View original document

The full text on this page is automatically extracted from the file linked above and may contain errors and inconsistencies.

JAMES J. D A V IS , Secretary

G R A C E A B B O T T . Chief




Bureau Publication N o. 120

Federal Reserve Bank of St. Louis




15 C E N T S P E R C O P Y
Federal Reserve Bank of St. Louis


/ £




■h )


PQ j



Letter of transmittal___________________________________________________________
Introduction_________________________________________ _____ ,_____ _______________ _
Scope of the Georgia survey_________ _____________________ ______________
The mountain county___________________________ ________ ___________ ._____ ____ _
Part of area within national fo rest-_______________________________ ____
, Copious water supply _____ _______ ______ _________________________________
Roads______________________________________ ____ ___________________________
Isolated homes___ _________ _________ ______________ „J_____ _ ___________ 6
Railroad, post, and telephone service__________ _________________ ___ >____
Agricultural development_________ _______________________„ ___________ _
Principal products__________________ _______________ ______:_______________
Mining a secondary industry_________________ i____ ___________ __________ _
County health service________ ____ ___________ __________________ ____________
Inaccessibility of medical care___________________________________________
Maternity care_________________________ _______________ _______A._________________ 11-22
Large families___________________________ ___________J __ __________________
Prenatal care_________________________- _________________________ __________
Attendant at birth________________ ____ r_ ______________________ '____ ____
Postnatal care by physicians-,__________________ r____________________ _______ __________
Physicians’ fees______________________ _________________ ___ _______
Mothers’ w ork______________________________________________
Field work— ______________
W ork in relation to childbearing_____ ______________________________
Care and rest following childbirth____ ^________________________________
Child care and infant mortality_______________________________________________ 23-33
Illiteracy______ «_________________________________ _________ __________ _____
Instruction in infant care_____ __________________ K_______________________
Infant feeding— ___ ________________________________________________________
General health____ ___________________
The snuff habit______________________________ _____________________________
. 29
Illnesses of children__________________________
Maternal histories________________ ^_______ ________________ _________________
Infant mortality_________________________
Losses in early infancy____________________________
Causes of death-------------------------------------- ------ -------- ----------__________________
Use of patent medicines and home remedies-^______________________________ 35-40
Federal food and drugs act_____________________________________________
Patent medicines given babies_____________________ *.____________________
Patent medicines used by pregnant women___________________________ ■>_
Teas used for medicinal purposes________________________________ ________
Other home treatment for babies_________________________________ ____

Federal Reserve Bank of St. Louis

£ l 3 i 4-




Housing and sanitation__________________________________________________________41-46
Crowded sleeping quarters------------------------------------------------------------------------42
Houses without windows__________________l_________________ i_____________
Attractive features of mountain homes_________________________________
Household equipment___________________»___»._____________________________
Lack of toilets:_________________________________
W ater supply______________________________________________________________
Typhoid fe v e r ------------------------------------------------ .--- ---------------------------------------46
State health activities relating to maternity and infancy_____ L ____ !____:__47-51
Birth and death registration_________ ________________________ ______ i___ _
Mortality statistics_______________________________________
Division o f child hygiene_________________________________________________
County health organization________________ _______________________________
Public-health nursing______________________________________________



Face page.


I. Typical roads_____________________________________________________
II. Primitive methods of farming__________________________________
III. Mountain mothers and their babies_____ »________________________
IV . Mountain children------------------------------------------------------------------------V. Types of mountain houses_______________________________________
Federal Reserve Bank of St. Louis



U. S.

D e p a r t m e n t of L abor,
C h il d r e n ’s B u r e a u ,

W ashing ton, Decem ber 13,1922.
S i r : There is transmitted herewith a report entitled “ Maternity
and Infant Care in a Mountain County in Georgia,” one of a series
o f bureau studies o f child welfare in rural areas. The field work
was done under the direction o f Miss Margaretta A. Williamson and
the report was written by Miss Glenn Steele. Dr. Frances Sage
Bradley was in charge o f the children’s health conferences held in the
course o f the investigation.
The Children’s Bureau is indebted to State and local health offi­
cials and to physicians and school officials o f Georgia for much
helpful cooperation.
It is a pleasure to report that since this survey was undertaken
there has been a great expansion of public-health activities in Geor­
gia. The bureau o f vital statistics was organized in the State board
o f health in January, 1919. Since that date the State haa been
admitted to the United States death-registration area and has insti­
tuted a campaign for complete birth registration which it is hoped
will result in its inclusion in the United States birth-registration
area. A division o f child hygiene has been created, and the work
o f the State department of health has been expanded in other direc­
tions. The Federal Maternity and Infancy Act has been accepted
by the legislature, and a State program for the reduction o f maternal
and infant mortality is now under way.
Respectfully submitted.
G r a c e A b b o t t , Chief.
Hon. J a m e s J . D a v i s ,
Secretary o f Labor.
Federal Reserve Bank of St. Louis
Federal Reserve Bank of St. Louis

Public protection o f maternity and infancy was accepted as a gov­
ernmental policy when the law for the promotion of the welfare and
hygiene o f maternity and infancy was enacted in November, 1921.
The act provides for the cooperation o f State and Nation in an effort
to safeguard the life and vigor o f mother and child. Recognition
o f the need for constructive public action in their behalf followed
nearly a decade of study of child welfare in the United States by the
Children’s Bureau.
Infant mortality was the first subject chosen for field investigation
after the bureau’s establishment in 1912. Little information touching
the problem was available at the time, although an appalling annual
loss o f young life was indicated by estimates for the Nation, based
upon meager data. To ascertain the facts, studies were commenced
and have since been carried forward in American cities o f diverse
characteristics, and in 1916 a series of surveys o f maternity care and
child welfare in rural regions typical of various sections o f the
United States was begun.
The approach to the problem was necessarily somewhat different
in town and country. In the cities fairly complete records o f births
and deaths permitted a measurement by infant mortality rates of the
effect o f various conditions upon the mortality under 1 year o f age.
The relation between existing conditions and infant mortality could
not be shown with such precision for the rural areas owing to the
careless accountancy o f births and infant losses. The rural studies
therefore, have been developed with a view to showing the environ­
ment, opportunities, and needs o f the country mother and child
rather than to connect various factors with the infant mortality
The subject o f maternity care has been especially emphasized in the
rural studies, because o f its important bearing upon child conserva­
tion. The high mortality in the first few weeks of life and the
losses from stillbirths and miscarriages have demonstrated clearly
that the safeguarding o f the infant must begin with the protection
Federal Reserve Bank of St. Louis



o f the mother before and at the birth of her baby. In this respect
the needs o f the city and the country mother do not differ, but
the problem o f providing proper care for childbearing women is
the more acute in rural districts because of isolation, lack o f suffi­
cient medical and nursing service, and limited opportunities for edu­
cation in the hygiene o f maternity. Therefore the problems con­
fronting mothers in childbirth and in the care of their children have
been coordinated in the rural studies.
The survey in Georgia is the eighth in the rural series, previous
reports having been issued on studies made in seven country dis­
tricts, representing five States—Kansas, Wisconsin, North Carolina,
Mississippi, and Montana.
Scope of the Georgia survey.
The Georgia county surveyed covers about 400 square miles in the
southernmost extension of the Blue Ridge Mountain belt and is bor­
dered by the bold escarpment of that range which forms the south­
eastern terminus o f the great mountain system.
In topographical, social, and economic aspects, and in the customs
and characteristics of its people, the county was considered repre­
sentative o f rural conditions in the mountain counties o f Georgia
as well as in the entire upland region of southern Appalachia. In
addition, it afforded an opportunity for the study o f child welfare
among a people American by birth and descent, sprung from the
sturdiest stocks—chiefly English, Irish, and Scotch. No other sec­
tion o f the country contains so large a percentage o f native white
persons o f native parentage as does the southern Appalachian Moun­
tain region, and in the county selected for study but 10 residents
of foreign birth were enumerated in the Federal Census of 1920.
The county had approximately 2,400 families and 12,000 inhabit­
ants at the time of the survey. O f the total population, about 4,000
were dwelling in six incorporated towns excluded from the study
because they were not typical o f farm conditions. This left about
1,600 families, including 8,000 persons, living in the open country.
In general, it was the purpose to limit the study to such of these
rural families as were rearing infants at the time o f the survey, in
order that information could be secured concerning current conditions
affecting maternal and infant welfare. An interview was sought
from the mother o f each baby born within two years preceding
March 1, 1918, who resided in the area at the time o f the baby’s
In the Georgia county, the problem of locating families in which
births had occurred presented difficulties not encountered in rural
surveys made in other parts o f the United States. Although the
Federal Reserve Bank of St. Louis



other rural surveys were conducted in States lacking complete
birth registration and therefore not in the United States birthregistration area, yet each section studied had some system o f
recording births and infant deaths. The names and addresses o f
the parents to whom babies had been bom could be secured from
these records and were utilized as a point o f departure in finding
the families. The total lack o f such public records in the Georgia
county necessitated a canvass o f every rural home to locate the
babies coming within the scope o f the study. In this way inter­
views were secured concerning 509 babies, including four sets of
twins, born during the selected two-year period. Schedules were
taken for infants who had died or were stillborn, as well as for the
living. No .colored infants or white infants o f foreign-bom
parentage were discovered in the entire canvass.
In general, the^ topics of inquiry concerned the family history
in relation to the well-being o f the child ; the health and care o f the
baby ; the mother’s prenatal, confinement, and nursing care during her
last pregnancy and confinement ; the size o f the family and the losses
sustained from stillbirths, miscarriages, and deaths; the mother’s
household and farm duties; the father’s occupation; nativity and
literacy o f both parents; and the housing, sanitation, and general
living conditions of the family.
In the main, the report is based upon information secured from
the mothers, but this was supplemented by a study o f all pertinent
data available concerning the county, by consultations with State
and county officials, and by interviews with physicians and mid­
wives of the county. In addition, the work included a series o f chil­
dren’s health conferences in various county centers, conducted at
the close o f the survey. A child-welfare exhibit was displayed, and
parents were invited to bring children to the conferences for a physi­
cal examination by a Government physician who advised about
their care, feeding, and general physical development.
Federal Reserve Bank of St. Louis
Federal Reserve Bank of St. Louis

Probably nowhere in the United States is maternal and infant
welfare more conditioned by natural surroundings than in the
Southern highlands; and a foreword on the physical characteristics
o f the county studied is essential to the understanding o f its family
Although less rugged and remote than many o f the upland regions
o f North Carolina and Tennessee, the entire county is a network
o f mountain spurs from the main Blue Bidge divide, with summits
reaching altitudes o f from 2,500 to more than 4,000 feet above sea
level. These deploy in every direction, skirted and cut up by count­
less valleys, ravines, and gaps which form a labyrinth o f intricate
Much o f the county is under heavy forest cover. The timber
includes a ' variety o f hardwood species typical of southern Appa­
lachia— oak, chestnut, poplar, bass, ash, hickory, and cherry. Pine
is sometimes found with the mountain hardwoods, and in the more
open country and along the larger streams elms, birches, and gums
are abundant.
Part of area within national forest.
To protect the headwaters o f navigable streams, about 54 square
miles o f the forested section o f the county—more than one-eighth
of its area— has been purchased by the United States for inclusion
in the Cherokee National Forest, and further purchases were pending
at the time o f the survey. This was virgin forest, except as it had
been culled by the settler for home construction and farm purposes.
Deserted cabins on lands already acquired by the Government
gave evidence o f rapid depopulation; yet the entire section covered
by the Government project could not be excluded from the county
survey, for her© and there within it families with little children
were living on tracts not yet relinquished. In spite o f increased
isolation as their neighbors moved away, some owners were reluctant
to part with their mountain home sites.
“ I grew up here and know every curve o f the hills,” said the
father o f one family, “ and I ’d hate to sell this patch of ground.”
Copious water supply.
With heavy rainfall and the protection o f forest cover, a copious
water supply for the region is insured the year around. Only two
Federal Reserve Bank of St. Louis



o f the county’s swift streams attain river size, but feeding these,
countless creeks sweep down the steep mountain slopes and debouch
by meandering courses into the main channels.
Illustrative o f the turbulent character o f these streams and o f their
coiling rock-cut courses is a description by the United States Geo­
logical Survey o f the county’s principal river:
Numerous small cascades and steep rapids alternate with quieter stretches.
There are two cascades about 100 feet high.
[A t one place] the river enters a tortuous mountain gorge, through which it
ows -9 miles to gain 2 miles of actual distance, with a grade approximating
20 feet to the mile. This part of the river is full o f rapids and is bordered
y steep slopes and many cliffs. After einerging from the gorge the river
flows across a plateau in a valley 200 to 300 feet deep.

The effect o f so rugged a topography on routes o f travel was mani­
fest, for the natural barricades o f mountain, forest, and stream had
seriously impeded the progress o f road building. Although it was
estimated that the county had about 400 miles o f public roads, there
were no improved highways. The roads were o f dirt only; and owing
to the character o f the soil, the amount o f rock, the steep grades, and
the heavy rainfall, most of them we,re in poor condition.
Prior to 1917 little progress had been made in road building,
owing to the operation o f what was known as the “ pick and shovel ”
law. Under that law each man “ worked ou t” his road tax in his
own vicinity, using his own tools. The county had no equipment.
Little beyond the most needed repair work was accomplished in
that way. This law was superseded in 1917 by a measure which de­
mands either 10 days’ work or a commutation tax o f $5 from citizens
subject to road tax. As a result, cash payments were usually made
and practically no one “ worked ’’ the roads.
In the year prior to this survey only about $13,000 was available
for road expenditures in the county. This sum included $5,000 re­
ceived from commutation taxes, which it was necessary to expend
upon repair work in the districts where it was raised; so that not
more than $8,000 was available for road building. An estimate made
by the State highway engineer for building earth roads in the most
accessible part o f the county placed the cost at $2,000 pqr mile.
With the money available for one year, the county could have im­
proved but 4 o f its 400 miles of public highways. No attempt
had been made to issue bonds to furnish funds for good roads, be­
cause it was not believed that the voters would favor the project
nor had State or Federal aid been secured.
Isolated homes.
In the more inaccessible parts of the county homes were visited
that could not be reached by wagon, access being by trail. Bridges
Federal Reserve Bank of St. Louis

