Birth Control in Its Medical, Social, Economic, and Moral Aspects

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'%- 1..;

BIRTH CONTROL

IN ITS MEDICAL, SOCIAL, ECONOMIC

AND MORAL ASPECTS

BY

S. ADOLPHUS gJOPF, M.D.

Prrfessor of Medicine, Department of Phthinotherapyt at the New York Pott-Graduate

Medical School and Hospital; Viniing Physician to the Riverside Hospital'

Sanatorium for the Consumptive Poor of the Health

Department of the City of New York.

With the discussion by Dbs. Ira S. Wile, J. H. Landib^

W. L. Holt, Louis I. Dublin, John W. Trask»

and the closing remarks by Dr. Knopf.

Reprinted from the American Journal or Pubuc Health, February, 101 7*

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BIRTH CONTROL IN ITS MEDICAL, SOCIAL, ECO-

NOMIC, AND MORAL ASPECTS*

S. Adolphub KsoFFy M. D.,

FrofeisoT of Medicine^ Department of Phihisiotherapyf at the New York Poi
Graduaie Medical School and Hospital; Visiting Physician to the Riversi\
Hospital-Sanaiorium for the Consumptive Poor of the Health Department \
the' City of New York.

WHEN at this very moment
across the sea in Europe the
best blood of the nations
which were heretofore considered the
most enlightened, cultured, and civil-
ized, is daily being shed and hundreds
of thousands of young men in the
prime of life sacrificed to the Moloch
of war, it must seem a hazardous
undertaking to talk of birth control,
which means artificial birth limitation
and by some superficial observers is
designated as race suicide. I trust,
however, that before I arrive at the
end of my paper, I wUl have con-
vinced you that the object of my ap-
peal is not a plea for reducing the
population 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, ha^
been able to rear a large number ^
children. In some instances all ha%l
survived and have grown up to L|
healthy and vigorous, but these iij
stances are rare and are becoming moi
and more so every day. On the othc
hand, large families, that is to sa^
numerous children as the issue of on
couple, among the ignorant, the pooi
the underfed and badly housed, th
tuberculous, the degenerate, the aj
coholic, the vicious, and even th*
mentaUy defective, is an everyda;
spectacle. It is well known to ever;
general practitioner whose field o
activity lies among the poor and th
above mentioned classes, that th
infant mortality among these is ver;
great. The same holds true of th*
mortality of school children comiu]
from large families among these dasse
of the population.

Concerning tuberculosis, with which
by reason of many years' experience
I am perhaps more familiar thai
with other medical and social diseases
let me relate the interesting fact tha
a carefully taken history of man}'
many cases has revealed to me tha
with surprising regularity the tubei

* Thi« address was first delivered at the 44tb Annual Meeting of the American Pubtic Health ABSOciati<
in dncinnatit 0.. October 27, 1916. It was again delivered upon invitation on subsequent dates before tl
East New York Medical Society, the New York Woman's City Club, and the Socisl Service League of the Ui
tariaa Church of the Messiah.

tf-^if,

Birth Control

uals who die annually of tuberculosis
in the United States, 50,000 are chil-
dren. Of the economic loss resulting
from these early deaths I will speak
later on, but in continuing along the
medical and sanitary lines of my sub-
ject, I must call your attention to the
fact that according to some authors
65 per cent, of women afflicted with
tuberculosis, even when afflicted only
in the relatively 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.*
Some times we succeed in saving such
a mother by a timely and careful
emptying of the uterus. But an
abortion even scientifically carried out
and only resorted to with the view of
saving the life of the mother, is never
desirable, either for the consultant to
advise, nor for the gynecologist or
obstetrician to perform; and who will
dare to say that even under the best
conditions 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
tuberculous 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 suflferers and before they
died they became disseminators of
the disease. Nearly all of the infec-
tious and communicable diseases are

♦C. A. Credi-Hoerder: "Tuberkuloae und Muttcr-
sehaft." (J. Kraecer, Berlin. 1915.)

more prevalent in the congests
overcrowded homes of the poor, an
particularly in those of large familie
The propagation of syphilis and gono:
rhoea by contact infection, other tha
sexual, can sometimes be avoided i
the homes of the well-to-do, by enj
lightenment and the conscientiousnes
of the afflicted. They are almos
invariably communicated to the in,
nocent in the homes of the ignoran^
and poor. Gonorrhoeal infection fron^
parent to child or from one infected
member of the family to the other, is|
responsible more than anything else
for the 57,272 blind persons in the
United States.*

The great syphilographer Fournierj
left us the following irrefutable statis-|
tical evidences of the seriousness 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, f

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 inherited
syphilis, less blindness from gonor-
rhoeal infection; in other words, less
unfortunate children in this world
handicapped for life and a burden to
the community.

