I. On the mother’s side;

a. Owing to peculiarities of the fluids and tissues of the maternal

body;

b. Owing to substances which penetrate the maternal organism and

reach the fertilized ovum.

II. On the father’s side, owing to substances which adhere to the

paternal reproductive cells, or are enclosed within these.

The number of consanguineous marriages at the present day is not less

than 5½ to 6½ per 1,000; the fertility of these marriages appears to be

identical with the fertility of ordinary marriages. _Mayet_ has made a

statistical investigation to determine the influence of consanguineous

marriages in the pathogenesis of mental disease. He finds that the

number of those congenitally affected with mental disorder is twice as

great in the offspring of consanguineous marriages as in the offspring

of crossed marriages; in the case of simple mental disorder, of

paralytic dementia, and of epileptic dementia, the ratio is actually

greater than two to one (the actual figures are 218, 257, 208 : 100).

Thus we see that when there exists any cause of inheritable mental

disorder, blood-relationship of the parents more than doubles the danger

to the children. In the case of imbecility and idiocy the danger is less

in this respect (the ratio is 150 : 100); the factor of inheritance

plays a less prominent part than in the case of other psychoses.

It was remarkable that among the offspring of marriages of nephew and

aunt, cases of mental disorder were almost entirely lacking. Among the

offspring of marriages of uncle and niece, the inheritance of mental

disorder was more prominent than among the children of first cousins. It

is interesting to determine the influence of blood-relationship in cases

in which the existence of inheritable predisposition could not be

proved. In these cases, as regards simple insanity, paralytic dementia,

and epileptic dementia, the number of cases among the offspring of

consanguineous marriages was only one-half as compared with the

offspring of crossed marriages; whereas in the case of imbecility and

idiocy this ratio was reversed. In idiocy, where inheritance generally

speaking plays a small part, the origination of the disease would often

appear to depend directly on the blood-relationship of the parents;

whilst as regards other forms of mental disorder, if there is no

inheritable predisposition, blood relationship in the parents appears to

be a positive advantage; where, however, a family predisposition to

insanity exists the likelihood of actual insanity appearing in the

offspring is notably enhanced by a consanguineous marriage.

_The Restriction of Fertility and the Use of Means for the Prevention of

Pregnancy._

As we have already pointed out, a restriction of the fertility of women

occurs in the majority of marriages, to this extent, that the potential

reproductive powers of the wife are not fully utilized. In recent times,

however, the restriction of fertility, by the deliberate use of measures

for the prevention of pregnancy, has become so widely diffused, that it

appears unwise from the scientific standpoint simply to ignore the

question, and it has become indispensable to study how the practice

developed, and to consider what are its actual results. From our own

point of view, it is the more necessary to do this, for the reason that

the use of preventive measures has come to play an important part in the

sexual life of woman, and therefore deserves the fullest attention, not

merely from the standpoint of the sociologist, but in addition from the

purely medical point of view.

In many divisions of the population, and even in entire nationalities,

the prevention of pregnancy, not merely in illicit intercourse, but also

in married life, has become so general a practice that the fertility of

the nation as a whole has been profoundly modified. Thus, in France at

the present day, the average number of children per marriage is less

than two; and the two-children-system is almost universally practised in

Transylvania and Norway, whilst it is very rapidly spreading in North

America. In the principal towns of the whole of Europe, this system is

largely on the increase among the upper classes of society. The

marriages of the poor, partly owing to ignorance, and partly to

indolence, are as yet comparatively little affected by this depopulative

principle.

In the days of antiquity, many lawgivers endeavoured to set bounds to

excessive fertility, and artificial abortion was methodically practised

by those who wished to avoid an inconveniently large family. Even among

savage peoples, we find that certain preventive measures are

occasionally employed in sexual intercourse. Among civilized peoples,

however, until the beginning of the nineteenth century, religious and

moral ideas derived from the Bible continued to dominate the sexual

life. It is well known that Old Testament law and Christian morality

alike forbid any artificial restriction of human increase. “Increase and

multiply” was the command given in Genesis to the first parents of the

race; and the psalmist exclaims, “Happy is the man that hath his quiver

full” of children.

A remarkable revolution in thought was initiated toward the beginning of

the nineteenth century by the great philanthropist and powerful thinker,

_Thomas Robert Malthus_, founder of the doctrine of the propriety of

checking the increase of population, author of the work “An Essay on the

Principle of Population,” London, 1798, whose Law of Population soon

attracted world-wide attention. Modern civilization having greatly

increased the cost of bringing up a family, while simultaneously there

has been a general rise in the price of the necessaries of life, there

has resulted an extraordinary diffusion of Malthusianism; in comparison

with the causes just alluded to for the use of preventive measures,

diseases which render renewal of pregnancy dangerous to the mother’s

life have comparatively little to do with the causation of voluntary

sterility.

In his “Essay on the Principle of Population,” _Malthus_ indicates, as

the cause which has hitherto hindered mankind in the pursuit of

happiness, the unceasing tendency of all organic life to increase in

excess of the means of subsistence. In the case of plants and of

unreasoning animals, the natural process is a very simple one. Both

animals and plants are impelled by a powerful instinct to reproduce

their kind, and the operation of this instinct is quite undisturbed by

any anxiety regarding the livelihood of their offspring. The

reproductive function is thus exercised at every available opportunity,

and the superfluous individuals of the next generation are destroyed by

lack of space and nutriment. In the human species the restriction of

population is effected by a more complex mode of operation. Man is

impelled to reproduce his kind by an instinct not less powerful than

that of other animals; but the gratification of this instinct is checked

by reason, which makes him ask himself whether he is not about to bring

into the world beings for whom he will be unable to provide the means of

subsistence. If he is influenced by this consideration, the resulting

restriction of population may often entail serious consequences; if, on

the other hand, he gratifies his instinct, regardless of the appeal of

reason, the human species will inevitably tend to increase more rapidly

than the means of subsistence.

_Malthus_ declared that population, when its increase was unrestricted,

doubled itself every twenty-five years, and therefore increased in a

geometrical progression; he considered that in the most favourable

circumstances the means of subsistence could not possibly increase more

rapidly than in an arithmetical progression. The contrast between these

two modes of increase will be more striking if we write out the actual

figures. According to the theory of _Malthus_, the increase of human

population would be represented by the figures 1, 2, 4, 8, 16, 32, 64,

128, 256, whereas the simultaneous increase in the means of subsistence

would be represented by the figures 1, 2, 3, 4, 5, 6, 7, 8, 9. Such an

increase in population is, however, always prevented by certain checks,

classed by _Malthus_ as of two kinds, preventive checks and positive

checks.

A preventive check, in so far as it is voluntary, is peculiar to the

human species, and originates in the intellectual faculty which enables

man to foresee the consequences of his actions. A man who looks around

him, and sees the poverty into which those with large families so often

fall, who reckons up his present property or earnings, which barely

suffice to provide for his own personal necessities, cannot fail, when

he considers how hardly they would suffice for seven or eight additional

persons, to doubt whether it would be possible for him to provide for

the offspring he might bring into the world. Such considerations as

these are likely to lead a large number of persons of all civilized

nations to resist their natural instincts, and to refrain from early

marriage. If abstinence entailed no serious consequences, it would be

the least of all evils resulting from the principle of population.

The positive checks to increase of population are manifold, and embrace

all the causes which are competent to lessen the natural duration of

human life. Among these we may enumerate: all unhealthy occupations,

severe toil, climatic conditions, poverty, errors in the rearing of

children, town life, excesses of all kinds, the whole army of illnesses

and epidemics, war, pestilence, and famine. In all countries, preventive

and positive checks are more or less powerfully operative, and yet there

are few in which the population is not continually tending to increase

beyond the means of subsistence. As a further consequence of this

tendency of population to increase, we observe the wider diffusion of

poverty among the lower classes, so that any permanent improvement in

their condition is rendered impossible.

After _Malthus_ had carefully stated his thesis, he gave a summary

record of the conditions of population in nearly all nations of the past

and of his own time, in order to show how in all alike the three

principal means of limiting population, moral restraint, disease, and

poverty, had been in continuous operation.

He showed, for instance, how the population of the South Sea Islands had

been limited by certain conditions, cannibalism, castration of the

males, infibulation of the females, late marriages, the sanctification

of virginity, contempt for marriage, etc.

In ancient Greece, Solon’s laws permitted infanticide. _Plato_, in “The

Republic” asserts that it is the duty of the Government to regulate the

number of the citizens, and to prevent an immoderate increase; men and

women should be allowed to procreate only during their period of maximum

strength, all weakly children should be killed. _Aristotle_ advised that

men should not be allowed to marry before the age of 37, and women

before the age of 18; the women should give birth to a limited number of

children only; if, after this, they again became pregnant, abortion

should be induced. He maintained that if all were at liberty, as was the

case in most countries, to bring into the world as many children as they

pleased, poverty, the mother of crime and insurrection, must inevitably

ensue.