P L A T E I.— T Y P I C A L R O A D S .
Federal Reserve Bank of St. Louis
Federal Reserve Bank of St. Louis



were few, and it was often necessary to ford many times in a mile.
The road leading to one home on the mountain side was crossed by a
creek five times between the foot o f the mountain and the cabin.
In one family, separated by a mountain range from the nearest
store and post office, the fathejr had not called for his mail in 12
months, the mother had not been to the settlement in 7 years, and
the father’s mother had lived 60 years before she saw a train.
Another woman living across the same range had never traveled
beyond the nearest village, and had not gone there during the 9 years
o f her married life. A third instance was that o f a mother who had
not been to the nearest settlement, 6 miles away, in 20 years.
Ten miles to the nearest store or 15 miles to the nearest physician,
“ as the crow flies,” were distances better measured by hazards than
by miles, and the mountain family was isolated by poor roads rather
than by distances. A mother who resided only 3 mile§ from town,
one-third o f the distance rugged trail, stated she had lived there
a year before she saw another woman. A t one home the father
gave most o f the requested information, and explaining his wife’s
shyness said: “ She has seen mighty nigh no strangers and never
seen a train.”
Not many farm families owned vehicles suitable for transporta­
tion. Automobiles were owned by townsmen and a few farmers,
but .could be driven only over main-traveled roads. Carriages and
buggies were not comipon, and horse and wagon or ox and cart were
the usual means o f family travel. Moreover many families were
without these.
Railroad, post, and telephone service.
The county was not, like some o f its neighbors, wholly without
railroad service, its two most accessible valleys being tapped by
branch roads. It had a larger number o f post offices than any other
county o f Georgia, owing to the lack o f rural delivery service. Two
Star routes carried mails from town to town, but delivery service
to rural homes was furnished only over one short route. The rural
resident was obliged to travel to the nearest post office for his mail—
sometimes a day’s journey.
The telephone had not come into common use, and house phones
were found installed in only 3 per cent o f the homes visited. Con­
nections between towns had been established but in most cases the
town telephone was too far away to be o f immediate assistance in
time o f need.
Agricultural development.
Agriculture is the chief industry o f the county, although only 57
per cent o f its land area is in farms, and o f the so-called farm land
Federal Reserve Bank of St. Louis




about three-fourths is woodland and but one-fourth under cultiva­
tion. 1 In the plateaus and valleys well-cultivated and productive
farms are found; but many farm sites are on the mountain slopes,
where clearing and tillage are so difficult that cultivation is con­
fined to a small fraction of each holding and the crop usually limited
to what can be cultivated by hoe and harvested by hand.
Poor roads and inaccessible markets play a large part in the
retardation o f farming. Without the prospect o f profitable market­
ing there is little incentive to increase crops by tillage on a larger
scale and the introduction o f modern machinery; consequently the
mountain farmer often raises only sufficient foodstuffs for his own
The agricultural data collected in the Federal Census o f 1920
furnish the following facts concerning the mountain county:
The average farm acreage was 106, with but one-fourth under improvement.
The value of the average farm was placed at $1,708 and the value per acre was
given as $9.27.
O f the 1,387 farmers but 5 were colored and 1 of foreign birth.
More than 70 per cent of all farms were worked by owners and but 29 per
cent by tenants, of whom the majority were share-tenants or croppers. Only
6 per cent o f the farms cultivated by owners were mortgaged.

Although farming by tenancy has increased noticeably in Geor­
gia—two-thirds of its farms are cultivated by tenants2—the tend­
ency o f the mountain farmer is to own his own land and to hold
it free from debt. The effect of land ownership by the farmer was
seen in the stability of the county’s population. The majority of
the families coming within the scope of the survey were permanent
residents, and there was little evidence o f the migration associated
with the landless farmer.
Principal products.
The corn crop is the mainstay of the county, with rye, wheat,
potatoes, beans, peas, sorghum, apples, and live stock as other prin­
cipal products. Often corn, potatoes, poultry, pigs, and the summer
garden products were the sum total of supplies raised for family
maintenance. In other cases more diversified crops pointed to inter­
esting possibilities for agricultural development.
At one hilltop farm reached by a rough and seldom-traveled trail
the home of a family of seven, including a baby o f 5 months, was
visited. This farm had a good orchard with a variety of fruit trees,
including apple, peach, cherry, and apricot. An interesting addition
to the staple crops was a large ginseng bed under a covering o f pine
boughs. The roots o f this medicinal herb are exported to China,
1 Fourteenth Census of the United States, 1920. Bulletin, Agriculture: Georgia, p. 17.
2 Fourteenth Census of the United States, 1920. Bulletin, Agriculture: Georgia, pp.
16. 56.
Federal Reserve Bank of St. Louis

Federal Reserve Bank of St. Louis
Federal Reserve Bank of St. Louis



and the farmer stated he received $1 a pound for his yield. Al­
though the roots take seven or eight years to mature, ginseng grow­
ing is profitable.
Sheep and cattle were scarcer than would be expected in a region
adapted to grazing, but usually hogs were kept, pork products and
corn being the chief articles o f family diet. Fortunately, milk was
frequently a most valuable addition to this limited fare, for about
90 per cent o f the families visited owned milch cows.
Mining a secondary industry.
Mining was the industry second in importance in the, county,
copper being the chief o f a considerable variety o f mineral deposits.
Copper prospects in one corner o f the county had been operated
sporadically for half a century and one mine had been extensively
developed. The ore was shipped to a smelting center across the
county border for treatment. The influence of*this adjacent m i n i n g
town was felt in the rural part of the county near by, both because
vegetation had been injured by sulphur fumes from the roasting and
smelting processes and because employment in mine and smelter was
open to the farmer.
County health service.
The county had not adopted important measures to safeguard the
general health o f its citizens which were authorized by State legis­
lation. The Ellis health law, an act providing for organized
county boards o f health and for full-time health commissioners, had
not been accepted by the county and it was without a full-time
health officer. The county physician had a few routine duties to
perform such as caring for the health o f prisoners, but he was a prac­
ticing physician who was not expected or paid to devote his entire
time to county health work.
The State law providing for the registration o f vital statistics was
another measure not enforced in the county at the time o f the survey.
Public records o f births and of deaths were thus nonexistent, and
figures were lacking whereby the county could take stock of the
well-being of its people by the index of infant, maternal, or general
The State o f Georgia had no law regulating the practice o f mid­
wifery, and at the time o f the survey had none requiring the use o f
prophylactics for the prevention of blindness in the newborn.
Facilities for medical care o f the mountain mother and child were
meager, the lack o f hospital service being most conspicuous. A l­
though some 400 square miles in area, the county had no hospital;
and none was located in any o f the adjacent counties o f Georgia.
O f the 505 mothers included in the study but one had been confined
Federal Reserve Bank of St. Louis



in a hospital. She had traveled 142 miles to the metropolis of an­
other State to secure hospital care when her baby was bom.
A t the time o f the survey seven physicians who were residents of
the county served its 12,000 people. Thus there were about 1,700
persons to each physician, as compared with 726 persons per physi­
cian for the United States as a whole.3 The county residents were
not wholly dependent upon this small staff for medical attention,
however, as physicians from bordering counties practiced in sections
o f the county within convenient range o f their headquarters.
Inaccessibility of medical care.
The difficulties o f travel were a serious handicap in obtaining med­
ical attention. 111 allow you couldn’t get a doctor to come over here
any time,” said the mother o f one mountain-bound family. “ Some­
times, they scarcely could get here. Horseback is the only way and
not safe in winter.”
The following story of the difficulty of securing medical attention
for a mother at childbirth under such conditions is but. one o f many
A Bad winter storm had set in when a young wife of 17, expecting her first
baby, realized that the child was about to be born. The father started on
horseback for the nearest physician, 8 miles distant, and was able to reach
his office, but the doctor could not use his car on the roads and feared to at­
tempt a horseback ride over the slippery roads and across creeks jammed with
drifting ice. The father returned home alone and found the mother in labor.
H e then went over a high mountain to secure the services of a very old woman
who practiced midwifery. She returned with him through the storm riding
behind him on his horse. Although covering but a few miles, the route led over
one of the highest and most difficult ridges of the county.
When it was found that the doctor, who had promised to come in the morn­
ing, had not arrived, a further attempt to secure him was made by the grand­
father, who went on muleback. The doctor finally undertook the trip in a
buggy but did not arrive at the mountain home until afternoon, seven hours
after the baby was born.

When as a last resort the remote mountaineer is* obliged to carry
his sick wife or child to the doctor, the lack o f good roads becomes
tragic. One mother, suffering from childbed fever, endured with
Spartan fortitude a wagon ride over 15 miles o f rough road to the
nearest physician. Another mother, 40 years o f age, had been ill
several months following the birth o f her child. Her sufferings
becoming acute, a drive to town to consult the physician was under­
taken. The physician found that she was in a serious condition
necessitating an operation. There was no place for this but her own
home, and after the physician’s examination the return trip over
many long rough hills was made with the mother lying on two chairs
in a homemade springless wagon.
* State Board Statistics for 1920, Journal of the American Medical Association, April
30, 1921, p. 1248.
Federal Reserve Bank of St. Louis

Marriage and motherhood come early to the mountain girl and
large families are the rule. Three-fifths o f the mothers included
in the study were married before they w e 20 years o f age; 61 be­
came wives before they were 16 and 9 before they were 14 years old.
Only 5 babies had been born to unmarried mothers, giving an
illegitimacy rate o f 10.1 per 1,000 live births for the mountain area.
Statistics on illegitimacy which would afford comparisons with other
rural areas o f the South or with highland and lowland regions are
not available, but the illegitimacy rate for the area studied was con­
siderably lower than those of the States o f North and South Caro­
lina— 14.8 and 16.9, respectively, per 1,000 white children born in
Large families.
Childbearing at frequent intervals is the rule among mountain
women. O f the mothers married 10 years or, longer, 44 per cent had
had eight or more pregnancies. One woman 36 years of age was the
mother o f 11 sturdy sons. She was married at 12 years o f age and
had lost none of her children during the 24 years of her married life.
A mother 38 years o f age who had borne 12 children during the 22
years’ duration of her marriage had lost but 1 child by death. But
many other mothers who had given birth to children at frequent in­
tervals were not so fortunate in saving them. One woman who had
had 15 pregnancies and 14 live births, including one set o f twins, had
only 9, children living. O f her 14 live-born children 5 died, and she
had had one miscarriage and one stillbirth.
Another mother, 37 years old, reported the birth o f 14 children
during her marriage, o f whom 1 was stillborn and 3 had died in
infancy. Even younger was the mountain mother of 34 years who
had had 12 pregnancies in the 19 years o f her married life, with four
losses, two from miscarriage and two from death in infancy.
Prenatal care.
From the replies o f mothers who were questioned with especial
reference to the care they received during their last pregnancy and
confinement, it was learned that the great majority (86 per cent)
went through the period of pregnancy without any medical super­
vision or aid whatsoever.
4 U. S. Bureau of the Census, Birth Statistics, 1919, p. 17.

Federal Reserve Bank of St. Louis




Moreover, the care received by the 71 mothers who reported some
medical attention during pregnancy must be classed as wholly inade­
quate. Five did not see a physician, but sent urine for examination,
and of the 66 who saw a physician 47 had neither a physical exami­
nation nor an examination o f urine. The majority o f the mothers
reporting visits to or from a physician had had but a single visit;
and o f the 18 reporting examinations o f urine, half had had but
one test made. Such care during pregnancy falls far short o f the
requirements for adequate prenatal care as outlined in previous rural
studies o f the Children’s Bureau. These call for a complete physical
examination; continued supervision by a physician through at least
the last five months of pregnancy; monthly examination o f the urine
at least through the last five months; and, in case o f a first preg­
nancy, measurement o f the pelvis.5
Further analysis o f the character o f the care received by the 66
mothers reporting visits to or from a physician during pregnancy
brings out the interesting fact that prenatal care was not sought as
a necessary and normal part of the hygiene o f maternity, but was
obtained only when the mother become so ill during pregnancy that
it was necessary to call a physician or when casual circumstances
resulted in medical attention.
T able I.— Mothers who saw a physician during pregnancy, classified by reason
for visit and character of prenatal care received.
Mothers who saw physician during pregnancy.

Reason for visit to or from physician during pregnancy.

Total................... ............. .................-............



examination or
test not


Physical examination or
urine test made.
Urine Physical
examina­ examina­











Only 4 of the 66 mothers who saw a physician during pregnancy
recognized the need of, and sought, prenatal supervision. Thirtytwo consulted physicians because o f complications arising during
6 See Maternity and Infant Care in a Rural County in Kansas, by Elizabeth Moore, p.
28. U. S. Children’s Bureau Publication No. 26, Rural Child Welfare Series No. 1. Wash­
ington, 1917. See also Minimum Standards for Child Welfare adopted by the Washing­
ton and Regional Conferences on Child Welfare, 1919, p. 7. U. S. Childreu’s Bureau
PubUcation No. 62. Washington, 1920,
Federal Reserve Bank of St. Louis



pregnancy which incapacitated them; 9 sought medical aid for illness
not related to pregnancy; 5 summoned aid for confinement, which
did not occur until later; 7 saw doctors who were attending other
members o f the family or “ happened to pass b y ” ; and 9 did not
report the reason for consultation. Some prenatal advice or treat­
ment was secured by mothers who came under a physician’s care
for the reasons enumerated, but 71 per cent of the mothers had
neither o f two vital essentials to the safe conduct o f pregnancy and
confinement—a physical examination, and analysis o f urine.
Good prenatal care is especially important for the woman bear­
ing her first child, in order that such complications as eclampsia
(convulsions) and those resulting from obstructions to labor may
be avoided. The former disease may be warded off by proper treat­
ment and diet, but its detection is dependent upon the examina­
tion of urine at frequent intervals. The requirement of complete
physical examination and pelvic measurements is considered
especially necessary in case o f a first child to determine whether
there may be any mechanical obstruction which will complicate
labor.® Yet o f the 89 mountain women facing motherhood for thé
first time, only 7 had had their urine examined and but 2 had had a
physical examination with pelvic measurements. The death o f a
young mother in this group, who was married at 14 and gave birth
to her first baby when she was 16, occurred a few months after her
confinement. The following information was given bv members
of her family:
The young mother was not strong during her pregnancy. She consulted a
physician but did not have an examination of urine. She had six convulsions
during the week before her confinement and six more after the birth of her
baby. She never regained her strength sufficiently to sit up for an entire day
after the baby came, although she nursed the child until three weeks before
her death, which occurred when the baby was about 4 months old. Members of
her family stated that the physician who attended her did not inform them
as to the cause of her death.

