      │       │            │        │       │
  $1,200 and  │   196│    199│           3│      50│    186│      49
   over       │      │       │            │        │       │
  Ample[43]   │ 1,728│  1,749│          21│     493│  1,674│     483
              │      │       │            │        │       │
 1 reportable │   339│    343│           4│     339│    322│     318
   pregnancy  │      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
 Husband      │      │       │            │        │       │
   earns:     │      │       │            │        │       │
  Under $521  │    48│     48│            │      48│     43│      43
  $521 to $624│    23│     23│            │      23│     22│      22
  $625 to $779│    46│     48│           2│      46│     46│      44
  $780 to $899│    35│     35│            │      35│     32│      32
  $900 to     │    38│     39│           1│      38│     36│      35
   $1,199     │      │       │            │        │       │
  $1,200 and  │    13│     13│            │      13│     13│      13
   over       │      │       │            │        │       │
  Ample[43]   │   136│    137│           1│     136│    130│     129
              │      │       │            │        │       │
 2 reportable │   566│    576│          10│     283│    544│     279
   pregnancies│      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
 Husband      │      │       │            │        │       │
   earns:     │      │       │            │        │       │
  Under $521  │    62│     64│           2│      31│     62│      31
  $521 to $624│    72│     74│           2│      36│     68│      36
  $625 to $779│   110│    111│           1│      55│    108│      55
  $780 to $899│    56│     56│            │      28│     53│      28
  $900 to     │    46│     46│            │      23│     41│      23
   $1,199     │      │       │            │        │       │
  $1,200 and  │    16│     16│            │       8│     14│       7
   over       │      │       │            │        │       │
  Ample[43]   │   204│    209│           5│     102│    198│      99
              │      │       │            │        │       │
 3 reportable │   642│    650│           8│     214│    626│     214
   pregnancies│      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
 Husband      │      │       │            │        │       │
   earns:     │      │       │            │        │       │
  Under $521  │   114│    115│           1│      38│    110│      38
  $521 to $624│   102│    104│           2│      34│    101│      34
  $625 to $779│    84│     84│            │      28│     82│      28
  $780 to $899│    87│     87│            │      29│     83│      29
  $900 to     │    57│     58│           1│      19│     55│      19
   $1,199     │      │       │            │        │       │
  $1,200 and  │     6│      7│           1│       2│      7│       2
   over       │      │       │            │        │       │
  Ample[43]   │   192│    195│           3│      64│    188│      64
              │      │       │            │        │       │
 4 reportable │   744│    752│           8│     186│    723│     186
   pregnancies│      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
 Husband      │      │       │            │        │       │
   earns:     │      │       │            │        │       │
  Under $521  │   104│    104│            │      26│    101│      26
  $521 to $624│    88│     89│           1│      22│     86│      22
  $625 to $779│   136│    137│           1│      34│    129│      34
  $780 to $899│    96│     97│           1│      24│     95│      24
  $900 to     │    56│     58│           2│      14│     55│      14
   $1,199     │      │       │            │        │       │
  $1,200 and  │    40│     41│           1│      10│     39│      10
   over       │      │       │            │        │       │
  Ample[43]   │   224│    226│           2│      56│    218│      56
              │      │       │            │        │       │
 5 reportable │   735│    740│           5│     147│    704│     147
   pregnancies│      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
 Husband      │      │       │            │        │       │
   earns:     │      │       │            │        │       │
  Under $521  │   130│    131│           1│      26│    125│      26
  $521 to $624│    90│     91│           1│      18│     85│      18
  $625 to $779│   100│    100│            │      20│     99│      20
  $780 to $899│   110│    110│            │      22│    106│      22
  $900 to     │    65│     66│           1│      13│     60│      13
   $1,199     │      │       │            │        │       │
  $1,200 and  │    30│     30│            │       6│     26│       6
   over       │      │       │            │        │       │
  Ample[43]   │   210│    212│           2│      42│    203│      42
              │      │       │            │        │       │
 6 reportable │   564│    568│           4│      94│    546│      93
   pregnancies│      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
 Husband      │      │       │            │        │       │
   earns:     │      │       │            │        │       │
  Under $521  │   132│    132│            │      22│    124│      21
  $521 to $624│    60│     60│            │      10│     59│      10
  $625 to $779│   114│    115│           1│      19│    110│      19
  $780 to $899│    48│     48│            │       8│     48│       8
  $900 to     │    72│     74│           2│      12│     70│      12
   $1,199     │      │       │            │        │       │
  $1,200 and  │    12│     12│            │       2│     11│       2
   over       │      │       │            │        │       │
  Ample[43]   │   126│    127│           1│      21│    124│      21
              │      │       │            │        │       │
 7 reportable │   581│    586│           5│      83│    555│      83
   pregnancies│      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
 Husband      │      │       │            │        │       │
   earns:     │      │       │            │        │       │
  Under $521  │    91│     92│           1│      13│     88│      13
  $521 to $624│    56│     56│            │       8│     51│       8
  $625 to $779│    98│    101│           3│      14│     97│      14
  $780 to $899│    35│     35│            │       5│     32│       5
  $900 to     │    84│     84│            │      12│     79│      12
   $1,199     │      │       │            │        │       │
  $1,200 and  │    21│     22│           1│       3│     22│       3
   over       │      │       │            │        │       │
  Ample[43]   │   196│    196│            │       8│    186│      28
              │      │       │            │        │       │
 8 reportable │   432│    437│           5│      54│    426│      54
   pregnancies│      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
 Husband      │      │       │            │        │       │
   earns:     │      │       │            │        │       │
  Under $521  │   120│    120│            │      15│    117│      15
  $521 to $624│    96│     98│           2│      12│     94│      12
  $625 to $779│    40│     41│           1│       5│     41│       5
  $780 to $899│    48│     49│           1│       6│     46│       6
  $900 to     │    24│     24│            │       3│     24│       3
   $1,199     │      │       │            │        │       │
  $1,200 and  │    16│     16│            │       2│     16│       2
   over       │      │       │            │        │       │
  Ample[43]   │    88│     89│           1│      11│     88│      11
              │      │       │            │        │       │
 9 reportable │   297│    299│           2│      33│    283│      33
   pregnancies│      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
 Husband      │      │       │            │        │       │
   earns:     │      │       │            │        │       │
  Under $521  │    81│     82│           1│       9│     80│       9
  $521 to $624│    72│     72│            │       8│     70│       8
  $625 to $779│    18│     18│            │       2│     15│       2
  $780 to $899│    18│     19│           1│       2│     17│       2
  $900 to     │    18│     18│            │       2│     18│       2
   $1,199     │      │       │            │        │       │
  $1,200 and  │    18│     18│            │       2│     16│       2
   over       │      │       │            │        │       │
  Ample[43]   │    72│     72│            │       8│     67│       8
              │      │       │            │        │       │
 10 or more   │      │       │            │        │       │
   reportable │   654│    666│          12│      58│    634│      58
   pregnancies│      │       │            │        │       │
 ─────────────┼──────┼───────┼────────────┼────────┼───────┼────────
 Husband      │      │       │            │        │       │
   earns:     │      │       │            │        │       │
  Under $521  │    56│     58│           2│       5│     52│       5
  $521 to $624│    32│     33│           1│       3│     32│       3
  $625 to $779│    70│     71│           1│       6│     70│       6
  $780 to $899│    78│     80│           2│       7│     76│       7
  $900 to     │   114│    114│            │      10│    110│      10
   $1,199     │      │       │            │        │       │
  $1,200 and  │    24│     24│            │       2│     22│       2
   over       │      │       │            │        │       │
  Ample[43]   │   280│    286│           6│      25│    272│      25
 ─────────────┴──────┴───────┴────────────┴────────┴───────┴────────

 ═════════════╤══════════════════════════╤══════════════════════════
   SPECIFIED  │                          │
   NUMBER OF  │                          │
  PREGNANCIES │                          │
    FOR ALL   │  BABIES DYING IN FIRST   │
    MARRIED   │          YEAR.           │       STILLBIRTHS.
  MOTHERS AND │                          │
    ANNUAL    │                          │
  EARNINGS OF │                          │
   HUSBAND.   │                          │
 ─────────────┼───────┬────────┬─────────┼───────┬────────┬─────────
              │       │        │         │       │        │
              │       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
              │       │ Number │ Infant  │       │ Number │Per cent.
              │Number.│   of   │mortality│Number.│   of   │ of all
              │       │mothers.│  rate.  │       │mothers.│ births
              │       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
      All     │       │        │         │       │        │
  reportable  │    804│   149.9│      509│    254│     194│      4.5
  pregnancies │       │        │         │       │        │
 ═════════════╪═══════╪════════╪═════════╪═══════╪════════╪═════════
 Husband      │       │        │         │       │        │
   earns:     │       │        │         │       │        │
  Under $521  │    178│   197.3│      110│     44│      31│      4.7
  $521 to $624│    129│   193.1│       75│     32│      25│      4.6
  $625 to $779│    130│   163.1│       88│     29│      21│      3.5
  $780 to $899│     99│   168.4│       61│     28│      23│      4.5
  $900 to     │     78│   142.3│       48│     33│      24│      5.7
   $1,199     │       │        │         │       │        │
  $1,200 and  │     30│   161.3│       18│     13│       9│      6.5
   over       │       │        │         │       │        │
  Ample[43]   │    160│    95.6│      109│     75│      61│      4.3
              │       │        │         │       │        │
 1 reportable │     35│   108.7│       34│     21│      21│      6.1
   pregnancy  │       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
 Husband      │       │        │         │       │        │
   earns:     │       │        │         │       │        │
  Under $521  │     11│        │       11│      5│       5│
  $521 to $624│      2│        │        2│      1│       1│
  $625 to $779│      6│        │        5│      2│       2│
  $780 to $899│      3│        │        3│      3│       3│
  $900 to     │      4│        │        4│      3│       3│
   $1,199     │       │        │         │       │        │
  $1,200 and  │      1│        │        1│       │        │
   over       │       │        │         │       │        │
  Ample[43]   │      8│    61.5│        8│      7│       7│      5.1
              │       │        │         │       │        │
 2 reportable │     59│   108.5│       54│     32│      28│      5.6
   pregnancies│       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
 Husband      │       │        │         │       │        │
   earns:     │       │        │         │       │        │
  Under $521  │     11│   176.4│       11│      2│       2│      3.1
  $521 to $624│      8│   177.6│        6│      6│       6│      8.1
  $625 to $779│     17│   157.4│       16│      3│       3│      2.7
  $780 to $899│      9│   169.8│        7│      3│       3│      5.4
  $900 to     │      2│        │        2│      5│       5│
   $1,199     │       │        │         │       │        │
  $1,200 and  │      1│        │        1│      2│       1│
   over       │       │        │         │       │        │
  Ample[43]   │     11│    55.6│       11│     11│       8│      5.3
              │       │        │         │       │        │
 3 reportable │     92│   147.0│       75│     24│      23│      3.7
   pregnancies│       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
 Husband      │       │        │         │       │        │
   earns:     │       │        │         │       │        │
  Under $521  │     27│   245.5│       23│      5│       4│      4.3
  $521 to $624│     16│   158.4│       13│      3│       3│      1.9
  $625 to $779│     13│   158.5│       11│      2│       2│      2.4
  $780 to $899│      6│    72.3│        6│      4│       4│      4.6
  $900 to     │     11│   200.0│        8│      3│       3│      5.2
   $1,199     │       │        │         │       │        │
  $1,200 and  │      1│        │        1│       │        │
   over       │       │        │         │       │        │
  Ample[43]   │     18│    95.7│       13│      7│       7│      3.6
              │       │        │         │       │        │
 4 reportable │     78│   107.9│       64│     29│      21│      3.9
   pregnancies│       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
 Husband      │       │        │         │       │        │
   earns:     │       │        │         │       │        │
  Under $521  │     13│   128.7│        9│      3│       2│      1.9
  $521 to $624│     10│   116.3│        9│      3│       1│      3.4
  $625 to $779│     19│   147.3│       15│      8│       6│      5.8
  $780 to $899│     13│   136.8│       12│      2│       1│      2.1
  $900 to     │      4│    72.7│        2│      3│       1│      5.2
   $1,199     │       │        │         │       │        │
  $1,200 and  │      5│        │        4│      2│       2│
   over       │       │        │         │       │        │
  Ample[43]   │     14│    64.2│       13│      8│       8│      3.5
              │       │        │         │       │        │
 5 reportable │    103│   146.3│       67│     36│      31│      4.9
   pregnancies│       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
 Husband      │       │        │         │       │        │
   earns:     │       │        │         │       │        │
  Under $521  │     21│   168.0│       12│      6│       6│      4.6
  $521 to $624│     20│   235.3│       12│      6│       5│      6.6
  $625 to $779│     18│   181.8│       13│      1│       1│      1.0
  $780 to $899│     13│   122.6│        8│      4│       4│      3.6
  $900 to     │      6│   100.0│        5│      6│       4│     10.0
   $1,199     │       │        │         │       │        │
  $1,200 and  │     10│        │        6│      4│       3│
   over       │       │        │         │       │        │
  Ample[43]   │     15│    73.9│       11│      9│       8│      4.2
              │       │        │         │       │        │
 6 reportable │     88│   161.2│       60│     22│      13│      3.9
   pregnancies│       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
 Husband      │       │        │         │       │        │
   earns:     │       │        │         │       │        │
  Under $521  │     26│   209.7│       14│      8│       3│      6.1
  $521 to $624│      9│   152.5│        8│      1│       1│      1.7
  $625 to $779│     14│   127.3│       11│      5│       2│      4.3
  $780 to $899│      7│        │        6│       │        │
  $900 to     │     12│   171.4│        9│      4│       3│      5.4
   $1,199     │       │        │         │       │        │
  $1,200 and  │      3│        │        1│      1│       1│
   over       │       │        │         │       │        │
  Ample[43]   │     17│   137.1│       11│      3│       3│      2.4
              │       │        │         │       │        │
 7 reportable │     78│   140.5│       48│     31│      22│      5.3
   pregnancies│       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
 Husband      │       │        │         │       │        │
   earns:     │       │        │         │       │        │
  Under $521  │     13│   147.7│        8│      4│       4│      4.3
  $521 to $624│     15│   294.1│        6│      5│       4│      8.9
  $625 to $779│     16│   164.9│        9│      4│       3│      4.0
  $780 to $899│      6│        │        5│      3│       2│
  $900 to     │      7│    88.6│        5│      5│       2│      6.0
   $1,199     │       │        │         │       │        │
  $1,200 and  │      1│        │        1│       │        │
   over       │       │        │         │       │        │
  Ample[43]   │     20│   107.5│       14│     10│       7│      5.1
              │       │        │         │       │        │
 8 reportable │     95│   223.0│       42│     11│       7│      2.5
   pregnancies│       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
 Husband      │       │        │         │       │        │
   earns:     │       │        │         │       │        │
  Under $521  │     31│   265.0│       12│      3│       2│      2.5
  $521 to $624│     22│   234.0│       10│      4│       2│      4.1
  $625 to $779│     11│        │        4│       │        │
  $780 to $899│     11│        │        5│      3│       2│
  $900 to     │      6│        │        3│       │        │
   $1,199     │       │        │         │       │        │
  $1,200 and  │      3│        │        2│       │        │
   over       │       │        │         │       │        │
  Ample[43]   │     11│   125.0│        6│      1│       1│      1.1
              │       │        │         │       │        │
 9 reportable │     41│   144.9│       20│     16│      11│      5.4
   pregnancies│       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
 Husband      │       │        │         │       │        │
   earns:     │       │        │         │       │        │
  Under $521  │     15│   187.5│        6│      2│       2│      2.4
  $521 to $624│     10│   142.9│        6│      2│       1│      2.8
  $625 to $779│       │        │         │      3│       1│
  $780 to $899│      5│        │        2│      2│       2│
  $900 to     │      2│        │        2│       │        │
   $1,199     │       │        │         │       │        │
  $1,200 and  │       │        │         │      2│       1│
   over       │       │        │         │       │        │
  Ample[43]   │      9│   134.3│        4│      5│       4│      6.9
              │       │        │         │       │        │
 10 or more   │       │        │         │       │        │
   reportable │    135│   212.9│       45│     32│      17│      4.8
   pregnancies│       │        │         │       │        │
 ─────────────┼───────┼────────┼─────────┼───────┼────────┼─────────
 Husband      │       │        │         │       │        │
   earns:     │       │        │         │       │        │
  Under $521  │     10│   192.3│        4│      6│       1│     10.3
  $521 to $624│     17│        │        3│      1│       1│
  $625 to $779│     16│   228.6│        4│      1│       1│      1.4
  $780 to $899│     26│   342.1│        7│      4│       2│      5.0
  $900 to     │     24│   218.2│        8│      4│       3│      3.5
   $1,199     │       │        │         │       │        │
  $1,200 and  │      5│        │        1│      2│       1│      8.3
   over       │       │        │         │       │        │
  Ample[43]   │     37│   136.0│       18│     14│       8│      4.9
 ─────────────┴───────┴────────┴─────────┴───────┴────────┴─────────

 ═════════════╤═══════════════════════════
   SPECIFIED  │
   NUMBER OF  │
  PREGNANCIES │
    FOR ALL   │
    MARRIED   │       MISCARRIAGES.
  MOTHERS AND │
    ANNUAL    │
  EARNINGS OF │
   HUSBAND.   │
 ─────────────┼─────────┬─────────────────
              │         │     Mothers
              │         │   reporting.
 ─────────────┼─────────┼────────┬────────
              │         │        │  Per
              │ Number  │Number. │cent. of
              │reported.│        │  all
              │         │        │mothers.
 ─────────────┼─────────┼────────┼────────
      All     │         │        │
  reportable  │      191│     130│     8.7
  pregnancies │         │        │
 ═════════════╪═════════╪════════╪════════
 Husband      │         │        │
   earns:     │         │        │
  Under $521  │       27│      17│    7.31
  $521 to $624│       22│      14│     8.0
  $625 to $779│       21│      15│     6.6
  $780 to $899│       30│      19│    11.4
  $900 to     │       25│      18│    12.3
   $1,199     │         │        │
  $1,200 and  │        8│       6│    12.0
   over       │         │        │
  Ample[43]   │       58│      41│     8.3
              │         │        │
 1 reportable │        8│       8│     2.4
   pregnancy  │         │        │
 ─────────────┼─────────┼────────┼────────
 Husband      │         │        │
   earns:     │         │        │
  Under $521  │         │        │
  $521 to $624│        1│       1│
  $625 to $779│        2│       2│
  $780 to $899│         │        │
  $900 to     │         │        │
   $1,199     │         │        │
  $1,200 and  │         │        │
   over       │         │        │
  Ample[43]   │        5│       5│
              │         │        │
 2 reportable │       23│      16│     5.7
   pregnancies│         │        │
 ─────────────┼─────────┼────────┼────────
 Husband      │         │        │
   earns:     │         │        │
  Under $521  │         │        │
  $521 to $624│        3│       1│
  $625 to $779│        2│       2│     4.4
  $780 to $899│        4│       2│
  $900 to     │        4│       4│
   $1,199     │         │        │
  $1,200 and  │        1│       1│
   over       │         │        │
  Ample[43]   │        9│       6│     5.9
              │         │        │
 3 reportable │       26│      18│     8.4
   pregnancies│         │        │
 ─────────────┼─────────┼────────┼────────
 Husband      │         │        │
   earns:     │         │        │
  Under $521  │        5│       3│
  $521 to $624│        1│       1│
  $625 to $779│        3│       2│
  $780 to $899│        5│       4│
  $900 to     │        7│       3│
   $1,199     │         │        │
  $1,200 and  │         │        │
   over       │         │        │
  Ample[43]   │        5│       5│     7.8
              │         │        │
 4 reportable │       22│      18│     9.7
   pregnancies│         │        │
 ─────────────┼─────────┼────────┼────────
 Husband      │         │        │
   earns:     │         │        │
  Under $521  │        4│       2│
  $521 to $624│        2│       2│
  $625 to $779│        3│       2│
  $780 to $899│        3│       3│
  $900 to     │        2│       2│
   $1,199     │         │        │
  $1,200 and  │        2│       2│
   over       │         │        │
  Ample[43]   │        6│       5│     8.9
              │         │        │
 5 reportable │       20│      14│     9.5
   pregnancies│         │        │
 ─────────────┼─────────┼────────┼────────
 Husband      │         │        │
   earns:     │         │        │
  Under $521  │        3│       3│
  $521 to $624│        3│       1│
  $625 to $779│        3│       2│
  $780 to $899│        3│       2│
  $900 to     │         │        │
   $1,199     │         │        │
  $1,200 and  │        2│       1│
   over       │         │        │
  Ample[43]   │        6│       5│
              │         │        │
 6 reportable │       23│      14│    14.9
   pregnancies│         │        │
 ─────────────┼─────────┼────────┼────────
 Husband      │         │        │
   earns:     │         │        │
  Under $521  │        2│       2│
  $521 to $624│        6│       2│
  $625 to $779│        3│       2│
  $780 to $899│        4│       2│
  $900 to     │        4│       3│
   $1,199     │         │        │
  $1,200 and  │         │        │
   over       │         │        │
  Ample[43]   │        4│       3│
              │         │        │
 7 reportable │       27│      15│    78.1
   pregnancies│         │        │
 ─────────────┼─────────┼────────┼────────
 Husband      │         │        │
   earns:     │         │        │
  Under $521  │        4│       2│
  $521 to $624│        1│       1│
  $625 to $779│         │        │
  $780 to $899│        3│       1│
  $900 to     │        5│       3│
   $1,199     │         │        │
  $1,200 and  │        2│       1│
   over       │         │        │
  Ample[43]   │       12│       7│
              │         │        │
 8 reportable │       15│       9│    16.7
   pregnancies│         │        │
 ─────────────┼─────────┼────────┼────────
 Husband      │         │        │
   earns:     │         │        │
  Under $521  │        5│       2│
  $521 to $624│        1│       1│
  $625 to $779│        2│       1│
  $780 to $899│        5│       3│
  $900 to     │        1│       1│
   $1,199     │         │        │
  $1,200 and  │        1│       1│
   over       │         │        │
  Ample[43]   │         │        │
              │         │        │
 9 reportable │       13│       8│
   pregnancies│         │        │
 ─────────────┼─────────┼────────┼────────
 Husband      │         │        │
   earns:     │         │        │
  Under $521  │        3│       2│
  $521 to $624│        3│       3│
  $625 to $779│        1│       1│
  $780 to $899│         │        │
  $900 to     │         │        │
   $1,199     │         │        │
  $1,200 and  │         │        │
   over       │         │        │
  Ample[43]   │        6│       2│
              │         │        │
 10 or more   │         │        │
   reportable │       14│      10│    17.2
   pregnancies│         │        │
 ─────────────┼─────────┼────────┼────────
 Husband      │         │        │
   earns:     │         │        │
  Under $521  │        1│       1│
  $521 to $624│        1│       1│
  $625 to $779│        2│       1│
  $780 to $899│        3│       2│
  $900 to     │        2│       2│
   $1,199     │         │        │
  $1,200 and  │         │        │
   over       │         │        │
  Ample[43]   │        5│       3│
 ─────────────┴─────────┴────────┴────────
Footnote 42:

  Excess of births over pregnancies due to plural births.

Footnote 43:

  See note on page 45.


   TABLE XIV.—DISTRIBUTION ACCORDING TO NUMBER OF PREGNANCIES AND AGE
            GROUPS OF MARRIED MOTHERS CLASSIFIED BY NATIVITY.

 ═══════════════════════╤═══════════════╤═══════════════╤═══════════════
 MOTHER’S AGE AND NUMBER│               │               │    FOREIGN
      OF REPORTABLE     │ ALL MOTHERS.  │NATIVE MOTHERS.│   MOTHERS.
      PREGNANCIES.      │               │               │
 ───────────────────────┼───────┬───────┼───────┬───────┼───────┬───────
                        │Number.│  Per  │Number.│  Per  │Number.│  Per
                        │       │ cent. │       │ cent. │       │ cent.
 ───────────────────────┼───────┼───────┼───────┼───────┼───────┼───────
    Total pregnancies   │  1,491│  100.0│    816│  100.0│    675│  100.0
 ═══════════════════════╪═══════╪═══════╪═══════╪═══════╪═══════╪═══════
  1                     │    339│   22.7│    234│   28.7│    105│   15.6
  2                     │    283│   19.0│    173│   21.2│    110│   16.3
  3                     │    214│   14.4│    111│   13.6│    103│   15.3
  4                     │    186│   12.5│     94│   11.5│     92│   13.6
  5                     │    147│    9.8│     65│    8.0│     82│   12.1
  6                     │     94│    6.3│     37│    4.5│     57│    8.4
  7                     │     83│    5.6│     38│    4.7│     45│    6.7
  8                     │     54│    3.6│     23│    2.8│     31│    4.6
  9                     │     33│    2.2│     13│    1.6│     20│    3.0
  10 and over           │     58│    3.9│     28│    3.4│     30│    4.4
                        │       │       │       │       │       │
   Under 20 years, total│     89│  100.0│     66│  100.0│     23│  100.0
   pregnancies          │       │       │       │       │       │
 ───────────────────────┼───────┼───────┼───────┼───────┼───────┼───────
 1                      │     74│   83.1│     55│   83.3│     19│   82.6
 2                      │     12│   13.5│     10│   15.2│      2│    8.7
 3                      │      3│    3.4│      1│    1.5│      2│    8.7
                        │       │       │       │       │       │
   20 to 24 years, total│    461│  100.0│    261│  100.0│    200│  100.0
   pregnancies          │       │       │       │       │       │
 ───────────────────────┼───────┼───────┼───────┼───────┼───────┼───────
 1                      │    178│   38.6│    114│   43.7│     64│   32.0
 2                      │    156│   33.8│     86│   33.0│     70│   35.0
 3                      │     77│   16.7│     42│   16.1│     35│   17.5
 4                      │     39│    8.5│     14│    5.4│     25│   12.5
 5                      │     10│    2.2│      4│    1.5│      6│    3.0
 6                      │      1│     .2│      1│    0.4│       │
                        │       │       │       │       │       │
   25 to 29 years, total│    395│  100.0│    199│  100.0│    196│  100.0
   pregnancies          │       │       │       │       │       │
 ───────────────────────┼───────┼───────┼───────┼───────┼───────┼───────
 1                      │     57│   14.5│     45│   22.6│     12│    6.1
 2                      │     74│   18.7│     46│   23.1│     28│   14.3
 3                      │     95│   24.1│     40│   20.1│     55│   28.1
 4                      │     75│   19.0│     40│   20.1│     35│   17.9
 5                      │     56│   14.2│     17│    8.5│     39│   19.9
 6                      │     22│    5.6│      7│    3.6│     15│    7.7
 7                      │     14│    3.5│      4│    2.0│     10│    5.1
 8                      │      2│     .4│       │       │      2│    1.0
                        │       │       │       │       │       │
   30 to 39 years, total│    466│  100.0│    245│  100.0│    221│  100.0
   pregnancies          │       │       │       │       │       │
 ───────────────────────┼───────┼───────┼───────┼───────┼───────┼───────
 1                      │     30│    6.4│     20│    8.2│     10│    4.5
 2                      │     39│    8.4│     29│   11.8│     10│    4.5
 3                      │     36│    7.7│     25│   10.2│     11│    5.0
 4                      │     63│   13.5│     33│   13.5│     30│   13.6
 5                      │     75│   16.1│     40│   16.3│     35│   15.8
 6                      │     60│   12.9│     24│    9.8│     36│   16.3
 7                      │     56│   12.0│     28│   11.4│     28│   12.7
 8                      │     51│   10.9│     23│    9.4│     28│   12.7
 9                      │     23│    4.9│      8│    3.3│     15│    6.8
 10 and over            │     33│    7.1│     15│    6.1│     18│    8.1
                        │       │       │       │       │       │
   40 years and over,   │     80│  100.0│     45│  100.0│     35│  100.0
   total pregnancies    │       │       │       │       │       │
 ───────────────────────┼───────┼───────┼───────┼───────┼───────┼───────
 2                      │      2│    2.5│      2│    4.4│       │
 3                      │      3│    3.8│      3│    6.7│       │
 4                      │      9│   11.3│      7│   15.6│      2│    5.7
 5                      │      6│    7.5│      4│    8.9│      2│    5.7
 6                      │     11│   13.8│      5│   11.1│      6│   17.1
 7                      │     13│   16.3│      6│   13.3│      7│   20.0
 8                      │      1│    1.3│       │       │      1│    2.9
 9                      │     10│   12.5│      5│   11.1│      5│   14.3
 10 and over            │     25│   31.3│     13│   28.9│     12│   34.3
 ───────────────────────┴───────┴───────┴───────┴───────┴───────┴───────


 TABLE XV.—DISTRIBUTION OF MARRIED MOTHERS BY LOSSES SUSTAINED, ACCORDING
           TO NATIVITY OF MOTHER AND NUMBER OF POSSIBLE LOSSES.

 ═════════╤════════╤══════════════════════════════════════════════
 NUMBER OF│        │
 BIRTHS OR│        │
 POSSIBLE │        │
  LOSSES  │        │DISTRIBUTION OF MOTHERS ACCORDING TO NUMBER OF
    AND   │        │                    LOSSES.
 NATIVITY │        │
    OF    │        │
  MOTHER. │        │
 ─────────┼────────┼──────┬───────┬───────┬───────┬───────┬───────
          │ Number │  1   │   2   │   3   │   4   │   5   │   6
          │   of   │loss. │losses.│losses.│losses.│losses.│losses.
          │mothers.│      │       │       │       │       │
 ─────────┼────────┼──────┼───────┼───────┼───────┼───────┼───────
    All   │   1,491│   399│    121│     60│     24│     13│      8
  mothers │        │      │       │       │       │       │
 ═════════╪════════╪══════╪═══════╪═══════╪═══════╪═══════╪═══════
  1 birth │     335│    53│       │       │       │       │
  2 births│     277│    67│     10│       │       │       │
  3 births│     216│    73│     14│      4│       │       │
  4 births│     187│    55│     13│      8│      1│       │
  5 births│     148│    48│     19│     11│      1│      2│
  6 births│      96│    44│     13│      8│      2│      1│      2
  7 births│      82│    22│     19│     10│      2│       │      1
  8 births│      54│    18│      8│     10│      4│      2│      2
  9 births│      36│     9│     10│      5│      1│      1│      2
  10 or   │        │      │       │       │       │       │
   more   │      60│    10│     15│      4│     13│      7│      1
   births │        │      │       │       │       │       │
          │        │      │       │       │       │       │
   Native │     816│   199│     59│     19│      5│      6│      1
   mothers│        │      │       │       │       │       │
 ─────────┼────────┼──────┼───────┼───────┼───────┼───────┼───────
 1 birth  │     232│    29│       │       │       │       │
 2 births │     170│    36│      5│       │       │       │
 3 births │     111│    35│      7│      1│       │       │
 4 births │      98│    33│      6│      3│       │       │
 5 births │      65│    19│     10│      4│       │       │
 6 births │      38│    19│      7│      1│       │      1│
 7 births │      37│    10│      8│      3│       │       │      1
 8 births │      21│     8│      5│      3│       │       │
 9 births │      15│     4│      4│      3│      1│       │
 10 or    │        │      │       │       │       │       │
   more   │      29│     6│      7│      1│      4│      5│
   births │        │      │       │       │       │       │
          │        │      │       │       │       │       │
   Foreign│     675│   200│     62│     41│     19│      7│      7
   mothers│        │      │       │       │       │       │
 ─────────┼────────┼──────┼───────┼───────┼───────┼───────┼───────
 1 birth  │     103│    24│       │       │       │       │
 2 births │     107│    31│      5│       │       │       │
 3 births │     105│    38│      7│      3│       │       │
 4 births │      89│    22│      7│      5│      1│       │
 5 births │      83│    29│      9│      7│      1│      2│
 6 births │      58│    25│      6│      7│      2│       │      2
 7 births │      45│    12│     11│      7│      2│       │
 8 births │      33│    10│      3│      7│      4│      2│      2
 9 births │      21│     5│      6│      2│       │      1│      2
 10 or    │        │      │       │       │       │       │
   more   │      31│     4│      8│      3│      9│      2│      1
   births │        │      │       │       │       │       │
 ─────────┴────────┴──────┴───────┴───────┴───────┴───────┴───────

 ═════════╤═══════════════
 NUMBER OF│
 BIRTHS OR│DISTRIBUTION OF
 POSSIBLE │    MOTHERS
  LOSSES  │  ACCORDING TO
    AND   │   NUMBER OF
 NATIVITY │    LOSSES.
    OF    │
  MOTHER. │
 ─────────┼───────┬───────
          │   8   │ 10 or
          │losses.│ more
          │       │losses.
 ─────────┼───────┼───────
    All   │      1│      2
  mothers │       │
 ═════════╪═══════╪═══════
  1 birth │       │
  2 births│       │
  3 births│       │
  4 births│       │
  5 births│       │
  6 births│       │
  7 births│       │
  8 births│       │
  9 births│       │
  10 or   │       │
   more   │      1│      2
   births │       │
          │       │
   Native │      1│
   mothers│       │
 ─────────┼───────┼───────
 1 birth  │       │
 2 births │       │
 3 births │       │
 4 births │       │
 5 births │       │
 6 births │       │
 7 births │       │
 8 births │       │
 9 births │       │
 10 or    │       │
   more   │      1│
   births │       │
          │       │
   Foreign│       │      2
   mothers│       │
 ─────────┼───────┼───────
 1 birth  │       │
 2 births │       │
 3 births │       │
 4 births │       │
 5 births │       │
 6 births │       │
 7 births │       │
 8 births │       │
 9 births │       │
 10 or    │       │
   more   │       │      2
   births │       │
 ─────────┴───────┴───────


  POPULATION, REGISTERED BIRTHS, DEATHS OF INFANTS UNDER 1 YEAR OF AGE,
   AND INFANT MORTALITY RATES FOR REGISTRATION STATES AND REGISTRATION
         CITIES HAVING A POPULATION OF AT LEAST 50,000 IN 1910.

