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 Knopf, S. Adolphus 
 
 Birth Control 1919. 
 
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BIRTH CONTROL 
 
 IN ITS MEDICAL, SOCIAL, ECONOMIC 
 AND MORAL ASPECTS 
 
 BY 
 
 S. ADOLPHUS KNOPF, M. D. 
 
 P)-ofessor of Medicine, Department of Phthisiotherapy, at the Neic York Post- 
 Graduate Medical School and Hospital; Visiting Phtisician to the Riverside 
 Hospital-Sanatorium of the Health Department of the City of 
 New York; formerly Captain in the Medical Corps, 
 U. 8. Army 
 
 With the discussion by Drs. Ira S. Wile, J. H. Laxdis, 
 
 W. L. Holt, Louis I. Dublin, John W. Teask, 
 
 and the closing remarks by Dr. Knopf. 
 
 1919 
 SECOND EDITION 
 
 Revised by the Author and reprinted with his permission by the 
 
 NEW YORK ^\TOMEN'S PUBLISHING CO., INC., 
 
 104 Fifth Avenue, New York. 
 

Birth Control in Its Medical, Social, Eco- 
 nomic, and Moral Aspects 
 
 Bj S. Adolphus Knopf, M.D. (Pans and New York) 
 
 Professor of Medicine^ Department of PhtMsiotherapy, at the New York 
 
 Post-Graduate Medical Schoov and Hospital; Visiting Physician to tlie 
 
 Riverside Hospital-Sanatorium of the Health Department of the City of 
 
 Nexv York; Formerly Captain in the Medical Corps, U. S. Army. 
 
 Preface to the Second Edition. 
 
 The first edition of my lecture on Birth Control in Its Medical, Social, 
 Economic, and Moral Aspects having been complete!}' exhausted, I have 
 been requested to permit the printing of a second edition. This lecture was 
 delivered for the first time in October, 1916, before the American Public 
 Health Association and has since been read a number of times before 
 medical, legal, church, and civic organizations. The question may now 
 arise whether it is up to date after the fearful worM war in which our own 
 country finally had to participate so that humanity might be safe from the 
 tyranny and oppression of autocratic rulers and governments. The Avar, 
 with its sequel of a terrible influenza plague, has probably cost from twelve 
 to fifteen million lives, and the casual observer might say verily no thought 
 should now be given to birth control, for we must replace the lost population 
 and particularly the lost man power. 
 
 I have discussed the various aspects of birth control in my paper, and 
 the remarks made by Assistant Surgeon General Trask df the U. S. Public 
 Health Service, reproduced in this pamphlet on page 27, ansAver all argu- 
 ments for uncontrolled increase of population during Avar times and there- 
 after. Our mobilization experience has shown us that one-third of the 
 millions of men who were examined were physically unfit to sei-ve in the 
 army, and I venture to say that if an examination of our female population 
 would have been made, the proportion of women mentally and physically 
 unfit to be mothers might have been equally as great. In connection with 
 this I Avish to emphasize Avhat I said in the first edition of this pamphlet, 
 namely, that my appeal is not for reducing the population but for increas- 
 ing its A'igor by reducing the number of the physicall}', mentally, and morally 
 unfit and adding to the number of the physically strong, mentally sound, 
 and higher morally developed men and Avomen. 
 
 On June 9th of tins year, before the American Academy of Medicine, I 
 delivered an address entitled "The Tuberculosis Problem After the World 
 
4 Birth Control 
 
 War," in which I gave some statistics of the fearful prevalence of tubercu- 
 losis in Europe at this time (Medical Record, July 26, 1919). What 
 France and Belgium have suffered from this disease is too well known to 
 need repetition here, but still more terrible are the reports which came to 
 me from Italy, Greece, and Servia by no less an authority than Col. Homer 
 Folks, former Charity Commissioner of the city of New York, who had just 
 returned from an extended visit to Italy, Greece, and Servia, where on behalf 
 of the Red Cross he had investigated the general, economic, and sanitary 
 conditions of these stricken countries. An additional report has come to 
 me from Dr. Rosalie Slaughter Morton, that brave woman who without 
 compensation served as a medical officer during the past years to the civilian 
 and military population of stricken Servia. To judge from these reports 
 the tuberculosis situation is exceedingly grave in all these countries. Col. 
 Folks reports an increase of tuberculosis mortality of 17 per cent through- 
 out Italy from 1914 to 1916, and a further increase in the cities of 12 per 
 cent in 1917. In Greece matters seem to be even worse. In Athens before 
 1914 there was a death rate of 1 in 6 from tuberculosis ; now, owing to war 
 conditions, this has undoubtedly considerably increased, although exact 
 statistics are not available. 
 
 In Servia, which held the enemy forces at bay for fourteen months, the 
 people have perhaps suffered from tuberculosis as much as any country of 
 the Allied or Central powers. Col. Folks estimates that the Servian popu- 
 lation is now 25 per cent less than it was at the outbreak of the war. The 
 mortality from tuberculosis in old Servia, i.e., the northern part, including 
 the cit^" of Belgrade, was already high before the war^ — 324 per 100,000 in 
 1911. In Belgrade in 1912 it was 720 per 100,000; in 1917, according to 
 an Austrian report, it had risen to 1,483 per 100,000. 
 
 Dr. Rosalie Slaughter Morton, who had recently returned for a brief visit 
 from Servia, described the tuberculosis situation to me personally as simply 
 appalling. Men, women, and children were dying by the thousands from this 
 disease. Out of 14,000 Servian prisoners who were returned to their home 
 country after the armistice, 6,000 had contracted tuberculosis, and in the 
 new Czecho-Slovac republic conditions seem to be fully as bad. 
 
 The question must now be asked should these tuberculous people not yet 
 cured and man}^ of whom are too far advanced to ever become cured, pro- 
 create children.'^ Should they not rather be taught birth control and not 
 people the world with additional invalids, burdens to themselves and the 
 community.^ I took up this question in my oi^ginal article in 1916, and my 
 views were endorsed at that time by Dr. J. N. Hurty of Indianapolis (see 
 page 26), but in my address on The Tuberculosis Problem After the World 
 War I stated that birth control, particularly in countries where there are 
 still thousands of people with little food, poor shelter, and insufficient cloth- 
 
Birth Control 5 
 
 ing, would be absolutely essential in order to combat this world plague. I 
 do not stand alone with this view. All students of the tuberculosis problem, 
 and the social problems in general that confront us in the war-stricken 
 countries, are of the same opinion. In a remarkable letter which I i-epro- 
 duced in my address before the American Academy of Medicine from tbe 
 Journal of the American Medical Association of April 19, 1919, Dr. C. K. 
 Millard, Health Officer of Leicester, England, writes as follows : 
 
 "The question of the birth rate is intimately bound up with that of birtli 
 control. It is unfortunate that scientific study of the subject has been 
 hitherto neglected. Owing to the supposed moral stigma many had tabooed 
 it, and it is only quite recently that unbiased discussion had become possible. 
 The subject is of special interest and importance at the present day, 
 through conditions arising out of the war. In many parts of Europe the 
 social conditions of the people, with starvation staring them in the face, 
 without proper clothing or shelter, with civilization itself broken down, 
 are deplorable in the extreme. It appears eminently' desirable that rigid 
 birth control should be practiced in those countries, and probably in others 
 also, if acute maternal suffering and terrible infant mortality are to be 
 avoided. The best things for the people of those countries to do is tempo- 
 rarily to stop having children, so far as it can be avoided, until happier 
 and more prosperous times arrive. It seems to be taken for granted in 
 most countries that rapid increase in population is needed in the national 
 interest, and that a stationary population would be disastrous. No doubt 
 this sentiment is really based on militarist considerations, and in the past, 
 when such considerations were vital, it might have been wise to encourage it. 
 But now, with the inteniational situation fundamentally altered, and with 
 the League of Nations (whose special function it would be to safeguard 
 the nations with small population), it is time to reconsider our attiude. 
 International competition in birth rates is to be avoided, just as was com- 
 petition in aiinaments. There are certain countries which are already 
 "saturated" as regards population, in the sense that any further increase 
 would not tend to increase the happiness or prosperity of the inhabitants. 
 Wherever that point has arrived, or is nearly at hand, birth control must 
 be regarded as the proper remedy, and as greatly preferable, in most cases, 
 to emigration. The case of England is complicated by the fact that she is 
 the mother country of an empire. Many people would agree that the popu- 
 lation of the British Isles is large enough, but the}' wanted to see her great 
 colonies filled up with an all British population. No doubt this is very 
 patriotic, from the standpoint of conditions before the war; but from the 
 point of view of the League of Nations they ought to regard their colonies 
 as the natural outlet for the surplus population of all European countries. 
 It is so necessary for the peace of Europe that such an outlet should exist 
 
^ Birth Control 
 
 that they need not be in any Imrry to see those territories filled up. As to 
 the question of practical methods, physicians have not o-iven it sufficient 
 attention to enable them to speak very authoritatively. Certain physicians, 
 with obviously a strong bias on moral grounds, have condemned all methods 
 as highly injurious, but the bishops in a special report on this subject 
 presented to the Pan-Anglican Conference in 1908, have seized an isolated 
 medical opinion of this kind and used it as though it were the considered 
 verdict of the medical profession. 
 
 "To ascertain what is the real opinion of the profession of the present 
 day Dr. Millard has recently issued a questionnaire to medical practition- 
 trs, and from some eighty rephes received he is quite satisfied that the great 
 majority of the profession does not regard birth control as necessarily 
 injurious." (London Letter, March 27, 1919, to Jour, of the A. M. A.) 
 
 A leading statesman and politician of England, Mr. Harold Cox, before 
 the English .National vB'irthrate Connmission, recently gave irrefutable 
 evidence of the great need of birth control at this very time, even in England 
 and Wales, countries which in comparison with France, Belgium, Italy, and 
 the Balkan states, have suffered comparatively little from tuberculosis or 
 other epidemics, as a consequence of the war. Mr. Cox's statements are 
 summarized as follows in the Journal : 
 
 "In opposition to the- endowment of motherhood by the State, Mr. Harold 
 Cox pointed out that the population of England and Wales doubled in the 
 sixty years that ended in 1911. Suppose that rate of increase were 
 continued indefinitely, then in the year 2201, the population of England and 
 Wales alone would be 2,295,000,000. No further argument was needed to 
 prove that the rate of increase in the population must decline as the volume 
 grows. The rate could only be reduced either by diminishing the birth rate 
 or by increasing the death rate. If birth control were in itself immoral, it 
 would still be immoral when the population had reached such a volume that 
 a reduced rate of increase became absolutely necessary. A high infantile 
 death rate was the almost invariable accompaniment of a high birth rate. 
 Thousands of children were fated only to live a few weeks or a few months. 
 This involved a vast waste of human effort. In the East the waste of 
 women's bodies and of infant life was even more appalling. Both in India 
 and in China, out of every thousand children bora often more than 500 died. 
 The socialist proposal to give a state subsidy to every woman who produces 
 a child would only increase the evil. Children reared by subsidized parents 
 would probably lounge through life leaning on the state. A few years ago 
 the Germans established an imperial grant to mothers who suckled their 
 babies. Last year's Local Government Board report on infant welfare in 
 Germany says : "It is recorded from a large number of centers that 
 
Birth '.Control 7 
 
 mothers discontinue breast-feeding immediately the imperial allowance ceases, 
 regardless of the well-being of their infants." It would be futile to deal with 
 the German peril by means of what might be called a cradle competition. In 
 such a contest we must inevitably be beaten, because Germany started the 
 race with a much largei- volume of population. England at the present 
 moment was over-populated. Doubtless considerable improvement would be 
 effected if our industries could be established in garden cities. But if this 
 process were carried to the point of giving all our overcrowded millions a 
 quasi-rural surrounding, there would be no real country left. Our island was 
 too small to afford possibilities for a full life to all the millions now crowded 
 on it. He therefore welcomed the decline in population, and hoped it would 
 continue." (London Letter, May 28, 1919, to the Journal of the A. M. A., 
 Vol. 72, No. 26, 1919.) 
 