Another young mother, bearing her first child, reported a difficult
delivery accompanied by convulsions. She had received no prenatal
care, although she stated she suffered with “ kidney trouble ” during
the last three months o f the pregnancy. Swollen limbs and “ kidney
trouble” were complications o f pregnancy frequently reported.
A mother who said she “ was not able to walk ” for three months
before her last confinement and “ couldn’t stand long enough to cook
a meal o f victuals ” had received no prenatal care. Another mother
going without treatment during pregnancy said she could not stand
on her fe e t i more than five minutes at a time ” during the last three
• M.efe«, Grace L. : Maternal Mortality From All Conditions Connected With Childbirth
SttLeS and Certain other Countries, p. 12.
cation No. 19. Washington, 1917,
Federal Reserve Bank of St. Louis

ü . S. Children’s Bureau Publi­



months o f her pregnancy. O f the 12 mothers who gaVe birth to still­
born infants but 1 had had any prenatal care, and she did not see a
physician until the last month of pregnancy.
Without minimizing the difficulties of securing medical care in
this rural area, the fact remains that the mountain woman does not
realize the need for the hygiene of pregnancy, so important to her
own well-being and that of her child. From the character of the
prenatal care given those mothers who received medical aid during
pregnancy it is noted, further, that requisite measures which obtain
in good obstetrical practice were not provided in the rural area. Yet
li much must be said for the native mountain physician, writes John
C. Campbell in The Southern Highlander and His Homeland. “ A t
the best it is a hard life, riding by day and by night the rough trails
that lead along creek, branch, and over mountain to isolated homes;
and there is little reward save in the knowledge o f duty performed.
The oft-repeated criticism, ‘ He won’t come unless he knows he can
get his money,’ must be tempered by adding that his field is far too
large for him to serve, and that he may easily spend a whole day
going 10 to 15 miles and back to see one patient.” 7
Attendant at birth.
At confinement, 337 mothers—two-thirds o f the entire group—
were attended by physicians; but in 41 cases the physicians did not
arrive until after the baby was born, although in time to give assist­
ance. In 34 additional instances physicians were summoned but
were not in attendance at birth, 27 arriving too late to perform any
obstetrical service and 7 failing to answer the call. This meant a
failure or partial failure o f service in 20 per cent of the maternity
cases to which physicians were summoned.
Many stories were told o f futile attempts to secure a doctor, and
o f the anxiety and suffering of mothers in labor who were awaiting
the arrival o f medical aid. Often bad weather and bad roads frus­
trated the efforts of the county practitioner to reach a maternity
case in time, or he was out on another case when called for mater­
nity service and the mother was obliged to wait while a physician
at some more distant point was sought. Not infrequently several
villages were scoured before a doctor could be secured. The delay
was lengthened if the messenger was obliged to go on foot or muleback, as was frequently the case.
A mother was in labor from one day until the next while her hus­
band spent the night on a roundabout trip to secure a physician.
The doctor at the nearest village, 3 miles distant, was out when
the husband arrived. He then drove 8 miles to another town and
7 Campbell, John C .: The Southern Highlander and His Homeland, p. 205.
Sage Foundation, New Torfe, 1921.
Federal Reserve Bank of St. Louis




found that the doctor there was on a case 2 miles farther distant.
This ^physician was finally secured and reached the mother before
the birth o f the child.
A mother who was prematurely confined in midwinter explained
that it was cold and the snow on the ground was frozen ” so that
the physician did not arrive until late afternoon though the baby
had been born and had died in the morning. An aunt had cared for
the mother.
In one case the physician sent for started immediately upon re­
ceiving the call, but, although he was only 5 miles distant, the
mother stated, it was “ such a muddy and bad time ”— in January—
that he did not arrive until too late to be of any service. Her baby
was stillborn.
A mother aged IT told of the loss of her first baby, born when
she was 15 years old: “ My husband and I were young and didn’t
know how much there was to having children, IFe called a neigh­
bor when labor pains began, but she didn’t know what to do.”
Aiter the mother had suffered 12 hours the father went for a physi­
cian, but he had trouble in finding one, as it was Sunday, and did
not return with the doctor until another 12 hours had passed. In
the meantime the baby had been born dead.
Fear that the physician would fail to reach them in time for
delivery was the source o f much worry among the mothers inter­
viewed who tried to secure medical aid at confinement. Others ad­
mitted they had no hope of securing a physician and did not attempt
to do so. “ I never had ,a doctor when any of the children were
born,” said the mother o f seven. “ We lived too far, and he couldn’t
get there.”
Postnatal car© by physicians.
Medical attention during the lying-in period, as during preg­
nancy, is not usually obtained by the mountain mother, for with
the confinement services performed the care p f the physician cus­
tomarily ceases. In TT per cent of the cases attended by physicians
the mother was not visited after confinement. One return visit
was made in 13 per cent o f the cases. Only 17 mothers had three
or more postnatal visits from physicians; and in the majority
of such cases the physician’s attendance was required because of
complications following labor, although one mother stated her
physician always called to see how the mother was getting on.”
Her statement was in line with other evidence that postnatal super­
vision o f maternity patients was to a large extent dependent upon
the character of the practice of the individual physician. Regard­
less of the distance to be traveled, it was the custom of a few doctors
to make at least one return visit to their patients. Others did not
Federal Reserve Bank of St. Louis



revisit unless called because the condition of the mother was un­
Physicians’ fees.
The standard charge for medical attendance at childbirth was
from $10 to $15. Ten dollars, the most common fee, was the charge
in 169 of the 337 cases attended by physicians; in 83 cases the fee
was $15. While aftercare by a physician was considered a part o f
confinement service and no specific charge was made for postnatal
visits in normal cases, postnatal attention was given more frequently
by physicians charging the larger fee. Visits following confinement
were made in 31 per cent o f the cases in which $15 was charged, as
compared with only 15 per cent of the cases in which the fee was $10.
The distance to be traveled apparently did not affect the cost o f
medical attention at childbirth. There was no mileage charge such
as was made in the rural area studied in Montana, where the cost o f
confinement care depended chiefly upon the distance traveled by
the doctor.8 In fact, the actual distance between mother and doctor,
although at times traversed with extreme difficulty, was not great
for a rural a re a -in only 7 o f the cases attended by physicians was
it so much as 10 miles.
As has already been noted, Georgia had no law regulating the
practice o f midwifery. In a bulletin issued by the Georgia State
Board o f Health in 1916 occurs the following statement about mid­
wives : “ They are particularly dangerous in Georgia, as this State
does not require them to take a course of training or pass satisfactory
examination. As a consequence, any woman, regardless^ of how
dirty, ignorant, and diseased she may be, can be a midwife.”
In all, there were 43 so-called midwives in the area, who had
attended 139 confinements during the period o f the study. They were
known as “ granny women,” and were usually older women in the
various communities who had brought up large families themselves
and who had a considerable practice, even if limited to attendance
at the births o f their grandchildren and great-grandchildren.
There were 10 midwives in the area who had attended five or more
childbirth cases during the period of the study. O f the 8 inter­
viewed— 1 had died and another had moved from the area only
1 had received training. Although not a graduate nurse, she had
had two and one-half years’ hospital training. For the rest, the
midwives o f the county, while well meaning, were without even a
rudimentary knowledge of the measures of cleanliness and asepsis
» Paradise, Viola I . : Maternity Care and the Welfare of Young Children in a Home­
steading County in Montana, p. 50. U. S. Children’s Bureau Publication No. 34. Washington. 1919.
Federal Reserve Bank of St. Louis



required in obstetrical care. Moreover, they were steeped in the
superstitions and practices o f a bygone generation. The nature of
obstetrical service given by the “ granny woman” is shown by the
following facts secured from the 7 untrained midwives interviewed:
None make special preparation for the cases. They carry no bag
or equipment with them, using the family shears to cut the cord and
whatever materials the family happens to have for other purposes.
They wash their hands with soap and water but do not use anti­
septics. The bed is prepared with pieces of old quilt and clean sheets,
when available. Six make internal examinations; the other believes
in “ letting nature take its course.” Teas of black pepper, black-gum
bark, ginger, witch-hazel, and squaw vine are usually given to hasten
the birth. Four mid wives also give quinine. Five call physicians in
cases o f prolonged labor or hemorrhage, or when the afterbirth is
not expelled. One midwife who said that she advised the family to
call a physician in abnormal cases added: “ But it is not much use,
because it would take seven hours to get a doctor, if he was in his
office and would come, but they har41y ever will come ovejr here.”
The midwives interviewed were from 50 to 80 years o f age—six
were over 60; their years of practice ranged from 30 to 50. Two
could both read and write, three could read but not write, two could
do neither. Their charges were from $2 to $5 for confinement
Incompetent as was the midwife to care for mothers in childbirth,
it should be noted that in many cases mothers were solely dependent
upon such care owing to the inaccessibility of medical aid. The serv­
ice o f the midwife was sometimes performed without pay, and even
when a charge was made the services were often in the nature o f
neighborly accommodation. One midwife aged 64 said she did not
want to practice, but people “ send and insist.” Certain mothers ex­
pressed a preference for midwives ratheSr than doctors, giving as
reasons the smaller charge for services, the longer stay (the midwife
often gave nursing care and helped with housework), and a preju­
dice against having a man attend them in confinement.
Midwives did not arrive in time for delivery in 11 per cent o f the
cases they attended. The delayed arrival in one case caused the
mother to be left entirely alone at the birth o f her child and for two
hours thereafter.
Nobody but a 2-year-old child was in the house with another
mother when her baby came. She was too frightened to do anything
fqr herself and waited alone an hour before her husband returned.
A midwife arrived in time to cut and tie the cord and take the after­
Federal Reserve Bank of St. Louis



Twenty-nine mothers gave birth to their babies without the aid of
either a physician or a midwife. The father was the sole attendant
at three births, and in the other cases relatives oir friends did what
they could for the mother.
With evidence limited to the statements o f mothers who in a
large number o f instances received no medical attention and diag­
nosis for complications of pregnancy and confinement, it is impos­
sible to arrive at an accurate measure o f the prevalence and nature
o f such complications or o f the extent to which they might have been
prevented by good prenatal, obstetrical, and nursing care.
Definite inquiries were made concerning stillbirths, puerperal con­
vulsions, premature and instrumental deliveries, and 40 mothers re­
ported one or more of those complications. There were 28 premature
deliveries, 12 stillbirths, 3 instrumental deliveries, and 3 cases of
No attempt was made to secure statistics on many other compli­
cations o f childbirth, including 'puerperal septicemia, known to be
responsible for more maternal deaths than any other single cause.
However, many mothers reported illnesses incident to childbirth,
either giving a definite statement o f disease as diagnosed by a physi­
cian or relating symptoms o f serious conditions resulting from their
last confinement. Childbed fever (puerperal septicemia), milk leg,
u gathered ” breasts, lacerations, and hemorrhage were among the
complications reported.
Five mothers reported severe illnesses from childbed fever, last­
ing from three weeks to two months after confinement. Twelve had
serious trouble with swollen limbs following confinement, including,
eight cases specified as milk leg. The death o f one mother five
months after her baby’s birth was attributed by hpr husband to
milk leg. O f two other mothers reporting milk leg, one was not
able to be about until six weeks and the other until more than seven
weeks after confinement. Both had physicians in attendance. A
mother who had not received medical attention stated that her feet
and limbs had been swollen throughout the eight months intervening
between the birth o f her baby and the interview—in the winter so
badly that she could not get her shoes on. She had taken six bottles
of one kind o f patent medicine and sent $5 to a vendor o f cures
who prescribed “ vinegar in which rusty nails had been soaked.”
This mother had never had a physician in attendance at any o f her
nine pregnancies. The family was isolated, being 14 miles from the
nearest doctor. Owing to her illness, the mother stated she had
“ cooked nary a meal of victuals or carried nary a bucket o f water ”
since the birth o f her baby.
Federal Reserve Bank of St. Louis

P L A T E III.— M O U N T A I N M O T H E R S A N D T H E I R B A B IE S .
Federal Reserve Bank of St. Louis
Federal Reserve Bank of St. Louis



Ten mothers told o f painful experiences with “ gathered ” breasts;
in three cases physicians lanced them, in another case a physician
was not called but the husband lanced his wife’s breast with his
jackknife on two occasions. “ The breast has never given milk since,”
the mother added.
Three mothers reported complications due to retention o f parts o f
the placenta. One of these had been attended by a midwife at con­
finement. Twelve days later she attempted to do her housework and
had a hemorrhage, “ nearly bleeding to death.” A physician was
summoned and found that the afterbirth had not been entirely
Difficult presentations and prolonged labor were complications
more frequently reported.
The foregoing incidents are given to show the nature of com­
plications in certain cases where the symptoms or results were de­
scribed, without attempting to estimate the amount of illness or
invalidism consequent upon childbirth. In many instances, in fact,
the mothers merely stated that they had had “ a hard tim e” or
“ had not been well since.” Moreover, the illustrations given are
confined to experiences at births within the period selected for study.
Mothers who had had a number o f previous pregnancies related
additional instances o f complications at former births, not infre­
quently stating that they were still suffering from the results of such
In gauging the value o f the mothers’ evidence, it should be noted
that the mountain woman is not given to exaggeration or complaint
o f her ills. Her tendency is rather to accept as unavoidable many
o f the complications of childbirth which could be prevented by good
prenatal and confinement care.
Mothers’ work.
The diversity o f the duties devolving upon the mountain house­
wife makes her work complex and often burdensome. The care of
the children, together with the ordinary housework, is no small task
where households are large—six persons were the average number
for the study—but in addition to a wide range o f domestic duties
the mother is called upon to perform many o f the farm chores and
to assist in working the crop.
The responsibility of preparing the winter supply o f foodstuffs
rests largely upon the mother’s shoulders. Only a few o f the most
necessary staples are purchased. Curing meat; gathering, drying,
and canning fruits and vegetables; and making soap, hominy, and
sorghum, are all added to the routine o f housework. Carrying water,
milking, churning, and poultry raising are usual chores the year
around and in seasons the mother helps to plant and garner the crop.
24949°—23---- 4
Federal Reserve Bank of St. Louis



