Contraception/Chapter 7

In the course of the descriptions of the various methods of contraception in current use, some indication of their value in special cases has already been given. It may be useful, however, to be more explicit about some of the difficulties which are of fairly common occurrence and which present themselves as special problems.

For normal couples on the bridal night.

Though it may well be argued that on the bridal night no thought of contraceptives should arise, yet for perfectly good reasons, either medical, financial, or due to the necessities of travel in remote districts, some bridal couples may require to use a contraceptive. It is true that the risk of pregnancy resulting from the first unions is much less than is generally supposed, but there are circumstances which demand that a young couple should take no risk what​ever. The assumption properly is that the bride is still virgo intacta; and therefore any preventive measure to be used by the woman should be in the ordinary way impossible. It is true that nowadays an increasing number of girls have, through athletic activity and other natural causes, had the hymen already ruptured; but a hymen partially, or even completely ruptured in this accidental way does not involve the internal stretching which is caused by successive acts of coitus, so that the bride is not physically in a condition to wear the occlusive cap, and though she might be able to utilize the quinine suppository, it is very liable to cause soreness and irritation in the first few days owing to the laceration and tenderness normal at the bridal period. Without doubt for the first two or three weeks of marriage responsibility for the contraceptive measures taken should properly devolve on the man.

When asked, as I frequently am, what course should be pursued by a young couple with good reasons to take contraceptive measures on the bridal night I generally recommend that for the first few weeks of marriage the man should use the ordinary condom or sheath (see p. 125). This has a double advantage because it not infrequently ​happens, particularly with men who have lived honourable lives, that at first the man may be inexperienced and hence a little clumsy and thus fail in the proper placement of the ejaculate. The use of the sheath prevents accidents which, unless guarded against, cause such revulsion on the part of the bride that the effect may be life-long and ineradicable. The sheath is indeed wellnigh essential in cases (which are actually very much more numerous than seems to be realized) of men who, for the first few weeks at least of their marriage, are inclined to premature ejaculation as a result of overstrain and excitement. Another advantage of the temporary use of the condom by the bridegroom is that it tends to retard somewhat the man's natural excitation and to make it easier for him to proceed with less haste than might otherwise be possible. As I have already pointed out in "Married Love" the woman is very apt under modern civilized conditions to suffer deprivation of the completed coital act owing to the excessive speed of the husband's completion of his share of the mutual rite.

After a few weeks of marriage when the local soreness due to the rupture of the hymen has entirely ceased, and the bride is able to take the necessary precautions her​self, the cessation of the sheath and the use of the internal occlusive cap (see p. 138) by the woman should be advised.

Unless the young woman has seen in her own home her mother brutally treated and martyred to child-bearing, fear of childbirth and pregnancy is not characteristic of the woman who has not borne a child. Indeed, I think, I may safely say that the great majority of healthy happy young women take on gaily their first motherhood. Thereafter their individual circumstances determine whether or not fear will develop.

In all the medical and scientific works I have read I think nowhere is justice done to the health-destroying, home-wrecking work of fear of pregnancy in our modern civilization. This fear in a woman is often less on her own behalf than on behalf of her husband, her children, or the family resources, and a number of other unselfish considerations; but the fact remains that fear of pregnancy is so intense as to hang like a great fog-cloud murkily ever-present and dimming the health of large numbers of our people. A woman in whom this ​fear is developed and who has tried some one or more "recommended" contraceptive which has failed her, is often a difficult case to advise. If her sufferings have been intense she may be unconvinced by any argument and no matter how bad the results in other ways, she will persist in her refusal to have coitus with her husband. Individual care, instructive talks and explanations of the harm this causes both to herself and her husband, and demonstrations of just how the advised contraceptives act, should coincide with reading by the patient herself of as much in the way of scientific and explanatory literature^[1] as she has the education to understand. A personal local examination, and, if suitable, the fitting of the cap or pessary and a demonstration by a doctor or midwife are essential. According to the degree of fear developed, three simultaneous or two simultaneous methods should be advised with an explanation of how greatly the security is increased by such duplication of safeguards.

