I
THE QUESTION OF HEREDITY

In his testimony before the British Interdepartmental Committee on Physical Deterioration, Dr. Alfred Eichholz, one of H. M. Inspectors of Schools, a Doctor of Medicine, and formerly Fellow and Lecturer of Emmanuel College, Cambridge, said:—

“I have drawn a broad distinction between physical degeneracy and hereditary deterioration. The object of my evidence is to demonstrate the range and the depth of degeneracy among the poorer population, and to show that it is capable of great improvement—I say improvement purposely even within the areas of the towns—and to show that there is a lack of any real evidence of any hereditary taint or strain of deterioration even among the poor populations of our cities. The point which I desire to emphasize is that our physical degeneracy is produced afresh by each generation, and that there is every chance under reasonable measures of amelioration of restoring our poorest population to a condition of normal physique.

“I draw a clear distinction between physical degeneracy on the one hand and inherited retrogressive deterioration on the other. With regard to physical degeneracy, the children frequenting the poorer schools of London and the large towns betray a most serious condition of affairs, calling for ameliorative and arrestive measures, the most impressive features being the apathy of parents as regards the school, the lack of parental care of children, the poor physique, powers of endurance, and educational attainments of the children.... While there are, unfortunately, very abundant signs of physical defect traceable to neglect, poverty, and ignorance, it is not possible to obtain any satisfactory or conclusive evidence of hereditary physical deterioration—that is to say, deterioration of a gradual retrogressive permanent nature, affecting one generation more acutely than the previous. There is little, if anything, in fact, to justify the conclusion that neglect, poverty, and parental ignorance, serious as their results are, possess any marked hereditary effect, or that heredity plays any significant part in establishing the physical degeneracy of the poorer population. In every case of alleged progressive hereditary deterioration among the children frequenting an elementary school, it is found that the neighborhood has suffered by the migration of the better artisan class, or by the influx of worse population from elsewhere. Other than the well-known specifically hereditary diseases which affect poor and well-to-do alike, there appears to be very little real evidence on the prenatal side to account for the widespread physical degeneracy among the poorer population. There is, accordingly, every reason to anticipate RAPID amelioration of physique so soon as improvement occurs in external conditions, particularly as regards food, clothing, overcrowding, cleanliness, drunkenness, and the spread of common practical knowledge of home management. In fact, all evidence points to active, rapid improvement, bodily and mental, in the worst districts, so soon as they are exposed to better circumstances, even the weaker children recovering at a later age from the evil effects of infant life. (P. 20.)

“To discuss more closely the question of heredity may I in the first instance recall a medical factor of the greatest importance: the small percentage of unhealthy births among the poor—even down to the very poorest. The number of children born healthy is even in the worst districts very great. The exact number has never been the subject of investigation, owing largely to the certainty which exists on the point in the minds of medical men—but it would seem to be not less than 90 per cent.

“I have sought confirmation of my view with medical colleagues in public work, e.g. public health, poor law, factory acts, education, and in private practice in poor areas, and I have also consulted large maternity charities and have always been strengthened in this view. In no single case has it ever been asserted that ill-nourished or unhealthy babies are more frequent at the time of birth among the poor than among the rich, or that hereditary diseases affect the new-born of the rich and the poor unequally. The poorest and most ill-nurtured women bring forth as hale and strong-looking babies as those in the very best conditions. In fact, it almost appears as though the unborn child fights strenuously for its own health at the expense of the mother, and arrives in the world with a full chance of living a normal physical existence.... The interpretation would seem to be that Nature gives every generation a fresh start.”

[Q. 558. There is a fresh chance of getting rid of rickets with every generation?]

“Yes; rickets, malnutrition, low height, poor weight, anÆmia, and all the other circumstances of neglected existence. It is from the moment of birth that the sad history begins,—the large infant mortality, the systematic neglect, the impoverishment of the constitution,—the resulting puny material which is handed over to the school to be educated.

“... It seems clear that every generation receives its chance of living a good physical life, and when to the fact of the large proportion of healthy new births we couple the evidence of improving health and physique in children who pass up the poorer elementary schools, it seems clear that we are not dealing with a hereditary condition at all, but with a systematic postnatal neglect by ignorant parents, and that heredity, if it makes for anything, makes for recuperation, and so do the other social forces which are brought into play in dealing with the poorer population.” (P. 31.)—Report of the Committee, Vol. II.

