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.

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).

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.

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 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.