The sexual life of woman in its physiological, pathological and hygienic aspects (part 3 of 5)

The sexual life of woman in its physiological, pathological and hygienic aspects (part 3 of 5)

As regards the composition of the gastric secretion, an increase of acidity is sometimes noticed. Gastric digestion is retarded; experimental evacuation of the stomach, after a simple test meal (beefsteak and roll) showed that small quantities of undigested remnants were to be found in the stomach as long as seven or eight hours afterwards. The frequent eructations evacuate flatus, or else a watery fluid with an acid reaction (pyrosis or water-brash—see note 38). By the act of vomiting, larger or smaller masses of the food that has been taken are evacuated; in the vomit, sarcinæ in large numbers may frequently be detected by the microscope. Constipation is present in nearly all cases of uterine dyspepsia; and even in cases in which attacks of diarrhœa occur from time to time, careful examination will show that these are generally transient, being sequelæ of constipation due to the irritation caused by the accumulated masses. In one case of long-standing uterine dyspepsia, I observed, in the absence of any gastric dilatation, the well-known phenomenon of “peristaltic restlessness of the stomach” (tormina ventriculi nervosa), in which the peristaltic activity of the stomach is greatly exalted, and becomes visible to the naked eye in the form of large and powerful undulations in the gastric region, moving from left to right.

With these symptoms affecting the digestive organs are associated variable nervous manifestations in different organs, such as neuralgia of various nerves, palpitation of the heart, vertigo, headache, and nervous asthma. The general nutrition of the body often suffers considerably in cases of long-enduring uterine dyspepsia; excessive emaciation and general marasmus may ensue; we see also mental depression, melancholia, an irritable disposition, and disinclination for every kind of work.

Very important, but very difficult, is the differential diagnosis between uterine dyspepsia, on the one hand, and, on the other, chronic gastric catarrh, chronic ulcer of the stomach, nervous dyspepsia, and sometimes even carcinoma of the stomach.

As regards the distinction from chronic gastric catarrh, in this latter disease loss of appetite and changes in the oral mucous membrane are prominent symptoms; the vomit also usually contains much mucus. More difficult is the differential diagnosis of chronic ulcer of the stomach, in cases in which anæmic subjects complain of anomalies of menstruation, associated with dyspeptic troubles and cardialgia. In severe cases of uterine dyspepsia, the distinction from carcinoma of the stomach may be very difficult—at any rate in cases in which no examination of the genital organs has been made. Obstinate dyspeptic troubles, resisting all curative measures (unless indeed these are directed to the relief of the local disorder of the reproductive organs), progressive anæmia, great emaciation, and pains localized in the stomach, are all conditions common to both of these maladies. The absence of a tumor of the stomach, careful examination of the vomit, and examination of the genital organs, will lead to a correct diagnosis if the case is one of uterine dyspepsia. A superficial investigation is exceedingly likely to result in a case of uterine dyspepsia being regarded as one of nervous dyspepsia (von Leube); none the less, even though a very close resemblance exists between the symptoms of the two diseases, to differentiate them is a matter of importance. In nervous dyspepsia, the act of digestion influences the nervous system in such a manner that, even when the chemical processes are normal, the organism as a whole is sympathetically affected by a reflex from the stimulation of the nerves of the stomach, and in return reacts on the mechanical process of digestion in a more or less violent manner. In uterine dyspepsia, however, the relationship that obtains is exactly the reverse of this, inasmuch as the gastric activity is influenced by the nervous system, by reflex impulses originating in the morbid processes in the reproductive organs; moreover, in this form of dyspepsia, in direct contrast with nervous dyspepsia, the chemistry of digestion is often disordered, and, in addition, the process is not completed within the normal period.

Oftentimes, the diagnosis of uterine dyspepsia can be made with certainty only ex juvantibus.[39] For this disorder cannot be cured unless the disease of the reproductive organs on which it depends is first relieved; and, conversely, local measures for the relief of uterine disease, will often at once remove all the dyspeptic troubles from which the patient suffers.

My own experience has led me to conclude that it is certain distinct local mechanical stimuli affecting the female genital organs which, acting for a long period on the sensory nerves of the uterus or its annexa, induce by reflex action the before-mentioned digestive disturbances. Diseases of the vulva and the vagina, catarrhal inflammation, colpitis and leucorrhœa, and prolapse of the vagina, do not by themselves lead to the occurrence of uterine dyspepsia; nor do inflammations of the uterine mucous membrane, such as endometritis (unless associated with parenchymatous changes of the whole uterus), chronic catarrh of the mucous membrane, erosion and ulceration of the cervix to an inconsiderable extent, or moderate perimetritic and parametritic exudations. On the other hand, uterine dyspepsia frequently ensues in cases of uterine displacements, flexions, or versions, or in cases of structural changes of the uterus accompanied by enlargement of the organ, chronic metritis, myomata, especially when intramural (interstitial), displacement of the Fallopian tubes and the ovaries, chronic oöphoritis, extensive inflammatory exudations, resulting from pelvic peritonitis, and leading to dislocation, “compression” or distortion of the uterus and its annexa, deep follicular or carcinomatous ulceration of the cervix, or, finally, ovarian tumors. As the commonest condition giving rise to dyspeptic disturbances of the kind under consideration, retroflexion of an enlarged uterus must be mentioned.

Under the head of uterine dyspepsia, we may also classify dyspeptic disturbances occurring at the time of puberty or of the menopause, and in association with certain amenorrhoeic and dysmenorrhœic conditions, and, in addition, the vomiting of pregnant women.

The vomiting of pregnant women, which must be regarded as a reflex disturbance of the stomach, occurs, with especial severity in first pregnancies, in the early months of pregnancy, with such regularity that it is regarded as one of the most typical signs of pregnancy. Thus, in 177 pregnant women, Horwitz observed vomiting in 147 (83 of whom were primiparæ, and 64 multiparæ), and in 29 only was this symptom wanting. In this series of cases, it most commonly made its appearance between the tenth and eleventh week of the pregnancy. The vomiting of pregnant women occurs most commonly early in the morning, immediately after rising (morning sickness), but also at other times of the day; it usually takes place easily, without any great distress, and after it is over the patient feels quite comfortable. It rarely continues later than the fourth month of pregnancy.

Very serious in its effect on the general state of nutrition is the uncontrollable vomiting that sometimes occurs in pregnant women (hyperemesis gravidarum), lasting throughout the whole term of pregnancy. It must be regarded as an exaggeration of the physiological vomiting of pregnant women, in patients whose nervous equilibrium is profoundly disturbed; but equally with the ordinary “morning sickness” is it dependent on the reflex stimulation of the nerves of the stomach exercised by the growing uterus. One source of such stimulation may be found in the stretching of the peritoneal investment of the uterus which results from the enlargement of that organ; another, in certain displacements of the uterus; but in addition to these local anomalies, we must assume the existence of a peculiar predisposition on the part of the nervous system, in virtue of which reflex irritability is increased, while the power of reflex inhibition is diminished.

The prognosis and treatment of uterine dyspepsia depend chiefly upon the nature of the diseases of the female genital organs that have given rise to the disturbances of digestion, and this pathological relationship demands above all a careful investigation. The following instance from my own case-book may be regarded as typical of cases of this class. Mrs. N., aged 25, married 6 years, barren, complains of severe dyspeptic trouble. Appetite fairly good, but after every meal severe gastralgia occurred, with heartburn and acid eructations, and very often the food was rejected; there was also obstinate constipation, and great distress from the accumulation of flatus in the intestinal canal. No blood was ever seen in the vomit. The patient was much emaciated, and was greatly depressed in spirits. Neither in the lungs nor in the digestive organs had any of the physicians under whose care the lady had been for the last four years found any abnormal change to account for the stormy manifestations. Now, at length, the gynecological examination, which had hitherto been neglected, was undertaken. The uterus was found to be strongly retroflexed and enlarged. Rectification of the position of this organ was immediately followed by the disappearance of all the stomach troubles; the vomiting ceased, some months later the woman became pregnant, and pregnancy and parturition were quite normal; since then there has been no return of the dyspepsia.

Since the appearance of my work on dyspepsia uterina, numerous observations have in recent years been published, proving even more clearly the causal dependence of disturbances of the gastric function upon diseases of the female genital apparatus.

Lamy, for example, has made an elaborate study of one of the above-mentioned symptoms of uterine dyspepsia, namely, excitement of the vomiting centre. His conclusions are as follows: Among the general symptoms of diseases of the uterus, dyspepsia, in all its forms and in all degrees of intensity, occupies the first rank in respect of frequency of occurrence. Among the accompaniments of these reflex processes, uterine vomiting must be mentioned. It seldom occurs as the sole symptom of disorder of the digestive organs; but when it does occur alone, it is of great importance that the cause of the affection should not be misunderstood. Diseases of the uterus and periuterine affections are the conditions that most commonly give rise to this trouble, but in a certain number of cases it is due to physiological changes in the female genital organs. Such changes are those associated with the functional activity of the reproductive apparatus at the time of puberty, during menstruation, in connection with coitus, during pregnancy, and at the change of life, the menopause. The vomiting of pregnant women is of the same nature, and confirms our belief in the uterine origin and pathogenesis of vomiting at other times than during pregnancy. The diagnosis of the true cause of uterine vomiting cannot be made from the nature of the latter, but only from a knowledge of the conditions in which it occurs, just as with other uterine reflexes, such as neuralgia or cough. The vomit may consist merely of the food last taken, or it may contain bile, without the presence of this latter constituent indicating the existence of any disease of the liver. The treatment of this disorder, which indeed does not threaten life, but does seriously impair the general state of nutrition, must be local, directed against the disease of the genital organs: Thus, in one case of this nature, a cure was effected by oöphorectomy.

The majority of the women in whom Lamy observed this symptom of uterine dyspepsia were chloro-anæmic individuals with an irritable nervous system, town-dwellers, young girls in whom frequent evening parties and dances, ill-chosen diet, and a generally unsuitable mode of life, had led to the development of a “virginal metritis.” The signs of the disturbance of the gastric functions were in the first place a retardation of gastric digestion while the appetite remained good. Moreover, the stomach was often distended with flatus, and this caused frequent gaseous eructations; there was also epigastric pain, which made it difficult for the patient to bear the pressure of the clothing, and sometimes great pain was aroused by the slightest contact. The attacks of vomiting, which occurred in a characteristic manner with periodical intervals of freedom, were usually preceded for a longer or shorter period by dyspeptic symptoms. The vomiting itself, if it occurred immediately after a meal, was not accompanied by nausea, a feeling of faintness, or cold sweats, but rather resembled a kind of painless regurgitation; but when the vomiting did not occur till some hours after food had been taken, it was painful, and the vomit was then green-tinted owing to the admixture of bile.

The gastric troubles that occur during menstruation are regarded by P. Müller as a further indication of the intimate connection between the genital organs and the digestive tract. In women who suffer from hysterical manifestations, gastric disturbances, cardialgia, and nervous dyspepsia, are very frequently associated with menstruation. These gastric symptoms generally make their appearance a few days before menstruation is due, and disappear as soon as the flow is established. In other forms, again, the digestive troubles set in with the appearance of the flow, to disappear during the later course of menstruation; and in yet other cases the gastric disturbance begins even later, and ceases only when the flow comes to an end. These symptoms may occur in women in whom the genital organs are perfectly healthy and in whom menstruation runs a regular course. More severe symptoms may, however, appear if menstruation is disturbed for any reason, or if it is suppressed. Not rarely such women, when they become pregnant, suffer, especially during the early months, from dyspeptic symptoms; but similar dyspepsia may occur in pregnant women who have previously been quite healthy.

To the same category belong the cases formerly described by von Leyden under the designation of neuralgia and hyperæsthesia of the stomach, which he observed in young girls as a sequel of menstrual disturbances, and more particularly of suppressio mensium. In these circumstances, the sensibility of the stomach may become so extreme that every time food is taken the patient suffers from such severe pains, or from so distressing a sense of anxiety and oppression, that she comes to eat less and less, and an extreme degree of emaciation and marasmus results. In one such case, congenital atrophy of the uterus was discovered on gynecological examination.

According to R. Arndt, it is especially in chloro-neurotic individuals that the stimuli proceeding from morbid conditions of the reproductive organs frequently induce, by reflex action, all kinds of disturbances of the alimentary tract, such as constipation and flatulence, gastric uneasiness and loss of appetite, weakness of digestion, cardialgia, and stricture of the œsophagus. Even simple menstruation suffices to give numerous proofs of this fact, but still more do such consequences arise from serious diseases of the reproductive organs, such as changes in form, displacements, and inflammatory states, and also, on the other hand, more or less pronounced hypoplasia.

G. Braun has published three cases illustrating the connection between neurosis of the stomach and uterine disorders. In the first of these cases, severe digestive disturbances occurred after every meal, with occasionally violent vomiting, in a woman, aged twenty-five years. No changes were found in the stomach or other digestive organs, and the symptoms obstinately resisted all direct treatment. Gynecological examination showed extreme mobility of the uterus, and for the relief of this a suitable pessary was introduced. The vomiting thereupon immediately ceased, all the other digestive troubles passed completely away, and the general state of nutrition, which had before been so much impaired as to necessitate the use of nutrient enemata of meat-solution, now became normal. The second case was that of a woman aged thirty, who, since her last confinement two years before, had continually suffered from disagreeable gastric sensations and from vomiting, which latter had proved quite uncontrollable. Gynecological examination disclosed extensive laceration of the cervix with ectropium of the mucous membrane. An operation was performed for the relief of this condition, and the vomiting of two years standing was also thereby cured. In the third case, that of a woman twenty-eight years old, vomiting began three months after her confinement, and recurred whenever the patient left the recumbent posture, in which latter she felt quite well. On local examination, the uterus was found to be prolapsed, the vaginal portion of the cervix moderately enlarged and just within the vaginal orifice. Amputation of the vaginal portion of the cervix cured the vomiting and completely restored the patient’s health.

The frequency of gastric affections in cases of retroflexion of the uterus is insisted on by Panecki. In eight instances he found neuroses of the stomach consequent upon such retroflexion, and in all cases a cure immediately followed rectification of the position of the uterus. He urges that if after the reposition of the retroflexed uterus the gastric troubles should still persist, a careful local examination of the stomach is indispensable.

Eisenhart, in a woman forty-two years of age, corrected a mobile retroflexion of the uterus, and thereupon very severe gastric symptoms of several months’ duration soon disappeared. Graily-Hewitt, in an unmarried woman twenty-seven years of age, cured by reposition of a retroflexed uterus a gastric disorder which had subsisted for nine years; Elder and Henrik report identical results in gastric troubles consequent on retroflexion or retroversion of the uterus. Jaffé, in a virgin, aged twenty-three, who had been brought near to death by gastric disorder with vomiting, found on local examination that there was a profuse, thick, purulent discharge from the interior of the uterus; curetting, and irrigation of the uterine cavity with antiseptic solutions, gave immediate relief to the stomach trouble. Similar experiences are recorded by C. van Tussenbeck and Mendes de Leon in cases of gastric disorder consequent on endometritis fungosa and endometritis interstitialis parenchymatosa; and by Gottschalk, in cases consequent on sarcoma of the chorionic villi. Lewy and Butler-Smythe have observed the relief of pernicious vomiting by Emmet’s operation (trachelorraphy).

As regards the relations of gastro-intestinal affections to the diseases of the reproductive organs, Theilhaber, in the cases observed by himself, distinguishes three groups. In the first group of cases, the gynecological abnormality was a chance accessory, and was not the cause of the gastric trouble. In the second group, he regards the gynecological trouble as dependent upon the affection of the gastro-intestinal tract, believing that, in consequence of atony of the intestine and an accumulation therein of fæces and flatus, a retardation of the circulation occurs in the region of the inferior vena cava, resulting in venous stasis in the uterus, and so giving rise to metrorrhagia, dysmenorrhœa, and fluor albus. In the third group of cases, Theilhaber believes that the uterine trouble is the cause of the disturbances in the stomach and intestine. He, like myself, has found in all these patients an inhibition of the intestinal movements; but he found, on the other hand, that the gastric secretions were more commonly normal, and that only in a small proportion of the cases was the vomiting centre excited. Further, in the majority of these women, the course of the digestive processes was quite normal; and, finally, in his series of cases, endometritis was one of the commonest causes of consecutive gastric disorders. His observations led him to conclude that “in consequence of affections of the uterus a large number of different symptom-complexes of gastric trouble occur:” the pure nervous dyspepsia of Leube, dependent on atony of the large intestine and atony of the stomach, hyperchlorhydria and anacidity, periodic gastralgia without anatomical cause, etc.

Cardiopathia Uterina.

I use the term cardiopathia uterina to denote the manifold cardiac disorders which occur in women as reflex processes excited by the physiological functions and the pathological disorders of the genital organs, and take the form of very various disturbances of the cardiac function. Every phase of the sexual life of women—that in which the reproductive organs attain complete development and menstruation first appears (the menarche); the commencement of sexual intercourse; pregnancy, parturition, and the puerperium; finally the retrogressive process at the climacteric age, of which the menopause is the outward manifestation—may give rise to the occurrence of such cardiac troubles. In order to explain these troubles as reflex in their nature, we must on the one hand recur to the anatomical changes in the uterus and its annexa that take place in every one of the above-mentioned phases of the sexual life; and on the other hand we must take into consideration the mental processes that accompany these anatomical changes, in order to estimate their influence upon the motor and sensory nerves of the heart (see the sections on the Menarche and the Menopause).

A certain predisposition to uterine cardiopathy exists in many individuals and in many families. This predisposition may be manifested in this way, that in women who at the time of the menarche have suffered from cardiac disorder, similar cardiac disorder is likely to recur at the time of the menopause, the symptoms of the recurrent attack being in most cases identical with those that occurred during the menarche. In the well-to-do and cultured circles of society, uterine cardiopathy is far more frequently encountered than among the working classes. Both unusually early and unusually late commencement of menstruation tend to favor the occurrence of uterine cardiopathy. The most valuable therapeutic measures that we can employ to combat these disorders are suitable dietetic and hygienic regulations, in association with favorable mental influences.

Diseases of the female reproductive organs, including simple functional disturbances, are very frequently accompanied—far more frequently than has hitherto been supposed—by cardiac disorders. But whereas in some cases these cardiac disorders are directly dependent upon the disease of the genital organs; in other cases no such etiological relationship can be shown to exist, and the association must, therefore, be regarded as fortuitous.

In cases of the former kind, the dependence of the cardiac disorder upon the disease of the genital organs is very variable in its nature.

Reflex manifestations on the part of the nervous system may be aroused by pathological changes in the genital organs, in a manner similar to that discussed in other parts of this work in regard to the cardiac troubles that are liable to occur during the menarche and the menopause; such cardiac disorders are indeed excited especially by changes in the ovaries, by disturbances of menstrual activity, by suppression of the menses—as manifestations, that is to say, of the menstrual reflex. The cardiac disorder most commonly takes the form of tachycardiac paroxysms, recurring periodically, either in association with the menstrual flow, or, if this is in abeyance, at the times at which it ought to appear. We must assume in these cases that the local stimuli aroused by the pathological changes in the uterus and the ovaries have a reflex influence upon the cardiac nerves, by means of which the heart’s action is increased in frequency, without inquiring more particularly whether the reflex influence is effective by inhibiting the normal action of the vagus, or by stimulating the sympathetic, or, perhaps, by a combination of these factors. Much more rarely do we notice, in association with disorders of the reproductive system, a reflex decrease in the frequency of the heart’s action, this effect being explicable in the same manner as the well-known experiment of Golz, in which, if the abdomen of a frog be laid bare, and the intestine be struck sharply with the handle of a scalpel, the heart will stand still in diastole with all the phenomena of vagus inhibition.

In another group of diseases of the genital organs, the disturbances of cardiac activity may be brought about by pressure which, in consequence of the morbid processes in the reproductive organs, is exercised upon individual nerves or upon an entire nerve plexus. Tumefied and prolapsed ovaries, an enlarged and misplaced uterus, inflammatory nodules and hyperplasias of the intrapelvic connective tissue, contractile processes in the parametric connective tissue,[40] tumors of the uterus whether intramural or in the interior of that organ, ovarian tumors, prolapse of the uterus, and intrapelvic peritoneal adhesions resulting from inflammatory processes—these are the principal conditions liable to occasion reflex cardiac disorder; but certain tissue changes, such as endometritis, erosions (chronic cervical catarrh), and ulcerations of the genital passages, with or without exposure of nerve-endings, are also competent to produce the same effect. Here the sympathetic nervous system constitutes the channel by means of which the stimuli affecting the nerves of the genital organs are conveyed to the central nervous system, and by means of which also the reflex manifestations of this stimulation are produced, taking the form, partly of disorder of the cardiac action, of palpitation of the heart and paroxysmal tachycardia, and partly of pains in the cardiac region and disturbances along the course of the great vessels.

Further, in cases of long-continued disease of the female genital organs associated with severe hæmorrhage and in some cases fluor albus, nutrition in general and hæmotopoiesis may be seriously affected, and disturbances of cardiac activity may result, as, for instance, is frequently witnessed in chloro-anæmic states. In such cases we have palpitation of the heart, both subjective and objective, a weak and compressible pulse, often irregularity of the heart’s action, singularly clear heart sounds, often, however, systolic murmurs at various orifices, increased frequency of heart and respiration to a disproportionate degree on slight exertion, strong pulsation of the carotids, and slight œdema of the ankles.

Often, however, the disturbance of cardiac activity is dependent also upon degenerative processes in the myocardium, upon fatty degeneration and the consequent dilatation of the cavities, this degeneration being a consequence of the growth of a uterine tumor and especially of uterine myomata, or resulting from some constitutional disorder which is itself dependent upon the affection of the genital organs. In such cases the signs of degeneration of the heart are very striking: weakening of the cardiac impulse, notable faintness of the sounds of the heart, occasionally reduplication of the second sound, a galloping rhythm, while percussion shows the existence of considerable dilatation of the left, and still more frequently of the right ventricle; in many cases also we have angina pectoris, passive hyperæmia of the lungs, the mucous membranes, and the extremities; and sudden death sometimes ensues.

No less important are the mental influences exercised by diseases of the genital organs in which operation is proposed or actually performed, also by long-lasting diseases of the reproductive organs and by the disturbances these diseases produce in the reproductive functions, more especially in relation to copulation and the actual process of reproduction. In this way cardiac neuroses of various kinds may be induced.

Finally, cases have come under my notice in which the cardiac trouble was not the direct result of the disease of the genital organs, but was a consequence of the therapeutic measures employed for the relief of the latter; and in this connection I must regard as especially blameworthy, in addition to intra-uterine manipulations, such as sounding and cauterization, the modern practice of gynecological massage.

Not all diseases, however, of the female reproductive apparatus, tend in a similar manner and with equal frequency to give rise to consecutive cardiac disorders. According to my own observations, the diseases of the vulva and the vagina, catarrhal inflammation, colpitis (vaginitis), leucorrhœa, and prolapse of the vagina (cystocele and rectocele), are those which most rarely induce cardiopathy; unless, indeed, the diseases just enumerated have led to the occurrence of vaginismus, for in this latter condition cardiac trouble not uncommonly ensues. More commonly than by vulval and vaginal diseases, cardiac troubles are induced by inflammation of the uterine mucous membrane, as by chronic endometritis, by erosion and “ulceration” of the cervix (chronic cervical catarrh); they also sometimes occur in connection with perimetritic and parametritic exudations. Most frequently of all, and most severely, cardiac disorders are aroused by displacements of the uterus, flexions or versions; by structural changes of the uterus accompanied by enlargement of that organ, such as chronic metritis and the growth of myomata (especially intramural); by prolapse, enlargement, and tumor of the ovary; by intrapelvic exudations which when extensive give rise to displacement or compression of the uterus or its annexa. In cases of carcinomatous or other malignant new growths affecting the reproductive organs, I have in comparison very rarely observed the occurrence of reflex cardiac disorders.

Disturbances of menstrual activity, amenorrhœa, menorrhagia, and dysmenorrhœa, owning the most varied causes, very frequently give rise to cardiac trouble, a point on which we have already insisted. (See page 142, et seq.)

Very violent forms of cardiac neurosis have been observed by me in women suffering from chronic disorder of the reproductive organs, who have consulted one gynecologist after another and have been subjected to many different methods of local treatment; also in women who have for a long time suffered from some gynecological ailment hitherto believed to be trifling, but who have at length suddenly been informed that some severe operative procedure has become necessary. In such cases the cardiac trouble took a paroxysmal form, the intervals being usually considerable, several weeks or months in duration, and the general system was as a rule seriously involved in the attacks. These latter began with severe cardialgia, radiating from the cardiac region outward along the intercostal spaces, upward to the shoulder and along the left arm, sometimes indeed extending into both arms. At the same time the heart’s action was greatly increased in frequency, there being sometimes more than 200 beats per minute, the pulse was soft, small, difficult to count, the respiration greatly increased in frequency, sometimes very shallow, with respiratory anxiety, and exceptionally severe general excitement and sense of impending death. In some cases also I observed spasm of various groups of muscles, dizziness (with a sense that the objects of vision were flickering), aphasia, and mental stupor. The paroxysms lasted for some time, two or three hours, as a rule, and gradually passed away. Their character was that of the cardiac disorder variously described under the names of pseudo-angina and angina pectoris hysteria.

Such attacks as these are followed by a sense of severe general depression and want of energy, and by a decline in body-weight. They are distinguished from true angina pectoris by the absence of any signs of arteriosclerosis or of degeneration of the myocardium. They may be regarded as cardiac disorder of duplex causation, being partly dependent on the disease of the genital organs, which gives rise to a number of local afferent stimuli, and partly dependent on mental influences which have a depressant, paralyzing influence on the cardiac nerves; it is possible also that spasmodic contraction of the walls of the coronary arteries or of the myocardium itself is induced as a reflex effect of the local disorder of the reproductive organs.

With regard to uterine myoma as the exciting cause of cardiac degeneration, very numerous observations and experiments have recently been made, and the reality of the occurrence is no longer open to dispute, even if its significance is subject to various interpretations, whilst no satisfactory explanation has yet been forthcoming.

L. Landau writes concerning the disturbances induced in the circulatory apparatus by the growth of myomata in the uterus: “The formation of varices, the occurrence of thrombosis, and, finally, the onset of degeneration of the myocardium, are very common. Should the last-named process result—and it is truly alarming to observe the frequency with which cardiac affections are associated with uterine myomata,—then, by a vicious circle, the uterine hæmorrhages become continually more profuse, in consequence of increasing passive hyperæmia dependent upon diminishing power of the cardiac pump. Venous congestion in the province of the inferior vena cava results in ascites, and sometimes in general œdema; and even in cases in which no increase of the uterine hæmorrhages is observed, the patient may succumb in consequence of secondary disease of the heart. * * * In the great majority of cases, the myoma and the uterine hæmorrhages that result from its growth are the primary cause of the morbus cordis. Naturally in cases which come under observation only when both uterine and cardiac disease are already present, it is difficult to determine with certainty the true causal connection. When, however, a number of patients suffering from uterine myomata are observed, in whom at first the heart was found to be healthy, and subsequently to have become affected; and when, on the other hand, we see patients affected with myoma uteri in whom operation is undertaken notwithstanding the existence of cardiac disease, and in whom, after the operation has been successfully performed, the cardiac murmurs disappear as well also as the other signs of heart disease, when dilatation can no longer be detected, when the pulse-frequency declines to normal, whilst a previously feeble and compressible pulse gains in tension and power—then it is impossible to doubt that the heart disease was secondary, and was etiologically dependent upon the primary myoma and the uterine hæmorrhages.”

Lehmann and P. Strassmann examined the material of the Charité-Policlinik at Berlin in order to throw light on the relation between uterine myomata and diseases of the heart, a connection already proved to exist alike by recent pathologico-anatomical researches, by clinical experience of the results of operations (death from shock), and, finally, by the subjective troubles of the patients (palpitation, venous congestion, giddiness, and syncope). Examining 71 women suffering from myoma uteri, Lehmann and Strassmann found in 29 (41%) that some abnormality existed in the cardio-vascular system, such abnormalities being extremely variable in character, as for instance: hypertrophy or dilatation of the heart, irregularity of the cardiac action, passive hyperaemias, œdema, albuminuria, angina pectoris, and cardiac asthma. The next point was to determine the mutual relations between the heart disease and the development of the uterine myoma. Hitherto it has been assumed that the latter is the primary disease, and such a sequence is certainly the commoner, more especially in cases in which hæmorrhage has been profuse, with consecutive anæmia and fatty degeneration of the heart. In these cases, a certain time after the commencement of the severe hæmorrhages, cardiac troubles make their appearance; such troubles are beyond question secondary, and they disappear as soon as the hæmorrhage has been controlled. In other patients, however, we obtain a history of the appearance of cardiac disorder at a date prior to that when any symptoms occurred indicating the growth of a myoma; in these cases, therefore, the heart disease has developed independently of the uterine disease, and has run a parallel course to the latter; perhaps, indeed, by leading to venous congestion or to rapid changes in blood-pressure, the heart disease may have favored the growth of the commencing or fully developed tumor. In some of the patients, operative measures were followed by rapid recovery from the cardiac disorder (cases of simple anæmia); in a second group of cases, however, the heart disease was uninfluenced by operation (cases of irreparable anæmia, and cases of heart disease independent of the myomata); and, finally, a considerable number of patients remained, constituting a third group, in whom, notwithstanding the removal of the tumor by operation, the heart disease continued to grow worse (cases of progressive heart disease independent of the myomata, especially cases of arteriosclerosis).

Among 120 women of ages between 17 and 48, in whom I found very various functional disorders of or pathological changes in the genital organs, and in whom I made a particular investigation concerning the presence or absence of heart disease and examined the heart carefully, I was able to detect the presence of cardiac troubles in 38 instances. Thus, heart trouble was found to exist in 32.7 per cent. of women suffering from disease of the reproductive organs.

In these 38 persons suffering from cardiac disorder, I found:

Nervous Tachycardia in 21 instances, that is, in about 55.2 per cent. of the cases. Hypertrophy of the Heart in 4 instances, that is, in about 10.4 per cent. of the cases. Pseudo-Angina Pectoris in 3 instances, that is, in about 7.8 per cent. of the cases. Asthenia Cordis in 7 instances, that is, in about 18.4 per cent. of the cases. Mitral Incompetence in 1 instance, that is, in about 2.6 per cent. of the cases. Fatty Heart in 2 instances, that is, in about 5.2 per cent. of the cases.

As regards the varieties of functional and organic disease of the genitals met with in the 120 cases, and the number of instances complicated with heart trouble in each variety, I found:

Chronic Metritis in 32 patients, complicated with cardiac disorder in 13 instances. Chronic Oöphoritis in 10 patients, complicated with cardiac disorder in 4 instances. Parametric Exudations in 14 patients, complicated with cardiac disorder in 6 instances. Chronic Endometritis in 16 patients, complicated with cardiac disorder in 2 instances. Flexions and Versions of the Uterus in 26 patients, complicated with cardiac disorder in 9 instances. Stenosis of the Cervix in 6 patients, complicated with cardiac disorder in 0 instances. Tumors of the Uterus and its Annexa in 8 patients, complicated with cardiac disorder in 4 instances. Infantile Uterus in 3 patients, complicated with cardiac disorder in 0 instances. Colpitis (Vaginitis) in 5 patients, complicated with cardiac disorder in 0 instances.

From these figures we obtain the following percentages, showing the frequency with which heart trouble occurred as a complication of the respective diseases of the genital organs:

In Chronic Metritis, cardiac disorder was found in 40.6 per cent. of the cases. In Chronic Oöphoritis, cardiac disorder was found in 40 per cent. of the cases. In Parametric Exudations, cardiac disorder was found in 42.8 per cent. of the cases. In Chronic Endometritis, cardiac disorder was found in 12.5 per cent. of the cases. In Versions and Flexions of the Uterus, cardiac disorder was found in 34.6 per cent. of the cases. In Tumors of the Uterus and its Annexa, cardiac disorder was found in 50 per cent. of the cases.

To summarize the result of my observations regarding the cardiac disorders secondary to diseases of the female genital organs:

1. Tachycardial paroxysms in cases of amenorrhœa were premenstrual in rhythm, the paroxysms occurred, that is to say, some days before the due date of the suppressed flow.

2. In cases of dysmenorrhœa, I observed heart trouble with severe dyspnœa and feelings of anxiety, also in some cases symptoms of cardiac asthenia; these symptoms were perhaps dependent upon acute dilatation of the heart. The heart trouble associated with profuse menorrhagia exhibited similar characters.

3. Attacks of pseudo-angina pectoris occurred in women in whom local treatment for disease of the genital organs had been carried out for a long time, and in cases in which operative measures were in contemplation.

4. Paroxysms of tachycardia and cardiac distress were observed in connexion with displacements of the uterus, and especially in cases of retroflexion; also in association with oöphoritis and with parametric exudations.

5. Cases of degeneration of the myocardium, sometimes running a rapidly fatal course, were found to be consecutive to tumors of the uterus and its annexa, especially to myomata of the uterus.

Nervous Diseases Secondary to Diseases of the Genital Organs.

In earlier chapters of this work we have frequently referred to the reflex influence exercised upon the nervous system in general, alike by the normal functions and the pathological states of the female genital organs. We must now briefly explain the more intimate connection between nervous diseases and diseases of the genital organs, the causal dependence of local nervous disturbances and of general neuroses upon diseases of the reproductive organs.

