Part 57

As a physiological means for preventing conception, passivity of the woman during sexual intercourse has also been recommended. It is well known that an active participation on the part of the woman in the sexual act, by increasing her voluptuous sensations, gives rise to certain reflex actions, viz., descent of the uterus, rounding of the os uteri, induration of the portio vaginalis, and, finally, ejaculation of the secretion of the cervical glands and of the glands of Bartholin; these changes accelerate the entrance of the semen into the cavity of the uterus, and increase the motility of the spermatozoa. Upon this fact is based the assumption, that, in consequence of deficient sexual excitement during intercourse, either spontaneous, or when the woman intentionally remains “cold,” the reflex actions by which the upward passage of the spermatozoa is favoured, fail to occur; there is a good deal of evidence in favour of the truth of this view. Riedel reports regarding the women of the Island of Buru, that they often have sexual intercourse with strange men, “but during sexual congress in such cases they maintain a passive and indifferent state, for the purpose of avoiding impregnation.” Von Krafft-Ebing points out that prostitutes, when having sexual intercourse with men to whom they are attached, experience voluptuous excitement, whilst in intercourse with men to whom they are indifferent they remain entirely passive. From this it would appear that these uterine reflexes are under the dominion of the conscious will; but sufficient dependence cannot be placed on this fact in all circumstances for it to be possible to employ such voluntary control as a trustworthy means of prevention. Allied to this is previously-mentioned Chinese practice of Kong-fou, a kind of hypnosis, in which during sexual intercourse the thoughts are concentrated on some other matter, and thereby conception is supposed to be prevented.

Artificial protraction of the period of lactation is an old and well-known method, practised by many savage peoples, for the prevention of fertilization. As a general rule, as long as lactation continues, amenorrhœa persists, and sexual intercourse remains unfruitful. But this rule also is not universally valid.

Artificial means for the attainment of facultative sterility are those by which the attempt is made to prevent pregnancy by some mechanical hindrance to the contact of the semen with the ovum, since without this contact conception cannot possibly occur.

The oldest of these means is that described in the book of Genesis (ch. xxxviii, verses 9, 10), congressus interruptus, where, however, the practice was punished by death, “And Onan knew that the seed should not be his; and it came to pass, when he went in unto his brother’s wife, that he spilled it on the ground, lest that he should give seed to his brother. And the thing which he did displeased the Lord, wherefore he slew him.” This mode of preventing pregnancy, in which the membrum virile is completely withdrawn from the vagina before the ejaculation of the semen takes place, is at the present time a very widely diffused practice; and, when properly carried out, it is thoroughly efficacious in the production of sterility. Thompson relates that this practice is employed by the Massai youths, who are allowed free intercourse with the girls, but if a girl becomes pregnant she is put to death.

The prolonged practice of coitus interruptus leads in my experience—in addition to the injury to the nervous system as a whole in consequence of the intense hyperæmia of the uterus and the uterine annexa, unrelieved by the occurrence of the orgasm—to a condition of stasis in the female reproductive organs; and this ultimately passes on into chronic metritis (with relaxation of the uterus, retroflexion or anteflexion, catarrhal disease of the mucous membrane, erosions, and follicular ulceration of the portio vaginalis), oöphoritis and perimetritis. As a result of certain remarkable observations, I must even regard it as not improbable, although actual proof is still lacking, that the recent striking increase in the frequency of neoplasmata of the female reproductive organs is causally dependent on the ever-increasing employment in all circles of society of means for the prevention of pregnancy.

