The Case for Birth Control_ A Supplementary Brief and Statement of Facts Margaret Sanger 954 downloads.pdf

The Project Gutenberg eBook of The Case for Birth Control: A
Supplementary Brief and Statement of Facts
This eBook is for the use of anyone anywhere in the United States and
most other parts of the world at no cost and with almost no restrictions
whatsoever. You may copy it, give it away or re-use it under the terms
of the Project Gutenberg License included with this eBook or online at
www.gutenberg.org. If you are not located in the United States, you
will have to check the laws of the country where you are located
before using this eBook.

Title: The Case for Birth Control: A Supplementary Brief and
Statement of Facts

Author: Margaret Sanger

Release date: April 24, 2017 [eBook #54599]
Most recently updated: October 23, 2024

Language: English

Other information and formats: www.gutenberg.org/ebooks/54599

Credits: Produced by Richard Tonsing and the Online Distributed
Proofreading Team at http://www.pgdp.net (This file was
produced from images generously made available by The
Internet Archive)

*** START OF THE PROJECT GUTENBERG EBOOK THE CASE FOR
BIRTH CONTROL: A SUPPLEMENTARY BRIEF AND STATEMENT
OF FACTS ***

Transcriber's Note:
The cover image was created by the transcriber and is
placed in the public domain.

The Case For Birth Control
A Supplementary Brief and Statement of Facts
PREPARED BY
MARGARET H. SANGER
To Aid the Court in its Consideration of the Statute designed to prevent the
dissemination of information for Preventing Conception

PUBLISHED, MAY 1917

JONAH J. GOLDSTEIN
COUNSEL

Copyright by
MARGARET H. SANGER
1917

CONTENTS

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

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

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

CHAPTER IV. INFANT MORTALITY 93
General Statistics,

Results of Children’s Bureau Survey at Johnstown, Pa., by
Emma Duke,
Manchester Report.

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

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

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

Syphilis,
Gonorrhea.

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

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

GLOSSARY 250

FOREWORD

T he purpose of the Appellant in presenting the various statistics and
medical and social facts incorporated in the supplementary brief,
entitled THE CASE FOR BIRTH CONTROL, is to give the Court a clear
conception of the meaning of birth control. The historical stages through
which this question has gone have been reviewed, its status in foreign
countries outlined. Finally, the effects upon the commonwealth of the
prohibition contained in the Section known as 1142 of the Penal Law have
been made clear. Said Section comprises in its prohibition the very points of
knowledge most necessary to human liberty, and has resulted in extreme
harm to the individual, to the family and to society at large.
The idea of the social and racial value of knowledge to prevent conception
is new in the United States, and therefore it has been difficult to get first-
hand facts and comprehensive statistics with a local bearing. Consequently,
the Appellant has been obliged to lay emphasis upon data from foreign
countries where the subject has been exhaustively studied, both
theoretically and practically. However, the American case for birth control,
as presented in this compilation, is the most complete possible in view of
the records available.
MARGARET H. SANGER

CHAPTER I.
INTRODUCTORY

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

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

CHAPTER I
THE CASE FOR BIRTH CONTROL
By Margaret H. Sanger

(The following is the case for birth control, as I found it during my fourteen
years’ experience as a trained nurse in New York City and vicinity. It
appeared as a special article in “Physical Culture,” April, 1917, and has
been delivered by me as a lecture throughout the United States. It is a brief
summary of facts and conditions, as they exist in this country.)
For centuries woman has gone forth with man to till the fields, to feed and
clothe the nations. She has sacrificed her life to populate the earth. She has
overdone her labors. She now steps forth and demands that women shall
cease producing in ignorance. To do this she must have knowledge to
control birth. This is the first immediate step she must take toward the goal
of her freedom.
Those who are opposed to this are simply those who do not know. Any one
who like myself has worked among the people and found on one hand an
ever-increasing population with its ever-increasing misery, poverty and
ignorance, and on the other hand a stationary or decreasing population with
its increasing wealth and higher standards of living, greater freedom, joy
and happiness, cannot doubt that birth control is the livest issue of the day
and one on which depends the future welfare of the race.
Before I attempt to refute the arguments against birth control, I should like
to tell you something of the conditions I met with as a trained nurse and of
the experience that convinced me of its necessity and led me to jeopardize
my liberty in order to place this information in the hands of the women who
need it.
My first clear impression of life was that large families and poverty went
hand in hand. I was born and brought up in a glass factory town in the
western part of New York State. I was one of eleven children—so I had
some personal experience of the struggles and hardships a large family
endures.

When I was seventeen years old my mother died from overwork and the
strain of too frequent child bearing. I was left to care for the younger
children and share the burdens of all. When I was old enough I entered a
hospital to take up the profession of nursing.
In the hospital I found that seventy-five per cent. of the diseases of men and
women are the result of ignorance of their sex functions. I found that every
department of life was open to investigation and discussion except that
shaded valley of sex. The explorer, scientist, inventor, may go forth in their
various fields for investigation and return to lay the fruits of their
discoveries at the feet of society. But woe to him who dares explore that
forbidden realm of sex. No matter how pure the motive, no matter what
miseries he sought to remove, slanders, persecutions and jail await him who
dares bear the light of knowledge into that cave of darkness.
So great was the ignorance of the women and girls I met concerning their
own bodies that I decided to specialize in woman’s diseases and took up
gynecological and obstetrical nursing.
A few years of this work brought me to a shocking discovery—that
knowledge of the methods of controlling birth was accessible to the women
of wealth while the working women were deliberately kept in ignorance of
this knowledge!
I found that the women of the working class were as anxious to obtain this
knowledge as their sisters of wealth, but that they were told that there are
laws on the statute books against imparting it to them. And the medical
profession was most religious in obeying these laws when the patient was a
poor woman.
I found that the women of the working class had emphatic views on the
crime of bringing children into the world to die of hunger. They would
rather risk their lives through abortion than give birth to little ones they
could not feed and care for.
For the laws against imparting this knowledge force these women into the
hands of the filthiest midwives and the quack abortionists—unless they bear
unwanted children—with the consequence that the deaths from abortions
are almost wholly among the working-class women.

No other country in the world has so large a number of abortions nor so
large a number of deaths of women resulting therefrom as the United States
of America. Our law makers close their virtuous eyes. A most conservative
estimate is that there are 250,000 abortions performed in this country every
year.
How often have I stood at the bedside of a woman in childbirth and seen the
tears flow in gladness and heard the sigh of “Thank God!” when told that
her child was born dead! What can man know of the fear and dread of
unwanted pregnancy? What can man know of the agony of carrying beneath
one’s heart a little life which tells the mother every instant that it cannot
survive? Even were it born alive the chances are that it would perish within
a year.
Do you know that three hundred thousand babies under one year of age die
in the United States every year from poverty and neglect, while six hundred
thousand parents remain in ignorance of how to prevent three hundred
thousand more babies from coming into the world the next year to die of
poverty and neglect?
I found from records concerning women of the underworld that eighty-five
per cent. of them come from parents averaging nine living children. And
that fifty per cent. of these are mentally defective.
We know, too, that among mentally defective parents the birth rate is four
times as great as that of the normal parent. Is this not cause for alarm? Is it
not time for our physicians, social workers and scientists to face this array
of facts and stop quibbling about woman’s morality? I say this because it is
these same people who raise objection to birth control on the ground that it
may cause women to be immoral.
Solicitude for woman’s morals has ever been the cloak Authority has worn
in its age-long conspiracy to keep woman in bondage.
When I was in Spain a year ago, I found that the Spanish woman was far
behind her European sisters in readiness or even desire for modern freedom.
Upon investigation as to the cause of this I found that there are over five
thousand villages and towns in Spain with no means of travel,
transportation and communication save donkeys over bridle paths. I was
told that all attempts to build roads and railroads in Spain had been met

with the strongest opposition of the Clergy and the Government on the
ground that roads and railroads would make communication easier and
bring the women of the country into the cities where they would meet their
downfall.
Do we who have roads and railroads think our women are less moral than
the Spanish women? Certainly not. But we in this country are, after all, just
emerging from the fight for a higher education of women which met with
the same objection only a few years ago.
We know now that education has not done all the dreadful things to women
that its opponents predicted were certain to result. And so shall we find that
knowledge to control birth, which has been in the hands of the women of
wealth for the past twenty-five years, will not tend to lower woman’s
standard of morality.
Statistics show us that the birth-rate of any given quarter is in ratio with and
to its wealth. And further figures prove that in large cities the rich districts
yield a birth-rate of a third of that of the poor districts. In Paris for every
1,000 women between the ages of 15 and 50 the poor districts yield 116
births and the rich districts 34 births. In Berlin conditions are approximately
the same. For every 1,000 women between the ages of 15 and 50 the poor
districts yield 157 births while the rich yield 47. This applies also to all
large cities the world over.
It can be inferred from these figures that the women of wealth use means to
control birth which is condemned when taught to the poor. But the menace
to our civilization, the problem of the day, is not the stationary birth-rate
among the upper classes so much as the tremendous increase among the
poor and diseased population of this country....
Is woman’s health not to be considered? Is she to remain a producing
machine? Is she to have time to think, to study, to care for herself? Man
cannot travel to his goal alone. And until woman has knowledge to control
birth she cannot get the time to think and develop. Until she has the time to
think, neither the suffrage question nor the social question nor the labor
question will interest her, and she will remain the drudge that she is and her
husband the slave that he is just as long as they continue to supply the
market with cheap labor.

Let me ask you: Has the State any more right to ravish a woman against her
will by keeping her in ignorance than a man has through brute force? Has
the State a better right to decide when she shall bear offspring?
Picture a woman with five or six little ones living on the average working
man’s wage of ten dollars a week. The mother is broken in health and spirit,
a worn out shadow of the woman she once was. Where is the man or
woman who would reproach me for trying to put into this woman’s hands
knowledge that will save her from giving birth to any more babies doomed
to certain poverty and misery and perhaps to disease and death.
Am I to be classed as immoral because I advocate small families for the
working class while Mr. Roosevelt can go up and down the length of the
land shouting and urging these women to have large families and is neither
arrested nor molested but considered by all society as highly moral?
But I ask you which is the more moral—to urge this class of women to have
only those children she desires and can care for, or to delude her into
breeding thoughtlessly. Which is America’s definition of morality?
You will agree with me that a woman should be free.
Yet no adult woman who is ignorant of the means to prevent conception can
call herself free.
No woman can call herself free who cannot choose the time to be a mother
or not as she sees fit. This should be woman’s first demand.
Our present laws force woman into one of two ways: Celibacy, with its
nervous results, or abortion. All modern physicians testify that both these
conditions are harmful; that celibacy is the cause of many nervous
complaints, while abortion is a disgrace to a civilized community.
Physicians claim that early marriage with knowledge to control birth would
do away with both. For this would enable two young people to live and
work together until such time as they could care for a family. I found that
young people desire early marriage, and would marry early were it not for
the dread of a large family to support. Why will not society countenance
and advance this idea? Because it is still afraid of the untried and the
unknown.
I saw that fortunes were being spent in establishing baby nurseries, where
new babies are brought and cared for while the mothers toil in sweatshops

during the day. I saw that society with its well-intentioned palliatives was in
this respect like the quack, who cures a cancer by burning off the top while
the deadly disease continues to spread underneath. I never felt this more
strongly than I did three years ago, after the death of the patient in my last
nursing case.
This patient was the wife of a struggling working man—the mother of three
children—who was suffering from the results of a self-attempted abortion. I
found her in a very serious condition, and for three weeks both the
attending physician and myself labored night and day to bring her out of the
Valley of the Shadow of Death. We finally succeeded in restoring her to her
family.
I remember well the day I was leaving. The physician, too, was making his
last call. As the doctor put out his hand to say “Good-bye,” I saw the patient
had something to say to him, but was shy and timid about saying it. I started
to leave the room, but she called me back and said:
“Please don’t go. How can both of you leave me without telling me what I
can do to avoid another illness such as I have just passed through?”
I was interested to hear what the answer of the physician would be, and I
went back and sat down beside her in expectation of hearing a sympathetic
reply. To my amazement, he answered her with a joking sneer. We came
away.
Three months later, I was aroused from my sleep one midnight. A telephone
call from the husband of the same woman requested me to come
immediately as she was dangerously ill. I arrived to find her beyond relief.
Another conception had forced her into the hands of a cheap abortionist,
and she died at four o’clock the same morning, leaving behind her three
small children and a frantic husband.
I returned home as the sun was coming over the roofs of the Human Bee-
Hive, and I realized how futile my efforts and my work had been. I, too,
like the philanthropists and social workers, had been dealing with the
symptoms rather than the disease. I threw my nursing bag into the corner
and announced to my family that I would never take another case until I had
made it possible for working women in America to have knowledge of birth
control.

I found, to my utter surprise, that there was very little scientific information
on the question available in America. Although nearly every country in
Europe had this knowledge, we were the only civilized people in the world
whose postal laws forbade it.
The tyranny of the censorship of the post office is the greatest menace to
liberty in the United States to-day. The post office was never intended to be
a moral or ethical institution. It was intended to be mechanically efficient;
certainly not to pass upon the opinions in the matter it conveys. If we
concede this power to this institution, which is only a public service, we
might just as well give to the street car companies and railroads the right to
refuse to carry passengers whose ideas they do not like.
I will not take up the story of the publication of “The Woman Rebel.” You
know how I began to publish it, how it was confiscated and suppressed by
the post office authorities, how I was indicted and arrested for bringing it
out, and how the case was postponed time and time again and finally
dismissed by Judge Clayton in the Federal Court.
These, and many more obstacles and difficulties were put in the path of this
philosophy and this work to suppress it if possible and discredit it in any
case.
My work has been to arouse interest in the subject of birth control in
America, and in this, I feel that I have been successful. The work now
before us is to crystallize and to organize this interest into action, not only
for the repeal of the laws but for the establishment of free clinics in every
large center of population in the country where scientific, individual
information may be given every adult person who comes to ask it.
In Holland there are fifty-two clinics with nurses in charge, and the medical
profession has practically handed the work over to nurses. In these clinics,
which are mainly in the industrial and agricultural districts, any woman
who is married or old enough to be married, can come for information and
be instructed in the care and hygiene of her body.
These clinics have been established for thirty years in Holland, and the
result has been that the general death-rate of Holland has fallen to the
lowest of any country in Europe. Also, the infant mortality of Amsterdam
and The Hague is found to be the lowest of any city in the world. Holland

proves that the practice of birth control leads to race improvement; her
increase of population has accelerated as the death-rate has fallen.
In England, France, Scandinavia, and Germany, information regarding birth
control is also freely disseminated, but the establishment of clinics in these
countries is not so well organized as it is in Holland, with the consequence
that the upper and middle classes, as in this country, have ready access to
this knowledge, while the poor continue to multiply because of their lack of
it. This leads, especially in France, to a high infant mortality, which, rather
than a low birth-rate, is the real cause of her decreasing population.
We in America should learn a lesson from this, and I would urge immediate
group action to form clinics at once. We have in this country a splendid
foundation in our hospital system and settlement work. The American
trained nurse is the best equipped and most capable in the world, which
enables us, if we begin work at once, to accomplish as much in ten years’
time as the European countries have done in thirty years.
The clinic I established in the Brownsville district of Brooklyn
accomplished at least this: it showed the need and usefulness of such an
agency.
The free clinic is the solution for our problem. It will enable women to help
themselves, and will have much to do with disposing of this soul-crushing
charity which is at best a mere temporary relief.
Woman must be protected from incessant childbearing before she can
actively participate in the social life. She must triumph over Nature’s and
Man’s laws which have kept her in bondage. Just as man has triumphed
over Nature by the use of electricity, shipbuilding, bridges, etc., so must
woman triumph over the laws which have made her a childbearing
machine.

RACE REGENERATION. HAVELOCK ELLIS. New Tracts for the Times.
Cassell & Co., Ltd., London, New York, Toronto and Melbourne.
1911.
Henry Havelock Ellis: L.S.A. Hon. Member Medico-legal Society of New
York. Hon. Fellow of the Chicago Academy of Medicine; Foreign Associate
of the Societe Medico-Historique of Paris, etc.; General Editor of the

Contemporary Science Series (1889); born Croydon, Surrey, 2nd Feb.,
1859; belonging on both sides to families connected with the sea; spent
much of childhood on sea, (Pacific, etc.); educated, private schools; St.
Thomas’s Hospital; engaged in teaching in various parts of New South
Wales, 1875–79. Returned to England and qualified as medical man, but
only practiced for a short time, having become absorbed in scientific and
literary work. Edited the Mermaid Series of Old Dramatists, 1887–89.
Publications: The New Spirit, 1890; The Criminal, 1890 (4th edition revised
and enlarged 1910); Man and Woman, a Study of Human Secondary Sexual
Characters, 1894 (5th edition revised and enlarged 1914); Sexual Inversion,
being Vol. II of Studies in the Psychology of Sex, 1897 (3rd edition revised
and enlarged 1915); Affirmations, 1897; The Evolution of Modesty, etc.,
being vol. I of the studies in Psychology of Sex, 1899 (3rd edition revised
and enlarged, 1910); The 19th Century; A Dialogue in Utopia, 1900; A
Study of British Genius, 1904; Analysis of the Sexual Impulse, 1903, (2nd
edition revised and enlarged 1913); Sexual Selection in Man, 1905; Erotic
Symbolism, 1906; Sex in Relation to Society, being vols. 3, 4, 5 and 6 of
studies in psychology of sex; The Soul of Spain, 1908; The World of
Dreams, 1911; The Task of Social Hygiene, 1912; Impressions and
Comments, 1914; Essays In War Time, 1916.
When we survey the movement of social reform which has been carried on
during the past one hundred years, we thus see that it is proceeding in four
stages. 1—The effort to clear away the gross filth of our cities, to improve
the dwellings, to introduce sanitation, and to combat disease. 2—The
attempt to attack the problem more thoroughly by regulating conditions of
work, and introducing the elaborate system of factory legislation. 3—The
still more fundamental step of taking in hand the children who have not yet
reached the age of work, nationalizing education, and ultimately pushing
back the care and over-sight of infants to the moment of birth. 4—Finally,
most fundamental step of all, the effort, which is still only beginning to
provide the conditions of healthy life even before birth. It must be
remembered that this movement in all its four stages is still in active
progress among us. It is not mere ancient history. On the contrary, it is a
movement that is constantly spreading and at every point becoming more
thorough, more harmoniously organized. Before long it will involve a
national medical service, which will impose on doctors as their primary
duty, not the care of disease, but the preservation of health. We have to

realize at the same time that this movement has been exclusively concerned,
not with the improvement of the quality of human life, but exclusively with
the betterment of the conditions under which life is lived. It tacitly assumed
that we have no control over human life and no responsibility for its
production. It accepted human life—however numerous it might be in
quantity, however defective in quality—as a God given fact, which it would
be impious to question. It heroically set itself to the endless task of
cleansing the channels down which this muddy torrent swept. It never went
to the source. Only take care of the soil, these workers at social reform said
in effect, and the seed is no matter. That, as we can now see, was a silly
enough position to take up. P. 26.
Here we have been spending enormous enthusiasm, labor and money in
improving the conditions of life, with the notion in our heads that we should
thereby be improving life itself, and after 70 years we find no convincing
proof that the quality of our people is one whit better than it was when for a
large part they lived in filth, were ravaged by disease, bred at random,
soaked themselves in alcohol, and took no thought for the morrow. Our
boasted social reform has been a matter of bricks and mortar—a piling up
of hospitals, asylums, prisons and workhouses—while our comparatively
sober habits may be merely a sign of the quietly valetudinarian way of life
imposed on a race no longer possessing the stamina to withstand excess.
One of the most obvious tests of our degree of success in social reform
directed to the betterment of social conditions is to be found in the amount
of our pauperism, and the condition of our paupers. If the amelioration of
the conditions of life can effect even a fraction of what has been expected of
it, the results ought to be seen in the diminution of our pauperism, and the
improvement of the condition of our paupers. Yet so far as numbers are
concerned, the vast army of our paupers has remained fairly constant during
the whole period of social reform, if indeed it has not increased. As to the
ineffectiveness of our methods the Royal Commissioners, especially
perhaps in their Minority Report, have shed much light. It was to be
expected that these muddled methods should be most marked in all that
concerns the beginnings of life, for that is precisely where our whole
treatment of social reform has been most at fault. Children under 16 form
nearly one-third of the paupers relieved. In the United Kingdom the Poor
Law authorities have on their books as outdoor paupers, 50,000 infants

under four years of age. As regards the annual number of births in the Poor
Law institutions of the United Kingdom, there are not even definite
statistics available, but it is estimated in the Minority Report that the
number is probably over 15,000, 30% of these being legitimate children,
and 70% illegitimate. There is no system in the treatment of mothers; and
often not the most elementary care in the treatment of the infants. It is
scarcely surprising that though the general infant mortality is excessively
high, the infant mortality of the workhouse babies is two or three times as
high as that among the general population. And the Royal Commissioners
pathetically ask, “To what is this retrogression due? It cannot be due to lack
of expenditure, or to lack of costly and elaborate machinery.” No, it
certainly is not. It is in large part due, as we are now just beginning to
recognize, to the concentration of our activities on the mere conditions of
life, to our neglect of the betterment of life itself. We have failed to realize
that the whitening of our sepulchres will not limit the number of corpses
placed in those sepulchres. It is the renewal of the spirit within that is
needed, not alone the improvement of material conditions, but the
regeneration of life. If we wish to realize more in detail the slight extent to
which our efforts to better the conditions of life have raised the quality of
life itself, we have but to turn to the problem of the feebleminded, which
during recent years has attracted so much attention. It is necessary to
remember that this feeblemindedness is largely handed on by heredity.
Exact investigation has now shown that feeblemindedness is inherited to an
enormous extent. Some years ago, Dr. Ashby, speaking from a large
experience, estimated that at least 75% of feebleminded children are born
with an inherited tendency to mental defect. More precise investigation has
shown since that this estimate was under the mark. Dr. Tredgold, who in
England has most carefully studied the heredity of the feebleminded, found
that in over 82% there is a bad nervous inheritance. Heredity is the chief
cause of feeblemindedness, and Tredgold has never seen a normal child
born of two feebleminded parents. The very thorough investigation of the
heredity of the feebleminded which is now being carried on at the
institution for their care at Vineland, N. J., shows even more decisive
results. By making careful pedigrees of the families to which the inmates at
Vineland belong it is seen that in a large proportion of cases
feeblemindedness is handed on from generation to generation, and is
transmissible through three generations, though it sometimes skips a

generation. Not only is feeblemindedness inherited, and in a much greater
degree than has been hitherto suspected, but the feebleminded tend to have
a much larger number of children than normal people. The average number
of children of feebleminded people seems to be usually about one-third
more than in normal families, and is sometimes very much greater. Page
26–36.
And it is not only in themselves that the feebleminded are a burden on the
present generation and a menace to future generations. They are seen to be
often a more serious danger when we realize that in large measure they
form the reservoir from which the predatory classes are recruited. This is
for instance the case as regards the fallen. Feebleminded girls of fairly high
grade may often be said to be predestined to immorality if left to
themselves, not because they are vicious, but because they are weak and
have little power of resistance. They cannot properly weigh their actions
against the results of their actions, and even if they are intelligent enough to
do that, they are still too weak to regulate their actions accordingly.
Moreover, even when, as so often happens among the high grade
feebleminded, they are quite able and willing to work, after they have lost
their respectability by having a child, the opportunities of work become
more restricted and they drift into prostitution. Criminality again is
associated with feeblemindedness in the most intimate way. Not only do
criminals tend to belong to large families, but the families that produce
feebleminded offspring also produce criminals. P. 40.
Closely related to the great feebleminded class, and from time to time
falling into crime are the inmates of workhouses, tramps and the
unemployable. The so-called able-bodied inmates of our workhouses are
frequently found on medical examination to be more than 50% cases of
mental defectives, equally so whether they are men or women. P. 42.
We have found that this movement for social reform, while it has been
inevitable and necessary, and is even yet by no means at an end, is not
fulfilling, and cannot fulfil the expectations of those who set it in motion. It
has even had the altogether undesigned and unexpected result of increasing
the burden it was intended to remove. Whatever the exact action of natural
selection may be, as soon as we begin to interfere with it, and improve the
conditions of life by caring for the unfit, enabling them to survive and to
propagate their like, as they will not fail to do, insofar as they belong to the

unfit stocks, then we are certainly, without intending it, doing our best to
lower the level of life. We increase, or at best retain the unfit, while at the
same time we burden the fit with the task of providing for the unfit. In this
way we deteriorate the general quality of life in the next generation, except
insofar as our improvement of the environment may enable some to remain
fit, who under less favorable conditions would join the unfit. It is now
possible for us to realize how the way lies open to the next great forward
step in social reform. On the one hand the progressive movement of
improvement in the conditions of life, by proceeding steadily back, as we
have seen, to the conditions before birth, renders the inevitable next step a
deliberate controlled life itself. On the other hand, the new social feeling
which has been generated by the task of improving the conditions of life,
and of caring for those who are unable to care for themselves, has made
possible a new explanation of responsibility to the race. We have realized
practically and literally that we are “our brother’s keepers.” We are
beginning to realize that we are the keepers of our children of the race that
is to come after us. Our sense of social responsibility is becoming a sense of
racial responsibility. It is that enlarged sense of responsibility which renders
possible what we call the regeneration of the race. We cannot lay too much
stress on this sense of responsibility for it is its growth which alone renders
possible any regeneration of the race. So far as practical results are
concerned, it is not enough for men of science to investigate the facts and
the principles of heredity and to attempt to lay down the laws of eugenics,
as the science which deals with the improvement of the race is now called.
It is not alone enough for moralists to preach. The hope of the future lies in
the slow development of those habits, those social instincts arising
inevitably out of the actual facts of life, and deeper than science, deeper
than morals. The new sense of responsibility, not only for the human lives
that now are, but the new human lives that are to come, is a social instinct
of this fundamental nature. Therein lies its vitality and its promise. It is only
of recent years that it has been rendered possible. Until lately, the methods
of propagating the race continued to be the same as those of savages
thousands of years ago. Children “came” and their parents disclaimed all
responsibility for their coming; the children were sent by God, and if they
all turned out to be idiots, the responsibility was God’s. That is all changed
now. It is we who are more immediately the creators of men. We generate
the race; we alone can regenerate the race. We have learned that in this, as

in other matters, the Divine Force works through us and that we are not
entitled to cast the burden of our evil actions on to any higher Power. The
voluntary control of the number of offspring which is now becoming the
rule in all civilized countries in every part of the world has been a matter of
concern to some people, who have realized that however desirable under
the conditions, it may be abused. But there are two points about it which
they should do well always to bear in mind. In the first place, it is the
inevitable result of the advance in civilization. Reckless abandonment to the
impulse of the moment, and careless indifference to the morrow, the selfish
gratification of individual desire at the expense of probable suffering to
lives that will come after, this may seem beautiful to some people, but it is
not civilization. All civilization involves an ever-increasing forethought for
others, even for others who are yet unborn. In the second place, it is not
only inevitable, but it furnishes us with the one available lever for raising
the level of our race. In classic days, as in the East, it was possible to
consider infanticide as a permissible method for attaining this end. That is
no longer possible to us. We must go further back. We must control the
beginnings of life. And that is a better method, even a more civilized
method, for it involves greater forethought, and a finer sense of the value of
life. To-day, all classes in the community, save the lowest and most unfit,
exercise some degree of forethought and control in regulating the size of
their families. That it should be precisely the unfit who procreate in the
most reckless manner is a lamentable fact, but it is not a hopeless fact, and
there is no need for the desperate remedy of urging the fit to reduce
themselves in this matter to the level of the unfit. That would merely be a
backward movement of civilization. It is education, sobriety, and some
degree of well-being which lead to the control of the size of families, and as
it is social amelioration which brings this result about, it is a result that we
may view with equanimity. It used to be feared that a falling birth rate was a
national danger. We now know that this is not the case, for not only does a
falling birth rate lead to a falling death rate, but in this matter no nation
moves by itself. Civilization is international, though one nation may be a
little before or behind another. Hitherto France has been ahead, but all other
nations have followed. In Germany, for instance, sometimes regarded as a
rival of England, the birth rate has fallen just as in England. Russia indeed
is an exception, but Russia is not only behind England, but behind Germany
in the march of civilization; its birth rate is high, its death rate is high; a

large proportion of its population live on the verge of famine. We are not
likely to take Russia as our guide in this matter; we have gone through that
stage long ago. But at the stage we have now reached it is no longer a
question of gaining control over the production of the new generation, but
of using that control, and of using it in such a way that we may help to
leave the world better than we found it. “What has posterity done for me
that I should do anything for posterity,” someone is said to have asked? The
answer is that to the human race that went before him he owes everything,
and that he can only repay the debt to those who come after him. There is
more than one way in which we can repay our debt to the race, but there is
no better way than by leaving behind us those who are fit to carry on the
tasks of life to higher ends than we have ourselves perhaps been able to
attain. Children have been without value in the world because there have
been too many of them; they have been produced by a blind and helpless
instinct, and have been allowed to die by the hundred thousand. For more
than half a century after the era of social reform set in there was no decline
at all in the enormous infant mortality. It has only now begun, as the
inevitable accompaniment of the decline in the birth rate. Not the least
service done by the fall in the birth rate has been to teach us the worth of
our children. We possess the power, if we will, deliberately and consciously
to create a new race, to mold the world of the future. As we realize our
responsibility we see that our new power of control is not merely for the
end of limiting the quantity of human life, perhaps for a selfish object, but
for the high end of improving its quality. It is in our power not only to
generate life, but, if we will, to regenerate life. If we realize that possibility,
and if we understand how the course of civilization has now brought it
within our grasp, we have reached the heart of our problem. Our greatest
foe, apart from indifference, is ignorance. Even science in this field is only
beginning to feel its way, while the mass have still to unlearn many
prejudices of the past. P. 48–54.
Galton, during the last years of his life, believed that we are approaching a
time when eugenic considerations will become a factor of religion, and
when our existing religious conceptions will be reinterpreted in the light of
a sense of social needs, so enlarged as to include the needs of the race
which is to come. Certainly for those who have been taught to believe that
man was in the first place created by God, it should not be difficult to
realize the divine nature of the task of human creation which has since been

placed in the hands of man, to recognize it as a practical part of religion,
and to cherish a sense of its responsibility. P. 63.

THE SEXUAL QUESTION. August Forel. A Scientific, Psychological,
Hygienic and Sociological Study. Translated by C. F. Marshall, M.D.,
F.R.C.S. Late Assistant Surgeon to the Hospital for Diseases of the
Skin. London.
August Forel: Doctor of Philosophy honoris causa; Doctor of Laws
honoris causa. Born September 1848 at Morges, Switzerland. Educated at
University of Zurich and Vienna. In 1873 assistant physician at the district
insane asylum at Munich; 1877, Privat-dozent at the University; 1879,
Privat-dozent and then Professor at Zurich, and until 1898 Director of the
State Insane Asylum at Burgholzli near Zurich. Works: Experience et
remarques crit. sur les sensations des insectes (in 4 vol. of Recueil Zoolog.
suisse Genf. 1886–7) Giftapparat u. d. Analdrusen der Ameisen, 1878; Les
Fourmis de la Suisse, 1874; Errichtg. v. Trinkerasylen, 1891; D.
Hypnotismus; Gehirn und Seele; Hygiene der Nerven und des Geistes; Die
Sexuelle Frage; Verbrecher und Konstit. Seelenabnormitat; Ges. Hirnanah.
Abhandl; Sinnesleben d. Insekten; Kulturstrebungen der Gegenwart.
He discovered in 1885 the seat of the auditory nerves in the brain;
researches into the psychology of ants.
We must not forget that among our brutal, yet human ancestors, the struggle
for life demanded the cruel and wanton exposure or slaughter of all weak
and decrepit individuals, and that epidemic diseases, plagues, and pests
ravaged the peoples without mercy. Of course our present civilization has
put up a barrier against all this. Yet for that very reason, the blind and
thoughtless propagation of degenerate, tainted and enfeebled individuals is
another atrocious danger to society. But then the sexual appetite cannot be
legislated out of existence, or killed by repressive measures. We can but
consider all legislation and all police measures which are intended to
regulate the sexual intercourse in the human family as absolute failures, as
inhuman, in fact as downright detrimental to the race. Exacting laws have
never improved the morals of any race or nation, hypocrisy and secret
evasion are the only results obtained. It would be better by far if steps were

taken to enlighten the masses on the questions of sexual heredity and
degeneration. Wisdom of this kind does not corrupt.
The law of heredity winds like a red thread through the family history of
every criminal, of every epileptic, eccentric and insane person. And we
should sit still and watch our civilization go into decay and fall to pieces
without raising the cry of warning and applying the remedy?
The sexual appetite is very pronounced in tuberculous persons. They marry
and beget children in the most wanton fashion. The law cannot and does not
prevent them, and the carnal instinct is not to be killed. What is to be done
when law and religion forbid the application of preventive measures and
even prosecute the person that recommends them? Local diseases and
pathological conditions in the woman (at times in man also) within
wedlock, may render parturition and immediate danger to the life of the
mother or of the child, or of both together. Surely in such cases it is the
bounden duty of the physician to intervene and counsel against, nay
absolutely forbid impregnation. Well, how is it to be done? Must husband
and wife who love each other be separated? It would be unnatural, in fact it
is quite impossible. Or should they abandon sexual intercourse altogether
and live like brother and sister? Well, a few exceptionally cold natures may
have will power enough to carry into effect such a pact. But in 99 out of
100 cases the interdict of the sexual act sends the husband to satisfy his
cravings elsewhere and contract disease, or he falls in love with another
woman and wrecks home and family. Similar conditions may be brought
about by other causes as well. Take for instance, the poor working man, or
mechanic, who has already six or seven children, and whose wife is
unusually fertile, giving birth to children year after year. The wages of the
father do not suffice to properly support them all. The food that can be
purchased with the slender means is not at all adequate. Rent and other bills
fall behind and they get in debt. They are both young yet. What is to be
done? If they follow the natural law there will be an increase in the family
every year. Moreover, these ever-recurring labors weaken the constitution
of the mother and sap away her strength. Starvation? Sexual continence in
wedlock? It is curious indeed to hear rich men, well fed clergymen, pious
zealots and reformers, leaning back in comfortable chairs discussing this
burning question and bewailing the immorality of the common people.
Statistics prove that these very people who extol to the poor all the

blessings of a poor family never live up to their teachings, either in theory
or in practice. The majority of these apostles of morality have no children at
all or at the utmost two or three. Why should that be so? What interesting
reading it would make if the sexual history of these persons were followed
up and printed.
Many hygienic reasons and the most elemental laws of humanity demand
that the wife who is fertile above the average should have a rest of at least
18 months between each succeeding pregnancy. But this cannot be achieved
in the natural course of events except in very rare cases without wrecking
the marriage. If we crystallize this sexual social question we arrive at the
following conclusions: There are a great many cases, especially of a
pathological character, but none the less, also, in normal and sound
individuals, in which procreation within wedlock or without either
definitely or temporarily either for the mother or the child, or for both, and
for that reason should be interdicted. Very few men and a very small
proportion of women—no matter how firmly they may be resolved—are
capable of suppressing their sexual needs. Even if they succeed the
consequences are generally of a disastrous nature, loss of marital love,
secret illicit relations with others, and subsequent infidelity, nervous
disorders, impotence, etc. In all these cases we are confronted with the
following dilemma: 1—In the unmarried person: onanism or prostitution, or
both. Is that morality? Such people must either forever forego love,
marriage, and normal lawful sexual intercourse, or face sterility in wedded
life. 2—Within marriage: onanism, prostitution and infidelity, or the
adoption of rational preventive measures. I leave it to the reader, and to the
law maker to pick out the correct alternative and to arrive at the one
possible decent and ethical solution of these conflicting questions.
It seems almost incredible that in some countries medical men who are not
ashamed to throw young men into the arms of prostitution, blush when
mention is made of anti-conceptional measures. P. 427b.
A year, at least, should elapse between parturition and the next conception;
this gives approximately two years between the confinements. In this way
the wife keeps in good health and can bear healthy children at pleasure. It is
certainly better to procreate seven children, than to procreate 14, of which
seven die, to say nothing of the mother, who rapidly becomes exhausted by
uninterrupted confinements. P. 430.

It is quite certain that the sexual life of man can never raise above its
present state without being freed from the bonds of mysticism and religious
dogma, and based on a loyal and unequivocal human morality which will
recognize the normal wants of humanity, always having as its principle
object the welfare of posterity. P. 459.
The true task of a political economy which has the true happiness of man at
heart should be to encourage the procreation of happy, useful, healthy and
hard-working individuals. To build an ever increasing number of hospitals,
asylums for lunatics, idiots and incurables, reformatories, etc., to provide
them with every comfort and manage them scientifically, is undoubtedly a
very fine thing, and speaks well of the progress and development of human
sympathy. But what is forgotten is that by concerning ourselves almost
exclusively with human ruins, the results of our social abuses, we gradually
weaken the force of the healthy portion of the population. By attacking the
roots of the evil and limiting the procreation of the unfit we shall be
performing a work which is much more humanitarian, if less striking in
effect. Formerly, our economists and politicians hardly have considered this
question, and even now very few are interested in it because it brings no
honors, nor money, as we do not ourselves see the fruits of such efforts. In
short, we amuse ourselves with repairing the ruins, but are afraid to attack
what makes these ruins. P. 465–6.
The anti-conceptional measures recommended have been often condemned,
sometimes as immoral, sometimes as contrary to aesthetics. To interfere in
this way with the action of nature is said to injure the poetry of love and the
moral feeling, and at the same time to disturb natural selection. There are
several replies to these objections. In the first place, it is wrong to maintain
that man cannot encroach on the life of nature. If this were the case, the
earth would now be a virgin forest, and a great many plants and animals
would not have been adapted to the use of man. We have proved without
deference, often with a brutal hand, to the misfortune of art and poetry, that
we are capable of successfully meddling with the machinery of nature, even
in what concerns our own persons.
The aesthetic argument appears, at first sight, more valid. It is unnecessary,
however, to discuss matters of taste. From all points of view, the details of
coitus leave much to be desired from the aesthetic point of view, and such a

slight addition as a protective does not appear to make any serious
difference. P. 497–8.
She, (woman) ought to develop herself strongly and healthily by working
along with man in body and mind by procreating numerous children when
she is strong, robust and intelligent. But this does not nullify the advantage
that may accrue from limiting the number of conceptions when the bodily
and mental qualities are wanting in the procreators. P. 332.
One of the most difficult and important future tasks of social science toward
humanity is to set free sexual relations from the tyranny of religious
dogmas by placing them in harmony with the true and purely human laws
of natural science. P. 357.
In no animal do we find the abuses which man is permitted to practice
toward his wife and children. P. 368.
The law should abandon its useless and even harmful chicanery concerning
the questions of sexual relations and love, and regulate more carefully the
duties of parents toward their children, and thus protect future generations
against the abuses of the present generation. P. 377.
It is important to bear in mind that modern legislation on marriage often
favors the reproduction of criminals, lunatics and invalids, while it hinders
the production of healthy children by men who are intelligent, honest and
robust. When an abnormal, unhealthy man is married his wife is obliged to
submit to the conception of tainted children. What we require is more
personal liberty for healthy, adaptable individuals and more restrictions for
the abnormal, unhealthy and dangerous. The civil law of the future will
have to take these facts into consideration if it wishes to keep level with
scientific progress. P. 393.

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

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

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

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

THE CONTROL OF BIRTHS. MARY ALDEN HOPKINS. Harper’s
Weekly, April 10th, 1915.
The European laws on this subject are in striking contrast to ours. They treat
contraception and abortion as two separate matters. The laws against
abortion are strict. The laws concerning contraception are directed against
distasteful advertising but not against private advice or public propaganda.
In England the applicant must state in writing over his or her signature that
he or she is married or about to be married. In Holland formulas and
methods may be supplied privately, but must not be publicly advertised. In
Germany there is no law on the matter, but sentiment is strongly opposed to
advertising. In Switzerland it is forbidden to advertise or circularize. In
Norway and Sweden advertising is not expected. Italy and France have no
law on the subject. In Russia advertising in the newspapers is common.
Everywhere in Europe contraceptives are for sale at pharmacies.
The Birth Control Movement is antagonistic to the general practice of
abortion. The Hungarian senate, a few years ago, declared that the
limitation of families by prevention of conception was absolutely necessary
in order to check the wide-spread evil of attempted abortion.