The origination of a local nervous disease by a primary disease of the genital organs is dependent upon a simple mechanical process, which is explained by Windscheid in the following terms: “In this connection, the two principal mechanical factors are pressure and traction. Pressure may affect individual nerves or an entire nerve plexus, and may be exercised by a tumour, an exudation or a misplaced organ (Hegar); further causes of pressure are furnished by inflammatory nodules, by connective tissue hyperplasias, and, according to Freund, by contractile processes in the organs themselves and in the ligaments. Traction on the nerves results from displacements, as from prolapse of the uterus or the ovaries, and, according to Hegar, from traction on the pedicle of small tumours. A combination of pressure and traction occurs especially in affections of the abdominal attachments of the uterus, also where there is scarring of the neck of the uterus and of the vaginal fornices. Great importance, also, in relation to the production of local nervous disorders, must be attributed to the laying bare of nerve-terminals by catarrhal and other inflammatory processes. Abnormal mobility of the genital organs as a partial manifestation of enteroptosis must also be mentioned as a cause of mechanical stimulation of the nerves. Finally, in this connection, must be considered the paresis of the abdominal walls that follows frequent and severe confinements.”

The symptoms of the local nervous disorders to which these mechanical stimuli may give rise, are very various, but may, according to Hegar, be comprised under the general designation of lumbar enlargement symptoms (Lendenmarksymptome), inasmuch as the local stimulation of the intrapelvic nerves, affects the nerve-centres of the lumbar enlargement of the spinal cord. Among the symptoms, severe pains are prominent, either continuous or intermittent, within the pelvis and in the sacral region, accompanied by a sense of weight and pressure in the abdomen, or by dragging pain in the region of the hips, in the gluteal region, in the outer and back parts of the thighs, in the inner surface of the leg, in the calf, in the dorsum of the foot, the sole of the foot, and the heel; or by coccydynia (pain over the coccyx and the lower extremity of the sacrum), or hyperæsthesia and anæsthesia of the external genitals in the region of the vaginal orifice, or, finally, by disorder of the processes of micturition and defæcation. In some of these cases, the weakness of the lower extremities is so severe that a paralytic condition is simulated. Actual paralysis may however occur, in consequence of the extension of peritoneal inflammation to the nerve-plexuses of the pelvis, leading to the occurrence of neuritis.

The development of a general neurosis in consequence of disease of the genital organs, either as a complication dependent upon the nervous stimulation excited by the primary disease, or as a reflex consequence of this disease, implies, as Windscheid strongly maintains, the existence prior to the occurrence of the disease of the genital organs of diminished power of resistance on the part of the nervous system. This neuropathic constitution may be the result of inheritance, and, according to Engelhardt, was so in 40 per cent. of his cases of women suffering from nervous disease secondary to the disease of the genital organs; or it may be acquired. Given this weakness of the nervous system, a local disturbance of the genital organs may act as the ultimate exciting cause of the onset of the neurosis in one of two different ways (Windscheid). “1. The stimulus which the nerves of the affected genital organ (or those of some adjacent area, affected by direct extension) have received, proceeds upward from segment to segment of the spinal cord, and ultimately passes to the highest centres. 2. Or, on the other hand, the local nerves are not directly involved in the morbid process in the genital organs, but this latter acts as a source of reflex disturbance, a disturbance which must also pass through nervous channels. To this latter class of cases belong the instances, comparatively so frequent, in which, for example, a trifling retroflexion of the uterus must be regarded as the exciting cause of the neurosis.” The commonest neurosis of those that may be excited by local disease of the genital organs is undoubtedly hysteria, next in frequency come chorea and epileptic seizures.

Schauta draws attention to the important fact that hereditarily predisposed, neurasthenic individuals bear very badly repeated gynecological examinations and long-continued local treatment, inasmuch as, in such persons, a notable increase in the severity of the nervous affection may result, and even the outbreak of actual mental disorder; and he further points out that in hereditarily predisposed individuals, psychoses not infrequently occur in consequence of the performance of gynecological operations.

The processes of pregnancy make a deep impression on woman’s entire nervous system, and more especially on her mental functions. This is especially noticeable in the case of primiparæ. The fact is easily understood, for a woman is filled with expectation and anxiety concerning the unknown event, the complete revolution in her organization, the powerful impressions on her physical ego, the formation of a new being within her womb. How many joyful hopes, how many distressing fears, are connected with that which is about to take place, with the act of creation within her bosom; what changeful glimpses into the future, on the one hand the gladness, on the other the terror, of motherhood; often, also, the anxious doubts as to the probable sex of the newcomer. Consider, too, the stormy sensations experienced by a woman who, unmarried, has become pregnant contrary to her desires and expectations, especially one in a poverty-stricken condition—consider the agonizing thoughts in such a case regarding the consequences of giving birth to a child. It is only to be expected that in pregnant women in general there will almost always be increased irritability of the nervous system combined with a tendency to the rapid variation of emotional states. Neumann found, in almost all the pregnant women he examined in respect to the point, that there was an increase of the knee-jerks, as a manifestation of the general increase of nervous irritability. Nor does this change depend upon mental influences exclusively; there are other factors, such as the reflex processes aroused by the enlargement of the uterus, and also the changes in the composition of the blood which occur during pregnancy, and cannot fail to have an influence on the nutrition of the brain. Finally, also, the deposit of carbonate of lime on the inner surfaces of the cranial bones (the parietal and frontal bones) which occurs during pregnancy, may be regarded as having some casual connection with the changes in the nervous system; and, again many authors assume that the cerebral circulation is influenced by the formation of the placental circulation.

The pathological consequences of pregnancy, as far as they affect the nervous system, take the form of neuralgia and of peripheral neuritis of various nerves, of chorea, of disturbances of the sense organs, and of actual psychoses.

Peripheral neuritis in pregnant women affects chiefly the lower extremities, but has been observed in the arms also; it is characterized by muscular wasting with reaction of degeneration, by trophic disturbances, and by disorders of sensation. A cure may ensue even during the pregnancy, but in other cases the illness persists until after parturition and on into the puerperium. To the same cause Windscheid assigns the paræsthesias of pregnancy, burning, prickling, and numb sensations of the finger-tips, less commonly of the toe-tips; these sensations are continuous, not paroxysmal, and cause very great suffering.

Pregnancy favors the occurrence of chorea, a circumstance explicable by the increased irritability of certain nerve centres characteristic of the pregnant woman. The chorea of pregnancy occurs for the most part in primiparæ, it is commoner in young than in older pregnant women, and appears especially in the early months of pregnancy. In the majority of cases the disease undergoes spontaneous cure before the end of the pregnancy, but cases with a fatal termination have been observed.

On the other hand, a curative influence in previously subsisting hysteria has been assigned to pregnancy. This in fact only occurs in cases in which the hysterical manifestations have been evoked by influences which are counteracted or removed by the occurrence of pregnancy, such, for instance, as intense longing to bear a child, dissatisfaction with the existing circumstances of married life, etc. Conversely, it is by no means unusual to observe that, in patients who have previously suffered from hysteria, the attacks become more frequent during pregnancy, and that other nervous disturbances associated with the hysteria become more prominent; hysterical paralysis, even, may appear. Very variable also is the influence of pregnancy in epileptics. Most commonly, indeed, a certain quiescence sets in, the attacks becoming less frequent and less severe; but the reverse of this is at times observed. In the domain of the sense organs we observe amblyopia and hemianopia, deafness, and tinnitus aurium, and disorders of taste; all these appear as pure nervous disturbances without known anatomical basis (Windscheid).

Finally, among neuroses, tetany may be mentioned. In women, this disease occurs almost exclusively during pregnancy and the puerperal state, in the form of paroxysmal spasm, affecting chiefly the extremities, and especially the hands; the spasm is bilateral, tonic in character, and painful. The tetany of pregnancy usually runs a favourable course.

The slighter forms of mental disorder consist of perversions of taste and smell. Of actual psychoses occurring during pregnancy, the commonest forms are melancholia and mania. The former condition, which, according to Ripping, occurs in 84.4 per cent. of the cases, is usually very severe, and is characterized by a peculiar dreamy condition; it often leads to suicide, or to infanticide immediately after parturition. The psychoses of pregnancy are seen with greater frequency in the second half of pregnancy, they occur especially in primiparæ, and are also commoner in unmarried women. The prognosis is on the whole an unfavorable one; sometimes, indeed, the mental disorder terminates with the pregnancy, but in other cases it continues during the puerperium. Mental alienation occurring in the early months of pregnancy is apt to be less severe and to permit of a more favorable prognosis, than that which makes its appearance during the later months or at the end of the pregnancy.

In 32 cases of insanity of pregnancy recorded by Ripping, 8 cases occurred in the first pregnancy, 5 in the second, 6 in the third, 3 in the fourth, 4 in the fifth, 1 in the sixth, 1 in the seventh, 3 in the eighth, 1 in the tenth. Of these women

3 became affected in the 1st month[41] of pregnancy. 4 became affected in the 2d month of pregnancy. 1 became affected in the 3d month of pregnancy. 2 became affected in the 4th month of pregnancy. 1 became affected in the 5th month of pregnancy. 0 became affected in the 6th month of pregnancy. 5 became affected in the 7th month of pregnancy. 5 became affected in the 8th month of pregnancy. 5 became affected in the 9th month of pregnancy. 6 became affected in the 10th month of pregnancy.

The neuralgias of pregnancy affect the most diverse nerve tracts, and may occur either spontaneously, without any discernible local exciting cause, or in consequence of the pressure exercised by the enlarging uterus. To the former class of cases belong severe trigeminal neuralgia, the familiar toothache affecting quite sound teeth at the very beginning of pregnancy, intercostal neuralgia, and paroxysms of mastodynia. The pressure neuralgias affect chiefly the domain of the great sciatic nerve, manifesting themselves by the occurrence of pain down the back of the thigh, in the calf, and on the dorsum of the foot, sometimes associated with formication and other kinds of paræsthesia.

Parturition, by its powerful effect on the emotional nature in combination with intense physical suffering, may give rise to numerous nervous disturbances. The chief of these are, neuralgia, occasioned by the pressure of the fœtal head as it passes through the pelvis of the mother, paræsthesias, convulsions, maniacal paroxysms, transitory mental alienation, cerebral hæmorrhages, and eclampsia.

The nervous disturbances dependent upon the processes of the puerperium are numerous and severe. According to Windscheid, four types of affection of the motor nerves may arise at this period. 1. Pressure-paralysis may occur in cases of generally contracted pelvis, or even in the absence of such contraction in cases of prolonged labor, from the pressure exercised by the child’s head upon the intrapelvic nerves, and above all on the great sciatic nerve; pressure-paralysis may also result from obstetric operations, and especially from forceps delivery. The symptoms of pressure-paralysis consist chiefly of paralysis of the extensors of the feet and the toes; sensory symptoms are usually wanting. 2. Inflammatory infective paralyses, due to the extension to adjacent nerves of puerperal inflammation of the pelvic connective tissue. 3. Acute multiple neuritis, occurring either during the latter half of pregnancy or a few days after delivery, and affecting not only the nerves of the lower extremities, but those of remote regions, even the cranial nerves. 4. The rare puerperal hemiplegia due to cerebral hæmorrhage, occurring usually at the time the patient leaves her bed after delivery; puerperal hemiplegia may also arise from embolism consecutive to endocarditis, which may itself have originated before the termination of the pregnancy.

Other puerperal diseases of the nervous system requiring mention are, on the one hand, tetany, occurring during lactation, and permitting of a favorable prognosis, and on the other, the infective puerperal tetanus, the prognosis of which is exceedingly unfavorable. Finally, the puerperal state has to be considered as a factor in determining the onset of psychoses.

The puerperal psychoses are for the most part dependent upon the great loss of blood occurring during delivery, leading to anæmia and increased irritability of the brain, in association also with the circulatory disturbances that arise in the central nervous organs in consequence of the sudden emptying of the abdomen by the act of childbirth; but additional causes of mental disorders are to be found in the changes in the composition of the blood that occur during pregnancy, and the influence of these changes upon the nutrition of the brain. Inherited predisposition plays its usual part in these cases; and accessory factors in producing mental disturbance during the puerperal state are to be found in puerperal infection, eclampsia, osteomalacia, and emotional shock.

Thus, for example, among 49 cases of puerperal psychoses, Hansen found that in 42 instances there was puerperal infection; and among 200 cases of puerperal eclampsia, Olshausen found 11 patients suffering from mental disorder. The principal forms of insanity occurring at the puerperium are mania and melancholia, next in frequency come monomania (Ger. Verrücktheit), dementia (Ger. Blödsinn), alternating or circular insanity (folie circulaire), hallucinatory paranoia (chronic delusional insanity with hallucinations), and hysterical mental disorder.

According to Windscheid, the commonest cases are those which are purely puerperal, the rarest those in which the insanity of pregnancy continues during the puerperal state; the age at which puerperal psychoses most commonly occur varies between 31 and 35 years, the average age being 29.1; multiparæ are more often affected than primiparæ; the outbreak of mental disorder most commonly occurs within a week after the birth of the child; there is nothing specific about the various forms of puerperal insanity, which are identical with the respective varieties owning another etiology. According to this author, before an attack of puerperal mania, prodromal symptoms usually occur, such as headache, dizziness (Ger. Augenflimmern), feelings of anxiety, insomnia, followed by various congestive symptoms, and either by great restlessness or by great apathy, and very often by indifference to the infant; to these symptoms succeeds the period of motor excitability, characterized by great bodily restlessness and by continued talkativeness; the culmination takes the form of a maniacal outburst, in which infanticide even may occur; the delirium runs mostly in erotic and religious channels. Puerperal melancholia also exhibits the usual clinical picture of this form of mental disorder; after prodromal headache, stupor sets in, often associated with attacks of anxiety and with hallucinations of sense, and always characterized by great loss of appetite and by a suicidal tendency.

In relation to the puerperal psychoses, it appears that the first menstruation after the birth of the child has, like the very first appearance of the menstrual flow during the menarche, a tendency to favor the onset of mental disorder. According to Marcé, this first post-puerperal menstruation has a very definite significance in the causation of psychoses. Among forty-four cases of puerperal psychoses, there were eleven instances in which the mental disorder made its appearance six weeks after childbirth, exactly at the moment, that is to say, in which, had the mothers not given suck to their children, menstruation ought to have reappeared. In those who did not nurse their infants, and in whom menstruation recommenced at the due date, the psychosis usually began on the first day of menstruation, less often on the fourth or fifth day. In some instances the psychosis appeared at the time at which menstruation might have been expected to occur, but when the flow was still in abeyance. And in some women who suckled their children for a time and then weaned them, the psychosis made its appearance at the time of the first recurrence of menstruation.

Among diseases of the sense-organs occurring during the menacme, ocular lesions are by no means rare as sequels of pathological changes in the genital organs. Thus, in cases of displacements of the uterus, especially prolapse, retroflexion, and retroversion, we sometimes see retinal hyperæsthesia and reflex amblyopia, photophobia and lachrymation, and accommodative or muscular asthenopia. Inflammation of the pelvic connective tissue, perimetritic and parametritic exudations, and especially parametritis atrophicans, may give rise to functional disorders of the eye, reflex hyperæmia of the trigeminal and optic nerves, various painful sensations, and photophobia. Severe metrorrhagia may also cause disturbances of vision, either by inducing local anæmia and consequent functional failure of the nervous apparatus, or by leading to serious infiltration of the optic nerve which manifests itself also in the retina in the form of a transudation. In cases alike of congenital and of acquired atrophy of the uterus, and frequently, therefore, in sterile women, optic nerve atrophy may occur.

COMPETENCE FOR MARRIAGE OF WOMEN SUFFERING FROM DISEASE.

In this section we must consider the competence for marriage of women suffering from heart disease, of those suffering from hereditary tendency to mental disorders and neurasthenic states, and, finally, of those affected with tuberculosis.

Every doctor is confronted during the practice of his profession by the problem whether a young woman known to suffer from heart disease is justified in entering upon marriage and in exposing herself to the dangers entailed on her diseased heart by copulation, pregnancy, parturition, and the puerperium. The solution of this problem is as important as it is difficult. On the one hand, it determines the whole future course of a human life which is still ascending the upward path of its vital career, and a negative decision often annuls in a moment the young woman’s ideals and hopes; on the other hand, an affirmative decision involves the responsibility for the consequences of marriage, often grave in these cases.

The consequences are in fact apt to be very serious indeed. The normal act of intercourse, in a young and sensitive woman, has already an exciting influence on the nerve apparatus by which the movements of the heart are controlled. The frequency of the heart’s action is greatly increased, the cardiac impulse becomes much stronger, there is marked pulsation of the peripheral arteries, the conjunctiva is injected, the respiration more frequent. These manifestations, which normally are quite transient, attain a greater intensity and exhibit a longer duration in persons affected with heart disease. In some instances, violent tachycardial paroxysms occur, with considerable dyspnœa, pains in the cardiac region, headache, and even syncopal attacks.

Pregnancy, in consequence of the extensive changes undergone not only by the reproductive apparatus but also by the general system, and further in consequence of the vital needs of the developing embryo, involves extensive claims upon the cardiac activity. It is easy to understand that the diseased heart must be taxed more severely than the healthy heart by the extension of existing vascular areas, the addition of new vascular areas, and the increase in the quantity of the blood, during pregnancy; and it is not surprising if the overtaxed organ threatens sometimes to give way under the strain. Thus, during pregnancy in women affected with morbus cordis, we observe numerous troubles in the way of disturbances of cardiac activity and passive congestion of various organs, culminating at times in abortion.

Parturition and the puerperium, moreover, bring several factors into play which tend to affect unfavorably even a heart that is quite normal; and in cases in which there is disease either of the heart or of the great vessels, these factors may lead to the occurrence of most alarming symptoms. In this connection we may refer to endocarditis, to fatty degeneration of the myocardium, and to the rupture of atheromatous arteries.

From the time of Galen onwards all medical writers have agreed that the heart is unfavorably influenced by pregnancy and its consequences—but from this incontestable proposition to deduce the general conclusion that young women affected with heart disease must be forbidden to marry is in my opinion too great a jump, and altogether too sweeping a statement. The apophthegm of Peters, an author to whom we are certainly indebted for some of our knowledge of the accidents gravido-cardiaques, that in the case of women suffering from morbus cordis the rule must be enforced, fille pas de mariage, femme pas de grossesse, mère pas d’allaitement, has a fine air of apodictic brevity, but is entirely devoid of justification. No such rigid prohibition is advanced by recent writers on heart disease, such as Huchard, von Leyden, and Rosenbach; not, at least, without qualifications.

The question as to the permissibility of marriage to girls and women affected with heart disease cannot, in fact, be answered by any general proposition; and each case demands separate inquiry and a careful balancing of individual considerations. I have known cases in which the marriage of young girls suffering from morbus cordis was equivalent to a sentence of death, the execution of which was delayed for a few months only. On the other hand, I have known many women belonging to the upper classes and suffering from cardiac defects to pass through numerous pregnancies and to give birth to a number of children with no more than trifling disturbances of compensation. I am acquainted with a lady who when a young girl was urgently advised against marriage, on account of extensive aortic valvular incompetency, by two celebrated physicians. The advice was disregarded, and this lady is now the mother of four children, the eldest of whom is twenty-two years of age, and her general condition is in no way worse than it was before her marriage. The dangers of marriage in women suffering from morbus cordis are in my opinion generally overrated.

The degree to which a woman affected with heart disease will be injured by married life, will depend on the nature of the cardiac affection, on the time it has already existed, on the adequacy of compensation or the intensity of existing disturbances of compensation, on the general state of nutrition of the patient, on the more or less favorable social position, and on the manner in which sexual intercourse is regulated.

My own opinions in respect of this question may be summed up as follows: A woman who has comparatively recently (within a few years) acquired a valvular defect, and in whom the disease has run such a course that, in consequence of dilatation of certain chambers of the heart and of hypertrophy of those segments of the myocardium on which increased work has been thrown, and thus in consequence of adaptation of the cardio-vascular apparatus to the new conditions, the circulation and distribution of the blood take place in a manner closely resembling that in which these functions are effected in a normal, healthy individual—in a word, a woman in whom the valvular disease appears to be adequately compensated,—if, in addition, the patient is well nourished, if the hæmatopoietic function has not undergone any notable disturbance, if the muscular system is powerful and the nervous system possesses sufficient power of resistance—then marriage may be permitted without hesitation. In the case of such a girl or woman, we can confidently assume that the adequate compensation of the valvular disease will enable the heart to meet with success the claims made upon its reserve energies by sexual intercourse, by pregnancy, and by parturition, and that these processes will not involve any excessive danger to life.

A woman with valvular heart disease, even when that disease is well compensated, will indeed during pregnancy and still more during parturition and the early days of the puerperium, be liable to suffer from various manifestations of cardiac disorder. The action of her heart will be subject to paroxysmal increase in frequency and force, sometimes also there may be transient attacks of cardiac asthenia; at the same time the breathing will become more frequent and deeper, and occasionally, even, there may be severe dyspnœa. Perhaps also symptoms of venous congestion may manifest themselves, digestive disturbances, sense of pressure in the head, swelling of the feet, œdema of the abdominal wall, even slight albuminuria. Just after childbirth, moreover, an abnormally intense depression of the circulation with infrequency of the heart’s action will be liable to ensue. In the great majority of cases, however, in which the conditions detailed above are fulfilled, the disturbances of compensation occasioned by pregnancy and the puerperal state will not seriously threaten life; and as soon as the puerperal period has been safely passed through, the heart will again be competent for its duties and will do its work as well as before.

These statements apply, not only to cases of well-compensated valvular disease, especially mitral insufficiency, mitral stenosis, and aortic insufficiency, but also to cases in which the heart has made a good recovery after an attack of pericarditis, and to cases of moderately extensive disease of the myocardium consequent on acute articular rheumatism or the acute infections.

As indispensable conditions for such a favorable prognosis, we naturally assume that the pregnant woman is in a position to command the extreme bodily care that in her condition is doubly needful, that she is able to avoid all severe physical exertion, and that she will be subjected to continuous medical supervision in respect of the adoption of suitable dietetic and hygienic measures.

Such a favorable prospect as regards marriage in cases of well-compensated heart disease will, however, be clouded in the case of women who are either very anæmic or predisposed to nervous disorders; nor is the prognosis favorable as regards women in whom the heart disease is either congenital, or acquired in early youth, or as regards women contemplating marriage when already well up in years.

For in very anæmic women, even when the heart is quite sound, frequently recurring attacks of tachycardia often occur during pregnancy, in the absence of any obvious exciting cause; œdema of the lower extremities, and the formation of extensive varices, are also common. Increased nervous reflex irritability has also an unfavorable influence upon cardiac innervation. In cases, again, in which the heart disease is of long standing, the functional capacity of the heart is so notably depressed that the organ is likely to prove incompetent to meet the increased demands made upon it by the processes of pregnancy. Finally, in elderly women, superadded to the valvular defects, we have the dangers dependent upon the already beginning arteriosclerotic changes in the bloodvessels. In all such cases, therefore, it will be the duty of the physician to advise his patient not to marry; and in any case to impress upon her mind the extreme probability, amounting almost to certainty, of serious aggravation of the heart disease by marriage, with permanent impairment of the general health.

In cases of valvular disease accompanied by serious disturbances of compensation, and in cases of notable degeneration of the myocardium in which pronounced symptoms of cardiac muscular insufficiency have made their appearance, marriage must be absolutely forbidden, as directly imperilling life. When even moderate bodily exertion suffices to cause palpitation, increased frequency of the pulse, and shortness of breath, when extensive œdema of the lower extremities is present and fails to disappear even after the patient has been strictly confined to bed, when the pulse very readily becomes irregular both in rhythm and force, whilst the urine is often scanty and contains variable quantities of albumin, when conditions of cardiac asthenia readily arise, characterized by a small, irregular pulse, coldness of the extremities, cyanotic tint, nausea, respiratory need,[42] and syncopal attacks—in all such cases, whether the symptoms just described are dependent upon valvular defects, upon pathological changes in the arteries, or upon diseases of the myocardium, in all alike the occurrence of pregnancy is a true disaster, which in the vast majority of cases causes a great and enduring aggravation of the disease, and frequently enough costs the patient her life.

Even in such cases as were previously described, in which, the heart disease not being severe, the patient was told that marriage was permissible, it is the duty of the physician to lay down certain rigid rules regarding sexual activity.

Women suffering from heart disease should not have sexual intercourse frequently, because, if the peripheral nervous stimulation of the genital organs is excessive in consequence of too frequent acts of coitus, cardiac activity is likely to be influenced powerfully in a reflex manner, leading to the occurrence of attacks of cardiac asthenia. Again, sexual intercourse must always be effected in such a manner that the act attains its physiological conclusion, and that in the woman as well as in the man the orgasm has its normal outcome, that is to say that at the conclusion of the act the woman’s cervical glands are evacuated with the accompaniment of the sense of ejaculation. The congressus interruptus, which precisely in these cases in which the wife suffers from heart disease is so frequently practiced by the husband with a view to preventing conception, must be strictly forbidden, since this mode of intercourse tends to give rise to various forms of reflex cardiac disturbance, most commonly to paroxysms in which the cardiac action becomes unduly frequent, in association with diminution of vascular tone, vasomotor disturbances, and states of mental depression; and where organic heart disease already exists, these reflex functional disturbances involve various dangers.

The physician is further justified in advising that a woman with organic heart disease should not give birth to more than one or two children. This advice is the more needful for the reason that with each successive pregnancy the functional capacity of the woman’s diseased heart diminishes according to a geometrical ratio, and to a corresponding degree the danger to life increases. These are cases in which in my opinion it is the physician’s duty to concern himself with the subject—in general so equivocal—of the use of preventive measures, and, having regard for the preservation of a woman’s life, and uninfluenced by any false delicacy, but with moral earnestness, to inform his patient with respect to the needful prophylactic measures. The artificial termination of pregnancy, which unquestionably is often justified in women suffering from heart disease, but which unfortunately is apt to have very unfavorable results, will rarely need to be discussed if by the proper employment of preventive measures care is taken that pregnancy does not recur too frequently.

To enable us to answer the question whether, in the case of neurasthenic and hysterical young women, and in those hereditarily predisposed to the occurrence of mental disorders, the physician shall advise for or against marriage, attention must in the first instance be directed to the established facts relating to the favorable or unfavorable influence, as the case may be, of sexual intercourse and its consequences (pregnancy and childbirth) upon existing nervous disorders and upon the predisposition to their occurrence.

Without regarding as fully justified the opinion that in the female sex sexual abstinence has in all circumstances an unfavorable influence upon the nervous system or even that such abstinence is to be regarded as the principal cause of nervous and hysterical troubles, we must consider it fully proved that in a number of the commonest varieties of nervous disease occurring in neurasthenically predisposed subjects, such as neurasthenia, hysteria and neurosis of anxiety[43], the lack of sexual satisfaction aggravates these troubles, whilst suitably regulated sexual intercourse has an actively beneficial effect. Not, indeed, that it is an infallible means, but none the less the effects are often striking, as I have frequently had occasion to observe, both in young women so affected entering upon marriage for the first time, and also in young widows who have remarried. Especially is this true of women in whom the sexual impulse is exceedingly powerful, and even pathologically increased to the extent of marked sexual hyperæsthesia; likewise also in women whose social circumstances and manner of life induce increased sexual appetite. Be it understood, I refer here to regular and moderate sexual intercourse, and not to sexual excesses, which latter, by inducing nervous exhaustion, may have a distinctly deleterious effect. In many cases, however, we observe in women suffering from sexual neurasthenia, that sexual intercourse, even when practiced at long intervals, gives rise to nervous prostration with deep emotional depression and long-lasting aggravation of the existing nervous disorder. This statement applies with especial force to very hysterical epileptic girls with hereditary predisposition to mental disorder.

From the fact that among persons hereditarily predisposed to mental disorder, the unmarried are on the average more often affected with insanity than the married, the inference has been drawn that marriage may be recommended to such persons as a measure likely to counteract their hereditary tendency to insanity. The argument, however, lacks validity, more especially as regards women; among whom, moreover, from the age of sixteen to the age of thirty, insanity is proportionately more prevalent among the married, though above the age of thirty it is more prevalent among the unmarried.

In the great majority of neurasthenic women, normal sexual intercourse, practiced in moderation, has, according to Löwenfeld, no deleterious effect; often, indeed, as a consequence of unaccustomed abstinence, an aggravation of existing nervous troubles may be observed. But, as this author maintains, nervous exhaustion may result in the complete disappearance of the orgasm during sexual intercourse, or in great difficulty in its production; this circumstance suffices for the most part to explain the fact that in women suffering from great depression of the nervous functions, the fulfilment of their sexual duties has sometimes an unfavorable influence on their general condition. As regards hysteria, it cannot be denied, that in many hysterical women marriage results in a favorable change in the general condition; we must, however, be careful not to overrate the significance of such observations. As a rule all that actually takes place is a diminution in the intensity or even a disappearance of certain morbid manifestations previously present, without, however, an eradication of the hysterical temperament.

In epileptic young women, the first experience of sexual intercourse may precipitate a fit. Cases are indeed on record in which, in hereditarily predisposed girls, the first coitus was the exciting cause of the first epileptic fit, the fits recurring every time sexual intercourse was repeated.

It is a comparatively frequent occurrence in psychopathically predisposed girls for severe mental disturbances to make their appearance during the honeymoon, after the first experience of sexual intercourse; when this occurs, it is doubtless to be accounted for by the combined influence upon the mind of all the changes in the circumstances of life which have resulted from the marriage. In the case of two newly married women, one of whom had well-marked hereditary predisposition, whilst in the other there was no known family history of mental disorder, Löwenfeld observed shortly after marriage the onset of severe melancholia, with refusal of food. The delicate, nervous temperament of these two women, on the one hand, and, on the other, possibly, a somewhat too eager and passionate attitude on the part of their respective husbands, led their first experience of sexual intercourse to result in a nervous impression of the nature of shock, which their nervous system was too weak to resist.

Frequently recurring pregnancy and childbirth may, according to Krönig, act as the predisposing cause in the production of neurasthenia. In regard to hysteria also we must admit that the onset of some disease of the organs of generation frequently leads previously latent hysteria to manifest itself openly, and further we have to recognize that diseases of the reproductive system often give the clinical picture of hysteria a quite distinctive coloration; the physiological course of the functions of the generative organs is also competent to produce both of these effects. Krönig, however, rejects the view that the lack of sexual intercourse has an unfavorable influence upon the nervous system in women, and gives rise to hysterical and neurasthenic disorders. The favorable influence which marriage is often observed to exercise upon the course of nervous disorders is explicable with reference to psychical considerations of a very different nature. Sexual abuses, masturbation, and the use of preventive measures, give rise in women far less often than in men to neurasthenic and hysterical conditions.

Féré asserts that in certain neurasthenic patients sexual intercourse induces a general blunting of the senses, and especially of hearing and sight. Actual amaurosis of short duration may even be observed; also cutaneous anæsthesias, paralytic conditions of the extremities taking the form either of hemiplegia or paraplegia, convulsive attacks, and somnolent paroxysms.

Delasiauve observed that epileptic patients, who during residence in an asylum had remained almost entirely free from fits, after returning home and resuming sexual intercourse, even in strict moderation, suffered from a recrudescence of the convulsive seizures; when intercourse was excessive, the relapse was naturally even more severe.

In two instances, in women who in a single night had practiced intercourse to very great excess, Hammond observed paralysis of both legs to ensue; he saw also in numerous cases spinal irritation and other nervous disturbances as a consequence of sexual excesses.

Von Krafft-Ebing points out, with reference to the prophylactic influence of marriage in respect of mental disorder, that in men early marriage diminishes the danger of the occurrence of such disorder, whereas in women marriage is undesirable before the attainment of complete physical maturity.

With regard to marriage in the case of persons suffering from nervous diseases, Ribbing lays down the rule that when such diseases have been severe and have occurred in numerous members of a family, whilst a few only in the family have remained healthy, when, moreover, the illness has been accustomed to make its first appearance only after the attainment of maturity, no indications of its onset being noticeable in childhood or youth—one belonging to a family thus afflicted should be advised not to marry. Where, however, the hereditary tendency is to a disease likely to manifest itself in childhood or youth, a member of such a family who has been fortunate enough to pass through the years of development without exhibiting any pronounced disturbance of the nervous system, may be permitted to marry if certain precautions are observed. A woman with a tendency to alcoholism should in no circumstances be allowed to marry. In the cases, fortunately rare, in which the drink-craving exists in women, marriage is even more undesirable than it is in the case of men similarly afflicted, for the female drunkard is in a position in which she can mishandle and neglect her children throughout the entire day; and, moreover, this affection appears to be even more obstinately incurable in women than it is in men.

Löwenfeld very rightly insists that in deciding on the advisability of marriage in the case of neurasthenic and hysterical girls the anticipated influence of sexual intercourse must not be the sole determinant. “Regulated sexual intercourse, such as is rendered possible by marriage, has often a favorable influence on previously existing states of nervous weakness. But we should go too far if we were to attribute the beneficial effect of married life on such conditions solely to sexual intercourse. This latter is but one factor among several, the others being no less important. These others are: The pleasures of an orderly domestic activity; the withdrawal of the patient’s attention from her own condition, partly by domestic duties and difficulties, and partly by the novelty of marital companionship; the gratification, especially strong in women, at having obtained a support in life; and, finally, the joyful expectation of motherhood. These factors, however, are not present in every marriage. When their presence cannot reasonably be anticipated, when, in consequence of insufficient means, the marriage is likely to entail increasing troubles, or when, owing to the want of suitability of temperament, annoyances and quarrels are likely to occur, we must throw the weight of our advice into the scale against the proposed marriage, since the advantages of regulated sexual intercourse are not likely to outweigh the disadvantages just detailed. Even when means are ample and the characters of the couple contemplating marriage are unquestionably harmonious, we must nevertheless (temporarily, at any rate) advise against marriage, we must, that is to say, advise the postponement of marriage, if the bride is suffering from severe hysterical or neurasthenic states. Where, further, such neurasthenic or hysterical troubles occur in a woman with pronounced hereditary predisposition to nervous disease, we must, both for the sake of the possible progeny and on account of the uncertain influence of married life on the health of the patient, absolutely and unconditionally prohibit marriage. In cases also in which severe hereditary predisposition to mental disorder exists (especially when derived from both parents), and in addition stigmata of psychopathic degeneration are actually apparent in the patient, or she has already suffered from the development of a psychosis, we must decisively object to the patient’s marriage.”