A case who may be, in every other respect, entirely normal and for whom ​therefore the method of contraception which should be advised is the cervical occlusive pessary, may yet be peculiar in having an under-developed or suppressed cervix, and for that reason will be unable satisfactorily to fit and use the cap. Similarly women who have had the cervix amputated will be unable to use that method.

Ill-considered advice has sometimes been given to such women to wear the "Dutch Cap" (see p. 160), but if they are small or normally shaped, potent, and capable of the properly completed act of coitus, I do not advise this for the reasons detailed on p. 162. For such women the sponge (see p. 132) is probably the best method, or the quinine suppository (see p. 105) by itself may be sufficient.

If, on the other hand, cervical deformation is coupled with a general obesity and stretching of all the parts, the "Dutch Cap" (properly made) will then probably be the best method to use, and it will be justified because the firm gripping movements of the vagina will have been lost already, and the "Dutch Cap," therefore will not be interfering with processes which the woman without it might complete.

In some cases the cervix is so deeply cleft that an ordinary woman might fit a cervical cap on to one half of the cervical neck and leave the other uncovered, and the cap would then be insecure and entirely unreliable. In cases where the cervix is proliferated or there are other extraneous growths adjacent to it, the small occlusive cap cannot be fitted. If a woman who suffers from cervical or adjacent growths tries to use the cap she may be misled into thinking the cap caused the growth! Hence, not only does the "cap method" get blamed for failing as a contraceptive, but it is said to "cause bleeding" or growths or whatever is wrong.

A woman wrote to me that the cap had caused cancer. Immediate inquiries elicitated from her the fact that bleeding ensued the day after she used a cap for the first time, and that cancer was at once diagnosed.

It is perhaps hardly necessary to point out that a soft rubber cap cannot cause a cancerous growth in eight hours! Nevertheless, this case, and a possible few scattered cases like it, are, I believe, the source of ​many of the rumours put into circulation by the opponents of contraception. On this subject pre-eminently, no scientific inquiry into the relevant details, nor even a clear statement of the facts, are given about cases which are quoted and re-quoted as "bogies" but not critically inquired into.

For cases such as the above, the first step to be taken is to put right whatever is wrong, and operate if necessary, after that contraceptive measures may be considered: the likeliest then to succeed are the sponge (p. 132), the Dutch Cap (p. 160), or the feminine sheath (p. 169). Of course, where the woman is left in such a state that she cannot use any method herself, the husband must wear the sheath, however unsatisfactory, or one of the pair must be sterilized.

The existence of such cases of local physical abnormality, which may occur in women who in all other respects appear normal, and who may think themselves in good health, affords the best justification for my demand for Clinics or properly trained midwives attached to antenatal and welfare centres, because ignorant women are often not able to determine whether or not they are normal. If the above abnormalities are present and unsuspected, and the woman uses the occlusive cap she may ​find it "fails" and she conceives, and she is thus not only a sufferer personally, but is a centre of these very untrue rumours that a "cap is unreliable."

Obesity, the stretching due to many child-births, and a lack of tonicity in the adjacent muscles sometimes result in local conditions making the use of the small occlusive cap impossible. For such cases, who are inherently unable to perform the sex act quite perfectly, the use of the properly made "Dutch Cap" is perhaps the best method available.

It is interesting to note that the Jewish women of the slum quarters of East London appear to have cervices much larger than those normal among more typically British stocks, and there is an extra very large size of cervical occlusive cap which was originally made for Jewish midwives and used by them among their patients.

Unfortunately in those women who have been injured by and improperly repaired after child-birth, or who have, in other ways, borne too great a strain, uterine displacements and prolapse of one sort or ​another are very prevalent. Prolapse if at all serious, is apt to render the use of the occlusive rubber cap (see p. 138) impossible, or at the best to make it unreliable.