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

THE MALTHUSIAN LEAGUE OF ENGLAND. The Origin and History
of Birth Control in Great Britain. Reprinted from The Malthusian,
April, 1880.
Little improvement can be expected in morality until the production of large
families is regarded in the same light as drunkenness, or any other physical
excess.—John Stuart Mill, 1872.
In obedience to the request of the Nestor of political economists of Europe,
the distinguished editor of the Journal des Economistes of Paris, M. Joseph
Garnier, we give a short account of the reasons which led to the foundation
of the Malthusian League, the latest product of the nineteenth century’s
ideas in the direction of social progress. It gives us unfeigned pleasure to be
the means of making the most thorough of all French writers on the
doctrines of our English latter-day economists acquainted with the position
which the great population question has recently assumed in this country. It
is not, we believe, too much to allege that the most advanced thinkers of
this country are at this moment well aware of the existence of the new-
Malthusian remedy for the evils of society. How this has come to pass we
proceed at once to show.
It was not long after the publication of Mr. Malthus’ work that some
thoughtful men began to notice that in modern France the late marriage
customs of most European states were replaced to a certain extent by
prudence after marriage. Mr. Francis Place was one of the first to write a
work on population, in which he recommended the physical checks so
commonly made use of by the French parents for adoption in England. He
is said to have remonstrated with Mr. Malthus about an expression in the
first edition of his essay, in which he spoke of such checks under the head
of Vice, and the tradition is that Malthus left out the expression in his

subsequent edition: and, as he himself had two children, Mr. Porter (of
Nottingham) believes that Mr. Malthus was, like Mr. Mill (the father of
John Stuart Mill), himself a believer in the conjugal prudence practised by
the better class of peasantry and townspeople. Mr. Place is also said to have
converted Mr. Robert Owen, the socialist to his opinion, and it is believed
that Mr. Owen owed the success of his colony of New Lanark to a
knowledge of this point, which he communicated to his workmen. Mr.
Robert Dale Owen, a son of Robert Owen, emigrated in his youth to the
United States of America, and became before his death, in 1877, one of the
foremost citizens of the western republic. That gentleman, having doubtless
heard the question discussed by his father, Mr. Francis Place, and other
friends in London, was induced in 1830 to publish a now well-known
treatise on the population question, entitled Moral Physiology, a work
written with the most philanthropic design and couched in the most careful
language consistent with clearness and the attainment of its end, in which
he gave a description of the above-mentioned physical checks. This work
was, however, written subsequently to the publication of Mr. Richard
Carlile’s tract, entitled Every Woman’s Book, which was a most outspoken
work, written by one of those fearless thinkers who have done so much to
complete the reformation in England and secure freedom of speech and of
the press for this country. Had it not been for him and his co-workers,
England might at this day have been in as backward a condition as modern
Spain. Dr. Charles Knowlton, an able physician of Boston, Massachusetts,
U.S.A., was the next person who wrote upon this question in his now
famous little pamphlet, the Fruits of Philosophy, wherein there was
contained a good deal of popular information on physiology, and a careful
account of the checks spoken of by Mr. Dale Owen and Mr. Carlile. This
work was followed after a long interval by a small pamphlet by Mr. Austin
Holyoake, entitled Large and Small Families, which, in company with the
tracts by Carlile, Owen, and two other works were sold for many years by
booksellers of the ultra-liberal party, latterly styled the Secularists.
In 1876 the Fruits of Philosophy, after circulating without notice for forty
years, was suddenly attacked as an obscene publication under an Act of
Parliament called “Lord Campbell’s Act,” and a bookseller in Bristol, of the
name of Cook, was sentenced to two years’ imprisonment for selling it. The
London publisher of the work, Mr. C. Watts, was also prosecuted for selling
it, but, on submission, was let off with merely the payment of costs, or

about two hundred pounds fine. The work would have been suppressed had
not Mr. C. Bradlaugh, the head of the Secularist party and editor of the
National Reformer, the most advanced liberal journal in England, in
company with a young but already most distinguished lady, Mrs. Annie
Besant, come forward and sold it openly. In order to try the case, Mr.
Bradlaugh and Mrs. Besant entered into partnership in a publishing
establishment in Stonecutter Street, Farringdon Street, London, and sold the
Fruits of Philosophy quite openly, sending copies of it to the city
authorities. Mr. Bradlaugh had for many years been an avowed Malthusian,
and the lady also was quite convinced of the importance of the question.
Both were determined that no bigoted society should put the work under the
ban of the law without a fight for it. The case was first tried at Guildhall,
and was sent on to the Court of Queen’s Bench, before the Lord Chief
Justice Cockburn. The trial began on the 18th of June, 1877, and lasted
three days. The jury contained, among other persons of wealth and position,
the name of Arthur Walter, Esq., the son of the proprietor of the Times
journal. After a most powerful defence, in which Mrs. Besant and Mr.
Bradlaugh delivered speeches which told most powerfully upon the judge
and all present in the Court, the jury delivered the following verdict: “We
are unanimously of the opinion that the book in question (the Fruits of
Philosophy) is calculated to deprave public morals; but at the same time we
entirely exonerate the defendants from any corrupt motives in publishing
it.” The judge—who had charged quite in favor of the defendants—would
have let them off with a nominal fine, but, influenced by the information
that they intended carrying on the sale of the work, strangely sentenced
them to a heavy imprisonment and fine. Fortunately, the higher Court of
Appeal decided that there had been an error in the indictment, and thus the
defendants were set free. The prosecution has not been repeated since that
date.
The excitement caused by the trial led to the formation of a society called
The Malthusian League, which was set on foot as a means of opposing both
active and passive resistance to the attempts made to stifle discussion on the
population question. Mr. Bradlaugh had commenced such a league many
years previously, but the time was not ripe for it. The first meeting of the
League was held in the Minor Hall of the Hall of Science, Old Street, on
July 17th, 1877, for the election of officers. That meeting elected Dr. C. R.
Drysdale president, and Mrs. Annie Besant honorary secretary, in company

with Mr. Hember and Mr. R. Shearer. The Council of the League consisted
of Messrs. Bell, Brown, Dray, Page, Mr. and Mrs. Parris, Mr. and Mrs.
Rennick, Messrs. Rivers, Seyler, G. Standing, Truelove, and Young. Mr.
Swaagman was elected treasurer to the League.
Very soon after the formation of the League, another prosecution of Mr.
Edward Truelove, bookseller, of High Holborn, took place in the Queen’s
Bench on February 1st, 1878. The works he was prosecuted for were quite
of the same character as Knowlton’s Fruits of Philosophy, and were
entitled: More Physiology, a most philanthropic pamphlet by Mr. Robert
Dale Owen, Senator of the United States, and another pamphlet entitled
Individual, Family and National Poverty. Mr. Truelove was most effectually
defended by Mr. William Hunter, and the case fell through, as one of the
jury considered the book quite moral and philanthropic in its tendencies.
The secretary for the “Society for the Suppression of Vice,” Mr. Collette by
name, followed up the prosecution, and Mr. Truelove was tried in the
Central Criminal Court on May 9th, 1878, and condemned to a fine of fifty
pounds and an imprisonment of four months duration, which he underwent.
An immense meeting was held in St. James Hall, on the evening of June 6,
1878, to protest against this disgraceful treatment of an honest man like Mr.
Truelove, at which the president of the League took the chair, and
enthusiastic addresses were delivered by Mrs. Besant and Mr. Bradlaugh.
The trial of Mrs. Besant and Mr. Bradlaugh lasted several days, and aroused
a greater interest in the subject than had been known since the days of
Malthus. The English Press was full of the subject; scientific congresses
gave it their attention; many noted political economists wrote about it; over
a hundred petitions were presented to Parliament requesting the freedom of
open discussion; meetings of thousands of persons were held in all the large
cities; and as result, a strong Neo-Malthusian League was formed in
London.

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

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

First President: The late Dr. Charles R. Drysdale

President: Dr. Alice Drysdale Vickery

Vice-Presidents

Señor Aldecoa, Director of Government Charities, Madrid.
Mr. G. Anderson, C.E.
Major-General E. Begbie, C.B., D.S.O., Brighton.
Dr. C. Callaway, Cheltenham.
M. Victor Ernest, Belgium.
M. G. Giroud, Paris.
Herr Max Hausmeister, Stuttgart.
Mrs. Heatherley.
Mr. S. Van Houten, Deputé of the First Chamber, The Hague.
Dr. Aletta Jacobs, Amsterdam.
Mr. Joseph McCabe.
Dr. Mascaux, Courcelles, Belgium.
Mr. Arthur B. Moss.
P. Murugesa Mudaliar, Madras.
Mr. Vivian Phelips.
Rt. Hon. J. M. Robertson, M.P.
Dr. J. Rutgers, Verhulststraat, 9 Den Haag, Holland.
Me. Hoitsema Rutgers, Verhulststraat, 9 Den Haag, Holland.
Frau Marie Stritt, Dresden.
Dr. (Ph.) Helene Stocker, Berlin.
Professor Knut Wicksell, Lund, Sweden.

Constituent Bodies.

England (1877).—The Malthusian League. Periodical, The Malthusian.
Holland (1885).—De Nieuw-Malthusiaansche Bond. Secretary, Dr. J.
Rutgers, 9 Verhulststraat, Den Haag. Periodical, Het Gellukkig
Huisgezin.
Germany (1889).—Sozial Harmonische Verein. Secretary, Herr M.
Hausmeister, Stuttgart. Periodical, Die Sozial Harmonie.
France (1895).—Génération Consciente. 27 Rue de la Duée, Paris XX.
Spain (1904).—Liga Española de Regeneración Humana. Secretary,
Señor Luis Bulffi, Calle Provenza 177, Pral, la, Barcelona.
Periodical, Salud y Fuerza.
Belgium (1906).—Ligue Néo-Malthusienne. Secretary, Dr. Fernand
Mascaux, Echevin, Courcelles. Periodical: Génération Consciente,
27 Rue de la Duée, Paris XX.
Switzerland (1908).—Group Malthusien. Secretary, Valentin Grandjean,
106 Rue des Eaux Vives, Geneva. Periodical, La Vie Intime.
Bohemia-Austria (1901).—Zadruhy. Secretary, Michael Kacha, 1164
Zizhov, Prague.
Portugal.—Paz e Liberdade, Revista Anti-Militarista e Neo-
Malthusiana. E. Silva, junior, L. da Memória, 46 r/e, Lisbon.
Brazil (1905).—Sección brasileña de propaganda. Secretaries: Manuel
Moscosa, Rua de’Bento Pires 29, San Pablo; Antonio Dominiguez,
Rua Vizcande de Moranguapez 25, Rio de Janeiro.
Cuba (1907).—Sección de propaganda. Secretary, José Guardiola,
Empedrado 14, Havana.
Sweden (1911).—Sallskapet for Humanitar Barnalstring. President: Mr.
Hinke Bergegren, Vanadisvagen 15, Stockholm, Va.
Flemish Belgium (1912).—National Verbond ter Regeling van het
Kindertal. President, M. L. van Brussel, Rue de Canal, 70, Louvain.
Italy (1913).—Lega Neomalthusiana Italiana. Secretary, Dr. Luigi Berta,
Via Lamarmora 22, Turin. Periodical, L’Educazione Sessuale.

Africa.—Ligue Néo-Malthusienne, Maison du Peuple, 10 Rampe
Magenta, Alger.
The English organization, with headquarters in London, has for its officers
some of the most distinguished men and women in England:

First President

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

President: Dr. ALICE DRYSDALE VICKERY.

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

Vice-Presidents:

Major-Gen. Elphinstone Begbie, C.B., D.S.O.
Arnold Bennett, Esq.
Chas. Callaway, Esq., M.A., D.Sc.
Lieut.-Col. J. Fallon, L.R.C.P., R.A.M.C.
E. S. P. Haynes, Esq.
Dennis Hird, Esq., M.A., J.P.
Mrs. Heatherley.
Captain Kelso, R.N.
Joseph McCabe, Esq.
C. Killick Millard, Esq., M.D., D.Sc., M.O.H.
A. B. Moss, Esq.
Vivian Phelips, Esq.
Eden Phillpotts, Esq.
Right Hon. J. M. Robertson, M.P.
Lieut.-Colonel A. W. Warden, late Indian Army.
H. G. Wells, Esq.

Hon. Treasurer:

W. V. OSBORNE, Esq.

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

General Secretary:
Miss O. M. JOHNSON, B.A.

Editors of “The Malthusian”:
DR. C. V. DRYSDALE; MRS. B. DRYSDALE.

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

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

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

II.—Objects.

That the objects of this Society be:—
1. To spread among the people, by all practicable means, a knowledge of
the law of population, of its consequences, and of its bearing upon human
conduct and morals.
2. To urge upon the medical profession in general, and upon hospitals and
public medical authorities in particular, the duty of giving instruction in
hygienic contraceptive methods to all married people who desire to limit
their families, or who are in any way unfit for parenthood; and to take any

other steps which may be considered desirable for the provision of such
instruction.

III.—Principles.

1. “That population (unless consciously and sufficiently controlled) has a
constant tendency to increase beyond the means of subsistence.”
2. That the checks which counteract this tendency are resolvable into
positive or life-destroying, and prudential or birth-restricting.
3. That the positive or life-destroying checks comprehend the premature
death of children and adults by disease, starvation, war, and infanticide.
4. That the prudential or birth-restricting check consists in the limitation of
offspring (1) by abstention from or postponement of marriage, or (2) by
prudence after marriage.
5. That prolonged postponement of marriage—as advocated by Malthus—is
not only productive of much unhappiness, but is also a potent cause of
sexual vice and disease. Early marriage, on the contrary, tends to ensure
sexual purity, domestic comfort, social happiness and individual health; but
it is a grave social offence for men and women to bring into the world more
children than they can adequately house, feed, clothe, and educate.
6. That over-population is the most fruitful source of pauperism, ignorance,
crime, and disease.
7. That it is of great importance that those afflicted with hereditary disease,
or who are otherwise plainly incapable of producing or rearing physically,
intellectually and morally satisfactory children, should not become parents.
8. That the full and open discussion of the Population Question in all its
necessary aspects is a matter of vital moment to Society.
It has been the object of this organization during these years to carry on the
theoretical propaganda of Birth Control mainly among the educators,
consisting of clergymen, physicians, scientists, sociologists, economists and
others who in turn would form a strong, reliable public opinion who would
force the dissemination of practical information among that element of
society who are propagating the diseased and unfit.

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

PRACTICAL METHODS OF FAMILY LIMITATION

Notice.—The Council of the Malthusian League, while continuing to regard
this as a matter which is strictly within the province of the medical
profession, and which ought to be taken over by them, has compiled a
leaflet entitled “Hygienic Methods of Family Limitation,” for the benefit of
those desirous of limiting their families, but who are ignorant of the means
of doing so, and unable to get medical advice on the subject. This leaflet
can only be issued, however, to persons over twenty-one years of age who
are either married or about to be married, and who declare their
conscientious belief that family limitation is justifiable on personal and
national grounds. Anyone wishing to obtain a copy of this leaflet must write
his or her name and address clearly upon both of the forms of declaration
below, and send them to the Hon. Secretary. The sealed leaflet will then be
sent them. In order to encourage family limitation among the poorest
classes, no charge will be made either for the leaflet or postage, but it is
hoped that those who can afford it will enclose stamps for postage or a
small donation to help the League in its work.
Under no circumstances whatever can the practical leaflet be supplied
without a properly filled up declaration, nor can more than one copy be
supplied to the same person. Those wishing to help others, may have
additional copies of the declaration form to hand on.
The Malthusian League regrets that it is unable to comply with applications
for this leaflet from the United States.

A BRIEF HISTORY OF THE MOVEMENT IN HOLLAND

Interest in the subject did not confine itself to England, for in 1878 at an
International Medical Congress in Amsterdam the subject was discussed
with great enthusiasm. A paper prepared and read by Mr. S. Van Houten
(later Prime Minister) caused a wider interest in the matter and a year later
the Neo-Malthusian (or Birth Control) League of Holland was organized.
Charles R. Drysdale, then President of the English League, attended the
conference.
As is usual in such causes, many of the better educated and intelligent
classes adopted the practice at once, as did the better educated workers; but
the movement had as yet no interest among the poorest and most ignorant.
The League set to work at once to double its efforts in these quarters. Dr.
Aletta Jacobs, the first woman physician in Holland, became a member of
the League, and established a clinic where she gave information on the
means of prevention of conception free to all poor women who applied for
it.
All classes, especially the poor, welcomed the knowledge with open arms,
and requests came thick and fast for the League’s assistance to obtain the
necessary appliances free of charge. The consequence has been that for the
past twelve years the League has labored chiefly among the people of the
poorest districts. Dr. J. Rutgers and Madame Hoitsema Rutgers, two ardent
advocates of these principles, have devoted their lives to this work. Dr.
Rutgers says that where this knowledge is taught there is a reciprocal action
to be observed: “In families where children are carefully procreated, they
are reared carefully; and where they are reared carefully, they are carefully
procreated.”
The Neo-Malthusian (or Birth Control) League of Holland has over 7,000
men and women in its membership, and more than fifty nurses whom it
indorses.
These nurses are trained and instructed by Dr. Rutgers in the proper means
and hygienic principles of the methods of Birth Control. They are
established in practice in the various towns and cities throughout Holland.

They advise women as to the best method to employ to prevent conception.
They work mainly in the agricultural and industrial districts, or are located
near them; and their teachings include not only the method of prevention of
conception, but instruction in general and sexual hygiene, cleanliness, the
uselessness of drugs, and the non-necessity of abortions. (The Council of
the Neo-Malthusian or Birth Control League calls attention to the fact that it
has for its sole object the Prevention of Conception, and not the causing of
abortion.)
The clinic organized by Dr. Jacobs,—the first clinic in the world for the
organized dissemination of information on Birth Control,—proved so
efficient and beneficial to the standards of the community that others were
opened and established until there are now more than fifty in operation.
There is no doubt that the establishment of these clinics is one of the most
important parts of the work of a Birth Control League. The written word
and written directions are very good, but the fact remains that even the best
educated women have very limited knowledge of the construction of their
generative organs or their physiology. What, then, can be expected of the
less educated women, who have had less advantages and opportunities? It is
consequently most desirable that there be practical teaching of the methods
to be recommended, and women taught the physiology of their sex organs
by those equipped with the knowledge and capable of teaching it.
It stands to the credit of Holland that it is perhaps the only country where
the advocates of Birth Control have not been prosecuted or jailed; because
the laws regarding the liberty of the individual and the freedom of the press
uphold it, and protect its practise.

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

Despite the outbreak of war, the progress of the League has been most
satisfactory. The membership increased from 5,057 at the beginning of 1914
to 5,521 at the end; and branches now exist in twenty-eight towns in
Holland. The list of officers and correspondents alone now occupies four
pages of the Report, and comprises nearly two hundred names. As these are
of persons in every part in the country, it will be realised how great are the

facilities for everyone to obtain practical information. Besides the great
amount of advice given by the trained workers, 7,200 copies of the
League’s booklet giving practical advice on methods of family limitation
(birth control) were supplied. It is instructive to see, in the reports from the
various branches open statements that Mrs. X (full name given) helped 149
women and supplied seven gross of preventives, the kinds being clearly
specified. The branch reports give particulars of nearly 1,300 women
personally instructed in preventive methods by trained workers, but the war
prevented the returns from being anything like complete. And this in a
country of only six million inhabitants.—The Malthusian, London, July 15,
1915.

RESULTS OF BIRTH CONTROL TEACHING IN HOLLAND

There is no doubt that the Neo-Malthusian (Birth Control) League of
Holland stands as the foremost in the world in organization, and also as a
practical example of the results to be obtained from the teaching of the
prevention of conception. Aside from the spreading influence of these ideas
in Belgium, Italy, and Germany, Holland presents to the world a statistical
record which proves unmistakably what the advocates of Birth Control have
claimed for it.
The infantile mortality of Amsterdam and The Hague is the lowest of any
cities in the world, while the general death rate and infantile mortality of
Holland has fallen to be the lowest of any country in Europe. These
statistics also refute the wild sayings of those who shout against Birth
Control and claim it means race suicide. On the contrary, Holland proves
that the practice of anti-conceptional methods leads to race improvement,
for the increase of population has accelerated as the death rate has fallen.
There has also been a rapid improvement in the general physique and health
of the Dutch people, while that of the high birth rate countries, Russia and
Germany, is said to be rapidly deteriorating.
The following figures will suffice to show some of the improvements which
have been going on in Holland since 1881, the time the League became
actively engaged in the work:—

VITAL STATISTICS OF CHIEF DUTCH TOWNS

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

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

1881– 1906–
1912
85 10
Birth Rate 37.1 24.7 23.3 per 1,000 of population
Death Rate 25.1 13.1 11.2 per 1,000 of population
Infantile
Mortality:
203 90 64 per thousand living births
(Deaths in
first year)

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

1881– 1906–
1912
85 10
Birth Rate 38.7 27.5 23.6 per 1,000 of population
Death Rate 23.3 13.2 10.9 per 1,000 of population
Infantile
Mortality:
214 99 66 per thousand living births
(Deaths in
first year)

Rotterdam.[2]

1881– 1906–
1912
85 10
Birth Rate 37.4 32.0 29.0 per 1,000 of population
Death Rate 24.2 13.4 11.3 per 1,000 of population
Infantile
Mortality
209 105 79 per thousand living births
(Deaths in
first year)

Fertility and Illegitimacy Rates.

1880– 1890– 1900–
2 2 2
Legitimate birth per 1,000
Legitimate
306.4 296.5 252.7 Married Women aged 15
Fertility
to 45.
Illegitimate births per 1,000
Illegitimate
16.1 16.3 11.3 Unmarried Women, aged
Fertility
15 to 45.

The Hague.

1880– 1890– 1900–
2 2 2
Legitimate
346.5 303.9 255.0
Fertility
Illegitimate
13.4 13.6 7.7
Fertility

Rotterdam.

1880– 1890– 1900–
2 2 2
Legitimate
331.4 312.0 299.0
Fertility
Illegitimate
17.4 16.5 13.1
Fertility

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

2. Lowest figure for the Continent.
There has been a marked improvement in the labor conditions in Holland
during these last ten years especially, wages having increased and hours of
labor decreased, with the cost of living taking a comparatively very small
rise.
There is no country in Europe where the educational advantages are so
great as in Holland.
That the Birth Control propaganda has been a success in Holland any one
travelling through that delightful, clean and cheerful country can testify.
In that enlightened country, Holland, the teaching by the medical profession
of the most hygienic methods of birth limitation has enabled the poor to
have small families which they could raise to be physically and morally
better equipped than formerly, and what is most interesting to observe is
that, whether as a result of this or for some other reason, the families among
the well-to-do are not nearly as small as in other countries.—Dr. S.
Adolphus Knopf, in The Survey for November, 1916.

GERMANY
Germany was the next to follow, in 1889, when Herr Max Hausmeister and
Herr Karl Lotter founded the Sozial Harmonische Verein, with its paper Die
Sozial Harmonie. Like the English League, this society has confined its
teachings to the theoretical and economic aspects of the subject, in which it
has especially distinguished itself. In Germany all such doctrines are of
course anathema, but the enormous decline in the birth-rate in several towns
testifies to the refusal of the German people to be hectored into misery. All
the signs point at present to an extraordinary ferment of new ideas in
Germany, and a large number of other movements are more or less openly
Neo-Malthusian.—From The Malthusian (London), January, 1909.
The German Sozial Harmonische Verein, founded in 1889, by Herr Max
Hausmeister, has continued its quiet, but effective, work, and its periodical,
Die Sozial Harmonie, has contained many articles of great economic value.
A remarkable feature in Germany, however, has been the rapid rise of the
Mutterschutz Society, under the able presidency of Dr. Helene Stocker, a
society which aims at obtaining greater security and freedom for married
and unmarried mothers, and at securing better conditions for the rearing of
their offspring. Neo-Malthusianism (Birth Control) is becoming an
important feature of this work, and is also dealt with in the Zeitschrift fur
Sexual-wissenschaft, a scientific journal devoted to sex matters. The birth-
rate of Prussia has seen one of the most rapid declines, from 36.2 in 1901 to
33.7 in 1906, and 33.0 in 1907; while the death-rates for the same years
have been 20.5, 17.9, and 17.8, and the infantile mortalities 200, 177, and
168 respectively. The birth-rate of Berlin in 1907 was 24.3, or below that of
London, 26.8.—From The Malthusian (London) for July 15th, 1909.

FRANCE

France differs from all other countries in having realized the individual
advantages of the practice of birth control long before any other country in
Europe. It is said that the sale of the lands (forfeited by the Emigrés or
confiscated by the Commune after the Revolution) to the people, together
with the law of equal inheritance in accordance with the principles of
Liberty, Equality and Fraternity adopted for their guidance formed the chief
incentive to restriction of the numbers of the family.
The birth-rate declined in an irregular manner from 1870 to the present
time, especially among the wealthy classes, while the poor and ignorant
continued to be burdened with large families. This led M. Paul Robin in
1896 to form the French Ligue de la Regeneration Humaine, and to employ
his enormous energy and enthusiasm towards the formation of leagues in
other countries. Bohemia, Spain, Brazil, Belgium, Cuba, Africa and
Switzerland formed leagues in succession, most of them circulating
periodicals dealing with Neo-Malthusian (Birth Control) theory and
practice. At the same time M. Robin formed a Federation Universelle de la
Regeneration Humaine, in which the various leagues have been associated
and which has held two international meetings—the first at Paris in 1900
and the second at Liege in 1905.—From The Malthusian (London) January,
1909.
Fifteen years after the founding of M. Robin’s work, the propaganda in
France is very complete and intense. Theoretical or practical, it appears
under many forms. It acts through books, pamphlets, leaflets, journals,
lectures, pictures, and even songs. Tens of thousands of theoretical volumes
and pamphlets are disseminated, hundreds of thousands of leaflets are
distributed. The practical pamphlets find their success in rapidly
disappearing editions. In every part of the land—in town, and even country
—lectures are given, and numerous militant workers diffuse the good
tidings in multitudes of papers. The centers of our propaganda are too
numerous to be fully quoted. In the first rank are the societies exclusively
Neo-Malthusian (Birth Control), which, in fact, each carry on in their own
manner the work undertaken by Regeneration. The most active, the most

enterprising, and the most combative of these organizations, Génération
Consciente, multiplies its efforts, extends its action, and prospers
unceasingly. Again there exists a different class of propagandists—the
individual—who, without periodical, place or society, works by
disseminating not only the pamphlets, leaflets, and books, but also the
means of prevention.—From The Malthusian (London) of September 15,
1910.
France has her population practically under control, and can increase or
diminish at will according to the prospects of good or bad times. (See Page
37 for French Birth and Death Rate).—From The Malthusian (London) of
April 15th, 1909.
France has set the example of real civilization and other nations are
following her more or less rapidly according to their advancement in
culture.
There has been a tendency to ascribe the low birth-rate in France to
infertility or degeneracy, although this is patently absurd to all those who
are acquainted with the French people. For the low birth-rate of France is
practically entirely due to prudential control of families among married
people who make no pretense to the avoidance of preventive intercourse.
Dealing with the conditions of the people in France there is little that does
not compare favorably with all other old countries. The average duration of
life is about fifty years, which is nearly the highest in Europe. The infantile
mortality is the worst feature,[3] but it has been declining for some years.

3. Note: This is a problem of hygiene and infant welfare. If the same
care were given the babies of France as is being given the infants of
other advanced countries there is little doubt that the mortality rate
would decline proportionately.—M. H. S.
There is no “too old at thirty-five” difficulty in France, elderly men being
employed where boys are (in other countries); there is no unemployment
worth speaking of; there is no land problem, and house rents, instead of
being forced up by excess of demand, are actually lowered by excess of
supply, so that the “unearned increment” is frequently negative.—From The
Malthusian (London) for April 15th, 1909.

Writing of France in 1879, a few years after the close of the disastrous
Franco-Prussian War, Johannes Swaagman said:
“France, notwithstanding the heavy war indemnity of five milliards, and
perhaps an equal expenditure of her own war material, is now the only
country that has a surplus on its estimated budget, and can even dream of
reducing taxation. Besides this, large sums are being spent on
improvements, with a view of accelerating commerce and industry.
“France has still many things to learn, notably as regards hygiene, but we
have no hesitation in asserting that as regards the solution of the most
distressing problems which humanity has to face and as regards general
happiness and culture she is far ahead of all other countries and she has
simply led the way in the direction in which all other nations are bound to
follow, and in which they are already hastening.”—From The Malthusian
(London) of April 15th, 1909.
Strong and vigorous movements exist in Switzerland, Belgium, Hungary,
Spain, Norway, Sweden, Denmark and Italy, while there are somewhat less
active ones in Russia, Japan, India, and even China. I will not take the space
to furnish the details of the movement in these countries because they are
mainly inspired in their activities from those well organized Leagues
already mentioned.

BIRTH AND DEATH RATE IN FRANCE

The actual facts as regards the French birth-rate are constantly
misrepresented. Taking the actual population, this appears to have been 24.8
millions in 1783, 28.9 millions in 1806, and to have gone on more or less
steadily increasing to 39.26 millions in 1907. Exceptions to this increase
have taken place six times since 1881, there being a deficit or excess of
deaths over births of 38,446 in 1890, of 10,505 in 1891, of 20,041 in 1892,
of 17,813 in 1895, of 25,988 in 1900, and of 19,920 in 1907. Despite these
deficits the natural increase, or excess of births over deaths, was 1,232,744
in the twenty-five years from 1881 to 1905, while the total increase,
including immigration, etc., was 1,690,000 during the same period. It is
worthy of note also in view of the suggestions that the deficit is about to
become chronic, and that France is therefore a “dying nation,” that in 1893

and 1894, after three years of deficits, there were excesses of 7,000 and
39,000; in 1897 and 1898 of 93,700 and 108,000; and in 1901 of 72,000.
There has been no report since 1907, but Le Jour Officiel of Paris has given
the figures for the first six months of 1908, which show an increase of
12,066, partly due to a rise of 8,657 in the births and partly a decline of
8,416 in the deaths.—From The Malthusian (London) of April 15th, 1909.

BIRTH RATE IN FRANCE

Compiled from The Malthusian (London), for April 15th, 1909

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

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

UNITED STATES OF AMERICA

It is interesting to know that the present agitation for the dissemination of
knowledge to prevent conception, as expressed in the various leagues
throughout the world to-day had its greatest impetus and inspiration from
two books written by Americans in the United States.
The first of these was a pamphlet entitled “Moral Physiology,” written by
United States Senator Robert Dale Owen, son of Robert Owen, which was
published in New York City in 1830 and gave a description of the physical
checks made use of in France, where it was the custom to limit the number
of children to the means at the command of the family. This book was much
read and commented favorably upon in America.
So favorably did this publication appeal to the thinking minds of the time,
that Dr. Charles Knowlton, an able Boston physician, on reading Owen’s
pamphlet, was so struck by its importance as a contribution to the science of
hygiene that he brought out a similar work in 1833, entitled “The Fruits of
Philosophy.” His book was addressed to young married people and gave a
popular description of the anatomy of the organs of reproduction, especially
in the female, and a somewhat more detailed account of the physical checks
to prevent conception than had been given in Owen’s pamphlet.
“The Fruits of Philosophy” circulated unchallenged for more than forty
years, and finally, in 1876, was attacked as an obscene publication under the
new act of Parliament called “Lord Campbell’s Act,” and a bookseller of
Bristol, England, was sentenced to two years’ imprisonment for selling it.
This work would have been suppressed altogether had not Charles
Bradlaugh and Mrs. Annie Besant, two ardent defenders of British liberty,
come forward and volunteered to sell it in order to test the case in the
English courts. The trial, as has been described herein under the title of
“Birth Control League of England,” attracted great attention to this
philosophy throughout the world. It is a sad commentary upon the
legislative bodies of this country that up to the present every attempt by
advocates of this principle to discuss this subject and awaken our people to
its needs has been met with prosecution and jail sentences.

During these last forty years the movement has made rapid progress in all
civilized countries except the United States. In this progressive matter we
find ourselves classed with Russia, Japan, India and China, where national
interest is concerned with quantity of human beings rather than with quality.
But during the last five years the subject has come forcibly to the front,
mainly through prosecutions. Again a message has gained a hearing from
the dock which it could never have won from the platform.
The people of this country are now awakened to the need of knowledge to
prevent conception. Social workers, nurses, and members of the medical
profession find their work hampered and their activities nullified by
oppressive laws denying the individual the right of health, life and the
pursuit of happiness.
The most advanced thinkers in America are with us in this movement, the
sentiment being largely in favor of the establishment of clinics, similar to
those in Holland, where the poor and overburdened mothers may come for
advice to be given by doctors, nurses or others competent to instruct.
Following are some of the names of men and women in the United States
who stand for the dissemination of such knowledge, have allied themselves
to this great humanitarian cause, and have come out in the press for birth
control as a national necessity:

WELL KNOWN WOMEN WHO ENDORSE BIRTH CONTROL

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

NOTED PHYSICIANS WHO ENDORSE BIRTH CONTROL

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

Dr. Hermann M. Biggs, State Commissioner of Health, New York.
Dr. John N. Hurty, secretary, State Board of Health, Indiana.
Dr. Godfrey R. Pisek, professor of diseases of children, New York Post-
Graduate Medical School and Hospital, New York City.
Dr. J. W. Trask, United States Public Health Service, Washington, D. C.
Dr. Ira S. Wile, editor, American Medicine, member Board of Education,
New York City.
Dr. John A. Wyeth, professor of surgery and president of the New York
Polyclinic Medical School and Hospital, ex-president of the
American Medical Assn., and New York Academy of Medicine, New
York City.
Dr. S. Adolphus Knopf, professor of medicine, department of Phthisio-
therapy, at New York Post-Graduate Medical School and Hospital,
New York City.
Dr. Lydia Allen de Vilbiss, formerly of New York State Department of
Health, now in charge of the division of Child Hygiene of the State
Board of Health of Kansas.

NOTED WRITERS AND TEACHERS WHO ENDORSE BIRTH
CONTROL

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

NOTED MINISTERS WHO ENDORSE BIRTH CONTROL

Rev. Dr. Frank Crane, formerly pastor of the Union Congregational
Church, Worcester, Mass., now notable writer of editorial articles for
New York Globe, etc.
Rev. Dr. Percy Stickney Grant, rector, Protestant Episcopal Church of the
Ascension, New York City.
Rev. Dr. Frank Oliver Hall, minister, Church of the Divine Paternity, New
York City.
Rev. Dr. John Haynes Holmes, minister, Unitarian Church of the
Messiah, New York City.

Rev. Dr. Harvey Dee Brown, minister, Unitarian Church of the Messiah,
New York City.
Rev. Dr. Stephen S. Wise, rabbi of the Free Synagogue, New York City.
Rev. Dr. Sidney E. Goldstein, rabbi of the Free Synagogue, New York
City.
Rev. Dr. Waldo Adams Amos, rector, Protestant Episcopal Church of St
Paul, Hoboken, N. J.

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

Dr. Isaac A. Abt
Rev. Myron E. Adams
Rev. Edward S. Ames
Dr. Charles S. Bacon
Mrs. E. W. Bemis
Mrs. I. S. Blackwelder
Mrs. Tiffany Blake
Dr. Anna E. Blount
Ralph E. Blount
Mrs. Joseph T. Bowen
Mr. and Mrs. Horace Bridges
Mr. and Mrs. Edward B. Burling
Mrs. Benjamin Carpenter
Dr. and Mrs. Frank Cary
Mr. and Mrs. William L. Chenery
Dr. Frank S. Churchill
Mr. and Mrs. Samuel Dauchy
Dr. J. B. De Lee
Mr. and Mrs. William F. Dummer
Mrs. Joseph N. Eisendrath
Mrs. Kellogg Fairbank
Dr. John Favill
Prof. and Mrs. James A. Field
Mrs. Walter L. Fisher
Mr. and Mrs. Jerome Frank
Rev. and Mrs. Charley W. Gilkey
Dr. and Mrs. Maurice L. Goodkind
Dr. Ethan A. Gray
Mr. and Mrs. E. T. Gundlach
Mrs. Alfred Hamburger
Dr. and Mrs. Ralph Hamill
Dr. Alice Hamilton
Mr. and Mrs. Charles F. Harding
Dr. N. Sproat Heaney
Mrs. Charles Henrotin
Dr. Rudolph W. Holmes
Mrs. Leila K. Hutchins
Dr Karl K Koessler

Dr. Karl K. Koessler
Mr. and Mrs. Herman Landauer
Dr. W. George Lee
Prof. and Mrs. Frank R. Lillie
Prof. and Mrs. J. Weber Linn
Mrs. Edwin L. Lobdell
Max Loeb
Judge and Mrs. Julian W. Mack
Prof. and Mrs. George H. Mead
Dr. James H. Mitchell
Mr. and Mrs. William S. Monroe
Prof. and Mrs. Addison W. Moore
Mrs. James W. Morrisson
Mr. and Mrs. George Packard
Mr. and Mrs. Benjamin Page
Mrs. Elia W. Peattie
Allen B. Pond
Mr. and Mrs. James F. Porter
Mrs. Julius Rosenwald
Mrs. Dunlap Smith
Mrs. Henry Solomon
Dr. Alexander F. Stevenson
Prof. Graham Taylor
Mrs. Harriet W. Walker
Mr. and Mrs. Willoughby Walling
Mrs. George Watkins
Mr. and Mrs. Payson Wild
Mrs. Wilmarth
Dr. Rachelle Yarros
Victor S. Yarros
Mr. and Mrs. Sigmund Zeisler

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

CHAPTER III
POPULATION AND BIRTH RATE

In this chapter it is demonstrated that a high birth rate invariably means a high death
rate, particularly a high infant mortality. Where a knowledge of methods to prevent
conception results in a lowering of the birth rate, proportionately more of those children
born survive, and a healthier, sturdier population is the result.

BIRTH CONTROL

By Havelock Ellis

It may be said that Nature has been seriously troubled with the problem of reproduction
even from the first creation of life. Our own doubts and difficulties in that sphere are but a
continuation of those experienced on the earth long before Man’s ancestors descended
from the forest trees. Nature’s first insistent impulse was for reproduction, and so the
lowlier organisms increase at an enormous rate, though by far the greater number of the
creatures thus produced are doomed to early destruction by other creatures which prey
upon them. Then sex arose and developed. And the object of sex may be said to act as a
check on reproduction, and not, as we have sometimes too hastily assumed, to ensure
reproduction, for that was already more than fully ensured by other methods already in
existence. The device of sex rendered reproduction more difficult, but in decreasing the
quantity of offspring it at the same time improved their quality. As the sexual process
increased in complexity the individuals produced equally grew more complex and better
equipped to resist the dangers they were subjected to. Fishes are spawned by the
thousand, but only a few come to maturity. The higher mammals produce but few
offspring and surround them with parental care until they are able to lead their own lives
with a fair chance of surviving. Thus the sexual process in its finally developed form may
be regarded as a mechanism for subordinating quantity to quality, and so promoting the
evolution of life to ever higher stages.
This process, which is plain to see on the largest scale throughout living nature, may be
more minutely studied, as it acts within a narrower range, in the human species. Here we
statistically formulate it in the terms of birth-rate and death-rate; by the mutual
relationship of the two courses of the birth-rate and the death-rate we are able to estimate
the evolutionary rank of a nation, and the degree in which it has succeeded in
subordinating the primitive standard of quantity to the higher and later standard of quality.
It is especially in Europe that we can investigate this relationship by the help of statistics
which in some cases extend for nearly a century back. We can trace the various phases
through which each nation passes, the effects of prosperity, the influence of education and
sanitary improvement, the general complex development of civilisation, in each case
moving forward, though not regularly and steadily, to higher stages by means of a falling
birth-rate, which is to some extent compensated for by a falling death-rate, the two rates
nearly always running parallel, so that a temporary rise in the birth-rate is usually
accompanied by a rise in the death-rate,—by a return, that is to say, to the conditions
which we find at the beginning of animal life,—and a steady fall in the birth-rate is
always accompanied by a fall in the death-rate.
The modern phase of this movement, soon after which our precise knowledge begins,
may be said to date from the industrial expansion, due to the introduction of machinery,

which Professor Marshall places in England about the year 1760. That represents the
beginning of an era in which all civilised and semi-civilised countries are still living. For
the earlier centuries we lack precise data, but we are able to form certain probable
conclusions. The population of a country in those ages seems to have grown very slowly
and sometimes even to have retrograded. At the end of the sixteenth century the
population of England and Wales is estimated at five millions and at the end of
seventeenth at six millions,—only 20% increase during the century—although during the
nineteenth century the population nearly quadrupled. This very gradual increase of the
population seems to have been by no means due to a very low birth-rate, but to a very
high death-rate. Throughout the Middle Ages a succession of virulent plagues and
pestilences devastated Europe. Smallpox, which may be considered the latest of these,
used to sweep off large masses of the youthful population in the eighteenth century. The
result was a certain stability and a certain well-being in the population as a whole, these
conditions being, however, maintained in a manner that was terribly wasteful and
distressing.
The industrial revolution introduced a new era which began to show its features clearly in
the early nineteenth century. On the one hand, a new motive had arisen to favor a more
rapid increase of population. Small children could tend machinery and thereby earn wages
to increase the family takings. This led to an immediate result in increased population and
increased prosperity. But on the other hand, the rapid increase of population always
tended to outrun the rapid increase of prosperity, and the more so since the rise of sanitary
science began to drive back the invasions of the grosser and more destructive infectious
diseases which had hitherto kept the population down. The result was that new forms of
disease, distress, and destitution arose; the old stability was lost, and the new prosperity
produced unrest in place of well-being. The social consciousness was still too immature
to deal collectively with the difficulties and frictions which the industrial era introduced,
and the individualism which under former conditions had operated wholesomely now
acted perniciously to crush the souls and bodies of the workers, whether men, women or
children.
As we know, the increase of knowledge and the growth of the social consciousness have
slowly acted wholesomely during the past century to remedy the first evil results of the
industrial revolution. The artificial and abnormal increase of the population has been
checked because it is no longer permissible in most countries to stunt the minds and
bodies of small children by placing them in factories. An elaborate system of factory
legislation was devised, and is still ever drawing fresh groups of workers within its
protective meshes. Sanitary science began to develop and to exert an enormous influence
on the health of nations. At the same time the supreme importance of popular education
was realised. The total result was that the nature of “prosperity” began to be transformed,
instead of being, as it had been at the beginning of the industrial era, a direct appeal to the
gratification of gross appetites and reckless lusts, it became an indirect stimulus to higher
gratifications and more remote aspirations. Foresight became a dominating motive even
in the general population, and a man’s anxiety for the welfare of his family was no longer
forgotten in the pleasure of the moment. The social state again became more stable, and

more “prosperity” was transformed into civilisation. This is the state of things now in
progress in all industrial countries, though it has reached varying levels of development
among different peoples.
It is thus clear that the birth-rate combined with the death-rate constitutes a delicate
instrument for the measurement of civilisation, and that the record of these combined
curves registers the upward or downward course of every nation. The curves, as we know,
tend to be parallel, and when they are not parallel we are in the presence of a rare and
abnormal state of things which is usually temporary or transitional.
It is instructive from this point of view to study the various nations of Europe, for here we
find a large number of small nations, each with its own statistical system, confined within
a small space and living under fairly uniform conditions. Let us take the very latest
official figures (which are usually for 1913) and attempt to measure the civilisation of
European countries on this basis. Beginning with the lowest birth-rate, and therefore in
gradually descending rank of superiority, we find that the European countries stand in the
following order: France, Belgium, Ireland, Sweden, the United Kingdom, Switzerland,
Norway, Scotland, Denmark, Holland, the German Empire, Prussia, Finland, Spain,
Austria, Italy, Hungary, Serbia, Bulgaria, Roumania, Russia. If we take the death-rate
similarly, beginning with the lowest rate and gradually descending to the highest, we find
the following order: Holland, Denmark, Norway, Sweden, Switzerland, the United
Kingdom, Belgium, Scotland, Prussia, the German Empire, Finland, Ireland, France, Italy,
Austria, Serbia, Spain, Bulgaria, Hungary, Roumania, Russia.
Now we cannot accept the birth-rates and death-rates of the various countries exactly at
their face value. Temporary conditions, as well as the special composition of a population,
not to mention peculiarities of registration, exert a disturbing effect. Roughly and on the
whole, however, the figures are acceptable. It is instructive to find how closely the two
rates agree. The agreement is, indeed, greater at the bottom than at the top; the eight
countries which constitute the lowest group as regards birth-rate are the identical eight
countries which furnish the heaviest death-rates. That was to be expected; a very high
birth-rate seems fatally to involve a very high death-rate. But a very low birth-rate (as we
see especially in the case of France) is not invariably associated with a very low death-
rate though it is never associated with a high death-rate. This seems to indicate that those
qualities in a highly civilised nation which restrain the production of offspring do not
always or at once produce the eugenic racial qualities possessed by hardier peoples living
under simpler conditions. But with these reservations it is not difficult to combine the two
lists in a fairly concordant order of descending rank. Most readers will agree, that taking
the European populations in bulk, without regard to the production of genius (for men of
genius are always a very minute fraction of a nation), the European populations which
they are accustomed to regard as standing at the head in the general diffusion of character,
intelligence, education, and well-being, are all included in the first twelve or thirteen
nations, which are the same in both lists though they do not follow the same order. These
peoples, as peoples—that is, without regard to their size, their political importance, or

their production of genius—represent the highest level of democratic civilisation in
Europe.
It is scarcely necessary to add that various countries outside Europe equal or excel them;
the death-rate of the United States, so far as statistics show, is the same as that of Sweden,
that of Ontario, still better, is the same as Denmark, while the death-rate of the Australian
Commonwealth with a medium birth-rate, is lower than that of any European country, and
New Zealand holds the world’s championship in this field with the lowest death-rate of
all. On the other hand, some extra-European countries compare less favorably with
Europe: Japan, with a rather high birth-rate, has the same high death-rate as Spain, and
Chili, with a still higher birth-rate, has a higher death-rate than Russia. So it is that among
human peoples we find the same laws prevailing as among animals, and the higher
nations of the world differ from those which are less highly evolved precisely as the
elephant differs from the herring, though within a narrower range, that is to say, by
producing fewer offspring and taking better care of them.
The whole of this evolutionary process, we have to remember, is a natural process. It has
been going on from the beginning of the living world. But at a certain stage in the higher
development of man without ceasing to be natural, it becomes conscious and deliberate. It
is then that we have what may properly be termed Birth Control. That is to say that a
process which had before been working slowly through the ages, attaining every new
forward step with waste and pain, is henceforth carried out voluntarily, in the light of the
high human qualities of reason and foresight and self-restraint. The rise of birth control
may be said to correspond with the rise of social and sanitary science in the first half of
the nineteenth century, and to be indeed an essential part of that movement. It is firmly
established in all the most progressive and enlightened countries of Europe, notably in
France and in England; in Germany, where formerly the birth-rate was very high, birth
control has developed with extraordinary rapidity during the present century. In Holland
its principle and practice are freely taught by physicians and nurses to the mothers of the
people, with the result that there is in Holland no longer any necessity for unwanted
babies, and this small country possesses the proud privilege of the lowest death-rate in
Europe. In the free and enlightened democratic communities on the other side of the
globe, in Australia and New Zealand, the same principles and practice are generally
accepted, with the same beneficent results. On the other hand, in the more backward and
ignorant countries of Europe, birth control is still little known, and death and disease
flourish. This is the case in those eight countries which come at the bottom of both our
lists.

