Contraception/Chapter 5

IN the following pages will be described in some detail the various methods classified in the preceding chapter, together with comments on and discussions of their physiological effects and their social values.

By the Female:—

The idea is very ancient that if a woman controls her own emotions so as to inhibit the natural orgasm she is safe from ensuing pregnancy, or, at any rate, her passivity materially reduces her risk of its onset. ​This "method" is available at any time, and its practice is certainly a "primitive form of birth control. Ploss^[1] quotes Riedel as saying that the women of Buru Island often have unions with strange men, but during such unions they keep themselves very passive so as to avoid fertilization. Its persistence ever among civilized women as a method of contraception, in spite of the existence of innumerable cases in which the most passive and cold type of woman is known to have become pregnant, is in my opinion explicable only on the assumption that there are individual women who find this method reliable. Such are probably of the type which I have described as undersexed (see p. 95). Such women probably also tend to have an excess of acid secretion in the vagina (see p. 61), and, therefore, naturally to destroy the motility of the spermatozoa without the use of accessory chemicals, so long as the spermatozoa do not actually get sucked into the uterus. Hence by controlling the orgasm the tendency would be for spermatozoa to be restricted to the vagina for a period long enough for the natural acid secretion to take effect upon them.

​Owing to the fact that the medical profession has been reluctant to give advice on the general theory of contraception women have very largely depended on individual help from each other, and therefore the experience of any women who have successfully practised any method is likely to be taken up by others. Evidence that women do still advise each other to use this method reaches me, and from time to time women tell me pathetically that they relied on this method and it failed them. I have not yet personally met a case in which it has proved reliable.

Galabin^[2] quotes a case of a lady married at 20, who after the age of 40, and with her second husband, experienced the orgasm in coitus for the first time and from that time dated her first pregnancy.

Comment.—In my opinion ordinary women should always be disabused of the idea that this is a safe or practical method. A woman should also always be informed that it is detrimental to her health deliberately to avoid the orgasm which is the ​natural completion and resolution of the stimulus of coitus. In this connection they should be encouraged, to read "Married Love," particularly Chapter VI.^[3] It should further be pointed out that the tendency of the woman to become a passive and fear-ridden instrument is also detrimental to the husband, particularly to one of a sensitive disposition, because a nice man does not like to feel that he is merely "using" his wife, and in real marriage mutual enjoyment and mutual completion of the orgasm should be the rule.

As a method, therefore, it is unreliable, and its other detrimental effects lead me to condemn it entirely as a voluntary method to control conception.

The facts noted above, however, are of interest, particularly when viewed as a natural method of involuntary control. The lack of orgasm in a woman of the type which has rather an excess of acid secretion in the vagina may definitely lead sometimes to undesired sterility. Such cases should be critically studied, particularly in view of Pell's position concerning the prevalence of a natural fall in the birth rate (see also p. 87 et seq).

Little need be said about this method as it is merely a sub-variety of (1) (p. 56). The action is based on the experience of certain women that they become pregnant only when the glans penis actually interlocks with the external os. That this ever takes place is, I am aware, contradicted. by some medical practitioners. Nevertheless it is a positive fact that it does take place. There is little doubt that pregnancy is much more certain when the glans penis does thus interlock with the os. Probably, therefore, there is a slight measure of security for the woman who prevents this taking place if her vagina also be of the "acid variety.^[4]

Case S. 1.—A lady, five years married, desirous of children, did not become pregnant till the first time she achieved orgasm ​in such a way as to interlock the os with the glans penis, when she at once became pregnant. After the birth of this child, no second orgasm of the kind could be achieved and no second child resulted in spite of every effort.

Comment.—This method is of much greater theoretical interest than practical utility for any but exceptional circumstances.

These methods, which are very primitive, probably prehistoric in origin, are of considerable interest in connection with the history of contraceptives (see p. 242). Such ​action is still relied on by a considerable number of women. This method appears to be one "of common knowledge," but was explicitly mentioned by R. T. Trall, M.D. (1868), when he said^[5]: "It is well known that, very soon after impregnation, or even conception, any sudden and violent motions which agitate the pelvic viscera and cause the uterus to contract vigorously, will prevent pregnancy . . . sometimes coughing or sneezing will have the same effect. Running, jumping, lifting and dancing are often resorted to successfully, immediately after connection."

Advice about this method of controlling conception has been repeated from time to time in the semi-popular literature on the subject in many countries; see for instance that given in 1868,^[6] and widely disseminated. In this category should be included the method still used in China, of the woman sitting up after coitus and drinking cold water.

​Though far from being a generally secure method, its effectiveness is undeniable in individual cases, and probably depends on the conjunction in the pair of a narrow os and a passive cervix on the part of the woman, and a compact ejaculate on the part of the man; also probably on a fairly good. muscular development on the part of the woman which would tend to voluntary movement of the vaginal canal. Thus the ejaculate would be expelled in a mass, not leaving individual spermatozoa in the vagina.

Comment.—This method has to recommend it the fact that no "artificial" substance or appliance is required. It should not be advised for use by a woman to whom pregnancy is a serious danger, but if one to whom an unexpected pregnancy is not serious chooses to try the method and finds it satisfactory in her own case, it is much less detrimental than many others. I personally disapprove of it because the accessory secretions in the seminal fluid should be retained by the woman longer than is possible in this method, and also because the very act of sitting up and making any definite contractive movement violates the proper psychological atmosphere which should be retained if the act is to be completely beneficial. Therefore I would ​never advise the method except for an emergency.

A common impression which has unfortunately been fostered by the advice not infrequently given both by doctors and nurses, is that a woman does not conceive while she is suckling.

Prominence has been given to this advice and its dissemination fostered by the current very proper movement to encourage women to nurse their own children. Unfortunately health visitors and even doctors and nurses will deliberately tell women that they will be free from conception if they nurse, in order to induce them to nurse if they are reluctant to do so. I have repeatedly been told by women that they have received this advice; and that medical practitioners of high standing are still actually giving it is seen in the words of Dr. Mary Scharlieb, published by her in a popular magazine in 1922 when she said^[7]: "If a woman suckles her child for eight or nine months, as she ought to do and as nearly all women can do, and then has a well-earned holiday from ​wifely duties, there will be an interval of about two years between the children."

While it is true that there are a good many women who find conception less likely to take place while they are nursing, it is absolutely untrue that suckling in itself affords a safe or even tolerably secure method of contraception.

While it is a very unsafe method of contraception, prolonged suckling has also other medical evils, among which may be noted the tendency it has in the poorer circles to starve the child, for so long as there is a supply of milk the mother does not inquire or consider whether it has all the necessary nourishing ingredients. Also it tends to weaken the mother, who is greatly emaciated and nervously run-down as a result of protracted nursing. The very fear of pregnancy, which is sometimes intense, also often affects the quality of the milk and hence, also, the quality of the child already born. (See also p. 186.)