 To the strong statements on the advisability of birth control made on 
 the one hand by so distinguished an authority as Dr. Millard, and on the 
 other by the political economist, Mr. Cox, I may finally add the opinion of 
 an eminent English divine, the Right Rev. H. Russell Wakefield, D.D., 
 Bishop of Birmingham, President Council of Public Morals, and Chairman 
 National Birth Rate Commission. I quote from the London Times of April 
 8, 1919, and "The Medical Critic and Guide" of July, 1919, which credit 
 the revei-end gentleman with having said that "The cry of many social 
 reformers was for a greatly increased birth rate, but what a nation needed 
 most was not an unlimited number of citizens, but a sufficient number of the 
 best quality. Morally, as well as eugenically, it was right for people in 
 certain circumstances to use harmless means to control the birth rate. 
 
 "The most unsatisfactory feature in regard to this matter was that child- 
 bearing was prolific, generally speaking, only in the very classes in which 
 the children very often did not get a fair opportunity of 'life, while in the 
 sections of the population where there were good prospects of ensuring a 
 healthy upbringing control was carefully exercised. 
 
 "It was contended, by objectors to birth control, that the object of 
 marriage being the production of children, preventive measures were neceb- 
 sarily wrong. The great Roman Catholic Church, with its magnificent 
 decisiveness of no compromise except one, and the Anglican Bishops had so 
 far taken the same line. The Jewish Church was also emphatic on the mat- 
 ter, but the Nonconformist Churches had not spoken formally. The reply 
 to the argument used might be that the procreation of children was not the 
 only object of matrimony, and there was surely a dishonoring of that very 
 object to have children bom when not wished for by both parents. 
 
 "Had not the sexual association of married people a spiritual meaning 
 which must be placed first in all definitions of it.f* It was surely the culminat- 
 
8 Birth Control 
 
 ing expression of the love of the two who had become one flesh. It brought 
 with it the creation of a child which was the combination of the two natures, 
 but it need not be an imperfect union if on occasion, for high and pure 
 motives, there was a sacrifice of this particular result of married love." 
 
 What the distinguished economist, Mr. Cox, stated concerning the present 
 and future condition of England and Wales is to a large extent applicable 
 to the United States, although it can hardly be said that at this moment the 
 United States are over-populated. However, if the increase in yjopulation 
 and additional immigration continues in the United States as it has during 
 ihe past fift}' years, there is a great likelihood that a condition of over- 
 population will be reached within two or three generations from now, and 
 in the meantime the result of an uncontrolled birth rate among the physi- 
 cally, mentally, and morally unfit will continue with its trail of crime, 
 suffering, and increased burdens to indi^adual families and the community 
 at large. 
 
 To any unbiased mind it must be evident that our very experience, before, 
 during, and after this world war, answers all objections to judicious birth 
 control in its medical, social, economic, moral, and even spiritual aspects. 
 Wliat this world Heeds now — after the fearful catastrophe which Avas started 
 by a nation in which unlimited procreation among rich and poor, the 
 educated and the uneducated, the well and the sick, was not only encouraged 
 but oflficially rewarded — is not a greater but a better population. The 
 empire which sought world dominion and the enslavement of other nations 
 had the highest birth rate and the most rapid growth of population, and 
 yet, it was France, which had by its birth control produced not as many but 
 better soldiers, which withstood the most terrific onslaughts of the enemy's 
 hordes. The generals of the German army sacrificed their soldiers en 
 masse in close columns ; it would seem that these military leaders felt that 
 the empire had produced such great masses of men that they did not need 
 to be so sparing and economical with human life. 
 
 The world needs now and for all the future the very best kind of men and 
 women, not servile masses blindly obej^ing war-drunk monarchs and mili- 
 taristic rulers, not a mass of weaklings, bound to succumb before reaching 
 man- or womanhood, unable to serve or to produce. We need children, but 
 only such as are welcome to the home which physically, mentally, and 
 morally sound parents have provided. The parents being economicalh' 
 situated so as to be able to give enough food, enough clothing, enough 
 playtime to their children and live in comfort and enjoy life themselves. 
 The state will then be able to provide enough educational facilities for 
 children, and child labor will be done away with. Parents and children of 
 the present generation should receive a training and education that with 
 the help of a wise government and enlightened statesmen should be instru- 
 
Birth Control 9 
 
 mental to create a future race of true men and women, physically, mentally, 
 and morally sound, spiritually hif^h minded, images of their creatoi-. 
 
 Now, as a final argument, I should like to add some interesting figures 
 from a recently published monograph entiHed "The Mathematical Theory of 
 Population, of Its Character and Fluctuations, and of the Factors Which 
 Influence Them." (Melbourne, Commonwealth Bureau of Census and Sta- 
 tistics, 1917), by Mr. G. H. Knibbs, the statistician of the Commonwealth 
 of Australia. 
 
 Some significant facts and estimates in regard to the present and future 
 population of the earth are given by Mr. Knibbs. He puts the population 
 of the earth for the year 1914 at 1,649,000,000, or about thirty-nine million 
 in excess of the estimate for 1910 by Jaraschek, the French statistician. 
 The annual rate of increase in the world's population for the five-year 
 period 1906 to 1911, Knibbs estimates at 0.01159, or 1.159 per cent. 
 Should such a rate of increase be continued, it must result in a severe strain 
 on the resources of Nature. Knibbs asks whether medical men in future 
 will take a stand in favor of so colossal a population that the masses will 
 scarcely be provided with the bare necessaries of lite, or .whether they will 
 favor birth control and a limitation of birth in such a manner that the 
 population of the earth shall never be greater than can be adequately pro- 
 vided for on a high plane of physical, mental and moral exist ence.'^ 
 
 This interesting report was copied by the Journal of the American 
 Medical Association, in its issue of November 22, 1919, which means that it 
 may have been read by 50,000 American physicians. Mr. Knibbs' report 
 has doubtless reached not only Great Britain and her colonies but also the 
 now sorely afflicted countries of Europe. May our own physicians and 
 statesmen as Avell as those of Europe realize the importance of such figures 
 and awake to the moral responsibility to save future generations from famine 
 and disaster. 
 
 S. Adolphus Knopf, M.D. 
 
 New York, December 1, 1919. 
 
Birth Control In Its Medical, Social, Eco- 
 nomic, and Moral Aspects 
 
 S. Adolphus Knopf, M. D. (Paris and New York), 
 
 Professor of Medicine, DepartTnent of Phthisiotherapy, at the New York 
 Post-Graduate Medical School and Hospital; Visiting Physician to the 
 Riverside Hospital-Sanatorium of the Health Department of the City 
 of New York; Formerly Captain in the Medical Corps, U. S. Army. 
 
 WHEN at this very moment, 
 October 27, 1916, across 
 the sea in Europe the best 
 blood of the nations which were here- 
 tofore considered the most enhght- 
 ened, cultured, and civilized, is daily 
 being shed and hundreds of thous- 
 ands of young men in the prime of 
 life sacrificed to the Moloch of war, 
 it must seem a hazardous undertak- 
 ing to talk of birth control, which 
 means artificial birth limitation and 
 by some superficial observers is desig- 
 nated as race suicide. I trust, how- 
 ever, that before I arrive at the end 
 of my paper, I will have convinced 
 you that the object of my appeal is 
 not a plea for reducing the popula- 
 tion but for increasing its vigor by 
 reducing the number of the physi- 
 cally, mentally, and morally unfit and 
 adding to the number of physically 
 strong, mentally sound, and higher 
 morally developed men and women. 
 
 In accordance with the program 
 outlined, I will deal first with the 
 medical and sanitary aspects of the 
 subject. No one will deny that we 
 occasionally come across a family, 
 well-to-do and intelligent, where the 
 parents by reason of unusual vigor, 
 and particularly by reason of the 
 
 physical strength of the mother, have 
 been able to rear a large number of 
 children. In some instances all have 
 survived and have grown up to be 
 healthy and vigorous, but these in- 
 stances are rare and are becoming 
 more and more so every day. On the 
 other hand, large families, that is to 
 say, numerous children as the issue 
 of one couple, among the ignorant, 
 the poor, the underfed and badly 
 housed, the tuberculous, the degen- 
 erate, the alcoholic, the vicious, and 
 even the mentally defective, is an 
 everyday spectacle. It is well known 
 to every general practitioner whose 
 field of activity lies among the poor 
 and the above mentioned classes, that 
 the infant mortality among these is 
 very great. The same holds true of 
 the mortality of school children com- 
 ing from large families among these 
 classes of the population. 
 
 Concerning tuberculosis, with 
 which, by reason of many years' ex- 
 perience, I am perhaps more familiar 
 than with other medical and social 
 diseases, let me relate the interesting 
 fact that a carefully taken history of 
 many, many cases has revealed to me 
 that with surprising regularity the 
 tuberculous individual, when he or 
 
 10 
 
Birth Control 
 
 11 
 
 she comes from a large family, is 
 one of the later born children — the 
 fifth, sixth, seventh, eighth, ninth, 
 etc. The explanation for this phe- 
 nomenon is obvious. When parents 
 are older, and particularly when the 
 mother is worn out bv frequent preg- 
 nancies and often weakened because 
 obliged to work in mill, factor}^, or 
 workshop up to the very da}' of con- 
 finement, the child will come into the 
 world with lessened vitality, its main 
 inheritance being a physiological 
 poverty. This systemic poverty will 
 leave it less resistant, not only to 
 tu'berculosis but to all other diseases 
 of infancy and childhood as well. 
 
 The morbidity and mortality 
 among these children is gi'eatost 
 v.'hen the children are most numerous 
 in one family. Miss Emma Duke, in 
 the third of the Infant Mortality 
 Series, gives the result of a field 
 study in Johnstown, Pa., based on 
 the births of one calendar year 
 (1911). 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 
 has had a chance to reach its first 
 birthday ; man}'^ of them were dead 
 long before that day. The follow- 
 ing is Miss Duke's table showing the 
 infant mortality rate for all chil- 
 dren borne by married mothers in 
 Johnstown during that year: 
 
 Deaths per 1,000 births in 
 
 Families of 1 and 3 children 108.5 
 
 Families of 3 and 4 children 136.0 
 
 Families of 5 and 6 children 153.8 
 
 Families of 7 and 8 children 176.4 
 
 Families of 9 and more children. .191.9 
 
 Dr. Alice Hamilton of the Memo- 
 
 rial Institute for Infectious Diseases, 
 
 Hull House, Chicago, made a study 
 
 of 1,600 families in the neighborhood 
 
 of the settlement. The following is 
 
 the table of the child mortality rate 
 
 of the 1,600 families as published by 
 
 Dr. Hamilton :* 
 
 Deaths per 1,000 l)irtlis in 
 
 Families of 4 children and less 118 
 
 Families of 6 children 267 
 
 Families of 7 children 280 
 
 Families of 8 children 291 
 
 Families of 9 children and more.... 303 
 
 Many families were found of thir- 
 teen, fourteen and even sixteen mem- 
 bers. The largest of all was that of 
 an Italian Woman who had borne 
 twenty-two and raised two. The 
 small families of every nationalitv'^ 
 had a lower mortality rate than the 
 large families of the same national- 
 ity. The Jewish families of four and 
 less had the astonishingly low mor- 
 tality rate of 81 per 1,000, while in 
 families of eight and less, the rate 
 rose to 260 per 1,000. 
 
 The larger the family, the more 
 congested w-ill be< the quarters they 
 live in and the more unsanitary wnll 
 be the environment. Last, but not 
 least, with the increase of the family 
 there is by no means a corresponding 
 increase of the earning capacity of 
 the father or mother, and as a result 
 malnutrition and insufficient clothing 
 enter as factors to predispose to 
 tuberculosis or cause an already ex- 
 isting latent tuberculosis to become 
 active. 
 
 AVhat is the result of this condition 
 in relation to tuberculosis — one sin- 
 
 * Bulletin of (he Amer. Acad, of Med., May, 
 1910, and Miss Mary Ald.en Hopkins in Harper's 
 Weekly. 
 