* United States CeneuB, 1910.
tBerkowits: "Late Congenital Syphilis." N. Y.
Mtdical Journal, June 17, 1915.

Birth Control

and less good food, less sanitary
housing, less care of the children, and
more sickness will almost inevitably
result. Every sickness or death of
child or adult has increased the ex-
penses of the family. There is the
doctor's bill, the druggist's hill, and
last but not least, that of the under-
taker. A grave had to be purchased.
It there have been savings, they are
gradually swallowed up and debts are
often contracted for the sake of a de-
cent funeral.

Next to the medical and sanitary
comes the physiological aspect of birth
control, which can be summarized in
a very few sentences. The average
mother with two, three, or four chil-
dren, not having arrived in too rapid
succession, say with two or three years
intervening, is physiologically, that is to
say physically and mentally, stronger
and better equipped to cope with life's
problems than the worn out and weak>
ened mother whose life is shortened by
frequent 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 helped to extend
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. According to the
Official Statistical Year Book of the

Netherlands, the proportion
men drawn for the army over
in height has increased froi
47} per cent, since 1865, ^
proportion below 5 ft. 2} in.
has fallen from 25 per cent.
8 per cent,*

In that enlightened coui
teaching by the medical prol
the most hygienic methods
limitation has enabled the po(
small families which they cc
to be physically and moral
equipped than formerly,
most interesting to observe,
is that, whether as a result of
some other reason, the famili
the well-to-do are not nearlj
as in other countries.

In Australia and New Zee
means of artificial restrictic
free circulation and the rest
families is almost universal,
two English colonies have
to their mother country in tti
of struggle the most effici
physically and mentally best
regiments. The soldiers of
and New Zealand have shoi
selves brave and fearless fig
certainly equal, if not super!
as physical endurance is coot
their English brethren. In
country, it is well known t
control is frowned upon by thf \

nearly all the ecclesiastical auxnoriiies.

And what of France? Before the
present war Drysdale, in his "SmaU
Family System," very aptly says: "It
has become the fashion to speak of the

• "Tbs Small Family Syatam; ta It Injariaua or Im-
moral:" By Dr. C. V. Dryadalsi Piibl. by B. W.
Hwb«h. Kew Yoik.

Birth Control

In answer to a letter from Doctor
Foote, containing suggestions on this
topic, the president of the New York
Association for Improving the Condi-
tion of the Poor very pertinently 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 subject that you
discuss is one that is worthy of serious
consideration and that has in the past
been treated with an excess of sent-
iment."

That judicious birth control does
not mean race suicide, but on the
contrary race preservation, may best be
shown from the reports from Holland.
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 reduction in the. mor-
tality of children under 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 informa-
tion concerning family limitation, per-
mit me to quote from a personal letter
to me from the great pioneer of this
humanitarian movement, Dr. J. Rut-
gers, the Honorable Secretary of the
Neo-Malthusian League of The Hague.
The league has been in existence since

* Birth Control iSTetrs, published by Birth Control
League of Ohio, Clev^landt Vol. I, No. 1.

1888 and received its legal sanction b
a royal decree January 30, 1895.
has 6,000 contributing members; a
information is given gratuitously. A
a result of this league in Holland on
does not see any children dresse<
in rags as in former years prior to th
starting of this movement. To use th
venerable secretary's own words: "Al
children you now see are suitabb
dressed, they look now as neat a;
formerly only the children of th(
village clergyman did. In the f amilieJ
of the laborers there is now a better
personal and general hygiene, a finei
moral and intellectual development.
All this has become possible by limita-
tion in the number of children in these
families. It may be that now and then
this preventive teaching has caused
illicit intercourse, but on the whole
morality is now on a much higher level
and mercenary prostitution with its
demoralizing consequences and pro-
pagation of contagious diseases is on
the decline. The best test (the only
possible mathematical test) of our
moral, physiological, and financial prog-
ress, is the constant increase in long-
evity 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 an-
ticipated by the advocates of clerical-
ism, militarism, and conservatism have
occurred. In spite of our low birth-
rate the population in our country is
rising faster than ever before, simply
because it is concomitant with a greater

