The sexual life of woman in its physiological, pathological and hygienic aspects

by E. Heinrich Kisch

Fertility in Women.

Fertility in women is the basis of the fecundity of a nation, of its growth, its power, and its importance. It is especially the fertility of married women which enters here into consideration, and forms the source of the statistical data of fertility; these are usually obtained by drawing a ratio between the number of marriages contracted in a given period, and the number of children born in the same period.

The fertility of women is a function beginning at an age varying in dependence on many conditions, and undergoing extinction at a definite period of life. It is, in fact, associated with the duration of the sexual life of woman, and, generally speaking, extends from the sixteenth to the fiftieth year of life. Climate, race, constitution, and morbid conditions, influence alike the first appearance of menstruation and the first pregnancy; and as they influence the duration of menstrual activity, so also do they influence the duration of fertility.

In the Bible are recorded numerous instances of the early commencement of fertility. At the present time also, in warm climates we meet with many examples of early motherhood. From the great work of Ploss-Bartels, from which we have already frequently quoted, we extract and summarize the following ethnographical details. Among the wives of the Bosjesman, mothers aged ten are frequently seen; travellers in New Zealand often saw mothers of eleven years, and mothers of the same age among the Samoyedes and in Palestine; mothers of twelve in British Guiana, in Jamaica, among the Schangallas, at Shiraz in Persia, among the Copts in Egypt; mothers aged thirteen in Cuba, among the Sioux and the Dakotas, and in New Caledonia; mothers aged fourteen among the Negroes of Gaboon.

According to the observations of Robertson, of sixty-five Indian women there gave birth for the first time:

At the age of 10 years	1
At the age of 11 years	4
At the age of 12 years	11
At the age of 13 years	11
At the age of 14 years	18
At the age of 15 years	12
At the age of 16 years	7
At the age of 17 years	1

Moreover, in the records of European countries, we find numerous instances of very early motherhood. Molitor’s case, a girl nine years old giving birth to a vesicular mole with an embryo; von Haller’s case, pregnancy in the ninth year of life; Carus’ case, pregnancy at the age of eight. Caspar saw a girl in Berlin who became pregnant at the age of twelve, and was delivered of a living child. Rüttel saw a girl nine years of age pregnant. King attended the confinement of a girl who at the time of her delivery was not yet eleven years old. Taylor reports the case of a girl twelve years and six months of age who was then in the last month of pregnancy. Koblanck attended a girl of fourteen who was delivered of a child weighing four and a half pounds.

In most of these cases the premature fertility is followed by a premature cessation of fertility. And there is more or less truth in Bruce’s statement regarding the Arab women in Africa, that those who began to bear children at the age of eleven were seldom still fertile at the age of twenty.

At times we may observe a remarkable extension of fertility beyond the average age, that is, beyond the age of fifty years.

In northern Europe pregnancy at a comparatively advanced age is by no means rare. From the official statistics of Denmark we learn that among 10,000 women, 465 were delivered at ages between 50 and 55 years. In Sweden, of 10,000 mothers, 300 gave birth to children when more than 50 years of age. In Ireland, the proportion of mothers over 50 was 345 per 10,000. In England the official figures dealing with the delivery of 483,613 women, showed that 7,022 were between 45 and 50 years of age, and 167 over 50 years of age.

The Surgical Academy of Paris, in an authoritative statement regarding the late age at which conception could take place, alluded to the fact that Cornelia, of the family of the Scipios, gave birth to Volusius Saturninus when sixty years of age, that the physician Marsa in Venice recorded the existence of pregnancy in a woman of sixty, that de la Motte recorded pregnancy in a woman of fifty-one, and that he believed it to be true that another Parisian woman had given birth to a girl at the age of sixty-three, and had herself suckled the infant.

In an important case, however, which came before the Court of Chancery in England, the court held that there was no definite evidence of the possibility of pregnancy in a woman sixty years of age; but that the greatest age at which, in England, pregnancy had indisputably occurred, was 54.

Among 4,925 deliveries occurring in the Prague Maternity Hospital, Schwing reports that there were 9 women delivered for the first time when over 40 years of age. Of these:

3 were 41 years of age.

2 were 42 years of age.

1 was 43 years of age.

2 were 44 years of age.

1 was 47 years of age.

Haller reports the cases of two women who gave birth to children, one at the age of 63, the other at the age of 70 years. Meissner delivered a woman of 60 years of her seventh child; Rush attended the delivery of a woman aged 60; Dewees that of a woman aged 61. Mende and Bernstein report cases of delivery at the age of 60. Marion Sims saw, in the state of Alabama, a negro woman 58 to 60 years of age, who gave birth to a child at this age, at an interval of twenty years since her last pregnancy. Nieden reports a case in which the first pregnancy occurred 26 years after marriage. When married, the wife was 18 years of age, the husband 30; during their first twenty-five years of married life there was no sign of pregnancy, but when the wife was 44 years of age, menstruation, hitherto regular, suddenly ceased; the cause of the cessation proved to be pregnancy, and at term a healthy girl weighing nine pounds was born; the mother was able to nurse the child herself. Smith attended a woman aged 52 who was delivered of twins; the youngest of her eight other children, who were then all living, was ten years of age.

Rodzewitsch collected from the Russian literature of the years 1872 to 1881, eleven cases in which women aged 50 to 55 had given birth to children. Talquist reports that in Finland, in the year 1883, a woman 58 years of age was delivered; whilst Ansell records the case of an Englishwoman who became a mother when 59 years of age. John Kennedy records the case of a woman of 62 who was normally delivered at this age; she had begun to menstruate at the age of 13, and since the age of 20 had previously given birth to 21 children, the last five when she was 47, 49, 51, 53, and 56 years of age, respectively. Prior even reports the case of a woman 72 years of age, who not only menstruated, but had an abortion(!)

