The Task of Social Hygiene

The net result is a slight increase on the part of the French Canadians, as compared with the English element in the province, as becomes clear when we compare the proportion of the population of English, Scotch, Irish, and all other nationalities with the total population of the province, now and thirty years ago. In 1871 it was 21 per cent; in 1901 it was only 19 per cent. The decrease of the Anglo-Saxons may here appear to be small, though it must be remembered that thirty years is but a short period in the history of a nation; but it is significant when we bear in mind that the English element has here been constantly reinforced by immigrants (who, as the experience of the United States shows, are by no means an infertile class), and that such reinforcement cannot be expected to continue in the future.

From Australia comes the same story of the decline of Anglo-Saxon fertility. In nearly all the Australian colonies the highest birth-rate was reached some twenty or thirty years ago. Since then there has been a more or less steady fall, accompanied by a marked decrease in the number of marriages, and a tendency to postpone the age of marriage. One colony, Western Australia, has a birth-rate which sometimes fluctuates above that of England; but it is the youngest of the colonies, and, at present, that with the smallest population, largely composed of recent immigrants. We may be quite sure that its comparatively high birth-rate is merely a temporary phenomenon. A very notable fact about the Australian birth-rate is the extreme rapidity with which the fall has taken place; thus Queensland, in 1890, had a birth-rate of 37, but by 1899 the rate had steadily fallen to 27, and the Victorian rate during the same period fell from 33 to 26 per thousand. In New South Wales, the state of things has been carefully studied by Mr. Coghlan, formerly Government statistician of New South Wales, who comes to the conclusion that the proportion of fertile marriages is declining, and that (as in the United States) it is the recent European immigrants only who show a comparatively high birth-rate. Until 1880, Coghlan states, the Australasian birth-rate was about 38 per thousand, and the average number of children to the family about 5.4. In 1901 the birth-rate had already fallen to 27.6 and the size of the family to 3.6 children. 100 It should be added that in all the Australasian colonies the birth-rate reached its lowest point some years ago, and may now be regarded as in a state of normal equipoise with a slight tendency to rise. The case of New Zealand is specially interesting. New Zealand once had the highest birth-rate of all the Australasian colonies; it is without doubt the most advanced of all in social and legislative matters; a variety of social reforms, which other countries are struggling for, are, in New Zealand, firmly established. Its prosperity is shown by the fact that it has the lowest death-rate of any country in the world, only 10.2 per thousand, as against 24 in Austria and 22 in France; it cannot even be said that the marriage-rate is very low, for it is scarcely lower than that of Austria, where the birth-rate is high. Yet the birth-rate in New Zealand fell as the social prosperity of the country rose, reaching its lowest point in 1899.

We thus find that from the three great Anglo-Saxon centres of the world—north, west, and south—the same story comes. We need not consider the case of South Africa, for it is well recognized that there the English constitute a comparatively infertile fringe, mostly confined to the towns, while the earlier Dutch element is far more prolific and firmly rooted in the soil. The position of the Dutch there is much the same as that of the French in Canada.

Thus we find that among highly civilized races generally, and not least among the English-speaking peoples who were once regarded as peculiarly prolific, a great diminution of reproductive activity has taken place during the past forty years, and is in some countries still taking place. But before we proceed to consider its significance it may be well to look a little more closely at our facts.

We have seen that the "crude" birth-rate is not an altogether reliable index of the reproductive energy of a nation. Various circumstances may cause an excess or a defect of persons of reproductive age in a community, and unless we allow for these variations, we cannot estimate whether that community is exercising its reproductive powers in a fairly normal manner. But there is another and still more important consideration always to be borne in mind before we can attach any far-reaching significance even to the corrected birth-rate. We have, that is, to bear in mind that a high or a low birth-rate has no meaning, so far as the growth of a nation is concerned, unless it is considered in relation to the death-rate. The natural increase of a nation is not the result of its birth-rate, but of its birth-rate minus its death-rate. A low birth-rate with a low death-rate (as in Australasia) produces a far greater natural increase than a low birth-rate with a rather high death-rate (as in France), and may even produce as great an increase as a very high birth-rate with a very high death-rate (as in Russia). Many worthy people might have been spared the utterance of foolish and mischievous jeremiads, if, instead of being content with a hasty glance at the crude birth-rate, they had paused to consider this fairly obvious fact.