Birth Control

mother at the prospect of another in-
eAatable confinement, and later the
sight of a puny babe destined to dis-
ease, poverty, and misery, has made
me take the stand I am taking today.
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 antituberculosis crusader,
I became accustomed to the fate of
those who venture on new and hereto-
fore untrodden paths of progress.

What would the moral outcome of
birth control, or let us rather say, ra-
tional family limitation be, if taught
judiciously to those seeking and need-
ing the advice? Millions of unborn
children would be saved by contra-
ception 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 extent
as to raise few children well. But
their fear of a large family retards, if
it does not prevent, their happiness
and ipso facto the procreation of a
better and stronger manhood and
womanhood. The woman withers
away in sorrowful maidenhood and
the man whose sexual instincts are
often so strong that he cannot refrain,
seeks relief in association with the un-
fortunate and often diseased sisters,
called prostitutes. The result is a
propagation of venereal diseases with
all its dire consequences. To an audi-
ence composed of physicians and sani-
tarians I need not say what these
consequences are. They involve ster-

ility, physical and mental suffering
the man, or sterility in both man ai|
wonum; and according to the severil
of the infection, pelvic disorders, abo
tion, premature labor, a dead chil^
or one lastingly tainted with diseasj

At times disease does not enter as;
factor in the tragedy, but the result ;
a girl mother, a blasted life, for oi
double standard of morality recognize
only the '*sin" in our sisters, not i
ourselves. Of her, compassionat
tongues only say she loved not wisel
but too well; of him, nothing is sai
at all. He is spotless and virtuous ii
the eyes of the world and can g<
through life as if he had never sinnei
and been responsible for a blasted lifi
or two. !

Even our moralists must acknowl
edge that by an early marriage witl
a man of her choice, enabled by under
standing to limit the niunber o
children, many a girl would be savec
from so called dishonor and in man}
instances from prostitution. One oi
the strongest arguments of our mor-
alists and purists is that the knowledge
of contraception would lead the youn^
to enter forbidden sexual relations anc
degrade them morally. Granted thai
this may happen in a number of in-
stances, the benefit derived from a dimi-
nution of venereal diseases, from s
greater number of happy and success-
ful marriages among the youngei
people, fewer but better and healthiei
offspring instead of an unrestrictec
procreation of the underfed, the tuber
culous, the alcoholics, the degenerate
the feeble-minded and insane, woulc
more than outweigh the isolated in

Birth Control

lishment of gratuitous clinics, directed
by regular physicians of high repute,
remunerated by city or state, who are
competent to give information as to
birth limitation in cases where they
deem the giving of such instructions
advisable.

Concerning the urgency and the wis-
dom of eflForts to change these laws* I
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, Professor A. Jacobi of New
York, the ex -president of the American
Medical Association; secondly, to Pro-
fessor Hermann M. Biggs of New York,
my beloved teacher, the distinguished
sanitarian and pioneer in the modem
warfare against tuberculosis. In his
preface to Dr. William J. Robinson's
book "The Limitation of Offspring,"

* United Stittes 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 »eq.). New
York Statute Book, (Section 1142 of the Penal Law).
The federal law prescribes a fine of $5,000 or imprison-
ment 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 of a recipe, drug
or medicine for the prevention of conception or for
causing unlawful abortion a misdemeanor punishable
with no less than ten days nor more than one year im>
prisonment 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 permitted 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
textbooks on gynecology describe the operation as care-
fully as an amputation of the cervix or a hysterectomy;
but concerning the advice to give, for example, to the
poor tubercidouB mother who has had her uterus
emptied once, so that she may not be obliged to submit
to such a "lawful" operation again, our teachers of
gynecology and our textbooks dare not say a word.