The ideal of fertility in women is that the first completed act of sexual intercourse should be followed immediately by conception, that the pregnancy should terminate after the normal lapse of time in the birth of a child, and that the same process should be repeated at intervals of about ten months until the end of active sexual life. In actual experience, however, this never occurs. Fertilization as an immediate consequence of the first act of sexual intercourse (which in the lower animals is regarded as the rule) is a very rare occurrence in human beings. Moreover, in no single marriage is the reproductive capacity of the wife utilized to the full, up to the time of extinction of her generative faculty; either because the potency of the male partner undergoes a gradual decline, or, it may be, because, after a while, sexual intercourse becomes less frequent, or because precautions against procreation are taken.

The number of children to which during the three decades of her sexual life, from the menarche to the menopause, a woman might theoretically give birth, is never actually born. If we assume that, during the period of active sexual life, a woman requires a period of fifteen months to two years for each pregnancy, parturition, and lactation, a woman could easily during this period have fifteen or sixteen children, and this figure would represent the normal product of the normal fertility of the human female. There are indeed, women who, it may be in consequence of an exceptionally long period of sexual activity, or through giving birth repeatedly to twins or triplets, or because they have married several husbands in succession, have given birth to twenty-four children or even more. In Berlin, in the year 1901, there lived a woman 41 years of age who had had 23 children; there were three women, aged respectively 40, 43, and 46 years, who had had each 21 children; 246 women with families numbering 13 to 20; and 169 women each of whom had given birth to 12 children. In the very great majority of cases, however, the fertility of the wife of the present day is never fully developed. It is modified in various ways by the conditions of marriage, by social circumstances, by considerations relating to the health of husband or wife, by actual illnesses, and by voluntary limitation of fertility. Generally speaking, according to the investigations of Quetelet, Sadler, and Finlayson, the fertility of women is greatest in marriages in which the husband is as old as the wife, or a little older, but without marked difference in age. Marriages contracted at a very early age are less fruitful; the highest fertility is found in marriages contracted when the husband is 23 and the wife 26 years of age.

Conception does not generally take place until sexual intercourse has been frequently repeated. As the result of a statistical enquiry of my own, relating to 556 fruitful marriages, I ascertained that in these the first delivery occurred:

Within 10 months after marriage in 156 cases.

Within 11 to 15 months after marriage in 199 cases.

Within 16 to 24 months after marriage in 115 cases.

Within 2 to 3 years after marriage in 60 cases.

More than 3 years after marriage in 26 cases.

Thus we learn that in 35.5% of the cases the first delivery occurred within 1¼ years after marriage; in 15.6% within 10 months; and in 19.9% within 15 months after marriage; and 11.5% of the cases, the first delivery was more than 1¼ years and less than 2 years after marriage; in 6.0% it was between 2 and 3 years after marriage; and in 2.6%, the first delivery did not occur until more than 3 years after marriage.

From examination of the birth registers of Edinburgh and Glasgow, Matthews Duncan determined the mean interval between marriage and the birth of a living child to be seventeen months. In the majority of cases, the first delivery does not occur until a complete year has elapsed since marriage; in fact, in nearly two-thirds of the instances the first delivery occurs during the second year of married life.

The interval between two successive births is, according to Matthews Duncan, on the average 18 to 24 months, according to Goehlert, 24 to 26 months; the latter, however, points out that in cases in which the child dies very soon after birth, the birth of the next child ensues on the average in 16 to 18 months. In this connection, we must not fail to take into consideration the influence of lactation, inasmuch as mothers who do not suckle their children become pregnant considerably earlier, on the average, than those who undertake this duty. In reigning families, for instance, it is by no means uncommon for the consort to be delivered twice within a single year. The degree to which lactation hinders conception is so widely known, that women often suckle their infant for a very long period, with the definite aim of preventing the speedy recurrence of pregnancy. A high official from the Dutch Indies informed me that for this reason the native women were accustomed to suckle their infants for several years, and that it was by no means uncommon to see a small boy running about smoking a cigar, and then hurrying to his mother in order to be suckled.

The age at which a woman contracts marriage has also to this extent an influence upon her fertility, inasmuch as it appears that those who marry very young are far less fertile than those who marry between the ages of 20 and 25 years; the latter moreover have, on the average, a shorter time to wait for their first conception than women who marry before the age of 20. Women who marry after the age of 25 have to wait longer after marriage for their first delivery; in fact the older the woman after 25, the greater, on the average, the interval between marriage and the first delivery.

Arranging the data already referred to, regarding 556 fruitful women, in relation to this point of view, it appears that the first birth ensued:

	Within 10 months of marriage.	10 to 15 months after marriage.	15 months to 2 years after marriage.	2 to 3 years after marriage.	More than 3 years after marriage.
In 163 women marrying at ages 15 to 20 years	36	53	46	18	10
In 313 women marrying at ages 20 to 25 years	98	113	56	32	14
In 70 women marrying at ages 25 to 33 years	18	30	12	9	1
In 10 women marrying at ages over 33 years	4	3	1	1	1

To give percentages, the first birth occurred,

	Within 10 months of marriage.	10 to 15 months after marriage.	15 months to 2 years after marriage.	2 to 3 years after marriage.	More than 3 years after marriage.
Women marrying at ages 15 to 20 years, in	22.0%	32.5%	28.2%	11.0%	8.1%
Women marrying at ages 20 to 25 years, in	31.3%	36.1%	17.8%	10.2%	4.4%
Women marrying at ages 25 to 33 years, in	25.7%	42.8%	17.1%	12.8%	1.4%
Women marrying at ages over 33 years, in	40.0%	30.0%	10.0%	10.0%	10.0%

Thus whereas in women who contracted marriage between the ages of 15 and 20 years, only 54.5% were confined for the first time within 15 months after marriage, in women who contracted marriage between the ages of 20 and 25 years, in 67.4% the first delivery occurred within 15 months of marriage. And whereas in those who married at the earlier age, the percentage of first deliveries occurring between 15 months and 2 years after marriage was 28.2, in those who married between the ages of 20 and 25, the percentage of first deliveries after the stated interval was only 17.8.