Among the Romans war was as a positive check unceasingly operative: in

this time of the Empire, preventive methods came into general use, in

the form of various kinds of sexual perversity. _Juvenal_ complains of

the skilled methods employed in the induction of abortion; during the

later period of the Roman Empire, sexual morality became so degenerate

that marriage was hated and despised.

Passing to the consideration of the checks on population among the

nations of modern Europe, _Malthus_ examined the registers of marriages

and deaths, and came to the conclusion that in few countries is the mass

of people sufficiently capable of self-restraint to postpone marriage

until they are reasonably assured of being able to provide for all the

children they are likely to have; still, he ascertained that at the

present day positive checks on population were less active, and

preventive checks more active, than in earlier times and among savage

races.

_Malthus_ did not base upon his conclusions the advice that in sexual

intercourse means of preventing pregnancy should be employed, as the

modern “Malthusians” advise; in his eyes, moral restraint, that is to

say, sexual abstinence, was the only remedy for the prevention of

poverty and the other evil consequences of the principle of population.

Moral restraint was in his opinion the only virtuous method of avoiding

the evils of excessive fertility. It was a man’s duty not to marry until

he had a definite prospect of being able to maintain his children; the

interval between puberty and marriage must be passed in strict chastity.

Man’s duty is not the mere reproduction of his species, but the

reproduction of virtue and happiness, and if he is not able to do the

latter, he has no right whatever to do the former. _Malthus_ lays great

stress on educating the people in this matter; “in addition to the

ordinary subjects of instruction, it is necessary to explain the

principle of population, and the manner in which it gives rise to

poverty.” In the nature of the case, no lasting and general improvement

in the condition of the poor is possible without an increase in the

preventive restriction of population.

The _Malthusian_ doctrine of the law of population gave rise to an

enormous sensation, and some of his disciples soon proceeded to

translate his conclusions into practice; such authorities as _James

Mill_ and _Francis Place_ recommended measures by means of which,

“without any injury to health, or to the feminine sense of delicacy,

conception can be prevented:” the avowed aim of these measures was to

prevent the increase of population beyond the means of subsistence.

Physicians and physiologists joined the ranks of these innovators; among

others _Raciborski_, _Robert Dale Owen_ in his “Moral Physiology,”

_Richard Carlile_ in his “Book of Woman,” the first work to give an

exact description of the means to employ for the prevention of

conception, _Knowlton_ in his “Fruits of Philosophy.” In the year 1827

in the Northern counties of England leaflets were for the first time

distributed among the working classes to instruct them in the use of

preventive measures. _Bradlaugh_ founded the Malthusian Society, which

aimed at the dissemination of instruction in the use of preventive

methods. There is now in England a “Malthusian League,” numbering

leading physicians among its members; this supplies to all classes the

means by which the family can be artificially limited. A new edition of

the above-mentioned book, “The Fruits of Philosophy,” was circulated in

London in an edition of several hundred thousand copies, and prominent

persons spoke at congresses on the subject of Neo-Malthusianism. In

Germany, also, a “Union of Social Harmony” was founded, for the free

distribution of a hand-book on the use of measures for the prevention of

conception, and for an investigation regarding the results of these.

We do not propose here to subject the teaching of _Malthus_ to a

critical examination; he has found formidable opponents, who have

endeavoured to prove that his fundamental assumption is false; they

maintain that work or the power of work increases in direct ratio with

the population; and they also assert that population tends to increase,

not, as _Malthus_ maintained, in a geometrical, but simply in an

arithmetical progression. We shall merely quote _Liebig’s_ reply to the

law of Malthus, “when human labour and manure are provided in sufficient

quantity, the soil is inexhaustible, and will continue to yield

unceasingly, the most abundant harvests;” and _Rodbertus’_ remark that

“agricultural chemistry will ultimately be competent to create nutritive

materials; this will some day be just as much within the power of

society, as it is at present to provide any requisite quantity of

textiles, given the necessary amount of raw material.” The celebrated

socialist _Bebel_, is a strong opponent of _Malthus_. He writes: “The

earth is doubtless thickly populated, but none the less only a small

fraction of its surface is occupied and utilized. Not merely could Great

Britain produce, as has been proved, a far larger supply of nutritive

materials than at present, but the same is true of France, Germany and

Austria, and in a still higher degree of the other countries of Europe.

European Russia, were it as thickly populated as Germany, could support,

instead of ninety millions, as at present, a population of four hundred

and seventy-five millions. For the purposes of the higher civilization,

toward which we are striving, we have to-day in Europe, and shall have

for a long time to come, not an excess of population, but an

insufficiency, and every day brings new discoveries and inventions

whereby the means of subsistence are potentially increased. In other

parts of the world, the insufficiency of population and the superfluity

of ground are even more noticeable. _Carey_ is of opinion that the

single valley of the Orinoco, fifteen hundred miles in length, would

suffice to provide nutritive material in sufficient quantities to feed

the whole existing population of the world. Central and South America,

and more especially Brazil, have a soil of extraordinary fertility, but

are as yet practically unutilized by the world. To increase, not to

diminish, the numbers of the human race, that is the appeal made by

civilization to mankind!” A similar position on this question was

recently taken by Roosevelt, the President of the United States, himself

the father of six children, in a letter to two American women, _Mrs. J._

and _M. Van Vorst_, authors of the book “Woman Who Toils (Factory Life

in America).” In this book, the writers prove that in the United States

the average size of the family is now less than in any other country of

the world, France alone excepted. President Roosevelt, in his letter,

declares himself an ardent supporter of the biblical injunction,

“increase and multiply!” He writes: “Whoever evades his

responsibilities, through desire for independence, convenience, and

luxury, commits a crime against the race to which he belongs, and should

be an object of contempt and horror to a healthy nation. When men avoid

becoming fathers of families, and when women cease to regard motherhood

as the most important career open to them, the nation to which these men

and women belong has cause for uneasiness about its future.” President

Roosevelt continues: “To the American woman marriage is no longer a

life-duty, a profession, as it is to her sisters who are members of the

older civilizations. A woman who manages an extensive business, who

supervises her own landed property, or who plays her own part in the

world of finance,—for such as these, the ‘lottery of marriage’ is

naturally something they dread rather than desire.” President Elliott,

of Harvard College, has expressed similar views in a speech on this

subject. He deplores the late marriages and small families of the

cultured Americans. According to the last census, an American family has

on the average less than three children; twenty years ago the average

number was from four to five children.

I pass now to consider the medical point of view of this question of the

prevention of pregnancy. It is my opinion that the physician as such

should intervene in the matter, not in any case for the relief of the

dominant economic parental dread of insufficient means for the

upbringing of children, but only on account of the purely medical

consideration of the physical dangers of motherhood. That is to say, the

physician should lend his skilled assistance toward the attainment of

facultative sterility, only when his own special scientific knowledge

leads him to consider this urgently necessary; it is not his province to

assist in preventing the birth of an immoderate number of offspring; his

intervention is justified only when deliberate reflection has convinced

him that his patient’s health or life would be endangered by pregnancy

or childbirth. A woman’s life and well-being must appear to him of

greater importance than the existence or non-existence of a possible

infant. That this view is morally sound, is shown by the fact that

public opinion justifies the accoucheur in the destruction of an already

living child, when the mother’s life is endangered. In this connection

we may recall the words of the great Napoleon; the physician Dubois,

attending Marie Louise in a difficult confinement, asked Napoleon

whether, if matters came to an extremity, he should save the mother or

the child; Napoleon, notwithstanding his strong desire for the birth of

an heir to his dynasty, replied, “The mother, it is her right.”

In isolated cases, which deserve always very serious consideration, some

pathological condition in the wife may justify the prevention of

pregnancy. In certain very serious general disorders, in diseases of the

heart or of the lungs, in pelvic deformity, and in pathological changes

of the female reproductive organs, it may be right to employ means for

the prevention of pregnancy—not merely sexual abstinence, but actual

measures to prevent fertilization.

The misuse of medical knowledge for the recommendation or employment of

preventive measures, on the ground of humanitarian sentiment or social

and economic considerations, must, however, be strongly resisted. Even

leading gynecologists have erred in this way. _Saenger_ writes,

“Scientifically-trained accoucheurs will do much more to promote the

health and well-being of women, and to protect them from sexual and

other diseases, than the humanitarian efforts of the Neo-Malthusians,

who transfer a purely scientific question, such as the disproportion

between the number of births and the supply of nutritive material, to

the sphere of medicine, regarding themselves as justified in preventing

conception whenever they please, independently of considerations

relating to the health of the mother * * * * * * * * A woman exhausted

by frequent child-bearing, anæmic and suffering, is certainly a figure

to arouse everyone’s sympathy; in so far as she is ill in consequence of

injury received in childbirth, it is our duty to prevent further injury,

and to relieve to the best of our ability that which has already

occurred; in so far, however, as she is not suffering from any affection

of the reproductive organs, but is ill owing to the lack of sufficient

food, or from overwork, it is the duty of society to render assistance.