At intervals she still finds time for the interesting mountain handi­
crafts of weaving, quilting, and basketry.
Homemade bedding is displayed with much pride by the mountain
housewife. Among the collections of pieced quilts exhibited by the
mothers interviewed were many of intricate design, bearing quaint
names—Dogwood, Gentlemen’s Bow, Lazy Girl, Sugar Bowl, Bocky
Mountain, Lone Star, Desert Leaf, Broken T, and others. The
woven coverlid is less frequently seen. One mountain woman who
was still weaving coverlids remembered the time when she wove all
the family garments, but the spinning wheel and loom are gradually
falling into disuse. One mother stated that she used to weave all
the cloth used, but found it impossible to get “ bunch” cotton now.
Another explained that she couldn’t spin and weave because o f lack
o f linen and cotton thread. In a cabin where one of the beds was
spread with a lovely coverlid of madder and black the grandmother
who wove it said that she had made the tree dyes for it herself.
One o f the most arduous daily tasks in the mountain home is
carrying water from the spring. O f the families using springs,
only one in three lived less than 100 feet from the water supply,
and an uphill journey of a quarter of a mile or more was sometimes
necessary. This work usually falls to the lot of the mother, threefourths signifying that water carrying was one o f their chores.
Laundry work is done at the spring or branch to save carrying water,
the clothes being boiled in a huge iron kettle placed over an open
fire. More than four-fifths o f the mothers reported churning, garden­
ing, and poultry raising as usual occupations and seven-tenths did the
Housework was performed without the services o f hired help. In
one-fourth o f the families there were daughters 14 years o f age or
older, or women relatives, who shared in the housekeeping, and in
one-fifth of the families the father or older boys aided in some of
the household tasks; but nearly one-half o f the mothers had no help
whatever with their housework.
Field w ork—The mothers had been accustomed to farm work from
girlhood; 86 per cent reported field labor before marriage, and o f
these more than two-fifths had been in the fields before they were 8
years o f age. “ I began in the field when big enough to kill, a weed ”
or “ when big enough to hold a hoe,” and “ hoed corn at 5 years of
age,” were statements o f mothers explanatory o f their farm labor
in childhood.
In the mountain county the “ crop ” is com and “ making the crop ”
is a family affair. “ Dropping corn ” in the planting season is light
work participated in by the mother and the children, even to the
toddlers. In a few weeks there follows heavier work with the hoe,
Federal Reserve Bank of St. Louis



chopping out weeds and hilling up the earth around the plants, a
process repeated several times. In July the crop is “ laid by ” until
fall, when “ pulling fodder ” becomes another item o f the mother’s
field labor. Picking beans and peas and digging potatoes were
other field tasks frequently reported by the mothers.
“ This mountain country is awfully rough on women,” stated one
father. “ They can’t hardly make a hand in the field, the fields are
so steep.”
So many demands upon the mother tie her closely to the home,
and if she leaves the small children must go with her. One mother
interviewed had just walked to the store, carrying her baby o f 13
months for 4 miles in her arms.
W ork in relation to childbearing.—Mothers who reported having
had previous miscarriages stated that in some cases they were brought
on by heavy work. Overwork and heavy lifting were causes given,
and among the specific tasks followed by miscarriage were men­
tioned: “ Carrying heavy milk pails,” “ hanging up meat that was
heavy,” “ lifting tubs of water,” “ tossing, com on wagon,” “ car­
rying water,” and “ big washing.”
It is the custom to continue housework up to the eve o f confine­
ment, with the exception of washing— and in fact more than half the
mothers reported no cessation of laundry work before the birth of
the baby. Almost three-fourths o f the mothers also continued their
chores to the time o f confinement, and some mothers whose babies
were born during the busy seasons of farm work reported no remit­
tance of field labor prior to confinement.
O f a number o f instances in which mothers performed heavy tasks
when labor was imminent, the following are examples: One mother
prepared the family meals, did a big washing, and churned on the
day her baby was born. Another carried 2 gallons o f water 100
yards uphill an hour before labor began. A third washed and
scrubbed on the day o f her confinement.
Care and rest following childbirth.
Trained nursing service during the lying-in period and at least
10 days’ rest in bed after a normal delivery, with sufficient house­
hold service for from four to six weeks to allow the mother to recu­
perate, are minimum requirementstof care after childbirth.9
Trained nursing care was wholly lacking in the mountain county.
A midwife or practical nurse was obtained by 27 mothers. About
one-fourth were nursed b^ the father or by other adult members of
the household, 7 reported care by children only, and the remain9

Minimum Standards for Child Welfare, p. 7.
Washington, 1920.
Federal Reserve Bank of St. Louis

U. S. Children’s Bureau Publication No.



der were nursed by untrained women secured from the neighborhood.
More than two-fifths o f these women took care of the mother as an
accommodation, without pay.
As with the nursing service, the mother’s chief dependence for
extra help with the housework is upon her family or friends. Onefifth o f the mothers had no additional assistance. Two-fifths hired
some extra household help on account o f pregnancy* or confinement,
the majority o f those engaged being women who came for a short
time after the confinement to act as both nurse and housekeeper.
Largely due to the lack o f help, the mothers were up and at their
work too soon. As early as the third day after confinement, a few
mothers were upon their feet, and more than two-fifths had less
than the 10 days’ rest in bed considered essential. Sixty-seven
women resumed their household duties less than two weeks after
confinement; 36 were doing chores and 16 washed within that time.
Before four weeks had passed, three-fifths o f the mothers were
doing all their housework except washing, two-fifths had resumed
their chores, and one-fourth were doing the washing.
Thus before the mother has time to regain her strength, and with
a newborn child to care for, she begins the work demanded by the
many calls upon her.
Federal Reserve Bank of St. Louis

Given safe-conduct through birth, the newborn child can have
no greater asset than a mother equipped with a knowledge of the
principles o f infant and child hygiene. The mother’s ability to
bring her baby safely through the critical span o f his first year
and to insure him a healthy childhood rests largely upon her under­
standing of the requirements o f feeding, cleanliness, sleep, clothing,
and the hygiene and sanitation of the home.
Aside from the advice of physician or nurse, the chief source of
instruction is the increasing stock o f informative literature relating
to such subjects, including many publications issued free of charge
by Federal, State, and private agencies. This avenue o f knowledge
was entirely closed to one-fifth of the mountain mothers because
they were unable either to read or to write. The education o f many
mothers not only in this group but in the group reported as literate
had been almost entirely neglected owing to the lack of schools or
o f the opportunity to attend school. Less illiteracy was found among
the mothers from 14 to 30 years of age than among those who were
older, indicating that educational advantages in the mountain area
are improving. O f the mothers 30 years o f age or over, one in every
three could not read or write, as compared with one in seven for
the group under 30. Such statements as “ never had a chance in my
time for schooling,” or “ there weren’t schools within reach in here
when I was little,” or “ we were brought up when there weren’t
ary school,” explained how many o f the older mothers had been
denied an opportunity for education. A mother aged 30 who was
illiterate had gone to school for 12 months but had no book except
a “ speller.” Another illiterate mother had gone to school four
months but did not have a “ reader.” Isolation was responsible for
much of the illiteracy among the older women, one stating that she
“ only went three or four days to a few schools ” because the schoolhouse was across a high mountain. Work in the house or field kept
others from school attendance. “ Would go a day and miss a week,”
stated one o f the mothers deprived o f an education because she was
needed at home.
Even many of the mothers who were reported as literate— able
to read and write— had learned but the barest rudiments during
Federal Reserve Bank of St. Louis



a few months of schooling. Their limited education was attributed
to long distances from school, home labor in house or field, loss of
parents, and ill health.
One who had been kept at home to work on the farm went to school
“ off and on over wet days ” ; another had been able to attend “ from
time corn was laid by until time for picking peas ” ; another had
not gone more than a month a year—“ from time corn was laid by to
fodder-pulling time.” Mothers who were the oldest of large families
said they had frequently been kept from school to do house­
work. Some had learned to read and write at home. One mother
had lived in the mountains where there was no school until she was
15 years old, then had moved to a place “ where school held ” but
“ was ashamed to go in primary classes.” She stated she had learned
her “ a b c’s ” at home and could read and write a little.
Most o f the mothers were mountain girls, but a few had attended
graded schools in towns of the area or in some other vicinity. In all
only 7 o f the 505 mothers had completed the eighth grade.
One o f the noticeable results o f illiteracy was the inability of some
mothers to give their exact age. “ In o u t family we never had our
ages put down,” stated one mother who was not sure how old she
was. Another who hesitated in giving the dates of birth and death
o f her baby said : “ I can’t read to keep up with the days on the
calendar.” Some o f the babies with illiterate mothers had fathers
who could read and write, and while in 32 per cent of the families one
parent was illiterate, in less than 10 per cent o f all families were
both parents illiterate.
In some cases the father’s skill in writing was limited to. the
ability to pen his signature. I f he could also “ read print,” he was
reported as literate.
Instruction in infant care.
Only 86 mothers reported printed matter as a source o f their infor­
mation on child care. The fact that three-fourths o f the mothers
who were reported as literate, as well as the illiterate mothers, had
had no guidance from the printed word can be attributed to the fact
that little reading matter is found in the mountain homes, owing to
the general lack of education. The handicap was more serious
because neither the physician’s advice nor the valuable and practical
demonstrations o f the public-health nurse were available—only 7
mothers had received instructions on infant care from a physician.
While the types o f reading matter on the subject o f child care
included standard works, Government bulletins, and newspaper and
magazine articles, in two-fifths o f the cases only books o f question­
able value or worthless advertising matter had been read.
Federal Reserve Bank of St. Louis



Infant feeding.
Thrown so largely upon her own resources in caring for her babies,
the mother relies upon the advice o f relatives and neighbors, which
results in the continuance o f many unwise and dangerous customs.
In no particular was this more marked than in the matter o f infant
feeding; and one of the greatest needs o f the mountain mother is
for modern, scientific instruction in methods of nurturing her young
While maternal nursing is universal in this section, there is a
tendency to let the baby have solid foods at an early age. The
mothers have not learned the risk young babies face when given
a miscellaneous diet before they are 6 months old, and the custom o f
supplementing the natural infant food with articles o f family diet
counteracts the full benefits to be derived from nursing. The prev­
alence o f this custom in the highlands generally has been a matter
o f frequent comment. “ Babies from the first month are fed on
anything they will swallow—grease, sugar, or strong coffee,” writes
Emma B. Miles in The Spirit o f the Mountains. “ I f you object, the
mother points with pride to her sturdy older children, never reflect­
ing that in such a severe weeding-out only the well-nigh invulnerable
survive.” 10
Feeding customs were haphazard in other respects, and rules for
“ feeding by the clock ” were not generally observed. Because the
baby’s crying is invariably interpreted by the mother as a hunger
signal, she is apt to feed her child both indiscriminately and irregu­
larly. One mother whose baby was fretful nursed her almost con­
stantly to keep her quiet. Many began giving solid food because the
baby cried. “ It would cry and I thought it was starved,” said one
mother whose baby was fed pickled beans, eggs, meat, and other
food from the table when he was 3 months o f age. One indulgent
mother began mixed feeding when her baby was 3 months old be­
cause “ it would watch me eat and it seemed like it wanted some­
thing, too.”
Artificial feeding—the term used when no breast milk is given—•
was resorted to only in exceptional cases. Nine o f the 497 live-bom
babies died before they were fed, but o f the remaining babies only
2 never received breast milk, and the mothers who began to nurse
their babies from birth with few exceptions continued the practice
throughout the babies’ first 9 months or whatever portion o f that
period was completed when the feeding record was secured. Only
14 babies had been weaned before they were 9 months o f age. Death
or illness o f the mother and lack o f sufficient milk were the causes

Emma B. M iles: The Spirit o f the Mountains, p. 23.
Federal Reserve Bank of St. Louis

8ew York, 1905.



for weaning, with one exception in which necessity to work in the
fields was the reason.
' In fact many of the mothers nursed their babies beyond the pe­
riod considered desirable. O f the infants who had reached their first
birthday only 10 per cent had been weaned. A t 15 months, threefourths of the children who had reached that age were still being
nursed, and even at 18 months more than one-half were kept at the
In view o f the varying ages of the babies for whom feeding records
were secured, a consideration of the type o f feeding at certain
months o f age for babies who had lived to complete the given months
serves best to show the feeding practices :
T able I I .— Type of feeding received by infants completing specified month of
Per cent of infants—

Per cent of infants—
Month of life.



cially fed.

Month of life.



cially fed.


O f the 480 babies who survived their first month, 91.5 per cent
were exclusively breast fed during the month. Thereafter, month
by month, a marked decline in the proportion exclusively breast fed
and an increase in the proportion given mixed feeding are noted.
As early as the fifth month there were more babies receiving mixed
diet than receiving mother’s milk exclusively. In some cases cow’s
milk, alone or modified, was the only supplement to the mother’s
milk, but most o f the babies on a mixed diet were more injudiciously
fed. Buttermilk, sweetened coffee, sirup, butter, eggs, corn bread,
meat, and potatoes and other vegetables were among the foods given
in the first month. Some mothers who began giving their babies
a mixed diet from the first month stated they gave “ tastes o f every­
thing.” A mother who gave supplemental feeding from the third
day said it was her custom to begin feeding “ as soon as they get to
crying for something—whatever we eat ourselves we feed the
On the list of foods given babies who began receiving mixed diet
after the first month but before the sixth were the following:
“ Canned stuff,” “ hog meat, mashed up with beans or potatoes,”
“ sausage,” “ coffee with potatoes,” “ pickled beans,” and “ chocolate
How serious had been the effect of such indiscriminate feeding it
would be difficult to determine. Mothers interviewed with regard
Federal Reserve Bank of St. Louis



to illnesses of the baby mentioned digestive disorders more fre­
quently than any other cause o f illness, and the deaths o f four babies
during the period studied were attributed by the mothers to gastro­
intestinal diseases. The feeding histories o f these four babies show
that none was exclusively breast fed throughout his lifetime. One,
a twin baby, was not nursed after his third week because the mother
did not have sufficient milk for two. Artificial feeding—cow’s
milk— was given from the third week until death at 7 weeks.
A second death was that of the fourteenth child o f one mother.
Owing to illness she did not have breast milk for the baby. She
gave him cow’s milk for two weeks, and then meat and vegetables
and “ anything he would eat.” The mother chewed the food before
feeding it to the baby. Death occurred shortly before the baby
would have been 6 months of age. The mother stated that he had
“ spells o f colic and much bowel trouble ” prior to death.
The feeding o f a third infant, who succumbed to “ stomach
trouble ” at 3£ months o f age, was changed from breast exclusively to
mixtid at 3 weeks and to artificial at 8 weeks. Mixed feeding was be­
gun because o f the scant supply of mother’s milk, and the baby was
weaned entirely at 2 months when the mother contracted typhoid
fever. Cow’s milk, crackers, rice, and potatoes were given the baby,
but “ nothing seemed to agree with it.” Death occurred 6 weeks
after weaning.
The fourth baby in the group was weaned at 6 weeks because the
mother’s breasts and the baby’s mouth were sore. Cow’s milk was
fed the baby. The father went 18 miles over the mountains to consult
a doctor, who did not come to see the baby or send medicine, but gave
the father a prepared baby food. The baby continued to grow worse,
developed “ bowel trouble,” and died at 5 months o f age.
General health.
Physical examinations o f 108 children under 6 years of age were
made at children’s health conferences held at the conclusion of the
survey in 10 community centers o f the county. Town mothers, as
well as country mothers, brought their children for examination by
the Government physician, so that the group for which data on
physical development were secured was not confined to children in
families covered by the intensive survey.
An interesting comparison is afforded between the heights and
weights of these mountain children examined and the average heights
and weights o f more than 165,000 white children under 6 years of
age tabulated by the Children’s Bureau from data secured in a
nation-wide weighing and measuring campaign.11 The average
11 Woodbury, Robert Morse, Ph. D. : Statures and Weights of Children Under Six
Years o f Age. U. S. Children’s Bureau Publication No. 87. Washington 1921.
Federal Reserve Bank of St. Louis



statures o f both boys and girls in the mountain county closely ap­
proach the averages shown for the boys and girls o f the same ages
in the national group.
The children in the mountain county were found to weigh more
on the average than the children o f the same statures included ,in
the nation-wide study. The difference in average weight for height
was slightly over a pound, when both sexes were grouped together;
the difference between the two groups of girls was relatively slight,
while the comparisons for boys indicated that those in the mountain
group were on the average 1£ pounds heavier. In both studies the
boys were found to be heavier than girls o f the same ages or of the
same heights.
It is a matter of general observation that the highland children
come from a people of large physique. “ Our highlanders are con­
spicuously a tall race,” writes Horace Kephart in Our Southern
Highlanders.12 “ Out of 76 men that I have listed just as they oc­
curred to me, but 4 are below average American height and only 2
are fat. About two-thirds o f them are brawny or sinewy fellows of
great endurance.”
Although their development as to size was average or above, more
than three-fifths o f the children examined had one or more physical
defects. Defects o f the skin and teeth were those most frequently
found. In this respect the findings are in line with the verdict o f
John C. Campbell, for many years an educator in the highland
South, who writes:
W hile specific data are wanting on many aspects of the health problem in the
mountains, an opportunity to observe some of the effects of existing conditions
upon the rural child and thus indirectly upon the general health, is offered in
the various boarding schools maintained throughout this region by church and
independent agencies. Naturally a large number of the pupils who come from
little isolated homes show many evidences of the want of ordinary care of the
person. The teeth, too, usually need attention, the only attention indeed com­
monly given them in very rural districts being to pull them out when they ache.”