Dr. Edward Malins, M.D., President of the Obstetrical Society of London and Professor of Midwifery in the University of Birmingham, was examined upon the same subject. From the Report of the Committee (Vol. II, p. 136), the following extracts are taken:—

“3124. You have been good enough to attend here in consequence of certain evidence that we received the other day in which it was stated by Dr. Eichholz, on the authority of other medical men, that if people are going to have children, they will have healthy children as though Nature were giving every generation a fresh start, and he went on to say that healthy births were about 90 per cent in the poor neighborhoods, and he suggested that we should go to the London Obstetrical Societies to ascertain how far their experience bore out this statement. What are you able to say on this point?—What I have to say at the present time is more a matter of observation and of opinion. We have not the figures at present to prove the accuracy of it, but I think the testimony of experienced observers would be in accordance with the views expressed by Dr. Eichholz, though perhaps not to such a large extent. I should say that from 80 to 85 per cent of children are born physically healthy.

“3125. Whatever the condition of the parents may be? Whatever the condition of the mother may be antecedently.

“3126. And you think the deterioration sets in later?—I do, materially so. The weight of children at birth as far as I know—and I have weighed a great many—is generally not below the average; the average keeps up very much no matter what the physical condition of the mother may be for the time. Since receiving this information we have instituted at the Obstetrical Society of London, in connection with Lying-in Charities and Hospitals in London, a tabulated form for ascertaining these facts—what the weight of children is at birth; their physical condition, and whether there is an increase or otherwise during the time a woman is under observation. That time is not very long, not more than 10 days or a fortnight generally.

“3127. Will you be able to furnish us with these facts when collected?—Certainly. I will give the information later on, but I think there is a general consensus of opinion, at all events irrespective of figures, which I am not able to give, that the average is kept up no matter what the condition of the mother may be.

“3128. That proves what you say in your prÉcis,—that Nature intends all to have a fair start?—Yes.”

II
MALNUTRITION

“One of the most striking things about children suffering from malnutrition is their vulnerability. They ‘take’ everything. Catarrhal processes in the nose (adenoids), pharynx, and bronchi are readily excited, and, once begun, tend to run a protracted course. There is but little resistance to any acute infectious disease which the child may contract. One illness often follows another, so that these children are frequently sick for almost an entire season. Their muscular development is poor, they tire readily, are able to take but little exercise, and their circulation is sluggish. Mentally, they are usually bright, often precocious. Many would be called nervous children.”—The Diseases of Infancy and Childhood, by L. Emmet Holt, M.D., LL.D., p. 231.

“General malnutrition is the commonest pathological feature of infant life. Probably 50 per cent of all infants in this country (England) suffer from a greater or less degree, and this large proportion is caused undoubtedly by the extremely unsatisfactory methods of substitute feeding at present in vogue. Illness, in the usually accepted sense of the word, is not present. No specific disease can be diagnosed, and unless the indications are realized, the degeneration is allowed to proceed until marasmus or some acute disorder supervenes....

“Marasmus represents the extreme result of gradual and long-continued malnutrition. Extreme wasting is the cardinal, and indeed only, specific symptom. The term is not applicable to those cases where the wasting is the result of exhaustion due to the incidence of specific disease, such, for instance, as tuberculosis....

“The most striking and perhaps the commonest result of impaired nutrition is the disease generally known by the name of rickets. Though some of its most obvious features are those associated with changes in the osseous system, those are by no means the only effects of the disease. Rachitis is the expression of profound pathological changes occurring in practically all the tissues of the body.

“No other disease illustrates so completely the effects of inadequate nutrition. An infant nursed by its mother and receiving from her a sufficient supply of adequate food, never contracts the disease, however disadvantageous its environment may be in other respects.

“Defect in the diet is the prime and essential cause of rachitis; while, as might be expected, the most advanced forms of the disease are to be seen when the effects of inadequate food are intensified by unhygienic environment....

“The effects of rachitis on the general constitution are extremely severe. The relationship between the nutrition of the infant and the condition of the child and adult has received but little attention. But there can be no doubt that the defects of nutrition occurring in infancy are of paramount importance in regard to the development of the adult. The cases of retarded physical and mental development in the child and the adult are numerous at the present time, and it is probable that their chief cause lies in defective nutrition during the period of infancy.

“Rachitis is a disease attended with a high mortality with which it is never credited, for the disease itself is seldom, if ever, fatal. In consequence of the cachectic condition and the extreme debility associated with advanced rachitis, the specific infectious diseases, such as measles, pertussis, and others, are associated with a much higher mortality in these cases than in others. Associated more or less closely with rachitis is a large class of disorders, such as bronchitis, diarrhoea, laryngismus stridulous, convulsions; these are attended with many fatal issues.”—The Nutrition of the Infant, by Ralph M. Vincent, M.D., pp. 226 et seq.