Here we have to do with the social problem; the solution of which will

be brought no nearer by the use of the occlusive pessary.” _Fehling_

also maintained that a text-book of gynecology is not the proper place

in which to pass judgment on so important a socio-political question.

The business of the gynecologist in this matter is merely to say a word

of caution against the use of various measures which are so often

recommended as harmless, but are in fact dangerous to the woman who uses

them.

_Kleinwächter_, who declares that he is far from recommending the use of

preventive measures when a healthy woman wishes to save herself the

trouble of child-bearing, gives as legitimate indications for their use:

1, the various forms of severe pelvic deformity; 2, certain tumours in

the pelvic cavity; 3, after the removal of malignant tumours of the

reproductive organs, certain general disorders, recently arrested

pulmonary tuberculosis, organic heart disease, etc. Regarding these

cases, _Kleinwächter_ writes: “The wife’s life would be endangered by

pregnancy, which must therefore be prevented without forbidding coitus,

and avoiding the practice of coitus interruptus, which endangers her

health, or of any mode of intercourse repugnant to the feelings of wife

or husband.”

The most trustworthy, but unquestionably at the same time the least

practicable method, for the prevention of pregnancy, is that of

_Malthus_—permanent sexual continence. This recommendation, to which

_Tolstoi_ in “The Kreuzer Sonata” gives his adhesion, has recently found

an advocate in a modified sense in a distinguished gynecologist,

_Hegar_, who considers that the great fertility of the modern civilized

countries of Europe entails many disadvantages—inferior physical

development, increased general mortality, emigration, an unfavourable

distribution of population in relation to dwelling and occupation,

occasional famine—and who sees the only effective remedy in a

“regulation of reproduction,” whereby the tendency to marriage and the

number of births are to be diminished. The question “when is the number

of children in a family too large?” is answered by _Hegar_ as follows “A

maximal limit is easy to establish. The most suitable age for

child-bearing is from twenty to forty. At an earlier and a later age

than this, both the mother and the offspring are liable to suffer.

Between two successive births there should be an interval of about two

and a half years; this would leave time for the birth of eight children.

If we assume that pregnancy lasts nine months, that lactation is

continued from nine to twelve months after delivery, (and if the mother

does not herself nurse the child, artificial feeding or careful

supervision of the wet-nurse will occupy her for a like period), to

devote an additional period of six months to nine months to the complete

restoration of the mother’s health cannot be regarded as excessive. For

this maximum family we assume a perfect state of health on the part of

the mother, a pure atmosphere, and a sufficient supply of all the

necessaries of life. Illnesses, weakness, or infirmity of the mother,

often indicate that the number of children should be further limited. It

is easier to provide a suitable dwelling and a pure atmosphere for a

small family than for a large one. The same thing is true as regards the

means of subsistence.

“If the reproductive function is to be intelligently controlled,”

continues _Hegar_, “above all it is necessary to devote attention to the

age and health of the parents; but occupation, dwelling, and general

environment, must also not be overlooked. Among the cultured classes of

our Fatherland, people are gradually learning to form sound opinions

about these matters. Among the working classes, on the other hand,

especially among those engaged in factory labour, the heedless

gratification of the sexual impulse is responsible for untold misery.”

_Hegar’s_ advice may be summarized as follows: If the marriage takes

place after the attainment of complete maturity, in the wife at twenty

and in the husband at twenty-five, and if procreation is discontinued in

the wife at forty and in the husband at forty-five to fifty, if between

successive deliveries the intervals necessary for the wife’s restoration

to health are maintained, if illness and states of debility are taken

into account, if sickly, hereditarily-tainted individuals are forbidden

to marry—the excessive increase in population, as far as Germany is

concerned, will cease to give cause for anxiety. The regulation of

reproduction will, however, still be incomplete, unless we enforce a

selection too rigorous for our present views. Moderation and continence

must aid as far as may be necessary in preventing an undue increase in

population. _Hegar_ does not fail to point out the evil effects of an

excessive limitation of the family. In a marriage when one child only is

born, this child is the object of unceasing anxiety and attention, and

real or imaginary dangers assume an excessive importance in the morbidly

excited imagination of the parents. Hence we find a continuous excess of

watchfulness and over-education in the case of the only child, to whom

independent thought and action are entirely unknown. Boys become

milksops, girls nervous and hysterical. In the two-children-system,

again, one or both of the children may die when the age of the parents

is already considerably advanced. Still in those districts of France in

which this system obtains the population is well-to-do, and an

exceptionally large proportion of the males are fit for military

service. The use of various measures for the prevention of conception is

considered by _Hegar_ to be harmful, at any rate in the case of young

women; this practice gives rise to anæmic conditions, and to nervous

weakness and irritability, seldom, however, to more serious disorders,

as indeed is apparent from the fact that the mortality of married women

as compared with unmarried women is lower in France than in other

countries.

_Gräfe_, with reference to the view that if for any reason conception

must be prevented, this should be done by abstinence from sexual

intercourse, remarks: “Doubtless an ideal demand, but one which even

those with exceptional strength of will are unlikely to satisfy. And the

worst of it is, that even a single indiscretion will often result in

impregnation. Moreover, it is distinctly contrary to natural conditions,

that a healthy married couple united by an intimate affection should

live together abstaining completely from sexual intercourse. The

question has already been much discussed, both in speech and writing,

and this will continue in the future, without altering the fact that the

physician will be asked, and will be compelled to give, advice regarding

the use of means of the prevention of pregnancy.”

_Ribbing_ writes, “Although the sexual impulse is the product of a

powerful natural developmental force, still the temporary, and sometimes

even the permanent, control of this impulse is a moral civilizing force

of enormous importance.” This writer is opposed to the use of artificial

preventive measures; he considers them untrustworthy and dangerous to

health. Untrustworthy, for the reason that nature has endowed living

organisms with a strong impulse toward conjugation and has equipped with

very powerful forces the processes by which fertilization is effected.

Every physician is familiar with cases in which preventive measures have

proved ineffective. This fact is proved also by the statistics of

prostitution. Although prostitutes are fully instructed in the use of

preventive measures, which they almost universally employ, nevertheless

every year a smaller or larger number of prostitutes become pregnant.

These measures are dangerous to health, partly because of their

interference with natural functions, because many of them are clumsy and

ill adapted; and partly, again, because owing to their use the woman

fails to enjoy the natural periods of repose which are entailed by

pregnancy, parturition, and lactation. Noteworthy also are the psychical

considerations adduced by _Ribbing_ against the use of preventive

measures. The majority of well-bred women feel deeply wounded if they

believe themselves to be regarded merely as a means of enjoyment, not as

individuals, as persons with inalienable rights. For the man also there

is danger, for it is easy for him to acquire a dislike to the wife who,

even though on his own initiative, occupies herself with the technique

of the sexual life in a manner which he feels instinctively to be

opposed to the chastity and puremindedness demanded by every man from

his wife. _Ribbing_ therefore advises a certain measure of sexual

abstinence in married life.

_Max Nordau_ also insists on the moral disadvantages of the wide

diffusion of the use of preventive measures. “If a race or nation has

reached this point in its downward career, the individuals of which it

is composed lose the capacity of loving in a healthy and natural manner.

The sense of the family disappears; the men will not marry, because they

find it inconvenient to burden themselves with the responsibility for

another human life, and to care for any other creature than themselves;

the women dread the pains and inconveniences of motherhood, and if they

marry, they endeavour, by the employment of the most immoral means, to

ensure barrenness. The reproductive instinct, of which reproduction has

ceased to be the aim, is in some annulled, whilst in others it

degenerates into the most peculiar and irrational perversities. The act

of sexual union, the most sublime function of the organism, is degraded

into a profligate act of lust; it is no longer undertaken in the

interest of the perpetuation of the species, but exclusively for the

pleasure of the individual, and without any relation to the needs of the

community.”

_Alfred Russel Wallace_ has advocated sexual continence as a preventive

measure during the period of maximum vitality and strength; he advises

that the age of marriage of women should be considerably advanced, in

order to diminish their fertility. If woman’s average age at marriage

were 29, instead of 20 years, the fertility of marriages would be

reduced in the ratio of 8 : 5.