While in this country it is only the very poor and ignorant who will continue to nurse a child that is able to walk, yet I have often seen in the East mothers still giving the breast to children of three or four years old because this sometimes secures freedom from the fresh conception which they dread.

Case 251.—A lady in very comfortable circumstances, finely built and exceptionally strong and healthy. After the birth of her first child was told by both doctor and nurse that she could allow her husband to have coitus while she was suckling with perfect safety from risk of conceiving. She suckled the infant regularly and became pregnant again within a month of the date of the birth of the first child. (Quoted also p. 42.)

Cases quoted by Allen Davenport^[8] in 1826 when he was speaking of the dread of the poor of further children after they had already had two or three: "This dread urges them on to adopt measures, with eagerness, which only promise to check the rapid succession of children. One of those measures is suckling the last child until it is a year and a half or two years old; I have known instances of children being kept to the breast for three years, when they could walk, talk and stand upon their feet, while they drained the last dregs from the flabby breast of the squalid and consumptive mother. Thousands of women are cut off in the prime of life, after suffer​ing the most excruciating pains, by the wretched practice of excessive suckling; and thousands more have perished by deleterious drugs which had been madly swallowed to procure abortions!"

I have been told by many poor mothers to-day that such and such a child in their families resulted from conception when nursing under the misapprehension that they would then be safe.

Comment.—While I give, of course, the warmest support to the view that mothers should nurse their own babies wherever it is physically possible, I most strongly condemn the suggestion that suckling should be advised as a contraceptive or that women should ever be misled by being told that they are safe from conception at this time. It is true, of course, that many women are less liable to conceive when they are suckling, but none are really safe from unexpected conceptions at that time. A woman who conceives again while she is nursing one infant, wrongs three people—the infant she nurses, herself, and the potential child in her womb. Suckling should never be encouraged as a contraceptive measure.

​Methods used by the Male:—

Methods which can be classed under the above heading vary in individual detail, and are probably more commonly used in illicit intercourse than in normal marriage. Essentially they consist of modifications of the procedure by which contact is arranged between the penis and the labia majora without entry into the vaginal orifice. The relative position of the sexes in this partial union and the actions of the female may be very greatly varied. Some women may participate more or less actively, while others may be passive.

Even this method is also unsafe: though it is very rare, conception can and does occur even in a virgo intacta. A recent illustration of this is found in the famous Russell case.

Comment.—Used as methods of "Birth Control" such abnormal procedures must be entirely condemned. Although possibly less detrimental to the participants than some other practices in vogue, such procedure is to be deprecated. principally on the grounds of the unwholesome nervous reactions involved. The main physiological objections are like those to other forms of ​abnormal coitus, and need not be repeated under this heading (see in particular pp. 71, 75 and 208.)

This form of truncated union is still one of the most prevalent—if not the most prevalent—among birth control methods still in general use in England, although the publication of "Wise Parenthood" with my explicit demonstration both of its harmfulness and unreliability has tended to reduce the number of people using it. Doubtless this method is used outside marriage, and it is certainly widely used in ordinary marriages. It consists in normal penetration before or after stimulation and erection have taken place, the "control" ​feature of this method being the fact that when the man feels ejaculation approaching, he withdraws the stimulated penis and permits the uncontrollable ejaculation to take place exteriorly and away from the vagina.

Described as "masculine prudence," it was one of the methods discussed in the very early days, and Francis Place and his associates knew of and spread knowledge of it about 1823-6, as I found by search in his original manuscripts, now in the British Museum.

This method is so widespread and has had in the past so many supporters and users, and is looked upon with considerable favour by so many ignorant of its harm, that it demands more detailed consideration than most other methods.

The main points of objection to it are two-fold. Although it may appear "harmless" to a good many rather strong or insensitive individuals, its tendency, and its actual result in a great many cases, is to injure the nervous systems of both the man and the woman.

Harmful Effects.—Briefly, the effect on the man's nervous system is that, at a moment when the power of thought and central control is or should be in abeyance ​and his emotions and reflex actions at their freest, he is called upon to exercise careful watchfulness and critical control from the central nervous system. The strain is very great even if successfully accomplished. In addition to this the local effect on his own organ is harmful, because at the time of ejaculation the surrounding gentle support and the general soothing influence of vaginal enclosure and contact are absent. The evil effect on individual men is sometimes so great as to destroy the general health and make them thoroughly nervous and run-down, or to induce more explicit symptoms of neurasthenia and even functional disorders.

On the woman the effect is harmful if she is of a nervous disposition owing to anticipatory fears of failure. Where this is not so and the woman' is placid and satisfied in this respect, it is nevertheless harmful because she is deprived of the full benefit of union. She is in a position comparable in this respect with that of the wife of a man suffering from too hasty ejaculation, of whom Porosz noted that such a woman may suffer neurasthenia even approaching insanity, and be cured when her husband was cured, as she needed the ​complete union.^[9] The woman is also deprived of the possibility of the man's penis interlocking with the cervix (which alone makes an absolutely complete and perfect union).

The effect on the woman's feelings at the time are rather well described by a patient of Booth's,^[10] who "confessed the practice, and when pressed for a description of her feelings after the act, replied that the only way she knew how to express it was that 'she felt like she wanted to sneeze and couldn't.'"

The woman subjected to this process is also deprived of the possibility, after the union has been completed, of the beneficial absorption from the seminal and prostatic fluids. I have many cases of private persons who look upon it as certain in their own lives or that of their friends that not only the orgasm in coitus, but also the presence of the seminal fluids is beneficial to women.

Various detrimental effects of coitus interruptus were explicitly made clear in "Wise Parenthood" in 1918, and since ​that date I have received a number of confirmatory opinions and cases including the valuable evidence of Sir Arbuthnot Lane (see also pp. 76 and 208).

No. 1052 (a Medical Officer of Health) writes me: "From my experience I am sure the presence of the semen in the vagina is beneficial to a woman."

No. 1002 (a practising doctor, M.B. and Ch.B.Edin.): "I was much struck by your opinion that the health of a married woman depends to some extent upon her experiencing the sexual orgasm and some absorption of the male ejaculate. I have long held this view. I have found that the physical signs of age are most noticeable in married women whose husbands practise withdrawal and who themselves never fully complete the sexual act. Especially is this noticeable just before or during the menopause."

No. 1050 (an M.D. married to a medical woman): "To us, personally, your books have been of much value, and indirectly, through me, to many of my patients. Amongst the uninformed 'coitus interruptus' is undoubtedly the only method made use of, and, in its train, it brings unhappiness sooner or later, I find."