 ═══════════════════════╤═══════════╤═══════════╤═══════════════════════
          AREA.         │           │           │ DEATHS[44] OF INFANTS
                        │           │           │ UNDER 1 YEAR OF AGE.
 ───────────────────────┼───────────┼───────────┼───────────┬───────────
                        │Population │Births.[45]│  Number.  │ Per 1000
                        │ in 1910.  │           │           │births.[46]
 ───────────────────────┼───────────┼───────────┼───────────┼───────────
  REGISTRATION STATES.  │           │           │           │
                        │           │           │           │
 Connecticut            │  1,114,756│     27,291│      3,476│        127
 Maine                  │    742,371│     15,578│      2,108│        135
 Massachusetts          │  3,366,416│     86,765│     11,377│        131
 Michigan               │  2,810,173│     63,566│      7,912│        124
 New Hampshire          │    430,572│      9,385│      1,373│        146
 Pennsylvania           │  7,665,111│    202,631│     28,377│        140
 Rhode Island           │    542,610│([47])6,595│([47])1,111│  ([47])168
 Vermont                │    355,956│      7,343│        791│        168
                        │           │           │           │
 REGISTRATION CITIES OF │           │           │           │
  50,000 POPULATION OR  │           │           │           │
      OVER IN 1910.     │           │           │           │
                        │           │           │           │
 Connecticut:           │           │           │           │
     Bridgeport         │    102,054│      2,976│        367│        123
     Hartford           │     98,915│      2,411│        286│        119
     New Haven          │    133,605│      3,772│        406│        108
     Waterbury          │     73,141│      2,150│        320│        149
                        │           │           │           │
 Washington, D. C.      │    331,069│      7,016│      1,068│        152
 Portland, Me.          │     58,571│      1,163│        167│        144
                        │           │           │           │
 Massachusetts:         │           │           │           │
     Boston             │    670,585│     17,760│      2,246│        126
     Brockton           │     56,878│      1,359│        134│         99
     Cambridge          │    104,839│      2,462│        293│        119
     Fall River         │    119,295│      4,591│        854│        186
     Holyoke            │     57,730│      1,702│        362│        213
     Lawrence           │     85,892│      3,165│        529│        167
     Lowell             │    106,294│      2,630│        607│        231
     Lynn               │     89,336│      2,218│        216│         97
     New Bedford        │     96,652│      3,873│        685│        177
     Somerville         │     77,236│      1,728│        174│        101
     Springfield        │     88,926│      2,438│        302│        124
     Worcester          │    145,986│      3,918│        536│        137
                        │           │           │           │
 Michigan:              │           │           │           │
     Detroit            │    465,766│     11,960│      2,138│        179
     Grand Rapids       │    112,571│      2,693│        329│        122
     Saginaw            │     50,510│        897│        130│        145
                        │           │           │           │
 Manchester, N. H.      │     70,063│      1,939│        375│        193
                        │           │           │           │
 New York, N. Y.        │  4,766,883│    129,316│      6,159│        125
     Bronx Borough      │    430,980│     10,926│     11,047│         96
     Brooklyn Borough   │  1,634,351│     43,128│      5,063│        117
     Manhattan Borough  │  2,331,542│     66,112│      8,900│        135
     Queens Borough     │    284,041│      7,095│        865│        122
     Richmond Borough   │     85,969│      2,055│        284│        138
                        │           │           │           │
 Pennsylvania:          │           │           │           │
     Allentown          │     51,913│      1,406│        202│        144
     Altoona            │     52,127│      1,392│        166│        119
     Erie               │     66,525│      1,713│        197│        116
     Harrisburg         │     64,186│      1,308│        169│        129
     Johnstown          │     55,482│      1,628│        268│        165
     Philadelphia       │  1,549,008│     38,666│      5,334│        138
     Pittsburgh         │    533,905│     15,059│      2,259│        150
     Reading            │     96,071│      2,370│        336│        142
     Scranton           │    129,867│      3,512│        520│        148
     Wilkes-Barre       │     67,105│      1,840│        269│        146
                        │           │           │           │
 Rhode Island:          │           │           │           │
     Pawtucket          │     51,622│  ([48])   │        191│  ([48])
     Providence         │    224,326│  ([48])   │        827│  ([48])
 ───────────────────────┴───────────┴───────────┴───────────┴───────────

Footnote 44:

  Exclusive of stillbirths.

Footnote 45:

  Provisional figures; exclusive of stillbirths.

Footnote 46:

  Based on provisional figures for births.

Footnote 47:

  The figures for Rhode Island are exclusive of Providence and
  Pawtucket.

Footnote 48:

  Returns of births not received from State board in time for inclusion.

It will be seen by this table that Johnstown is among the 10 cities of
more than 50,000 population which had an infant mortality rate of 1910
in excess of 150 per 1,000 births. These 10 cities and their respective
rates are as follows: Lowell, Mass., 231; Holyoke, Mass., 213;
Manchester, N. H., 193; Fall River, Mass., 186; Detroit, Mich., 179; New
Bedford, Mass., 177; Lawrence, Mass., 167; Johnstown, Pa., 165;
Washington, D. C., 152; and Pittsburgh, Pa., 150.

It should be borne in mind that the absolute infant mortality rate of
134, computed for the group of babies included in this investigation,
that is, for those born in Johnstown in 1911, can not be compared with
any of the approximate rates in the foregoing table, since the basis of
computation is entirely different. But the method used in this report
seemed to be the only practicable one for our purpose, namely, to
measure the infant mortality rate in different districts of the city
where the babies are subjected to varying conditions.

Conditions similar to those existing in Johnstown were found in Chicago
by Dr. Alice Hamilton, Bacteriologist in the Memorial Institute for
Infectious Diseases, Hull House. The results of a study made of 1,600
families in the neighborhood was published in 1910. The investigation
was undertaken to find out the truth or falsity of a general feeling
among the district nurses that a high birth rate was accompanied by a
high death rate. It was found that a high birth rate was not so much
accompanied as outrun by a high death rate. The number of children
live-born was compared with the number of children who reached the age
of three, so it is a study of child mortality, rather than of infant
mortality. The child mortality rate rises and falls very much as does
the infant mortality rate in Johnstown. A table calculated from the data
of all the families shows an ascending mortality rate:


                   No. in Family    Child Mortality Rate
                4 children and less                  118
                6 children and more                  267
                7 children and more                  280
                8 children and more                  291
                9 children and more                  303

Expressed in words this table says that child mortality increases as the
number of children per family increases, until we have a death rate in
families of eight and more, which is two and a half times as great as
that in families of four children and under.


 FOURTH ANNUAL REPORT OF THE CHIEF, CHILDREN’S BUREAU, U. S. DEPARTMENT
                         OF LABOR, Washington,
                            October 7, 1916


                      INFANT MORTALITY—MANCHESTER

The findings of the bureau’s earlier study in Johnstown, Pa., are
confirmed in many respects by the findings in Manchester—the coincidence
of a high infant mortality rate with low earnings, poor housing,
mother’s work, and large families.

The mortality rate among the 1,564 live-born babies studied in
Manchester was 165 per 1,000 births, which is considerably higher than
the estimated rate for the whole country.

Manchester is primarily a textile town, and the textile mills employed
36.3 per cent. of all the fathers of babies born in Manchester during
the 12 months covered by the study. Of the fathers, 13.7 per cent. were
earning less than $450 per year; 48.5 per cent. less than $650; 22.9 per
cent. $850 or more; 6.4 per cent. $1,250 or more.

Of the babies with fathers earning less than $450, about 1 in 4 died
before it was 12 months old. The great majority of the babies had
fathers in the wage group from $450 to $849, and of these about 1 in 6
died. Of the babies whose fathers earned $850 but less than $1,050, 1 in
8 failed to survive. Where the fathers earned $1,050 or more, 1 baby in
16 died in the first year.

Where families lived two or more persons per room, the infant death rate
was twice as high as where they lived less than one person per room. The
babies living in houses occupied by a single family died at the rate of
86.1 per 1,000, but those in tenements occupied by more than six
families died at the rate of 236.6 per 1,000.

When the mother was a wage earner the baby’s chances of living were less
than when she was not. Babies of mothers who had worked at some time
during the year before the baby’s birth died at the rate of 199.2 per
1,000, while babies of nonworking mothers died at the rate of 133.9.
Babies of mothers employed away from home some time during the year
after childbirth while the baby was still alive and under four months
old had a rate of 277.3, while babies of mothers not employed during
that time had a rate of 122.

Babies of foreign-born mothers did not fare so well as babies of native
mothers. The differences of rates, however, are only partly accounted
for by their lower earnings. The largest foreign element in Manchester
is Canadian French, and among them the infant mortality rate, 224 per
1,000 live births, is greater than that among any other group of the
population, although their earnings are in general higher than those of
other foreigners.

Sheer size of family appears to be one factor in this high
Canadian-French rate, one-third of their babies being sixth or later in
order of birth, while over one-sixth of these mothers had had from 9 to
18 children. These Canadian-French babies in families of 6 or more
children died at the rate of 246.2 per 1,000 and the rate rises to 277.2
per 1,000 when only babies ninth or later in order of birth are
considered.



                               CHAPTER V
         MATERNAL MORTALITY AND DISEASES AFFECTED BY PREGNANCY


_This chapter shows that the female death-rate is much greater during
the child-hearing age than at other periods and notably greater than the
male death-rate at any period. The outstanding fact is that this
abnormal female death-rate, between the ages of 15 and 45, must be
ascribed to too frequent pregnancies and to those diseases of the lungs,
heart and kidneys which are hastened by pregnancy. Ninety-five per cent.
of such deaths could be averted by the dissemination of knowledge to
prevent conception._


  _THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL BIOLOGICAL AND HYGIENIC
      ASPECTS. E. HEINRICH KISCH, M.D., Professor of the German Medical
      Faculty of the University of Prague, Physician to the Hospital and
      Spa of Marienbad, Member of the Board of Health, etc. Translated
      by M. Eden Paul, M.D. Rebman Co., New York._

It is astonishing to observe the number of full term deliveries and
miscarriages that a woman will experience within a comparatively short
period of time, as is seen too frequently among the laboring classes,
and more especially, among the factory workers. If we assume the
original mortality of childbirth to be 6 per mille, a woman who in the
course of 15 years undergoes labor (at full term or prematurely) 16
times, runs a risk of death to be expressed by the ratio of 6 × 16 = 96
per mille; that is to say, on the average of 1,000 women who became
pregnant as often as this, nearly one in ten will die in childbed. P.
278.

In certain serious general disorders, in diseases of the heart, or of
the lungs, in pelvic deformity, and in pathological changes of the
female reproductive organs, it may be right to employ means for the
prevention of pregnancy—not merely sexual abstinence, but actual
measures to prevent fertilization. P. 395.

Based upon the observations of Schauta and Fellner, the latter author
advances the rule that in the case of a woman suffering from disease,
marriage should be forbidden only when the mortality from the disease in
question is not less than 10%. In this category we must include severe
cases only of pulmonary tuberculosis, whilst cases of laryngeal
tuberculosis will, according to this rule, be absolutely unfit for
marriage. Among heart affections contra-indicating marriage, he includes
mitral stenosis, other valvular affections in which there is serious
disturbance of compensation, and myocarditis; he considers marriage
inadmissible also in cases of chronic nephritis, and among surgical
affections, in case of malignant tumor. No case in which during a
previous pregnancy the patient has been affected by one of the following
diseases; viz. severe chorea, mental disorders, severe epilepsy,
pulmonary tuberculosis which progressed much during pregnancy, morbus
cordis, with considerable disturbance of compensation, severe heart
trouble due to Graves disease—in all such cases a repetition of
pregnancy should be avoided. P. 261.


  FOURTH ANNUAL REPORT OF THE CHIEF OF CHILDREN’S BUREAU OF THE U. S.
                          DEPARTMENT OF LABOR,
                             JUNE 30, 1916


                           MATERNAL MORTALITY

A study of maternal mortality, by Dr. Grace L. Meigs, head of the
hygiene division of this bureau, has been undertaken as a direct
corollary to the infant mortality inquiry. The sickness or death of the
mother inevitably lessens the chances of the baby for life and health. A
large proportion of the deaths of babies occur in the first days and
weeks of life, and these early deaths can be prevented only through
proper care of the mother before and at the birth of her baby.

In the introduction to the report on “Maternal mortality in connection
with childbearing,” issued as a supplement to his report as medical
officer of the local government board of Great Britain for 1914–15, Sir
Arthur Newsholme says:

The present report is intended to draw attention to this unnecessary
mortality from childbearing, to stimulate further local inquiry on the
subject, and to encourage measures which will make the occurrence of
illness and disability due to childbearing a much rarer event than at
present.

The attainment of these ends is important as much in the interest of the
child as of its mother. That the welfare of the child is wrapped up in
that of the mother was fully recognized in the board’s circular letter
of 31st July, 1914, and the schedule appended to that letter; and each
year it is becoming more fully realized that, in order to insure healthy
infancy and childhood, it is necessary that, both during pregnancy and
at and after the birth of the infant, increased maternal care and
guidance and medical assistance should be provided.

The Children’s Bureau studies of infant mortality in town and country
reveal clearly the connection between maternal and infant welfare and
make plain that infancy can not be protected without the protection of
maternity.

In her report Dr. Meigs undertakes to do no more than to assemble and
interpret figures already published by the United States Bureau of the
Census and in the mortality reports of various foreign countries and to
state accepted scientific views as to the proper care of maternity. She
shows that maternal mortality, although in great measure preventable, is
not decreasing in the United States. Her report reveals an unconscious
public neglect due to age-long ignorance and fatalism. As soon as the
public realizes the facts to which Dr. Meigs calls attention it
doubtless will awake to action, and suitable provision for maternal and
infant welfare will become an integral part of all plans for local
protection of public health.

The report is summarized as follows:

“In 1913 in this country at least 15,000 women, it is estimated, died
from conditions caused by childbirth; about 7,000 of these died from
childbed fever, a disease proved to be almost entirely preventable, and
the remaining 8,000 from diseases now known to be to a great extent
preventable or curable. Physicians and statisticians agree that these
figures are a great underestimate.

“In 1913 the death rate per 100,000 population from all conditions
caused by childbirth was but little lower than that from typhoid fever;
this rate would be almost quadrupled if only the group of the population
which can be affected, women of childbearing age, were considered.

“In 1913 childbirth caused more deaths among women 15 to 44 years old
than any disease except tuberculosis.

“The death rate due to this cause is almost twice as high in the colored
as in the white population.

“Only 2 of a group of 15 important foreign countries show higher rates
from this cause than the rate in the registration area of the United
States. The rates of three countries, Sweden, Norway, and Italy, which
are notably low, show that low rates for these conditions are
attainable.

“The death rates from childbirth and from childbed fever for the
registration area of this country are not falling; during the 13 years
from 1900 to 1913 they have shown no demonstrable decrease. These years
have been marked by a revolution in the control of certain other
preventable diseases, such as typhoid, diphtheria, and tuberculosis.
During that time the typhoid rate has been cut in half, the rate of
tuberculosis markedly reduced, and the rate for diphtheria reduced to
less than one-half. During this period the death rate from childbirth
has decreased in England and Wales, Ireland, Australia, and Japan. The
other foreign countries studied show stationary or slightly increasing
rates. The death rate from childbed fever has decreased only in England
and Wales, Ireland, and Scotland.

“These facts point to the need in this country and in foreign countries
of higher standards of care for women at the time of childbirth.

“The low standards at present existing in this country result chiefly
from two causes: (1) General ignorance of the dangers connected with
childbirth and of the need for proper hygiene and skilled care in order
to prevent them; (2) difficulty in the provision of adequate care due to
special problems characteristic of this country. Such problems vary
greatly in city and in country. In the country inaccessibility of any
skilled care, due to pioneer conditions, is a chief factor.

“Improvement will come about only through a general realization of the
necessity for better care at childbirth. If women demand better care,
physicians will provide it, medical colleges will furnish better
training in obstetrics, and communities will realize the vital
importance of community measures to insure good care for all classes of
women.”

While the figures given by Dr. Meigs are a startling indication of the
great number of maternal fatalities occurring in various parts of the
country, no estimates can be made of the number of mothers who survive
only to suffer from a degree of preventable ill health which limits or
defeats the well-being and happiness of their households.


  _MATERNAL MORTALITY FROM ALL CONDITIONS CONNECTED WITH CHILD BIRTH IN
      THE UNITED STATES AND CERTAIN OTHER COUNTRIES. By Grace L. Meigs,
      M.D. U. S. Department of Labor, Children’s Bureau, 1917._


 STATISTICS RELATING TO CHILDBIRTH IN THE UNITED STATES AND IN CERTAIN
                           FOREIGN COUNTRIES

For the last two decades civilized countries have been absorbed in the
problem of preventing the enormous and needless waste of human life
represented by their infant death rates. The importance of this problem
has been felt more keenly in the last two years in the countries now at
war; in these countries the efforts toward saving the lives of babies
have redoubled since the war began. Side by side with this problem,
another, which is only of late finding its true place, is that of the
protection of the lives and health of mothers during their pregnancy and
confinement. This is a question so closely bound up with that of the
prevention of infant mortality that the two can not be separated.

It is now realized that a large proportion of the deaths of babies occur
in the first days and weeks of life, and that these deaths can be
prevented only through proper care of the mother before and at the birth
of her baby. It is also realized that breast feeding through the greater
part of the first year of the baby’s life is the chief protection from
all diseases; and that mothers are much more likely to be able to nurse
their babies successfully if they receive proper care before, at, and
after childbirth. Moreover, in the progress of work for the prevention
of infant mortality it has become ever clearer that all such work is
useful only in so far as it helps the mother to care better for her
baby. It must be plain, then, to what a degree the sickness or death of
the mother lessens the chances of the baby for life and health.

This question has also another side. Each death at childbirth is a
serious loss to the country. The women who die from this cause are lost
at the time of their greatest usefulness to the State and to their
families; and they give their lives in carrying out a function which
must be regarded as the most important in the world.

Questions then of the most vital interest to the whole Nation are these:
How are the lives of the mothers in this country and other countries
being protected? To what degree are the diseases caused by pregnancy and
childbirth preventable? If preventable, how far are they being prevented
in this country? Has there been the same great decrease in the last few
years in sickness and death from these causes as that which has marked
the great campaigns against other preventable diseases such as typhoid,
tuberculosis, or diphtheria? How do the conditions in the United States
compare with those in other countries?

_Puerperal septicemia (childbed fever)._—The fact is now well known that
puerperal septicemia, or childbed fever, is in reality a wound
infection, similar to such an infection after an accident or an
operation, and that it can be prevented by the same measures of
cleanliness and asepsis which are used so universally in modern surgery
to prevent infection. The proof of the nature of this disease is one of
the tremendous results of the scientific discoveries which were made in
the latter part of the nineteenth century.

During the early part of that century childbed fever was one of the
greatest hospital scourges known. It occurred also in private practice;
but in hospitals where there was great opportunity for the spreading of
infection the death rate from this disease was appalling. The average
death rate in hospitals in all countries was 3 to 4 per cent. of all
women confined; sometimes it reached 10 to 20 per cent. and even over 50
per cent. during short periods of epidemics. In the face of this
terrific mortality many obstetrical hospitals were closed. Commissions
were appointed to investigate the cause of these epidemics, and medical
congresses devoted sessions to the discussion of the problem. In 1843
Oliver Wendell Holmes, and in 1847 Semmelweiss, published articles
stating the theory that this fever was similar to a wound infection and
was due chiefly to the carrying of infectious material on the hands of
attendants from one case to another.


         NUMBER OF DEATHS IN THE UNITED STATES FROM CHILDBIRTH

In 1913 in the “death-registration area” of the United States 10,010
deaths were reported as due to conditions caused by pregnancy and
childbirth. Of these deaths, 4,542 were reported as caused by puerperal
septicemia or childbed fever.

Using the death-registration area as a basis, we are justified in
estimating that in 1913 in the whole United States 15,376 deaths were
due to childbirth, and 6,977 of these were due to childbed fever. As
will be shown later, these figures are without doubt a gross
underestimate. As it is, they are striking enough—almost 7,000 deaths in
one year in this country due to childbed fever, a disease to a large
degree easily preventable; and over 8,000 due to the other diseases
caused by pregnancy and confinement, most of which are preventable or
curable by means well known to science.


            DEATH RATES IN THE UNITED STATES FROM CHILDBIRTH

The death rate from all diseases caused by pregnancy and confinement in
1913 in the registration area was 15.8 per 100,000 population (which
includes all ages and both sexes). The death rate from puerperal
septicemia was 7.2.

These figures, however, mean little to us unless we compare them with
the death rates from other preventable diseases. In the same year and
area the typhoid rate was 17.9 per 100,000 population; the rate from
diphtheria and croup 18.8. The highest death rate from any one disease
was that from tuberculosis, 147.6 per 100,000 population. Any such
comparison with the rates from diseases to which both sexes and all ages
are liable is of course very misleading; but in spite of that fact it is
interesting to note that typhoid fever, the disease against which so
great an amount of effort is now directed, has a rate at present but 2
per 100,000 population higher than that from the diseases caused by
pregnancy and confinement.

_Death rates per 100,000 women._—The death rates from childbirth are
approximately doubled when worked on the basis of 100,000 women. This
will be seen when Tables IV and III (p. 50) are compared. The former
gives for the period 1900 to 1910, the annual death rates per 100,000
women in the group of 11 States which were in the death-registration
area in 1900, the latter the death rates per 100,000 population in the
same group of States for the same period. It is evident that the rates
in Table IV for each year are slightly more than twice those in Table
III for the same year.

_Death rates per 100,000 women of childbearing age...._ Again, a much
higher but a more accurate death rate from these diseases is found when
the basis taken is the group which alone is affected by these
diseases—women of childbearing age. When the rate is based not upon
100,000 population of both sexes and all ages but upon 100,000 women 15
to 44 years of age, the rate as ordinarily given is multiplied several
times.

In 1900, the only year for which the rates can be computed, the death
rate in the registration area per 100,000 women 15 to 44 years of age
from all diseases of pregnancy and confinement was 50.3; from puerperal
infection, 21.6. The corresponding rates for the same year per 100,000
population were 13.1 and 5.6. In this year, therefore, the rates are
almost quadrupled when based on that group of the population which alone
can be affected by these diseases.

Moreover, the death rates as ordinarily given per 100,000 population
conceal the fact that the diseases of pregnancy and childbirth are
indeed among the most important causes of death of women between 15 and
44 years of age; the actual number of deaths shows this to be the case.
In 1913 in the registration area these diseases caused more deaths than
any other one cause of death except tuberculosis. In that year there
were, among women 15 to 44 years of age, 26,265 deaths from
tuberculosis; 9,876 deaths from the diseases of pregnancy and
confinement; 6,386 from heart disease; 5,741 from acute nephritis and
Bright’s disease; 5,065 from cancer; and 4,167 from pneumonia. Other
diseases, such as typhoid, appendicitis, and the infectious diseases
show far fewer deaths.

_Death rates per 1,000 live births._—This rate, as will be shown
repeatedly throughout the report gives a far clearer picture of the
actual risk of childbirth than do any of the rates so far considered.
This rate can be given only for one year, 1910, and only for the
provisional birth-registration area for that year. The rate from all
diseases caused by pregnancy and confinement is 6.5, from puerperal
septicemia, 2.9, and from all other diseases of pregnancy and
confinement, 3.6 per 1,000 live births. That is, in this area for every
154 babies born alive one mother lost her life.


COMPARISON OF THE AVERAGE DEATH RATES FROM CHILDBIRTH IN CERTAIN FOREIGN
                   COUNTRIES AND IN THE UNITED STATES

Are the death rates from these diseases in the death-registration area
of the United States higher or lower than those in other civilized
countries? Have these rates in other countries been falling or rising in
the last 13 years, while the rates of this country have been apparently
stationary? These questions, like all those of comparative international
statistics, are of immense interest, but they involve many difficulties
and sources of error. They should be considered in reading the following
summary.

In order to make possible a comparison of the death rates from these
causes for 15 foreign countries with those for the United States, an
average rate has been computed for the years 1900 to 1910 for each of
the countries, using the same method as that in use in the United
States. When the 16 countries studied are arranged in order, with the
one having the lowest rate first, the death-registration area of the
United States stands fourteenth on the list. (See Table XII, p. 56.)
Only two countries, Switzerland and Spain, have higher rates; many of
the countries, however, show rates differing but little from that of the
United States. Markedly low rates are those of Sweden (6), Norway (7.8),
and Italy (8.9); a strikingly high rate is that of Spain (19.6).

The death rate from childbirth per 1,000 live births is not available
for the death-registration area of the United States, but can be given
only for the small number of States and cities included in the
provisional birth-registration area and for one year, 1910. (See p. 31.)
This rate, 6.5, is considerably higher than that for 1910 of any of the
countries studied. When the average rates for a number of years of the
15 countries are reckoned per 1,000 live births and arranged in order,
it will be seen that the same group of countries—Sweden, Italy, and
Norway—shows the lowest rates. (See Table XIII, p. 56.) Spain in this
table shows the rate which is next to the highest, while Belgium now has
the highest rate. For a comparative study of the rates of these
countries the rates per 1,000 live births give undoubtedly the clearest
picture of the actual conditions.

These rates show a wide variation. While in Sweden but one mother is
lost for every 430 babies born alive, in Belgium one mother dies for
every 172 babies, and in Spain one for every 175 babies born alive. The
rates in Belgium and Spain are two and a half times as high as the rate
in Sweden.

Far more significant than a comparison of actual death rates of various
countries is a comparison of the changes which have occurred in these
death rates in each country in recent years. England and Wales, Ireland,
Japan, New Zealand, and Switzerland have shown a decrease in the death
rate per 1,000 live births from all diseases caused by pregnancy and
confinement; but, in this group, only in England and Wales and in
Ireland has the death rate from puerperal septicemia decreased; in the
other three countries this rate has remained practically the same,
though the total rate has decreased.

In Australia, Belgium, Hungary, Italy, Norway, Prussia, Spain, and
Sweden both the rate from childbirth and that from puerperal septicemia
remained almost stationary during the periods studied.

The total rate for Scotland shows a definite increase, though the rate
from puerperal septicemia has decreased. (See Table XVI, p. 66.)

Communities are still to a great extent indifferent to or ignorant of
the number of lives of women lost yearly from childbirth; many
communities which are proud of their low typhoid or diphtheria rates
ignore their high rates from childbed fever. Communities are only
beginning to realize that among their chief concerns is the protection
of the babies born within their limits, and necessarily also of the
mothers of those babies before and at confinement.


                        DEATH-REGISTRATION AREA

The statistics of causes of death are available only for a certain
portion of the United States, included in the so-called
“death-registration area.” Unlike other civilized countries, the United
States has no uniform laws for the registration of births and deaths.
Moreover, the efficiency of enforcement of existing laws varies greatly
in the different States. The Bureau of the Census in 1880 therefore
established a “death-registration area,” which comprises “States and
cities in which the registration of deaths is returned as fairly
complete (at least 90 per cent. of the total), and from which
transcripts of the deaths recorded under the State laws or municipal
ordinances are obtained by the Bureau of the Census.” In 1880 this area
included but 17 per cent. of the total population of the United States.
As States and cities have passed better laws and obtained better
enforcement they have been added to the registration area; the latter
has increased greatly in size, but even in 1913 included only 65.1 per
cent. of the population of the United States. For the remaining 34.9 per
cent. of the population of the country we have no reliable statistics.
This 34.9 per cent. includes the population of the greater number of the
Southern States and of many Middle Western and Western States outside of
certain registration cities in these States which are included in the
area. No statements can be made, therefore, of the number of deaths from
any cause in the United States as a whole; only an estimate can be made
on the assumption that for any cause of death the same rate prevails in
the remainder of the United States as in the death-registration area.


                  PROVISIONAL BIRTH-REGISTRATION AREA

The registration of births is still more incomplete in this country than
is the registration of deaths. For 1910 the United States Bureau of the
Census established a “provisional birth-registration area,” including
the New England States, Pennsylvania, Michigan, New York City and
Washington, D. C.

_Death rates per 1,000 births._—As shown above, the method of
computation of death rates which gives the clearest picture of the
hazards of childbirth is that which takes into account only the women
giving birth to children in that year. This is the method in use in a
large number of foreign countries. The advantages of the method are
self-evident. A demonstration of the superiority of this method of
computation is obtained by a study of the tables giving the death rates
from these diseases for foreign countries. In certain countries, as for
instance Belgium and Hungary, there has been in recent years an apparent
fall in the average death rates as computed per 100,000 population,
while the average rates computed per 1,000 live births have remained
stationary or risen. This phenomenon is due, evidently, to a decline in
the birth rate in these countries during these years, and shows how
misleading the rates as given per 100,000 population undoubtedly are in
countries with declining birth rates. Whether a fall in the birth rate
has occurred in the United States is not known. If it has occurred in
the registration area, it would mean that the slight rise in rates per
100,000 population between 1900 and 1913 means a greater rise in rates
computed according to the number of births. Such an error might
compensate for the opposite error due to the more complete registration
of deaths from childbirth in the later years of this period.

Miscarriages are not reportable in any country, although a number of
miscarriages (as the term is usually defined) probably are reported as
stillbirths in certain countries. The fact that women having
miscarriages are not considered in the base would lead to a somewhat
higher death rate than that which would express absolutely the number of
deaths per 1,000 women at risk.


COMPARISON OF THE CHANGES IN THE DEATH RATES FROM CHILDBIRTH IN CERTAIN
              FOREIGN COUNTRIES FOR THE YEARS 1900 TO 1913

Far more valuable than a comparison of average rates of foreign
countries is a study of the rates of each country for a series of years
in order to discover whether they are decreasing or increasing and to
compare such changes in the various countries. While it may be dangerous
on account of different countries, no such source of error is attached
to the comparison of rates in the same country for a number of years.
The period 1900 to 1913 (or the latest year for which figures are
available) is a very short one for a study of a change in death rates.
It would have been far more interesting to study the death rates for a
long series of years in each country, choosing a period beginning before
the introduction of methods of asepsis. But such a study for the
complete list of countries considered was not thought advisable, because
of the difficulties caused by variations in classification of causes of
death in the earlier years.

