SAFE MARRIAGE A RETURN TO SANITY
ETTIE A. ROUT
WITH PREFACE BY
SIR WILLIAM ARBUTHNOT LANE, BART., C.B., M.S., (Consulting Surgeon to Guy's Hospital), etc.
LONDON: WILLIAM HEINEMANN (Medical Books) Ltd. 1922
PREVENTION OF VENEREAL DISEASE By SIR ARCHDALL REID, K.B.E., M.B. With an Introduction by SIR BRYAN DONKIN, M.D. Crown 8vo. 447 pages. 15s. net. Weight 2 lbs. Inland postage, 9d. This book is addressed on the one hand to those who would prevent venereal disease in themselves, and on the other, to those who would prevent it in the community. Lancet. "A powerfully written and valuable volume." The Medical Press. "We positively assert that it is the duty of every medical man to master its contents." LONDON: WM. HEINEMANN (Medical Books) Ltd.
The French Government has bestowed the premier decoration for women, The Reconnaissance Francaise, upon Miss Ettie Rout, of the New Zealand Volunteer Sisters, "for work done during the war (as head of Anzac Soldiers' Club in Paris), and in 1919-1920 as head of American Red Cross Depot and Canteen at Villers-Bretonneux, where she helped a great many French soldiers, and rendered precious service to the civilian population of the commune." The War Office also conveyed thanks to Miss Rout "for gallant and distinguished services in the field." "I have it in command from the King," wrote the Secretary of State for War, on 1st March, 1919, "to record His Majesty's high appreciation of the services rendered."
It affords me great pleasure to write a short preface to this book, since it deals with a matter in which I (in common with all those who are intensely interested in the health of our race) am glad to take an active part.
To no woman has it been permitted to do the same amount of good, and to save more misery and suffering, both during and after the war, than to Miss Ettie Rout. Her superhuman energy and indomitable perseverance enabled her to perform, in the most efficient manner possible, a work which few women would care to handle, and of which but an infinitesimally small number are capable. The French Government fully recognised the great services she rendered to the Allies, and did her honour. The book she has written is one of very great value, in that its object is the Health, Happiness, Morality and Well-being of the Community.
Not only has Miss Ettie Rout the qualities that characterise all great humanitarians, but she also possesses, in a unique degree, an intimate knowledge of the terrible troubles that arise from irregular intercourse, and of the manner in which they can be reduced and perhaps eliminated.
In this book she deals with such simple hygienic measures as are little known in England, though they are in common use in France and in the United States, in both of which countries sound practical common sense prevails.
She is persuaded that marriage is the goal to be reached by all, and that everything possible should be done to facilitate it, and so to diminish vice. In her efforts to bring about this happy issue she has the good wishes and congratulations of all who have the health of the community at heart.
W. ARBUTHNOT LANE. 21, Cavendish Square, London, W.1.
March 25th, 1922.
I. INTRODUCTION 17
II. PRACTICAL METHODS OF PREVENTION A. FOR WOMEN 32 B. FOR MEN 51
III. MEDICAL FORMULAE 59
IV. COMPULSORY TREATMENT 63
V. CONCLUSION 65
APPENDIX I 69
APPENDIX II 73
NOTE AND ADVERTISEMENT 75
"Knowledge comes, but Wisdom lingers, and I linger on the shore, And the Individual withers, and the World is more and more."
This book embodies the considered opinions of twenty-five years' practical experience of adult life—as an official reporter and journalist, as a voluntary war-worker, and as a married woman. For many of the thoughts and expressions used I am indebted to large numbers of men and women whom I cannot name, and with whom I have been personally and professionally associated in different parts of the world. I am also indebted to the following medical journals for the publication, during the last five years, of many letters, articles, notes, etc.: The Lancet, The British Medical Journal, Public Health, Municipal Engineering, Hospital, New York Medical Journal, etc., etc.
I have to thank the Society for the Prevention of Venereal Disease, the National Birth-Rate Commission, and the Joint Select Committee (House of Lords) on Criminal Law Amendment Bills for recording various statements and evidence.
It remains only to state this fact: That on January 25th, 1922, Sir Arbuthnot Lane, Sir Frederick Mott, Surgeon-Commander Hamilton Boyden, of the Royal Navy, and Mr. Harman Freese, of Freese & Moon, manufacturing chemists, of 59, Bermondsey Street, London, S.E.1, met at my home to decide upon the best medical formulae for self-disinfecting ointment for men and contraceptive-disinfecting-suppositories for women. Mr. Freese made up sanitary tubes and sanitary suppositories in accordance with these formulae, but he is prohibited by law from recommending these for the prevention of venereal disease, and forbidden to supply printed directions with them, whereas similar medicaments are being retailed with printed directions in the State of Pennsylvania, and the Health Department circularises medical practitioners thus:—
"The self-treatment packet, obtainable at drug stores, to arrest venereal infection after exposure, is approved by the State Department of Health on the same principle as is antitoxin given to diphtheria contacts. Proof is lacking that the use of this packet lowers social standards. Reduction in the incidence of venereal disease is a direct result."
But not only in the clear, cool air of American State Departments of Health is the knowledge and love of sexual cleanliness fructifying. In the Dublin Review for January-March, 1922, there is a wonderfully fine article on "The Church and Prostitution," by the Right Rev. Monsignor Provost W.F. Brown, D.D., V.G., in which he quotes from a very recent Moral Theology, "De Castitate," by the Rev. A. Vermeersch, S.J., Professor of Moral Theology at the Gregorian University, Rome, published in May, 1921. The author of "De Castitate" gives brief answers to three questions put to him, which Mgr. Brown quotes in the original Latin, and of which the following is a translation furnished by a Catholic priest:—
1. Whether or not it is formally sinful to use antiseptic ointment before illicit intercourse.
2. Whether or not the use of such ointment may be advocated.
3. Whether or not it is lawful for chemists to sell it.
Ad. 1. Although it seems that in England (cf. Times, January, 1917) some have made a scrupulous distinction between the use of this ointment before and after, and have forbidden the former while approving the latter, you need make no such distinction (of course, supposing the ointment is not used by a woman to sterilize). It is not wrong to seek means, indifferent in themselves, which will prevent the evil consequences of sin.
Ad. 2. It would indeed be a sin to reveal such drugs or to persuade their use with the intention to induce a man to commit sin; but there is no harm in telling a man who is certainly going to sin how to avoid the consequences. Ad. 3. If men could be restrained from vice by prohibiting the sales, this should be done; but so many are ready to expose themselves to danger that you cannot hope for such a result from forbidding the sale. It is true this removes fear, but the general good, and the removal of danger to the innocent justifies this. Besides, it is a poor virtue which is kept from sin only by the fear of disease."
Having gone so far as to admit the desirability and necessity of the medical prevention of sexual diseases, the Roman Catholic Church will certainly find itself later unable to deny the desirability and necessity of preventing the birth of children liable to be born diseased or unfit. It is not practicable for a wife to take any suitable precautions against infection by a diseased husband, which precautions will not at the same time be effective, to a greater or lesser extent, in the prevention of conception. There is no half-way house in the matter of sexual hygiene.
ETTIE A. ROUT.
At present marriage is easily the most dangerous of all our social institutions. This is partly due to the colossal ignorance of the public in regard to sex, and partly due to the fact that marriage is mainly controlled by lawyers and priests instead of by women and doctors. The legal and religious aspects of marriage are not the primary ones. A marriage may be legal—and miserable; religious—and diseased. The law pays no heed to the suitability of the partners, and the Church takes no regard for their health. Nevertheless, the basis of marriage is obviously mating, or sexual intercourse. Without that there is no marriage, and with it come not merely health and happiness but life itself. Cut out sexual intercourse, and society becomes extinct in one generation. Every generation must, of necessity, pass through the bodies of its women; there is no other way of obtaining entry into the world. Hence, it is clearly the duty of women to understand precisely the processes involved, from beginning to end.
With the lower animals sexual intercourse is desired only seasonally, and only for the purpose of reproduction. With the higher animals—man and women—sexual intercourse is desired more or less continuously throughout adult life, and desired much more for romantic than for reproductive considerations—that is, for the sake of health and happiness rather than for the sake of procreation only. A few women, and still fewer men, have no sexual desires. To them sexual abstinence seems more natural than sexual satisfaction. But for the majority of mankind and womankind—for all normally healthy men and women—there is this continuous desire to be happily mated.
For the sake of health and happiness there is everything to be said for early marriage, but better late than never.[A] The chief obstacles to early and happy marriage are financial, and these would largely disappear if women were able to control fecundity. The chief obstacles to healthy marriage are the venereal diseases, and these could be extirpated in two or three generations if sexual cleanliness was properly taught to all adults, and if promiscuous intercourse was properly regulated during the same period. Unfortunately most women's idea of regulating promiscuous intercourse is to have none of it. This is impossible in the present stage of moral evolution, but it will become increasingly possible as we succeed in extirpating the venereal diseases, particularly syphilis. Syphilis is the one great cause of immorality, because persons born with a syphilitic taint (and what family is entirely free from this hereditary disease?) are apt to be mentally and morally deficient; hence, tend to indulge in anti-social and unnatural practices, such as engaging in promiscuous intercourse.
[Footnote A: Marriage, whether early or late, cannot of course benefit and elevate society until the present mischievous and archaic Divorce Laws are simplified and reformed in accordance with modern sociology and ethics. Unhappy and unsuitable marriages necessarily foster immorality and promote disease, and the community as a whole gains by their being dissolved in a ready but responsible and dignified manner. The refusal of the Church to marry diseased persons would greatly benefit the nation, whereas its refusal to marry healthy divorced persons not only injures the nation but dishonours the Church.—E.A.R.]
