Contraception/Chapter 1

THE community in a beehive deals with its population problems according to the needs of the varying seasons, and in ways calculated to yield results ensuring the well-being of the hive regardless of the lives of individuals. In the spring populations are hastened into existence; in the autumn individuals once carefully reared are ruthlessly slaughtered.

The human community, guided by less clear and logical instincts, does not so definitely correlate its racial activities with the changes in its circumstances. Nevertheless, although it be unconsciously, the general drift and trend of events does, to some extent, control the production of human beings although such control is so ill-adjusted to the circumstances that many individuals suffer acutely and needlessly. The victims ​of unconscious forces such as diseases, wars, and famines in excessive populations, have always been harried; but these blind "checks to population" have not been the only regulators of the populations as is often supposed; steadily, though invisibly, conscious control, however ineffective, has been exerted, in the form of infanticide, abortion or control of conception of some sort.

A recent monograph by Carr-Saunders^[1] developed well, and with a wealth of illustrative detail, the theme of optimum populations which all nations at all times have tended toward achieving consciously, though in the past often by the primitive and painful means of taboos, abortion and infanticide on the one hand, or by polygamy on the other. Carr-Saunders shows convincingly that the theory of Malthus has long been disproved, though it is still dinned into the ears of the uncritical public by persons insufficiently documented, and incapable of the serious application of thought. He says (p. 201): "This idea of an optimum number is one which can be developed in great detail. It is only necessary here to ​notice that when, as in the higher economic stages, the arts of production on the one hand are improving, and the habits and so on of any people are on the other hand constantly altering, the most desirable density is in consequence frequently changing. In the lower stages, when progress in skill is slow and social conditions more or less stationary, the optimum number may remain about the same over long periods of time. . . This idea of an optimum density of population is wholly different to that put forward by Malthus. To him the problem was one of the relative increase of population and of food; with us it is one of the density of population and of the productiveness of industry."

Killick Millard, in a general consideration of the various aspects of birth-control, very truly concluded that "The fall of the birth-rate is not a symptom of national decadence, but a mark of advancing civilization."^[2]

In the course of its history every civilization, every community, has been faced at different times both by excess of population and by the lack of certain elements in the ​population which were, perhaps temporarily, desirable. Mercier^[3] said, "As an historical fact, there has never been any nation, people, or language, however little removed from barbarism, or even savagery, in which infanticide, the practice of abortion, or the limitation of conception, has not prevailed extensively. The three practices are complementary to one another, and where any of them is effectually forbidden, one or other of the remaining two will become efficient. Of these three modes, the prevention of conception is the most innocuous, and however we may deprecate its prevalence in excess, it is chimerical to suppose it will ever be abolished, nor is it desirable that it should be."

Hitherto no population has intelligently controlled the conception of its units in such a way as to meet its real needs. But for long past thoughtful individuals have controlled their own families. They have done so by various means, presumably the best available to their limited knowledge. The demand that knowledge of contraception shall be extended both in its range and application is now so great that medical ​practitioners in England at the present time must give attention to the subject. This necessity is all the more urgent because economic conditions are such that at present many people will not and dare not increase their families, and they use any means known to them to prevent the birth of a living child. The result too often is the use of harmful contraceptives. Further, alas, it is true that even in our most civilized cities there are many to whom abortion by some means or other is the only method known by which they can limit the size of their families. Official evidence of this is difficult to obtain, for unless something unexpectedly goes wrong no woman allows it to be known that she has practised abortion. Yet so recently as this year (1922) the American Journal of Obstetrics and Gynecology says, "It has been estimated that in New York City alone there are 80,000 criminal abortions annually,"^[4] and large numbers of "therapeutic abortions in addition."

In later chapters some attention will be given to an historical survey of the deliberate control of populations by various nations, but meanwhile, as this book is addressed to ​medical practitioners, we will enter immediately upon that which is its prime concern, namely, the practical aspects of the problem which to-day faces almost everyone in his own family practice. Whatever may be the ultimate needs of our race, whatever were the recent habits even of the passing generation, the undoubted, fact of the immediate present is that for a variety of sound reasons medical practitioners are daily called upon to advise patients who are involved in the problems of the individual control of their own reproductive powers.