In order to study the rates for any increase or decrease occurring
during the last 13 years, the rates per 1,000 live births will be used
rather than those per 100,000 population. In several countries—Belgium,
Hungary, Italy, Norway, Prussia, and Spain—the rate from childbirth per
100,000 population apparently has fallen during the period, while the
rate per 1,000 live births has remained almost the same, or has risen.
The cause of this inconsistency is the fact that in these countries the
birth rate or the proportionate number of births to the number of
inhabitants has decreased.


  _Number of deaths of women from 15 to 44 years of age in the
      death-registration area from each cause and class of causes
      included in the abridged International List of Causes of Death
      (revision of 1909),[49] 1913._

Footnote 49:

  Except No. 25, diarrhea and enteritis (under 2 years), and No. 34,
  senility.

(Computed from figures in Mortality Statistics, 1913, pp. 338 to 349, in
which causes of death are given according to the detailed International
List of Causes of Death.)


   Abridged                                                      Number
 International                 Cause of death.                     of
   List No.                                                     deaths.

    13, 14, 15 Tuberculosis of the lungs, tuberculous             26,265
                 meningitis, other forms of tuberculosis

               Puerperal septicemia (puerperal fever,
        31, 32   peritonitis) and other puerperal accidents of     9,876
                 pregnancy and labor

            19 Organic diseases of the heart                       6,386

            29 Acute nephritis and Bright’s disease                5,741

            16 Cancer and other malignant tumors                   5,065

            22 Pneumonia                                           4,167

            35 Violent deaths (suicide excepted)                   3,262

             1 Typhoid fever                                       2,706

            30 Noncancerous tumors and other diseases of the       2,669
                 female genital organs

            26 Appendicitis and typhlitis                          1,620

            36 Suicide                                             1,562

            23 Other diseases of the respiratory system            1,458
                 (tuberculosis excepted)

            18 Cerebral hemorrhage and softening                   1,398

            24 Diseases of the stomach (cancer  excepted)            940

            27 Hernia, intestinal obstruction                        854

            28 Cirrhosis of the liver                                598

             9 Influenza                                             489

            17 Simple meningitis                                     484

             8 Diphtheria and croup                                  330

            12 Other epidemic diseases                               312

             6 Scarlet fever                                         307

             5 Measles                                               304

             3 Malaria                                               250

            21 Chronic bronchitis                                    184

            20 Acute bronchitis                                       90

            33 Congenital debility and malformations                  24

            11 Cholera nostras                                        18

             4 Smallpox                                               16

             7 Whooping cough                                          9

             2 Typhus fever                                            2

            10 Asiatic cholera

            37 Other diseases                                     11,688

            38 Unknown or ill-defined diseases                       458


  _A MUNICIPAL BIRTH CONTROL CLINIC. MORRIS H. KAHN, M. D., in New York
      Medical Journal for April 28, 1917._

_Showing that large families among the poor are the result of ignorance
of methods to prevent conception among the mothers._

The following studies were undertaken with a view to determining whether
there was an actual need and demand for birth control education and
whether such a demand, if it existed, could be supplied with any effect
by a scientifically conducted clinic in the dispensaries of the
Department of Health of the City of New York; we felt that it might be
of scientific and sociological interest to publish a report and an
analysis of the observations made, probably the first of their kind in
this country. Section 1142 of our Penal Code was ignored in conducting
this birth control study.

The social and economic status of the patients was fairly uniform, about
the same as that of patients attending the other dispensary institutions
in this city. A tabulation of the results was made under the following
headings: Name and nationality; age; number of years married; number of
living children and their ages; number of deceased children; number of
miscarriages or abortions; contraceptive methods known or practised.
More or less complete data were secured in 464 cases.

The average number of procreative years of married life was 16.1, the
age of fifty years being considered in this study as the end of the
procreative period for the seventy-two women who were older than that.
The average number of living children was 3.27 and of deceased children
1.2, making a total average of 4.47 children born to each family. Of the
464 women, 176, or three eighths, had had abortions or miscarriages, the
total number of such interruptions of pregnancy being 324, or an average
of 1.8 each for the women involved.

Of the 464 women, 192 knew of no contraceptive methods and therefore had
used none. The remaining 272 women knew of one or more methods, more or
less effectual, for the prevention of conception. Of the 192 women who
were ignorant of the use of contraceptives, practically one half, or
104, had a history of abortions, with a total of 202 abortions, or an
average of two apiece. In contrast with this, of the 272 women who knew
of one or more contraceptives, only one fourth, or seventy-two, had
undergone abortions, with a total of 122 abortions, or an average of
only 1.6 apiece.

A further analysis of our tables shows an interesting and striking
relationship between ignorance of methods for the prevention of
conception and the number of children. Sixty-eight women had had three
children each. Of these, twenty-six, or thirty-eight per cent., were
ignorant of contraceptives. Twenty-eight women had had four children
each. Of these fourteen, or fifty per cent., were ignorant of
contraceptives. Fifty-five women had had five children each. Of these
thirty were ignorant of contraceptives, or fifty-four per cent.
Thirty-two women had had six children each. Of these twenty were
ignorant of contraceptives, or sixty-two per cent. Forty women had had
seven children each. Of these thirty-eight were ignorant of
contraceptives, or ninety-five per cent. Twenty-one women had had eight
children each. Of these twenty were ignorant of contraceptives, or
ninety-five per cent. Forty-four women had had nine or more children
each, and of these all were ignorant of contraceptive measures. Arranged
in tabular form, these data would appear as follows:


  Number of Women      Number of      Number Ignorant     Percentage
                       Children      of Contraceptives
        68                 3                26                        38
        28                 4                14                        50
        55                 5                30                        54
        32                 6                20                        62
        40                 7                38                        95
        21                 8                20                        95
        44              9 to 17             all                      100

It is sometimes stated by opponents of birth control that contraceptive
methods are known by every married person and that the fault and
immorality of having a large family of unprovided for dependents lies
not in ignorance of contraceptives but rather in a lack of determination
on the part of one or both parents to use preventive measures; in other
words, that the failure to use contraceptives results from the
inconvenience attending some methods and also from the influence of
religious sentiment.

The above data, however, tend to show that ignorance of contraceptives
not only is a great factor in the production of large families, but is
also a great factor in increasing the number of abortions. From the fact
that two thirds of these women knew absolutely no contraceptive method,
while the methods used by many of the others were ineffectual or
positively harmful, it is apparent that there is a definite opportunity
for educating these women in methods of regulating conception. That
there is need and demand for such education is voiced in unmistakable
language by the multitude of poor who seek advice from all practising
physicians.


                           MATERNAL MORTALITY

Prof. Theodate L. Smith, director of the Library Department, Child Study
Institute, Clark University, investigated the records of the families of
early graduates of Yale University (1701 to 1745) and of Harvard
University (1658 to 1690); and found that of the wives of Harvard men,
37.3 per cent. died under the age of 45 years, while of the wives of
Yale men, 40 per cent. died under 50 years. Prof. Smith also showed that
there is a tendency for families very large in the first generation to
die out in the third or fourth generation. One family of twenty
children, by two wives, has living descendent by one son only, one
daughter being untraceable. A family of ten brothers and sisters, only
two of whom lived until 50, produced three surviving children, who in
turn have produced one, and that a sickly specimen. Another family had
fourteen in the first generation, eight in the second, six in the third
and only two in the fourth.—Mary Alden Hopkins in _Harper’s Weekly_,
June, 1915.


TUBERCULOSIS, CAUSE OF THE GREATEST NUMBER OF DEATHS OF WOMEN DURING THE
                          CHILD-BEARING PERIOD


  _OBSTETRICS. A Text Book for the Use of Students and Practitioners. J.
      Whitridge Williams, Professor of Obstetrics, John Hopkins
      University, Obstetrician-in-Chief to the John Hopkins Hospital,
      Gynaecologist to the Union Protestant Infirmary, Baltimore, Md. D.
      Appleton & Co. 1912._

As a rule, all diseases which subject the organism to a considerable
strain are much more serious when occurring in the pregnant woman. In
general it may be said that pregnancy exerts a deleterious influence
upon all chronic organic maladies, while its effect is usually less
marked in acute infectious processes. The latter, however, frequently
lead to premature delivery and the additional physical strain attending
the latter matter render the course of the disease much less favorable.
Page 489.

“Owing to the well known fact that pulmonary tuberculosis usually
progresses much more rapidly after child bearing, it is advisable that
tubercular women take every precaution to avoid the possibility of
conception.” Page 383.

It would appear therefore that in the vast majority of cases the disease
(tuberculosis) is not transmitted directly from the mother to the fetus,
and that the latter is born with a tendency to tuberculosis, rather than
with the disease itself. Hence it follows that the children of
tubercular mothers should be brought under the best hygienic
surroundings, and should not be suckled by their mothers. In view of the
fact that the tubercular process usually becomes exacerbated either
during pregnancy or after child birth, most authorities recommend that
abortion be induced as a matter of routine in all tubercular women, and
many that they be rendered sterile by artificial means. This appears to
be a somewhat too extreme point of view, but I consider that abortion
should be induced in the first pregnancy occurring after the onset of
the disease, and whenever it makes its appearance during the early
months of pregnancy. Page 494.


  _THE PRACTICE OF OBSTETRICS. In original contributions by American
      Authors. Edited by Reuben Peterson, A.B., M.D., Professor of
      Obstetrics and Gynaecology in the University of Michigan, Ann
      Arbor, Mich. Obstetrician-in-Chief to the University of Michigan
      Hospital. Lea Bros. & Co. Philadelphia and New York. 1907. Chapter
      IX._


       COMPLICATIONS ARISING FROM MATERNAL DISEASES AND ANOMALIES

Exact observations on a large number of cases have demonstrated beyond
doubt that with very rare exceptions a pregnancy exerts a harmful effect
upon the course of the disease (tuberculosis). Page 344.

So seriously is the tubercular process affected by a concomitant
pregnancy that it seems the duty of the physician to warn every
tubercular girl against marriage. Especially deleterious to the patient
are pregnancies which follow each other at short intervals. In such
instances the patient must be strongly advised against a new
impregnation. It hardly can be denied that in some of these cases
artificial sterilization may be justified. An additional argument in
favor of this procedure is the comparative frequency with which, if not
the infection itself, at least a marked disposition to it is transmitted
to the fetus in utero. P. 344.


  _A TEXT BOOK OF OBSTETRICS. Barton Cooke Hirst, M.D., Professor of
      Obstetrics in the University of Pennsylvania; Gynaecologist to the
      Howard and Orthopaedic and the Philadelphia Hospitals, etc. W. B.
      Saunders Co. 1909._

The influence of pregnancy upon tuberculosis is most unfavorable and in
women predisposed to tuberculosis, gestation may be the determining
factor in lighting up an attack. It is the duty of a physician to advise
strongly against marriage and maternity in the case of a woman already
infected, or predisposed to tuberculosis. If the patient is pregnant an
induction of labor should be considered. P. 427.


  _THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Jos. B. De Lee, M.D.,
      Professor of Obstetrics at the Northwestern University Medical
      School; Obstetrician to the Chicago Lying-in-Hospital and to
      Wesley and Mercy Hospitals, etc. W. B. Saunders Co. 1913._

Women with tuberculosis should not marry, first, because this aggravates
their own disease. Second, they may infect the husband, and third, they
propagate tuberculous children. Knowing the tendency for a latent
tuberculosis to break out in pregnancy, marriage is to be forbidden. If
the woman marries, she should avoid conception. P. 481.

If tuberculosis of the lungs is manifested in early pregnancy, if there
is fever, wasting, hemoptysis and advancing consolidation, that is, the
process seems to be florid, abortion should be induced without delay.
Trembley, of Saranac Lake induces abortion in the early months in all
cases. Urgent symptoms of cardiac nature, persistent hemoptysis and
dyspnea may require emptying of the uterus. Complicating nephritis,
heart disease, and contracted pelvis, which is said to be more frequent
in the tuberculous, will give early indications for interference. P.
481.


  _TUBERCULOSIS. Jos. B. De Lee._

The woman should be instructed how to avoid pregnancy in the future.
Something must be done until the woman is cured of her tuberculosis, so
that she may safely go through a confinement, because every accoucheur
recoils with horror from the task of repeatedly doing abortions on these
tuberculous women. P. 482.


  _THE PRACTICE OF OBSTETRICS. Designed for the use of Students and
      Practitioners of Medicine. J. Clifton Edgar, Prof. of Obstetrics
      and Clinical Midwifery in the Cornell University Medical College;
      Visiting Obstetrician to Bellevue Hospital, New York City; Surgeon
      to the Manhattan Maternity and Dispensary; Consulting Obstetrician
      to the New York Maternity and Jewish Maternity Hospitals. 5th
      Edition. Revised. P. Blakiston’s Co., Phil._

The subject of the relationship between tuberculosis and pregnancy has
recently attained an increased degree of importance through the
agitation in favor of the justification of abortion in the tuberculous
pregnant woman. P. 314.

Statistics appear to show, according to Lancereaux, that a considerable
number of cases of tuberculosis develop solely as a result of pregnancy.
If pregnancy can thus affect health, how much more likely would it be
for the disease to assert itself in a woman who is a fit subject for it,
or in one who is actually consumptive. In the former class are so called
candidates for tuberculosis who have a family history of the disease of
much significance under these circumstances. One should strongly
dissuade girls with tubercular history and antecedents from early
marriage, fearing that repeated childbearing will infallibly light up
the dreaded malady. What has been said of the candidate for tuberculosis
applies with the same, or greater force in the case of so-called latent
tuberculosis and of apparent recovery from the disease. Present
sentiment is beginning to dissuade such women from marriage, not less
for their own benefit than for the sake of posterity, and all organized
movements which are seeking to eradicate tuberculosis from the world lay
much stress on discouraging marriage in tuberculosis suspects. Until
this view prevails there will necessarily be some justification for
interrupting a pregnancy already under way. P. 314.

Sanatoria for consumptives do not care to admit pregnant women, and this
prohibition is equivalent to ranking them as incurable. The fact that a
candidate for tuberculosis runs a very great risk of becoming
consumptive through childbirth is a most stubborn one, and when in
addition to becoming a consumptive herself she also brings into the
world an individual who is likely to become tubercular, it readily
becomes apparent that the question of the propriety of therapeutic
abortion is bound to become an issue in the future in the practice of
obstetrics. P. 315.


                           EXCEPTIONAL CASES

A tubercular woman may go through gestation with no undue acceleration
of her malady, only to succumb after delivery to acute general
tuberculosis, or acute tubercular pneumonia. P. 315.

Tubercular pregnant women also show no little tendency to abort. P. 316.


  _TUBERCULOSIS A PREVENTABLE AND CURABLE DISEASE. S. Adolphus Knopf,
      M.D.; Professor of Phthisio-therapy at the New York Post-Graduate
      Medical School and Hospital; Associate Director of the Clinic for
      Pulmonary Disease of the Health Department; Attending Physician to
      the Riverside Sanitorium for Consumptives of the City of New York,
      etc. Moffat Yard & Co., 1909. New York._

We have emphasized the fact that tuberculosis is very rarely directly
hereditary, but that what is often transmitted by tuberculous parents is
a weakened system, or physiological poverty. Nevertheless it is evident
that tuberculous individuals ought not to marry, and when tuberculosis
develops in a married couple it is best that they should have no
children. P. 354.


  _PULMONARY TUBERCULOSIS. Its Modern Prophylaxis and the Treatment in
      Special Institutions and at Home. S. Adolphus Knopf, M.D. P.
      Blakiston’s Sons & Co., Phil., 1899._

If conception has taken place in a tuberculous woman institute
treatment, preferably in a sanatorium near the home of the patient. But
as Treaudeau says, it is essential that the treatment be continued for a
long time afterwards, and I should like to add that a repetition of
pregnancy must be prevented. P. 283.


  _THE TUBERCULOSIS PROBLEM AND SECTION 1142 OF THE PENAL CODE OF THE
      STATE OF NEW YORK. S. Adolphus Knopf, M.D. Reprinted from the New
      York Medical Journal for June 12th, 1915._

There seems to be no difference of opinion in the minds of men and women
who have studied rational eugenics and sociology concerning the
necessity of beginning to work with the preceding generation, and of
teaching parents that quality is better than quantity, and that a large
number of children, underfed or of mental, moral and physical
inferiority, means race suicide, while the reverse means race
preservation.

I cannot defend my attitude better than by telling you the conclusions I
have arrived at in my study of the tuberculosis situation in the United
States. In the families of the poor where there are usually numerous
children, it really matters little whether it is the father or the
mother who is acutely tuberculous. Since almost invariably they live in
close and congested quarters, are underfed and insufficiently clad, it
is of relatively rare occurrence when most of the children do not become
infected with tuberculosis. In some of our tuberculosis clinics where we
insist on an examination of all the children of the tuberculous parents
visiting these special dispensaries, we find as many as fifty per cent.
of the children to be afflicted with tuberculosis as the result of
postnatal infection. In taking the history of a patient in my private
consultation work, it is my invariable custom to ask whether he comes
from a large family, and if so whether he was among the first or latter
born children. As a rule, especially among the poor, it proves to be one
of the latter born, (the fifth, sixth, seventh, eighth, ninth, etc.) who
contracts tuberculosis, and I believe this to be because when he came to
the world there were already many mouths to feed and food was scant, for
the father’s income rarely increases with the increase of the family;
and the mother, worn out with repeated pregnancies, cannot bestow upon
the latter born children the same care which was bestowed upon the
first. We know tuberculosis to be a preventable and curable disease, but
we also know that it is the disease of poverty, privation, malnutrition,
and bad sanitation. P. 4.

I do not know the penalty to be visited upon a physician who offends the
majesty of the law as set forth in section 1142 of the penal code, but I
for one am willing to take the responsibility before the law and before
my God for every time I have counselled, and every time I shall counsel
in the future, the prevention of a tuberculous conception, with a view
to preserving the life of the mother, increasing her chances of
recovery, and, last, but not least, preventing the procreation of a
tuberculous race. P. 5.


  _THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL, BIOLOGICAL AND
      HYGIENIC ASPECTS. E. Heinrich Kisch, M.D., Professor of the German
      Medical Faculty of the University of Prague; Physician to the
      Hospital and Spa of Marienbad; Member of the Board of Health, etc.
      Translated by M. Eden Paul, M.D. Rebman Co., New York._

As regards the marriage of any woman suffering from tuberculosis we must
take into consideration a fact that medical experience has conclusively
established, namely, that the processes of generation have an
unfavorable influence upon pulmonary tuberculosis. P. 259.

During pregnancy tuberculosis advances with such rapid strides that
pregnancy and lying-in accelerate the fatal event. In some cases of
consumption it is the first pregnancy that is the most perilous, but in
other cases a later pregnancy proves more perilous. P. 260.


  _Dr. S. Adolphus Knopf, M.D., Professor of Medicine, Department of
      Phthisio-therapy of the New York Post Graduate Medical School
      and Hospital; Senior Visiting Physician to Riverside
      Hospital-Sanatorium for the Consumptive Poor of the City of New
      York, etc._

     Reprinted from the _Women’s Medical Journal_, September, 1915.

Of the 150,000 who it is estimated die annually from tuberculosis in the
United States, I venture to say 50,000 have been bread winners.
Estimating the value of such a single life to the community at only
about $5,000, this makes a loss of $250,000,000 each year. Another
third, I venture to say, represents children at school age. They have
died without having been able to give any return to their parents or to
the community. Making the average duration of their young life only 7.5
years, and estimating the cost to parents and the community at only $200
per annum, the community loses another $75,000,000. The value of lives
of little babes, children below and above school age, adolescents not
yet bread winners, and men and women no longer able to earn their living
can not be estimated in exact figures, but is reasonable to suppose the
total annual financial loss from tuberculosis in the United States to be
at least half a billion dollars. This does not include the expenditures
for hospitals, sanatoria, clinics, dispensaries, colonies, preventoria
and other agencies, devoted to the solution of the tuberculosis problem.

In the face of these figures and the suffering, misery and
disappointment of parents who lose their children after having tenderly
loved and cared for them for some years, I wonder if there can be any
doubt in the minds of sane men that it would have been better if these
children had never been born. Surely all this is race suicide instead of
race preservation.

Not so very long ago I was asked by a young colleague to aid in the
diagnosis of tuberculosis in a day laborer. The man earned $12 a week,
was thirty-six years of age on the day the examination and diagnosis was
made, had been married fourteen years, and his eleventh child had been
born on his last birthday; four or five had already died, two of them of
tuberculous meningitis. A glance at the rest of the family showed that
nearly all of them were predisposed to tuberculosis, if not already
infected, and that a few years of continued underfeeding and bad housing
would finish their earthly career. With two or three children to provide
for the family might have lived in relative comfort; with better food
and better home environments the father might never have become
tuberculous and none of the children might have contracted the disease.
The commonwealth would have been the gainer by two or three mentally and
physically vigorous future citizens.

Only a few days ago, while an article for the _Journal of Sociologic
Medicine_ was in preparation, an Italian woman presented herself to me
for examination. She gave her age as fifty-six, and had married quite
young. She had borne her husband seventeen children, of which, however,
only four were living. Some had died in infancy, some at school age, and
some during adolescence. What useless suffering! What useless economic
loss to the individual family and society at large. Upon examination, I
found the woman’s mental condition even worse than her physical status.
The repeated pregnancies, the frequent diseases in the family, thirteen
deaths among her children, had made a mental and physical wreck of her.
Yet the woman belonged to the better and well-to-do class of our
population of Italian birth. What would her condition have been if she
had also had to share in the struggle for the existence of the family,
and had had to work in sweatshops or factories, as so many of the poor
Italians have to do?

When pregnancy means danger to the life of the mother, or exacerbation
of an existant mental or physical ailment, as, for example,
tuberculosis, which is always aggravated by child-bearing, every
conscientious physician should do his utmost to prevent childbirth in
such an invalid.

Where there is tuberculosis or any other serious transmissible disease
in one or both of the parents, or there is danger that it may be
transmitted to the offspring, it should not only be the right but the
sacred duty of the physician to prevent the conception of any physically
and mentally handicapped offspring destined to become a burden to the
community.


                            KIDNEY DISEASES


  _THE PRACTICE OF OBSTETRICS. In Original Contributions by American
      Authors. Edited by Reuben Peterson, A.B., M.D., Professor of
      Obstetrics and Gynecology in the University of Michigan, Ann
      Arbor, Mich. Obstetrician and Gynecologist in Chief to the
      University of Michigan Hospital. Lea Bros. & Co., Phil. and New
      York. 1907. Chapter XIX._

Pephritis. From statistics we find that even excluding the cases of
eclampsia, the maternal mortality from nephritis during pregnancy is
33%, and the fetal mortality between 50% and 60%. P. 352.

Women suffering from a chronic nephritis should be advised strongly
against marriage, especially in the presence of a cardiac or pulmonary
lesion. Married women should be warned against impregnation. P. 354.

Pyelitis. “On account of the increased dangers of pyelitic and
especially of a pyelonephritic process during pregnancy, women suffering
from these diseases should be warned against marriage. Married women
should be warned against a new impregnation, on account of the marked
tendency of pyelitis to recur with every pregnancy.” P. 355.


  _PRACTICAL OBSTETRICS. Thos. Watts Eden. Obstetrician, Physician and
      Lecturer on Midwifery and Gynecology, Charing Cross Hospital;
      Consulting Physician to Queen Charlotte’s Lying-in-Hospital;
      Surgeon to In-Patient Chelsea Hospital for Women. 4th Edition. C.
      V. Mosby Co. 1915._

Certain of the conditions enumerated form _absolute_ indications for the
induction to abortion. These are nephritis, (a form of kidney disease),
uncompensated valvular lesions of the heart, advanced tuberculosis,
insanity, irremediable malignant tumors, hydatidiform mole,
uncontrollable uterine haemorrhage, and acute hydramnios. P. 652.


  _PRINCIPLES AND PRACTICE OF OBSTETRICS. Jos. B. De Lee, M.D.,
      Professor of Obstetrics at the Northwestern University Medical
      School; Obstetrician to the Chicago Lying-in-Hospital and
      Dispensary, and to Wesley and Mercy Hospitals, etc. W. B. Saunders
      Co. 1913._

All forms of nephritis have a very bad influence on the pregnancy,
abortion and premature labor being common. (66% Hofmeier) Seitz found
that only from 20% to 30% of the children survived. One of the causes of
habitual death of the fetus, abortion, and premature labor is chronic
nephritis. P. 497.

“The children of nephritics are usually puny and pale.” P. 497.

Both mother and child are seriously jeopardized by chronic nephritis,
the mortalities being about 30% respectively. P. 497.

Women with chronic nephritis should not marry, and if married, should
not conceive. P. 498.

Diabetes. Sterility is common. Abortion and premature labor occur in 33%
of the pregnancies. The children, if the pregnancy goes to term, often
die shortly after birth, the total mortality being 66%. P. 502.

True diabetes has a very bad diagnosis. Offergold found over 50%
mortality. Of the children 51% were still born, 10% died within a few
days after birth, and 5% more before six months. P. 503.

If a woman comes under treatment with a history of diabetes it is best
to terminate the pregnancy at once. P. 503.


  _THE PRACTICE OF OBSTETRICS. Designed for the use of Students and
      Practitioners of Medicine. J. Clifton Edgar. Professor of
      Obstetrical and Clinical Midwifery in the Cornell University
      Medical College; Visiting Obstetrician to Bellevue Hospital, New
      York City; Surgeon to the Manhattan Maternity Dispensary;
      Consulting Obstetrician to the New York Maternity and Jewish
      Hospitals. 5th Edition, Revised. P. Blakiston’s & Co.,
      Philadelphia._

Statistics appear to show that labors in these women, (diabetes) are
quite apt to end unfavorably, in one or another way. When diabetic women
become pregnant their disease usually takes a turn for the worse.
According to Lecorche, true diabetes who become pregnant, usually
succumb to the disease within a short time after delivery. P. 305.


                               ECLAMPSIA


  _THE PRINCIPLES AND PRACTICE OF OBSTETRICS. By Joseph B. De Lee, M.D._

Over 20% of women with eclampsia die and statistics show that 10% of
such cases developed in the maternities. For the child the chances are
not good, nearly one half of the children dying as a result, that is,
due to: prematurity, toxemia, asphyxiation by repeated convulsions of
the mother, drugs administered to the mother, and injuries sustained
during birth, especially forced delivery. Eclampsia is more easily
developed in a pregnant woman because the kidneys are carrying an
increased burden, and too often diseased through the pregnancy changes.
The cause of eclampsia are unknown but in 20% of cases the convulsions
begin during pregnancy, in 60% during labor, and in 20% after delivery.
Page 365.

The treatment is to stop the gestation at a point before either mother
or child, or both, are in danger either to life or to health. Page 1041.


  _MATERNAL MORTALITY. Grace L. Meigs, M.D., U. S. Department of Labor.
      1917._

Puerperal albuminuria and convulsions, called also eclampsia, or toxemia
of pregnancy, is a disease which occurs most frequently during pregnancy
but may occur at or following confinement. It is a relatively frequent
complication among women bearing their first children. When fully
established its chief symptoms are convulsions and unconsciousness. In
the early stages of the disease the symptoms are slight puffiness of the
face, hands, and feet; headache; albumen in the urine; and usually a
rise in blood pressure. Very often proper treatment and diet at the
beginning of such early symptoms may prevent the development of the
disease; but in many cases where the disease is well established before
the physician is consulted, the woman and baby can not be saved by any
treatment. In the prevention of deaths from this cause it is essential,
therefore, that each woman, especially each woman bearing her first
child, should know what she can do, by proper hygiene and diet, to
prevent the disease; that she should know the meaning of these early
symptoms if they arise, so that she may seek at once the advice of her
doctor; and that she should have regular supervision during pregnancy,
with examination of the urine at intervals.


                                DIABETES


  _THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Joseph B. De Lee, M.D.
      Page 514._

Without doubt pregnancy has a bad effect on the course of this disease.
It may develop a latent diabetes, there being cases where severe
symptoms appeared only during successive pregnancies, and others where
the disease grew progressively worse each time. Coma occurs in 30% of
the cases and is almost always fatal. It may be brought on by a slight
shock in pregnancy, but more often during and just after labor. Delivery
seems to have a worse effect than most surgical operations, causing
collapse, coma, or sudden death. Bronchitis has been noted in the
puerperium, and this has been found to eventuate in tuberculosis. True
diabetes has a very bad prognosis, authorities finding over 50%
mortality, of which 30% died in coma, within two and one half years, and
too often the child dies in utero.


                           PELVIC DEFORMITIES


  _MATERNAL MORTALITY. Grace L. Meigs, M.D., U. S. Department of Labor,
      1917._

Some obstruction to labor in the small size or abnormal shape of the
pelvic canal causes many deaths of mothers included in the class “other
accidents of labor” and also many stillbirths. If such difficulty is
discovered before labor, proper treatment will in almost all cases
insure the life of mother and child; if it is not discovered until labor
has begun, or perhaps until it has continued for many hours, the danger
to both is greatly increased. Every woman, therefore, should have during
pregnancy—and above all during her first pregnancy—an examination in
which measurements are made to enable the physician to judge whether or
not there will be any obstruction to labor. A case in which a
complication of this kind is found requires the greatest skill and
experience in treatment, but with such treatment the life and health of
the mother are almost always safe.


  _PRINCIPLES AND PRACTICE OF OBSTETRICS. Jos. B. De Lee, M.D.,
      Professor of Obstetrics at the Northwestern University Medical
      School; Obstetrician to the Chicago Lying-in-Hospital and
      Dispensary, and to Wesley and Mercy Hospitals, etc. W. B. Saunders
      Co. 1913._

No subject in medicine presents greater difficulties in all its aspects
than this one, (treatment of contracted pelves) and none demands such
art or practical skill. Science aids little here. P. 709.

Outside factors must also be considered: 1—The environment, whether the
parturient is in a squalid tenement, in the country, in a home where
every appliance is attainable, or in a well equipped maternity.
2—Whether in the hands of a general practitioner or a trained
specialist. 3—If the patient is a Catholic, all medically indicated
procedures not being permitted. 4—The age of the parturient, and the
probability of her having more children. Even with these enumerations,
the possible factors which might influence a labor, or our decision
regarding the course to pursue have not all been mentioned. P. 709.


  _THE PRACTICE OF OBSTETRICS. Designed for the use of Practitioners and
      Students of Medicine. J. Clifton Edgar, Professor of Obstetrics
      and Clinical Midwifery in the Cornell University Medical College.
      Visiting Obstetrician to Bellevue Hospital, New York City; Surgeon
      to the Manhattan Maternity Dispensary; Consulting obstetrician to
      the New York Maternity and Jewish Maternity Hospitals. 5th
      Edition, Revised. P. Blakiston’s & Co., Phila._

A knowledge of the female bony pelvis is the very alphabet of
obstetrical science, and the foundation of obstetrical art. This
structure is most important since it is from the disproportion between
its size and that of the fetus, or from its abnormal shape that many of
the difficulties of labor arise.


  _PRACTICAL OBSTETRICS. Thos. Watts Eden. Obstetrician; Physician and
      Lecturer on Midwifery and Gynecology, Charing Cross Hospital;
      Consulting Physician to Queen Charlotte’s Lying-in-Hospital;
      Surgeon to In-Patient Chelsea Hospital for Women. 4th Edition. C.
      V. Mosby Co. 1915._

The general course of labor is modified by pelvic contractions in
various ways. 1—Abnormal presentations are three or four times commoner
in contracted than in normal pelves. 2—Prolapse of the cord is much
commoner than in normal pelves. 3—When natural delivery occurs labor is
prolonged and the mechanism is modified. 4—Unless the true conjugate is
at least 3¼ inches, even with artificial aid the survival of the child
is seriously jeopardized. 5—The maternal risks are increased by the
greater length and difficulty of the labor and by the frequent necessity
of employing artificial methods of delivery. 6—The fetal risks are
increased in natural delivery by severe compression of the head during
its passage through the narrow pelvis, and other circumstances by the
operations required to effect delivery, some of which involve the
destruction of the fetus. P. 409.


  _THE PRACTICE OF OBSTETRICS. In Original Contributions by American
      authors. Edited by Reuben Peterson, A.B., M.D. Lea Bros. & Co.,
      Phil. and New York. 1907._

Labor complicated by anomalies of the Bony Pelvis. John F. Moran, M.D.

