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.”