The normally healthy man is a highly selective creature, and the normally healthy woman still more fastidiously selective in romantic relationship. Neither man nor woman is naturally in the least attracted by promiscuous intercourse. On the contrary, it is repugnant to both. Both regard the elements of romance, reciprocity and permanence as essential. These elements are present in marriage and absent in prostitution. Therefore, it is beneath the dignity of any decent, intelligent woman to suppose that promiscuous relationship can ever be as happy and satisfying and attractive as marriage. This, apart altogether from the fact that marriage is fertile and prostitution infertile. No, both man and woman desire love-relationship, not loveless-relationship; and they are really quite fit to be trusted with the evolution of the race through passionate love and the worship of beauty, as soon as society makes harmonious provision for their normal sexual needs. Until society does make early marriage practicable for all healthy adult men and women, say between twenty and twenty-five years of age, extra-marital relationship, however undesirable, is inevitable, because there are many men to whom, at times, any woman is better than no woman.
But extra-marital relationship is never even safe, because of its promiscuity and impermanence, except in properly conducted and effectively supervised tolerated houses. The tolerated house is absolutely necessary at present to protect women from disease and immorality, by confining this kind of intercourse as far as possible in certain definite channels. The abolition of the tolerated house spreads both disease and immorality into classes of women who would otherwise be immune, and enormously increases the dangers of promiscuous intercourse. Separated from their toilet equipment the women cannot make and keep themselves clean; on the streets they are not taught to refuse intercourse with diseased men; thus their occupation becomes more and more dangerous as medical supervision is removed. They inevitably become diseased; sometimes contract mixed infections, which they pass on to their clients—the future husbands and fathers of the nation—and "The sins of the fathers are visited upon the children even unto the third and fourth generation." All this would be impossible if women generally would recognise the primary fact that because a man is immoral that it is no reason why he should become syphilitic. We all want to abolish sin, but failing that we must cease wanting to poison the sinner. We must actively work to save him from the penalties of his folly, for that is the only way in which we can save his victims and succeed ultimately in "Making Marriage Safe."
Similarly every effort should be made to prevent women becoming diseased, no matter how immoral they may be. The prostitute is very often a woman of peculiar mentality or overdeveloped animal instincts; and many women are driven to prostitution by drink and poverty. The prostitute class is largely recruited from mentally and morally deficient girls, who are themselves the offspring of syphilitic or alcoholic parents. Prostitution is the effect—not the cause—of anti-social acts and conditions. We must remedy the causes of these before we can hope to remove the effects. Under present social conditions, attempting to abolish prostitution by shutting up tolerated houses is just as idle as attempting to lower the temperature of a room by smashing the thermometer. All we can do is to make and keep these women clean. If we decline to do even that, then diseased women will succeed in contaminating our men much faster than we can instruct the men in sexual cleanliness.[B]
[Footnote B: Diseased women will continue to cater for men so long as they are left free to do so, but as knowledge grows their clients will tend to be limited to diseased men. Once men clearly understand that every casual connection is a risk of disease, they will certainly tend to run fewer risks.—E.A.R.]
And again, just as the medical prevention of venereal disease was not proposed, and has not been applied for the purpose of fostering or condoning promiscuous intercourse,[C] so the conscious control of fecundity by contraception must not be applied in such a way as to lessen the proportion of well-born citizens in the nation taken as a whole. Birth-control applied only by the responsible classes of the community combined with indiscriminate fecundity among the irresponsible masses, must inevitably lead to the lowering of the general average in character, brains and physique. It is a form of reverse selection—the responsible being out-bred by the irresponsible. What is wanted is the general application of birth-control by voluntary contraception, and the particular application of voluntary and compulsory sterilisation of the feeble-minded and unfit.
[Footnote C: My own experience among the troops quite convinced me that the more thoroughly and carefully self-disinfection was taught, the less immorality there was. It was impossible to teach self-disinfection properly without at the same time instilling a living sense of danger into the minds of men and women; and this danger-sense certainly led to more self-restraint.—E.A.R.]
Enthusiastic advocates of birth-control claim it as a means of improving the race. It is not necessarily anything of the kind. You cannot improve a flock of sheep or a herd of cattle by letting all the individuals breed; whether each individual has a small number or a large number of offspring makes comparatively little difference. The way to improve the flock or herd is to breed only from the best and eliminate the unfit as breeding material. Changes in environment may improve or deteriorate the individuals of one generation, but such changes are not inheritable, excepting in the case of venereal disease. Syphilis, e.g., may damage the germ-cells of a man's body, and thus lead to his procreating diseased and damaged offspring—idiots, imbeciles, mental or moral deficients, and so forth, who unfortunately are fertile. Thus the prevention of venereal disease is a eugenic force. It is in fact the only eugenic force in operation at present. Generally speaking, it is the well-developed and high-spirited and enterprising young men who travel most, and who, therefore, are most likely to contract and spread venereal disease. They come in contact with a much larger number of women than those who stay at home instead of wandering abroad. These well-to-do young travellers often marry the finest of our women, and later in life damage or sterilise them through latent or chronic venereal disease. Hence many one-child marriages—due not to the use of contraceptives, but to the action of the gonococcus transferred to the body of the wife.
But there is this hope. It is among the mentally alert and well-informed men and women that birth-control is first understood and applied, and it is among this very same class that the medical prevention of venereal disease is also first understood and applied. Thus, there will tend to be less disease among this class than among the mentally torpid and ill-informed masses of the community. This in itself will not improve the race, but it will prevent the deterioration of certain classes and increase their numbers. Nevertheless, so long as the irresponsible and feeble-minded and diseased are permitted to multiply indiscriminately, as at present, they must ultimately outnumber and overwhelm the classes which are practising self-restraint or applying birth-control. This process may even be hastened by a political enfranchisement, which enables twelve feeble-minded persons to outvote two wise men six times over. Thus, to succeed democracy must raise and maintain the general average of brains and character throughout the community. In so far as it permits low-grade individuals to be born in the homes of the masses, and high-grade individuals in the homes of the classes, it is manufacturing a rod to thrash its own back, successful rebellion against which mode of Government ends in mere anarchy and chaos.[D]
[Footnote D: The present need of the white race is to increase its numbers of fit and decrease its numbers of unfit. Over-population (except in a few patches of the Old World) is not likely to be a problem for the white race for centuries. They have several continents practically empty and undeveloped, and science has as yet touched only the fringe of the possible productivity of the earth in the matter of food supplies. The worst feature of the British Empire is that there are too many Englishmen and not enough Anzacs.—E.A.R.]
One duty at any rate is quite clear. No woman should run any chance of conception unless she is certain of her own health and the health of her partner—the man who is to be the father of the child she is to bring into the world. If her husband's health is unsound, and she cannot avoid intercourse, she can certainly take precautions against conception and against infection. The control of fecundity and the control of infection are parallel problems, and generally speaking, the measures a woman takes to prevent conception will also prevent infection. If these precautions are not taken, a woman may not only become seriously ill herself, but she may blast the health of her unborn babe—or infect it herself during or after birth. Clearly then it is her personal, as well as her maternal and national, duty to apply preventive measures.
Women should understand that there is always a great deal of venereal disease—millions of fresh cases every year in the British Empire. During the war there were about half-a-million fresh infections per annum among the soldiers in the British armies alone—about two million men infected altogether at the very least.[E] Some were cured, others patched up; some very badly treated; some not treated at all; many demobilised while in an infective condition, and thus liable to come home and sow in the bodies of clean women the seeds of diseases picked up in foreign lands in moments of excitement and folly. Blame these men if we must, but in all fairness let us ask ourselves: Who infected them? And the answer is: Diseased women.
[Footnote E: The devastation of these diseases among the British armies abroad (in the Rhine, Black Sea, and Palestine areas, etc.) has been much worse since the Armistice than during the war. Approximately one-fourth (sometimes one-half) of these armies become infected with venereal disease every year. From 1919 to 1921 somewhat soothing statistics were issued for the army of the Rhine, but these have now been admitted in Parliament to be "quite unreliable" (Parliamentary Debates, House of Commons, November 3rd, 1921, p. 1952). It must be remembered that, owing to the exchange value of the L, the English soldier on the Rhine is now being paid about L8 or L10 per day; that is, he draws a far higher salary than the highest paid German official; hence there is no riotous pleasure, however expensive and extravagant, which he cannot afford. These conditions do not promote manly virtue or even sexual cleanliness.—E.A.R]
The venereal diseases are passed on from one sex to the other in a continuous chain, but the chain can be broken at any time by either sex. And now it is the married women on whom we must rely to see that these infections are stopped. Leaving women to the chance protection of their partners is demonstrably a failure. Here is an extract from a letter sent me recently by an old and experienced medical practitioner:—
"I have had many women under treatment who have been continually re-infected by their husbands."
Men and women must both seek knowledge and both accept responsibility for the venereal problem. They must face this problem independently and in co-operation, and above all—face it honestly. There is no other way.
It is all very well to say that the man is responsible. That is only a partial truth.[F] The woman is equally responsible as soon as she is equally well informed. A woman's body is her own, and she will never be really free until she knows how to look after it properly. If she is fit to vote, fit to pay taxes, fit to hold her own estate under the Married Women's Property Act, why should she not learn to exercise intelligent and responsible control over her own self? Why do so many women allow themselves to be impregnated and infected against their will? Because they do not understand the construction and functions of their own body. When they do understand this, they will guard their own health as carefully as they guard their reputation. They will then not only keep their own sexual organs scrupulously clean, but they will encourage their husbands to do the same. Sexual intercourse is far more refreshing and exhilarating in every way when both husband and wife have cleansed their parts immediately before enjoying it. It is only natural that both should wish to be sweet and clean before approaching the closest of all bodily intimacies.