The frequency with which pelvic contraction occurs can only be
determined with relative accuracy. There is in existence a comparatively
large amount of statistical data on this subject, but the reports of
different investigators vary within wide limits, and these variations
are naturally not to be explained entirely on the assumption of racial
conditions, or geographic distribution. Between these wide limits are
arrayed the figures of about 20 modern observers in different parts of
the civilized world who have reported statistics of cases. The combined
figures of 19 observers include a total of over 150,000 cases examined
for pelvic contraction. In these cases the average of contraction is
found to be about 10%. Williams concludes that contracted pelves occur
in from 7% to 8% of the white women of this country. P. 658–659.


                             HEART DISEASE


  _THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL, BIOLOGICAL AND
      HYGIENIC ASPECTS. E. Heinrich Kisch, M.D. Professor of the German
      Medical faculty of the University of Prague; Physician to the
      Hospital and Spa of Marienbad; Member of the Board of Health, etc.
      Translated by M. Eden Paul, M.D. Rebman Co., New York._

These are cases (severe heart disease) in which, in my opinion, it is
the physician’s duty to concern himself with the subject of the use of
preventive measures, and having regard for the preservation of a woman’s
life, and uninfluenced by any false delicacy, but with simple
earnestness to inform his patient with respect to the needful
prophylactic measures. The artificial termination of pregnancy, which
unquestionably is often justified in women suffering from heart disease,
but which unfortunately is apt to have very unfavorable results, will
rarely need to be discussed if by the proper employment of preventive
measures care is taken that pregnancy does not recur too frequently. P.
255.


  _OBSTETRICS. A Text Book for the use of Students and Practitioners.
      Whitridge Williams, Professor of Obstetrics, Johns Hopkins
      University; Obstetrician in Chief to the Johns Hopkins Hospital;
      Gynecologist to the Union Protestant Infirmary, Baltimore, Md. D.
      Appleton & Co., 1912._

Some authorities recommend that women suffering from heart lesions
should be dissuaded from marriage, or if married, from becoming
pregnant. This, however, appears to be an extreme view, though of course
when the lesion is serious and the compensation faulty the dangers of
child-bearing should be carefully explained. P. 498.


  _THE PRACTICE OF OBSTETRICS. In Original Contributions by American
      authors. Edited by Reuben Peterson, A.B., M.D., Professor of
      Obstetrics and Gynecology in the University of Michigan, Ann
      Arbor, Mich.; Obstetrician and Gynecologist-in-Chief to the
      University of Michigan Hospital. Lea Bros. & Co., Phil. and New
      York. 1907. Chapter XIX._

“Leyden claims that about 40% of all women with serious heart lesions
meet their death in connection with childbirth. Still greater than the
demands upon the heart during pregnancy are those made by labor. The
strain, mental excitement, and especially the sudden changes in the
blood pressure, conditions which are well recognized as extremely
harmful to every patient with a chronic heart lesion, and which cannot
be avoided in the course of labor, make the situation extremely
dangerous.” (Hugo Ehrenfest, M.D.) P. 357.

“The prognosis for the fetus is unfavorable. Fellner, whose figures
undoubtedly are low, places the frequency of premature, spontaneous
interruption of pregnancy as 20%, other writers at from 40% to 60%.” P.
358.

“No marriage for the unmarried, no pregnancy for the married, no nursing
for the confined,” is a statement which has been made by a French
author, and has been accepted by many writers. It is incompatible with
the results of recent investigations. It would be too harsh and
unjustifiable to deny marriage to a woman who has a well compensated
valvular lesion. She should be informed of the risks of impregnation,
but should be warned against marriage only where there exist distinct
evidences of incompensation, especially in cases of mitral stenosis. P.
359.


  _A TEXT BOOK OF OBSTETRICS. Barton Cooke Hirst, M.D.; Professor of
      Obstetrics in the University of Pennsylvania; Gynecologist to the
      Howard and Orthopaedic, and the Philadelphia Hospitals, etc. 7th
      Edition. W. B. Saunders Co., Philadelphia and London. 1912._

Abortion is induced in about 25% of all cases, as the result of
placental apoplexies, or of the stimulation of the uterus to contraction
by the accumulation of carbondioxid gas in the blood. Pregnancy
distinctly increases the danger of the heart lesion. In 58 serious
cases, 23 died after premature delivery of the child. In milder cases
prognosis is not grave, yet the woman’s condition is by no means free
from danger. If the disease be of long standing and serious in
character, it appears from statistical studies that about half the women
die. P. 423.


  _PRINCIPLES AND PRACTICE OF OBSTETRICS. Jos. B. De Lee, M.D.;
      Professor of Obstetrics at the Northwestern University Medical
      School; Obstetrician to the Chicago Lying-in-Hospital, and to
      Wesley and Mercy Hospitals, etc. W. B. Saunders Co. 1913._

Abortion and premature labor, especially the latter, occur in cases of
dis-compensation, in from 20% to 40%, and stillbirth in 29% to 70%,
giving figures collected from various sources by Fellner. P. 489.


  _THE PRACTICE OF OBSTETRICS. Designed for the use of Students and
      Practitioners of Medicine. J. Clifton Edgar, Professor of
      Obstetrics and clinical midwifery in the Cornell University
      Medical School; Visiting Obstetrician to Bellevue Hospital, New
      York City; Surgeon to the Manhattan Maternity and Dispensary;
      Consulting Obstetrician to the New York Maternity and Jewish
      Maternity Hospitals. 5th Edition, Revised. P. Blakiston’s & Co.,
      Philadelphia._

Acute Endocarditis not only has an injurious influence upon pregnancy,
but it is also apt itself to become extremely grave. Regarding
treatment, induced labor will be demanded. P. 310.


                        TOO FREQUENT PREGNANCIES


  _BEING WELL BORN. An Introduction to Eugenics. Michael F. Guyer,
      Ph.D., Professor of Zoology, University of Wisconsin.
      Bobbs-Merrill Co. Indianapolis. 1916._

Too short an interval between childbirths would also seem to be an
infringement on the rights of the child as well as of the mother. Thus
Dr. R. J. Ewart, (“The Influence of Parental Age on Offspring,” _Eugenic
Review_, Oct., 1911) finds that children born at intervals of less than
two years after the birth of the previous child still show at the age of
six a notable deficiency in height, weight and intelligence, when
compared with the children born after a longer interval, or even with
first-born children. P. 166.


  _FREQUENT PREGNANCIES. The Contributions of Demography to Eugenics.
      Dr. Corrado Gini, Professor of Statistics at the Royal University
      of Cagliari, Italy._

If the possibility of generation at any season of the year cannot, as
has been shown, have any deleterious effect on the vitality of human
offspring, it can none the less have indirect deleterious consequences,
in so far as it allows pregnancies to succeed each other at too short
intervals. P. 323.

“The deleterious consequences which too short a period after the
preceding birth have upon the vitality of the child are indisputable, at
least during the first year of life.” P. 323.


  _THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL, BIOLOGICAL AND
      HYGIENIC ASPECTS. E. Heinrich Kisch. Rebman Co., N. Y._

“Frequently recurring pregnancies and childbirth, according to Kronig,
act as the predisposing cause in the production of neurasthenia.” P.
257.


  _NEO-MALTHUSIANISM AND RACE HYGIENE, IN “PROBLEMS IN EUGENICS.” Vol.
      2. Dr. Alfred Ploetz, President of the International Society for
      Race Hygiene. London, 1913._

Malthusianism further affects the quality of the offspring by increasing
the intervals between single births. In families in which the parents
intend to have only a few children, the mother is usually exempt from so
frequent child-bearing, and she has ample time for regaining her
strength. The greater interval between births has evidently a favorable
effect upon the expectation of life of the children that are born.
Westergard has stated that in 21,000 births, if the interval between
birth is:—


                                       The percentage of deaths before
                                            five years of age is
 Less than one year                                  20%
 One to two years                                    14%
 More than two years                                 12%

That means a difference in the mortality between first and last class of
40% in favor of the longer interval. P. 186.


  _THE LIFE INSURANCE EXAMINER. A Practical Treatise by Charles F.
      Stillman, M.S., M.D., Medical Examiner for the Mutual Life
      Insurance Co.; Clinical Professor of Orthopaedic Surgery in the
      Women’s Medical College of the N. Y. Infirmary; Orthopaedic
      Surgeon to the N. Y. Infant Asylum; Member of the Am. Orthopaedic
      Association; Permanent member of the American Medical Association;
      Fellow N. Y. Academy of Medicine, etc. 3rd Edition. Spectator Co.,
      N. Y., 1890._

“Postpone (as dangerous insurance risks) all cases of pregnancy; all
instances where the mother seems, in the judgment of the Examiner, to
have been bearing children too fast.” P. 186.


  _RASSENVERBESSERUNG. Translated from the Dutch of Dr. J. Rutgers. 2nd
      Edition. Dresden, 1911._

The combatting of self-induced abortion is one of the problems of Sexual
Hygiene. The two causes of most weight in this situation are syphilis
and too frequent pregnancy. It is quite evident that both of these
causes would be favorably influenced by the use of contraceptive
measures. P. 81.


  _THE MALTHUSIAN, May 15, 1914. Sexual Ethics. A Study of Borderland
      Questions. Robert Michels, (Review)._

Prof. Michels perceives that race control has two aspects; it may be an
urgent duty, and it is in any case an inalienable human right. It may be
regarded as a duty to actual or potential children, in view of either
bad economic conditions,—such as affect the bulk of all European
populations,—or defective heredity, and it may also be considered as an
obligation of humanity towards the wife and mother. Prof. Michels here
speaks with no uncertain voice: “The type of woman continually engaged
in child-bearing is a primitive one, out of harmony with the needs and
ideas of modern civilized life. Even as few as six pregnancies that go
to full term rob a woman of about ten years of her life, and these the
best. It is evidently far easier to provide a clear-sighted affection
and a wisely conceived and individualized upbringing for two or three
children than it is for eight or nine.”


  _MR. SIDNEY WEBB, in The Times of October 16, 1906._

Assuming, as I think we may, that no injury to physical health is
necessarily involved (in the volitional regulation of the marriage
state); aware, on the contrary, that the result is to spare the wife
from an onerous and even dangerous illness for which in the vast
majority of homes no adequate provision in the way of medical
attendance, nursing, privacy, rest, and freedom from worry can possibly
be made, it is, to say the least of it, difficult on any rationalist
morality to formulate any blame of a married couple for the deliberate
regulation of their family according to their means and opportunities.


                          PERNICIOUS VOMITING


  _THE PRINCIPLES AND PRACTICE OF OBSTETRICS. By Joseph B. De Lee, M.D._

Among diseases incidental to pregnancy must be counted pernicious
vomiting. Page 370.

Statistics are uncertain, but out of 118 cases there were 46 deaths.
Page 357.

The keynote of treatment is to stop the gestation at a point before
either mother or child, or both, are in danger to life or to health.
Page 1041.


  _THE PRACTICE OF OBSTETRICS. By J. Clifton Edgar, M.D., Professor of
      Obstetrics and Clinical Midwifery in the Cornell University
      Medical College; Visiting Obstetrician to Bellevue Hospital, New
      York City; Surgeon to the Manhattan Maternity and Dispensary;
      Consulting Obstetrician of the New York Maternity and Jewish
      Maternity Hospitals, New York City._

Under certain circumstances labor may be much disturbed by pernicious
vomiting. The causes comprise actual organic disease of the stomach and
functional disturbances from errors in diet. The determining cause of a
paroxysm of vomiting is a severe labor pain. The coincidence of labor
and vomiting is not unusual in anemic primiparae. Mental emotion is also
a cause. As this vomiting may presage the development of eclampsia or
some other affection it is best to terminate labor at once. Page 648.



                               CHAPTER VI
           HARMFUL METHODS PRACTICED TO AVOID LARGE FAMILIES


_In this chapter it is shown that ignorance of scientific means of
preventing conception involves women in harmful practices. The most
common is coitus interruptus which results in nervous disorders. Long
continued celibacy or unnatural continence leads to sex inversions.
When, in spite of these unscientific practices, pregnancy follows,
abortion, the greatest disgrace of modern civilization, is the only
resort of the harassed mother, unless she will bear unwanted offspring._


                           COITUS INTERRUPTUS


  _THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL, BIOLOGICAL AND
      HYGIENIC ASPECTS. E. Heinrich Kisch, M.D._

The prevailing practice of coitus interruptus leads, in my experience in
consequence of the intense hyperaemia of the uterus and the uterine
annexa unrelieved by the occurrence of the orgasm, to a condition of
stasis in the female reproductive organs, and this ultimately passes on
into chronic netritis, (with relaxation of the uterus, retro-flexion, or
ante-flexion, catarrhal diseases of the mucous membrane, erosions and
follicular laceration of the portio vaginalis) oophoritis and
perimetritis. The evil effects of coitus interruptus for a woman are
dependent on the fact that the woman fails to obtain complete sexual
gratification, and that this has an important influence on her entire
organism. If this ungratifying coitus interruptus is frequently repeated
in a voluptuous woman disorders of the reproductive organs ensue, and
even more frequently nervous disorders in the form of neurasthenia
sexualis. P. 403.

Mantegazza believes that organic disease of the spinal cord may actually
result from coitus interruptus.

Hirt considers that even when marital intercourse is carefully regulated
with respect to frequency, coitus interruptus may lead to neurasthenic
manifestations.

Eulenberg also declares that coitus interruptus is already a frequent
cause of sexual neurasthenia in women and that its evil influence in
this respect is becoming more and more frequently manifest. P. 405.

Valenta declared that coitus interruptus was one of the chief causes of
chronic netritis.

According to Kleinwachter, coitus interruptus is harmful to the woman to
an extent by no means trivial, whereas the man in whom ejaculation
occurs, suffers comparatively little. P. 407.


  _DISORDERS OF THE SEXUAL FUNCTION. By Max Huhner, M.D., Chief of
      Clinic, Genitourinary Department, Mt. Sinai Hospital Dispensary,
      New York City._

If the act of coitus is stopped before it is completed, the seminal
vesicles have not been able to completely empty themselves, or to empty
themselves as completely as during a normal coitus, and are thus left
more or less filled. The mucous membrane in the prostalic urethra has
not been able to completely deplethorize itself, and thus remains more
or less congested after the act. As a result of all this, impulses are
sent much sooner from the distended vesicles and the prostatic urethra
to the erection center and the cerebrum, so that the desire for coitus
is felt sooner than after normal coitus. The seminal vesicles, being
never completely emptied during withdrawal coitus, are constantly
sending impulses to the erection center, while the mucous membrane of
the prostatic urethra, being in a condition of chronic congestion in
consequence of repeated acts of withdrawal, is likewise sending
continuous impulses to the same center whether coitus is indulged or
not. The result of these continued impulses sent from both sources, as
well as the repeated demands made upon the center itself from the oft
repeated acts of coitus, is, that the erection center does not
completely recover itself and finally remains in a state of
hyperexcitability.... It must be remembered, however, that all this does
not occur as a result of a single act of withdrawal; and it is often
only after years of this practice that the harmful effects above
described become evident. Page 227.


                               CONTINENCE


  _THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL, BIOLOGICAL AND
      HYGIENIC ASPECTS. E. Heinrich Kisch, M.D._

Grafe, with reference to the view that if for any reason conception must
be avoided this should be done by abstinence from sexual intercourse,
remarks, “doubtless the ideal demand, but one which even those with
exceptional strength of will are unlikely to satisfy. And the worst of
it is that even a single indiscretion will often result in
impregnation.” Moreover, it is distinctly contrary to natural conditions
that a healthy married couple, united by an intimate affection should
live together, abstaining completely from sexual intercourse. The
question has already been much discussed, both in speech and writing,
and this will continue in the future without altering the fact that the
physician will be asked, and will be compelled to give advice regarding
the use of means of prevention of pregnancy. P. 399.

The desired goal of artificial sterility will not, however, be reached
through advocacy of moderation and continence. P. 400.


  _EFFECTS OF ABSTINENCE. Rassenverbesserung. Translated from the Dutch
      of Dr. J. Rutgers._

And if we could penetrate still more deeply into the recesses of the
instincts, and project into the light of day the world of phantasy of
those who live in enforced continence, we would draw away in horror from
the spectacle of what each individual must conceal from himself and
others. We would not then be so eager for the consummation of what is
called sexual abstinence. P. 14.

Physiology teaches that every function gains in power and efficiency
through a certain degree of control, but that the too-extended
suppression of a desire gives rise to pathological disturbances and in
time cripples the function. Especially in the case of women may the
damage entailed by too long continued sexual abstinence, bring about
deep disturbances, all the more because women more often than men
misunderstand, or are unaware of this etiological moment, and have not
the slightest idea of the true cause of their psychic and somatic
injury. P. 15.

The unmarried state is a trying and often injurious condition for a man
as well as a woman, when they live in strict continence; and if the
latter is not the case and they resort to prostitution, there are even
more pain and suffering in store for them. P. 16.

We must not forget that there are always two parties to the situation.
What can a physically weaker and spiritually stronger woman do even if
she desires continence with her whole soul, but her husband will have
none of it? Is it not then her duty to protect herself in order that she
may not give birth to a weakly progeny?


  _HARPER’S WEEKLY. 1915._

When Dr. A. A. Brill, Lecturer in Abnormal Psychology, New York
University, and formerly Chief of Clinic in Psychiatry, Columbia
University, was asked how he regarded contraception in relation to
nervous diseases, he replied emphatically: “You can say that I am for
it. It is much better than an abortion. For instance, I have in mind a
woman who was discharged from the insane hospital. She had three
children and had been three times insane. What chance in life has a
child born between two attacks of insanity, whose mother is mentally
defective? Even sane women, if they are nervous and emotional, should
never bear children against their will. It is foolish to talk about
making people have children when they do not want them. It’s bad for the
woman and bad for the child. It is very bad for a child to be born into
a home where he is not desired. I find that many adult, nervous patients
were unwished-for-children, and it was the early attitude of their
parents toward them that contributed much to their bent toward nervous
invalidism.” In reply to the contention of the anti-regulationists that
contraception is physically and mentally harmful, he stated that certain
methods are injurious, while others are not. He commented on the
unfortunate fact that it is the undesirable methods which are employed
by the poorer people, because druggists put a high price upon the better
means on the plea that they run a risk in selling them at all.
Remembering that Dr. Brill was for years connected with Central Islip,
he was asked if he did not consider it demanding a good deal to expect a
man discharged from an insane asylum and sent home to his wife, to live
a sexually abstinent life. He replied: “Only people who know nothing of
the sex impulse can make such a demand of a person who has a poor mental
organization. Of course it is impossible. It is impossible even for the
average normal man, and especially for those who live crowded in two or
three rooms.”


  _THE SEXUAL LIFE. By P. W. Malchow, M.D., Professor of Proctology, and
      Associate in Clinical Medicine, Hamline University, College of
      Physicians and Surgeons; member Hennepin County Medical Society,
      Minnesota State Medical Society, American Medical Association,
      etc._

There can be no doubt that the influence of prolonged continence upon
either the male or female is to dwarf and in many respects destroy that
which goes to make a broad and full physical and intellectual
personality and that to perform the sexual act whenever there is an
existing state of sexual excitement, with the usual marital
restrictions, is rather beneficial that otherwise. Page 201.

In cases of nervousness in either sex it may be found that, as a rule,
the first indication is a disturbance of the sexual function, following
which there will be digestive troubles, then affections of special
nerves, of which disorders of sight are the first and most frequent,
with neuralgias, etc., later. Observation has shown this to be the
general rule, and that is also in accordance with the law of
self-preservation. With the conviction that nervousness is first
manifested and begins with an alteration in the natural sexual function
we may conclude that other functional disorders are a natural sequence.
It thus becomes evident that the most prolific cause of nervousness is
an inability for natural sexual living. Page 296.

A life of celibacy cannot be said to be a natural one, and when this
state of celibacy is combined with propinquity, in which there must of
necessity be a source of repeated and more or less constant sexual
excitability there is added to one already incomplete life a greater
burden of increased tension, which must be a very considerable factor in
the causation of unrest or nervousness. Page 155.

How best to circumvent family complications is the burning question of
the hour with the average young wife, and a satisfactory solution of
this problem would be a boon to society and prevent untold suffering.
When confronted with the question, the usual answer is, in effect, “be
natural,” which in these days of stress, is no answer at all, as it is
not practical. Page 158.


                        THE OBJECTS OF MARRIAGE

                           BY HAVELOCK ELLIS

What are the legitimate objects of marriage? We know that many people
seek to marry for ends that can scarcely be called legitimate, that men
may marry to obtain a cheap domestic drudge or nurse, and that women may
marry to be kept when they are tired of keeping themselves. These
objects in marriage may or may not be moral, but in any case they are
scarcely its legitimate ends. We are here concerned to ascertain those
ends of marriage which are legitimate when we take the highest ground as
moral and civilized men and women living in an advanced state of society
and seeking, if we can, to advance that state of society still further.

The primary end of marriage is to beget and bear offspring, and to rear
them until they are able to take care of themselves. On that basis Man
is at one with all the mammals and most of the birds. If, indeed, we
disregard the originally less essential part of this end,—that is to
say, the care and tending of the young,—this end of marriage is not only
the primary but usually the sole end of sexual intercourse in the whole
mammal world. As a natural instinct, its achievement involves
gratification and well-being, but this bait of gratification is merely a
device of Nature’s and not in itself an end having any useful function
at the periods when conception is not possible. This is clearly
indicated by the fact that among animals the female only experiences
sexual desire at the season of impregnation, and that desire ceases as
soon as impregnation takes place, though this is only in a few species
true of the male, obviously because, if his sexual desire and aptitude
were confined to so brief a period, the chances of the female meeting
the right male at the right moment would be too seriously diminished; so
that the attentive and inquisitive attitude towards the female by the
male animal—which we may often think we see still traceable in the human
species—is not the outcome of lustfulness for personal gratification
(“wantonly to satisfy carnal lusts and appetites like brute beasts,” as
the Anglican Prayer Book incorrectly puts it) but implanted by Nature
for the benefit of the female and the attainment of the primary object
of procreation. This primary object we may term the animal end of
marriage.

This object remains not only the primary but even the sole end of
marriage among the lower races of mankind generally. The erotic idea in
its deeper sense, that is to say the element of love, arose very slowly
in mankind. It is found, it is true, among some lower races, and it
appears that some tribes possess a word for the joy of love in a purely
psychic sense. But even among European races the evolution was late. The
Greek poets, except the latest, showed little recognition of love as an
element of marriage. Theognis compared marriage with cattle-breeding.
The Romans of the Republic took much the same view. Greeks and Romans
alike regarded breeding as the one recognizable object of marriage; any
other object was mere wantonness and had better, they thought, be
carried on outside marriage. Religion, which preserves so many ancient
and primitive conceptions of life, has consecrated this conception also,
and Christianity—though, as I will point out later, it has tended to
enlarge the conception—at the outset only offered the choice between
celibacy on the one hand and on the other marriage for the production of
offspring.

Yet from an early period in human history a secondary function of sexual
intercourse had been slowly growing up to become one of the great
objects of marriage. Among animals, it may be said, and even sometimes
in man, the sexual impulse, when once aroused, makes but a short and
swift circuit through the brain to reach its consummation. But as the
brain and its faculties develop, powerfully aided indeed by the very
difficulties of the sexual life, the impulse for sexual union has to
traverse ever longer, slower, more painful paths, before it reaches—and
sometimes it never reaches—its ultimate object. This means that sex
gradually becomes intertwined with all the highest and subtlest human
emotions and activities, with the refinements of social intercourse,
with high adventure in every sphere, with art, with religion. The
primitive animal instinct, having the sole end of procreation, becomes
on its way to that end the inspiring stimulus to all those psychic
energies which in civilization we count most precious. This function is
thus, we see, a by-product. But, as we know, even in our human
factories, the by-product is sometimes more valuable even than the
product. That is so as regards the functional products of human
evolution. The hand was produced out of the animal fore-limb with the
primary end of grasping the things we materially need, but as a
by-product the hand has developed the function of making and playing the
piano and the violin, and that secondary functional by-product of the
hand we account, even as measured by the rough test of money, more
precious, however less materially necessary, than its primary function.
It is, however, only in rare and gifted natures that transformed sexual
energy becomes of supreme value for its own sake without ever attaining
the normal physical outlet. For the most part the by-product accompanies
the product, throughout, thus adding a secondary, yet peculiarly sacred
and specially human, object of marriage to its primary animal object.
This may be termed the spiritual object of marriage.

By the term “spiritual” we are not to understand any mysterious and
supernatural qualities. It is simply a convenient name, in distinction
from animal, to cover all those higher mental and emotional processes
which in human evolution are ever gaining greater power. It is needless
to enumerate the constituents of this spiritual end of sexual
intercourse, for everyone is entitled to enumerate them differently and
in different order. They include not only all that makes love a gracious
and beautiful erotic art, but the whole element of pleasure in so far as
pleasure is more than a mere animal gratification. Our ancient ascetic
traditions often make us blind to the meaning of pleasure. We see only
its possibilities of evil and not its mightiness for good. We forget
that, as Romain Rolland says, “Joy is as holy as Pain.” No one has
insisted so much on the supreme importance of the element of pleasure in
the spiritual ends of sex as James Hinton. Rightly used, he declares,
Pleasure is “the Child of God,” to be recognized as “a mighty storehouse
of force,” and he pointed out the significant fact that in the course of
human progress its importance increases rather than diminishes. While it
is perfectly true that sexual energy may be in large degree arrested,
and transformed into intellectual and moral forms, yet it is also true
that pleasure itself, and above all, sexual pleasure, wisely used and
not abused, may prove the stimulus and liberator of our finest and most
exalted activities. It is largely this remarkable function of sexual
pleasure which is decisive in settling the argument of those who claim
that continence is the only alternative to the animal end of marriage.
That argument ignores the liberating and harmonising influences, giving
wholesome balance and sanity to the whole organism, imparted by a sexual
union which is the outcome of the psychic as well as physical needs.
There is, further, in the attainment of the spiritual end of marriage,
much more than the benefit of each individual separately. There is, that
is to say, the effect on the union itself. For through harmonious sex
relationships a deeper spiritual unity is reached than can possibly be
derived from continence in or out of marriage, and the marriage
association becomes an apter instrument in the service of the world.
Apart from any sexual craving, the complete spiritual contact of two
persons who love each other can only be attained through some act of
rare intimacy. No act can be quite so intimate as the sexual embrace. In
its accomplishment, for all spiritually evolved persons, the communion
of bodies becomes the communion of souls. The outward and visible sign
has been the consummation of an inward and spiritual grace. “I would
base all my sex teaching to children and young people on the beauty and
sacredness of sex,” writes a distinguished woman of today; “sex
intercourse is the great sacrament of life, he that eateth and drinketh
unworthily eateth and drinketh his own damnation; but it may be the most
beautiful sacrament between two souls who have no thought of children.”
To many the idea of a sacrament seems merely typo for ecclesiastical,
but that is a misunderstanding. The word “sacrament” is the ancient
Roman name of a soldier’s oath of military allegiance, and the idea, in
the deeper sense, existed long before Christianity, and has ever been
regarded as the physical sign of the closest possible union with some
great spiritual reality. From our modern standpoint we may say, with
James Hinton, that the sexual embrace, worthily understood, can only be
compared with music and with prayer. “Every true lover,” it has been
well said by a woman, “knows this, and the worth of any and every
relationship can be judged by its success in reaching, or failing to
reach, this standpoint.”

I have mentioned how the Church—in part influenced by that clinging to
primitive conceptions which always marks religions and in part by its
ancient traditions of asceticism—tended to insist mainly if not
exclusively on the animal object of marriage. It sought to reduce sex to
a minimum because the pagans magnified sex; it banned pleasure because
the Christian’s path on earth was the way of the Cross; and though
theologians accepted the idea of a “Sacrament of Nature” they could only
allow it to operate when the active interference of the priest was
impossible, though it must in justice be said that, before the Council
of Trent, the Western Church recognized that the sacrament of marriage
was effected entirely by the act of the two celebrants themselves and
not by the priest. Gradually, however, a more reasonable and humane
opinion crept into the Church. Intercourse outside the animal end of
marriage was indeed a sin, but it became merely a venial sin. The great
influence of St. Augustine was on the side of allowing much freedom to
intercourse outside the aim of procreation. At the Reformation, John à
Lasco, a Catholic Bishop who became a Protestant and settled in England,
laid it down, following various earlier theologians, that the object of
marriage, besides offspring, was to serve as a “sacrament of
consolation” to the united couple, and that view was more or less
accepted by the founders of the Protestant churches. It is the generally
accepted Protestant view today.[50] The importance of the spiritual end
of intercourse in marriage, alike for the higher development of each
member of the couple and for the intimacy and stability of their union,
is still more emphatically set forth by the more advanced thinkers of
today.

Footnote 50:

  It is well set forth by the Rev. H. Northcote in his excellent book,
  _Christianity and Sex Problems_, (2nd edition, 1916, F. A. Davis
  Company, Philadelphia), especially Ch. XIII.

There is something pathetic in the spectacle of those among us who are
still only able to recognize the animal end of marriage, and who point
to the example of the lower animals—among whom the biological conditions
are entirely different—as worthy of our imitation. It has taken God—or
Nature, if we will—unknown millions of years of painful struggle to
evolve Man, and to raise the human species above that helpless bondage
to reproduction which marks the lower animals. But on these people it
has all been wasted. They are at the animal stage still. They have yet
to learn the A. B. C. of love. A representative of these people in the
person of an Anglican bishop, the Bishop of Southwark, appeared as a
witness before the National Birth-Rate Commission which, two years ago,
met in London to investigate the decline of the birth-rate. He declared
that procreation is the sole legitimate object of marriage and that
intercourse for any other end was a degrading act of mere
“self-gratification.” This declaration had the interesting result of
evoking the comments of many members of the Commission, formed of
representative men and women with various standpoints,—Protestant,
Catholic, and other,—and it is notable that while not one identified
himself with the Bishop’s opinion, several decisively opposed that
opinion, as contrary to the best beliefs of both ancient and modern
times, as representing a low and not a high moral standpoint, and as
involving the notion that the whole sexual activity of an individual
should be reduced to perhaps two or three effective acts of intercourse
in a life-time. Such a notion obviously cannot be carried into general
practice, putting aside the question as to whether it would be
desirable, and it may be added that it would have the further result of
shutting out from the life of love altogether all those persons who, for
whatever reason, feel that it is their duty to refrain from having
children at all. It is the attitude of a handful of Pharisees seeking to
thrust the bulk of mankind into Hell. All this confusion and evil comes
of the blindness which cannot know that, beyond the primary animal end
of propagation in marriage, there is a secondary but more exalted
spiritual end.

It is needless to insist how intimately that secondary end of marriage
is bound up with the practice of birth control. Without birth control,
indeed, it could frequently have no existence at all, and even at the
best seldom be free from disconcerting possibilities fatal to its very
essence. Against these disconcerting possibilities is often placed, on
the other side, the un-esthetic nature of the contraceptives associated
with birth control. Yet, it must be remembered, they are of a part with
the whole of our civilized human life. We at no point enter the
spiritual save through the material. Forel has in this connection
compared the use of contraceptives to the use of eye-glasses.
Eye-glasses are equally un-esthetic, yet they are devices, based on
Nature, wherewith to supplement the deficiencies of Nature. However in
themselves un-esthetic, for those who need them they make the esthetic
possible. Eye-glasses and contraceptives alike are a portal to the
spiritual world for many who, without them, would find that world
largely a closed book.

Birth control is effecting, and promising to effect, many functions in
our social life. By furnishing the means to limit the size of families
which would otherwise be excessive it confers the greatest benefit on
the family and especially on the mother. By rendering easily possible a
selection in parentage and the choice of the right time and
circumstances for conception it is again, the chief key to the eugenic
improvement of the race. There are many other benefits, as is now
generally becoming clear, which will be derived from the rightly applied
practice of birth control. To many of us it is not the least of these
that birth control effects finally the complete liberation of the
spiritual object of marriage.