Defective teeth receive little attention, because the dentist is even
more inaccessible than the doctor in the mountain area. In addition
to the menace to health from neglected teeth much discomfort and
disfigurement result. Among the mountain families visited the lack
o f dental attention was particularly noticeable in young mothers
whose teeth were badly broken or missing. One mother aged 25 had
had her upper teeth extracted after the birth of her second child, when
she suffered greatly with neuralgia. Two years later, at the time of
the interview, she had no artificial teeth to replace those missing.
The appearance of a mother 27 years of age was marred by the loss of

H orace: Our Southern Highlanders, p. 213. New York, 1921.
lS Campbell, John. C .: The Southern Highlander and His Homeland, p. 215.
Federal Reserve Bank of St. Louis

New York,

P L A T E IV.— M O U N T A I N C H I L D R E N .
Federal Reserve Bank of St. Louis
Federal Reserve Bank of St. Louis



nearly all her teeth. Her little girl of 6 had a badly swollen face at
the time o f the interview, due, the mother explained, to a “ holler”
tooth which the mother was treating with medicine. Among young
children discolored and broken teeth bore evidence that the parents
were ignorant o f the need for preserving the deciduous teeth as long
as possible.
The snuff habit.
The custom o f dipping snuff was not uncommon among mothers
and children in the mountain area. No specific inquiry was made
concerning the habit but when mothers were using snuff at the time
o f the interview the fact was noted. Nearly two-fifths of all the
mothers were thus reported as using snuff. The habit was more
prevalent among older women; of the mothers 25 years o f age or
older 43 per cent were found using snuff, while only 30 per cent o f the
mothers under 25 gave evidence of the habit at the time o f the inter­
'The snuff is “ dipped ” from the can by means o f a small twig or
stick frayed at one end, and then spread over the surface o f the teeth
and rubbed from time to time with the stick. Snuff was used for
toothache by one mother who, although only 28 years old, “ hoped ”
soon to have all her teeth extracted. One mother explained that if
the teeth were not rubbed they were more liable to decay, instancing
the case o f her sister who used snuff without rubbing, and had lost
her front teeth.
^ One 8-year-old girl who had used snuff for two years said, “ At
first it tasted as sharp as pepper, but now when I am hungry it
makes the hungry feeling go away just by rubbing it on my gums.”
Another little girl of 8 bit off a piece from a plug o f tobacco and
chewed it during the agent’s visit to the mother.
Illnesses of children.
In accounts given by the mothers concerning the illnesses o f the
babies under 2, diseases o f the digestive tract were most frequently
mentioned. Next in number came communicable diseases, with
whooping cough and diphtheria most prevalent. By the term “ ris­
in gs” the mothers referred to swellings o f various kinds, which
included a number o f cases o f “ swollen ” and “ running ” ears. One
baby’s ear “ burst and fan four times, once a month during the first
four months,” the mother said. “ Colds ” were frequently referred
to, and it was noted that barefoot babies and those allowed to crawl
about cabin floors, swept by drafts from the fireplace and open doors,
were exposed to risk in cold weather.
A considerable morbidity among the older children from many
causes was indicated by the mothers’ reports, but no profitable dis­
cussion is possible because o f the mothers’ lack o f credible informa-
Federal Reserve Bank of St. Louis



tion as to the nature o f the diseases. Communicable diseases had
been the most common cause o f illness among the older group.
In a few cases, helpless children were found in the mountain home.
An epileptic boy of 10, helpless since he was 2 years of age, was con­
stantly held in the arms o f some member of his family. A little girl 5
years old, in,another family, had lost the sight of one eye and could
not walk. Her disease was diagnosed by the doctor as tuberculosis.
This child was barefoot and crawling about the floor, although one of
her limbs was seriously affected. Another child, injured at birth,
was helpless for 6 years, and at 8 could walk a little but was “ stiff­
legged.” Pathetic cases, where conditions were remediable, are in­
stanced in the story of a boy of 14 whose mother said, “ He can
hardly see, but there is no place nearer than Atlanta to take him
to get glasses that would be right ”— a journey too long to be thought
of. This boy was growing to manhood without an education because
his poor eyesight kept him from school.
The difficulties in securing medical attention in the rural parts
o f the mountain county which were related in connection with the
needs of mothers were repeated in the experiences o f mothers with
sick children. No better illustration of the serious import o f the
situation can be given than the fact that in the cases o f more than
two-thirds of all the babies in the group studied who died in their
first year no physician was in attendance at the death.
In a few instances mothers told of treatment administered to
their babies in cases of extreme need by men who were not regular
practitioners. A mother who had lost her fourth child when he
was 17 months old “ had a doctor when the baby died, but he was
a herb doctor, not a regular doctor.” Treatment o f a baby o f 8
months by a “ stock” doctor (veterinarian) was described by one
mother in relating the circumstances o f the death of one o f her
children. The baby had been very healthy, but began to “ fret and
vomit.” The nearest physician had gone to a distant city, so
another physician, 16 miles distant, was sent for the first day of the
baby’s illness. The father was absent from home and the neighbors,
thinking it would be a long time before the physician could arrive,
advised the mother to send for the “ stock doctor.” He came and
gave the baby a “ dose.” The child died the next day, before the
regular practitioner arrived.
Maternal histories.
In addition to the more detailed data relating to infants born
within the selected two-year period, a maternity history was se­
cured from each mother giving the total number o f her pregnancies,
the resulting number o f live births, stillbirths, and miscarriages, the
Federal Reserve Bank of St. Louis



number o f children who survived or died, and for the latter the
age at death.
About half o f all the mothers reported losses. The loss o f poten­
tial child life from stillbirths and miscarriages throughout the
childbearing history o f these mothers was high. O f the total of
2,275 issues reported from all pregnancies 144 (6.3 per cent) were
miscarriages and 66 (3.1 per cent of the total births) were still­
births. The miscarriage rate is the highest found in any of the
rural studies o f the Children’s Bureau. The percentage o f still­
births, also, is high in comparison with rates similarly computed for
other rural areas surveyed—the highest except for a lowland county
o f North Carolina, where the percentage of stillborn white babies
was 3.9. These rates, as exemplifying conditions in the mountain
county, point again to the need for better prenatal and obstetrical
care that the mothers may bring safely through birth the life
Infant mortality.
Among the live-bom babies the extent o f loss is expressed by the
infant mortality rate—the number dying under 1 year o f age per
1,000 born alive. The mothers reported a total o f 2,065 live births.
Excluding the 291 babies who were under 1 year o f age when the
maternity records were secured, there remain 1,774 babies for whom
an infant mortality rate can be computed. Among these children 135
failed to survive their first year, giving an infant mortality rate
o f 76.1.
This rate for the Georgia families is considerably lower than the
highest rate (89) recorded for any o f the rural studies o f the
Children’s Bureau—the rate found for families in a northern county
o f Wisconsin. It is also exceeded by the rate o f 80 for families in
a mountain county o f North Carolina, where conditions were some­
what similar to those prevailing in the Georgia area. The mortality
among babies in Georgia, however, is much higher than that found in
the rural areas o f Kansas, Mississippi, Montana, and the lowland
rural county o f North Carolina.14
Losses in early infancy.
Turning to the group o f 497 babies bom alive in the area within
the two-year period, there were 28 deaths o f infants under 1 year o f age.
Here the full extent of the loss o f infant life for the entire group
can not be accurately measured by the infant mortality rate, because
more than half o f the babies were under 1 year o f age when their
records were secured and some then alive may have failed to survive
their first year. Moreover, omissions o f some births and deaths are
u Rates based on losses throughout family histories.
lina the comparison is for white babies only.
Federal Reserve Bank of St. Louis

In Mississippi and North Caro*



probable where no official records are available and the house-tohouse canvass covers so rugged a country.
For the second year covered by the study, March, 1917, to Feb­
ruary, 1918, which immediately preceded tfcie canvass, fewer omis­
sions were likely because births and infant deaths o f recent occur­
rence are more readily traced. O f the 291 live-born babies in this
group, all had had a chance to complete their first month and all but
5 a chance to complete their second month o f life by the time the
information was secured. Therefore, an accurate measure o f mor­
tality in early infancy is permitted for the group. The infant deaths
in the first month were 12 and in the first two months 16, the corre­
sponding mortality rates per 1,000 live-born babies being 41.2 under
1 month o f age and 55 under 2 months o f age.
The first few weeks following birth are known to constitute the
most perilous period o f infancy, and these rates afford a comparison
between the hazards of early babyhood in the mountain county and
In this connection it is interesting to note first that comparisons
o f infant mortality in city and country, shown by rates for the
United States birth-registration area year by year since 1915, indi­
cate somewhat lower'infant mortality rates for rural than for urban
communities, when the entire first year of life is considered.
T able I I I .— Infant mortality, United States birth-registration area, 1915-1919,1

Infant mortality rate.

Infant mortality rate.


Birthregistra­ Urban.
tion area.



» 94

Birthregistra­ Urban.
tion area.

1918...... i...............





1TJ.- S. Bureau of the Census, Birth Statistics, 1920, p. 26.

No such difference in favor of the country baby exists, however,
in the first month o f life, during which deaths are known to be
in large part due to natal and prenatal conditions—conditions which
can be directly influenced by the mother’s care during pregnancy
and at confinement. In 1915, when the general infant mortality
rate for city babies was 103 as compared with 94 for babies in rural
parts o f the birth-registration area, conversely the death rates under
1 month o f age showed a higher mortality among rural babies, the
urban and rural rates under 1 month being 43.4 and 46, respec­
tively.16 Statistics are not available whereby such comparisons
for the birth-registration area can be followed year by year there15Unpublished

figures o f the U. S. Bureau of the Census, 1915.
Federal Reserve Bank of St. Louis



after, but again for 1919 thp appreciable advantage of the country
baby denoted by the general infant mortality rate is lost when the
rates under 1 month are compared—41.7 and 41.2, respectively, for
urban and rural parts o f the area.16
The rate o f loss in the mountain county for the first month of
life (41.2) was identical with that of the rural part o f the birthregistration area in 1919, but in the first two months of life mor­
tality in the mountain county, expressed by the rate of 55, was con­
siderably in excess o f that shown by the rate o f 48.6 for the rural
part o f the registration area in the same year.17
A comparison o f the death rate under 1 month for the strictly
rural mountain area (41.2) with that for New York City (33.9—for white babies in 1919) shows a noticeable advantage for the large f
urban center where prenatal supervision has been stressed in a sys­
tematic campaign for the reduction of infant mortality.
That deaths in early infancy are largely preventable through
proper prenatal supervision is even more strikingly illustrated in
results obtained by the prenatal nursing service o f the Bureau o f
Child Hygiene o f New York City in 1918. The mortality rate under
1 month o f age was 37 for the city as a whole, whereas among the
group o f babies whose mothers received the prenatal care afforded
by the child-hygiene bureau it was reduced to 14.7.18
Causes of death.
A further analysis o f mortality in the mountain county by cause
o f death to show the extent to which the deaths occurring in the
first and second months o f life might be definitely ascribed to
natal or prenatal conditions can not be made, because three-fourths
o f the babies in the group considered who died had no physician in
attendance at death and the mothers’ statements o f causes contribut­
ing to death were indefinite. However, all deaths in the first month
among the group considered, with one exception, are indicated as
attributable to natal or prenatal conditions, either because the
babies were prematurely bom, because they died at 1 day o f age
or under, or because the mothers stated they were ill from birth until
The relationship, i f any, between deaths in the second month
and conditions at or before birth is obscured by the mothers’ state­
ments o f cause. Such terms as “ bold hives ” and “ pneumonia fever ”
were loosely used by the mountain women to indicate almost any
infant ailment o f serious character.
16 S.

Bureau o f the Census, Birth Statistics, 1919, Table II

Monthly Bulletin o f the Department of Health, City of New York, October, 1921, p.
Federal Reserve Bank of St. Louis
Federal Reserve Bank of St. Louis

Patent medicines find a ready sale in the mountain county in
spite o f the widespread propaganda o f recent years directed against
the nostrum evil. As long ago as 1909 the dangers o f the traffic
in patent or proprietary remedies in general was brought to official
notice by the Report o f the President’s Home Commission on Social
Betterment, and the menace to babies was particularly emphasized in
a section o f the report on Infanticide by Systematic Drugging of
Children. Referring to infant mortality, the report states : “ In this
connection it is desirable to point out the serious consequences of
the systematic drugging o f children by ‘ soothing sirups,’ ‘ teething
sirups,’ ‘ children’s comfort,’ and ‘ the infant’s friend,’ etc., such
compounds all containing opium or morphine, not to mention the
numerous cough and croup remedies in the market.” 19
Federal legislation enacted since the report o f the home commis­
sion, such as the Sherley amendment to the food and drugs act and
the Harrison Antinarcotic Act, has made it increasingly difficult for
manufacturers to market preparations o f this sort. However, in a
list o f patent medicines used in the mountain families, compiled from
the mothers’ statements, there occur a considerable variety o f “ teeth­
ing sirups,” “ cordial drops,” “ cough remedies,” and other nostrums—
some known to contain opiates. Nearly 50 per cent of the babies
included in the study, all under 2 years of age, were given patent or
proprietary medicines of some kind.
In all cases these preparations were referred to as “ patent medi­
cines ” and are so called in this report without reference to the real
distinction between patent and proprietary compounds, explained
as follows in the Report o f the President’s Home Commission :
B y the term patent medicine, as properly employed, it must be understood
that the composition is known and can be seen at the Patent Office. The pro­
prietary medicine is a secret preparation protected by a trade-mark, and hence
preferred by the owner, but both are vaguely termed by the public patent