There is an intimate connection between a high birth-rate and a high death-rate, between a low birth-rate and a low death-rate. It may not, indeed, be an absolutely necessary connection, and is not the outcome of any mysterious "law." But it usually exists, and the reasons are fairly obvious. We have already encountered the statement from an official Canadian source that the large infantile mortality of French Canadian families is due to parental carelessness, consequent, no doubt, not only on the dimly felt consciousness that children are cheap, but much more on inability to cope with the manifold cares involved by a large family. Among the English working class every doctor knows the thinly veiled indifference or even repulsion with which women view the seemingly endless stream of babies they give birth to. Among the Berlin working class, also, Hamburger's important investigation has indicated how serious a cause of infantile mortality this may be. By taking 374 working-class women, who had been married twenty years and conceived 3183 times, he found that the net result in surviving children was relatively more than twice as great among the women who had only had one child when compared to the women who had had fifteen children. The women with only one child brought 76.47 per cent of these children to maturity; the women who had produced fifteen children could only bring 30.66 of them to maturity; the intermediate groups showed a gradual fall to this low level, the only exception being that the mothers of three children were somewhat more successful than the mothers of two children. Among well-to-do mothers Hamburger found no such marked contrast between the net product of large families as compared to small families. 101

It we look at the matter from a wider standpoint we can have no difficulty in realizing that a community which is reproducing itself rapidly must always be in an unstable state of disorganization highly unfavourable to the welfare of its members, and especially of the new-comers; a community which is reproducing itself slowly is in a stable and organized condition which permits it to undertake adequately the guardianship of its new members. The high infantile mortality of the community with a high birth-rate merely means that that community is unconsciously making a violent and murderous effort to attain to the more stable and organized level of the country with a low birth-rate.

The English Registrar-General in 1907 estimated the natural increase by excess of births over deaths as exceptionally high (higher than that of England) in several Australian Colonies, in the Balkan States, in Russia, the Netherlands, the German Empire, Denmark, and Norway, though in the majority of these lands the birth-rate is very low. On the other hand, the natural increase by excess of births over deaths is below the English rate in Austria, in Hungary, in Japan, in Italy, in Sweden, Switzerland, Spain, Belgium, and Ontario, though in the majority of these lands the birth-rate is high, and in some very high. 102 In most cases it is the high death-rate in infancy and childhood which exercises the counterbalancing influence against a high birth-rate; the death-rate in adult life may be quite moderate. And with few exceptions we find that a high infantile mortality accompanies a high birth-rate, while a low infantile mortality accompanies a low birth-rate. It is evident, however, that even an extremely high infantile mortality is no impediment to a large natural increase provided the birth-rate is extremely high to a more than corresponding extent. But a natural increase thus achieved seems to be accompanied by far more disastrous social conditions than when an equally large increase is achieved by a low infantile death-rate working in association with a low birth-rate. Thus in Norway on one side of the world and in Australasia on the opposite side we see a large natural increase effected not by a profuse expenditure of mostly wasted births but by an economy in deaths, and the increase thus effected is accompanied by highly favourable social conditions, and great national vigour. Norway appears to have the lowest infantile death-rate in Europe. 103

Rubin has suggested that the fairest measure of a country's well-being, as regards its actual vitality—without direct regard, of course, to the country's economic prosperity—is the square of the death-rate divided by the birth-rate. 104 Sir J.A. Baines, who accepts this test, states that Argentina with its high birth-rate and low death-rate stands even above Norway, and Australia still higher, while the climax for the world is attained by New Zealand, which has attained "the nearest approach to immortality yet on record." 105 The order of descending well-being in Europe is thus represented (at the year 1900) by Norway, Sweden, Denmark, Holland, England, Scotland, Finland, Belgium, Switzerland, Germany, Ireland, Portugal, Italy, Austria, France, and Spain.

On the other hand, in all the countries, probably without exception, in which a large natural increase is effected by the efforts of an immense birth-rate to overcome an enormous death-rate the end is only effected with much friction and misery, and the process is accompanied by a general retardation of civilization. "The greater the number of children," as Hamburger puts it, "the greater the cost of each survivor to the family and to the State."