                                ABORTION


  _THE PRINCIPLES AND PRACTICE OF OBSTETRICS. By Joseph De Lee, M.D...._

It is said that there is one abortion to eight labors, but in all
probability it is more frequent than this. Almost half of the
child-bearing women have had a miscarriage before the thirty-fifth year.
Statistics are of questionable value because hospital figures do not
represent the conditions of private practice. Further, many occur in
first weeks and pass under the diagnosis of delayed or profuse
menstruation. Finally, many abortions are deliberately concealed. Page
426.


  _PRACTICE OF OBSTETRICS. By J. Clifton Edgar, M.D._

Immediate dangers of abortions are: hemorrhage, retention of an adherent
placenta, sepsis, tetanus, perforation of the uterus. They also cause:
sterility, anemia, malignant diseases, displacements, neurosis, and
endometritis. Pages 338–9.


  _TRUCHTABTREIBUNG UND PRAVENTIVVERKEHR, IN ZUSAMMENHANG MIT DEM
      GEBURTENRUCKGANG; Eine Medizinische, Juristische und
      Sozialpolitische Betrachtung von Dr. Max Hirsch. Wurtzburg,
      Kabitzsch Verlag, 1914._

He who would combat abortion and at the same time assail contraceptive
measures may be likened to the person who would fight contagious
diseases and forbid disinfection. For contraceptive measures are
important weapons in the fight against abortion. The use of
contraceptive measures is largely responsible for the fact that the
number of abortions does not increase immeasurably. The apprehension is
perfectly justified that the prohibition of contraceptive measures would
enormously increase the practice of abortion with its dangerous
consequences for the life and health of women. P. 131–2.

America has a law since 1873, if I am not mistaken, which prohibits by
criminal statute the distribution and regulation of contraceptive
measures. It follows therefore, as I have already stated in my
introduction, that America stands at the head of all nations in the huge
number of abortions. P. 132.


  _THE DISEASES OF SOCIETY AND DEGENERACY. The Vice and Crime Problem.
      G. F. Lydston, M.D., Professor of Genito-Urinary Surgery, State
      University of Illinois; Professor of Criminal Anthropology,
      Chicago; Kent College of Law; Member of the American Medical
      Association, etc., etc. The Riverton Press, Chicago, 1912._

The familiar cry of “public demand” would fit the abortion business
better than it does some other things. The evil is wide-spread, both in
and out of matrimony. Its existence is recognized “under the rose” as a
social necessity, yet the law calls it murder. For every man and woman
caught in its commission and punished a thousand escape detection.


  _THE DISEASES OF SOCIETY AND DEGENERACY. G. F. Lydston._

In many instances abortion results directly in the death of the woman.
Such are the consequences resulting from ungoverned natural law on the
one side, and moral on the other. It must be confessed that an element
of sympathy is evoked by the mental distress of the unfortunate woman
who is extra-matrimonially pregnant. P. 370.


  _SEXUAL PROBLEMS OF TO-DAY. Wm. J. Robinson, Critic and Guide. 1912._

I have gone on record with the statement that about a million abortions
are brought about every year in the U. S. Exact statistics are not and
never will be available, but I am sure that my estimate is very
conservative, and that three million would be nearer the truth. Justice
John Proctor Clark stated that 100,000 abortions are performed annually
in New York City alone, and if these figures are correct, then the
number for the U. S. would be in the neighborhood of two and a half
million. P. 158.

There is one measure and one only which will positively do away with the
evil of abortion and that is teaching people how to prevent conception.
P. 164.


  _ABORTION AND ECONOMIC NECESSITY. (Hirsch)._

According to a report in the _Medical Record_ 80,000 abortions are
performed annually in New York and only one case in 1,000 is brought
before the authorities.

According to Lewin it has been determined by court investigations that
there are at least 200 people in New York who make a profession of
performing abortions.

It has been estimated that 2,000,000 abortions are performed annually in
the U. S. P. 7.

Bertillon estimates the number of criminal abortions in Paris at 50,000
annually, in Lyons at 19,000. (Le depopulation de la France). P. 8.

We must first attack a very wide-spread fallacy, namely that abortion is
more prevalent among unmarried girls than among married women. In other
words, that it is concomitant with free sex relations. This fallacy is
exploded by practical medical experience as well as by observation and
statistics of social conditions. P. 23.

Among the causes of criminal abortion the fear on the part of the woman
of the pains and dangers of confinement plays a not inconsiderable role.
P. 54.

In marriage the cause for the practice of abortion springs in most cases
from economic necessity. Most frequently this necessity is a genuine
dire need arising from overcrowded quarters, lack of food and clothing,
sickness and lack of employment. P. 33.

This economic need finds its most obvious expression in the congestion
of the city populations. P. 34.

The dangers of childbirth are still serious enough to cause a certain
degree of uneasiness in the woman and the family circle. This foreboding
is due partly to our higher valuation upon health and life, and also to
a shifting of pre-eminence from a solely generative function in women to
other interests in their life. P. 84.

This greater consideration and valuation of woman’s individuality is the
expression of continued progress and a higher culture. P. 87.


  _TRUCHTABTREIBUNG UND PRAVENTIVVERKEHR, In Zusammenhang mit dem
      Geburtenruckzang; Eine medizinische, juristische und
      sozialpolitische Betrachtung von Dr. Max Hirsch, Wurtzburg,
      Kabitzsch Verlag, 1914._

In Chicago six to ten thousand abortions are performed yearly, of which
75–90% are married women. P. 7.

I believe I may say without exaggeration that absolutely spontaneous or
unprovoked abortions are extremely rare, that the vast majority—I should
estimate it at more than 80% of abortions have a criminal origin. P. 9.

We may affirm that next to sexual diseases, abortion and its
consequences are the most important factor in the etiology of chronic
genital inflammations and of sterility. P. 9.

Our examinations have informed us that the largest number of abortions
are performed on married women. This fact brings us to the conclusion
that contraceptive measures among the upper class, the practice of
abortion among the lower class, are the real means employed to regulate
the number of offspring. P. 32.


  _THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL, BIOLOGICAL AND
      HYGIENIC ASPECTS. E. Heinrich Kisch. Translated by M. Eden Paul,
      M.D. Rebman & Co., New York._

A means of insuring artificial sterility, which in all civilized
countries is punishable as a criminal offense, and which is nevertheless
very frequently practiced, is the artificial induction of abortion.
Especially in North America it would appear that there exist regular
professional abortionists. P. 413.


  _THE FAMILY AND THE NATION. A Study in Natural Inheritance and Social
      Responsibility. Wm. Cecil Dampier Whetham, M.A., F.R.S. Fellow and
      Tutor of Trinity College, Cambridge, and Catherine Durning
      Whetham. Longmans Green & Co., N. Y., Bombay and Calcutta, 1909._

There is no finality, a nation must either be losing or gaining ground,
either improving or degenerating. Hence the scientific study of the
effect of the existing conditions of any time on the rates of
reproduction of different stocks of the nation, should be the chief work
of the sociologist, and the control of these conditions the supreme duty
of the statesman. P. 5.



                              CHAPTER VII
         PROSTITUTION, FEEBLE-MINDEDNESS AND VENEREAL DISEASES


_In this chapter it is shown that the feeble-minded parent is many times
as prolific as the normal parent. A considerable percentage of girls
living in prostitution are mentally defective, and if careful statistics
were collated it would be found that 95 per cent. of these women come
from large families. The feeble-minded should be instructed how to
prevent conception, thereby diminishing prostitution and its invariable
accompaniment,—venereal disease._


  _SOME PROBLEMS OF THE SOCIAL EVIL. Hon. Chas. N. Doodnow, Judge of the
      Morals Court, Chicago. “The Light.” B. S. Steadwell, Editor.
      Jan.-Feb., 1915._

The Court of Morals conducted an investigation of prostitution along
three lines, social, physical and mental. In the first report, April
10th, to December 31st, 1913, 639 cases were examined, representing
every race, creed, and nationality. 334 were colored, 298 white, 2
Armenian, 1 Japanese. Occupations: 225 housework, 174 waitresses, 136
laundresses, 83 clerks or cashiers, 6 seamstresses, 4 stenographers, 1
trained nurse, 1 manicurist, 24 scrub women, 110 had no occupation.
Venereal disease in infectious stage was diagnosed in 108 cases. 315
showed evidence of having syphilis, and of the remaining 116, had
bacteriological tests been made, 50% at least would have been found
victims of the disease. As to intelligence, over 400 were mentally
deficient, two were found to be insane, and 68 were little more than
imbeciles, having mental capacity of less than a seven year old child.
Later statistics of 100 women going through the Court were taken showing
again that usually their work was of a character which required the
least skill and mental effort, and that 97% either were, or had been
afflicted with disease, and that the majority were mentally deficient.
We did not have any imbeciles, or idiots from the Morals Court, though
quite a number of the morons were of the low grade type bordering on the
imbecile group. In other words, 89.37% of our cases are feeble-minded,
or borderland. If we leave out the borderland cases it shows that 85% of
our cases, exclusive of the insane, alcoholics, and drug habitues are
distinctly feeble-minded. This finding is interesting since it
corresponds to our findings in the Boys’ Court, where we found 84.49%
were feeble-minded. It is therefore to be clearly seen here that with
the girl defective-delinquent, as with the boy, the basic cause is
feeble-mindedness. This is the intrinsic cause, which environment and
other causes on the whole, are extrinsic.


  _REPORT OF CHICAGO MORALS COURT. December, 1913._

Dr. W. J. Hickson of the Psychopathic Laboratory tested 126 cases
excluding insane, alcoholics and drug addicts, for the Chicago Morals
Courts, and found 85.83% distinctly feeble-minded.

Of 639 prostitutes examined by a woman physician for the Chicago Morals
Court, over 400 were mentally deficient; 2 were found to be insane; 68
were little above imbeciles, having mental capacities of less than a
seven year old child.

The State Training School for Girls, at Geneva, Ill., has a population
of about 400, of whom a great majority have been committed for sexual
immorality. Dr. Olga Bridgman reports that of 118 consecutive cases that
were examined upon entry, 105 (or 89%) were graded as feeble-minded. 14
of the 118 had been committed as dependents or uncontrollable. Of the
104 remaining all of whom had been sexually immoral 101 were graded as
feeble-minded while only 3 were found normal according to the Binet
test.


  _THE LAW OF POPULATION. Its Consequences and its Bearing upon Human
      Conduct and Morals. Annie Besant. Asa K. Butts, Publisher. 1879._

The more marriage is delayed the more prostitution spreads. Prostitution
is an evil we should strive to eradicate, not to perpetuate, and late
marriage, generally adopted would most certainly perpetuate. Marriage is
deferred owing to the ever increasing difficulty of maintaining a large
family in anything like comfort. Celibacy is not natural to man or to
woman, all bodily needs require their legitimate satisfaction, and
celibacy is a disregard of natural law. Until nature evolves a neuter
sex, celibacy will ever be a mark of imperfection. P. 27–8.

But the knowledge of these scientific checks would, it is argued, make
vice bolder, and would increase unchastity among women by making it
safe. And if so, are all to suffer, so that one or two already corrupt
at heart may be preserved from becoming corrupt in act? Are mothers to
die solely that impure women may be held back, and wives to be
sacrificed that the unchaste may be curbed. As well say that no knives
must be used because throats may be cut, no matches sold because
incendiarism may result from them, no pistols allowed, because murders
may be committed by them. P. 38.


  _SLAVERY OF PROSTITUTION. A Plea for Emancipation. Maude E. Miner,
      Secretary of the New York Probation and Protective Association.
      McMillan Co., 1916._

The study of young women in prostitution shows that mental deficiency is
an important factor in delinquency. 34%, or approximately ⅓ of 577
delinquent young women at Waverly House were so retarded in mental
development as to be considered feeble-minded, and others were mentally
retarded enough to need protection and over-sight. Close knowledge of
the individual girls convince us that their deficiency facilitates their
entrance into prostitution. P. 43.

Explanation of the mental deficiency of these wayward girls which has
predisposed them to prostitution is usually found in bad inheritance. P.
44.

A feeble-minded girl was found to be one of 13 illegitimate children to
whom her mentally deficient mother had given birth. P. 46.

Over-crowding in rooms, tenements, and neighborhoods is an obvious
menace. In congested sections of the lower part of New York, large
families, to which these girls belong, were herded into two or three
narrow rooms, 12 in three small rooms, seven in two rooms, or a family
of five eating and sleeping and living in a single room. P. 55.

Have we realized that every feeble-minded girl is a potential
prostitute? Have we realized that feeble-minded mothers give birth to
large numbers of children doomed to mental deficiency? Have we realized
what this will ultimately mean in deterioration of human stock and in
the complication of social problems? To stop the stream which is
bringing into prostitution large numbers of mentally deficient girls and
women, we must safe-guard these girls and prevent them from having
offspring. Evidence presented to the Royal Commission on the Care and
Control of the Feeble-minded in Great Britain, and careful studies in
America, show conclusively that mental deficiency tends strongly to be
inherited, and that feeble-minded mothers are more prolific than normal
women. P. 267.


  _DOWNWARD PATHS. An Inquiry into the Causes which Contribute to the
      Making of the Prostitute. With a foreword by A. Maude Royden. T.
      Bell & Sons, Ltd. London._

It is astonishing to find experts denying the element of economic
pressure as a factor in the creation of the prostitute. It is an
influence constantly present and it is only when we interpret it to mean
actual physical starvation that we can say it is rarely a determining
factor. Economic pressure does not begin with starvation, it ends there.
There is again the long strain of underfeeding and overwork, of the
absence of interest, variety and color, and all that makes life worth
living to a human being. Poverty often means isolation, and isolation
the absence of all those ties which keep us in our place in the social
order, and make it worth while to preserve our self-respect. To be
without this is to be constantly in danger and it is economic pressure
which has thrust many over the brink of the precipice, though few would
say their fall was due to actual starvation. P. 10.

Intimately connected with this aspect of the question is that of home
and housing, especially of the child. The age at which children are
first corrupted is almost incredibly early, until we consider the nature
of the surroundings in which they grow up. Insufficient space,
over-crowding, the herding together of all ages and both sexes, these
things break down the barriers of a natural modesty and reserve. Where
decency is practically impossible, unchastity will follow, and follow
almost as a matter of course. There are certainly natural defences in
the right instincts of young people brought up in the right kind of
home, which we look for in vain among those who have never had space
enough for growth, or privacy enough for refinement. P. 11.

We must allot to bad housing and over-crowding a foremost place, not
only as undermining the physical health which conduces to normal sexual
relationship, but also as a danger to the wholesome innocence of youth.
P. 21.

It cannot be too strongly impressed upon persons interested in the
housing problem that over-crowding means a violation of childhood in
every degree, from the indecencies of mere childish horse-play to
complete debauchery. P. 22.

There are two types of feeble-minded girls who are almost inevitably
destined to prostitution. There is first the large proportion whose
sexual inclinations are abnormally strong, or whose power of
self-control over natural impulses is abnormally weak. 2—There is the
large class who are non-resistant. They have no active impulse to seek
out men, but they will yield to any one who approaches them. There are
three important factors that drive the feeble-minded into prostitution
by excluding them from other occupations. 1—They often lose their
characters at a very early age. A marked characteristic of the
feeble-minded is the precocity of their sexual impulse. 2—It is easy
enough for any feeble-minded girl to get and keep light, unskilled work
at girl’s wages, but not so easy for her to pass like the girl of normal
intelligence, from girl’s to woman’s work at the age of 17 or 18, for
she is rarely worth woman’s wages. Therefore she finds herself bored by
monotonous work and low pay just at the time that she is particularly
attractive to man, and her sexual impulses are at their strongest. Very
naturally the feeble-minded girl with her incapacity to perceive the
consequences turns from her unsatisfying employment to the new life of
excitement and easy gain that offers itself. 3—If feeble-minded girls do
succeed in getting respectable situations they are very likely to lose
them because of their lack of intelligence and general inefficiency. And
even if they should discharge their duties in a satisfactory manner they
have a curious distaste for staying for any time in one place, and tend
to drift from situation to situation. P. 127–128.

Another characteristic of the feeble-minded is their notorious
fertility. The superior fertility of the feeble-minded has been proved
beyond dispute by statistical inquiry.


  _DELINQUENCY AND MENTAL DEFICIENCY. Dr. Olga Bridgman. The Survey,
      June 13, 1914._

Report of examination of 118 consecutive admissions at the Illinois
Training School for Girls at Geneva. Of the 118, 105, or 89%, showed a
retardation of three years or more, thus ranking as mentally deficient,
6% were backward, being one or two years retarded, and six, or 5% were
graded as normal. According to the Binet tests then, 97% of the children
sent to this institution are mentally defective.


  _COMMERCIALIZED PROSTITUTION IN NEW YORK CITY. George Kneelands.
      Century Co., New York, 1913. (Chapter by Katherine B. Davis on a
      Study of Prostitutes Committed from New York City to the State
      Reformatory for Women at Bedford Hills.)_

It is difficult to get at the actual truth as to the number of children
the unmarried women have had. The Table shows the admission of 209 women
on this point. There are 73 unmarried women who admit having had
children, 16 were pregnant at the time of entering, and 18 had
previously been pregnant. 428 claimed to have had no children. In this
connection it may not be amiss to note the fact that an unmarried woman
who has had a child is more apt to belong to the mentally defective
class. Of the 647, 20.09% were shown to have hereditary degenerate
strains, and 20.56% venereal disease. Page 180.


                           FEEBLE-MINDEDNESS


  _SOCIAL HYGIENE. March 1915. Vol. 1, No 2. Recent Progress in Social
      Hygiene in Europe. James B. Reynolds, Counsel, The American Social
      Hygiene Association._

Recent studies of prostitutes there (in Europe) as here have strikingly
brought to light the significant relationship between prostitution and
mental defectiveness. A far reaching contribution to the solution of the
problems of sex education and prostitution was the Mental Deficiency Act
of 1913 for England and Wales. This Act was based on the Report of a
Royal Commission on the Care and Control of the Feeble-minded which made
a careful and exhaustive study of the entire subject, including the
methods of treatment of the mentally defective in all countries. The
Commission declares that a great proportion of the evidence unmistakably
indicates that mentally defective children are greatly lacking in
self-control and peculiarly open to suggestion and hence specially
susceptible to the influence of depraving companions. The testimony of
numerous experts who appeared before the Commission is highly
illuminating on these points. Dr. Kerr, medical officer of the London
County Council, declared that sooner or later many of these children
will be found in the hands of the police, or in maternity hospitals. Dr.
Ashby, late medical officer of the Manchester Special Schools stated
that the mental defectives tend to an increase of the criminal and
immoral classes. Dr. Whittell, Medical Superintendent of the Suffolk
County Asylum, argued that the natural and physical evolution of this
class is apt to result in various offenses of sexual, or perverted
sexual, nature. Dr. Corner, Lecturer on Mental Diseases in the North
East London Post Graduate Hospital, said, “One of the most common and
dangerous characteristics of the feeble-minded is that they tend to sink
socially.” Another expert testified that mentally defective girls in
large cities are subject to overwhelming temptations and pressure toward
sexual immorality, while still another, looking to the larger aspects of
the problem, called attention to the danger resulting from the immoral
laxness of mentally defective girls, and the lowering of the mental
stamina of the whole nation by the increase of a population of defective
intellect. Sir Francis Galton went so far as to declare that mentally
defective women commonly become prostitutes. The feeble-minded, as
distinguished from idiots, are an exceptionally fecund class, mostly of
illegitimate children, and a terrible proportion of their offspring are
born mentally deficient. All these experts were in agreement that
mentally defective girls are in great danger of becoming immoral, hence
prostitutes.


  _DEGENERACY, ITS CAUSES, SIGNS AND RESULTS. Eugene S. Talbot, M.D.
      Walter Scott, Ltd., London; Chas. Scribner’s Sons, N. Y. 1898._

Pauline Tarnowsky in her study “Etudes Anthropometriques sur les
Prostituées” finds that in Russia prostitution is crime in women taking
the line of least resistance. She concludes from her researches, which
mine tend to verify, that the prostitute as a rule is a degenerate
being, the subject of an arrest of development, tainted with a morbid
heredity, and presenting stigmata of physical and mental degeneracy
fully in consonance with her imperfect evolution. C. Andronico of
Messina, Italy, arrived some time previously at the same conclusions as
those of Tarnowsky.


  _FEEBLE-MINDEDNESS, ITS CAUSES AND CONSEQUENCES. Henry Herbert
      Goddard, Director of the Research Laboratory of the Training
      School at Vineland, N. J., for Feeble-minded Boys and Girls.
      McMillan Co., 1914._

Among the different causes for the social evil feeble-mindedness has
been suggested, but nowhere has it been given the prominence that is due
it. Anyone who understands feeble-mindedness, especially the moron,
cannot expect anything less than that great numbers of these girls will
fall into the life of prostitution. As to the actual statistics on this
subject we have almost none. One very significant record comes from
Geneva, Illinois, made by Dr. Bridgman. She found that of 104 girls in
the Reformatory who were committed for an immoral life 97% were
feeble-minded. This does not by any means indicate that 97% of
prostitutes are feeble-minded, because it is only natural to expect that
the feeble-minded ones would be the ones to be caught and sent to an
institution. These figures, nevertheless, give us some idea of the
prevalence of feeble-mindedness in this traffic. Many competent judges
estimate that 50% of prostitutes are feeble-minded. Pages 14–15.

The 327 cases here presented constitute a unitary group. They have not
been selected. They are of all ages and grades of defect. Page 7.

Our 327 families naturally fall into six fundamental groups, as follows:
4—Accident Group, 57; 5—No Cause, 8; 6—Unclassifiable, 27. Pages 47–48.

The following table gives an idea of the fecundity of these groups of
women.


                           No. of Mothers No. of Children Average
       Hereditary                     139             992     7.1
       Probably Hereditary             27             168     6.2
       Neuropathic                     36             204     5.6
       Accident                        50             258     5.1
       No Cause                         8             258     5.7
       Unclassified                    27             118     4.3
                                      ———           —————     ———
                                      287           1,786     6.2

In addition to the mentality, whether normal or feeble-minded, record
has been kept of certain diseases and conditions supposed to be more or
less associated with feeble-mindedness in a causal relation. These are
the following: 1—Alcohol; 2—Tuberculosis; 3—Sexual Immorality;
4—Paralysis, Insanity, Epilepsy, Neurotic Condition, Syphilis,
Criminality, Deafness, Blindness, Migraine, Goitre, Vagrancy. Page 473.

Sexual immorality is closely associated with hereditary
feeble-mindedness. Closely connected with the subject of sexual
immorality is the one of illegitimacy. Our records show 278 illegitimate
children of whom 259, or 93% are in the pure Hereditary group, 12 in the
Probably Hereditary group, 3 in the Neuropathic, and 4 in the Accident
group. There is nothing new in these facts. They are simply confirmatory
of what we have found in other lines. Page 499.

The feeble-minded person is not desirable; he is a social encumbrance,
even a burden to himself. In short, it were better, both for him and for
Society had he never been born. Should we not then in our attempt to
improve the race begin by preventing the birth of more feeble-minded?
Page 558.


  _THE FEEBLE-MINDED A SOCIAL DANGER. A. F. Tredgold, L.R.C.P., London.
      M.R.C.S., England. Medical Expert to the Royal Commission on the
      Feeble-minded, etc. Eugenics Review. Vol. 1, April, 1909. Pub.
      Eugenics Education Society, London._

In England and Wales on January 1st, 1906 there were a total of 138,529
persons in the country who were defective in mind. This corresponds to
4.03 per thousand population, or to one mentally defective person in
every 248. In England and Wales on January 1st, 1906, there were no less
than 125,827 insane persons. If we add these to the number of the
mentally deficient which I have just stated, we find that in this
country there is one person out of every 130 who suffers from severe
disease of the mind. P. 98–99.

According to the Registrar General, the average number of births to a
marriage in the whole population of this country is 4.6. I have
ascertained that the average number of births in these degenerate
families is no less than 7.3. It is obvious that if this alarming
propagation is not checked, the time must inevitably come when our
nation will contain a preponderance of citizens lacking in that
intellectual and physical vigor which is absolutely essential to
progress. P. 98.


  _RASSENVERBESSERUNG. Translated from the Dutch of Dr. J. Rutgers.
      Second Edition, Dresden, 1911._

A not insignificant factor in the use of houses of prostitution is
furnished by married men who in the “old fashioned” way wish to
“protect” their wives, in order not to be burdened with too many
children. Neo-Malthusianism is also the best weapon against this class
of supporters of prostitution. P. 73.


  _MASSACHUSETTS COMMISSION FOR INVESTIGATION OF THE WHITE SLAVE
      TRAFFIC._

This investigation under Dr. Walter Fernald, included a physical
examination study of family and personal history, social reactions, and
standards, etc. Out of the 300 prostitutes 154 were feeble-minded (all
doubtful were called normal). The 154 were so pronounced as to warrant
legal commitment. None of them had the mentality of a normal child of 12
years old. Majority were that of 10 or 9 years old.


  _INVESTIGATION OF VIRGINIA STATE BOARD OF CHARITIES._

This investigation presents a very high percentage of aments among the
prostitute residents of the Richmond red light district. Of 120 persons
tested the examiner found 42 or 35% imbeciles and 58 or 48.3% to be
morons. That is 100 or 83.3% were mentally defective and only twenty or
16.7% were declared normal. Out of this number 93 were found to be
between the ages of 20 to 30 and 16 between 30 to 40. All in the
child-bearing age, as one will note. That 100 out of the 120 needed
institutional care, that they should not reproduce their kind, was of
course apparent.


  _THE MENTALITY OF THE CRIMINAL WOMAN. A Comparative Study of the
      Criminal Woman, the Working Girl and the Efficient Working Woman
      in a Series of Mental and Physical Tests. Jean Weidensall,
      formerly Director of the Department of Psychology, Laboratory of
      Social Hygiene, Bedford Hills, N. Y. Warnick and York Inc. 1916._

Tests applied to a group of children of working age by the Bureau of
Educational Guidance of Cincinnati were also used on a group of 20 maids
at Vassar as a norm for testing the women committed to Bedford. 100
reformatory subjects were used for the tests. It is a matter for
question whether loss of the parent is the cause of the child’s leaving
school and going to work early and of the ultimate unsocial conduct in
the case of the Bedford group, or whether loss of parent, retardation,
misconduct, etc., are not for the most part but manifestations of the
same thing—irresponsibility, mental, physical and social inferiority on
the part of both parents and child. The facts at our disposal and
eugenic investigations lead us to believe that the latter is in the
larger measure true. Out of 100 women recorded 30 had had from one to
five illegitimate children. Of the 100 tests for syphilis and
gonorrhoea, 45% positive, 4% doubtful, 51% negative, for syphilis. 60%
positive, 22% doubtful, 18% negative for gonorrhoea. At best strong
character cannot be the rule among individuals ⅔ of whom have less
intelligence than that possessed by the average individual among a group
of children of 15, (of whom half are themselves retarded), and almost
surely not when they have been too untrained industrially and too
unschooled socially to have acquired simple every-day habits of
restraint and inhibition. Even the more intelligent third of the
reformatory subjects differed very obviously and unmistakably in
stability and emotional control from the group of Vassar maids.


  _THE MENACE OF MENTAL DEFICIENCY FROM THE STANDPOINT OF HEREDITY.[51]
      By Henry H. Goddard, Ph.D., Vineland, N. J. New Jersey Training
      School._

Footnote 51:

  Read before the conference of the Massachusetts Society for Mental
  Hygiene, Boston, November 19, 1915.

From the standpoint of the child, something can be done to make them a
little happier; from the standpoint of society, no amount of mental
hygiene can ever render them efficient citizens. Society can, by proper
treatment, render them less of a menace than they are naturally, and the
ills that we now suffer on account of them can be largely reduced.

It is estimated that there are from 300,000 to 400,000 mental defectives
in the United States. That is based upon the United States census of
1890, in which the question was asked “Whether defective in mind, sight,
hearing or speech, or whether crippled, maimed or deformed, with name of
defect.” Now if anyone can estimate what proportion of the true number
of the feeble-minded would be returned in answer to that question, he
will be able to estimate how near the truth is the 200,000 which the
census report gives. Three hundred thousand or 400,000 seems to be a
conservative estimate.

I am to discuss this topic from the standpoint of heredity. It has not
yet been successfully contradicted that two-thirds of this army of
300,000 or 400,000, owe their condition to heredity. A quarter of a
million of these people are feeble-minded because their ancestors were
feeble-minded. They have inherited the condition just as you have
inherited the color of your eyes, the color of your hair, and the shape
of your head. There is a tendency in these days to attribute a great
deal to heredity. But of this particular thing there seems to be no
question. The menace of the problem comes, not from the fact that a
quarter of a million inherited their condition, but because they are
transmitting that condition to their offspring. Of that quarter of a
million feeble-minded persons in the United States, do you know how many
are being cared for, guarded and kept from propagating their kind? About
24,000 out of 250,000 are to-day being cared for in such institutions as
you have here at Waverley. The rest are living their lives, are raising
families, and providing abundant opportunity for the exercise of the
charitable impulses of numberless generations to come. And that
condition of things is getting worse rather than better.

What shall we do? There have been two answers. Some say, “Segregate,
shut them up. Keep the sexes apart.” We are told that if we could do
this for a generation our problem would be largely solved. The
two-thirds in which the condition is largely hereditary would be
eliminated. I want to assure you that the problem is larger than that.
In the first place, looked at from the practical standpoint, we do not
seem to be able to segregate. We are taking care of 24,000, and there
are at least 250,000 to be cared for. If the State of New York cared for
its estimated proportion of mental defectives, it would require thirty
institutions of 1,000 each. They find it hard to raise money for the
three or four institutions they now have. Their appropriations are cut
every year. In the State of Massachusetts there are at least 14,000
feeble-minded persons. It would require ten institutions the size of
Waverley,—a demand upon the public treasury which we are not willing to
meet. I have not found anyone yet who is optimistic enough to think that
we shall meet the demand within any reasonable length of time,—a time so
short that we can safely rely upon that as a solution of the problem.

I have said that this quarter of a million, this army of feeble-minded
people, are propagating. They are propagating a progeny of feeble-minded
at somewhere from two to six times as fast as the intelligent people are
propagating their kind. That is another serious part of the problem. I
should like to digress from my particular field for a moment to make a
suggestion on the other side. It makes one feel pessimistic when we find
that the good stock here in New England—the stock than which there is no
better in the world—is gradually disappearing for lack of issue. Of one
family after another one reads all too frequently, “The last of his
family has passed away.” We are told sometimes that two children in a
family are all that can be properly reared; that it is better to rear
two children and rear them properly than to rear a larger family and
rear them badly. If _two children in a family_ are all that our best and
finest and nobler families can properly raise, _how many children_ ought
to be raised in a family of these low-grade people? The average in the
United States is, for all classes, something less than two, and the
average for these defectives is from four to twelve. In that little
family that we ran across down in New Jersey, which we call the
Kallikaks, you will recall that the good side started from six
ancestors. That is to say, Old Martin Kallikak, after he married, had
seven children, one of whom died without marrying. From the six who
lived and married, sprang all the normal descendants. Martin’s
illegitimate son, the child of the feeble-minded girl, was the only one
on the bad side, and yet to-day the number of descendants from the
illegitimate mating is practically the same as the number descended from
the six legitimate children. You can see that it does not take many
generations for the progeny of the unrestrained feeble-minded to equal
and even outstrip the normal. Our good stock is multiplying very slowly.
Our poor stock—the lowest strata of society—multiplies in what might
really be called a brutal ratio. If civilization is to advance, our best
people must replenish the earth. I think it should be a part of our
religion to replenish the world with good, clean people.

We need to know vastly more than we know to-day before we can give
definite answers, except in the case of marriage between two
feeble-minded persons. Now, that being the case, the argument that I
want to make to you is: the propagation of the feeble-minded is going on
at an enormous rate. If we could do, and if we did, everything that we
wanted to do, and that we knew enough to do, we should be getting only
at the surface of the problem, and should be sure in only about one case
out of the six possibilities. Now if that is the case, my friends, does
it seem that we ought to put off attacking the problem until we cannot
stand it any longer? Or does it mean that we had better attack it right
away? Is it not best to begin hunting for these defective children
wherever they may be found? And they can be found in the school, in our
juvenile courts, in our almshouses, in our insane hospitals, in our
reform schools, in our homes for cripples, in our asylums for the
blind,—in short, wherever there is a dependent group there is an undue
proportion of these mental defectives.