Dr. Thomas Darlington, President of the New York Board of Health, says: Any movement for a proper regulation of midwives has my earnest support. Under the laws of New York as they now exist there is no adequate regulation. It is very easy for a woman to become a midwife in this city. She is required, it is true, to come to the department of health with a certificate from some school of midwifery, here or abroad, or to present statements from two physicians as to her fitness and character, but the status of the school does not enter into the consideration, and that it is not difficult to obtain the indorsement from the two doctors is indicated by the great degree of incompetency and carelessness to be found in the ranks of the 800 midwives of New York City. Under the laws now existing we have no right to demand further proof of qualification. If the applicant meets the slight requirements, we must put her down as a “registered midwife.” She brings this phrase prominently into use in her solicitations for business in her neighborhood, and it inspires confidence—a good deal more confidence than it should. Thus are the people deceived by the laxity of the law. A measure was introduced in the legislature, providing for a much stricter supervision of midwives than is now the case. The bill had the support of this department and of the medical societies of standing, and yet, because of ignorance and indifference concerning the evils of the practice, it failed to reach a place on the statute books. My own opinion is that the midwife should, before being allowed to practise, undergo a schooling at least as long and as careful as that of the trained nurse.

Dr. Henry C. Coe, Professor of Gynecology at Bellevue Hospital, New York, and Chief Surgeon of Gynecology and Obstetrics at the General Memorial Hospital, New York, says: Midwives are responsible for the majority of cases sent to public hospitals. It is a sad commentary on the mediÆval customs of obstetrics that such facts, known to all doctors, should be ignored by coroners. The remedy is plain,—to have educated midwives, as in Germany.

Dr. J. Clarence Webster, of the Rush Medical College, Chicago, says: The midwives are, as a class, uneducated and untrained. They are responsible for the great majority of maternal deaths. Every gynecologist who works in a large charity hospital can give evidence of the morbidity among poor women resulting from infection where the attendant was a midwife. The splendid results obtained by the lying-in hospitals and dispensaries, where women are attended by skilled physicians and trained nurses, are chiefly due to a rigid technique, the essential feature of which is cleanliness. It is a disgrace to every city that the benefits of such institutions cannot be extended to all poor women. Any surgeon who would dare to operate under the conditions observed by midwives would be denounced not only by the medical profession, but also by the enlightened laity. Yet the latter are apparently indifferent to the work of the midwife, and allow her to carry on her dangerous career uncensured. The extension of the benefits of scientific obstetrics is chiefly due to the persistence and self-sacrifice of the medical profession, but the doctors are unable, unaided, to do what remains to be done.

Dr. Francis Quinlin, President of the New York County Medical Association, says: All reputable physicians who have given the matter the slightest consideration are of one mind in regard to the menace to life in the ignorant work of the great majority of midwives. The New York County Medical Association has let slip no opportunity to throw the weight of its influence on the side of remedial measures. That little has been accomplished so far is due to the fact that the midwife, as she exists to-day, is a time-honored institution, difficult to uproot. Most midwives have apparently no conception of the scientific cleanliness which is rightly regarded by physicians as being of prime importance. The most ordinary antiseptic precautions are ignored, with the result that, every day, women who have been attended by midwives are brought to hospitals suffering from blood-poisoning. In their habits of carelessness the midwives also carry from one house to another the germs of infectious diseases. In the interest of a host of poor mothers and of children whose lives are valuable to the nation, I say that the practice of midwifery should come under a much closer scrutiny of the law than is now the case.

Dr. Eleanor B. Kilham, Head of the Maternity Department of the Women’s Infirmary, New York City, says: That much injury results to mothers and children from the unrestrained practice of midwives there can be no doubt in the mind of any physician who has been brought in contact with the conditions. There is an opportunity here for an important reform, and I am very glad to know that something is being done in this direction.

(These letters are quoted from Success, April, 1905.)

IV
MUNICIPALIZATION OF THE MILK SUPPLY AND THE DANGERS OF STERILIZATION

“The real solution of the milk problem is not the supply of sterilized milk of doubtful purity, but rather the supply of clean milk from sources above all suspicion. The transport of milk from long distances under present conditions, as to cooling, transit, etc., may render sterilization all important, but the necessity for sterilization indicates the presence of avoidable organic impurity, and to obtain a naturally pure milk supply is the really important thing....