As regards the marriage of young women suffering from tuberculosis, we must take into consideration a fact that medical experience has conclusively established, namely, that the processes of generation have an unfavorable influence upon pulmonary phthisis. Girls with an inherited predisposition to tubercular disease, sometimes first manifest the symptoms of pulmonary tuberculosis at the time of the menarche. In cases of developed tuberculosis, copulation and the excitement of the vascular system associated therewith have a more or less unfavorable influence—and all the more inasmuch as, in accordance with the saying omnis phthisicus salax, women affected with tuberculosis often exhibit a very lively sexual impulse, an almost insatiable sexual appetite. Sexual excesses are, moreover, very likely to lead to the occurrence of hæmoptysis.

In former days it was believed that conception and pregnancy, when occurring in women suffering from tuberculosis, had a restraining influence on the progress of the pulmonary disease, a view which found expression in the assertion of Baumes and Rosières de la Chassagne that of two women affected with tuberculosis to the same degree of severity, one who became pregnant would always outlive the other who failed to become so. Careful and sufficient observations on the part of physicians and gynecologists have, however, shown that this view was fallacious, and, on the contrary, that during pregnancy tuberculosis advances with more rapid strides, that pregnancy, and lying-in accelerate the fatal event (Grisolle, Lebert), that tuberculosis acquired shortly before pregnancy or in the course of that condition, progresses with exceptional rapidity (Larcher), and that the lying-in period is especially perilous to these patients (A. Hanau). In some cases of consumption it is the first pregnancy that is the most perilous, but in other cases a later pregnancy proves more destructive.

Ribbing goes even further, insisting that neither man nor woman affected with pulmonary consumption should marry. “If, indeed,” he writes, “consumptives desire to enter upon marriage, merely with the aim of being faithful to one another and assisting one another for the short time that remains to them, I should offer no opposition. But there must be a complete mutual understanding of the facts of the case, and an unalterable determination on the part of both to carry out the resolutions made prior to marriage, for failing this the consequences will be most disastrous. In most cases, however, the course adopted by Bulwer’s Pilgrims of the Rhine is to be preferred, the lovers contenting themselves with the condition of a betrothed pair, and in that state awaiting the approach of death—or, if exceptionally fortunate, proceeding to marriage only after restoration to health.”

It would certainly appear that in the case of girls suffering from pronounced phthisis, we are justified in advising against marriage, on account of the great danger which this state entails of a rapid advance in the pulmonary disease.

Based upon the observations of Schauta and Fellner, the latter author advances the rule that in the case of a woman suffering from disease, marriage should be forbidden only when the mortality from the disease in question is not less than 10 per cent. In this category we must include severe cases only of pulmonary tuberculosis; whilst cases of laryngeal tuberculosis will, according to this rule, be absolutely unfitted for marriage. Among heart-affections contra-indicating marriage, he includes mitral stenosis, other valvular affections in which there is serious disturbance of compensation, and myocarditis; he considers marriage inadmissible also in cases of chronic nephritis, and, among surgical affections, in cases of malignant tumour. In cases in which during a previous pregnancy the patient has been affected by one of the following diseases, viz., severe chorea, mental disorders, severe epilepsy, pulmonary tuberculosis which progressed much during the pregnancy, morbus cordis with considerable disturbance of compensation, severe heart trouble due to Graves’ disease—in all such cases, a repetition of pregnancy should be avoided.

HYGIENE DURING THE MENACME.

During the sexual epoch of the menacme a woman’s principal hygienic need is marriage completely satisfactory alike to body and to mind. It cannot be denied that sufficient sexual gratification, regular, of course, and free from all excess, such as is usually experienced in married life, is very advantageous to the health of a woman who has attained sexual maturity—even though we admit that the drawbacks of sexual abstinence, regarded as a cause of disease of the female genital organs and the nervous system have been as a rule greatly exaggerated.

The inability to marry always makes a deep impression on the mental life of woman, and in many cases also gives rise to burning desire and tormenting yearning of an erotic nature. The unmarried miss life’s true goal and fail to enjoy the natural exercise of their functional capacities; alike in the cultured lady and in the poor working woman who has failed to marry, the thoughts and feelings return again and again to her own condition in a self-tormenting manner.

The physical and mental disadvantages entailed by sexual gratification when obtained by an unmarried woman, one who, according to modern phraseology, “wishes to secure her natural share of the joys of love,” and who regards voluntary chastity as “a sacrifice to meaningless prejudices”—need not be more particularly described.

Free love, moreover, is the most important disseminator of gonorrhœal infection. “In any future commonwealth,” says Runge, “in which marriage is abandoned in favour of the general practice of free love, the human race will be overwhelmed by gonococci in a manner now hardly conceivable, and the reproductive capacity in both sexes will be diminished by the results of gonorrhœa to a very serious extent.”

Frequently enough, also, free love leads to prostitution, which at the present day is so widely prevalent. Various reasons have been suggested to account for the increase of prostitution. Among these are: The growth of modern industry, with the consequent aggregation of the population in large towns; the decline in the marriage rate; the postponement of marriage; universal military service; the freer mutual companionship of the sexes; and many others. At any rate, the fact would appear to be established, that in the case of woman the determining cause of prostitution is hunger rather than the sexual impulse. The worst paid classes of workwomen are shown by official statistics to furnish the largest number of recruits to the ranks of prostitutes; and it is during times of deficient employment that the number of women practicing occasional prostitution increases. Thus, material need is the most important of the causes of prostitution.

This remains true even though the doctrine of Lombroso and Tarnowsky should find fuller justification, the doctrine that the practice of prostitution by women is the natural expression of a congenital morbid predisposition, “which impels them, in defiance of their direct advantage, of reason, and of all counter-advice, to adopt this accursed mode of life.” Prostitution, in this view, is to be regarded as the inevitable outcome of congenital moral insanity. This is certainly true of a small proportion of prostitutes, but is as certainly false of the great majority, in whom unfavorable, difficult conditions of life form the determining cause. A certain inherited or acquired mental disposition may, indeed, be assumed to exist in these cases also—an unstable moral equilibrium, an insufficient development of the force of the will and of the power of resistance.

The hygienic requirement of married life for woman during the menacme is undoubtedly sometimes hard to fulfil in our day, when the more elaborate and expensive standard of life has increased the difficulty of supporting a family; but from the medical point of view it is necessary to insist forcibly on this categorical imperative, in opposition to the view advanced by the modern women’s rights’ party, that “love is moral also in the absence of legal marriage” (Ellen Key); in opposition to the yet more extreme opinion of George Sand and of Almquist, who, regardless of consequences, declare marriage to be immoral; and, finally, in opposition to the advocates of “free love,” who wish woman to be as free as man in sexual relations.

Much as we may wish that man and wife should be in complete harmony in marriage, and that they should feel themselves to be firmly united alike by mutual love and by a reciprocal sense of duty, none the less we must consider the modern maiden ripe for marriage as unjustified in demanding, before undertaking marriage, “perfect love as typifying the inner yearning of two beings to become one;” and we must regard the latter-day woman as extravagant in insisting that the man shall enter upon marriage in a condition as virgin as that of his contemplated wife. “Perfect love” is as rare and as little to be expected as perfect beauty; and the sexual life of man differs entirely in nature and in the course of its development from the sexual activity of women.

Doubtless they spring deep from the soul of woman, the demands expressed by the writer of the book “Vera” and by her numerous imitators, the apostles of “Veraism,”—the demands of the maiden entering upon marriage that her husband shall be as chaste and sexually as unspotted as herself. Difficult of fulfilment as they are, if fulfilment is even possible, these demands must none the less be regarded as characteristic of the sexual life of modern womanhood. “Is man’s sexual honor,” exclaims Vera, “then altogether different from that of woman? Is not the alleged necessity for sexual gratification in youth either a well-organized fraud or an enormous error on the part of physicians? Is it possible that chastity can entail diseases as terrible, as destructive to life and happiness as those that result from unchastity? And is it not a crying sin, even if some of these fears are justified, to ruin both mentally and physically the whole race of women? * * * Man demands from the girl of his choice, not chastity alone, but an absolutely unblemished character. And rightly so. But the wife must share her husband with street-walkers? She must bear the pangs of maternity, while fortified by the terrible knowledge that the father of her children has wasted his youthful virility in purchased embraces, that he has not recoiled from impurity, that he has exposed himself to the risk of infection with the most horrible diseases, that he has squandered his virginity in the most bestial sensuality? * * * We girls must also be granted the right to demand from the man of our choice the same purity, the same unspottedness by sensuality, that he so rigorously demands from ourselves! We must no longer content ourselves with the remnants that are left for us by others! We must no longer be satisfied with man’s moral inferiority! Then there will be more happiness, more love, more health and joy of life!”

These accusations and demands so boldly made are not to be disposed of by mere mockery. With deep sorrow we must admit the absolute truth of the charge that too many men clamber out of the abyss of debauchery to a blighted marriage. But the demand for equal moral rights, for the abandonment of the hitherto prevalent bisexual ethical standards, is in vain conflict with actuality, with the defensive instincts of young men, with the difficulties entailed by the struggle for existence, with the increasing pretensions (to sexual freedom) of women themselves; but above all is it in conflict with the thousand-year-old notions of sexual honor in the male and the female respectively, and with the undeniable fact that the mature man is capable of elevating himself out of the base intoxication of the senses characteristic of youth, to attain the noblest and most intimate married love, whereas the girl who has once descended into such an abyss sinks therein and is beyond the possibility of rescue. Thus early marriage with equal purity of husband and wife remains a postulate which the present can hardly be expected to satisfy, and one whose fulfilment must be left to the future.

In consequence of modern writings and discussions concerning the erotic problem, there has arisen a hypersensibility on the part of women in respect of the conditions in which they pass their married life, leading them to demand greater independence, a greater expansion of their own individuality; this tendency must, however, be resisted, if the marriage is to be a happy one, with mutual comfort and reciprocal consideration, one suitable, not for exceptional beings in an ideal state, but for men and women as they really are. In such a marriage, affection and a sense of duty will strengthen love and preserve fidelity. A prudent, clever woman will always understand how, notwithstanding all necessary self-surrender, to preserve the freedom of her own individuality and the esteem of her husband.

Marriages based upon true inclination usually result in the birth of stronger and more beautiful children than marriages in which the money-bags were the sole or the principal determining cause. In England, where people commonly marry when still quite young, beautiful and healthy children are more often seen than in France, where marriages of expediency form the great majority. According to Bertillon, of 1,000 young men from 20 to 25 years of age, in England 120 marry, but in France less than half that number, viz., 57 only. And 100 wives between the ages of 15 and 40 give birth annually, in England to 39 children, in France to 26 only, a number less by one-third.

In deciding upon marriage, hereditary influences deserve careful consideration in respect alike of the family of the prospective husband and that of the prospective wife. For it is well established that the law of inheritance relates not only to the peculiarities of external configuration, to the features, the stature, the tint of the skin, but also that children inherit from their parents their mode of bodily development, the functional activity of their organs, the duration of their life, their predisposition to disease, and even their intellectual and moral qualities. As regards hereditary predisposition to disease, the most important are, as is well known, the predisposition to tuberculosis, that to malignant tumors, and that to mental disorders.

Great disparity in the respective ages of prospective husband and wife entail various kinds of unsuitability for marriage. An elderly man who marries a young girl, even if he still possesses a certain amount of virility, is unlikely to procreate healthy and powerful children; and these latter for the most part will be weakly, scrofulous cachectic, endowed with deficient powers of resistance, and often badly equipped from the intellectual standpoint. Similar considerations prevail in respect of marriages in which the husband has been exhausted by earlier sexual excesses, so that he retains no more than remnants of virility, whilst his semen is of doubtful fertilizing power. D. Richard relates that Louis XIV asked his physician why it was that the children he (the king) had by his wife were delicate and deformed, whilst those he had by his mistresses were beautiful and powerful. “Sire,” was the answer, “c’est parce que vous ne donnez à la reine que les rincures.”

Plato maintains that before every marriage the man and the woman should both undergo official examination to determine their fitness or unfitness for the married state, the man being absolutely nude, and the woman stripped to the waist, for the examination. This author goes so far as to regard it as “a form of homicide for a man to embrace a woman when he is incapable of fertilizing her.” How rarely it happens in our day, however, that the physician, the official with the requisite knowledge to fulfil Plato’s requirements, is asked for his opinion regarding the desirability of a contemplated marriage! The only occasion on which this is likely to occur is when a man intending to marry wishes to be assured that he is completely cured from an earlier infection with syphilis, and, therefore, runs no risk of transmitting the disease to his wife or to possible offspring. But it never occurs to the parents of a girl about to marry to ask the physician whether she is physically suitable for marriage.

In deciding on marriage, however, care should before all be taken to determine that the girl has attained complete physical and especially complete sexual development. The age at which woman attains complete sexual maturity is in our climate and race coincident on the average with the twentieth year of life.

For the hygiene of marriage it is necessary that the bride should not be extremely youthful. Notwithstanding the fact that the legal codes of civilized countries nowhere demand for girls a greater age than fifteen years before permitting marriage, this limit is, generally speaking, fixed far too low. Before becoming a wife, the girl should not merely have attained complete physical development, with her reproductive organs in a state of maturity, but she must also be developed intellectually to such an extent that she is fully capable of understanding the nature and significance of marriage. At the age at which marriage is legally permissible, a girl is still far from having attained physical and mental ripeness for marriage, reproduction, and maternity.

Especially with reference to the last consideration is it inadvisable that in our climates a girl should marry earlier than from 18 to 20 years of age, and preferably even she should first attain the age of from 20 to 22. In that case her happiness as a mother will be more secure, and there will be a greater probability of her producing a healthy progeny. In the East, indeed, quite different views prevail. According to the laws of Manus, a girl might marry on attaining the age of eight years; if within three years thereafter her father failed to provide her with a husband, she might choose one for herself. Among the Hindus it is regarded as a disgrace to the parents if a girl does not marry quite young, indeed before the first appearance of menstruation. Atri and Kasypa state that if a girl begins to menstruate before she leaves her father’s house, the latter must be punished as if he had destroyed a fœtus, while the daughter herself loses caste. Marriage delayed till after the appearance of menstruation being regarded as sinful, girls are married while still children, in order to prevent the loss of mature ova, which is regarded as equivalent to infanticide. Very early marriage has thus in India been legally ordained for thousands of years. The Hindus, who even now regard every menstruation which has not been preceded by coitus in the light of infanticide, marry their daughters before the age of puberty.

According to oriental tradition, Mahomet married Khadijah when five years of age, and cohabited with her three years later. In the Bible, numerous similar examples are recorded. Among many savage tribes, as, for instance, among some of the aborigines of India, and among the indigens of Australia, copulation is usually effected before girls reach the age of puberty; in India, indeed, according to Ploss and Bartels (Das Weib in der Natur und Völkerkunde), marriage with immature girls is a widely diffused custom, and in Australia a child of ten or eleven is often found to be the wife of a man of fifty or the concubine of a sailor. In general, according to these authors, we find that the age of nubility in girls is lower in proportion to the lowness of the stage of civilization attained by the race or people to which they belong. Among the ancient Romans, girls were commonly married between the ages of thirteen and sixteen years.

In the Talmud, Rabbi Joshua gives the following advice regarding early marriage in Jewish girls: “If your daughter has attained puberty and is twelve years and six months old, she must be married at any cost. If no other means are available, manumit one of your slaves, and give her to the freedman to wife.”

Experience proves, however, that in our climate, at any rate, girls who marry at a very early age are inferior in fertility to those who refrain from marriage until the genital organs have attained complete maturity; and statistics show that those women who marry before attaining the age of twenty must wait longer for their first pregnancy than those who marry between the ages of twenty and twenty-four. At the higher age also, women bear parturition and its consequences more easily than those who marry very young. A similar influence in marriage to that resulting from undue juvenility is exercised by its opposite, marriage when a woman is already elderly; in this case fertility is limited, and health also is especially apt to suffer. When the indications of the climacteric are clearly apparent, marriage is contra-indicated, not only on account of the impossibility of fertilization, but also in respect of its general unsuitability in the closing stage of the sexual life.

Not only is the absolute age of the woman of importance in deciding on the advisability of marriage, but the relative ages of the proposed husband and wife must also be taken into account, first of all in respect of the wife’s possible fertility, and secondly in respect of her general health. The most suitable arrangement is that in which there is no marked difference in age. The husband may be, and indeed in existing social circumstances almost necessarily is, somewhat older than his wife, as much perhaps as eight or ten years. But a very great disparity of age (in either direction) is a serious error. If a very young girl marries an elderly man, or a developed matron marries a young man, the true purpose of marriage is unfulfilled, the eternal laws of nature and all ethical principles are infringed. In the breeding of animals, the fundamental principle has long prevailed that the animals chosen for coupling should be well suited each to the other and should be in perfect physical condition; and breeders are also familiar both with the favorable influence of good nourishment and with the advantage of the opportune crossing of distinct varieties. The same principles are equally applicable to the human race, neglected as they commonly are in practice.

With regard to the marriage of near kin, we can only remark that the marriage of those closely related by blood should as far as possible be avoided, and that such a marriage must be absolutely prohibited when in both families there is a history of tuberculosis, mental disorders, diabetes, and the like. When first cousins contemplate marriage, it is indispensable, not only that both individuals should be in perfect health, but also that on neither side there should be any serious family history of transmissible disease or transmissible morbid tendency; and, further, it is absolutely necessary that no such marriage of near kin should have taken place in the proximate ancestry of the cousins, i. e., their cousinship must not be a double one, derived both from the paternal side and the maternal. It is indeed to be recommended, with a view to the production of a healthy and powerful posterity, that marriage should bring about a crossing of healthy individuals proceeding from different families, different places, and different constitutional types. An instance of the advantage to be found in this practice is pointed out by Ribbing, who shows that the most powerful aristocracy in Europe, that of England, by the gradual creation of new peers, on the one hand, and by the gradual decline of younger sons and their descendants into the middle class, on the other, has undergone a continual crossing with less exalted but originally sounder stocks; in this way its vigor and fertility have been maintained, in contrast to the nobility of many continental states, which has so largely perished, in consequence of its exclusiveness in the matter of marriage.

“In this connection,” continues Ribbing, “we must bear in mind, that blood-relationship is not the only matter that has to be considered; in the interest alike of the family, and of society, it is necessary to demand that certain degrees of relationship by marriage alone, should fall within the ‘prohibited degrees’ of love and marriage. There are certain groups related by marriage and held together by the bond of affection, from which foster-parents and guardians may most suitably be selected to fulfil the duties as regards education and training of children who have been orphaned in early years. For such a purpose none seem better adapted than the brothers and sisters of the deceased parents; but the upbringing of the children can be confidently entrusted to the former only if the relationship between the older and the younger branches of the family is one regarded by law, and still more by morality and custom, as one precluding the possibility of the occurrence of sexual love and marriage.”

Möbius, writing on “The Ennobling of the Human Race by Selection in Marriage,” observes: “The most important aim of natural development is the perfection of humanity. The qualities of the coming generation depend for the most part upon the qualities of the parents. Marriage from affection ensures the fulfilment of nature’s aims with more security than marriage from reason; since what we have to think of is not the happiness of the married pair but the quality of their children. Of great importance, also, to the development of the human race are the conditions during the commencement of life, and the mode of education. The improvement of the race has not hitherto been the conscious aim of the generality of people. The law does not as yet, as it should, take into account the advantage of posterity. Capital punishment is fully justified and purposive. Criminals should not be allowed to marry. The perpetuation of disease by inheritance should be checked by the utmost powers of the state. Any one marrying while suffering from any venereal disease still in an infective condition should be punished. The marriage of persons suffering from tuberculosis should be prohibited. For the prevention of disease is more important than its cure. The most important factor in preventive medicine is an improvement in the conditions of life. The human ideal should be, goodness of heart in association with physical and mental health. Goodness, beauty, and strength should be simultaneously pursued. Since, however, man is made by birth far more than by education, selection in marriage is of fundamental importance. In the choice of a partner, attention is rightly paid to beauty, since beauty and health are fundamentally identical; moreover, a human being endowed with beauty is usually also more moral than one devoid of that attribute. Equality of birth is as a rule desirable in marriage; but not the family only is to be considered in determining the existence of such equality, individual characteristics must likewise be taken into account. Whether the crossing of races is desirable is not yet certainly determined.”

From the hygienic standpoint it is necessary that in marriage also the frequency and the manner of sexual intercourse should be regulated.

Wise men and lawgivers of all the nations of antiquity have insisted upon the necessity of certain intervals between the acts of intercourse. Thus, Mahomet prescribed 8 days, Zoroaster 9 days, Solon 10 days, Socrates also 10 days. Moses forbade intercourse during menstruation and for a week after the cessation of the flow. Luther prescribed intercourse “twice a week.”

Birds and many mammals are competent to perform intercourse at exceedingly short intervals. A well-bred cock will repeat this act 50 times daily; a sparrow, 20 times in an hour; a bull, 3 to 4 times in an hour. In the human species, however, too rapid repetition of intercourse is deleterious not only to the male, but to the female also, though the latter certainly suffers in less degree. For in this act the female plays a more passive part, and for this reason can repeat it with impunity more frequently than the male, who loses semen at each repetition. It is not possible, however, to lay down precise rules as to the permissible frequency of intercourse in either sex; the matter must depend upon physical needs. Moderate and regular indulgence in sexual intercourse is unquestionably advantageous to women both physically and mentally, regulating all the functions of the body, and tending to produce a contented and cheerful frame of mind.

During menstruation, a woman should refrain from intercourse. By the Mosaic law the death punishment was allotted both to the man and to the woman who indulged in coitus while the latter was menstruating. As a matter of fact, considerations alike of hygienic cleanliness and of sanitary precaution prohibit the performance of coitus during this period. Severe menorrhagia, perimetritic irritation, and parametritic inflammations, have been observed to follow such indiscretions. On the other hand, it is more than doubtful whether, in the event of pregnancy resulting from intercourse performed during menstruation (and conception is especially apt to occur at this time), the child is likely, as earlier authors maintained, to be unfavorably affected, and to suffer from cachexia, scrofula, or rickets.

After the act of intercourse, a woman should rest; and indeed sleep for some hours is especially to be recommended. A vaginal douche should not be administered until several hours have elapsed, otherwise there will be a risk of preventing fertilization of the ovum. The water employed for vaginal irrigation should never be quite cold; a temperature of 79°–82° F. (26°–28° C.) is best.

All measures for the purpose of artificially increasing sexual desire, such as alcoholic beverages (especially champagne), and certain drugs (especially cantharides), are even more harmful to women than they are to men. The woman who conceives while in a state of intoxication commits a great sin against the coming generation.[44] Just as harmful, however, are the anaphrodisiacs sometimes employed to diminish the intensity of sexual desire when this cannot be gratified. When affected with intense sexual excitement, a woman is much more unfavorably situated than a man, since man claims the right to indulge in sexual intercourse whenever he feels disposed, and has, moreover, ample opportunity for sexual gratification. A woman, however, properly endowed with self-respect, will understand how to bridle her senses. Bodily exercise, moderate, unstimulating diet, intellectual occupation with serious matters, the avoidance of equivocal literature and of sensual dramatic representations, cold bathing, and the use of a hard mattress and light bed-clothing—these means will coöperate powerfully toward the prevention of excessive sexual desire. Horace already remarked: “Otia si tolles, periere Cupidinis arcus.”

The wife should know how to bridle, not her own desires only, but also those of her husband. She must not demand too much during the intoxication of youthful vigor; she must prevent the complete combustion of the flames of masculine passion, and must keep sparks glowing in the ashes. Economy during the sexual prime preserves sexual power, enables a man to continue intercourse to a ripe age, and avoids premature exhaustion and satiety. When the husband is drawing near the end of his sixth decade, the wife must accustom herself to see in him rather the father of her children than her own husband, and must reduce her sexual demands to that measure which will not be injurious to his health. Demosthenes, writing of the sexual life of the Athenians of his time, said: “In order to obtain legitimate offspring and to provide a faithful guardian of our household, we marry a wife; for our service and for the performance of daily household duties, we keep concubines; for the joys of love, we seek the hetairai.” The task is extremely difficult, but a clever and virtuous modern wife must endeavor to combine in her single personality the sensual attractiveness of an Aspasia, the chastity of a Lucrece, and the intellectual greatness of a Cornelia; she must bear in mind the epigram of Bacon, “A wife must be a young man’s mistress, a middle-aged man’s companion, an old man’s nurse.”

In the act of intercourse the woman must always play the more passive part; she must be desired, rather than desire. Woman’s modesty increases man’s desire. By this coquetry, permissible because natural, the woman can bind the man to herself, and can give the lie to the assertion that marriage is the grave of love. Partial concealment of her desire on the part of the woman is more stimulating to the man than an open manifestation of the sexual impulse; and a certain amount of modest reluctance is more alluring to him than a plain invitation. Plenty of room must be left for the play of fancy and imagination. Schiller makes Fiesco say to the Countess Julia, as he covers up her bosom, “The senses must be blind letter-carriers only, and must not be aware of that which nature and the imagination communicate each to the other. The best of news is stale as soon as it has become the talk of the town.”

For this reason, also, it is more suitable that intercourse should take place, not by day, consequent on the brutal prompting of vision, but by night only, beneath the protecting veil of darkness. A night’s rest, moreover, will serve to restore the exhausted nerves, and to replace the expended secretions. Less advisable is coitus in the morning, on awaking from sleep, since the labors of the day must immediately thereafter be undertaken. Partially impotent men only, who wake up with an erected penis, endeavour to avail themselves without delay of this favorable opportunity, bearing in mind the French proverb, “On aime quand on peut, et non pas quand on veut.”

The French custom, in accordance with which the married pair sleep together in a double-bed is undesirable on several hygienic grounds, and, in the first place, for the reason that this continuous nocturnal proximity is likely to give rise to the habit of indulging in excessively frequent acts of intercourse. The best and most affectionate of men has neither disposition nor capacity to play the part of Romeo every night, and thus the value and enjoyment of marital duties becomes lessened. The fulfilment of his desires should not be rendered quite so easy to the husband; he should always appear the lover, one who seeks a woman’s favours because he longs for her; he should not be the master, exacting an unquestioned right. For this reason, separate beds are advisable for the married pair, and, when possible, even separate bedrooms.

Among the ancients, Lycurgus, the Spartan law-giver, regarded maternity as woman’s principal attribute, and considered the sexual impulse to be the means merely by which healthy citizens were provided for the state. In accordance with this view, the sanctity of marriage was violated, and every powerful, handsome, and valiant Spartan had the right to request the privilege of intercourse with the wife of another, in order to enrich that other’s family with his seed. Elderly, impotent men conducted well-formed young men into the arms of their own wives. The girls, like the young men, went through a course of gymnastic exercises, in order to harden their bodies, and to fit them for the bearing of strong and healthy children. No man might marry before attaining the age of thirty, no woman before attaining the age of twenty. Girls ripe for marriage were assembled in a dark place, and there the young men chose their brides, as chance might direct. The young men were allowed to visit their wives by night only, and secretly, in order that the vigor of the sexual impulse might be increased and maintained.

Among the Spartans, it happened quite frequently, that a man whose wife had remained childless, and who believed himself to be at fault in the matter, would beg one of his fellow-countrymen, or even a foreigner, to come to his assistance. It was enacted by one of Solon’s laws, to prevent a man from neglecting his marital duties, that he should have intercourse with his wife not less than three times monthly. According to another of Solon’s laws, an Athenian heiress might call upon her nearest relative for the gratification of her sexual desires.

The bluntest contrast to this Spartan simplicity is furnished by the unbridled lasciviousness that prevailed in Rome under the Cæsars, when women’s sole desire was sexual enjoyment, while maternity was a state to be avoided. To such an extreme was this carried, that the Roman ladies of that day preferred to marry eunuchs, and further, as Pliny reports, hermaphrodites were in great request. Juvenal writes: “There are women who prize the infertile embraces of base eunuchs; thus they are able to dispense with the use of abortifacients.”

The hygiene of the nuptial night deserves from the physician more attention than it has hitherto generally received. He should warn and enlighten the young husband, in order that the brutality with which the act of defloration is apt to be performed may be lessened, and further in order that mistakes in this connection, resulting from ignorance and likely to have serious consequences, may be avoided. It is well known that lacerations of the hymen and its environment, and even serious injuries of the genital organs, may result from maladroit attempts at penetration. The physician will admonish the husband in the words of Michelet: “Bear in mind in this hour that thou art an enemy, a tender, considerate, and gentle enemy!”

The young woman entering upon marriage should receive instruction from her mother regarding all the sexual processes of copulation, instruction at once earnest and complete. By such enlightenment, the young bride will be spared much suffering, and a sudden disillusionment which might seriously affect the whole of her future life will be avoided; complete ignorance, on the other hand may lead, not merely to needless mental and physical suffering, but to the most tragic consequences on the bridal night. In one case known to me, the young wife, who before marriage was utterly ignorant of the nature of physical love, was so completely overwhelmed in her ideals by the somewhat energetic procedure of the bridegroom as soon as he found himself alone with his wife, that she fled from her new home then and there in the night, and by no persuasions could be induced to return.

In that decisive moment in which the maiden loses her virginity, she must find in her husband, not the brutal man who forcibly takes possession of her body, but the chosen man of all, to whom her love can refuse nothing.

“Delicate foresight and restraint,” writes Ribbing, “are needful above all at the commencement of married life. The young wife, coming to the bridal bed a pure virgin, is not, like her husband, fully prepared for what is to take place. In all cases she is somewhat fearful of the new experience. The first act of intercourse involves for her a certain amount of pain, and this pain is not solely physical. * * * Moreover, we must remember that the entire change in her mode of life makes a deep impression upon a woman’s mind; time and quiet are needed before she can find herself at home in the novel surroundings, before she can adapt to the changed circumstances her moral and religious convictions, and before she can ‘think true love acted simple modesty’ (Romeo and Juliet, III, 2.16). Impatient husbands, through want of knowledge and lack of consideration during the honeymoon, have often ruined the happiness of subsequent married life.”

It happens often, unfortunately, that the wife has reason to complain of the reckless manner in which her husband has used, or misused, his sexual powers. Frequently enough, on the bridal night, the man proceeds with such violence in his assault on the virgin reproductive organs of his newly-wedded wife, that we must actually speak of him as ravishing an ignorant and timid girl. Later, when the stimulus of novelty has passed away, the husband often performs intercourse in a manner more calculated to awaken his wife’s sexual desires, but in seeking his own lordly gratification and obtaining it he is still apt to leave out of the reckoning the need for effecting coitus in such a way as will give complete satisfaction also to his wife.

The wedding journey likewise deserves consideration from the hygienic standpoint. Much is to be said in favor of such a journey, inasmuch as it endows the necessarily somewhat brutal first act of intercourse with an aspect of romance. The removal to a foreign country, to a strange environment, will spare the chaste maiden much shame and vexation. On the journey, moreover, the young couple are much in each other’s company, and the process of mutual adaptation is agreeably favored. And yet this modern custom of making a wedding journey entails certain serious disadvantages. The young woman leaves her home and her nearest relatives, and is in a moment involved in the excitement of travel, an excitement liable to increase to the degree of morbid anxiety. The fatigues of railway-travel, of wandering about strange towns, of visits to museums and picture-galleries, are apt to cause general loss of nervous tone, and also local hyperæmia of the genital organs. In addition, false modesty and the prescribed arrangements for the journey may lead the onset of menstruation to be ignored and the customary rest at this period to be dispensed with. Still more, the possibility of the occurrence of conception and of the commencement of pregnancy is usually left altogether out of the account. Many an attack of menorrhagia, of perimetritis, and of endometritis, many a miscarriage, and many instances of protracted sterility, are dependent upon the hygienic mistakes of the wedding journey, and less, indeed, upon the abuses arising out of the intoxication of passion, than upon the fatigues of excessive travel both by day and by night. The bride who on her wedding-day was young, healthy, and full of vitality, not infrequently returns from the wedding journey a sickly and debilitated woman.

With regard to wedding journeys in relation to the causation of chronic metritis, Scanzoni has expressed an authoritative opinion. “After many weeks of unsatisfied sexual desire, the young married pair, now freed from all restraint, give themselves up to the joys of love; the intense sexual excitement causes great stimulation and hyperæmia of the female sexual organs; in addition, the noxious influences of travel make themselves felt, and also hygienic indiscretions are perpetrated, dependent upon the young wife’s modesty; it is, therefore, by no means to be wondered at that, having left home a perfectly healthy woman, she returns from her wedding journey with the germs of an illness from which she never fully recovers, and which is the source of unending suffering, and more particularly of a sterile marriage.”

Sexual hygiene demands a certain moderation in the enjoyment of physical love, and also a certain constancy, such as may be expected in a happy marriage.

