Book Review

Contraception and Abortion from the Ancient World to the Renaissance

Contraception: Newer Pharmacological Agents, Devices, and Delivery Systems

N Engl J Med 1993; 329:143-144July 8, 1993

Article

Contraception and Abortion from the Ancient World to the Renaissance
By John M. Riddle. 245 pp., illustrated. Cambridge, Mass., Harvard University Press, 1992. $39.95. ISBN: 0-674-16875-5

Contraception: Newer Pharmacological Agents, Devices, and Delivery Systems
Edited by Regine Sitruk-Ware and C. Wayne Bardin. 228 pp., illustrated. New York, Marcel Dekker, 1992. $99.75. ISBN: 0-8247-8700-5

These two books approach the topic of birth control from very different perspectives. Riddle's work represents a historian's sweep over some millennia; that of Sitruk-Ware and Bardin presents the views of 27 scientists focused on just a few decades. Not surprisingly, the single-author format of the historian's review is stylistically more attractive, whereas the multiauthored book ranges all the way from pithy, well-formulated reviews to verbose, journal-type boilerplate. But the same question can be asked about both books: Who are the intended readers?

Riddle's survey, with 64 pages of notes and references, will be useful to historians of birth control -- clearly a minute circle. But general readers do not need 32 entries in the index for the reputed use of pennyroyal in indigenous birth control, or 45 entries for rue or 26 for myrrh. Instead of overkill, such readers want instruction and some amusement., and Riddle can offer both.

In Aristophanes' Lysistrata (411 B.C.), Athenian women withhold their sexual favors until their men stop waging war. By describing a woman as “a very lovely land, well cropped, and trimmed, and spruced with pennyroyal,” Aristophanes was doubly clever: the word for “land” in Greek is also applicable to female genitalia, and the reference to pennyroyal implies the practice of birth control through the alleged abortifacient effect of this plant, which is handsomely illustrated in a 13th-century drawing.

Throughout the book, the historian naively implies that such remedies from past centuries should be used more widely by today's sexually active couples, while ignoring his own answer: “In 1978, three women in Colorado, believing themselves pregnant, read that pennyroyal induced an abortion and took its oil.” According to Riddle, one died, another was hospitalized, and only the third was seemingly unharmed.

The book is replete with attempts -- some absurd, others more plausible -- to provide rational explanations for the reputed use of such home remedies. Under the heading “Dioscorides and Oral Contraceptives,” we are presented with a recipe for a contraceptive agent consisting of white poplar and mule kidney. Since willows are reported to contain estriol (many plants contain steroidal as well as nonsteroidal estrogens) and white poplar belongs to the same plant family (Salicaceae), Riddle hypothesizes that the claimed contraceptive efficacy is due to estrogen. Furthermore, estrogens might be expected to be found in horses' kidneys because they have been found in horses' urine. But since the prescription referred to mule, rather than horse, kidneys, Riddle invokes “the ancient principle of `like causing like'; eating a mule's kidney could be thought to cause sterility, on the same principle that a man would eat a bull's testicles for virility.”

Lay and technical readers alike will be put off by the overabundance of hodgepodge in Riddle's book and by the clumsy organization -- first in chronological order and then according to classical authors -- reflecting a historian's bias. A great deal of repetition could have been avoided by organizing the book according to the putative mode of action and then the species of plant or animal, because there are interesting leads hidden among the “burned testicles of castrated mules” and the “scorpion of the sea on wool pad,” some of which have been examined by modern pharmaceutical companies. The ultimately unsuccessful investigations of Mexican zoapatle by scientists from one company and of miroestrol of Thai origin by researchers of another company could have been described to show why indigenous therapeutic practices should not be romanticized and why the extremely time-consuming and expensive road from reputed indigenous consumption to final acceptance based on contemporary standards of efficacy and safety should not be skipped.

Sitruk-Ware and Bardin, in their quite different book, attempt to review recent and prospective improvements in contraception. (Not one of the methods described in their book, it should be noted, is based on leads from indigenous medical practice.) I am puzzled about the intended readership of this book even more than I am about that of Riddle's. It can hardly be aimed at the cognoscenti wishing to be brought up to date on new developments, since the coverage of the literature stops for the most part in 1988 or 1989. Some chapters are virtual research reports overloaded with highly esoteric details, whereas others are concise surveys addressed to nonspecialists.