[Footnote F: It would be much less untrue to say that the remedy for the venereal problem is clean women.—E.A.R.]
But more than this. Every well-informed woman knows that there is far more venereal disease in the world to-day, among men and among women, than there was before the war, and she should train all the members of her household in habits of strict cleanliness. Instinctively they will then avoid risking their health by contact with a possible source of defilement, or if the risk has most unfortunately been taken, they will instantly and instinctively remove and destroy the possible infection, in the same rapid and effective way as they would cleanse their boot from filth accidentally coming in contact with it. By all means let the mothers continue to inculcate virtue, but they should also teach sexual cleanliness directly and indirectly, themselves setting the example. After all, the microbes of venereal disease grow almost exclusively in the genital passages, and if these were kept sweet and clean there would soon be an end to venereal disease. It is not a matter of making vice safe: it is a matter of making marriage safe: a matter of restoring and maintaining physical health, family and national, and above all, of protecting innocent women and children, for if vice has its dangers so also in these days has innocence its own peculiar perils, and it is the cry of these victims—often so young and so fair—that must affect us most deeply.
More than fourteen years ago, Mr. George Bernard Shaw, in the Preface to "Getting Married," wrote the following regarding "The Pathology of Marriage":—
"As to the evils of disease and contagion, our consciences are sound enough: what is wrong with us is ignorance of the facts. No doubt this is a very formidable ignorance in a country where the first cry of the soul is, 'Don't tell me: I don't want to know,' and where frantic denials and furious suppressions indicate everywhere the cowardice and want of faith which conceives life as something too terrible to be faced. In this particular case, 'I don't want to know' takes a righteous air, and becomes 'I don't want to know anything about the diseases which are the just punishment of wretches who should not be mentioned in my presence or in any book that is intended for family reading.' Wicked and foolish as the spirit of this attitude is, the practice of it is so easy and lazy and uppish that it is very common, but its cry is drowned by a louder and more sincere one. We who do not want to know, also do not want to go blind, to go mad, to be disfigured, to be barren, to become pestiferous, or to see such things happening to our children. We learn, at last, that the majority of the victims are not the people of whom we so glibly say, 'Serve them right,' but quite innocent children and innocent parents, smitten by a contagion which, no matter in what vice it may or may not have originated, contaminates the innocent and the guilty alike, once it is launched, exactly as any other contagious disease does; that indeed it often hits the innocent and misses the guilty, because the guilty know the danger and take elaborate precautions against it, whilst the innocent, who have been either carefully kept from any knowledge of their danger, or erroneously led to believe that contagion is possible through misconduct only, run into danger blindfold. Once knock this fact into people's minds, and their self-righteous indifference and intolerance soon change into lively concern for themselves and their families."
The facts seem so plain, and yet there is still great opposition to the promotion of a knowledge of sexual cleanliness and self-disinfection. Only a short time ago (the end of 1920), Sir Frederick Mott, the great authority on syphilis, felt obliged to oppose some opponents of self-disinfection at a public enquiry in London in this fashion:—
"The point is that large numbers of innocent women have suffered from disease. They are rendered sterile, have miscarriages and abortions, and large numbers have been ruined. I have been connected with the London County Asylums for twenty-five years, and I have seen in those asylums people from all states of society, and I have seen them die of general paralysis. Five per cent. of the people who get syphilis, in spite of treatment, develop this disease. That is only one aspect of it. I was on the Royal Commission on Venereal Disease, and Sir William Osier, who was a great authority, said that he could teach medicine on syphilis alone, because every tissue in the body is affected by it, and that the diseases of blindness, deafness, insanity and every form of disease may be due to syphilis. You have only to consider the effect that it had upon the army, and I understand that more than two army corps were invalided during the war on account of venereal disease. What have you to say to that? Does not that create some anxiety?"
It is difficult even to read this eloquent appeal—the more eloquent perhaps because it was quite unpremeditated—without being deeply moved. Yet the witnesses opposing Sir Frederick Mott were apparently unaffected. Of them, as of men of old, it might justly be said:—
"He hath blinded their eyes, and hardened their heart; that they should not see with their eyes, nor understand with their heart, and be converted."
And now large numbers of hospitals all over the Empire are issuing appeals for the means to treat venereal disease.
"It is tragic," says one London hospital, "to see the sufferers—men, women and even little children—innocent little mites, knowing not from what they suffer or why they should. It is thought by many that venereal disease is a sign of guilt, but large numbers of our patients are innocent victims."
Is it not time then that we all stopped repeating timid platitudes about making vice safe, and did something practical to make marriage safe?
Why don't we?
Is it because we are afraid to define the terms we use so glibly? We talk of promoting chastity, for example. What is chastity? Surely chastity is happy, healthy sexual intercourse between a man and a woman who love one another; and unchastity is sexual intercourse between those who do not love one another. No sexual intercourse at all is neither chastity nor unchastity; it is the negation of both, and it ends in extinction. Why trouble so much about a negation that inevitably means racial death? Why not devote ourselves to life and love; to the building of a happy healthy human family—a family that instinctively realises that the clean blood-stream of a nation is its most priceless possession?
But the national blood-stream can never be clean until there is a complete knowledge of sexual control and sanitation among all of us, and especially among women. One of the very first things which women must learn to understand is the control of conception and the control of venereal diseases. They must learn how to prevent the birth of the unfit; how to secure the birth of the fit; and even though their husbands are infective they must learn how to break the chain of infection in their own bodies, so that what is bad for the race does not become worse. If women are brave enough and wise enough, they can in most cases wipe out the scourge of venereal diseases from their own hearths and homes, and ensure that every child born is at least physically fit. But this cannot be done without knowledge, and that knowledge is at present lacking.
The following pages are written with the object of imparting useful, practical knowledge to sensible and serious women. The women who accept and apply this knowledge can rest calm in the sure and certain faith that it is their offspring who will build up the coming race.
II.—PRACTICAL METHODS OF PREVENTION.
A. FOR WOMEN:
To understand the practical methods of birth-control, or the control of conception, we must first have a clear view of the processes involved when the reproductive organs are in activity, and of the nature and situation of the sexual organs themselves. The diagrams on pages 34, 35 and 36 show in general outline the reproductive organs of man and woman.
Now fertilisation does not necessarily occur whenever the male organ comes in contact with the female organ. Fertilisation occurs only when a male-cell (spermatazoon) unites with a female-cell (ovum); in other words, when the spermatazoa in the seminal fluid of a man meet and unite with the germ or ovum in the body of a woman. That is the beginning of the child. This union of the two cells need not take place during or immediately after sexual intercourse. It may occur many hours, or even two or three weeks, after connection, because the spermatazoa have motion of their own. They are tiny threadlike bodies, which may work their way towards the ovum long after they have left the body of the man and been placed in the body of the woman, and the uterus has a searching movement, and may by its pulsations draw the spermatazoa upwards. For these reasons a woman cannot be quite sure of the exact time of fertilisation, and hence cannot predict exactly the date of the child-birth. Generally the pregnancy lasts nine months, but it may last longer—say ten months on rare occasions; and it may be extended apparently by a delay in fertilisation.
PREVENTION OF CONCEPTION.
For many reasons which I need not enumerate here, the precautions against impregnation can most easily and effectively be taken by the woman, rather than by the man. She is the one fertilised, and therefore she is the one to guard herself against fertilisation.
There are two methods of preventing fertilisation:—
(1) The chemical method, that is, the destruction of the male cells (spermatazoa) by means of a suitable germicidal substance, such as many of the disinfectants; and
(2) The mechanical method, that is, the adoption of measures which keep the male and the female cells apart from one another.
[Illustration: INNER SIDE OF THIGH.
DIAGRAM 1.—Female organs of generation in normal condition. This shows diagrammatically the position of the organs if a woman were cut in two between the thighs. The rubber pessary is shown in position, slightly distending upper end of vagina (or front passage), and covering the opening into interior of womb. A suppository introduced beforehand will dissolve and occupy the dotted space above rubber pessary, forming a pool around the mouth of the womb. The walls of the vagina are elastic and collapsible. Infection with gonorrhoea may occur in the female urethra (or water passage) or in the vagina, etc. Syphilis may infect internal and external parts of female organs; also breasts, mouth, tongue, etc., and other openings of the body.]
Neither of these two methods in practical application by ordinary women can be said to be completely certain. Both are apt to fail at times. The chemical method, that is, the application by the woman of a suitable soluble contraceptive suppository before connection, or of a germicidal douche (such as a dilute solution of lysol) after connection, or both these measures taken consecutively, may fail because of some fault in application, or because the seminal fluid actually enters the womb during intercourse; that is to say, when emission takes place, the end of the male organ may be exactly opposite and close to the mouth of the womb, and the spermatazoa in the seminal fluid enter directly into the womb, and cannot then be removed or destroyed by douching or contraceptives of any kind. Now if the physical conformation of the reproductive organs of the husband and the wife render this event possible or probable, then soluble suppositories and contraceptive douching are alike unreliable, by themselves or in combination. On the other hand, the mechanical method, that is, the use of a rubber protector, preferably the spiral-spring occlusive[G] "Dutch" pessary, by the woman may also fail, because the protector is porous or ill-fitting. But—if the two methods are combined, the chemical method and the mechanical method, then the protection against fertilisation may be regarded as almost absolute. The completeness of the protection depends, of course, upon the proper application and combination of the measures advised.