It is not possible to lay down a general rule with regard to the frequency of sexual intercourse, notwithstanding the earnestness with which religious zealots, physicians, and moral teachers have in all ages endeavored to determine how often it was proper for a man to cohabit with his wife. The rules that have been prescribed by the various authorities had in view, for the most part, the protection of the wife from excessive demands on the part of her husband; sometimes, however, by the establishment of a minimum period, a certain amount of sexual gratification was secured to the wife; finally, also, the generation of a healthy posterity had to be taken into consideration. Ribbing, however, justly observes: “Sexual intercourse results from a natural impulse, and he whose senses are unimpaired, and who has learned, at the same time, amid the tumult of his sensations, to preserve proper consideration for his wife—such a man runs little danger of making any mistake. In opposition to the opinion of many, I regard it as entirely right and reasonable that husband and wife should have intercourse whenever physically and mentally impelled to that act. Nor do I see any reason why, during the first period in which they are able to enjoy without intermission the pleasures of sexual intercourse, they should, in accordance with any theory whatever, impose on themselves further restraints than those demanded by care for their physical and mental health. The touchstone of marital hygiene is this, that on the day following intercourse both husband and wife should feel perfectly fresh, vigorous, and lively, alike in body and mind—even more so, perhaps, than on other days. In the absence of such feelings, we may feel assured of the occurrence of sexual excesses.” The same author quotes a saying of Pomeroy’s: “We may quaff the nectar as freely as we will—nature herself mixes the draught and holds the goblet to our lips; if, however, we drink too much, she first dilutes the draught with water, later adds gall, and ultimately perhaps deadly poison.”

The occupation, trade, or profession, and the nutritive condition and physical constitution of the married pair, have an important bearing on the frequency with which, without detriment to health, cohabitation is permissible. The rules of the Hebrew Talmud already take these circumstances into account, ordering as they do that young and powerful men not engaged in any regular occupation shall have intercourse with their wives daily; manual labourers, on the other hand, once a week only; whilst brain-workers, finally, or those whose work is extremely arduous, should allow an interval of one or more months to elapse between the acts of intercourse. Acton also prescribes that in the case of brain-workers and of those manual workers whose labours are exhausting, intercourse must not occur more frequently than once every week or ten days.

The married couple should understand how to impose on themselves a certain restraint in the matter of marital intercourse, without, however, going so far as on altogether trifling grounds to refuse the husband access to his wife. In this respect also, the opinions that have recently come to prevail concerning the rights of women have had an influence. W. Acton relates a case that came under his observation in which the wife refused to allow her husband any voice in determining when and how often intercourse should take place; the wife, she maintained without hesitation, since she had to bear the consequences of intercourse, was fully justified, whenever she thought fit, in refusing her husband’s embraces.

The dangers to the sexual life of woman which are involved by the modern woman’s rights agitation are seen already in the changes which the emancipation of women in North America has produced in the functions of woman as wife and mother. In that part of the world, everything possible has been done “to transform” (to quote the words of a brilliant journalist) “the doll into an independent existence, to enable the helpless woman to earn her own subsistence, and the result of these endeavors has been most striking. The American woman has obtained the right to enter every profession and to follow every kind of occupation which have hitherto been reserved for men; she is physician, lawyer, merchant, professor; her boudoir has become an office, often connected with the stock exchange by a private wire. Legally, also, she now possesses the same rights as man; in many States she has both the suffrage and the right of entering the house of representatives; she has fully emancipated herself from her former condition of tutelage, and in her shrillest tones can cry to heaven ‘I am free, I am independent, I am emancipated, I am myself!’ And observe, as the result of all these attempts at the conversion of woman into man, that in the matter of marriage also she acts as if she were no longer woman. The American woman no longer marries; perhaps, indeed, because she no longer has the capacity. So long and so eagerly has she given herself up to masculine occupations, that her inward feminine nature has also perhaps undergone transformation, so that she has become affected with a kind of neutral lack of desire. Unquestionably, the desire for marriage on the part of this modern ‘emancipated’ woman has vanished in the most alarming manner, there is a notable fall in the birth-rate, and the indigenous (white) population actually threatens to disappear.”

The wife acts wisely, not on hygienic grounds alone, in not always acceding at once and unconditionally to her husband’s demand for the repetition of intercourse. Her modest reluctance enhances her desirability in the eyes of her amorous husband. Thus, Shakespeare makes Posthumus exclaim (Cymbeline, Act II., Sc. 5, l. 9):

“Me of my lawful pleasure she restrained And prey’d me oft forbearance; did it with A pudency so rosy the sweet view on’t Might well have warmed Old Saturn.”

Especially justified is such refusal when coitus has been already once or twice performed, or when the consumption of alcoholic beverages has made the husband unduly lustful. On the other hand, the refusal of intercourse when demanded by the husband should never depend upon baseless feminine caprice, or upon the now so frequently asserted “rights of women.”

Experience has long ago established as a fact that unduly frequent satisfaction of the sexual impulse entails serious consequences to the health of the individual. And in the case of the wife these consequences may be especially disastrous when intercourse is indulged in recklessly during menstruation, during all stages of pregnancy, and even during the puerperium. “Incontinence during menstruation leads to serious circulatory disturbances and to the consequences of these disturbances; during pregnancy it is likely to give rise to miscarriage; during the puerperium, to congestions and inflammations. Should conception occur as a result of intercourse during the lying-in period (and this may happen very shortly after childbirth), abortion, and even more serious consequences, are likely to ensue. By intercourse during lactation, the premature recurrence of the menstrual flow is induced, and the gradual reversion of the reproductive apparatus to the condition in which it was before pregnancy (the process of involution) is hindered; moreover, the secretion of milk is diminished or even entirely suppressed.” In these terms Hegar depicts the consequences of premature resumption of marital intercourse, taking perhaps a somewhat extreme view of the matter.

Nevertheless, this author is undoubtedly right in declaring that one of the principal disadvantages to a woman of excessively frequent sexual intercourse is that pregnancy occurs too often. It is astonishing to observe the number of full-term deliveries and miscarriages that a woman will experience within a comparatively short period of time, as is seen too frequently among the labouring classes and more especially among factory workers. “If we assume the ordinary mortality of childbed to be 6 per mille, a woman who in the course of 15 years undergoes labour (at full term or prematurely) 16 times, runs a risk of death to be expressed by the ratio of 6 × 16 = 96 per mille; that is to say, on the average, of 1,000 women who become pregnant as often as this, nearly 1 in 10 will die in childbed.”

Young men who have previously suffered from gonorrhœa and who wish to marry, must, unless they wish to cause unspeakable misery, undergo an exact and thorough examination; not only must the physician inquire as to the presence of certain symptoms, such as smarting during micturition, adhesion of the lips of the urethral meatus, “clap-threads” in the urine, etc., but during a considerable period of time repeated microscopical examinations of the urine must be undertaken, and the filaments, if present, must be examined for gonococci. The physician will also have to determine whether any vestiges remain of epididymitis, and whether the quality of the semen has been impaired by the attack of gonorrhœa. Unfortunately, it is not yet within our power absolutely to forbid marriage to a man exhibiting all the symptoms of chronic gonorrhœa; but it is the duty of the physician to explain to such a man the scientific views regarding this matter that now prevail, in order to furnish him with the grounds for a decision.

It is not possible, when discussing the hygiene of married life, to preserve silence respecting the extremely pressing question of the use of measures for the prevention of conception, for in recent years their use has become extraordinarily general, chiefly, indeed, in the upper and middle classes of society, but to some extent also among the working-class population. Although we devote a special chapter to this topic, we must here express the opinion that, except in certain instances in which their employment can be justified on carefully weighed and well-established medical grounds, the use of any mechanical or chemical means for the prevention of conception must be discountenanced as injurious to health. The wife who wishes to preserve her psychical purity and moral chastity, which is not only possible in marriage but also greatly to be desired, must not concern herself much with the technique of the sexual life, but must give herself up to sexual enjoyment only as the result of a delicate and immediate bodily and mental desire. Not only for reasons of national economy regarding the means of providing for the family, but also for well-grounded personal reasons regarding the wife’s health, must the latter be spared an unduly rapid succession of pregnancies and confinements. And this should be effected by a certain degree of continence and by the observation of extensive periods of sexual quiescence.

To preserve a woman’s health during the acme of her sexual activity, a careful general hygiene is an important requisite. The dwelling should be dry and roomy; above all the bedroom should not be too small, neither damp nor dark, and it should be well ventilated. The wife’s occupations should be so arranged as to afford a suitable alternation of activity and repose, and there should be as little night work as possible. Certain occupations are especially potent in the causation of the diseases peculiar to women, principally, for the reason that they do not permit of the requisite repose during menstruation. Thus, washerwomen, vocalists, and sewing-machine operatives, suffer with especial frequency from diseases of the genital organs.

Great care in the cleansing of the genital organs is indispensable in the case of women; the vulva and its environment should be frequently and carefully washed; and an occasional vaginal injection is advantageous. As regards the last-named measure, however, we must point out that it is possible to err by excess as well as by defect, and that a daily vaginal douche can by no means be regarded as a necessary part of the hygiene of the reproductive organs. For recent researches have shown, on the one hand, that the vagina constitutes a natural mechanism for the destruction of pathogenic organisms, and on the other hand, that complete disinfection of the vagina is extremely difficult to effect. Inflammations of the vulva, which are somewhat frequent in consequence of excessive perspiration and undue discharge from the genital canal, demand careful cleansing with soap and water and the use of a soft brush. The addition to the water of lysol (in the proportion of ¼ to ½ per cent.) is advantageous. A general bath or a local sitz bath, the water being moderately warm (95°–99° F.; 35°–37° C.), may be recommended on grounds of beauty as well as of health, and should be taken at least once a week.

The regular use of lukewarm sitz baths is a most valuable hygienic measure for the prevention of various general or local disturbances consequent upon increased flow of blood to the genital organs. These local baths are best taken at a temperature of 95° F. (35° C.), and should last twenty minutes; they should be taken just before going to bed, and while sitting in the hip bath the skin of the abdomen and of the lower part of the back should be rubbed with the hand encased in a friction-glove. The bather on leaving the bath should get straight into bed, and should dry herself beneath the bedclothes, rubbing the skin till it glows. Such sitz baths serve also to keep the external genitals clean, and to guard against infection. For vaginal douching, water sterilized by boiling should be employed, and where any catarrh of the vaginal mucous membrane is present, some alum, permanganate of potassium, or boric acid may be added with advantage; the pressure of water, when a vaginal douche is given, should never be high, the reservoir of the irrigator being raised not more than twenty inches above the outlet of the nozzle; as a rule the water should be lukewarm; the patient should be in the recumbent posture. The reservoir of the irrigator and the intra-vaginal nozzle are most suitably made of glass, to insure cleanliness; the nozzle should not be thrust too far in, two inches being quite sufficient. After the use of the douche, the woman should remain ten or fifteen minutes in the recumbent posture.

In addition to the hygienic employment of such full baths and local baths, a number of mineral baths have important therapeutic applications in cases of disease of the female genital organs, the traditional value of such baths having been scientifically endorsed by the modern science of balneo-therapeutics. By means of suitably selected mineral water baths, a powerful derivative stimulus may be given to the skin, and the affected reproductive organs may thus be beneficially influenced. Further, in acute inflammatory conditions or hyperæmia of the uterus or its annexa, these baths have an antiphlogistic influence; on the other hand, when intrapelvic exudations have formed, the baths promote the absorption of these inflammatory products; again, in congestive states of the female genital organs, with relaxation, thickening, and hypersecretion of the genital mucous membrane, the baths have an astringent and tonic influence on the tissues; finally, they have a favorable effect on the innervation and nutrition, not only of the reproductive apparatus, but of the entire organism. It is easy to understand why women during the menacme are frequent visitors to spas.

At this period of life, and especially in women who lead luxurious “society” lives, the thoughts tend strongly in the sexual direction; to avoid this, and to prevent the ever more and more frequent breaches of marital fidelity, the best means are the practice of vigorous bodily exercises, and active employment, either in household affairs or in intellectual occupations. Cold sponging of the body or cold full baths will also be found an excellent measure for the prevention of sexual excess. In such cases also the diet should be limited, strong and stimulating food should be avoided, but little butcher’s meat should be taken, whilst green vegetables and raw and cooked fruits should be liberally consumed; at the same time, all alcoholic beverages must be rigidly prohibited. Moreover, care must be taken that during the night there should be no undue physical stimulation in consequence of excessively warm and soft bedding; hair mattresses are to be preferred to feather beds, with light down quilts for a covering. Finally, no stimulation of an erotic character should be offered to the imagination, and for this reason equivocal literature and lascivious dramatic representations must be avoided. By a sufficiency of occupation, regular, interesting, and demanding a considerable expenditure of physical energy, a woman may be enabled to a great extent to escape the inconvenience and distress attendant on entire or partial lack of gratification of the sexual impulse.

It cannot be disputed that a certain and moderate amount of sexual gratification is requisite for the perfect maintenance of physical health in woman, and that the absence of this gratification, or the gratification of the impulse in an abnormal or incomplete manner, entails disturbance of alike the mental and the physical equilibrium; but, on the other hand, the deleterious consequences of sexual abstinence have been greatly exaggerated by many writers—both by physicians and social economists. Owing to the fact that to the cultivated woman sexual gratification is possible only in the married state, whilst social conditions render marriage impossible to many women greatly in need of such gratification; in consequence, also, of the modern and ever more widely diffused practice by husbands of coitus interruptus altogether regardless of the woman’s need for complete sexual gratification—there arise in women numerous local disorders and nervous disturbances, hysteria and even insanity being results by no means infrequent. The significance of ungratified sexual impulse in the pathogenesis of nervous disorders has been established by von Krafft-Ebing, who points out that in unmarried women insanity most frequently occurs between the ages of twenty-five and thirty-five years, during the decade, that is to say, in which youthful bloom and the hopes of marriage simultaneously disappear; whereas in the male sex the greatest incidence of insanity is between the ages of thirty-five and fifty years, the period of life in which the struggle for existence is fiercest.

Hegar, on the other hand, is a firm opponent of the view that the favourable influence of marriage is overrated. According to this author, the favourable effect of marriage in respect of mental disorders is to be found, not in the gratification of the sexual impulse, but in the ethical factors of marriage. Statistics show that even in the favourable circumstances of marriage, sexual gratification has in women an unfavourable influence, inasmuch as the proportion of sufferers from mental disorders is higher among married women than it is among married men. A study of the mental disorders which in women are especially associated with the process of reproduction (puerperal mania) confirms this impression. Hegar insists that he has never seen nymphomania arise in women in consequence of forcible repression of the sexual impulse; but that he has not infrequently seen this disorder result from unnatural excesses or from long-continued sexual irritation, especially in hereditarily predisposed persons. Such unnatural stimulation of the female is not infrequently practiced by the male—by the lover and even by the husband—it may be because he himself derives pleasure from such perverted practices, and wishes to obtain sexual gratification without the risk of impregnation, or because he is himself incompetent for normal complete intercourse. Hegar is further of opinion that in the causation of hysteria and also in that of chlorosis the repression of the sexual impulse plays a quite subordinate rôle. And he regards as pure fable the belief that continence in women is liable to lead to the formation of mammary, uterine, or ovarian tumors. He would more readily incline to the contrary opinion; the reproductive process being in this respect distinctly disadvantageous to the female sex. The unfavorable influence of the reproductive process is shown most clearly in the case of carcinoma of the uterus; the majority of the patients suffering from this disease are either married or widowed, and many of them have given birth to a large number of children. “Gratification of the sexual impulse, and more particularly the reproductive process, give rise in women to the formation and growth of tumors, cause numerous mechanical disturbances, and open the way to infection with various pathogenic organisms.”

Hegar considers that there is hygienic justification for the limitation of the number of children to which a woman gives birth. The most suitable age for motherhood lies in his opinion between the ages of twenty and forty years. Childbirth in women younger or older than this entails too much danger both to mother and child. At least two and a half years ought to elapse between two successive births; and these figures give us eight as the maximum family. If we assume that the duration of pregnancy is nine months, and that of lactation nine to twelve months (or in cases in which the mother does not nurse her own infant, that a like period must be devoted to the careful supervision of the wet-nurse or of the methods of artificial feeding), we cannot consider it unreasonable to devote a further period of from six to nine months to the complete reestablishment of the woman’s health. “Moreover, woman does not exist solely for the purpose of subserving during two decades of her life the processes of reproduction. And to permit the maximum number of children to be as great as eight, we must presuppose that the woman is in perfect health, and that she lives in a perfectly healthy environment. Any illness or infirmity which renders the duties of housekeeping and the rearing of the existing family unduly difficult, indicates the need for a further limitation of child-bearing. And if the reproductive function is to be rationally controlled, we must above all attend to the age and the health of the parents. Occupation, habitation, and general environment have also to be considered. The correct ideal is indeed not difficult to discover.”

Hegar concludes that strict moderation and even absolute continence in sexual matters are often, and for long periods of time, a pressing duty. “The numerous and various disasters which are brought upon the world by unbridled and unregulated sexual passion can be prevented only by enlightenment, moderation, and continence. If marriage were postponed until the attainment of complete physical maturity, in women till the age of 20, in men till the age of 25, while at the same time procreation were no longer undertaken by women above the age of 40 or by men above the age of 45 to 50 years; if, again, between successive pregnancies a sufficient pause for the woman’s recuperation were insisted upon, and intercurrent illnesses and states of debility were taken into account; and if, finally, sickly individuals, those hereditarily predisposed to disease, and those in any way below par either mentally or physically, were more than heretofore prevented from marrying; then the increase of population, which in Germany is unquestionably too rapid, would to some extent be checked. Thoroughgoing regulation of the reproductive process will not, however, be thus attained without the adoption of a method of selection too rigorous for present-day notions; and for a further advance we must in the meantime depend upon moderation and continence.” As regards the modern demand of the “right to love,” the same experienced gynecologist writes: “Whoever preaches to mankind the doctrine that ‘a man sins against his own personality if he neglects to exercise every limb he possesses, and if he denies himself the gratification of every natural impulse,’ or the doctrine that ‘it is the duty of every human being to gratify all his natural impulses, since these are most intimately inter-connected with his personality—are indeed his personality itself;’ such a preacher does harm to his kind. Such rights and such duties are chimerical for this reason if for no other, because two persons are necessary in the case of sexual gratification, and sometimes—though not as often as might be wished—Hans fails to find his Grete, without any consequent loss to society at large.”

An especially important chapter in the history of woman at this period of life relates to the dietetics of pregnancy and parturition, and to the regulations to be observed for the maintenance of health at this time and in connection with the processes of pregnancy, parturition, puerperal involution of the uterus, and lactation. This subject cannot now however be considered at length, and for our present purposes it is sufficient to point out how important it is alike for mother and child, alike for family and society, that the ever more and more widely and generally diffused practice of the artificial feeding of infants should be abandoned, and that there should be a return to the natural method according to which each mother nurses her own infant. The prevailing custom costs every year thousands of mothers their health, and thousands of children their lives.

COPULATION AND CONCEPTION.

Copulation.

The reproduction of the species is effected by means of an act of copulation on the part of a male and a female individual, both of whom must have attained complete sexual development. In all the sequence of reproductive processes it is copulation alone that is a voluntary act, all the other processes being independent of the will and even of consciousness.

A characteristic difference between man and the lower animals lies in the fact that in the human species sexual pleasure and the act of copulation may occur at any season of the year; and a further characteristic difference may perhaps be found in the fact that in the great majority of individuals of the human species the psychical process of “love” plays a determinative part. Voltaire pointed out that to man alone among animals are known the embrace and the joy of the kiss.

The significance of the kiss is depicted by Grillparzer in the following verses:

Auf die Hände küsst die Achtung, Auf die Wangen Wohlgefallen, Seelige Liebe auf den Mund. Auf den Nacken das Verlangen; Uberall sonsthin Raserei.[45]

In this act of conjugation between two individuals of the same species, differentiated each from the other by the characteristics of sex, the active, provocative rôle is allotted to the male, the passive, receptive rôle, to the female. The modest and coy reluctance characteristic alike of the maiden and of the wife, promote an increase of sexual excitement in the opposite sex, and this not only in a man of purely sensual character, whose vanity is stimulated by his being the chosen one among many—a circumstance which, in view of the great dependence of the sexual act upon psychical processes and imaginative influences, is by no means devoid of importance. The woman’s coy reluctance must be overcome by means of a tender strategy before she is willing to grant the final possession of her body; and the act of copulation forms at the same time the conclusion of the physical and mental yearnings of the lover, and the commencement of the new-coming being. There is thus a physiological reason for the advice given by the celebrated surgeon, Ambroise Paré, that a man, before completing coitus, should employ some of the delicate and sensually stimulating manipulations of the earlier stages of courtship, for, he writes, “aucunes femmes ne sont pas si promptes à ce jeu que les hommes.”

The potency for intercourse of the sexually mature man, his capacity for the introduction of the erect penis during the act of copulation, is dependent on the fact that sexual excitement gives rise to a sufficient stimulus which, acting on the erection centre (and presuming that the centre and its afferent and efferent tracts are normal), leads to an increased flow of arterial blood to the penis and a diminished outflow through the veins of that organ, and consequently to its erection. The cerebrum is the organ in which the sensation of libido sexualis, of sexual excitement, has its seat; with this higher centre is connected by means of intercentral nerve tracts a lower, mechanical, reflex centre, situated in the lumbar enlargement of the spinal cord, and presiding over the performance of the act of copulation; it is moreover probable that nerve fibres proceed from the spinal cord direct to the blood vessels of the erectile tissue, by means of which the calibre of these vessels can be lessened or their extensibility diminished. The relation of the erector nerves (nervi erigentes) to the penis is by many physiologists compared to the relation of the vagus nerve to the heart. In the quiescent state the small arteries of the penis and perhaps also the cavernous spaces of that organ are in a state of mean contraction, so that they offer a considerable resistance to the passage of the blood current. When now the nervi erigentes are excited to activity, the hitherto tonically contracted vessels of the penis undergo, according to the school of physiologists just mentioned, relaxation, so that they dilate under the pressure of the blood within their walls, and, the previous resistance to the flow being now removed, the blood pours freely into the cavernous spaces of the penis, and distends these to the uttermost. In this manner erection is effected, rendering possible the insertion of the penis into the genital passage of the female; with the culmination of the sexual act, the semen is ejaculated, the muscles of the prostate and the membranous portion of the urethra together with the ischiocavernosus and bulbocavernosus muscles, all acting strongly and simultaneously.

By the contraction of the muscular apparatus just described, the penis is constricted in the neighborhood of the pubic symphysis, and this further hinders the outflow of the blood from the corpora cavernosa, increasing the intensity of the state of erection of the penis. Should the relaxation of the corpora cavernosa, dependent upon the stimulation of the nervi erigentes, be incomplete, it is not possible for sufficient blood to pass into the cavernous spaces to exercise considerable pressure upon the efferent veins, and thus complete erection fails to occur. If, again, the contraction of the muscular apparatus at the root of the penis is insufficiently vigorous, complete erection likewise fails to occur; the organ becomes semi-erect only, or erect for a period too short to permit of the completion of intercourse.

Since, physiologically speaking, conception is the purpose with which copulation is effected, the ejaculation of the semen must be regarded as the principal object of that act; now in normal conditions, ejaculation takes place only when the penis is fully erect. Associated with the erection of the corpora cavernosa is a swelling of the caput gallinaginis, whereby the orifices of the ejaculatory ducts are directed forwards toward the membranous portion of the urethra, and at the same time the backward passage to the bladder is cut off. By this mechanism, the urethra, which usually serves as the canal for the outflow of urine, is made for the time being solely subservient to the purposes of the sexual act. That the outlet from the bladder is obstructed by the swollen caput gallinaginis when the penis is erect, is shown by the familiar fact that a man whose penis is erect cannot pass water, although the way is freely open for the ejaculation of the semen.

Before ejaculation begins, the urethral glands already begin to secrete; and when erection is powerful and prolonged, this secretion often makes its appearance at the urethral orifice in the form of drops of a clear somewhat tenacious fluid. Ultzmann considers that the function of this secretion is probably to moisten the walls of the urethra, over which the acid urinary secretion is continually flowing, with a protective alkaline fluid, and thus to prepare the canal for the passage of the semen. An analogy may be found in the secretion of the cervical glands of the uterus in the female, for this secretion has been found to enhance the activity of the movements of the spermatozoa. If now during copulation the moment of ejaculation begins, the male experiences at the same time a sense of voluptuous pleasure and a feeling of muscular spasm in the perineal region, and this indicates the commencing evacuation of the contents of the seminal vesicles through the ejaculatory ducts. Simultaneously, the secretion of the prostate is poured into the urethra. The semen now gradually passes out through the narrow ejaculatory ducts, and, since in consequence of the swelling of the caput gallinaginis, it cannot pass backwards towards the bladder, it runs forwards, and accumulates in the bulb of the urethra, the physiological excavation of that tube. As soon as a considerable quantity of the semen has collected in this situation, so that the bulb of the urethra becomes distended, reflex contractions of the bulbocavernosus muscles ensue, by means of which the seminal fluid is forced out of the urethral orifice. In cases in which this muscular apparatus does not function properly, as in the paralytic form of impotence, the semen during ejaculation is not ejected in a forcible jet, but rather flows slowly, as from a lax tube partially filled with fluid, from the urethral orifice.

We are indebted to Roubaud for a classical description of the phenomena of copulation, and this description is here appended. It runs as follows: “As soon as the penis enters the vaginal vestibule, it first of all pushes against the glans clitoridis, which yields and bends before it. After this preliminary stimulation of the two chief centres of sexual sensibility, the glans penis glides over the inner surfaces of the two vaginal bulbs; the collum and the body of the penis are then grasped between the projecting surfaces of the vaginal bulbs, but the glans penis itself, which has passed further onward, is now in contact with the fine and delicate surface of the vaginal mucous membrane, which membrane itself, owing to the presence of erectile tissue between its layers, is now in an elastic, resilient condition. This elasticity, which enables the vagina to adapt itself to the size of the penis, increases at once the turgescence and the sensibility of the clitoris, inasmuch as the blood that is driven out of the vessels of the vaginal wall passes thence to those of the vaginal bulbs and the clitoris. On the other hand, the turgescence and the sensitiveness of the glans penis itself are heightened by compression of that organ, in consequence of the ever increasing fulness of the vessels of the vaginal mucous membrane and the two vaginal bulbs.

“At the same time the clitoris is pressed downward by the anterior portion of the compressor muscle, so that it is brought into contact with the dorsal surface of the glans and of the body of the penis; in this way a reciprocal friction between these two organs takes place, repeated at each copulatory movement made by the two parties to the action, until at length the voluptuous sensation rises to its highest intensity and culminates in the sexual orgasm, marked in the male by the ejaculation of the seminal fluid, and in the female by the aspiration of that fluid into the gaping external orifice of the cervical canal; so true, indeed, is this, that it is a difficult matter to give a picture at once accurate and complete of the phenomena attending the normal act of copulation. Whilst in one individual the sense of sexual pleasure amounts to no more than a barely perceptible titillation, in another that sense reaches the acme of both mental and physical exaltation.

“Between these two extremes we meet with innumerable states of transition. In cases of intense exaltation, various pathological symptoms make themselves manifest, such as quickening of the general circulation, and violent pulsation of the arteries; the venous blood, being retained in the larger vessels by general muscular contractions, leads to an increased warmth of the body; and further, this venous stagnation, which is still more marked in the brain in consequence of the contraction of the cervical muscles and the backward flexion of the neck, may cause cerebral congestion, during which the consciousness and all mental manifestations are momentarily in abeyance. The eyes, reddened by injection of the conjunctiva, become fixed, and the expression becomes vacant; lids close conclusively, to exclude the light. In some, the breathing becomes panting and labouring; but in others, it is temporarily suspended, in consequence of laryngeal spasm, and the air, after being pent up for a time in the lungs, is finally forcibly expelled, and they utter incoherent and incomprehensible words.”

The impulses proceeding from the congested nerve-centres are confused. There is an indescribable disorder both of motion and of sensation, the extremities are affected with convulsive twitchings, and may be either moved in various directions or extended straight and stiff; the jaws are pressed together so that the teeth grind against each other; and certain individuals are affected by erotic delirium to such as an extent that they will seize the unguarded shoulder, for instance, of their partner in the sexual act, and bite it till the blood flows.

A period of exhaustion follows, which is the more intense in proportion to the intensity of the preceding excitement. The sudden fatigue, the general sense of weakness, and the inclination to sleep, which habitually affect the male after the act of intercourse, are in part to be ascribed to the loss of semen; for in the female, however energetic the part she may have played in the sexual act, a mere transient fatigue is observed, much less in degree than that which affects the male, and permitting far sooner of a repetition of the act. “Triste est omne animal post coitum, praeter mulierem gallumque,” wrote Galen, and the axiom is essentially true, at any rate so far as the human species is concerned.

The question has been mooted, and many earnest inquirers have devoted much thought thereto, whether in this moment of most intense sexual gratification it is the male or the female that experiences the greatest amount of pleasure. As in the case of all questions the data for the solution of which are at once very various and very variable, so in this case also, very different opinions have been put forward. “In fact,” writes Roubaud, “when we take into consideration all the circumstances by which the intensity of sexual sensation is influenced, it may well be doubted if it is at all possible to find an a priori solution for the problem. When we take into consideration the influence exercised by temperament, constitution, and a large number of conditions both general and special, on sexual sensibility, we cannot fail to be convinced that this problem, in consequence of all the complicated characteristics it presents, is actually insoluble.”

In regard to the pleasure experienced in the act of intercourse, a remarkable distinction is drawn by Gutceit. The male, in every case and with every woman, experiences the full degree of pleasure; and even though from the mental point of view this pleasure may be enhanced by inclination, attraction, and mutual love, from the physical point of view there is no difference between different acts of intercourse, so that the cynical old Roman was right when he wrote. “Sublata lucerna nullum discrimen inter foeminas.” But in the case of the female it is very different. Her first experience of sexual relations is a very painful one, and this pain prevents all enjoyment as long as it continues, as it does in many women for one, two, or even four weeks. And when this period is once over, not more than two women in every ten experience the pleasure of sexual intercourse in its full intensity. Of the remaining eight, four have indeed an agreeable sensation during the rubbing movements of the sexual act, but it is a long time before they experience a sensation analogous in its intensity to that which in man accompanies the act of ejaculation. In some women it may be six months after marriage before the true sexual orgasm is experienced, in others it may be a year, or even several years; in a considerable number this does not happen until after they have given birth to several children. As a result of numerous observations on this point, Gutceit asserts that in women sexual pleasure is experienced only in intercourse with a man who is beloved, or against whom, at least, no repulsion is felt; and that no pleasure is felt by a woman in intercourse with a man towards whom she feels an actual dislike. Further, he maintains, that a woman, loving another man, and feeling pleasure in intercourse with him, has on the other hand no voluptuous sensations during intercourse with her husband, whose embraces she permits only from a sense of duty. Thus in the male, intercourse is always pleasurable, while in the female, pleasure is experienced only when certain conditions are fulfilled.

Contact with the male genital organs stimulates in the female the sensory nerves of the vulva, the vestibule, and the vagina; the nervous stimulus is transmitted to the cerebral cortex, where it gives rise to the sensation of sexual pleasure, and causes, through the intermediation of the genito-spinal centre, a number of reflex actions. As sensory nerve terminals of such reflex arcs, the final ramifications of the pudic branch of the sciatic plexus play the most important part; in the clitoris these nerves are beset with a peculiar kind of end-bulbs, the genital corpuscles discovered by W. Krause; from their structure these corpuscles seem admirably adapted to respond to the very slightest stimulation, producing voluptuous sensations and perceptions, and giving rise to various reflex manifestations. The first part of the path of the afferent impulses by which sexual pleasure is aroused is constituted by the dorsal nerves of the clitoris. The reflex changes consequent upon sexual excitement begin already in the vestibule, inasmuch as the secretion of Bartholin’s glands, which are compressed by the action of the constrictor cunni muscle, is expelled during coitus, the secretion, owing to the situation of the orifices of Bartholin’s ducts, passing over the external genitals. The clitoris becomes erect; the blood in the bulbs of the vestibule, the venous plexus situated around the margin of the vestibule along the boundary between the labia majora and the labia minora, is pressed into the glans clitoridis, the erection and sensibility of this structure being proportionately heightened. By the action of the constrictor cunni and ischiocavernosus muscles, the clitoris, the distal extremity of which is bent downwards at a right angle, is drawn down and pressed against the penis.

At the entrance of the vagina is the sphincter vaginæ muscle, whose action is reinforced by muscular fibres running in the middle coat of the vagina itself. It is probable that the muscular activity of the vagina and the uterus facilitates the entrance of the semen into the cavity of the uterus.

Dorsal decubitus is rightly regarded as the most correct position, physiologically speaking, for the woman to assume during coitus. That from the earliest times and in the most diverse races, this position has been customary, is shown by numerous antique paintings and statues, and by the reports of those who have studied the customs of savage races. Various other positions are, however, occasionally assumed; thus, Ploss and Bartels report, that among the Soudanese, coitus is practiced in the erect posture, with the man standing behind the woman; that among the Inuits (Eskimo), the act is performed in the manner usual among quadrupeds; that among the Swahelis in Zanzibar, and among the indigens of Kamschatka, the lateral posture is customary; and that among the Australian blacks, coitus is usually effected in the crouching posture, both parties squatting on their hams. The same writers remind us, that in the old calendars of the fifteenth, sixteenth, seventeenth, and eighteenth centuries, definite commands and prohibitions for the conduct of marital intercourse are to be found, and that lucky and unlucky days, respectively, are specified for the performance of the act. These recommendations would appear to be relics of antiquity, for in the Sanscrit work Kokkogam, under the heading “Sexual Intercourse According to the Days of the Month,” exact instructions are given for the proper performance of coitus.

In the Kamasutra (the Indian ars amatoria, a work only in recent days rendered accessible to European readers in the translation of R. Schmidt), several chapters are devoted to the detailed description of the various methods of copulation, and rules are given for the carnal union of man and wife. But, as the Indian author justly remarks, “Rules are of value only for the control of moderate desire; when the wheel of passion has once begun to roll, to prescribe a course is no longer of any avail.” In this work, sixty-four varieties of erotic enjoyment are enumerated, and we find an explicatio coitus secundum mensuram, tempus, naturam, de modis inter coitum procumbendi, de minis coitibus, de coitu inverso, de viri inter coitum consuetudinibus.