Dr. Jacobi says: "Our federal
state laws on the subject of prevent
of conception are grievously wr^
and unjust. It is important
these laws be repealed at the earli
possible moment; it is important
useful teaching be not crippled, th
personal freedom be not interfere
with, that the independence of marric
couples be protected, that families I
safe-guarded in regard to health an
comfort, and that the future childre
of the nation be prepared for comp(|
tent and comfortable citizenship. "

Dr. Hermann M. Biggs, prior t
the recent dismissal of the case h
Judge Dayton of the Federal Court
against Mrs. Sanger for sending infor
mation about birth control througl
the mails, gave to the press the follow
ing statement: **T am strongly of the
opinion that the present laws in regard
to the giving out of information ii^
relation to the governing of infant
control are unwise and should be re-
vised. There can be no question in
the mind of anv one familiar with the
facts that the unrestricted propaga-
tion of the mentally and physically
unfit as legally encouraged at the
present time is coming to be a serious
menace to civilization and constitutes
a great drain on our economic re-
sources. This is my personal view."

To the foregoing expressions of opin-
ions let me add what one of our most
distinguished jurists, the Hon. Judge
William H. Wadhams, of the Court
of General Sessions, wrote me con-
cerning these laws: "In order to save
the state from the burden of large
families, where there is no possibility
of their being supported and where

Birth Control

if it IS thou^t wiser, to form a com-
mittee 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.
Unconscious, irresponsible procrea-
tion produces domestic misery, and
half-starved children. 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, hij
est ethical, moral, and economic i
sons. I believe in it because with
aid of it man and woman can dec
when to have a child, work and prep
for its arrival, welcome it as the ful
ment of their heart's desire, watch o'
it, tenderly care for and educate it, a
raise it to be what every child shoi
be destined to be — a being hapj
healthy, strong in mind, body, a
soul. If we but use our God-giv
sense to regulate the affairs of govei
ment and family wisely and econo
ically, this great world of ours will
one of plenty and beauty where t
good will predominate over the e
and the children bom in it will becod
men and women only a little lowj
than the angels — images of th^
Creator.

DISCUSSION.

Dr. Iba S. Wile, New York City: In reading
the thoughtful paper of Doctor Knopf a number
of thoughts suggested themselves. Birth con-
trol is recognized today as a factor in eugenic
control. Some states take cognizance of the
advantages of limiting the number of offspring
in BO far as defectives and criminals are con-
cerned. The laws of numerous states permitting
sterilisation or asexualization place the seal of
governmental approval upon the prevention of
procreation in the interests of the public weal.
Numerous regulations providing for the segrega-
tion of defectives represent crystallizations into
law of the principle that the state has a vital
interest in controlling the birth of certain types
of citizens. States requiring a certi6cate of
health previous to marriage point out a deep
interest in the character of health of those who
are to become parents. The underlying prin-
ciple b the protection of the state from the
development of undesirable children.

The law recognizes the interruption of preg-
nancy as legal and justifiable in order to save

the lives of women suffering from tuberculos
nephritis, cardiac diseases, or from conditio]
whose fatal progress would be hastened throu
continued pregnancy, but the law holds it to
illegal to teach these same women how to avc
conception. It is manifestly contrary to eve
principle of modem preventive medicine tl
there should be such interference with the juc
ment and action of physicians where it see
most rational and medically sound to give adv
as to the methods of preventing a conditi
containing a hazard to life.

Despite the existing laws, contraception
practiced and undoubtedly taught by memb
of the medical and nursing profession, as well
by midwives. What is equally important is
fact that contraceptives are sold in drug sto
throughout the country without any inter!
ence, providing conscience is stretched and
instrumentalities are dispensed on the plea t
they are agents for the prevention of disease.

It is known that in 1900 there were only thi
quarters as many living children to each 1;

Birth Control

i*;

ni«ed duty of an phyaidans in the presence of any

eontagicms disease to P«>^ ^*^^^.f~°^,?"
risks of infecUon. In the case of syphilis, where

there is a question of its introduction into mar-
riage, the physicians' protective duty embreces
not only the prospective wife, but the Addren
she may bring into the world and through them

the interests of society." (Page 4«4 ) After
marriage has occurred -* when a mamed man has

syphihs the first indication is to prevent the
contamination of his wife, tiie second is to guard

against pregnancy." The interpreUtion of tiie
term "guarding against pregnancy" opens up
the question as to how Uiis is to be accomphshed
without vioUiting e»stmg laws.