The desired goal of artificial sterility will not, however, be reached

through the advocacy of moderation and continence. The numerous

additional measures employed for this purpose may be classified as

_physiological_ and _artificial_; the latter class may be further

subdivided into _mechanical_ and _operative_.

By physiological means for the prevention of conception, we understand

measures which aim at producing sterility by reducing the number of acts

of intercourse and by restricting these acts to certain defined periods

of time. The physiological preventive measures, apart from the higher

ethical value they possess in comparison with artificial measures, have

the advantage that they may be regarded as harmless to the general

health of the woman and to the integrity of her reproductive organs in

particular; they have, however, this very serious disadvantage, that the

results of their use are very uncertain, so that they offer no more than

a probability, and often a very moderate probability that conception

will be prevented.

As a physiological measure for the attainment of facultative sterility

“without breaking any moral law,” _Capellmann_ advised abstinence from

coitus during a period of fourteen days after menstruation and three to

four days before the commencement of the flow. Without laying too much

stress on the fact that by following this recommendation the period

during which the intercourse is permissible would be extremely

restricted, it is necessary to point out that, whilst in this way the

occurrence of conception may be rendered less probable, its prevention

is by no means guaranteed, for it is an established fact that a woman

may be impregnated by intercourse on any single day of the

intermenstrual interval. _Capellmann’s_ advice, embodying, as he

expresses it, the “only morally permissible” means for the prevention of

conception, was not original, for the same recommendation was given at

an earlier date by _Raciborski_, who, however, regarded the measure as

very uncertain. _Capellmann_ is of opinion that it is sufficiently

trustworthy for practical purposes.

_Bebel_, who is a declared opponent of Malthusianism, none the less lays

down positive rules for the diminution of procreative capacity and of

fertility by regulation of the diet. He refers to the example of the

bees, which, by a change of nutriment, can produce a new queen-bee at

will. “Thus the bees,” he says, “are in advance of human beings in their

knowledge of sexual development. Presumably they have not been

compelled, for a couple of thousand years, to listen to sermons

informing them that to occupy themselves about sexual matters is

‘improper’ and ‘immoral.’ There is no doubt whatever that the mode of

nutrition has an influence on the composition of the male semen, and

also on the susceptibility to fertilization of the female ovum; hence

the increase in population must to a very important extent depend on the

mode of nutrition. If this could be definitely established, we should

have, in the supply of nutriment, a means of regulating the population.

As an example of the effect, in this connection, of the mode of

nutrition in the human species, it is reported that in consequence of

the fatty and nutritious diet of the old Bavarian peasants, who lived

chiefly on very rich puddings, the marriages of the well-to-do peasants

were frequently childless. However, it must not be forgotten that

pre-conjugal intercourse, which was customary in that part of the world,

and was somewhat promiscuous in character, may have contributed to cause

this sterility.” Finally, _Bebel_ points out that the woman of the

future “will be unwilling to bear a large number of children. She will

wish to enjoy a measure of personal freedom and independence, and will

not consent to pass half or three-quarters of the best years of her life

either pregnant, or with a child at her breast. From this it will result

that the population will be regulated, without unwholesome sexual

abstinence, and without the employment of unpleasant preventive

measures.” However, _Bebel_ gives us no details as to the precise manner

in which this regulation is to be effected.

_Tolstoi_, in his widely celebrated book “The Kreuzer Sonata,” condemns

absolutely the gratification of the sexual impulse. He demands the

recognition of the fact that “sexual congress, in which a man either

avoids the natural consequences—the birth of children,—or else throws

the whole burden of these consequences on the woman, is opposed to the

simplest demands of morality, is in fact utterly base.” To render

possible the sexual abstinence he regards as morally necessary, men must

not only endeavour to live in a natural way, but they must consume no

alcohol, eat with great moderation, abstain from meat, and not be afraid

of hard work. _Tolstoi_ even demands that men and women shall be so

brought up “that both before and after marriage they may regard love,

and the sensual passion associated therewith, not as they do at present,

as a sublime and poetical state, but as a bestial condition degrading to

humanity.” _Tolstoi_ is, however, utterly opposed to the use of

preventive measures: “first, because they liberate men from the cares

and sorrows entailed by having children, which must be regarded as the

penance to be paid for sensual love; and, secondly, because their use is

closely allied to the crime most repugnant to the human conscience, the

crime of murder.” Chastity is no less a duty after marriage than before;

after marriage man and wife must “continue to pray to be delivered from

temptation, and must endeavour to replace sensual love by the pure

relationship of brother and sister.”

_Eulenburg_ regards the modern diffusion and the continuous increase in

the use of preventive measures as signs of decadence; _Löwenfeld_, on

the other hand, regarding the social conditions of the present day as

the principal source of the use of preventive measures, sees therein no

moral decay, but on the contrary rather a rise in the moral standard of

life.

Another physiological means of prevention is to be found in avoiding

cohabitation in that season or month in which, judging by the woman’s

previous deliveries, she would appear to have been peculiarly

susceptible to impregnation. _Cohnstein_ maintained that in woman, as in

the lower animals, the capacity for conception was associated with a

particular season of the year, that there was, in fact, an individual

time of predilection for impregnation. The assumption that there is such

a time of predilection is, however, traversed by the fact, familiar to

all who have recorded the birthdays of children in large families, that

these occur in the most diverse months of the year. It has, indeed, been

statistically proved that certain months and seasons are especially

favourable to conception, that a maximum of conceptions occurs in the

spring, and a second much smaller maximum in the winter; but these

variations in the number of conceptions depend mainly on social factors,

as, for instance, upon the customary season for marriage, opportunity

for intercourse between the sexes, common labours in the house or in the

open, etc. This alleged time of predilection for conception cannot,

therefore, seriously be considered in the discussion of measures for the

prevention of pregnancy.

As a physiological means for preventing conception, passivity of the

woman during sexual intercourse has also been recommended. It is well

known that an active participation on the part of the woman in the

sexual act, by increasing her voluptuous sensations, gives rise to

certain reflex actions, viz., descent of the uterus, rounding of the os

uteri, induration of the portio vaginalis, and, finally, ejaculation of

the secretion of the cervical glands and of the glands of Bartholin;

these changes accelerate the entrance of the semen into the cavity of

the uterus, and increase the motility of the spermatozoa. Upon this fact

is based the assumption, that, in consequence of deficient sexual

excitement during intercourse, either spontaneous, or when the woman

intentionally remains “cold,” the reflex actions by which the upward

passage of the spermatozoa is favoured, fail to occur; there is a good

deal of evidence in favour of the truth of this view. _Riedel_ reports

regarding the women of the Island of Buru, that they often have sexual

intercourse with strange men, “but during sexual congress in such cases

they maintain a passive and indifferent state, for the purpose of

avoiding impregnation.” _Von Krafft-Ebing_ points out that prostitutes,

when having sexual intercourse with men to whom they are attached,

experience voluptuous excitement, whilst in intercourse with men to whom

they are indifferent they remain entirely passive. From this it would

appear that these uterine reflexes are under the dominion of the

conscious will; but sufficient dependence cannot be placed on this fact

in all circumstances for it to be possible to employ such voluntary

control as a trustworthy means of prevention. Allied to this is

previously-mentioned Chinese practice of Kong-fou, a kind of hypnosis,

in which during sexual intercourse the thoughts are concentrated on some

other matter, and thereby conception is supposed to be prevented.

Artificial protraction of the period of lactation is an old and

well-known method, practised by many savage peoples, for the prevention

of fertilization. As a general rule, as long as lactation continues,

amenorrhœa persists, and sexual intercourse remains unfruitful. But this

rule also is not universally valid.

Artificial means for the attainment of facultative sterility are those

by which the attempt is made to prevent pregnancy by some mechanical

hindrance to the contact of the semen with the ovum, since without this

contact conception cannot possibly occur.

The oldest of these means is that described in the book of Genesis (ch.

xxxviii, verses 9, 10), congressus interruptus, where, however, the

practice was punished by death, “And Onan knew that the seed should not

be his; and it came to pass, when he went in unto his brother’s wife,

that he spilled it on the ground, lest that he should give seed to his

brother. And the thing which he did displeased the Lord, wherefore he

slew him.” This mode of preventing pregnancy, in which the membrum

virile is completely withdrawn from the vagina before the ejaculation of

the semen takes place, is at the present time a very widely diffused

practice; and, when properly carried out, it is thoroughly efficacious

in the production of sterility. _Thompson_ relates that this practice is

employed by the Massai youths, who are allowed free intercourse with the

girls, but if a girl becomes pregnant she is put to death.