The evil effects of coitus interruptus for a woman are dependent on the fact that the woman fails to obtain complete sexual gratification, and that this has an important influence upon her entire organism. Owing to the failure of ejaculation to occur, the blood, which during the stage of sexual excitement has accumulated in the erectile structures and cavernous spaces of the genital passage, does not, as in normal conditions, flow rapidly away; but the congestion persists for an indefinite period, and is said by von Krafft-Ebing to give rise to functional disorders, and also to serious tissue changes. The functional disorders take the form of hyperæmia of the pelvic organs, and probably also of the lumbar portion of the spinal cord (dull pain in the sacral region, a sensation of pain and dragging in the pelvis and in the lower extremities, lassitude); these symptoms often continue for several hours after intercourse. If this ungratifying coitus is frequently repeated, in a voluptuous woman, disorders of the reproductive organs ensue; and even more frequently, nervous disorders, in the form of neurasthenia sexualis. This author considers that, more especially in women, coitus interruptus, and unphysiological modes of sexual intercourse in general, are extremely potent causes of sexual neurasthenia—as potent as masturbation.

Beard, in his work on sexual neurasthenia, maintains that the sudden interruption of coitus (and also the use of condoms and similar appliances) is not only far more deleterious than unduly frequent normal intercourse; but he points out that it is necessary also to take into account the fact that (inasmuch as, owing to the unnatural mode of sexual intercourse, the possibility of fertilization is almost completely prevented) sexual intercourse is apt, in such cases, to be indulged in far more frequently, and often to gross excess. More particularly in such circumstances are evil effects on the nervous system likely to ensue, since we have a combination of excessively prolonged and frequent sexual intercourse, and of interference with complete sexual gratification.

Mantegazza believes that organic diseases of the spinal cord may actually result from congressus interruptus.

Hirt considers that even when marital intercourse is carefully regulated in respect of frequency, congressus interruptus may lead to neurasthenic manifestations.

Von Hösslin believes it to be indisputable that preventive methods of sexual intercourse may cause nervous troubles, and more particularly neurasthenic disorders, manifesting themselves chiefly in the sphere of the reproductive organs.

Eulenburg also declares that coitus interruptus is already a frequent cause of sexual neurasthenia in women, and that its evil influence in this respect is becoming more and more frequently manifest. He publishes two typical cases, in which, from this cause, in the one case, functional neuropathy, and in the other, local disorder of the reproductive organs, ensued.

Freud describes an “anxiety-neurosis,” which is due to incomplete gratification of the woman during sexual intercourse. Coitus interruptus is almost invariably harmful to the man; to the woman it is harmful if the man thinks only of himself, and interrupts the coitus as soon as ejaculation is imminent, without concerning himself about the woman’s state of sexual excitement. If, on the other hand, the man waits until the woman’s sexual gratification is complete, the significance of such an interrupted coitus as far as the woman is concerned is that of normal intercourse.

Isolated authorities, as for instance Stille and Thompson, have contested the alleged evil consequences of preventive methods of sexual intercourse. “It is habitual excess,” says Fürbringer, “which does the mischief, not the unnatural character of the isolated act.” Löwenfeld, who considers the opposition of medical men to “Malthusianism” not wholly justified, and believes that the dangers to health “which occur in isolated cases” are not very serious, maintains none the less that the medical man must advise his patients not to practise coitus interruptus. The mode in which conception is prevented is not, he thinks, a matter of indifference to the woman. The use of occlusive pessaries and similar appliances does not in any way interfere with the normal development of sexual gratification and cannot, therefore, have any direct influence in the production of nervous disturbances. A forgotten occlusive pessary, however, has in many cases caused local disorder in the vagina. When the man is fully potent the use of condoms can do no harm to the woman, since the only effect of the condom (in a very excitable woman) is to render the development of the orgasm a little more difficult, but not to prevent it. Congressus interruptus itself is, according to Löwenfeld, harmful to the woman only when, owing to deficient potency in the male or to deficient excitability in the female, the interruption takes place before the occurrence of the orgasm.