12 
 
 Birth Control 
 
 gle disease? Out of the 200,000 
 individuals who die annually of tuber- 
 culosis in the United States, 50,000 
 are children. Of the economic loss 
 resulting from these early deaths I 
 will speak later on, but in continu- 
 ing along the medical and sanitary 
 lines of my subject, I must call your 
 attention to the fact that according 
 to some authors 65 per cent, of 
 women afflicted with tuberculosis, 
 even when afflicted onl}^ in the rela- 
 tively early and curable stages, die 
 as a result of pregnancy which could 
 have been avoided and their lives been 
 saved had they but known the means 
 of prevention.* Sometimes we suc- 
 ceed in saving such a mother by a 
 timely and careful emptying of the 
 uterus. But an abortion even scif 
 entifically carried out and only re- 
 sorted to with the view of saving the 
 life of the mother, is never desirable, 
 cither for the consultant to advise, 
 nor for the gynecologist or obstetri- 
 cian to perform; and who will dare 
 to say that even under the best con- 
 ditions this operation is devoid of 
 danger ? 
 
 What Is the explanation and what 
 are the consequences from the point 
 of view of sanitation, of the death of 
 50,000 tuberculous children? They 
 have mostly become infected from tu- 
 berculous parents or tuberculous 
 boarders who had to be taken into 
 the family to help pay the rent. In 
 the crowded homes of the poor there 
 was neither sunlight, air, nor food 
 enough to cure the sufferers and be- 
 
 * C. A. Credi-Hoerder: "Tuberkulose und Mut- 
 terschaft^' CJ. Kraeger, Berlin, 1915.) 
 
 fore they died they became dissemi- 
 nators of the disease. Nearly all of 
 the infectious and communicable dis- 
 eases are more prevalent in the con- 
 gested, overcrowded homes of the 
 poor, and particularly in those of 
 large families. The propagation of 
 syphilis and gonorrhoea by contact 
 infection, other than sexual, can 
 sometimes be avoided in the homes of 
 the well-to-do, b}" enlightenment and 
 the conscientiousness of the afflicted. 
 They are almost invariably commu- 
 nicated to the innocent in the homes 
 of the ignorant and poor. Gonor- 
 rhoeal infection from parent to child 
 or from one infected member of the 
 family to the other, is responsible 
 more than an^^thing else for the 57;- 
 272 blind persons in the United 
 States.* 
 
 The great syphilographer Four- 
 nier left us the following irrefutable 
 statistical evidences of the serious- 
 ness of syphilitic transmission. As 
 a result of paternal transmission 
 there is a morbidity of 37.0 per cent., 
 and a mortality of 28.0 per cent. ; 
 maternal transmission results in 84.0 
 per cent, morbidity and 60.0 per 
 cent, mortality ; and the combined 
 transmissions are no less than 90.0 
 per cent, of morbidity and 68.5 per 
 cent, mortality.! 
 
 I venture to say right here that 
 would or could a syphilitic or gonor- 
 rhoeic parent be taught how to pre- 
 vent conception during the acute and 
 infectious stages of his or her disease, 
 there would certainly be less inher- 
 
 * United States Census, 19in. 
 t Berkowitz: "Late Congenital Syphilils." N. Y. 
 Medical Journal, June 17, 1915. 
 
Birth Control 
 
 13 
 
 ited syphilis, less blindness from 
 gonorrhoeial infection ; -in other 
 words, less unfortunate children in 
 this world handicapped for life and 
 a burden to the oonnnunity. 
 
 That insanity, idiocy, epilepsy, and 
 alcoholic predisposition are often 
 transmitted from parent to child is 
 now universally admitted, and cor- 
 roborated 'by every day experience 
 and by an abundance of statistics. 
 Countless are the Inillions of dollars 
 expended for the maintenance of 
 these mentally unfit. The State of 
 New York alone spends $2,000,000 
 annually for the care of its insane. 
 Whether sterilization of these indi- 
 viduals would be the best remedy is 
 a question still open for discussion. 
 The constitutionality of the proced- 
 ure is doubted by some of our legal 
 authorities. Segregation is resorted 
 to in the meantime with more or less 
 rigor according to the State laws. 
 Every year, however, many of the 
 individuals who had been committed 
 to institutions for the treatment of 
 mental disorders are discharged as 
 cured. They are allowed to pro- 
 create their kind. Would it not be 
 an economic saving if at least the 
 individuals whose intelligence has 
 been restored were instructed in the 
 prevention of bringing into the world 
 children who are most likely to be 
 mentally tainted and to become a 
 burden to the community? 
 
 The economic loss to our common- 
 wealth from bringing into this world 
 thousands of children mentally and 
 physically crippled for life is 'beyond 
 calculation. But considering tuber- 
 
 culosis we have been able to calcu- 
 late at least approximately what it 
 costs. I stated above that 50,000 
 children die annually from tubex-cu- 
 losis in the United States. Figuring 
 the average length of life of these 
 children to be seven and one-half 
 years and their cost to the commu- 
 nity as only $200 per annum, repre- 
 sents a loss of $75,000,000. Such 
 children have died without having 
 been able to give any return to their 
 parents or to the community. Who 
 will dare to calculate in dollars and 
 cents the loss which has accrued to 
 the community because so many 
 mothers died of tuberculosis when an 
 avoidable pregnancy was added to a 
 slight tuberculous ailment in a cura- 
 ble stage.? Who will dare to estimate 
 the cost of the loss of an equally 
 large or perhaps larger number of 
 mothers afflicted with serious cardiac 
 or renal diseases, or frail or ill from 
 other causes, whose lives could have 
 been prolonged had an additional 
 pregnancy not , aggrevated their 
 condition.'^ 
 
 Of the many mothers, married and 
 unmarried, who have become chronic 
 invalids and even lost their lives as a 
 result of having resorted to abortive 
 measures in order to rid themselves 
 of an unwelcome child, no statistics 
 are available. If there were, they 
 would be an appalling evidence of the 
 great danger of such criminal pro- 
 cedures and would certainly show the 
 advantage of a more enlightened at- 
 titude regarding the means of con- 
 traception, at least for the married 
 women who ai-e enfeebled or diseased. 
 
14 
 
 Birth Control 
 
 The many diseases I have men- 
 tioned Avhereby children in large 
 families and mothers because of too 
 frequent pregnancies are carried off 
 to an early grave, are not limited to 
 the poor. In regard to economics, 
 the middle class suffers also. Thus, 
 if even a relatively well-to-do family 
 begins to increase out of all propor- 
 tion to the earnings of the father, 
 the family will soon be in want and 
 approaching poverty. Less and less 
 good food, less sanitary housing, less 
 care of the children and more sick- 
 ness will almost inevitably result. 
 Every sickness or death of child or 
 adult has increased the expenses of 
 the family. There is the doctor's bill, 
 the druggist's bill and last but not 
 least, that of the undertaker. A 
 grave had to be purchased. If there 
 have been savings, they are gradu- 
 ally swallowed up and debts are often 
 contracted for the sake of a decent 
 funeral. 
 
 Next to the medical and sanitary 
 comes the physiological aspect of 
 birth control, which can be sum- 
 marized in a very few sentences. The 
 average mother with two, three or 
 four children, not having arrived in 
 too rapid succession, say with two or 
 three years intervening, is physilogi- 
 cally, that is to say, physically and 
 mentally, stronger and better 
 equipped to cope with life's problems 
 than the worn out and weakened 
 mother whose life is shortened by fre- 
 quent and numerous pregnancies. 
 
 What is the physiological effect of 
 voluntary artificial restriction of the 
 birth rate.? In Holland, where the 
 
 medical and legal professions have 
 openly approved and lielped to ex- 
 tend artificial restriction of the birth 
 rate, the health of the people at 
 large, as shown by its general death 
 rate, has improved faster than in any 
 other country in the world. At the 
 recent Eugenics Congress it was 
 stated that the stature of the Dutch 
 people was increasing more rapidly 
 than that of any other country — the 
 increase being no less than four 
 inches within the last fifty years. Ac- 
 cording to the Official Statistical 
 Year Book of the Netherlands, the 
 proportion of young men drawn for 
 the army over 5 ft. 7 in. in height 
 has increased from 24^/2 to 47^/2 per 
 cent, since 1865, while the proportion 
 below 5 ft. 2^ in. in height has fallen 
 from 25 per cent, to under 8 per 
 cent.* 
 
 In that enlightened country, 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 equiped than fonnerly. What 
 is more interesting to observe, how- 
 ever, 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. 
 
 In Australia and New Zealand, the 
 means of artificial control are in 
 free circulation and the restriction 
 of families is almost universal. Yet 
 these two English colonies have fur- 
 nished to their mother country in 
 
 * "The Small Family. System; Is It Injurious oi 
 [mmoral?" By Dr. C. V. Drysdale; Publ. by 
 B. W. Huebsch, New York. 
 
Birth Control 
 
 15 
 
 these hours of struggle the most effi- 
 cient, and physically and men tally 
 best equipped regiments. The sol- 
 diers of Australia and New Zealand 
 have shown themselves brave and 
 fearless fighters and certainly equal, 
 if not superior, as far as physical 
 endurance is concerned, to their Eng- 
 lish brethren. In the latter country, 
 it is well known that birth control is 
 frowned upon by the legal and nearly 
 all the ecclesiastical authorities. 
 
 And what of France? Before the 
 present war Drysdale, in his "Small 
 Family System," very aptly says : 
 "It has become the fashion to speak 
 of the depravity of France, of her 
 alcoholism, of her disregard for law 
 and order, and of her terrible 'crimes 
 passionels,' and to ascribe to them 
 the falling birth rate. If this were 
 the case it is obvious that these evils 
 would be most intense where the 
 process had gone furthest, i. e., in 
 the cantons of the lowest birth rate 
 (The French islands of Re and 
 Oleron)." The passions of the in- 
 habitants of these islands are very 
 innocent. "They are reading and 
 dancing. The dancing, always de- 
 cent, is the preparation for mar- 
 riage; illegitimate births ai-^ very 
 rare. One could not imagine man- 
 ners more pleasant or more honor- 
 able. Nevertheless the birth rate in 
 these islands is among the lowest. It 
 is because everyone there is more or 
 less of a proprietor. Each person 
 has some property to protect; each 
 is ambitious for his children." But 
 w^e have the authority of Dr. Bertil- 
 lon, the great French statistician, 
 
 that it is just in the cantons of these 
 islands in wliich the greatest moral 
 improvement has taken place, and 
 that where the French have obeyed 
 the command to increase and multi- 
 ply, there alcoholism and crime 
 abound. 
 
 Let me quote briefly from an 
 editorial on contraception which ap- 
 peared in the Medical Times of April, 
 1916: "France to-day is presenting 
 her splendid spectacle of utter effi- 
 ciency to the world because only the 
 'fittest of her people have survived, 
 and the chief factor there has admit- 
 tedly been contraception. Surely we 
 have heard the last of the croakers 
 about decadent France. Holland 
 would give an equally good account 
 of herself if the need should arise and 
 for the same reason." 
 
 We have already touched in part 
 on the economic cost growing into 
 the millions which accrues annually 
 to the nation because of a high birth 
 rate concomitant with a high infant 
 and child mortality rate. Well may 
 we ask the question whether disease 
 and the deaths of thousands of 
 women and children cannot be pre- 
 vented by an enlightened attitude 
 toward the question of birth con- 
 trol. Why is it not done? If the 
 millions of dollars expended uselessly 
 reverted to the nation's wealth, 
 would they not add immeasurably to 
 the health and economic happiness of 
 the nation at large? 
 
 And now we come to the social or 
 sociological aspect of our topic, so 
 closely interwoven with economics. 
 That the social and moral life of a 
 
16 
 
 Birth Control 
 
 smaller family, where the father 
 earns enough to support wife and 
 children, where the mother can de- 
 vote her time to the care of them, 
 and where neither she nor the chil- 
 dren must go out and help in the 
 support of the family, is superior to 
 that of a famil}^ with a large num- 
 ber of children where the mother and 
 often the older children must slave, 
 does not permit discussion. The 
 larger the family* of the poor the 
 more child labor, the more there is 
 disruption and irregularity, and the 
 more frequentl}'^ one finds a lower 
 standard of life and morals in 
 general. 
 
 The records of our charities and 
 benevolent societies amply prove that 
 as a rule the larger the families are 
 that apply for relief the greater is 
 their distress. 
 
 In answer to a letter from Dr. 
 Foote, containing suggestions on 
 this topic, the president of the New- 
 York Association for Improving the 
 Condition of the Poor very perti- 
 nently said: 
 
 "The race suicide theory which has 
 been so much exploited of late, is 
 an immense encouragement to the 
 large family idea and the illiterate 
 are hardly to be blamed if they are 
 misled upon this question. The sub- 
 ject that you discuss is one that is 
 worthy of serious consideration and 
 that has in the past been treated with 
 an excess of sentiment." 
 
