CHAPTER IVINFANT 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 oflaissez-fairecan 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 natureof 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 inthe four first-born, and then increased to a very high rate. Following are Geissler’s figures, (marriages with only one or two children are omitted).

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

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

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

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

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

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

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

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.

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.

U. S. DEPARTMENT OF LABOR CHILDREN’S BUREAUJulia C. Lathrop, ChiefINFANT MORTALITYRESULTS OF A FIELD STUDY IN JOHNSTOWN, PA., BASED ONBIRTHS IN ONE CALENDAR YEARBy Emma Duke1915(Certain tables omitted)

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.

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:

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

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 statisticswere 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 theycalled 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 furthermeans 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 Table1for babies included in the investigation. In reality, however, it is perhaps a little higher, as some of these babies no doubt died outside of Johnstown and their deaths were recorded elsewhere.

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

Johnstown is a hilly, somewhat Y-shaped area of about 5 square miles which spreads itself out into long, narrow, irregularly shaped strips, detached by rivers and runs and steep hills. In some places it is not over a quarter of a mile wide, but its extreme length is about 4 miles. The city is composed of21 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.

12.Federal census of 1910.

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 waterconstantly 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.)

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 theDemocratof 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.

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 therewere 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.

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