“If we municipalize water because the public health aspect is of such vital importance, then from the same standpoint we should municipalize the milk supply. We nearly all need milk—many live on it exclusively; its supply is as regular as the water supply, and its distribution demands even greater care for a longer time. The milkman calls more regularly than the postman and the milk bill comes in as regularly as the rate card. Like the liquor trade, the milk trade is a simple one, and the dividends of modern dairy companies show that it is profitable....

“We should bear in mind that, although under present conditions of supply any stringent enforcement of the most thorough sanitary regulations on farmers, or any distinct raising of the legal minimum of fat in milk, would certainly tend to raise the price of milk to the consumer, and any rise in price would be most unfortunate, yet a high standard of production and distribution is essential. The only way to get both low price and a better article is by means of the enormous economies in distribution, cartage, etc., which would at once result from municipal ownership....

“Finally, it has been shown that all successful attempts to solve the question have been those in which the aim has been other than the ordinary commercial one, and those organizing the supply have been interested in the public health, and in which there has been thorough organization on a large scale both in supply and distribution. These facts alone show that the only solution possible under modern conditions is that suggested by the municipal ownership and control of the milk supply.”—F. Lawson Dodd, M.R.C.S., L.R.C.P., L.D.S., Eng., D.P.H., London, in The Problem of the Milk Supply.

Sir Richard Douglas Powell, in his lecture to the Congress of the Sanitary Institute at Glasgow, in July, 1904, said: “There can be no doubt that scientifically conducted dairy farms on a large scale, with urban depots for the reception and dispensing of pure milk in clean bottles at a fair price to the poor, would pay, and would be a most laudable employment of the municipal enterprise that is often devoted to matters of much less urgent public interest and importance. Apart from the primary benefit of affording a pure milk supply at a fair price, the object lesson to mothers and families in food cleanliness would be beyond price.”

Mrs. Watt Smith, an expert employed by the British Medical Journal, author of The Milk Supply in Large Towns, in her evidence before the Interdepartmental Committee on Physical Deterioration, condemned the policy of the English Infants’ Milk Depots, saying: “The milk comes from an uninspected source; they get it from a local dealer.... Then they sterilize that milk to make it safe. It is like purifying sewage to make it into clean water. It is not right.” Dr. Ralph M. Vincent also condemned the sterilization process for the same reason, and, in addition, insisted that sterilization impaired the nutritive value of the milk, causing at least one specific disease, scorbutus.—Report of the Committee, Vol. II, Minutes of Evidence.

Dr. George W. Goler, whose work in Rochester has been so much referred to, says: “For two more years the milk was Pasteurized, though considerable trouble was had with sour milk and in finding a man to furnish reasonably clean milk. After the first year four stations in all were required for the needs of four quarters of the city. Then, in 1899, we established our central station on a farm, and instead of Pasteurizing milk, with all its contained filth and bacteria, we strove to keep dirt and germs out of the milk, and began to sterilize all of the utensils, bottles, etc., and to put out milk that was clean. Clean milk, or milk approximately clean, having no more than 20,000 bacteria per cubic centimeter needs no application of heat to render it fit food for babies. Heat applied to milk alters it, makes its curd tougher and more difficult to digest, often gives rise to indigestion, diarrhoea, or constipation in the infant, and, further, the application of heat to milk in the operation of Pasteurizing or sterilizing leads people to think they may cure a condition that is more easily prevented by care in the handling of milk used for food.”—“But a Thousand a Year,” reprinted from Charities, August 5, 1905.

V
A COMMISSIONER OF CHARITIES ON CHILD LABOR

“The objection that is offered most frequently, and perhaps with most effect, to further restriction of child labor, is the alleged fact that in a great many instances the earnings of these little children are needed to supplement the incomes of widows, of families in which the husband and wage-earner may be either temporarily or permanently or partially disabled, and that without the small addition which the earnings of these little boys and girls can bring in, there would be suffering and distress. It would be easy, I think, to overestimate the extent to which that is true.... So we should not admit that that side is more serious than it is, but do let us cheerfully, frankly, gladly add that there would be many cases in which the proposed legislation (for the restriction of child labor) would deprive many families of earnings from their children, and that we propose ourselves to step into the breach and provide that relief in good hard cash that passes in the market.... If larger means are necessary to support these children so that they need not depend on their own labor, by all means let us put up the money and not push the children for a part of their support before the time when they should naturally furnish a part of their support.... In the long run it is never cheap to be cruel or hard. It is never wise to drive a hard bargain with childhood.”—Extract from an address by Homer Folks, Commissioner of Charities, New York.