Although continually advised and used ​by some members of the medical profession, various careful observers have spoken against it, but perhaps the reason their sound attitude did not become universal may have been the briefness and incompleteness of their exposure of the dangers of the method. The great French scientist, Ch. Féré, said in 1899: "Le coït réservé joue un grand rôle dans la production de la neurasthénie et en particulier de la neurasthénie' sexuelle; si l'effet n'est pas constant, il ne peut pas être nié."^[11]

Without discussing the method with much detail or subtlety, Kisch^[12] in the "Real Enzyklopädie" quotes a variety of authors who think it harmful: "Von Gynäkologen hat Valenta den coitus interruptus als eine Hauptursache der chronischen Metritis bezeichnet. Elischer sah davon Perimetritis eintreten. Graefe führt als Folgen des anhaltenden Coitus interruptus chronische Hyperämie des Uterus und Oophoritis an, Goodell Beobachtete als solche Folge eine Verlängerung des cervix uteri, mensinga giebt also consecutive Erkrankungen Uterus infarct Oedem der Portio Anätzung de​Orificium, hysterische Anfälle, Convulsionen, Cephalalgien, Kardialgien U.S.W." Kisch^[13] also, in his own book, notes the cardiac injuries to women due to coitus interruptus. Booth^[14] in 1906 detailed three cases of extreme nervous disorder, affecting locomotion and functions, which he attributed to the use of coitus interruptus.

Freud also lists coitus reservatus as one of the causes of anxiety neuroses in men, and Fürbringer speaks against it.^[15] Nevertheless Havelock Ellis^[16] who recognizes that it may injure the woman, mistakenly says: "The injurious effect on the man, who obtains ejaculation, is little or none."

As regards the deprivation of the woman it should be noted that she is not only ​deprived of the full and prolonged contact, but also of the seminal fluid itself. That seminal fluid is probably a stimulant was suggested long ago by John Hunter,^[17] who said: "The semen would appear, both from the smell and taste, to be a mawkish kind of substance; but when held some time in the mouth it produces a warmth similar to spices, which lasts some time."

Havelock Ellis brings together a number of data bearing on the question of the value of the seminal fluid for women, concluding: "If semen is a stimulant when ingested, it is easy to suppose that it may exert a similar action on the woman who receives it into the vagina in normal sexual congress."^[18] And after I published "Wise Parenthood," in which I expressed my personal disapproval of the method, Sir Arbuthnot Lane, the famous surgeon, told me of some interesting cases of his own which certainly seem to indicate that part at least of the prostatic secretion is beneficially absorbed by the woman from the male ejaculate deposited in her vagina.

​A few cases have used this method a long time and have found it satisfactory, but the great majority of observant persons are conscious of and recognize some harmful effects from the procedure.

Unreliable.—As regards the reliability of this method as a contraceptive there is also something to say. It fails from time to time owing to the man's lack of control; but it also tails at times apparently inexplicably, and when the man and woman both assert absolutely that no failure could have taken place! One reason of failure is clear, for it is naturally difficult for a man in the state of emotion induced by proper coitus to be quite sure what happens. There is, however, a more fundamental and more interesting cause of failure. Before the main ejaculation takes place (of which the man is conscious) small preliminary exudations are general, and in these, active sperm may be present. In his own person, one of my distinguished medical correspondents observed active sperm cells at the time of erection and before ejaculation had even approached onset.^[19] ​This doctor (who desires me not to publish his name) writes: "It is easy to prove with a microscope and a warm stage (as for observations on white blood corpuscles) that living and active spermatozoa are present in the beads of clear secretion which often—probably always—are seen at the urethra when an erection of the penis has lasted for even a short time. This is mostly secretion of Cowper's glands, like the Bartholin secretion in women, and serves as a natural lubricant. I have myself seen the spermatozoa in it." This takes place even in perfectly healthy men. We must also bear in mind cases of "spermatorrhœa "in which even large drops of semen exude during rectal evacuation and may remain clinging to the glans penis.

Coitus interruptus is, therefore, an inherently unreliable method. Many medical practitioners now recognize this as a very unsafe as well as harmful method, although Dr. J. Rutgers, the Dutch Malthusian expert, says: "Withdrawal is also a secure method when the husband has, or acquires, sufficient control of himself."^[20] This I deny.

Comment.—For general use the method should always be advised against, although ​perhaps it may be satisfactory in isolated instances of emergency. I condemn the method both on the grounds of its harmfulness to the male central nervous system, and its local effect, and because it deprives the female of the proper completion of the physiological reactions set in motion by the onset of the coital act.

By Both Parties:—

This method consists, like coitus interruptus, in the normal and unclothed and unhindered entry of the penis into the vagina, but differs from coitus interruptus in controlling the nervous excitation so as never to approach the onset of the orgasm. The union is protracted, and the erection, after being active for a length of time varying from twenty minutes to ten hours, naturally subsides before withdrawal from the vagina.

Noyes claimed that he discovered it in 1846, and he gave an interesting account of the method,^[21] but it was undoubtedly known ​and practised in the Orient, centuries before his time.

This separation of the amative from the propagative act has theoretically much to recommend it, but I do not know of many successful cases, and this is probably due to the fact that the process of normal ejaculation results in benefit to both contracting parties. Men who have not the power to produce ejaculations more often than once or twice a year, however, do exist and in my opinion are commoner than is generally supposed. For such men, possibly, this method might prove useful.

Dr. Rutgers says, "Just as it is possible to keep back one's tears when deeply moved, so can some men have prolonged connection by using will-power to hold back emission of semen. This method of intercourse without impregnation has been called carezza or Zugassent's discovery, and it requires very considerable effort of the will and practice. But this variety of continence can also cause nervous trouble. It may also fail, unless the husband uses condoms, or withdraws if he feels his semen about to escape."

The method is chiefly practised by a variety of sets of people in America, the best known being those who formed the ​Oneida Colony which was founded by John Humphrey Noyes. A full account of the theory and practice is given by a medical woman in "Karezza"^[22] and a pamphlet with letters about successful cases by Mrs. Margaret Sanger.^[23] A fuller and more interesting account was published long before by Dr. Foote in his popular "Home Cyclopedia."^[24]

As Mrs. Sanger tersely puts their rather elaborate views, "The advocates of the magnetation theory claim that the sexual organs have three distinct functions, viz., urinary, propagative, and amative—i.e., they are conductors firstly of urine, secondly of semen, and thirdly of social magnetism. Each are separate and distinct in itself" . . . so that they use the erected organs for love but control ejaculation so as not to inseminate save on special occasions:

I have personally only come across about half a dozen people who use this method. ​All these were exceptionally intelligent people and all spoke enthusiastically of it. As I stated in "Married Love," however, I do not think it suited to the requirements of the average healthy man or woman. One case known to me failed without the man's knowledge and pregnancy resulted in the wife.

I have some details from a correspondent about a small colony for its practice founded in this country, but the data seem to me to be still insufficient to convince others of the claims made by those who practise this.

Case No. 1,001. A British man describes himself, "It was not until at 53 I was married and could test the Oneida method, but when I did so, I found it easy, healthful, safe, and all that could be desired." He continues to eulogize the method and says what "puzzles me is the persistency of European writers to ignore the best check of all, as many think, and the only check which has been thoroughly investigated (in the U.S.A.) medically, socially, and in every other way." In addition to the large-scale experiment in Oneida, "Recently in England a group of eight intellectuals put male continence to the ​test for several months, and I have a very beautiful statement from the lady promoter in which she says—'I have never seen anything but good come from this training.' The claim is made that "during ten years we had but two accidental children born to a family of three hundred members."