Some will say, “If they are in almshouses they are being cared for.” In
reality they are being raised and brought to manhood and womanhood and
then sent out, to propagate their kind. Fifty years ago the problem was
not as serious as it is to-day, because these defectives were out in the
world by themselves, getting killed by a runaway horse, or falling into
machinery, or in some way meeting an untimely death. To-day we are
exceedingly careful; we are protecting them in every possible way; we
are taking care of them in our institutions and giving them every
advantage, and then sending them out into the world—a menace to the rest
of humanity.

It would be a dreadful thing if all these problems were solved and we
didn’t have any people to give our money and charity to. I suppose we
should become hard-hearted if we didn’t have any to befriend. Perhaps we
want to keep enough of these unfortunates so that we can still
contribute to their safety and welfare. But, my friends, when we realize
the suffering, the terrors, the losses of all kinds that these people
unintentionally, unwittingly cause us, we have another side of the
problem. The menace of the feeble-minded is not a figure of speech. It
is no undue sentimentalism that assures us that we need to take care of
this group of people. We need to study them very seriously and very
thoroughly; we need to hunt them out in every possible place and take
care of them, and see to it that they do not propagate and make the
problem worse, and that those who are alive to-day do not entail loss of
life and property and moral contagion in the community by the things
that they do because they are weak-minded.


  _HEALTH FIRST AND MATRIMONY AFTERWARD. By Edward C. Spitzka, M.D. The
      Semi-Monthly Magazine Section of the Boston Globe, the Washington
      Post, the Philadelphia North-American, the Pittsburgh Dispatch,
      the Chicago Tribune, the St. Louis Globe-Democrat, the Cincinnati
      Enquirer, etc. May 11, 1913._

We cannot tell men and women how they should mate in order to insure
positive types of offspring. But we can state, emphatically, and without
reserve, that persons suffering from certain diseases should not enter
into the marriage relationship, at peril of the health and happiness of
children that may be born to them and the well being of the community at
large.

I believe that municipal and state governments should take cognizance of
this fact. Eventually it will be regarded as a matter for Federal,
perhaps for international action. Every candidate, man or woman,
applying for a marriage license should be required to present a
physician’s certificate declaring him or her to be free from insanity
and certain virulent transmissible diseases.

What then are these diseases? I will list them in the order of
importance as menaces to humanity.

1. Constitutional insanity.

2. The two great forms of constitutional venereal disease: syphilis and
gonorrhoea—the former as a source of danger to both the marriage partner
and offspring, the latter to the marriage partner only.

3. Deformities that are likely to be associated with the transmission of
serious defects of the nervous system, such as cleft palate,
hermaphroditism, etc.

4. Epilepsy of the standing of more than one generation.

Medical statistics prove that a proportion of three out of every five
children born to imbecile parents are certain to be weak-minded, and
that the marriage of such unfortunates is a calamity to the race.
Syphilis persists from generation to generation. Any sufferer from this
disease who marries before he is certain that it has been eradicated
from his system is guilty of a crime against society.

I have hesitated about including epilepsy in this list. It is
undoubtedly transmissible to the offspring, though transmission does not
occur in every case. A conservative ruling would be that an epileptic
who is believed to be the first of his line to contract the disease
should be permitted to marry, in the event of his being declared cured.
But the epileptic sons and daughters of epileptic parents should, under
no circumstances, be licensed to marry.

NOTE: The late Dr. Spitzka, along with other authorities quoted as being
opposed to the marriage of the unfit, was concerned with the diseased
offspring which almost invariably result from such marriages. Except in
the case of gonorrhoea, which can be transmitted to the marriage
partner, he did not object to the union itself, provided the latter
remained childless. He would have recommended the use of contraceptives,
as the solution of the problem, had he not been prohibited by the law
from doing so.


  _HEREDITARY SYPHILIS IN THE LIGHT OF RECENT CLINICAL STUDIES.
      Pamphlet. Borden S. Veeder, M.D., St. Louis, Mo. From the American
      Journal of the Medical Sciences, October, 1916. No. 4, Vol. CXII.
      P. 522._

In the present state of our knowledge we can summarize the evidence as
pointing to the view that in hereditary syphilis the mother is always
infected, although very frequently the infection is latent and that true
germinal infection does not occur.

SYPHILIS AS A SOCIAL PROBLEM. No accurate figures are available as to
the incidence of hereditary syphilis. The disease is not reportable, and
even if it were it is doubtful if the records obtained in this way would
be of any value, as the condition is frequently overlooked, and when
recognized would be concealed in many cases because of the stigmata
attached. With improved methods of diagnosis we are beginning to learn
that it is far more common than previously thought, as many conditions
in which the etiology was obscure have been found to be the result of a
syphilitic infection. Hospital statistics are of little value in this
connection. In St. Louis we have been particularly interested in
hereditary syphilis, and have admitted many cases to the Children’s
Hospital for study which would normally have been cared for in the
out-patient clinic, and hence the proportion of syphilis to the total
number of admissions is relatively high. We have seen between 300 and
350 children with an hereditary infection in three and a half years and
have undoubtedly failed to recognize a number of cases. We have also
found many cases of latent syphilis by testing the apparently healthy
children of syphilitic families. What is more important is the number of
obscure clinical conditions which have been found to be syphilitic in
origin.

The importance and cost of syphilis to the family and the community is
not generally appreciated. About this point we have collected some
interesting information: For a period of about a year an attempt was
made to obtain extensive data in regard to the family of every
syphilitic child coming to the clinic, to examine all of the other
living children as well as the parents, and to test the blood of each
member by the complement-deviation method. In this way data was
assembled for 100 syphilitic families. Many marriages (10 to 30 per
cent.) remain sterile as a result of syphilis and others (13 per cent.
according to Haskell) result only in abortions. Our material includes
only those families in which a living child came under our direct
observation and care.

In these 100 syphilitic families 331 pregnancies occurred which resulted
as follows:


                  Abortions     100 or 30.2 per cent.
                  Stillbirths    31 or  9.3 per cent.
                  Living births 200 or 60.5 per cent.

Thus 40 per cent. of the pregnancies terminated in the death of the
fetus before term. If the parents had been healthy and of the same
social strata we might have expected 30 to 35 deaths before term, or a
mortality of 10 per cent. instead of 40 per cent.

Considering next the 200 living births: At the time the data were
collected 39 were dead and 161 alive, but 12 of the 161 died during the
course of the investigation. Of the 161 examined 107 had both clinical
signs of syphilis and a positive Wassermann; 5 were clinically positive
but gave negative tests (in all of these the family gave a history of
syphilis); 16, although negative as regards clinical manifestations,
gave positive reactions, and therefore belong to the group of latent
syphilitics. Thus but 33 of the 161 living children were free from the
infection, and if we attribute the deaths occurring before term to
syphilis, we find that of the 331 pregnancies in 100 syphilitic families
but 10 per cent. escaped the infection. The toll is summarized in the
following table:


               331 PREGNANCIES IN 100 SYPHILITIC FAMILIES

 131 or 40 per cent. died before term          }
  51 or 15 per cent. died after birth          } 55 per cent. dead
 116 or 35 per cent. living but syphilitic       35 per cent. syphilitic
  33 or 10 per cent. living and free from        10 per cent. escaped
                       syphilis
 ———
 331

If we add to this record and take into consideration the physical
condition of the parents—both of whom were syphilitic in almost all of
our cases—we begin to grasp the appalling importance of syphilis from a
social standpoint.

In order to show this in another way, studies[52] were made in our
clinic in which the waste (total deaths to total pregnancies) occurring
in 100 families in which we were treating children with contagious
disease, and in 100 families selected at random from our records, were
contrasted with the waste in 100 syphilitic families. These groups are
designated as C. R. and S. respectively and the data briefly summarized
in the following table:

Footnote 52:

  Jeans and Butler, Hereditary Syphilis as a Social Problem, Am. Jour.
  Dis. Child., 1914, viii, 327.


                Total      Deaths    Born living              Per cent.
    Group    pregnancies   before     now dead      Total       waste
                            birth

     C.              444          46          70         116          26

     R.              442          42          59         101          22

     S.              453         116         104         220          48

The increase in the waste for the syphilitic group of 100 per cent. does
not represent the total waste, as it is fair to assume that
three-quarters of the living children are syphilitic and many of these
defective.

SYPHILIS. None of the causes supposed to be potent causes of
feeble-mindedness is so difficult of investigation, so enigmatical as
Syphilis. Not only in the popular mind but in the professional thought,
it is given a prominent place, yet of all the causes there is perhaps
none for which there is less evidence. This does not necessarily mean it
is not a cause, but simply that it is not proved. The terrible nature of
the disease, the serious results that it is known to produce, such as
miscarriage, deaths in infancy, general paralysis of the insane, the
fact that it is one of the two diseases that can be transmitted from the
mother to the child because the germs can pass through the chorion
cells, the fact of its close connection with sexual immorality, all tend
to render it in the minds of most people a horror of which anything can
be believed. It is well understood by the medical profession that a
mating which shows, first a number of miscarriages followed by deaths in
infancy, and finally live offspring, is a picture that means syphilis in
one or both of the parents almost without question. In conclusion, there
is abundant evidence that syphilis produces miscarriages and early
death.

It is claimed that syphilis is responsible for 42 per cent. of abortions
and miscarriages, the remaining 58 per cent. embracing all cases of
whatever character, artificial or otherwise.


            SYPHILIS IN THE OFFSPRING OF SYPHILITIC PARENTS


  _FAMILIAL SYPHILIS. By P. C. Jeans, M.D., “American Journal of
      Diseases of Children.” January, 1916. Vol. XI. pp. 11–19._

As the result of syphilis numerous families remain sterile. The figures
for sterility vary from 10 per cent. to 30 per cent., depending on the
material studied. When there is an embryo there is a variety of fates to
which it may come. Many marriages result only in abortions (nearly 13
per cent. in Haskell’s material[53]). Since the starting point in our
material was a syphilitic child, we have no data bearing on this phase.

Footnote 53:

  Haskell: Jour. Am. Med. Assn., 1915, lxiv, 890.

Among our syphilitic patients all the living children of 100 families
have been examined, Wassermann tests made and the family history
studied. In these 100 families there were 331 pregnancies. Of these 100
(30.2 per cent.) were abortions, 31 (9.3 per cent.) still births and 200
(60.4 per cent.) living births. Of the 200 living births 35 children
died early and 4 died late, and 161 remained alive and were examined. Of
these, 12 are now dead. Of the 35 who died early, 5 gave an undoubted
history of syphilis and a number gave suspicious histories. Of the four
who died late, one was an idiot. Of the 161 examined, 107 were
clinically positive and had positive Wassermann tests. Five were
clinically positive and had negative Wassermann reactions. Sixteen, who
showed no evidence of syphilis, gave positive Wassermann reactions.
Thirty-three, who gave no clinical proof of syphilis, gave a negative
Wassermann reaction.

Of the five who were clinically positive but gave negative Wassermann
reactions, one was a young infant who had snuffles and a large spleen.
The mother and sister both gave a positive history and a positive
Wassermann reaction. Shortly after beginning treatment the baby
developed a syphilitic rash. The baby was removed from the hospital and
a second Wassermann was not done. The second case was a nursing baby.
The mother had active syphilis and was taking treatment. The baby had an
active process in the nose. The third case was a 7-year-old girl who had
a markedly sunken nose and who for that reason was the starting point
for investigating that family. Both the mother and younger brother gave
a positive Wassermann. The fourth case was a 4-year-old girl whose
mother and younger sister were both positive and the patient had a
general rash which was thought to be syphilitic. The fifth case was a
3-year-old boy with a positive history, and who had had some treatment.
His mother and younger brother both had syphilis.

A negative Wassermann reaction is obtained in the presence of active
syphilis only under certain definite conditions. As had been noted in
cases not of this series, very young babies, even with undoubted active
syphilis, not infrequently give a negative Wassermann. It has also been
noted that even small amounts of mercury tend to cause a positive blood
to react negatively.

H. Boas[54] states that of fifty-seven babies of syphilitic mothers
giving negative Wassermann reactions at birth, thirteen during a three
months’ period of observation developed syphilitic manifestations and a
positive Wassermann, and two others showed syphilitic changes at
necropsy, having had no manifestations during life.

Footnote 54:

  Quoted by Haberman: Jour. Am. Med. Assn., 1915, lxiv, 1146.


                            LATENT SYPHILIS

It is seen that 10 per cent., of the children examined had latent
syphilis, i.e., a positive Wassermann and no clinical evidence of
syphilis. One of these children gave a history of epiphysitis at 3
months. Other than this no early history was acknowledged by any of the
mothers. The question naturally arises, Are these children actively
infected with syphilis? When we inquire into the history of those
showing late manifestations, we frequently find, so far as obtainable
history is concerned, that there has been no previous warning that the
disease existed. One of our patients developed, as her first known
symptom, an interstitial keratitis at 20 years. We know that the
spirochete can lie dormant much longer than this and then manifest
itself. One patient of this latent group who had taken very irregular
treatment for about a year and who had never had previous
manifestations, recently developed an active lesion in the throat.
Another developed an interstitial keratitis after about two months of
anti-syphilitic treatment. A positive Wassermann reaction in these
apparently healthy children has the same significance that it does in
the parent, and it is our belief that the children in this group are
actively infected.

The fact that there are thirty-three children, 10 per cent. of the total
pregnancies, who show no evidence of syphilis, and at the same time give
a negative Wassermann reaction, is rather hopeful. Yet the pleasure to
be taken in this fact is not altogether unalloyed. In this small group
there were two mental defectives and an idiot, and it is impossible to
say that all of this group are free from syphilitic infection. In one
instance, one such negative child returned about a year after his
original examination with a tertiary type of lesion and a positive
Wassermann. Though no classification of those in this group showing
stigmata of degeneration was attempted, it can be truthfully stated that
a goodly proportion did show degenerative influences, either physical or
mental.


                 TOTAL SYPHILIS IN THE FAMILIES STUDIED

In summing up the total syphilitic infection in these families, we find
that where marital relations are uninvolved, all of the fathers and
probably all of the mothers have been infected. Presuming that the
abortions, stillbirths, all of the early deaths and at least one of the
late deaths were due directly or indirectly to syphilitic infection,
syphilis among the offspring amounts to 89 per cent. of the total
pregnancies, and total syphilis in the family amounts to 93 per cent. of
all its members.


                                SUMMARY

It is highly probable that all the mothers of syphilitic children have
been infected with syphilis. Of eighty-five mothers of syphilitic
children 86 per cent. gave positive Wassermann reactions. All of the
remaining cases but six gave a history of infection or treatment, or
both. Five of these six patients were examined at least ten years after
the birth of their last syphilitic children and the infection is
probably dying out.

Eighty-seven per cent. of the mothers deny all knowledge of the
infection. The mothers are for the most part infected during the latent
stage of the father.

Of 331 pregnancies in 100 families, 30 per cent. were abortions, 9 per
cent. stillbirths, 61 per cent. living births. Of the living births 24
per cent. had died. Of those living 80 per cent. had syphilis.

Of the total pregnancies 90 per cent. were presumably syphilitic and
although 10 per cent., seem free from syphilis, there is no proof that
they all are. The total syphilis in these families amounts to 93 per
cent. of the entire family.

For the most part our families followed Kassowitz’s rule; i.e.,
decreasing grades of infection in the children.

In case of syphilitic mothers bearing non-syphilitic children, it is
probable that the infection in the mother is localized in places where
it is not readily transmitted.

The idea that there are different strains of spirochetes receives some
support from these families.

Transmission to the third generation, though not proved, is distinctly
an occasional probability.


  _OBSTETRICS. A Text-book for the Use of Students and Practitioners.
      Whitridge Williams, Professor of Obstetrics Johns Hopkins
      University. Obstetrician-in-Chief to the Johns Hopkins Hospital;
      Gynecologist to Union Protestant Infirmary, Baltimore, Md. D.
      Appleton and Co., 1912._

Syphilis is one of the most important complications of pregnancy as it
is one of the most frequent causes of repeated abortion, or premature
labor. The influence of syphilis upon pregnancy differs materially, and
three classes of cases are distinguished, according as infection has
taken place: 1—before pregnancy; 2—at the time of conception; or,
3—during pregnancy. When inoculation with the specific poison has
occurred before conception the disease nearly always gives rise to
abortion or premature labor, more frequently the latter. Le Pileur
obtained a striking illustration of the disastrous effects of syphilis
from a study of the reproductive histories of 130 women, before and
after its inception, 3.8 per cent. of the children being born dead
before, as compared with 78 per cent. after infection. In premature
labor due to syphilis the child is usually dead when it comes into the
world; less frequently it is born alive with definite manifestations of
the disease. When the mother is suffering from the affection at the time
of conception the offspring is always syphilitic. P. 495.


  _THE PRACTICE OF OBSTETRICS. In Original Contributions by American
      Authors. Edited by Reuben Peterson, A.B., M.D., Professor of
      Obstetrics and Gynecology in the University of Michigan, Ann
      Arbor, Mich.; Obstetrician-in-Chief to the University of Michigan
      Hospital. Lea Bros. and Co., Philadelphia and New York, 1907._

In marked contrast to the comparatively slight interference of pregnancy
with the course of syphilis is the decidedly unfavorable influence of
syphilis upon the course of pregnancy. Syphilis, more often than any
other infectious disease, is responsible for a great variety of
pathological changes in the fetus, placenta and uterus, and for the
premature interruption of gestation. Statistics show that the fetal
mortality in this disease averages 50%. This figure is lower than that
given in the preceding paragraphs for some of the acute infectious
diseases, but considering the prevalence of syphilis among all civilized
and uncivilized races, it is obvious that the effect of this disease
deserves a most careful consideration, not only from the medical, but
also from the economic and sociologic point of view. Fournier gives the
fetal mortality for cases in which the maternal infection occurs
simultaneously with fecundation as 75%, the fetal morbidity being above
91%. Page 347. (Hugo Ehrenfest, M.D.)


  _A TEXT BOOK OF OBSTETRICS. Barton Cooke Hirst, M.D., Professor of
      Obstetrics in the University of Pennsylvania; Gynecologist to the
      Howard and Orthopaedic and Philadelphia Hospitals, etc. W. B.
      Saunders Co., Philadelphia and London, 1912._

Syphilitis as the most frequent cause of habitual death of the fetus
must be excluded before another cause is sought. P. 352.

Of 657 pregnancies in syphilitic women collected by Charpentier 35%
ended in abortion, and of the children that went to term a large number
were stillborn. Of 100 conceptions in syphilitic women only seven
children were alive a year later. P. 333.


  _PRACTICAL OBSTETRICS. Thomas Watts Eden, Obstetrical Physician and
      Lecturer on Midwifery and Gynecology, Charing Cross Hospital;
      Consulting Physician to Queen Charlotte’s Lying-in-Hospital;
      Surgeon to In-Patient Hospital for Women. 4th Edition. C. V. Mosby
      Co. 1915._

Of all the systematic causes of abortion however, the most important in
all respects is syphilis. In all probability more abortions are due to
this disease than to any other cause. P. 220.

It will be clear from this enumeration of the conditions which cause it
that abortion is not an uncommon event. From some recent statistics
presented by Professor Malins to the Obstetrical Society of London it
appears that in this country about 16% of pregnancies terminate by
abortion, i.e., one abortion occurs to every five births of viable
children, and further, it appears that abortion is nearly twice as
frequent among the classes from which hospital patients are drawn as
among the well-to-do. Women who are the subjects of syphilis or Bright’s
disease often sustain a succession of abortions without carrying any
pregnancy to term. P. 221.


  _THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Jos. B. De Lee, M.D.,
      Professor of Obstetrics at the Northwestern University Medical
      School; Obstetrician to the Chicago Lying-in-Hospital and
      Dispensary and to Wesley and Mercy Hospitals, etc. W. B. Saunders
      Co. 1913._

Premature labor is produced by the same factors that bring on abortion,
but syphilis plays the most common role here, it being estimated that
from 50% to 80% of the cases are thus caused. Next comes nephritis.
Habitual abortion means that successive pregnancies are interrupted at
the same period of development. Syphilis is usually found as the active
factor and more especially in miscarriages of the later months. Each
successive abortion occurs at a later period until a living child is
born, but it perishes from congenital syphilis, and finally the disease
has become so attenuated that a viable child is born. P. 419.

Obstetricians should constantly be on the alert for this protean
disease. Its baneful action is often discovered when least expected and
it spreads its blight on all three individuals concerned in the
procreation of the species, often being transmitted to the second
generation. Ricord says that in Paris one in eight is syphilitic, and
while in America conditions are better, the disease is not rare and in
its lesser manifestations quite common, though often not diagnosed. P.
482.

Interruption of gestation is the commonest symptom (of syphilis) and von
Winckel found 61% fetal mortality. P. 483.


  _THE PRACTICE OF OBSTETRICS. Designed for the use of Students and
      Practitioners of Medicine. J. Clifton Edgar, Professor of
      Obstetrics and Clinical Midwifery in the Cornell University
      Medical College; Visiting Obstetrician to Bellevue Hospital, New
      York City; Surgeon to the Manhattan Maternity and Dispensary;
      Consulting Obstetrician to the New York Maternity and Jewish
      Maternity Hospitals. 5th Edition Revised. P. Blakiston’s & Co.,
      Philadelphia._

This (syphilis) is one of the most common causes of abortion. P. 321.

The causes of interrupted pregnancy may be placed in three classes. The
maternal causes are divisible into systemic and the local. The systemic
causes include obesity, marriages of consanguinity, _pregnancies in
rapid succession_, etc., and the toxemia of kidney insufficiency. The
local causes include all cases of acute and chronic pelvic congestion.
P. 332.

Chief among the paternal causes is syphilis, tuberculosis, extreme youth
or old age, great constitutional depression, exhaustion from any cause.
P. 333.


  _MEDICAL GYNECOLOGY. Howard Kelly, A.B., M.D., LLD., F.R.C.S.,
      Professor of Gynecological Surgery in Johns Hopkins University,
      and Gynecologist to the Johns Hopkins Hospital; Fellow of the
      American Gynecology Society; Honorary Fellow of the Edinburgh
      Obstetrical Society; Hon. Fellow Royal Academy of Medicine in
      Ireland; Fellow British Gynecology Society, etc., etc., etc. D.
      Appleton & Co., New York and London, 1912._

The susceptibility of syphilis to hereditary transmission is a
fundamental character of the disease. It may be transmitted to the
offspring directly by the infected sperm of the father, or from the
infected ovule of the mother at the time of impregnation, or the
infective principle may be conveyed through the medium of the
utero-placental circulation during the course of pregnancy. P. 432.

Whether the infection is communicated through the sperm solely, the
ovule, or the utero-placental circulation, the uterine death of the
fetus is the most habitual expression of hereditary syphilis. Hereditary
syphilis is one of the most common causes of abortion. P. 434.

Clinical observation shows most conclusively that certain dystrophies
and organic defects in the subjects of hereditary syphilis may be
transmitted to the third generation. P. 436.

While we cannot conclude that syphilis is transmitted in its essential
nature as a virulent contagious disease, to the third generation, yet it
is well known that heredo-syphilis kills the product of conception, or
transmits to the survivor an impaired vitality with various dystrophies,
and thus constitutes a chief factor in the physical, mental and moral
degeneration of the race. From an exhaustive study of heredo-syphilis,
Tarnowsky concludes that syphilis has an incomparably more fatal
influence upon the species and on society than on the individual. P.
437.


  _PRINCE A. MORROW, M.D. Eugenics and Racial Poisons. Pamphlet
      published by the Society of Sanitary and Moral Prophylaxis, 105 W.
      40th St., New York. 1912._

Syphilis is the only disease transmitted to the offspring in full
virulence, killing them outright, or blighting their normal development.
When the father alone is infected the mortality is about 38%. When the
mother also becomes infected the mortality averages from 60% to 80%.
Fully ⅓ of all infected children die within the first six months. Even
when the subjects of inherited syphilis successfully run the gauntlet of
diseases incident to infancy and childhood they do not always escape the
effects of the parental disease. They are subject to various organic
defects or stigma of degeneration, as they are termed. A final result of
hereditary syphilis is the inability to procreate healthy children. If
the subjects of inherited syphilis grow up and marry they are liable to
transmit the same class of organic defects to the third generation.


  _FEWER AND BETTER BABIES, OR THE LIMITATION OF OFFSPRING. Wm. J.
      Robinson, M.D., Chief of the Department Genito-Urinary Diseases
      and Dermatology, Bronx Hospital and Dispensary; Fellow of the
      American Medical Association and of the New York Academy of
      Medicine._

There are thousands of syphilitic men and women who are perfectly safe
as far as their partner is concerned, but are not safe enough to become
parents. They cannot infect, but they must not give birth to children
for fear that the children may have the taint in them. The use of
preventives settles this problem and saves the world from thousands of
pitiable hereditary syphilitics. P. 126.


  _MEDICAL GYNECOLOGY. Howard A. Kelly._

Two fundamental characteristics, contagiousness and susceptibility of
hereditary transmission, give to syphilis an altogether special
importance in relation to marriage. The statement has been made that
syphilis constitutes a far greater danger to Society and the race than
to the individual. The chief significance of syphilis as a racial danger
comes from its hereditary effects. In addition, hereditary syphilis
undoubtedly creates a terrain, or soil, favorable for the reception and
germination of tubercle bacilli, and perhaps other bacilli. It does this
by impoverishing the organism and diminishing the capacity of resistance
against microbic invasion. From the view point of race perpetuation,
syphilis is antagonistic to all the family represents in our social
system. The essential aim of marriage is not simply the procreation of
children, but of children born in conditions of vital health and
physical vigor. The effect of syphilis is to so vitiate the procreative
process as to produce abortions, or else a race of inferior beings,
endowed with defects and infirmities and unfit for the struggle of life.
It is this pernicious effect of syphilis upon the offspring which gives
to the disease a dominant influence as a factor in the degeneration and
depopulation of the race. P. 444.

When a married man has syphilis the first indication is to prevent
contamination of his wife, the second is to guard against pregnancy. The
interdiction of pregnancy should be absolute until time and treatment
have exerted an attenuating and curative influence upon the diathesis.
P. 448.

A consultation of the works of most authorities shows them to agree that
the frequency of abortion to births at full term is from one in five or
six to one in ten. P. 453.


  _SOCIAL DISEASES AND MARRIAGE. Social Prophylaxis. Prince Morow, M.D.,
      Emeritus Professor of Genito Urinary Diseases in the University
      and Bellevue Hospital Medical College, New York; Surgeon to the
      City Hospital; Consulting Dermatologist to St. Vincent’s Hospital,
      etc. Lea Bros. & Co., New York and Phil., 1904._

The influence of inherited syphilis is manifest in the production of
various dystrophies, malformations, and lesions of important organs, it
seriously compromises the physical development, mental vigor and vital
stamina of the descendants and constitutes a harmful factor in the
degeneration of the race. The social aim of marriage is not simply the
production of children who are to continue the race, but of children
born in conditions of vitality and physical health fit to produce a race
well-formed and vigorous, not to procreate beings malformed and stamped
with physical and mental infirmity, destined to early death, or to drag
out a miserable existence of invalidism. P. 21.

The statistics of European observers which have been collected from both
private and hospital practice show in a most positive manner the noxious
influence of syphilis upon the offspring. An analysis of these
statistics taken from all quarters and aspects of the social condition
of the parents show that when both parents are infected the mortality is
68 per 100. P. 27.

No other disease is so susceptible of hereditary transmission, so
pronounced in its influence, and so fatal to the offspring.

While death in utero may occur as the most habitual expression of
hereditary syphilis, its lethal influence is not limited to the period
of intra-uterine existence. The child may be born alive, but in many
cases the sentence of death is not commuted, it is simply reprieved, it
may be for a few months, weeks, or only days. P. 212.


  _THE WORLD’S SOCIAL EVIL. A Historical Review and Study of the
      Problems Relating to the Subject. Wm. Burgess. With Supplementary
      chapter on a constructive policy by Judge Harry Olson, Chief
      Justice Municipal Court, Chicago. Saul Bros., Publishers, Chicago,
      1914._

Based upon statements, experiences and opinions of physicians, public
officials and other responsible persons, 50% to 80% of all men between
the ages of 18 and 30 years contract gonorrhea. 10% to 18% of the male
population contract syphilis. 40% to 60% of all operations upon women
for diseases of the generative organs result from gonorrheal infection.
80% of the inflammatory diseases peculiar to women are the result of
gonorrheal infection. A large per cent., some say one half, of still
born and premature deaths of children is due to syphilis. 25% to 35% of
all cases of insanity are caused by syphilis contracted years before.
15% to 20% of all blindness is attributed to these diseases. P. 159.


  _A CONSTRUCTIVE POLICY WHEREBY THE SOCIAL EVIL MAY BE REDUCED. Harry
      Olson._

The large group of mentally retarded persons who may be included in the
term “sub-normal” number in this country, according to the best
authorities about 300,000. An important distinction must be made between
two groups of the defective classes, those who may, and those who should
not enjoy social privileges as members of the community. From a racial
and eugenic point of view the inborn, or heredity defectives are by far
the most important because the defect is germinal and therefore
transmissible to the offspring. This class forms 75% or more of the
defective classes. When so many as 75% of the feeble-minded are such by
reason of germinal or hereditary taint, and since perhaps 50% of the
women of the underworld are sub-normal, it becomes at once apparent that
not only in order to reduce the number of women in public prostitution,
but also to protect the race itself, we must adopt other methods of
eliminating vice than those now employed. P. 358–359.


  _PROCEEDINGS OF THE NATIONAL CONFERENCE ON RACE BETTERMENT. January
      8–12, 1914. Published by the Race Betterment Foundation. Edited by
      the Secretary._

Statistical Studies. The Significance of a Declining Birth Rate.
Frederick L. Hoffman, Statistician of the Prudential Insurance Company,
Newark, N. J.

From an economic and social point of view a low birth rate and a low
death rate would unquestionably be more advantageous than the opposite
condition, which involves much needless waste of human energy and
pecuniary expenditure. For reasons which require no discussion, every
civilized country desires a normal increase in population, though a high
degree of social and economic well-being is not at all inconsistent with
even a stationary population condition such as for some years past has
prevailed in France. P. 23.

All the available statistical information seems to justify the
conclusion that the world’s population in general, and of the more
civilized countries in particular is increasing at the present time at a
more rapid rate than in earlier years—a condition largely the result of
a persistent and considerable decline in the birth rate. P. 28.

The important causes of death which have increased during the five years
ending 1910, as compared with the previous five years, are briefly the
following:—Syphilis increased from 4.1 to 5.4, per 100,000 of
population. Cancer, and other malignant tumors from 11.5 to 13.7;
locomotor ataxia, and other diseases of the spinal cord from 7.3 to 8.4;
all diseases of the circulatory system combined from 161.2 to 171.7;
ulcers of the stomach from 2.9 to 3.6; diarrhea and enteritis under two
years, from 89.0 to 96.2; diseases of the puerperal state considered as
a group from 14.2 to 15.5; malformations, chiefly congenital, from 12.2
to 14.9; diseases of early infancy, chiefly congenital debility and
premature births, from 73.9 to 75.0. P. 45.


                               GONORRHEA


  _THE PRACTICE OF OBSTETRICS. In Original Contributions by American
      Authors. Edited by Reuben Peterson, A.B., M.D. Lea Bros. & Co.,
      Phil. and New York. 1907._

The reciprocal relation of gonorrhea and pregnancy is most unfavorable.
Gonorrhea exerts a very unfavorable effect upon pregnancy and is
responsible for a large number of abortions in the early months. Finally
the gonococcus is a great source of danger to the fetus whose eyes may
become affected during his passage through the diseased maternal parts.
P. 373.