The prolonged practice of coitus interruptus leads in my experience—in

addition to the injury to the nervous system as a whole in consequence

of the intense hyperæmia of the uterus and the uterine annexa,

unrelieved by the occurrence of the orgasm—to a condition of stasis in

the female reproductive organs; and this ultimately passes on into

chronic metritis (with relaxation of the uterus, retroflexion or

anteflexion, catarrhal disease of the mucous membrane, erosions, and

follicular ulceration of the portio vaginalis), oöphoritis and

perimetritis. As a result of certain remarkable observations, I must

even regard it as not improbable, although actual proof is still

lacking, that the recent striking increase in the frequency of

neoplasmata of the female reproductive organs is causally dependent on

the ever-increasing employment in all circles of society of means for

the prevention of pregnancy.

The evil effects of coitus interruptus for a woman are dependent on the

fact that the woman fails to obtain complete sexual gratification, and

that this has an important influence upon her entire organism. Owing to

the failure of ejaculation to occur, the blood, which during the stage

of sexual excitement has accumulated in the erectile structures and

cavernous spaces of the genital passage, does not, as in normal

conditions, flow rapidly away; but the congestion persists for an

indefinite period, and is said by _von Krafft-Ebing_ to give rise to

functional disorders, and also to serious tissue changes. The functional

disorders take the form of hyperæmia of the pelvic organs, and probably

also of the lumbar portion of the spinal cord (dull pain in the sacral

region, a sensation of pain and dragging in the pelvis and in the lower

extremities, lassitude); these symptoms often continue for several hours

after intercourse. If this ungratifying coitus is frequently repeated,

in a voluptuous woman, disorders of the reproductive organs ensue; and

even more frequently, nervous disorders, in the form of neurasthenia

sexualis. This author considers that, more especially in women, coitus

interruptus, and unphysiological modes of sexual intercourse in general,

are extremely potent causes of sexual neurasthenia—as potent as

masturbation.

_Beard_, in his work on sexual neurasthenia, maintains that the sudden

interruption of coitus (and also the use of condoms and similar

appliances) is not only far more deleterious than unduly frequent normal

intercourse; but he points out that it is necessary also to take into

account the fact that (inasmuch as, owing to the unnatural mode of

sexual intercourse, the possibility of fertilization is almost

completely prevented) sexual intercourse is apt, in such cases, to be

indulged in far more frequently, and often to gross excess. More

particularly in such circumstances are evil effects on the nervous

system likely to ensue, since we have a combination of excessively

prolonged and frequent sexual intercourse, and of interference with

complete sexual gratification.

_Mantegazza_ believes that organic diseases of the spinal cord may

actually result from congressus interruptus.

_Hirt_ considers that even when marital intercourse is carefully

regulated in respect of frequency, congressus interruptus may lead to

neurasthenic manifestations.

_Von Hösslin_ believes it to be indisputable that preventive methods of

sexual intercourse may cause nervous troubles, and more particularly

neurasthenic disorders, manifesting themselves chiefly in the sphere of

the reproductive organs.

_Eulenburg_ also declares that coitus interruptus is already a frequent

cause of sexual neurasthenia in women, and that its evil influence in

this respect is becoming more and more frequently manifest. He publishes

two typical cases, in which, from this cause, in the one case,

functional neuropathy, and in the other, local disorder of the

reproductive organs, ensued.

_Freud_ describes an “anxiety-neurosis,” which is due to incomplete

gratification of the woman during sexual intercourse. Coitus interruptus

is almost invariably harmful to the man; to the woman it is harmful if

the man thinks only of himself, and interrupts the coitus as soon as

ejaculation is imminent, without concerning himself about the woman’s

state of sexual excitement. If, on the other hand, the man waits until

the woman’s sexual gratification is complete, the significance of such

an interrupted coitus as far as the woman is concerned is that of normal

intercourse.

Isolated authorities, as for instance _Stille_ and _Thompson_, have

contested the alleged evil consequences of preventive methods of sexual

intercourse. “It is habitual excess,” says _Fürbringer_, “which does the

mischief, not the unnatural character of the isolated act.” _Löwenfeld_,

who considers the opposition of medical men to “Malthusianism” not

wholly justified, and believes that the dangers to health “which occur

in isolated cases” are not very serious, maintains none the less that

the medical man must advise his patients not to practise coitus

interruptus. The mode in which conception is prevented is not, he

thinks, a matter of indifference to the woman. The use of occlusive

pessaries and similar appliances does not in any way interfere with the

normal development of sexual gratification and cannot, therefore, have

any direct influence in the production of nervous disturbances. A

forgotten occlusive pessary, however, has in many cases caused local

disorder in the vagina. When the man is fully potent the use of condoms

can do no harm to the woman, since the only effect of the condom (in a

very excitable woman) is to render the development of the orgasm a

little more difficult, but not to prevent it. Congressus interruptus

itself is, according to _Löwenfeld_, harmful to the woman only when,

owing to deficient potency in the male or to deficient excitability in

the female, the interruption takes place before the occurrence of the

orgasm.

_Valenta_ declared that coitus interruptus was one of the chief causes

of chronic metritis. _Elischer_ saw perimetritis result from this

practice; _Gräfe_ enumerates, as consequences of frequently repeated

coitus interruptus, chronic hyperæmia of the uterus and oöphoritis;

_Goodell_ observed elongation of the cervix uteri; _Mensinga_,

infarction of the uterus, œdema of the portio vaginalis, ulceration of

the cervix, hysterical paroxysms, convulsions, cephalalgias,

cardialgias, etc. _Lier_ reports a case in which, after three years’

continued practice of coitus interruptus, the menopause set in, with

atrophy of the uterus; _Ascher_, in a similar case, saw chronic metritis

ensue. According to _Kleinwächter_, coitus interruptus is harmful to the

woman to an extent by no means trifling, whereas the man, in whom

ejaculation occurs, suffers comparatively little. _Fehling_ believes

that when coitus interruptus is practised only a small proportion of

women experience sexual excitement. _Neugebauer_ states that among the

very numerous cases of uterine carcinoma he has treated, the majority of

the patients admitted having practised coitus interruptus. _Pigeolot_

makes a similar statement.

It must, however, be admitted that a certain number of medical men

absolutely deny the dangers of coitus interruptus, whilst others

consider them altogether trifling. Just as the trend of modern opinion

is to believe that in normal men and women the dangers of masturbation

are far less serious than was formerly maintained, so also many are now

found to maintain that coitus interruptus is harmful only to those with

hereditary neuropathic predisposition. Still more unwilling are many to

admit that other preventive methods do women any harm. Thus _Wille_

maintains that the continued fear of pregnancy will in most instances do

more injury to the feminine nervous system than all the preventive

measures in the world. To the nervously weak woman a trustworthy

preventive of pregnancy is therefore often necessary and most helpful.

An artificial method for the prevention of the ejaculation of semen was

communicated to me by a celebrated anatomist. It is practised in

Transylvania and in France. During intercourse the woman, just before

the male ejaculation begins, presses forcibly with her finger on the

base of the erect penis just in front of the prostate; the urethra is

occluded by this digital compression, the semen regurgitates into the

bladder and is subsequently evacuated with the urine.

This practice may be compared with the mechanical expulsion of the semen

from the female genital passage immediately after coitus. _Tairi_

reports that women of the poorer classes in Italy sit upright in bed

immediately after intercourse, and by coughing, in conjunction with

pressure on the abdomen, effect the expulsion of the semen. _Morton_

informs us that the native women of Northern Australia, when they have

had intercourse with a white man and wish to avoid impregnation,

likewise deliberately effect the outflow of the semen _post actum_. The

woman squats upright, with the legs widely separated, and by a sinuous

movement of the perineum and a simultaneous powerful bearing-down

pressure she expels the semen on to the ground.

Another way in which the attempt is made to avoid impregnation is by the

use of vaginal injections; a fluid lethal to the spermatozoa being used

for this purpose immediately after coitus. Douches of cold water, ½ to

1% solution of copper sulphate, 1% solution of alum, ¼% solution of

sulphate of quinine, are the fluids most commonly employed; but all

these are quite untrustworthy, for it is impossible to be sure that all

the spermatozoa will be acted on and destroyed. _Allbutt_, who as

medical secretary of the Malthusian League in London has unquestionably

had a very wide experience, agrees with _Haussmann_ in denying that the

widely advocated cold water douche can be relied on for the prevention

of pregnancy. The sudden driving of the blood out of the vessels of the

genital passage at the very moment when they are intensely congested,

which must inevitably result from a cold douche, is, moreover, likely to

give rise to metritis, perimetritis and oöphoritis.