[Footnote G: Judging by certain original letters (dated December, 1888, to November, 1892), which I have seen myself, by the courtesy of Messrs. E. Lambert & Son, of 60, Queen's Road, Dalston, London, E.8, the rubber spring pessary was first suggested here by an English doctor, and manufactured for him by Mr. E. Lambert Sen. Under date December 23rd, 1888, the doctor wrote:—
"I think highly of the watch-spring rim. There will be very little fear of conception with one of these new pessaries properly adjusted, as the rim will press equally all round. The inflated pessary would be the most perfect, however, if you could only contrive some method to prevent escape of air and consequent flattening. Such a pessary would be most comfortable."]
I have discussed the various measures fully with leading medical authorities in London and Paris and elsewhere during the last five years, and have gradually evolved the recommendations made here, and these recommendations have the highest medical and scientific support and approval. Other methods than those recommended are referred to in Appendix I; to enumerate here those that have been eliminated would be purposeless and confusing. We are satisfied that we have selected the least harmful and most reliable methods known to science yet. These methods and these only will be explained and recommended. Everything possible has been done to make the methods acceptable to women.
Before detailing these methods, I want to ask every woman to rid her mind of certain false hopes and impossible demands. It is no use asking for something which gives no trouble at all, which costs nothing, and which is at the same time absolutely certain to prevent conception. These conditions are unattainable. But almost absolute control of her reproductive functions is most certainly attainable by every careful, intelligent woman willing to spend a good deal less time and money over her sexual toilet than she now spends over the care of her teeth, for example.
SEXUAL TOILET OUTFIT.
To begin with, it is necessary to obtain suitable sexual toilet outfit, and the requirements for this are as follows:—
Enamel bidet, soluble suppositories, suitable syringe, and properly-fitting rubber pessary. These are illustrated on pages 38 and 43.
1. Cleanliness.—Sexual control is largely a matter of sexual cleanliness. We must all learn to keep the genital passages cleansed in the same way as we keep all the other openings of the body clean. The ears, eyes, nostrils, mouth, anus, orifice to the urethra, and the vagina should be appropriately cleansed daily. The openings of the body which stand most in need of daily cleansing are the anus and the vagina, and yet many women fail to cleanse these properly at all. Every home should have a suitable bidet (preferably fitted into the bath-room, with hot and cold water attached), and every member of the family should be trained from childhood to use the bidet, night and morning, with the same care and regularity as they use their sponge or toothbrush. All over the Continent and in the United States of America this is done in well-ordered households nowadays, but hardly anywhere in the British Empire is it done at all.
2. Soluble Suppositories.—Generally speaking, the soluble quinine pessaries or suppositories which are sold in the shops are unreliable. Several brands have recently been analysed and found to contain no quinine at all—or particular pessaries have been without sufficient quinine. Quinine is fatal to the spermatazoa, and without it these pessaries are simply pieces of soluble cocoa-butter. Cocoa-butter is the substance generally chosen for cheap soluble pessaries, because it is easily obtainable, and has what is called a sharp melting point—that is, it dissolves or melts very suddenly and readily at body-heat, but is solid below that heat. Cocoa-butter in itself is quite harmless—usually non-irritating (unless it is "rancid")—and it gives some mechanical protection, in the same way as vaseline or any kind of fat or oil would do, provided, of course, it is in the right place to catch and entangle the spermatazoa and thus prevent their uniting with the ovum. Research and experiment have proved conclusively that no spermatazoa—indeed, no microbes or germs of any kind—can pass through a film of oil. But if the protective covering of grease is incomplete at any point, it may there prove ineffective, and there is no chemical protection whatever if the particular germicide relied upon, such as quinine, has been omitted. Quinine is sometimes omitted on the ground of expense, and sometimes because it proves irritating to many women. Only really suitable suppositories, guaranteed to be made in accordance with accredited medical formulae, should be used. These suppositories should be composed of specially selected and tested fats, should be soothing and cleansing, as well as protective; should be stainless, odourless, and quite non-irritating. If they do cause any woman discomfort temporarily, vaseline or soap-suds could be substituted, but might not be quite so certain to prevent conception.
3. Syringe.—The ordinary enema is not a particularly suitable appliance for the purpose of douching. The kind of syringe required is one which will not only flood the vaginal passage with warm water or very weak antiseptic lotion (such as dilute solution of lysol), but one which is sufficiently large for the contents on injection to distend slightly the walls of the vagina, straighten out their folds and furrows, and thus let the cleansing and protecting lotion touch every part as far as possible. A movable rubber flange is necessary to act as a stopper at the mouth of the vagina, and thus enable the woman to retain the lotion for a minute or so. Care should be taken, when filling the syringe, to express all the air from it—by filling and refilling it two or three times with the nozzle under water; otherwise the first thing put into the vagina would not be warm water or antiseptic lotion, but simply a large bubble of air.
4. Soluble Suppositories and Rubber Pessaries.—It is quite true that the use of a suitable soluble suppository alone may be sufficient to protect against impregnation, but the protection by this means does undoubtedly fail at times, and therefore, by itself, the soluble suppository is unreliable. Still it eliminates the majority of the chances of impregnation. The use of the rubber pessary is also sometimes unsuccessful because it does not fit properly, or because it is porous, or because in removing it some of the seminal fluid from the under-surface may be accidentally spilt in the vagina, and in this way the spermatazoa may later find their way upwards to an ovum. Therefore, the soluble suppository and the rubber pessary should be used in combination. A woman should first push up, as far as possible, a suitable suppository, and then insert the rubber pessary (slightly soaped—with soap-suds), so as to occlude the whole of the upper part of her genital passage and thus cover the mouth of the womb and effectively prevent entrance of the spermatazoa. The rubber pessary must in the first instance be fitted by a doctor, because if it does not fit properly it will be ineffective. The seminal fluid may pass by its loose rim and impregnation may result. If the rubber pessary has been properly fitted, and it is not porous, the protection should be complete; but if, by any accident, spermatazoa should get beyond the rubber pessary, they will be destroyed and tangled in the melted suppository—provided, of course, that a suitable suppository has been used. It is all a question of getting the right articles to begin with and using them intelligently. But there is this chance—a bare chance—of accidental impregnation, and we want to eliminate all chances, if possible. Assuming the rubber pessary fits properly, as it will if skilfully selected and applied in the first instance by a competent medical practitioner, then the seminal fluid must remain in the lower part of the vaginal passage. An hour or two after intercourse, or next morning, this seminal fluid can all be washed away by the use of syringe and bidet. It is far better to sit over the bidet and syringe in that position than to squat down over a basin—an uncomfortable and unsuitable position for douching, because the walls of the vagina in that position may be pressed hard together. The fluid should be retained in the vagina for a minute or two, by pressing the flange of syringe closely against the orifice of the vagina. After syringing, but not before, the rubber pessary should be removed (to be washed with soap and water, dried carefully, and put away till required again), and immediately after removing the rubber pessary it is a good plan to facilitate the ejection of the surplus fat of the suppository by urinating and re-syringing. It is quite easy for a woman to insert and remove these rubber pessaries for herself as occasion requires, provided that whilst inserting and removing the pessary she has placed her body in a suitable posture—say, lying on the back with knees drawn up, sitting on bidet, or standing with one foot on a chair, or whatever other position she finds suitable. A doctor's help is needed only when first selecting the right size of pessary. The pessaries are made in ten different sizes, each size being numbered, and the right size can always be obtained on order. No harm may come from wearing the pessary for a day or two, but it is highly desirable as a matter of cleanliness and otherwise to remove the pessary in the morning when performing the sexual toilet. The pessary should, of course, never be worn during the menstrual period. A good rubber pessary should last from three to four months, and it should be tested occasionally by filling it with water to see that there is no hole in it. If it has been fitted shortly after a miscarriage or confinement, refitting is desirable at the end of a few months. But in normal circumstances refitting is not necessary.
5. Antiseptic Douching.—If antiseptics of any kind are used, such as lysol, they should always be used in very very weak solutions, and should be varied from time to time. There is no necessity ordinarily to use anything but plain warm water, with perhaps a little table-salt in it, for internal cleansing, and soap and water for external cleansing; then dry parts carefully. But some women prefer a weak antiseptic vaginal wash, as they do a weak antiseptic mouth wash. If a woman is unfortunate enough to be married to a man liable to infect her, then she should follow the same practice as detailed here (every effort, of course, being made for her husband to be cured as soon as possible), and she should use a special suppository, as prescribed by her doctor or otherwise authoritatively recommended, and should douche and urinate immediately after each sexual connection. She should also, before douching with weak disinfecting lotion, wash thoroughly—internally and externally—with suitable soap and water. This will certainly help to prevent infection in the vagina and elsewhere. The rubber pessary and the suppository will give her a very real measure of protection against the worst of all forms of infection, viz., uterine and ovarian. She can also protect herself against infection in the female urethra—that is, the passage from the bladder—by urinating immediately after each connection, as advised. A good deal of nonsense is still talked by some medical practitioners about the alleged harmfulness of douching. The same kind of distracting and misleading statements were made a few years ago regarding antiseptic mouth-washes, which were similarly condemned. Fortunately, we are passing out of these dark ages! Soon it will be regarded as quite as natural and necessary and desirable to cleanse the genital passages as to rinse out the mouth or wipe the nostrils.
It is important to remember that the "personal equation" counts for something in choosing a disinfectant, some substances suiting one person and some suiting others. "One man's meat is another man's poison." It is also very desirable to "ring the changes" by using, say, lysol one day, something else the next, and so on. Using three or four simple disinfectants alternately on different days of the week tends to make the disinfectants less irritating and more efficacious, as well as adding a fresh interest to the toilet performance. On this and other points personal instruction is far the best—provided you can find a good instructor. Every man and every woman should seek an opportunity of learning, from competent authority, precisely what to do in the matter of prevention, and what it all means. Reading books is all very well, but personal tuition as well is a great advantage.