Russia presents not only the most typical but the most stupendous and appalling example of this process. Thirty years ago the mortality of infants under one year was three times that of Norway, nearly double that of England. More recently (1896-1900) the infantile mortality in Russia has fallen from 313 to 261, but as that of the other countries has also fallen it still preserves nearly the same relative position, remaining the highest in Europe, while if we compare it with countries outside Europe we find it is considerably more than four times greater than that of South Australia. In one town in the government of Perm, some years ago if not still, the mortality of infants under one year regularly reached 45 per cent, and the deaths of children under five years constituted half the total mortality. This is abnormally high even for Russia, but for all Russia it was found that of the boys born in a single year during the second half of the last century only 50 per cent reached their twenty-first year, and even of these only 37.6 per cent were fit for military service. It is estimated that there die in Russia 15 per thousand more individuals than among the same number in England; this excess mortality represents a loss of 1,650,000 lives to the State every year. 106

Thus Russia has the highest birth-rate and at the same time the highest death-rate. The large countries which, after Russia, have the highest infantile mortality are Austria, Hungary, Prussia, Spain, Italy, and Japan; all these, as we should expect, have a somewhat high birth-rate.

The case of Japan is interesting as that of a vigorous young Eastern nation, which has assimilated Western ways and is encountering the evils which come of those ways. Japan is certainly worthy of all our admiration for the skill and vigour with which it has affirmed its young nationality along Western lines. But when the vital statistics of Japan are vaguely referred to either as a model for our imitation or as a threatening peril to us, we may do well to look into the matter a little more closely. The infantile mortality of Japan (1908) is 157, a very high figure, 50 per cent higher than that of England, much more than double that of New Zealand, or South Australia. Moreover, it has rapidly risen during the last ten years. The birth-rate of Japan in 1901-2 was high (36), though it has since fallen to the level of ten years ago. But the death-rate has risen concomitantly (to over 24 per 1000), and has continued to rise notwithstanding the slight decline in the birth-rate. We see here a tendency to the sinister combination of a falling birth-rate with a rising death-rate. 107 It is obvious that such a tendency, if continued, will furnish a serious problem to Japanese social reformers, and at the same time make it impossible for Western alarmists to regard the rise of Japan as a menace to the world.

It is behind China that these alarmists, when driven from every other position, finally entrench themselves. "The ultimate future of these islands may be to the Chinese," incautiously exclaims Mr. Sidney Webb, who on many subjects, unconnected with China, speaks with authority. The knowledge of the vital statistics of China possessed by our alarmists is vague to the most extreme degree, but as the knowledge of all of us is scarcely less vague, they assume that their position is fairly safe. That, however, is an altogether questionable assumption. It seems to be quite true—though in the absence of exact statistics it may not be certain—that the birth-rate in China is very high. But it is quite certain that the infantile death-rate is extremely high. "Out of ten children born among us, three, normally the weakest three, will fail to grow up: out of ten children born in China these weakest three will die, and probably five more besides," writes Professor Ross, who is intimately acquainted with Chinese conditions, and has closely questioned thirty-three physicians practising in various parts of China. 108 Matignon, a French physician familiar with China, states that it is the custom for a woman to suckle her child for at least three years; should pregnancy occur during this period, it is usual, and quite legal, to procure abortion. Infants brought up by hand are fed on rice-flour and water, and consequently they nearly all die. 109

Putting aside altogether the question of infanticide, such a state of things is far from incredible when we remember the extremely insanitary state of China, the superstitions that flourish unchecked, and the famines, floods, and pestilences that devastate the country. It would appear probable that when vital statistics are introduced into China they will reveal a condition of things very similar to that we find in Russia, but in a more marked degree. No doubt it is a state of things which will be remedied. It is a not unreasonable assumption, supported by many indications, that China will follow Japan in the adoption of Western methods of civilization. 110 These methods, as we know, involve in the end a low birth-rate with a general tendency to a lower death-rate. Neither in the near nor in the remote future, under present conditions or under probable future conditions, is there any reason for imagining that the Chinese are likely to replace the Europeans in Europe. 111

This preliminary survey of the ground may enable us to realize that not only must we be cautious in attaching importance to the crude birth-rate until it is corrected, but that even as usually corrected the birth-rate can give us no clue at all to natural increase because there is a marked tendency for the birth-rate and the infantile death-rate to rise or sink together. Moreover, it is evident that we have also to realize that from the point of view of society and civilization there is a vast difference between the natural increase which is achieved by the effort of an enormously high birth-rate to overcome an almost correspondingly high death-rate and the natural increase which is attained by the dominance of a low birth-rate over a still lower death-rate.