 That judicious birth control does 
 not mean race suicide, but on the 
 contrary race presei^vation, may best 
 be shown from the reports from Hol- 
 
 land. The average birth rate in the 
 three principal cities of Holland was 
 37.7 per 1,000 in 1881, when birth 
 control clinics were started. In 
 1912 it had fallen to 25.3 per 1,000. 
 The general death rate, however, had 
 dropped in the same period from 
 24.2 to 11.1 per 1,000, or to less 
 than half, while the two-thirds reduc- 
 tion in the mortality of children un- 
 der one year of age — from 209 to 70 
 per 1,000 living births — is even more 
 significant.* 
 
 As a final evidence of the social 
 and economic value of imparting in- 
 formation concerning family limita- 
 tion, pennit me to quote from a per- 
 sonal letter to me from the great pio- 
 neer of this humanitarian movement. 
 Dr. J. Rutgers, the Honorable Sec- 
 retary of the Neo-Malthusian League 
 of The Hague. The league has been 
 in existence since 1888 and received 
 its legal sanction by a royal decree 
 January 30, 1895. It has 6,000 con- 
 tributing members ; all information is 
 given gratuitously. As a result of 
 this league in Holland one does not 
 see any children dressed in rags as 
 in former years prior to the starting 
 of this movement. To use the 
 venerable secretary's own words : 
 "All children you now see are suit- 
 ably dressed, they look now as neat 
 as formerly only the children of the 
 village clergyman did. In the fami- 
 lies of the laborers there is now a 
 better personal and general hygiene, 
 a finer moral and intellectual devel- 
 opment. All this has become pos- 
 
 * Birth Control News, published by Birth Gon- 
 trol League of Ohio, Cleveland, Vol. I, No. 1. 
 
Birth Control 
 
 17 
 
 sible by limitation in the number of 
 children in, these families. It may be 
 that now and then this preventive 
 teaching has caused illicit inter- 
 course, but on the whole morality is 
 now on a nmch higher level and mer- 
 cenary prostitution with its demoral- 
 izing- consequences and propagation 
 of contagious disease is on the de- 
 cline. The best test (the only pos- 
 sible mathematical test) of our 
 moral, physiological and financial 
 progress, is the constant increase m 
 longevity of our population. In 1890 
 to 1899 it was 46.20; in 1900 to 
 1909 it was 51 years. Such rise 
 cannot be equalled in any other 
 country except in Scandinavia where 
 birth limitation was preached long 
 before it was in Holland. None of 
 the dreadful consequences antici- 
 pated by the advocates of clericalism, 
 militarism and conservatism have oc- 
 curred. In spite of our low birth 
 rate the population in our country 
 is rising faster than ever before, sim- 
 ply because it is concomitant with a 
 greater economic improvement and 
 better child hygiene." 
 
 To verify these figures statisti- 
 cally. Dr. Rutgers refers to Drys- 
 dale's diagrams.* The good doctor 
 closes his splendid letter by saying: 
 "One must have been a family physi- 
 cian for twenty-five years like myself 
 in a large city (Rotterdam) to ap- 
 preciate the blessings of conscious 
 motherhood resulting in the better 
 
 * "Diagrams of International Vital Statistics 
 With Description in English and Esperanto, to- 
 gether with a Table of Correlation Coefficients 
 Between Birth and Death-rates, etc." By C. V. 
 Drysdale, D. Sc; London: W^m. Bell, 162 Drury 
 Lane, W. C, 1912. 
 
 care of children, the higher moral 
 standard. And all these blessings 
 are taken away from you by your 
 government's peculiar laws, made to 
 please the Puritans." 
 
 To these latter well-meaning peo- 
 ple and those similarly minded who 
 fear race suicide, particularly a de- 
 cline of the American stock, I 
 strongly recommend the reading of 
 that splendid address by Prof. Chas. 
 A. S. Read, A.M., M.D., fonner 
 president of the American Medical 
 Association, entitled "The American 
 Family." In the chapter on "The 
 Outlook of the American Family" 
 he very pertinently says : "We see 
 in a dechning birth rate only a nat- 
 ural and evolutional adjustment of 
 race to environment — an adjustment 
 that insures rather than menaces the 
 perpetuation of our kind under 
 favoring conditions." And concern- 
 ing under-population in general, this 
 distinguished writer says in the same 
 address : "It seems, indeed, to the 
 careful student that the danger to 
 the American family to-day and still 
 more in the future lies in the direc- 
 tion of over-population rather than 
 under-population. 
 
 According to Mulhall and Reed, 
 the increase in the density of popu- 
 lation from 1820 to 1890 was 650 
 per cent, in the United States (only 
 25 per cent, in the United Kingdom 
 and less than 100 per cent, in France 
 and Belgium). The rate of increase 
 in this country has been vastly accel- 
 erated in the twenty-five years that 
 have since elapsed. Our population 
 to-day of over 100,000,000 has been 
 
18 
 
 Birth Control 
 
 doubling itself on an average of once 
 in less than twenty-five years since 
 1790, and. it will probably continue 
 to do so in the future. May I say 
 in passing, that in the State of New 
 York we have observed the alarming 
 phenomenon that the proportional 
 increase among the insane is double 
 that among the sane population? 
 
 And now I approach the last and 
 most important phase of my subject, 
 namely the moral, which to me means 
 no less than the religious phase of 
 this great problem. Let me say to 
 you, my colleagues, that I approach 
 it with awe and reverence, for I be- 
 lieve I fully understand the import 
 of it. 
 
 A quarter of a century of practice 
 among the tuberculous, the rich and 
 the poor, in palatial homes, humble 
 cottages, dark and dreary tenements, 
 and in overcrowded hospitals, has 
 shown me enough to bring to my 
 mind the utter immorality of 
 thoughtless procreation, and my ex- 
 perience has been limited to this one 
 disease of the masses. The tears and 
 sufferings I have witnessed when I 
 have had to decline help because it 
 was too late to prevent the despair of 
 the poor, frail mother at the pros- 
 pect of another inevitable confine- 
 ment, and later the sight of a puny 
 babe destined to disease, poverty, and 
 misery, has made me take the stand 
 I am taking to-day. I am doing it 
 after profound reflection, and I am 
 fully aware of the opposition I am 
 bound to meet. But in my early 
 career as an anti-tuberculosis crusa- 
 der, I became accustomed to the fate 
 
 of those who venture on new and 
 heretofore untrodden paths of 
 progress. 
 
 What would the moral outcome of 
 birth control, or let us rather say, 
 rational family limitation be, if 
 taught judiciously to those seeking 
 and needing the advice? Millions of 
 unborn children would be saved by 
 contraception from the curse of 
 handicapped existence as members of 
 a family struggling with poverty or 
 disease. 
 
 There are hundreds of young men 
 and women, physically and morally 
 strong, who gladly would enter wed- 
 lock if they knew that they could 
 restrict their family to such an ex- 
 tent as to raise few children well. 
 But their fear of a large family re- 
 tards, if it does not prevent, their 
 happiness and ipso facto the pro- 
 creation of a better and stronger 
 manhood and womanhood. The 
 woman withers away in sorrowful 
 maidenhood and the man whose sex- 
 ual instincts are often so strong that 
 he cannot refrain, seeks relief in asso- 
 ciation with the unfortunate and 
 often diseased sisters, called prosti- 
 tutes. The result is a propagation 
 of venereal diseases with all its dire 
 consequences. To an audience com- 
 posed of physicians and sanitarians 
 I need not say what these conse- 
 quences are. They involve sterility, 
 physical and mental suffering in the 
 man or sterility in both man and 
 woman ; and according to the severity 
 of the infection, pelvic disorders, 
 abortion, premature labor, a dead 
 
Birth Control 
 
 19 
 
 child or one lastingly tainted with 
 disease. 
 
 At times disease does not enter as 
 a factor in the tragedy, but the re- 
 sult is a girl mother, a blasted life, 
 for our double standard of morality 
 recognizes only the "sin" in our sis- 
 ters, not in ourselves. Of her, com- 
 passionate tongues only say she loved 
 not wisely but too well ; of him, noth- 
 ing is said at all. He is spotless and 
 virtuous in the eyes of the world and 
 can go through life as if he had never 
 sinned and been responsible for a 
 blasted life or two. 
 
 Even our moralists must acknowl- 
 edge that by an early marriage with 
 a man of her choice, enabled by un- 
 derstanding to limit the number of 
 children, many a girl would be saved 
 from so-called dishonor and in many 
 instances from prostitution. One of 
 the strongest arguments of our mor- 
 alists and purists is that the knowl- 
 edge of contraception would lead the 
 young to enter forbidden sexual rela- 
 tions and degrade them morally. 
 Granted that this may happen in a 
 number of instances, the benefit de- 
 rived from a diminution of venereal 
 diseases, from a greater number of 
 happy and successful marriages 
 among the younger people, fewer but 
 better and healthier offspring instead 
 of an unrestricted procreation of the 
 underfed, the tuberculous, the alco- 
 holics, the degenerate, the feeble- 
 minded and insane would more than 
 outweigh the isolated instances of 
 sexual intercourse prior to marriage. 
 
 I absolutely agree with our moral 
 teachers when they say that self-con- 
 
 ti'ol is possible — I believe it to be 
 the cleanest, purest, and best pre- 
 ventive measure for family limitation 
 — 'but while it may be easy for many 
 it is not easy for all. Sociologically 
 speaking, it is even more difficult 
 when you deal with a married couple 
 belonging to the poorer classes who 
 can not have separate bedrooms. 
 Selfcontrol can be more easily exer- 
 cised prior to marriage than after- 
 wards. 
 
 The critics of birth control main- 
 tain that with the knowledge of birtli 
 limitation many women, whether poor 
 or rich, w^ho should and can bear 
 children will shirk the duties of 
 motherhood. This I do not believe to 
 be true. You can no more prevent 
 the desire for motherhood in the nor- 
 mal, healthy woman than you can 
 stem the tide of the ocean. It is 
 inherent in every woman's heart. 
 With more marriages of young peo- 
 ple and a rational birth control, I 
 do believe there will not be fewer 
 children but the same number of bet- 
 ter ones. There will be, of course, 
 instances — and there are too many in 
 certain classes of society now — 
 where for purely selfish reasons the 
 marriage remains barren, but it is a 
 question in my mind whether it would 
 be really desirable for society to have 
 such women be mothers. 
 
 It has been asserted by the same 
 critics that the enfeebled, diseased, 
 ignorant and poverty stricken woman 
 in whose case birth control might be 
 justified, will never know about the 
 existence of birth control clinics. In 
 Holland, however, there must have 
 
20 
 
 Birth Control 
 
 been some such ignorant women, yet 
 they seem to have learned to avail 
 themselves of the service of such 
 clinics. Besides, these classes will 
 sooner or later come under the ob- 
 servation of some physician, either 
 privately or in a hospital. Some 
 opponents to the birth control prop- 
 aganda say that the measure advo- 
 cated would not reach the feeble- 
 minded, the idiotic, half insane, 
 chronic alcoholics, and chronic crimi- 
 nals. This I will grant, and steriliza- 
 tion of those totally unfit for parent- 
 hood will some day have to become a 
 state measure, unless segregation is 
 resorted to more universally and 
 m,ore rigorously. Birth control is 
 only one measure toward a saner and 
 happier manhood, womanhood, and 
 childhood. 
 
 Finally, I must mention the almost 
 pathetic critcisms of some of my col- 
 leagues who wrote me, in answer to 
 my request for an expression of opin- 
 ion, that the matter of birth control 
 was a question not for the medical 
 profession, but for the laity. To 
 such I can only express my regret at 
 their attitude. The physician of the 
 twentieth century who deals only 
 with the purely medical and curative 
 part of his profession, who is indif- 
 ferent to measures to prevent disease, 
 and cannot feel with the social suf- 
 ferings of the masses, is lacking in 
 the highest ideals of his calling and 
 misses the greatest opportunity of 
 benefiting suffering mankind. 
 