Even in the more progressive countries, however, birth control has not been established
without a struggle which has frequently ended in a hypocritical compromise, its principles
being publicly ignored or denied and its practice privately accepted. For at the great and
vitally important point in human progress which birth control represents, we really see the
conflict of two moralities. The morality of the ancient world is here confronted by the
morality of the new world. The old morality, knowing nothing of science and the process

of Nature as worked out in the evolution of life, based itself on the early chapters of
Genesis, in which the children of Noah are represented as entering an empty earth which
it is their business to populate diligently. So it came about that for this morality, still
innocent of eugenics, recklessness was almost a virtue. Children were given by God, if
they died or were afflicted by congenital disease, it was the dispensation of God, and,
whatever imprudence the parents might commit, the pathetic faith still ruled that “God
will provide.” But in the new morality it is realised that in these matters Divine action can
only be made manifest in human action, that is to say through the operation of our own
enlightened reason and resolved will. Prudence, foresight, self-restraint—virtues which
the old morality looked down on with benevolent contempt—assume a position of the
first importance. In the eyes of the new morality the ideal woman is no longer the meek
drudge condemned to endless and often ineffectual child-bearing, but the free and
instructed woman, able to look before and after, trained in a sense of responsibility alike
to herself and to the race, and determined to have no children but the best.
Such were the two moralities which came into conflict during the nineteenth century.
They were irreconcilable and each firmly rooted, one in ancient religion and tradition, the
other in progressive science and reason. Nothing was possible in such a clash of opposing
ideas but a feeble and confused compromise such as we still find prevailing in various
countries of old Europe. It was not a satisfactory solution, however inevitable, and
especially unsatisfactory by the consequent obscurantism which placed difficulties in the
way of spreading a knowledge of the methods of birth control among the masses of the
population. For the result has been that while the more enlightened and educated have
exercised a control over the size of their families, the poorer and more ignorant—who
should have been offered every facility and encouragement to follow in the same path—
have been left, through a conspiracy of secrecy, to carry on helplessly the bad customs of
their forefathers. This social neglect has had the result that the superior family stocks have
been hampered by the recklessness of the inferior stocks.
Such is the situation to-day when we find America entering this field. Up till now
America had meekly accepted at Old Europe’s hands the traditional prescription of our
Mediterranean book of Genesis, with its fascinating old-world fragrance of Mount Ararat.
On the surface, the ancient morality had been complacently, almost unquestionably
accepted in America, even to the extent of permitting a vast extension of abortion—a
criminal practice which ever flourishes where birth-control is neglected. But to-day we
suddenly see a new movement in the United States. In a flash, America awoke to the true
significance of the issue. With that direct vision of hers, that swift practicality of action,
and above all, that sense of the democratic nature of all social progress, we see her
resolutely beginning to face this great problem. In her own vigorous native tongue we
hear her demanding: “What in the thunder is all the secrecy about anyhow?” And we
cannot doubt that America’s own answer to that demand will be of immense significance
to the whole world.

BIRTH CONTROL. MARY ALDEN HOPKINS, in Harper’s Weekly, 1915.

No one knows what the birth rate of the United States is, or what it ever has been. Every
European country knows its birth rate and its death rate, because every birth and every
death is registered. Where the number of births, the number of deaths and the number of
the population are all known, it is an easy matter to calculate the rates per thousand. But
in the international tables of vital statistics our country’s figures are omitted.
Our 1910 census announced that 23 states had “fairly complete” death registration. They
recorded about 90% of their deaths. But the birth registration situation was shocking. The
New England States, Pennsylvania and Michigan were the only acceptable states. The
figures for the cities of Washington, D.C., and New York City passed muster also. The
1910 census birth rate is not yet published, but the 1900 census made shift to figure it out
by means of the number of the population’s increase and the death rate. This would be
surer if the death rate were not itself approximate. However, the calculated rates were,
birth rate, 35.1 per 1000 population; death rate, 17.4 per 1000; excess of births over
deaths 17.7 per 1000. Comparing these rates with the rates of the European countries for
the same decade, we find ourselves near the head of the list for high birth rate, near the
foot of the list for low death rate, and increasing faster than any other nation. These
figures leave nothing to be desired from an emotional viewpoint. But they leave much to
be desired in the way of accuracy. In addition to our lack of statistics we are confused by
the effect of immigration.
The birth rate of every civilized country is falling. The following comparison of national
birth rates is based on the ten largest countries of Europe. The less important ones show
the same general characteristics. Asiatic countries must be excluded as they have no
reliable vital statistics. The United States must be considered separately because both our
mortality records and our birth registration are so defective that only approximate
calculations can be made. The maximum birth rate preceding the present decline occurred
in France 1811–20; in Norway, Sweden, Finland, Austria and Prussia 1821–30; Belgium
1831–40; Denmark 1851–60; Scotland and Spain 1861–70; England, Wales, Ireland,
Hungary, Switzerland, Germany, Bavaria, Saxony, and the Netherlands 1871–80;
Portugal, Italy, Serbia and Roumania, 1881–90.
The figures of the following table are taken from the Report of the Registrar General of
Great Britain for 1910. Five year periods are used in place of single years to eliminate
variations of exceptional years.
Seventy-third Annual Report of the Registrar-General of Births, Deaths and Marriages in
England and Wales, 1910, London. Pub. by His Majesty’s Stationery Office. Printed by
Darling and Sons, Ltd., Bacon St., E. London. 1912.

Yearly Number of Births per 1000 Inhabitants.

1881–5 1906–10
Russia (European) 49.1 47.7[4]

Hungary 44.6 36.7
German Empire 37.0 34.3[4]
Spain 36.4 33.6
Austria 38.2 33.6
Italy 38.0 32.6
The Netherlands 34.8 29.6
Belgium 30.7 27.7[4]
England and Wales 33.5 26.6
France 24.7 19.7

4. Figures for previous five years.
The countries are arranged in order of their 1906–10 rates.
By subtracting the figures in the second column from the first we obtain the fall in the
rates between 1881–5 and 1906–10. Russia, in 1910, had the highest birth rate, and had
suffered the slightest diminution, only 1.4 per thousand. Curiously Hungary, standing
second in line, showed the greatest fall, 7.9. England and Wales, far down the scale, had a
drop of 6.9 per thousand. Italy, The Netherlands, France, and Austria kept a fairly even
pace with a fall of around 5. Belgium, Spain, and the German Empire lost only about 3
per thousand.
Much discussion has arisen concerning the cause of this decline. Two distinct stages occur
in the fecundity of animal life. In the species below the human race it is checked by
biological causes. In the human race it is checked by social and economic causes. As the
scale of life rises, the number of offspring become fewer. The higher the animal, the fewer
the offspring.
When we reach the human animal, we find in addition to pestilence, war, and “acts of
God,” various forms of voluntary check. Semi-civilized countries manage the affair rather
crudely; in India the Ganges is hardly yet free from infant corpses, and in China girl
babies show an assisted mortality. More civilized countries limit the birth rate more
felicitously, reducing the number of marriages and advancing the age of marriage, by
imposing social, ethical, and financial obligations. This decreases the number of possible
children. These indirect checks held back the increase of population so slightly, evenly
and over so long a period as to be hardly perceptible. In the seventies appeared a
phenomenon of spectacular novelty—the small family. Harmless methods of
contraception had been perfected, the knowledge disseminated, and the means supplied.
The birth rate, which had slowly declined through aeons, from eggs by the millions to
yearly babies, dropped with dizzying rapidity.
As the birth rates of the nations fall, so fall the death rates. Here are the death rates for the
same ten nations for the same years as the previous birth rate table.

Yearly Number of Deaths per 1,000 Inhabitants

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

5. Figures for previous five years.
A comparison of the two tables shows immediately that the countries having the highest
birth rate have also the highest death rate. Russia, which heads the list in births, heads the
list in deaths. Hungary comes second in both lists. Next come, in a slightly altered order,
the four countries, German Empire, Spain, Austria and Italy. An exception occurs in
France which has the unusual combination of a low birth rate and a medium death rate.
Belgium, and England and Wales occupy the same position in both lists with low birth
rates and low death rates. The Netherlands is the notable country with its medium birth
rate and its low death rate. The Neo-Malthusians love to mention at this point that this
country has governmental encouragement in teaching contraception.
The increase of a country is the difference between its birth rate and its death rate. The
population of a country depends, not upon its birth rate, but upon its birth rate, minus its
death rate. If the two are identical, the population is stationary. This happened in France in
the 1891–5 period. The number of births per thousand inhabitants was exactly the number
of deaths per thousand inhabitants. The rest of the world tolled the knell for France. But
France instead of declining into the have-been nations showed that a controlled birth rate
can be raised as well as lowered. Slowly and apparently intentionally she raised her rate
during the succeeding years.
Decline and rise of French Birth rate: 1881–5, 2.5; 1886–90, 1.1; 1891–5, 0.0; 1896–
1900, 1.2; 1901–5, 1.6; 1906–10, .7. Nor has France since those early nineties allowed her
birth rate to fall below her death rate.
The populations of European nations are increasing, because the death rates are falling
faster than the birth rates.
If we subtract the deaths per thousand inhabitants, given in the second table, from the
births per thousand inhabitants given in the first table, we shall have the natural rate of

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

Natural Increase in Population per 1,000 Inhabitants

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

6. Figures for previous five years.
From the second column we find that Russia is increasing most rapidly. The Netherlands
comes second in rate of increase—an honorable position to which the regulationists point
triumphantly when they assert that control of the birth rate does not mean the ruin of the
nation. The German Empire comes next, with Hungary following. England stands fifth in
the rating of increase, and England takes the position with woeful lamentations. Italy,
Austria, Belgium, and Spain are near the foot of the list, and France brings up the rear a
long, long way behind. France is the only one that is anywhere in sight of a stationary
population.
Excepting France and England, every one of these countries is increasing at a faster rate
than formerly, because though the birth rate has fallen fast, the death rate has fallen faster.
By comparing the second column showing the increase in the 1906–10 period with the
first column showing the increase in the 1881–5 period, in the preceding table, we see
how much each country is gaining in her rate of increase. This increase may or may not
be considered desirable according to whether one wishes to conserve the food supply or
increase the army. To every one it presents an interesting condition. It is unexpected to
find with a falling birth rate an increasingly increasing population,—always excepting
France and England.

FROM “THE EMPIRE AND THE BIRTH-RATE”

By C. V. Drysdale, D.Sc.

When we are considering the growth of population it is not the births but the survivals
that count; and it is a remarkable fact, of which illustrations will appear anon, that
comparatively few of those who have made strong remarks on the birth-rate question
seem to have realised this. The child that perishes before entering on a productive
existence is not an asset to the numbers or efficiency of the community, but a drain upon
it for which there is no compensating gain.

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

We shall now study the principal parts of our Empire seriatim, and it will suffice if we
consider Great Britain and Ireland, Australasia, Canada, South Africa, and India.
England and Wales.—Special attention should be given to this diagram (Fig. 2), as, apart
from England’s intrinsic Imperial importance, it exhibits changes typical of those taking
place in the majority of civilised countries at the present time. Our Registrar-General’s
Reports give us figures starting from the year 1853, and it will be seen that there was a
fairly definite rise in the birth-rate till the year 1876, after which there set in that rapid and
steady decline which we hear so much about to-day.
As to the cause of this remarkable decline, it is now pretty generally known that the chief
factor is the voluntary reduction of the fertility rate (the average number of children to a
marriage). Further, the decline has been largely a class one, affecting first the richer and
more cultured classes, rapidly extending through the various grades of the middle classes
until it has now reached the skilled artizans, but not the poorest and most unskilled
laborers.
The evidence for these contentions is briefly (a) that just before the year 1876 an actuarial
enquiry made by Mr. Ansell on behalf of the National Life Assurance Society revealed the
fact that the average number of children to a family in the upper and professional classes
at that time was somewhat over five, while the average for the whole population was 4.63
according to the Registrar-General’s Report; (b) that the birth-rate reckoned on the
number of married women has since fallen from 304.1 per thousand in 1876 to 196.2 in
1911; (c) that families are now notoriously very small among the professional classes; and
(d) that the birth-rate in some of the poorest districts of our large towns is still about as
high as it was in 1876. We have not yet got the detailed returns of families for the census
of 1911 in England and Wales; but for Scotland, where the variations in the birth-rate
have been very similar, Dr. J. C. Dunlop, in a paper read before the Royal Statistical
Society the other day, gave these details. The average number of children to a family

among the poorest unskilled laborers is still about seven, while it is only 3.91 for medical
practitioners, 4.33 for the clergy, and 3.76 for army officers.

Fig. 1.—
POPULATION OF
VARIOUS
COUNTRIES.

VARIATIONS IN BIRTH RATE &c., IN ENGLAND & WALES

Fig. 2.—ENGLAND AND WALES.

Fig. 3.—IRELAND.
Turning at once, however, to the accompaniments of these changes in the birth-rate, we
find that the death-rate has also shown very decided changes, although the temporary
fluctuations prevent our locating them with the same precision. For between fifteen and
twenty years after 1853 the general deathrate was approximately stationary, or perhaps
slightly rising; but since then there has been a rapid and steady fall from about 22 per
thousand to a little over 13. The infantile mortality, after various minor fluctuations, has
fallen very rapidly since 1900. The net result of these changes is that the rate of natural
increase of population (excess of birth-rate over death-rate) during the last five years has
averaged 11 per thousand, which is nearly the same as in the first five years 1853–57,
when it was 11.7 per thousand, although it temporarily increased to 14.3 per thousand in
the quinquennium 1874–78. The cry of “depopulation” or of “race suicide” has little more
justification to-day when our birth-rate is only 24 and the average family probably
between three and four children than it had in 1855 with a birth-rate of 34 and an average
of 5 births per marriage. In an article in the Daily Telegraph of January 17 last, a writer
pointed out that mortality was very high among the large families of the seventeenth and
eighteenth centuries, and asked: “If to lose half, or more than half, their children was
common among well-to-do people, how did poor folks fare?”
The actual rise of the population, after allowing for migration, is, of course, given by the
census returns. Fig. 1 shows the variation of the total population of the United Kingdom
and of England and Wales, from 1850 onwards.
Many of you will have heard alarmist statements from various quarters to the effect that
our population is rapidly becoming stationary owing to the combined results of a

declining birth-rate and an accelerated emigration. In the Fortnightly Review for February
last an article on “The Danger of Unrestricted Emigration,” by Mr. Archibald Hurd,
contained a characteristic statement of this kind:—“The population of Ireland and
Scotland is rapidly declining, and that of England and Wales is now practically stagnant,
the natural increase only slightly exceeding the outflow due to emigration.”
We will deal with Ireland in a moment; but as regards both England and Wales and
Scotland the statement appears entirely unwarranted. The actual increase of population in
England and Wales between the censuses of 1901 and 1911 was 10.9 per cent., which is
only a little below the “natural” increase (in Wales it reached the unprecedentedly high
increase of 18.1 per cent.); while in Scotland the actual increase of population was 6.4 per
cent. over the decade. Probably these alarms were due to consideration of emigration
apart from immigration or from return of our own emigrants.[7] The actual increase of
population for the whole of the United Kingdom was 9.1 per cent.; and this has only been
exceeded twice in the past six decades.

7. Further investigation appears to indicate that the official statistics concerning
emigration and immigration are very unreliable. The Statistical Abstract for the
United Kingdom for 1912 gives the total emigration in the ten years 1901–10 as
4,724,233, and the total immigration 2,409,490, leaving an outward balance of
2,314,723. In the same period there were 11,628,493 births and 6,780,266 deaths,
giving a natural increase of 4,848,227; and since the actual increase by the census
returns was 3,757,944, the net loss by emigration could only have been 1,091,283
or less than half of the officially recorded number. Thus it appears that little over
one-fifth of our natural increase is lost by emigration. (Since writing this, I find the
Registrar-General admits the returns prior to 1908 were defective.)
We need not consider Scotland further, as its variations resemble those of England and
Wales.

Fig. 4.—AUSTRALIA.

Fig. 5.—NEW ZEALAND.

Fig. 6.—ONTARIO,
CANADA.

Fig. 7.—TORONTO.

Ireland.—Ireland’s statistics differ so much from those of most other countries that they
merit special consideration. In Fig. 3 are shown the variations of its birth and death-rates.
From these it appears that, for many years past, Ireland has had very low but practically
steady birth-and death-rates. On further studying the matter, however, we find that
Ireland’s low birth-rate is not due to small families, but to a low marriage rate (probably

due to immigration of young people). The fertility rate of its women has remained high
and steady, 283 per thousand in 1881, and 289 in 1901. The excess of births over deaths
has averaged 6 per thousand recently, although it was much higher forty-five years ago.
But the terrible poverty succeeding the famine produced the great tide of emigration
which has reduced the population from eight to little over four millions. It should be
observed, however, that it is late in the day to deplore the depopulation of Ireland, as it
has now practically ceased. The fall of population was 11.8 per cent. between the
censuses of 1851 and 1861, but only 1.7 per cent. between those of 1901 and 1911; while
in the closing years of the decade, the Registrar-General’s returns gave the population as
almost exactly stationary. It is highly probable that the next census will show an increase
in the population of Ireland for the first time since 1846.
We may now turn to the various parts of our Empire overseas, and it will be sufficient if
we consider the four principal divisions: Australasia, Canada, Union of South Africa, and
India. The order is chosen as dealing with the populations of British origin first.
Australasia.—Australia and New Zealand both call for particular attention in this
connection, as family limitation appears to be very general in them, and many authorities
have spoken about it in strong terms. Mr. Roosevelt, for example, wrote as follows in
1911: “The rate of natural increase in New Zealand is actually lower than in Great Britain,
and has tended steadily to decrease; while Australia increases so slowly that, even if the
present rate were maintained, the population would not double itself in the next century.”
Again, the Bishop of London, last year appears to have told the North-West Australian
Diocesan Association “that the birth-rate in Australia is going down even more rapidly
than at home (United Kingdom), and that he did not know how we are going to keep
Australia even British.”
In addition to these grave warnings, fears have been continually expressed concerning the
danger of Australia from the Japanese or Chinese. We are told also that from the industrial
point of view Australia is calling out for population; and a law giving a bonus of £5 for
each child was passed a twelve-month ago. It would appear, therefore, that the birth-rate
question is a very serious one in Australasia, especially when we are aware that
determined attempts at checking the resources of family limitation have signally failed.
Let us now examine the actual figures for the variation of the birth-rate, etc., and compare
them with the above statements. These are given in Figs. 4 and 5.
In both countries the birth-rate fifty years ago was remarkably high (well over 40 per
thousand), and it has since fallen very rapidly to 26 or 27 per thousand. But in both of
them the death-rate has fallen somewhat, and they now have the lowest death-rates in the
world, that of New Zealand having been about 9.5 per thousand for many years past. So,
instead of increasing slowly, their rate of natural increase by excess of births over deaths
is actually the highest in the world (with the possible exception of Bulgaria). The natural
increase of New Zealand during the last five years has been more than 50 per cent. greater
than in Great Britain, instead of being less, as stated by Mr. Roosevelt; and instead of the
birth-rate going on falling, it has, on the contrary, risen lately. The natural increase of

Australia is 16 per thousand, which would cause the population to double in forty-four
years, or to become five times as large in a century. The Australian birth-rate has been
well maintained during the past seven years, and the death-rate has slightly declined; so
the natural increase has slightly accelerated.
The foregoing statements are, of course, quite independent of immigration, and the
following are the actual census figures for the increase of population.

1860 1870 1880 1890 1900 1910
Australia,
1,145,585 1,647,766 2,231,531 3,151,355 3,765,339 4,425,083
population
Per cent.
increase 43.8 35.5 41.2 19.5 17.5
in decade
New
Zealand, 625,508 768,278 1,002,679
population
Per cent.
increase 22.6 30.5
in decade
It is worthy of note that in Australia, which is supposed to be needing population so
much, the actual increase in the last two decades has been only slightly in excess of the
natural increase. This means that the net immigration must have been very small, or that
nearly as many people must have left Australia as entered it—a curious commentary on
the alleged need for them.[8] New Zealand, on the other hand, shows a phenomenally large
increase by the combination of natural increase and immigration.

8. In the five years 1901–05 there was an actual net loss of over 16,000 persons by
excess of emigration.
It will be well at this point to examine the justification for the yellow peril theory as
regards Australia. Japan has certainly moved in the opposite direction to Australia in
having increased its birth-rate from 26 to 33 per thousand between 1891 and 1910. But its
general and infantile mortality have also increased. Thus its natural increase to-day is
only 12.5 per thousand as against the 16 or 17 per thousand of Australia and New
Zealand, while its actual rate of increase is far short of theirs. Although the population of
Japan is about ten times that of the whole of Australasia, every year makes the
proportionate disparity of numbers less instead of greater; while as regards health,
physique and financial resources, the advantage, of course, lies heavily with our people.
That Australasia will be well advised to look to her defences may be granted; but there
seems no reason whatever to be dissatisfied with the increase of her population.

Canada.—Little can be said about this part of our Empire, owing to paucity of statistical
information; but that little is most interesting and significant. As regards the total
population, the census returns show a very rapid increase, that of 34 per cent. (from
5,371,315 in 1901 to 7,204,838 in 1911) being without parallel in modern times. When
we come to consider the birth-rate, however, a remarkable phenomenon appears. The only
part of the Dominion for which vital statistics appear to be available is the Province of
Ontario. Fig. 6 shows that the birth-rate of Ontario was only 22 or 23 per thousand in the
eighties, and actually dropped to 19 in 1895, since then it has recovered (owing to an
increased marriage-rate) to about 25 per thousand. Its lowest birth-rate was equal to that
of France to-day. But the death-rate had also fallen—namely, to 10 per thousand, so that
the natural increase was 9 per thousand, or not much behind that of most civilised
countries. This fact may be commended to the consideration of those who think that the
slow rate of increase of the French population is due to its low birth-rate.
The remarkable phenomenon now appears. The increase of the birth-rate in Ontario to 25
per thousand has been accompanied, not by a corresponding rise in the natural increase,
but by an increase of the death-rate to 14 per thousand! So the additional births appear to
have populated the graveyards rather than the country. It has been suggested to me by Dr.
Stevenson that the increase in the birth and death rates of Ontario may be exaggerated, in
that due allowance has not been made by the Canadian authorities for the effect of
immigration. But even making the fullest allowance for this, there can be no doubt that
both the birth and death rates have risen, and by nearly the same amount. The city of
Toronto (Fig. 7) is a most striking example of the same phenomenon.
There need be no great difficulty in understanding this result. We have continually heard
in the papers recently of poverty and unemployment in most of the large towns of
Canada. Although the resources of the country are no doubt enormous, they can only be
brought relatively slowly into operation, owing to the shortness of the summer and the
difficulties of transport. The frequently quoted statement that her food exports show signs
of lessening indicates that the inability of food to keep pace with an unrestricted
population will prove true here as elsewhere.
Canada offers excellent opportunities for sturdy efficient workers, and will be able to
support an immense population some day. But any attempt to crowd it rapidly with
children or inefficient town-bred immigrants will only raise the death-rate, unemployment
and labor unrest. The lives of women settlers are generally exceedingly strenuous and
trying; and this, in combination with the long distances from medical or other help, makes
the bringing up of large families very precarious.
South Africa.—Beyond the fact that the population of the Union of South Africa increased
from 5,175,824 in 1904 to 5,973,394 in 1911 (i.e., an increase of 15.4 per cent. in seven
years) little information appears to be available. The white population seems to have
increased from 1,116,806 to 1,276,242 (i.e., by 14.28 per cent.) in the interval, while the
native population increased from 3,491,056 to 4,019,006 (i.e., by 15.12 per cent.). But
since no figures as to birth-rates are available nothing can be said beyond the fact that the
actual increase works out at about 20 per thousand per annum, which is fairly high.

India.—We now turn from colonies mainly occupied by our own race and exhibiting our
modern characteristics to a most marked degree, and come to our great Eastern possession
which has preserved the ancient traditions of rapid reproduction. Writer after writer has
launched into panegyrics on “the glorious fertility of the East,” and the Bishop of Ripon a
few years ago issued this impressive warning: “Learn from the East. If we could but bring
ourselves to do so, perhaps at no very distant period the Yellow Peril might turn out to be
the White Salvation.”
That India is a country of high birth-rate is of course notorious. The custom of almost
universal child marriage, and the anxiety which prevails among some (apparently not all)
of the religious sects for a large posterity would alone render this inherently probable.
According to the Statesman’s Year Book for 1913 the average birth-rate for India in the
three years 1908–10 was 37.7 per thousand. This, however, was “officially but
imperfectly recorded,” and the census report for 1901 gave the probable birth-rate for
India as 48.8 per thousand. This figure is not at all an unlikely one, for the same rate has
prevailed in Russia and parts of Egypt; but such figures as have appeared in the 1911
census report seem to confirm the lower estimate. Here are the figures for three of the
important provinces:—

Excess
Total for decade 1901– Percentage of Actual
Births, –
11 Population 1901 Increase
Deaths
Births Deaths Births Deaths
Bengal,
Behar
29,351,442 25,373,322 39.10 33.80 3,978,120 4,552,293
and
Orissa
Punjab 8,286,261 8,843,708 40.8 43.5 –557,447 355,383
Assam 1,883,545 1,564,022 35.70 29.65 319,523 489,892
It is possible that these figures are correct, even without any restraint upon births, as the
census report of 1901 mentioned that premature and repeated maternity combined with
chronic under-nutrition appeared to lead to exhaustion and loss of fertility. In any case,
however, the birth-rate counts among the highest at the present day.
But when we turn to the death-rate and the natural and actual increase of population there
seems little reason for congratulation. The death-rate, given by the Statesman’s Year
Book, for the three years above quoted was no less than 34.3, leaving a natural increase of
only 3.4 per thousand—the lowest in our Empire, and nearly as low as that of France. The
figures for Bengal, etc., above only show a natural increase of 4.7 per thousand, half that
of Ontario at its lowest birth-rate of 19 per thousand; those for the Punjab reveal, despite
the high birth-rate, an actual diminution of population by excess of deaths over births.

The emigration from India appears to be so infinitesimal in comparison with its
population that the actual increase represents the natural increase almost exactly. In Fig. 1
is shown the variation of population in the whole of India and in the British Provinces
according to the census returns.

1872 1881 1891 1901 1911
Total
206,162,360 263,896,330 287,314,671 294.361.056 315.001.099
population
Per cent.
increase 23.1 13.1 2.4 7.0
in decade
British
195,840,000 199,200,000 221,380,000 231,600,999 244,279,888
Provinces
Per cent.
increase .08 1.6 11.0 4.5 5.5
in decade
Thus the rate of increase of population has been exceedingly slow except as regards the
totals for 1881 and 1891, and for the British Provinces in 1891. But the Census
Commissioners themselves state that the first few enumerations rapidly increased in
completeness, which probably accounted for a good deal of the two former increases;
while as regards the British Provinces, there was an increase in area of no less than 25 per
cent. between 1881 and 1901, which heavily discounts the increase of 11 per cent. in
population in 1891. The average increase in the British Provinces comes out at only 4.3
per cent. per decade over the whole period from 1861 to 1911; so when the increase of
area is taken into account it may be doubted whether there has been any great excess of
births over deaths at all.
A more absolute contradiction to the theory that a “glorious fertility” produces numbers
and vigor it would be difficult to conceive. India is a land of famine. We all know of the
terrible holocausts of 1876–8 when over five million perished, and that of 1899–1901,
which was held responsible for over a million deaths, besides numerous smaller ones. But
as Mr. W. S. Lilly has written in India and its Problems, “We may truly say that in India,
except in the irrigated tracts, famine is chronic—endemic. It always has been.” Sir
Frederick Treves in his charming work, The Other Side of the Lantern, has expressed the
same opinion, and he says:—“These are some of the great hordes who provide in their
lean bodies victims for the yearly sacrifice to cholera, famine, and plague.” The average
death-rate of 34.3 per thousand, which is probably underestimated, means, with a
population of 315 millions, over ten million deaths annually. Were the Indian death-rate
10 per thousand as in Australasia, there would be only three million deaths. Hence, unless
medical authorities can give good reason for postulating an inherent racial predisposition
to premature death among the inhabitants of India, this means that at least seven millions

of lives are wasted annually by starvation or the diseases to which it renders them an easy
prey.
There can be no doubt in the mind of anyone who studies the figures, that India is a
chronically, seriously over-populated country, despite the oft-quoted dictum of Sir
William Hunter. That India might produce food enough to feed her present population
need not be contested. But that any action on the part of the authorities will succeed in
providing for an increase of ten millions annually is inconceivable. The whole Empire
owes a tribute of gratitude and admiration to Sir A. Cotton whose magnificent irrigation
schemes have so greatly increased the possibilities of agriculture. They have no doubt
been the real cause of the 7 per cent. increase of population in the last decade. This,
however, only means providing for two out of the seven millions to be saved; and
irrigation like everything else has its limits.[9] Nothing will remove starvation, pestilence,
misery and unrest from India, except the adoption by her people of the parental prudence
of western nations.

9. In the article on India in the “Encyclopaedia Britannica” it is stated that the
Irrigation Commission of 1901–03 emphatically asserted that irrigation alone could
not cure famine.
The idea has been constantly put forward that the religious prejudices of the Indian
population make such a contingency impossible. Is it certain, however, that this is so? The
Census Report of 1901 suggested that in Assam some restraints upon births had been in
vogue. In 1911, again, the Vice-President of the Calcutta Municipality, Babu Nilambara
Mukerji, M.A., called attention to the extreme poverty caused by over-population, and
strongly advocated such restraints. His address seems to have been received with
considerable favor, and I have been asked to write articles for prominent native papers on
the subject.
The project of encouraging emigration from India has, of course, been put forward. But
the recent experiences in South Africa and elsewhere hardly favor this proposition, and
Mr. Archer in an interesting article on “India and Emigration,” in the Daily News of
December 26, pointed out that the real difficulty of over-population could not be
appreciably lessened in this way.
Ceylon.—In view of the foregoing, reference may be made to Ceylon which has
published its birth and death rates continuously since 1881, though I do not know what
reliance can be placed on them. Fig. 8 shows that the birth-rate has rapidly risen from 27
to 41 per thousand, but that the death-rate and infantile mortality have also greatly
increased.
The Empire.—The top line in Fig. 1 shows the increase of the population of the whole of
our Empire according to the Statistical Abstract just issued. The figures are as follows:—

Census 1891 1901 1911
Population 345,356,000 385,572,000 417,268,000

Per cent. increase in decade 11.6 8.3
Of course the increase from 1891 to 1901 was swelled by the addition of the Union of
South Africa, etc., but the addition in the second period probably fairly represents the
natural increase. The countries which go to swell this increase are those in which small
families are the rule, and have rates of increase varying from 11 to 17 per thousand. It is
India with the highest birth-rate which pulls down the average.
The population of the world is now probably about 1,800,000,000, and increasing at the
rate of 5 per cent. or 6 per cent. in a decade. So our Empire includes about a quarter of the
world’s population and is increasing more rapidly than the remainder.

OTHER COUNTRIES

No consideration of this subject would be complete if comparison were not made with the
more important nations outside our own Empire. If Imperialist security depends upon
numbers, it is relative, not absolute, numbers which count, and our attitude towards the
falling birth-rate must depend upon what is happening among our rivals.
France.—The case of France appears to be the chief cause of the fears concerning the
declining birth-rate, and she is variously spoken of as “dying,” “becoming depopulated,”
“decadent,” etc. In Fig. 9, I have collected the vital statistics for France over the whole
period of her declining birth-rate, i.e. from before the Revolution. They show the
following characteristics:—
1. France is not becoming depopulated. Her population has been slowly but steadily rising
ever since the Franco-German war, both actually and by excess of births over deaths,
although in some years the deaths have exceeded the births.
2. The excess of births over deaths in the last decade 1901–10, though small, is double
that of the previous decade, notwithstanding that the birth-rate fell from 22.2 to 20.6. It
averaged about 48,000 per annum.
3. In 1781–84, before the decline of the birth-rate set in, the birth-rate had the high value
of 38.9 per thousand. But instead of this giving a high natural increase of population, the
death-rate was no less than 37 per thousand, giving an excess of births over deaths of only
1.9 per thousand—little more than that (1.2) of the last decade.
4. The enormous fall of the birth-rate from 38.9 to 20.6 per thousand, has been
accompanied by a fall in the death-rate from 37 to 19.4 per thousand. Thus a fall of 18.3
in the birth-rate has been accompanied by a fall of 17.6 in the death-rate, and only a drop
of .7 per thousand in the rate of increase.

Fig. 8.—CEYLON.

Fig. 9.—FRANCE.

Fig. 10.—GERMANY.

Fig. 11.—BERLIN.

5. The present low rate of natural increase in France is not necessarily due to its low birth-
rate, as Ontario in Canada, with a similar birth-rate, had a death-rate of 10 per thousand,
or a natural increase of 9 per thousand—nearly as great as our own. The low increase of
France is therefore due to its high death-rate, not to its low birth-rate, and an explanation
or remedy should be found for the former before objection is made to the latter.

6. Possibly as a result of the present agitation in France in favor of large families, the
births in the first half of last year increased by 8,000 over those of the corresponding
period of 1912. Instead of producing a greater increase of population, the deaths
increased by 12,000, so that the survivals actually diminished.
It appears from the foregoing that while it is true that France is increasing in population
much more slowly than other countries, there is no justification for believing that an
increased birth-rate would populate it more rapidly. Much more likely is it that the result
would be the same as that shown in Ontario and other countries—a higher death-rate
without any advantage as regards numbers.
Germany.—As France is held up as the awful example of a low birth-rate, so is Germany
regarded as the good example of a high one. It is certainly fear of Germany that is
responsible for so much of the anxiety concerning our birth-rate.
That the population of Germany is increasing very rapidly is quite true, and it certainly
has also a relatively high birth-rate. (Fig. 10). But the birth-rate has fallen rapidly since
1876, and despite this the natural increase of population has actually accelerated, because
the death-rate has fallen still more rapidly. As the German death-rate is still considerably
above the 9 or 10 per thousand line, there is plenty of room for this process to continue.
The curve of actual increase of population in Fig. 1, shows that it has become exceedingly
high of late years, despite the great fall in the birth-rate.
Those, however, who still think that Germany’s high birth-rate is a source of advantage to
her may be consoled to know it will not continue long. The fall in the last few years has
been phenomenal; and the statement made in a German paper a few days ago that at the
present rate the German birth-rate will be down to that of France in ten years’ time
appears to be justified. The birth-rates of her large towns are already close to this point
(Berlin 20.4, Hamburg 21.8, Dresden 20.2, Munich 21.9, while that of London is still
about 24) and the country districts are sure to follow. But the example of Berlin is a most
striking one as to the fallacy of regarding high birth-rates as conducive to rapid increase.
Fig. 11 shows that the birth-rate of Berlin rose with great rapidity from 32 per thousand in
1841 to over 45 in 1876, since when it has fallen even more rapidly. But, neglecting
sudden variations due to war and epidemics, the death-rate has risen and fallen in such
close correspondence as to produce comparatively little change in the rate of natural
increase. The variation of the infantile mortality is very similar. On all grounds, therefore,
it seems difficult to see what advantage Germany has derived from her high birth-rate,
and the disadvantages were so obvious that it is little wonder that the German people have
decided in favor of a low one.
Austria shows very similar variations to Germany.
Russia.—Russia has the largest population of any European nation, 120,588,000 in 1911.
Its birth-rate for many years was the highest in the world, very nearly 50 per thousand.
But its death-rate and infantile mortality have been the highest in Europe, so that its rate
of increase of population, though rapid, has been less than that of New Zealand or
Australia. Over two millions of unnecessary deaths have taken place annually, and one

infant in every four (or over a million annually) dies in its first year. The war with Japan,
a country of half its population and a much lower birth-rate, strikingly illustrated the
inefficacy of mere numbers. In the Standard of March 6, it was stated that although the
general recruiting standard in Russia is lower than in Austria, France, Germany, or Great
Britain, the rejections in many localities reach the enormous figure of 70 per cent.
The Netherlands.—The foreign countries already dealt with are quite sufficient to give us
a fair idea of our position among the great powers as regards the birth-rate question. No
thoughtful person, however, can fail to see that this has another aspect which has
generally been quite overlooked. It will therefore be of special interest to study the record
of a nation in which this has been kept in view for many years. Holland is an intensely
patriotic country, and its need for military efficiency is beyond dispute. It is inconceivable
that her statesmen could contemplate a policy in any way detrimental to this. Yet it
appears that in 1881 an organisation having as its direct object the reduction of the birth-
rate, especially among the poor, was formed in Amsterdam, and that it received the warm
support of Dr. van Houten, Minister of the Interior, and of Mynheer N. G. Pierson, the
Finance Minister. It was thus enabled to conduct an energetic propaganda in favor of
small families among the poorest classes, whose means or health did not permit them to
do justice to large families. In 1895 its work had become so appreciated that it was
approved by Royal Decree as one of the Societies of Public Utility. To-day it is a large
and flourishing association with medical and other helpers in all the great centers. Thus in
Holland the diminution of the birth-rate has been favored and directed on humanitarian
and eugenic lines; and there has been a tendency for the State to become more
individualistic in character, rather than to adopt that policy of State assistance which has
been forced on most other nations by the gravity of their social problems, and which, by
pressing on the educated classes, has led them seriously to restrict their numbers.
The results of their policy as regards the numbers and health of the population can be seen
from Fig. 12. The birth-rate has fallen steadily and rapidly, especially in the last decade.
The death-rate, however, has fallen so much more rapidly, that it has now reached 12.3
per thousand in 1912—the lowest figure in Europe; and the natural increase has reached
15.7 per thousand, the highest figure in Western Europe. The infantile mortality has also
fallen more rapidly than in any other country. Indeed, Amsterdam and The Hague, the
principal centres of the propaganda, had the lowest general and infantile mortality of all
the great cities of the world, according to our Registrar-General’s Annual Summary for
1912.

Fig. 12.—THE NETHERLANDS.

When we turn from the question of numbers to the physical and social condition of the
people, the results are even more gratifying. Those who have traveled in Holland will, I
think, admit that the country looks prosperous, and the men, women and children robust
and contented. Slums such as we have in our great cities seem practically non-existent;
nor is there any sign of the stunting and anaemia so noticeable in our large towns, and
even in our countryside. Dr. Soren Hansen in the Eugenics Congress of 1912 stated that
the average stature of the Dutch people had increased by four inches in the last fifty years.
The army records given in the official Year Book of the Netherlands are also most
striking. The number of young men drawn annually for conscription by lot has increased
from 27,559 in 1865 to 48,509 in 1911 (out of a population of 6,000,000); and of these
the proportion over 5 ft. 7 in. in height has increased from 24.5 per cent. to 47.5 per cent.,
while that of those under 5 ft. 2½ in. has fallen from 25 per cent. to under 8 per cent. This
is doubtless due to the fact that in Holland the poorest and least fit have been encouraged
to be prudent, while in our country they have been having the largest families—the fitter
classes having smaller families in consequence. Real wages which have fallen here and in
Germany have apparently gone up in Holland, and her agriculture has rapidly improved.
In every way that I have been able to test, her prosperity and progress has been most
satisfactory. Moreover, Holland stands next to ourselves as a successful coloniser. Her
possessions in the East and West Indies occupy an area of 783,000 square miles with a
population of 38,000,000 (seven times her own population), 81,000 being Europeans.
Germany, with a home population ten times greater, has colonies aggregating 1,029,000
square miles with a population of only 14,000,000 inhabitants, of whom but 25,000 are
whites.