The figures compiled by Whitehead and Pfannkuch give similar results. Of 700 women who married between the ages of 15 to 20 years, there were 306 only who gave birth to a child within the first two years after marriage; whereas of 1,835 women who married between the ages of 20 and 25 years, no less than 1,661 gave birth to a child within two years after marriage—a percentage of 43.7 in the former case, and 90.6 in the latter case. Pfannkuch, as the result of a very large collection of figures relating to this question, found that in women marrying before the age of 20 years, the average number of months before the first delivery was 26; whereas in women marrying after the age of 20 years, the average number of months before the first delivery was 20.

According to Matthews Duncan

Of Every 100 Women Who Marry	There Become Mothers
	In the 1st year of married life.	In the 2d year of married life.
Between the ages of 15 and 20 years	13.71	43.70
Between the ages of 20 and 25 years	18.48	90.51
Between the ages of 25 and 30 years	12.41	75.80
Between the ages of 30 and 35 years	11.44	62.93
Between the ages of 35 and 40 years	9.27	40.97

Sadler examined the relationship between the age at which marriage was contracted and the number of offspring in the case of the wives of English peers. He obtained the following results:

Age at marriage.	Births per marriage.
12 to 16 years	4.40
16 to 20 years	4.63
20 to 24 years	5.21
24 to 28 years	5.43

From exact statistical data of births in the Scandinavian countries of Europe (Denmark, Sweden and Norway), Goehlert compiled the following table, showing the percentages of fertility at various ages:

Ages.	Married Women.			Unmarried Women.
	Denmark.	Sweden.	Norway.	Denmark.	Sweden.	Norway.
Under 20 years.	1.0	1.0	0.7	9.1	7.0	4.9
From 20 to 25 years.	13.9	12.8	11.9	43.9	35.1	37.0
From 25 to 30 years.	26.5	24.7	24.7	28.1	27.9	32.4
From 30 to 35 years.	26.7	26.1	25.3	11.4	16.8	14.9
From 35 to 40 years.	21.0	21.6	21.3	5.4	9.0	7.1
From 40 to 45 years.	9.9	12.0	13.0	2.1	4.2	3.7
Over 45 years.	1.1	1.8	3.1

From this table it appears that the fertility of married women increases steadily up to the age of 35 years, but after this age it begins to decline. What a marked influence the age at marriage has upon fertility is shown by the comparison of the figures relating to married women with those relating to unmarried women; the fertility of unmarried mothers attains its maximum at the ages of 20 to 25 years. In the countries under consideration the average age of women at the time of marriage is 25 to 27 years.

In order to obtain a still clearer picture of the fertility of women in relation to age, Goehlert has combined the figures relating to the married and the unmarried, and then calculated the percentages, with the following results:

Ages.	Married and Unmarried Women.
	Denmark.	Sweden.	Norway.
Under 20 years.	1.7	1.6	1.1
From 20 to 25 years.	16.6	15.1	14.1
From 25 to 30 year	26.6	25.0	25.3
From 30 to 35 years.	25.3	25.1	24.4
From 35 to 40 years.	19.6	20.4	20.0
From 40 to 45 years.	9.2	11.2	12.2
From 45 to 50 years.	1.0	1.6	2.9
Over 50 years.

If, finally, we combine into a single table the figures relating to all three of these countries, we obtain the following results:

Under 20 years	1.5%
From 20 to 25 years	15.3%
From 25 to 30 years	25.6%
From 30 to 35 years	24.9%
From 35 to 40 years	20.0%
From 40 to 45 years	10.9%
Over 45 years	1.8%

From these figures it appears that the maximum fertility of married women is attained, in Denmark at the age of 31, in Norway at the age of 31.7, and in Sweden at the age of 32 years. In the case of unmarried women, the maximum fertility is at the ages of 24 to 26 years. In the Austrian Empire, the maximum fertility of women is attained at about the age of 30 years; in England it is attained between the ages of 20 and 25 years.

Divergent results as regards the fertility of married women at different ages were obtained by Goehlert from the examination of 5,290 cases from the reigning families of Europe. In the favourable position as regards means of subsistence occupied by the members of these families, marriage naturally occurs, in most cases, much earlier in life, the mean age at marriage being between 19 and 22 years—the youngest mother (in the Capet dynasty) was only 13 years of age—and for this reason the figures relating to the younger age-classes are larger than in the previous tables. But as a result of this, the reproductive capacity also undergoes an earlier extinction, so that of these women, not one gave birth to a child when she was over 50 years of age. Goehlert gives the following table, compiled from these 5,290 instances:

Under 20 years	8.8%
From 20 to 25 years	25.4%
From 25 to 30 years	29.4%
From 30 to 35 years	21.6%
From 35 to 40 years	11.5%
Over 40 years	3.3%

In these cases the maximum fertility was obtained at the age of 27.

The physiological fertility of women is much more clearly manifested when we compare the fertility of women who have been married a few years only, with the fertility of women in the later years of married life. In the earlier period, the effective fertility more nearly approaches the physiological fertility, because at this time the various influences by means of which fertility is later so greatly diminished have not yet come into operation. In this connection the following data, published by Körösi, regarding the percentage fertility of recently married women, and that of married women in general, will be found of interest:

	Recently-married women.	All married women.
At ages 20 to 35 years.	32.9%	20.6%
At ages 35 to 40 years.	32.7%	14.7%
At ages 40 to 45 years.	21.4%	5.9%

Inasmuch as we learn from this table that in the case of women aged 40 and upward, the newly married exhibit a fertility of four times as great as that of married women in general, in whom pregnancy has already become rare, we can infer the influence upon fertility of abstinence and of artificial measures for the prevention of conception.