 After all is said, I feel impelled to 
 plead with great earnestness for the 
 abolishment of the state and federal 
 
 laws which make the imparting of 
 knowledge for contraception a crim- 
 inal offense. I plead for the estab- 
 lishment of graituitous clinics, di- 
 rected by regular physicians of high 
 repute, remunerated by city or state, 
 who are competent to give informa- 
 tion as to birth limitation in cases 
 where they deem the giving of such 
 instructions advisable. 
 
 Concerning the urgency and the 
 wisdom of efforts to change these 
 laws,* 1 am sure that you will be 
 willing to listen to the words of two 
 of our greatest American physicians ; 
 first, to those of our venerable nestor 
 of the medical profession, Prof. A. 
 Jacobi of New York, the ex-presi- 
 dent of the American Medical Asso- 
 ciation ; secondly, to Prof. Hermann 
 M. Biggs of New York, my esteemed 
 teacher, the distinguished sanitarian 
 
 * United States Criminal Code;, Section 211 
 (Act of March 4, 1909, Chapter 321, Section 211, 
 U. S. Statutes at Large, Vol. 35, part 1, page 
 1088 et seq.). New York Statute Book, (Section 
 1142 of the Penal Law). The federal law pre- 
 scribes a fine of $5,000 or imprisonment of not 
 more than five years, or both, for any one using 
 the mails to give advice for producing abortion 
 or preventing conception. The New York State 
 law, above mentioned,, makes the giving ot a 
 recipe, drug or medicine for the prevention of 
 conception or for causing unlawful abortion a mis- 
 demeanor punishable with no less than ten days 
 nor more than one year imprisonment or a fine 
 of not less than $50 nor more than $1,000, or 
 both, fine and imprisonment for each offense. It 
 will be noticed that both laws make the giving of 
 advice for the prevention of conception as great an 
 offense as producing abortion. According to the 
 New York State law, a "lawful" abortion is per- 
 mitted and not punishable, but to prevent such 
 abortion, always more or less dangerous to life. 
 is not permitted and punishable by law. In all 
 medical colleges careful instruction is given how 
 to perform the "lawful" abortion. All good text- 
 books on gynecology describe the operation as 
 carefully as an amputation of the cervix or a 
 hysterectomy; but concerning the advice to give, 
 for example, to the poor tuberculous mother who 
 has had her uterus emptied once, so that she may 
 not be obliged to submit to such a "lawful" opera- 
 tion again, our teachers of gynecology and our 
 textbooks dare not say a word. 
 
Birth Control 
 
 21 
 
 and pioneer in the modern warfare 
 against tuberculosis. In his preface 
 to Dr. William J. Robinson's book 
 "The Limitation of Offspring," Dr. 
 Jaoobi says : "Our federal and state 
 laws on the subject of prevention of 
 conception are grievously wrong and 
 unjust. It is important that these 
 laws be repealed at the earliest pos- 
 sible moment ; it is important that 
 useful teaching be not crippled, that 
 personal freedom be not interfered 
 with, that the independence of mar- 
 ried couples be protected, that fami- 
 lies be safeguarded in regard to 
 health and comfort, and that the fu- 
 ture children of the nation be pre- 
 pared for competent and comfortable 
 citizenship." 
 
 Dr. Hermann M. Biggs, prior to 
 the recent dismissal of the case by 
 Judge Dayton of the Federal Court, 
 against Mrs. Sanger for sending in- 
 formation about birth control 
 through the mails, gave to the press 
 the following statement: "I am 
 strongly of the opinion that the pres- 
 ent laws in regard to the giving of 
 information in relation to the govern- 
 ing of infant control are unwise and 
 should be revised. There can be no 
 question in the mind of anyone famil- 
 iar with the facts that the unre- 
 stricted propagation of the mentally 
 and physically unfit as legally en- 
 couraged at the present time is 
 coming to be a serious menace to 
 civilization and constitutes a great 
 drain on our economic resources. 
 This is my personal view." 
 
 To the foregoing expressions of 
 opinions let me add what one of our 
 
 most distinguished jurists, the Hon. 
 Judge William H. Wadhams of the 
 Court of General Sessions, wrote me 
 concerning these laws : "In order to 
 save the state from the burden of 
 large families, where there is no pos- 
 sibility of their being supported and 
 where the neglect which follows often 
 I'esults in their becoming State 
 charges not only because they are 
 mentally but often physically unfit to 
 bear the burden of life, I am of the 
 opinion that there should be some 
 proper birth regulation after a cer- 
 tain number of children have been 
 born, and that, therefore, there 
 should also be some modification of 
 the laws with respect to the giving 
 of information upon this subject. I 
 think the sanitary, medical, social, 
 economic, and moral status of the 
 population would be improved by 
 proper and more general information 
 upon this subject." 
 
 Besides the letter from this emi- 
 nent judicial authority and the 
 strong expressions 'of opinion of A. 
 Jacobi, M. D., and Hermann M. 
 Biggs, M. D., I have been the recipi- 
 ent of communications from many 
 leading physicians, divines, political 
 economists, and sociologists, all 
 agreeing with me that judicious birth 
 control, under the highest ethical and 
 medical guidance, is a national neces- 
 sity and that our present laws on the 
 subject need urgent revision. For 
 want of space I will mention only the 
 following: Dr. John N. Hurty, sec- 
 retary Indiana State Board of 
 Health; Dr. Godfrey R. Pisek, pro- 
 fessor of diseases of children, New 
 
22 
 
 Birth Control 
 
 York Post-Graduate Medical School 
 and Hospital; Dr. J. W. Trask of 
 Washington, D. C. ; Dr. Lydia 
 Allen de Vilbiss, formerly of the New 
 York State Department of Health, 
 now in charge of the division of Child 
 Hygiene of the State Board of Kan- 
 sas ; Dr. Ira S. Wile, editor of 
 American Medicine, New York; Dr. 
 John A. Wyeth, professor of surgery 
 and president of the New York 
 Polyclinic Medical School and Hospi- 
 tal, ex-president of the American 
 Medical Association and New York 
 Academy of Medicine ; Frank Crane, 
 D. D., formerly pastor of the Union 
 Congregational Church of Worces- 
 ter, Mass., now well known writer of 
 leading editorial articles ; Percy S. 
 Grant, D. D., rector, Protestant 
 Episcopal Church of the Association 
 of New York City; Frank Oliver 
 Hall, D. D., minister of the Church 
 of the Divine Paternity, New York 
 City; John Haynes Holmes, M. A., 
 Minister, Unitarian Church of the 
 Messiah, New York City ; Stephen S. 
 Wise, D. D., Rabbi of the Free Syna- 
 gogue, New York City; James A. 
 Field, Ph. D., Professor of Eco- 
 nomics, University of Chicago ; Irv- 
 ing Fisher, Ph. D., professor of 
 political economy of Yale University 
 and chairman of the Hygiene Refer- 
 ence Board of the Life Extension 
 Institute; Franklin H. Giddings, 
 Ph. D., professor of political sci- 
 ence, Columbia University; William 
 H. Allen, Ph. D., director of the In- 
 stitute for Pubhc Service of New 
 York City. ; Hon. Homer Folks, for- 
 mer Commissioner of Charities of 
 
 New York, now secretary of the 
 State Charities Aid Association of 
 New York ; Lillian D. Wald, founder 
 of the Henry Street Settlement and 
 originator of the work of the School 
 Nurse in New York; Prof. Melvil 
 Dewey, LL. D., educator and presi- 
 dent of the National Society for 
 Efficiency. 
 
 I leave it to this distinguished body 
 of physicians and sanitarians either 
 to send a memorandum to the federal 
 and all state governments setting 
 forth the reason for a change of 
 these laws, or, if it is thought wiser, 
 to form a committee to study the 
 best and most practical suggestions 
 for federal or state legislatures to 
 act upon. 
 
 Dr. William L. Holt, writing on 
 birth control as a social necessity and 
 duty, says : "Conscious and limited 
 procreation is dictated by love and 
 intelligence ; it improves the race. 
 LTnconscious, irresponsible procrea- 
 tion produces domestic misery and 
 half-stai'ved chldren. Conscious pro- 
 creation of human lives elevates man 
 to the gods. Unconscious procrea- 
 tion degrades man to the level of 
 brutes." 
 
 May I be permitted to close with 
 what I am free to confess is my inner- 
 most conviction.'' I believe in birth 
 control, that is to say, birth limita- 
 tion, based on medical, sanitary, 
 highest ethical, moral, and economic 
 reasons. I believe in it because with 
 the aid of it man and woman can 
 decide when to have a child, work and 
 prepare for its arrival, welcome it as 
 the fulfilment of their heart's desire, 
 
Birth Control 
 
 23 
 
 watch over it, tenderly care for and 
 educate it, and raise it to be what 
 every child should be destined to be — 
 a being happy, healthy, strong in 
 mind, body, and soul. If we but use 
 our God-given sense to regulate the 
 affairs of government and family 
 
 wisely and economically, this great 
 world of ours will be one of plenty 
 and beauty where the good will pre- 
 dominate over the evil and the chil- 
 dren born in it will become men and 
 women only a little lower than the 
 angels — images of their Creator. 
 
 DISCUSSION 
 
 Dr. Ira S. Wii.e, New York City: In 
 reading the thoughtful paper of Doctor 
 Knopf a nnmher of thoughts suggested 
 themselves. Birth control is recognized to- 
 day as a factor in eugenic control. Some 
 states take cognizance of the advantages of 
 limiting the number of offspring in so far 
 as defectives and criminals are concerned. 
 The hiws of numerous states permitting 
 sterilization or asexualization place the seal 
 of governmental approval upon the preven- 
 tion of procreation in the interests of the 
 public weal. Numerous regulations provid- 
 ing for the segregation of defectives repre- 
 sent crystallizations into law of the principle 
 that the state has a vital interest in con- 
 trolling the birth of certain types of citizens. 
 States requiring a certificate of health pre- 
 vious to marriage point out a deep interest 
 in the character of health of those who are 
 to become parents. The underlying prin- 
 ciple is the protection of the state from the 
 development of undesirable children. 
 
 The law recognizes the interruption of 
 pregnane}' as legal and justifiable in order 
 to save the lives of women suffering from 
 tuberculosis, nephritis, cardiac diseases, or 
 from conditions, whose fatal progress would 
 be hastened through continued pregnancy, 
 but the law holds it to be illegal to teach 
 these same women how to avoid conception. 
 It is manifestly contrary to every principle 
 of modern preventive medicine that there 
 should be such interference with the judg- 
 ment and action of physicians where it 
 seems most rational and medically sound to 
 give advice as to the methods of preventing 
 a condition containing a hazard to life. 
 
 Despite the existing laws, contraception is 
 practiced and undoubtedly taught by mem- 
 bers of the medical and nursing profession. 
 
 as well as by midwives. What is equally im- 
 portant is the fact that contraceptives are 
 sold in drug stores throughout the country 
 without any interference, providing con- 
 science is stretched and the instrumentalities 
 are dispensed on the plea that they are 
 agents for the prevention of disease. 
 
 It is known that in 1900 there were only 
 three-quarters as many living children to 
 each 1,000 potential mothers in the United 
 States as in 1860. The reason for this de- 
 creased birth-rate is undoubtedly in a large 
 part due to "the deliberate and voluntary 
 avoidance or prevention of child bearing on 
 the part of a steadily irtcreasing number of 
 married people, who not onlv prefer to have 
 but few children, but who know how to 
 obtain their wash," to quote the words of 
 Dr. John Shaw Billings. At the present 
 time, the practice of birth control is more 
 or less limited to the more intelligent part 
 of the population and indeed to those whose 
 means would most warrant the development 
 of large families. 
 
 Public health sees in poverty its great 
 enemy and realizes that education is its 
 most capable ally. The education of poten- 
 tial (parents as to the methods of prevent- 
 ing conception may be regarded distinctly 
 as a public health measure. From the stand- 
 point of the welfare of the race, those inter- 
 ested in public health measures are more 
 vitally interested in the vigor and quality of 
 children born than in their absolute numbers. 
 The birth of the most vigorous children, 
 those least susceptible to disease, and pos- 
 sessing the greatest chance of living are the 
 particular types of infancy in which health 
 officers should be interested. The reduction 
 of dysgenic types of ofi"spring and the de- 
 crease of infants variously handicapped, 
 
24 
 
 Birth Control 
 
 whose care-needing existence lessens family 
 vitality represents a considerable part of tlie 
 public health problem. 
 