CONCLUSION

In view of all these records I cannot think that any unbiassed person will be able to avoid
the conclusion that large numbers and national efficiency are not to be secured by a high
birth-rate, especially in the lower strata of society. High birth-rates to-day invariably
mean high general and infantile death-rates, and, when accompanied by humanitarian
legislation, a serious process of reversed selection.
The explanation of this apparent paradox lies in the fact, which never seems to be
properly understood, that the population of the world and of nearly all countries is
constantly being kept in check by insufficiency of food. A French statistician, M. Hardy,
has calculated (and his figures, though challenged by great authorities, have now been
accepted) that if the total food production of the world were fairly distributed among its
inhabitants, the ration of proteids available for each would only be two-thirds of that
recognised as necessary for efficiency. Mr. Seebohm Rowntree has shown that large
numbers of families in our own country—the richest in the world—have deficiencies of
protein in their diet by amounts up to 40 per cent., and over 2,500,000 adult male workers
have wages of 25s. a week or less, upon which with the present cost of living and rent in
towns it is impossible to bring up more than three children properly. As a result, whenever
families are large a considerable proportion of the children die, and of those who survive
many grow up stunted and incapable of assimilating a good training. The over-crowding
caused by large families with an ever decreasing margin for rent is also a potent cause of
disease and of immorality—the latter evil being further greatly intensified by the
economic difficulties in the way of marriage that are the chief bar to the prevention of
those terrible diseases for which the Royal Commission, presided over by our Chairman,
is investigating a remedy.
That the rate of increase of population of a country depends in almost every case upon its
power of feeding its people by its own or imported food, and not upon its birth-rate, is a
matter which statesmen will have to recognise; and those who are anxious for the increase
of the population of our country and Empire, should turn their attention to the acceleration
of food production instead of deploring the declining birth-rate. No intelligent person will
claim that the food producing possibilities of the world are exhausted, but it does appear
difficult to increase them at more than a very slow rate (probably at present not more than
6 per cent. or 7 per cent. in a decade); and the world’s population cannot increase faster
than the food does. Irrigation in India has been followed by an increase in population far
greater than before, and encouragement of agriculture or of the industries which bring
food to this country is the only means by which our increase of population can be
accelerated. No shuffling of the incidence of taxation, and no humanitarian schemes, will
affect it—except prejudicially by favoring the increase of the inefficient rather than the
efficient. Nor will emigration, the panacea of the orthodox Imperialist, solve the problem.
We do not want effective producers to leave us, and these are the only people our colonies
really desire. Our town-bred weaklings are frequently less fitted to succeed in the
Colonies than at home, as the experience of Canada appears to testify. It has been said
that “no Empire can survive which is rotten at the core”; and if we persist in the policy of

encouraging the excessive reproduction of the poor, of taxing the capable for their
support, of keeping about a third of our men and women unmarried, and of seeing many
of our best emigrate for want of decent prospects at home, we need not be surprised if our
Imperial efficiency diminishes.
On the other hand, if we consider the example of Holland we may be assured that a
further fall in the birth-rate among the poorer classes will be accompanied by an
immediate and progressive improvement in their conditions, by a checking of the output
of physical and mental defectives, and by a gain in the national efficiency, and probably
also in the rate of increase of our population. As the Bishop of Ripon said at the Church
Congress of 1910: “If the diminution of the birth-rate could be shown to prevail among
the unfit, we might view the phenomenon without apprehension, and we might even
welcome the fact as evidence of the existence of noble and self-denying ideals.” There is
no reason why the death-rate in any part of our Empire should be higher than the 9 per
thousand of New Zealand, where poverty as we know it scarcely exists. The birth-rate of
Great Britain can therefore fall to 20 per thousand before our normal natural increase of
11 per thousand is reduced. As this paper is being concluded, the Registrar-General’s
figures for 1913 have come to hand, and show that the fall of the birth-rate in the last
three years has been accompanied by a recovery in the natural increase to 10.8 per
thousand.

DIAGRAMS OF INTERNATIONAL VITAL STATISTICS
Prepared by Charles V. Drysdale, D.Sc., 1911

In the accompanying diagrams white strips imply birth-rates, shaded strips death-rates,
and black strips infantile mortality, or deaths of children under one year. The amount of
the white strip visible above the shaded strip is, of course, the excess of birth over death-
rate, or the rate of natural increase of population.
Fig. 1.—Shows the relation between birth and death-rates and infantile mortality in
various countries in 1901–05.
Fig. 2.—Relation between birth-rate and corrected death-rates in various countries. (This
shows that France is healthier than appears in Fig. 1.)
Fig. 3.—Shows relation between birth and death-rates from various causes in five districts
of London.
Fig. 4.—Relation between the birth-rate and death-rate for various arrondissements of
Paris in 1906. (Note that the increase in the Elysée quarter is as high as the average in the
quarters of high birth-rate.)
Figs. 5 and 6.—Variations of the total population of birth- and death-rates in the United
Kingdom and the German Empire. (Note that the fall in the death-rate corresponds fairly
closely to that in the birth-rate.)
Fig. 7.—The same for France. (Note that the population is still increasing, although
slowly.)
Fig. 8.—Birth and death-rates for France since 1781. (Note that the rate of increase of
population in 1781 was no higher with a birth-rate of 39 per 1,000 than in 1901–6 with a
birth-rate of only 21 per 1,000. A fall of 17.8 per 1,000 in the birth-rate has resulted in a
fall of 17.5 per 1,000 in the death-rate.)
Fig. 9.—Birth and death-rates and infantile mortality for England and Wales. Also
marriage rate, fertility of married women, illegitimacy, and variation of diseases. (Note
that the illegitimate birth-rate has fallen to half since the fall of the birth-rate set in.)
Fig. 10.—Birth and death-rates and infantile mortality in the Netherlands. (Notice the
rapid increase of population as the death-rate falls, and the great fall of infantile mortality,
probably due to the practical work of the Dutch Neo-Malthusian Birth Control League
among the poor.)
Figs. 11–13.—Protestant Countries. (Notice the correspondence between the birth and the
death-rates and infantile mortality in all.)
Figs. 14–16.—Roman Catholic Countries. (Note that the fall of the birth-rate has taken
place almost equally with that in the Protestant countries, and with the same result.)

Figs. 17–20.—The only four countries in which the birth-rate is approximately stationary.
(Notice that the death-rate has not fallen—except perhaps in Russia—and that the
infantile mortality has not fallen. Also that the highest birth-rate produces the highest
death rate and infantile mortality, and the lowest birth-rate the lowest mortality.)
Figs. 21–24.—The only four countries with rising birth-rates. The death rate and infantile
mortality have increased in every one.
Fig. 25.—Australia. The death-rate has fallen with the birth rate, and is now only about 10
per 1,000.
Fig. 26.—New Zealand. The only country in which the fall in the birth-rate has not
produced a fall in the death-rate, and which is not therefore over populated. The infantile
mortality is the lowest in the world, and the death-rate less than 10 per 1,000, which gives
us an ideal which we can reach in all countries by lowering the birth-rate sufficiently.
Fig. 27.—The City of Toronto. The birth-rate has fallen and afterwards risen. The death-
rate has fallen with the birth-rate, and afterwards risen, indicating that the improvements
in sanitation have not been the cause of the falling death rate in other countries.
Fig. 28.—Berlin. The birth-rate rose rapidly from 1841 to 1876, and afterwards fell even
more rapidly. The death-rate, except for epidemics and wars, rose and fell in almost
precise correspondence with the birth-rate.
Fig. 29.—Berlin. The dotted area shows the fertility rate or births per 1,000 married
women, and indicates the remarkably rapid fall since 1876. The correspondence of the
infantile mortality with the birth-rate shown in Fig. 28 is very close.
Figs. 30 and 31.—Europe and Western Europe. These show that the total population of
Europe is increasing faster the more the birth-rate falls, while in Western Europe the birth
and death-rates correspond almost exactly. Calculations made from this show that about
25,000,000 fewer births and deaths have occurred in Europe since 1876, due to the fall in
the birth-rate caused by the Knowlton Trial and the Neo-Malthusian movement. It should
be noted that in the great majority of cases the decline of the birth-rate commenced in
1877, the year of the Knowlton Trial.
CHARLES V. DRYSDALE, D.Sc.
1911.

VARIOUS COUNTRIES
1901–05.

Fig. 1.

VARIOUS COUNTRIES.
CRUDE & CORRECTED DEATH-RATES.

Fig. 2.

LONDON
1905–1909.

Fig. 3.

PARIS
1906.

Fig. 4.

UNITED KINGDOM. Growth of Population.

Fig. 5.

UNITED KINGDOM. Birth and Death Rates.

Fig. 5a

GERMAN EMPIRE. Growth of Population.

Fig. 6

GERMAN EMPIRE. Birth and Death Rates.

Fig. 6a.

FRANCE POPULATION.

Fig. 7

FRANCE.
BIRTH & DEATH RATES.

Fig. 7a.

VARIOUS DISEASES.

Fig. 7b.

FRANCE.
BIRTH & DEATH RATES.

Fig. 8.

ENGLAND & WALES.
BIRTHS & DEATHS. MARRIAGE, FERTILITY, & ILLEGITIMACY.
VARIOUS DISEASES.

Fig. 9

THE NETHERLANDS.

Fig. 10.

NORWAY.

Fig. 11.

SWEDEN.

Fig. 12.

DENMARK.

Fig. 13.

BELGIUM.

Fig. 14.

ITALY.

Fig. 15.

SPAIN.

Fig. 16.

COUNTRIES WITH NEARLY STATIONARY BIRTH-RATE

RUSSIA.

Fig. 17

ROUMANIA.

Fig. 18

JAMAICA.

Fig. 19

IRELAND.

Fig. 20

COUNTRIES WITH RISING BIRTH-RATES

Figs. 21-23

BRITISH COLONIES

CANADA (Ontario).

Fig. 24

AUSTRALIA (Commonwealth).

Fig. 25

NEW ZEALAND.

Fig. 26

THE CITY OF TORONTO.

Fig. 27

BERLIN.

Fig. 28

BERLIN.

Fig. 29

EUROPE.

Fig. 30

WESTERN EUROPE.

Fig. 31

CHAPTER IV
INFANT MORTALITY

In the preceding pages it was stated that a high birth-rate is always accompanied by a high infant mortality. The
material presented in this chapter demonstrates the fact that ignorance of methods to prevent conception forces the
wives of ill-paid wage-workers to bear an excess of unwanted children. Figures are adduced to show an appalling
death rate of infants under five years of age and the economic distress of the survivors in families unwanted and
too large.

MEDICAL GYNECOLOGY. Howard A. Kelly, A.B., M.D., LLD., Professor of Gynecological Surgery in Johns
Hopkins University, and Gynecologist to the Johns Hopkins Hospital, etc. D. Appleton Co. New York and
London, 1912.
As long as a community can rest content in the belief that a large infant mortality is the natural method of reducing
the race of the unfit, the doctrine of laissez-faire can be accepted with complaisance. If, however, it seems probable
that the influence of environment must be reckoned as a greater cause of infant mortality and of physical unfitness
than the influence of heredity, it may be wiser for society, as it certainly will be easier, to preserve the lives and
health of the children born, than to stimulate an increase in a birth rate now diminishing. As it is an open question
whether the race as a whole suffers mental and physical deterioration from a diminished rate of production among
the superior stocks, it is unquestionably a matter of public policy, as well as of common humanity, that conditions
of living in communities should be made favorable to the preservation of the life and health of all infants and
children. P. 41.

EUGENICS AND RACIAL POISONS. Prince A. Morrow, M.D. Pamphlet published by the Society of Sanitary
and Moral Prophylaxis, N. Y., 1912.
Observation shows that the class known as degenerates is increasing much more rapidly than the general
population and that their average duration of life has been lengthened. Diseases may be cured, but degeneracy,
which is usually due to some inherited defect in the physical, mental or moral nature of the individual, is rarely
amenable to curative treatment. It is only through applied eugenics that the vast volume of disease and degeneracy
which flows through the channels of heredity can be prevented. Obviously this can be accomplished only through
education and legislative restriction upon the procreation of the unfit.
In the making of the child, the mother not only contributes one half of the ancestral qualities which enter into its
constitution, but furnishes all the nutrition and energy which serve to support its life. From this point of view the
mother is the supreme parent of the child, she is the source of its life and from her blood is drawn the material
which contributes to its growth and development. The welfare of the mother is the welfare of the child. We have
thus come to recognize the dominant influence of the mother’s relation to the health, as well as the life of the race.
A high standard of physical motherhood is the most favorable asset of a nation. Havelock Ellis, in his recent work,
on the Psychology of Sex, says, “Nations have begun to recognize the desirability of education, but they have
scarcely yet come to recognize that the nationalization of health is even more important than the nationalization of
education. If it were necessary to choose between the task of getting children educated and the task of getting them
well born and healthy, it would be better to abandon education. There have been many great people who never
dreamed of national systems of education; there has been no great people without the art of producing healthy and
vigorous children.”
Newman, the distinguished author of the work on “Infant Mortality” declares that the problem of infant mortality
is not one of sanitation alone, or housing, or indeed of poverty as such, it is mainly a question of motherhood.

It is not probable that the scientific methods which have been successfully applied to plants and the selective
breeding of animals will ever replace the haphazard methods of human reproduction.
There is no fact better established than that a man can transmit only that which he is. If his system is weakened by
excess or tainted with disease he can beget only physical weakness, or beings tainted with disease. The syphilitic,
the consumptive, the epileptic, the alcoholic, should not produce his kind.

NEO-MALTHUSIANISM AND RACE HYGIENE IN “PROBLEMS IN EUGENICS.” Vol. 2. London, 1913. Dr.
Alfred Ploetz, President of the Int. Soc. for Race Hygiene.
Arthur Geissler concluded from a study of about 26,000 births of unselected marriages among miners that the
mortality of children was least in the four first-born, and then increased to a very high rate. Following are
Geissler’s figures, (marriages with only one or two children are omitted).

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

INFANT MORTALITY. Results of a Field Study in Johnstown, Pa., based on Births in one calendar year. By
Emma Duke, Infant Mortality Series, No. 3. Bureau Publication No. 9. U. S. Department of Labor,
Children’s Bureau.
The pamphlet embodies the result of a field study in Johnstown, Pa., based on one calendar year. The inspection
was made in 1913, of the 1911 babies, so that even the last born baby included had reached its first birthday—or
rather had had a chance to reach its first birthday; many of them were dead long before that day. Every mother of a
1911 baby was visited. She was questioned about the health of that child and all her other children. The report
takes up the familiar factors—neighborhood environment, sanitary conditions, sewage, housing, nativity,
attendance at birth, feeding, age of mother, and like matters. Full information is given on these points. Then the
report considers infant mortality from a novel viewpoint—the relation of the death rate to the size of the family.
The Johnstown statistics include families varying in number from one child to ten and over, and varying in health
from none living to all living. The result of the study of infant mortality in relation to the size of the family is thus
stated: “The statistics, based on the results of all her reportable pregnancies, show a generally higher infant
mortality rate where the mother has had many pregnancies, but there is not always an increase from one pregnancy
to the next.” The following table shows this tendency. It is based on the reproductive histories of 1,491 married
mothers who had 5,617 births. Miscarriages are not included.

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

Number of Pregnancies. Infant Mortality Rate.
1 and 2 108.5 per 1,000
3 and 4 126.0 per 1,000

5 and 6 152.8 per 1,000
7 and 8 176.4 per 1,000
9 or more 191.9 per 1,000
Average 149.9 per 1,000
In contemplating these figures we think immediately of wage-earning mothers away from home, ignorant feeding,
and lack of care. These are powerful factors in raising the death rate.
Of all the 1911 babies who died before they were a year old, 37% died in the first month of life. So much pain and
misery and then no baby after all. All the skill in the world could not have saved those babies who lived only long
enough to die.
The infant mortality rate for the babies whose fathers earn under $521 is almost twice as great as for those born
into families in the most prosperous group. These figures strengthen the conclusion reached in the study of the
babies born in 1911, namely that the economic factor is of far-reaching importance in determining the baby’s
chance of life.
One of the tables showing the influence of the economic factor, is calculated on the basis of 1,434 live-born babies
with fathers. 187 of these babies succumbed during the first year, giving a general mortality rate of 130.7 per
1,000. In these families a very few of the mothers worked outside the homes.

Father’s earnings Live-births Deaths 1st year Infant mortality rate
Under $625 384 82 213.5
$625 to $899 385 47 122.1
$900 or more 186 18 96.8
Ample 476 40 84.0
Expressed in words, this table asserts that when the family income is under $625 a year, the children born alive die
before the first birthday at the rate of 213.5 to the 1,000. In striking contrast when the income is $900 or more,
they die only 96.8 to the 1,000. “Ample” was the expression used when the investigator could not obtain exact
information as to the amount, but saw no evidence of actual poverty. The same ratio held good when it was
calculated for the native-born mothers alone and when it was calculated for the foreign-born mothers alone. Even
where mothers are American-born women, staying at home to look after their children, the amount of money to be
spent on the child strongly influences its chance of life and death.
According to this table the superiority which children in indigent households show over children in well-to-do
households is preeminent skill in dying. When father earns $12 a week the children die at the rate of 213 per 1,000;
but when father earns $18 a week, only 96 children per 1,000 pass away the first year of their lives. The lower the
father’s wages, the higher the babies’ death rate. Many a death certificate should read, “Died of poverty.”
The following table is compiled from the 5,617 children borne by 1,491 married mothers, in Johnstown, Pa.

Order of Birth Deaths per 1,000
1st and 2nd born children 138.3
3rd and 4th born children 143.2
5th and 6th born children 177.0
7th and 8th born children 181.5
9th and later born children 201.1
Apparently the size of the family has much to do with the child’s chance of living, and apparently the earlier in the
succession the child is born, the better chance of life it possesses. Death warrants await the coming of the youngest
born.

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

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

U. S. DEPARTMENT OF LABOR CHILDREN’S BUREAU

Julia C. Lathrop, Chief

INFANT MORTALITY

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

By Emma Duke

1915

(Certain tables omitted)

INFANT MORTALITY: JOHNSTOWN, PA.

INTRODUCTION

The term infant mortality, used technically, applies to deaths of babies under 1 year of age. An infant mortality rate
is a statement of the number of deaths of such infants in a given year per 1,000 births in the same year. Some
countries include stillbirths in making the computations, but this method is not generally followed in this country
nor has it been followed in this report.
Ordinary procedure is to compare the live births in a single calendar year with the deaths of babies under 12
months of age occurring in that same year, even though those who died may not have been born within the
calendar year of their death. The infant mortality rates in this report, however, have not been computed on the
usual basis, but for the purpose of securing greater accuracy in measuring the incidence of death this bureau has
considered, in making the computation, only so many of the babies born in the year 1911 as could be located by its
agents, and has compared with this number the number of deaths within this group of babies who died within one
year of birth, even though some of these deaths may have occurred during the calendar year 1912.
Infant mortality can be accurately measured in no other way than by means of a system of completely registering
all births as well as all deaths. In 1911 the United States Bureau of Census regarded the registration of deaths as
being “fairly complete (at least 90 per cent. of the total)” in 23 States, but the same degree of completeness in the
registration of births was found only in the New England States, Pennsylvania, and Michigan, and in New York
City and Washington, D.C. An exact infant mortality rate for the United States as a whole cannot be computed
owing to this generally incomplete registration. In the 1911 census report on mortality statistics, however, the
infant mortality rate is estimated at 124 per 1,000 live births. How this estimated rate compared with the computed
rates for other countries is shown in the following summary:

Deaths of Children under 1 Year of Age per 1,000 Live Births, by Quinquennial Periods from 1901 to
1910, and also for the Single Calendar Years 1909 to 1910.[10]

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

Norway 81 72
New Zealand 75 70 62 68

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 statistics were
both working zealously to enforce birth-registration laws; both were actively interested in reducing infant
mortality, and they welcomed a study of the subject in their State. In Johnstown the mayor, the president of the
board of health, the health officer, and other local officials all showed the same spirit of hearty cooperation and
interest.
Inasmuch as the study was confined to babies born in a single calendar year and work was begun in January, 1913,
the latest year in which the babies could have been born and still have attained at least one full year of life was
1911.
Work was begun on January 15, 1913, with the transcription from the original records at Harrisburg of the names
and other essential facts entered on the birth certificates of babies born in 1911, and, if the baby had died during its
first year of life, items on the death certificate were also copied.
In the meantime the people of Johnstown through the press, and through the clergy in the foreign sections, had
been informed of the purpose and plan of the investigation. Without the friendly spirit thus aroused and the interest
manifested by the Civic Club and other organizations the work could not have been brought to a successful issue.
The investigation was absolutely democratic; every mother of a baby born in 1911, rich or poor, native or foreign,
was sought, and it is interesting to note refusals were met with in but two cases.
The original plan was to limit the investigation to those babies born in the calendar year selected whose births had
been registered, the purpose being to secure facts concerning a definite group and not to measure the completeness
of birth registration. Shortly after beginning the work, however, agents of this bureau were told that the Serbian
women in Johnstown seldom had either a midwife or a physician at childbirth; that they called in a neighbor or
depended upon their husbands for help at such times, or that they managed alone for themselves, and that therefore
their babies usually escaped registration. The omission of these babies meant the exclusion of a number of mothers
in a group that was too important racially to be omitted from an investigation embracing all races and classes.
Accordingly a list of babies christened in the Serbian Church and born in the year 1911 was secured and an attempt
made to locate them. In addition an agent called at each house in the principal Serbian quarter to inquire
concerning births in 1911. A number of unregistered babies of Serbian mothers were thus found and included in
the investigation.
The agents were sometimes approached by mothers of babies born in 1911 who resented being omitted from the
investigation simply for the reason that their babies’ births had not been registered. The agents were therefore
instructed to interview mothers thus accidentally encountered and to include their babies in the investigation. But

no additional baptismal records were copied nor was a house-to-house canvass made of the city; in fact, no further
means were resorted to to locate unregistered babies for the purpose of including them in the investigation.
There were 1,763 certificates copied at Harrisburg, and 1,383 of the babies named in them were reached by the
agents. In addition, 168 babies for whom there were no birth certificates, but who were located in the ways just
noted, were included, making a total of 1,551 completed schedules secured.
Of the 380 not included in the investigation there were 149 who could not be located at all; 220 others had moved
out of reach—that is, into another city or State; 6 of the mothers had died; 3 could not be found at home after
several calls, and 2 refused to be interviewed.
From the following summary of data recorded on the certificates of the 380 unlocated babies just referred to it
appears that the infant mortality rate (134.3) among them is almost the same as that (134) shown in Table 1 for
babies included in the investigation. In reality, however, it is perhaps a little higher, as some of these babies no
doubt died outside of Johnstown and their deaths were recorded elsewhere.

Certifi
NATIONALIT SEX OF BABY. ATTENDANT AT BIRTH. show
Total Live Still-
Y OF deat
births. births. births.
MOTHER. Male. Female. Physician. Midwife. Unknown. duri
first y
Total 380 350 30 227 153 158 180 33
Native 134 118 16 76 58 122 5 7
Foreign 246 232 14 151 95 36 184 26
Slovak, Polish, etc 43 41 2 27 16 4 37 2
Croatian and
13 11 2 10 3 7 6
Servian
Magyar 1 1 1 1
German 8 8 6 2 2 5 1
Italian 41 39 2 26 15 3 36 2
Syrian and Greek 7 6 1 3 4 3 4
British 7 7 3 4 5 2
Austrian (not
otherwise 123 116 7 73 50 19 89 15
specified)
Not reported 3 3 2 1 3

RELATION OF INFANT MORTALITY TO ENVIRONMENT NEIGHBORHOOD
INCIDENCE

The rate of infant mortality is regarded as a most reliable test of the sanitary condition of a district. (Sir Arthur
Newsholme, Elements of Vital Statistics, p. 120. London, 1899.)
Johnstown is a hilly, somewhat Y-shaped area of about 5 square miles which spreads itself out into long, narrow,
irregularly shaped strips, detached by rivers and runs and steep hills. In some places it is not over a quarter of a
mile wide, but its extreme length is about 4 miles. The city is composed of 21 wards and is an aggregation of what
were formerly separate unrelated boroughs or towns. The names of these different sections, together with the
numerical designations of the wards included in or comprising them, are shown in the following table. This table
gives for each section not only the total population according to the Federal census of 1910, but also the number of
live-born babies included in the investigation and the number and proportion of deaths among such babies during
their first year.

Table 1.—Distribution of Population, Live Births and Deaths During First Year, and Infant Mortality
Rate According to Section of Johnstown, for all Children Included in this Investigation.

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

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 water constantly trickle down the numerous alleys and streets that descend the
hill. (See Plate J.) This section makes a very unfavorable first impression because of the open drainage and of the
many dirty, badly paved streets. (See Plate K.) Unlike some of the other wards, it has a rather evenly distributed
population and is without the vast uninhabited areas and acutely congested spots found in some other sections. On
the whole there is little crowding on the lots and there are many good-sized yards. One-third of the population is
foreign born. Of these the Italians are the most numerous. Despite certain ugly spots this section has not the
unwholesome atmosphere that characterizes Woodvale and to a lesser extent Prospect, Cambria City, and
Minersville.
The infant mortality rate of 117.6 per thousand in Roxbury is the same as that of Conemaugh Borough. For reasons
not plainly apparent the rate here is higher than in Moxham, Morrellville, Kernville, or the down-town section,
although it appears to be as favorably conditioned as these sections are from a social, economic, and sanitary
standpoint. Here, as in all these sections, however, are many conditions not conducive to health. For example, parts
of Franklin Street are in bad repair. The roadway is full of ruts and holes; the street, which is seldom sprinkled, is
dusty in dry weather and muddy in wet weather, and in front of good houses along one section of this street runs an
open ditch that receives house drainage.
Moxham has the eighth highest infant mortality rate, it being 89.2. Conditions here are generally rather favorable,
although there is some complaint that at “high water” the sewage received by one of the runs in this section backs
into some of the houses and then the sinks and water-closets overflow. Some of the homes here, near the city
limits, are not supplied with city water but are still dependent upon wells and springs.
One of the three wards constituting Morrellville (ward 18) has a rural appearance; there is little house crowding on
lots, big yards are common, and the streets are not paved. It is, however, marred by an offensive open-ditch sewer.
Ward 19 of Morrellville has a more finished, less rural appearance. One of its objectionable features is that house
drainage and the bloody waste of slaughterhouses are emptied into a shallow stream that flows through it. Ward 20
adjoins ward 19, and although it spreads out into a suburb it appears for the most part to be a comfortable and busy
little village. Strayer’s Run winds about here and receives sewage. The fact that it is without a guardrail in some
places and that the railing is inadequate in others makes it a source of danger, and according to common report
such accidents as children falling into the stream have occurred. The infant mortality rate for Morrellville is 82.5.
Kernville, a section with a considerable proportion of prosperous people, has a very favorable infant mortality rate,
it being 57.7. Parts of this section, however, are on a hill stretching upward from Stony Creek, which is both
unsightly and offensive in warm weather and when the water is low.
The down-town section, i.e., wards 1, 2, 3, and 4, where are to be found many of the best conditioned houses, the
homes of many of the well-to-do people, has the lowest infant mortality rate in the city, it being but 50.
No infant mortality rate is presented in the tables for Coopersdale or for Peelorville. In the first-named section only
36 live-born infants were considered, and 8 of them died in their first year. But this high rate need not be
considered as especially significant, as the base number is small for such a computation. Coopersdale, however, is
a suburban-appearing community in which one would expect the infant mortality rate to be low.
Peelorville is that part of the thirteenth ward which adjoins Prospect. A number of company houses are located
here in which sanitary conditions are fairly good. The ward seems to have good drainage and no sewage nuisances.
It is a community of wage earners and not of prosperous homes. Only 18 babies are included in the report for this
district, one of whom died. With such a small base the infant mortality rate is not significant. (See Plate L.)

SANITARY CONDITIONS—SEWERAGE, PAVEMENTS, GARBAGE COLLECTIONS

The general inadequacy of the sewerage system which has been indicated for the city as a whole is due in part to
the fact that the city is largely an aggregation of sections, formerly independent of Johnstown itself, which have
been annexed at different periods. Some of these boroughs had sewer systems more or less developed when they
were taken into Johnstown; others had none. Not only the sewerage of Johnstown but that of outlying boroughs
pollutes the two shallow rivers, the Conemaugh and the Stony Creek, that flow through Johnstown. These are
burdened with more waste than they can properly carry away, and the deposits which are left on the rocks in
various sections of both rivers create nuisances that are the subject of much complaint, especially during the warm
summer months. (See Plates M, N, O, and P.) At various times agitation has been started to improve the rivers
which, as they flow through Johnstown, are, at the low-water stage, little better than swamps of reeking slime from
the waste matter emptied into them from the hundreds of sewers along their banks. The pipes through which waste
matter is emptied into the streams go only to the river edge, leaving their mouths uncovered and making the river
beds at times pools of slowly flowing filth. These unsightly, malodorous conditions could be remedied if pipes
were extended out into the middle of the streams, where the water is deeper.
With the exception of sprinkling a few wagon loads of lime along the banks of the streams each year, the city has
done nothing to abate the nuisances arising from the use of these rivers as sewers or to restrain the coal and steel
companies from allowing the drainage from mines and mills to enter the streams.
The engineer’s records show that Johnstown had in 1911 a total of 41.1 miles of sewers and 36 sewer outlets, and
82 miles of streets, 52.7 miles being paved. The alleys in Johnstown are generally inhabited. They are narrow and
without sidewalks. Their length is 52.88 miles and 47.35 miles are unpaved. The combined length of streets and
alleys is 134.88 miles. A comparison of this combined length of streets and alleys with the 41.1 miles of sewers
having 36 outlets shows the inadequacy of the sewer system.
Not only is there an absence of paving, but the roadways are in very bad condition. A protest by “A Citizen” in the
Democrat of June 26, 1913, says that there are nine months in the year when it would be impossible for the
proposed fire-department automobile engines to attend a fire in the seventh, eighth, eleventh, seventeenth,
eighteenth, nineteenth, twentieth, and twenty-first wards owing to the condition of the streets.
The scavenger system is also very defective. Citizens are required to pay for the removal of their ashes, trash, and
garbage. Garbage collections are not made by the municipality, but by private contractors, and any sort of
receptacle, covered or uncovered, can or box, is pressed into service by householders. It is by no means uncommon
to find streets and alleys littered with ashes, garbage, bottles, tin cans, beer cases, and small kegs. Dirty streets are
by no means exceptional in Johnstown, even though the State of Pennsylvania has a law (act of Apr. 20, 1905)
which provides for the punishment of any person who litters paved streets. It reads, in part, as follows (sec. 7 of
Pamphlet Laws, 227):
“From and after the passage of this act, it shall be unlawful, and is hereby forbidden, for any person or persons to
throw waste paper, sweepings, ashes, household waste, nails, or rubbish of any kind into any street in any city,
borough, or township in this Commonwealth, or to interfere with, scatter, or disturb the contents of any receptacle
or receptacles containing ashes, garbage, household waste, or rubbish which shall be placed upon any of said
paved streets or sidewalks for the collection of the contents thereof.
“Any person or persons who shall violate any of the provisions of this act shall, upon conviction thereof before any
magistrate, be sentenced to pay the cost of prosecution and to forfeit and pay a fine not exceeding $10 for each
offense, and in default of the payment thereof shall be committed and imprisoned in the county jail of the proper
county for a period not exceeding ten days.”
In a report on infant mortality to the registrar general of Ontario, 1910, Dr. Helen MacMurchy says: “Improve the
water supply, the sewerage system, and the system of disposing of refuse; introduce better pavements, such as
asphalt, and at once there is a decline in infantile mortality.” All these are sanitary features in need of great
improvement in Johnstown, and unquestionably a lowered infant mortality rate would reward any efforts for their
betterment.

HOUSING

In Johnstown the so-called “double” house predominates, usually frame. The double house is in reality two
semidetached houses built upon a single lot. Rows of three or more houses of two, three, or four rooms each are
common, and they are known locally as three-family, or six-family houses, as the case may be. Sometimes these
are “rear houses,” that is, they are built behind other houses that face the street, on the same lots and in fact are
approached by way of a narrow alley running alongside the house that has its frontage directly on the street. For
this type of house water-closets or privies are often in rows in the yard or court that is used in common by all
families. (See Plates Q and R.) In some places they are too few in number to permit each family to have the
exclusive use of one.
Johnstown has three or four comparatively high-grade apartment houses, and in several office buildings rooms are
rented to families for housekeeping. These are generally taken by native families.
In one of these office buildings the two lower floors are used for business purposes and the two upper floors are
given over entirely to tenement purposes. From 40 to 50 families live here, many of whom have but one room. To
serve the 20 or 25 families on each floor there is one bath and toilet room for men and another for women.
Adjoining the toilet rooms is a small room containing garbage cans and trash receptacles for the use of the tenants.
The sanitary conditions in some of the best tenements or apartments, however, are not up to the standards of other
cities, and in those occupied by the poorer people conditions are much worse than are usually permitted to exist in
cities having large tenement houses in great numbers, where a tenement-house problem is recognized as such and
active efforts are made by the municipality to improve conditions.
An absolute measure of the importance of each single housing defect in a high mortality rate can not be secured
from this study. But it is not without interest to note that in homes where water is piped into the house the infant
mortality rate was 117.6 per thousand, as compared with a rate of 197.9 in homes where the water had to be carried
in from outdoors. Or that in the homes of 496 live-born babies where bathtubs were found the infant mortality rate
was 72.6, while it was more than double, or 164.8, where there were no bathtubs. Desirable as a bathtub and bodily
cleanliness may be, this does not prove that the lives of the babies were saved by the presence of the tub or the
assumed cleanliness of the persons having them. In a city of Johnstown’s low housing standards, the tub is an
index of a good home, a suitable house from a sanitary standpoint, a fairly comfortable income, and all the
favorable conditions that go with such an income.
The same trend of a high infant mortality rate in connection with other housing defects is noted in the next table.

Table 3.—Distribution of Live Births and of Deaths During First Year, and Infant Mortality Rate,
According to Housing Conditions.

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

Total 1,463 196 134.0
Dry homes 808 99 122.5
Moderately dry homes 336 47 139.9
Damp homes 319 50 156.7
Bath 496 36 72.6
No bath 965 159 164.8
Not reported 2 1 ([14])
Water supply in house 1,173 138 117.6
Water supply outside 288 57 197.9
Not reported 2 1 ([14])
City water available 1,333 176 132.0

City water not available 128 19 148.4
Not reported 2 1 ([14])
Yard clean 801 80 99.9
Yard not clean 632 107 169.3
No yard 28 8 ([14])
Not reported 2 1 ([14])
Water-closet 739 80 108.3
Yard privy 722 115 159.3
Not reported 2 1 ([14])

14. Total live births less than 50; base therefore considered too small to use in computing an infant mortality
rate.
The following summary may be of interest in indicating some relation between infant mortality and cleanliness or
uncleanliness combined with dryness or dampness of homes:

Table 4.—Distribution of Live Births and of Deaths During First Year, and Infant Mortality,
According to Cleanliness and Dryness of Home.

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

All types 1,463 196 134.0
Clean 943 107 113.5
Moderately clean 354 58 163.8
Dirty 166 31 186.7
Dry 807 99 122.7
Damp 656 97 147.9
Clean:
Dry 581 61 105.0
Damp 362 46 127.1
Moderately clean:
Dry 158 27 170.9
Damp 196 31 158.2
Dirty:
Dry 68 11 161.8
Damp 98 20 204.1
Dirt is doubtless unhealthful, but the amount of ill health or the number of infant deaths caused by a home being
dirty can hardly be measured, when, as is usually the case, the dirt is accompanied by so many other bad
conditions arising from poverty. For example, a home in close proximity to railroad tracks or mills whose stacks
send forth clouds of soot, smoke, and ashes is generally the poorly built home of those who have neither time nor
means to secure and retain cleanliness under such difficulties.
Overcrowding in homes is another factor the relative importance of which can not be exactly determined, because
of its close connection with other ills. But the degree of overcrowding is greatest in the small cheaper houses, those
of one, two, three, or four rooms. The average number of persons per room in the homes of all live-born babies for
whom the data were secured was found to be 1.38. Homes of four rooms were more numerous than those of any
other size and they housed an average of 1.58 persons per room. The number of babies in homes of various sizes
with the number of persons per room for homes of each size was as follows:

Table 5.—Number of Babies Living in Homes of Each Specified Size, and Average Number of Persons Per
Room in Homes of Each Size.

Size of home Live-born babies Persons per room

All homes 1,463
1 room 33 4.42
2 rooms 165 2.27
3 rooms 147 1.83
4 rooms 526 1.58
5 rooms 222 1.22
6 rooms 233 1.07
7 rooms 38 .96
8 rooms 43 0.83
9 rooms 22 .93
10 rooms 4 .88
11 rooms 4 .64
12 rooms 1 .75
13 rooms 1 .69
14 rooms 2 .43
Not reported 22
In homes of one, two, three, or four rooms or where the number of occupants ranged from 4.42 to 1.58 persons per
room the infant mortality rate was 155, as compared with a rate of but 101.8 in larger homes, where the number
ranged from 1.22 to 0.43 persons per room.
The 1910 census returns show that the greatest overcrowding was in ward 15, where the average number of
persons per dwelling was 9.9. Wards 16, 11, and 14 came next with rates of 8.3, 7.7, and 7.2 respectively. The
infant mortality rate for these four wards is 190.2, which is over one-third more than the rate for the whole city.
The mortality rate among infants who slept in a room with no other person than their parents was much lower than
among those who slept in a room with more than two persons. The babies that slept in separate beds also had a
much lower infant mortality rate than those who did not sleep alone, as shown in the next table. (Table omitted.)
In presenting statistics on sleeping and ventilation, only the babies who lived at least one month have been
considered, for the reason that so many deaths during the first month of life were due to prenatal causes.
The incidence shown in the foregoing table is significant, even though it can by no means be deduced therefrom
that the health of a large proportion of babies was so impaired by sleeping with older and more or less unhealthy
persons that death resulted. But irregular night feeding and overfeeding are undoubtedly harmful, and the mother is
tempted to subject the baby to this when it sleeps with her and disturbs her rest.
Of the 1,389 babies who lived at least one month, 600, or 43.2 per cent., lived in homes where the baby slept in a
room with not more than two other persons. The fact that the baby slept in a room with no more persons than its
parents generally argues that the family’s means permitted them to have one or more additional rooms for other
members of the family, but in other cases, of course, merely that there were no other persons in the family.
Almost every home visited had means for good ventilation of the baby’s room at night, yet but 604, or 43.5 per
cent., of the 1,389 babies who lived at least a month slept at night in well-ventilated rooms—that is, in rooms
where, according to the mother’s statement, a window was open all night. Some mothers opened windows when
the weather was neither cold nor damp; or opened them in a hall or room adjoining that where the baby slept;
others emphatically stated that at night the windows were “always shut tight.” The babies subjected to differences
of ventilation show corresponding variations in infant mortality rates.
A high death rate in badly ventilated homes can not be charged wholly to bad air. The mother who did not, or could
not, provide proper ventilation was generally the mother without the means or the knowledge necessary to enable

her to care for her baby properly in other respects, and yet the marked differences suggest that ventilation is itself a
very important ally of the baby in its first year of struggle for existence.
In many rooms that were poorly ventilated, windows were not opened for the reason that the room was not
properly heated and the houses themselves were flimsy and drafty. The problem in such houses is to keep warm. If
the windows were frequently or constantly opened, the houses would be too cold to live in. In some localities the
outside air is so laden with soot, ashes, dirt, and smoke that every effort is made to keep it out of the house.
The foreigners, who generally have the most miserable homes, are not dirty people who select bad living
conditions through innate poor judgment, low standards, and lack of taste. The squalid homes which housed the
natives and later the Germans and the Irish until the present type of immigrants came to do the more poorly paid
work were the only homes available within the purchasing power of their low wages. The new immigrants
demanded practically nothing and the owners did practically nothing in the matter of improving these homes,
which naturally became more and more squalid as time went on. An excessive infant mortality rate and insanitary
homes in unhealthful sections were found to be coexistent.

NATIONALITY

GENERAL NATIVITY

The investigation embraced 860 babies of native mothers (of whom 6 were negroes) and 691 babies of foreign
mothers, making a total of 1,551. The infant mortality rate for the entire group was 134 per 1,000 live births; for
the babies of native mothers 104.3, and for those of foreign mothers 171.3. The stillbirth rate for native mothers
having children in 1911 was less than that for foreign mothers, being 52.3, as compared with 62.2 per 1,000 total
births.
The line between the natives and foreigners is very sharply drawn in Johnstown. The native population as a rule
knows scarcely anything about the foreigners, except what appears in the newspapers about misdemeanors
committed in foreign sections. The report of the Immigration Commission[15] comments “on the attitude of the
police department toward foreigners ... with regard to Sunday desecration,” and states that “the Croatians are
accustomed to spend Sunday in singing, drinking, and noisy demonstrations. The police have been instructed to
show no leniency on account of ignorance of the municipal regulations, and, without any attempt at explaining the
laws, they arrest the offenders in large numbers.” Again, it states: “They are arrested more often for crimes that
make them a nuisance to the native population than for mere infractions of the law.... Few arrests are made for
immorality among foreigners.” “Sabbath desecration” is the crime foreigners are most frequently charged with.

15. United States Immigration Commission Reports, Volume VIII., “Immigrants in Industries: Part 2, Iron and
Steel Manufacturing in the East,” p. 387. Reference is to Johnstown and is a very true picture of various
immigrant institutions and of the comparative progress and assimilation of different races there. Although
the immigration report was made five years before our investigation, conditions remain practically the same.
Foreigners are employed largely in the less skilled occupations of the steel mills, which operate 24 hours a day,
seven days a week. At the time the investigation was made some of the men in the steel mills worked for a period
of two weeks on a night shift of 14 hours, then two weeks on a day shift of 10 hours, and back again to the night
shift of 14 hours for another two weeks, and so on. When shifts were changed, one group of men was required to
work throughout a period of 24 hours instead of for the usual 10 or 14 hour period and another group had 24 hours
off duty. Some departments of the steel mills, however, shut down on Sundays, and in some departments for
certain occupations an eight-hour day prevails, but these more favorable conditions do not prevail among the
majority of the unskilled foreign workers whose homes were visited.
The foreigners who work on a 24-hour shift in a mill on one Sunday frequently “desecrate” their alternate free
Sabbath by “singing, drinking, and noisy demonstrations,” in spite of the known danger of arrest for “crimes that
make them a nuisance to the native population” or for “Sabbath desecration,” laws concerning which are strictly
enforced in Johnstown; for example, children are not permitted to play in public playgrounds on Sunday and
mercantile establishments are required to be closed on that day. Also, it is “unlawful for any person or persons to
deliver ice cream, or to sell or deliver milk from wagon or by person carrying same, within the city on the Sabbath
day, commonly called Sunday, after 12 o’clock m.” The ordinance from which the foregoing sentence was quoted
became a law on January 25, 1914.