Finally, the following briefly summarises the recommendations for women:—
1. Before Intercourse, Wash and be Clean.—Insert soluble suppository, and then place rubber pessary in position, concave side downwards. This will slip up more easily if slightly soaped. No harm can possibly come either to husband or wife from these appliances, and neither party will be conscious of the presence of the occlusive rubber pessary (some other kinds of rubber pessary have not these advantages). The pessary can be inserted some hours before intercourse, and need not be removed till some hours afterwards. The rubber pessary should not be worn continuously. If you have mislaid the rubber pessary, a small sponge, a piece of clean cotton-wool, or even a piece of soft tissue paper can be used. Native women in different countries use seaweed, moss, sponge, etc., and Japanese women use rice-paper. But these articles are not so clean or effective as the occlusive rubber pessary. If sponge or cotton-wool is used, it should be saturated in contraceptive lotion or smeared with contraceptive ointment before insertion. But always remember—the rubber pessary is cleanest and safest.
2. After Intercourse.—Douche next morning (or earlier), remove rubber pessary, wash and dry it and put it away slightly powdered. Where there is any chance of venereal infection, the woman should urinate immediately after each connection, wash with soap and water, and then at once douche with weak and warm disinfecting lotion. If medically directed, she should also use a little calomel ointment for anointing parts that have been touched in any way.
3. Daily.—Cultivate in yourself and in the members of your household habits of sexual cleanliness. Wash and be clean. Apply this to all the openings of the body, but in particular to the vagina, urethra and anus, which should all be cleansed night and morning. This practice is not simply cleansing and refreshing, but it is preventive of many forms of disease, such as piles, etc., etc., and
4. Always remember that the spread of this kind of knowledge has been made possible by the long and patient efforts of hundreds of doctors, many of them unknown and forgotten, and that women will best be able to apply this knowledge efficiently by working in loyal co-operation with medical practitioners who have made a special study of these matters.[H]
[Footnote H: The chief pioneers in teaching Birth-Control in England were Mrs. Annie Besant, Mr. Charles Bradlaugh, and Dr. Drysdale, Senior.]
DIGEST OF BEST PREVENTIVE PRECAUTIONS.
1. Douche with warm water or weak antiseptic lotion (warm).
2. Insert suitable suppository.
3. Place rubber pessary in position
5. Remove rubber pessary. (Urinate to facilitate ejection of surplus fat.)
6. Douche and dry parts.
The use of rubber pessary does not do away with desirability of douching, but it does enable the woman to douche at her own convenience with safety.
Dr. K.R.D. Shaw, of 144, Harley Street, London, W.1, who has had a very wide experience of "prevention" in different parts of the world during the last twenty-five years, has named the following as suitable disinfecting lotions:—
Half a teaspoonful of Lysol in 5 pints of warm water; or One teaspoonful of Sanitas " " or One quarter teaspoonful of Bacterol " or 2 grains of Sulphate of Copper " "
N.B.—Where there is grave danger of venereal infection, it is an excellent additional precaution to douche first with soap and water, and douche again with antiseptic lotion. The sooner this is done the better.
If all or most of these hygienic measures are widely made known to women, it can rightly be claimed that women have been released from the twin terrors of unwanted pregnancy and venereal infection, which are at the present time ruining their marital health and happiness in so many cases. Even if some only of these measures are adopted, the nation as a whole cannot fail to benefit mentally, morally and physically. The success of the measures, of course, depends to some extent on their being taken in time, but in this, as in many other directions, the old proverb holds good: Better late than never.
II.—PRACTICAL METHODS OF PREVENTION.—(Contd.)
B. FOR MEN:
Marriage cannot be made safe, of course, so long as men are permitted to contract venereal diseases, and spread them. Early marriage will greatly lessen the chances of this; tolerated houses under effective medical supervision (such as we had in Paris during the War)[I] would enormously lessen the chances of infection, even where marriage was delayed or interrupted; prophylactic depots where disinfection was properly applied, and efficiently taught on request, would be invaluable; but it is at present from self-disinfection, properly understood and efficiently applied, that the community can hope for the greatest and most immediate gain in sexual cleanliness.[J] The following were the directions I gave the Anzacs during the war, distributing these with prophylactics for men and for women (the directions for women being printed in French and English); this action was endorsed by all the leading British, American and French military and medical authorities, from the Commanders-in-Chief downwards, and the effort undoubtedly saved many thousands of men from damage and ruin:—
"If you become infected with V.D., the fault is really your own. Either do not risk infection at all, or, risking infection, take proper precautions. These are quite simple. If you take the following precautions without delay you are very very unlikely to contract disease:—
1. Use vaseline or some other grease (such as calomel ointment) beforehand, to prevent direct contact with the source of infection.*
(* Note: Any personal discomfort or unpleasantness grease causes is counteracted by the woman's having douched beforehand, as should always be done for the sake of cleanliness. A mere film of grease is sufficient to fill up pores of the skin, cover over abrasions, and prevent penetration of microbes, and it greatly facilitates subsequent cleansing.)
2. Urinate immediately after each connection to wash away all infective material, and to prevent the invasion of the urethra by the microbes of V.D.
3. Wash thoroughly with soap and water, because ordinary soap is destructive to germs—of syphilis and of gonorrhoea—and bathe parts with weak solution of pot. permang.
You had far better carry a blue-light outfit with you as a "town dressing," in the same way as you would carry a "field dressing." If you cannot get an outfit, carry a tiny bottle of pot. permang. lotion and a scrap of cotton wool. If you swob yourself carefully with this, you will not become diseased. Remember always it is delay that is dangerous. If there has been delay, use a syringe sufficiently large for the contents to flood the urethra and slightly distend it, so that every nook and cranny is cleansed.
Whatever you do, make certain of going home clean. Be sure of your health and doubly sure before you embark. While you are in the army and on this side of the world you can be cured easily and privately. If you go home infected, there will be embarrassment and expense to yourself and great danger to the women and children you love.
Get cured NOW." (Paris, April, 1919).[K]
[Footnote I: The following is taken from a paper read by Captain H.L. Walker, Canadian Medical Service, O.C. Report Centre (British), Paris, at Conference on V.D., organised by the American Red Cross in April, 1918:—
"Speaking in regard to licensed houses, Captain Walker said that he had not found one case of venereal disease contracted in a licensed house in the City of Paris, and he could only suppose that the people who were responsible for putting the licensed houses in Paris out of bounds knew nothing at all about the real facts of the case.... In the licensed houses in the City of Paris, during the year 1917, only five cases of venereal disease were contracted; and in 1918, up to April 20th (the day he was speaking), there had not been one case of venereal disease contracted in a licensed house in the City of Paris. But out of 200 women arrested on the streets of Paris during the month of April, over twenty-five per cent. were found to be infected with venereal disease. In the months of November and December, 1917, the French authorities had made a round-up on one boulevard of seventy-one women, of whom fifty-five were infected with venereal disease; a few days later the French authorities repeated the same procedure on another boulevard; something like one hundred women were arrested, and ninety-one per cent. were infected with venereal disease."—p. 134, Public Health (England), September, 1918.
I supervised a tolerated house in Paris for over twelve months (1918-1919), and had no cases of disease either among the women or the men. The women attended from 2 p.m. to midnight and resided in their own homes.—E.A.R.]
[Footnote J: Among the first medical men in Great Britain to recognise the importance and effectiveness of self-disinfection was Mr. Frank Kidd, M.A., M.Ch. (Camb.), F.R.C.S. (Eng.), etc., of the London Hospital. A full statement of his evidence before the Royal Commission on Venereal Diseases is given in Mr. Kidd's book, "Common Diseases of the Male Urethra" (published by Longmans, Green and Co., 39, Paternoster Row, London, etc., in 1917). The diagram of male organs of generation I have used on page 36 was taken in outline from Mr. Kidd's frontispiece, and during the war I found all the illustrations he gave most helpful with the soldiers, although the book itself was written for the purpose of enabling doctors in outlying districts to treat patients on modern lines with success. Mr. Kidd designed prophylactic tubes, which have been sold in England on his order for more than fifteen years. He tells me they have been used all over the world by his patients, and that as far as he can ascertain "they have never failed, when used properly and intelligently."—E.A.R.]
[Footnote K: Since this was written, a large number of experiments have been made with the single treatment tube, containing an ointment destructive of all forms of venereal disease microbes, whether used before or after connection. The Pennsylvania Department of Health is within measurable distance of finding a solution of this problem—the production of a cheap, portable, easily applied and thoroughly efficient self-disinfecting ointment.—E.A.R.]
It was clearly proved that so long as men took these simple precautions (which I always explained personally) they were very unlikely to contract disease; most cases of disease came from multiple connections with the women of the cafes, etc. It was difficult to impress on ordinary men's minds the fact that each and every connection was a danger; that the danger of infection began immediately there was any contact, and that it continued until disinfection, and was renewed as well with each fresh connection during the night. If the danger had continued for several hours in this way, the men were told to go to the medical depot or report to a doctor as soon as possible. When they did so they were saved from disease in the vast majority of cases, even up to twenty-four hours afterwards or a little longer.[L]
[Footnote L: In 1915-1916 Colonel Sir James Barrett, then A.D.M.S. of the Australian Force in Egypt, had successfully applied prophylaxis, but unfortunately he was invalided for a time to England in November, 1916, and with the evacuation of the Dardanelles there was a severe outbreak of v.d. in Egypt. Prophylaxis was then steadily applied during 1917 by Colonel Sir James Barrett and others, and at the end of 1917 v.d. had been reduced to small proportions. In December, 1917, Colonel P.G. Elgood, Base Commandant of Port Said, wrote:—
"Fortunately, however, at this stage, I came into contact with Colonel Sir James Barrett, K.B.E., R.A.M.C, and Miss E. Rout, New Zealand Volunteer Sisterhood. The first suggested that the solution of the problem would not be found in police measures or in medical examination, but in prophylaxis; while the second, in correspondence relating to her own experiences gained in England, encouraged me to advocate this remedy."