Federal food and drugs act.
A number o f the patent medicines on the list o f those given babies
in the mountain county have been analyzed by the Bureau o f Chem19Reports of the President’s Home Commission, Senate Document No. 644, p. 266.
Washington, 1909.
"Ibid., p . 263.
Federal Reserve Bank of St. Louis



istry, United States Department o f Agriculture, and declared mis­
branded under the Federal food and drugs act. Under this measure
Federal control is exercised over products that enter into interstate
commerce. The act requires that a declaration as to the presence
and amount of 11 drugs, including alcohol, morphine, opium,
and chloroform, be made on the trade package of a medicinal prepa­
ration; and the manufacturer may be declared guilty of misbrand­
ing if he makes false or fraudulent statements on the label of a
medicine or in the printed matter accompanying it regarding either
its composition or its curative value.
Patent medicines given babies.
The following examples o f certain patent medicines declared mis­
branded under the act will suffice to show the nature o f some o f the
preparations given babies:21
One o f the remedies most commonly used for the mountain babies
contained approximately 36.1 per cent o f absolute alcohol and 3|
mis. of tincture of opium in 1,000 mis. o f the article, at the time
when it was analyzed by the United States Bureau of Chemistry,
Misbranding o f the article was alleged because the label did not
bear a correct statement o f the amount o f alcohol and opium con­
tained and—for the further reason that certain statements appearing on the wrapper
falsely and fraudulently represented it to be effective as a remedy for all fluxes,
spitting o f blood, agues, measles, colds, coughs, and to put off the most violent
fever; as a treatment, remedy, and cure for stone and gravel in the kidneys,
bladder, and urethra, shortness of breath, straightness of the breast; and to
rekindle the most natural heat in the bodies by which they restore the lan­
guishing to perfect health; whereas, in truth and in fact, it was not.22

Another remedy used which was claimed to be effective for diar­
rhea, dysentery, etc., and as a remedy for ailments of teething chil­
dren, contained both alcohol and morphine and was so labeled. It
was declared misbranded because the label did not contain a correct
statement o f its alcoholic content and because the representations on
label and carton—
were false and fraudulent in that the same were applied to the article know­
ingly, and in reckless and wanton disregard of their truth or falsity, so as to
represent falsely and fraudulently to the purchasers thereof, and create in
the minds of purchasers thereof the impression and belief, that it was, in
whole or in part, composed of, or contained, ingredients of medicinal agents
effective, among other things, as a remedy for all cases of cholera, diarrhea,
dysentery, and flux, for restoring the bowels to their normal condition, and as
a remedy for ailments of teething children, when, in truth and in fact, it was
ai Specific samples o f patent medicines used in the homes of the area were not ana­
lyzed, but the descriptions quoted from notices of judgment show the contents o f samples
o f the same medicines analyzed by the U. S. Bureau of Chemistry when cases against
their manufacturers for violation of the food and drugs act were pending.
32Notice of Judgment No. 6222, Federal food and drugs act.
Federal Reserve Bank of St. Louis



not, in whole or in part composed, of, and did not contain, such ingredients or
medicinal agents.**

Analysis by the Bureau o f Chemistry o f one o f the cough and
croup remedies used showed it to be an alcohol-water solution, con­
taining ammonia, glycerin, pine tar, sassafras, red pepper, reducing
sugars, a laxative drug, and alkaloids. The manufacturer was fined
$100 for falsely and fraudulently claiming the preparation Vas a
cure for croup, whooping cough, etc.24
The largest percentage o f alcohol contained in any o f the patent
medicines given children, which had been declared misbranded, was
a substance containing 60 per cent o f alcohol, by volume, and in which
chloroform, ether, and red pepper were present, according to analy­
sis by Federal chemists. It was claimed to be a panacea for internal
and external use and was sold as a cure for diphtheria, bloody flux,
inflammatory rheumatism, la grippe, and all aches and pains. These
claims were declared false and fraudulent and applied knowingly,
and the company was fined $50 and costs.25
The mother o f a baby who died at 31 days o f age said the only
remedy she had given her baby during his illness was a patent cough
medicine. The composition o f this preparation, according to the
label of the bottle showed by the mother, included 11 per cent of
alcohol, and 2f minims o f chloroform to each fluid ounce. Another
mother showed a bottle o f “ baby bowel medicine,” half o f the con­
tents of which she had already given her baby, 4 months old at the
time o f the interview. This remedy, as labeled, admittedly con­
tained 7 per cent of alcohol. Neither o f these preparations is men­
tioned in the records o f judgments secured under the Federal food
and drugs act.
Patent medicines used by pregnant women.
More than 20 per cent of the mothers interviewed had taken patent
medicine during their last pregnancy. The list of such preparations
included 22 varieties, some advertised specifically “ to make child­
birth easy” and others being either remedies for “ female weakness”
or “ kidney trouble,” or general “ cure-alls.” The following example
o f the alluring promises made by the vendors o f one nostrum on
the list leads to an understanding o f the use of patent medicines by
pregnant women in a community where prenatal care by a physician
is not readily available to mothers and where public-health aid is
nonexistent. The misbranded article at the time o f investigation
by the Bureau o f Chemistry bore on its label the following:
For the relief of the suffering incident to childbirth. This is one of the
greatest comforts to those expecting to be confined. It is a remedy upon

83Notice o f

“ Notice o f Judgment
** Notice o f Judgment

No. 4838,Federal food and drugs act.
No. 5271,Federal food and drugs act.
No. 4414,Federal food and drugs act.
Federal Reserve Bank of St. Louis



which confidence can be placed, one that will assist in a safe and quick delivery,
and one that shortens the duraton of labor. Try it. It is a blessing to suffer­
ing women * * * has been used by many of our best physicians and all
pronounce it a success, giving relief from the dreadful pains and sufferings of
this time. Every woman expecting to become a mother should use it.

The notice o f judgment states that—
[The] form of labeling was false, misleading, and deceptive and tended to
deceive and mislead the purchaser into the belief that the product contained
in the bottles was a drug valuable for the alleviation of the suffering incident
to child bearing, whereas, in fact, the bottles contained a liquid consisting
essentially of an oil, together with a small amount of soap, and had not the
properties claimed for it upon the label.1*

The continued sale o f this article, after its exposure, points to the
conclusion that such preparations continue to be marketable, owing
to the fact that little publicity is given to their exposé and that
the fines imposed upon manufacturers for misbranding are small.
In some instances, however, the manufacturer may be obliged to
change the formula for his nostrum or to modify his claims for its
curative value.
An alcoholic nostrum shipped from Tennessee to Georgia, and
used by some o f the mothers during their pregnancy, contained 16£
per cent o f alcohol, according to the analysis o f the United States
Bureau o f Chemistry. A notice o f judgment under the food and
drugs act states that misbranding o f the article was alleged in the
information for the reason that certain statements on the carton,
bottle, and accompanying circulars were—
false and fraudulent in that the same were applied to the article knowingly,
and in reckless and wanton disregard of their truth or falsity, so as to repre­
sent falsely and fraudulently to the purchasers thereof, and create in the
minds of purchasers thereof the impression and belief, that it was, in whole
or in part, composed of, or contained, ingredients or medicinal agents effective,
among other things, as a remedy for all female weaknesses and diseases, in
the relief of all hemorrhage from the womb, as a cure for leucorrhea, and for
correcting all irregularities peculiar to women, when, in truth and in fact,
it was not, in whole or in part, composed of, and did not contain, such ingre­
dients or medicinal agents.”

The defendant company entered a plea o f guilty to the informa­
tion and the court imposed a fine o f $75 and costs. Although the
judgment o f misbranding in this case, secured in 1915, clearly set
forth the inefficacy o f the product, it was used during the following
two years by mothers o f the mountain county and was widely adver­
tised in 1918 in the community surveyed by means o f an almanac.
In this almanac the nostrum is advertised by the testimonial method,
its praises being set forth in letters secured by the manufacturer


of Judgment No. 366, Federal food and drugs act.
o f Judgment No. 4389, Federal food and drugs act.
Federal Reserve Bank of St. Louis


from persons claiming benefit.
almanac advises, and—


“ Read these letters carefully,” the

you will understand why we place an unqualified guarantee on this great medi­
cine for women’s ills. You will understand that we guarantee it because it
benefits women. This is our reason why we continue from year to year to
guarantee it, but an equally satisfactory reason is that the sales grow larger
each year by many thousands of bottles, while the failures do not increase in

A so-called “ quick relief ” on the list of patent medicines used by
mothers when analyzed by the Federal chemists was found to con­
tain 32 per cent o f alcohol, together with Peru balsam, camphor, and
red pepper.
The most common remedy used was an alcoholic nostrum widely
advertised as a “ woman’s tonic.” Analyses made public by the
American Medical Association have shown that aside from alcohol
the nostrum contains no potent ingredient in quantities capable o f
producing any physiologic effects.28
One mother showed a box o f tablets obtained from a mail-order
concern labeled “ for diseases o f women and the alleviation o f the
annoyance o f pregnancy and the pains o f childbearing,” which she
had taken during pregnancy and liked “ because they made me sleep.”
The foregoing instances refer only to preparations used by preg­
nant women and little children; in other instances the use of nos­
trums for various ailments by all members o f the family was addi­
tional evidence of the frequency with which the patent medicine
bottle found a place on the shelf o f the mountain cabin.
Teas used for medicinal purposes.
More time-honored remedies in the highland region are the home­
made teas o f herbs and roots gathered in the mountains. A list o f
those named by mothers as used for medicinal purposes included
teas made from wild cherry, pinkroot, boneset, white horsemint,
spignet, pennyroyal, black snakeroot, ginseng, lady’s-slipper, red
alder, butterfly root, and many other mountain herbs. For babies
with “ hives,” teas o f catnip, dog fennel, ground ivy, and partridge
berry.( also known as hive vine and squaw vine) were mentioned as
remedies. Salves as well as teas were made from herbs, one mother’s
recipe for a cold and croup salve calling for fever weed, garlic, peach
tree, and elder “ fried up.” Thirty-two mothers had given their
babies paragonc and 10 told o f the use o f whisky as a home remedy
for their infants. A combination o f 4 drops o f asafetida and 4
drops o f whisky in a teaspoonful o f milk was one remedy giventincture o f lobelia and whisky was used for a baby with intestinal
1921CramP’ ArthUr J*: Nostrums and Quackery.
Federal Reserve Bank of St. Louis

American Medical Association, Chicago,



trouble; and whisky in breast milk had been fed by a third mother to
a baby about 2 months o f age.
Other home treatment for babies.
“ Scarifying” is the mothers’ designation o f a curious practice,
similar to the old-fashioned blood-letting, which is sometimes re­
sorted to as a “ baby cure” in the mountain county. The impres­
sion prevails that the disease known as “ bold hives” is caused by
“ too .much blood,” hence the treatment described by one mother as
follow s:
You wash the baby between his shoulders with warm water and soap.


make three little slits in the shoulder flesh with a razor. W arm a horn and put
the large end over the slits in the skin. Put beeswax over the small end and
make a very small hole in the wax with a pin and suck up through the hole
and close it by pinching the wax together. The horn will stay on until it has
drawn about a teaspoonful of blood. Then it will fall off. It is this blood that
causes the hives. You can see it’s all dark and hard.

The mother o f another baby, scarified for hives when he was 3
months old, said that she “ washed baby’s back, slit it a little, sucked
the blood and washed it off.” A 1-month-old baby, according to the
statement o f his mother, was “ scarified ” every other morning until
nine such operations has been performed. Each time from three to
five drops of blood were taken. Afterwards the spot was greased
and the mother reported that it “ healed in no time.”
Home treatment o f babies in some cases appeared to be based on
superstition. A mother whose 4-months-old baby had had colic
tried to cure her by “ smoking over bran.” The mother stated she
put bran on the hearth, set it on fire, and held the baby over the
smoke. When the treatment failed to cure the baby the mother
resorted to the use o f patent medicine.
“ Dirt tea ” was the home remedy given a 7-weeks-old infant suf­
fering from intestinal trouble. The mother prepared the tea by
“ scraping soot from the back o f the chimney, where it was burned,
and pouring boiling water on it.” Other home remedies given this
baby were “ drops of all kinds,” paregoric, and patent medicine.
Federal Reserve Bank of St. Louis

Two prevailing types of houses in the mountain county are the
pioneer log cabin, often the identical structure fashioned by a
forefather, and its successor, the box house, erected since the advent
o f the sawmill. The latter is usually made o f upright undressed
boards battened as a protection from the elements. The clapboarded
frame cottage o f better finish is not so frequent a type, although
found on farms near town.
The mountain home site is often one o f extreme beauty. I f it is
located on a “ branch,” to insure a convenient water supply, the ap­
proach in spring is past thickets o f blooming dogwood, rhododen­
dron, and laurel which line the stream, and over fields o f mountain
wild flowers. The homes situated upon the heights have more bar­
ren surroundings, but their sites are vantage points commanding
imposing vistas o f the highland region with its panorama o f moun­
tain peaks. The appeal o f the picturesque cabin in its attractive set­
ting can not, however, divert attention from its deficiencies. As a
rule the homes are overcrowded, dark, and lacking in convenient ar­
rangement and equipment for the housewife.
The number o f occupants in the households visited ranged from 2
to 12, the average being 6 persons per dwelling. This included the
immediate family and relatives or others living with them. Nearly
three-fourths o f the families were occupying small houses o f one,
two, or three rooms. Sixty-eight families—14 per cent o f all vis­
ited— were living in houses with but one room. The number of
occupants in these houses ranged from 2 to 10 persons, and in half o f
the households limited to a single room there were 5 or ^paore persons.
In the two-room cabins which housed one-fourth of the families, the
living room was also a bedroom, with a lean-to for a kitchen, or there
was a living-room kitchen with a smaller room adjoining for sleep­
ing purposes. Only 5 per cent o f the homes had more than five
Number. Percent.
Total____ __________ 505
Houses with—
1 room____ .__________
2 rooms_______________ 121
3 rooms______________ 174
4 rooms________
5 rooms______________ 42
6 or more rooms____ 26




Number. Per cent.

Houses with—
1 bedroom- _
2 bedrooms
3 bedrooms _
4 bedrooms _ .______
5 bedrooms
_ ^
6 or more bedrooms.



Federal Reserve Bank of St. Louis



For parents with but one or two young children the small house
sufficed; but, because it was not customary to enlarge the home to
accommodate the enlarged family, cramped living quarters were
common. In a county where timber is plentiful the cause of con­
gestion could not be attributed entirely to economic necessity.
The following examples show conditions in three families o f vary­
ing sizes, each o f which was limited to the one-room house.
A family of four— father, mother, little girl of 4 years, and a baby 9 months
old— lived in a one-room frame house situated on a mountain side barren of
Although the house^ was windowless, its interior presented a cozy
appearance at twilight. A bright fire blazing in the fireplace lighted up the
room. The furnishings included two beds covered with white counterpanes,
dresser, table, and tiny cookstove. A fresh “ ironing ” hung from a line at
one side, and in another corner strings of dried corn dangled from the ceiling.
Everything was clean. The mother had made for the baby a simple creepingpen out of a box.
(Such a pen is a great advantage, as most cabin floors
are rough and “ splintery ” even if not dirty, and the unscreened fireplaces are
a menace to creeping children.)
Father, mother, and four children, the oldest 12 and the youngest a baby
o f 6 months, lived in another one-room cabin. There were no windows, but
two doors were kept open to light the interior when the weather permitted.
The room, about 20 feet square, was crowded with three beds and a long table
with benches upon each side. There were no other furnishings, the fireplace
being used for cooking.
A small log cabin with broad stone chimney stood at the foot of a steep hill
and could be reached only by trail, being about l i miles from the road. It
was on a farm yielding no produce for marketing and scarcely enough for the
family livelihood. On the hills beyond the cabin clearing, a few tall pines
spared by the sawmill towered high above a thick new forest growth. Home­
made farm implements, sled, primitive harrow, and yoke cluttered the dooryard. Occupying the one room of this home were the father, mother, and six
children ranging in age from 1 to 13 years. The interior o f the cabin was
disorderly, a natural consequence when eight people with all their possessions
and supplies are crowded into one room.