SERBO-CROATIAN

The foreign group having the highest infant mortality rate is the Serbo-Croatian[16] where infant deaths numbered
263.9 per 1,000 live births.

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

Three Krainers have also, for convenience, been included in this group. Krainers are Slovenians from the
Austro-Hungarian Province of Carniola and are designated “close cousins of the Croatians but with a
different though nearly related language” by Emily Greene Balch in her book entitled “Our Slavic Fellow
Citizens.”
The men of the Serbo-Croatian group are fine looking and powerful and are employed in the heavy unskilled work
of the steel mills and the mines. They greatly outnumber the women of their race in Johnstown, and a man with a
wife frequently becomes a “boarding boss”; that is, he fills his rooms with beds and rents out sleeping space to his
fellow countrymen at from $2.50 to $3 a month each. The same bed and bedding is sometimes in service both
night and day to accommodate men on the night and the day shifts of the steel mills.
The wife, without extra charge, makes up the beds, does the washing and ironing, and buys and prepares the food
for all the lodgers. Usually she gets everything on credit and the lodgers pay their respective shares biweekly.
These conditions exist to some extent among other foreigners, but are not as prevalent among other nationalities in
Johnstown as among the Serbo-Croatians.
In a workingman’s family, it is sometimes said, the woman’s work-day is two hours longer than the man’s. But if
this statement is correct in general, the augmentation stated is insufficient in these abnormal homes where the
women are required to have many meals and dinner buckets ready at irregular hours to accommodate men working
on different shifts.
The Serbo-Croatian women who, more than any of the others, do all this work are big, handsome, and graceful,
proud and reckless of their strength. During the progress of the investigation, in the winter months, they were
frequently seen walking about the yards and courts, in bare feet, on the snow and ice-covered ground, hanging up
clothes or carrying water into the house from a yard hydrant.
Whether it harmed them to expend their force and vigor as they did could not be determined in individual cases,
but their babies are the ones who died off with the greatest rapidity, their infant mortality rate being 263.9, as
compared with the rates of 171.3 for all the foreign; 104.3 for the natives; and 134 for the entire group as shown in
Table 18. Excluding babies of Serbo-Croatian mothers, the infant mortality rate for babies of foreign mothers is but
159.7.

ITALIAN

The Italian mothers visited in Johnstown bore 75 children in 1911, 4 being stillborn. The infant mortality rate
among the live born was 183.1, the highest of any racial group excepting the Serbo-Croatian, where it was 263.9.
The Italians have been in Johnstown somewhat longer than the Serbo-Croatians and they seem to have a little
firmer grip on the community life there. Their homes are a shade better, a trifle cleaner, and somewhat less
crowded than those of the Serbo-Croatians, although their hygienic standards seem little if any higher and they
rank no better in literacy. The women do not perform the arduous duties that are the lot of so many of the Serbo-
Croatian women; they have not the robust physique of the latter and the men are not found in those branches of the
steel industry which require the extraordinary strength possessed by the Serbo-Croatians. The occupations of the
Italian fathers were found to be more diversified than those of the Serbo-Croatians, some being fruit, grocery, or
cheese merchants; steamship agents; bricklayers, carpenters, or workers at other skilled and semiskilled trades.

SLOVAK, POLISH, ETC.

The infant mortality rate in the group designated “Slovak, Polish, etc.” is 177.1. In this group are included all the
Slavic races represented in the investigation excepting the Serbo-Croatian. The babies of Slovak[17] mothers were
found to be most numerous, there being 276 of them. There were 108 babies of Polish,[18] 2 of Bohemian,[19] and 7
of Ruthenian[20] mothers. In addition, one baby of a Scandinavian (Danish) mother was included, not because
Scandinavians bear the least racial resemblance to the Slavic races, but because the few Scandinavians in
Johnstown happened to be on about the same economic footing as the “Slovak, Polish, etc.”

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

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

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

20. Also known as Little Russians; live principally in southern Russia; also share Galicia with the Poles but
greatly surpassed by Poles in number. In language and physical type resemble Slovaks. Generally Greek
Orthodox, but a few are Greek Catholics of the Roman Catholic Church, whose priests marry, and are
separated from other Roman Catholics by marked religious differences.
The rate for this group is lower than that for either the Serbo-Croatians or the Italians, but it is nevertheless very
high and one exceeded by only a few European countries, as shown by the table on page 12.
Some of the “Slovaks, Poles, etc.,” live in the same squalid sections as the Serbo-Croatians, and in the same type
of inferior houses, but on the whole they have been in Johnstown longer, are more prosperous, and are therefore
beginning to move from Cambria City and Woodvale, where formerly practically all lived, into more desirable
sections. Those who have been in this country longest and intend to stay here are buying homes with large yards in
the less crowded sections and are raising vegetables and flowers. Others, however, still remain in poor
neighborhoods and sometimes buy houses there for from $300 to $600 each, built close together on rented ground.
Lodgers are by no means uncommon among the people in this group, but usually their homes are cleaner, less
crowded, and possessed of more comforts than those of the Serbo-Croatians and Italians.

OTHER NATIONALITIES

The British[21] infant mortality rate in Johnstown is 129 and the German 127.7. The British and Germans in
Johnstown are more prosperous than the Slavic, Magyar, Jewish, Italian, Syrian, and Greek peoples, and regard the
others as “foreigners.” It was strange to hear a man, one who could speak English, say, “We are not foreigners; we
are Germans.” The British and Germans occupy the same relative position economically that they occupy in the
infant mortality scale with relation to other races.

21. English, Irish, Scotch, and Welsh included in the term British.
In the Magyar group, of 38 babies born alive 4 died in their first year, making an infant mortality rate of 105.3,
which is almost as low as that for babies of native mothers. The Magyars are little if any better off than the other
“foreigners” among whom they live, but they possess somewhat higher standards of living. They live in poor
neighborhoods and have inferior houses, but their homes are cleaner and they themselves somewhat more alert,
personally cleaner, and less illiterate than the other foreigners.
There were but 10 babies of Hebrew mothers and 12 of Syrian and Greek mothers; among these there were no
deaths. These groups are too small numerically to be significant in a comparative race study of infant mortality.

STILLBIRTHS
In all there were but 88 stillbirths included in the investigation. They were more numerous proportionately among
the Germans than among the mothers of any of the other nationalities. No single nationality group, however, has a
very large representation, and hence a comparison of the rate for one with that for another nationality is not as
significant as the difference in rate between native and foreign mothers. Although a special study of the causes of
stillbirths was not made in connection with a study of deaths of infants during their first year of life, nevertheless
the incidence of these births among the different nationality groups is believed to be of some interest, and therefore
shown in the next table. (Omitted.)

ATTENDANT AT BIRTH

The native mother usually had a physician at childbirth; the foreign-born, a midwife. The more prosperous of the
foreign mothers, however, departed from their traditions or customs and had physicians, while the American-born
mothers, when very poor, resorted to midwives. The midwives usually charged $5, and sometimes only $3; they
waited for payment or accepted it in installments, and they performed many little household services that no
physician would think of rendering.
Two-thirds of those having no attendant were Serbo-Croatians. It was a Polish woman, however, who gave the
following account of the birth of her last child:
At 5 o’clock Monday evening went to sister’s to return washboard, having just finished day’s washing. Baby born
while there; sister too young to assist in any way; woman not accustomed to midwife anyway, so she cut cord
herself; washed baby at sister’s house; walked home, cooked supper for boarders, and was in bed by 8 o’clock. Got
up and ironed next day and day following; it tired her, so she then stayed in bed two days. She milked cows and
sold milk day after baby’s birth, but being tired hired some one to do it later in week.
This woman keeps cows, chickens, and lodgers; also earns money doing laundry and char work. Husband deserts
her at times; he makes $1.70 a day. A 15-year-old son makes $1.10 a day in coal mine. Mother thin and wiry; looks
tired and worn. Frequent fights in home.
The infant mortality rate was lower for babies delivered by physicians than for those delivered by midwives or for
those at whose birth no properly qualified attendant was present. This is not necessarily an indication of the quality
of the care at birth, although in some cases the inefficiency of the midwife may have directly or indirectly caused
deaths, just as in some instances a physician’s inefficiency may have caused them. The midwife, however, is
resorted to by the poor, and in their homes are found other conditions that create a high infant mortality rate.
Frequently the Serbo-Croatian women dispense altogether with any assistance at childbirth; sometimes not even
the husband or a neighbor assists. Over 30 per cent. of the births among the women of that race took place without
a qualified attendant. More than one-half of those delivered by midwives, less than one-fifteenth of those delivered
by physicians, and about one-fifth of those delivered without a qualified attendant had babies who died in their
first year of life.
Fifteen of the 19 Serbo-Croatian women whose babies died under 1 year of age kept lodgers.
In Johnstown the midwife is resorted to principally by the poor. Recent laws that the State is now trying to enforce
require that the standard for the practice of midwifery be raised. If this can be done midwives might become
definitely helpful persons in the community. One or two of the intelligent graduate midwives in Johnstown have
been an educational force among the foreign mothers for some years past. On the other hand there were others who
were so dirty and so ignorant that they were a menace to the public health.

MOTHERS

LITERACY[22]

There are differences in the infant mortality rate between the babies of literate and the babies of illiterate mothers;
between those with mothers who can speak English and those with mothers who can not; and between babies of
the mothers who have been in this country for a considerable period and those of the newer arrivals. Comparisons
of this nature are confined to the foreign mothers, as only three cases of illiteracy were found among native
mothers, and the other comparisons would not, of course, be applicable in any case to native mothers.

22. By literacy is meant ability to read and write in any language and not simply in English.
The next table shows that the infant mortality rate among the children of illiterate foreign mothers was 214, or 66
per thousand greater than the rate among literate foreign mothers.

Table 13.—Distribution of Births and of Deaths During First Year, Infant Mortality Rate, and Number
and Per Cent of Stillbirths, According to Literacy of Foreign Mothers.

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

ABILITY TO SPEAK ENGLISH

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

Table 14.—Distribution of Births and of Deaths During First Year, Infant Mortality Rate, and Number
and Per Cent of Stillbirths, According to Ability of Foreign Mother to Speak English.

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

YEARS IN THE UNITED STATES

In addition to a consideration of the babies according to their mothers’ ability to speak English, it is of interest to
note the infant mortality rates among babies whose mothers have been in this country for different periods of time.

The high infant mortality rate for the children of newer immigrants, illiterates, and those who can not speak
English is perhaps affected by the fact that they are at the same time generally of the poorest families and are
housed in the most insanitary and unhealthful part of the city.

AGE

The age of the mother is frequently believed to be a factor in the health of the child. The highest infant mortality
rate was found to be that for the group of babies with mothers over 40 years of age, and the lowest for babies of
mothers from 20 to 24 years of age.

Table 16.—Distribution of Births and of Deaths During First Year, Infant Mortality Rate, and Number
and Per Cent of Stillbirths, According to Age of Mother.

DEATHS DURING
STILLBIRTHS.
FIRST YEAR.
Total Live
AGE OF MOTHER. Infant
births. births.
Number. Per cent. Number. mortality
rate.
All mothers 1,551 1,463 88 5.7 196 134.0
Under 20 105 95 10 9.5 13 136.8
20 to 24 476 454 22 4.6 55 121.1
25 to 29 410 391 19 4.6 56 143.2
30 to 39 480 449 31 6.5 61 135.9
40 and over 80 74 6 7.5 11 148.6
The youngest mothers have a higher stillbirth rate than other mothers, and the oldest group of mothers has the next
highest rate. In this connection not only the foregoing table is of interest, but also Table XII, based upon the entire
reproduction histories of the mothers included in this study. As all the children borne by these mothers are
included, the base numbers in the latter table are larger and the figures therefore somewhat more significant.

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

A baby who comes into the world has less chance to live one week than an old man of 90, and less chance to live a
year than one of 80.—Bergeron.
The most dangerous time of life is early infancy; even old age seldom has greater risk. Death strikes most often in
infancy. The Johnstown babies died during their first year of life at the rate of 134 per 1,000 born alive, and they
paid their heaviest toll in their very earliest days. If the total of 196 deaths had been distributed evenly throughout
the 12 months, 8.3 per cent. of the babies would have died each month and 25 per cent. during each quarter. But
instead of that 37.8 per cent. died in the first month; 9.2 per cent. in the second, and 8.2 per cent. in the third, or
over 55 per cent. in the first quarter.

Table 17.—Number and Per Cent Distribution of Deaths of Babies, by Age at Death.

DEATHS OF BABIES OF ALL MOTHERS.
AGE AT DEATH.
Number. Per cent. distribution.
Total deaths in first year 196 100.0
First quarter 108 55.1
First month 74 37.8
First week 45 23.0
Less than 1 day and 1 day 30 15.3
2 days 4 2.0
3 to 6 days 11 5.6

Second week 14 7.1
Third week 7 3.6
Fourth week 8 4.1

Second month 18 9.2
Third month 16 8.2

Second quarter 42 21.4
Third quarter 31 15.8
Fourth quarter 15 7.7
The large number of deaths in the first few hours or days of life indicates that many babies are born with some
handicap and that in many instances the mother has been subjected to some condition which resulted in the birth of
a child incapable of withstanding the ordinary strain of life. Of the 45 babies who died in Johnstown less than a
week after birth, 38 died of prematurity, congenital debility or malformations, or injuries received at birth. In one
other case the cause of death was given as “bowel trouble” and in six other cases it was not clearly defined. In
addition to the 45 babies just referred to as having died in their first week, 12 died later either from prematurity or
from congenital defects.
Of the deaths from causes arising after birth, 52 were attributed by the attending physicians to diarrhoea and
enteritis, 50 to respiratory diseases; and 44 to some other or to some ill-defined cause.

Table 18.—Distribution of Deaths During First Year and Infant Mortality Rate, According to Cause of
Death and Nativity of Mother.

CAUSE OF DEATH. DEATHS DURING FIRST YEAR OF BABIES OF—
All mothers. Native mothers. Foreign mothers.

Infant Infant Infant
Number. mortality Number. mortality Number. mortality
rate. rate. rate.
All causes 196 134.0 85 104.3 111 171.3
Diarrhea and enteritis 52 35.5 17 20.9 35 54.0
Respiratory diseases 50 34.2 19 23.3 31 47.8
Premature births 24 16.4 11 13.5 13 20.1
Congenital debility or
19 12.9 5 6.1 14 21.6
malformation
Injuries at birth 7 4.8 6 7.4 1 1.5
Other causes or not reported 44 30.1 27 33.1 17 26.2
The latest census report on mortality statistics characterizes diarrhoea and enteritis as the “most important
preventable cause of infant mortality” in the United States, and numerically at least it proves to be the most
important cause of infant death in Johnstown.
Holt[23] says that one of the most striking facts about diarrheal diseases in infants is their prevalence during the
summer season. In Johnstown the infant diarrheal deaths were least prevalent in the first quarter of the year, next in
the second, next prevalent in the fourth, and most prevalent in the third or summer quarter.

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

Table 19.—Distribution of Deaths, According to Cause of Death and Quarter of Calendar Year in which
Death Occurred.

QUARTER OF CALENDAR YEAR IN
All
CAUSE OF DEATH. WHICH DEATH OCCURRED.
deaths.
First. Second. Third. Fourth.
All causes 196 54 29 74 39
Diarrhea and enteritis 52 3 5 32 12
Respiratory diseases 50 24 8 7 11
Premature births 24 7 5 9 3
Congenital debility or malformation 19 5 2 8 4
Injuries at birth 7 5 1 1
Other causes or not reported 44 10 8 18 8
Our figures are too small to admit of broad generalizations or a very full discussion of infant deaths according to
the period of the year.
This excess of infant deaths from diarrhea in the summer months has been established by statistics in many
countries, and the cause of such an excess has been the subject of much discussion, but as yet there is no general
agreement. Liefmann and Lindemann[24] conclude, however, that in this field of controversy there are certain facts
which are at present well established, these being the dependence of the high summer mortality on methods of
feeding, on hot weather, and on the living and social condition of the parents. The last factor mentioned by these
authors, including as it does housing conditions, economic status, and degree of intelligence, is becoming more
and more the subject of study and investigation. It has been shown that the distinctly harmful effect of hot weather
on the infant is increased when the housing conditions are bad; in overcrowded homes with bad ventilation the
indoor temperature may be many degrees higher than the outdoor temperature. The ignorance and carelessness of
mothers has also been shown to increase the bad effect of hot weather. With hygienic care, including cool baths,
much fresh air, and careful feeding, many infants are able to pass through extremely hot weather without diarrheal
disturbances.

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

Respiratory diseases were reported as a cause of death with almost as great frequency as diarrheal diseases. As
shown by Table 19, these deaths occurred principally in the colder months of the first and fourth quarters of the
calendar year.

FEEDING

Food is recognized as of such importance in relation to infant mortality that studies of this subject frequently
resolve themselves into studies of feeding only. Invariably these demonstrate the truth of the statement of Dr. G. F.
McCleary[25] that “in human milk we have a unique and wonderful food for which the ingenuity of man may toil in
vain to find a satisfactory substitute.” Many mothers, however, still fail to appreciate the risk their young babies
face in being given any except the natural infant food, and consequently babies are in large numbers wholly or
partly weaned from the breast in the earliest months of their lives.

25. Infantile Mortality and Infants’ Milk Depots. London.
Breast feeding is far more general, comparatively, among the poorer mothers than among the well to do, as shown
by the following summary which gives the number and per cent. of babies of mothers with husbands earning
varying incomes, who had been completely weaned from the breast when they were 3, 6, or 9 months of age,
respectively. For each of the periods indicated the percentage completely weaned from the breast is much greater
in the groups where earnings are highest.

Table 20.—Distribution of Babies Alive at 3, 6, and 9 Months of Age by Type of Feeding at Each of Said
Ages, According to Annual Earnings of Father and Nativity of Mother.

BABIES LIVING AT AGE OF—
ANNUAL 3 months. 6 months. 9 months.
EARNINGS OF Completely Completely Completely
FATHER AND weaned from weaned from weaned from
NATIVITY OF Total. breast. Total. breast. Total. breast.
MOTHER. Per Per Per
Number. Number. Number.
cent. cent. cent.
Total 1,355 193 14.2 1,313 250 19.0 1,282 358 27.5
Under $624 341 22 6.5 322 32 9.9 309 57 18.4
$625 to $899 358 48 13.4 351 63 17.9 342 85 24.9
$900 and over[26] 629 114 18.1 616 146 23.7 608 201 33.1
Not reported[27] 27 9 33.3 24 9 37.5 23 10 43.3

Mother native 765 155 20.3 747 195 26.1 735 251 34.1
Under $624 69 10 14.5 66 13 19.7 65 18 27.7
$625 to $899 180 36 20.0 177 46 26.0 173 55 31.8
$900 and over[26] 491 100 20.4 482 127 26.3 476 168 35.3
Not reported[27] 25 9 36.0 22 9 40.9 21 10 47.6

Mother foreign 590 38 6.4 566 55 9.7 547 102 18.6
Under $624 272 12 4.4 256 19 7.4 244 39 16.0
$625 to $899 178 12 6.7 174 17 9.8 169 30 17.8
$900 and over[26] 138 14 10.1 134 19 14.2 132 33 25.0
Not reported[27] 2 2 2

26. Includes those reported as earning “ample.” “Ample,” as used in this report has a somewhat technical
meaning; when information concerning the father’s earnings was not available and the family showed no

evidences of poverty, the word “ample” was used. When, however, the family was clearly in a state of abject
poverty, it was included in the group “Under $521.”

27. Unmarried mothers’ babies also included.
Breast feeding, wholly or in part, is continued for a longer period by foreign than by native mothers, as indicated in
the preceding table, showing that 20.3, 26.1, and 34.1 per cent. of the native mothers’ babies as compared with 6.4,
9.7, and 18.6 per cent. of the foreign mothers’ babies had been weaned from the breast at the age of 3, 6, and 9
months, respectively.

Table 25.—Distribution of All Births, Live Births, and Stillbirths and of Deaths During First Year, and
Infant Mortality Rate, According to Sex of Baby and Nativity of Mother.

DEATHS DURING
STILLBIRTHS.
FIRST YEAR.
SEX OF BABY AND NATIVITY OF All Live
Rate per Infant
MOTHER. births. births.
Total. 1,000 Total. mortality
births. rate.
BABIES OF NATIVE MOTHERS.

Total number 860 815 45 52.3 85 104.3
Male:
Number 433 406 27 62.4 46 113.3
Per cent. 50.3 49.8 60.0 54.1
Female:
Number 427 409 18 42.2 39 95.4
Per cent. 49.7 50.2 40.0 45.9

BABIES OF FOREIGN MOTHERS.

Total number 691 648 43 62.2 111 171.3
Male:
Number 380 355 25 65.8 59 166.2
Per cent. 55.0 54.8 58.1 53.2
Female:
Number 311 293 18 57.9 52 177.5
Per cent. 45.0 45.2 41.9 46.8

MOTHER’S HOUSEHOLD DUTIES, CESSATION AND RESUMPTION OF

The extent to which the native and foreign mothers in Johnstown relinquished a part of their household duties as
the time for their confinement approached is shown below:

Table 26.—Distribution of Births According to Time of the Mother’s Relinquishment of Part of
Household Duties Before Confinement, by Nativity of Mother.

To
TIME OF RELINQUISHMENT OF PART OF HOUSEHOLD All To native
foreign
DUTIES BEFORE CONFINEMENT. births. mothers.
mothers.
All mothers 1,551 860 691
No household duties relinquished to day of confinement 1,350 695 655
Part of duties relinquished:
Less than 7 days before confinement 3 1 2
7 to 13 days before confinement 7 5 2
2 weeks to 1 month before confinement 16 12 4
1 month or more before confinement 174 146 28
Had no household duties 1 1
Among the 174 babies of mothers who relinquished part of their household duties a month before confinement, the
infant mortality rate was 112.5, as compared with 136.7 for those of other mothers.

Table 27.—Distribution of Births and of Deaths During First Year, and Infant Mortality Rate,
According to Time of Relinquishment of Part of Household Duties of Mother Before Confinement.

Deaths Infant
TIME OF RELINQUISHMENT OF PART OF All Live
during mortality
HOUSEHOLD DUTIES BEFORE CONFINEMENT. births. births.
first year. rate.
All mothers 1,551 1,463 196 134.0
No cessation or less than 1 month 1,376 1,302 178 136.7
1 month or more 171 160 18 112.5
No housework 1 1
To what extent the relinquishment of household duties at a given time directly affected the health of the child can
not be definitely shown. A relation may exist, but on the other hand the difference in the mortality rate may be due
to the fact that the mothers could afford to give consideration to their condition and escape some of their heaviest
tasks as their pregnancy approached its end, and were members of families who were thoughtful of them and
relieved them of these tasks or employed extra household assistance at such times.
Another indication of intelligence and of comfortable surroundings is the care given a mother in the early days of
her baby’s life, particularly if she is a nursing mother. The duration of her rest period before the resumption of part
of her household duties is one measure of this. The foreign mothers, with less education, more numerous and
arduous tasks, less opportunity for leisure, and smaller incomes, begin to resume their housework sooner than the
native mothers with young babies.

Table 28.—Distribution of Live Births and of Deaths During First Year, and Infant Mortality Rate,
According to Time of Mother Resuming Part of Household Duties After Confinement, by Nativity of
Mother.

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

28. Total number of live births less than 50; base therefore considered too small to use in computing an infant
mortality rate.
The fact that a mother takes up her housework in the early days of her baby’s life does not necessarily increase the
danger of its death. In some cases, however, mothers stated that the quantity of their breast milk was noticeably
impaired when they got up and resumed their work too soon. Naturally this would affect the baby’s nutrition. In
other cases a mother’s cares and duties may be so absorbing that she can not give the baby full attention. Whatever
the exact explanation, attention should be called to the greater frequency of infant deaths when the mother resumed
household duties very soon after childbirth.
A statement of the time of the mother’s resumption of household duties in full, like that giving the time of
resumption in part, shows that the native mothers have the longer period of rest.

Table 29.—Distribution of Live Births and of Deaths During First Year, and Infant Mortality Rate,
According to Time of Mother Resuming all Household Duties After Confinement, by Nativity of
Mother.

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

29. Total live births less than 50; base therefore considered too small to use in computing an infant mortality
rate.
The infant mortality rates for all mothers in the group just referred to, according to the time of resuming
housework in full after childbirth, show fewer infant deaths proportionately when the mother has had a longer rest;
that is, a rest of two weeks or more.

ECONOMIC FACTORS

EARNINGS OF FATHER

A grouping of babies according to the income of the father shows the greatest incidence of infant deaths where
wages are lowest, and the smallest incidence where they are highest, indicating clearly the relation between low
wages and ill health and infant deaths.
For all live babies born in wedlock the infant mortality rate is 130.7. It rises to 255.7 when the father earns less
than $521 a year or less than $10 a week, and falls to 84 when he earns $1,200 or more or if his earnings are
“ample.”[30] The variation in the infant mortality rate from one earnings group to another is not perfectly regular
and consistent, but if any two or more consecutive groups are combined an invariable lowering of the infant
mortality rate from one such combined group to that next higher results.

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

Table 30.—Distribution of Live Births and of Deaths During First Year, and Infant Mortality Rate,
According to Annual Earnings of Father and Nativity of Mother, for Legitimate Live-Born Babies.

Deaths Infant
ANNUAL EARNINGS OF FATHER ACCORDING TO Total live
during first mortality
NATIVITY OF WIFE. births.
year. rate.
Total 1,431 187 130.7
Under $625 384 82 213.5
Under $521 219 56 255.7
$521 to $624 165 26 157.6

$625 to $899 385 47 122.1
$625 to $779 224 24 107.1
$780 to $899 161 23 142.9

$900 or more 186 18 96.8
$900 to $1,199 138 14 101.4
$1,200 or more 48 4 83.3

Ample[1] 476 40 84.0

Husbands with native wives 785 76 96.8
Under $625 80 16 200.0
Under $521 32 9 ([31])
$521 to $624 48 7 145.8

$625 to $899 193 20 103.6
$625 to $779 86 6 69.8
$780 to $899 107 14 130.8

$900 or more 129 10 77.5

$900 to $1,199 92 7 76.1
$1,200 of more 37 3 ([31])

Ample[1] 383 30 78.3

Husbands with foreign wives 646 111 171.8
Under $625 304 66 217.1
Under $521 187 47 251.3
$521 to $624 117 19 162.4

$625 to $899 192 27 140.6
$625 to $779 138 18 130.4
$780 to $899 54 9 166.7

$900 or more 57 8 140.6
$900 to $1,199 46 7 152.2
$1,200 or more 11 1 ([31])

Ample[32] 93 10 107.5

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

32. See note on page 45.
In considering the babies of native and of foreign mothers separately in the foregoing table, similar variations in
mortality rates according to earnings of father are found, although the foreign infant death rate is higher in each
group. The foreign are less numerous both actually and relatively in the higher wage groups.
The foreigners of a given wage group almost always live in a poorer neighborhood than the natives earning the
same amount. The foreigners go where they find their own countrymen, most of whom are poor, and hence even
those who earn a fair wage find themselves, until they become Americanized, surrounded by poor conditions and
an ignorant class of people.
It is of interest to note what per cent. of the native and what per cent. of the foreign are in the several earnings
groups. The next table shows this for all married mothers and not simply for those of live-born babies as in the
foregoing table.

Table 31.—Number and Per Cent of Mothers by Nativity, According to the Annual Earnings of Husband.

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

33. See note on page 45.

The 1,491 married mothers included in the foregoing table bore 1,517 babies in 1911, the excess being due to
plural births. The 33 unmarried mothers and their 34 babies (one mother had twins), although included in some of
the general tables, are not included in those relative to the earnings of the husband.

GAINFUL WORK OF MOTHER

In localities where large numbers of women are engaged in industrial work, comparisons are frequently made of
the death rates among their babies with those of the babies of mothers not so engaged. In Johnstown, however,
industrial occupations are not open to women, and but 3.1 per cent. of the mothers visited went outside their homes
to earn money. All mothers who gained money by keeping lodgers or in any other way are, for convenience,
designated “wage-earning” mothers, even though their earnings were not in the form of a definite wage at stated
periods.
Although not industrially engaged, nearly one-fifth of the mothers did resort to some means of supplementing the
earnings of their husbands. Usually they kept lodgers. This was done by the foreign mothers principally, exactly
one-third of whom had lodgers, as compared with less than 1 per cent. of the native women. Usually work done
outside the home consisted either of char work or of assisting husbands in their stores. Generally these stores were
in the same building with the home.
When a mother of a young baby does not give her full time to her duties within the home but resorts to means of
earning money, it generally indicates poverty. This is true to a greater degree in Johnstown than in places which
have many inducements for women to work. In Johnstown, with its excess of males, especially in the foreign
population, the woman’s services are particularly needed to make the home.
In the group where the husband earns $10 a week or less—that is, under $521 a year—many of the women are
wage earners. In each group showing better earnings for the husband the number and percentage of wage-earning
wives decline. Such a tabulation as the following almost automatically fixes the minimum wage on which a man,
wife, and a child or two can live with any degree of comfort in Johnstown at about $780 a year. When the
husband’s wage is less than $780 a year, it is shown that the wives, in considerable number, must be wage earners.
As shown in the next table, in nearly half of the families where the husband earns $10 a week or less (less than
$521 a year), the wife resorted to some means of earning money; when he earned as much as $900 a year, only 8.9
per cent. of the wives worked, and in the small group where the man earns as much as $1,200 a year, only 1 in 50.

Table 32.—Number and Per Cent of Husbands with Wage-Earning Wives, by Nativity of Wife and Annual
Earnings of Husband.

HUSBANDS HAVING HUSBANDS HAVING
TOTAL HUSBANDS.
NATIVE WIVES. FOREIGN WIVES.
ANNUAL
Husbands with Husbands with Husbands with
EARNINGS
wage-earning wage-earning wage-earning
OF
Number. wives. Number. wives. Number. wives.
HUSBAND.
Per Per Per
Number. Number. Number.
cent. cent. cent.
Total 1,491 278 18.6 816 26 3.2 675 252 37.3
Under $521 233 111 47.6 36 9 25.0 197 102 51.8
$521 to $624 174 57 32.8 50 3 6.0 124 54 43.5
$625 to $779 229 51 22.3 86 4 4.7 143 47 32.9
$780 to $899 166 25 15.1 108 6 5.6 58 19 32.8
$900 to $1,199 146 13 8.9 98 1 1.0 48 12 25.0
$1,200 and
50 1 2.0 39 11 1 9.1
over
“Ample”[34] 493 20 4.1 399 3 .8 94 17 18.1

34. See note on page 45.

It is impossible to judge from statistics alone whether or not the work done by an individual woman, either her
own housework or work for money, is so excessive as to affect her during pregnancy or while nursing to the extent
of reacting on the health of the baby; but the fact is that the infant mortality rate is higher among the babies of
wage-earning mothers than among others, being 188 as compared with a rate of 117.6 among the babies of
nonwage-earning mothers. Wage-earning mothers and low-wage fathers are in practically the same groups, and it
is difficult to secure an exact measurement of the comparative weight of the two factors in the production of a high
infant mortality rate.

Table 33.—Distribution of Live Births and of Deaths During First Year, and Infant Mortality Rate for
Babies of Wage-earning and Nonwage-earning Mothers, According to Annual Earnings of Father.

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

35. See note on page 45.

ILLEGITIMACY

Of the 1,551 birth included in this investigation 34, or 2.2 per cent., occurred out of wedlock. Nine of the 32
illegitimate babies who were born alive died during their first year. It is recognized that these figures are a very
small base from which to draw conclusions concerning the effect of illegitimacy on the infant mortality rate. It is
of interest, nevertheless, to note that the findings for this small group are similar to those of countries which
compute an infant mortality rate for legitimate and illegitimate children separately, that is, a rate for illegitimates
more than twice as high as for children born in wedlock.

Table 34.—Distribution of Births and of Deaths During First Year, and Infant Mortality Rate,
According to Legitimacy.

Total DEATHS DURING FIRST YEAR.
LEGITIMACY. Live births.
births. Number. Infant mortality rates.
Illegitimate 34 32 9 281.3
Legitimate 1,517 1,431 187 130.7
Thirty-two, or 3.7 per cent., of the 860 native mothers, as compared with 2, or 0.3 per cent., of the 691 foreign
mothers visited, had illegitimate children in 1911.

REPRODUCTIVE HISTORIES

In addition to the data relating exclusively to babies born in 1911, a statement was secured from each mother as to
the number and duration of each of her pregnancies and the result thereof; that is, the number of children she had
borne, alive or dead, the number of miscarriages she had had, and the age at death of each live-born child who had
died. Although this information was secured for all mothers, tabulations are presented of the data furnished by

married mothers only. Comparatively few single mothers reported more than one child, and information from them
on this point is not believed to be as reliable as that from married mothers.
The 1,491 married mothers of babies born in 1911 had had an aggregate of 5,554 pregnancies, resulting in 5,617
births, the excess of 63 births over pregnancies being due to plural births. Eight hundred and four of these children
died under 1 year of age, making an infant mortality rate of 149.9 for all their babies, as compared with the rate of
134 for those born in 1911. The stillbirths of these women numbered 194, or 4.5 per cent. of the total number of
births; miscarriages reported numbered 191, but these were not added to the total reportable[36] pregnancies.

36. “Reportable” pregnancies are those terminating either in the birth of a live child or of a dead child when the
period of gestation exceeds 28 weeks; that is, when its registration or report is required by law.
Details as to the infant mortality rates for all babies born to native and foreign mothers included in this study, not
only in the year 1911 but at any other time, are presented in the next table, which classifies the babies according to
the total number of reportable pregnancies that their mothers had had, to and including the pregnancy resulting in
the 1911 birth.

Table 35.—Distribution of Mothers, of Live Births, and of Deaths During First Year, and Infant
Mortality Rate for Babies of Native and Foreign Married Mothers, According to the Number of
Reportable Pregnancies.

INFANT MORTALITY RATE
REPORTABLE Number NUMBER OF BABIES.
AMONG BABIES OF—
PREGNANCIES FOR of married
MARRIED MOTHERS. mothers. Born Died in All Native Foreign
alive. first year. mothers. mothers. mothers.
Total 1,491 5,363 804 149.9 113.1 184.6
1 339 322 35 108.7 75.9 183.7
2 283 544 59 108.5 76.5 156.7
3 214 626 92 147.0 118.0 177.6
4 186 723 78 107.9 99.4 116.3
5 147 704 103 146.3 86.1 191.5
6 94 546 88 161.2 157.4 163.6
7 83 555 78 140.5 100.0 173.8
8 54 426 95 223.0 157.6 272.7
9 33 283 41 144.9 128.4 155.2
10 or more 58 634 135 212.9 164.5 257.6
The statistics, based upon the results of all her reportable pregnancies, show a generally higher infant mortality rate
where the mother has had many pregnancies, but there is not always an increase from one pregnancy to the next.
This is more clearly shown when the pregnancies are grouped as in the next table.

Table 36.—Infant Mortality Rate for all Children Borne by Married Mothers, According to Specified
Number of Reportable Pregnancies.

REPORTABLE PREGNANCIES FOR MARRIED MOTHERS. Infant mortality rate.
Total 149.9
1 and 2 108.5
3 and 4 126.0
5 and 6 152.8
7 and 8 176.4
9 or more 191.9
This tendency is shown in still another form of summary: Combinations of four or less pregnancies are, for
convenience, considered as group 1, while the combinations of over four are designated group 2. The differences

in rates in the two groups are notable. The infant mortality rate is much lower for the first than for the second
group.

Table 37.—Infant Mortality Rate for All Children Borne by Married Mothers, According to Specified
Number of Reportable Pregnancies, by Groups

REPORTABLE PREGNANCIES FOR MARRIED MOTHERS. Infant mortality rate.

GROUP 1.

2 or less 108.5
3 or less 124.7
4 or less 119.2

GROUP 2.

Over 4 171.5
Over 5 178.8
Over 6 183.9
This influence of the size of the family upon the infant mortality rate is shown in the computations giving the
relative infant mortality rate for the different children borne by married mothers. The rate is most favorable for the
second-born child, being 131.2. Among first born it is 143.6; for tenth or later born children 252.3.

Table 38.—Infant Mortality Rate for All Children Borne by Married Mothers, According to the
Order in which the Child was Born

ORDER OF BIRTH. Infant mortality rate.
First-born child 143.6
Second-born child 131.2
First and second born children 138.3
Third-born child 144.2
Fourth-born child 142.0
Third and fourth born children 143.2
Fifth-born child 178.1
Sixth-born child 175.5
Fifth and sixth born children 177.0
Seventh-born child 192.1
Eighth-born child 165.4
Seventh and eighth born children. 181.5
Ninth-born child 128.2
Tenth or later born child 252.3
Ninth and later born children 201.1
The next table gives a further elaboration of the same data; that is, it shows the infant mortality rate where such
rates are lowest and highest, respectively, according to the age of the mother at the child’s birth and the order in
which the child was born. Attention is again directed to the fact that the statistics presented in this section on
“Reproductive histories” are based upon the total number of reportable pregnancies; that is, in addition to the
pregnancies resulting in births in 1911, all prior pregnancies of the women considered in the investigation have
been included.

Table 39.—Lowest and Highest Infant Mortality Rates, According to Age of Mother at Birth of Child
and the Order in which Child was Born.

INFANT MORTALITY RATES, ACCORDING TO MOTHER’S
AGE.
ORDER OF BIRTH.
Lowest mortality. Highest mortality.
Mother’s age. Mortality rate. Mother’s age. Mortality rate.
All children 20–24 140.0 Under 17 367.3
First child 25–29 92.1 17–19 190.4
Second child 25–29 100.3 17–19 178.6
Third child 30–39 106.4 25–29 160.8
Fourth child 30–39 122.4 20–24 155.0
Fifth child 30–39 105.8 25–29 236.6
Sixth child 30–39 164.8 25–29 171.4
The difference in size of family for native and foreign mothers of different ages are indicated in the next table. The
total and average number of live-born children, not reportable pregnancies, are given.

Table 40.—Total and Average Number of Live-Born Children Borne by Married Mothers Having Either
a Live Birth or a Stillbirth in 1911, Classified by Nativity and Age of Mother.

AGE OF ALL MARRIED NATIVE MARRIED FOREIGN MARRIED
MOTHER MOTHERS. MOTHERS. MOTHERS.
AT BIRTH
Live-born children. Live-born children. Live-born children.
OF CHILD Total. Total. Total.
IN 1911. Number. Average. Number. Average. Number. Average.
All ages 1,465 5,363 3.7 801 2,600 3.2 664 2,763 4.2
Under 20 years 81 96 1.2 62 70 1.1 19 26 1.4
20 to 24 years 456 908 2.0 258 483 1.9 198 425 2.1
25 to 29 years 389 1,261 3.2 196 536 2.7 193 725 3.8
30 to 39 years 459 2,480 5.4 240 1,188 5.0 219 1,292 5.9
40 years and
80 618 7.7 45 323 7.2 35 295 8.4
over.
The next table shows all losses of pregnancy sustained by 628 mothers and the rate of loss per 1,000 births for
mothers having different numbers of births or reportable pregnancies. For all mothers it was 188.4. “Loss,” as here
used, means the sum of infant deaths (or deaths in first year) and stillbirths.

Table 41.—Aggregate Number of Births, Losses, and Rate of Loss Per 1,000 Births, According to
Number of Births per Mother.

NUMBER OF BIRTHS PER Aggregate number Aggregate number Rate of loss per
MOTHER. of births. of losses. 1,000 births.
Total 5,617 1,058 188.4
1 335 53 158.6
2 554 87 157.0
3 648 113 174.4
4 748 109 145.7
5 740 133 179.7
6 576 119 206.6
7 574 104 181.2
8 432 102 236.1

9 324 65 200.6
10 or more 686 173 252.2
The influence of the economic factor on infant mortality among the babies born prior to 1911 can not be
determined with exactness, as no inquiry was made concerning earnings of the father when the other children were
born. But it is believed that his earnings during the year following the birth of the 1911 baby can be regarded as an
index of the economic standing of the family for some time past. In individual cases, of course, revolutionary
changes in the family’s income may have occurred, but for the great mass of people in the group considered it is
not likely that within such a short space of time as that covered by the child-bearing period of the women
considered—most of whom had not had numerous pregnancies—marked changes had taken place. If these known
earnings are accepted as an index, the following variations are found to occur in the infant mortality rate for all the
babies of whom a record was secured:

Table 42.—Infant Mortality Rate for all Children of Married Mothers Included in this Investigation,
Distributed According to the Father’s Earnings.

FATHER’S ANNUAL EARNINGS. Infant mortality rate.
Under $521 197.3
$521 to $624 193.1
$625 to $779 163.1
$780 to $899 168.4
$900 to $1,199 142.2
$1,200 and over 102.2
The infant mortality rate for the babies whose fathers earn under $521 is almost twice as great as for those born
into families in the most prosperous group. These figures strengthen the conclusion reached in the study of the
babies born in 1911, namely that the economic factor is of far-reaching importance in determining the baby’s
chance of life.

Table V.—Distribution of Live Births and of Deaths During First Year, According to Number of Persons
Rooms per Family.