Many women suffering from prolapse wear a ring to support the uterus which makes it impossible to adjust the occlusive cap. If the cervix is fairly supported so as to be approximately in its natural position their choice of contraceptive would lie between a sponge (see p. 132) and the quinine pessary (see p. 105) either of which might be sufficient by itself. If, however, the danger involved in a pregnancy is very great a woman will probably be well advised to use both of these methods for further security. If the cervix is very seriously out of place (as is unfortunately not rare in women of middle age who have borne a good many children) the use even of both the sponge and quinine may be little or no safeguard, for if the cervix is placed low down in the vaginal canal, neither of these methods is effectively secure.

Although I think it has serious drawbacks, the only method which a woman with a low-lying cervix can herself use with any degree of safety is the feminine sheath (see p. 169). On the other hand, if she has an affectionate and reliable husband, he may ​wear a sheath, but both these methods have the disadvantage of depriving her, as well as her husband, of the full benefit of coitus.

I confess, alas, that I know of no satisfactory method of birth control for the woman herself to use when she has a badly displaced uterus with the cervix low down.

This, of course, is no reflection on the value of contraceptive methods, but merely brings home the fact (which should be selfevident from other points of view) that no woman should be permitted to go about with a badly displaced uterus. I may say that my experience in the last year or two, when I have learnt the history of a number of poor women, has been such as to intensify my horror and amazement at the gross neglect with which the average poor working woman is treated in this connection.

A woman personally known to me, having had five children (which was far more than the weekly earnings of her family were sufficient to support) desired to use birth control methods herself as her husband was negligent, and found the cervix to be badly out of place. I advised her to go into hospital and be operated upon so as to have the uterus restored to its proper position. She ​said she had wanted to get this done and had been to two hospitals, at both of which the doctors had laughed at her and said that as she could go about they would do nothing as there were thousands of women worse than she and they had no time to attend to such comparative trivialities. The "triviality" in this case involved this poor working woman in a back-ache so continuous that she had to stop two or three times a day in the middle of her work nearly crying with the dragging pain to snatch a few moments lying down. She also ran the continued risk of further pregnancies owing to the impossibility of any cheap and simple method of contraception being of any use to her.

While it seems to me revolting that any diseased person should either indulge in or be called upon by another to co-operate in the coital act, nevertheless it is useless to disguise the fact that it is done with extreme frequency. Where the disease is local and contagious, as are either of the venereal diseases, there is no doubt that the condom by the male or the feminine sheath by the woman, should be used, and these ​should be well smeared with a disinfecting ointment such as calomel ointment, and the sheaths should preferably be used by both parties.

In such circumstances as this the contraceptive is not a contraceptive pure and simple but performs the double function of preventing a conception which would be a crime against society, while it also helps to minimize to some extent the risk of contagion from the diseased to the healthy person. In my opinion, however, patients should be told in the plainest terms they can understand, of the risks they run and the virulent nature of the germs they are liable to convey.^[2]

When one or other of the uniting pair is diseased, but not locally—such for instance as those who are tuberculous, or when a woman suffers from diabetes, renal disorders, or other maladies of a serious nature—no special local disinfectant need be used; but as a pregnancy would have very serious effects both for the mother and the child, special care is wanted to secure the avoidance of even the smallest possible chance of failure. Therefore, at least two contraceptive measures should be ​used simultaneously. In a great many of such cases, however, I should advise not a temporary and continuously troublesome measure of contraception, but permanently effective sterilization (see below). This is also even more necessary in those who suffer from insanity or definite feeblemindedness.

The same applies even more explicitly to all cases of women where a fortuitous pregnancy would involve the necessity for an evacuation of the uterus (see p. 54). In such circumstances, no further risks should be taken and the woman should, therefore, be permanently sterilized.