The successful results of the Port Said efforts are quoted in full by Colonel Sir James Barrett in his book, "A Vision of the Possible" (Lewis), and Colonel Barrett had early in 1917 sent me to London the following tremendously valuable letter of advice and warning:—
"I suppose my instinct is rather more in the moral direction than many people, but I recognise, as you will see from these articles (published by Lancet), that it is by direct prophylaxis, and direct prophylaxis alone that we are likely to get rid of this abomination. I should never in any campaign exclude all the additional aids—proper soldiers' clubs, such as I have established in Egypt, the influence of decent women, and the one hundred and one factors that go to make a decent and reputable life; but you have, in the long run, to recognise the fact that a percentage of men are certain to seek women who are prepared to cater for them. If the steps indicated are taken, the proof is absolute that the disease can be practically extirpated and without great difficulty. The failure of prophylaxis depends on two factors—firstly, it requires someone charged with responsibility, earnestness and high character to explain to men precisely what they are doing and what it means; and secondly, prophylaxis is of very little use to drunken men. My experience has been that when these precautions are properly used venereal disease may disappear."
That proved to be exactly my own experience in the army. Failures in the army were due to the absence of proper personal instruction of the men and the laxity of control, and these conditions can always be assumed to exist in any army having a high v.d. infection rate.—E.A.R.]
Nevertheless, the people who would put sacerdotalism before science, and the still meaner minds who would substitute legality for morality, raised storms of objection to my work, in the midst of which came a few strong, clear calls of understanding and encouragement.
One Scotch padre wrote me in 1918:—
"It is a magnificent adventure for a woman to go practically alone on the very edge of things, and I salute you, and congratulate you, and wish you God-speed."
An old family doctor, then with a colonial ambulance, wrote:—
"Many women ... will owe their health and happiness to you, and not a few will be indebted to you for their lives."
The editor of the Sydney Bulletin (Australia) was continually publishing helpful articles and paragraphs—after my letters and articles were censored;[M] and from Dr. W.H. Symes, of Christchurch, New Zealand, I heard by personal correspondence steadily and wisely all through the war. Much later came the following tribute, in a most valuable book written by Sir Archdall Reid and Sir Bryan Donkin ("Prevention of Venereal Disease," published by William Heinemann (Medical Books) Limited)[N]:—
"Sir Bryan Donkin's letter, which appeared in The Times, in January, 1917, and other communications which he published as opportunity offered, brought him an introduction from Sir J.W. Barrett, M.D., then serving as A.D.M.S. with the Australian Force in Egypt, to Miss Ettie Rout, who, by profession a journalist, had come with the Australian and New Zealand Forces with the object of ameliorating, as far as possible, the hardships of war. She had been horrified by the pestilence of venereal disease which broke out among the troops in Egypt, England, and elsewhere, and, with extraordinary resolution and courage, had embarked almost single-handed on a campaign of prevention. She furnished Sir Bryan, and later myself also, with much valuable information, and for her own part fought the battle most strenuously—living among the men, lecturing, finding and instructing lecturers, providing disinfectants, importuning authorities, writing most trenchant letters, establishing medical clubs in England and France, and the like. I think that when the names of those who opposed her are forgotten, the memory of this brave lady will still be green among the descendants of the valiant men for whose welfare she struggled"—p. 176-177.
[Footnote M: The New Zealand Times daily newspaper published my first article and was severely reprimanded by the New Zealand Government for doing so, and all New Zealand newspapers were then prohibited from publishing any further articles relating to V.D. in the New Zealand Forces.—E.A.R.]
[Footnote N: See Publishers' notice.]
It should be noted here that another great difficulty we had was to make men beware of the dangers of drink. A man who is in liquor is much more liable to contract venereal disease than a man who is sober. Alcohol increases sexual desire, lessens sexual ability, and lowers the sense of responsibility. Hence, drunkenness, immorality and disease go hand in hand: a dreadful three. But more than this. The drunken man takes much longer over the sex-act, thereby prolonging the risk of disease, and he runs risks which he would rule out instantly if the fumes of alcohol had not changed the tawdry girl into the glittering fairy. Worse than all, he neglects to apply disinfection properly and promptly—he falls asleep or forgets all about it till too late. Men who are determined to have a "night out" should use calomel ointment (or some other substitute) before they start; and if they have been in liquor they should disinfect instantly when they recover their sober senses. Generally speaking, an ounce of calomel is worth a ton of salvarsan.
As with young men, so with young girls: a few glasses of wine taken at a supper or a dance—and the first downward step is taken, not because any wrong was intended, but the simple actualities of sex were unknown, and the stimulant took advantage of the ignorance that is miscalled innocence. This kind of thing will continue till the older generation realise that morality depends—not on the maintenance of ignorance and the fear of disease, but on the spread of knowledge and the promotion of virtue.
It is not morality, but caution, that is developed by fear, and in this case caution is counteracted by the practical experience that many men are immoral without becoming diseased. One man commits many immoral acts and suffers not at all; another man becomes syphilitic by yielding for the very first time; the penalty is purely fortuitous. There is no necessary connection at all between immorality and disease. The dangers of sexual intercourse are due to dirt and promiscuity rather than to immorality, and in part to the physical conformation of the individual. Virtue has far deeper and more substantial foundations than the mere gusts of fear. It is founded on necessary and responsible guardianship of the very gates of life.
The medical formulae for venereal disease preventive ointments for men, and venereal disease preventive suppositories and ointments for women, should be decided upon, after thorough investigation and test, by the Departments of Public Health, and none other should be permitted to be sold. Printed directions should be issued, duly authorised by the Departments of Public Health, and no other directions should be supplied to the public with the venereal disease preventives. In these respects, to the best of my belief, the Division of Venereal Diseases of the Pennsylvania Department of Health, co-operating with the United States Public Health Service, will play the leading part; is, indeed, already doing so. Under the direction of Dr. Edward Martin, Commissioner of Health, and Dr. S. Leon Gans, Director, Division of Venereal Diseases, specimen tubes are tested and approved (with directions and other printed matter)[O] by the Health Laboratories of the Department; and certificates are issued to manufacturing chemists authorising the manufacture of ointments made in accordance with approved formulae. Requests are made officially by the Department to retail chemists and druggists to sell, and to medical practitioners to recommend, suitable venereal disease preventives to the general public in a proper manner. In time it will probably be found advisable to authorise only a standard type of tube—preferably the metal tube with elongated nozzle and expanded metal cap—filled with one simple self-disinfecting ointment.
[Footnote O: In some cases the printed matter used by the drug companies also bears the "Official Endorsement" of the local "Social Purity Association" stamped upon it in indelible ink—a magnificent tribute to the educative work of the Public Health Department, as well as to the enlightened courage of the Social Purity Associations.
The following is quoted as sample of directions authorised in U.S.A.:—
"The use of this package is not to be construed as a licence to exposure. Pro-Ven, the original preventive. The only sure way to prevent infection: Do not expose yourself. All exposures should be considered as infections, for 90 per cent. of all "easy women" are infected. By proper use of the contents of this package disease may be prevented, as the action upon the germs is as effective as can be secured by the latest scientific knowledge; if exposed, use within two hours. After contact: 1st. Urinate. 2nd. Remove the cap from tube; take organ in the hand, holding the canal open; insert tip of the tube and squeeze half of the contents into the canal. 3rd. Squeeze the remainder on the outside of the organ, rubbing well into the creases and folds under and back of head and clear to the body. 4th. Leave ointment on three or four hours. Remember: It is best to use Pro-Ven immediately after exposure; never delay more than two hours if possible. Pro-Ven is not a cure—it is designed to keep men from getting disease; it can be used as a lubricant and preventive both before and after exposure. Pro-Ven is harmless and will not cause pain or injury to the sexual organs. Insist upon having Pro-Ven. At all good druggists, or directly by mail, 25 cents a tube; 5 tubes, $1.00. Booklet mailed free upon request. The Pro-Ven Laboratories, Washington, D.C. This product has been tested and approved by the Pennsylvania State Department of Health Laboratories."
In addition to Pro-Ven, the following proprietary tubes of self-disinfecting ointment have, to my knowledge, been authorised by the Department of Health, and samples were sent to me:—
Procaline, manufactured by the Hawthorne Drug Speciality Co., Inc., 88-90, Reade Street, New York City.
Cargenios, manufactured by H.K. Mulford Company, Philadelphia.
Andron, manufactured by Andron Hygienic Co., 120, W. 32nd St., New York City.
Sanitube, manufactured by the Sanitube Co., Newport, R.I., U.S.A.
Excellent printed directions and pamphlets accompany these tubes.—E.A.R.]
It has been found that the 30 per cent. to 33 per cent. calomel ointments (and suppositories) are not suitable in all cases; and careful investigations are being made to ascertain the best germicide to use. Whatever is used must be non-irritating, odourless, stainless, and yet strongly antiseptic. It is possible, I think, that chinosol[P] best fulfils the required conditions. It was first suggested by Surgeon-Commander Hamilton Boyden, R.N., of the Whale Island Gunnery School, England, who was led to choose it because of its known usefulness in ophthalmic work. It does not matter to the general public what drug is finally selected; all that matters is that it should be of proven value for the purposes required. Women can help forward this great work by deciding in their own mind: (1) That the medical prevention of venereal disease is right and wise; and (2) That the authorisation by the Public Health Departments of efficient means of preventing venereal disease will consequently have their support.