NUMBER OF BABIES WHO WERE BORN ALIVE AND NUMBER OF SU
PERSONS
All WHO DIED DURING FIRST YEAR IN HOMES HAVING—
PER FAMILY
live 1
(NOT
born 1 2 3 4 5 6 7 8 9 roo
INCLUDING
babies. room rooms rooms rooms rooms rooms rooms rooms rooms an
BABY).
ov
{Births 1,463 33 165 147 526 222 233 38 43 22
Total {Deaths 196 3 29 24 79 20 20 6 6 4
{Births 24 3 7 4 6 2
2 {Deaths 19 1 5 4 6 1

{Births 275 14 46 35 96 29 37 4 6 1
3 {Deaths 31 5 4 12 2 3 3 2

{Births 234 7 44 20 83 40 23 4 5 2
4 {Deaths 30 1 12 5 9 2

{Births 229 27 24 88 31 43 4 5 1
5 {Deaths 22 1 6 9 1 4 1

{Births 182 2 21 17 56 37 34 5 7 2
6 {Deaths 18 4 8 2 3 1

{Births 164 2 10 20 50 32 30 9 6 3
7 {Deaths 15 1 2 6 1 3 1 1

{Births 107 2 5 14 37 16 18 4 6 2
8 {Deaths 17 2 6 3 1 2 1 1

{Births 79 2 2 6 27 13 13 6 2 4
9 {Deaths 8 1 2 2 1 2

{Births 58 1 1 2 26 7 15 1 1 3
10 {Deaths 15 1 11 2 1

{Births 36 1 1 16 3 10 3 2
11 {Deaths 4 1 1 1 1

{Births 21 1 1 10 2 6 1
12 {Deaths 5 2 1 1 1

{Births 20 1 13 4 1 1
13 {Deaths 4 3 1

{Births 8 1 5 2
14 {Deaths 2 1 1

{Births 6 3 2
15 {Deaths 1

{Births 4 4
16 {Deaths 2 2

{Births 3 1 1 1
17 {Deaths

{Births 5 1 1 1 1 1
18 {Deaths 1 1

{Births 2 2
19 {Deaths

{Births 3 1 1 1
20 {Deaths 1 1

{Births 1 1
22 {Deaths 1 1

{Births 1 1
23 {Deaths

Not {Births 1 1
reported. {Deaths

Table VIII.—Distribution of Deaths of Infants at Specified Age, According to Cause of Death of Inf

AGE AT DEATH.
CAUSE OF
Less than 1 week. 1 week but less than 1 month. 1 mon
DEATH OF Total
INFANT deaths 1 2 3 1
AND under 1 week weeks weeks month
3 to m
NATIVITY 1 year day 2 but but but but
Total. 6 Total. Total.
OF of age. or days. less less less less
days.
MOTHER. less. than than than 1 than
th
2. 3. month. 2.
All causes 196 45 30 4 11 29 14 7 8 122 18
Native mothers 85 25 18 3 4 9 2 1 6 51 9
Foreign
111 20 12 1 7 20 12 6 2 71 9
mothers

Diarrhea and
52 1 1 5 3 2 46 5
enteritis
Native mothers 17 1 1 16 3
Foreign
35 5 3 2 30 2
mothers

Respiratory
50 3 3 47 7
diseases
Native mothers 19 19 2
Foreign
31 3 3 28 5
mothers

Premature
24 21 19 2 3 3
births
Native mothers 11 11 11
Foreign
13 10 8 2 3 3
mothers

Congenital
debility or 19 10 7 1 2 6 2 3 1 3 1
malformation
Native mothers 5 4 3 1 1 1
Foreign
14 6 4 1 1 5 2 3 3 1
mothers

Injuries at
7 7 3 2 2
birth
Native mothers 6 6 3 2 1
Foreign
1 1 1
mothers

Other or not
44 6 1 1 4 12 6 1 5 26 5
reported

Native mothers 27 3 1 1 1 8 2 1 5 16 4
Foreign
17 3 3 4 4 10 1
mothers

Table X.—Distribution of Births to Married Wage-earning Mothers, According to Husband’s Annual
Earnings and Nativity and Earnings of Mother.

BIRTHS TO MARRIED WAGE-EARNING MOTHER WITH
NATIVITY AND HUSBAND EARNING ANNUALLY—
Total
ANNUAL EARNINGS OF $521 $625 $780 $1,200
births. Under $900 to Ample.
MARRIED MOTHER. to to to and [37]
$521. $1,199.
$624. $779. $899. over.
All wage-earning mothers 281 112 57 51 25 14 1 21
Under $53 20 6 5 1 4 1 — 3
$53 to $103 57 23 12 11 7 3 — 1
$104 to $207 89 46 16 19 3 3 — 2
$208 to $311 60 23 16 12 4 3 1 1
$312 and over 46 14 8 8 7 2 — 7
Not reported 9 — — — — — 2 7

Native wage-earning
26 9 3 4 6 1 — 3
mothers
Under $53 6 2 1 — 2 1 — —
$53 to $103 5 2 1 2 — — — —
$104 to $207 5 1 1 2 1 — — —
$208 to $311 4 3 — — 1 — — —
$312 and over 3 1 — — 2 — — —
Not reported 3 — — — — — — 3

Foreign wage-earning
255 103 54 47 19 13 1 18
mothers
Under $53 14 4 4 1 2 — — 3
$53 to $103 52 21 11 9 7 3 — 1
$104 to $207 84 45 15 17 2 3 — 2
$208 to $311 56 20 16 12 3 3 1 1
$312 and over 43 13 8 8 5 2 — 7
Not reported 6 — — — — 2 — 4

37. See note on page 45.

Table XI.—Distribution of Results of Reportable Pregnancies (Live Births and Stillbirths) and Mis

NUMBER OF
REPORTABLE REPORTABLE PREGNANCIES AND RESULTS THE
PREGNANCIES
PER MOTHER Total Total Excess Number
AND pregnancies. births. due to of Live births.
NATIVITY OF plural mothers.
MOTHER. births. Number. Numbe Deaths in first ye
r of Number. Numbe
mothers r of

having mothers
live having
births. babies
die.
All married
5,554 5,617 63 1,491 5,363 1,465 804 509
mothers
1 339 343 4 339 322 318 35 34
2 566 576 10 283 544 279 59 54
3 642 650 8 214 626 214 92 75
4 744 752 8 186 723 180 78 64
5 735 740 5 147 704 147 103 67
6 564 568 4 94 546 93 88 60
7 581 586 5 83 555 83 78 48
8 432 437 5 54 426 54 95 42
9 297 299 2 33 283 33 41 20
10 or more 654 666 12 58 634 58 135 45

Native 2,717 2,744 27 816 2,600 801 294 206
1 234 236 2 234 224 222 17 17
2 346 351 5 173 327 170 25 23
3 333 338 5 111 322 111 38 31
4 376 377 1 94 362 94 36 31
5 325 326 1 65 302 65 26 21
6 222 222 37 216 37 34 22
7 266 267 1 38 250 38 25 18
8 184 187 3 23 184 23 29 17
9 117 118 1 13 109 13 14 7
10 or more 314 322 8 28 304 28 50 19

Foreign 2,837 2,873 36 675 2,763 664 510 303
1 105 107 2 105 98 96 18 17
2 220 225 5 110 217 109 34 31
3 309 312 3 103 304 103 54 44
4 368 375 7 92 361 92 42 33
5 410 414 4 82 402 82 77 46
6 342 346 4 57 330 56 54 38
7 315 319 4 45 305 45 53 30
8 248 250 2 31 242 31 66 25
9 180 181 1 20 174 20 27 13
10 or more 340 344 4 30 330 30 85 26

38. Not shown when base is less than 50.

Table XII.—Distribution of Results of Reportable Pregnancies (Live Births and Stillbirths) and Misc
Pregnancy.

NUMBER OF BABIES DYING I
REPORTABLE PREGNANCIES. LIVE BIRTHS.
REPORTABLE YEAR.
PREGNANCIES Total. Number Number. Number Number. Number
Resulting births.
AND AGE OF of of of
MOTHER AT mothers. mothers. mothers.

BIRTH OF
Excess over
BABY BORN IN
1911. Number. pregnancies.
[39]

All married
5,554 5,617 63 1,491 5,363 1,465 804 509
mothers
Under 20 years 107 108 1 89 96 81 12 11
20 to 24 years 933 946 13 461 908 456 140 115
25 to 29 years 1,316 1,329 13 395 1,261 389 185 132
30 to 39 years 2,570 2,595 25 466 2,480 459 382 207
40 years and over 628 639 11 80 618 80 85 44
Average age: 28
years.

1 reportable
339 343 4 339 322 318 35 34
pregnancy
Under 20 years 74 75 1 74 67 66 8 7
20 to 24 years 178 179 1 178 176 175 18 18
25 to 29 years 57 58 1 57 54 53 4 4
30 to 39 years 30 31 1 30 25 24 5 5
Average age: 23
years.

2 reportable
566 576 10 283 544 279 59 54
pregnancies
Under 20 years 24 24 12 21 12 3 3
20 to 24 years 312 317 5 156 302 154 42 37
25 to 29 years 148 151 3 74 141 73 9 9
30 to 39 years 78 80 2 39 76 38 5 5
40 years and over 4 4 2 4 2
Average age: 25
years.

3 reportable
642 650 8 214 626 214 92 75
pregnancies
Under 20 years 9 9 3 8 3 1 1
20 to 24 years 231 234 3 77 227 77 40 31
25 to 29 years 285 288 3 95 277 95 41 33
30 to 39 years 108 110 2 36 105 36 8 8
40 years and over 9 9 3 9 3 2 2
Average age: 26
years.

4 reportable
744 752 8 186 723 186 78 64
pregnancies
20 to 24 years 156 160 4 39 148 39 28 21
25 to 29 years 300 301 1 75 290 75 26 23
30 to 39 years 252 255 3 63 249 63 21 17
40 years and over 36 36 9 36 9 3 3
Average age: 29
years.

5 reportable
735 740 5 147 704 147 103 67
pregnancies
20 to 24 years 50 50 10 49 10 9 7
25 to 29 years 280 283 3 56 266 56 51 31
30 to 39 years 375 377 2 75 361 75 40 27
40 years and over 30 30 6 28 6 3 2
Average age: 30
years.

6 reportable
564 568 4 94 546 93 88 60
pregnancies
20 to 24 years 6 6 1 6 1 3 1
25 to 29 years 132 133 1 22 127 21 23 17
30 to 39 years 360 362 2 60 347 60 54 36
40 years and over 66 67 1 11 66 11 8 6
Average age: 33
years.

7 reportable
581 586 5 83 555 83 78 48
pregnancies
25 to 29 years 98 99 1 14 90 14 23 13
30 to 39 years 392 395 3 56 377 56 45 28
40 years and over 91 92 1 13 88 13 10 7
Average age: 34
years.

8 reportable
432 437 5 54 426 54 95 42
pregnancies
25 to 29 years 16 16 2 16 2 8 2
30 to 39 years 408 413 5 51 403 51 87 40
40 years and over 8 8 1 7 1
Average age: 35
years.

9 reportable
297 299 2 33 283 33 41 20
pregnancies
30 to 39 years 207 208 1 23 195 23 32 15
40 years and over 90 91 1 10 88 10 9 5
Average age: 37
years.

10 or more
reportable 654 666 12 ([41])58 634 58 135 45
pregnancies
30 to 39 years 360 364 4 33 342 33 85 26
40 years and over 294 302 8 25 292 25 50 19
Average age: 39
years.

39. Excess of births over pregnancies due to plural births.

40. Rate not computed because of small base.

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

Table XIII.—Distribution of Results of Reportable Pregnancies (Live Births and Stillbirths) and Mi

SPECIFIED BABIES DYING I
REPORTABLE PREGNANCIES. LIVE BIRTHS.
NUMBER OF YEAR.
PREGNANCIES
FOR ALL Resulting births.
MARRIED Number Number Number
MOTHERS Total. of Number. of Number. of
Excess over
AND ANNUAL mothers. mothers. mothers.
Number. pregnancies.
EARNINGS OF [42]
HUSBAND.
All reportable
5,554 5,617 63 1,491 5,363 1,465 804 149.9
pregnancies
Husband earns:
Under $521 938 946 8 233 902 227 178 197.3
$521 to $624 691 700 9 174 668 173 129 193.1
$625 to $779 816 826 10 229 797 227 130 163.1
$780 to $899 611 616 5 166 588 163 99 168.4
$900 to $1,199 574 581 7 146 548 143 78 142.3
$1,200 and over 196 199 3 50 186 49 30 161.3
Ample[43] 1,728 1,749 21 493 1,674 483 160 95.6

1 reportable
339 343 4 339 322 318 35 108.7
pregnancy
Husband earns:
Under $521 48 48 48 43 43 11
$521 to $624 23 23 23 22 22 2
$625 to $779 46 48 2 46 46 44 6
$780 to $899 35 35 35 32 32 3
$900 to $1,199 38 39 1 38 36 35 4
$1,200 and over 13 13 13 13 13 1
Ample[43] 136 137 1 136 130 129 8 61.5

2 reportable
566 576 10 283 544 279 59 108.5
pregnancies
Husband earns:
Under $521 62 64 2 31 62 31 11 176.4
$521 to $624 72 74 2 36 68 36 8 177.6
$625 to $779 110 111 1 55 108 55 17 157.4
$780 to $899 56 56 28 53 28 9 169.8
$900 to $1,199 46 46 23 41 23 2
$1,200 and over 16 16 8 14 7 1
Ample[43] 204 209 5 102 198 99 11 55.6

3 reportable
642 650 8 214 626 214 92 147.0
pregnancies
Husband earns:
Under $521 114 115 1 38 110 38 27 245.5
$521 to $624 102 104 2 34 101 34 16 158.4
$625 to $779 84 84 28 82 28 13 158.5
$780 to $899 87 87 29 83 29 6 72.3
$900 to $1,199 57 58 1 19 55 19 11 200.0
$1,200 and over 6 7 1 2 7 2 1
Ample[43] 192 195 3 64 188 64 18 95.7

4 reportable
744 752 8 186 723 186 78 107.9
pregnancies
Husband earns:
Under $521 104 104 26 101 26 13 128.7
$521 to $624 88 89 1 22 86 22 10 116.3
$625 to $779 136 137 1 34 129 34 19 147.3
$780 to $899 96 97 1 24 95 24 13 136.8
$900 to $1,199 56 58 2 14 55 14 4 72.7
$1,200 and over 40 41 1 10 39 10 5
Ample[43] 224 226 2 56 218 56 14 64.2

5 reportable
735 740 5 147 704 147 103 146.3
pregnancies
Husband earns:
Under $521 130 131 1 26 125 26 21 168.0
$521 to $624 90 91 1 18 85 18 20 235.3
$625 to $779 100 100 20 99 20 18 181.8
$780 to $899 110 110 22 106 22 13 122.6
$900 to $1,199 65 66 1 13 60 13 6 100.0
$1,200 and over 30 30 6 26 6 10
Ample[43] 210 212 2 42 203 42 15 73.9

6 reportable
564 568 4 94 546 93 88 161.2
pregnancies
Husband earns:
Under $521 132 132 22 124 21 26 209.7
$521 to $624 60 60 10 59 10 9 152.5
$625 to $779 114 115 1 19 110 19 14 127.3
$780 to $899 48 48 8 48 8 7
$900 to $1,199 72 74 2 12 70 12 12 171.4
$1,200 and over 12 12 2 11 2 3
Ample[43] 126 127 1 21 124 21 17 137.1

7 reportable
581 586 5 83 555 83 78 140.5
pregnancies
Husband earns:
Under $521 91 92 1 13 88 13 13 147.7
$521 to $624 56 56 8 51 8 15 294.1
$625 to $779 98 101 3 14 97 14 16 164.9
$780 to $899 35 35 5 32 5 6
$900 to $1,199 84 84 12 79 12 7 88.6

$1,200 and over 21 22 1 3 22 3 1
Ample[43] 196 196 8 186 28 20 107.5

8 reportable
432 437 5 54 426 54 95 223.0
pregnancies
Husband earns:
Under $521 120 120 15 117 15 31 265.0
$521 to $624 96 98 2 12 94 12 22 234.0
$625 to $779 40 41 1 5 41 5 11
$780 to $899 48 49 1 6 46 6 11
$900 to $1,199 24 24 3 24 3 6
$1,200 and over 16 16 2 16 2 3
Ample[43] 88 89 1 11 88 11 11 125.0

9 reportable
297 299 2 33 283 33 41 144.9
pregnancies
Husband earns:
Under $521 81 82 1 9 80 9 15 187.5
$521 to $624 72 72 8 70 8 10 142.9
$625 to $779 18 18 2 15 2
$780 to $899 18 19 1 2 17 2 5
$900 to $1,199 18 18 2 18 2 2
$1,200 and over 18 18 2 16 2
Ample[43] 72 72 8 67 8 9 134.3

10 or more
reportable 654 666 12 58 634 58 135 212.9
pregnancies
Husband earns:
Under $521 56 58 2 5 52 5 10 192.3
$521 to $624 32 33 1 3 32 3 17
$625 to $779 70 71 1 6 70 6 16 228.6
$780 to $899 78 80 2 7 76 7 26 342.1
$900 to $1,199 114 114 10 110 10 24 218.2
$1,200 and over 24 24 2 22 2 5
Ample[43] 280 286 6 25 272 25 37 136.0

42. Excess of births over pregnancies due to plural births.

43. See note on page 45.

Table XIV.—Distribution According to Number of Pregnancies and Age Groups of Married Mothers
Classified by Nativity.

MOTHER’S AGE AND NUMBER NATIVE FOREIGN
ALL MOTHERS.
OF REPORTABLE MOTHERS. MOTHERS.
PREGNANCIES. Number. Per cent. Number. Per cent. Number. Per cent.
Total pregnancies 1,491 100.0 816 100.0 675 100.0
1 339 22.7 234 28.7 105 15.6
2 283 19.0 173 21.2 110 16.3
3 214 14.4 111 13.6 103 15.3

4 186 12.5 94 11.5 92 13.6
5 147 9.8 65 8.0 82 12.1
6 94 6.3 37 4.5 57 8.4
7 83 5.6 38 4.7 45 6.7
8 54 3.6 23 2.8 31 4.6
9 33 2.2 13 1.6 20 3.0
10 and over 58 3.9 28 3.4 30 4.4

Under 20 years, total pregnancies 89 100.0 66 100.0 23 100.0
1 74 83.1 55 83.3 19 82.6
2 12 13.5 10 15.2 2 8.7
3 3 3.4 1 1.5 2 8.7

20 to 24 years, total pregnancies 461 100.0 261 100.0 200 100.0
1 178 38.6 114 43.7 64 32.0
2 156 33.8 86 33.0 70 35.0
3 77 16.7 42 16.1 35 17.5
4 39 8.5 14 5.4 25 12.5
5 10 2.2 4 1.5 6 3.0
6 1 .2 1 0.4

25 to 29 years, total pregnancies 395 100.0 199 100.0 196 100.0
1 57 14.5 45 22.6 12 6.1
2 74 18.7 46 23.1 28 14.3
3 95 24.1 40 20.1 55 28.1
4 75 19.0 40 20.1 35 17.9
5 56 14.2 17 8.5 39 19.9
6 22 5.6 7 3.6 15 7.7
7 14 3.5 4 2.0 10 5.1
8 2 .4 2 1.0

30 to 39 years, total pregnancies 466 100.0 245 100.0 221 100.0
1 30 6.4 20 8.2 10 4.5
2 39 8.4 29 11.8 10 4.5
3 36 7.7 25 10.2 11 5.0
4 63 13.5 33 13.5 30 13.6
5 75 16.1 40 16.3 35 15.8
6 60 12.9 24 9.8 36 16.3
7 56 12.0 28 11.4 28 12.7
8 51 10.9 23 9.4 28 12.7
9 23 4.9 8 3.3 15 6.8
10 and over 33 7.1 15 6.1 18 8.1

40 years and over, total pregnancies 80 100.0 45 100.0 35 100.0
2 2 2.5 2 4.4
3 3 3.8 3 6.7
4 9 11.3 7 15.6 2 5.7
5 6 7.5 4 8.9 2 5.7
6 11 13.8 5 11.1 6 17.1
7 13 16.3 6 13.3 7 20.0
8 1 1.3 1 2.9

9 10 12.5 5 11.1 5 14.3
10 and over 25 31.3 13 28.9 12 34.3

Table XV.—Distribution of Married Mothers by Losses Sustained, According to Nativity of Mother and
Number of Possible Losses.

NUMBER
OF DISTRIBUTION OF MOTHERS ACCORDING TO NUMBER OF LOSSES.
BIRTHS
OR
POSSIBLE
LOSSES Number 10 or
2 3 4 5 6 8
AND of 1 loss. more
losses. losses. losses. losses. losses. losses.
NATIVITY mothers. losses.
OF
MOTHER.
All mothers 1,491 399 121 60 24 13 8 1 2
1 birth 335 53
2 births 277 67 10
3 births 216 73 14 4
4 births 187 55 13 8 1
5 births 148 48 19 11 1 2
6 births 96 44 13 8 2 1 2
7 births 82 22 19 10 2 1
8 births 54 18 8 10 4 2 2
9 births 36 9 10 5 1 1 2
10 or more
60 10 15 4 13 7 1 1 2
births

Native
816 199 59 19 5 6 1 1
mothers
1 birth 232 29
2 births 170 36 5
3 births 111 35 7 1
4 births 98 33 6 3
5 births 65 19 10 4
6 births 38 19 7 1 1
7 births 37 10 8 3 1
8 births 21 8 5 3
9 births 15 4 4 3 1
10 or more
29 6 7 1 4 5 1
births

Foreign
675 200 62 41 19 7 7 2
mothers
1 birth 103 24
2 births 107 31 5
3 births 105 38 7 3
4 births 89 22 7 5 1
5 births 83 29 9 7 1 2
6 births 58 25 6 7 2 2

7 births 45 12 11 7 2
8 births 33 10 3 7 4 2 2
9 births 21 5 6 2 1 2
10 or more
31 4 8 3 9 2 1 2
births

Population, Registered Births, Deaths of Infants under 1 Year of Age, and Infant Mortality Rates for
Registration States and Registration Cities having a Population of at Least 50,000 in 1910.

DEATHS[44] OF INFANTS
UNDER 1 YEAR OF AGE.
AREA.
Population in Per 1000
Births.[45] Number.
1910. births.[46]
REGISTRATION STATES.

Connecticut 1,114,756 27,291 3,476 127
Maine 742,371 15,578 2,108 135
Massachusetts 3,366,416 86,765 11,377 131
Michigan 2,810,173 63,566 7,912 124
New Hampshire 430,572 9,385 1,373 146
Pennsylvania 7,665,111 202,631 28,377 140
Rhode Island 542,610 ([47])6,595 ([47])1,111 ([47])168
Vermont 355,956 7,343 791 168

REGISTRATION CITIES OF
50,000 POPULATION OR OVER
IN 1910.

Connecticut:
Bridgeport 102,054 2,976 367 123
Hartford 98,915 2,411 286 119
New Haven 133,605 3,772 406 108
Waterbury 73,141 2,150 320 149

Washington, D. C. 331,069 7,016 1,068 152
Portland, Me. 58,571 1,163 167 144

Massachusetts:
Boston 670,585 17,760 2,246 126
Brockton 56,878 1,359 134 99
Cambridge 104,839 2,462 293 119
Fall River 119,295 4,591 854 186
Holyoke 57,730 1,702 362 213
Lawrence 85,892 3,165 529 167
Lowell 106,294 2,630 607 231
Lynn 89,336 2,218 216 97
New Bedford 96,652 3,873 685 177
Somerville 77,236 1,728 174 101
Springfield 88,926 2,438 302 124
Worcester 145,986 3,918 536 137

Michigan:
Detroit 465,766 11,960 2,138 179
Grand Rapids 112,571 2,693 329 122
Saginaw 50,510 897 130 145

Manchester, N. H. 70,063 1,939 375 193

New York, N. Y. 4,766,883 129,316 6,159 125
Bronx Borough 430,980 10,926 11,047 96
Brooklyn Borough 1,634,351 43,128 5,063 117
Manhattan Borough 2,331,542 66,112 8,900 135
Queens Borough 284,041 7,095 865 122
Richmond Borough 85,969 2,055 284 138

Pennsylvania:
Allentown 51,913 1,406 202 144
Altoona 52,127 1,392 166 119
Erie 66,525 1,713 197 116
Harrisburg 64,186 1,308 169 129
Johnstown 55,482 1,628 268 165
Philadelphia 1,549,008 38,666 5,334 138
Pittsburgh 533,905 15,059 2,259 150
Reading 96,071 2,370 336 142
Scranton 129,867 3,512 520 148
Wilkes-Barre 67,105 1,840 269 146

Rhode Island:
Pawtucket 51,622 ([48]) 191 ([48])
Providence 224,326 ([48]) 827 ([48])

44. Exclusive of stillbirths.

45. Provisional figures; exclusive of stillbirths.

46. Based on provisional figures for births.

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

48. Returns of births not received from State board in time for inclusion.
It will be seen by this table that Johnstown is among the 10 cities of more than 50,000 population which had an
infant mortality rate of 1910 in excess of 150 per 1,000 births. These 10 cities and their respective rates are as
follows: Lowell, Mass., 231; Holyoke, Mass., 213; Manchester, N. H., 193; Fall River, Mass., 186; Detroit, Mich.,
179; New Bedford, Mass., 177; Lawrence, Mass., 167; Johnstown, Pa., 165; Washington, D. C., 152; and
Pittsburgh, Pa., 150.
It should be borne in mind that the absolute infant mortality rate of 134, computed for the group of babies included
in this investigation, that is, for those born in Johnstown in 1911, can not be compared with any of the approximate
rates in the foregoing table, since the basis of computation is entirely different. But the method used in this report
seemed to be the only practicable one for our purpose, namely, to measure the infant mortality rate in different
districts of the city where the babies are subjected to varying conditions.
Conditions similar to those existing in Johnstown were found in Chicago by Dr. Alice Hamilton, Bacteriologist in
the Memorial Institute for Infectious Diseases, Hull House. The results of a study made of 1,600 families in the
neighborhood was published in 1910. The investigation was undertaken to find out the truth or falsity of a general
feeling among the district nurses that a high birth rate was accompanied by a high death rate. It was found that a

high birth rate was not so much accompanied as outrun by a high death rate. The number of children live-born was
compared with the number of children who reached the age of three, so it is a study of child mortality, rather than
of infant mortality. The child mortality rate rises and falls very much as does the infant mortality rate in
Johnstown. A table calculated from the data of all the families shows an ascending mortality rate:

No. in Family Child Mortality Rate
4 children and less 118
6 children and more 267
7 children and more 280
8 children and more 291
9 children and more 303
Expressed in words this table says that child mortality increases as the number of children per family increases,
until we have a death rate in families of eight and more, which is two and a half times as great as that in families of
four children and under.

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

INFANT MORTALITY—MANCHESTER

The findings of the bureau’s earlier study in Johnstown, Pa., are confirmed in many respects by the findings in
Manchester—the coincidence of a high infant mortality rate with low earnings, poor housing, mother’s work, and
large families.
The mortality rate among the 1,564 live-born babies studied in Manchester was 165 per 1,000 births, which is
considerably higher than the estimated rate for the whole country.
Manchester is primarily a textile town, and the textile mills employed 36.3 per cent. of all the fathers of babies
born in Manchester during the 12 months covered by the study. Of the fathers, 13.7 per cent. were earning less
than $450 per year; 48.5 per cent. less than $650; 22.9 per cent. $850 or more; 6.4 per cent. $1,250 or more.
Of the babies with fathers earning less than $450, about 1 in 4 died before it was 12 months old. The great majority
of the babies had fathers in the wage group from $450 to $849, and of these about 1 in 6 died. Of the babies whose
fathers earned $850 but less than $1,050, 1 in 8 failed to survive. Where the fathers earned $1,050 or more, 1 baby
in 16 died in the first year.
Where families lived two or more persons per room, the infant death rate was twice as high as where they lived
less than one person per room. The babies living in houses occupied by a single family died at the rate of 86.1 per
1,000, but those in tenements occupied by more than six families died at the rate of 236.6 per 1,000.
When the mother was a wage earner the baby’s chances of living were less than when she was not. Babies of
mothers who had worked at some time during the year before the baby’s birth died at the rate of 199.2 per 1,000,
while babies of nonworking mothers died at the rate of 133.9. Babies of mothers employed away from home some
time during the year after childbirth while the baby was still alive and under four months old had a rate of 277.3,
while babies of mothers not employed during that time had a rate of 122.
Babies of foreign-born mothers did not fare so well as babies of native mothers. The differences of rates, however,
are only partly accounted for by their lower earnings. The largest foreign element in Manchester is Canadian
French, and among them the infant mortality rate, 224 per 1,000 live births, is greater than that among any other
group of the population, although their earnings are in general higher than those of other foreigners.
Sheer size of family appears to be one factor in this high Canadian-French rate, one-third of their babies being
sixth or later in order of birth, while over one-sixth of these mothers had had from 9 to 18 children. These
Canadian-French babies in families of 6 or more children died at the rate of 246.2 per 1,000 and the rate rises to
277.2 per 1,000 when only babies ninth or later in order of birth are considered.

CHAPTER V
MATERNAL MORTALITY AND DISEASES
AFFECTED BY PREGNANCY

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

THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL
BIOLOGICAL AND HYGIENIC ASPECTS. E. HEINRICH KISCH,
M.D., Professor of the German Medical Faculty of the University of
Prague, Physician to the Hospital and Spa of Marienbad, Member of
the Board of Health, etc. Translated by M. Eden Paul, M.D. Rebman
Co., New York.
It is astonishing to observe the number of full term deliveries and
miscarriages that a woman will experience within a comparatively short
period of time, as is seen too frequently among the laboring classes, and
more especially, among the factory workers. If we assume the original
mortality of childbirth to be 6 per mille, a woman who in the course of 15
years undergoes labor (at full term or prematurely) 16 times, runs a risk of
death to be expressed by the ratio of 6 × 16 = 96 per mille; that is to say, on
the average of 1,000 women who became pregnant as often as this, nearly
one in ten will die in childbed. P. 278.

In certain serious general disorders, in diseases of the heart, or of the lungs,
in pelvic deformity, and in pathological changes of the female reproductive
organs, it may be right to employ means for the prevention of pregnancy—
not merely sexual abstinence, but actual measures to prevent fertilization. P.
395.
Based upon the observations of Schauta and Fellner, the latter author
advances the rule that in the case of a woman suffering from disease,
marriage should be forbidden only when the mortality from the disease in
question is not less than 10%. In this category we must include severe cases
only of pulmonary tuberculosis, whilst cases of laryngeal tuberculosis will,
according to this rule, be absolutely unfit for marriage. Among heart
affections contra-indicating marriage, he includes mitral stenosis, other
valvular affections in which there is serious disturbance of compensation,
and myocarditis; he considers marriage inadmissible also in cases of
chronic nephritis, and among surgical affections, in case of malignant
tumor. No case in which during a previous pregnancy the patient has been
affected by one of the following diseases; viz. severe chorea, mental
disorders, severe epilepsy, pulmonary tuberculosis which progressed much
during pregnancy, morbus cordis, with considerable disturbance of
compensation, severe heart trouble due to Graves disease—in all such cases
a repetition of pregnancy should be avoided. P. 261.

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

MATERNAL MORTALITY

A study of maternal mortality, by Dr. Grace L. Meigs, head of the hygiene
division of this bureau, has been undertaken as a direct corollary to the
infant mortality inquiry. The sickness or death of the mother inevitably
lessens the chances of the baby for life and health. A large proportion of the
deaths of babies occur in the first days and weeks of life, and these early
deaths can be prevented only through proper care of the mother before and
at the birth of her baby.
In the introduction to the report on “Maternal mortality in connection with
childbearing,” issued as a supplement to his report as medical officer of the
local government board of Great Britain for 1914–15, Sir Arthur
Newsholme says:
The present report is intended to draw attention to this unnecessary
mortality from childbearing, to stimulate further local inquiry on the
subject, and to encourage measures which will make the occurrence of
illness and disability due to childbearing a much rarer event than at present.
The attainment of these ends is important as much in the interest of the
child as of its mother. That the welfare of the child is wrapped up in that of
the mother was fully recognized in the board’s circular letter of 31st July,
1914, and the schedule appended to that letter; and each year it is becoming
more fully realized that, in order to insure healthy infancy and childhood, it
is necessary that, both during pregnancy and at and after the birth of the
infant, increased maternal care and guidance and medical assistance should
be provided.
The Children’s Bureau studies of infant mortality in town and country
reveal clearly the connection between maternal and infant welfare and make

plain that infancy can not be protected without the protection of maternity.
In her report Dr. Meigs undertakes to do no more than to assemble and
interpret figures already published by the United States Bureau of the
Census and in the mortality reports of various foreign countries and to state
accepted scientific views as to the proper care of maternity. She shows that
maternal mortality, although in great measure preventable, is not decreasing
in the United States. Her report reveals an unconscious public neglect due
to age-long ignorance and fatalism. As soon as the public realizes the facts
to which Dr. Meigs calls attention it doubtless will awake to action, and
suitable provision for maternal and infant welfare will become an integral
part of all plans for local protection of public health.
The report is summarized as follows:
“In 1913 in this country at least 15,000 women, it is estimated, died from
conditions caused by childbirth; about 7,000 of these died from childbed
fever, a disease proved to be almost entirely preventable, and the remaining
8,000 from diseases now known to be to a great extent preventable or
curable. Physicians and statisticians agree that these figures are a great
underestimate.
“In 1913 the death rate per 100,000 population from all conditions caused
by childbirth was but little lower than that from typhoid fever; this rate
would be almost quadrupled if only the group of the population which can
be affected, women of childbearing age, were considered.
“In 1913 childbirth caused more deaths among women 15 to 44 years old
than any disease except tuberculosis.
“The death rate due to this cause is almost twice as high in the colored as in
the white population.
“Only 2 of a group of 15 important foreign countries show higher rates
from this cause than the rate in the registration area of the United States.
The rates of three countries, Sweden, Norway, and Italy, which are notably
low, show that low rates for these conditions are attainable.
“The death rates from childbirth and from childbed fever for the registration
area of this country are not falling; during the 13 years from 1900 to 1913
they have shown no demonstrable decrease. These years have been marked
by a revolution in the control of certain other preventable diseases, such as

typhoid, diphtheria, and tuberculosis. During that time the typhoid rate has
been cut in half, the rate of tuberculosis markedly reduced, and the rate for
diphtheria reduced to less than one-half. During this period the death rate
from childbirth has decreased in England and Wales, Ireland, Australia, and
Japan. The other foreign countries studied show stationary or slightly
increasing rates. The death rate from childbed fever has decreased only in
England and Wales, Ireland, and Scotland.
“These facts point to the need in this country and in foreign countries of
higher standards of care for women at the time of childbirth.
“The low standards at present existing in this country result chiefly from
two causes: (1) General ignorance of the dangers connected with childbirth
and of the need for proper hygiene and skilled care in order to prevent
them; (2) difficulty in the provision of adequate care due to special
problems characteristic of this country. Such problems vary greatly in city
and in country. In the country inaccessibility of any skilled care, due to
pioneer conditions, is a chief factor.
“Improvement will come about only through a general realization of the
necessity for better care at childbirth. If women demand better care,
physicians will provide it, medical colleges will furnish better training in
obstetrics, and communities will realize the vital importance of community
measures to insure good care for all classes of women.”
While the figures given by Dr. Meigs are a startling indication of the great
number of maternal fatalities occurring in various parts of the country, no
estimates can be made of the number of mothers who survive only to suffer
from a degree of preventable ill health which limits or defeats the well-
being and happiness of their households.

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

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

For the last two decades civilized countries have been absorbed in the
problem of preventing the enormous and needless waste of human life
represented by their infant death rates. The importance of this problem has
been felt more keenly in the last two years in the countries now at war; in
these countries the efforts toward saving the lives of babies have redoubled
since the war began. Side by side with this problem, another, which is only
of late finding its true place, is that of the protection of the lives and health
of mothers during their pregnancy and confinement. This is a question so
closely bound up with that of the prevention of infant mortality that the two
can not be separated.
It is now realized that a large proportion of the deaths of babies occur in the
first days and weeks of life, and that these deaths can be prevented only
through proper care of the mother before and at the birth of her baby. It is
also realized that breast feeding through the greater part of the first year of
the baby’s life is the chief protection from all diseases; and that mothers are
much more likely to be able to nurse their babies successfully if they
receive proper care before, at, and after childbirth. Moreover, in the
progress of work for the prevention of infant mortality it has become ever
clearer that all such work is useful only in so far as it helps the mother to
care better for her baby. It must be plain, then, to what a degree the sickness
or death of the mother lessens the chances of the baby for life and health.
This question has also another side. Each death at childbirth is a serious loss
to the country. The women who die from this cause are lost at the time of
their greatest usefulness to the State and to their families; and they give
their lives in carrying out a function which must be regarded as the most
important in the world.
Questions then of the most vital interest to the whole Nation are these: How
are the lives of the mothers in this country and other countries being
protected? To what degree are the diseases caused by pregnancy and

childbirth preventable? If preventable, how far are they being prevented in
this country? Has there been the same great decrease in the last few years in
sickness and death from these causes as that which has marked the great
campaigns against other preventable diseases such as typhoid, tuberculosis,
or diphtheria? How do the conditions in the United States compare with
those in other countries?
Puerperal septicemia (childbed fever).—The fact is now well known that
puerperal septicemia, or childbed fever, is in reality a wound infection,
similar to such an infection after an accident or an operation, and that it can
be prevented by the same measures of cleanliness and asepsis which are
used so universally in modern surgery to prevent infection. The proof of the
nature of this disease is one of the tremendous results of the scientific
discoveries which were made in the latter part of the nineteenth century.
During the early part of that century childbed fever was one of the greatest
hospital scourges known. It occurred also in private practice; but in
hospitals where there was great opportunity for the spreading of infection
the death rate from this disease was appalling. The average death rate in
hospitals in all countries was 3 to 4 per cent. of all women confined;
sometimes it reached 10 to 20 per cent. and even over 50 per cent. during
short periods of epidemics. In the face of this terrific mortality many
obstetrical hospitals were closed. Commissions were appointed to
investigate the cause of these epidemics, and medical congresses devoted
sessions to the discussion of the problem. In 1843 Oliver Wendell Holmes,
and in 1847 Semmelweiss, published articles stating the theory that this
fever was similar to a wound infection and was due chiefly to the carrying
of infectious material on the hands of attendants from one case to another.

NUMBER OF DEATHS IN THE UNITED STATES FROM
CHILDBIRTH

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

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

DEATH RATES IN THE UNITED STATES FROM CHILDBIRTH

The death rate from all diseases caused by pregnancy and confinement in
1913 in the registration area was 15.8 per 100,000 population (which
includes all ages and both sexes). The death rate from puerperal septicemia
was 7.2.
These figures, however, mean little to us unless we compare them with the
death rates from other preventable diseases. In the same year and area the
typhoid rate was 17.9 per 100,000 population; the rate from diphtheria and
croup 18.8. The highest death rate from any one disease was that from
tuberculosis, 147.6 per 100,000 population. Any such comparison with the
rates from diseases to which both sexes and all ages are liable is of course
very misleading; but in spite of that fact it is interesting to note that typhoid
fever, the disease against which so great an amount of effort is now
directed, has a rate at present but 2 per 100,000 population higher than that
from the diseases caused by pregnancy and confinement.
Death rates per 100,000 women.—The death rates from childbirth are
approximately doubled when worked on the basis of 100,000 women. This
will be seen when Tables IV and III (p. 50) are compared. The former gives
for the period 1900 to 1910, the annual death rates per 100,000 women in
the group of 11 States which were in the death-registration area in 1900, the
latter the death rates per 100,000 population in the same group of States for
the same period. It is evident that the rates in Table IV for each year are
slightly more than twice those in Table III for the same year.
Death rates per 100,000 women of childbearing age.... Again, a much
higher but a more accurate death rate from these diseases is found when the

basis taken is the group which alone is affected by these diseases—women
of childbearing age. When the rate is based not upon 100,000 population of
both sexes and all ages but upon 100,000 women 15 to 44 years of age, the
rate as ordinarily given is multiplied several times.
In 1900, the only year for which the rates can be computed, the death rate in
the registration area per 100,000 women 15 to 44 years of age from all
diseases of pregnancy and confinement was 50.3; from puerperal infection,
21.6. The corresponding rates for the same year per 100,000 population
were 13.1 and 5.6. In this year, therefore, the rates are almost quadrupled
when based on that group of the population which alone can be affected by
these diseases.
Moreover, the death rates as ordinarily given per 100,000 population
conceal the fact that the diseases of pregnancy and childbirth are indeed
among the most important causes of death of women between 15 and 44
years of age; the actual number of deaths shows this to be the case. In 1913
in the registration area these diseases caused more deaths than any other
one cause of death except tuberculosis. In that year there were, among
women 15 to 44 years of age, 26,265 deaths from tuberculosis; 9,876 deaths
from the diseases of pregnancy and confinement; 6,386 from heart disease;
5,741 from acute nephritis and Bright’s disease; 5,065 from cancer; and
4,167 from pneumonia. Other diseases, such as typhoid, appendicitis, and
the infectious diseases show far fewer deaths.
Death rates per 1,000 live births.—This rate, as will be shown repeatedly
throughout the report gives a far clearer picture of the actual risk of
childbirth than do any of the rates so far considered. This rate can be given
only for one year, 1910, and only for the provisional birth-registration area
for that year. The rate from all diseases caused by pregnancy and
confinement is 6.5, from puerperal septicemia, 2.9, and from all other
diseases of pregnancy and confinement, 3.6 per 1,000 live births. That is, in
this area for every 154 babies born alive one mother lost her life.

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

Are the death rates from these diseases in the death-registration area of the
United States higher or lower than those in other civilized countries? Have
these rates in other countries been falling or rising in the last 13 years, while
the rates of this country have been apparently stationary? These questions,
like all those of comparative international statistics, are of immense interest,
but they involve many difficulties and sources of error. They should be
considered in reading the following summary.
In order to make possible a comparison of the death rates from these causes
for 15 foreign countries with those for the United States, an average rate has
been computed for the years 1900 to 1910 for each of the countries, using
the same method as that in use in the United States. When the 16 countries
studied are arranged in order, with the one having the lowest rate first, the
death-registration area of the United States stands fourteenth on the list.
(See Table XII, p. 56.) Only two countries, Switzerland and Spain, have
higher rates; many of the countries, however, show rates differing but little
from that of the United States. Markedly low rates are those of Sweden (6),
Norway (7.8), and Italy (8.9); a strikingly high rate is that of Spain (19.6).
The death rate from childbirth per 1,000 live births is not available for the
death-registration area of the United States, but can be given only for the
small number of States and cities included in the provisional birth-
registration area and for one year, 1910. (See p. 31.) This rate, 6.5, is
considerably higher than that for 1910 of any of the countries studied.
When the average rates for a number of years of the 15 countries are
reckoned per 1,000 live births and arranged in order, it will be seen that the
same group of countries—Sweden, Italy, and Norway—shows the lowest
rates. (See Table XIII, p. 56.) Spain in this table shows the rate which is
next to the highest, while Belgium now has the highest rate. For a
comparative study of the rates of these countries the rates per 1,000 live
births give undoubtedly the clearest picture of the actual conditions.
These rates show a wide variation. While in Sweden but one mother is lost
for every 430 babies born alive, in Belgium one mother dies for every 172
babies, and in Spain one for every 175 babies born alive. The rates in
Belgium and Spain are two and a half times as high as the rate in Sweden.
Far more significant than a comparison of actual death rates of various
countries is a comparison of the changes which have occurred in these

death rates in each country in recent years. England and Wales, Ireland,
Japan, New Zealand, and Switzerland have shown a decrease in the death
rate per 1,000 live births from all diseases caused by pregnancy and
confinement; but, in this group, only in England and Wales and in Ireland
has the death rate from puerperal septicemia decreased; in the other three
countries this rate has remained practically the same, though the total rate
has decreased.
In Australia, Belgium, Hungary, Italy, Norway, Prussia, Spain, and Sweden
both the rate from childbirth and that from puerperal septicemia remained
almost stationary during the periods studied.
The total rate for Scotland shows a definite increase, though the rate from
puerperal septicemia has decreased. (See Table XVI, p. 66.)
Communities are still to a great extent indifferent to or ignorant of the
number of lives of women lost yearly from childbirth; many communities
which are proud of their low typhoid or diphtheria rates ignore their high
rates from childbed fever. Communities are only beginning to realize that
among their chief concerns is the protection of the babies born within their
limits, and necessarily also of the mothers of those babies before and at
confinement.