Crowded sleeping quarters.
From the standpoint of health the crowding o f sleeping quarters
was a serious problem. In two-fifths of the homes visited there
was but one sleeping room, and it was not unusual to see three or
four beds in the same room. From a tabulation o f the number of
persons in the household according to the number of sleeping rooms
was derived the following statement o f persons per sleeping room,
which gives an index of congestion in all homes included in the study.
Average number of persons
per sleeping room;


1, less than 2_-------------2, less than 3---------------3, less than 4__________
4, less than 5— ---------5 and over---------------------
Federal Reserve Bank of St. Louis

_ 505
_ 120
_ 132

Per cent.

P L A T E V.— T Y P E S O F M O U N T A I N
Federal Reserve Bank of St. Louis

Federal Reserve Bank of St. Louis



No family had a spare room, very few a bedroom for each mem­
ber; and in more than one-fourth o f the houses, there were five or
more persons per bedroom.
The menace to health from such congested sleeping quarters was
increased when there was illness in the family, and the sick member
slept in the same room, often in the same bed, with those who were
well. In one family o f 10 occupying one bedroom the 8 children,
including a baby of 4 months, had whooping cough at the same
time. During illness it is customary for neighbors to gather at the
bedside o f the sick person, thus adding to the household congestion.
One mother sought for an interview was found with her baby in
a neighboring home where a woman lay seriously ill. With her
child, she and four other women were crowded about the bedside of
the afflicted neighbor in a stifling, windowless room. In another
home visited a typhoid fever patient—a boy of 8—lay in bed in the
living room surrounded by father, mother, and three men of the
neighborhood. In addition to the noise o f conversation a telephone
in the room rang frequently, for every ring on a rural telephone is
heard by each subscriber. The mother consented to be interviewed
on the porch, but neither she nor her husband and neighbors seemed
to realize that so much confusion was bad for the sick child.
The lack o f privacy was another serious consequence o f the
crowded sleeping quarters for growing children o f both sexes. A
family o f 10, consisting of father and mother, 3 girls aged 17, 13,
and 8, 3 boys aged 16, 12, and 10, and 2 younger children, were
limited to one bedroom.
In a log cabin with one bedroom and a lean-to kitchen, which
housed a family o f six, the bedridden grandfather was ill in the same
room in which the mother was confined, their beds being in close
Houses without windows.
The lack o f windows in a number o f homes proved a defect more
serious in lighting than in ventilation, for many houses were of such
loose construction that fresh air came in through the crevices. In
some o f the dark rooms daylight could be seen through the un­
chinked logs or through gaps between the chimney and siding.
Only 15 per cent o f the homes were ceiled or plastered, the remainder
being boarded, roughly papered, or without any interior finish.
Where window frames were provided there was often no glazed sash,
the openings being covered with wooden shutters.
Attractive features of mountain homes.
In spite o f the frequent defects o f insufficient space, light, and
equipment, many o f the mountain families had succeeded in achiev-
Federal Reserve Bank of St. Louis



ing genuinely attractive homes. Vines added to the exterior attrac­
tiveness o f the houses. The crimson rambler, trumpet vine, myrtle,
ivy, and fragrant wild honeysuckle trailed over the weatherbeaten
logs with softening and beautifying effect. One mountain home
visited was covered thick with ivy and had a bed of brilliant tiger
lilies in front. The yards were usually bare of grass, but even the
poorest cabins seldom lacked a flower garden in which might be
found roses, iris, columbine, syringas, the snowball bush, and many
other varieties of shrubs and flowers.
An interior with deep fireplace, wooden mantel blackened like
ebony by smoke, high soft beds covered with gay quilts or coverlets,
splint-bottomed chairs, strings o f red com, “ shucky” bean pods,
peppers, and herbs hanging from the beams, and the spinning
wheel, fallen into disuse but not deposed from its honored nook by
the fire, gave an impression o f beauty and comfort achieved by the
mountain home-maker.
Household equipment.
House furnishings were simple, sometimes consisting merely o f
beds, tables, and plain chairs. Families with more complete domes­
tic equipment had in addition chests, bureaus, center tables, clocks,
and window shades. Pantries were rare, and unless a loft was
available for storage space the reserve food was hung from rafters
or sacked and stowed away in convenient corners.
Nearly every house visited was sadly in want of modem conven­
iences for the farm home. In a list of a dozen such items consid­
ered necessities in the rural home o f to-day only one—the sewing
machine—was found to be a usual article o f equipment.
The sink, bathtub, indoor toilet, and other conveniences depend­
ent upon running water, as well as power machinery to lighten such
household tasks as churning and washing, have yet to reach the
mountain home. In fact, only 25 housewives had water conven­
iently at hand in the house or on the porch. The spring house, the
only means o f refrigeration, was often some distance from the
Few families had stoves for heating and even the kitchen stove
was by no means universal, many housewives cooking in the open
fireplaces. Dinner for six was being prepared at the hearth o f one
family visited. Corn bread was baking in a shallow iron kettle,
coals being placed on top o f the lid and underneath the kettle. The
mother stated that if the kettle was heated well first, the bread
baked better than in a stove. She broiled ham in a pan, around
which the flames licked, and served a simple but appetizing meal o f
corn bread, ham, and honey. In many homes provided with cookstoves the housewife preferred the fireplace for her “ kettle o f beans”
or other food which required time in cooking.
Federal Reserve Bank of St. Louis



The dearth o f labor-saving devices for the mothers in the area
studied is emphasized by a comparison between the equipment in
their homes and that in rural homes in other sections of the eountry.
Data secured by home-demonstration agents of the United States
Department of Agriculture in 1919 for farm homes in the eastern,
central, and western sections o f the United States permit a com­
T able

IV .— Household conveniences in mountain and other rural sections.
Per cent of rural homes having—

The mountain county...........
Rural areas in other sectionss. ..


Screened Water in
Sewing Washing windows kitchen
machine. machine.
or on








1 Less than 1 per cent.
! £ 0SchenFon™ Woman’s Problfims' States Rela«on Service, U. S. Department of Agriculture.

Lack of toilets.
The general lack o f toilets o f any kind in the area indicated wide­
spread ignorance of the essential principles o f home sanitation.
The rural residents of the mountain county, like those in many
districts o f the rural South, have not learned the dangers o f soil
pollution. The sanitary survey conducted by the Eockefeller Sani­
tary Commission for the Eradication o f Hookworm Disease, 1911—
1914, revealed the amazing fact that of a quarter o f a million farm
homes in 11 Southern States more than half were without privies.29
Even a larger proportion of homes in the mountain county lacked
this essential o f sanitation, 85 per cent being without toilets o f any
kind ; and of the privies provided at the remainder of the hoipes half
were o f the insanitary, open-back type.
The menace o f flies was increased owing to the lack o f toilets, the
open-back privy, and the disposal o f waste water in the yards, yet
only 31 homes had adequate screening. Many mothers, however,
took the precaution o f protecting their sleeping babies from the
numerous flies by the use of mosquito netting or cheesecloth thrown
over the bed.
Water supply.
Four out o f every five families secured their water supply from
springs. I he clear, cold spring water is much prized and no thought
29Fifth Annual Report. The Rockefeller Sanitary Commission for the Eradication of
Hookworm Disease, 1914, pp. 12-13.
Federal Reserve Bank of St. Louis



is given to the contamination which may result from seepage of
polluted water through the soil above, from the direct flow of sur­
face water into the spring, or from dipping soiled utensils into it.
Both springs and wells were found in some cases below the house,
barnyard, or hogpen, where they were liable to pollution by seep­
age. As a rule, the springs were not protected from the wash of
rairf water carrying surface filth, a heightened menace where soil
pollution is caused by the lack o f toilets.
Typhoid fever.
Without mortality or morbidity statistics for the county, it is im­
possible to show for any period the fatalities from or the prevalence
o f diseases attributed to impure water and lack of sanitation. The re­
plies o f mothers interviewed concerning previous illnesses in their
families indicated a considerable prevalence of typhoid fever in the
mountain county, but its extent could not be estimated because many
cases reported had not been diagnosed by a physician. The follow­
ing instances are those o f cases diagnosed by a physician:
A few weeks after a mother gave birth to a baby who lived but a short time,
three of her daughters, aged 17, 8, and 6, became ill with typhoid. The mother
stated the attending physician did not inquire about the water supply, but that
they had had trouble with their well. “ It was in a, low place and got to filling
up with water. It hadn’t been cleaned for two years. W e cleaned it out three
times that summer, but when the fall rains came and there was so much water
in the ground, it was a regular flood.” The poor water supply caused the
family to move to a home where there was a good spring.
Another mother, questioned about the source of the water supply at the time
when one of her children had typhoid, stated that they used water from both
a spring and a well. “ The spring was muddy and full of leaves,” she said,
“ and the well was full of old tin cans and the water was milky.”
W ater for another family was secured from a spring used by seven families.
The privy at this home jutted over a small stream at a point where it was
crossed by a footlog leading to the barn. The mother stated that her 9-year-old
son contracted typhoid two months before her baby was born. She did not know
whether he was infected at home or elsewhere, but said that shortly before
he was taken sick he accompanied her on a visit to a neighboring home where
there were six cases of the disease.
Federal Reserve Bank of St. Louis

Rapid strides in public-health achievement in Georgia since the
study covered by this report was made are denoted by a survey o f
the work accomplished by the State up to the close o f 1921. Note­
worthy results, especially in the protection o f maternity and infancy,
were obtained through legislation and an exceptionally»-vigorous and
effective administration of the State board of health.
. |2|
Birth and death registration.
At the time o f the Children’s Bureau survey, records o f vital
statistics for the mountain county were nonexistent, a situation
which obtained generally for the rural areas of Georgia. Although
an act embodying the provisions of the model law for the registra­
tion o f births and deaths passed the Georgia Legislature in 1914,
the finances for its enforcement were not provided until five years
thereafter. Therefore, the bureau of vital statistics in the State de­
partment o f health was not organized until January 1, 1919. With
the creation o f the bureau, plans for the enforcement o f registration
in Georgia were at once pushed forward. Justices of the peace
and city clerks who act as local registrars were instructed in the
duties o f registration. Every physician and undertaker in the State
was called upon for aid and was furnished with the necessary regis­
tration blanks.
Early returns o f certificates indicated that about one-fourth were
incorrect or incomplete, owing to unfamiliarity with the law. In a
systematic endeavor to make registration accurate as well as complete,
the State bureau demanded corrections by physicians, undertakers,
and registrars, with a resulting improvement in the character o f the
work. Prosecutions o f those who failed to obey the law followed.
Therefore, although the first year o f enforcement was o f necessity
devoted mainly to organization, by the close o f the year every county
in Georgia was responding to the law.
Georgia was then one o f the three States east o f the Mississippi
River that had not yet gained admission to the United States deathregistration area. Improvement in registration continued through­
out 1920 and 1921; in the latter year the registration o f deaths was
accepted by the United State Bureau o f the Census as at least 90'
per cent complete, and Georgia was admitted to the death-registra­
tion area January 1,1922.
Federal Reserve Bank of St. Louis



Birth registration, in Georgia as elsewhere, is more difficult of
enforcement than the registration of deaths. Many States with
satisfactory legislation o f long standing have failed to bring birth
registration up to the standard required for admission to the birthregistration area. With a background o f only three years’ work for
enforcement, birth registration in Georgia is not yet sufficiently
complete to warrant admission to the area. The bureau of vital
statistics is working earnestly to perfect birth registration, and if
the same progress which, has resulted in effective death registration
is maintained, admission to the birth-registration area will not be
long delayed.
Mortality statistics.
In addition to its active campaign for registration, the bureau of
vital statistics has made some analyses of the data secured from the
death certificates. Thus, for the first time in'the history o f Georgia,
statistics are available whereby the State can gauge the extent and
causes o f its mortality. The classification of deaths in 1920 by cause
shows a significant comparison between mortality from certain
causes affecting infants only and mortality from important causes
affecting persons o f all ages. Influenza, tuberculosis, and pneumonia
were the diseases which caused the largest numbers o f deaths in
Georgia in 1920, named in the order o f importance. Yet among in­
fants under 2 years the deaths from diarrhea and enteritis combined
with the deaths from causes peculiar to early infancy exceeded in
number the deaths from any of the leading causes. While in such a
classification the deaths from the specified diseases affecting infants
rank first in Georgia, in the death-registration area in 1920 they
ranked fourth, being exceeded in number by deaths from or­
ganic diseases o f the heart, pneumonia, or tuberculosis. The infant
mortality rate in Georgia for the same year, based upon registered
births and infant deaths, showed that of every 1,000 live-born in­
fants, both white and colored, 90 failed to survive their first year.
This rate is higher than that o f 86 for the entire birth-registration
area in 1920. It must be remembered, however, that the rate may
give an overstatement of infant mortality due to less complete regis­
tration o f births than o f deaths.
Another benefit obtained through the enforcement o f the registra­
tion law is that relating to the practice of midwifery. While mid­
wives are not under State supervision in Georgia, under the regis­
tration law State control is exercised to the extent that all mid­
wives must register with the local registrar and must report births
within 10 days. In addition, the law for the prevention of blindness
enacted by the Georgia Legislature in 1918 requires the midwife as
Federal Reserve Bank of St. Louis



well as the physician to use silver nitrate solution in the eyes o f a
newborn child.
Division of child hygiene.
Further recognition o f the needs of mothers and children in
Georgia came with the organization o f a division o f child hygiene in
the State department of health in 1920.
“ We believe that child hygiene is fundamentally the most im­
portant branch o f public-health work,” writes the secretary o f the
State board o f health in his annual report for that year.
haS aS its obiect> ( ! ) Proper prenatal care o f the
cnild, (2) proper post-partum care o f the mother and child, (3)
registration o f the child’s birth, (4) proper care o f the infant and
preschool age child, (5) a physical examination and follow-up work
tor every school child in Georgia.
“ The child-hygiene work will eventually be carried on by the
county commissioners o f health, who are full-time health officers, but
who number only 20 at the present time. The problem is at present,
therefore, a double-fold one, (1) presenting the work to the county
commissioners o f health, (2) the more difficult one of getting the
work across in those counties that have no health organization. It
is an interesting commentary, by the way, that commissioners of
health are, as a whole, conversant with problems of water supply
sewage disposal, epidemic control, venereal diseases, etc., but know5
very little about child hygiene or the organization o f this work;
and, what is a sadder reflection, the usual medical school has little
m its curriculum to supply the need.”
Briefly summarized, the activities o f the child-hygiene division in
1921 included physical examinations o f 59,213 school children, with
correction o f defects in some 5,000 cases; the operation of 36 chil­
dren s health centers in 20 counties and 39 throat, nose, and dental
clinics in 27 counties; a series o f lectures on child hygiene at 84
community centers throughout the State; and the distribution o f
nearly 150,000 pieces o f literature relating to maternal and child
The educational literature issued by the child-hygiene division
includes publications in three series—the prenatal, the preschool, and
the school child. Among the publications in the prenatal series are
eight lessons to midwives. Each lesson is written in simple lan­
guage and printed on a separate sheet, the essential instructions for
procedure before, at', and after the baby’s birth being given step by
step. In the preschool series come the “ Georgia Baby Book ” on
infant care and diet slips “ to be tacked above the kitchen table”
for ready reference as to the proper feeding o f children at various
Federal Reserve Bank of St. Louis