[Footnote P: Chinosol (C9H6NKSO4), potassium oxyquinol in sulphonate, is a proprietary disinfectant and deodoriser. After some little experience of it in ointments and suppositories, I believe it deodorises these—an important advantage. But further investigation is necessary.—E.A.R.]
We must all of us first learn to separate the moral from the medical campaign. Both are necessary, but they must be conducted independently. America is doing this; England is not. In England venereal disease is still officially regarded as something to be discussed; in America—as something to be destroyed. Thus America is winning and England losing the battle against the venereal microbe. The Overseas British Dominions will undoubtedly follow the lead of America—particularly that of Pennsylvania. Hence, these newer countries may have a glorious future, England—only a splendid past.[Q]
[Footnote Q: In England the Ministry of Health refuses to authorise the sale of v.d. preventives; refuses to authorise suitable printed directions; recommends immediate and thorough cleansing but refuses to explain methods or name disinfectants; and claims that persons who sell v.d. preventives as such, with directions, are liable to police prosecution and imprisonment. (Vide Circular 202, Ministry of Health, May 31st, 1921.) This may be mere "politics," but it looks uncommonly like fooling with death.—E.A.R.]
All women should be in favour of reasonable measures for ensuring the voluntary, and failing that the compulsory, treatment of venereal disease among men and among women.[R] It is troublesome to prevent a man getting disease if he is running into a pool of infection, and such cesspools should be cleaned up or cleared out of the community—i.e., cured or quarantined. Similarly, it is even more troublesome to prevent a woman becoming infected if she is having relationship with an active gonorrhoeic or syphilitic man, and such men should be treated voluntarily, or compulsorily if they refuse or neglect voluntary treatment. Free treatment should be available to poor persons only; providing free treatment for all and sundry, whether they can afford to pay for it or not, is simply encouraging men and women to trust to luck rather than to disinfection. This presupposes that the teaching of self-disinfection has been done confidently and authoritatively. When prevention has been properly taught, then it is fair to penalise those who wilfully neglect to take precautions. It was a great misfortune to the Anglo-Saxons when the Contagious Diseases Acts were abolished; instead they should have been improved and extended to both sexes. Their abolition was the worst blow ever struck at marriage. Fortunately, their main principles we are now beginning to re-enact in various Sexual Hygiene Acts. The more "drastic"—i.e., the more efficient—these are, the more they should be supported by those who honestly desire to make marriage safe.
[Footnote R: The argument that compulsory treatment would "drive the disease underground" is absurd. Venereal disease is underground now.—E.A.R.]
Apart from voluntary and compulsory treatment for venereal diseases, we certainly need voluntary and compulsory sterilisation of the unfit—diseased and feeble-minded and otherwise unfit persons, who, whatever their other qualifications may be, are unsuitable as parents. But whatever operation is decided upon, for men and for women, must in no way interfere with ordinary sexual activity; otherwise it will be promptly turned down by the general public, no matter what its medical advocates may say. In marriage the partner to be sterilised is obviously the one who is unfit for parenthood.[S]
[Footnote S: Towards the end of last year, extraordinary interest was aroused throughout the United States by a decision of Judge Royal Graham, of the Children's Court of Denver. He had ordered Mrs. Clyde Cassidente to submit to an operation to make further motherhood impossible, because of the under-nourishment of her five children and the habitual insanitary condition of her home. This was the first time any American court had imposed such conditions. Judge Graham could not legally compel the mother to agree to the operation, but he told her that if she refused he would commit all her children to a home. She then agreed. Judge Graham was much influenced by the testimony of Dr. Sunderland, who described the progressive insanitary environment as more children came, and declared that in his opinion the home condition was not due to poverty but to too frequent child-bearing.
In the February, 1922, issue of The Birth Control Review (New York) edited by Mrs. Margaret Sanger, the Medical Officer of a London Welfare Centre (Dr. Norman Haire, M.B., Ch.M.) definitely advocates contraception and sterilisation as a result of his experiences in a very poor part of London. Medical officers of many welfare centres now hold similar views. In The New Generation, the official organ of the Malthusian League, Dr. Barbara Crawford, M.B.E., M.B., Ch.B., strongly urges birth-control, and says:—
"I would go further and say that all those with incurable transmissible disease, all addicted to drugs or alcohol in excess, those habitually criminal or vicious, and the mentally defective, should be rendered sterile by operation, for such as these cannot or will not use control, and their children tend to inherit their parents' taint and to lead maimed and vicious lives."—Vol. I, No. 4, p. 3. The New Generation.—E.A.R.]
With the moral and social aspects of birth-control there is no need to deal further, except to say that they have recently been endorsed in England, with fine grace and high authority, by Lord Dawson of Penn (one of the King's Physicians), in an address given before the Church Congress at Birmingham, on October 12th, 1921, which has since been republished by Messrs. Nisbet at a shilling, under the title of "Love—Marriage—Birth-Control." The following short extract may be quoted here:—
"Generally speaking," says Lord Dawson, "birth-control before the first child is inadvisable. On the other hand, the justifiable use of birth-control would seem to be to limit the number of children when such is desirable, and to spread out their arrival in such a way as to serve their true interests and those of their home."
As to the prevention of venereal disease, as I have said, what we must aim at is not merely the prevention of sin, but the prevention of the poisoning of the sinner; for, if not, we shall have blind babies, invalid wives, and ruined husbands: broken-hearted and broken-bodied mothers adding one fragment after another to the Nation's pile of damaged goods.
To the great-hearted public this is becoming intolerable. But they know so little, and they wait so long for what the wise ones fear to tell. Not all these fears are sordid; there is a kind and gracious reluctance to shatter ideals. It is hard at times to combine beauty and duty. The way of the truth-teller is not made easier by charges of iconoclasm. "To know all is to forgive all"; that is not paganism but Christianity. So also, "Let him that is without sin cast the first stone." "To err is human: to forgive divine." Humanity, wisdom, tolerance, are wrapped up in these sayings. Yet when we think, as think at times we must, of the romantic faith that once was ours, contrasted with the realities of present experience, sex seems to have lost something of its soul of loveliness. And yet—can it ever regain this till men and women are at least clean?
If not—if the immoral man cannot be made better but rather worse, much worse, by needlessly infecting him with syphilis, then clearly the ideals of beauty and duty demand that we should apply effective sexual sanitation to the Nation until such time as we are all, every one of us, free from venereal disease. That time is not yet—and this is the essence of the whole problem. But victory is within sight. When it comes—then, and not till then—sex will regain its soul of loveliness. To this end—
"Let knowledge grow from more to more, But more of reverence in us dwell, That mind and soul, according well, May make one music as before, But vaster."
The Author will reply personally to any serious question concerning the subject matter of this book, provided stamped and addressed envelope is sent to her, c/o the Publishers.
OTHER METHODS OF CONTRACEPTION.
1. Withdrawal.—Immediately before emission the male organ is quickly withdrawn, to avoid emission of seminal fluid in the vagina. Many men and women feel this to be unromantic and nerve-racking, and otherwise objectionable. The method is quite commonly practised, but it is unreliable in multiple connections, and where the man has not complete control over himself. It leaves the woman at the mercy of the man for protection against impregnation.
2. Sheath or Condom ("French Letter").—This prevents both conception and infection (excepting in parts not covered by the sheath), but sheaths are apt to break, and sometimes a man infects himself whilst removing the sheath. Sheaths impose an impermeable medium between husband and wife, destroy contact, and may thereby prevent the joy of sexual intercourse. In some cases both husband and wife become nervous wrecks, recovering their health when the sheaths are discarded; in other cases it is claimed that no harm has resulted.
3. Antiseptic Syringing.—This is generally successful, but not entirely reliable by itself, because seminal fluid may enter the womb during connection. This method is unreliable unless applied immediately after each connection, and syringing at that time is inconvenient and unromantic.
4. Douche Can.—This is better than syringing in some ways, because the irrigation can be so arranged as to let the lotion flow into the vagina faster than it can flow out—hence distension of walls of vagina and thorough cleansing. But the arrangement of a runaway for outflowing lotion is inconvenient in most households.
5. Quinine Pessaries, etc.—By themselves these are unreliable, no matter what the makers claim on the label. There is usually not enough quinine in them; or if there is enough, it proves irritating.
6. Solid-Ring Check Pessary.—These are reliable only when carefully adjusted over the mouth of the womb, and many women find it very difficult to adjust this kind of pessary correctly; hence numbers of failures.
7. Vaseline and Soap-and-Water.—Using vaseline beforehand, and urinating and using soap-and-water immediately after each connection, is a fairly safe way of avoiding conception and infection. But the vaseline needs to be inserted fairly high up—if possible over the mouth of the womb, and the subsequent washing needs to be very thoroughly done (internally and externally). This method is commonly used by Continental women, but it is not entirely reliable by itself.
8. Gold Spring Check Pessary.—This is an instrument, the arms of which spread out inside the womb, and the gold spring keeps the mouth of the womb open, thus facilitating infection and conception. It is claimed as a "preventive"; it is really an abortifacient, and cannot be too strongly condemned, as causing septic miscarriage (authentic records of this are available). A woman can neither insert nor remove this instrument herself.
9. Safe Period.—It is often supposed that sexual intercourse midway between the menses is unlikely to result in pregnancy. There is no such "safe period."