Comment.—The method does not appear to be one to recommend, except for special cases. The whole idea appears to me one about which scientific opinion should be cautiously reserved, yet alert and inquiring.

Although among primitive races there are peoples to be found among whom a regular seasonal exhibition of sex activity still exists, as, for instance, the Esquimaux, some native tribes in Siam, and so on (see Marshall,^[25] and various works on Anthropology), yet among the Anglo-Saxon and Celtic races which compose Western European peoples none remain so definitely seasonal in their potentialities for fertilization as to possess an annual "safe period," although there is a certain amount of evidence that the spring months of May and ​June are more liable to yield conceptions than the mid-summer and mid-winter months.^[26] Hence, there can be no "birth control method" involving a seasonal restriction of intercourse. The use of the "safe period" among our peoples implies a mensual safe period and not an annual one, such as might be still. practical among the primitive peoples.

This method of birth control is a very old one and has had a very interesting history. The earliest reference in the scientific literature of Europe which I have is Pouchet in 1842,^[27] but unfortunately I have not been able to see this book and depend on Hans Ferdy's quotation. At the present time it is, as a matter of fact, the only method in addition to total abstention which is sanctioned by a variety of religious bodies, because, owing to clerical ignorance of the true functions of sex union, ​the clerics are under the impression that it is "natural." It is, however, quite an unnatural method; no natural female animal allows the male entry when she is not "on heat." It is also unnatural because it prescribes the times at which a man is to approach his wife without any relation whatever to his feelings, to her natural disposition and rhythm, or to incidental and quite right stimuli such as anniversaries, romantic remembrances, &c. It therefore tends to thwart the natural and romantic feeling at the time when it may be roused, and tends also to lead to an unnatural sense of duty at the available times for the man to perform the act when he may not be particularly inclined to do so, yet feels that he had better do so when he may, as the opportunity may not be available at the time he naturally desires union.

A similar argument applies with still more cogency to the woman, for the ordinary "safe period" which comes at the inter-menstrual phase is the time when she is less likely to have normal sex potentiality.^[28]

Nevertheless, the Roman Catholic Church, otherwise so violently opposed to control ​of conception, allows the preventive means of the use of the "safe period." The Rev. Mgr. W. F. Brown, Vicar-General of a Roman Church, said, under cross-examination by the Birth Rate Commission: "Where all other deterrents fail, married couples may be allowed to limit intercourse to the inter-menstrual period, sometimes called tempus ageneseos."^[29] He follows this by the warning that the method is not perfectly safe, thus showing more wisdom than the Anglicans who now give the same advice but treating the "safe period" as really safe, bring both themselves and the ecclesiastical position into contempt.

The length of the supposed "safe period" varies in individual women; in some it lasts over a fortnight; in some it lasts but three or four days; in many it does not exist at all. It is recorded in the literature that the woman can determine this for herself,^[30] and I have had this confirmed by women who have been known to me, not by mere cor​respondence only but by direct personal confidences, on which I have cross-examined them, I have noticed these women, however, are of the type which I should call "ascetic" or intellectual, with the sex activity rather below than above the normal, although their emotional and affectional activity is strong and romantically felt.

In giving evidence before the Birth Rate Commission I^[31] said something about these types, for it seemed to me that to discuss such physiological points without recognizing that different types of women exist, was futile. The point appears to me particularly important and interesting in connection with the idea that there is a natural reduction in fertility (see pp. 59 and 88).

In my opinion what truth there is in the idea of our natural tendency toward reduction of fertility is not explicable on the basis of mere environmental conditions, but depends on the existence of this physiological type of woman, and the correspondingly undersexed type of man.

In this connection I feel that we have in this type of woman who has, and is able to verify in her own life that she has, a really ​reliable "safe period," the only true form of relative sterility which we can at present recognize and investigate. I say this with deliberate intention because in my opinion intelligent study of this matter is at present always confused and almost all the arguments of thinkers and statisticians are invalidated by the fact of the enormous prevalence of gonorrhœa, mumps and other sterilizing diseases, histories of which are not inquired into before statistical and other arguments are deduced from merely numerical records.

It will be recalled that recently Pell reopened discussion on the subject of the tendency to natural infertility.^[32] His data were mostly statistical, but I feel the need of inquiring into the physiological basis of these data, and I think I see the physiological type tending toward a natural sterility, in those who have a well-marked "safe period." The subject is full of interest and should be further investigated; it is, however, rather outside the scope of the present work.

To return, therefore, to the use of the ​"safe period" as a method of controlling conception. It is, in my opinion, only safe in certain types of women, and these are the types which have a natural tendency towards sterility, although they may not be sterile for the whole month. It is a method which individual women find satisfactory and useful, and may legitimately be explained to any patient who desires to use the method, and is herself able to determine what is the limit of her own "safe period." It should not be taught as suitable for general use by the Churches, by Health Visitors, Social Reformers, and others who assume to themselves the position of instructors. Because even if a woman of the "below par" type may find it in her own life absolutely reliable, the poor woman whom she may be instructing, who is probably normal or even a strongly sexed, fertile type of woman, may be entirely and cruelly misled, for, so far as observations and experiences confided to me go, the ordinary working-class healthy woman has no safe period at all. The advocacy of the "safe period," therefore, as a general rule, particularly by those who set themselves up to be spiritual advisers and social reformers, brings the whole subject of sex reform into contempt, as the advice is misleading when applied to normal people. ​Nevertheless, it is now very actively advocated by clerics^[33] and by clerically influenced medical practitioners, as in Lady Barrett's small book with its preface by the Archbishop of Canterbury.^[34]

Comment.—The "safe period" may be used by individuals who are acquainted with the above facts, and who find that their own type is such that the "safe period" is suitable, but it should never be recommended in general. Even for those whom it appears to suit, I think the method a cold, calculating, pseudo-restraint which tends to debase the true sex relation, and reacts unfavourably on the character of both participating parties, and is, moreover, quite unnatural.

BY BOTH PARTIES.

Although this is a negative form of birth control, and consists in the absence of coitus, yet the physiological effects of this ​procedure should be noted under the heading of contraceptive measures, because this is the chief method of control advocated by a large number of very religious persons.

Total abstention from the coital act on all occasions when conception is not deliberately desired is advocated by individual so-called reformers, and this, and slight modifications of it, are advocated by the leading Churches. Excellent authoritative statements of the positions of the Anglicans, Roman Catholics and Jews are given in the Report of the National Birth Rate Commission.* Although in an ordinary way the use of the "safe periods" (see p. 86) is permitted, and the Churches unite in their denunciation of "artificial" methods, yet in some circumstances they demand a total abstention, which does not appear to present itself to them as equally artificial in marriage! For instance, discussing the procreation of feeble-minded persons, the Roman Catholic authority replied to the questioning Commissioners (^[35]p. 397) "it may be perfectly well counselled to such persons that if the results of their inter​course had been deformed or defective children, that there should be a duty on them to abstain."