At times, in order that coitus may be effective, some other position than the natural one is indispensable. Such a necessity has been recognized even by theologians, by whom any divergence from nature in this matter has usually been regarded as sinful. For instance, in the work of Craisson, De Rebus Venereis ad Usum Confessariorum, we read: “Situs naturalis est ut mulier sit succuba et vir incubus, hic enim modus aptior est effusionis seminis virilis et receptioni in vas femineum ad prolem procreandum. Unde si coitus aliter fiat, nempe sedendo, stando, de latere, vel praepostere (more pecudum), vel si vir sit succubus et mulier incuba, innaturalis est.... Sed tamen minime peccant conjuges si ex justa causa situm mutent, nempe ob aegritudinem, vel viri pinquetudinem, vel ob periculum abortus; quandoque ait St. Thomas, sine peccato esse potest quando dispositio corporis alium modum non patitur.”

In certain pathological states, as for the prevention of sterility, an abnormal posture during coitus may advantageously be recommended, in order to favour the entrance of the semen into the cervical canal, and to allow the semen to stay longer in the vagina before it flows out. An old and often efficacious means for this purpose is the performance of coitus with the woman in the knee-elbow posture. In order to favour the entrance of the semen into the deeper portion of the genital tract, Hegar and Kaltenbach recommend that after coitus the woman should remain for some time in the knee-elbow posture, while the man from time to time gently presses up the anterior abdominal wall, and then abruptly relaxes the pressure.—In the Talmud, coitus was regarded as unfruitful if performed when the woman was in the erect posture.

Casper reports the case of a woman with severe scoliosis, who had long remained sterile, and who only conceived (and was subsequently happily delivered) after performing coitus in the abdominal decubitus.

Guéneau de Mussy suggests the following, very characteristic, method of ensuring fertilization, one which also certainly dates from great antiquity: “Sed haud illicitum mihi visum est, si post diversa tentamina diutius uxor infecunda manserit, ipsum maritum digitum post coitum in vaginam immittere, et ita receptum semen uteri osteo admovere. Et cum ostiolo uteri haeret, ut in pervium canalem spermatozoidum motibus faventibus, prodeat, sperare non absurdum.” Eustache reports a case, the wife of a physician, in which this manoeuvre was effective in ensuring conception.

A similar procedure has been employed with success by Kehrer, in a case of enfeebled potency on the part of the male, leading to premature ejaculation. A speculum was introduced into the vagina, and through this instrument the semen, ejaculated in consequence of sexual excitement, was introduced into the vaginal fornix; conception ensued. In an analogous manner, A. Peyer recommended, in a case of partial impotence, in which special manipulations were needed to bring about ejaculation, that conception should be favoured in the following manner: Erection having been effected by ordinary sexual contact, the manipulations needed to produce ejaculation were carried out, and the penis was intromitted into the vagina the moment before ejaculation occurred. This has been done with fruitful results. Englisch reports the case of a hypospadiac who, in order to render coitus effective, used a condom in the anterior extremity of which he made an aperture. In this way he became the father of three children.

In very obese men with extremely protuberant abdomens, we may recommend for the furtherance of conception that they should have intercourse with their wives a parte posteriori; and the same recommendation may be made in cases in which the wife herself is extremely obese. In Australia, it is said that among the indigens, coitus is usually practiced a posteriori; and there is a saying in the Talmud to the effect that sexual intercourse performed in the ordinary manner does not lead to the conception of infants so good, wise, talented, and promising as those whose conception is the result of coitus a posteriori. Mohammed, on the other hand, declares, “Your wives are your tillage, go therefore unto it in whatsoever manner ye will.”

In cases of retroflexion of the uterus, with a markedly forward direction of the vaginal portion of the cervix, I have recommended to the husband that he should perform coitus with his wife in the upright sitting posture. In this posture the fundus uteri passes downwards and forwards, whilst the vaginal portion of the cervix passes upwards and backwards.

In cases of retroversion of the uterus with the formation of a cul-de-sac in the posterior vaginal fornix, Pajot recommends, with the aim of temporarily restoring the uterus to a position in which the occurrence of conception is favored, that for three or four days prior to coitus the patient should retain the fæces, eating the while freely of eggs and rice, and taking a small opium pill every evening; in cases of anteversion, the patient should retain her urine for a considerable time—five or six hours—before coitus; and in cases of lateral version he recommends that the patient should have intercourse while lying on that side towards which the vaginal portion of the cervix is directed.

Edis recommends that in cases in which there is sterility dependent upon backward displacements of the uterus, that the organ should be replaced while the patient is in the genu-pectoral posture, and a pessary inserted; coitus should then be effected without the patient’s changing her posture.

In the human species as compared with the lower animals, there has been a notable diminution in the frequency of the separate acts of intercourse, a diminution dependent upon the higher vital aims of the former. Burdach formulates as a physiological law that the frequency of sexual intercourse is inversely related to the duration of the act.

Amongst all civilized races, sexual intercourse ceases during menstruation, since in the normal man there is aversion to intercourse with a menstruating female.

By the Mosaic law, intercourse with a woman during menstruation and for seven days after the cessation of the flow, was forbidden under pain of death. The Talmud further ordains that a purifying bath shall be taken by the woman a week after menstruation. By intercourse itself, moreover, both man and woman were rendered unclean to the evening; and, according to the Mosaic law, both must bathe after the act of coitus. In the Koran, also, intercourse is forbidden during menstruation, and until the woman has been purified with water. The law’s of Islam demand from a man who marries a virgin that he shall have intercourse with her the first seven nights in succession; whilst he who marries a wife no longer virgin, needs to visit her only the first three nights in succession. Subsequently, during married life, the Mohammedan shall have intercourse with his wife regularly once a week. Amongst many savage races, intercourse is forbidden with a woman during pregnancy, the puerperium, and lactation.

The first act of intercourse is difficult and painful to the virgin. At times the rupture of the hymen is exceedingly difficult. Even after this, it is some time before genuine pleasure is experienced in sexual intercourse.

To the female, intercourse is harmful when performed with undue frequency, or during menstruation, or indiscriminately throughout pregnancy, or during the puerperium, or incompletely or in an unnatural manner, or finally when performed in an unsuitable bodily attitude.

“Unduly frequent performance of the act of coitus,” writes Hegar, “which is liable to occur either in marital or in illicit intercourse, gives rise to anæmia, defective nutrition, muscular weakness, intellectual and nervous exhaustion. Young and healthy individuals recuperate rapidly after excesses of brief duration, as is often seen in young married pairs. Sickly and elderly persons, on the other hand, are much more severely affected by sexual excess, and recover therefrom but slowly if at all. Long continued sexual excesses ultimately wear out even the strongest.”

Intercourse effected by force, or with a girl of immature age, is distinguished as rape, a punishable offence both in Germany and in Austria. The offence is defined as extra-marital intercourse with a female under the age of fourteen years, with or without the latter’s consent; or extra-marital intercourse with a female of any age against her will or deprived of the power of resistance—either by the use of actual force, by the employment of threats, or by loss of consciousness. With regard to the last specification, the law regards as rape intercourse with a woman unable to resist through loss of consciousness, whether that loss of consciousness is or is not produced by the direct action of the violator.

In the female, the act of intercourse, alike physically, in its natural consequences, and mentally, is at once more difficult and of more enduring results than in the male. A writer of the new school, who according to his own admission has no other interest than the study of the sexual life, writes of himself: “I have often enough had intercourse with members of the other sex, in a few cases, indeed, out of pure inclination; but in all cases alike the aim and the result were the same—as soon as I had gained my end, the affair was finished. Passion, a bestial act, exhaustion, commonly a feeling of loathing; in the best possible case a fugitive but not an agreeable memory; voilà tout.” To women, such a description, happily, is applicable only in the most exceptional cases.

With the completion of coitus, the voluntary and conscious action of the two parties to the act is at an end; the subsequent stages of the function of generation are independent alike of consciousness and will.

When complete intromission of the penis has been effected, and ejaculation takes place, the semen is usually deposited at the os uteri or in the immediate neighborhood of that orifice. During the act of ejaculation, a peristaltic contraction of the vagina occurs, by means of which the semen at the os uteri is subjected to a moderate degree of pressure; the contraction and the pressure may perhaps persist for some little time after the completion of the coitus. In rabbits on heat, such contractions of the vagina, by means of which the semen was forced under pressure into the interior of the uterus, have been actually observed.

During coitus, the uterine muscle is also active. During strong sexual excitement, the uterus descends in the pelvis, the downward movement being increased by the pressure on the woman’s abdomen. The os uteri externum is drawn open, and the aperture, hitherto flattened, now becomes rounded. At the same time, the secretion of the cervical glands is expelled, and small quantities of semen are sucked into the cervical canal. The plicae palmatae offer a certain hindrance to the entrance of the semen; but the surface of the interior of the canal is rendered much smoother by the free secretion of mucus by the cervical glands. Further, it appears highly probable that during the excitement of coitus, the mouths of the Fallopian tubes, ordinarily more or less tightly closed, become widely opened, so that the entrance of the spermatozoa is favored.

The muscular movements of the uterus were observed by J. Beck in a woman suffering from prolapse. During sexual excitement, the os uteri opened and closed rapidly five or six times in succession, remaining at last firmly closed. Further, in bitches on heat, Basch and Hoffmann observed the vaginal portion of the cervix to descend in the vagina, the os uteri opened, mucus was extruded, and the os was then retracted.

Hohl, Litzmann, and others have reported, that in women endowed with great nervous susceptibility, friction of the vaginal portion of the cervix with the finger arouses sexual sensation, with rounding of the os uteri externum, descent of the uterus, and hardening of the vaginal portion; this latter is regarded by Graily Hewitt and by Wernich as a necessary accompaniment of copulation. Henle believes that the hardening and protrusion of the vaginal portion of the cervix are due to a change in the tension of the delicate vessels of this structure, which have an exceptionally thick muscular coat; Rouget compares the mechanism with that by which erection of the penis is produced. These authors consider that sexual excitement is indispensable for the erection of the vaginal portion of the cervix.

Thus, Hohl writes: “Numerous observations have shown that in females endowed with a considerable degree of nervous susceptibility, and especially in nulliparae, during examination and during any increasing irritation, not only is there an increased secretion of the vaginal mucus, but also a momentary descent of the uterus and an opening of the os uteri externum, so that this orifice has the appearance for the instant of the open mouth of a tube.” Litzmann reports that during the vaginal examination of a young, extremely erethistic woman, the uterus suddenly assumed a more vertical position, and came lower down in the pelvis; at the same time, the lips of the cervix became equal in length, the os uteri externum became rounded, soft, and penetrable by the finger; whilst the breathing and the voice indicated the occurrence of intense sexual excitement. Rouget assumes that the body and the fundus of the uterus constitute an erectile organ, which however possesses capability for erection only during the period of ovulation; Hewitt, on the other hand, considers it extremely probable that the erection may occur at any time during sexual intercourse, whether ovulation is proceeding or not. A. Wernich considers, basing his views in part on personal observations, that erection of the lower segment of the uterus occurs, like erection of the penis, whenever a moderate degree of sexual excitement is experienced; in women, however, he believes that erection is seldom extreme, and that it declines with the other symptoms of sexual excitement, viz., flushing of the face, moisture and glistening of the eyes, peculiar groaning expiration, etc. Whereas during ovulation, erection is merely a necessary concomitant of the other menstrual processes; during coitus, erection not only occurs much more powerfully, but it is also an important—perhaps the most important—contributory factor in effecting fertilization.

It is no longer possible to accept the view of earlier physiologists that the purpose of this erection of the lower segment of the uterus is “to constitute with the penis a continuous canal between the male and the female genital organs.” Contact between the glans penis and the os uteri externum is not indeed an occurrence of extreme rarity; but, on the other hand, it is in no sense a constant nor even a frequent incident of sexual intercourse. It is ejaculation, especially, which is subserved by the erection of the vaginal portion of the cervix. In the female, ejaculation occurs at the moment of the most intense sexual pleasure, and is marked by the evacuation from the os uteri externum of a moderate quantity of mucous fluid with an alkaline reaction. In some cases, in which a chronic discharge of this cervical mucus occurs, it forms an elongated coagulum of delicate vitreous jelly, the “mucus-string” of Kristeller. The last-mentioned author is of opinion that the spermatozoa slowly, but by active movements, find their way along this string into the cavity of the uterus. This assumption, however, is met by C. Mayer and Marion Sims with the objection, that Kristeller’s observations were for the most part carried out on women who were out of health, and that a gelatinous secretion of this character obstructs the orifice of the cervical canal, and hinders the occurrence of conception. From the erection of the portio vaginalis during sexual excitement, and its sudden relaxation post cohabitationem, Wernich deduces the occurrence of a process of aspiration, by which the semen is drawn up through the cervical canal into the cavity of the uterus; a process which has been seen in actual occurrence in vivisected animals. It is said that to many women this feeling of a process of suction is so well known, that thereon, in association with the consequent almost complete absence of mucus and seminal fluid from the vagina, they are accustomed to base a belief that conception will occur. It is said that this aspiratory activity on the part of the uterus may be perceived during coitus by the male also (?). It is assumed by Grohe that the wave motion of the cilia of the epithelium lining the cervical canal, is of importance in promoting the ascent of the spermatozoa; it may be that the vibration of the cilia exercises a motile stimulus on the spermatozoa, it may be that the continually repeated stroke of the cilia serves to prevent the permanent agglutination of the spermatozoa into groups.

According to Sims, the aspiratory action of the uterus is effected in the following manner: By the contraction of the constrictor vaginae superior muscle, the cervix is pressed downwards against the glans penis, and by this pressure its contents are evacuated; the parts then relax, the uterus suddenly returns to its normal state, and thus the seminal fluid with which the vagina is filled is drawn into the interior of the cervical canal.

Eichstadt also attributes to the uterus an aspiratory force, dependent upon coitus, and competent to force into the interior of the uterus the semen ejaculated into the os uteri. The changes in the uterus which are the necessary antecedents of this aspiration, namely, an engorgement with blood whereby the flattened form of the uterus gives place to a more rounded form, and the cavity of the organ is increased in capacity, take place, in the opinion of this author, only when during intercourse the woman has attained the acme of sexual gratification, by which alone can the aforesaid change in the uterus be brought about. E. Martin and Chrobak have also directed attention to the fact, that some importance in this connexion must be attached to the facultative enlargement in the size of the os uteri externum.

Lott, by his researches into the behaviour of the cervix uteri in relation to the act of conception, is led to the conclusion that the locomotive capacity of the spermatozoa forms the principal factor in effecting a fertilizing contact between the spermatozoa and the ovum. This locomotive capacity may be increased or diminished by a number of conditions, among which the principal are: the activity of the cervix uteri (the ciliated epithelium); the character of the secretions; and the position, shape, and size of the cervix. Thus, this author concludes, the part played in conception by the normal cervical canal is a purely passive one, with the sole exception of the activity of the ciliated epithelium—and the influence of this factor must be regarded as extremely doubtful. That during ejaculation the external orifice of the male urethra and the os uteri externum are in close apposition, is denied by Lott, who adduces in support of his views data derived from comparative investigations on various animals. In the dog, the configuration of the genital organs is such that it is impossible to suppose that any apposition can occur; the same is the case with the sheep; and still more so with the rabbit, who possesses two quite distinct portions vaginales, projecting freely into the vagina. In the human species also, the character of the walls of the cervical canal, where in the normal state the plicae palmatae may almost be said to interlock, separated only by a thin stratum of mucus, offers a hindrance to the entrance of the ejaculated semen by the direct force of ejaculation itself. As regards the independent motile powers of the spermatozoa, the researches of Lott showed that not only can they overcome strong capillary currents, and can traverse the width of a coverglass (18mm.—about ¾ in.) in about five minutes; but further that they are capable of migration through the finest interstices (those of an animal membrane) provided that the fluid with which the membrane is moistened is one favourable to their vital activity.

Kehrer, who in general supports the view that the modus coeundi and an active attitude on the part of the female have an important influence on the occurrence of conception, assumes that independent contractions of the cervix occur, whereby is expelled the delicate plug of mucus that fills the cervical canal and offers an obstacle to the passage of the spermatozoa. He believes that the duration of the act of intercourse, the mechanical relations between the penis and the vagina, the activity of the uterine muscle, the secretory activity of the utero-vaginal mucosa during the act, and the posture of the female post coitum, are all important factors in the occurrence of conception. Thus, he believes that if during intercourse there is a failure of the uterine contractions, which should expel the plug of cervical mucus, the semen flows away without effecting fertilization; if an unsuitable posture is assumed during intercourse the woman remains sterile, but can be fertilized without difficulty by coitus effected in the proper manner.

Haussmann has shown, that in the same woman, and in similar conditions, spermatozoa will on one occasion be found in the cervical canal, and on another occasion will not be found there; and he has further shown, that in some women we fail to find spermatozoa in the cervical canal in circumstances in which, in other women, we regularly find them in that situation.

Far as we may be from a complete knowledge of the conditions upon which conception depends, this at least is certain, that the passage of spermatozoa through the os uteri externum is a sine qua non of fertilization. Indeed, it would seem that we must accept as true the assumption of Meyerhofer, that fertilization is possible only if the semen passes at once into the cervical canal, mingles, that is, at once with the alkaline cervical mucus—unless, indeed, the coitus takes place during the catamenial flow, when the blood has neutralized the acid reaction in the vagina, or takes place when some morbid condition has had the same result. The theory of Johann Müller, regarding the piston-like action of the penis during coitus, by which the semen is actually forced through the cervix, must be rejected; equally unsound is Holst’s assumption that during intercourse the semen is ejaculated through the enlarged cervical canal directly into the cavity of the uterus. It would appear, however, to be a necessary condition of fertilization, that the semen should be ejaculated into the uppermost segment of the vagina, so that the fluid comes into actual contact with the os uteri externum; it may be that the alleged aspiratory force of the uterus then comes into play, by means of which the semen is sucked into the cavity of that organ; it may be, on the other hand, that Beigel is right in his theory of the existence of a receptaculum seminis, formed by the anterior and posterior lips of the cervix uteri and the uppermost segment of the vagina—in this space, he supposes, a part of the semen is retained in contact with the orifice of the cervical canal.

It is, also, exceedingly probable that during coitus a reflex nervous mechanism becomes active, by means of which the uterine orifices of the Fallopian tubes are opened, the vaginal portion of the cervix descends in the vagina, the os uteri externum enlarges, the orifice becoming rounded where before it was flattened, and finally small quantities of semen may be aspirated into the cavity of the uterus.

I further regard it as important in promoting conception, that simultaneously with the changes above described, the reflex nervous stimulation should lead to the secretion by the cervical glands of a gelatinous material, alkaline in reaction, and therefore adapted to increase the locomotive powers of the spermatozoa, so that these latter, aided by the activity of the ciliated epithelium lining the cervical canal, will gain the interior of the cavity of the uterus, and thence pass onwards to the Fallopian tubes. The significance of the glands in the mucous membrane lining the cervical canal has hitherto been underestimated in this connexion.

Whereas in the primitive state of mankind, among savage races at the present day, as among our own prehistoric ancestry, nakedness is the rule, so also intercourse in these circumstances is effected altogether without any regulation by law or custom, on the mere prompting of unbridled natural passion, and, moreover, there is the fullest promiscuity in sexual relations; but civilization has led man to impose restraints upon sexual intercourse, and has introduced marriage as a sacred institution. Among certain primitive peoples, however, among whom the wives are common to all the men, transitory pairings nevertheless occur, especially when a woman becomes pregnant; to cease, however, during the period of lactation. “This is the origin of marriage, which has evolved from rape and prostitution, as law has evolved from crime” (Lombroso). This author makes an interesting observation when describing the entire freedom of sexual intercourse that obtains among the Red Indians of North America, to the effect that “often, times of general promiscuity occur, as with rutting animals, generally in the warm season of the year, when nutriment is abundant; it is difficult to indicate any distinction between the tumultuous orgies of the baboon, and those of the Australian Blackfellows, among whom the sexes keep apart during the greater part of the year, to intermingle like rutting beasts during the season of the yam-harvest.”

The paths of civilization, from the complete promiscuity of sexual intercourse to the lofty ideal of life-long monogamic union, has not been a straightforward one, but has been marked by various aberrations of sexual relationship; hetairism, prostitution, polyandry, incest, rape, the jus primae noctis, etc. The anthropologist is able to trace the successive stages of the development of the institution of monogamic marriage; the community of wives within the clan; free sale of wives and daughters; bestowal of a man’s wife or concubine for the honour of a guest; ritual prostitution for the honour of the gods and at numerous religious festivals; æsthetic and literary hetairism, with bestowal of favours according to free inclination; community of wives among all males of the same family; the claim of the wife to as many as five or six husbands; the right of brothers to their sisters; the defloration of virgins by the priests in heathen temples; the temporary possession of the wife by the chief of the community, prior to her possession by her permanent husband; defloration of the bride by the bonze before her marriage; the feudal right of the mediæval seigneur to the prima nox of the bride of his retainer.

In the lower stages of civilization, copulation appears so natural an action that it is performed in public entirely without shame. Thus, Cook, in his first voyage, describes having seen an indigen engage in sexual intercourse with a girl of eleven years, under the very eyes of the queen, with whom Cook was then having audience; the sexual act was, according to Cook, the favourite topic of conversation between the sexes. Herodotus reports that many peoples of antiquity had no regard for privacy in sexual intercourse, but that, like the lower animals, they had connexion in any company. In the Bible, also, it is recorded that sexual intercourse was practised in public: “So they spread Absalom a tent upon the top of the house; and Absalom went in unto his father’s concubines in the sight of all Israel.” (II. Samuel, XVI. 22.) According to Athenaeus, the Etruscans, at their public banquets, were equally unrestrained. Plutarch reports that among the Spartans the maidens and the young men went about naked together. Even, indeed, after the sense of modesty had begun to develop, it was long before any secret was made about the act of intercourse. In classical antiquity, it was very frequently the subject of pictorial and plastic representation. Even in more recent days, there have been artists who have not hesitated to depict the sexual act: thus we have the Venus with a Faun by Caracci; the Jupiter and Io of Correggio; the Leda and the Swan of Tintoretto; and similar pictures by Luca Giordano, Rubens, Titian, and Franceschini.

Even in the early centuries of the Christian era, the sect of the Adamites practised intercourse openly in the light of day, on the ground that that which was right in the dark, could not be wrong in the light. The same is reported of the sect of Turlupins, in France in the fourteenth century. We cannot refrain from quoting at length from Lombroso and Ferrero a passage relating to the evolution of sexual manners in the female sex (Woman as Criminal and Prostitute): “In the lowest stages of development, the feeling of modesty is entirely wanting; limitless freedom in sexual intercourse is the general rule; and even where no system of promiscuity prevails, marriage rather fosters than discourages prostitution, especially in countries in which husbands are accustomed to expose their wives for sale. This fact may be brought into relation with the well known lasciviousness of apes and other animals high in the scale, showing that sexual excitability increases pari passu with intelligence, so that to man it is as impossible as to an ape to satisfy his sexual needs with a single female. Whilst among the apes, a single male possesses a number of wives, we find in the gregarious life of primitive man that community of wives has taken the place of polygamy, which institution, however, reappears in a higher stage of culture for the benefit of the more powerful masculine natures.

“To the dominion of prostitution as a normal institution succeeds the period in which it persists as a variously metamorphosed survival: it may be as the duty of the wife to surrender her person to any other male of the same family; or the woman may have to bestow her favors on a religious or political chief, as in the institution of temple-prostitution, where the wife must give herself, it may be to any one and at any time, or it may be to defined persons only and at stated festivals. Frequently we meet with another development of prostitution, finding that while the wife must remain chaste, the unmarried woman is allowed unrestricted intercourse; or, again, the wife at certain definite periods may dispense with fidelity to her husband, and return to the primitive condition of promiscuity. In certain instances prostitution is combined with the duties of hospitality, and marriage, though approximating to the monogamic ideal, must tolerate the intrusion of the guest into the marriage bed.”

“In a third period, prostitution no longer fills the place of a traditional survival, but is a morbid manifestation confined to a certain class of the community. But bridging this transition of prostitution from a normal to a morbid manifestation, we have the remarkable phenomenon of æsthetic prostitution. Thus, in India and in Japan, an agreeable class of prostitutes practices the arts of singing and dancing, and forms a privileged caste; similarly, in the most flourishing period of Grecian culture, the leading men of the time formed a social circle around the hetairæ, from whom they derived a fruitful stimulus to intellectual and political activity. In this respect, history repeated itself in Italy in the sixteenth century. Alike in classical Greece and in mediæval Italy, this æsthetic prostitution fanned the flames of a period of intense spiritual activity—for in individuals as in races, intellectual quickening is ever accompanied by erotic excitability.”

The unbridled passion of the primitive races of mankind, the coercive love of beauty felt by the ancient Greeks, the swelling flood of erotism of the great mass of people of all times, is gradually guided into the quiet channel of the marriage bed; and even though monogamic marriage is incapable of fully providing for all manifestations of sexual passion, still, from the medical point of view, we must maintain that marriage is for women the most hygienic and the most proper means of gratification of the sexual impulse.

Conception.

The union between ovum and spermatozoön, whereby fertilization is effected, appears to occur in the human species as a rule in the outer third of the Fallopian tube, the ampulla of this structure (receptaculum seminis in Henle’s terminology) serving to store the semen for a considerable period; in the lower animals, the usual occurrence of fertilization in this region has been established by direct observation. The open mouth of the tube receives the mature ovum, guided thither from the ovary by appropriate movements of the ovarian fimbriae; these movements have been seen in active occurrence in the guinea pig by Hensen. Once within the tube, the onward movement of the ovum is effected by the cilia of the epithelium lining of the canal.

His has formulated the theory that in the human species fertilization is possible only in the uppermost segment of the tube; an assumption that is probable enough, but cannot be regarded as definitely established. An analogy certainly exists among the lower divisions of the animal kingdom, for Coste, His, and Ohlschläger have proved that an ovum which passes through the Fallopian tube without being fertilized, undergoes notable alterations. Further, Coste has shown, in the case of the ovum of the domestic fowl, that this is no longer capable of being fertilized after it has passed through the upper segment of the oviduct. Other authorities, however, namely Löwenthal, Mayrhofer, and Wyder, oppose the extension of this rule to the human species. Löwenthal assumes that in the human female, fertilization ordinarily occurs in the cavity of the uterus, in the wall of which the unfertilized ovum has already embedded itself; and he supports his contention by the statement that spermatozoa are not to be found in the Fallopian tubes or on the surface of the ovaries. Mayrhofer and Wyder point out that the movement of the cilia of the ciliated epithelium is in the interior of the uterus in an upward direction, but in the Fallopian tubes is downwards in the direction of the uterus.

The contention of Löwenthal was disproved by Birch and Hirschfeld, who, in a prostitute dying during the act of intercourse, found, fifteen hours after death, living spermatozoa in the Fallopian tubes. On the other hand, more recent investigations, those, for instance, of Hofmeier, Mandl, and Bonn, have confirmed the data given above with regard to the direction of the ciliary movement in the interior of the genital passages. Moreover, O. Becker has shown that the ciliated epithelium of the tubes extends over the fimbriae and even on to the adjoining pavement epithelium of the peritoneum; and he believes that the ciliary movement of this region keeps up a constant current, the purpose of which is to sweep the ovum into the ostium of the tube, and thence down towards the uterus. Lode has adduced positive experimental evidence of the occurrence of such a movement of translation.

The general result of anatomical investigation is, that the conjugation of the ovum with the spermatozoön takes places in the ampulla of the Fallopian tube; but it is established that fertilization may also take place lower down in the tubes, or in the uterine cavity, or even on the surface of the ovary, i. e., in the abdominal cavity.

The fertilization of the mature ovum—maturation having occurred within the ovarian follicle before its rupture—has been shown by numerous researches on the ova of other animals to consist in the fusion of the male and the female nuclear substance; and it appears that of the enormous number of spermatozoa, estimated by Lode at 226 million at a single ejaculation, that enter the female genital passage, but a single one penetrates the ovum. Towards the head of this spermatozoön there extends from the surface of the ovum a process, flat at first, but becoming more and more prominent, until it surrounds the head, and fuses with it. The motile tail of the spermatozoön disappears, whilst the head, which has now passed through the vitelline membrane and entered the ovum, assumes the appearance of a nucleus, and is called the male pro-nucleus. The original nucleus of the ovum has previously prepared itself for fertilization by the extrusion through the vitelline membrane of portions of its substance (known as polar globules), and now constitutes the female pro-nucleus. Towards this latter, situated somewhere near the centre of the cell, the male pro-nucleus continues to move, the vitelline granules meanwhile being disposed round about it in radiating lines, forming a star-shaped figure. Having come into contact, the two pronuclei fuse completely to form a new nucleus, the nucleus of the now fertilized egg-cell. The result of fertilization is the formation of the first segmentation-sphere, from which, by further subdivision, the new individual is formed. Thus is effected that which Hippocrates describes in the words: “The seed possessed both by man and by woman, flow together from all parts of the body; the fruit is formed by the mingling of the two seeds.”

The most favourable period for the occurrence of fertilization appears to be when intercourse takes places from eight to ten days after the termination of the menstrual flow. In 248 instances in which the date of the fruitful coitus was exactly known, it was ascertained by Hasler that in 82½ per cent. of all cases, conception was effected in the fourteen days succeeding the menstrual period. In general it may be stated that the theory of the periodicity of ovulation and of the causal relation of this process to menstruation, has not been shaken by the result of researches recently undertaken by opponents of that theory; hence it appears that the fertilized ovum is the ovum of the last completed menstruation.

Already in the writings of the old Indian physician Susruta, we find expression of the view that the period that immediately succeeds the cessation of the menstrual flow is one most favourable to conception. “The time of generation,” he says, “is the twelfth night after the commencement of menstruation.” In the Jewish Talmud, the day before the onset of menstruation, and the days immediately succeeding the cessation of the flow, are indicated as those most favourable to the occurrence of conception; moreover, in the Talmud, notwithstanding the fact that intercourse during menstruation is prohibited on pain of death, and that coitus is not regarded as permissible until the lapse of twelve clear days after the cessation of the flow, nevertheless the assertion is made that intercourse during menstruation may lead to conception.

Hippocrates writes: Hae nempe post menstruam purgationem utero concipat. Aristotle says: Plerasque post mensum fluxum nonnullas vero fluentibus adhuc menstruis. Galen writes: Hoc autem conceptionis tempus est vel incipientibus vel cessantibus menstruis.

Soranus writes to a similar effect: Just as the soil is suitable only at certain seasons for the reception of the seed, so also in the human race intercourse does not always take place at a time suited for the reception of the semen. To be effective, coitus must occur at the proper time.... The act of intercourse that is to lead to conception may best occur either just before or just after the menstrual flow, when, moreover, there is strong desire for the sexual embrace, and neither when the body is fasting, nor when it is full of drink and undigested food. The time before menstruation is, however, unsuitable, for then the womb is heavy from the flow of blood, and two conflicting tendencies will come into operation, one for the absorption of material and the other for its outflow. During menstruation, again, conception is unlikely to occur, for then the semen is wetted and washed away by the flowing blood. The sole proper time is that immediately after the flow, when the womb has freed itself from its humours, and warmth and moisture stand in harmonious relationship.

Among many of the castes of Hindustan, it is a religious ordinance that on the fourth day of menstruation a man shall have intercourse with his wife, “since this day is that on which conception is most likely to occur.” Indian physicians advise, in order to bring about conception, “that coitus be effected always as soon as the menstrual flow has ceased, at the end of the day, and when the lotus has closed.” In Japan, medical opinion is to the effect that a woman is capable of conceiving during the first ten days after menstruation, but not later (Ploss and Bartels).

The view that the first days of the intermenstrual interval are those most favourable to the occurrence of conception, is further confirmed by the statistical data collected by Löwenfeld, Ahlfeld, Hecker, and Veit; and it appears that as the date of the next menstruation is approached, there is a continual decline in the frequency of conception; just before the flow, conception hardly ever occurs. Hensen, from the records of 248 conceptions in which the date of the fruitful intercourse was exactly known, draws the following conclusions:

1. The greatest number of conceptions follow coitus effected during the first days after the cessation of the menstrual flow.

2. When coitus is effected during menstruation, the probability of conception increases day by day as the end of the flow is approached.

3. The number of conceptions following coitus effected shortly before menstruation is minimal.

4. However, there is no single day either of the menstrual flow or of the intermenstrual interval, on which the possibility of the occurrence of conception can be excluded.

Feokstitow has drawn up from statistical data an ideal “conception-curve,” which teaches that conception most readily ensues upon coitus effected soon after the end of the menstrual flow, in the first week, that is to say, of the intermenstrual interval; moreover, the curve shows that the highest percentage of conceptions occurs on the very first day after the cessation of the flow, and that after this day the percentage of conceptions declines. The percentage frequency of conceptions from coitus effected on the last day of menstruation, and on the first, ninth, eleventh, and twenty-third days, respectively, of the intermenstrual interval, is expressed by the ratio 48 : 62 : 13 : 9 : 1; and between the points given, the course of the curve is almost rectilinear. The probability of the occurrence of conception on the twenty-third day of the interval (on which day the curve reaches its lowest point), is one-sixty-second of the maximum probability.

The proper performance of coitus depends upon the potentia coeundi of the male; the attainment of conception depends upon his potentia generandi. The potentia generandi demands from the man the functional competence of the testicles, the perviousness of the seminal passages (namely, of the vasa deferentia and the urethra), the secretion of a normal semen, and, finally, a proper formation of the penis, whereby during ejaculation the semen may be deposited in sufficient proximity to the os uteri externum.