NOTE.—The method of "self-control" is not referred to here, because one marital relationship per annum might lead to an annual child. In the matter of limitation of offspring, therefore, "self-control" has no value.
Rubber Pessaries.—Medical practitioners can obtain sets of occlusive rubber pessaries from Messrs. E. Lambert & Son, of 60, Queen's Road, Dalston, E.8. This firm has been manufacturing such articles in England since 1888, and now makes them in a wide range of sizes, and of special shape where required.
Bidets and Syringes.—Syringes are easily procurable, but bidets in England at present are sometimes difficult to obtain. Good strong enamel bidets can be obtained from Messrs. E. Lambert & Son, of 60, Queen's Road, E.8., and they also keep the contraceptive suppositories made by Mr. Harman Freese in accordance with medical directions mentioned in Foreword.
Soluble Suppositories (for women).—These are now being manufactured by Mr. Harman Freese, of Freese & Moon, 59, Bermondsey Street, S.E.1, from whom they can be obtained. These suppositories are disinfective as well as contraceptive, but they are at present sold for the ordinary purposes of birth-control.
Sanitary Tubes (for men).—These tubes are also manufactured by Mr. Harman Freese, of Freese & Moon, 59, Bermondsey Street, S.E.1, in accordance with medical directions mentioned in Foreword. It is quite possible to manufacture an ointment which, if properly used, would be a preventive of all forms of venereal disease. The sale of such an ointment is authorised by the State Health Department of Pennsylvania.
Information as to the medical prevention of venereal disease may be obtained from the Hon. Sec., Society for the Prevention of Venereal Diseases, 143, Harley Street, W.1. Information regarding birth-control has been made available to adults in England for the last half-century by Dr. Drysdale, Sen., and his family and supporters, through the Malthusian League, whose present address is 124, Victoria Street, London, S.W.1., and these pioneers have made a most self-sacrificing effort for the benefit of poor women by establishing a welfare centre at 153a, East Street, Walworth, London, S.E.17, where free advice is given in birth-control and sexual hygiene, and where medical supplies are available at nominal prices. This centre is supported entirely by voluntary subscriptions and at present stands in dire need of financial help.[T]—E.A.R.
[Footnote T: At my personal request the publishers have agreed to name the firms and societies mentioned in Appendix II. These notifications are made gratis for the benefit of the medical profession and the general public, and not by way of advertisement.—E.A.R.]
NOTE.—Every thoughtful woman is urged to buy and study carefully the great work entitled: "PREVENTION OF VENEREAL DISEASE," by Sir Archdall Reid, K.B.E., M.B., C.M., F.R.S.E., with an introductory chapter by Sir Bryan Donkin, M.D., F.R.C.P., in order that she may understand the nature of the problems involved and the strength of the opposition to cleanliness.
This book is endorsed by the Society for the Prevention of Venereal Disease and contains the evidence and arguments on which the Society bases its policy, and is addressed to all who would prevent venereal diseases in themselves or in the community.
Children may be taught any system of morals—sexual or other; Christian, Mahomedan, Hindoo, Papuan, or other. They are intensely imitative and acquire a bias towards local ideas of right and wrong through association with intimate companions. A bias once acquired tends to persist. For that reason parents choose good companions and schools. On the other hand, it is difficult or impossible to convert "hardened sinners," for example, adult non-Christians. Children, therefore, may be really taught; adults, as a rule, can only be preached at. Any man may test the truth of all this by examining his own consciousness. Would any amount of preaching cause him to change his present ideas of right and wrong? As little can he alter the bias of other men. As the twig is bent so the tree grows.
In various times and places, almost everything from promiscuous sexual intercourse to absolute abstinence from all intercourse has been held holy, or permissible, or damnable. Even among Christians the widest differences have prevailed as regards the local and contemporary tone. Among them, especially among the English speaking peoples, a convention forbids the familiar discussion of sexual matters between children and adults. This convention may be right or wrong. In any case it exists, and is likely to persist for ages. But a knowledge of sex is traditional among boys, and to some extent among girls of the school age. For good or evil, therefore, children are the real teachers of sexual morals in England. Children deal with the impressionable age and give the early bias. Adults stand aside, and teach only extreme reticence. The discussions of boys are often obscene. As a consequence vast numbers grow up with the idea that unchastity is a gallant adventure, or, at worst, only a peccadillo. Even in old age such men look back to past intrigues with satisfaction. After marriage another tradition, or bias, also taught by English boys, comes into action—the tradition to keep the plighted word, to "play the game." The great majority of married Englishmen, therefore, are chaste.
Judging from history, the world, and in particular England, is not more—or less—immoral to-day than at any time during the last 2000 years. During all that time children have taught and adults have preached. Doubtless there have been many campaigns of purity in the past—mere campaigns of preaching to adults. They were ineffectual and are forgotten. Epochs of licence have almost invariably followed epochs of austerity. Modern campaigns of purity never arise except as consequents on medical attempts to prevent venereal disease, and always cease when the attempt to procure sanitation has ceased. In effect, they have been merely campaigns to secure the poisoning of sinners and their victims.
The extent of current immorality may be judged from the prevalence of venereal disease. The Royal Commission of 1913-16 found that ten per cent. of the urban population suffered from syphilis. Eighty per cent. of the population of the United Kingdom is now urban, and gonorrhoea is six or seven times as prevalent as syphilis. It follows that at least every other person in the Kingdom has suffered from venereal disease. Probably not a family has escaped infection. In proportion to its prevalence syphilis is not very deadly, yet it has been reckoned as the fourth killing disease. The victims of gonorrhoea are incalculable. Venereal diseases fill our hospitals, asylums, and workhouses. They are the principal causes of heart disease, apoplexy, paralysis, insanity, blindness in children, and of that life of sterility and pain to which so many women are condemned. It is said that chastity is the only real safeguard against venereal disease. But this is always said by people who have never stirred a finger to teach chastity, but who have only preached it. At any time there are at least a million of perfectly innocent sufferers, principally women and children, in the United Kingdom.
During the war a disloyal faction in every Dominion endeavoured to prevent the sending of help to the Mother Country. A principal cry of this faction was, "Do not let us send our clean lads to that cesspool, England." England is more than the world-cesspool. Since Englishmen are the greatest travellers, she has been the principal source of infection for the world. At one time during the war the Australasian Governments threatened to withdraw their forces unless measures were taken to protect them.
When the German offensive was impending a sanitary method was published, so effective that the venereal rate was reduced from 92 to 15 per thousand per annum. The Government proposed to bring the method into general use in the Army, but was prevented by influences which preferred to see the country poisoned and the British Army defeated. While the opponents of sanitation sat snugly at home hundreds of thousands of British soldiers were killed or maimed, enormous material was lost with territory which other hundreds of thousands of brave men had died to win, the war was prolonged, thousands of millions were added to the National Debt, and half trained boys and elderly fathers of families were hurried into the firing line. At that time there were in hospitals or in depots, convalescent from venereal disease, enough fully-trained allied soldiers to furnish, not an army corps but a great army, complete almost from G.O.C. to trumpeter.
Fear of disease does not prevent immorality, as may be judged from the immense prevalence of venereal disorders. But it does drive baser characters to the pursuit and seduction of "decent" girls. In this way nearly all prostitutes begin their careers. Prostitutes are much more diseased than other women, who, though often diseased, are seldom suspected of disease. Yet, since it has been found statistically that three out of four men acquire their maladies from amateurs, it is manifest that prostitutes only hang on the fringe of a vaster immorality. Men, who know more of these diseases than women, are, on the average, much less chaste. Medical students who know most are not more moral than other men. Plainly venereal diseases are causes, not preventives, of immorality. Nothing, therefore, is gained from their prevalence except a flood of death, disability, and misery, which falls alike on the just and unjust.
During the war Sir Archdall Reid, employing very simple means, reduced the incidence of disease among the large body of troops in his charge almost to the vanishing point. He could not make them more moral, he did not make them less moral, but at any rate he preserved their services for the country in its hour of need. And he preserved their future wives and children from unmerited death and suffering. Other doctors were equally successful. The town authorities of Portsmouth and many other boroughs are about to employ these methods for the prevention of disease among the civil population. This book describes them and tells the story of the fight against a wicked and cruel fanaticism. Its policy is endorsed by many of the leading men and women in the Kingdom—members of both Houses of Parliament, town authorities, doctors, authors, sociologists and others.
PREVENTION OF VENEREAL DISEASE By Sir ARCHDALL REID, K.B.E., M.B. With an Introduction by Sir BRYAN DONKIN, M.D. Crown 8vo, 15s. net. SEX-PROBLEMS IN WOMEN By A.C. MAGIAN, M.D. Demy 8vo, 12s. 6d. net. THE SEXUAL QUESTION A Scientific, Psychological and Sociological Study. By Dr. AUGUST FOREL. Royal 8vo, 25s. net. THE SEXUAL LIFE OF OUR TIME In its Relation to Modern Civilization. By IWAN BLOCH, M.D. Medium 8vo, 25s. net. Sold only to the Medical and Legal Professions. THE SEXUAL LIFE OF WOMAN A Physiological, Pathological and Hygienic Study. By Professor HEINRICH KISCH. Super royal, 25s. net. Sold only to the Medical and Legal Professions. PSYCHOPATHIA SEXUALIS With special reference to Antipathic Sexual Instinct. A Medico-forensic study by the late Dr. R. VON KRAFFT EBING. Royal 8vo, 25s. net. Sold only to the Medical and Legal Professions. WILLIAM HEINEMANN (Medical Books) Ltd., 20, BEDFORD STREET, LONDON, W.C.2.
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