How lacking also in scientific knowledge of the complexities of the act of coitus, and how inhumanly uncharitable are some of the Anglican Bishops, may be gathered from the reply to the Birth Rate Commission in cross-examination of their representative who said to the question, "Then, the end being secured by conception, would you say that intercourse was unlawful until it was for another conception!" A. "I disapprove entirely of intercourse if there is any other motive." And also from the fact that in their more recent Encyclical Letter the Bishops go so far as to class all scientific contraceptives as "incitements to vice"!^[36] This amazing paragraph should be quoted in full; it is (p. 45): "70. The Conference urges the importance of enlisting the help of all high-principled men and women, whatever be their religious beliefs, in co-operation with, or if necessary, in bringing pressure to bear upon, authorities both national and local, for ​removing such incentives to vice as indecent literature, suggestive plays and films, the open or secret sale of contraceptives, and the continued existence of brothels" (my italics).

Although it is not a positive Birth Control measure, total abstention from the coital act in marriage has psychological and physiological reactions of sufficient seriousness to warrant its consideration in a medical work. This method of procedure is more usually insisted upon by the woman than by any but sub-normally sexed men, although there are ordinary men who have been led to believe that it is their duty to take this attitude towards marriage.

The physiological results on the man of total abstention extending over many months or years are very numerous, and depend in their intensity of expression on the physiological type of the man.^[37]

It should be noted that the deprivation of coitus in marriage is physiologically a different thing from chastity in the unmarried man. The daily (sometimes hourly) ​stimulus or contact with a beloved wife is a very different thing from celibate absorption in work apart from feminine companionship. Temporary periods of abstention in marriage, particularly when the abstention is an act of love in the interests of a temporarily indisposed wife, are not likely to have any harmful physiological result, and are attainable by any man with a normal strength of will and character. But total abstention for life, or for many years, does have results in general harmful both to the individual and the society in which he lives.

Depending on the physiological characters and temperament of the man, three main results are to be expected from total abstention in marriage over protracted periods:—

1. The man of sex vitality below par or the man engaged on very absorbing and strenuous intellectual work is, on the whole, likely to achieve this enforced celibacy within marriage without any very material disturbance of his physiological functions, but with the probable result that if it is extended over many years his potential fertility may be reduced or totally lost (see p. 98). And even with the best will in the world he will hardly prevent himself getting ​at least a little "queer" and fidgety if not actually irritable.
2. The normally sexed, healthy man, if on good terms and affectionately disposed towards his wife will probably be subjected to a strain which will be detrimental to his health, tending to nervous reactions, sleeplessness, possibly debilitating nocturnal emissions and to a development of irritability and general lack of sense of wellbeing and nervous control.
3. The third, or possibly oversexed type of man will, it is almost certain, give up the struggle after some time has elapsed and add to the number of those who support prostitution and illicit mistresses.

Similarly the effects on the woman would be as follows:—

1. If she is of the "frigid" or undersexed type, she may imagine that she feels better without union, but at the same time she will probably develop some form of sleeplessness, digestive complaint, nervousness or hysteria. She will probably resent any indication that she would be better for the normal sex act as she will be of the type who considers herself "superior" to ordinary human sex life. If she is of the extremely ascetic type, reasoned argument will probably not prevail and the situation ​offers little hope of rectification for a normal husband who may be married to her.
2. If she is a normally sexed, healthy type of woman who has acquired such ideas against sex union as the result of false education or contact with abnormal or under-sexed women, then the medical practitioner by suggesting suitable books^[38] will probably be able to put the matter right and to restore her and her husband to normal health.
3. If the woman is of the very strongly sexed type she is less likely to have come into this category and unlikely to have demanded this form of Birth Control, although it is not impossible that such a strongly sexed type may have married a man who has got the crank idea that union should be for procreation only, in which case her predicament is not one easy to solve unless the husband be particularly broadminded.

Case A 21.—A normally sexed man married to a very cold woman who de​manded "union for procreation only." On the first night of the marriage the husband learned this and realized his bitter mistake. He was a loyal and conscientious man and remained faithful till after the birth of four children, when his wife refused to have any more. Then for twenty years he was permitted no unions and no pleasantness or human endearments. After some years he resorted to prostitutes, as his health suffered. Then he fell seriously in love and desired freedom to marry, but his wife refused absolutely to divorce him. He has no redress. Nocturnal emissions made him feel ill and unable to do the hard brain work of his profession, and so he is one of those who are assisting to maintain the institution of prostitution. The wife is unhealthy, sleepless and very "difficile."

Dr. Robie writes "The present writer has the advantage of knowing the inner lives of thousands of married people whose whole lives are exemplary and whose idealism is unquestioned. His knowledge of many of these men and women extends over more than a quarter of a century. . . . The method of moral restraint and sublimation wrecks homes among the people who have high ideals just as surely as unbridled licen​tiousness wrecks homes among those who have low ideals or none."^[39]

An Illustrative Case taken from Dr. Robie is as follows (p. 386): "A woman married with a definite purpose of having intercourse for procreation only, first ascertaining that her husband-to-be was of the same mind. She has several children, is devoted to social questions, and especially seeks to be helpful to young men and women. Her health is frail. Her husband visits her for a week or two at a time on an average of about twice a year. She is evidently not happy in her home. He is evidently a fanatic or a crank."

Many propagandists of "purity" assert that long periods of total abstinence have no deleterious effect on men, but even Dr. Mary Scharlieb has pointed out the danger of resulting impotence. She said: "Men in a great many cases abstain during the first few years of marriage, and then, when they are most anxious to have children they cannot. I cannot explain it except by assuming that it is the result of thwarting nature. They are quite capable when first married, but in consequence of persistently ​thwarting nature they become incapable,"^[40] and continued: "Directly a couple are living together in the intimacy of marriage, abstention appears to have a very deleterious effect" (p. 271).

This is confirmed also by Dr. Cooper,^[41] who said: "Everything depends on the individual, but probably it may be laid down as a general rule that enforced and protracted continence is almost always injurious to a less or greater extent, according to its duration."

Dr. Robie, the famous American Sexologist, in a letter to me on this subject writes: "I can remember many men, clergymen and educators principally, who have denied themselves as a matter of principle, erroneously thinking thus to conserve their energies and attain to the highest mental efficiency. After convincing explanations they readily recovered, a part at least, of the virility that had been lost through repression; and it would be difficult to say to-day whether these men or their wives were most delighted at the ​increased health, happiness and efficiency of both."

And Lord Dawson of Penn said:^[42] "If this harmful restraint succeeds in preventing conception there eventuates the inevitable prevalence of sex excitement followed by abortive and half-realized satisfaction, and the enhanced risk of the man or woman yielding to outside sex temptations. No—birth control by abstention is either ineffective, or, if effective, is pernicious."