Having thus cleared the ground, we may proceed to attempt the interpretation of the declining birth-rate which marks civilization, and to discuss its significance.

It must be admitted that it is not usual to consider the question of the declining birth-rate from a broad or scientific standpoint. As we have seen, no attempt is usually made to correct the crude birth-rate; still more rarely is it pointed out that we cannot consider the significance of a falling birth-rate apart from the question of the death-rate, and that the net increase or decrease in a nation can only be judged by taking both these factors into account. It is scarcely necessary to add, in view of so superficial a way of looking at the problem, that we hardly ever find any attempt to deal with the more fundamental question of the meaning of a low birth-rate, and the problematical character of the advantages of rapid multiplication. The whole question is usually left to the ignorant preachers of the gospel of brute force, would-be patriots who desire their own country to increase at the cost of all other countries, not merely in ignorance of the fact that the crude birth-rate is not the index of increase, but reckless of the effect their desire, if fulfilled, would have upon all the higher and finer ends of living.

When the question is thus narrowly and ignorantly considered, it is usual to account for the decreased birth-rate, the smaller average families, and the tendency to postpone the age of marriage, as due mainly to a love of luxury and vice, combined with a newly acquired acquaintance with Neo-Malthusian methods, 112 which must be combated, and may successfully be combated, by inculcating, as a moral and patriotic duty, the necessity of marrying early and procreating large families. 113 In France, the campaign against the religious Orders in their educational capacity, while doubtless largely directed against educational inefficiency, was also supported by the feeling that such education is not on the side of family life; and Arsène Dumont, one of the most vigorous champions of a strenuously active policy for increasing the birth-rate, openly protested against allowing any place as teachers to priests, monks, and nuns, whose direct and indirect influence must degrade the conception of sex and its duties while exalting the place of celibacy. In the United States, also, Engelmann, who, as a gynæcologist, was able to see this process from behind the scenes, urged his fellow-countrymen "to stay the dangerous and criminal practices which are the main determining factors of decreasing fecundity, and which deprive women of health, the family of its highest blessings, and the nation of its staunchest support." 114

We must, however, look at these phenomena a little more broadly, and bring them into relation with other series of phenomena. It is almost beyond dispute that a voluntary restriction of the number of offspring by Neo-Malthusian practices is at least one of the chief methods by which the birth-rate has been lowered. It may not indeed be—and probably, as we shall see, is not—the only method. It has even been denied that the prevalence of Neo-Malthusian practices counts at all. 115 Thus while Coghlan, the Government Statistician of New South Wales, concludes that the decline in the birth-rate in the Australian Commonwealth was due to "the art of applying artificial checks to conception," McLean, the Government Statistician of Victoria, concludes that it was "due mainly to natural causes." 116 He points out that when the birth-rate in Australia, half a century ago, was nearly 43 per 1000, the population consisted chiefly of men and women at the reproductive period of life, and that since then the proportion of persons at these ages has declined, leading necessarily to a decline in the crude birth-rate. If we compare the birth-rate of communities among women of the same age-periods, McLean argues, we may obtain results quite different from the crude birth-rate. Thus the crude birth-rate of Buda-Pesth is much higher than that of New South Wales, but if we ascertain the birth-rate of married women at different age-periods (15 to 20, 20 to 25, etc.) the New South Wales birth-rate is higher for every age-period than that of Buda-Pesth. McLean considers that in young communities with many vigorous immigrants the population is normally more prolific than in older and more settled communities, and that hardships and financial depression still more depress the birth-rate. He further emphasizes the important relationship, which we must never lose sight of in this connection, between a high birth-rate and a high death-rate, especially a high infantile death-rate, and he believes, indeed, that "the solution of the problem of the general decline in the birth-rate throughout all civilized communities lies in the preservation of human life." The mechanism of the connection would be, he maintains, that prolonged suckling in the case of living children increases the intervals between childbearing. As we have seen, there is a tendency, though not a rigid and invariable necessity, 117 for a high birth-rate to be associated with a high infantile death-rate, and a low birth-rate with a low infantile death-rate. Thus in Victoria, we have the striking fact that while the birth-rate has declined 24 per cent the infantile death-rate has declined approximately to the still greater extent of 27 per cent.