Where the diseased or degenerate person is the man, this is of course a much easier and lighter operation by means of vasectomy than where the one to be sterilized is the woman. For women probably the cutting and double tying of the Fallopian tubes is the best of the various methods of sterilization, but as it involves rather a serious operation, the expense tends to take it out of the reach of a great many just of those women who most need it.

The old-fashioned method of sterilization which was for some time rather fashionable ​in America, namely, the excision of the ovaries, is now no longer advocated except where local disease necessitates their removal. Even then an effort is always made to leave a small portion of the ovary owing to the extreme importance to the entire system of the internal secretions from these organs. The double tying and cutting of the Fallopian tubes does not involve any detrimental loss of the internal secretions and is, therefore, the method best suited for general use. This is generally safe and can be relied on, but the older method of a single ligature is not entirely safe. Recently Dr. McArthur advised in place even of the double ligature, the complete removal of the tubes, his words being: ^[3]"The reparative power of a mutilated tube is extraordinary, and now, when sterilization is demanded, I adopt only one method—namely, complete removal of the tubes and the greater portion of the uterine ostium. By doing so one is, in the first place, certain of sterilization, and, secondly, that there are at least no receptacles for infection."

Dr. McArthur's case, ^[3]"Some years ago operated on a woman for prolapsus uteri, ​performing amputation of the cervix, anterior colporrhaphy, extensive colpoperineorrhaphy, and suspension of the uterus, and ligatured both Fallopian tubes with silk. Eighteen months afterwards she appeared in my consultation room four months pregnant. I had told her she need not be afraid of becoming pregnant again. She took no precautions, whereas for nine years previously she had taken precautions with success. Ultimately a child weighing 14 lb. was born; the mother was torn to the uttermost and prolapse occurred worse than ever. I had to operate again; there was no sign of the silk, no evidence of stricture of the tubes, which both looked quite normal."

The Sterilization of the male, where necessary, is a much less serious operation. The old method of castration is never employed where sterilization pure and simple is desired. The best practical method is vasectomy.

Of Vasectomy, Belfield said as long ago as 1909^[4] that it "is an office operation; it can be performed in a few minutes under cocain anæsthesia, through a skin cut half​an-inch long; it entails no wound infection, no confinement to bed; it is less serious than the extraction of a tooth . . . it does not impair the mechanism of erection and ejaculation."

X-ray sterilization has now a voluminous literature of its own, since its first, more or less accidental introduction. In 1909 Regaud and Nogier reported the successful sterilization of male rats by one application only of X-rays filtered through an aluminium plate. This left no injury of any sort.^[5]

Schäfer's textbook on Endocrine organs generalizes upon the condition of male sterilization, and says: ^[6]"If the testicles are exposed to the action of X-rays, the seminiferous epithelium undergoes degeneration; although the interstitial tissue is not, at first at any rate, attacked."

Numerous recent advances in the study of X-ray and radium sterilization have been made, and their consideration is outside the scope of the present book. Reference might, however, be made to the interesting ​paragraphs in the Lancet^[7] under the heading, "Control of Conception by Irradiation," in which a brief account is given of the work of Markovitz and Kriser. The procedure suggested by Markovitz being the production of a temporary sterility by means of a minimal dose in one of the married pair, and then "irradiating the man before the ability to conceive returns in the woman, as indicated by the recommencement of menstruation. Since the duration of the sterilization in the man is as yet unknown, he admits that periodical examinations of the spermatic fluid will be necessary. . . . The treatment has the merit of avoiding finality."

It is outside the scope of the present survey to discuss sterilization fully, and the above notes are merely included as a connecting link between the present work and some of the many medical works on sterilization to which reference should be made.

It is much to be desired in the interests of the race that inexpensive methods of temporary sterility should be devised, improved, and rendered available in practice for those in whom disease or a degenerate or undeveloped mental capacity, render likely to produce detrimentals if they breed without restriction.