An interesting suggestion was made to me by a medical practitioner, who wrote, (No. 2016) "My own belief is that enlarged prostate is due to sexual congestion unrelieved. It is most often found in men with a clean record. In books and articles upon the subject the sexual history is seldom or never referred to. In middle class life, after middle life, wives develop a disgust for sexual life. In many cases the husband, out of consideration for the wife, gives up sexual intercourse while retaining sexual passion. This leads to sexual congestion and in some cases to prostatic enlargement."

I embody this suggestion here as it is one ​which at least indicates an interesting line of inquiry.

Comment.—The method of total abstention is in my opinion essential to be used in every home as a temporary measure during the ill-health of either wife or husband. I think, on the other hand, it should not be used by normal persons as a measure extended over long periods of time, for its subsidiary ill-effects more than counterbalance any "moral" advantages if it is used for long periods. It is, moreover, the most "unnatural" of all methods of contraception which can be used by a loving pair.

Long before the true nature of the spermatozoa could have been known (that is, centuries before microscopes were invented) it was already recognized that the introduction of certain chemical substances into the vagina tends to inhibit conception. Thus in an ancient Sanscrit book of love the use of alum was advised, as well as various decoctions of herbs.

​The object of the introduction of chemicals of any sort is the intention to incapacitate the spermatozoa and thus render them incapable of movement or of union with the ovum. The minute size and delicate structure of the spermatozoa render plasmolysis in vitro easy of achievement. As is well known, each human spermatozoon is 0.05 mm., or ⁠1/300⁠th of an inch, including its long. cilium or tail. (For descriptions of the spermatozoa of man and other animals, reference should be made to Marshall's excellent "Physiology of Reproduction."^[43]) In a normal ejaculate there are not only, as is so often stated, thousands of these, but millions; the ejaculate of a healthy man containing between one and six hundred million live, motile spermatozoa, the whole bulk of the ejaculate being as a rule 3 to 5 c.c. The quantity of plasmolysing chemical therefore required, although it has to deal with innumerable spermatozoa, is not great; and individual experience has shown that with the use of such a plasmolyser as quinine salicylate, a few grains is amply sufficient to leave a wide margin of safety. But, on the other hand, it is well known that ​results obtained in vitro are often dissimilar from those obtained in vivo, and I am much inclined to think that the reason that the quinine plasmolyser, for instance, is so much more reliable when applied in the medium of grease (such as low melting-point cocoa butter or oil), than when applied in other ways, is due to the additional physical effect of the grease itself which acts as a clog to the movements of the spermatozoa. I have heard it said in discussion that quinine pessaries with the quinine left out are quite as effective as those containing it, but I do not entirely assent to this.

The number of chemicals in general use is curiously restricted. The reason for this does not seem to have any real scientific basis, but to depend on the fact that hitherto knowledge on the whole subject of contraception has largely been left in the hands of the unscientific commercial retailer, even of the hanger-on of vice. Such persons are profoundly ignorant of the scientific basis for any procedure they may advocate, and therefore the few substances which long ago became known have tended still to be used to the exclusion of a larger number of other substances theoretically of equal value, which might have been used, or whose advantage might have been discovered had the subject ​been handled in an open and scientific manner.

The form in which the chemical intended as a spermaticide is introduced into the vagina varies; most of the important ways are tabulated below with a few notes about each.

Of all the chemical substances used as spermaticides, undoubtedly quinine is in the most general use. It is applied in a variety of ways.

The injection of powdered quinine compounds is not very generally favoured owing to the difficulty of distributing it suitably in the vagina, although it can be used, and is injected with a special form of syringe. It is used in this form particularly when combined with a sponge, the powdered quinine being well rubbed into the sponge.

Incorporated with some other substances, particularly in the form of a small soluble pessary, it is so much more practical and convenient that there seems no reason why the powder should be used at all, except by those who dislike the grease of the pessary.

Owing to the difficulty of inserting the ​powder, it is sometimes enclosed in capsules to be inserted in the vagina; but the method is not particularly reliable as the powder does not get well distributed.

Quinine mixed with a fatty base in the form of ointment is prepared, and is sold by chemists for the special purpose of use during coitus. It may be smeared thickly on an ordinary sponge or on a pad of cotton wool. It is also used for surrounding the caps (see p. 143) and for smearing over them. It should, however, be noted that the use of grease tends to rot the rubber. The use of ointment is a matter of individual choice, some relying upon it and finding it satisfactory, others never making use of it at all.

The commonest form in which quinine is used is as a vaginal suppository in which quinine sulphate, usually with salicylic acid, quinine salicylate, or other form of quinine, are included in a small quantity of cocoa-butter (see formulæ p. 108). The form of suppository is generally that of a flattened, ellipsoid cone, rendering insertion easy, and ​cocoa butter is used because of its very low melting point. The use of such suppositories is very widespread. In this country they appear to have been first made by Mr. J. Rendell, who had a chemist's shop in the early eighties, and got the idea through Sir J. G. Simpson's recommendation of medicated pessaries. Such makes as "Rendell's," "Lambutts," and "Ottocones," appear to be very reliable. Their convenience is great, as they can be slipped in unobtrusively at the last few moments before coitus takes place. Their advantages are thus many, including the important psychological and æsthetic one of non-interference with the psychological feeling during and after the act.

The millions of these suppositories which have been used are in a sense their best testimonial, both of convenience and of security. Although announcements are made by individuals from time to time to the effect that the makers of these articles are in league with the anti-birth controllers, and make individual pessaries that contain no quinine, such statements have never been authoritatively substantiated, and in my opinion they are deliberately spread by opponents of birth control. I have traced a variety of these rumours to earth and ​never yet found them to be substantiated. If an authentic case exists and is available I should be glad to have it submitted to me. I have noticed more than once that this rumour is spread by those who manufacture or advocate some other method. I have questioned the biggest and most reliable manufacturing firms closely, and have their absolute assurance that no such thing is true or has been attempted with any recognized makes. Inferior firms may, of course, be venal in this way. It must also be remembered that to mix the fatty substance and the quinine quite thoroughly requires expert care, and the work may be done carelessly.

A certain type of opponent of contraception who is now vocal accuses quinine of a variety of harmful effects; most of these are obviously fantastic, but as the statements are oft-repeated, it may be useful to member the pronouncement of Sir Francis Champneys, Bart, M.D., who is not by any means an advocate of contraception,^[44] in cross-examination by the Birth Rate Commission. To the question: "Do you consider soluble pessaries harmful?" he ​answered, "I believe the common ingredient is quinine, and I do not believe that does any physical harm whatever" (p. 136). Continuing, he said: "As regards the direct effect of quinine pessaries, I have never seen a case in which I thought any damage had been done" (p. 138).

As already noted, it appears to me that the quinine is by no means the only thing which gives security, and that the quantity of grease is sufficient in itself to be a fair safeguard even if there were no quinine to secure immunity.