Normal semen is a whitish, semi-transparent fluid, of the consistency of thin cream. It contains aggregations of a nearly spherical shape, consisting of a vitreous, transparent, colourless or light yellow, gelatinous, elastic substance. Under the microscope this substance has a hyaline appearance, and exhibits in its interior innumerable clear spaces of varying size, which are apparently filled with a clear fluid. Not infrequently, these spaces are extremely narrow and therewith greatly elongated and disposed in parallels, so that the whole substance thus obtains a striated appearance. When treated with water, this material becomes whitish and non-transparent, and assumes under the microscope a finely granular aspect. When allowed to stand without agitation for twenty-four hours, this substance dissolves and becomes so intimately mingled with the seminal fluid that it can no longer be clearly differentiated therefrom. In all probability it is merely a secretory product of the seminal vesicles.

The truly fluid portion of the semen contains the following morphological elements:

1. Microscopic aggregations of hyaline substance, variously shaped.

2. Very numerous granules, small and extremely pale, albuminous in their nature, and disappearing on treatment with acetic acid.

3. A small number of rounded or oval cells, about the size of leucocytes, containing one, or sometimes two small round nuclei.

4. Prostatic calculi. These are an inconstant constituent, but are very frequently met with after repeated coitus. According to some observers they are derived also from the bladder and urethra. They are distinguished by their yellowish colour, their irregular form (sometimes triangular, sometimes rounded or oval), and by their characteristic structure. They are composed of a substance arranged in concentric laminæ, which in the centre has a granulated appearance; they often exhibit one or more oval nuclei.

5. Spermatozoa in countless numbers.

In exceptional cases we find as additional morphological elements, especially in elderly people, scattered erythrocytes, cylinder-epithelium cells, and masses or granules of yellow pigment.

The spermatozoa are about fifty micromillimetres in length. Two parts may be distinguished in each, a head and a tail. The head, four or five micromillimetres in length, is flattened, and differs in apparent shape—though generally more or less pear-shaped—according as to whether it is seen sideways or on the flat.

The tail, which is about forty-five micromillimetres in length, narrows from before backwards. The fine posterior extremity is said to contain the contractile element, so that it is upon this portion that the familiar movements of the spermatozoa depend (Fig. 61).

The spermatozoa are made up of a substance very rich in sodium chloride, and strongly resistent to reagents and to putrefaction. In consequence of their richness in mineral constituents, the ash, when they are calcined, retains their original form.

The movements of the spermatozoa can be properly observed only in fresh, pure semen (Fig. 62).

If freshly ejaculated semen is treated with water, the movements of the spermatozoa very shortly cease, and their tails become rolled up in a spiral form.

If semen is left undisturbed for twenty-four hours or longer, the vitreous substance dissolves in the surrounding fluid, and this latter separates into two layers, an upper which is thinner, and a lower, which is thicker and non-transparent. In the former, the morphological elements are found but sparingly, whilst in the latter, they are plentiful. In addition to the elements already described, we find often two varieties of crystals. One of these varieties, which appears only when decomposition is far advanced, consists of ammonium magnesium phosphate. The other variety has a chemical composition not yet determined. These crystals belong to the monoclinic system, forming prisms or pyramids, often with curved surfaces; they are colourless or light yellow; they lie superimposed, often forming beautiful star-shaped figures. They are soluble in mineral and vegetable acids, and in ammonia, but are insoluble in alcohol, ether, and chloroform; they are remarkably resistent to the solvent powers of cold water, but not so to those of boiling water. Shreiner has proved that these crystals consist of a phosphate of a base which is represented by the formula C2. H5. N. According to Fürbringer, these crystals are produced as a result of the action of the semen upon the prostatic secretion.

The quantity of semen ejaculated during coitus is very variable, depending upon the age and size of the individual and the formation of his testicles, upon his individual sexual capacity, and upon the question whether antecedently there has been sexual excess on the one hand or long continued continence on the other. In general, the quantity of semen ejaculated at one time varies between 0.75 and 6 c.c. (10 to 100 minims).

If healthy, normal semen, with adequate fertilizing potency, is properly preserved from cold and light, we may, even after the lapse of twenty-four hours, find under the microscope spermatozoa still engaged in active movement. Ultzmann employs for the description of a drop of fresh semen, the comparison that it is full of movement, “like a stirred up ant-heap.” Influenced by the whiplike lashings of the tail, the spermatozoön moves steadily forwards, finding its way through the narrowest passages on the microscopic field without striking any of the cellular structures that may lie in its path. The longer the semen remains under observation, the less active are these movements of the spermatozoa, for after ejaculation they gradually die, exhibiting after death an extended, or at most a slightly curved tail; those spermatozoa, on the other hand, that were dead before ejaculation, have the tail spirally twisted, rolled up, or acutely bent. In the case of spermatozoa which have been destroyed by the action of some other deleterious secretion, as by urine or by acid vaginal secretion, such a condition of the tail is very commonly seen. When the semen is treated with water, the movements of the spermatozoa soon cease, and the ends of their tails frequently roll up to form loops. By the addition, however, of concentrated solutions of neutral salts, of albumen, of urea, etc., it is possible to reanimate these motionless spermatozoa, so that they once more are seen to perform active movements. Moderately concentrated animal secretions of an alkaline reaction are favourable to the motor activity of the spermatozoa, whilst on the other hand dilute and acid secretions, such as urine, acid mucus (including the acid vaginal mucus), and catarrhal secretions, even when alkaline in reaction, have a depressant influence on this activity. Caustic potash and caustic soda stimulate the movements of the spermatozoa. When they are cooled down to a temperature below 15° C. (59° F.), the movements cease entirely. Salts of the heavy metals, and mineral acids in solution, also bring their movements to a pause. Frequent repetition of coitus causes a diminution in the number and in the motor activity of the spermatozoa.

Semen which contains no spermatozoa, or in which the spermatozoa are motionless, is absolutely devoid of fertilizing power; in the case of such semen, it makes no difference whatever that the external genitals of the man generating it are strongly formed, that his testicles are of normal size, and that erection and ejaculation take place promptly. Of very little value, though not absolutely sterile, is semen containing very few living spermatozoa, or, among very numerous motionless spermatozoa, containing a few only that are engaged in active movement. Suspect, is semen which does not possess the normal light greyish white tint, but is brownish-red, brownish-yellow, yellow, or violet; these variations in colour indicating an admixture with the semen of varying quantities of blood or pus, in consequence of disease of the urethra, the prostate, the seminal vesicles, or some other part of the uropoietic system; such admixtures seriously impair the quality of the semen. An unfavourable judgment must also be passed on semen which, at each successive ejaculation, is voided in very small quantities only—from half a drachm to a drachm. When thus scanty, semen is often found to contain an exceptionally large proportion of dead spermatozoa. We may regard very favourably semen which is voided in quantities considerably in excess of the average; sometimes, when there is a veritable polyspermia, there may be an ounce or upwards, more than three times as much as normal—provided, of course, that this semen so richly voided is of a satisfactory quality, and contains an ample proportion of active spermatozoa. The most valuable characteristic in semen is exhibited when the spermatozoa it contains are not only very numerous and vigorously active, but when they are also very long-lived, when, that is to say, they retain the power of active movement sometimes for as long as three days. A decisive opinion as to the quality of a man’s semen can be given only as the result of precise and repeated microscopic examinations, and the medical man must be most careful, when in his first examination he has not been able to detect the presence of any living spermatozoa, to abstain from giving, on that account alone, an adverse decision—from pronouncing sentence of death on the man’s reproductive potency.

It has not hitherto been accurately determined how long spermatozoa can continue to live in the interior of the uterus, although the point is of great importance, not only in relation to conception, but also in regard to the theory of menstruation. Percy has published a case in which, eight and a half days after the last coitus, he saw living spermatozoa emerge from the os uteri externum. Sims bases upon his own researches the decisive opinion that in the vaginal mucus, spermatozoa can never survive longer than twelve hours, but states that in the mucus of the cervical canal they can live much longer. If thirty-six to forty hours after coitus, we examine the cervical mucus under the microscope, we commonly find living and dead spermatozoa in about equal numbers. Many of the living ones will survive their removal from the cervix for as much as six hours longer.

Of especial interest are the conditions which are liable to deprive a man of the power to produce fertilizing semen. In the first place must be mentioned congenital absence of both testicles—a condition which, in otherwise normally formed male individuals, is one of extreme rarity. Congenital absence of one testicle is less rare, and is usually accompanied by absence also of the epidydimis, vas deferens, and seminal vesicle of the same side. The potentia gestandi of a monorchid depends upon the proper development of his single testicle, and the functional capacity of this organ must be ascertained by a careful microscopic examination of his semen. Much more frequent than absence of the testicle, though still sufficiently rare, is the condition of cryptorchism, non-descent of one or both testicles, a state not necessarily associated with functional incapacity of the organ. Most commonly, however, an undescended testis is an imperfectly developed testis, and in the very great majority of cases the ejaculated fluid contains no spermatozoa.

A further cause of the lack of potent semen is atrophy of the testicles with notable diminution in the size of the glands, and more or less complete disappearance of the seminiferous tubules and their cellular contents. This state is rarely congenital, being nearly always acquired: in consequence of inflammatory conditions affecting the testicle proper or the epididymis (syphilitic inflammation, especially, is apt to lead to overgrowth of the interstitial connective tissue and to gradual destruction by pressure of the seminal tubules)[46]; or in consequence of the pressure of a hernia, a varicocele, a hydrocele, or a tubercular, carcinomatous, or other new growth; or in consequence of constitutional disorders, especially long-lasting, severe, and exhausting diseases, such as diphtheria, diabetes, or chronic alcoholism; in consequence of diseases affecting that portion of the central nervous system from which the nerves supplying the genital organs arise; in consequence of degenerative changes resulting from sexual excesses; or, finally, in consequence of senile changes, such as fatty changes in the cells of the seminiferous tubules. Certain drugs also, digitalis, salicylic acid, mercury, iodide of potassium, arsenic, and morphine, have an unfavourable influence alike on the quality of the testicular secretion and on the potency of the individual. Von Gyurkovechky reports that in Bosnia a plant locally known as “neven” is employed among the peasantry for the temporary suppression of sexual potency, wives giving it to their husbands when the latter are about to leave them and go upon a journey, and sprinkling the leaves of the plant among the underclothing.

By the name of azoospermia is denoted a condition whose existence can be determined only by microscopic examination.

The subject of this affection has normal potentia coeundi, the semen is ejaculated in quite normal fashion, and it is its constitution only that is faulty. In appearance it is extremely fluid, and is somewhat cloudy; its sediment contains molecular detritus and spermatic crystals, but no spermatozoa (Fig. 63). If the medical man makes it his rule, in all cases in which he is consulted on account of sterility, in deciding how far this sterility is dependent on the condition of the husband, not to confine himself solely to the customary questions, whether intercourse is regularly practised, whether before or after menstruation, etc.—but if in every case he makes a careful examination of the semen under the microscope, he will be astonished to learn the comparative frequency with which he will note the complete or nearly complete absence of spermatozoa. This condition of azoospermia may be permanent or transitory.

To Kehrer belongs the credit of having pointed out that sterility is less often due to impotence or to aspermatism than to azoospermia—a condition often unsuspected by husband and wife, and one to be diagnosed by the physician only after repeated microscopic examinations of the semen. For this reason, indeed, its existence is often overlooked. Kehrer believes himself to be justified in asserting that one-fourth of all cases of sterility (if not indeed more) must be referred to conditions affecting the husband, and most often to azoospermia; hence he concludes, that the husband must still more often be regarded as the one to blame for the occurrence of sterility, when the cases are borne in mind in which a man marries with an imperfectly healed gonorrhœa, and infects his wife, giving rise to a chronic tubo-uterine blennorrhœa, and ultimately to sealing up of the tubes and to sterility.

Complete absence or marked scarcity of spermatozoa in the semen may occur also without any change in the testicle that can be detected by an external examination, as a consequence of contusions of the testicle, or of gonorrhœal inflammation of the epididymis or vas deferens; further as a sequel of severe general diseases, long-continued physical exertion, or great sexual excess.

In some cases, a microscopical examination reveals, not azoospermia, but oligozoöspermia, that is to say, the number of living spermatozoa in the semen is remarkably small. Or, again, the anomaly may be of this character that the spermatozoa are smaller than normal, that they are motionless, and that their tails are broken off—such are the peculiarities, as a rule, of the semen of old men.

A less common condition than azoospermia, but one the pathological importance of which is equally great, is aspermatism, in which the man, neither during coitus, nor in any other form of sexual excitement, is able to ejaculate any semen. This condition may be congenital or acquired; it may be permanent, or transitory (lasting a few weeks or months). In these cases we have to do with organic changes in the testicles, diseases of the prostate, gonorrhœal processes, or nervous disturbances resulting in a loss of irritability in the reflex centre for ejaculation. Aspermatism in the narrower sense of the term, a condition, that is to say, in which there is total suspension of the activity of all the three glands which combine to secrete the composite fluid known as semen, namely, of the testicle, the prostate, and the seminal vesicles—is, according to Fürbringer, probably non-existent. The pathological state underlying aspermatism would rather appear to be, not a failure to secrete semen, but a failure to ejaculate it.

Last of all, we have to speak of conception without copulation, of artificial fertilization. In consequence of the mechanical hindrances which in many cases prevent the entrance of the semen into the interior of the uterus, the idea has arisen to introduce the semen by means of instruments directly into the cervical canal, dispensing with the natural act of copulation. Experience long ago gained in artificial pisciculture, no doubt gave rise to this idea. Spallanzani and Rossi by means of a syringe injected the semen of a dog into the vagina of a bitch, the procedure resulting in impregnation. Girault appears to have been the first,[47] in the year 1838, to introduce semen artificially into the human uterus, if we leave out of consideration the experiment of Léseurs, who introduced a tampon moistened with semen into the interior of the vagina. The procedure employed by Girault is thus described: The patient having been placed in the position usually employed for gynecological examination, a canula resembling a male catheter with the eye in its point, and with a funnel-shaped enlargement at the opposite extremity, is introduced into the uterus, this instrument having first been prepared by moistening its interior with mucilage and filling it with semen; by insufflation, the semen is now expelled into the uterine cavity. It is stated that neither uterine colic nor any other dangerous symptom has ever been brought on by this procedure. The experiments were made at various periods between the year 1838 and the year 1861; they were ten in number, and of these eight proved successful, two unsuccessful. In the ten cases, the total number of insufflations made was twenty-one—the minimum number in any single case being one, the maximum five. In one case, the insufflation was effected immediately after the cessation of menstruation; in the majority, from one to four days after the cessation of menstruation; in one case twelve days, in one case twenty-three days, after the cessation of the flow. Gautier, instead of insufflations, has employed injections of semen, using two injections in each case, one just before menstruation was expected, the other a day or two after the cessation of the flow. Marion Sims endeavoured in twenty-seven cases to bring about conception by the injection of semen into the uterus; in one of these cases only was the desired result obtained. In this latter instance the patient was twenty-eight years of age, had been married for nine years, but had remained barren. Throughout her menstrual life, she had suffered more or less from dysmenorrhœa, often accompanied by severe constitutional disturbance, such as syncope, vomiting, and headache. Local examination disclosed the existence of retroversion of the uterus with hypertrophy of the posterior wall, an indurated, conical cervix, with stricture of the cervical canal, especially in the region of the os uteri internum. In addition to all these mechanical obstacles to conception, it was found that the semen was never retained in the vagina after coitus. Sims examined the patient immediately after coitus had taken place, but never found a single drop of semen in the vagina, notwithstanding the fact that this fluid had been ejaculated in abundance. Sim’s first care was to bring about reposition of the uterus, and to keep the organ in its proper place by the insertion of a suitable pessary. Injections of semen were then undertaken, and were continued throughout a period of nearly twelve months. In two instances, the injection was effected immediately before the onset of the menstrual flow; in eight instances it was effected at varying times (two to seven days) after the cessation of the flow. At first, three drops of semen were injected, but later only half a drop. The semen (first ejaculated into the vagina during normal intercourse) was injected by means of a glass syringe, which was kept in a vessel of warm water at a temperature of 98° F. Since during the removal of the instrument from the water and its insertion into the vagina, some fall in temperature necessarily occurred in the vagina, Sims allowed the syringe to remain for some minutes in the vagina before he drew the semen into it, in order that he might feel assured that syringe and vagina had regained the temperature most adapted to the vital activity of the spermatozoa. The nozzle of the syringe was then carefully introduced into the cervical canal, and half a drop of semen was slowly injected into the uterine cavity. For two or three hours after the operation, the patient remained lying quiet in bed. After the tenth experiment, conception ensued—the first recorded case of artificial fertilization in the human species.

With right, however, this case of Sim’s was not regarded as conclusive, since both before and after the injection, ordinary coitus had been effected, and it is therefore impossible to determine whether the fertilizing spermatozoön was one of those introduced by means of the syringe, or in the antecedent or subsequent coitus—more especially in view of the fact that by the insertion of a pessary Sims had, previously to undertaking the injections, restored the uterus to a position more suited to the occurrence of conception in the natural manner.

In a case which a priori seemed exceedingly well adapted for the performance of artificial fertilization, one of marked hypospadias in a man whose semen was abundant and contained a large number of vigorously moving spermatozoa, I saw this experiment fail, in spite of all possible care in its performance. In fact, not a single conclusive instance of successful artificial fertilization in the human species is known to me, though I have seen reports of numerous disagreeable and even dangerous results of attempts to effect it. Both parametritis and perimetritis have occurred in such cases; and semen, being a material in a state of most intense molecular movement, may be regarded as extremely liable to noxious transformations.

Sim’s procedure has been modified by other gynecologists. Thus, Courty’s plan was that during coitus the semen should be collected in a condom, fitting not too closely, from which receptacle it was drawn up into a syringe and carefully injected into the cervical canal. Pajot’s plan was that the semen should be ejaculated into the vagina in natural coitus, and should thence be pressed into the uterine cavity by means of a piston-like instrument introduced into the vagina.

In London, Harley frequently made the experiment of injecting semen into the uterine cavity, but in all cases without any result.

P. Muller, in two cases, on account of extreme anteflexion of the uterus, performed this experiment. Though the general conditions were in both cases extremely favourable, in neither instance was there any result. It must, however, be mentioned that in one of his cases only had there been any preliminary examination of the semen under the microscope.

Fritsch reports a case in which gonorrhœal secretion was injected in place of semen. Peritonitis, which for a month endangered life, was the result.

In Paris, Lutaud has earnestly advocated artificial impregnation in cases of sterility in which all other means have failed. It is obvious that it would be useless to employ this measure after the menopause, or in women in whom menstrual activity has ceased prematurely, with simultaneous disappearance of all menstrual molimina. Equally useless would it be in uterine atrophy and in cases of irremediable malformation of the female genitals. Further contra-indications, according to Lutaud, are offered by chronic pelvic peritonitis, since here, on account of the obliteration of the lumen of the Fallopian tubes, the operation is foredoomed to failure. Chronic inflammatory states of the uterus and its mucous membrane, will also render the attempt useless. Moreover, it is a condition indispensable to success that the semen to be employed shall have been examined microscopically, and shall have been found to be thoroughly healthy. The operation has the greatest prospect of success when undertaken from three to two days before the due date of menstruation. The method employed is that of Sims. If after the first attempt, the due menstruation should begin, the injection should be repeated a week after the flow has ceased; the attempt should not, however, be repeated more than about six times in all, since the probability of success rapidly diminishes with each successive endeavour. Before the operation is undertaken, the permeability of the cervical canal must be ascertained. Further, in order that the spermatozoa shall be placed in conditions in which they have the best possible chance of survival, a weak alkaline solution, such as 1 per cent. of potassium bicarbonate, should as a preliminary measure be injected into the vagina.

Lutaud thus describes the procedure he employs. Immediately after the woman has had intercourse with her husband, a Fergusson’s speculum is introduced into the vagina, the patient remaining in the dorsal decubitus. As the speculum passes in, its margin scrapes the surface of the vagina, and by this means the semen is collected in the vicinity of the cervix. The semen is then drawn up into a Pravaz syringe or an analogous instrument, such as a uterine catheter armed at one end with a rubber ball. The fluid is then carefully injected into the cervical canal, or preferably into the uterine cavity, great care being taken not to injure the mucous membrane in any way, since the slightest bleeding may nullify the whole procedure. Finally, a small tampon of absorbent cotton-wool is inserted into the os uteri externum. For some hours the woman must remain quiet in bed; the tampon is not removed for ten hours. As regards results, Lutaud informs us that he has in this way treated twenty-six cases. In twenty-two of these, failure was complete; in one case, success was partial—the patient was impregnated, but abortion occurred two weeks later; in another case, abortion occurred after three months pregnancy; finally, in two cases, success was complete.

Indications for the employment of artificial impregnation are: first, the existence of stenosis in the upper part of the cervical canal, especially stenosis from flexion, provided, of course, that other measures are contra-indicated or have been fruitlessly employed; secondly, a deleterious character of the secretion of the cervical canal; thirdly, extreme cases of hypospadias in the male. Haussmann recommends the employment of artificial impregnation in cases in which the spermatozoa are found to enter the cervical canal, but fail to pass through the os uteri internum. Whilst artificial impregnation is theoretically a sound measure, yet in the practice the indications for its performance are by no means easy to establish. For, in cases in which there is some mechanical hindrance to the contact of the spermatozoön with the ovum (and it is for such cases only that this method of artificial fertilization can properly be employed), it is often extremely difficult, and may even be quite impossible, to exclude the possibility of there being some failure in ovulation itself, or in the maturation of the ova; or, again, sterility may depend, not on the fact that no ova are fertilized, but on the fact that when fertilized they always fail, for some reason, to find a resting place in the uterus; in a word, in any case in which sterility appears to be due to mechanical obstacles to conception, it may in reality be due to some other disease which has escaped recognition, some organic disease of the uterus, the tubes, the ovaries, of the periuterine tissues.

Finally, it must be remembered that the manipulation is far from easy in its performance. Above all, the semen must be subjected to a most rigorous microscopical examination in respect of its fertilizing capacity. But this examination cannot be made in the case of the semen that is actually used for the attempt at artificial fertilization; it can only be done with an earlier specimen from the same man. If the semen contains no living spermatozoa, or very few only and these sluggish in their movements, still more if it contains pus corpuscles or gonococci, all idea of its employment for artificial fertilization must be rejected.

The method employed by Sims, in which the semen is drawn into a syringe inserted into the vagina post coitum, is one which I am not able to recommend, since in this way together with the semen some vaginal mucus is drawn up, thus, instead of pure semen, we inject into the vagina semen mixed with various impurities, and more especially with an acid secretion known to be unfavourable to the life of the spermatozoa—a circumstance that will doubtless explain many of the failures that have hitherto taken place. It is certainly better that the semen of the husband should be collected in a rubber condom. The preservation of the material to be injected at a suitable temperature (the normal body-temperature), is by no means easy. The syringe, an ordinary Braun’s uterine syringe, is first disinfected, and then lies ready in water of the proper temperature. The semen is rapidly drawn up into the syringe, the nozzle of which is then passed down to the fundus uteri. Quite a small quantity of semen will suffice. After the manipulation, which should of course be undertaken at the time most favourable to conception, just after menstruation, the woman should lie quiet in bed for some hours.

In considering the probability of a successful issue to any such attempt to secure artificial fertilization, we cannot leave out of consideration the likelihood that that result may be prejudiced by the lack of all normal sexual feeling on the part of the wife; concerning the significance of such feeling in relation to the sexual act, we have however as yet no certain knowledge.

That this procedure of artificial fertilization is extremely disagreeable to all concerned therein, the physician not excepted, and that various moral and social considerations can be alleged against it, is incontestable. It is indeed recorded that in Bordeaux a legal penalty was inflicted on a medical man who undertook to bring about artificial fertilization. The Society of Medical Jurists debated this matter, and came to the conclusion that, whilst a medical man was not justified in recommending the practice, neither was he justified in refusing to undertake it when requested by his patients. In Paris, a candidate for the degree of Doctor of Medicine made artificial fecundation the subject of his thesis, and maintained that its practice, when effected with all proper social precautions and according to scientific principles, was possible, reasonable, useful, and moral, and that in many instances it should be recommended by the physician. After a long and stormy debate, the Faculty of Medicine determined to reject the thesis and to destroy all specimens of it already printed, on the ground that “they feared, if they gave their sanction to the practice, that a number of more or less unscrupulous physicians would make that sanction the basis of improper practices, dangerous alike to the family and to the state, since the operative method under consideration was one likely to be eagerly exploited by the whole tribe of medical charlatans.” This weighty pronouncement would appear to be sufficient ground for rejecting artificial fecundation as a matter of routine practice; still, very exceptional cases may be encountered in which it may be seized as an ultimum refugium.

Pathology of Copulation.

The act of copulation may be interfered with or entirely prevented by pathological conditions affecting the genital canal of the woman, and also by disturbances of the nervous system—naturally also by any abnormality affecting the performance of the male partner in the act.

Abnormality of the hymen, such as excessive strength and rigidity, rendering the organ unduly persistent, is a not infrequent hindrance to intercourse, one that sometimes is not overcome even after years of married life; to such a state of affairs ignorance on the part of the married pair in respect to the proper method of intercourse, lack of sufficient sexual power on the part of the male, or inflammation of the fossa navicularis brought on by maladroit attempts at penetration, may contribute, likewise undue passivity on the part of the female partner.

A notable and sometimes an insuperable obstacle (of which it has been written, nec Hannibal quidem has portas perfringere valuisset) is constituted by that abnormality of the hymen in which the aperture in that membrane is guarded by a sagittally placed or sometimes oblique septum, dense and almost tendinous in structure. In a woman of twenty-four years, who for two years had lived in sterile wedlock, I found such a tendinous hymen septum. She had menstruated regularly since the age of seventeen years, but always painfully. She complained that her husband was “very weak,” inasmuch as on her bridal night he was unable to succeed in completing intercourse, and since then whenever he attempted intercourse, premature ejaculation resulted, before penetration of the penis had been effected. In consequence of this repeated ineffectual sexual excitement, she had herself become very nervous. On local examination, I found an elongated oval hymen, not completely covering the vaginal orifice, rather strong and thick, and divided in two halves by a median sagittal septum, of a densely tendinous consistency. On either side of the septum, the vaginal orifice would admit no more than the head of an ordinary uterine sound. I divided this septum, and was informed later that the woman had become pregnant as a result of the first subsequent act of intercourse (Fig. 65).

A remarkable case of abnormality of the hymen is recorded by Heitzmann, having been observed by him in a woman aged twenty-seven years. In this instance, the hymen was represented by a swelling, smooth on the surface and separated from the nymphæ by a deep furrow. Behind this swelling, between it and the posterior commissure, there was a deep depression, into which the finger could be passed to a depth of an inch and a half or more. Anteriorly, the very firm and fleshy prominence was bounded by a ridge, from the middle of which to the urethral orifice ran a short but strong and tense septum. Right and left of this septum were small apertures, with difficulty admitting the point of a probe. Between the anterior extremity of the septum and the urethral orifice was a nodular representative of the swelling normally present in this situation. Surrounding the urethral orifice were two or three additional small nodules. The two lateral margins of the hymen were prolonged around the urethral orifice, and united in front thereof to form a raphe, which could be traced as far as the base of the clitoris. The young woman had been married for some months, and asserted that she had repeatedly had intercourse. With such a condition of the female genitals, penetration of the penis into the vagina was however quite impossible. During coitus, the penis must have been inserted into the aforesaid depression behind the swelling, which was sufficiently extensible for the purpose.

A less serious hindrance to intercourse, but one more frequently encountered, is a partial persistence of the septum of the hymeneal orifice, in such a manner that there is a projecting tongue of membrane from the anterior and posterior margins of the orifice, partially blocking this latter; or there may be a single median projection only, either in front or behind. Such processes may be remarkable alike for their size and their shape. Liman describes a cordiform hymeneal orifice, constituted by an anterior or posterior protection of the kind here described.

In cases of imperforate hymen in which the occlusion of the vagina is not complete, impregnation may in rare instances occur, even though proper intromission of the penis is quite impossible. Cases of this kind have been observed by Scanzoni, Horton, K. Braun, Leopold, Brill, Breisky, and others.

In most of these cases there was a thick, dense, “imperforate,” or rather persistent hymen, with an orifice no larger than the head of an ordinary probe, notwithstanding which pregnancy had occurred. The cases reported by Brill were of a different character, being those of two young unmarried Russian girls, with normal undestroyed hymens, who were found to be pregnant. According to Brill, such cases are by no means uncommon among the peasantry of Little Russia, where the barbarous practice prevails of adolescent girls and boys sleeping together. In these circumstances, sexual intercourse takes place, but, from fear of consequences, it is often incomplete. Hence, in occasional cases, results pregnancy in a young girl with intact hymen.

In the first complete act of intercourse, the defloration of the virgin, the hymen is as a rule torn in several directions, and in consequence there is usually moderate bleeding. The lacerations of the hymen soon skin over. When the initial coitus is effected maladroitly or roughly, more extensive lacerations are apt to occur, and the injury may not be limited to the hymen, but may extend longitudinally along the vaginal wall, and even involve the posterior vaginal fornix. Or, again, without any such extensive laceration, there may result very profuse bleeding, in consequence of abnormally profuse vascularization of the hymen. Cases are also recorded in which (presumably not from normal coitus alone, but from other, unacknowledged manipulations), whilst the hymen has been left intact, false passages have been made, leading to the formation of fistulæ, with subsequent death from haemorrhage or sepsis.

Apart from impotence in the male, the hymen may remain intact when it is not touched at all during coitus. Inexperience, as Veit remarks, will in this matter lead to results almost incredible. This author has been informed by such inexperienced married couples, that in attempts at intercourse “the penis of the man is introduced between the thighs of the woman, which are closely pressed together, the man having his legs on either side. Naturally, in this method of intercourse, the hymen escapes destruction. In such attempts at coitus, things are done which can hardly be compared with the normal act of copulation.”

In isolated instances, the introduction of the penis is prevented by congenital or acquired defects in the formation of the external genitals. Adhesion between the labia majora and the labia minora is sometimes met with a congenital deformity, which may or may not be associated with atresia of the urethral orifice; in some cases the adhesion is dependent merely upon a superficial epithelial continuity, but in others the labia are firmly adherent throughout. Less rare are acquired adhesions, the result of accident, between the labia majora and the labia minora, leading to atresia of the vulva, and thus making copulation impossible.

Intromission of the penis may be rendered quite impossible by excessive size of the labia majora, consequent upon elephantiasis, in which disease there is enormous hypertrophy of the subcutaneous connective tissue. New growths may have the same result, fibroids, for instance, lipomata, and cysts, which may attain a remarkable size in the cellular tissue of the labia, the mons veneris, and the perineum, and also in the nymphæ and in the cellular tissue between the clitoris and the urethral orifice. In a very obese woman twenty-eight years of age I saw a lipoma attached to the right labium majus. In the course of six years it had grown to such an enormous size, that it extended downwards over the thigh, blocked the entrance to the vagina, and made coitus absolutely impossible (Fig. 67). Various forms of labial hernia are also competent to occlude the vaginal orifice.

Hypertrophy of the nymphæ, which, as the so-called Hottentot Apron has to be regarded as a racial peculiarity, is known also in Europe as a pathological condition which may at times constitute a hindrance to sexual intercourse (Fig. 68). According to Otto there are three fundamental forms of the Hottentot apron, viz., excessive enlargement of the nymphæ, overgrowth of the labia majora, and, lastly, the formation of a peculiar lobe of flesh and skin, attached to the mons veneris by a pedicle, containing the clitoris, and covering the genital fissure as with a valve. Hypertrophy of the nymphæ is said to be common also in Turkish and in Persian women. Owing to the obstacle to intercourse presented by hypertrophied nymphæ, it is among certain races an established custom to amputate clitoris and nymphæ together. Virey writes: “The Portuguese Jesuit missionaries to Abyssinia in the sixteenth century, endeavoured to abolish this practice of the circumcision of women, which they regarded as a relic of Mohammedanism; the uncircumcised maidens, however, could find no husbands, owing to the inconvenient length of their nymphæ. The pope sent surgeons to the country, to enquire into the matter, and their reports were in such sense that circumcision was permitted as necessary.” Davis reports observations made by Sonini on the female indigens of lower Egypt, in whom the vulva hangs down in the form of a loose, flabby mass of flesh, of striking length and thickness, completely covering the genital fissure. He believes that the circumcision that was practised on the women of ancient Egypt consisted in the removal of this hypertrophied vulva.

Courty saw a case in which the remarkable length of the labia minora, which when an attempt was made to introduce the penis, covered the vaginal orifice, had rendered coitus ineffective, and had caused sterility for five years. Resection of the labia minora was followed by successful intercourse and conception.

The lipomatous form, especially, of elephantiasis vulvae often attains a gigantic size. Growths of this nature, of the size of a child’s head, weighing six or seven kilo (thirteen to fifteen pounds), and reaching down to below the knee, are by no means rare. I have known several cases in which an excessive accumulation of fat in the vulva associated with pendulous belly has constituted a mechanical obstacle to the completion of sexual intercourse.

Hypertrophy of the clitoris may constitute an obstacle to coitus. In exceptional cases, this organ is as large as the male penis, and hangs down over the genital fissure like a valve. Hyrtl relates that in certain African races, this congenital enlargement of the clitoris is so enormous, that the organ, made fast to the perineum with rings, serves for the protection of virginity. Schönfeld describes the case of a woman aged twenty-eight years, in whom the vaginal orifice was almost completely occluded by a dry and firm growth, with a granulated surface. Close observation proved this growth to be produced by a hypertrophied and degenerated clitoris, which had attained the size of a child’s head. Elephantiasis of the clitoris is especially inconvenient in consequence of the hindrance which the enlarged organ offers to sexual intercourse. Bainbridge describes a case of tumour of the clitoris measuring 8 cm. (3.2 in.) in length and 5 cm. (2 in.) in width. The following remarkable case is recorded by Oesterlen: A young man wished to break off his engagement on the ground that his intended wife was a hermaphrodite. Examination, however, disclosed the existence of a strong intact hymen, a very large clitoris, and pregnancy of the twentieth week.