More trustworthy are the various apparatus, the aim of which is to

prevent the contact of the semen with the ova by the interposition of an

artificial wall. Although even as regards these we must bear in mind the

observation of _Lott_, who found that spermatozoa were capable of

passing through the intact membrane in favourable regions in as short a

time as ten minutes. The commonest of all these apparatus is the article

known as a condom, which envelops the penis with a membrane, variously

consisting of isinglass, the lamb’s cæcum, or caoutchouc. Condoms, if

made of suitable material, and if carefully used, are the most

trustworthy of all preventives. Moreover, the injury caused by their use

to the woman’s health is trifling, for they do no more than diminish to

a degree the intensity of the stimulus, thus necessitating a somewhat

longer duration of its action in order to effect the most intense

orgasm, and thus to induce the natural physiological termination of the

nervous excitement. In fact, though somewhat delayed, the normal

reaction takes place in the reproductive organs. The evil effect of the

use of the condom bears no comparison with that of coitus interruptus.

There is, however, some justification for _Ricord’s_ well-known epigram,

that the condom is “a spider’s web for the prevention of danger, and a

cuirass for the prevention of voluptuous pleasure.”

When the gynecologist, from well-considered reasons based on some

pathological condition affecting his patient, feels justified in

recommending the prevention of pregnancy, it is my opinion that the most

trustworthy and least harmful measure at present available, and one

preferable to all other mechanical apparatus, is a carefully selected

and well-made condom.

The condom was already in use in Italy in the middle of the sixteenth

century, in the form of a linen investment adapted to the shape of the

penis; subsequently, according to _Grünfeld_, condoms were made from the

cæcum of the lamb; while later still, isinglass was employed for this

purpose. According to _Hans Ferdy_, the cæcal condom is made from the

connective-tissue layer of the cæcum of the sheep or of the calf (a very

young animal); to a less extent, also, the cæca of the goat, the stag,

and the roe-deer, are employed for this purpose. The different varieties

of cæcal condom are distinguished chiefly by variations in the thickness

and the softness of the membrane. _Ferdy_ states that the four best

kinds are made from the cæcum of the sheep; these have a thickness: I.

0.008 to 0.01 mm. (0.00032 to 0.0004 in.); II. 0.012 to 0.015 mm.

(0.00048 to 0.0006 in.); III. 0.017 to 0.023 mm. (0.00068 to 0.00092

in.); IV. 0.025 to 0.03 mm. (0.001 to 0.0012 in.) Next in quality come

four varieties obtained from the calf, varying in thickness from 0.015

to 0.04 mm. (0.006 to 0.016 in.) Finally we have three varieties

obtained from the three other animals already mentioned. Thus there are

in all eleven varieties of cæcal condom, and in so far as during the

process of manufacture the membrane has remained free from any injury,

they are sold as “undamaged.” But if in the process of preparation a

hole has been made in the membrane, this aperture is closed by sticking

on a small patch of membrane. Such patched condoms are naturally quite

useless, since the patch is readily loosened by the moisture to which it

is exposed, and falls off, when the protective and preventive functions

are entirely destroyed; nevertheless, such defective condoms are often

sold. Rubber condoms, continues _Ferdy_, are prepared from a caoutchouc

membrane 0.03 to 0.1 mm. (0.0012 to 0.04 in.) in thickness; but these,

he says, are not hygienic, for “such a rubber membrane, which both in

the man and in the woman completely covers the erogenic zones normally

stimulated in coitus, deadens the necessary stimulation, so that the

sensations during coitus are seriously dulled by the interposition of

this foreign body; by nervously predisposed individuals, this kind of

condom cannot be used regularly for a long period, without rendering

probable the onset of serious functional disturbances of the genital

apparatus.” This opinion appears to me to be unfounded. We must also

mention the “glans-condom,” made of rubber membrane, which serves to

cover the glans penis only during coitus, and to retain the seminal

secretion; its grave defect, however, consists in this, that in the act

of withdrawing the penis, the condom is very likely to be peeled off,

when the semen will, after all, pass into the vagina.

Passing now to the consideration of apparatus which are inserted into

the woman’s genital canal, in order to prevent impregnation, we may

first mention sponges, which have long been in use; after thorough

cleaning, these may be rendered aseptic by immersion in carbolic acid or

lysol solution. These sponges should be very soft; they are cut into

balls of 3 to 7 cm. (1.2 to 2.8 in.) in diameter; before coitus they are

introduced into the vagina and after coitus they are withdrawn by means

of the tape which should always be attached to them. This method is,

however, quite untrustworthy, for the sponge offers no impermeable wall

to the passage of the spermatozoa, and on its withdrawal, some of the

semen may very likely be left in the vagina. The same objection must be

made to the similarly constructed anti-conceptional cotton-wool plugs;

sometimes these are moistened with a fluid intended to destroy the

spermatozoa. Recently _Gunzburg_ has recommended the introduction into

the vagina of a cotton-wool plug moistened with a three per cent.

solution of carbolic acid in glycerine; he considers this method safe,

because the spermatozoa are immediately destroyed on contact with the

weakest carbolic acid solutions.

To destroy the vitality of the spermatozoa, vaginal suppositories made

of cocoa-butter medicated with hydrochlorate of quinine have also been

employed; these, the so-called “security-pessaries” or “security-ovals,”

are inserted into the vagina half an hour before coitus; the

cocoa-butter is melted by the body heat, and the vaginal mucous membrane

and the os uteri are covered with the medicated fatty material, by which

the spermatozoa are (or should be) destroyed. This method is one easy to

employ, but it is extremely uncertain.

Even more uncertain are the insufflators charged with various powders

(boric acid, citric acid, thymol, etc.); the tube of the insufflator

having been passed into the vagina, the powder is blown over the vaginal

mucous membrane and the portio vaginalis. This procedure may sometimes

be followed by symptoms of intoxication; and in any case, owing to the

desiccative effect which the powder has upon the vaginal mucous

membrane, it exercises a disturbing influence on coitus.

_Kleinwächter_, in cases in which pregnancy must be prevented in the

interest of a woman’s health or her life, has recommended the

introduction into the vagina of globules of which the active constituent

is boric acid.

A rationally constructed apparatus, and one which in general appears to

fulfil its purpose very well, is the _pessarium occlusivum_ constructed

by _Mensinga_, and now manufactured in various modifications. The

occlusive pessary is a hollowed hemisphere of rubber membrane, around

the margin of which passes a steel ring. The size of the pessary must be

adapted to the individual case. It is introduced into the vagina in such

a way that the outer surface of the hemisphere occupies the vaginal

fornix, while the steel ring touches the vaginal wall all round; by this

means, the vaginal fornices and the os uteri are completely shut off

from the lower part of the vagina. The disadvantage of this instrument

is, that either the woman must wear it continuously, which involves

numerous inconveniences, or else it must be introduced by the skilled

hand immediately before coitus—and not every woman becomes competent to

adjust it herself, even after careful explanation, since the pessary

must be accurately placed with the anterior margin of the ring

immediately behind the pubic symphysis, and the posterior margin of the

ring behind the os uteri. Moreover, the instrument may easily be

displaced by violent movements, coughing, sneezing, etc. In any case,

the pessary must be carefully selected to correspond within the

configuration of the vagina, as otherwise it may exercise a deleterious

pressure upon the vaginal walls, and may give rise to other bad

consequences, such as are apt to attend the wearing of any pessary for a

prolonged period—excoriations, erosions, fluor albus, etc. In the

majority of cases it will be found that the woman herself is not

competent to introduce the occlusive pessary. The skilled hand is needed

for the proper adjustment of the surrounding ring.

_Gall’s balloon-occlusive-pessary_ consists of a soft elastic rubber

disc, surrounded by a thin-walled rubber ring, the interior of which is

connected by means of a fine tube with an inflating rubber ball. The

woman can herself insert the instrument and inflate the ring; it

occludes the vaginal passage without exercising any deleterious

pressure.

Other pessaries consist of hollow rubber balls containing some fluid

lethal to the spermatozoa, which can be discharged into the vagina on

opening a valve by pulling a string. These, however, are as insecure as

the above-mentioned vaginal discs and the insufflators. The

duplex-occlusive-pessary has the form of a truncated cone with double

walls; in its base are a number of rounded apertures, and a single

elongated aperture; through this latter a boric acid tablet is

introduced into the cavity of the cone. By means of the cone the passage

to the uterus is mechanically occluded; the semen passes through the

apertures in the base into the interior of the instrument, and as the

boric acid tablet is dissolved by the moisture to which it is now

exposed, the vitality of the spermatozoa is destroyed. The management of

this apparatus is, however, not easily effected by the woman herself.

The “Matrisalus-Pessary” differs but little from other occlusive

pessaries. The latest instrument for the prevention of impregnation is

known as the “Venus-Apparatus;” it consists of a syringe with two balls,

a large and a small one, at either end of a rubber tube; by pressure on

the larger ball, and subsequent relaxation of pressure, the smaller ball

is filled with a fluid for the destruction of the spermatozoa (prepared

by the solution of one of the “Venus-powders” sold with the instrument);

when filled, this smaller ball is introduced into the vagina and remains

connected by means of the tube with the larger ball, which lies between

the woman’s thighs. At the moment of the male ejaculation the woman

presses on this ball, and by this means the fluid filling the smaller

ball is expressed into her vagina.