On the average, the maximum fertility of woman, that is, the maximum of effective fertility, is attained at the age of 18 to 20 years. Extreme youthfulness, and also the opposite condition, too advanced an age, when marriage is entered on, impair a woman’s fertility; whereas the conditions most favourable to fertility are that, at the time of marriage, the uterus should have attained its fullest development, and the ovaries also should be completely mature; this is not usually the case at puberty, but rather at the age of 20, 21, or 22 years. In Austria-Hungary, of 100 marriages in which the wife’s age at marriage was less than 18 years, the average offspring in the course of a single year were 36 to 38 children; in the case of 100 marriages in which the wife’s age at marriage was 18 to 20 years, the average offspring in a year were 40; this being the maximum fertility, the number of offspring in a year per hundred marriages (i. e., the percentage fertility), now undergoes a regular decline as the wife’s age at marriage increases; at an age of 25, the percentage fertility is 32; at the age of 30 years, the fertility is 24%; at the age of 35, 17%; at the age of 40 years barely 10%; at the age of 45, 7%; at ages 45 to 50, 0.1%. Thus, from the last figure, we see that of a thousand women marrying at the age of 50 years, one only gives birth to a child. Men obtain their maximum fertility (i. e., procreative capacity) at the age of 25 or 26 years; at this age their fertility amounts to 35% (that is, of 100 marriages at this age, 35 children will on the average be born within a single year); at the age of 35 years, the percentage fertility of men falls to 23; at the age of 45 years, it is 9½%; at 55, 2.2%; at 65, ½% (Körösi-Blaschko).

Whereas hitherto we have considered only the monogenous fertility of married women, we must remember that the figures relating to their biogenous fertility are also of interest—that is to say, the changes which a woman’s fertility experiences in married life in respect of the peculiarities of her husband; and of these peculiarities, the easiest to make the object of statistical investigation is the husband’s age. The age of the husband exercises an important influence upon the fertility of the wife, as is proved by the following figures published by Körösi:

Age of the Father.	Age of the Mother.
	25 years.	30 years.	35 years.
25 to 30 years	35.6%	25.0%	21.2%
30 to 35 years	31.2%	23.6%	19.9%
35 to 40 years	27.5%	21.8%	19.4%
40 to 45 years		16.7%	14.0%
45 to 50 years		14.4%	10.9%
50 to 55 years			10.9%

Also:

Age of the Mother.	Age of the Father.
	25 years.	35 years.	45 years.	55 years.
Under 20 years	49.1%
20 to 25 years	43.0%	31.3%	16.0%
25 to 30 years	30.8%	27.3%	18.5%
30 to 35 years	33.5%	23.7%	14.4%	8.1%
35 to 40 years		18.9%	11.8%	6.7%
40 to 45 years		6.6%	6.1%	3.0%

We learn from these figures that the maximum fertility is exhibited by a woman 18 years of age, when married to a man 25 years of age; less fertile is a woman 25 to 30 years of age married to a man 28 years of age; still less fertile is a woman 35 years of age married to a man 29 years of age. Neither the age of the mother alone, nor that of the father alone, is determinative of the fertility of the marriage, for the fertility of young wives married to elderly husbands is quite different from that of young wives married to young husbands. Very various age-combinations are possible, and each exhibits an average fertility peculiar to itself.

We can also regard the question from the standpoint of the difference between the ages of husband and wife respectively. In this connection, Körösi is led by his tables to the conclusion that wives between the ages of 18 and 20 years attain their maximum fertility when married to men 7 years older than themselves; women of 25 years when married to men 3 years older than themselves; women of 29 years when married to men of the same age; women of 30 years and upward attain their maximum fertility only when married to men younger than themselves. Men, on the contrary, always attain their maximum fertility when married to women younger than themselves. The age of maximum fertility differs in the two sexes, and those marriages will be most fruitful in which husband and wife are each of the age most favorable to fertility. This will be the case when the age of the wife is 18 to 20 years, and that of the husband 24 to 26 or perhaps 29 years.

In connection with the question of fertility, we have also to take into consideration the vitality of the children born, that is, what proportion of those born survive. According to Körösi’s interesting papers regarding the fertility of the inhabitants of Buda-Pesth, we learn that for every 100 marriages which have persisted for thirty years and upward, there were born, on the average, 539 children, of whom during this period 241 died, so that the percentage of survivals was 55.28. Parents who have lost one only of several children must, therefore, regard themselves as exceptionally favoured by fortune.

Social position, occupation, and religion, have, according to the last-quoted author, a notable influence on fertility. His investigations showed that the Roman Catholics and the Jews exhibited the greatest fertility; among the Catholics there were 541 children, and among the Jews 557 children, per 100 marriages. Amongst 100 Protestant families, on the other hand, only 479 children had been born. It will be seen that the theory of the comparatively enormous fertility of the Jewish race is not supported by these statistics. The Jews do, however, exhibit a greater power of rearing children, for among them the marriages of more than 30 years’ duration had 61⅔ % of the children still living; among the Protestants 57¾% survived; and among the Catholics only 52–⅗%. It thus appears that the surviving offspring per 100 marriages of 30 years’ duration were, among the Catholics 278, among the Protestants 252, and among the Jews 349.

The question whether, and to what extent, the age of the parents has an influence on the vitality of the children, is answered by Körösi’s mortality statistics in the sense that mothers below 20 years of age give birth to a larger proportion of children deficient in vital power. Where the mothers had married at the age of 16, the mortality of their offspring was, among Catholics 43%, among Jews 33%; married at 17, Catholic mortality 44%, Jewish 30%; married at 18, Catholic mortality 42%, Jewish 32%; married at 19, Catholic mortality 41%, Jewish 29%; married at 20, Catholic mortality 40%, Jewish 26%. Of the children whose fathers had married at the age of 24, 32% had died; of those whose fathers had married at 23, 37% had died; of those whose fathers had married at 20, 42% had died; and of those whose fathers had married before 20, actually 44% had died. It thus appears that the children alike of very young mothers and of very young fathers have a lessened chance of survival.