DEATH-REGISTRATION AREA

The statistics of causes of death are available only for a certain portion of
the United States, included in the so-called “death-registration area.” Unlike
other civilized countries, the United States has no uniform laws for the
registration of births and deaths. Moreover, the efficiency of enforcement of
existing laws varies greatly in the different States. The Bureau of the
Census in 1880 therefore established a “death-registration area,” which
comprises “States and cities in which the registration of deaths is returned
as fairly complete (at least 90 per cent. of the total), and from which
transcripts of the deaths recorded under the State laws or municipal
ordinances are obtained by the Bureau of the Census.” In 1880 this area
included but 17 per cent. of the total population of the United States. As
States and cities have passed better laws and obtained better enforcement
they have been added to the registration area; the latter has increased

greatly in size, but even in 1913 included only 65.1 per cent. of the
population of the United States. For the remaining 34.9 per cent. of the
population of the country we have no reliable statistics. This 34.9 per cent.
includes the population of the greater number of the Southern States and of
many Middle Western and Western States outside of certain registration
cities in these States which are included in the area. No statements can be
made, therefore, of the number of deaths from any cause in the United
States as a whole; only an estimate can be made on the assumption that for
any cause of death the same rate prevails in the remainder of the United
States as in the death-registration area.

PROVISIONAL BIRTH-REGISTRATION AREA

The registration of births is still more incomplete in this country than is the
registration of deaths. For 1910 the United States Bureau of the Census
established a “provisional birth-registration area,” including the New
England States, Pennsylvania, Michigan, New York City and Washington,
D. C.
Death rates per 1,000 births.—As shown above, the method of computation
of death rates which gives the clearest picture of the hazards of childbirth is
that which takes into account only the women giving birth to children in
that year. This is the method in use in a large number of foreign countries.
The advantages of the method are self-evident. A demonstration of the
superiority of this method of computation is obtained by a study of the
tables giving the death rates from these diseases for foreign countries. In
certain countries, as for instance Belgium and Hungary, there has been in
recent years an apparent fall in the average death rates as computed per
100,000 population, while the average rates computed per 1,000 live births
have remained stationary or risen. This phenomenon is due, evidently, to a
decline in the birth rate in these countries during these years, and shows
how misleading the rates as given per 100,000 population undoubtedly are
in countries with declining birth rates. Whether a fall in the birth rate has
occurred in the United States is not known. If it has occurred in the
registration area, it would mean that the slight rise in rates per 100,000
population between 1900 and 1913 means a greater rise in rates computed
according to the number of births. Such an error might compensate for the

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

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

Far more valuable than a comparison of average rates of foreign countries is
a study of the rates of each country for a series of years in order to discover
whether they are decreasing or increasing and to compare such changes in
the various countries. While it may be dangerous on account of different
countries, no such source of error is attached to the comparison of rates in
the same country for a number of years. The period 1900 to 1913 (or the
latest year for which figures are available) is a very short one for a study of
a change in death rates. It would have been far more interesting to study the
death rates for a long series of years in each country, choosing a period
beginning before the introduction of methods of asepsis. But such a study
for the complete list of countries considered was not thought advisable,
because of the difficulties caused by variations in classification of causes of
death in the earlier years.
In order to study the rates for any increase or decrease occurring during the
last 13 years, the rates per 1,000 live births will be used rather than those
per 100,000 population. In several countries—Belgium, Hungary, Italy,
Norway, Prussia, and Spain—the rate from childbirth per 100,000
population apparently has fallen during the period, while the rate per 1,000
live births has remained almost the same, or has risen. The cause of this
inconsistency is the fact that in these countries the birth rate or the
proportionate number of births to the number of inhabitants has decreased.

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

49. Except No. 25, diarrhea and enteritis (under 2 years), and No. 34,
senility.
(Computed from figures in Mortality Statistics, 1913, pp. 338 to 349, in
which causes of death are given according to the detailed International List
of Causes of Death.)

Abridged
Number of
International List Cause of death.
deaths.
No.
Tuberculosis of the lungs, tuberculous
13, 14, 15 meningitis, other forms of 26,265
tuberculosis
Puerperal septicemia (puerperal fever,
31, 32 peritonitis) and other puerperal 9,876
accidents of pregnancy and labor
19 Organic diseases of the heart 6,386
29 Acute nephritis and Bright’s disease 5,741
16 Cancer and other malignant tumors 5,065
22 Pneumonia 4,167
35 Violent deaths (suicide excepted) 3,262
1 Typhoid fever 2,706
Noncancerous tumors and other
30 diseases of the female genital 2,669
organs
26 Appendicitis and typhlitis 1,620
36 Suicide 1,562
Other diseases of the respiratory
23 1,458
system (tuberculosis excepted)
18 Cerebral hemorrhage and softening 1,398

Diseases of the stomach (cancer
24 940
excepted)
27 Hernia, intestinal obstruction 854
28 Cirrhosis of the liver 598
9 Influenza 489
17 Simple meningitis 484
8 Diphtheria and croup 330
12 Other epidemic diseases 312
6 Scarlet fever 307
5 Measles 304
3 Malaria 250
21 Chronic bronchitis 184
20 Acute bronchitis 90
33 Congenital debility and malformations 24
11 Cholera nostras 18
4 Smallpox 16
7 Whooping cough 9
2 Typhus fever 2
10 Asiatic cholera
37 Other diseases 11,688
38 Unknown or ill-defined diseases 458

A MUNICIPAL BIRTH CONTROL CLINIC. MORRIS H. KAHN, M. D.,
in New York Medical Journal for April 28, 1917.
Showing that large families among the poor are the result of ignorance of
methods to prevent conception among the mothers.
The following studies were undertaken with a view to determining whether
there was an actual need and demand for birth control education and
whether such a demand, if it existed, could be supplied with any effect by a
scientifically conducted clinic in the dispensaries of the Department of
Health of the City of New York; we felt that it might be of scientific and
sociological interest to publish a report and an analysis of the observations

made, probably the first of their kind in this country. Section 1142 of our
Penal Code was ignored in conducting this birth control study.
The social and economic status of the patients was fairly uniform, about the
same as that of patients attending the other dispensary institutions in this
city. A tabulation of the results was made under the following headings:
Name and nationality; age; number of years married; number of living
children and their ages; number of deceased children; number of
miscarriages or abortions; contraceptive methods known or practised. More
or less complete data were secured in 464 cases.
The average number of procreative years of married life was 16.1, the age
of fifty years being considered in this study as the end of the procreative
period for the seventy-two women who were older than that. The average
number of living children was 3.27 and of deceased children 1.2, making a
total average of 4.47 children born to each family. Of the 464 women, 176,
or three eighths, had had abortions or miscarriages, the total number of such
interruptions of pregnancy being 324, or an average of 1.8 each for the
women involved.
Of the 464 women, 192 knew of no contraceptive methods and therefore
had used none. The remaining 272 women knew of one or more methods,
more or less effectual, for the prevention of conception. Of the 192 women
who were ignorant of the use of contraceptives, practically one half, or 104,
had a history of abortions, with a total of 202 abortions, or an average of
two apiece. In contrast with this, of the 272 women who knew of one or
more contraceptives, only one fourth, or seventy-two, had undergone
abortions, with a total of 122 abortions, or an average of only 1.6 apiece.
A further analysis of our tables shows an interesting and striking
relationship between ignorance of methods for the prevention of conception
and the number of children. Sixty-eight women had had three children each.
Of these, twenty-six, or thirty-eight per cent., were ignorant of
contraceptives. Twenty-eight women had had four children each. Of these
fourteen, or fifty per cent., were ignorant of contraceptives. Fifty-five
women had had five children each. Of these thirty were ignorant of
contraceptives, or fifty-four per cent. Thirty-two women had had six
children each. Of these twenty were ignorant of contraceptives, or sixty-two
per cent. Forty women had had seven children each. Of these thirty-eight

were ignorant of contraceptives, or ninety-five per cent. Twenty-one women
had had eight children each. Of these twenty were ignorant of
contraceptives, or ninety-five per cent. Forty-four women had had nine or
more children each, and of these all were ignorant of contraceptive
measures. Arranged in tabular form, these data would appear as follows:

Number of Number of Number Ignorant of
Percentage
Women Children Contraceptives
68 3 26 38
28 4 14 50
55 5 30 54
32 6 20 62
40 7 38 95
21 8 20 95
44 9 to 17 all 100
It is sometimes stated by opponents of birth control that contraceptive
methods are known by every married person and that the fault and
immorality of having a large family of unprovided for dependents lies not in
ignorance of contraceptives but rather in a lack of determination on the part
of one or both parents to use preventive measures; in other words, that the
failure to use contraceptives results from the inconvenience attending some
methods and also from the influence of religious sentiment.
The above data, however, tend to show that ignorance of contraceptives not
only is a great factor in the production of large families, but is also a great
factor in increasing the number of abortions. From the fact that two thirds
of these women knew absolutely no contraceptive method, while the
methods used by many of the others were ineffectual or positively harmful,
it is apparent that there is a definite opportunity for educating these women
in methods of regulating conception. That there is need and demand for
such education is voiced in unmistakable language by the multitude of poor
who seek advice from all practising physicians.

MATERNAL MORTALITY

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

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

OBSTETRICS. A Text Book for the Use of Students and Practitioners. J.
Whitridge Williams, Professor of Obstetrics, John Hopkins
University, Obstetrician-in-Chief to the John Hopkins Hospital,
Gynaecologist to the Union Protestant Infirmary, Baltimore, Md. D.
Appleton & Co. 1912.
As a rule, all diseases which subject the organism to a considerable strain
are much more serious when occurring in the pregnant woman. In general it
may be said that pregnancy exerts a deleterious influence upon all chronic
organic maladies, while its effect is usually less marked in acute infectious
processes. The latter, however, frequently lead to premature delivery and
the additional physical strain attending the latter matter render the course of
the disease much less favorable. Page 489.
“Owing to the well known fact that pulmonary tuberculosis usually
progresses much more rapidly after child bearing, it is advisable that
tubercular women take every precaution to avoid the possibility of
conception.” Page 383.
It would appear therefore that in the vast majority of cases the disease
(tuberculosis) is not transmitted directly from the mother to the fetus, and
that the latter is born with a tendency to tuberculosis, rather than with the
disease itself. Hence it follows that the children of tubercular mothers
should be brought under the best hygienic surroundings, and should not be
suckled by their mothers. In view of the fact that the tubercular process
usually becomes exacerbated either during pregnancy or after child birth,
most authorities recommend that abortion be induced as a matter of routine
in all tubercular women, and many that they be rendered sterile by artificial
means. This appears to be a somewhat too extreme point of view, but I
consider that abortion should be induced in the first pregnancy occurring
after the onset of the disease, and whenever it makes its appearance during
the early months of pregnancy. Page 494.

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

COMPLICATIONS ARISING FROM MATERNAL
DISEASES AND ANOMALIES

Exact observations on a large number of cases have demonstrated beyond
doubt that with very rare exceptions a pregnancy exerts a harmful effect
upon the course of the disease (tuberculosis). Page 344.
So seriously is the tubercular process affected by a concomitant pregnancy
that it seems the duty of the physician to warn every tubercular girl against
marriage. Especially deleterious to the patient are pregnancies which follow
each other at short intervals. In such instances the patient must be strongly
advised against a new impregnation. It hardly can be denied that in some of
these cases artificial sterilization may be justified. An additional argument
in favor of this procedure is the comparative frequency with which, if not
the infection itself, at least a marked disposition to it is transmitted to the
fetus in utero. P. 344.

A TEXT BOOK OF OBSTETRICS. Barton Cooke Hirst, M.D., Professor
of Obstetrics in the University of Pennsylvania; Gynaecologist to the
Howard and Orthopaedic and the Philadelphia Hospitals, etc. W. B.
Saunders Co. 1909.
The influence of pregnancy upon tuberculosis is most unfavorable and in
women predisposed to tuberculosis, gestation may be the determining factor
in lighting up an attack. It is the duty of a physician to advise strongly
against marriage and maternity in the case of a woman already infected, or
predisposed to tuberculosis. If the patient is pregnant an induction of labor
should be considered. P. 427.

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

Women with tuberculosis should not marry, first, because this aggravates
their own disease. Second, they may infect the husband, and third, they
propagate tuberculous children. Knowing the tendency for a latent
tuberculosis to break out in pregnancy, marriage is to be forbidden. If the
woman marries, she should avoid conception. P. 481.
If tuberculosis of the lungs is manifested in early pregnancy, if there is
fever, wasting, hemoptysis and advancing consolidation, that is, the process
seems to be florid, abortion should be induced without delay. Trembley, of
Saranac Lake induces abortion in the early months in all cases. Urgent
symptoms of cardiac nature, persistent hemoptysis and dyspnea may require
emptying of the uterus. Complicating nephritis, heart disease, and
contracted pelvis, which is said to be more frequent in the tuberculous, will
give early indications for interference. P. 481.

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

THE PRACTICE OF OBSTETRICS. Designed for the use of Students and
Practitioners of Medicine. J. Clifton Edgar, Prof. of Obstetrics and
Clinical Midwifery in the Cornell University Medical College;
Visiting Obstetrician to Bellevue Hospital, New York City; Surgeon to
the Manhattan Maternity and Dispensary; Consulting Obstetrician to
the New York Maternity and Jewish Maternity Hospitals. 5th Edition.
Revised. P. Blakiston’s Co., Phil.
The subject of the relationship between tuberculosis and pregnancy has
recently attained an increased degree of importance through the agitation in
favor of the justification of abortion in the tuberculous pregnant woman. P.
314.
Statistics appear to show, according to Lancereaux, that a considerable
number of cases of tuberculosis develop solely as a result of pregnancy. If

pregnancy can thus affect health, how much more likely would it be for the
disease to assert itself in a woman who is a fit subject for it, or in one who
is actually consumptive. In the former class are so called candidates for
tuberculosis who have a family history of the disease of much significance
under these circumstances. One should strongly dissuade girls with
tubercular history and antecedents from early marriage, fearing that
repeated childbearing will infallibly light up the dreaded malady. What has
been said of the candidate for tuberculosis applies with the same, or greater
force in the case of so-called latent tuberculosis and of apparent recovery
from the disease. Present sentiment is beginning to dissuade such women
from marriage, not less for their own benefit than for the sake of posterity,
and all organized movements which are seeking to eradicate tuberculosis
from the world lay much stress on discouraging marriage in tuberculosis
suspects. Until this view prevails there will necessarily be some justification
for interrupting a pregnancy already under way. P. 314.
Sanatoria for consumptives do not care to admit pregnant women, and this
prohibition is equivalent to ranking them as incurable. The fact that a
candidate for tuberculosis runs a very great risk of becoming consumptive
through childbirth is a most stubborn one, and when in addition to
becoming a consumptive herself she also brings into the world an individual
who is likely to become tubercular, it readily becomes apparent that the
question of the propriety of therapeutic abortion is bound to become an
issue in the future in the practice of obstetrics. P. 315.

EXCEPTIONAL CASES

A tubercular woman may go through gestation with no undue acceleration
of her malady, only to succumb after delivery to acute general tuberculosis,
or acute tubercular pneumonia. P. 315.
Tubercular pregnant women also show no little tendency to abort. P. 316.

TUBERCULOSIS A PREVENTABLE AND CURABLE DISEASE. S.
Adolphus Knopf, M.D.; Professor of Phthisio-therapy at the New
York Post-Graduate Medical School and Hospital; Associate Director
of the Clinic for Pulmonary Disease of the Health Department;

Attending Physician to the Riverside Sanitorium for Consumptives of
the City of New York, etc. Moffat Yard & Co., 1909. New York.
We have emphasized the fact that tuberculosis is very rarely directly
hereditary, but that what is often transmitted by tuberculous parents is a
weakened system, or physiological poverty. Nevertheless it is evident that
tuberculous individuals ought not to marry, and when tuberculosis develops
in a married couple it is best that they should have no children. P. 354.

PULMONARY TUBERCULOSIS. Its Modern Prophylaxis and the
Treatment in Special Institutions and at Home. S. Adolphus Knopf,
M.D. P. Blakiston’s Sons & Co., Phil., 1899.
If conception has taken place in a tuberculous woman institute treatment,
preferably in a sanatorium near the home of the patient. But as Treaudeau
says, it is essential that the treatment be continued for a long time
afterwards, and I should like to add that a repetition of pregnancy must be
prevented. P. 283.

THE TUBERCULOSIS PROBLEM AND SECTION 1142 OF THE
PENAL CODE OF THE STATE OF NEW YORK. S. Adolphus Knopf,
M.D. Reprinted from the New York Medical Journal for June 12th,
1915.
There seems to be no difference of opinion in the minds of men and women
who have studied rational eugenics and sociology concerning the necessity
of beginning to work with the preceding generation, and of teaching parents
that quality is better than quantity, and that a large number of children,
underfed or of mental, moral and physical inferiority, means race suicide,
while the reverse means race preservation.
I cannot defend my attitude better than by telling you the conclusions I have
arrived at in my study of the tuberculosis situation in the United States. In
the families of the poor where there are usually numerous children, it really
matters little whether it is the father or the mother who is acutely
tuberculous. Since almost invariably they live in close and congested
quarters, are underfed and insufficiently clad, it is of relatively rare
occurrence when most of the children do not become infected with

tuberculosis. In some of our tuberculosis clinics where we insist on an
examination of all the children of the tuberculous parents visiting these
special dispensaries, we find as many as fifty per cent. of the children to be
afflicted with tuberculosis as the result of postnatal infection. In taking the
history of a patient in my private consultation work, it is my invariable
custom to ask whether he comes from a large family, and if so whether he
was among the first or latter born children. As a rule, especially among the
poor, it proves to be one of the latter born, (the fifth, sixth, seventh, eighth,
ninth, etc.) who contracts tuberculosis, and I believe this to be because
when he came to the world there were already many mouths to feed and
food was scant, for the father’s income rarely increases with the increase of
the family; and the mother, worn out with repeated pregnancies, cannot
bestow upon the latter born children the same care which was bestowed
upon the first. We know tuberculosis to be a preventable and curable
disease, but we also know that it is the disease of poverty, privation,
malnutrition, and bad sanitation. P. 4.
I do not know the penalty to be visited upon a physician who offends the
majesty of the law as set forth in section 1142 of the penal code, but I for
one am willing to take the responsibility before the law and before my God
for every time I have counselled, and every time I shall counsel in the
future, the prevention of a tuberculous conception, with a view to
preserving the life of the mother, increasing her chances of recovery, and,
last, but not least, preventing the procreation of a tuberculous race. P. 5.

THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL,
BIOLOGICAL AND HYGIENIC ASPECTS. E. Heinrich Kisch, M.D.,
Professor of the German Medical Faculty of the University of
Prague; Physician to the Hospital and Spa of Marienbad; Member of
the Board of Health, etc. Translated by M. Eden Paul, M.D. Rebman
Co., New York.
As regards the marriage of any woman suffering from tuberculosis we must
take into consideration a fact that medical experience has conclusively
established, namely, that the processes of generation have an unfavorable
influence upon pulmonary tuberculosis. P. 259.

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

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

Reprinted from the Women’s Medical Journal, September, 1915.

Of the 150,000 who it is estimated die annually from tuberculosis in the
United States, I venture to say 50,000 have been bread winners. Estimating
the value of such a single life to the community at only about $5,000, this
makes a loss of $250,000,000 each year. Another third, I venture to say,
represents children at school age. They have died without having been able
to give any return to their parents or to the community. Making the average
duration of their young life only 7.5 years, and estimating the cost to
parents and the community at only $200 per annum, the community loses
another $75,000,000. The value of lives of little babes, children below and
above school age, adolescents not yet bread winners, and men and women
no longer able to earn their living can not be estimated in exact figures, but
is reasonable to suppose the total annual financial loss from tuberculosis in
the United States to be at least half a billion dollars. This does not include
the expenditures for hospitals, sanatoria, clinics, dispensaries, colonies,
preventoria and other agencies, devoted to the solution of the tuberculosis
problem.
In the face of these figures and the suffering, misery and disappointment of
parents who lose their children after having tenderly loved and cared for
them for some years, I wonder if there can be any doubt in the minds of
sane men that it would have been better if these children had never been
born. Surely all this is race suicide instead of race preservation.
Not so very long ago I was asked by a young colleague to aid in the
diagnosis of tuberculosis in a day laborer. The man earned $12 a week, was
thirty-six years of age on the day the examination and diagnosis was made,

had been married fourteen years, and his eleventh child had been born on
his last birthday; four or five had already died, two of them of tuberculous
meningitis. A glance at the rest of the family showed that nearly all of them
were predisposed to tuberculosis, if not already infected, and that a few
years of continued underfeeding and bad housing would finish their earthly
career. With two or three children to provide for the family might have lived
in relative comfort; with better food and better home environments the
father might never have become tuberculous and none of the children might
have contracted the disease. The commonwealth would have been the
gainer by two or three mentally and physically vigorous future citizens.
Only a few days ago, while an article for the Journal of Sociologic
Medicine was in preparation, an Italian woman presented herself to me for
examination. She gave her age as fifty-six, and had married quite young.
She had borne her husband seventeen children, of which, however, only
four were living. Some had died in infancy, some at school age, and some
during adolescence. What useless suffering! What useless economic loss to
the individual family and society at large. Upon examination, I found the
woman’s mental condition even worse than her physical status. The
repeated pregnancies, the frequent diseases in the family, thirteen deaths
among her children, had made a mental and physical wreck of her. Yet the
woman belonged to the better and well-to-do class of our population of
Italian birth. What would her condition have been if she had also had to
share in the struggle for the existence of the family, and had had to work in
sweatshops or factories, as so many of the poor Italians have to do?
When pregnancy means danger to the life of the mother, or exacerbation of
an existant mental or physical ailment, as, for example, tuberculosis, which
is always aggravated by child-bearing, every conscientious physician
should do his utmost to prevent childbirth in such an invalid.
Where there is tuberculosis or any other serious transmissible disease in one
or both of the parents, or there is danger that it may be transmitted to the
offspring, it should not only be the right but the sacred duty of the physician
to prevent the conception of any physically and mentally handicapped
offspring destined to become a burden to the community.

KIDNEY DISEASES

THE PRACTICE OF OBSTETRICS. In Original Contributions by
American Authors. Edited by Reuben Peterson, A.B., M.D., Professor
of Obstetrics and Gynecology in the University of Michigan, Ann
Arbor, Mich. Obstetrician and Gynecologist in Chief to the University
of Michigan Hospital. Lea Bros. & Co., Phil. and New York. 1907.
Chapter XIX.
Pephritis. From statistics we find that even excluding the cases of
eclampsia, the maternal mortality from nephritis during pregnancy is 33%,
and the fetal mortality between 50% and 60%. P. 352.
Women suffering from a chronic nephritis should be advised strongly
against marriage, especially in the presence of a cardiac or pulmonary
lesion. Married women should be warned against impregnation. P. 354.
Pyelitis. “On account of the increased dangers of pyelitic and especially of a
pyelonephritic process during pregnancy, women suffering from these
diseases should be warned against marriage. Married women should be
warned against a new impregnation, on account of the marked tendency of
pyelitis to recur with every pregnancy.” P. 355.

PRACTICAL OBSTETRICS. Thos. Watts Eden. Obstetrician, Physician
and Lecturer on Midwifery and Gynecology, Charing Cross Hospital;
Consulting Physician to Queen Charlotte’s Lying-in-Hospital;
Surgeon to In-Patient Chelsea Hospital for Women. 4th Edition. C. V.
Mosby Co. 1915.
Certain of the conditions enumerated form absolute indications for the
induction to abortion. These are nephritis, (a form of kidney disease),
uncompensated valvular lesions of the heart, advanced tuberculosis,
insanity, irremediable malignant tumors, hydatidiform mole, uncontrollable
uterine haemorrhage, and acute hydramnios. P. 652.

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

All forms of nephritis have a very bad influence on the pregnancy, abortion
and premature labor being common. (66% Hofmeier) Seitz found that only
from 20% to 30% of the children survived. One of the causes of habitual
death of the fetus, abortion, and premature labor is chronic nephritis. P. 497.
“The children of nephritics are usually puny and pale.” P. 497.
Both mother and child are seriously jeopardized by chronic nephritis, the
mortalities being about 30% respectively. P. 497.
Women with chronic nephritis should not marry, and if married, should not
conceive. P. 498.
Diabetes. Sterility is common. Abortion and premature labor occur in 33%
of the pregnancies. The children, if the pregnancy goes to term, often die
shortly after birth, the total mortality being 66%. P. 502.
True diabetes has a very bad diagnosis. Offergold found over 50%
mortality. Of the children 51% were still born, 10% died within a few days
after birth, and 5% more before six months. P. 503.
If a woman comes under treatment with a history of diabetes it is best to
terminate the pregnancy at once. P. 503.

THE PRACTICE OF OBSTETRICS. Designed for the use of Students and
Practitioners of Medicine. J. Clifton Edgar. Professor of Obstetrical
and Clinical Midwifery in the Cornell University Medical College;
Visiting Obstetrician to Bellevue Hospital, New York City; Surgeon to
the Manhattan Maternity Dispensary; Consulting Obstetrician to the
New York Maternity and Jewish Hospitals. 5th Edition, Revised. P.
Blakiston’s & Co., Philadelphia.
Statistics appear to show that labors in these women, (diabetes) are quite apt
to end unfavorably, in one or another way. When diabetic women become
pregnant their disease usually takes a turn for the worse. According to
Lecorche, true diabetes who become pregnant, usually succumb to the
disease within a short time after delivery. P. 305.

ECLAMPSIA

THE PRINCIPLES AND PRACTICE OF OBSTETRICS. By Joseph B. De
Lee, M.D.
Over 20% of women with eclampsia die and statistics show that 10% of
such cases developed in the maternities. For the child the chances are not
good, nearly one half of the children dying as a result, that is, due to:
prematurity, toxemia, asphyxiation by repeated convulsions of the mother,
drugs administered to the mother, and injuries sustained during birth,
especially forced delivery. Eclampsia is more easily developed in a
pregnant woman because the kidneys are carrying an increased burden, and
too often diseased through the pregnancy changes. The cause of eclampsia
are unknown but in 20% of cases the convulsions begin during pregnancy,
in 60% during labor, and in 20% after delivery. Page 365.
The treatment is to stop the gestation at a point before either mother or
child, or both, are in danger either to life or to health. Page 1041.

MATERNAL MORTALITY. Grace L. Meigs, M.D., U. S. Department of
Labor. 1917.
Puerperal albuminuria and convulsions, called also eclampsia, or toxemia of
pregnancy, is a disease which occurs most frequently during pregnancy but
may occur at or following confinement. It is a relatively frequent
complication among women bearing their first children. When fully
established its chief symptoms are convulsions and unconsciousness. In the
early stages of the disease the symptoms are slight puffiness of the face,
hands, and feet; headache; albumen in the urine; and usually a rise in blood
pressure. Very often proper treatment and diet at the beginning of such early
symptoms may prevent the development of the disease; but in many cases
where the disease is well established before the physician is consulted, the
woman and baby can not be saved by any treatment. In the prevention of
deaths from this cause it is essential, therefore, that each woman, especially
each woman bearing her first child, should know what she can do, by
proper hygiene and diet, to prevent the disease; that she should know the
meaning of these early symptoms if they arise, so that she may seek at once
the advice of her doctor; and that she should have regular supervision
during pregnancy, with examination of the urine at intervals.

DIABETES

THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Joseph B. De
Lee, M.D. Page 514.
Without doubt pregnancy has a bad effect on the course of this disease. It
may develop a latent diabetes, there being cases where severe symptoms
appeared only during successive pregnancies, and others where the disease
grew progressively worse each time. Coma occurs in 30% of the cases and
is almost always fatal. It may be brought on by a slight shock in pregnancy,
but more often during and just after labor. Delivery seems to have a worse
effect than most surgical operations, causing collapse, coma, or sudden
death. Bronchitis has been noted in the puerperium, and this has been found
to eventuate in tuberculosis. True diabetes has a very bad prognosis,
authorities finding over 50% mortality, of which 30% died in coma, within
two and one half years, and too often the child dies in utero.

PELVIC DEFORMITIES

MATERNAL MORTALITY. Grace L. Meigs, M.D., U. S. Department of
Labor, 1917.
Some obstruction to labor in the small size or abnormal shape of the pelvic
canal causes many deaths of mothers included in the class “other accidents
of labor” and also many stillbirths. If such difficulty is discovered before
labor, proper treatment will in almost all cases insure the life of mother and
child; if it is not discovered until labor has begun, or perhaps until it has
continued for many hours, the danger to both is greatly increased. Every
woman, therefore, should have during pregnancy—and above all during her
first pregnancy—an examination in which measurements are made to
enable the physician to judge whether or not there will be any obstruction to
labor. A case in which a complication of this kind is found requires the
greatest skill and experience in treatment, but with such treatment the life
and health of the mother are almost always safe.

PRINCIPLES AND PRACTICE OF OBSTETRICS. Jos. B. De Lee, M.D.,
Professor of Obstetrics at the Northwestern University Medical
School; Obstetrician to the Chicago Lying-in-Hospital and
Dispensary, and to Wesley and Mercy Hospitals, etc. W. B. Saunders
Co. 1913.
No subject in medicine presents greater difficulties in all its aspects than
this one, (treatment of contracted pelves) and none demands such art or
practical skill. Science aids little here. P. 709.
Outside factors must also be considered: 1—The environment, whether the
parturient is in a squalid tenement, in the country, in a home where every
appliance is attainable, or in a well equipped maternity. 2—Whether in the
hands of a general practitioner or a trained specialist. 3—If the patient is a
Catholic, all medically indicated procedures not being permitted. 4—The
age of the parturient, and the probability of her having more children. Even
with these enumerations, the possible factors which might influence a labor,
or our decision regarding the course to pursue have not all been mentioned.
P. 709.

THE PRACTICE OF OBSTETRICS. Designed for the use of
Practitioners and Students of Medicine. J. Clifton Edgar, Professor of
Obstetrics and Clinical Midwifery in the Cornell University Medical
College. Visiting Obstetrician to Bellevue Hospital, New York City;
Surgeon to the Manhattan Maternity Dispensary; Consulting
obstetrician to the New York Maternity and Jewish Maternity
Hospitals. 5th Edition, Revised. P. Blakiston’s & Co., Phila.
A knowledge of the female bony pelvis is the very alphabet of obstetrical
science, and the foundation of obstetrical art. This structure is most
important since it is from the disproportion between its size and that of the
fetus, or from its abnormal shape that many of the difficulties of labor arise.

PRACTICAL OBSTETRICS. Thos. Watts Eden. Obstetrician; Physician
and Lecturer on Midwifery and Gynecology, Charing Cross Hospital;
Consulting Physician to Queen Charlotte’s Lying-in-Hospital;

Surgeon to In-Patient Chelsea Hospital for Women. 4th Edition. C. V.
Mosby Co. 1915.
The general course of labor is modified by pelvic contractions in various
ways. 1—Abnormal presentations are three or four times commoner in
contracted than in normal pelves. 2—Prolapse of the cord is much
commoner than in normal pelves. 3—When natural delivery occurs labor is
prolonged and the mechanism is modified. 4—Unless the true conjugate is
at least 3¼ inches, even with artificial aid the survival of the child is
seriously jeopardized. 5—The maternal risks are increased by the greater
length and difficulty of the labor and by the frequent necessity of employing
artificial methods of delivery. 6—The fetal risks are increased in natural
delivery by severe compression of the head during its passage through the
narrow pelvis, and other circumstances by the operations required to effect
delivery, some of which involve the destruction of the fetus. P. 409.

THE PRACTICE OF OBSTETRICS. In Original Contributions by
American authors. Edited by Reuben Peterson, A.B., M.D. Lea Bros.
& Co., Phil. and New York. 1907.
Labor complicated by anomalies of the Bony Pelvis. John F. Moran, M.D.
The frequency with which pelvic contraction occurs can only be determined
with relative accuracy. There is in existence a comparatively large amount
of statistical data on this subject, but the reports of different investigators
vary within wide limits, and these variations are naturally not to be
explained entirely on the assumption of racial conditions, or geographic
distribution. Between these wide limits are arrayed the figures of about 20
modern observers in different parts of the civilized world who have
reported statistics of cases. The combined figures of 19 observers include a
total of over 150,000 cases examined for pelvic contraction. In these cases
the average of contraction is found to be about 10%. Williams concludes
that contracted pelves occur in from 7% to 8% of the white women of this
country. P. 658–659.

HEART DISEASE

THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL,
BIOLOGICAL AND HYGIENIC ASPECTS. E. Heinrich Kisch, M.D.
Professor of the German Medical faculty of the University of Prague;
Physician to the Hospital and Spa of Marienbad; Member of the
Board of Health, etc. Translated by M. Eden Paul, M.D. Rebman Co.,
New York.
These are cases (severe heart disease) in which, in my opinion, it is the
physician’s duty to concern himself with the subject of the use of preventive
measures, and having regard for the preservation of a woman’s life, and
uninfluenced by any false delicacy, but with simple earnestness to inform
his patient with respect to the needful prophylactic measures. The artificial
termination of pregnancy, which unquestionably is often justified in women
suffering from heart disease, but which unfortunately is apt to have very
unfavorable results, will rarely need to be discussed if by the proper
employment of preventive measures care is taken that pregnancy does not
recur too frequently. P. 255.

OBSTETRICS. A Text Book for the use of Students and Practitioners.
Whitridge Williams, Professor of Obstetrics, Johns Hopkins
University; Obstetrician in Chief to the Johns Hopkins Hospital;
Gynecologist to the Union Protestant Infirmary, Baltimore, Md. D.
Appleton & Co., 1912.
Some authorities recommend that women suffering from heart lesions
should be dissuaded from marriage, or if married, from becoming pregnant.
This, however, appears to be an extreme view, though of course when the
lesion is serious and the compensation faulty the dangers of child-bearing
should be carefully explained. P. 498.

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

“Leyden claims that about 40% of all women with serious heart lesions
meet their death in connection with childbirth. Still greater than the
demands upon the heart during pregnancy are those made by labor. The
strain, mental excitement, and especially the sudden changes in the blood
pressure, conditions which are well recognized as extremely harmful to
every patient with a chronic heart lesion, and which cannot be avoided in
the course of labor, make the situation extremely dangerous.” (Hugo
Ehrenfest, M.D.) P. 357.
“The prognosis for the fetus is unfavorable. Fellner, whose figures
undoubtedly are low, places the frequency of premature, spontaneous
interruption of pregnancy as 20%, other writers at from 40% to 60%.” P.
358.
“No marriage for the unmarried, no pregnancy for the married, no nursing
for the confined,” is a statement which has been made by a French author,
and has been accepted by many writers. It is incompatible with the results
of recent investigations. It would be too harsh and unjustifiable to deny
marriage to a woman who has a well compensated valvular lesion. She
should be informed of the risks of impregnation, but should be warned
against marriage only where there exist distinct evidences of
incompensation, especially in cases of mitral stenosis. P. 359.

A TEXT BOOK OF OBSTETRICS. Barton Cooke Hirst, M.D.; Professor
of Obstetrics in the University of Pennsylvania; Gynecologist to the
Howard and Orthopaedic, and the Philadelphia Hospitals, etc. 7th
Edition. W. B. Saunders Co., Philadelphia and London. 1912.
Abortion is induced in about 25% of all cases, as the result of placental
apoplexies, or of the stimulation of the uterus to contraction by the
accumulation of carbondioxid gas in the blood. Pregnancy distinctly
increases the danger of the heart lesion. In 58 serious cases, 23 died after
premature delivery of the child. In milder cases prognosis is not grave, yet
the woman’s condition is by no means free from danger. If the disease be of
long standing and serious in character, it appears from statistical studies that
about half the women die. P. 423.

PRINCIPLES AND PRACTICE OF OBSTETRICS. Jos. B. De Lee, M.D.;
Professor of Obstetrics at the Northwestern University Medical
School; Obstetrician to the Chicago Lying-in-Hospital, and to Wesley
and Mercy Hospitals, etc. W. B. Saunders Co. 1913.
Abortion and premature labor, especially the latter, occur in cases of dis-
compensation, in from 20% to 40%, and stillbirth in 29% to 70%, giving
figures collected from various sources by Fellner. P. 489.

THE PRACTICE OF OBSTETRICS. Designed for the use of Students and
Practitioners of Medicine. J. Clifton Edgar, Professor of Obstetrics
and clinical midwifery in the Cornell University Medical School;
Visiting Obstetrician to Bellevue Hospital, New York City; Surgeon to
the Manhattan Maternity and Dispensary; Consulting Obstetrician to
the New York Maternity and Jewish Maternity Hospitals. 5th Edition,
Revised. P. Blakiston’s & Co., Philadelphia.
Acute Endocarditis not only has an injurious influence upon pregnancy, but
it is also apt itself to become extremely grave. Regarding treatment, induced
labor will be demanded. P. 310.

TOO FREQUENT PREGNANCIES

BEING WELL BORN. An Introduction to Eugenics. Michael F. Guyer,
Ph.D., Professor of Zoology, University of Wisconsin. Bobbs-Merrill
Co. Indianapolis. 1916.
Too short an interval between childbirths would also seem to be an
infringement on the rights of the child as well as of the mother. Thus Dr. R.
J. Ewart, (“The Influence of Parental Age on Offspring,” Eugenic Review,
Oct., 1911) finds that children born at intervals of less than two years after
the birth of the previous child still show at the age of six a notable
deficiency in height, weight and intelligence, when compared with the
children born after a longer interval, or even with first-born children. P. 166.

FREQUENT PREGNANCIES. The Contributions of Demography to
Eugenics. Dr. Corrado Gini, Professor of Statistics at the Royal
University of Cagliari, Italy.
If the possibility of generation at any season of the year cannot, as has been
shown, have any deleterious effect on the vitality of human offspring, it can
none the less have indirect deleterious consequences, in so far as it allows
pregnancies to succeed each other at too short intervals. P. 323.
“The deleterious consequences which too short a period after the preceding
birth have upon the vitality of the child are indisputable, at least during the
first year of life.” P. 323.

THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL,
BIOLOGICAL AND HYGIENIC ASPECTS. E. Heinrich Kisch.
Rebman Co., N. Y.
“Frequently recurring pregnancies and childbirth, according to Kronig, act
as the predisposing cause in the production of neurasthenia.” P. 257.

NEO-MALTHUSIANISM AND RACE HYGIENE, IN “PROBLEMS IN
EUGENICS.” Vol. 2. Dr. Alfred Ploetz, President of the International
Society for Race Hygiene. London, 1913.
Malthusianism further affects the quality of the offspring by increasing the
intervals between single births. In families in which the parents intend to
have only a few children, the mother is usually exempt from so frequent
child-bearing, and she has ample time for regaining her strength. The
greater interval between births has evidently a favorable effect upon the
expectation of life of the children that are born. Westergard has stated that
in 21,000 births, if the interval between birth is:—

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

More than two
12%
years
That means a difference in the mortality between first and last class of 40%
in favor of the longer interval. P. 186.

THE LIFE INSURANCE EXAMINER. A Practical Treatise by Charles F.
Stillman, M.S., M.D., Medical Examiner for the Mutual Life
Insurance Co.; Clinical Professor of Orthopaedic Surgery in the
Women’s Medical College of the N. Y. Infirmary; Orthopaedic
Surgeon to the N. Y. Infant Asylum; Member of the Am. Orthopaedic
Association; Permanent member of the American Medical
Association; Fellow N. Y. Academy of Medicine, etc. 3rd Edition.
Spectator Co., N. Y., 1890.
“Postpone (as dangerous insurance risks) all cases of pregnancy; all
instances where the mother seems, in the judgment of the Examiner, to have
been bearing children too fast.” P. 186.

RASSENVERBESSERUNG. Translated from the Dutch of Dr. J. Rutgers.
2nd Edition. Dresden, 1911.
The combatting of self-induced abortion is one of the problems of Sexual
Hygiene. The two causes of most weight in this situation are syphilis and
too frequent pregnancy. It is quite evident that both of these causes would
be favorably influenced by the use of contraceptive measures. P. 81.

THE MALTHUSIAN, May 15, 1914. Sexual Ethics. A Study of
Borderland Questions. Robert Michels, (Review).
Prof. Michels perceives that race control has two aspects; it may be an
urgent duty, and it is in any case an inalienable human right. It may be
regarded as a duty to actual or potential children, in view of either bad
economic conditions,—such as affect the bulk of all European populations,
—or defective heredity, and it may also be considered as an obligation of
humanity towards the wife and mother. Prof. Michels here speaks with no
uncertain voice: “The type of woman continually engaged in child-bearing

is a primitive one, out of harmony with the needs and ideas of modern
civilized life. Even as few as six pregnancies that go to full term rob a
woman of about ten years of her life, and these the best. It is evidently far
easier to provide a clear-sighted affection and a wisely conceived and
individualized upbringing for two or three children than it is for eight or
nine.”

MR. SIDNEY WEBB, in The Times of October 16, 1906.
Assuming, as I think we may, that no injury to physical health is necessarily
involved (in the volitional regulation of the marriage state); aware, on the
contrary, that the result is to spare the wife from an onerous and even
dangerous illness for which in the vast majority of homes no adequate
provision in the way of medical attendance, nursing, privacy, rest, and
freedom from worry can possibly be made, it is, to say the least of it,
difficult on any rationalist morality to formulate any blame of a married
couple for the deliberate regulation of their family according to their means
and opportunities.

PERNICIOUS VOMITING

THE PRINCIPLES AND PRACTICE OF OBSTETRICS. By Joseph B. De
Lee, M.D.
Among diseases incidental to pregnancy must be counted pernicious
vomiting. Page 370.
Statistics are uncertain, but out of 118 cases there were 46 deaths. Page 357.
The keynote of treatment is to stop the gestation at a point before either
mother or child, or both, are in danger to life or to health. Page 1041.