Injuries of the vagina resulting from coitus are, generally speaking, rare. The usual cause of such injuries is disproportion in size between the erect penis and the calibre of the vagina, or else brutal violence in the performance of coitus; sometimes, however, it is dependent on the pathological state of the female genital organs, which have undergone senile atrophy.

To the first group belongs the case reported by Albert, in which a girl of eleven years was found to have a laceration of the vagina communicating with the peritoneal cavity, the injury resulting from coitus. To the second group belongs the case reported by Böhm, of lacerations of the vaginal mucous membrane resulting from forcible coitus in elderly women. E. Frank reports a case of injury due to violent coitus in a woman in whom the vagina was already greatly stretched by retroflexion; and another case in which injury occurred during intercourse in a woman with vagina duplex—in this case, not only was the hymen of the right vagina torn, but also the septum between the two vaginae.

By no means extremely rare are injuries to the vagina in the act of defloration, causing severe hemorrhage. Martin records a fatal case of this nature. Maschka and Hofmann, the authorities on Forensic Medicine, deny that vaginal laceration is the result of simple coitus, and Hofmann maintains that such serious injury can occur only from digital manipulations; in fact, these writers believe that the penis alone cannot be employed with sufficient force to cause laceration. Barthel and Anderson, however, saw vaginal lacerations in nulliparous women; and Zeis records a case of vaginal laceration in a woman twenty-five years of age, with whom, six weeks after parturition, her husband, then in a state of intoxication, had had intercourse in the position à la vache.

Anomalies of the vagina, absence, stricture, duplication, and abnormal apertures, also diseases of the vaginal tissues, may induce incapacity for sexual intercourse. In frequency as in significance, among these disorders, absence of the vagina and stenosis and atresia of the canal, stand in the first rank. Congenital atresia may be complete or only partial, according as the two ducts of Müller from the fusion of which the tube is formed, remain totally or only partially solid—or, having duly canalized, subsequently, by a foetal inflammatory process, become transformed into a thick, more or less solid cord. If the obliteration of the vagina is at the lower extremity of the canal, coitus is impossible, unless, as sometimes happens, by frequent attempts at intercourse, the short blind sac representing the lower end of the vagina has been stretched upwards in the form of a pouch. When the obliteration of the ducts of Müller is complete, we have total atresia of the vagina, in which case the uterus is also as a rule wanting, or is but imperfectly represented. In some cases, from the ducts of Müller, instead of the normal vagina, there is formed a tract of membrane of varying density and width, through which passes a small canal for the passage of the menstrual discharge; this condition is known as atresia vaginalis membranacea.

When, notwithstanding malformation of the external genital organs and partial absence of the vagina, there is no defect in the internal genital organs, conceptions may sometimes be effected through some abnormal channel, as for instance through a communication established per anum; or, again, some operative procedure may bring relief. Rossi reports a case of congenital absence of the external genital organs, in which an incision was made in the region of the absent vagina, and an artificial vagina was thus constructed; copulation was in this way rendered possible, and conception ensued. In this connection, we may turn with interest to the essay by Louis, entitled Deficiente Vagina, Possuntne per Rectum Concipere Mulieres? Here we are told of a case in which vulva and vagina were absent, and there was a monthly discharge of blood per anum; the woman’s lover employed this passage also ad immissionem penis, and the woman became pregnant. Pope Benedict XIV expressly allowed to women suffering from imperforatio vaginae the practice of coitus parte posteriori.

Further, in cases of atresia vaginae in which the genital canal terminates in the urethra, conception can result from urethral coitus, as is proved by cases recorded by K. von Braun, Weinbaum, and Wyder. In Weinbaum’s case, the obliteration of the vagina was complete, neither eye nor finger could detect the slightest aperture; the woman having become pregnant after coitus per urethram, delivery was effected by Caesarian section. In Wyder’s case, the vaginal orifice was closed, with the exception of a minute aperture, by means of dense fibrous tissue; the woman was in labour and the head of the child was in the pelvis. Under anæsthesia, the septum, which was nearly an inch thick, was divided, the opening was enlarged, and the child was extracted by forceps. An investigation disclosed that the husband had always had intercourse by introducing his penis into the dilated urethra; it was evident that the semen had passed through the urethra into the bladder, and thence had found its way through a vesico-vaginal fistula into the vagina and uterus.

Acquired obliteration and stricture of the vagina from the contraction of scar tissue, in consequence of deep ulceration, especially when croupous or diphtheritic in nature, following typhus or typhoid, pyaemia, puerperal sepsis, and the acute exanthemata (especially variola)—may likewise serve as obstacles to coitus. Syphilitic affections also, through contraction of exudations, the adhesion of ulcerated opposing surfaces, condylomata, etc., may give rise to stricture or obliteration of the vagina. The same conditions may be induced by trauma, as by wounds, by attempts at rape, or by the use of caustic acids and alkalis.

Thus, Ahlfeld saw severe stricture of the vagina as a sequel of the excision of four large condylomata. Hennig the same, after variola, and again in lunatics who had introduced caustic fluids into the vagina. By L. Mayer, atresia vaginae was seen as a sequel of typhoid; by Weiss as a sequel of diphtheria; by Martin from the action of irritant secretions in cases of uterine tumour; by Billroth as a result of continued irrigation of the vagina with alkaline urine after lithotomy or urethrotomy, and in cases of vesico-vaginal fistula. Ulcerative processes set up by the long continued action of a vaginal tampon, a pessary, or some other foreign body, have been noted as leading to consecutive obliteration of the vagina.

Such stenosis, when partial only, may prevent complete coitus, and yet allow conception to occur. Cases illustrating this fact have been numerously recorded. Thus, van Swieten already reported the case of a girl aged sixteen years, whose vagina was strictured to such an extent that the passage would barely admit a crow-quill; nevertheless she became pregnant, and was successfully delivered. Similar cases are mentioned by von Scanzoni, Kennedy, Devilliers, Varge, Moreau, and Plenk.

Serious obstacles to coitus, of a nature analogous to acquired stenosis of the vagina, are constituted by the irregular ligamentous bridges which sometimes arise in the vagina from the adhesion of a strip torn from the mucous membrane on one side of the vagina to the other side of that tube—or, again, a portion of a lacerated cervix may adhere to the wall of the vagina. An interesting case of this nature came under my own observation. It was a woman aged thirty-two years, who had twice had difficult deliveries, the last time nine years before. Since then she had been barren. On local examination I found in the vagina a fleshy bridge, about 4 cm. (1.6 in.) wide and 6 cm. (2.4 in.) long, extending from the left side of the portio vaginalis to the right wall of the vagina; this mass of tissue was so placed that the intromitted penis must necessarily have slipped past it into a blind sac, such as the French name une poche copulatrice. Similar membranes in the vagina have been described by Breisky, Murphy, and Thomson.

Various tumours may narrow or even completely close the vaginal passage, myoma, sarcoma, carcinoma, and especially the polypoid form of fibromyoma, which may even project without the vaginal orifice. And even when tumours of or in the vagina do not actually hinder coitus by the space they occupy, they may affect that operation by bleeding whenever it is undertaken, a manifestation extremely alarming to young married persons.

The vagina may also be partially occupied, and coitus may be impeded, by elongation of the hypertrophied cervix uteri, by inversion or prolapse of the uterus, by cystocele or rectocele, and by uterine polypi. Horwitz records the case of a woman aged twenty-two years in whom impotentia coeundi was dependent upon the occlusion of the vaginal orifice by a rounded, strongly projecting body, which proved on closer examination to be a hypertrophied vaginal bulb.

Tumours of the rectum and other intrapelvic growths may encroach upon the vaginal passage and impede coitus. Closure of the vagina has been brought about even by abnormal size and abnormal toughness of the perineum.

Finally, in extreme degrees of pelvic contraction, the vagina may be so much narrowed as to interfere with coitus. Von Hofmann records a case of this nature: In a woman thirty years of age, affected with kypho-scoliosis, who suffered extreme pain whenever her husband attempted sexual intercourse, the pelvis was twisted and narrowed to such an extent that the conjugate measured barely one inch, and the vagina was so small as barely to admit the finger.

Duplication of the vagina will constitute an obstacle to coitus when both halves of the passage are too narrow to allow of intromission of the penis. Difficulty in intercourse will also be caused by abnormal termination of the vagina, as by its termination in the rectum, likewise by severe perineal laceration which has converted the lower parts of the vagina and rectum into a cloaca, likewise by recto-vaginal and vesico-vaginal fistulæ; in the case of all these latter states a feeling of disgust is apt to be aroused in the male which may effectually check sexual desire. Still, coitus, and even conception, are quite possible in these conditions. Kroner, among sixty cases of vaginal fistula, observed six in which conception took place while the fistula was actually open.

Apart from all local pathological conditions, coitus may be interfered with by general nervous disturbances, manifesting themselves locally, and depriving the woman so affected of potentia coeundi. First among such states must be mentioned vaginismus, a condition so important as to demand discussion in a separate chapter.

An important and by no means rare obstacle to the completion of intercourse, affecting the male partner in the act, is partial or complete incapacity for erection of the penis. Even excessive smallness of the penis may render coitus inadequate; still more so, however, organic diseases of the membrum, such as obliteration of the corpora cavernosa, or of some of the trabecular channels of these bodies, nodular formations resulting from injury, or cavernitis from gonorrhoea. In such cases, erection is extremely irregular, and the erect penis is sharply bent (chordee) instead of being straight, a condition which renders intromission mechanically difficult if not impossible. A similar effect is produced by ossification of some part of the tunica albuginea of the corpora cavernosa—the so-called penis bone. Mechanical obstacles to coitus are also offered by inguinal and scrotal hernias; and by excessive obesity, where the increase in thickness of the panniculus adiposus of the abdominal wall and the mons pubis, whilst the penis itself remains as slender as before, causes the organ almost to disappear from view.

Psychical impotence in the male is much more frequently observed than organic impotence. We meet with this condition especially in neurasthenically predisposed individuals, or in men who have been given to excessive venery or have masturbated excessively in youth, and who, when entering upon married life, fear they will be unable to satisfy the legitimate desires of their wives; or in newly married men who have suffered often from gonorrhoeal inflammations, such as prostatitis, vesical catarrh, and epididymitis. The fear and anxiety from which such persons suffer has an inhibitory influence upon the erection of the penis. In some instances, this inhibitory influence is partial only, and the man thus affected, while perfectly competent in intercourse with a prostitute, who employs means of sexual stimulation to which he has become accustomed, is unable to complete intercourse with his wife, who is ignorant and innocent, and assumes a purely passive role; or it may be that erection is not sufficiently powerful to bring about rupture of the hymen, and thus to overcome the difficulties primae noctis.

As regards gonorrhoeal infection, it appears that in men who in other respects are perfectly competent, this disease has an inhibitory influence upon the nervous mechanism concerned in producing erection of the penis.

Psychical impotence is usually transitory, but it may endure for a very long time; and it may be many months before the husband, whose nervousness has led to failure in the decisive moment at the outset of married life, is able to command an erection sufficiently powerful to bring about the defloration of his wife. Occasionally such psychical impotence is not absolute but relative, it relates, that is to say, to one particular woman—unfortunately, as a rule, a man’s own lawful wife,—whilst coitus with another woman, even in default of any measures for artificial sexual stimulation, is easily effected. This fatal misfortune is especially liable to occur in cases in which a man fully experienced in sexual matters marries a woman whom he dislikes or for whom he has no regard; the marriage being determined by material considerations. From such women I have heard the painful confession that the husband, a man renowned for his gallantries, played a very poor part in the bridal bed.

The impotence of irritable weakness is characterized by premature, and therefore fruitless ejaculation. A man thus affected has a powerful erection of the penis, preparatory to coitus, but at the moment of contact with the female genital organs, before there has been time for penetration to occur, ejaculation takes place, and is immediately followed by relaxation of the penis. Such irritative impotence is often met with in young men at the outset of their sexual career, in beginners, whose sexual passion is very readily excited, whose imagination shoots forward to the goal, and who are unable to restrain themselves. This form of impotence can also be cured by wisely chosen measures.

The paralytic form of impotence, on the other hand, is characterized by the entire absence of erections of the penis, both overnight in bed, and during the early morning hours; the penis always remains flaccid, or at most becomes semi-erect only, insufficiently rigid for penetration. Ejaculation is much retarded or altogether wanting.

Impotentia coeundi in the male may be complete, in cases in which the erection-apparatus is entirely inactive, and in which even an attempt at intercourse is out of the question; or, and this is more frequently met with, it may be partial only, and manifests itself in various degrees of imperfection in the performance of coitus.

This latter form may often escape the woman’s notice. Whilst complete impotentia coeundi, in which intromission of the penis is impossible, is a state about which neither husband and wife can fail to be fully informed, cases of partial impotence, with semi-erection of the penis or premature ejaculation, are often glozed over by the husband, ignored by the wife, and underestimated by the physician—and yet such incomplete intercourse entails a series of ill-consequences alike upon the genital organs and upon the nervous system of the wife. Erection is incomplete, and thus the penis passes into the vestibule only, and not deep into the vagina; even if penetration is more thorough, the venous return of the blood from the corpora cavernosa is not checked sufficiently to distend the penis to its full size, and to bring it into close contact with the vaginal walls; or ejaculation occurs prematurely, before the sexual organism of the wife has attained that supreme degree which is needful alike for the attainment of sexual gratification and for the occurrence of conception.

Vaginismus.

Vaginismus is a disordered state, characterized by hyperaesthesia of the hymen and of the entrance to the vagina, so extreme that, even though the organs may be entirely free from any anatomical abnormality, coitus is prevented, whenever attempted, by violent, involuntary spasmodic contractions of the constrictor cunni and the other muscles of the urogenital and anal region.

The centripetal paths of the reflex spasm characteristic of vaginismus, run through the branches of the inferior hypogastric plexus, and especially through the utero-vaginal plexus. The spinal nerves connected with this part of the sympathetic are the 2d, 3d, and 4th sacral. The plexuses are constituted by fibres in part from sympathic and in part from the 2d, 3d, and 4th sacral nerves. Through the same nerves passes the centripetal motor tract for the transversus perinei muscle, and for the sphincter and levator ani muscles. According to Eulenburg, the centre for this reflex is to be found at the level of the first sacral nerve; when the disturbance irradiates more widely, the lumbar and sacral plexuses as a whole are involved. The constrictor cunni (sphincter vaginæ or bulbocavernosus muscle) is supplied by the perineal branch of the pudic nerve. The symptom-complex of vaginismus consists of violent spastic contraction, for a term varying greatly in duration, of the constrictor cunni (bulbocavernosus), sphincter ani, levator ani, and transversus perinei muscles, the spasm spreading, in severe cases, to other muscles in the neighbourhood, and especially to the adductor muscles of the thigh; the spasm comes on when any attempt at intercourse is made, and even when the genitals are merely touched.

In young married couples especially, vaginismus is an extremely distressing condition, and one that entails very serious consequences, inasmuch as the pains and reflex spasms which result from any attempt at coitus, and even from the mere approximation of the penis to the female genital organs, render sexual intercourse absolutely impossible. The cause of this pathological manifestation is in part to be found in unskilful attempts at intercourse, which have stimulated the female genital organs at some improper region. It may be that the young husband is not fully instructed in sexual matters, and does not really know how coitus ought to be effected; in other cases there is some abnormality of the hymen, which has rendered the rupture of that membrane extremely difficult; in some cases there is partial impotence in the male, whose penis becomes semi-erect only, so that ever-renewed attempts at intercourse are followed by ever-renewed failure. Any of these causes may suffice, in susceptible women, to originate vaginismus. The sufferer in these cases will usually be found on enquiry to be hereditarily predisposed to nervous disorder, and to be extremely sensitive to pain. By the fruitless efforts of her ignorant or partially impotent husband, she is sensually excited without ever being satisfied; the injured nervous system responds by these local spasms, whilst ultimately, in some of these cases, an actual psychosis ensues.

In a certain number of cases, however, the husband is in no way responsible for the origin of vaginismus, which may depend on pathological states of the female external genitals, leading to hyperaesthesia; or, again, on primary hyperaesthesia of the pudic nerve and its branches; or, finally, on general neurasthenia and hysteria, on excessive sensibility and lack of self-control on the part of a young girl, who has entered upon married life under the dominion of extravagant ideas. Vaginismus dependent upon general neurasthenia especially in cases in which there is no strong affection for the husband to give the spur to desire, and to enable the woman to bear with fortitude the pangs which form the necessary introduction to the joys of wedded life. It must not be forgotten, as throwing light on the origin of vaginismus, that in the digital vaginal examination of a virgin or even of a young wife, unless extreme care is taken, pain and painful muscular spasms are liable to be evoked.

The local pathological conditions of the female genital organs that are most often met with in cases of vaginismus are: a very rigid state of the hymen; inflammation and excoriation of the hymen and its surroundings; fissures at the vaginal orifice; inflammatory affections of the vaginal follicles; inflammation of the carunculæ myrtiformes; a peculiar formation of the vulva, which extends forwards over the pubic symphysis, whereby the urethral orifice and the hymeneal aperture come to lie upon the pubic symphysis or the subpubic ligament; vulvitis; herpes or eczema of the vulva; colpitis; urethritis; fissure of the anus; papillary growths; pruritus papules; urethral caruncle; inflammation of Bartholin’s glands; at times gonorrhoeal infection.

A case came under my own observation in which a newly married woman suffered from vaginismus. The husband believed the cause of the trouble was his own partial impotence, consequent upon youthful venereal excesses, and yielded to the desire of his wife and her relatives that a divorce should be obtained. A year later, the woman remarried, when, to her horror, the symptoms returned in full force. Now for the first time she consulted me, and on local examination I could detect no abnormality whatever. The vaginismus was in this instance a pure neurosis, the only possible cause of which was to be found in bygone overstimulation of the vaginal orifice, the wife admitting previous onanistic excesses. In another case known to me, vaginismus in the wife made the husband an involuntary sodomite. The movements of the wife when the spasm came on led to the introduction of the penis per anum, and coitus had repeatedly been effected by this abnormal route, when the fact first became apparent as the result of a local examination.

Le Fort reports the case of a young Russian wedded pair who were spending their honeymoon in Paris. The husband took so much to heart his inability to fulfil his marital obligations in consequence of the vaginismus from which his wife suffered, that he shot himself through the heart. The distressing situation of a husband whose wife suffers from vaginismus, rendering coitus impossible, is depicted in the well-known French romance, “Mademoiselle Giraud, Ma Femme.” From a false shame, women often continue to suffer from vaginismus for months and even years, without a single effective coitus having ever taken place; it is only the consequent sterility which at last leads to medical advice being sought. The physician then usually ascertains that the hymen is still intact, or at least incompletely destroyed, that on this membrane and on various parts of the vulva there are erosions, and that the whole of the external genitals outside the hymen are in a state of inflammation more or less acute. In other cases, however, neither excoriations, erosions, nor inflammation can be detected, and the existence of vaginismus can be proved only by the pain and the muscular spasm set up by contact with the vagina. Often, indeed, the cause of this most distressing affection cannot be discovered.

Introduction of the penis may be rendered impossible by spasm of the constrictor cunni (bulbocavernosus) muscle, but equally so by spasm of the transversus perinei or the levator ani muscle. Sometimes the spasm affects all three muscular groups; in which case the narrowing of the vagina is extreme, and extends for some way up into the canal. When the levator ani alone is affected by the spasm, the penis can, indeed, be introduced into the vagina, to encounter a powerful obstacle in the interior of that canal; and it may happen, when the spasm comes on and affects the levator ani only after complete intromission of the penis, that the glans is retained in the vaginal fornix by the active contraction of the pelvic floor.

More or less credible instances of penis captivus thus brought about are on record. The following history is by Davis: A gentleman entering his stable found therein his coachman and a servant-maid in a most compromising position. All endeavours of the pair thus surprised to separate proved ineffectual, and their attempts to draw apart caused them intense pain. Davis was sent for, and ordered an iced douche, which, however, failed to liberate the imprisoned penis. Release was impossible until the woman had been placed under chloroform. The swollen and livid penis exhibited two strangulation-furrows, a proof that two distinct areas of the levator ani muscle had been spasmodically contracted.

Hildebrand records three cases observed by himself in which there was spasm of the upper part only of the vagina, unaccompanied by vaginismus (i. e., by pain). In two of these cases, the spasm was originated by the contact of the examining finger with very painful ulcers of the portio vaginalis; the third patient had a very sensitive prolapsed ovary. Fritsch reports having had on one occasion to give a woman chloroform for the release of a swollen and imprisoned penis.

Hildebrand suggests that vaginismus may be caused by an abnormal size of the penis, or by a condition occurring in weaklings and alcoholic subjects, in whom the greatest swellings of the glans penis occurs before intromission, whilst this greatest swelling is normally deferred until towards the end of the act, when the glans is in the vaginal fornix.

Schröder writes as follows regarding the etiology of vaginismus: “The affection is dependent upon trauma, sustained in maladroit, frequently repeated attempts at sexual intercourse; for this reason it is met with, in the great majority of cases in young, newly married women. Impotence in the male is by no means necessary for its production, and such impotence is not even a frequent antecedent. Abnormal narrowness of the vagina, or extreme firmness of the hymen, is occasionally found, but neither is in any way necessary; all that can be said in this connection of a small vaginal orifice is, that it predisposes to vaginismus. If the husband is devoid of previous experience in sexual matters, maladroit attempts at intercourse are exceedingly likely to occur. The penis is thrust in the wrong direction, pressing against either the anterior or the posterior commissure of the vulva. Very often, moreover, the position of the vulva, which is subject to very striking individual variations, is concerned in the production of vaginismus. There are many women in whom the vulva lies in part in front of the symphysis pubis, so that the lower border of the symphysis lies below the urethral orifice. In such cases the penis is directed too far backwards, and instead of passing into the vaginal orifice, slips into the fossa navicularis. The frequent repetition of such maladroit attempts at intercourse gives rise to a gradually increasing sensitiveness of the parts concerned, with the formation of excoriations. It now results that, on the one hand, the woman dreads attempts at intercourse on account of the pain to which they give rise; she shrinks away from the man, so that penetration of the vagina by the penis is rendered even more difficult than it was before; and, on the other hand, ungratified sexual desire leads to the frequent repetition of attempts at complete intercourse (from which, moreover, if conception should ensue, a cure of the trouble is expected). In this way, the trauma is rendered more severe, the congestion and excoriation of the fossa navicularis or of the urethral region are aggravated, and the sensitiveness of the parts increases to such a degree that the woman thus affected screams out when the vulva is merely touched. Ultimately reflex cramps set in whenever intercourse is attempted, and we then have the fully developed clinical picture of vaginismus.”

Winckel maintains that in most cases there are two principal elements in the causation of vaginismus. In the first place, in consequence of more or less pronounced anatomical changes, there is undue sensitiveness and tenderness of the vaginal inlet and its neighbourhood, and in exceptional cases also of the upper part of the vagina, the uterus, and the ovaries. In the second place, the patient manifests an increased general sensitiveness and nervous irritability; this is in some cases primary, but in others it is entirely the result of the repeated stimulation; and in either case it is heightened by the effects of ungratified sexual desire.

A. Martin points out that the spasm of the muscles of the pelvic floor, and especially of the levator ani muscle, upon which vaginismus depends, may be due in some cases to the influence of chill, since the same cause will lead to pathological contractions in other muscular areas. But in such cases it is always open to question if masturbation or some other sexual perversion is not the true cause of the disorder. In some instances vaginismus is merely a symptom, in extremely sensitive women, of various diseases of the reproductive organs, and is brought on by the increased pain which in such cases is caused by attempts at intercourse; when produced in this way, vaginismus is usually a transient manifestation.

Veit considers that among the pathological conditions giving rise to vaginismus, we must also enumerate diseases of the internal pelvic organs, such as chronic metritis, displacements of the uterus, oöphoritis, etc.; but he also attaches great importance to nervous predisposition, consequent upon previous sexual stimulation, and upon pre-existing inflammatory changes due to gonorrhœal infection. A peculiar form of vaginismus is, according to Veit, sometimes observed after the birth of the first child; happily the duration of this is usually brief. After parturition the vulval mucous membrane remains for a time very tender, and when cohabitation is resumed, often too soon, and perhaps, after the enforced abstinence, too frequently repeated at brief intervals, fissures are readily produced. Moreover, vaginismus which has existed prior to parturition may, in some cases, recur after that event. An unusual position of the vulva, undue smallness of the vaginal inlet, and relative impotence of the man, may combine to cause such a recurrence. Finally, vaginismus often persists throughout pregnancy, and manifests itself during parturition. The magical effect which chloroform has in some primiparæ, when the head is delayed at the vulva, is explicable only by the supposition of vaginismus.

According to Arndt, vaginismus is not purely a local disorder, but is in many cases the local manifestation of a neuropathic diathesis, which may in some instances lead to general mental disorder.

Olshausen regards hyperæsthesia and vaginismus as different stages of a single disease; he believes that the excessive sensitiveness is seated chiefly in the hymen; he explains the spasm as the reflex result of fissures and inflammatory changes. Pozzi considers that excessive nervous irritability and an irritable state of the vulva are the indispensable preliminaries to the occurrence of vaginismus. Herman distinguishes between excessive smallness of the vaginal inlet and vaginismus; he regards the latter as a nervous disorder, characterized by hyperæsthesia of the vulva, and by spasmodic contraction of the levator ani and adjoining muscles. Frost distinguishes vaginodynia from vaginismus; in vaginodynia the pain is so intense as to cause syncope, and the muscular spasm involves the entire length of the vagina.

It is a notable fact, to which Veit has especially drawn attention, that among the poorer classes of the population, vaginismus is practically unknown. Among women of these classes, their sexual needs, not having been so much lessened by “culture,” suffice to withdraw their attention even from the pains of defloration, which would otherwise often be very severe; whereas the sexually neurasthenic woman of the upper classes, filled with dread at the idea of the pain she expects to suffer, and not infrequently in a condition of hyperexcitability or hypersensibility dependent upon previously employed abnormal means of sexual gratification, is unable to endure the pains of defloration even when these might be expected to prove far from severe.

In some cases, painful contractions of the vagina, to which we cannot properly give the name of vaginismus, arise from organic diseases of the uterus and the uterine annexa; these painful contractions render copulation impossible. Von Hofmann reports the case of a young prostitute, who found herself unable to continue the practice of her profession owing to the severe pain she suffered during intercourse; she died, and the post mortem examination disclosed bilateral salpingitis, with reproductive organs in other respects normal.

Maladroit and incomplete attempts at intercourse, and the consequent repeated failure to obtain complete sexual gratification, affect a woman’s nervous system to a varying degree; but apart from this, in women who have long cohabited with men of deficient sexual potency, we often find a remarkable condition of complete relaxation of the genital organs, associated with great hypersecretion of the mucous membrane, flaccidity of the muscles of the pelvic floor, and displacements of the uterus. Moreover, the nervous shock to which the repeated but unsatisfying attempts at intercourse give rise, affects the spinal cord in such a manner that symptoms of spinal irritation ensue. The patient complains of pains in the back, the loins, and the nape of the neck; these pains also radiate round the front of the abdomen and along the intercostal spaces; hyperæsthetic points may be detected when the finger is passed along the spine; there is weakness of the limbs with a sensation of numbness; and neuralgic manifestations of varying nature occur.

The dangers which sexual intercourse may entail upon women—over and above the irritable conditions and inflammatory disorders of the female reproductive organs, dependent upon impetuous or unduly frequent coitus, or upon coitus practised during menstruation—are principally due to gonorrhœal and syphilitic infection transmitted by the cohabitating male.

Cardiac Troubles Due to Sexual Intercourse.

Among the troubles from which women at times suffer as a result of sexual intercourse, certain cardiac disorders are especially worthy of attention.

Every act of sexual intercourse in a young and sensitive woman exercises an exciting influence on the nervous mechanism controlling the cardiac movements, and this influence is more clearly manifested in a degree directly proportional to the intensity of the sexual orgasm. The heart’s action is markedly increased in frequency, the cardiac impulse is more powerful, the large arteries of the neck are seen to pulsate far more vigorously, the conjunctiva is markedly injected, the respiration is increased in frequency, the respiratory movements are more superficial and have a panting character.

But when, in a woman who is sexually irritable in an excessive degree, the peripheral stimulation occurring in the act of sexual intercourse is unusually powerful, there may result a notable increase or modification of the reflex manifestations which normally occur during sexual intercourse in the province of cardiac activity; similar results ensue when there is a summation of stimuli owing to excessive sexual intercourse, or contrariwise when the act of intercourse is broken off just before its physiological climax and the natural termination of the orgasm fails to occur.

The former cause is not infrequent in young wives during the period of the honeymoon. The latter cause is in operation when there are diseases of the female reproductive organs preventing the physiological completion of intercourse; but especially in consequence of the modern practice of coitus interruptus, in which the man breaks off the act of intercourse the moment he feels that ejaculation is imminent, without troubling himself regarding the natural course of sexual excitement in the woman. Yet another cause of excessive cardiac reflex manifestations in women is incomplete potency of the male, which may either cause a premature ejaculation of semen, or may lead to incomplete penetration of the penis.

In all such cases, as a result of sexual intercourse, there may arise cardiac disorders of various kinds; among these, tachycardial paroxysms are the most frequent, occurring either inter actum, or at a longer or shorter interval after intercourse.

In several cases of vaginismus occurring in young married women which have come under my notice, it was observed that the attempts at intercourse gave rise to violent involuntary spasmodic contractions of the constrictor cunni and the other muscles of the urogenital and anal regions, and in addition it was found that these attempts were followed by tachycardial paroxysms with dyspnœic manifestations, lasting for a considerable period, it might be as long as one or two hours.

In women who had practised coitus reservatus for a prolonged period, in fact for several years, in such a manner that, notwithstanding the occurrence of intense voluptuous excitement, complete sexual gratification rarely, if ever, occurred—in such women, in whom these marital malpractices seemed to have profoundly influenced their psychical life, I have frequently witnessed a form of reflex cardiac disorder which I must regard as a variety of the multiform neurasthenia cordis vasomotoria. In such women, still at the climax of their physical powers and of their sexual needs, attacks of palpitation suddenly occur at irregular intervals, several times daily or less frequently. Associated with this increased frequency of the cardiac activity are an extremely distressing feeling of anxiety, a sensation of faintness, headache, vertigo, a weakness of the muscular system, and at times actual attacks of syncope. Physically, the women are extremely depressed, irritable, inclined to weep, unhappy, and weary of life. At the same time, digestion is impaired, the appetite is small, and there is constipation. The pulse is in most cases feeble, small, of low tension, easily compressible, increased in frequency, often intermittent, sometimes more distinctly arhythmical. The heart is found to be sound on physical examination, nor can any abnormality be detected in the great vessels. The lower extremities are free from œdema; the urine does not contain albumen.

Women thus affected are sometimes believed to be suffering from cardiac disorder, in other cases they are subjected to various modes of gynecological treatment; until at length the physician, by appropriate questions, becomes enlightened regarding the true cause of the cardiac disorder, namely, coitus interruptus. If it is possible to prohibit effectually this unwholesome practice, the cardiac symptoms soon cease to recur.

Finally, in women at the climacteric age, cardiac troubles sometimes ensue, which are dependent on interference with sexual intercourse in consequence of anatomical changes in the vagina; changes of this character frequently occur at the time of the menopause; owing to hyperaemic or inflammatory processes, a partial or general stricture of the vaginal passage results; in many cases this passage becomes narrower, shorter, and almost conical in shape, whilst the vaginal inlet is greatly diminished in size. Such a vaginal stricture, which Hegar has also seen in younger women after an artificial climacteric (oöphorectomy), interferes with sexual intercourse; and the incomplete sexual gratification gives rise to a series of nervous manifestations, and, among others, to the above described reflex cardiac neurosis.

Whether, and in which cases, the cardiac disorders evoked as a result of the local stimulatory influences of sexual intercourse, are dependent on a reflex stimulation of the sympathetic nerve on the one hand, or upon a transient paresis of the inhibitory centre of the heart and of the vasomotor centre on the other, cannot here be fully discussed; just as little can we consider in what manner the psyche is sympathetically affected by the irritative processes in the genital organs, and its functional activity thus impaired.

Here I can do no more than briefly state that experience has taught me that sexual intercourse is competent to originate cardiac troubles in women.

1. In extremely sensitive, sexually very irritable women, tachycardial paroxysms may result from sexual excesses.

2. Tachycardial paroxysms with dyspnœa occur in young women affected with vaginismus; also in women at the climacteric with constrictive changes in the vagina.

3. Cardiac troubles, characterized mainly by symptoms indicating diminished vascular tone, occur in women who have long practised coitus interruptus with incomplete gratification of their voluptuous desires.

Dyspareunia.

In normal conditions the act of sexual intercourse is accompanied in women, as in men, by a voluptuous sensation, and this sensation must be regarded as a necessary link in the chain of those processes by which gratification of the sexual impulse—the most powerful of all our natural impulses—is obtained. The absence of this voluptuous sensation in a woman, the state in which she experiences during coitus no voluptuous sensations, but feels either apathy, or positive distaste, is termed dyspareunia: in former times it was also known as anaphrodisia. This abnormal state of sexual sensibility, which up to the present is hardly alluded to in gynecological textbooks, has received remarkably little attention from the medical standpoint, and its importance has been underestimated. Most unfortunately so, for dyspareunia is an important symptom, exercising a powerful influence on the general health of the woman who suffers from it, upon her social status in marriage, and, as is easy to understand, upon her procreative capacity.