The medical man has, or may have, on his shelves many textbooks and memoirs on almost every conceivable branch of medical practice, with the exception of this subject, the most vital of all to the health and well-being of his most important patient, the fertile married woman. On contraception no comprehensive scientific manual exists, and it is four years since my first small scientific text was published. There is, therefore, little need to apologize for adding the present work to the enormous number of books extant, since among them all no other covers the field from which its harvest will be drawn, and few other themes are of greater moment to the individual or to the nation.

​The medical practitioner, too long trained as a doctor of disease, is. beginning to realize that his prime function is the preserver of health. As so large a proportion of female ill-health can be directly traced to an excessive number of pregnancies in too rapid succession, and to pregnancies under unsuitable conditions, it is obvious that the proper use of contraception as a fundamental health measure is the practitioner's concern. Havelock Ellis tersely said:^[5] "We possess in birth control an invaluable instrument, not merely for immediate social betterment, but for the elevation of the race." Nevertheless, "as carried on at present, neo-malthusian methods may even be dysgenic rather than eugenic, for they tend to be adopted by the superior stocks, while the inferior stocks, ignorant and reckless, are left to propagate freely. This unfortunate result is encouraged by the notorious failure—still so conspicuous amongst us—to spread the knowledge of contraceptives among the classes which from the eugenic standpoint most urgently need them."

In the interest of the race "feeble-mindedness, hereditary insanity, and hereditary criminal tendencies (if such occur) ​should be nipped in all the buds they show. Individuals showing these traits definitely should not be allowed to reproduce."^[6]

Moreover, the time has come when the ordinary patient is no longer content to be kept in ignorance by her medical practitioner, and when she is learning that if her own doctor refuses her or is incapable of giving her the information she demands, there are other sources of knowledge and other doctors who will comply with her reasonable request.

So long as such facts as appear in the Annual Report of the Ministry of Health are true, so long will women continue to demand that their sacrifice shall be made at least voluntarily. "The death-rate of women in childbirth remains approximately what it was twenty-five years ago, and we lose by death every year upwards of 3,000 mothers . . . a substantial number of the 700,000 who gave birth to children in 1919 were so injured or disabled in pregnancy or childbirth as to make them chronic invalids."^[7]

Individual practitioners, therefore, all ​over the country are taking an unprecedented interest in contraceptive methods, and many are feeling justly aggrieved that no information on the subject was included in their academic courses of training. A few letters selected from large numbers in the possession of the author of this book are given in Chapter XIII, p. 368, and indicate feelings which are widespread. A modern and humane civilization must control conception or sink into barbaric cruelty to individuals. What our progenitors achieved crudely and clumsily, often painfully, we, aided by modern scientific knowledge, can and should achieve painlessly and precisely.

Apart from the needs of individual patients, a word should be said of the national, indeed the racial position. For want of contraceptive measures the low-grade stocks are breeding in an ever-increasing ratio in comparison to the high-grade stocks, to the continuous detriment of the race. Hence the medical practitioner who has a practice among the poor and ignorant, and particularly among the low-grade elements, has a double duty to inculcate contraceptive knowledge, a duty to his individual patients and a duty to the State. This aspect of the subject will not be enlarged upon in this book, but is ​well expressed in the following quotation. from Holmes^[8] (p. 139): "We are losing the elements of our population that have achieved success financially, socially, or in the field of intellectual achievement. Speaking generally, none of these classes is reproducing itself." [They are now taxed into relative penury in comparison with the demands on them.] This condition is quite as bad in Europe, at least in several countries, as in the United States. It constitutes a very serious menace to our present social welfare, and one which is striking at the very roots of our civilization. The menace is all the more dangerous because its effects do not, like those of war, pestilence, or famine, obtrude themselves upon our notice. The forces for evil that work insidiously are the most to be feared because they may produce great havoc before they are detected, or at least before the extent of their damage is adequately realized. The elements of the population that are of subnormal mentality exhibit at present the highest degree of fecundity."

Professor E. Alsworth Ross, one of ​America's greatest sociologists and the original coiner of the much used phrase "race suicide," came to this racially serious conclusion years ago. By 1912^[9] he was awake to the danger of the swamping of the good old American stock by the too prolific immigrant stock and he recently made impressive public utterances to the effect that changed conditions have changed the meaning of the phrase he coined so long ago and "race suicide" to-day is to be seen in unrestricted breeding.^[10] In short, that the world is in greater danger from the stork, than it is from the eagle or the vulture.

It is the medical man's business to tame and control the stork.