Inasmuch as the fertility of the wife is a product of two factors, her own peculiar fertility, and that of the procreating male, the question of the fertility of women cannot be accurately treated independently of this second consideration; hereby, however, is introduced a multiplicity of obscure combinations, by which the value of all the statistical data of fertility in women is seriously impaired.

These data give as the measure of fertility, the number of children per marriage actually brought up, embracing fruitful marriages, sterile marriages, and those not yet fruitful. In Berlin, in Copenhagen, and in Buda-Pesth, the average thus attained was slightly less than three births to each family, whilst the number of children actually living averaged two per family. A more accurate representation of fertility is obtained by ascertaining the number of children born, and the number of children living in relation to the duration of marriages reckoned in years, that is beginning with marriages of one year’s duration, and proceeding year by year to the highest recorded duration of marriage. In this way interesting statistics have been obtained; for example, one who has completed thirty years of married life may count on the average that five or six children will have been born to him, but may also reckon on having buried two or three at least of these. (Körösi.)

Fertility is, as many facts indicate, also dependent on nutrition. A distinct proof, says Spencer, writing on the “Coincidence between high Nutrition and Genesis,” that abundant nutriment increases the number of births, and vice versa, is found among the mammalia; compare, for instance, the litter of the dog with that of the wolf and the fox. Whilst the dog’s litter numbers 6 to 14, that of the wolf numbers 5 to 7, that of the fox 4 to 6. The wild cat gives birth to 4 or 5 kittens once a year, the domesticated cat to 5 or 6, twice or thrice annually. The most remarkable contrast, in this respect, exists between the wild and the domesticated breeds of swine. The wild sow gives birth once a year to a litter of 4, 8, or 10 pigs (the number increasing in successive litters); the domesticated sow has often as many as 17 in a single litter, whilst in two years five litters, each numbering 10 pigs, are commonly born.

Darwin also draws attention to the fact that animals under domestication, being fed more abundantly and regularly than their wild allies, procreate at shorter intervals and are markedly more fertile than the latter. He states that the wild rabbit has four litters annually, each numbering 4 to 8 young; whereas the tame rabbit reproduces its kind six to seven times annually, and gives birth to litters numbering 4 to 11. Among birds, analogous phenomena are observed. The wild duck, for instance, lays 5 to 10 eggs in the course of the year, whereas the tame duck lays from 80 to 100; the wild grey goose lays 5 to 8 eggs, the domesticated goose 13 to 18.

It must be added that this exceptional fertility is manifested in animals that are quite inactive in comparison with their wild allies; not only are they richly fed, but they get their food without working for it. Moreover, it is easy to observe that among the domesticated mammals the well-fed are more fertile than the ill-fed.

That in the human species also, fertility is influenced to a notable degree by nutritive conditions, is shown by statistical investigation. After years distinguished by an exceptionally good harvest the number of children born is considerably greater than in normal conditions; whereas after a famine the opposite is observed. Malthus’s law of population states, inter alia, that the population increases when the amount of available nutriment increases, that is, that favourable nutritive conditions cause an increase, that unfavourable nutritive conditions cause a decrease, of population. Hardships and exhausting occupations diminish the fertility of women. The remarkable fertility of the Kaffirs is referred to the fact that this people, possessing large herds of cattle, lead a life comparatively free from care; it is no less true that the Boer women, who lead a life of well-fed leisure, have very large families; whereas the Hottentot women, poor, ill-nourished, and hard working, seldom bear more than three children.

Generally speaking, it may be said that fertility of the soil, in connection with an easily gained livelihood, favours also human fertility, notwithstanding the fact that certain statistical data seem to conflict with this proposition. Sadler, for instance, concludes that an increase in the price of the necessaries of life does not per se check fertility, but, indeed, rather increases it; he considers that the apparent decline in fertility is due to the fact that the number of marriages diminishes, owing to the rise in prices. We must, however, point out, that an increase in price of the necessaries of life is often associated with a rise in wages, and is therefore not necessarily identified with deficient nutrition; when, however, such a rise in prices leads to actual want, a limitation of fertility will certainly result; this has been proved by Legoyt and Villermé with regard to failure of the crops. Famine and disease lower the number of births; a less severe deficiency of nutriment often lowers only the quality of those born. Malthus was of opinion that the population of a country at any time was related to the quantity of nutriment produced or imported therein, on the one hand, and, on the other, to the liberality with which this nutriment was distributed to the individual. In countries where corn forms the principal crop, we find a thicker population than in pasture lands; and where rice is the principal crop, the population is even more abundant than it is in corn growing countries.

Passing to the consideration of the individual nutritive elements, we find that these also influence fertility. Above all, it has been proved that alcohol notably diminishes the fertility of women. Lippich states that of 100 women in Kärnten and Krain suffering from chronic alcoholism, 28.3 were barren. In England, where the abuse of alcoholic beverages is also very frequently observed in women, the same phenomenon has been noted. Matthews Duncan held that alcohol exercised a specific deleterious influence on fertility. Moreover, in addition to the constitutional disturbances produced by the abuse of alcohol, this beverage also exercises a well-known pathogenetic influence upon the female reproductive organs; with especial frequency, chronic oöphoritis may be shown to depend on this exciting cause.

A diet consisting mainly of fish is known to increase the sexual impulse, and is said also to increase fertility. Further, a diet consisting mainly of potatoes or rice is said to favour reproduction; compare, for instance, the fertility of the Hindoos, who abstain entirely from animal food, and of the Chinese, who live chiefly on rice. Davy maintained that the women of races living chiefly on fish were handsomer and more fertile than others: and Montesquieu suggested that there was an association between the abundant population of sea-ports and also of Japan and China, and the large quantity of fish consumed in those places. On the other hand, a diet consisting chiefly of meat is said to have an unfavourable influence in this direction; in support of this view it is pointed out that races living by the chase, and living therefore almost entirely on meat, have very small families. This generalization is invalidated by the fact that Englishwomen, who eat far more meat than the women of the Latin races, are nevertheless distinguished by their great fertility.

