and sorrow. Protest against the use of an anesthetic to assuage the pain of an expectant mother is a case in point. Medical science must frequently combat religious prejudice, which has no right to interfere with social reform. The achievements of medicine and of sanitary science have done much to emancipate the human mind, and to prepare men for the acceptance of a program of social betterment, but the social and moral energy of a people living under bad conditions is to a large extent misdirected and impotent.

6. Physical Degeneracy.

A final consideration worthy of notice is the relation of infant and child mortality to physical deterioration and to our standards of physique. To this question no definite answer has as yet been given, and data upon the subject are too inadequate for broad and definite conclusions. The eugenists are busy gathering facts on this subject, but they must always work under very serious limitations. They cannot easily separate the inherited from the acquired weaknesses, and it is difficult to prove their case. Meanwhile prenatal work among prospective mothers is pointing the way to individual improvement. The author has no patience with those men, whether eugenists or not, who regard with favor a considerable wastage of child life because it accords with their theory of the improvement of the human race through the operation of the law of natural selection. Beneficent as results may be for the race of the future, this law, unmitigated and untempered by human hands and hearts, is harsh and cruel, and its operation tends to debase the sensibilities of men and to retard progress. Race improvement cannot be left to the cold-hearted methods of unconscious nature, and man can act less harshly and with equal effect by means of a process of social selection. Instead of permitting the unfit to die, the more humane and economical method is that of refusing to permit the unfit to come into the world. This avoids the brutality of natural selection, and accomplishes the same result. Standards of fitness must eventually be created, and these must be positive in character and independent of the caprices of environment. Accordingly they cannot be secured

through the operation of natural selection; for mind, not matter; reason, not instinct, must hereafter direct our line of progress.

Before the days of the physician, disease could not be controlled, and the weaker individuals perished, because mankind suffered from a long category of children's diseases. Certain races and peoples have in this way purchased considerable immunity from various diseases. The individuals most unfit to withstand some particular disease succumbed, and this long-continued process of elimination resulted in strengthening a people against further attacks of disease.

The

We are so far from a knowledge of what constitutes a correct standard of fitness that we must be cautious in our methods of attempting to improve the race. For example, when measles was first introduced into the Hawaiian Islands, it proved a terrible and most deadly plague, but later epidemics were less severe, and the present population is still susceptible to the disease, though not in such a severe form. A selection of this kind protects against certain forms of attack but does not immunize a people from other diseases. It is not clear that in this way a race is provided with the physical standards best adapted to the conditions of modern life. We must not assume that the malaria-breeding mosquito and other germ-carrying insects form a necessary part of the environment of men. susceptibility of the negro to yellow fever is unquestionably less than that of the white man, but this comparative immunity does not extend to all diseases, and in other respects the white man enjoys a similar superiority. Again immunity from disease is not the chief or only ground on which to judge physical standards. In fact, some diseases prefer the strong rather than the weak, and race vigor and susceptibility to a certain disease may indeed go together. Actual physical strength, productive capacity, and mental and moral vigor are the criteria of fitness, but immunity from disease bears no direct causal relation to these qualities. Furthermore, no single race has gained a superiority in all these respects.

Smallpox serves as an eloquent illustration of the fact that we have little to fear from the elimination of such diseases.

How brutally selective this malignant scourge has been can be read in the history of its ravages among the savage tribes to which civilization has introduced it. Their proneness to the disease is due in part to their former isolation from the smallpox germs. The determining question, however, is, has the elimination of the children vulnerable to this disease improved the race or people long subject to smallpox? It has undoubtedly lessened the relative intensity of future attacks upon the Caucasian race: for example, an athletic Indian of splendid physique may succumb, while a diminutive Englishman or American may escape with a slight attack only. Who then can measure the actual physical gain from the decimating effects of smallpox? There is no certainty that it has accomplished anything in that direction which other forces would not have done with equal efficiency; and so with the entire army of germ diseases. They have been selecting for survival those most capable of resisting the germ, but here their labors cease. Being proof against germs is not an inherent characteristic of good physique. The two, on the contrary, have very loose connections. In the future we will endeavor to destroy the germ as well as to discover antidotes for the disease, and if any deterioration should accom pany these scientific triumphs, the remedy will consist in positive measures to rear a more vigorous progeny, not to eliminate weaklings. The most that we can hope to gain from immunity against some particular germ is the elimination of the disease of which the germ is the cause, for physical strength and bodily vigor will be but slightly affected thereby.

Although death rates may represent certain forms of physiological selection, infant mortality is hardly a method of such selection. It is really a measure of the depths of the ignorance and backwardness of a civilization. If the reduction in infant mortality which will follow aggressive social reform should occasion a positive loss in physique and strength, then only will it become necessary to utilize positive methods of selection. Meanwhile the problem of physical degeneracy need cause little worry. The increasing death rate among persons in the higher age groups cannot be charged to a reduced infant mortality,

since death rates were high when those now dying at the age of sixty were mere infants. The indifference and moral obtuseness consequent upon a misunderstood infant mortality should have no place in the lives of men and women, and opportunity for enjoying the fruits of life should be provided for all. Then only have we instituted a proper system of social economy.

CHAPTER III

CONDITIONS UNDERLYING CHILD MORTALITY

HEALTH Conditions, climate, customs, and industries in the United States vary widely from the conditions prevailing in Western Europe, and therefore the problem of infant and child mortality is somewhat different in character. Until recently our population has been largely rural, but with the development of urban and industrial centers and the increase of a wage-earning class, new conditions have been thrust upon us.

These condi

tions are reflected in the varied rates of infant mortality.

1. Rural vs. Urban Mortality.

The first characteristic variation in infant death rates is the difference between the mortality of rural and urban districts. This difference, although not necessarily inherent, will tend to persist for an indefinite length of time. Our urban growth has been so rapid that cities of 10,000 and over now contain more than three-eighths of our entire population; consequently a steadily increasing percentage of children are becoming subject to the health conditions of the cities. City life has suffered from a number of very grave and almost insuperable disadvantages, and for these reasons the urban death rate has appeared hopeless. For a long time to come children in the city must suffer from a congestion of population. A pall of smoke or dust continually hovers over some cities and contaminates the air; the atmosphere is always more or less vitiated by impurities, and billions of injurious germs are ever ready to destroy human life. The lack of fresh air is perhaps the city's chief handicap, although children also suffer from an insufficient amount of light and sunshine. The salubrious effects of nature's healing forces are well known, but the country child is the chief gainer, as it is difficult to provide adequately for the city child.