No doubt the chief cause of the reduction of the birth-rate has been its voluntary restriction by preventive methods due to the growth of intelligence, knowledge, and foresight. In all the countries where a marked decline in the birth-rate has occurred there is good reason to believe that Neo-Malthusian methods are generally known and practised. So far as England is concerned this is certainly the case. A few years ago Mr. Sidney Webb made inquiries among middle-class people in all parts of the country, and found that in 316 marriages 242 were thus limited and only 74 unlimited, while for the ten years 1890-9 out of 120 marriages 107 were limited and only 13 unlimited, but as five of these 13 were childless there were only 8 unlimited fertile marriages out of 120. As to the causes assigned for limiting the number of children, in 73 out of 128 cases in which particulars were given under this head the poverty of the parents in relation to their standard of comfort was a factor; sexual ill-health—that is, generally, the disturbing effect of child-bearing—in 24; and other forms of ill-health of the parents in 38 cases; in 24 cases the disinclination of the wife was a factor, and the death of a parent had in 8 cases terminated the marriage. 118 In the skilled artisan class there is also good reason to believe that the voluntary limitation of families is constantly becoming more usual, and the statistics of benefit societies show a marked decline in the fertility of superior working-class people during recent years; thus it is stated by Sidney Webb that the Hearts of Oak Friendly Society paid benefits on child-birth to 2472 per 10,000 members in 1880; by 1904 the proportion had fallen to 1165 per 10,000, a much greater fall than occurred in England generally.

The voluntary adoption of preventive precautions may not be, however, the only method by which the birth-rate has declined; we may have also to recognize a concomitant physiological sterility, induced by delayed marriage and its various consequences; we have also to recognize pathological sterility due to the impaired vitality and greater liability to venereal disease of an increasingly urban life; and we may have to recognize that stocks differ from one another in fertility.

The delay in marriage, as studied in England, is so far apparently slight; the mean age of marriage for all husbands in England has increased from 28.43 in 1896 to 28.88 in 1909, and the mean age of all wives from 26.21 in 1896 to 26.69 in 1909. This seems a very trifling rate of progression. If, however, we look at the matter in another way we find that there has been an extremely serious reduction in the number of marriages between 15 to 20, normally the most fecund of all age-periods. Between 1876 and 1880 (according to the Registrar-General's Report for 1909) the proportion of minors in 1000 marriages in England and Wales was 77.8 husbands and 217.0 wives. In 1909 it had fallen to only 39.8 husbands and 137.7 wives. It has been held that this has not greatly affected the decline in the birth-rate. Its tendency, however, must be in that direction. It is true that Engelmann argued that delayed marriages had no effect at all on the birth-rate. But it has been clearly shown that as the age of marriage increases fecundity distinctly diminishes. 119 This is illustrated by the specially elaborate statistics of Scotland for 1855; 120 the number of women having children, that is, the fecundity, was higher in the years 15 to 19, than at any subsequent age-period, except 20 to 24, and the fact that the earliest age-group is not absolutely highest is due to the presence of a number of immature women. In New South Wales, Coghlan has shown that if the average number of children is 3.6, then a woman marrying at 20 may expect to have five children, a woman marrying at 28 three children, at 32 two children, and at 37 one child. Newsholme and Stevenson, again, conclude that the general law of decline of fertility with advancing age of the mother is shown in various countries, and that in nearly all countries the mothers aged 15 to 20 have the largest number of children; the chief exception is in the case of some northern countries like Norway and Finland, where women develop late, and there it is the mothers of 20 to 25 who have the largest number of children. 121 The postponement in the age of marriage during recent years is, however, so slight that it can only account for a small part of the decline in the birth-rate; Coghlan calculates that of unborn possible children in New South Wales the loss of only about one-sixth is to be attributed to this cause. In London, however, Heron considers that the recognized connection between a low birth-rate and a high social standing might have been entirely accounted for sixty years ago by postponement of marriage, and that such postponement may still account for 50 per cent of it. 122