In his “History of Civilisation in England” Buckle writes: “The population of a country, although influenced by many other conditions, unquestionably rises and falls in proportion as the supply of nutriment is abundant or the reverse.” Herbert Spencer also states that “every increment in the supply of nutriment is followed by an increment in fertility.”

It must not be forgotten that, in addition to the more or less abundant supply of nutriment, there are always other influences affecting fertility; the general mode of life, race, climatic conditions, etc., may, in various ways, co-operate with or countervail the influence of nutritive conditions. If, with the best possible supply of nutriment, there is associated a luxurious and enervating mode of life, the abuse of alcohol, severe intellectual exertion, or sexual excesses, the general result will be a diminution in fertility. And it is easy to understand why Cros, although perhaps with little justification, goes so far as to regard easy circumstances as an active cause of depopulation. “It is the poor,” he writes, “and the less wealthy departments of France, in which we find the most children.” In estimating fertility, however, we must never fail to take into consideration the more extensive employment of means for the prevention of pregnancy among the upper classes of society.

To a certain extent we can trace the influence of climate and of season upon fertility. Heat appears to favour fertility; Haycraft’s figures for the eight largest towns of Scotland show clearly how the number of conceptions rises and falls pari passu with the temperature. Lower animals also, when brought from a colder to a warmer neighbourhood, exhibit an earlier and more frequently recurring “heat.” In Europe, however, the Northern races appear more fertile than those of the south.

Of the seasons, spring is the one especially favourable to fertility. Quetelet, who proves by numerous statistical data that the maximum of conceptions occurs in May, attributes this fact to a general increase in the vital forces occurring in spring, after the cold of winter. Villermé, however, goes back to the older explanation, that the increase in the number of conceptions in May and June is due to social and economic conditions. The return of spring, especially the end of spring and the beginning of summer, a time of year in which the means of subsistence are provided in exceptional quantity, and of especially good quality, the season also of festivals and social reunion, when the two sexes are brought into more intimate contact and when the majority of marriages occur—these are the conditions associated with the season of greatest fertility. The figures of Wappaeus also confirm the influence of spring in favouring fertility. He found, however, that there were two seasons of maximal fertility. The first at the end of spring and the beginning of summer; the second in winter, especially in December. Mid-winter is for most people a period of domestic amusement and relaxation, one of exceptionally good nutrition, and of social reunion; the spring increase in fertility is a part of the awakening and increase of the reproductive forces of nature at large, which recurs every spring-time.

Every marked and sudden change in the mode of life has an unfavourable influence on fertility. Darwin reports that mares who have for some time been stall-fed with dry fodder and are then put out to grass are at first infertile after the change. Europeans going to reside in the tropics experience a notable decline in fertility as a result of the change of climate. According to Virchow, the fertility of European women who become acclimatized in the tropics declines very gradually, but in the course of a few generations is almost completely annulled.

The marriage of near kin is believed also to diminish fertility. As regards inbreeding in the lower animals, it is well known that when nearly related animals copulate, the number of the offspring is below the average. Nathusius paired a sow with its own uncle, the boar having proved productive in intercourse with other sows; the litter numbered five to six only. This sow, which belonged to the great Yorkshire race, was then paired with a small black boar, which in intercourse with sows of its own variety had procreated litters numbering six or seven; as a result of her first pairing with the black boar, the sow cast a litter numbering twenty-one whilst the second attempt produced a litter of eighteen. Similar results were obtained by Crampe, in his experiments in the inbreeding of rats.

Some authorities declare that the results of inbreeding are similar in the human species, that the marriages of near kin are less fruitful than the average. Darwin writes in this connection: “With regard to human beings, the question whether breeding in-and-in is also deleterious, will probably never receive a direct answer, for man reproduces his kind so very slowly, and cannot be made the object of experiment. The very general disinclination of nearly all races to the marriage of near kin, which has existed from the very earliest times, is of weight in relation to this question. Indeed we appear almost justified in applying to the human race the experience gained by experiment on the higher mammals.”

Darwin’s assumption regarding the effect upon fertility of the marriage of near kin in the human species, cannot, however, be accepted without qualification. In ancient times there was no uniformity of opinion on this topic. It is well known that among the Phœnicians, a son might marry his mother, and a father his daughter; and among the ancient Arabs it was the legal duty of the son to marry his widowed mother. Moses, on the contrary, forbade marriages between parents and children, between brothers and sisters, also marriage with a father’s sister, with a wife’s mother, and with an uncle’s widow.

Darwin considered that the marriage of first cousins was not unfavourable to fertility. Of 97 such marriages, 14 were sterile, whilst of 217 marriages of those not akin, 35 were sterile; the percentage in both cases being almost identical. Mantegazza, who regards kinship in marriage as unfavourable to fertility, found nevertheless that among 512 marriages of near kin, only 8 to 9% were sterile. It is widely believed that the dying out of many aristocratic families is dependent on the inbreeding so common in this class—but it must be admitted that scientific evidence in support of this belief is lacking. Incest in the human species may certainly result in fertilization. Among the Jews, marriages of near kin are very common, and often prove extremely fruitful.

Göhlert made a statistical investigation of the fertility of the reigning families of Europe, in order to throw light on this question. In the Capet dynasty, 118 marriages of near kin took place, and of these 41 were sterile; in the Wettin dynasty (Saxony), there were 28 such marriages, of which 7 were sterile, and 1 produced one child only; in the Wittelsbach dynasty (Bavaria), 29 such marriages, of which 9 were sterile, and 3 produced only one child each. Thus of 175 marriages of near kin, 57, or 32.6% remained sterile. Further, in the Habsburg-Lothringen dynasty, of 110 marriages, 25 were marriages of near kin, and of these 33% remained sterile.

It has been assumed since the days of antiquity that temperament and constitution exercise some influence on fertility. Hippocrates, Soranus, and Diokles, are among the ancient authors who refer to this matter. Soranus says very justly: “Since most marriages are contracted, not from love, but for the procreation of children, it is irrational, when choosing a wife, to have regard, not to her probable fruitfulness, but instead of this to the social position and the wealth of her parents.”