 The tremendous wastage of liiiman life 
 resulting from stillbirths, congenital diseases, 
 malformations, puerperal injuries and in- 
 fections, and economic pressures may be 
 partially offset by a properly controlled sys- 
 tem of dissemination of information con- 
 cerning the limitation of offspring. The old 
 doctrine of the survival of the fittest ha.s 
 been superseded by our more artificial and 
 humanitarian program which permits the 
 survival of even many of. the weakest of the 
 infantile population. 
 
 It is well known that the rate of infant 
 mortality, as pointed out in the paper of 
 Doctor Knopf, increases with the size of 
 the family. To quote from Doctor Hilibs 
 in his discussion of Infant Mortality: Its 
 Relations to Social and Industrial Condi- 
 tions, "However dangerous 'race suicide' 
 and the declining birth-rate may he, there 
 can be little doubt that excessively large 
 families is no remedy and however desirable 
 a high rate of births may be, it is mere 
 waste to bring children into the world 
 faster than the laws of nature decree to be 
 desirable." Race suicide is not due to limit- 
 ing the number of births, but is determined 
 by the ratio between births and deaths. 
 From the standpoint of public health, it is 
 a greater degree of race suicide to bring 
 six children into the world and lose two or 
 three than to have two born and reared. 
 The social consequences of large families 
 with the accompanying loss in lives and 
 vitality have been suflBciently described, so 
 that further comment is unnecessary. 
 
 From the standpoint of public health, it 
 is important that a very sharp line of 
 demarcation should be established between 
 abortions and the prevention of conception. 
 The interruption of pregnancy to destroy a 
 developing ovum entails physical hazards to 
 the woman which often adds to the mor- 
 tality rate. At the same time this is equally 
 the destruction of life as foeticide and, liter- 
 ally speaking, infanticide. According to 
 DeLee, while abortion occurs oftener among 
 the lower classes, criminal abortion is more 
 frequent among the more educated classes. 
 
 Howard Kelly (Medical Gynecology, page 
 449) comments "to what extent the medical 
 profession is responsible for the murder of 
 
 the unborn" is shown by the methods that 
 women employ to induce abortions upon 
 themselves, making use of antiseptic technic 
 in which tliey obviously had been instructed. 
 
 The Report of the Special Committee on 
 Criminal Abortions quoted in Textbook of 
 Legal Medicine and Toxicology (Peterson 
 and Haines, Volume II, page 92) "estimated 
 Ihat one-third of all pregnancies throughout 
 the country end in abortions. This is esti- 
 mated at not less than 100,000 yearly. A 
 large number of these are criminal abortions 
 from which the committee estimated that 
 6,000 women die yearly." A fact of this 
 character merits careful consideration by a 
 public health association with a view to 
 pointing out to the intelligent laity and 
 legislators the importance of differentiating 
 between the prevention of conception, which 
 carries practically no morbidity and cer- 
 tainly no mortality, and abortion, which may 
 cause destruction of two lives. 
 
 Howard Kelly in discussing syphilis 
 (Medical Gynecology, page 493) states "It 
 is the recognized duty of all physicians in 
 the presence of anj^ contagious disease to 
 protect others from the risks of infection. 
 In the case of syphilis, wiiere there is a 
 question of its introduction into marriage, 
 tlie pliysicians' protective duty embraces 
 not only the prospective wife, but the chil- 
 dren she may bring into the world and 
 through them the interests of society." (Page 
 424.) After marriage has occured "when 
 a married man has syphilis the first indica- 
 tion is to prevent the contamination of his 
 wife, the second is to guard against preg- 
 nancy." The interpretation of the term 
 "guarding against pregnancy" opens up the 
 question as to how this is to be accom- 
 plished without violating existing laws. 
 
 It is urged that the frank discussion of 
 methods of contraception by physicians will 
 lead to an increase of clandestine relations 
 among unmarried girls by virtue of the 
 new knowledge. Clandestine prostitution 
 exists today and fear of pregnancy is not 
 an impassilile barrier. The development of 
 a conscious morality, which is the greatest 
 protective force, should not be based upon 
 fear. Admitting for the sake of argument 
 that the same degree of immorality might 
 exist, there would be at least a decreased 
 destruction of life for the women now ille- 
 gitimately pregnant and the fetus to be 
 
Birth Control 
 
 25 
 
 destroyed. Fewer homes would suffer dis- 
 grace, foundlings would decrease in number, 
 while an accursed bastardy would be greatly 
 diminished. 
 
 I do not advocate however that knowl- 
 edge concerning the prevention ni concep- 
 tion should be given to the young, but merely 
 to adults and only to those who are wedded. 
 It cannot be denied that a law of this char- 
 acter would undoubtedly be broken ju.st as 
 is the present law today. The transmission 
 of some facts with reference to contracep- 
 tion is constantly going on, but they eman- 
 ate from polluted sources and reflect folk 
 lore rather than intelligent medical opinion. 
 
 I do not favor the abolition of federal or 
 state laws which deal with abortions, though 
 owing to the weight of public opinion con- 
 victions for violations of these laws are 
 remarkably limited in view of the large 
 number of violations occurring annually. I 
 believe and would urge that the federal and 
 state laws be amended so that in effect the 
 procuring of an abortion and the preventing 
 of conception will be dissociated as acts 
 not synonymous in character and meriting 
 entirely different treatment. The procuring 
 of an abortion should still be penalized. The 
 prevention of conception should be per- 
 mitted. The New York State law links pre- 
 vention of conception and unlawful abor- 
 tion, thus indicating the legality of certaiit 
 types of abortion. 
 
 Because the state already recognizes its 
 right to limit procreation among certain 
 groups of the population, because the de- 
 crease in the birth-rate will result in im- 
 proved public health and the social economic 
 improvement of the masses of this country, 
 because prevention of conception would add 
 to the health and racial betterment of the 
 nation, I believe that the American Public 
 Health Association should take a stand upon 
 the subject of limitation of offspring. To 
 this end, I urge that resolutions be passed 
 favoring the amendment of federal and state 
 laws, so that the words preventing or pre- 
 vention of conception be eliminated there- 
 from. 
 
 Db. J. H. Landis, Health Officer, Cin- 
 cinnati, Ohio: It goes without saying that 
 we are all in favor of reducing the number 
 of those who are physically, mentally, and 
 morally unfit and adding to the number of 
 those who are physicallj' fit, mentally sound 
 and more highly developed morally. 
 
 The paper brings to our attention a num- 
 ber of facts that have long Ijeen recognized 
 as true. No one will deny that the off- 
 spring of a tuberculous mother has a poorer 
 chance of living than one from a mother 
 without a wasting disease or that the healthy 
 mother has a better chance of surviving 
 pregnancy than has her diseased sister. 
 
 No one doubts that infant mortality is 
 greatest among the offsprings of the ignor- 
 ant, the poor, the undcj^/ed and badly 
 housed, the tuberculous, the degenerate, the 
 alcoholic, the vicious and the mentally de- 
 fective. 
 
 Congestion and lack of air and sunshine 
 have long been recognized as powerful pre- 
 disposing factors in the dissemination of 
 disease and death among those exposed. 
 
 The remedy suggested for all of these 
 conditions is birth control. The remedy is 
 directed towards the effects produced in- 
 stead of being directed at the causes pro- 
 ducing them. 
 
 I am unable to see how birth control is to 
 solve the problems created by vice, poverty, 
 ignorance and alcoholism while these con- 
 ditions go on unchecked, and am unwilling 
 to believe that the size of the family has 
 anything to do with any of them with the 
 possible exception of poverty. 
 
 The pride and glory of the medical pro- 
 fessiion is bound up in the word ''preven- 
 tion." Humanity owes us a far greater debt 
 for sickness prevented than for sickness 
 cured. 
 
 A multitude of causes are responsible for 
 the high tuberculosis rates that prevail. The 
 disease is one of the most contagious with 
 which we have to deal. Nature's favorite 
 method of removing the unfit, from any 
 cause, is by the tuberculosis route. 
 
 The control of tuberculosis involves all of 
 the factors active in producing individuals 
 who are rendered susceptible by these fac- 
 tors, the quarantining of those who are 
 spreading the disease and the care of those 
 other members of the family rendered de- 
 pendent. Birth control can play only a 
 minor role in the control of this disease. 
 
 Birth control will not enlighten the ignor- 
 ant, render the poverty-stricken affluent^ 
 transform the alcoholic into a total ab- 
 stainer, make the vicious virtuous, or re- 
 move the cloud from the brain of the men- 
 tally defective. 
 
26 
 
 Birth Control 
 
 Definite causes are combining to produce 
 tliese results and the logical point of attack 
 is the combination of causes. 
 
 The ignorant can be educated; the poor 
 made more thrifty; the vicious forcibly re- 
 strained; and the mentally defective ren- 
 dered incapable of reproducing their kind. 
 
 The prevalence of typhoid fever is an 
 index to the purity of a community's water 
 and milk supply. Filtration of water and 
 pasteurization tf milk have solved the 
 typhoid fever problem in those communities 
 in which they have been efficiently carried 
 on. 
 
 Vice, crime, tuberculosis, poverty, degen- 
 eracy, alcoholism, ignorance and feeble- 
 mindedness are as distinctly due to particu- 
 lar preventive causes as typhoid fever is 
 to impure water and milk, and it appears 
 to me that birth control would be as impo- 
 tent to control the first set of conditions as 
 it would be to control typhoid fever. 
 
 Dissemination of the knowledge of birth 
 control would, in my humble judgment, de- 
 crease the number of fit and increase the 
 number of unfit for the reason that the 
 knowledge would be applied by those capa- 
 ble of producing normal children and 
 ignored by those unfit individuals who are 
 under the guidance and control of the most 
 powerful primal instinct. 
 
 Dr. J. N. HuBTY, Indianapolis, Ind.: We, 
 tne people, are suffering from many delu- 
 sions. Nearly everj'one entertains the delu- 
 sion that they can violate the laws of nature, 
 abuse their bodies, bring on disease and 
 degeneracy, and then find repair in a medi- 
 cine. It is a fool idea, yet it is very general. 
 There are other delusions. There is only 
 one way to improve the human race, and 
 that is the natural way. The first high 
 point of interest in the paper is when Doctor 
 Knopf says: "My appeal is not a plea for 
 reducing the population but for increasing 
 its vigor by reducing the number of the 
 physically, mentally, and morally unfit and 
 adding to the number of the physically 
 strong, mentally sound, and higher morally 
 developed men and women." Certainly no 
 one on any score can object to this. The 
 idea is practical, pure and lofty. If general 
 birth control will help it onward, even a 
 little bit, then I am for general birth con- 
 trol. I suppose no one would advocate the 
 raising of idiots or physically deformed 
 
 people, yet when it is proposed not to raise 
 them, through the practical application of 
 sterilization or segregation, up goes a howl 
 from the prudes which is of a character 
 likely to provoke emesis. It is important 
 and interesting to learn that when tuber- 
 culosis appears in a large family, it is gen- 
 erally nunabers 5, 6, 7, 8 or 9 of the children 
 that are stricken. This is indeed significant, 
 and I believe it to be true. When I read 
 this in Doctor Knopf's paper I made some 
 inquiries of two men who have done a great 
 deal of tuberculosis work, and they con- 
 firmed it and said they believed it was true. 
 Again, Miss Duke's Johnstown figures speak 
 loudly against families of above four chil- 
 dren. For a pair to have more is generally 
 to invite sickness, invalidism and deatli, 
 and if we will stop to think and look around 
 among the prosperous, great and strong 
 people as a rule (of course there are ex- 
 ceptions) they do not have families of more 
 than four and generally about two. I do 
 not believe that this condition has been 
 brought about by continence. Surely preg- 
 nancy is contra-indicated in a tuberculosis 
 woman unless it is desirable to kill her and 
 add to the number of pitiful motherless 
 babies. A husband who cannot be conti- 
 nent with a tuberculous wife is a sorry 
 specimen of manhood and truly such speci- 
 mens are many. And here I think it proper 
 to say that birth control will not likely ever 
 be a resultant of voluntary continence. Like 
 education and monogamy, it must be forced 
 upon most of the animals we call men. An 
 important point made by Doctor Knopf is, 
 "would or eould a syphilitic or gonorrhoeic 
 parent know how to prevent conception dur- 
 ing the acute and infectious stages of his or 
 her disease, there would certainly be less 
 of congenital syphilis, less blindness from 
 gonorrhoeal infection." If these ends can 
 be gained, even in slight degree, by birth 
 control, I'm for it strong. I remember the 
 doctor in "Damaged Goods" says: "It is 
 better to have fifty soimd and whole men 
 than to have a hundred, sixty or seventy 
 of whom are more or less rotten." 
 