It is urged that the frank discussion of methods
of contraception by physicians wiU lead to an
increase of clandestine reUtions among un-
married giris by virtue of tiie new knowledge
Clandestine prostitution exists today and fear of
pregnancy is not an impassible barrier. The
development of a conscious moraUty. which is
the greatest protective force, should not be
based upon fear. Admitting for the sake of
argument that tiie same degree of immoraUty
might exist, tiiere would be at least a decreased
destruction of Ufe for tiie women nowiUegitimate-
lypregnantandtiiefetustobedestroyed. Fewer
homes would suffer disgrace, foundUngs would
decrease in number, while an accursed basterdy
would be greatiy diminished.

I do not advocate, however, that knowledge
concerning the prevention of conception should
be given to the young, but merely to adults and
only to tiiose who are wedded. It cannot be
denied that a law of this character would un-
doubtedly be broken just as is tiie present law
today. The transmission of some facts with
reference to contraception is constantly going
on, but they emanate from polluted sources and
refiect folk lore rather than intelligent medical

opinion.

I do not favor the aboUtion of federal or state
laws which deal with abortions, though owing
to the weight of public opinion convictions for
violations of these laws are remarkably limited
in view of the large number of violations occur-
ring annuaUy. I beUeve 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
acU not synonymous in character and meriting

entirely different treatment. The procuring
of an abortion should still be penalised. Th^
prevention of conception should be permitted
The New York State law links prevention oi
conception and unlawful abortion, thus indicat
ing the legality of certun types of abortion.

Because the state already recognizes its right
to limit procreation among certain groups of th<
population, because the decrease in the birth-
rate will result in improved public health and the
social economic improvement of the masses o(
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 cnd.1
I urge that resohitions be passed favoring thej
amendment of federal and sUte laws, so that thd
words preventing or preA'ention of conception
be eliminated thereform.

Dr. J. H. Landis, HeaUh Officer, Ciwinnaii,
Ohio: It goes without sa>'ing that we are all in
favor of redudng the number of those who arc
physically, mentally and morally unfit and add-
ing to the number of those who are physicallj
fit, mentally sound and more highly developed

morally.

The paper brings to our attention a number o
facts that have long been recognized as true
No one will deny that the offspring of a tuber
culous mother has a poorer chance of liWng thai
one from a mother without a wasting disease o
that the healthy mother has a better chance o
surviving pregnancy than has her disease

sister.

No one doubts that infant morUlity is greal
est among the offsprings of the ignorant, tb
poor, the underfed and badly housed, the tube;
culous, the degenerate, the alcoholic the N-icioi
and the mentally defective.

Congestion and lack of air and sunshine ha^
long been recognized as powerful predisposii
factors in the dissemination of disease and deal
among those exposed.

The remedy suggested for all of these cone
tions is birth control. The remedy is direct
towards the effects produced instead of beii
directed at the causes producing them.

I am unable to see how birth control is
solve the problems created by vice, poverl
ignorance and alcoholism while these conditio
go on unchecked, and am unwilling to belie

Birth Control

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 could a syphilitic or gonorrhoeic
parent know how to prevent conception during
the acute and infectious stages of his or her
diseasCi there would certainly be less of congeni-
tal syphilis, less blindness from gonorrhoeal
infection.** If these ends can be gained, even
in slight degree, by birth control, I'm for it
strong, r remember the doctor in "Damaged
Goods*' says — "It is better to have fifty sound
and whole men than to have a hundred, sixty or
seventy of whom. are more or less rotten."

That b an important interrogatory in the
paper which reads — "What is the physiological
effect of voluntary artificial restriction of the
birth-rate of the offspring?" The answer is
satisfactory, for the reports from Hollandt.where
the medical profession have openly approved and
helped to extend artificial restriction, are to the
effect that the morbidity and mortality rates
have improved more rapidly than in other
countries. HoUand also supplies data to prove
that rational birth control does not mean race
suicide, but on the contrary^ race preservation
and strengthening. Doctor Holt, as quoted by
Doctor Knopf, talks wisely when he says —
"Conscious and limited procreation is dictated
by love and intelligence; it improves the race.
Unconscious, irresponsible procreation produces
domestic misery and half-starved children.
Conscious procreation of human lives elevates
man to the gods; unconscious procreation de-
grades mian to the level of brutes." It is plain
that 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 at-
tention to the fact that we as a nation, like all the
dviliied nations, are already practicing birth
oontrot; but in a very stupid and mistaken way.
Namely just that part of the population which
ii called ** the upper dass, " which is undoubtedly
fuperior physically and mentally as well as
financially and accordingly produces the most
desirable children and ought to produce at least
its share of the future generation, is practicing
biitli control to such an extent that the old