ages up to the sixth year. Also included in this series are outlines
on breast feeding, milk, and the summer care o f infants to prevent
gastrointestinal diseases, prepared by the Georgia Pediatrics Asso­
ciation for the division o f child hygiene. In the series for the
school child are pamphlets on physical examinations, weight and
nutrition, the school clinic, and score and record cards.
Much has already been accomplished by the young division, and
broadened activities are planned as the work develops. These plans
call for a greater emphasis on prenatal work, especially needed in
the rural districts of Georgia.
County health organization.
County organization for health work is included in the discus­
sion o f measures relating to maternity and infancy because o f its
important bearing upon improvement in rural conditions and be­
cause the State health board proposes to have'the county unit, when
perfected, carry on the rural work for child hygiene. The Ellis
health law, an act o f 1914 providing for organized county boards
o f health and for full-time county commissioners of health under
the supervision of the State board, becomes effective in each county
o f Georgia only after the recommendation o f two successive grand
juries. Its operation then hinges upon provision in the county
budget for maintenance. O f Georgia’s 160 counties, 33 have had
the necessary recommendations by the grand jury, but in 1921 only
18 counties were operating under the law with full-time health com­
missioners. Twelve counties had adopted the law but were not
yet prepared to carry it out, and three others had discontinued its
operation. As would be expected, the organized counties are the
progressive, accessible, and well-populated ones, each having at least
one city o f considerable size. Such counties are the ones best
equipped to finance the law. The isolated and less prosperous coun­
ties, most in need o f its provisions, are slower to respond.
Without discussion o f the more general activities o f the State
board of health, its progress from 1918 to 1921 is best indicated
by a comparison of activities in the two years. Prior to and includ­
ing 1918, the work of the board was confined chiefly to the labora­
tory. Ift 1921 its organization included the following divisions:
Laboratories, sanitary engineering and water analysis, vital sta­
tistics, communicable diseases, venereal disease control, child hy­
giene, and county health work.
Public-health nursing.
Public-health nursing service in Georgia is not fostered by State
legislation, and is not organized under the State department o f
health, although in 1921 seven counties operating under the Ellis
Federal Reserve Bank of St. Louis



Health Law had public-health nurses attached to the county organiza­
tion under State supervision. The public-health nursing service in
Georgia is essentially urban. Atlanta, Savannah, Augusta, Macon,
and Columbus, all cities of more than 25,000 population, have nursing
forces. Nine additional counties had one public-health nurse each in
1921; and in six o f these, also— Clarke, Dougherty, Floyd, Glynn,
Troup, and Ware—the work may be classed as chiefly urban, as there
are cities in each between 10,000 and 25,000 in population. Three
counties rural in make-up, Cobb, Seminole, and Colquitt, maintained
public-health nurses in 1921. In the case o f Seminole, a new
county established on January 1 , 1921, provision was made for a
public-health nurse under the act establishing the county.
Federal Reserve Bank of St. Louis
Federal Reserve Bank of St. Louis

The findings o f the survey o f the mountain county in Georgia
are in general accordance with those o f surveys made by the Chil­
dren’s Bureau in other rural sections of the United States, in that
they clearly indicate the need for more adequate provision for the
protection o f maternity and infancy. In the mountain county the
difficulties and needs o f mother and child were intensified by the
rugged topography and consequent isolation, retardation o f develop­
ment, and lack o f good roads.
The families were made up exclusively o f native-born white per­
sons o f native parentage, many of whom were living under pioneer
conditions. A resume o f the findings shows the following outstand-V
ing features in regard to maternity and infant care :
JBacilities for medical care in the county were meager. There was
no hospital within its borders, and the number of physicians, in pro­
portion to population, was much smaller than the average for the
United States. Difficulties o f travel and lack of telephone service
added to the inaccessibility o f medical aid. A striking illustration
o f the situation was seen in the fact that no physician was reported
in attendance at the deaths of more than two-thirds o f the babies
in the group studied who died in their first year. In some measure
lack o f medical care was caused by failure to recognize its need, as
in the cases o f the large number of mothers who sought no prenatal
A high birth rate was indicated by the frequent childbearing o f
the mothers interviewed. During their last pregnancy, more than
four-fifths o f these mothers had had no prenatal care and the care
received by the remainder was wholly inadequate. Among the 505
mothers were 89 bearing their first babies, and of these only 7 had
medical advice prior to confinement. Physicians attended twothirds o f the mothers at childbirth, but in more than 10 per cent of
these cases did not arrive Until after delivery. More than one-fourth
o f the mothers were attended by midwives, and 29 gave birth to their
babies without the aid o f either physician or midwife.
The practice of midwifery was not regulated by the State, and
the mountain midwives interviewed were ignorant of the measures
o f cleanliness and asepsis required in obstetrical care. Their prac­
tice was dangerous for the further reason that they fostered super53
Federal Reserve Bank of St. Louis



stitious and primitive customs. Medical attention during the lyingin period was not customary, and more than 'three-fourths o f the
mothers attended by physicians at confinement received no postnatal
calls. None o f the mothers had trained nursing care, and they de­
pended largely upon members o f the household and neighbors for
both nursing care and help with the housework after the baby’s birth.
The work o f the mountain women was arduous, and they had no
regular domestic help. Large families, the care of children, and a
wide range o f duties made heavy housework; and in addition the
majority o f mothers performed various farm chores. H alf o f them
also reported working in the field either during pregnancy or
shortly after the birth o f the baby. As the result o f onerous duties
and lack o f help, many mothers were at work before they had fully
regained their strength after childbirth. In some instances heavy
tasks performed were reported as the causes o f miscarriage.
Lack o f schools, and housework or field labor in girlhood, were
responsible for the high percentage o f illiteracy found among
mothers. One-fifth could neither read nor write and many others,
reported as literate, had learned but the barest rudiments during a
few months at school. For this reason, printed advice on infant
.care could not be profited by and only 17 per cent o f the mothers
reported printed matter as a source of instruction on infant care.
This was a serious handicap where neither the physician’s advice nor
the valuable and practical demonstrations o f the public-health nurse
were available.
The absence and need of scientific instruction íd infant feeding
were marked. While breast feeding was universal, the custom of
giving solid food and family diet too soon counteracted the full bene­
fits o f nursing, and again the mothers nursed their babies beyond
the period considered desirable.
Physical examinations given to a group o f town and country
children at the child-health conferences held in the county follow­
ing the survey showed that although the children were average or
above in size, more than three-fifths had physical defects. Defects
of skin and teeth were the most prevalent. The diseases most com­
monly reported by mothers as affecting the babies bom during the
selected period were those of the digestive tract. Among older
children communicable diseases had been the most frequent cause of
About half of all the mothers reported losses during their mater­
nal histories, from miscarriages, stillbirths, or infant deaths. The
miscarriage rate was the highest found in any o f the rural studies
of the Children’s Bureau, and the stillbirth rate was exceeded by
that for only one other rural area studied.
Federal Reserve Bank of St. Louis



Losses in early infancy among the babies bom during the second
year o f the study point to a high mortality due to natal and
prenatal conditions. Although general comparisons o f infant mor­
tality in city and country indicate somewhat lower rates for the
rural babies when the entire first year is considered, this is not the
case if the comparison is limited to the first month o f life, when
deaths are known to be in a large part due to causes related to
pregnancy and confinement. In the mountain county the death
rate under one month was considerably higher than that for white
babies in New York City in 1919, and almost three times as great
as the rate, in 1918, shown for a group o f New York babies whose
mothers received instruction and care through the prenatal nursing
service o f the New York City Bureau o f Child Hygiene.
Nearly one-half of the babies under 2 years of age had been given
patent medicines, and more than one-fifth o f the mothers had used
such preparations during their last pregnancy. A number o f the
remedies used had been judged misbranded under the Federal food
and drugs act and analyses o f their contents indicated they were
either worthless or harmful.
The typical mountain home, while picturesque, was unsatisfactory
in size and convenience. The crowding of sleeping quarters was the
most serious defect o f housing. In more than one-fourth o f the
homes there were five or more persons per bedroom. The lack of
convenient equipment for the housewife was evident in nearly every
home visited; and in a list o f a dozen modem conveniences which
are generally considered necessities in the rural home of to-day,
only one—the sewing machine—was frequently found. Telephones,
screens, sinks, and a convenient water supply were conspicuously
wanting. The essential principles o f home sanitation were not un­
derstood, and 85 per cent of the families were without toilets o f any
kind. The source o f water supply, usually a spring, was not as a
rule properly protected from pollution. Records o f illness in the
families studied indicated a considerable prevalence o f typhoid
fever, and in some instances contamination of the water supply was
reported as coincident with cases of the disease.
Birth and death registration was wholly lacking in the county
at the time o f the survey, due to nonenforcement o f the State law
for the registration o f vital statistics. This condition has subse­
quently been corrected by state-wide enforcement of registration.
A survey o f State health activities up to the close o f 1921 shows
marked progress in Georgia in the promotion of measures o f protec­
tion for maternity and infancy. The State has been admitted to
the United States death-registration area and registration o f births
is rapidly being perfected to meet the requirements for admission to
Federal Reserve Bank of St. Louis


m a t e r n it y


in f a n t


the birth-registration area. A division o f child hygiene organized
in the State board o f health has developed a well-rounded program
for the conservation of the health of mother and child. State legis­
lation for the prevention o f blindness was enacted in 1918. County
organization for health work, provided for by legislation in 1914,
has developed slowly. Its adoption in each county depends first
upon recommendation by two successive grand juries and then upon
financial provision in the county budget. This legislation was not
operative in the county surveyed nor had it been adopted at the close
of 1921. The county was therefore without the services o f a full­
time health commissioner and did not benefit from the public-health
work dependent upon county organization.
Public-health nursing service in Georgia is not fostered by State
legislation or organization under the State department of health.
In the larger cities nursing forces were maintained in 1921, but only
a few of the essentially rural counties had provisions for a publichealth nurse. These did not include the mountain county studied.
Federal Reserve Bank of St. Louis

While the province of this report is confined to the problems con­
fronting mothers in bearing and rearing their children, the funda­
mental needs o f the people as a whole in the more remote sections
o f the Southern highlands can not be disassociated from this more
specific phase o f family life.
The mountain people are to he regarded as a great social group
o f families somewhat isolated and retarded in the development and
change which have visited their fellow countrymen in other parts
o f the land. Whatever are the needs o f rural communities any­
where are the needs of the mountain region in still greater degree,”
writes the president of a mountain college in a symposium on the
needs o f white people in the uplands of the South collected by the
Conference o f Southern Mountain Workers. Further expressions
of opinion to the conference by churchmen, educators, physicians,
and social workers present a composite plea for education in its
broadest sense, good roads, development of agricultural resources by
scientific cultivation of crops suited to soil and climate, and preven­
tive and efficient public-health work.
The highlanders are known to be a steady, self-reliant, honest
people with great native ability, who will ultimately conquer the
conditions which have deprived them o f many o f the opportunities
o f life. While, with their economic and social development, improved
living conditions will come, the pressing problems affecting mater­
nity and infancy disclosed for the area surveyed point to urgent
need for immediate relief.
A rural public-health nursing service seems to offer the most
immediate and tangible solution o f the problem. The rapid de­
velopment and success of public-health nursing in many parts of
the country has carried it beyond the experimental stage. Nursing
services maintained in many communities by private agencies have
been taken over as a public obligation, and a number of States are
organizing public-health nursing service in their State departments
o f health.30 A further stimulus to the movement is now offered by
the financial aid available through the Federal act for the pro­
motion of the welfare and hygiene o f maternity and infancy. Finan­
cial provision for public-health nursing service in the county sur30An Analysis o f Present State Recognition of Public Health Nursing.
the Public Health Nurse, Oct., 1920.

Reprinted from

Federal Reserve Bank of St. Louis



veyed, as well as in other mountain counties, will be forthcoming
when the public is convinced of the need and value o f such service.
The findings o f the survey seem convincing proof of the need of the
public-health nurse to teach the mountain mothers the hygiene of
pregnancy and thè principles o f infant and child hygiene. Because
o f isolation and illiteracy it is especially important that instruction
be brought to the mother in her home. In the home visits the nurse
will advise the pregnant mother about daily details o f care to avoid
discomfort and disability, she will see that regular urinalyses are
made, watch for symptoms of complications, help to arrange house­
hold affairs for the lying-in period, and convince the mother and
her husband o f the necessity for good obstetrical service.
Instruction by the nurse on child care, with emphasis upon proper
methods o f infant feeding, is especially needed in the area studied.
The earnest efforts o f many mothers to do their best for their chil­
dren are unavailing because they do not understand the needs of
the growing child. The nurse may also help the mother with prac­
tical suggestions for adjustments that will lighten her work and
improve the household management.
O f the actual saving o f life and improvement o f health and home
conditions through a public-health nursing service, no better illus­
tration can be given than the results effected by the prenatal nursing
service o f the New York City Bureau of Child Hygiene, the director
o f which states :
W ith a more extended and, if possible, a general application of prenatal
instruction to mothers of the city, who stand in need o f such care, the bureau
o f child hygiene is convinced that there would result a lower infant mortality
rate, especially during the first month of life, fewer deaths from congenital
diseases, fewer premature and stillbirths, fewer accidents to mother and child,
fewer deaths of mothers, fewer cases of sore eyes, better home conditions,
increased maternal nursing, fewer deliveries by midwives, increased birth reg­
istration, better care of babies, or, to summarize— better mothers, better babies
and better homes.81

While rural public-health nursing is regarded as the most feasible
initial step toward the betterment o f conditions affecting maternity
and infancy in the mountain county, other important needs include
hospital service Which would provide beds for maternity cases;
medical care available to every home in the area ; a full-time county
commissioner of health ; and regulation of the practice of midwifery.
81Baker, Josephine S., M. D., and Sobel, Jacob, M. D. : Control of Infant Morbidity and
Mortality in New York City. Monthly Bulletin of the Department of Health, City ©f
New York, October, 1921, p. 233.

Federal Reserve Bank of St. Louis