 That is an important interrogatory in the 
 paper which reads^ — -"What is the physio- 
 logical effect of voluntary artificial restric- 
 tion of the birth-rate of the offspring?" 
 The answer is satisfactory, for the reports 
 from Holland, where the medical profes- 
 sion have openly approved and helped to 
 
Birth Control 
 
 27 
 
 extend artificial restriction, are to the effect 
 that the niorliidity and niorlality rates' iiave 
 improved more rapidly tiiaii in <jther coun- 
 tries. Holland also supplies data to prove 
 that rational birth control docs not mean 
 race suicide, l)ut on the contrary, race ]ires- 
 ervation and strengthening. Doctor Holt, 
 as quoted by Doctor Knopf, talks wisely 
 when he sajs — "Conscious and liiriited pro- 
 creation is dictated by love and intelligence; 
 it improves the race. Unconscious, irre- 
 sponsible procreation produces domestic 
 misery and half-starved children. Conscious 
 procreation of human lives elevates man to 
 the gods; unconscious proci-eation degrades 
 man to the level of brutes." It is plain tliat 
 Doctor Knopf has contended and written 
 well. Conscientiousness in his contention is 
 apparent. I am sure good will follow his 
 effort. 
 
 Dr. W. L. Holt: I should like to call your 
 attention to tlie fact that we as a nation, 
 like all the civilized nations, are already 
 practicing birth control; but in a very 
 stupid and mistaken way. N<amely just that 
 part of the population which is called "the 
 upper class," which is undoubtedly superior 
 physically and mentallj' as well as finan- 
 cially and accordingly produces the most 
 desirable children and ought to produce at 
 least its share of the future generation, is 
 practicing birth control to such an extent 
 that the old families are dying out; whereas 
 the inferior part of our population, which 
 is also financially least able to raise four 
 children, is raising four and more. What 
 could be more stupid? 
 
 Dr. Louis I. Dublin, New York City: 
 The other day I contributed a paper in 
 another section on the commoner errors in 
 statistical work. I wish I had had Doctor 
 Knopf's paper at my disposal, for I could 
 have used it very profitably for my text. 
 I do not recall any paper that I have read 
 for some time that is more subject to criti- 
 cism on the score of method than the paper 
 we have just heard. I believe it is funda- 
 mentally erroneous because of the emo- 
 tional attitude of the writer which has 
 caused him to draw general conclusions from 
 an examination of only a very limited part 
 of his subject. His emphasis is entirely in 
 the wrong place. There is altogether too 
 much birth control now and what the com- 
 munity needs is emphasis on birth release 
 
 by the healthy, capable and self-respecting 
 elements of the comnumity. 
 
 There is time only for one word and I 
 want to limit that to the story of France. 
 In France, we have today a sorry spectacle 
 of the results of birth control. The lesson is 
 obvious. France is today crying for men; 
 for men wlio were either not txirn or died 
 at an alarming rate in infancy or later of 
 tuberculosis. The attitude of mind which 
 is engendered by • a nation-wide policy of 
 birth control ultimately brings about more 
 infant mortality and more tuberculosis be- 
 cause of the general weakening of the stock 
 which directly results therefrom. 
 
 A Member: It strikes me that the whole 
 question resolves itself into who should 
 marry and who sliould not marry. Unless 
 we have some laws regulating marriage, to 
 teach young men and young women the na- 
 ture of the social diseases and the conditions 
 necessary for a good physical body, why, 
 we will have tulserculosis, we will have de- 
 generates, we will have idiots and imbeciles 
 and our penitentiaries and almshouses and 
 every other penal institution will be filled. 
 The whole question is prevention; I believe 
 strictly in the doctrine of heredity. Hered- 
 ity, environment and education is the tri- 
 angle that leads to greatness. If we do not 
 hover around those three points, we will 
 never succeed. We know that if two de- 
 generates marrj^ they beget degenerate chil- 
 dren, beget imbeciles. If an imbecile mar- 
 ries a normal person, half of the children 
 will be imbeciles or degenerates, and we 
 have the records of criminality and all those 
 deficiencies and the penalty is the result of 
 improper marriage. Teach the laws of na- 
 ture and our mothers will demand that their 
 daughters don't marry a man who has in 
 his veins the virus of a venereal disease 
 circulating through his body. 
 
 Dr. John W. Trask, United States Public 
 Health Service, Washington, D. C: The 
 subject may be approached from a number 
 of different angles. During the discussion 
 a thought has occurred to me which may 
 be worth presenting. WHiat is the cominoB 
 reason for wanting the population to grow? 
 What is at the bottom of the more or less 
 prevalent idea that it is meritorious- to be 
 the parent of many children? It has oc- 
 curred to me while sitting here that cham- 
 bers of commerce and boards of trade want 
 
28 
 
 Birth Control 
 
 the populations of their respective cities to 
 increase — tlie faster, the better — because it 
 is to their interest to have more individuals 
 to sell things to, more individuals to whom 
 they can sell dry goods, clothing, and gro- 
 ceries, more individuals to whom to sell 
 houses and land. The greater the popula- 
 tion the more business will be done and the 
 greater the increase in the value of real 
 estate. On the other hand, those interested 
 in affairs of state may want the population 
 of their coimtry to grow that there may be 
 a larger group from which to draw an army 
 for purposes of defence or perhaps offence. 
 Birth control is opposed in a way to the 
 interests of business and of the holders of 
 real estate. Nor will it be the best national 
 policj' where a growing population and large 
 armies are necessary as a protection against 
 invasion or oppression by lawless peoples. 
 However, it would seem at least worthy of 
 consideration whether the best conditions 
 would not be attained by families commen- 
 surate in size with the household incomes 
 and by nations commensurate in population 
 with their areas, economic conditions and 
 natural resources. Better people, living 
 cleaner, healthier and more rational lives, 
 and not more people, would seem to be the 
 logical objective. 
 
 Dr. Kkopf:* My first duty is of course 
 to thank you all for the very kind atten- 
 tion you have given to my paper on a rather 
 unusual and, in some circles, rather unpopu- 
 lar subject. It shows that you have come 
 here determined to listen and then to judge 
 — -to accept my ideas, to reject them, or 
 to suspend judgment. 
 
 Dr, Ira S. Wile agrees with me so thor- 
 oughly that I see very little reason to take 
 up time in referring to his paper, except 
 to thank him for his cooperation and par- 
 ticularly for the strong opinion he has ex- 
 pressed concerning the urgent need of rec- 
 ommending an amendment of the federal 
 and state laws to the effect that the pro- 
 curing of an abortion and the prevention 
 of conception will be disassociated, and 
 considered as acts meriting entirely differ- 
 ent treatment. We all agree that produc- 
 ing an abortion for no other reason than to 
 rid a healthy mother of an unwelcome child 
 is a crime and should continue to be con- 
 sidered as such. 
 
 * This discussion has been revised and enlarged 
 since its presentation. — Editor. 
 
 Doctor Landis' paper is a little surprising 
 to me. When the doctor says in today's dis- 
 cussion that birth control will not do away 
 with our social evils, will not render the 
 poverty stricken affluent, transform the alco- 
 holic into a total abstainer, nor remove the 
 cloud from a mentally defective, he is but 
 partially right. Birth control has enlight- 
 ened the ignorant in Holland nnd has ren- 
 dered the poverty stricken not affluent but 
 economically more comfortable; it has de- 
 creased crime, immorality, and illegitimacy. 
 At the same time, I do not for a moment 
 think that birth control alone will do away 
 with the procreation of the feeble-minded, 
 idiotic, half insane, chronic alcoholics, or 
 chronic criminals. Birth control is not a 
 panacea for all the ills of society, it is only 
 one measure toward a saner and happier 
 man-, woman-, and childhood. To minimize 
 the harm to society and to future genera- 
 tions produced by the just mentioned class 
 of unfortunates, the state should step in 
 and demand medical examination of both 
 the prospective father and mother, prior to 
 granting them a marriage license. Even 
 with our present limited but growing knowl- 
 edge of the laws of heredity, we should be 
 able to prevent many of the evidently imfit 
 from becoming parents and save many a 
 chUd of tomorrow from a. handicapped ex- 
 istence — a burden to himself and others. 
 
 As already indicated in my paper, there 
 is a certain class so mentally and physically 
 diseased that sterilization, or at least segre- 
 gation, must be resorted to. Doctor Landis 
 i§ absolutely right when he says that "A 
 multitude of causes are responsible for the 
 high tuberculosis rates that prevail." If I 
 did not think that, would I have devoted 
 twenty-five of the best years of my life to 
 the combat of tuberculosis? Bad housing 
 conditions, bad factory hygiene, overcrowded 
 and unhygienic schools, useless studies and 
 not enough outdoor play for the children, 
 child labor, ignorance on the part of the 
 laity, the late diagnosis of the disease on 
 the part of the profession, failure of ra- 
 tional treatment and lack of institutions, 
 are some of the multiple causes responsible 
 for the high tuberculosis morbidity and mor- 
 tality rate. 
 
 Those of my colleagues who have honored 
 me by their steadfast friendship and con- 
 stant cooperation will bear me out when I 
 say that I have done my best to help to 
 
Birth Control 
 
 29 
 
 remove these causes during years of con- 
 scientious labor. 
 
 I have approached the subject. of birth 
 control after deep reflection and with the 
 saine earnestne.ss and zeal I am devoting 
 to my tuberculosis work, and with due 
 reverence for all that is sacred in man's 
 physical, moral, and religious life. I now 
 believe in it with all the sincerity and earn- 
 estness I am capable of. I believe in it be- 
 cause by its aid there will rise a generation 
 of men, physically, mentally, and morally 
 fit, and children free from disease andpife- 
 pared to take up the struggle for life. 
 
 I must revert oinoe more to my friend. 
 Doctor Landis' discussion of the tubercu- 
 losis problem. I said he was absolutely right 
 in the statement that a multitude of causes 
 were responsible for the high tuberculosis 
 death rates that prevail. But I say with equal 
 emphashis that he is absolutely wrong when 
 he says in the following sentence that "the 
 disease is one of the most contagious with 
 which we have to deal." It is not the most 
 but the least contagious and should always 
 be classed with communicable diseases. It 
 should not be considered as most contagious 
 like smallpox for example. On the contrary, 
 strictly speaking, it is not contagious at all. 
 The word contagious comes from the Latin 
 contingere, "to touch," but the touch of the 
 honest, conscientious, and clean consumptive 
 is no more contagious than that of a healthy 
 person. This can hardly be said of the 
 smallpox patient, be he ever so clean. It 
 is best for an unvaccinated individual never 
 to touch him, and still better to stay away 
 from him as far as possible. 
 
 I would consider it a most regrettable 
 thing if it should go out to the public that 
 a distinguished member of the American 
 Public Health Association has suddenly de- 
 clared tuberculosis to be the most con- 
 tagious of diseases. We have already too 
 much phthisiophobia which makes ±he lot 
 of the unfortunate consumptives hard 
 enough. 
 
 For the kindly words said by my good 
 friend, Doctor Hurty, I am deeply grateful. 
 He is always progressive, fearless, and out- 
 spoken. He agrees with me so thoroughly 
 that I feel he will do his share toward a 
 better understanding of the problem under 
 consideration and be an enthusiastic sup- 
 porter of the all important movement for 
 
 the betterment of mankind, which he loves 
 .so much. 
 