  _THE PRINCIPALS AND PRACTICE OF OBSTETRICS. Jos. B. De Lee, M.D.,
      Professor of Obstetrics at the Northwestern University Medical
      School; Obstetrician to the Chicago Lying-in-Hospital and
      Dispensary and to Wesley and Mercy Hospitals, etc. W. B. Saunders
      Co. 1913._

Abortion is probably often the result of gonorrhea, acute or chronic.
Chronic endometritis is most often the result of gonorrhea. P. 516.


  _THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL, BIOLOGICAL AND
      HYGIENIC ASPECTS. E. Heinrich Kisch, Professor of the German
      Medical Faculty of the University of Prague, Physician to the
      Hospital and Spa of Marienbad; Member of the Board of Health, etc.
      Translated by M. Eden Paul, M.D. Rebman Co., New York._

The physician should lend his skilled assistance in producing
facultative sterility only when his own special scientific knowledge
leads him to consider this urgently necessary. A woman’s life and well
being must appear to him of greater importance than the existence, or
non-existence of a possible infant. That this view is morally sound is
shown by the fact that public opinion justifies the accoucheur in the
destruction of a living child when the mother’s life is in danger. P.
395.


  _EUGENICS AND RACIAL POISONS. Prince A. Morrow, M.D., Emeritus
      Professor of Genito Urinary Diseases in the University and
      Bellevue Hospital Medical College, New York; Surgeon to the City
      Hospital; Consulting Dermatologist to St. Vincent’s Hospital, etc.
      Lea Bros. Co., New York and Philadelphia, 1904._

While the gonococcus is not transmissible through heredity it carries
with it serious infective risks to the offspring. Fully 80%, and some
authorities declare practically all of the blindness of the new born is
caused by the gonococcus.



                              CHAPTER VIII
               OTHER TRANSMISSIBLE DISEASES AND PAUPERISM


_When authorities prohibit marriage for the unfit, they have in mind the
probable fruits of such marriage. Women suffering from the diseases
mentioned in this chapter give birth to children mentally and physically
inferior, likely to sink into pauperism and certain to be in some way a
burden upon society. If physicians were free to instruct parents how to
prevent conception, the reproduction of their kind by defective and
diseased parents living outside of institutions would be eliminated as a
social problem._


                                INSANITY


  _DR. S. ADOLPHUS KNOPF IN THE SURVEY FOR NOVEMBER, 1916_

That insanity, idiocy, epilepsy and alcoholic predisposition are often
transmitted from parent to child is now universally admitted and
corroborated by every-day experience and by an abundance of statistics.
Countless are the millions of dollars expended for the maintenance of
these mentally unfit. The state of New York alone spends $2,000,000
annually for the care of its insane. Whether sterilization of these
individuals would be the best remedy is a question still open for
discussion. The constitutionality of the procedure is doubted by some of
our legal authorities. Segregation is resorted to in the meantime with
more or less rigor according to state laws. Every year, however, many of
the individuals who had been committed to institutions for the treatment
of mental disorders are discharged as cured. They are allowed to
procreate their kind. Would it not be an economic saving if at least the
individuals whose intelligence has been restored were instructed in the
prevention of bringing into the world children who are most likely to be
mentally tainted and to become a burden to the community?

Of approximately every 500 persons in the United States in 1910, there
was one an inmate of an insane asylum.

The exact figures expressed in a recent report (Hill, Joseph A. Report
on the Insane in the United States, Bureau of the Census, Department of
Commerce) that in a typical community of 200,000 persons, equally
divided as to sex, 208 of the males and 200 of the females would be
found in the insane asylums. In the course of a year 72 males and 60
females would be admitted to the asylums.

In 1880 the total of inmates in insane asylums in the United States
included 20,695 males and 20,307 females. In 1910, thirty years later,
the number of male inmates had increased to 98,695 and the number of
female inmates to 80,096. The excess of men among admissions in 1910
indicated a still further increase in the proportion, namely, 128 males
to 100 females.


  _BEING WELL-BORN. An Introduction to Eugenics. Michael F. Guyer, Prof.
      Zoology, University of Wisconsin. Bobbs-Merrill Co., Indianapolis,
      Ind. 1916._

The records of the inheritance of insanity, imbecility,
feeble-mindedness and other forms of nervous and mental defects are
truly startling. Active researches in this field have been in progress
now for several years, and as each new set of investigations comes in
the tale is always the same. It is questionable if there is a single
genuine case on record where a normal child has been born from a union
of two imbeciles. Yet the universal tendency is for defective to mate
with defective. Davenport gives a list of examples, beginning with such
a one as this: “A feeble-minded man of thirty-eight has a delicate wife
who in twenty years has borne him nineteen defective children.” Little
wonder, in the light of such facts as these, that the number of
degenerates is rapidly increasing in what are called civilized
countries. But it may be urged, these are exceptional cases, there is
surely no considerable number of mental defectives who are married. Let
us look at the available facts. In Great Britain in 1901, of 60,000
known feeble-minded, imbeciles and idiots, 19,000 were married, and in
the same year, of 117,000 lunatics, 47,000 were married; that is a sum
total of 66,000 mentally defective individuals were legally multiplying,
or had had the opportunity to multiply their kind, to say nothing of the
unmarried who were known to have produced children.

In the State of Wisconsin I note from the tenth Biennial Report of the
Board of Control that of 574 patients admitted to the Northern Hospital
for the Insane during the year from July 1st, 1908 to June 30th, 1909,
274 were married, and 29 others were known to have been married; this is
a total of 303 out of 574, considerably over half. At the Wisconsin
State Hospital for the Insane we find the conditions are no better, for
out of 499 admitted in the year of 1909–10, 208 were married and 65
others had at some time been married, or a total of 273 out of 499.
There is every reason to believe that conditions are approximately
similar in other states. P. 231–232.

One of the most disquieting facts in the situation in most states is
that many patients—an average of approximately 1,000 a year, in
Wisconsin for example—are on parole, subject to recall. This means that
although it is recognized that these patients are likely to have to be
returned to the asylum or hospital, little or no restraint in the
meantime is placed on their marital relations. P. 234.


  _SOCIAL ASPECTS. Wm. E. Kellicott._

In the U. S. the census of 1880 reported 40,942 insane in hospitals, and
51,017 not in hospitals, a total of 91,959 known insane. In 1903 the
number in hospitals had increased to 150,151. The number not in
hospitals was not known and cannot be determined accurately, but it is
conservatively estimated as certainly not less than 30,000, and probably
it is far greater than this. But taking a total of 180,000 known insane
as a conservative figure, the ratio of known insane in the total
population was 225 per 100,000 in 1903, as compared with 183 per 100,000
in 1880. P. 33.

The latest census reports for the U. S. give data relative to the
dependents and defective in institutions. Insane and feeble-minded, at
least 100,000; paupers in institutions 80,000, ⅔ of whom have children
and are also physically and mentally deficient: prisoners 100,000;
juvenile delinquents 23,000 in institutions; the number cared for in
hospitals, dispensaries, homes of various kinds in the year 1904 was in
excess of 2,000,000. From these figures we get a rough total of nearly
3,000,000. The foregoing are representative data:—they are published by
the volume. It is always the same story—rapid increase of the unfit,
defective, insane, criminal, slow increase, even decrease, of the normal
and gifted stocks. It is with such conditions in mind that Whetham
writes: “This suppression of the best blood of the country is a new
disease in modern Europe; it is an old story in the history of nations,
and has been the prelude to the ruin of states and the decline and fall
of empires.” P. 35.


  _EUGENICS RECORD BULLETIN. No. 5. A Study of Heredity of Insanity in
      the Light of the Mendelian Theory. A. J. Rosanoff, M.D., and
      Florence I. Orr, B.S. Reprinted from American Journal of Insanity.
      Vol. XXVIII ... 1911. Cold Spring Harbor, N. Y._

In the report of the year ending September 30th, 1909, the New York
State Commission in Lunacy gives the number of insane patients in state
hospitals and private institutions as 31,540, or one to 276 in the
general population. This figure does not include the inmates of
institutions for the feeble-minded and for epileptics, it does not
include the neuropathic subjects who find their way into prisons,
reformatories, almshouses, dispensaries, hospitals for incurables,
general hospitals, neurological clinics, etc., and above all, it does
not include the many neuropathic subjects whose infirmities are latent,
or of such nature as not to incapacitate them for ordinary occupations
and life at large. P. 245.


  _EUGENICS RECORD OFFICE. Bulletin No. 10 A. Report of the Committee to
      study and to report on the best practical means to cut off the
      defective germ-plasm in the American population. The scope of the
      Committee’s work. By Harry H. Laughlin, Secretary to the
      Committee. Cold Spring Harbor, N. Y. 1914._

According to the last census, 1910, .914% of the total population, or
841,244 persons, were inmates of institutions in the anti-social and the
unfortunate classes in the U. S. Besides these persons who have been
committed to institutions, there are many others of equally unworthy
personality and hereditary qualities, who have, through the caprice of
circumstances never been committed to institutions. In so far as the
defective traits of the members of these varieties are inborn, they are
to be cut off only by cutting off the inheritance lines of the strains
that produce them. This is the natural outcome of an awakened social
conscience, which is in keeping, not only with humanitarianism, but with
law and order and national efficiency. Society must look upon germ-plasm
as belonging to Society, and not solely to the individual who carries
it. Humanitarianism demands that every individual born be given every
opportunity for decent and effective life that our civilization can
offer. Racial instinct demands that defectives shall not continue their
unworthy traits to menace Society. There appears to be no compatibility
between the two ideals and demands. P. 15–16.


  _J. H. KELLOGG, LLD., M.D., Superintendent of Battle Creek Sanitarium,
      Battle Creek, Mich._

A careful study of the returns of the Registrar General of England,
according to Dr. Tredgold, an eminent English authority shows that out
of every 1,000 children born to-day, as many infants die from “innate
defects of constitution” as 50 years ago, and this notwithstanding that
the total death rate of infants has been diminished nearly ⅓. The
increase of insanity, is cited by Dr. Tredgold, as another evidence of
race degeneracy. While the increase of the population of England and
Wales in 52 years has been 85.8%, the increase of the certified insane
has been 262.2%. At present there is one insane person to 275 of the
normal population of England and Wales. Tredgold shows that mental
unsoundness, lunacy, idiocy, imbecility and feeble-mindedness may be
traced to hereditary influence in 90% of the cases. Mr. David Heron and
others have shown that while there has been a marked decline in the
birth rate in the population in general, the diminution is almost
entirely confined to the healthy and thrifty class. In a section of
population numbering a million and a quarter persons, thrifty and
healthy artisans, the decline in the birth rate in 24 years, 1889—1904
was over 52%, or three times that in England and Wales as a whole. Study
of a large number of families of the working class of incompetent and
parasitic character found that the average number of children to the
family was 7.4, while in thrifty and competent working families, the
number was 3.7. In other words, the incompetent and defective classes
are multiplying much more rapidly than are the competent and efficient.
P. 440.


  _THE INCREASE OF INSANITY. James T. Searcy, A.B., M.D., LLD.,
      Superintendent Alabama Hospitals for Insane. First National
      Conference on Race Betterment. January, 1914._

The population of the State of Alabama, according to the census during
the ten years which the census includes, insanity increased 16%; the
admissions into the insane hospitals increased 45%. These are appalling
figures, and we can parallel them all over the U. S., not like them
exactly in each state, for they differ. The general population of the U.
S. increased 18%, and that of the insane hospitals increased 28% during
the years of the census. P. 167.


                                EPILEPSY


  _THE PRACTICE OF OBSTETRICS. Joseph De Lee, M.D._

Epilepsy may practically be regarded as an in-hereditary affection, and
children of one subject to this disorder are almost sure to be
epileptic. Under no circumstances should parents who are both epileptics
bring children into the world.


  _THE PRACTICE OF OBSTETRICS. In Original Contributions by American
      Authors. Edited by Reuben Peterson, A.B., M.D., Prof. of
      Obstetrics and Gynecology in the University of Michigan, Ann
      Arbor, Mich.; Obstetrician and Gynecologist-in-Chief to the
      University of Michigan Hospital. Lea Bros. & Co., Phil. and New
      York. 1907. Chapter XIX._

Marriage should always be discouraged on account of the marked tendency
of epilepsy to be transmitted to the offspring. In all grave cases,
marriage, or new impregnation, should be prohibited. P. 363. (Hugo
Ehrenfest, M.D.)


                               ALCOHOLISM


  _PARENTHOOD AND RACE CULTURE. An Outline of Eugenics. C. W. Saleeby,
      M.D., Ch.B., F.Z.S., F.R.S., Edinburgh; Fellow of the Obstetrical
      Society of Edinburgh; Member of Council of the Eugenics Education
      Society; of the Psychological Society, and of the National League
      for Physical Education and Improvement; Member of the Royal
      Institution and of the Society for the Study of Inebriety, etc.,
      etc. Cassell & Co., Ltd., London, N. Y., Toronto and Melbourne.
      1909._

A foremost authority, Dr. F. W. Mott, has independently reached the same
conclusion as Dr. Branthwaite, that the chronic inebriate comes as a
rule of an inherently tainted stock. Dr. Mott, however, reminds us that
if alcohol is a weed killer, preventing the perpetuation of poor types,
it is probably even more effective as a weed producer. Professor David
Ferrier, the great pioneer of brain localisation, in reference to these
people speaks of the “risk of propagation of a race of drunkards and
imbeciles.” Dr. J. C. Dunlop, Inspector under the Inebriates Act,
Scotland, states that his experience leads him to precisely the same
conclusion as that of Dr. Branthwaite. Dr. A. R. Urquhart, an Asylum
authority, affirms that chronic inebriety is largely an affair of habit,
is a symptom of mental defect, disorder, or disease. Dr. Fleck, another
authority, says, “It is my strong conviction that a large percentage of
our mentally defective children, including idiots, imbeciles and
epileptics, are the descendants of drunkards. Mr. McAdam Eccles, the
distinguished surgeon agrees; so does Dr. Langdon Down, physician to the
National Association for the Welfare of the Feeble-minded; so does Mr.
Thos. Holmes, the Secretary of the Howard Association.”


  _MARRIAGE AND GENETICS. Laws of Human Breeding and Applied Eugenics.
      Chas. A. L. Reed, M.D., F.C.S.; Fellow of the College of Surgeons
      of America; Member and former president of the American Medical
      Association; Professor in the University of Cincinnati. The Galton
      Press, Cincinnati, Ohio._

The present demand for alcohol is generally the demand of the system for
something with which to make up for some persistent defect. In other
words, alcoholism is the sign and index of some form of degeneration.
Thus the degeneracy that finds expression in alcoholism in one
generation may be manifested in the next in the form of epilepsy,
feeble-mindedness, insanity, immorality, or criminality. Unfortunately,
alcoholism does not seem to lessen the fecundity of its victims. The
quality of their progeny is, however, progressively lowered. It is due
to the combined influence of transmitted degeneracy and the pernicious
effect of environment. As a genetic factor, alcoholism, considered in
its immediate relation to the marriage state may be summarised as
follows:—

1—The chronic alcoholist generally develops lowered sexual efficiency.

2—General failure of sexual power, associated with strong desire,
generally manifested by alcoholics, often results in sexual promiscuity,
associated with perversion.

3—Progressive alcoholism destroys the normal psychic type and thus
breaks up family ties.

4—Lowered general efficiency of alcoholics tends to pauperism and crime.

5—Lowered general resistance of alcoholics makes them the easier prey of
infections and shortens their expectancy of life.

6—Alcoholism is a germinal defect, the degeneracy underlying which is
transmitted in some form to 100% of the progeny of two alcoholic
parents.

Marriage with or between degenerates of the alcoholic type is advised
against and should be prohibited by law. P. 125–126.

Pauline Tarnowsky in _Etudes Anthrope metriques sur le Prostitutees_
1887 gives figures derived from measurements of fifty prostitutes in
Petrograd in which she found four-fifths of her cases were offspring of
alcoholic parents while one fifth were the last survivors of very large
families.


  _THE PRACTICE OF OBSTETRICS. In Original Contributions by American
      Authors. Edited by Reuben Peterson, M.D._

A chronic state of intoxication may be found in patients (Mothers) with
such bad habits as alcoholism, morphinism, cocainism, etc., and in
sufferers of trade poisoning, plumbism, nicotism of workers in tobacco
factories, etc. Most of these diseases are characterized by a tendency
to abortion and a high infantile mortality and morbidity. P. 368.

It is generally admitted that the effect of chronic alcoholism upon
pregnancy is most harmful. On account of the frequency with which
drunkards are afflicted with venereal diseases, especially syphilis, it
is almost impossible to obtain reliable statistics and exact figures,
but the fact has been established that chronic alcoholism predisposes
the woman to abortion, and that the children of dipsomaniac parents show
a strikingly large percentage of malformations and mental abnormalities,
especially imbecility and epilepsy. P. 370 (Hugo Ehrenfest, M.D.)


  _THE PATHOLOGY OF THE FETUS. Aldred Scott Warthin, M.D. (The Practice
      of Obstetrics, in original Contributions by American Authors, Ed.
      by Reuben Peterson, M.D.)_

Of the antenatal treatment of fetal diseases we at present know little
or nothing, but there can be no doubt that a wonderful field is here
offered to the medicine of the future. According to our present
knowledge such germinal and fetal therapeutics must be chiefly in the
line of prevention. We are already in a position to apply some knowledge
toward this end. The effects upon the fetus of intoxications, such as
plumbism, alcoholism, etc., may be avoided. The production of syphilitic
offspring may be restricted, and our knowledge of the later effects upon
the fetus of certain diseases, or pathologic states of one or both
parents may be utilized toward the bringing into existence of progeny
under such conditions as to escape such evils. Our knowledge of
heredity, of morbid conditions and predispositions should also be
brought to bear upon the question of marriage and fitness to produce
healthy children. Moral, as well as physical considerations should here
be gravely weighed. The health of parents, the hygiene of pregnancy
throughout its entire course, etc., are important factors in the
improvement of the race, to which the coming civilization and the new
medicine must give increasing attention. P. 535.


  _THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL, BIOLOGICAL AND
      HYGIENIC ASPECTS. E. Heinrich Kisch. Rebman Co., New York._

A woman with a tendency to alcoholism should under no circumstances be
allowed to marry. In the cases, fortunately rare, in which the drink
craving exists in women, marriage is even more undesirable than it is in
the case of men similarly afflicted, for the female drunkard is in a
position in which she can mishandle and neglect her children throughout
the entire day. P. 258.


  _RASSENVERBESSERUNG. Translated from the Dutch of Dr. J. Rutgers.
      Second Edition. Dresden, 1911._

Pelman examined 709 of the 834 descendants of an alcoholic vagrant,
named Ada Inke, who died in 1740. Among these were found 106
illegitimate children, 142 were vagrant beggars, 64 were charity
dependents, 181 prostitutes, 96 were tried for various offenses, among
these 7 were for murder. These descendants during 75 years cost the
State 5,000,000 marks. P. 97.

August Forel, who for years was the psychiatrist at the head of a large
insane asylum at Zurich, Switzerland, has this to say about the effects
of narcotic poisons and alcohol in particular: “The offspring tainted
with alcoholic blastophthoria suffer various bodily and physical
anomalies, among which are dwarfism, rickets, a predisposition to
tuberculosis and epilepsy, moral idiocy in general, a predisposition to
crime and mental diseases, sexual perversions, loss of suckling in
women, and many other misfortunes. But what is of much greater
importance is the fact that acute and chronic alcoholic intoxication
deteriorates the germinal protoplasm of the procreators.”


  _MICHAEL F. GUYER, Ph.D., Professor of Zoology, University of
      Wisconsin in “Being Well Born.”_

In an investigation on the effects of parental alcoholism on the
offspring, Sullivan (Journal of Mental Science, Vol. 45, 1899) gives
some important figures. To avoid other complications he chose female
drunkards in whom no other degenerative features were evident. He found
that among these the percentage of abortions, still-births and deaths of
infants before their third year was 55.8% as against 23.9% in sober
mothers. In answer to the objection that this high percentage may be due
merely to neglect, and not to impairment of the fetus by alcoholism, he
points out the fact, based on the history of the successive births, that
there was a progressive increase in the death-rate of offspring in
proportion to the length of time the mother had been an inebriate. P.
169.


  _A TEXT BOOK OF OBSTETRICS. Barton Cooke Hirst, M.D., Professor of
      Obstetrics in the University of Penn.; Gynecologist to the Howard,
      the Orthopaedic and the Phil. Hospitals, etc. 7th Edition. W. B.
      Saunders Co., Phil, and London, 1912._

The effect of chronic diseases of the mother upon the fetus. Women
affected with tuberculosis, cancer, or chronic malarial poisons may give
birth to a succession of dead children. P. 353.

Fetal mortality exceeds that of any other period of life. For every four
or five labors there is one abortion, and if to this number is added
still-births the proportion of fetal deaths to living births is larger.
P. 332.


  _THE DISEASES OF SOCIETY AND DEGENERACY. G. F. Lydston, M.D._

That a multiplicity of children in poverty-stricken families often
impels to abortion, is evident. The necessary evils of our prohibitive
laws and ethics bearing upon illegitimacy, are obvious; viz:

First, and worst, is infanticide, committed usually before, but only too
often after birth. In the latter category I would place abandoned
children who die of exposure or starvation, and the bulk of mortalities
in foundling asylums and for baby farms. The social ostracism placed
upon the mother is a prime factor in this child’s murder. Condemnation
and shame are hers if she allows nature to take its course, and the
penalty of infanticide stares her in the face if she interferes with the
conception. A rarely anomalous state of affairs this.

Second—The brand of infamy placed upon the unborn child, from which only
its murder can save it.

Third—The prostitution or suicide of the woman who is found out.

Branded with ignominy from the moment of conception, a burden to
society, and a still greater burden to its parent, or parents from the
moment of its birth, with no systematic endeavor on the part of society
to prevent its growing up a criminal, a drunkard, a pauper, a
prostitute, or a physical wreck, what wonder that many a poor woman’s
fingers become too tightly entwined around her offspring’s neck. If her
motive for the act were always as altruistic as its consequences, so far
as the child’s welfare is concerned, there are some clear-minded
thinkers in the world who could not be brought to judge her harshly. P.
371.

The rights of the unborn will one day be considered. Until they are so
considered, and practical efforts made to secure them, we cannot hope
for much improvement in the prevention of degeneracy. P. 559.


  _AMERICAN JOURNAL OF DISEASES OF CHILDREN, November 1914. Vol. 8, pp.
      327–335. Question of Hereditary syphilis as a social problem._

Of all deaths of infants in St. Louis in 1913, 1,070 were illegitimate.

Of all deaths in infants due to syphilis 1,550 were illegitimate.


  _AUGUST FOREL. The Sexual Question. A Scientific, Psychological,
      Hygienic and Sociological Study. Translated by C. F. Marshall,
      M.D., F.R.C.S., Late Assistant Surgeon to the Hospital for
      Diseases of the Skin. London._

The stigma of shame which has branded all illegitimate maternity
unfortunately justifies the many cases of abortion, and even
infanticide. Things ought to change in this respect, and in the future
no pregnancy ought to be a source of shame for any healthy woman
whatever, nor furnish the least motive for dissimulation. P. 411.


  _THE SMALL FAMILY SYSTEM. C. V. Drysdale, D.Sc._

ILLEGITIMACY.—As far as statistics are concerned, the most valuable
evidence is that relating to illegitimacy. The Registrar General’s
Reports contain a useful amount of information upon this point, and give
us the number of illegitimate births per thousand unmarried women within
the fertile period, between the ages of 15 and 45. This illegitimacy
rate for England and Wales is represented in Fig. 13, and it is
noticeable that the fall since the year 1876 has been extremely rapid,
much more so in fact than that of the fall in the general birth-rate or
in the fertility rate of the married women. While the general birth-rate
has fallen from 36.3 to 25.6 (or by 26.5 per cent.), the illegitimate
birth-rate has fallen from 14.6 to 7.9 per thousand unmarried women (or
by nearly 50 per cent.). This is most striking and satisfactory. An
extreme instance is given in the county of Radnorshire, which in 1870–2
had a fertility rate of 308.6 births per 1,000 married women, which sank
to 188.7 in 1909, or by 39 per cent. In the same interval the
illegitimate birth-rate fell from 41.8 per 1,000 unmarried women to 7.2,
or by no less than 83 per cent. In Holland a drop of the legitimate
fertility from 347 to 315 per 1,000 coincided with a fall of the
illegitimate fertility from 9.7 to 6.8 per 1,000, _i.e._, at a much
greater rate. It is true that France, with its low and decreasing
fertility rate (from 196 to 158 per 1,000 between 1881 and 1901), has
had a comparatively high and increasing illegitimacy rate (from 17.6 to
19.1 per 1,000); and that Ireland, with a somewhat high and slightly
increasing fertility (from 283 to 289 per 1,000), has the lowest and a
falling illegitimacy rate (from 4.4 to 3.8 per 1,000). But this has been
heavily outweighed by Austria with an equally high and steady fertility
(from 281 to 284 per 1,000) with the highest illegitimacy rate known
(43.4 to 40.1 per 1,000), while Germany comes second with an
illegitimacy rate of 27.4 per 1,000 in 1901. Though it cannot be said,
therefore, that the lowest birth-rate produces the lowest illegitimacy
rate, it most certainly cannot be said that family limitation has had
any evil effect in increasing legitimacy. The bulk of the evidence is
quite decidedly the other way. In the case of the most notable
exception—that of France—we have the authority of Dr. Bertillon for
saying that the greatest decency and lowest illegitimacy are found where
the birth-rate is lowest. We may also quote from our own Registrar
General, who said in his Annual Report for 1909:—

    “Except in the cases of the German Empire, Sweden, France,
    Belgium, and the Australian Commonwealth, the falls shown in
    illegitimate fertility in Table LXXXIV are greater than the
    corresponding falls in legitimate fertility.”

So far as the evidence of illegitimacy is concerned, therefore, it may
be taken as definitely established that the adoption of family
restriction has not led to greater laxity among the unmarried. But it
would, of course, be quite unjustifiable to claim that this evidence is
final. It may not mean that there is less lax conduct but only that
there are fewer results of lax conduct. It is perfectly open for the
orthodox moralist to claim that the greater knowledge of preventive
methods has permitted an increase of laxity with a reduction of the
ordinary effects. This must remain a matter of conjecture. When we find,
however, that not only has illegitimacy decreased, but also deaths from
abortion and from the diseases ordinarily associated with irregularity,
there seems no justification whatever for the contention that chastity
has been relaxed. It must not be forgotten in this connection that the
encouragement to early marriage afforded by the possibility of avoiding
the economic burden of a too early or too large family affords the most
likely of all methods for removing the temptations to unchastity and for
conquering the hitherto untractable “social evil.” Although the average
age of marriage in this country has been rising somewhat lately
(probably on account of the increasing cost of living), it is
interesting to note that it is lower and fairly steadily decreasing in
France. For first marriages the average age at marriage of French men
has fallen from 28.6 in 1856 to 27.88 in 1896–1900, and of French women
from 24.25 to 23.5 in the same period. This cannot be regarded as
otherwise than a very good sign.

(NOTE: It is noteworthy in this connection that the French marriage laws
are so strict that many thousands of couples live out of wedlock in
preference to complying with them.)


                               PAUPERISM

We need not dwell upon this question, as the amount of pauperism depends
upon a large variety of circumstances. But it is satisfactory to note
that pauperism in England and Wales, _i.e._, the number of persons
relieved annually per thousand of the population, has fairly steadily
fallen from 34.5 in 1875 to 26.4 in 1910, or by 23.5 per cent. during
the period of the declining birth-rate. This is so far reassuring, in
that it indicates that the easier circumstances engendered by smaller
families do not lead to idleness, as is frequently contended. The
industry and saving habits of the French peasantry are world-renowned,
and it is worthy of note that France is almost the only country in which
the real wages of the working classes have been _increasing_ of late
years, while they have dropped 15 per cent. in this country, and nearly
25 per cent. in prolific Germany.


  _THE REPORT OF THE POOR LAW COMMISSION. By Sir Edward Bradbrook, C.B.
      Eugenics Review, Vol. 1, April 1909. Eugenics Education Society,
      London._

The Commissioners throw a strong light upon the ineffectiveness of
existing measures when they show that the great and growing expenditure
upon education and upon the public health has had no result in reducing
pauperism, which is on the contrary of late years deplorably increasing,
and that the advance in the rate of wages, and the diminution in the
cost of living have been equally ineffectual.

In the words of the Commissioners, children who are brought up in such
conditions, surrounded by disease and immorality and drunkenness are
almost doomed to pauperism. If relief be given it should be used to
check the creation of another generation of paupers. Much that is very
instructive is contained in the report on the subject of children who
come by one means or another to be under the control of the Guardians of
the Poor, and important suggestions are made for reforms in the manner
and training of such children. This, however, we need not discuss, as
the spread of eugenic principles would tend to reduce their number until
the time should come when the children dependent on public care should
be few and exceptional. In their discussion of the causes of pauperism,
the Commissioners quote a statement from a relief officer of Leeds, that
one of the most important causes is early marriage of persons dependent
upon casual labor. Large families are the rule. Unless we can cut off
some of the sources from which that stream is being fed, the attempt to
do more constructive work, whether by public assistance or by voluntary
charity will continue to be swamped by hopeless cases—men and women
ruined by bad habits or disease from infancy who propagate their own
misery and hand on another generation of hopeless cases to the future. A
great evil justifies strong measures to remedy it. This is true eugenic
doctrine. P. 47–50.


  _THE METHODS OF RACE REGENERATION. C. W. Saleeby, M.D., CH.B., F.Z.S.,
      F.R.S., Edinburgh; Fellow of the Obstetrical Society of Edinburgh;
      Member of Council of the Eugenic Education Society, of the
      Psychological Society, and of the National League for Physical
      Education and Improvement; Member of the Royal Institution and of
      the Society for the Study of Inebriety, etc., etc. New Tracts for
      the Times. Cassell & Co., Ltd., London, New York, Toronto and
      Melbourne. 1911._

At the National Conference on the Prevention of Destitution, held in
London at Whitsuntide, 1911, we gathered together in the section dealing
with this subject a number of papers by authoritative writers, whose
knowledge of the problem is first-hand, and the following is an extract
from the paper, the Eugenic Summary and Demand, in which I endeavored to
express the substance of the evidence. The mentally defective and
diseased, existing in it and as part of it, injure the community in the
following ways:

1—They contribute largely to the ranks of chronic alcoholism and
inebriety, with all their consequences.

2—They contribute largely to the illegitimate birth rate, that is to
say, to the production of children for whose nurture, quite apart from
the question of their natural defect, adequate and satisfactory
provision is not, or indeed cannot be made.

3—They contribute largely to the ranks of prostitution.

4—They thus contribute largely to the propagation of the venereal
diseases, with all their consequences to the present and the future.

5—They are responsible for much crime, major and minor.

6—Both directly, as chronically inefficient, and indirectly, in the ways
here cited, they contribute to the number of the destitute, constituting
the majority of the naturally, as distinguished from the nurturally
unemployable.

7—They contribute largely as parents, married or unmarried, to parental
neglect and cruelty to children which is probably more injurious to the
adult life of the next generation, than most, or any of us realize.

8—They contribute largely to the ranks of the wastrel and the hooligan.
In such ways, and to such a degree these persons injure the community.
But it is particularly to be noted that therein the community also
injures them. The fact is obvious to all of us here. The injury wrought
by the present relations between the community and these unfortunate
persons is mutual, they injure it and it injures them. And not until we
recall the words of Burke, in the light of modern genetics, shall we
realize the full measure of this injury, for as that great thinker said,
a community is “a partnership, not only between those who are living,
but between those who are living and those who are dead, and those who
are to be born.” To the foregoing indictment of the present state of
things, and remembering that whatever is inherent is transmissible, I
therefore add:

9—They become parents and thus contribute incalculably to the
maintenance of these evils after we are dead, but not after we are
responsible. P. 49–50.

But it does not suffice to pursue positive methods, the encouragement of
parenthood on the part of the worthy, and negative methods, the
discouragement of parenthood on the part of the unworthy, if there be
any agencies in the world which are forever turning worthy stocks into
unworthy stocks. If there be such racial poisons, plainly we must stand
between healthy stocks and their influence. By the term racial poisons I
mean to indicate those agents, whatever they may be which, in greater or
less degree, injurious to individuals as individuals, prejudices their
subsequent parenthood. The racial poisons are very various, they include
substances inorganic, such as lead, organic, such as alcohol, and
organized, such as the living causes of certain forms of disease.
Circulating in the parental blood, they reach and injure the racial
tissues, or germ-plasm. P. 56.