Valenta declared that coitus interruptus was one of the chief causes of chronic metritis. Elischer saw perimetritis result from this practice; Gräfe enumerates, as consequences of frequently repeated coitus interruptus, chronic hyperæmia of the uterus and oöphoritis; Goodell observed elongation of the cervix uteri; Mensinga, infarction of the uterus, œdema of the portio vaginalis, ulceration of the cervix, hysterical paroxysms, convulsions, cephalalgias, cardialgias, etc. Lier reports a case in which, after three years’ continued practice of coitus interruptus, the menopause set in, with atrophy of the uterus; Ascher, in a similar case, saw chronic metritis ensue. According to Kleinwächter, coitus interruptus is harmful to the woman to an extent by no means trifling, whereas the man, in whom ejaculation occurs, suffers comparatively little. Fehling believes that when coitus interruptus is practised only a small proportion of women experience sexual excitement. Neugebauer states that among the very numerous cases of uterine carcinoma he has treated, the majority of the patients admitted having practised coitus interruptus. Pigeolot makes a similar statement.

It must, however, be admitted that a certain number of medical men absolutely deny the dangers of coitus interruptus, whilst others consider them altogether trifling. Just as the trend of modern opinion is to believe that in normal men and women the dangers of masturbation are far less serious than was formerly maintained, so also many are now found to maintain that coitus interruptus is harmful only to those with hereditary neuropathic predisposition. Still more unwilling are many to admit that other preventive methods do women any harm. Thus Wille maintains that the continued fear of pregnancy will in most instances do more injury to the feminine nervous system than all the preventive measures in the world. To the nervously weak woman a trustworthy preventive of pregnancy is therefore often necessary and most helpful.

An artificial method for the prevention of the ejaculation of semen was communicated to me by a celebrated anatomist. It is practised in Transylvania and in France. During intercourse the woman, just before the male ejaculation begins, presses forcibly with her finger on the base of the erect penis just in front of the prostate; the urethra is occluded by this digital compression, the semen regurgitates into the bladder and is subsequently evacuated with the urine.

This practice may be compared with the mechanical expulsion of the semen from the female genital passage immediately after coitus. Tairi reports that women of the poorer classes in Italy sit upright in bed immediately after intercourse, and by coughing, in conjunction with pressure on the abdomen, effect the expulsion of the semen. Morton informs us that the native women of Northern Australia, when they have had intercourse with a white man and wish to avoid impregnation, likewise deliberately effect the outflow of the semen post actum. The woman squats upright, with the legs widely separated, and by a sinuous movement of the perineum and a simultaneous powerful bearing-down pressure she expels the semen on to the ground.

Another way in which the attempt is made to avoid impregnation is by the use of vaginal injections; a fluid lethal to the spermatozoa being used for this purpose immediately after coitus. Douches of cold water, ½ to 1% solution of copper sulphate, 1% solution of alum, ¼% solution of sulphate of quinine, are the fluids most commonly employed; but all these are quite untrustworthy, for it is impossible to be sure that all the spermatozoa will be acted on and destroyed. Allbutt, who as medical secretary of the Malthusian League in London has unquestionably had a very wide experience, agrees with Haussmann in denying that the widely advocated cold water douche can be relied on for the prevention of pregnancy. The sudden driving of the blood out of the vessels of the genital passage at the very moment when they are intensely congested, which must inevitably result from a cold douche, is, moreover, likely to give rise to metritis, perimetritis and oöphoritis.

More trustworthy are the various apparatus, the aim of which is to prevent the contact of the semen with the ova by the interposition of an artificial wall. Although even as regards these we must bear in mind the observation of Lott, who found that spermatozoa were capable of passing through the intact membrane in favourable regions in as short a time as ten minutes. The commonest of all these apparatus is the article known as a condom, which envelops the penis with a membrane, variously consisting of isinglass, the lamb’s cæcum, or caoutchouc. Condoms, if made of suitable material, and if carefully used, are the most trustworthy of all preventives. Moreover, the injury caused by their use to the woman’s health is trifling, for they do no more than diminish to a degree the intensity of the stimulus, thus necessitating a somewhat longer duration of its action in order to effect the most intense orgasm, and thus to induce the natural physiological termination of the nervous excitement. In fact, though somewhat delayed, the normal reaction takes place in the reproductive organs. The evil effect of the use of the condom bears no comparison with that of coitus interruptus. There is, however, some justification for Ricord’s well-known epigram, that the condom is “a spider’s web for the prevention of danger, and a cuirass for the prevention of voluptuous pleasure.”