 To the member whose name I could not 
 catch and who maintained that the whole 
 question resolves itself into who should 
 marry and who .should not marry, I wish to 
 say that it was merely for lack of time that 
 I did not touch on this subject in my paper. 
 That I strongly advocate a medical exami- 
 nation of the man as well as the woman 
 prior to granting a marriage license, I have 
 already said in my reply to Doctor Landis' 
 criticisms. Much unhappiness and misery 
 could be avoided by such obligatory exami- 
 nation and if we could add to our institu- 
 tions of learning a school of parenthood 
 with obligatory attendance for every (Mie 
 desiring to enter the matrimonial state, we 
 would add still more to the happiness and 
 prosperity of the individual and the com- 
 munity at large. 
 
 Now a M'ord to our Catholic friends and 
 those of other faiths who are so strongly 
 opposed to contraception and limiting family 
 increase. Let us have no word of bitter- 
 ness or reproach because millions of devout 
 Catholics hold these views. Let us not an- 
 tagonize either the Catholic priest or lay- 
 man, who have a right to their con%ictions 
 as much as we have to ours. This is a 
 purely scientific meeting, composed of men 
 who should not have, and I hope do not 
 have, any hatred in their heart because of 
 differences of opinion regarding religious 
 views. Therefore, in reply to the somewhat 
 passionate remarks of the distinguished sta- 
 tistician of the Metropolitan Life Insurance 
 Company who questions the accuracy of my 
 statistics and my statements, and says that 
 it is all fundamentally erroneous, I vnsh to 
 reply wth less vehemence. I would calmly 
 state that if we do not believe in oflBcial 
 statistics of one kind, we cannot believe in 
 official statistics of another kind. Mine were 
 prepared by the government in Holland and 
 by the United States government and offi- 
 cials of various cities. The gentleman makes 
 the statement that because of my emotional 
 attitude toward the question of birth con- 
 trol, my conclusions are fundamentally erro- 
 neous and drawn from an examination of 
 only a very limited part of my subject. 
 Mr. Dublin is not a physician; he is a Doctor 
 of Philosophy, and this perhaps is an ex- 
 cuse for finding fault with my emotional 
 attitude. My experience as a physician has 
 
30 
 
 Birth Control 
 
 brought me into contact not only with the 
 happ3' and well-to-do but also with the 
 poverty stricken and the mentally and 
 morally diseased, with the unfortunate girl- 
 mother and our unfortunate sister the so- 
 called prostitute, and last bnt not least, 
 with the honest but poor and ignorant 
 mother of a large family who is a sla\'e by 
 day and by night. It has been my earnest de- 
 sare to lessen tlie misery caused by thoughtless 
 procreation, and I may perhaps be forgiven 
 if I have approached the subject with deep 
 conviction and not without emotion. 'We 
 physicians cannot, and God forbid that we 
 ever shall, deal merelj^ with cold figures 
 and statistical facts. We love science, yes, 
 and accuracy in science and statistics, but 
 this does not prevent us from feeling witli 
 our parents in their sufferings of mind, 
 body, or soul. 
 
 I do not at all disagree with the gentle- 
 man when he speaks of birth release by 
 the healthy and well-to-do. In my paper 
 I have referred to this and also believe to 
 have distinctly shown that I do not plead 
 for race suicide but most emphatically for 
 race preservation and multiplication of the 
 best and noblest, physically, mentally, and 
 morally. What I think of France of today, 
 I have already said, and when the gentle- 
 man says that France is crying for more 
 men, I might first say that the quality of 
 the French soldiers has made up for the 
 quantity. Russia has had and has the most 
 men. It does not cry for more men, and 
 still its achievements do not compare, at 
 least not up to this day, with the achieve- 
 ments of France. 
 
 La.stly, when Dr. Dublin says: "The atti- 
 tude of mind which is engendered by a 
 nation-wide policy of birth control, brings 
 about more infant mortality and more 
 tuberculosis because of the general weaken- 
 ing of the stock which directly results there- 
 from," I most thoroughly disagree with this 
 argument. My personal statistics regarding 
 the frequency of tuberculosis among the 
 later born children in large families have 
 been, as you have heard, corroborated by 
 Dr. Hurty's investigations; and all physi- 
 cians know that women, particularly those 
 of the working classes when worn out by 
 frequent pregnancies, are more subject to 
 tuberculosis thin almost any other class of 
 people. How then can Dr. Dublin believe 
 that birth limitation would cause more 
 
 tuberculosis? In Russia, where the. word 
 birth control is unknown, tuberculosis and 
 infant mortality are the highest of all civil- 
 ized countries. On the other hand, in Hol- 
 land, where we might speak of nation-wide 
 birth control, as already stated in my paper, 
 after forty years of this policy there is less 
 infant mortality, an increase in population, 
 a better physique, and a higher morality. 
 Furthermore, there has not been a general 
 weakening but a general improvement in 
 the strength of the stock which is shown 
 by an increase in stature and increase in 
 ^he longevity of the population at large. 
 
 My good friend, Assistant Surgeon-Gen- 
 eral John W. Trask, has admirably answered 
 Ihe question as to what, aside of the war 
 and its demands for more men, is the com- 
 mon reason for wanting the population to 
 grow. It is a splendid answer and I could 
 not possibl_v improve on it but -wish to 
 thank him most heartily for what he said, 
 but I wish to go a step further by saying 
 I feel now more than ever convinced that 
 the over-population of Germany has been 
 one of the vital causes of this disastrous 
 war which has lirought so much misery to 
 all humanity. Prof. Robert J. Sprague, of 
 the Massachusetts Agricultural College, ex- 
 pressed this view very strongly the other 
 day at the meeting of the Genetic Associa- 
 tion when he said: "The barbaric birth-rate 
 of Germany hemmed in as she is b.y the 
 other nations, made the great war inevitable 
 and will, if it keeps up, make war foi-ever 
 in the future. Some believe this will work 
 eugenically for the survival and predomi- 
 nance of the strongest and best race, but 
 this is still a mooted question. The survival 
 of the merely strong may result in the sur- 
 vival of the strong animal. Pressure of 
 population on subsistence and area develops 
 brutality, selfishness, and disregard of 
 human life. It crushes leisure, generosity, 
 and art and makes impossible some of the 
 finest virtues of the race.' 
 
 I have already said how anxious I am 
 tliat we may treat this subject as a scien- 
 tific one and that we should only have in 
 view the iiighest ideal, namely, a normal 
 imcrcase of population concomitant with 
 our resources and an improvement of the 
 quality of our population ; in other words, 
 we should strive to render the lives of man, 
 woman, and child more healthy and more 
 
Birth Control 
 
 31 
 
 happy, and economically secure. My per- 
 sonal belief is that we shall thereby become 
 more highly developed spiritually and ap- 
 proach more rapidly towards the millennium. 
 When at last an enlightened government 
 will permit contraception to be taught wliere 
 it is likely to be productive of the most 
 good, when in years to come we can show 
 our Catholic brethren and all those who 
 oppose us now that because of judicious 
 birth control resulting in a rational family 
 limitation, we have decreased poverty, dis- 
 ease, and crime and have produced a better 
 generation of men and women, better 
 equipped for life's mission, in short, men 
 worthy to be called true citizens of a great 
 republic, then I am sure our Catholic 
 friends and other opponents will see that 
 after all we have not been so wrong and 
 they may then be willing to follow along 
 the same lines of teaching rational birth 
 control. 
 
 I have been asked why I became inter- 
 ested in birth control so suddenly, which 
 is apparently so foreign to my specialty, 
 but I can assure you that while I have 
 taken up the work only recently, my inter- 
 est was not sudden at all. As already 
 stated,^ it began many j'ears ago in con- 
 nection with my work in the tenements and 
 overcrr,wded hospitals where I witnessed the 
 sufi'erings of many a tuberculous mother 
 whom 1 could not help because it was too 
 late to prevent. The despair of some poor, 
 frail creature at the prospect of another 
 inevitable confinement, the likelihood of 
 her early decease as a result of this newly 
 added pregnancy, the thought of her other 
 children who would be deprived of a 
 mother's care at ages when they need it 
 most, and later the sight of a puny babe 
 destined to disease, poverty, and misery, 
 opened my eyes to the utter immorality of 
 thoughtless procreation, not only of the 
 tubercvilous, but of all others physically and 
 mentally diseased and impoverished. 
 
 Nature's forces are blind. She creates 
 without thought of provision for the off- 
 spring. Think of bacterial life if it had 
 remained unchecked by the genius of a Pas- 
 teur, a Koch, a Lister; of the insects, such 
 as the yellow fever and malaria-spreading 
 mosquitoes, if unchecked by a Reed and a 
 Gorgas ! I could continue the theme of 
 man's triumph and control over nature in- 
 
 definitely if I were to enter into the field 
 of agricultural and industrial science. I 
 could tell you of the battles of the Aus- 
 tralian farmer with the rapidly multiplying 
 rabbit. Here nature's blind tendency to 
 procreate devastated the fields destined to 
 nourish the population. 
 
 The excessive birth rate of human beings 
 in India and China is to my mind also 
 largely responsible for the frequent famines 
 and their sequellse of pestilence, plagues, 
 etc. The idea that there is and always will 
 be enough room and food for all mankind 
 on this earth, no matter how great the in- 
 crease in population, is, to say the least, 
 erroneous. In my address I have already 
 referred to the work of Doctor Reed, who 
 says, "It seems, indeed, to the careful stu- 
 dent that the danger to the American fam- 
 ily to-day and still more in the future lies 
 in the direction of overpopulation rather 
 than underpopulation." 
 
 Is there no danger at all in this country 
 of ours of a possible famine due to over- 
 population and underproduction of food 
 substances? In his forthcoming book on 
 Food Problems (Goodhue & Co., Publ., New 
 York), of which I had the privilege to see 
 the proof, my friend. Dr. Henry Smith 
 Williams, the well knov.m physician and 
 economist, makes the following statement: 
 "In the census period 1900-1910, the popu- 
 lation of the United States increased by 21 
 per cent., but the production of cereal grain 
 increased by only 1.7 per cent. In the mean- 
 time there has been such a falling ofP in the 
 animal industry that there would have been 
 required 60,000,000 more meat animals (cat- 
 tle and sheep) on the hoof in order that 
 meat should have been as abundant per 
 capita as it was in 1890." 
 
 This authoritative statement should give 
 serious food for thought to statesmen and 
 sociologists, as well as to us physicians. The 
 difference between the increase in produc- 
 tion and population is too great even at 
 this time for family limitation alone to 
 prevent food problems becoming intensified 
 from year to year. There must be very 
 soon a wiser distribution of wealth and 
 population, that is to say, more social jus- 
 tice for all — man, woman and child — ^and a 
 return to the field of some of the masses 
 through making farming more profitable. 
 Besides taxing unimproved property in and 
 
32 
 
 Birth Control 
 
 around cities or utilizing it for the public 
 good or temporary cultivation, there should 
 be an intensive cultivation of the vast areas 
 as yet unused. A steady decrease in the 
 food supply will not only lead ultimately to 
 famine but prior to that will increase tuber- 
 culosis and other diseases of malnutrition 
 to an alarming degree, as is demonstrated 
 at this time in the warring countries of 
 Europe. In order to thrive physically, 
 mentally, and morally, man must have room. 
 Overpopulation and overcrowding is injuri- 
 ous to man, beast, and plant. Profe'ssor 
 Spraguc, whom I have already referred to, 
 is right when he says: "Man has learned 
 that corn and potatoes must be given proper 
 spacing lest Mother Earth be crowded and 
 they do not grow well, but he has often 
 forgotten to place sufficient spacing be- 
 tween his human children that they might 
 develop to the highest." 
 
 If non-interference with thoughtless na- 
 ture comprises one of the tenets of the re- 
 ligion of others, to me man's intellectual 
 control over nature's blind forces and na- 
 ture's thoughtless procreation of undesirable 
 bacterial, insect, or animal life, and his 
 powers to bring forth more useful products 
 and make life for man, woman, and child 
 not only more bearable but even more beau- 
 tiful and glorious, are among the greatest 
 proofs of the existence of God's power in 
 man. But the greatest of all achievements, 
 the most divine gift which god has bestowed 
 upon man, is conscious procreation. To me, 
 .j^icious birth control under the guidance 
 af the best and ablest among our own pro- 
 fession, among the clergy and the sociolo- 
 gists, based on tlie highest conception of 
 sanitary, medical, moral, ethical, and eco- 
 nomic reasons, can well be considered a 
 spiritual asset which will uplift the race. 
 
 The Cp-Operative Press, 15 Spruce Street, New York 
 
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