  _WOMEN AND LABOR. New York Evening World, May 8, 1917._

With American industry preparing to put women into the places of male
workers called to the war, it is a rather surprising thing to learn that
there already are 7,438,686 women in the United States who earn their
own living. Of these no less than one-fourth are married. Here are the
figures: Single, 4,401,000; married, 1,890,626; widowed or divorced,
1,147,060.

In 1900 only 4,833,630 women left their homes to work, showing an
increase of approximately one-half since then.

In 1890 the married formed 14.3 per cent. of all women sixteen years of
age and over engaged in gainful occupations. By 1900 this proportion had
increased to 15.9 per cent. From 1900 to 1910 it jumped to the
unprecedented proportion of 25.4 per cent. While there were important
variations, the great increase was not confined to any one occupation or
group of occupations, nor to any one State or group of States. In every
occupation examined the married formed a larger proportion of all women
sixteen years of age and over in 1910 than in 1900.

The proportions were exceptionally high in the South and Arizona—50.8
per cent. in South Carolina, 46.8 per cent. in Georgia, 46.7 per cent.
in Florida, 47.4 per cent. in Alabama, 54.2 per cent. in Mississippi,
45.6 per cent. in Arkansas, 40.7 per cent. in Arizona. In contrast, the
proportion was only 15.8 per cent. in Connecticut, 15.1 per cent. in
Pennsylvania, 13.1 per cent. in Wisconsin, 11.9 per cent. in Minnesota,
and 15.7 per cent. in Iowa.

The unusually large proportion of married women engaged outside their
homes in the South is explained by the number of negroes living in that
section of the country. The total of white women working for a living in
the same States is perhaps smaller than in any other part of the United
States.

Even more significant than the great increase in the proportion which
the married form of all women sixteen years of age and over engaged in
gainful occupations is the marked increase in the proportion of all
women so employed.

Statistics show that in 1890 just 4.6 per cent. of married women went to
work. The figures had expanded to 5.6 per cent. ten years later, and in
1910 had reached 10.7 per cent.

It may be safely assumed that in the years which have elapsed between
then and now the increase has more than kept pace with earlier figures.
And it is equally certain that once men have been replaced by women
under war conditions neither they nor employers will be inclined to
restore ante-bellum conditions. The problem is one to give economists
grave concern.


                              CHILD LABOR


  _MARY ALDEN HOPKINS, Harper’s Weekly, 1915._

“Too many children is as great a danger to family life as too few
children,” said Mr. Owen Lovejoy, General Secretary of the National
Child Labor Committee. A secretary of this Committee, working for the
abolition of child labor, the improvement of the compulsory education
laws, and the raising of the standards of education in backward states,
Mr. Lovejoy has first knowledge of the condition of children in every
state in the Union.

“How many are too many?” he was asked. “I should say any more than the
mother can look after and the father earn a living for. There are always
too many children in a family if they have to go to work before they get
their growth and schooling. It may be that some day the state will help
support the children, but under present conditions, as soon as there are
too many children for the father to feed, some of them go to work in the
mine or factory or store or mill near by. In doing this they not only
injure their tender growing bodies, but indirectly they drag down the
father’s wage. They go to work to help the family, but they really
injure it. The wage tends to become an individual wage, the father
receiving only enough for his personal maintenance, the mother working
both at home and outside, and the children supporting themselves as soon
as they can toddle into the cotton fields or hang onto the back of a
delivery wagon. Thus the home is dissolved into constituent parts and
the burden of the struggle for existence is laid on each. The more that
children work, the lower the father’s wages become; the lower the
father’s wages become, the more the children must work. So we evolve the
vicious circle. The home becomes a mere rendezvous for the nightly
gathering of bodies numb with weariness and minds drunk with sleep. No
fine spiritual relation can exist between parents and children where the
children are an economic asset to the parents. There are people who
approve this state of affairs, but no one can who really cares for the
welfare of children. We fight this condition with Child Labor Laws. If
the children stay out of industry, the fathers have more work and make
more money in the end. But one of the strongest factors against getting
laws passed or enforced after they are passed, is the families’
immediate need of the children’s pitiful earnings. If there were fewer
children in these families, it would be possible to keep them in school
and leave the mines and factories to the fathers. There is another
aspect to the matter. Not only do these unfortunate children drag down
the physique and mentality of the race, but they keep many children of
more thoughtful parents from being born at all. Just as long as there
are many families that are too large, there will be other families that
are too small. Yet these small families are potentially the best
families of all. Serious-minded laboring people whose trades are being
captured by child laborers are reluctant to bring offspring into a world
which cannot promise a life of the simplest comforts in reward for hard
labor. Here is the real danger of that race suicide so vigorously
condemned by Ex-President Roosevelt and others; for while the man of
virtue and strength is deterred from propagating his kind because of the
jeopardy in which his children would stand, the vicious and the
ignorant, the physically unfit and the discouraged are not deterred by
any such consideration, but, regardless of consequences, continue to
propagate their kind and swell the proportion of those who will be from
birth to death a heavy liability against society. We regard the
family—one father, one mother, a group of children to be fed, clothed,
and educated during the years that precede maturity—as the fundamental
institution of our civilization and the glory, thus far, of all social
evolution. One of the causes out of which the family grew has direct
bearing upon this matter—that to which Professor Fisk called attention
as his chief contribution to the evolutionary theory—the prolonged
period of infancy. The evolutionary trend has been to prolong infancy
and adolescence, and thus to launch upon society better individuals.
This is impossible where the older children in a family are crowded out
of the home into the workshop.”

The Child Labor Bulletin, November, 1912, contains special articles on
the child workers in New York tenement houses. Record after record shows
a two-child income supporting a six-child family.

In connection with Mr. Lovejoy’s statement that a high birth rate
encourages child labor, it is significant to find from the Galton
Laboratories of the University of London, the statement that drastic
child labor laws directly lower the birth rate. In “The Report on the
English Birth Rate,” from the Eugenics Laboratory, Memoir XIX, Part 1,
England, North of the Humber, Ethel M. Elderton, after touching on the
influence of the raised standard of decency and comfort, lays the
responsibility of the change chiefly upon the lessened economic value of
the child to its parents.

Miss Elderton says, “Between 1871 and 1901 the number of children
employed largely diminished. Neo-Malthusianism spread and the child
ceased largely to be born, because it was no longer an economic asset.
The Compulsory Education Act of 1876, the Factories and Workshops Act of
1878, and the Bradlaugh-Besant Trial of 1877 (concerning the lawfulness
of publishing pamphlets on contraception) are not unrelated movements;
they are connected with the lowered economic value of the child, and
with the corresponding desire to do without it.” The relation which Miss
Elderton traced between the higher ideals of protection to childhood and
the lowered birth rate is the more interesting because she is deeply,
passionately alarmed at England’s falling birth rate.

Mr. Lovejoy does not regard the falling birth rate as a wholly
undesirable phenomenon. He says: “Children should be born when the
parents are in good health, at intervals that will allow the mother to
recover her strength, and only as many should be born as the parents can
care for. There is no deeper sorrow than to know that a child has died
for causes that might have been prevented if the parents had had more
wisdom and foresight. The ideals of care and education which we have for
our own children should be our ideals for all children. I shall not
consider it a calamity if the birth rate falls to a point where every
child is so precious to the nation that not one will be allowed to work
in a factory or workshop or mine or store under the age of sixteen, and
up to that time every one will have proper food and clothes and
education. Our race-suicide danger is a danger, nor of quantity, but of
quality.”


  _LATEST OFFICIAL FIGURES ON CHILD LABOR. From United States Census of
      Occupations, 1910. New York State._


                                                 Age 10 to 13  14 to 15
                                                       years     years

 Manufacturing and mechanical                              518    18,502

 Extraction of Minerals                                      3        47

 Agriculture                                             1,566     5,034

 All other occupations                                   2,765    36,659

 Total in all gainful occupations New  York State        4,852    60,242

 Total in all gainful occupations United States of     895,976 1,094,249
   America

 Total child laborers in the United States of                  1,990,225
   America


  _WAGES AND THE COST OF LIVING. Together with its relation to
      Prevention of Conception. Compiled by C. V. Drysdale, D.Sc._

Apart from the special problems of experts, the great economic question
of the day is that of the remuneration of labor and its relation to the
cost of living. In Parliament and the press the questions of a minimum
or living wage and of the purchasing power of existing wages are
continually debated; and it is perfectly evident from the tone of these
debates that we are confronted with a most serious difficulty, for which
none of the political parties or economic authorities has any
satisfactory solution. The recognition of this difficulty is due not to
the fact that any new phenomena are present, or that the workers are
worse off than at many periods in the past; but to the fact that the
compilation of more accurate and official statistics during recent years
has brought to light facts which were formerly only surmised, and has
made two important conclusions practically indisputable. These are as
follows:

A. That the wages of a large fraction of the working classes are
insufficient, even when most skilfully employed, for the adequate
support of a normal family.

B. That during the last ten or fifteen years of social legislation and
of strenuous effort on the part of the working classes and social
reformers, the purchasing power of average wages has declined instead of
increasing, and this decline shows no definite sign of being arrested.

In order to improve the efficiency of production, it is important that
the efficiency of the race should be improved. Hence the reduction of
births should be especially encouraged among the poor and those
suffering from physical or mental defect or disease, who, it may be
noted, should have the strongest personal motives for voluntary
restriction.

The restriction of births in proportion to economic or physiological
deficiency would steadily improve economic conditions in the following
ways:

(a) It would immediately reduce the burden upon the poor with their
existing wages.

(b) It would immediately check increased demand, and therefore a further
rise in price of food.

(c) It would reduce the burden of charity and taxation.

(d) It would permit the workers to be better nourished and educated.

(e) It would permit the children to be better educated and technically
trained.

(f) In course of time it would reduce the number of workers competing
and further raise wages.

(g) The evils of overcrowding, with its serious hygienic and moral
dangers, would be rapidly diminished, and the housing problem made
easier of solution. A three bedroom house only provides decency for a
family not exceeding four children.

(h) It would give better opportunities for thrift among the workers and
for their emancipation from the position of “wage slaves.” It would then
give them an opportunity of co-operating and owning their own
instruments of production.

In support of these statements it may be recalled that in Prof. Thorold
Rogers’s Six Centuries of Work and Wages a striking example is given of
the continued rise of wages after the Black Death of 1349, despite all
efforts of Parliament to fix them.

“It is certain that the immediate consequence of the plague was a dearth
of labor, an excessive enhancement of wages, and a serious difficulty in
collecting the harvests of those landowners who depended on a supply of
hired labor for the purpose of getting in their crops.... The plague, in
short, had almost emancipated the surviving serfs.

“I shall point out below what were the actual effects of this great and
sudden scarcity of labor. At present I merely continue the narrative.
Parliament was broken up when the plague was raging. The King, however,
issued a proclamation, which he addressed to William, the Primate, and
circulated among the sheriffs of the different counties, in which he
directed all officials that no higher than customary wages should be
paid, under the penalties of amercement. The King’s mandate, however,
was universally disobeyed, for the farmers were compelled to leave their
crops ungathered or to comply with the demands of the laborers. When the
King found that his proclamation was unavailing, he laid, we are told,
heavy penalties on abbots, priors, barons, crown tenants, and those who
held lands under mesne lords, if they paid more than customary rates.
But the laborers remained masters of the situation. Many were said to
have been thrown into prison for disobedience; many, to avoid punishment
or restraint, fled into forests, where they were occasionally captured.
The captives were fined, and obliged to disavow under oath that they
would take higher than customary wages for the future. But the
expedients were vain; labor remained scarce and wages, according to all
previous experience, excessive.”

Mr. Thorold Rogers tells us of all the expedients employed by
Parliament, in the Statute of Laborers, in order to check the rise of
wages, and how they broke down and were evaded by the employers
themselves. “The rise in agricultural labor is, all kinds of men’s work
being taken together, about 50 per cent., of women’s work fully 100 per
cent.” Artisans fare equally well. And, despite the rise in price of
manufactured articles consequent upon this rise of wages, “there was no
corresponding rise in the price of provisions.... The free laborer, and,
for the matter of that, the serf, was in his way still better off.
Everything he needed was as cheap as ever, and his labor was daily
rising in value.”

It would, of course, be absurd to apply the lesson of one period of
history to another, without consideration of the changed circumstances.
But it is equally absurd to pass over such a vivid object lesson as the
above without giving it due consideration, especially when it has a
sound theoretical basis. Prof. Thorold Rogers was not a disciple of the
Malthusian school, and he takes Mill and others to task for the
importance they ascribed to the population difficulty. Yet he tells us
that the reign of prosperity lasted for some time after the reduction of
population by the Black Death, and that a rapid growth of population
followed. This is quite in accordance with the doctrine of Malthus, and
justifies our belief that, if this increase had been prudentially
restricted, prosperity would have been permanently maintained.

A modern illustration of the same principle appears to be given in New
Zealand, where the practice of family restriction seems to be almost
universal. In the _Standard_ of June 20th, 1912, appeared a note
commenting upon the great and increasing prosperity of New Zealand; and
it contains the following significant passage:—

“The wages paid to employees and the output of the printing
establishments in the country have pretty nearly doubled in the same ten
years, rising respectively from £284,605 to £490,246 and £704,285 to
£1,377,926. A curious point in connection with the grain mills is that
while there were fewer establishments and fewer hands employed in 1910
than in the previous years—although wages are higher—yet the value of
the output has almost doubled, being £1,248,001 as against £682,884.”

Some mention should be made of the question of emigration. Strange as it
may seem, emigration does not, as a rule, greatly mitigate the
population difficulty (though it may have done so to a certain extent in
Ireland), and it may even enhance it. The reason for this apparent
paradox is not far to seek, and it serves to explain a good many common
fallacies as regards the population question. Human beings are not all
of equal producing power. Each child born into the world is an immediate
consumer, and he remains a consumer without being a producer until his
education and training are completed. After that time he becomes a
producer, and, if of average talents, he may _for a certain period_
produce enough to support himself and perhaps a wife. It is at the
beginning of the effective period that emigration so frequently takes
place, so that the old country is burdened with all the consumption of
immature children, without any possible return. Emigration can only be a
remedy for over-population when it is emigration of non-producers, i.e.,
children, aged people, tramps, paupers, or lunatics; and it need hardly
be said that these are not the types which emigrate, or who are wanted
by the colonies. It is quite possible for an already greatly
over-populated country to be in great need of further accessions of
ready trained workers; but until someone discovers how our children may
be born at this stage of development it is absolutely absurd to say that
such a country is “calling out for population,” in the sense of needing
a higher birth-rate. The fact that Ontario, in Canada, has experienced
an increase of its death-rate following on an increase of its birth-rate
is a vivid illustration of this absurdity.

It is interesting to note, as a confirmation of this theory, that
considerable changes in the rate of emigration appear to have had very
little influence upon the death-rate. It may be, however, that
emigration increases in times of dearth, and thus tends to prevent
increased mortality.


  _NEO-MALTHUSIANISM AND EUGENICS. C. V. Drysdale, D.Sc._

The last few years has been a period of continual persecution of the
Neo-Malthusians whenever they try to instruct the poorer classes, and
more stringent laws are being framed against them in many countries.

I am glad to say that a recent attempt on the part of the dominant
agrarian party in Hungary in this direction has been foiled by a
judgment of the Hungarian Medical Senate, which has strongly reported
against any attempt to check the practice of family limitation, in the
interests of the quality of the race.



                               CHAPTER IX
                      CONCLUSION: EMINENT OPINIONS


                        THE PROGRESS OF HOLLAND


  _WAGES AND THE COST OF LIVING. C. V. Drysdale, D.Sc._

Unlike those of other countries, who, in Lord Morley’s words, have
shirked the population question, the statesmen of Holland have been
fully alive to it, and have made their country the only one where
facilities have been given to the poorer classes to freely obtain
knowledge as to the best means of restricting families. The following
strong statement by Heer S. van Houten, late Minister of the Interior in
the Netherlands (Staats Kundige Brieven, 1899), leaves no doubt as to
this difference of outlook:—

“Wage-slavery exists as a consequence of the carelessness with which the
former generation produced wage-slaves; and this slavery will continue
so long as the adult children of these wage-slaves have nothing better
to do than to reproduce wage-slaves. The fault lies in our poorer
classes themselves, and also in some clergymen and _orthodox pedants_
who, in their preaching about morality, only permit a choice between an
unnaturally lengthened celibacy or an ever-increasing family with the
bonds of marriage, and who prevent the acceptance of the higher
morality, which finds such easy acceptance among the better classes, of
marriage and restriction of the family to the number which the parents
can feed and comfortably rear.”

And Heer N. G. Pierson, late Dutch Minister of Finance, has expressed
himself equally strongly in his Political Economy, which has just been
translated into English:—

“No improvement in the economic situation can be hoped for if the number
of births be not considerably diminished.”

Under the ægis of these gentlemen and of Heer Gerritsen, a prominent
Councillor of Amsterdam, a Dutch Neo-Malthusianische Bond was formed in
1881, and has carried on an active propaganda among the working classes,
with the help of a number of qualified medical men and trained midwives.
So great has its success been that it now numbers over 5,000 members,
and it was recognised by Royal Decree in 1895 as a society of public
utility. An enormous number of practical brochures describing methods of
limitation are sent out gratis annually, and poor men and women can get
gratuitous advice in every important centre in Holland.

The result of this work, as indicated by the vital statistics, is
clearly seen in Fig. 11. The birth-rate has fallen from 37 in 1876 to 28
in 1912, and with especial regularity and rapidity during the last few
years. The death-rate has fallen more regularly and rapidly than in any
other country in the world (from a value averaging about 25 per 1,000 to
only just over 12 per 1,000 in 1912), and the infantile mortality has
similarly shown the most rapid fall on record. It will be observed that,
far from this decline in the birth-rate having checked the increase of
population, the rate of “natural increase” is now higher than at any
previous period, and the highest in Western Europe. This indicates not
only that social conditions are rapidly improving, but that the
productive efficiency of the population is increasing, instead of
diminishing, as in our own country, where the “natural increase” has
fallen from 12 to 10 per 1,000. This is explainable on the eugenic
ground that in Holland family restriction has taken place among the
poor, and has thus tended to eliminate unfitness; while in this and
other countries the poor are almost entirely ignorant of restrictive
methods. And this view is strikingly confirmed by the paper read by Dr.
Soren Hansen at the Eugenics Congress of 1912, in which he stated that
the average stature of the Dutch people had increased by four inches
within the last fifty years. An examination of the heights of the young
men drawn for military service shows that since 1865 the proportion
under 5 ft. 2½ in. in height has fallen from 25 per cent. to under 8 per
cent., while that of those above 5 ft. 7 in. has increased from 24.5 per
cent. to 47.5 per cent. This is a most decided evidence of increased
well-being and elimination of unfitness. On the many occasions that I
have been in Holland, I have never yet seen any cases of that terrible
physical deterioration and economic misery which are so conspicuous in
this country. Further, the emigration of the Dutch population is almost
infinitesimal.

As regards wages and cost of living, Dutch statistics do not give
weighted index numbers to compare with the other figures. But the
unweighted mean of money wages of workers in the different government
services show the most rapid increase recorded, being about 25 per cent.
in Holland between 1894 and 1908, as against 18 per cent. in France and
10 per cent. in England and Wales. (Fig. 12).

As to prices, it is not easy to come to a definite conclusion, as some
articles have risen and some fallen in price; but there seems good
ground for believing that the cost of living has risen comparatively
little in Holland, and that real wages have therefore risen very
materially during the period when they have been declining in this and
other countries. It is certainly difficult in any case to see how the
undoubtedly great advance in health and physique experienced by the
Dutch population could have taken place without a great increase in real
wages.

According to a diagram given in the Manchester Guardian of August 16th
last the cost of living in Holland had gone up by 23 per cent. in 1912.
An examination of detailed prices, however, showed a relatively small
rise up to 1909.

These facts, together with many others which could be adduced, make it
clear that in Holland, the only country in which the population problem
has been realised and facilities for family limitation been extended to
the poor, the expectations of the Neo-Malthusians have been completely
justified, and their doctrines have received the confirmation of
experience. Amsterdam, in which the first lady doctor in Holland opened
a gratuitous clinic for the instruction of poor women in preventive
methods, has now the lowest deathrate and infantile mortality of any
European capital. And this is in no way attributable to any extension of
State help either of a socialistic type, or of that familiar to us in
this country, as Holland has been distinguished for its adherence to
individualism, and has apparently adopted hardly any measure of State
assistance.


  _DR. S. ADOLPHUS KNOPF IN THE SURVEY, quoting Dr. J. Rutgers,
      Honorable Secretary to Neo-Malthusian League of Holland._

“All children you now see are suitably dressed, they look now as neat as
formerly only the children of the village clergyman did. In the families
of the laborers there is now a better personal and general hygiene, a
finer moral and intellectual development. All this has become possible
by limitation in the number of children in these families. It may be
that now and then this preventive teaching has caused illicit
intercourse, but on the whole morality is now on a much higher level,
and mercenary prostitution with its demoralizing consequences and
propagation of contagious diseases is on the decline.

The best test (the only possible mathematical test) of our moral,
physiological and financial progress is the constant increase in
longevity of our population. In 1890 to 1899 it was 46.20; in 1900 to
1909 it was 51 years. Such rise cannot be equalled in any other country
except in Scandinavia where birth limitation was preached long before it
was in Holland. None of the dreadful consequences anticipated by the
advocates of clericalism, militarism and conservatism have occurred. In
spite of our low birth-rate the population in our country is rising
faster than ever before, simply because it is concomitant with a greater
economic improvement and better child hygiene.”

The good doctor closes his letter by saying: “One must have been a
family physician for twenty-five years like myself in a large city
(Rotterdam) to appreciate the blessings of conscious motherhood
resulting in the better care of children, the higher moral standard. And
all these blessings are taken away from you by your government’s
peculiar laws, made to please the Puritans.”

Dr. Jacobi, Ex-President of the American Medical Association and the New
York Academy of Medicine, said:

“The future of mankind is conditioned by its children. Unless they be
healthy and fit to work physically and mentally, they can not perform
any duty in the service of the family, the municipality or the state.
Hereditary influences propagate epilepsy, idiocy, feeble-mindedness and
cretinism. Such children should not have been permitted to be born. Yet
the prohibition of unnecessary and not wanted accessions of human beings
is considered criminal.”

Dr. Lydia Allen de Vilbis of the New York State Department of Health,
said that among the 25,000 deaths of children under one year of age that
occur annually in New York State, half were due to causes with which
medical boards could not hope to cope—the defective, the deformed, the
crippled, the diseased.

“What are we going to do about these babies who are born only to suffer
and die?” she asked. “There are at least 12,000 a year, 1,000 for each
month, more than thirty a day. What for? Because we are so stupid that
we still believe a pound of cure is better than an ounce of prevention.”


  _MARY ALDEN HOPKINS. Harper’s Weekly, 1915._

“Last year more than ten thousand children were proposed to the
Department of Charities of New York City for commitment to
institutions,” writes John A. Kingsbury, Commissioner of Charities in
the Department of Public Charities of New York City, in reply to my
inquiry concerning his view of the limitation of families. “Poverty or
sickness or unemployment has outworn the welcome of more than ten
thousand innocent little citizens in their own homes. These children are
paying the penalty of the social error of too large families. It is
frequently remarked that children are often found in the largest number
in those homes which are least equipped to properly provide for them. I
believe it is as serious a mistake for parents in adverse circumstances
to bring children into the world for whom they are not prepared, as for
parents in affluent circumstances to decline to bear children because of
the inconvenience or embarrassment to their scheme of living. If
contraception can benefit the born by limiting the unborn, without
bringing about any physical or moral deterioration in human lives, I am
unqualifiedly in sympathy with it.”


  _JUDGE WM. H. WADHAMS, Court of General Sessions, New York. “The
      Spreading Movement for Birth Control.” The Survey, Oct. 21, 1916._

In the Court of General Sessions, New York City, Judge Wadhams suspended
sentence upon a woman, mother of six children, who had pleaded guilty to
a charge of burglary, her second offense. His investigation showed, the
judge declared, that the mother had made a hard, but unsuccessful
attempt to support her children since the father had been driven from
his work in garment working five years ago. Meantime, two of the
children had been born. Said Judge Wadhams:—

“Her husband is not permitted by the authorities to work because of his
being ill with tuberculosis. It would be dangerous for him to work on
children’s garments. It might spread consumption to the innocents. There
is a law against that. As a result of this law the husband has had no
work for four years. Nevertheless, he goes on producing children who
have very little chance under the conditions to be anything but
tubercular, and, themselves growing up, repeat the process with society.
There is no law against that. But we have not only no birth regulation
in such cases, but if information is given with respect to birth
regulation people are brought to the bar of justice for it. There is a
law they violate. The question is whether we have the most intelligent
law on this subject we might have. These matters are regulated better in
some of the old countries, particularly in Holland, than they are in
this country. I believe we are living in an age of ignorance, which at
some future time will be looked on aghast.”


  _LETTER ADDRESSED TO PRESIDENT WILSON BY A GROUP OF NOTABLE ENGLISH
      WRITERS AND SOCIOLOGISTS, September, 1915._

 To the President of the United States,
           White House, Washington, D.C.

Sir,—We understand that Mrs. Margaret Sanger is in danger of criminal
prosecution for circulating a pamphlet on birth-problems. We therefore
beg to draw your attention to the fact that such work as that of Mrs.
Sanger receives appreciation and circulation in every civilised country
except the United States of America, where it is still counted as a
criminal offence.

We, in England, passed a generation ago, through the phase of
prohibiting the expressions of serious and disinterested opinion on a
subject of such grave importance to humanity, and in our view to
suppress any such treatment of vital subjects is detrimental to human
progress.

Hence, not only for the benefit of Mrs. Sanger, but of humanity, we
respectfully beg you to exert your powerful influence in the interests
of free speech and the betterment of the race.

                   We beg to remain, Sir,
                         Your humble Servants,
                   (Signed)

                               Lena Ashwell,
                               Dr. Percy Ames,
                               William Archer,
                               Arnold Bennett,
                               Edward Carpenter,
                               Aylmer Maude,
                               Prof. Gilbert Murray,
                               M. C. Stopes,
                               H. G. Wells.



            _GLOSSARY OF MEDICAL TERMS USED IN THIS VOLUME._


_Abortion_: As soon as the male _sperm_ has met and joined with the
female _ova_ any attempt at removing it or preventing its development or
further growth is called _Abortion_. _Abortion_ is not to be confused
with the _prevention of conception_. The practice of _Birth Control_,
founded on the _prevention of conception_ will eventually do away with
the necessity of _abortion_.

_Abortion_: the expulsion of the fetus before it is viable.—Dorland’s
Medical Dictionary.

_Abortion_: the arrest of any action or process before its normal
completion, as the _abortion_ of pneumonia.—Stedman’s Medical
Dictionary.

_Birth_: the delivery of a child—Gould’s Practitioner’s Medical
Dictionary.

_Birth Control_: a new social philosophy dedicated to conscious and
voluntary motherhood, and racial betterment.

_Conception_: the act of becoming pregnant.—Stedman’s Medical
Dictionary.

_Conception_: the fecundation of the _ovum_ by the
_spermatozoon_.—Gould’s Practitioner’s Medical Dictionary.

_Contraception_: the prevention of conception.—Stedman’s Medical
Dictionary.

_Contraceptive_: anything used to prevent conception.—Dorland’s Medical
Dictionary.

_Contraceptive_: an agent for the prevention of conception.—Stedman’s
Medical Dictionary.

_Fecundation_: impregnation or fertilization.—Dorland’s Medical
Dictionary.

_Fetus_: the unborn offspring of any viviparous animal; the child in the
womb after the end of the third month: before that time it is called the
_embryo_.

_Malthusianism_: (Thomas Robert Malthus, English political economist,
1766–1834). The doctrine that population increases in geometrical
progression; and the teaching, founded on this doctrine, that
over-population should be prevented.—Stedman’s Medical Dictionary.

_Doctrine of Malthus_: the doctrine that the increase of population is
proportionately greater than the increase of subsistence.—Gould’s
Practitioner’s Medical Dictionary.

_Theory of Malthus_: that small families will abolish poverty and
disease; recommends _continence_ and _late marriage_ to bring about this
result.

_Theory of Neo-Malthusians_: that small families will abolish poverty
and disease; recommends _early marriage_ and use of _preventive checks_
to bring about this result.

_Pregnancy_: gestation, fetation, gravidity.—Stedman’s Medical
Dictionary.

_Pregnancy_: results from the meeting and fusion of two living cells,
the cell furnished by the male (_spermatozoon_) and that by the female
(_ovum_). To avoid or to prevent conception or pregnancy, then, consists
of stopping the male cell from uniting with the female cell.

_Prevention of Conception_: to prevent the male _sperm_ from meeting the
female _ova_.

_Prevention of Conception_: the only logical and practical means for
eliminating _abortions_ when a child cannot be carried to full term.

_Preventive_: anything which arrests the threatened onset of
disease.—Stedman’s Medical Dictionary.



Modern Art Printing Co., New York.

------------------------------------------------------------------------



                          TRANSCRIBER’S NOTES


 1. Changed ‘importing’ to ‘imparting’ on p. 6.
 2. Added missing targets for the footnotes on pp. 33 and 34.
 3. Changed ‘There are given’ to ‘These are given’ on p. 57.
 4. Changed ‘since when’ to ‘since then’ on p. 59.
 5. Changed ‘dotted are’ to ‘dotted area’ on p. 71.
 6. Added missing caption ‘Fig. 21-23’ to the three illustrations on p.
      90 per discussion on p. 71. Since no countries were identified the
      three were left as one image.
 7. Added missing caption ‘Fig. 24’ to the first illustration on p. 90
      per discussion on p. 71.
 8. Added missing caption ‘Fig. 25’ to the second illustration on p. 90
      per discussion on p. 71.
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      per discussion on p. 71.
10. Added missing caption ‘Fig. 27’ to the first illustration on p. 91
      per discussion on p. 71.
11. Added missing caption ‘Fig. 28’ to the second illustration on p. 91
      per discussion on p. 71.
12. Added missing caption ‘Fig. 29’ to the third illustration on p. 91
      per discussion on p. 71.
13. Changed ‘Neuman’ to ‘Newman’ on p. 94.
14. Changed ‘they they’ to ‘that they’ on p. 103.
15. Changed ‘it shall be lawful’ to ‘it shall be unlawful’ on p. 110.
16. Changed ‘Table 8’ to ‘Table 18’ on p. 117.
17. Changed all mentions of the Michigan city from ‘Ann Harbor’ to ‘Ann
      Arbor’.
18. Changed ‘Hubner’ to ‘Huhner’ on p. 186.
19. Changed ‘prostalic’ to ‘prostatic’, ‘diplethorize’ to
      ‘deplethorize’, and ‘chronic suggestion’ to ‘chronic congestion’
      on p. 186.
20. Changed ‘physic and somatic’ to ‘psychic and somatic’ on p. 187.
21. Changed ‘always two paries’ to ‘always two parties’ on p. 187.
22. Changed ‘STANDPOINT OR’ to ‘STANDPOINT OF’ on p. 205.
23. Changed ‘65.5’ to ‘60.5’ on p. 210.
24. Changed ‘records, were contracted’ to ‘records, were contrasted’ on
      p. 211.
25. Changed ‘Alfred Scott Warthin’ to ‘Aldred Scott Warthin’ on p. 229.
26. Changed ‘which is 1870–2’ to which in 1870–2’ on p. 232.
27. Changed ‘provision is’ to ‘provision is not’ on p. 235.
28. Changed ‘contions’ to ‘relations’ on p. 236.
29. Changed ‘about mortality’ to ‘about morality’ on p. 245.
30. Silently corrected typographical errors.
31. Retained anachronistic and non-standard spellings as printed.
32. Enclosed italics font in _underscores_.





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