families are dying out; whereas the infei
part of our population, which is also finanda
least able to raise four children, is raising f^
and more. What could be more stupj

Dr. Louis I. Dublin, New York City: 'i
other day I contributed a paper in another «
tion on the commoner errors in statistical wo
I wish I had had Doctor Knopf's paper at i
disposal for I could have used it very profital
for my text. I do not recall any paper that
have read for some time that is more subject
criticism on the score of method than the pap
we have just heard. I believe it is fundame
tally erroneous because of the emotional attitu<
of the writer which has caused him to dra|
general condusions from an examination of onl
a very limited part of his subject. His emph
is entirely in the wrong place. There is al
gether too much birth control now and what t
community needs is emphasis on birth release b
the healthy, capable and self-respecting eh
ments of the oonmiunity.

There is time only for one word and I want
limit that to the story of France. In Fran
we have today a sorry spectade of the results
birth control. The lesson is obvious. Fran
is today crying for men; for men who were eithe
not bom or died at an alarming rate in infanc
or later of tuberculosis. The attitude of min
which is engendered by a nation-wide policy o^
birth control ultimately brings about more in-^
fant mortality and more tuberculosis because
of the general weakening of the stock which
directly results therefrom.

A Membes: It strikes me that the whole
question resolves itself into who should marry
and who should not marry. Unless we have
some laws regulating marriage, to teach young
men and young women the nature of the sodal
diseases and the conditions necessary for a good
physical body, why, we will have tuberculosis,
we will have degenerates, we will have idiots
and imbeciles and our penitentiaries and alms-
houses and every other penal institution will
be filled. The whole question is prevention;
I believe strictly in the doctrine of heredity.
Heredity, environment and education is the
triangle that leads to greatness. If we do not
hover around those three points, we will never
succeed. We know that if two degenerates
marry, they beget degenerate children, beget
imbedles. If an imbecile marries a norma)

Birth Control

i

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
hounng conditions, bad factory hygiene, over-
•crowded 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 rational treatment and
lack of institutions, are some of the multiple
•causes responsible for the high tuberculosis
morbidity and mortality rate.

Those of my colleagues who have honored me
by th3ir steadfast friendship and constant co-
operation will bear me out when I say that I
have done my best to help to remove these
•causes during years of conscientious labor.

I have approached the subject of birth control
after deep reflection and with the same earnest-
ness 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 earnestness I am capable of. I believe in
it because by its aid there will rise a generation
•of men physically, mentally, and morally fit, and
-children free from disease and prepared to take
•up the struggle for life.

I must revert once more to my friend. Doctor
Landis' discussion of the tuberculosis 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 emphasis 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 ths least contagious and should always
be classed with communicable diseases. It
should not be considered as most contagious
like smallpox foi examph. On the contrary,
strictly speaking, it is not contagious at
•all. The word contagious comes from the
Latin eo7i/tny«rf,"to touch, " but the touch of the
honest, conscientious, and clean consumptive
18 no more contagious than that of a healthy
person. This can hardly be said of the smallpox
patient, be he ever so dean. It is best for an
uovaccinated individual never to touch him, and
still better to stay away from him as far as
posnble.

I would consider it a most regrettable thing

if it should go out to the public that a disti
guished member of the American Public Hea|
Association has suddenly declared tuSerculol
to be the most contagious of diseases. We ha
already too much phthisiophobia which mak
the lot of the unfortunate consumptives haj
enough.

^or the kindly words said by my good frieni
Doctor Hurty, I am deeply grateful. He ^
always progressive, feariess, and outspoke!
He agrees with me so thoroughly that I feel \
will do his share toward a better understand! li
of the problem under coasideration and be i
enthusiastic supporter of the all importa^
movement for the betterment of mankinj
which he loves so much.