All these mechanical occlusive pessaries are open to the objection that

they are apt to give rise to irritative conditions of the genital

organs, causing offensive discharges, pruritus, etc. (Recently in order

to diminish this drawback, the pessary has been constructed of

vulcanized cambric, instead of rubber, and appears then to have a less

irritating effect.) Still worse is the injury to the uterus and to the

cervical mucous membrane caused by certain intra-uterine instruments

which have been recommended for the prevention of conception. The latest

of these is an “obturator,” consisting of a silver or silver-gilt tube,

which is passed through the os uteri into the interior of the uterus,

and left _in situ_. It is claimed for it that “it allows the menstrual

discharge to flow freely away, but renders the entrance of the

spermatozoa extremely difficult.” _Biermer_ reports five cases in which

serious injury to health followed the use of one of these obturators. In

one of these cases in which there were very severe pains and a discharge

from the uterus, _Biermer_ removed from the interior of the uterus a

broken wing of the obturator; the patient died, however, and the autopsy

disclosed perforation of the uterus. In another of the cases the

apparatus was also broken.

Less dangerous is the recently invented tampon-speculum. This is passed

into the vagina by the woman herself, in order that through it she may,

by means of a special introducer, insert a tablet of boric acid,

hydrochlorate of quinine, citric acid, or some other substance lethal to

the spermatozoa. Without some such instrument, the introduction of these

“ovals” to the proper place is often found difficult by women.

A very remarkable means of bringing about artificial sterility, one

resembling the operative procedures sometimes adopted in western

countries, is employed in various parts of the world, and notably in the

East Indies and in the Sunda Islands, namely, the induction of an

artificial malposition of the uterus, more especially of anteversion.

Thus, _van der Burg_ writes from the Dutch Indies: “In the girls the

sexual impulse develops very early, and is gratified without fear of

consequences, when the services of certain skilled elderly women have

been requisitioned.” These women appear, in fact, to understand, by

means of pressure, rubbing, and kneading, through the abdominal walls

(not by the vaginal route), how to induce anteversion or retroversion of

the uterus, to such an extent as to prevent the occurrence of

conception. It is said that the only inconvenient consequences of this

procedure are trifling pains in the lumbo-sacral and inguinal regions,

and some trouble in passing water during the first few days after the

manipulations have been effected. Later, when a girl who has been

treated in this way wishes to marry and become a mother, by a reversal

of the manipulations the uterus is restored to its natural position. It

is said that these skilled women have been called in by European women

in the Dutch Indies, who did not wish to have many children; but it

appears that in a woman who has once given birth to a child, the result

of the manipulations is less to be depended upon, than in the case of a

virgin.

A means of ensuring artificial sterility, which in all civilized states

is punishable as a criminal offence, and which is nevertheless very

frequently practised, is the artificial induction of abortion.

Especially in North America it would appear that there exist regular

professional abortionists. In this connection, _Thomas_, the well-known

American gynecologist, writes as follows: “Statistics showing the

frequency of criminal abortion are not, and probably never will be,

available, for this crime cannot be adequately controlled by human

society, and commonly eludes legal punishment. It seems a hard saying,

but it is a true one, to assert, that the law pursues unremittingly him

who has killed his fellow-man, while it leaves immune him who has killed

the embryo in the mother’s womb. On my table there lies at this moment

one of the most widely circulated, most respected, and most carefully

edited daily newspapers of New York—a paper which finds its way into the

best circles of society, and also into the hands of girls and women

throughout the country. In its columns I find fifteen advertisements

which emanate beyond all question from professional abortionists—from

men and women who gain their livelihood by child-murder.”

_O. Reyher_ remarks also that in American newspapers advertisements such

as the following are of every-day occurrence: “Pills for the regulation

of the periods. Ladies expecting to be confined are warned not to use

them on any account, for if they do so abortion will infallibly ensue.”

_Emmet_, in his “Textbook of Gynecology” also complains of the terrible

frequency of criminal abortion, so that “every day we see more

unhappiness and misery result from the misuse of conjugal relationships

than we see in an entire month as a result of births which take place in

a natural manner.”

_Pomeroy_ also says that “The prevention of conception and the

destruction of the unborn life are pre-eminently American sins;” and he

adds that if no bounds are set to their spread, “they must, sooner or

later, lead to universal misfortune. In the course of our practices we

come into contact with women who would hesitate to kill a fly, but who

think nothing of having destroyed half a dozen or more of their own

unborn children.”

The American Medical Congress offered a prize for a brief and readable

essay, suitable for diffusion among women, showing the criminality and

the physical harmfulness of artificial abortion. The prize was awarded

to _Storer’s_ essay, entitled “Why Not?”

Among the ancient Greeks, the fear of over-population led to the

practice of homosexual intercourse. The states of ancient Greece were in

most cases of a very small area, so that a very moderate increase in

population would render the means of subsistence insufficient. Hence

intercourse with women was avoided, and the sexual impulse was gratified

in unnatural ways. Inspired by this fear of over-population, Aristotle

urged upon men that they avoid women, and should indulge in the love of

men and boys, and at an earlier date, Socrates had celebrated the love

of boys as a mark of higher culture. The most notable men of classical

Greece practised homosexual intercourse; authors and poets celebrated

the love of boys. Stimulated by their example, Sappho of Lesbos became

the inspired poetess of the love of women for members of their own sex

(Lesbian love).

Among the Romans it was rather satiety in consequence of sexual excesses

which led in that country to the diffusion of the Greek love of boys;

the consequent childlessness diminished to such an extent the numbers of

the Roman burghers and patricians, that Augustus, in the year 16 B. C.,

enacted the Julian law, by which the procreation of children was

rewarded, whilst celibacy became a punishable offence.

At the present day the fear of an excessively large number of children,

in relation to the property possessed by the parents and in regard to

nutritive possibilities, has led among whole classes, and even among

entire nations, to the adoption of preventive measures in sexual

intercourse; these measures have, in fact, been developed into a system,

which finds adherents among all strata of the population, but more

especially, as it is easy to understand, among certain well-to-do

sections of the community. In France this system has been adopted to

such an extent as to amount to a national calamity.

In few countries of the civilized world, remarks _Bebel_, are marriages

so frequent, relatively to the population, as they are in France, whilst

in no country is the average number of children per marriage so small,

or the increase of population so slow. The French bourgeoisie long ago

adopted this system, and the peasantry and the artizan classes are

following their example. In many parts of Germany the same causes have

led to the same results. In France, in addition to the prevention of

pregnancy and the practice of artificial abortion, infanticide and the

exposure of children are also actually employed to keep down the

population.

Operative measures for the production of artificial sterility have been

practised from very ancient times, and by civilized and savage peoples

alike. According to _Strabo_, the ancient Egyptians and Lydians were

acquainted with the art of removing the ovaries from girls and women.

The kings of Lydia, Andromytes and Gyges, had the women of their harems

castrated, _ut iis semper ætate et forma florentibus uteretur_. _Von

Micklucho-Mackay_ reports that in some parts of Australia the indigens

remove the ovaries of certain girls, in order to provide their young men

with hetairæ who cannot possibly become pregnant. _M. Gillirray_ saw at

Cape York a native deaf and dumb woman whose ovaries had been removed,

to prevent her procreating deaf and dumb infants.

We cannot refrain from reference to the astounding proposal of _C. A.

Weinhold_, contained in his work upon the over-population of Central

Europe and its consequences to the countries concerned and to

civilization in general. He advises, “as a general and urgently required

measure, the widespread practice of a sort of infibulation, which is to

be undertaken at the age of fourteen and preserved until marriage, and

is to be performed in the case of all those individuals who can be

proved not to possess sufficient property for the upbringing of an

infant, if they should become pregnant as a result of extra-conjugal

intercourse. And in those who never attained a financial position in

which they might be able to bring up a family, the infibulated condition

should be allowed to persist throughout life!”

This proposal is, in fact, no novelty, inasmuch as the bringing about of

an artificial adhesion of the labia with a view to the prevention of

conception—the operation of _infibulation_—is practised by many savage

peoples. According to the detailed account given by _Ploss-Bartels_,

this operation, in which the inner surfaces of the labia majora are

freshened, stitched together, and allowed to adhere, is practised by the

Bedschas, the Gallas, the Somalis, the inhabitants of Harrar, at

Massaua, etc. The purpose of this practice is to preserve the chastity

of the girls until marriage, when the reverse operative procedure is

undertaken. If the husband goes away on a journey, in many cases the

operation of infibulation is once more performed upon his wives.

