Chapter 3

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.

SUMMARY.

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.

_Before Connection._

1. Douche with warm water or weak antiseptic lotion (warm).

2. Insert suitable suppository.

3. Place rubber pessary in position

_After Connection._

4. Douche.

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.

ANTISEPTIC LOTIONS.

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:--

"AVOID INFECTION.

"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]:--