When the gynecologist, from well-considered reasons based on some pathological condition affecting his patient, feels justified in recommending the prevention of pregnancy, it is my opinion that the most trustworthy and least harmful measure at present available, and one preferable to all other mechanical apparatus, is a carefully selected and well-made condom.

The condom was already in use in Italy in the middle of the sixteenth century, in the form of a linen investment adapted to the shape of the penis; subsequently, according to Grünfeld, condoms were made from the cæcum of the lamb; while later still, isinglass was employed for this purpose. According to Hans Ferdy, the cæcal condom is made from the connective-tissue layer of the cæcum of the sheep or of the calf (a very young animal); to a less extent, also, the cæca of the goat, the stag, and the roe-deer, are employed for this purpose. The different varieties of cæcal condom are distinguished chiefly by variations in the thickness and the softness of the membrane. Ferdy states that the four best kinds are made from the cæcum of the sheep; these have a thickness: I. 0.008 to 0.01 mm. (0.00032 to 0.0004 in.); II. 0.012 to 0.015 mm. (0.00048 to 0.0006 in.); III. 0.017 to 0.023 mm. (0.00068 to 0.00092 in.); IV. 0.025 to 0.03 mm. (0.001 to 0.0012 in.) Next in quality come four varieties obtained from the calf, varying in thickness from 0.015 to 0.04 mm. (0.006 to 0.016 in.) Finally we have three varieties obtained from the three other animals already mentioned. Thus there are in all eleven varieties of cæcal condom, and in so far as during the process of manufacture the membrane has remained free from any injury, they are sold as “undamaged.” But if in the process of preparation a hole has been made in the membrane, this aperture is closed by sticking on a small patch of membrane. Such patched condoms are naturally quite useless, since the patch is readily loosened by the moisture to which it is exposed, and falls off, when the protective and preventive functions are entirely destroyed; nevertheless, such defective condoms are often sold. Rubber condoms, continues Ferdy, are prepared from a caoutchouc membrane 0.03 to 0.1 mm. (0.0012 to 0.04 in.) in thickness; but these, he says, are not hygienic, for “such a rubber membrane, which both in the man and in the woman completely covers the erogenic zones normally stimulated in coitus, deadens the necessary stimulation, so that the sensations during coitus are seriously dulled by the interposition of this foreign body; by nervously predisposed individuals, this kind of condom cannot be used regularly for a long period, without rendering probable the onset of serious functional disturbances of the genital apparatus.” This opinion appears to me to be unfounded. We must also mention the “glans-condom,” made of rubber membrane, which serves to cover the glans penis only during coitus, and to retain the seminal secretion; its grave defect, however, consists in this, that in the act of withdrawing the penis, the condom is very likely to be peeled off, when the semen will, after all, pass into the vagina.

Passing now to the consideration of apparatus which are inserted into the woman’s genital canal, in order to prevent impregnation, we may first mention sponges, which have long been in use; after thorough cleaning, these may be rendered aseptic by immersion in carbolic acid or lysol solution. These sponges should be very soft; they are cut into balls of 3 to 7 cm. (1.2 to 2.8 in.) in diameter; before coitus they are introduced into the vagina and after coitus they are withdrawn by means of the tape which should always be attached to them. This method is, however, quite untrustworthy, for the sponge offers no impermeable wall to the passage of the spermatozoa, and on its withdrawal, some of the semen may very likely be left in the vagina. The same objection must be made to the similarly constructed anti-conceptional cotton-wool plugs; sometimes these are moistened with a fluid intended to destroy the spermatozoa. Recently Gunzburg has recommended the introduction into the vagina of a cotton-wool plug moistened with a three per cent. solution of carbolic acid in glycerine; he considers this method safe, because the spermatozoa are immediately destroyed on contact with the weakest carbolic acid solutions.