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

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

CHAPTER VI
HARMFUL METHODS PRACTICED TO
AVOID LARGE FAMILIES

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

COITUS INTERRUPTUS

THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL,
BIOLOGICAL AND HYGIENIC ASPECTS. E. Heinrich Kisch, M.D.
The prevailing practice of coitus interruptus leads, in my experience in
consequence of the intense hyperaemia of the uterus and the uterine annexa
unrelieved by the occurrence of the orgasm, to a condition of stasis in the
female reproductive organs, and this ultimately passes on into chronic
netritis, (with relaxation of the uterus, retro-flexion, or ante-flexion,
catarrhal diseases of the mucous membrane, erosions and follicular
laceration of the portio vaginalis) oophoritis and perimetritis. The evil
effects of coitus interruptus for a woman are dependent on the fact that the
woman fails to obtain complete sexual gratification, and that this has an
important influence on her entire organism. If this ungratifying coitus
interruptus is frequently repeated in a voluptuous woman disorders of the
reproductive organs ensue, and even more frequently nervous disorders in
the form of neurasthenia sexualis. P. 403.
Mantegazza believes that organic disease of the spinal cord may actually
result from coitus interruptus.
Hirt considers that even when marital intercourse is carefully regulated with
respect to frequency, coitus interruptus may lead to neurasthenic
manifestations.
Eulenberg also declares that coitus interruptus is already a frequent cause of
sexual neurasthenia in women and that its evil influence in this respect is
becoming more and more frequently manifest. P. 405.
Valenta declared that coitus interruptus was one of the chief causes of
chronic netritis.
According to Kleinwachter, coitus interruptus is harmful to the woman to
an extent by no means trivial, whereas the man in whom ejaculation occurs,
suffers comparatively little. P. 407.

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

CONTINENCE

THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL,
BIOLOGICAL AND HYGIENIC ASPECTS. E. Heinrich Kisch, M.D.
Grafe, with reference to the view that if for any reason conception must be
avoided this should be done by abstinence from sexual intercourse,
remarks, “doubtless the ideal demand, but one which even those with
exceptional strength of will are unlikely to satisfy. And the worst of it is that
even a single indiscretion will often result in impregnation.” Moreover, it is
distinctly contrary to natural conditions that a healthy married couple,
united by an intimate affection should live together, abstaining completely
from sexual intercourse. The question has already been much discussed,
both in speech and writing, and this will continue in the future without
altering the fact that the physician will be asked, and will be compelled to
give advice regarding the use of means of prevention of pregnancy. P. 399.
The desired goal of artificial sterility will not, however, be reached through
advocacy of moderation and continence. P. 400.

EFFECTS OF ABSTINENCE. Rassenverbesserung. Translated from the
Dutch of Dr. J. Rutgers.
And if we could penetrate still more deeply into the recesses of the
instincts, and project into the light of day the world of phantasy of those
who live in enforced continence, we would draw away in horror from the
spectacle of what each individual must conceal from himself and others. We
would not then be so eager for the consummation of what is called sexual
abstinence. P. 14.
Physiology teaches that every function gains in power and efficiency
through a certain degree of control, but that the too-extended suppression of
a desire gives rise to pathological disturbances and in time cripples the
function. Especially in the case of women may the damage entailed by too
long continued sexual abstinence, bring about deep disturbances, all the
more because women more often than men misunderstand, or are unaware

of this etiological moment, and have not the slightest idea of the true cause
of their psychic and somatic injury. P. 15.
The unmarried state is a trying and often injurious condition for a man as
well as a woman, when they live in strict continence; and if the latter is not
the case and they resort to prostitution, there are even more pain and
suffering in store for them. P. 16.
We must not forget that there are always two parties to the situation. What
can a physically weaker and spiritually stronger woman do even if she
desires continence with her whole soul, but her husband will have none of
it? Is it not then her duty to protect herself in order that she may not give
birth to a weakly progeny?

HARPER’S WEEKLY. 1915.
When Dr. A. A. Brill, Lecturer in Abnormal Psychology, New York
University, and formerly Chief of Clinic in Psychiatry, Columbia
University, was asked how he regarded contraception in relation to nervous
diseases, he replied emphatically: “You can say that I am for it. It is much
better than an abortion. For instance, I have in mind a woman who was
discharged from the insane hospital. She had three children and had been
three times insane. What chance in life has a child born between two attacks
of insanity, whose mother is mentally defective? Even sane women, if they
are nervous and emotional, should never bear children against their will. It
is foolish to talk about making people have children when they do not want
them. It’s bad for the woman and bad for the child. It is very bad for a child
to be born into a home where he is not desired. I find that many adult,
nervous patients were unwished-for-children, and it was the early attitude of
their parents toward them that contributed much to their bent toward
nervous invalidism.” In reply to the contention of the anti-regulationists that
contraception is physically and mentally harmful, he stated that certain
methods are injurious, while others are not. He commented on the
unfortunate fact that it is the undesirable methods which are employed by
the poorer people, because druggists put a high price upon the better means
on the plea that they run a risk in selling them at all. Remembering that Dr.
Brill was for years connected with Central Islip, he was asked if he did not
consider it demanding a good deal to expect a man discharged from an

insane asylum and sent home to his wife, to live a sexually abstinent life.
He replied: “Only people who know nothing of the sex impulse can make
such a demand of a person who has a poor mental organization. Of course it
is impossible. It is impossible even for the average normal man, and
especially for those who live crowded in two or three rooms.”

THE SEXUAL LIFE. By P. W. Malchow, M.D., Professor of Proctology,
and Associate in Clinical Medicine, Hamline University, College of
Physicians and Surgeons; member Hennepin County Medical Society,
Minnesota State Medical Society, American Medical Association, etc.
There can be no doubt that the influence of prolonged continence upon
either the male or female is to dwarf and in many respects destroy that
which goes to make a broad and full physical and intellectual personality
and that to perform the sexual act whenever there is an existing state of
sexual excitement, with the usual marital restrictions, is rather beneficial
that otherwise. Page 201.
In cases of nervousness in either sex it may be found that, as a rule, the first
indication is a disturbance of the sexual function, following which there
will be digestive troubles, then affections of special nerves, of which
disorders of sight are the first and most frequent, with neuralgias, etc., later.
Observation has shown this to be the general rule, and that is also in
accordance with the law of self-preservation. With the conviction that
nervousness is first manifested and begins with an alteration in the natural
sexual function we may conclude that other functional disorders are a
natural sequence. It thus becomes evident that the most prolific cause of
nervousness is an inability for natural sexual living. Page 296.
A life of celibacy cannot be said to be a natural one, and when this state of
celibacy is combined with propinquity, in which there must of necessity be
a source of repeated and more or less constant sexual excitability there is
added to one already incomplete life a greater burden of increased tension,
which must be a very considerable factor in the causation of unrest or
nervousness. Page 155.
How best to circumvent family complications is the burning question of the
hour with the average young wife, and a satisfactory solution of this
problem would be a boon to society and prevent untold suffering. When

confronted with the question, the usual answer is, in effect, “be natural,”
which in these days of stress, is no answer at all, as it is not practical. Page
158.

THE OBJECTS OF MARRIAGE
By Havelock Ellis

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

This object remains not only the primary but even the sole end of marriage
among the lower races of mankind generally. The erotic idea in its deeper
sense, that is to say the element of love, arose very slowly in mankind. It is
found, it is true, among some lower races, and it appears that some tribes
possess a word for the joy of love in a purely psychic sense. But even
among European races the evolution was late. The Greek poets, except the
latest, showed little recognition of love as an element of marriage. Theognis
compared marriage with cattle-breeding. The Romans of the Republic took
much the same view. Greeks and Romans alike regarded breeding as the
one recognizable object of marriage; any other object was mere wantonness
and had better, they thought, be carried on outside marriage. Religion,
which preserves so many ancient and primitive conceptions of life, has
consecrated this conception also, and Christianity—though, as I will point
out later, it has tended to enlarge the conception—at the outset only offered
the choice between celibacy on the one hand and on the other marriage for
the production of offspring.
Yet from an early period in human history a secondary function of sexual
intercourse had been slowly growing up to become one of the great objects
of marriage. Among animals, it may be said, and even sometimes in man,
the sexual impulse, when once aroused, makes but a short and swift circuit
through the brain to reach its consummation. But as the brain and its
faculties develop, powerfully aided indeed by the very difficulties of the
sexual life, the impulse for sexual union has to traverse ever longer, slower,
more painful paths, before it reaches—and sometimes it never reaches—its
ultimate object. This means that sex gradually becomes intertwined with all
the highest and subtlest human emotions and activities, with the refinements
of social intercourse, with high adventure in every sphere, with art, with
religion. The primitive animal instinct, having the sole end of procreation,
becomes on its way to that end the inspiring stimulus to all those psychic
energies which in civilization we count most precious. This function is thus,
we see, a by-product. But, as we know, even in our human factories, the by-
product is sometimes more valuable even than the product. That is so as
regards the functional products of human evolution. The hand was produced
out of the animal fore-limb with the primary end of grasping the things we
materially need, but as a by-product the hand has developed the function of
making and playing the piano and the violin, and that secondary functional
by-product of the hand we account, even as measured by the rough test of

money, more precious, however less materially necessary, than its primary
function. It is, however, only in rare and gifted natures that transformed
sexual energy becomes of supreme value for its own sake without ever
attaining the normal physical outlet. For the most part the by-product
accompanies the product, throughout, thus adding a secondary, yet
peculiarly sacred and specially human, object of marriage to its primary
animal object. This may be termed the spiritual object of marriage.
By the term “spiritual” we are not to understand any mysterious and
supernatural qualities. It is simply a convenient name, in distinction from
animal, to cover all those higher mental and emotional processes which in
human evolution are ever gaining greater power. It is needless to enumerate
the constituents of this spiritual end of sexual intercourse, for everyone is
entitled to enumerate them differently and in different order. They include
not only all that makes love a gracious and beautiful erotic art, but the
whole element of pleasure in so far as pleasure is more than a mere animal
gratification. Our ancient ascetic traditions often make us blind to the
meaning of pleasure. We see only its possibilities of evil and not its
mightiness for good. We forget that, as Romain Rolland says, “Joy is as
holy as Pain.” No one has insisted so much on the supreme importance of
the element of pleasure in the spiritual ends of sex as James Hinton. Rightly
used, he declares, Pleasure is “the Child of God,” to be recognized as “a
mighty storehouse of force,” and he pointed out the significant fact that in
the course of human progress its importance increases rather than
diminishes. While it is perfectly true that sexual energy may be in large
degree arrested, and transformed into intellectual and moral forms, yet it is
also true that pleasure itself, and above all, sexual pleasure, wisely used and
not abused, may prove the stimulus and liberator of our finest and most
exalted activities. It is largely this remarkable function of sexual pleasure
which is decisive in settling the argument of those who claim that
continence is the only alternative to the animal end of marriage. That
argument ignores the liberating and harmonising influences, giving
wholesome balance and sanity to the whole organism, imparted by a sexual
union which is the outcome of the psychic as well as physical needs. There
is, further, in the attainment of the spiritual end of marriage, much more
than the benefit of each individual separately. There is, that is to say, the
effect on the union itself. For through harmonious sex relationships a deeper
spiritual unity is reached than can possibly be derived from continence in or

out of marriage, and the marriage association becomes an apter instrument
in the service of the world. Apart from any sexual craving, the complete
spiritual contact of two persons who love each other can only be attained
through some act of rare intimacy. No act can be quite so intimate as the
sexual embrace. In its accomplishment, for all spiritually evolved persons,
the communion of bodies becomes the communion of souls. The outward
and visible sign has been the consummation of an inward and spiritual
grace. “I would base all my sex teaching to children and young people on
the beauty and sacredness of sex,” writes a distinguished woman of today;
“sex intercourse is the great sacrament of life, he that eateth and drinketh
unworthily eateth and drinketh his own damnation; but it may be the most
beautiful sacrament between two souls who have no thought of children.”
To many the idea of a sacrament seems merely typo for ecclesiastical, but
that is a misunderstanding. The word “sacrament” is the ancient Roman
name of a soldier’s oath of military allegiance, and the idea, in the deeper
sense, existed long before Christianity, and has ever been regarded as the
physical sign of the closest possible union with some great spiritual reality.
From our modern standpoint we may say, with James Hinton, that the
sexual embrace, worthily understood, can only be compared with music and
with prayer. “Every true lover,” it has been well said by a woman, “knows
this, and the worth of any and every relationship can be judged by its
success in reaching, or failing to reach, this standpoint.”
I have mentioned how the Church—in part influenced by that clinging to
primitive conceptions which always marks religions and in part by its
ancient traditions of asceticism—tended to insist mainly if not exclusively
on the animal object of marriage. It sought to reduce sex to a minimum
because the pagans magnified sex; it banned pleasure because the
Christian’s path on earth was the way of the Cross; and though theologians
accepted the idea of a “Sacrament of Nature” they could only allow it to
operate when the active interference of the priest was impossible, though it
must in justice be said that, before the Council of Trent, the Western Church
recognized that the sacrament of marriage was effected entirely by the act
of the two celebrants themselves and not by the priest. Gradually, however,
a more reasonable and humane opinion crept into the Church. Intercourse
outside the animal end of marriage was indeed a sin, but it became merely a
venial sin. The great influence of St. Augustine was on the side of allowing
much freedom to intercourse outside the aim of procreation. At the

Reformation, John à Lasco, a Catholic Bishop who became a Protestant and
settled in England, laid it down, following various earlier theologians, that
the object of marriage, besides offspring, was to serve as a “sacrament of
consolation” to the united couple, and that view was more or less accepted
by the founders of the Protestant churches. It is the generally accepted
Protestant view today.[50] The importance of the spiritual end of intercourse
in marriage, alike for the higher development of each member of the couple
and for the intimacy and stability of their union, is still more emphatically
set forth by the more advanced thinkers of today.

50. It is well set forth by the Rev. H. Northcote in his excellent book,
Christianity and Sex Problems, (2nd edition, 1916, F. A. Davis
Company, Philadelphia), especially Ch. XIII.
There is something pathetic in the spectacle of those among us who are still
only able to recognize the animal end of marriage, and who point to the
example of the lower animals—among whom the biological conditions are
entirely different—as worthy of our imitation. It has taken God—or Nature,
if we will—unknown millions of years of painful struggle to evolve Man,
and to raise the human species above that helpless bondage to reproduction
which marks the lower animals. But on these people it has all been wasted.
They are at the animal stage still. They have yet to learn the A. B. C. of
love. A representative of these people in the person of an Anglican bishop,
the Bishop of Southwark, appeared as a witness before the National Birth-
Rate Commission which, two years ago, met in London to investigate the
decline of the birth-rate. He declared that procreation is the sole legitimate
object of marriage and that intercourse for any other end was a degrading
act of mere “self-gratification.” This declaration had the interesting result of
evoking the comments of many members of the Commission, formed of
representative men and women with various standpoints,—Protestant,
Catholic, and other,—and it is notable that while not one identified himself
with the Bishop’s opinion, several decisively opposed that opinion, as
contrary to the best beliefs of both ancient and modern times, as
representing a low and not a high moral standpoint, and as involving the
notion that the whole sexual activity of an individual should be reduced to
perhaps two or three effective acts of intercourse in a life-time. Such a
notion obviously cannot be carried into general practice, putting aside the
question as to whether it would be desirable, and it may be added that it

would have the further result of shutting out from the life of love altogether
all those persons who, for whatever reason, feel that it is their duty to
refrain from having children at all. It is the attitude of a handful of Pharisees
seeking to thrust the bulk of mankind into Hell. All this confusion and evil
comes of the blindness which cannot know that, beyond the primary animal
end of propagation in marriage, there is a secondary but more exalted
spiritual end.
It is needless to insist how intimately that secondary end of marriage is
bound up with the practice of birth control. Without birth control, indeed, it
could frequently have no existence at all, and even at the best seldom be
free from disconcerting possibilities fatal to its very essence. Against these
disconcerting possibilities is often placed, on the other side, the un-esthetic
nature of the contraceptives associated with birth control. Yet, it must be
remembered, they are of a part with the whole of our civilized human life.
We at no point enter the spiritual save through the material. Forel has in this
connection compared the use of contraceptives to the use of eye-glasses.
Eye-glasses are equally un-esthetic, yet they are devices, based on Nature,
wherewith to supplement the deficiencies of Nature. However in
themselves un-esthetic, for those who need them they make the esthetic
possible. Eye-glasses and contraceptives alike are a portal to the spiritual
world for many who, without them, would find that world largely a closed
book.
Birth control is effecting, and promising to effect, many functions in our
social life. By furnishing the means to limit the size of families which
would otherwise be excessive it confers the greatest benefit on the family
and especially on the mother. By rendering easily possible a selection in
parentage and the choice of the right time and circumstances for conception
it is again, the chief key to the eugenic improvement of the race. There are
many other benefits, as is now generally becoming clear, which will be
derived from the rightly applied practice of birth control. To many of us it is
not the least of these that birth control effects finally the complete liberation
of the spiritual object of marriage.

ABORTION

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

PRACTICE OF OBSTETRICS. By J. Clifton Edgar, M.D.
Immediate dangers of abortions are: hemorrhage, retention of an adherent
placenta, sepsis, tetanus, perforation of the uterus. They also cause: sterility,
anemia, malignant diseases, displacements, neurosis, and endometritis.
Pages 338–9.

TRUCHTABTREIBUNG UND PRAVENTIVVERKEHR, IN
ZUSAMMENHANG MIT DEM GEBURTENRUCKGANG; Eine
Medizinische, Juristische und Sozialpolitische Betrachtung von Dr.
Max Hirsch. Wurtzburg, Kabitzsch Verlag, 1914.
He who would combat abortion and at the same time assail contraceptive
measures may be likened to the person who would fight contagious diseases
and forbid disinfection. For contraceptive measures are important weapons
in the fight against abortion. The use of contraceptive measures is largely
responsible for the fact that the number of abortions does not increase
immeasurably. The apprehension is perfectly justified that the prohibition of
contraceptive measures would enormously increase the practice of abortion
with its dangerous consequences for the life and health of women. P. 131–2.

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

THE DISEASES OF SOCIETY AND DEGENERACY. The Vice and Crime
Problem. G. F. Lydston, M.D., Professor of Genito-Urinary Surgery,
State University of Illinois; Professor of Criminal Anthropology,
Chicago; Kent College of Law; Member of the American Medical
Association, etc., etc. The Riverton Press, Chicago, 1912.
The familiar cry of “public demand” would fit the abortion business better
than it does some other things. The evil is wide-spread, both in and out of
matrimony. Its existence is recognized “under the rose” as a social
necessity, yet the law calls it murder. For every man and woman caught in
its commission and punished a thousand escape detection.

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

SEXUAL PROBLEMS OF TO-DAY. Wm. J. Robinson, Critic and Guide.
1912.
I have gone on record with the statement that about a million abortions are
brought about every year in the U. S. Exact statistics are not and never will
be available, but I am sure that my estimate is very conservative, and that
three million would be nearer the truth. Justice John Proctor Clark stated
that 100,000 abortions are performed annually in New York City alone, and
if these figures are correct, then the number for the U. S. would be in the
neighborhood of two and a half million. P. 158.

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

ABORTION AND ECONOMIC NECESSITY. (Hirsch).
According to a report in the Medical Record 80,000 abortions are
performed annually in New York and only one case in 1,000 is brought
before the authorities.
According to Lewin it has been determined by court investigations that
there are at least 200 people in New York who make a profession of
performing abortions.
It has been estimated that 2,000,000 abortions are performed annually in the
U. S. P. 7.
Bertillon estimates the number of criminal abortions in Paris at 50,000
annually, in Lyons at 19,000. (Le depopulation de la France). P. 8.
We must first attack a very wide-spread fallacy, namely that abortion is
more prevalent among unmarried girls than among married women. In other
words, that it is concomitant with free sex relations. This fallacy is exploded
by practical medical experience as well as by observation and statistics of
social conditions. P. 23.
Among the causes of criminal abortion the fear on the part of the woman of
the pains and dangers of confinement plays a not inconsiderable role. P. 54.
In marriage the cause for the practice of abortion springs in most cases from
economic necessity. Most frequently this necessity is a genuine dire need
arising from overcrowded quarters, lack of food and clothing, sickness and
lack of employment. P. 33.
This economic need finds its most obvious expression in the congestion of
the city populations. P. 34.
The dangers of childbirth are still serious enough to cause a certain degree
of uneasiness in the woman and the family circle. This foreboding is due
partly to our higher valuation upon health and life, and also to a shifting of

pre-eminence from a solely generative function in women to other interests
in their life. P. 84.
This greater consideration and valuation of woman’s individuality is the
expression of continued progress and a higher culture. P. 87.

TRUCHTABTREIBUNG UND PRAVENTIVVERKEHR, In
Zusammenhang mit dem Geburtenruckzang; Eine medizinische,
juristische und sozialpolitische Betrachtung von Dr. Max Hirsch,
Wurtzburg, Kabitzsch Verlag, 1914.
In Chicago six to ten thousand abortions are performed yearly, of which 75–
90% are married women. P. 7.
I believe I may say without exaggeration that absolutely spontaneous or
unprovoked abortions are extremely rare, that the vast majority—I should
estimate it at more than 80% of abortions have a criminal origin. P. 9.
We may affirm that next to sexual diseases, abortion and its consequences
are the most important factor in the etiology of chronic genital
inflammations and of sterility. P. 9.
Our examinations have informed us that the largest number of abortions are
performed on married women. This fact brings us to the conclusion that
contraceptive measures among the upper class, the practice of abortion
among the lower class, are the real means employed to regulate the number
of offspring. P. 32.

THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL,
BIOLOGICAL AND HYGIENIC ASPECTS. E. Heinrich Kisch.
Translated by M. Eden Paul, M.D. Rebman & Co., New York.
A means of insuring artificial sterility, which in all civilized countries is
punishable as a criminal offense, and which is nevertheless very frequently
practiced, is the artificial induction of abortion. Especially in North
America it would appear that there exist regular professional abortionists. P.
413.

THE FAMILY AND THE NATION. A Study in Natural Inheritance and
Social Responsibility. Wm. Cecil Dampier Whetham, M.A., F.R.S.
Fellow and Tutor of Trinity College, Cambridge, and Catherine
Durning Whetham. Longmans Green & Co., N. Y., Bombay and
Calcutta, 1909.
There is no finality, a nation must either be losing or gaining ground, either
improving or degenerating. Hence the scientific study of the effect of the
existing conditions of any time on the rates of reproduction of different
stocks of the nation, should be the chief work of the sociologist, and the
control of these conditions the supreme duty of the statesman. P. 5.

CHAPTER VII
PROSTITUTION, FEEBLE-MINDEDNESS AND
VENEREAL DISEASES

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

SOME PROBLEMS OF THE SOCIAL EVIL. Hon. Chas. N. Doodnow,
Judge of the Morals Court, Chicago. “The Light.” B. S. Steadwell,
Editor. Jan.-Feb., 1915.
The Court of Morals conducted an investigation of prostitution along three
lines, social, physical and mental. In the first report, April 10th, to
December 31st, 1913, 639 cases were examined, representing every race,
creed, and nationality. 334 were colored, 298 white, 2 Armenian, 1
Japanese. Occupations: 225 housework, 174 waitresses, 136 laundresses, 83
clerks or cashiers, 6 seamstresses, 4 stenographers, 1 trained nurse, 1
manicurist, 24 scrub women, 110 had no occupation. Venereal disease in
infectious stage was diagnosed in 108 cases. 315 showed evidence of
having syphilis, and of the remaining 116, had bacteriological tests been
made, 50% at least would have been found victims of the disease. As to
intelligence, over 400 were mentally deficient, two were found to be insane,
and 68 were little more than imbeciles, having mental capacity of less than
a seven year old child. Later statistics of 100 women going through the

Court were taken showing again that usually their work was of a character
which required the least skill and mental effort, and that 97% either were, or
had been afflicted with disease, and that the majority were mentally
deficient. We did not have any imbeciles, or idiots from the Morals Court,
though quite a number of the morons were of the low grade type bordering
on the imbecile group. In other words, 89.37% of our cases are feeble-
minded, or borderland. If we leave out the borderland cases it shows that
85% of our cases, exclusive of the insane, alcoholics, and drug habitues are
distinctly feeble-minded. This finding is interesting since it corresponds to
our findings in the Boys’ Court, where we found 84.49% were feeble-
minded. It is therefore to be clearly seen here that with the girl defective-
delinquent, as with the boy, the basic cause is feeble-mindedness. This is
the intrinsic cause, which environment and other causes on the whole, are
extrinsic.

REPORT OF CHICAGO MORALS COURT. December, 1913.
Dr. W. J. Hickson of the Psychopathic Laboratory tested 126 cases
excluding insane, alcoholics and drug addicts, for the Chicago Morals
Courts, and found 85.83% distinctly feeble-minded.
Of 639 prostitutes examined by a woman physician for the Chicago Morals
Court, over 400 were mentally deficient; 2 were found to be insane; 68
were little above imbeciles, having mental capacities of less than a seven
year old child.
The State Training School for Girls, at Geneva, Ill., has a population of
about 400, of whom a great majority have been committed for sexual
immorality. Dr. Olga Bridgman reports that of 118 consecutive cases that
were examined upon entry, 105 (or 89%) were graded as feeble-minded. 14
of the 118 had been committed as dependents or uncontrollable. Of the 104
remaining all of whom had been sexually immoral 101 were graded as
feeble-minded while only 3 were found normal according to the Binet test.

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

The more marriage is delayed the more prostitution spreads. Prostitution is
an evil we should strive to eradicate, not to perpetuate, and late marriage,
generally adopted would most certainly perpetuate. Marriage is deferred
owing to the ever increasing difficulty of maintaining a large family in
anything like comfort. Celibacy is not natural to man or to woman, all
bodily needs require their legitimate satisfaction, and celibacy is a disregard
of natural law. Until nature evolves a neuter sex, celibacy will ever be a
mark of imperfection. P. 27–8.
But the knowledge of these scientific checks would, it is argued, make vice
bolder, and would increase unchastity among women by making it safe.
And if so, are all to suffer, so that one or two already corrupt at heart may
be preserved from becoming corrupt in act? Are mothers to die solely that
impure women may be held back, and wives to be sacrificed that the
unchaste may be curbed. As well say that no knives must be used because
throats may be cut, no matches sold because incendiarism may result from
them, no pistols allowed, because murders may be committed by them. P.
38.

SLAVERY OF PROSTITUTION. A Plea for Emancipation. Maude E.
Miner, Secretary of the New York Probation and Protective
Association. McMillan Co., 1916.
The study of young women in prostitution shows that mental deficiency is
an important factor in delinquency. 34%, or approximately ⅓ of 577
delinquent young women at Waverly House were so retarded in mental
development as to be considered feeble-minded, and others were mentally
retarded enough to need protection and over-sight. Close knowledge of the
individual girls convince us that their deficiency facilitates their entrance
into prostitution. P. 43.
Explanation of the mental deficiency of these wayward girls which has
predisposed them to prostitution is usually found in bad inheritance. P. 44.
A feeble-minded girl was found to be one of 13 illegitimate children to
whom her mentally deficient mother had given birth. P. 46.
Over-crowding in rooms, tenements, and neighborhoods is an obvious
menace. In congested sections of the lower part of New York, large

families, to which these girls belong, were herded into two or three narrow
rooms, 12 in three small rooms, seven in two rooms, or a family of five
eating and sleeping and living in a single room. P. 55.
Have we realized that every feeble-minded girl is a potential prostitute?
Have we realized that feeble-minded mothers give birth to large numbers of
children doomed to mental deficiency? Have we realized what this will
ultimately mean in deterioration of human stock and in the complication of
social problems? To stop the stream which is bringing into prostitution large
numbers of mentally deficient girls and women, we must safe-guard these
girls and prevent them from having offspring. Evidence presented to the
Royal Commission on the Care and Control of the Feeble-minded in Great
Britain, and careful studies in America, show conclusively that mental
deficiency tends strongly to be inherited, and that feeble-minded mothers
are more prolific than normal women. P. 267.

DOWNWARD PATHS. An Inquiry into the Causes which Contribute to
the Making of the Prostitute. With a foreword by A. Maude Royden. T.
Bell & Sons, Ltd. London.
It is astonishing to find experts denying the element of economic pressure
as a factor in the creation of the prostitute. It is an influence constantly
present and it is only when we interpret it to mean actual physical starvation
that we can say it is rarely a determining factor. Economic pressure does not
begin with starvation, it ends there. There is again the long strain of
underfeeding and overwork, of the absence of interest, variety and color,
and all that makes life worth living to a human being. Poverty often means
isolation, and isolation the absence of all those ties which keep us in our
place in the social order, and make it worth while to preserve our self-
respect. To be without this is to be constantly in danger and it is economic
pressure which has thrust many over the brink of the precipice, though few
would say their fall was due to actual starvation. P. 10.
Intimately connected with this aspect of the question is that of home and
housing, especially of the child. The age at which children are first
corrupted is almost incredibly early, until we consider the nature of the
surroundings in which they grow up. Insufficient space, over-crowding, the
herding together of all ages and both sexes, these things break down the

barriers of a natural modesty and reserve. Where decency is practically
impossible, unchastity will follow, and follow almost as a matter of course.
There are certainly natural defences in the right instincts of young people
brought up in the right kind of home, which we look for in vain among
those who have never had space enough for growth, or privacy enough for
refinement. P. 11.
We must allot to bad housing and over-crowding a foremost place, not only
as undermining the physical health which conduces to normal sexual
relationship, but also as a danger to the wholesome innocence of youth. P.
21.
It cannot be too strongly impressed upon persons interested in the housing
problem that over-crowding means a violation of childhood in every degree,
from the indecencies of mere childish horse-play to complete debauchery. P.
22.
There are two types of feeble-minded girls who are almost inevitably
destined to prostitution. There is first the large proportion whose sexual
inclinations are abnormally strong, or whose power of self-control over
natural impulses is abnormally weak. 2—There is the large class who are
non-resistant. They have no active impulse to seek out men, but they will
yield to any one who approaches them. There are three important factors
that drive the feeble-minded into prostitution by excluding them from other
occupations. 1—They often lose their characters at a very early age. A
marked characteristic of the feeble-minded is the precocity of their sexual
impulse. 2—It is easy enough for any feeble-minded girl to get and keep
light, unskilled work at girl’s wages, but not so easy for her to pass like the
girl of normal intelligence, from girl’s to woman’s work at the age of 17 or
18, for she is rarely worth woman’s wages. Therefore she finds herself
bored by monotonous work and low pay just at the time that she is
particularly attractive to man, and her sexual impulses are at their strongest.
Very naturally the feeble-minded girl with her incapacity to perceive the
consequences turns from her unsatisfying employment to the new life of
excitement and easy gain that offers itself. 3—If feeble-minded girls do
succeed in getting respectable situations they are very likely to lose them
because of their lack of intelligence and general inefficiency. And even if
they should discharge their duties in a satisfactory manner they have a

curious distaste for staying for any time in one place, and tend to drift from
situation to situation. P. 127–128.
Another characteristic of the feeble-minded is their notorious fertility. The
superior fertility of the feeble-minded has been proved beyond dispute by
statistical inquiry.

DELINQUENCY AND MENTAL DEFICIENCY. Dr. Olga Bridgman. The
Survey, June 13, 1914.
Report of examination of 118 consecutive admissions at the Illinois
Training School for Girls at Geneva. Of the 118, 105, or 89%, showed a
retardation of three years or more, thus ranking as mentally deficient, 6%
were backward, being one or two years retarded, and six, or 5% were
graded as normal. According to the Binet tests then, 97% of the children
sent to this institution are mentally defective.

COMMERCIALIZED PROSTITUTION IN NEW YORK CITY. George
Kneelands. Century Co., New York, 1913. (Chapter by Katherine B.
Davis on a Study of Prostitutes Committed from New York City to the
State Reformatory for Women at Bedford Hills.)
It is difficult to get at the actual truth as to the number of children the
unmarried women have had. The Table shows the admission of 209 women
on this point. There are 73 unmarried women who admit having had
children, 16 were pregnant at the time of entering, and 18 had previously
been pregnant. 428 claimed to have had no children. In this connection it
may not be amiss to note the fact that an unmarried woman who has had a
child is more apt to belong to the mentally defective class. Of the 647,
20.09% were shown to have hereditary degenerate strains, and 20.56%
venereal disease. Page 180.

FEEBLE-MINDEDNESS

SOCIAL HYGIENE. March 1915. Vol. 1, No 2. Recent Progress in Social
Hygiene in Europe. James B. Reynolds, Counsel, The American
Social Hygiene Association.
Recent studies of prostitutes there (in Europe) as here have strikingly
brought to light the significant relationship between prostitution and mental
defectiveness. A far reaching contribution to the solution of the problems of
sex education and prostitution was the Mental Deficiency Act of 1913 for
England and Wales. This Act was based on the Report of a Royal
Commission on the Care and Control of the Feeble-minded which made a
careful and exhaustive study of the entire subject, including the methods of
treatment of the mentally defective in all countries. The Commission
declares that a great proportion of the evidence unmistakably indicates that
mentally defective children are greatly lacking in self-control and peculiarly
open to suggestion and hence specially susceptible to the influence of
depraving companions. The testimony of numerous experts who appeared
before the Commission is highly illuminating on these points. Dr. Kerr,
medical officer of the London County Council, declared that sooner or later
many of these children will be found in the hands of the police, or in
maternity hospitals. Dr. Ashby, late medical officer of the Manchester
Special Schools stated that the mental defectives tend to an increase of the
criminal and immoral classes. Dr. Whittell, Medical Superintendent of the
Suffolk County Asylum, argued that the natural and physical evolution of
this class is apt to result in various offenses of sexual, or perverted sexual,
nature. Dr. Corner, Lecturer on Mental Diseases in the North East London
Post Graduate Hospital, said, “One of the most common and dangerous
characteristics of the feeble-minded is that they tend to sink socially.”
Another expert testified that mentally defective girls in large cities are
subject to overwhelming temptations and pressure toward sexual
immorality, while still another, looking to the larger aspects of the problem,
called attention to the danger resulting from the immoral laxness of
mentally defective girls, and the lowering of the mental stamina of the
whole nation by the increase of a population of defective intellect. Sir

Francis Galton went so far as to declare that mentally defective women
commonly become prostitutes. The feeble-minded, as distinguished from
idiots, are an exceptionally fecund class, mostly of illegitimate children, and
a terrible proportion of their offspring are born mentally deficient. All these
experts were in agreement that mentally defective girls are in great danger
of becoming immoral, hence prostitutes.

DEGENERACY, ITS CAUSES, SIGNS AND RESULTS. Eugene S. Talbot,
M.D. Walter Scott, Ltd., London; Chas. Scribner’s Sons, N. Y. 1898.
Pauline Tarnowsky in her study “Etudes Anthropometriques sur les
Prostituées” finds that in Russia prostitution is crime in women taking the
line of least resistance. She concludes from her researches, which mine tend
to verify, that the prostitute as a rule is a degenerate being, the subject of an
arrest of development, tainted with a morbid heredity, and presenting
stigmata of physical and mental degeneracy fully in consonance with her
imperfect evolution. C. Andronico of Messina, Italy, arrived some time
previously at the same conclusions as those of Tarnowsky.

FEEBLE-MINDEDNESS, ITS CAUSES AND CONSEQUENCES. Henry
Herbert Goddard, Director of the Research Laboratory of the
Training School at Vineland, N. J., for Feeble-minded Boys and
Girls. McMillan Co., 1914.
Among the different causes for the social evil feeble-mindedness has been
suggested, but nowhere has it been given the prominence that is due it.
Anyone who understands feeble-mindedness, especially the moron, cannot
expect anything less than that great numbers of these girls will fall into the
life of prostitution. As to the actual statistics on this subject we have almost
none. One very significant record comes from Geneva, Illinois, made by Dr.
Bridgman. She found that of 104 girls in the Reformatory who were
committed for an immoral life 97% were feeble-minded. This does not by
any means indicate that 97% of prostitutes are feeble-minded, because it is
only natural to expect that the feeble-minded ones would be the ones to be
caught and sent to an institution. These figures, nevertheless, give us some
idea of the prevalence of feeble-mindedness in this traffic. Many competent
judges estimate that 50% of prostitutes are feeble-minded. Pages 14–15.

The 327 cases here presented constitute a unitary group. They have not
been selected. They are of all ages and grades of defect. Page 7.
Our 327 families naturally fall into six fundamental groups, as follows: 4—
Accident Group, 57; 5—No Cause, 8; 6—Unclassifiable, 27. Pages 47–48.
The following table gives an idea of the fecundity of these groups of
women.

No. of Mothers No. of Children Average
Hereditary 139 992 7.1
Probably Hereditary 27 168 6.2
Neuropathic 36 204 5.6
Accident 50 258 5.1
No Cause 8 258 5.7
Unclassified 27 118 4.3
——— ————— ———
287 1,786 6.2
In addition to the mentality, whether normal or feeble-minded, record has
been kept of certain diseases and conditions supposed to be more or less
associated with feeble-mindedness in a causal relation. These are the
following: 1—Alcohol; 2—Tuberculosis; 3—Sexual Immorality; 4—
Paralysis, Insanity, Epilepsy, Neurotic Condition, Syphilis, Criminality,
Deafness, Blindness, Migraine, Goitre, Vagrancy. Page 473.
Sexual immorality is closely associated with hereditary feeble-mindedness.
Closely connected with the subject of sexual immorality is the one of
illegitimacy. Our records show 278 illegitimate children of whom 259, or
93% are in the pure Hereditary group, 12 in the Probably Hereditary group,
3 in the Neuropathic, and 4 in the Accident group. There is nothing new in
these facts. They are simply confirmatory of what we have found in other
lines. Page 499.
The feeble-minded person is not desirable; he is a social encumbrance, even
a burden to himself. In short, it were better, both for him and for Society
had he never been born. Should we not then in our attempt to improve the
race begin by preventing the birth of more feeble-minded? Page 558.

THE FEEBLE-MINDED A SOCIAL DANGER. A. F. Tredgold, L.R.C.P.,
London. M.R.C.S., England. Medical Expert to the Royal
Commission on the Feeble-minded, etc. Eugenics Review. Vol. 1,
April, 1909. Pub. Eugenics Education Society, London.
In England and Wales on January 1st, 1906 there were a total of 138,529
persons in the country who were defective in mind. This corresponds to
4.03 per thousand population, or to one mentally defective person in every
248. In England and Wales on January 1st, 1906, there were no less than
125,827 insane persons. If we add these to the number of the mentally
deficient which I have just stated, we find that in this country there is one
person out of every 130 who suffers from severe disease of the mind. P. 98–
99.
According to the Registrar General, the average number of births to a
marriage in the whole population of this country is 4.6. I have ascertained
that the average number of births in these degenerate families is no less than
7.3. It is obvious that if this alarming propagation is not checked, the time
must inevitably come when our nation will contain a preponderance of
citizens lacking in that intellectual and physical vigor which is absolutely
essential to progress. P. 98.

RASSENVERBESSERUNG. Translated from the Dutch of Dr. J. Rutgers.
Second Edition, Dresden, 1911.
A not insignificant factor in the use of houses of prostitution is furnished by
married men who in the “old fashioned” way wish to “protect” their wives,
in order not to be burdened with too many children. Neo-Malthusianism is
also the best weapon against this class of supporters of prostitution. P. 73.

MASSACHUSETTS COMMISSION FOR INVESTIGATION OF THE
WHITE SLAVE TRAFFIC.
This investigation under Dr. Walter Fernald, included a physical
examination study of family and personal history, social reactions, and
standards, etc. Out of the 300 prostitutes 154 were feeble-minded (all
doubtful were called normal). The 154 were so pronounced as to warrant

legal commitment. None of them had the mentality of a normal child of 12
years old. Majority were that of 10 or 9 years old.

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

THE MENTALITY OF THE CRIMINAL WOMAN. A Comparative Study
of the Criminal Woman, the Working Girl and the Efficient Working
Woman in a Series of Mental and Physical Tests. Jean Weidensall,
formerly Director of the Department of Psychology, Laboratory of
Social Hygiene, Bedford Hills, N. Y. Warnick and York Inc. 1916.
Tests applied to a group of children of working age by the Bureau of
Educational Guidance of Cincinnati were also used on a group of 20 maids
at Vassar as a norm for testing the women committed to Bedford. 100
reformatory subjects were used for the tests. It is a matter for question
whether loss of the parent is the cause of the child’s leaving school and
going to work early and of the ultimate unsocial conduct in the case of the
Bedford group, or whether loss of parent, retardation, misconduct, etc., are
not for the most part but manifestations of the same thing—irresponsibility,
mental, physical and social inferiority on the part of both parents and child.
The facts at our disposal and eugenic investigations lead us to believe that
the latter is in the larger measure true. Out of 100 women recorded 30 had
had from one to five illegitimate children. Of the 100 tests for syphilis and
gonorrhoea, 45% positive, 4% doubtful, 51% negative, for syphilis. 60%
positive, 22% doubtful, 18% negative for gonorrhoea. At best strong
character cannot be the rule among individuals ⅔ of whom have less
intelligence than that possessed by the average individual among a group of
children of 15, (of whom half are themselves retarded), and almost surely

not when they have been too untrained industrially and too unschooled
socially to have acquired simple every-day habits of restraint and inhibition.
Even the more intelligent third of the reformatory subjects differed very
obviously and unmistakably in stability and emotional control from the
group of Vassar maids.

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

51. Read before the conference of the Massachusetts Society for Mental
Hygiene, Boston, November 19, 1915.
From the standpoint of the child, something can be done to make them a
little happier; from the standpoint of society, no amount of mental hygiene
can ever render them efficient citizens. Society can, by proper treatment,
render them less of a menace than they are naturally, and the ills that we
now suffer on account of them can be largely reduced.
It is estimated that there are from 300,000 to 400,000 mental defectives in
the United States. That is based upon the United States census of 1890, in
which the question was asked “Whether defective in mind, sight, hearing or
speech, or whether crippled, maimed or deformed, with name of defect.”
Now if anyone can estimate what proportion of the true number of the
feeble-minded would be returned in answer to that question, he will be able
to estimate how near the truth is the 200,000 which the census report gives.
Three hundred thousand or 400,000 seems to be a conservative estimate.
I am to discuss this topic from the standpoint of heredity. It has not yet been
successfully contradicted that two-thirds of this army of 300,000 or
400,000, owe their condition to heredity. A quarter of a million of these
people are feeble-minded because their ancestors were feeble-minded. They
have inherited the condition just as you have inherited the color of your
eyes, the color of your hair, and the shape of your head. There is a tendency
in these days to attribute a great deal to heredity. But of this particular thing
there seems to be no question. The menace of the problem comes, not from
the fact that a quarter of a million inherited their condition, but because they
are transmitting that condition to their offspring. Of that quarter of a million