There are many formulæ for the formation of such suppositories, and some contain quinine only, others a mixture of chemicals. An American medical practitioner recommends the following:—

I think this formula needlessly difficult to weigh out.

A formula devised by another American practitioner for use by his poor patients who desired to make the suppositories themselves, is as follows:—

​

All purchased separately and mixed together, the cocoa butter melted over a slow heat and all stirred in with a wooden spoon. When thoroughly mixed the mass should be stirred till cool and cut up into thirty equal pieces.

However reliable with other couples, any soluble pessary is likely to be unreliable in the case of a married pair whose adjustment is so perfect that they do on each occasion interlock the glans penis and the cervical opening. This type will probably be well advised not to trust to the quinine pessaries alone, but to wear also an Occlusive Cap (see p. 139). Similarly women whose cervical opening is permanently stretched and open will find them fail.

The disadvantages of the greasy pessary are dependent more on the individual characteristics of the users than on the method itself. In general it suits a great many people, but some exceptions may be noted. On the part of the man: it has been found that, to men with a particularly sensitive skin on the glans penis the quinine ointment or the quinine pessary is irritating, even ​sometimes inflammatory. Furthermore, for use by a couple where the man is rather small and the woman either naturally big, or as a result of several childbirths has a considerably stretched vagina, the excessive lubrication of the greasy pessary is liable to reduce the efficiency of the coital act by reducing the normal contact and friction. On the part of the woman: those with marked prolapse may find them useless. Contraceptives of any sort for such women are a specially difficult problem (see also p. 191).

Then among normal women the use of the quinine pessary is sometimes inadvisable where the woman is one of those whose systems reject quinine, for there is no doubt at all that some of the quinine is absorbed through the vaginal walls and penetrates the system. I know from a number of cases that sleeplessness, and in a few cases, more acute symptoms result from the use of any form of quinine either orally or per vaginam. This I noted in general in "Wise Parenthood" in 1918, and have since had several interesting confirmatory cases.

Case 3023.—Healthy, aged 23, very anxious to use quinine and cap together as I advised in "Wise Parenthood," "because ​it is so convenient and safe," but always finds quinine affecting her unfavourably. In her own words: "I know the feelings of the effect of an overdose of quinine taken. in the ordinary way, internally, because of repeated efforts to take it when I was nursing during the war and during epidemics. The smallest dose made my head buzz, and made distinct kinds of griping pain in my bowels, and I gave over trying to take it. . . . As a contraceptive I tried quinine pessaries with the cap in the hope that your doubt about its absorption would not apply to me, but in twenty-four hours I had exactly the same feeling as I had when I'd taken quinine internally and a distinct quinine head; it worked off in about another twenty-four hours or so, and I was again quite all right again, but the very next time I had the pessary I was exactly the same in just the same length of time, and I've tried it at least a dozen times to test it in the hopes that I might throw it off, but with always the same results."

A quinine suppository can also be made by mixing quinine with gelatine instead or cocoa-butter. These have the advantage that they have not the objectionable effects of the greasy pessary in their contact with ​linen, but the gelatine, although pleasant to use, at the same time is much less reliable, for, being non-greasy, it has not the same inhibitory effect on the activities of the spermatozoa; so that quinine and gelatine is less reliable than the same amount of quinine in cocoa-butter. They may be made to the formula:—

But I do not advise the gelatine suppositories as they often fail.

The smell of cocoa-butter being extemely repulsive to some people, it is useful to know that it may be obtained in a scented form, but a pessary has recently been devised where the cocoa-butter is replaced by a low melting point non-odorous fat, which has all the good qualities of cocoa-butter without its odour.

Comment.—The soluble greasy quinine pessary, properly made and used, is in general harmless, easy to use and reliable in most cases. Those who have personal idiosyncrasies, abnormality or even specially well adjusted coital union, may not find them suitable, but should ascertain these ​facts about themselves and use other methods. In a general way such pessaries are certainly one of the most useful contraceptives.

Quinine in various forms of solutions and mixed with other substances may be introduced, mixed with oil, and inserted before coitus with a special introducing syringe which distributes the quinine over the vagina before coitus. There are many varieties of such syringes specially designed for the purpose by surgical instrument manufacturers and chemists.

"Dr. Baxter's patent" (now called K.P.O.) was brought to me before it was patented (it is No. 140282, 1920, Patent Office Specification) and I did not then and I do not now approve of it. It has all the psychological disadvantages of a douche, and its metal construction is such that it is certainly beyond the ordinary, rather stupid person's powers: to cleanse it satisfactorily. I have no evidence of its reliability.

Comment.—Though I know one or two individuals who use for choice syringes to ​introduce quinine contained in oil, anything in the form of apparatus or complicated procedure at the time of coitus appears to me to be psychologically so unsatisfactory, that were the method otherwise satisfactory (which it is not) it stands condemned for general use.

Quinine with or without chemical substances, and various other chemical substances without quinine, are made up in a variety of forms of pastilles, large tablets or suppositories of various sorts. Many of these are patented under special names, and much is claimed for several of them. For instance, "Patentex" has had great claims made for it, so also has "Speton," but so far as I can discover, chemical analyses do not support the reliance placed on these things. I await sufficient favourable evidence about any of them to justify me in recommending them in preference to the tried and established compounds.

What has been said above (p. 104) in regard to quinine powder applies in the main also to powdered alum. The interest of alum is twofold. In the first place it is ​one of the oldest of spermaticides; and in the second it has accessory virtues which are particularly valuable for women who have become too much stretched and relaxed through childbirth. Alum has the secondary quality of contracting the mucous membrane of the vagina, which in some cases is of value in restoring perfect sex relations. Where the vaginal canal has been unduly stretched by childbirth the natural reactions of the coital act are sometimes thereby so much interfered with that the husband ceases to feel satisfaction from coitus with his wife. Alum, having a contracting effect, tends to restore the canal to its antepartum condition, and I have even been told in the East that it is possible to restore it to approximately the virginal state.

It must be used with discrimination for it would tend, of course, to have an excessive hardening effect if used too frequently. I do not know of any English woman who uses it as a spermaticide in this powdered form. Whether this is because the public does not know of its possible use, or from experience of any detrimental effects, I cannot yet ascertain; but I should judge that it is chiefly through ignorance of its efficacy and subsidiary value. In the form of an aqueous douche it is, of course, often ​prescribed by practitioners for leucorrhœa, but its effect is then somewhat different.

The habit of douching is one of the three most commonly advocated methods of birth control, and even in spite of the variety of its inconveniences and disagreeable characteristics, is still undoubtedly much used.

Innumerable vaginal douches are on the market—a number of them patented. The old-fashioned douche-can or bag, which depends on the downward flow of water when it is hung on a raised nail in the wall, is still often advised, but is now generally discarded in favour of a compressible rubber douche. This gives a good whirling spray of solution penetrating to the end of the vaginal canal and calculated to lave the interstices of the vaginal corrugations.