Is the book addressed to the controllers of public and private purse strings, or to policy makers wondering how to undo the devastation of research and development on contraception that occurred during the Reagan-Bush years? Are such readers likely to pay the obscene price of almost $100? At nearly 50 cents a page, one could construct a highly readable condensate for $19.95 by distilling the important ingredients from the highly diluted starting material, as follows.

I would retain much of the first chapter. This is an excellent precis of topics relevant to all new contraceptives (the risks of cancer, the crucial need for better post-marketing surveillance, the dubious value of obligatory animal models, the noncontraceptive benefits, social expectations, and cost implications). It also summarizes in one superb table -- well worth the 50 cents for one-page coverage -- the pros and cons of the methods described in the next five chapters, which, with one exception, can be skipped because they are mostly research reports of material already published elsewhere.

The one detailed chapter that would merit inclusion in my condensed version is the masterly review of the Norplant levonorgestrel implant by Bardin and Sivin. With one important omission, it describes the tortuous quarter-century-long path taken by the Population Council in bringing this newest steroid-hormone delivery system to the general public. Omitted is a description of the operational difficulties encountered by a nonindustrial newcomer (the Population Council), inexperienced in obtaining approval from the Food and Drug Administration (FDA), and of the appalling lack of interest by the American pharmaceutical industry, which was overcome only when the complete clinical and regulatory package had been assembled.

The next four chapters, dealing with antihormones and vaccines, illustrate what is good and bad about the book. In five pages, Haspels succeeds admirably in covering everything worth saying about the neglected field of postcoital contraception. Almost as impressively, Bouchard takes fewer than seven pages to present a concise survey of the contraceptive potential of hypothalamic releasing factors, a topic often promoted unrealistically in the literature.

The chapter on the most notorious antihormone, mifepristone (RU 486), $14 long, though well written, does not answer at all the question posed in its title and so relevant to America: “Is There a Future for Its Use in Contraception?” Rather than squander precious pages on experimental details published elsewhere before 1989, why not focus on the crucially important political aspects of this drug; on the reasons for the unwillingness of the developer, Roussel-Uclaf (and its parent company, Hoechst), to file for FDA approval; on the candidates for the requisite prostaglandin in the United States; and on the unwillingness of Searle and Upjohn to see their FDA-approved prostaglandins used in conjunction with mifepristone?

By far the poorest chapter is the longest one, with the most authors (nine). It reviews progress with the most revolutionary and, in the long run, most innovative approach to human contraception -- birth-control vaccines -- in a strikingly self-aggrandizing manner (32 of the references are self-citations by Talwar's group, and 2 are by V.C. Stevens, one of the principal scientists involved with the anti-human chorionic gonadotropin vaccine). This chapter is replete with somnolent details, useless photographs, and annoyingly general statements. For instance, the conclusion that “vaccines for fertility control are now a feasible reality” is supposedly justified by the following: “An injectable vaccine which sterilizes non-human male mammals without loss of libido has passed through experimental laboratory studies, safety testing, and field evaluation. It is being marketed commercially” in India. In graphic support of this statement, the reader is offered an amateurish half-page photograph of the back of a bull seemingly mounting some unrecognizable dark object. The chapter ends with two sentences illustrating its unrealistically optimistic flavor: “Some vectors, such as genetically engineered vaccinia virus, can also achieve effective immunization by a single or limited number of doses. Such vaccines would be low in cost and affordable in large numbers by economically developing countries.” The answers to Why? When? and How? are not provided.

In contraception, more than any other field, scientists should not promise what they cannot deliver. John Riddle's stories about pennyroyal, Queen Anne's lace, and mule kidneys may amuse a young woman. But what she really wants to know is whether she will be past the menopause before her male partner will use his pill, or why it should take decades for new delivery systems for older contraceptives to enter the market., and when it comes to politicians, we all know about their time frames, which are measured in months rather than decades.

Carl Djerassi
Stanford University, Stanford, CA 94305-5080