To destroy the vitality of the spermatozoa, vaginal suppositories made of cocoa-butter medicated with hydrochlorate of quinine have also been employed; these, the so-called “security-pessaries” or “security-ovals,” are inserted into the vagina half an hour before coitus; the cocoa-butter is melted by the body heat, and the vaginal mucous membrane and the os uteri are covered with the medicated fatty material, by which the spermatozoa are (or should be) destroyed. This method is one easy to employ, but it is extremely uncertain.

Even more uncertain are the insufflators charged with various powders (boric acid, citric acid, thymol, etc.); the tube of the insufflator having been passed into the vagina, the powder is blown over the vaginal mucous membrane and the portio vaginalis. This procedure may sometimes be followed by symptoms of intoxication; and in any case, owing to the desiccative effect which the powder has upon the vaginal mucous membrane, it exercises a disturbing influence on coitus.

Kleinwächter, in cases in which pregnancy must be prevented in the interest of a woman’s health or her life, has recommended the introduction into the vagina of globules of which the active constituent is boric acid.

A rationally constructed apparatus, and one which in general appears to fulfil its purpose very well, is the pessarium occlusivum constructed by Mensinga, and now manufactured in various modifications. The occlusive pessary is a hollowed hemisphere of rubber membrane, around the margin of which passes a steel ring. The size of the pessary must be adapted to the individual case. It is introduced into the vagina in such a way that the outer surface of the hemisphere occupies the vaginal fornix, while the steel ring touches the vaginal wall all round; by this means, the vaginal fornices and the os uteri are completely shut off from the lower part of the vagina. The disadvantage of this instrument is, that either the woman must wear it continuously, which involves numerous inconveniences, or else it must be introduced by the skilled hand immediately before coitus—and not every woman becomes competent to adjust it herself, even after careful explanation, since the pessary must be accurately placed with the anterior margin of the ring immediately behind the pubic symphysis, and the posterior margin of the ring behind the os uteri. Moreover, the instrument may easily be displaced by violent movements, coughing, sneezing, etc. In any case, the pessary must be carefully selected to correspond within the configuration of the vagina, as otherwise it may exercise a deleterious pressure upon the vaginal walls, and may give rise to other bad consequences, such as are apt to attend the wearing of any pessary for a prolonged period—excoriations, erosions, fluor albus, etc. In the majority of cases it will be found that the woman herself is not competent to introduce the occlusive pessary. The skilled hand is needed for the proper adjustment of the surrounding ring.

Gall’s balloon-occlusive-pessary consists of a soft elastic rubber disc, surrounded by a thin-walled rubber ring, the interior of which is connected by means of a fine tube with an inflating rubber ball. The woman can herself insert the instrument and inflate the ring; it occludes the vaginal passage without exercising any deleterious pressure.

Other pessaries consist of hollow rubber balls containing some fluid lethal to the spermatozoa, which can be discharged into the vagina on opening a valve by pulling a string. These, however, are as insecure as the above-mentioned vaginal discs and the insufflators. The duplex-occlusive-pessary has the form of a truncated cone with double walls; in its base are a number of rounded apertures, and a single elongated aperture; through this latter a boric acid tablet is introduced into the cavity of the cone. By means of the cone the passage to the uterus is mechanically occluded; the semen passes through the apertures in the base into the interior of the instrument, and as the boric acid tablet is dissolved by the moisture to which it is now exposed, the vitality of the spermatozoa is destroyed. The management of this apparatus is, however, not easily effected by the woman herself. The “Matrisalus-Pessary” differs but little from other occlusive pessaries. The latest instrument for the prevention of impregnation is known as the “Venus-Apparatus;” it consists of a syringe with two balls, a large and a small one, at either end of a rubber tube; by pressure on the larger ball, and subsequent relaxation of pressure, the smaller ball is filled with a fluid for the destruction of the spermatozoa (prepared by the solution of one of the “Venus-powders” sold with the instrument); when filled, this smaller ball is introduced into the vagina and remains connected by means of the tube with the larger ball, which lies between the woman’s thighs. At the moment of the male ejaculation the woman presses on this ball, and by this means the fluid filling the smaller ball is expressed into her vagina.