The douche has been repeatedly recommended by those advocating what are called "Malthusian" methods; see, for instance, the "Practical Leaflet," issued for many years by the Malthusian League, and the advice given by Dr. J. Rutgers, of the Dutch Malthusian League, and by Dr. G. Hardy, of Paris, and indeed almost all the ​various books and pamphlets advising "Malthusian" methods.

My own book, "Wise Parenthood" (1918) was, I think, the first publication giving general advice on contraceptive methods which specifically advised against douching.

Most unfortunately "Birth Controllers" in general have encouraged women to douche daily, or often "as an ordinary measure of hygienic cleanliness."^[45] I most strongly deprecate this and have long thought the effects, both physiological and· psychological, of douching frequently are very bad, except, of course, in cases of specific disease where douching may be a necessary part of the treatment. In my opinion, douching is to be condemned for all healthy ordinary women. The natural contents of the vagina should not be thus intruded upon. The general effect on the system, particularly of cold douching, is a tendency to catarrh, congestion and other troubles. Frequent douching also has a tendency to destroy the natural secretions and also the normal bacterial inhabitants of ​the vagina which are of value. It tends further to reduce the sensitiveness of the vagina, and therefore to diminish its capacity to play its normal part in the act of coitus. Various objections to douching on other grounds were made in 1918 by Dr. W. E. Fothergill.^[46]

The substances added to the douche may be grouped into two series, (a) ordinary disinfectants, and (b) other chemicals which plasmolyse sperm, such as alum solution, soap mixtures, and so on.

Of the disinfectant solutions of one sort or another used by various people some are certainly undesirable, among which I include such substances as carbolic acid, lysol, and other corrosive disinfectants which have been advocated and widely disseminated. The injurious effect of such strong disinfectants has not been sufficiently realized, and sometimes even such dangerous substances as corrosive sublimate have been used as a vaginal douche with most serious results.

If for any reason the medical adviser desires the use of a douche as contraceptive in spite of these drawbacks, it should be pointed out that as a spermaticide plain ​cold water is in itself sufficient to destroy the activity of the sperm, and that only the safest and most harmless solutions should be advised for use by the ordinary uneducated woman. In particular, only solutions should be advised, which if absorbed (as they undoubtedly partially will be) by the vaginal walls, will do .no harm to the system. Common salt, diluted vinegar, weak alum and water are all quite sufficient for the purpose if a douche is demanded.

Bearing in mind the disadvantages and drawbacks of douching at all, if a douche is still desired, one of the best things is a solution of common salt. It may be made twice or three times "normal" strength with the specially prepared tablets, but common "kitchen" salt is quite good enough. A tablespoonful to a quart jug dissolves quickly and makes a cheap douche which is quite as effective as any other.

(15) Vinegar or acetic acid in water, or lactic or citric acid in water have some uses, and are liked and trusted by some women. They are in line with "nature," both because they can be safely absorbed into the system as they are safely consumed as articles of "food," and also because the natural ​secretions of the vagina are acid, and such acid naturally disposes of the inoperative sperms. Some women use half and half vinegar and water in which to soak a sponge, which is placed in front of the cervix before coitus, and then douche out with vinegar and water rather more diluted after coitus. The method is a very old one and is widely used.

Lactic acid is a more recent suggestion, and was made a few years ago by a medical man. I have heard it repeated as a suggestion from a variety of quarters but have not yet encountered a case of its practical use by a woman.

A great variety of disinfectants of one sort or another have been advocated as spermaticides. I think they should be considered under two categories, and those which are (or may be in special circumstances) dangerous if used too strong should never be advocated for general use, but should be specially restricted to cases under specific medical treatment. The other group of disinfectants is composed of those which are harmless however strong they may be used. These may be generally advocated when a douche with a disinfectant ​is desired in spite of the drawbacks outlined on p. 116.

In the first of these two groups, i.e., among those I consider dangerous, carbolic acid should be included in spite of its advocacy by an important authority.^[47]

Corrosive sublimate, which is often advised in 1 in 2,000 parts, is very dangerous for general use, and should be given only when disease is present. Deaths are on record^[48] from the use of corrosive sublimate as a contraceptive in the vagina, and I know of ruined health which was induced by regular douching with the corrosive sublimate in solution.

Potassium permanganate (1 in 2,000) is often used as a douche, and is easily made. The recently popular disinfectant Chinosol is liked by Sir Arbuthnot Lane and other medical practitioners specially conversant with the problems of the prevention and cure of venereal diseases because chinosol is considered one of the best preventive disinfectants available and it is always wise to ​combine two useful results from one action if possible. The assistance in safeguarding or reducing the danger of infection however is a secondary feature of the practice of contraception which may often be necessary in individual cases but which is essentially a separate theme.

In my opinion, where other considerations of disease do not complicate matters, and yet a disinfectant douche is desired, the best disinfectant to use is listerine. Its accessory properties are most valuable, and it can cause no pain or damage even if used stronger than it is ordered. Indeed, undiluted listerine can do no harm.

Much of what is said above applies to the douche, even if only cold water is used. Its chilling effects cause a liability to catarrh, &c., although the water itself has no direct poisonous effect. The frequent presence of cold water where it is not intended to penetrate can hardly be advisable. Nevertheless, as in most douches the object achieved is really achieved by the physical effect of the sluicing and not by the disinfectants at all, cold water by itself is probably quite effective when any douche at all would be effective. ​Cold water, of course, is sufficient in itself to plasmolyse motile spermatozoa.

In General.—To the douche in any form in addition to the objections mentioned above, there is the very important psychological objection that both for the man and the woman the use of the douche interrupts seriously the sequence of the completed coital act. If the woman gets up to douche immediately after the coital act (when relaxation and profound rest are demanded) this prevents her natural relaxation and sleep. The processes of the douche coming at this time demand energy, and the sordid procedure of the woman getting up, moving about the room, and so on, have a psychologically destructive effect on both of the married participants in the act. This tends so much to reduce the value of the coital act that in many cases it becomes abhorrent to one or other of the pair. I know cases of husbands who prefer to go to prostitutes rather than have coitus with their wives followed by the objectionable douching after the act.

In addition to this there is in the ordinary home, when coitus is conducted late at night (as is very usual), very considerable risk of the woman catching an ordinary cold or giving herself an internal chill. ​And, finally, the douche is by no means a reliable contraceptive, seeing that in the nature of things it must come after the ejaculation has taken place. Its effects can hardly be expected to follow up the sperm after their entry into the uterus. Presumably, often if the douche is at all effective, it is due to local chill and shock, neither of which can be good for the woman. Unfortunately, those who are now forced by reason of its ineffectiveness to concede that the douche is an unreliable contraceptive, nevertheless, still continue to advocate it as a daily hygienic measure.

Comment.—I condemn douching entirely except for rare and occasional use, or as a definite form of treatment for disease. As a contraceptive measure by itself all douching is unreliable, unwholesome, and psychologically harmful.