Slave-dealers also make use of this operation so as to prevent their

slaves from becoming pregnant. It is reported, however, that the

operation does not invariably produce the desired effect. _Hartmann_

informs us that in Nubia, in Senaar, and in part of Kordofan, the

præputium clitoridis or the entire clitoris is cut away, and the margins

of the nymphæ are then freshened and stitched together, so that the only

aperture left is one sufficiently large for the outflow of the urine.

_Brehm_ states that the operation is performed by old women, who make

the necessary incisions with razors; shortly before marriage, the

bridegroom sends the girl’s relatives a model of his penis, carved in

wood, according to the size of which an aperture is made between the

adherent nymphæ; when the woman becomes pregnant, the incision is still

further enlarged. In the kingdom of Darfur, the labia majora as well as

the nymphæ are freshened and stitched together. In the Berber country,

_Werne_ became acquainted with a young widow whose husband had had her

submitted to the operation of infibulation no less than seven times.

Another somewhat less brutal method of performing infibulation is

described by _Ploss_, as being practised by many Eastern races; a ring

is fastened through the labia in such a way as to guard the introitus

vaginæ In Europe, during the Middle Ages, such and similar apparatus

(“girdles of chastity”) are said to have been employed for the

protection of the honour of an absent husband.

Of gynecologists who have advised operative measures for the prevention

of pregnancy, in women in whom that condition involved serious dangers,

the first, as far as I know, was _Blundell_. As a result of experiments

made on rabbits, he suggested division of the Fallopian tubes as the

best way of attaining this end. Later, _Froriep_ and _Kocks_ also

endeavoured to induce artificial sterility in women by occlusion of the

Fallopian tubes. _Froriep’s_ idea was to bring about obliteration of the

lumen of the tubes by means of cauterization with nitrate of silver;

_Kocks_ constructed for the same purpose a galvano-caustic uterine

sound. But, in the first place, both the methods advocated are too

uncertain to be relied upon; and, in the second place, their application

is neither easy, nor devoid of serious risk.

Much more effective, however, is the method recommended by _Kehrer_ for

the sterilization of women, namely, division of the Fallopian tubes by

the vaginal route. _Kehrer_ considers that the physician is justified in

preventing the occurrence of pregnancy in a number of morbid

conditions—incurable nervous, cardiac, pulmonary, gastric, and renal

disorders; various constitutional affections; and, finally, in cases of

pelvic deformity of such a degree that the delivery of a living child is

impossible except by means of Cæsarean section, but the patient does not

wish to be exposed to the risks of this operation. He believes,

moreover, that all the methods commonly recommended for the prevention

of pregnancy are untrustworthy. So powerful, however, is the sexual

impulse, that, as experience shows, the mere prohibition of sexual

intercourse, however earnestly made, invariably proves ineffectual. For

coitus interruptus to be effective, the interruption must occur at the

right moment; and this does not always take place. Cold water douches

after coitus are unhygienic; douches of warm water, medicated with

sublimate, alcohol, and other drugs lethal to the spermatozoa, are

indeed rationally conceived, but often fail of their effect, either

because they are deferred until too late, or else because they fail to

irrigate all parts of the vagina. Plugs of cotton wool, sponges, etc.,

are not always introduced in such a way as effectually to occlude the

vaginal passage. A suitable and properly introduced occlusive pessary

is, indeed, a relatively trustworthy preventive apparatus, but if worn

continuously it is apt to become very foul. A thorough douching of the

genital passage with an antiseptic solution, performed by the skilled

hand, immediately after coitus, would doubtless destroy the spermatozoa

with the like certainty with which the same procedure destroys

micro-organisms when performed prior to a gynecological operation—but

when carried out by the layman, the value of the method is more than

doubtful. The operation, for a time actually fashionable, of extirpation

of the uterine annexa, certainly gives rise to sterility, but entails

the serious disadvantage that the consequent premature menopause is

attended by the same disturbances as the natural change of life. On the

other hand, section and ligature of the Fallopian tubes is considered by

_Kehrer_ to induce sterility without in any other way disturbing the

functions of the female reproductive organs. By means of anterior

colpotomy we obtain a suitable route for the ligature and section of

both tubes at the isthmi. When carried out with the proper antiseptic

precautions the operation is almost entirely free from risk; and when

the organs are healthy the closure of both the upper and the lower

segments of the tubes is effected, and no retention of secretions need

be feared as a result of the operation.

With regard to the indications for the performance of this operation,

_Kehrer_ insists that it should be undertaken only in cases of serious

disease, and when the pros and cons have been conscientiously weighed. A

consultation is also indispensable. Moreover, it is essential that

husband and wife should both fully understand the nature of the proposed

operation, and should form an unbiassed judgment regarding its

advisability. To avoid any possibility of subsequent reproaches,

_Kehrer_ advises that a written report should be drawn up, giving the

reasons for undertaking the sterilization, and that this should be

subscribed by the physicians in consultation, by the patient herself,

and by her husband.

_Arndt_ considers that in cases in which there already exists serious

constitutional disease, the performance of this operation may lead to

fever, severe hæmorrhage, injury to adjacent organs, and even death. He

holds, therefore, that in such cases the physician should advise the use

of some of the more ordinary methods of preventing conception (if simple

abstinence from intercourse cannot be practised). Only in women with

pelvic contraction of the second or third degree, in whom previous

children have been still-born, or subjected to craniotomy, is operative

sterilization by _Kehrer’s_ method justifiable. But in preference to

anterior colpotomy, as recommended by _Kehrer_, he prefers the

longitudinal incision in the posterior vaginal fornix advised by

_Boileux_. If the uterus is drawn down firmly, and the portio vaginalis

then pushed forward against the pubic symphysis, it is easy, at any rate

with the assistance of a little abdominal pressure, to draw part of the

Fallopian tubes into the vaginal incision.

Recently _Pincus_ has recommended the cauterization of the uterine

cavity with superheated steam (_atmocausis_, _castratio uterina_). He

advises it only in women who are incurably ill (tuberculosis, morbus

Brightii, hæmophilia), so that pregnancy and parturition would involve

almost certain death.

_Kossmann_ considers that when pregnancy and parturition will endanger a

woman’s health and life, it is the physician’s duty to acquaint both

husband and wife with this fact; but having done so his duty is fully

discharged. “If, after being warned, the married pair choose to indulge

in sexual intercourse, they have knowingly and voluntarily run into

danger, and for this the physician is in no way responsible.”

As indications for facultative sterility _Levy_ enumerates tubercular

disease of the lungs, mental disorders, severe organic or functional

diseases of the central nervous system, active syphilis (in certain

circumstances), pernicious anæmia, hæmophilia, diabetes mellitus, severe

heart disease, chronic disease of the kidneys or liver, certain pelvic

deformities, and the tendency to habitual abortion.

I have myself before now stated my opinion that it is the duty of the

physician, in the case of a married woman suffering from heart disease,

with due regard to the danger which pregnancy will entail upon her, to

give needful advice in the matter of the prevention of conception. In

women affected with valvular heart disease, and in whom there are

serious disturbances of compensation, conception is absolutely to be

avoided; also in conditions of marked cardiac degeneration, and when

there are distinct symptoms of insufficiency of the heart muscle. When,

on slight exertion, palpitation, increased frequency of the pulse, and

respiratory need (“air-hunger”), ensue; when there is extensive œdema of

the lower extremities which persists even after confinement to bed; when

the pulse readily becomes arhythmical both in respect of the strength

and the temporal succession of the beats; when the urine is scanty and

contains varying quantities of albumen; when there are frequent attacks

of heart-weakness, with a small irregular pulse, coldness of the

extremities, a cyanotic tint of complexion, nausea, dyspnœa, sense of

faintness, or actual syncope—in all such cases, whether dependent upon

valvular disease, on pathological changes in the arteries, or upon

disease of the myocardium, the occurrence of pregnancy is a true

disaster, giving rise in most cases to a grave aggravation of the heart

trouble and often enough costing the patient her life. I further regard

it as a sound medical axiom that in cases of cardiac disorder of a less

severe type than that just described the woman thus affected should not

have more than one or two children. This is the more necessary because

with each successive pregnancy the functional capacity of the diseased

heart decreases in geometrical progression and the danger to life

proportionately increases. But in such cases of heart disease the

prevention of pregnancy must never be effected by the interruption of

coitus by the man before ejaculation, for the reason that this procedure

gives rise to manifold reflex cardiac troubles, and especially to

paroxysms of tachycardia, with simultaneous diminution in vascular tone,

vasomotor disturbances, and states of mental depression—and these entail

exceptional dangers in women suffering from heart disease.