It would appear that a certain dissimilarity in physical constitution and temperament between husband and wife is favourable to the fertility of the marriage. For instance, a vivacious, dark husband, and a lethargic, fair wife, are better suited to one another than a husband and wife both extremely active, or both of extremely phlegmatic temperament.

Toussaint Loua published the following figures regarding the fertility of the women of the various countries of Europe:

Country.	Number of births per hundred inhabitants.	Fertility of Women Between the Ages of 15 and 45 Years.
		Married.	Unmarried.	Average.
Hungary	4.94			17.8
Russia	4.12			20.5
Austria	3.93			16.4
Germany	3.77	34.8	2.9	17.7
Italy	3.67	28.8	2.4	16.1
Holland	3.67	35.3	1.0	16.0
Finland	3.63			15.8
England	3.58	29.7	1.6	15.5
Scotland	3.53	32.8	2.5	15.8
Belgium	3.25	33.7	1.8	14.8
Denmark	3.12	28.5	2.8	14.4
Roumania	3.12			13.5
Norway	3.10	29.3	2.2	14.0
Sweden	3.05	29.1	2.5	13.7
Switzerland	3.04	29.7	1.1	13.1
Greece	2.96			13.2
Ireland	2.69	29.8	0.5	12.3
France	2.63	20.3	1.8	11.6

In towns, conjugal fertility is less, extra-conjugal fertility greater, than in the country. An increase in factory labour gives rise to an increase in the population, but to a decline in the vitality of the offspring; that is to say, it causes a quantitative increase, and a qualitative decrease, in fertility. An increase in agricultural labour has precisely the opposite effect. The influence of war upon fertility is unfavourable both quantitatively, and qualitatively. According to Tschouriloff, the introduction of universal military service, by withdrawing for a time all the most vigorous men from domestic life, tends to diminish fertility. Extensive emigration from a country in which the soil is fertile, and where the vital conditions are generally favourable, is stated by Bertillon to cause an increased fertility in the mother country; he further states that an increase in the number of the proprietors of the soil is followed by diminished fertility, and vice versa.

Prostitutes show as a rule a very low fertility. According to the data of Tarnowskaja, the fertility of prostitutes in Russia is 34%, whilst married women of similar ages in Russia exhibit a fertility of 51.8%. Gurrieri found 60% of prostitutes childless.

The fertility of female criminals was found by Lombroso to be undiminished. On the average, poisoners had given birth to 4.5 children, other murderesses to 3.2 children, child-murderesses to 2 children; thus the prisoners whose crime is commonly dependent on an abnormal eroticism had a fertility above the average.

The diminished fertility of prostitutes depends in part upon frequent venereal infection, in part upon the unfavourable influence of the mercury and iodide of potassium administered for the cure of such infection, also upon the frequency with which they consume excessive quantities of alcohol, upon the excessive frequency of coitus, which exercises a traumatic influence, upon the irregular mode of life, and upon their disinclination to be burdened with children.

Conjugal fertility, that is to say, the ratio between legitimate births and the number of married women between the ages of 15 and 50 years, has declined in Germany during the last decades. It was:

During the years 1872 to 1875	29.7%
During the years 1879 to 1882	27.4%
During the years 1889 to 1892	26.5%

This decline is small, but it is much more manifest in urban than in rural districts. This fact is shown by the following figures, relating to fertility in Prussia:

	1872 to 1879.	1894 to 1897.
In all towns	26.9	24.0
In Berlin	23.8	16.9
In other large towns	26.7	23.5
In rural districts	28.8	29.0

This difference depends principally on the fact that in the large towns of Germany (and still more in those of France) the use of means for the prevention of pregnancy is continually increasing, whereas the population of the rural districts is as yet less familiar with the use of these measures.

According to Hellstenius, conjugal fertility, that is, the number of children per married couple, is as follows:

In the	Netherlands	4.88
	Norway	4.70
	Prussia	4.60
	Bavaria	4.55
	Sweden	4.52
	Saxony	4.35
	England	4.33
	Belgium	4.23
	Denmark	4.18
	France	3.46

Talquist, who has published a statistical investigation concerning the modern tendency to diminished fertility, arrives at lower figures than Hellstenius. According to him, conjugal fertility is:

In	Prussia	4.11
	England	4.10
	Belgium	4.12
	France	2.09
In	various States of the American Union	2.5 to 3.0

From the Almanach de Gotha Vacher obtained figures showing that each family of the higher aristocracy has on the average the following number of children.

In	France	2.0
	Italy	3.0
	Germany	4.8
	England	4.9
	Russia	5.1

According to the figures we have published, the fertility of women suffices for the production during the sexual life of a small number only of children, averaging, in fact, 4 to 5 children per marriage. Many mothers, however, give birth to a very large number of children. Among 73,000 families inhabiting Buda-Pesth, Körösi found 300 mothers who had had 15 children or more; 7 mothers who had each had 21 children; and 3 mothers who had given birth respectively to 22, 23 and 24 children.

A newspaper report states that the wife of a citizen of Buda-Pesth, during the 43 years of her married life, gave birth to 32 children. In the year 1902, a Bohemian woman gave birth to her twenty-fourth child. Stieda reports the cases of two mothers, one of whom had 21, and the other 23 children. The wife of the German Emperor, Albrecht I, and the wife of Prince Jost of Lippe-Biesterfeld, each bore 21 children.

The so-called two-children-system obtains most commonly in France.