To the member whose name I could not catc
and who maintained that the whole questio
resolves itself into who should marry and wfa
should not marry, I wish to say that it W8
merely for lack of time that I did not touch o
this subject in my paper. That I strongl
advocate a medical examination of the man a
as well as the woman prior to granting a marriag
license, I have already said in my reply to Docto
Landis* criticisms. Much unhappiness an
misery could be avoided by such obligator;
examination and if we could add to our institu
tions of learning a school of parenthood witl
obligatory attendance for every one desiring t<
enter the matrimonial state, we would add stil
more to the happiness and prosperity of th
individual and the community at large.

Now a word to our Catholic friends am
those of other faiths who are so strongly opposes
to contraception and limiting family increase
Let us have no word of bitterness or reproad
because millions of devout Catholics hold thes
views. Let us not antagonize either th
Catholic priest or layman, who have a right t*
their convictions as much as we have to ours
This is a purely scientific meeting, composed o
men who should not have, and I hope do no
have, any hatred in their heart because g
differences of opinion regarding religiou
views. Therefore, in reply to the somewha
passionate remarks of the distinguished statis
tician of the Metropolitan Life Insurance Com
pany who questions the accuracy of my statis
tics and my statements, and says that it i
all fundamentally erroneous, I wish to reply witl
less vehemence. I would calmly state that i

Birth Control

the survival of the strong animal. Pressure of
population on subsistence and area develops
brutality, selfishness, and disregard of human
life. It crushes leisure, generonty, and art and
makes impossible some of the finest virtues of
the race.'

I have already said how anxious I am that we
may treat this subject as a scientific one and that
we should only have in view the highest ideal,
namely, a normal increase of population con-
comitant with our resources and an improve-
ment 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
happy, and economically secure. My personal
belief is that we shall thereby become more
highly developed spiritually and approach more
rapidly towards the millennium. When at last
an enlightened government will permit contra-
ception to be taught where it is likely to be pro-
ductive 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, disease,
and crime and have produced a better genera-
tion of men and women, better equipped for
life's mission, in short, men woHhy 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 interested
in birth control so suddenly, which is apparently
so foreign to my specialty, but I can assure
you that whUe I have taken up the work only
recently, my interest was not sudden at all. As
already stated it began many years ago in con-
nection with my work in the tenements and
overcrowded hospitals where I witnessed the
sufferings of many a tuberculous mother whom
I 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
mn a result of this newly added pr^nancy, 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 tuberculous, bul
all others physically and mentally diseased &
impoverished. |

Nature's forces are blind. She creates wi
out thought of provision for the offspri^
Think of bacterial life if it had remained
checked by the genius of a Pasteur, a Koch
Lister; of the insects, such as the yellow fever a
malaria-spreading mosquitoes, if unchecked I
a Reed and a Gorgas! I could continue tj
theme of man's triumph and control over natu
indefinitely if I were to enter into the field i
agricultural and industrial science. I oou
tell you of the battles of the Australian farm^
with the rapidly multiplying rabbit. Hei
nature's blind tendency to procreate devastate
the fidds destined to nourish the populatioi

The excessive birth rate of human beings i
India and China b to my mind also largel
responsible for the frequent famines and thej
sequeilie of pestilence, plagues, etc. The ide|
that there is and always will be enough room an^
food for all mankind on this earth, no mattel
how great the increase in population, is, to saj
the least, erroneous. In my address I hav^
already referred to the work of Doctor Reecj
who says, **It seems, indeed, to the careful
student that the danger to the American family
to-day and still more in the future lies in thd
direction of overpopulation rather than under-i
population."

Is there no danger at all in this country of
ours of a possible famine due to overpopulation
and underproduction of food substances.^ In
his forthcoming book on Food Problems (Good-
hue & Co., Publ., New York), of which I had
the privilege to see the proof, my friend, Dr.
Henry Smith Williams, the well known 4>hysician
and economist, makes the following statement:
" In the census period 1900-1910, the population
of the United States increased by 21 per cent.,
but the production of cereal grain increased by
only 1.7 per cent. In the meantime there has
been such a falling off in the animal industry
that there would have been required 60,000,000
more meat animals (cattle 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 production

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