It is true that even in France there are on an average nearly three children born per marriage; but if we take into account surviving children only we find an average per family of 2.1 children only. Similar conditions obtain in New England, and in Transylvania; and the same practice is spreading throughout the United States. Another way in which the attempt is made to keep down the population is that customary in Alsace, where, if there are several children in a family one only marries, in order to avoid a division of the family property. It cannot be denied that in France, doubtless in consequence of the two-children system, a somewhat widely diffused prosperity exists, a prosperity which is lacking in the rare districts in France, such as Brittany, in which limitation of the family is not practised. What a disastrous influence the general use of measures for the prevention of pregnancy exercises on the military power and political status of a nation has, however, in recent years been made especially manifest in the case of France. In that country, of ten million families, two million are absolutely childless, and two million have only one child each, so that two-fifths of the French families are as good as inactive in maintaining the population of the country. The injury thus done to France is shown still more clearly by a tabular comparison of the excess of births over deaths in the German and French nations, respectively, during the two decades 1874 to 1894 (from G. von Mayr’s Population Statistics).

Year.	Germany.	France.
1874	+13.4	+4.8
1875	13.0	2.9
1876	14.6	3.6
1877	13.6	3.9
1878	12.7	2.6
1879	13.3	2.5
1880	11.6	1.7
1881	11.5	2.9
1882	11.5	2.6
1883	11.7	2.6
1884	11.2	2.3
1885	11.3	1.4
1886	10.8	1.5
1887	12.7	1.3
1888	12.9	2.5
1889	12.7	1.2
1890	11.3	–0.3
1891	13.6	–0.5
1892	11.7	+0.1
1893	12.2	–1.2
1894	13.6	–0.4

To what an extent in all times, and among all peoples, the fertility of women was esteemed, is shown by religious writings and traditional customs which aimed at enabling a wife who had had no children by her own husband, to seek other conjugal embraces. Among the Jews, it was the duty of a man to marry his widowed and childless sister-in-law; if he were unwilling or unable to perform this duty he was compelled to take a part in a ritual termed “chaliza,” in which his foot was bared and the bereaved woman spat upon him, because he was unwilling to maintain his brother’s house. In the law book of the Hindoos of Manus, we read, “If husband and wife have no children, it is proper for them to obtain the desired offspring by a union between the wife and the husband’s brother, or some other relative;” the child obtained in this way was legally regarded as the child of the husband. Confucius wrote: “If your wife is barren, take a second wife; she must be subordinate to the first wife, for her only duty is the bearing of children.” An analogy to this ordinance is to be found in the Bible; Abraham’s barren wife Sarai says to Abraham: “Behold now, the Lord has restrained me from bearing: I pray thee, go in unto my maid; it may be that I may obtain children by her. And Abraham hearkened unto the voice of Sarai.” In the same way the barren Rachel speaks to her husband Jacob, “Behold my maid Billah, go in unto her; and she shall bear upon my knees, that I may also have children by her.”

Luther, in his treatise on marital love published in the year 1522, bases, doubtless on the above biblical precedents, the following statement regarding fertility: “If a sexually potent woman is married to an impotent man, if she is unable to take any other man openly, yet is unwilling to do anything dishonourable, she should say to her husband, “Dear husband, you cannot fulfil your duty to me, and you have deceived my young body, you have endangered my honour and my happiness, and in the eye of God our marriage is null, forgive me therefore if I form a secret union with your brother or with your nearest friend; the fruit of this union will be yours in name, thus your possessions will not fall to strangers, and you will willingly allow me to deceive you, because involuntarily you have deceived me.””

In ethnography, the term endogamy is used to denote a law or custom by which marriage is allowed only within the limits of a specified race, tribe, or caste; thus, in the Old Testament, Jews are forbidden to marry women of other races. The ethnographical term exogamy indicates the prohibition of marriage between persons who are more closely allied, as, for instance, the Mosaic prohibition of marriage within certain degrees of blood-relationship. Such exogamic prohibitions persist even in the legislation of the present day. In many ecclesiastical and national laws we find the marriage of first cousins and of uncle or aunt with niece or nephew forbidden; and even a prohibition of the marriage of a man with his deceased wife’s sister.

Hegar considers the danger of inbreeding to be very great in the human species; for whereas in the lower animals breeders employ a methodical and carefully considered selection of the best specimens, nothing of this kind occurs among human beings; and the health of modern civilized man is such that there are few families without a skeleton in the closet. “Not only in families, but also in villages, in small and large towns, even in classes, and in entire nations, certain peculiar qualities, morbid tendencies, and predispositions, are handed down from generation to generation. We have, for instance, the tendency of the Jews to nervous disorders and diabetes, that of the English to gout, that of the Germans to myopia.” Strahan has therefore employed the term “social consanguinity,” to indicate that by means of common customs, environment, occupation, and mode of nutrition, a similarity in type is produced, leading to a similar predisposition to disorders and diseases transmissible from father to son.

The dangers of inbreeding are believed by Hegar to be, under present-day conditions, so considerable that he would allow the marriage of near kin in exceptional cases only, and where the circumstances are peculiarly favourable—for instance, where both parties to the projected marriage are in excellent health, and where there is no great similarity between them in feature or mental type. Certain anomalies transmitted from remote ancestors, dependent on deeply-marked peculiarities of the germ cells, may be so developed by inbreeding as to become absolutely fixed characteristics. If the morbid manifestations can be traced back for several generations, if the bodily defects and disturbances of development (the so-called stigmata of degeneration), are well marked and numerous, if the functional disorders of the nervous system and of the sense organs are pronounced, leading to idiocy, insanity, epilepsy, congenital deafmutism, blindness, instinctive criminality,—there is in such cases little or no hope of the regeneration of the family. It dies out, because the members are sterile; because they are confined in prisons or asylums; or because the children, if any are born, are deficient in vitality, and fail to reach maturity.

According to the brief summary of the subject given by Hegar, the peculiarities of the offspring at the time of birth depend upon:

Factors which give rise to peculiarities of the germ-cells:

I. Germinal rudiments derived from the ancestors;

II. Influences acting on the germ-cells within the parent organism;

a. Owing to peculiarities of the fluids and tissues of the parental body;

b. Owing to substances which penetrate the parental body and reach the germ.

Germinal rudiments altered by the conjugation of the male and female reproductive cells:

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.