Dyspareunia must be clearly distinguished from two somewhat similar conditions, with which at first sight it is liable to be confused, namely, from anæsthesia sexualis, and from vaginismus. By sexual anæsthesia we understand, as previously explained, the absence of the sexual impulse, a symptom which, when the reproductive organs are normal in structure and function, is either of central nervous origin, a result of disease of the brain or spinal cord, or else is due to general nutritive disorders such as diabetes, morphinism, or alcoholism. A woman affected with dyspareunia does, however, experience the sexual impulse, it may be very actively, but sexual intercourse brings about no gratification of her desires. In vaginismus, on the other hand, the introduction of a foreign body, that is to say of the membrum virile, into the vagina, gives rise to painful reflex cramps of the sphincter vaginæ, or of the muscles of the pelvic floor, whereby the completion of coitus is rendered impossible: whereas in dyspareunia coitus can be effected, but gives rise to no voluptuous sensations.

The pleasure which normally occurs in woman during sexual intercourse is brought about in this way, that contact with and friction by the penis stimulates the sensory nerves of the clitoris, the vulva, the vestibule, and the vagina; this stimulus is propagated to the cerebral cortex, where it gives rise to voluptuous sensations, and then, by reflex stimulation of the genito-spinal centre, gives rise to a series of reflex discharges. The pudic nerve, a branch of the sacral plexus, supplies the female external genital organs. Some of its branches pass in the clitoris to a peculiar form of nervous end-organ discovered by W. Krause, Krause’s genital corpuscles: the structure of these corpuscles appears to fit them exceptionally well for the transmission of stimulatory waves to the nerve centres. “When this stimulus,” says Hensen, in his work on the physiology of reproduction, “in addition to other effects, also gives rise to a voluptuous sensation, the cause must be sought in central nervous connections and apparatus. Similar relations are to be found in connection with the mechanism of nutrition, for example, in the association of hunger, appetite, agreeable sensations of taste, the act of mastication, and the secretion of saliva.” By means of this stimulus, several reflex processes are originated in the reproductive canal, the most notable of which are the erection of the clitoris, and the ejaculation of the secretions of various glands. The cavernous tissue of the clitoris is connected with that of the bulbus vestibuli, and the dorsal nerve of the clitoris is one of the principal nerves of voluptuous sensation. The venous plexus constituting the bulb of the vestibule lies at either side along the margin of the vestibule at the boundary between the labium majus and the labium minus, and laterally it is covered by the constrictor cunni[48] muscle. During coitus the blood is driven out of this bulb into the glans clitoridis, and thus the sensibility and the erection of the glans are increased. The constrictor cunni and ischiocavernosus muscles draw the clitoris, which is bent at a right angle downwards, into contact with the penis. By means of the pressure of the constrictor cunni, the mucous secretion of Bartholin’s glands, which open into the vulva at the back of the labia majora, is expressed.

As additional reflex actions, dependent upon the activity of the reflex centre in the lumbar enlargement of the spinal cord, there ensue contractions of the vagina, peristaltic movement of the tubes, some descent of the uterus, relaxation of the os uteri and rounding of this orifice, and induration of the portio vaginalis, whereby the tubal and uterine mucus and the secretion of the cervical glands are expressed. This process of ejaculation constitutes the culminating point of the voluptuous sensation occurring in the sexual act; this act thus exhibits two phases, the sensation of friction, and the sensation of ejaculation.

With regard to voluptuous sensations, and processes analogous to pollutions, occurring in women, we append an extract from von Krafft-Ebing.

“The occurrence of voluptuous excitement during coitus is dependent in the women, just as in the man, upon:

“1. The peripheral influence of the intensity and duration of the sensory stimulation (anæsthesia of the genital passage may be the cause of the absence of voluptuous sensation). 2. The condition of excitability of the reflex (ejaculation) centre in the lumbar spinal cord. The activity of this centre varies within wide limits, not merely in different individuals, but in the same individual at different times. There are, indeed, women in whom it seems as if this centre were always in vigorous activity. In normal women, the irritability of the centre appears to be most marked at the menstrual epoch, and to decline rapidly soon after menstruation. In pathological conditions, the activity of the centre may be temporarily in abeyance (organic inhibitory processes, such as are seen in certain cases of hysteria with temporary frigidity); or again the centre may be abnormally active owing to irritable weakness (neurasthenia sexualis), in consequence of which ejaculation may, just as in the male in similar circumstances, occur too easily. 3. The occurrence of the voluptuous sensation in woman is unfavourably influenced by psychical inhibitory perceptions (analogous to the inhibitory influence of psychical processes in the male, such as, for example, fear of incapacity to perform sexual intercourse). As examples of such inhibitory perceptions in women may be mentioned, dislike of the man, physical loathing to sexual intercourse, etc.”

Gutceit records interesting experiences, which are readily intelligible in view of what we have already quoted. He finds that of ten women after defloration, two only immediately experience full sexual pleasure. Of the eight others, four only have an agreeable sensation produced by the friction during coitus: but the sensation of ejaculation does not make its appearance until the lapse of at least six months, or it may be even several years, after marriage. In the remaining four women, pleasure during sexual intercourse may never become properly established. The women of the first class are described by the author as being of a very ardent temperament, and passionately attached to their husbands. In such women, the sensation of ejaculation occurs during intercourse with any man toward whom they are sympathetic. Women of the second class are of a less ardent temperament, and are often comparatively indifferent toward the man with whom they cohabit. Women of the third class have little or no amatory feeling, and they either hate the man with whom they are cohabiting, or at least feel physical repulsion to the idea of intercourse with him. Gutceit considers that meretrices usually belong to the third category. In the practice of their trade, they make a counterfeit of voluptuous enjoyment, and only experience real sexual gratification in intercourse with the man of their choice.

It is of great practical interest, alike from the gynecological and from the neuropathological standpoint, to determine the consequences in women of ungratifying sexual intercourse. In the present state of our experience it must be assumed that the effect of abnormal sexual intercourse, that is of intercourse which does not culminate in gratification produced by the sensation of ejaculation, is deleterious. This is explained by the fact that, owing to the absence of the muscular contraction of the genital passage, the latter remains engorged with blood; the resultant hyperæmia passes away very slowly, and, when frequently repeated, gives rise to chronic tissue changes, manifesting themselves as diseases of the reproductive organs. Injury to the nervous system ensues, partly in consequence of these organic changes, partly also in consequence of psychical non-gratification in the widest sense of the term. The nervous disorders thus produced are typical forms of (sexual) neurasthenia; and in cases in which the pathogenesis is predominantly psychical (antipathy to the husband, etc.) hysterical types of disorder are especially frequent. Von Krafft-Ebing believes that incomplete coitus, that is, coitus not culminating in the sensation of ejaculation, is a frequent cause of hysterical disorders in women.

When once the clinical picture of neurasthenia sexualis is fully developed, each act of intercourse (like pollutions or coitus in the sexually neurasthenic male) gives rise to renewed troubles, which are easily recognized as symptoms of venous stasis in the reproductive organs (sacrache, sensations of weight and bearing-down in the pelvis, fluor albus): in addition we observe exacerbations of the lumbar spinal disorder, in the form of spinal irritation, irradiating pains in the sacral plexus, etc. In this way general neurasthenia develops. The conditions found in such cases on gynecological examination (chronic endometritis, metritis, oöphoritis, etc.) are produced by the same cause as the nervous symptoms, namely, by an unhygienic mode of sexual intercourse. They are not the cause of the neurosis, but important concomitant disorders; and their effect in rendering the nervous disturbances more severe must be freely admitted.

Among important causes of ungratifying coitus must be enumerated: weak erection and ejaculatio praecox in the male, rendering the stimulation inefficient; in addition, coitus reservatus, coitus interruptus, and coitus condomatus. If the noxious influence is frequently repeated, the occurrence of neurasthenia sexualis and its consequences is greatly to be feared, and in women of neuropathic constitution it is practically inevitable.

Unsympathetic coitus appears to act, not merely in a somatic manner, but mainly upon the psyche, and to originate states of hystero-neurasthenia or pure hysteria. If the influence of such unhygienic conditions of the vita sexualis co-operates with that of inherited or acquired sensuality, further dangers ensue: in cases of ungratifying sexual intercourse, the danger of manustupration; in cases of unsympathetic intercourse, the danger of psychical onanism, or that of marital infidelity.

Although until recently the matter received but little attention, it must now be regarded as a well-established fact, that in the female (as in the male) the climax of voluptuous sensation in sexual intercourse is normally characterized by a process of ejaculation, accompanied by a voluptuous sensation of ejaculation, dependent upon the acme of excitement of a reflex centre in the lumbar enlargement of the spinal cord.

Just as in the male, this centre may be excited to action, not only by local stimulation of the genital organs, but also by (psychical) stimuli proceeding from the brain (pollutions), so also in the female a similar process may occur, and for this reason it is correct to speak of “pollutions in the female.” Rosenthal appears to have been the first writer to speak of pollutions in women. In his clinical study of nervous diseases, Rosenthal described processes of the nature of pollutions, originated in erotically over-stimulated women by lascivious dreams. In one case he detected the outflow of a “mucus-like” fluid from the apparently intact genital organs; he believed this to proceed from the ducts of Bartholin’s glands, and from the mucous glands surrounding the urethral orifice. Féré reports the case of a patient who had an erogenic zone in the region of the upper part of the sternum; pressure on this zone gave rise to a profuse secretion of vulvo-vaginal fluid. In this connection we may also recall the “clitoris-crises” to which tabetic women are subject. Gutceit described the process of pollution in women in the following words: “It is remarkable that in dreams such women experience the sensation of ejaculation.”

The psychical preliminary is invariably constituted by lascivious dream perceptions. It merely remains open to question whether this process, which in the male is indisputably physiological, in the female may be said to occur within physiological limits. The researches published by von Krafft-Ebing more than twenty years ago, under the title “Concerning Processes Analogous to Pollutions Occurring in the Female,” gave negative results as far as healthy individuals were concerned; on the other hand, the phenomenon in question was by no means rare in nervously disordered, and above all in sexually asthenic women. The neurosis was in part found as a result of psychical or manual onanism in virgins with morbidly intensified libido: in part in married women, as a result of ungratifying coitus, as previously described: in part, also, in married women with powerful libido and enforced abstinence from intercourse, owing to acquired impotence or death of the husband.

Just as in the case of the neurasthenic male, these pollutions made the primary neurosis more severe, and relief from the nervous trouble was not obtained until the factor of the “pollutions” had been recognized, and made the object of special treatment. In exceptional cases the “pollutions” appeared to be the starting point of the entire neurosis.

It was further remarkable, again here displaying analogy with what occurs in the male, how much stronger and more deleterious was the shock-effect of an inadequate process of ejaculation occurring in a sexual dream, as compared with the far less deleterious influence of similar incomplete ejaculation when occurring viâ coitus. In very severe degrees of neurasthenia sexualis, just as in the male, the waking imagination may give rise to a “pollution.” In such cases the shock-effect on the nerve centres tends to be excessively severe. A still higher degree of irritability of the genital system appears to exist in cases in which excitement and orgasm of the reproductive organs may culminate in a “pollution” by purely spinal paths, without the intervention of the imagination. The significance of this fact would appear to be considerable for the proper comprehension and for the treatment of certain conditions of neurasthenia (sexualis) in the female. The “pollution” may here be the actual cause of the neurosis. But in any case, in the female, the occurrence of pollutions is an extremely important symptom as regards both diagnosis and therapeutics. It is extremely probable that hallucinations of coitus, and the complaints made by insane women of attempted violation during the night, are really dependent upon such “pollutions.”

Von Krafft-Ebing reports the following characteristic case. Miss X., thirty years of age, belonging to a family predisposed to insanity, and herself neuropathic since early childhood, declared that since she was six years old she had been subject to lascivious imaginations, to which she became continually more liable as she grew older. Ultimately, typical psychical onanism developed, and in recent years her trouble assumed the form of sexual neurasthenia. The patient herself suspected there was a connection between her nervous disorder and her evil habit. The popular work by Bock finally brought her full enlightenment, associated with severe emotional disturbance. This latter was now increased by misfortunes from which the family suffered. The patient then relinquished her bad habit, but her state of health nevertheless became worse. She was nervously extremely irritable; her sleep was insufficient, unrefreshing, and disturbed by lascivious dreams; she suffered from spinal irritation, anæmia, scanty and painful menstruation. Inclination toward the opposite sex and toward marriage, hitherto but slight, now sank to a minimum: on the other hand, the patient, in spite of all efforts to the contrary became more and more subject to a condition analogous to priapism in the male, a genital orgasm by no means voluptuous in character, and often indeed actually painful. Associated therewith, nocturnal pollutions occurred, the patient awaking from lascivious dreams with a voluptuous sensation and moistness of the external genital organs. After such pollutions, throughout the ensuing day, she felt extremely weary and depressed and suffered from severe spinal irritation. After a time, the nocturnal pollutions occurred without being preceded by lascivious dreams, and ultimately analogous states were experienced in the daytime. With much difficulty the patient now made up her mind to seek medical advice. She was anæmic, emaciated, emotional, and moody. The lumbar and cervical regions of the spine were extremely sensitive to pressure. Sleep was scanty and unrefreshing, the patient felt weary and miserable, she complained of dragging sensation and other paralgic sensations, in the regions supplied by the lumbar and sacral plexuses. The deep reflexes were increased. She dreaded the onset of disease of the spinal cord, and believed that the cause of her illness was to be found in the prolonged indulgence in psychical onanism. The perusal of Bock’s book had first made her understand the true nature of her misconduct. She had never practised manual masturbation. Her principal complaint was of an almost unceasing uneasiness and excitement in the genital organs. She compared it to the uneasiness in the stomach produced by hunger. In the genital organs (which on examination appeared quite normal), she had a distressing sense of burning heat, of pulsation, of disquiet as if there were a clockwork mechanism working there. Very rarely now were these sensations associated with voluptuous ideas. This sexual neurosis had an intensely depressing constitutional effect. She had transient relief only when the local sensations culminated in pollution; but this, on the other hand, increased her general neuropathic troubles. She suffered most severely during the menstrual period. She was ordered sitz-baths at a temperature of 23° to 19° R. (84° to 75° F.), suppositories of monobromide of camphor, 0.6 (9 grains), with extr. belladon. 0.04 (⅗ gr.), sodium bromide 3.0 to 4.0 (45 to 60 grains), every evening; also powders containing camphor 0.1 (1½ grains), lupulin 0.05 (¾ grain), extr. secal 0.08 (1¼ grains), twice daily. This treatment gave the patient great relief, and secured complete ease during the daytime. Therewith returned her greatly impaired trust in the future, and her emotional calm was restored.

The frequent occurrence of pollutions in women, the so-called vulvo-vaginal crises and clitoris-crises, is regarded by Eulenburg as a striking manifestation of sexual neurasthenia in woman; in such cases a lascivious dream is spontaneously followed by a more or less abundant discharge of the clear gelatino-mucous secretion of Bartholin’s glands. In women who masturbate, and in tribadists, a profuse and even violent secretion of these glands is produced by touching the clitoris or the erogenic zones at the entrance to the vagina, close to the orifices of Bartholin’s ducts.

Dyspareunia, the absence of voluptuous sensation in women during coitus, may be referred to three fundamental causes:

1. Insufficient or completely wanting peripheral stimulation of the sensory nerve terminals in the female reproductive canal: in these cases the conducting tracts to the nerve centres never become active.

2. Diminution or cessation of the excitability of the reflex centre in the lumbar enlargement of the spinal cord: this leads to failure of the sensation of ejaculation.

3. Inhibitory influences proceeding from the cerebral cortex whereby voluptuous sensations and perceptions are checked.

The first-named of these etiological influences is in my experience the commonest. Incomplete or quite inadequate stimulation of the sensory nerves of the genital canal may be due to the maladroit performance of copulation on the part of the male, owing to inexperience, or it may depend on gross disproportion in size between the reproductive organs of the man and the woman; in other cases it may be due to disease of the reproductive organs in either sex, influencing unfavourably the sensibility to stimulation of the nerves of the genital canal. Awkward or incomplete performance of coitus may thus lead to failure of voluptuous sensation, and this may ultimately pass into permanent dyspareunia. Temporary dyspareunia is very common in young wives during the first months of married life, ensuing on the pains of defloration; and very gradually gives place to normal voluptuous sensation. It may be one or two years after marriage before the sensation of ejaculation is first experienced. Not infrequently, dyspareunia depends on incomplete potency in the husband, who is incompetent to arouse voluptuous sensation in his wife. For this reason, dyspareunia is common in young women married to elderly men; but is common also, where (as so frequently among Russo-Polish Jews) the men also marry very young, at an age of from sixteen to seventeen years, and where, moreover, the husband has often before marriage impaired his potency by masturbation: finally dyspareunia is common when girls still undeveloped sexually are married to powerfully built men.

Regarding the pathological conditions of the female reproductive organs which counteract the peripheral sensory excitants of voluptuous sensation, we exclude from further consideration the obvious causes, absence and atrophy of the reproductive organs, and senile marasmus. Of prime importance as a cause of the failure of sexual sensibility in the early period of married life must be mentioned inflammation of the fossa navicularis, due to awkward attempts at intercourse. Other causes of deficient sensibility are: complete or partial persistence of the hymen, lesions of the vaginal inlet, acute or chronic vulvitis in consequence of irritating abundant secretion, especially as a sequel of gonorrhœal vaginitis. The last named infective disorder is especially harmful, because Bartholin’s glands are involved in the associated vulvitis. Even after the cure of the vulvitis, permanent dyspareunia may remain. Perineal fissures may result in the stimulant effect of coitus being insufficient, owing to the slight friction possible at the vaginal inlet in these cases. Not less serious sometimes are small, hardly discernible fissures in the vagina. Additional causes of deficient sexual sensibility are recto-vaginal, and vesico-vaginal fistulæ.

The second cause of dyspareunia, diminution or complete lack of irritability of the reflex centre of the lumbar enlargement of the spinal cord, appears to be less frequently operative. We must, however, assume that certain nervous disorders, such as hysteria and pathological changes in the spinal cord, are responsible in this connection. The activity of the lumbar sexual centre appears in women to be normally subject to variation within certain limits; and seems usually to attain its maximum irritability during menstruation. But normally these variations are never so great as to produce in women complete though merely temporary dyspareunia; in this respect offering a marked contrast to what occurs in other animals at other times than the rutting season, and of which every bitch not on heat furnishes an example when she refuses the sexual advances of the dog.

As regards the third causal influence in the production of dyspareunia, the influence of the brain, this, though important, is less frequently in operation. Diseases of the brain, degenerative processes, may constitute a cerebral cause for the failure of sexual sensation. But more frequently, certain cortical perceptions, such as dislike or hatred of the cohabiting male, an ardent passion for some other lover, grief and trouble, exercise inhibitory influences, which render the occurrence of voluptuous pleasure during the sexual act difficult or quite impossible.

A condition like dyspareunia, our knowledge of which depends entirely upon the subjective sensations of the woman concerned, is naturally one regarding whose existence accurate information is difficult to obtain. Very rarely does it happen that women spontaneously approach the physician with complaints of this condition; indeed, in my experience, they do so only when they are sterile, and when they assume, in accordance with the widespread popular belief, that their sterility is connected with the absence of voluptuous sensation during sexual intercourse. More commonly, however, it is the husband who feels it his duty to confide to the medical man the remarkable apathy of his wife in sexual intercourse. But when once the medical man’s attention has been directed to this question, and when he institutes enquiries among his patients in a scientific, passionless manner, one making due allowance for a woman’s modesty, as the moral importance of the subject demands, he will be astonished at the frequency of dyspareunia, and he will find herein the explanation of many obscure phenomena in the life of women. On the other hand, it must never be forgotten that a certain number of women complain of dyspareunia without any justification whatever, in order to arouse interest and sympathy, by representing themselves as unwilling sacrifices on the marital altar: the experienced gynecologist will readily detect the cases in which he is being misinformed; he can, moreover, always check the wife’s statements by conversation with the husband.

The constant sign of dyspareunia is the failure of ejaculation during coitus. We have previously described the muscular contractions which lead to ejaculation of the secretion of Bartholin’s glands and to the expulsion of the uterine and cervical mucus, as reflex actions evoked by the sensory stimulus dependent on friction of the female genital organs. The voluptuous sensation of ejaculation, associated with these muscular contractions, which the woman whose sensibility is normal experiences as the culminating point of her sexual “gratification,” is either quite unknown to a woman affected by dyspareunia, or is experienced by her only in a voluptuous dream, as a pollution, in which the sexual dream-perceptions act as the psychical stimuli by which the reflex discharge is originated. It has repeatedly happened to me, that on enquiring of women suffering from dyspareunia regarding their experience of the sensation of ejaculation, I have been informed that such sensations are known to them only from the descriptions of their female friends, or occasionally from dreams from which they have awakened with a feeling of moisture in the external genitals. Von Krafft-Ebing refers this process to a peristaltic contraction of the muscular fibres of the Fallopian tubes and the uterus, “whereby the tubal and uterine mucus is expressed;” whereas, for my part, I am of opinion, that ejaculation affects in the first place and principally the glands of Bartholin, the secretion of which is expressed by the contraction of the constrictor cunni muscles, and secondarily only affects the cervical glands of the uterus.

As a second sign of dyspareunia, I recognize a remarkably rapid outflow of the male semen from the female genital canal, immediately after coitus (profluvium seminis). The woman thus affected complains, when suitably questioned, that she is unable to retain the semen, and that it flows out of the vagina immediately after ejaculation. The cause of this remarkable phenomenon no doubt lies in the fact, that, owing to the absence of the voluptuous sensation, the reflex contractions of the muscles of the female genital organs, normally accompanying this sensation during intercourse, fail to occur. At the vaginal inlet, in normal conditions, the constrictor cunni muscle contracts, and farther up in the vagina a peristaltic contraction of the circularly disposed muscular fibres of the tunica media occurs: in this way the semen ejaculated into the vagina is for a time retained under a certain pressure. But in the absence of these muscular contractions, as well as of the muscular contraction of the pelvic floor, retention of the semen fails to occur. Cattle-breeders and horse-breeders have made similar observations regarding cows and mares, namely, that these animals are sometimes unable to retain the semen after coitus, and it is suggested that in these cases the animals are not properly on heat. Experienced cattle-breeders recommend in such cases that the retention of the semen should be promoted by douching the root of the tail and the external genitals with cold water. It is well known that by stimulating the peripheral sensory nerves in the neighbourhood of the genital organs, a reflex excitement of the lumbar sexual nerve centre is produced, as is seen, for example, in the practice of flagellation of the buttocks, for the increase of sexual desire.

Passing to the consideration of the pathological changes to be found in the reproductive organs of women suffering from dyspareunia, the nature of these will for the most part be obvious in relation to the etiology of the disorder. Most frequent, in my experience, were chronic inflammatory states of the vulva and of the vaginal and uterine mucous membrane, chronic metritis and parametritis. A very frequent appearance, and one practically characteristic of dyspareunia when of long standing, is a marked total relaxation of the reproductive apparatus. The uterus is extremely mobile, usually retroverted and partially prolapsed, thin, with lax walls, and usually an enlarged cavity; the portio vaginalis is flaccid, and runs to a point; the vagina is roomy; there is marked hypersecretion of the mucous membrane of the entire genital canal; there is great flaccidity of the constrictor cunni and levator ani muscles, and of the perineum. In several women with dyspareunia, I found old unhealed lacerations of the perineum. In some cases, the very small size of the clitoris is noteworthy. In one case amenorrhœa was present with an infantile uterus. In a large proportion of the cases I was able to detect a diminution both of the tactile and algic sensibility of the vaginal mucous membrane. The women were for the most part anæmic; many were extremely obese, and of lymphatic constitution. In some cases, however, no pathological changes whatever could be detected in the reproductive apparatus.

Dyspareunia is a condition which affects a woman’s whole nature, powerfully influences her mental life, and thus gives rise to greater psychical than physical damage. The consciousness of being deprived of the greatest joy of physical love produces great emotional depression, even in a woman by no means sensually inclined, and gives rise to a hypochondriacal state, at times even to melancholia. In other cases, the idea, not infrequently suggested by more happily situated women friends, that the woman herself is not to blame for this condition, has a demoralizing effect upon her, and destroys the happiness of married life. (It has been confessed to me, in isolated cases, that the dyspareunia was relative only.) Apart from this, the absence of sexual gratification gives rise to a series of nervous troubles, presenting either the variable characters of hysteria, or else the symptoms of neurasthenia. Finally, the frequently repeated incomplete coitus, incomplete inasmuch as the woman does not experience the sensation of ejaculation, induces chronic hyperæmia in the female reproductive organs, passing on into blood stasis, and ultimately into chronic inflammatory tissue changes; in this way arise metritis, perimetritis, and parametritis, salpingitis, oöphoritis, disorders of menstruation, menorrhagia, and atypical uterine hæmorrhages. The possibility cannot be disproved, that in this way new-growths of the reproductive organs may also originate. The act of sexual intercourse, which at first may be to the woman a matter of comparative indifference, and in which she plays her part merely from a sense of duty, becomes, in cases of long-standing dyspareunia, something to which she feels a positive dislike, and is recognized by her as the actual cause of the troubles that ensue upon intercourse, such as sacrache, sensations of weight and pressure in the pelvis, strangury, fluor albus, a feeling of exhaustion, etc.

At times, perverse sexual sensation is associated with dyspareunia. Women who find no enjoyment in normal sexual intercourse with a male, sometimes masturbate, sometimes indulge in amor lesbicus, etc.

Of great importance appears to me the relation between dyspareunia and sterility in women. As already pointed out, dyspareunia comes chiefly under medical observation in cases in which it is associated with sterility. The husband, seeking advice concerning his wife’s failure to conceive, complains of her frigidity in sexual intercourse as the probable cause; or the wife comes to seek advice, saying that she never experiences sexual gratification, and that for this reason she has failed to become pregnant. As a matter of actual fact, dyspareunia and sterility are associated with such remarkable frequency, that my own experience leads me to believe in the existence of an etiological connection between the two conditions, at least in a certain proportion of the cases. Among 69 sterile women whom I questioned regarding dyspareunia, the latter condition was present in 26, that is to say, in 38% of the cases. Matthews Duncan reported that of 191 sterile women, 62 did not experience sexual enjoyment. Sexual excitement of the woman during copulation would certainly appear to have a definite bearing upon the occurrence of conception, for we know that by the voluptuous sensation reflex actions are aroused in the genital canal, favouring the retention of semen and its passage through the os to the interior of the uterus, and perhaps also giving rise to reflex changes in the cervical secretion which favour the passage of the spermatozoa into the uterine cavity.

In cases of relative dyspareunia, the influence of this condition in producing sterility is also manifested, the unfaithful wife being impregnated by her lover though she has remained sterile in intercourse with the husband to whom she is indifferent. To dyspareunia of this nature (dependent upon sexual disharmony), we may also refer the sterility of a married pair who have for some time lived together in unfruitful intercourse, whereas, after divorce and the contraction of fresh unions, both the man and the woman prove normally fertile. Such cases have been personally known to me; and similar instances aroused the attention of the natural philosophers of antiquity, for instance, that of Aristotle. The importance of voluptuous sensation in promoting conception is also manifest from the fact that in the majority of women, after the pains of defloration, dyspareunia usually persists for a season during the early period of married life; and, corresponding with this, the first conception is usually deferred for some little time after marriage, to a period corresponding with the awakening of the sensation of ejaculation. In this connection, Courty reports the case of a lady who, although in blooming health, remained sterile during the first fifteen years of her married life; she then gave birth to a child whose father was unquestionably her lover; and after this in succession to two other children whose progenitor was the legal husband. This lady had never experienced voluptuous sensation in intercourse prior to the time of her first conception. Similar circumstances with an even clearer significance have been frequently observed among the lower animals; and Darwin records several striking observations of this character. Taking all the evidence into consideration, we are compelled to regard dyspareunia as a condition capable of causing sterility in women, although the sequence is not an absolutely necessary or invariable one.

In order to excite voluptuous sensation during intercourse, savage races make use of various means, some of which we here transcribe from the work of Ploss-Bartels. In Abyssinia, and on the Zanzibar coast, young girls receive instruction in certain rotary muscular movements known by the name of duk-duk, which they employ during coitus for the increase of sexual pleasure. Many Daiaks perforate the glans penis with a silver needle from above downwards; this needle is kept in place like a seton, until a permanent canal is formed through the glans: in order during coitus to stimulate the woman more powerfully, into this canal, just before coitus, various small articles are inserted, such as little rods of brass, ivory, silver, or bamboo, or silver instruments ending in small bundles of bristles; these project from the surface of the glans, and exercise a more powerful friction of the vagina, thus increasing the sexual pleasure of the woman. Men without such an apparatus are rejected by the women, whilst those who have made several such canals in the glans, and can therefore insert several instruments, are especially sought after and prized by the women. Such an apparatus is known as an ampallang, and in a symbolic manner the woman indicates to a man of her choice her desire that he should make use of one; he finds in his bowl of rice a rolled-up leaf, enclosing a cigarette which represents the size of the desired ampallang. Among the Alfurs of North Celebes, in order to increase the voluptuous pleasure of the woman during intercourse, the men bind round the corona glandis the eyelids of a goat, beset with the eyelashes, thus forming a bristly collar; in Java and in Sunda, before coitus, the men surround the penis with strips of goat-skin, leaving the glans free. In China they wind round the corona glandis torn fragments of a bird’s wing; these also project like bristles and increase the friction. Among the Batta of Sumatra, travelling medicine-men perform an operation by means of which they insert, beneath the skin of the penis, small stones, sometimes to the number of ten, at times also angular fragments of gold or silver; these heal in beneath the skin, and increase the stimulus of coitus for the women. Among the Malays of Borneo the penis is perforated, and some fine brass wire with the ends turned inwards is inserted: before coitus, the sharp ends of the wire are drawn out so as to project from the skin.

In our own part of the world, voluptuaries make use of an india-rubber ring beset with spines, which before coitus is passed over the corona glandis, in order to promote sexual gratification in the woman during intercourse. In cases of diminished potency in the male, in order to produce sufficient sexual excitement in the female by more powerful erection of the penis, various mechanical means are now employed. For instance, in such a partially impotent man, a constricting band of india-rubber may be passed over the root of the penis, whereby the reflux of blood from the corpora cavernosa is hindered, and a more complete and more enduring erection is induced. Elderly men have frequently declared to me that they were well satisfied by the employment of this simple measure, whilst behind their backs, their wives have assured me that the results were far from satisfactory. The apparatus described by Roubaud for the enlargement of the penis is no longer employed. Partially impotent men make use, however, of an instrument known by the name of “schlitten,” made of gold, silver, or white-metal; it consists of two delicate laminæ, united at the base by a metal ring, and at the upper end by an india rubber ring. This small apparatus, which must be made exactly to measure, renders possible the introduction of the imperfectly erect penis into the vagina; it supports the penis, and readily accommodates itself to the change in size of the organ as it slowly becomes erect.

FERTILITY IN WOMEN.

Fertility in women is the basis of the fecundity of a nation, of its growth, its power, and its importance. It is especially the fertility of married women which enters here into consideration, and forms the source of the statistical data of fertility; these are usually obtained by drawing a ratio between the number of marriages contracted in a given period, and the number of children born in the same period.

The fertility of women is a function beginning at an age varying in dependence on many conditions, and undergoing extinction at a definite period of life. It is, in fact, associated with the duration of the sexual life of woman, and, generally speaking, extends from the sixteenth to the fiftieth year of life. Climate, race, constitution, and morbid conditions, influence alike the first appearance of menstruation and the first pregnancy; and as they influence the duration of menstrual activity, so also do they influence the duration of fertility.

In the Bible are recorded numerous instances of the early commencement of fertility. At the present time also, in warm climates we meet with many examples of early motherhood. From the great work of Ploss-Bartels, from which we have already frequently quoted, we extract and summarize the following ethnographical details. Among the wives of the Bosjesman, mothers aged ten are frequently seen; travellers in New Zealand often saw mothers of eleven years, and mothers of the same age among the Samoyedes and in Palestine; mothers of twelve in British Guiana, in Jamaica, among the Schangallas, at Shiraz in Persia, among the Copts in Egypt; mothers aged thirteen in Cuba, among the Sioux and the Dakotas, and in New Caledonia; mothers aged fourteen among the Negroes of Gaboon.

According to the observations of Robertson, of sixty-five Indian women there gave birth for the first time:

At the age of 10 years 1 At the age of 11 years 4 At the age of 12 years 11 At the age of 13 years 11 At the age of 14 years 18 At the age of 15 years 12 At the age of 16 years 7 At the age of 17 years 1

Moreover, in the records of European countries, we find numerous instances of very early motherhood. Molitor’s case, a girl nine years old giving birth to a vesicular mole with an embryo; von Haller’s case, pregnancy in the ninth year of life; Carus’ case, pregnancy at the age of eight. Caspar saw a girl in Berlin who became pregnant at the age of twelve, and was delivered of a living child. Rüttel saw a girl nine years of age pregnant. King attended the confinement of a girl who at the time of her delivery was not yet eleven years old. Taylor reports the case of a girl twelve years and six months of age who was then in the last month of pregnancy. Koblanck attended a girl of fourteen who was delivered of a child weighing four and a half pounds.

In most of these cases the premature fertility is followed by a premature cessation of fertility. And there is more or less truth in Bruce’s statement regarding the Arab women in Africa, that those who began to bear children at the age of eleven were seldom still fertile at the age of twenty.

At times we may observe a remarkable extension of fertility beyond the average age, that is, beyond the age of fifty years.

In northern Europe pregnancy at a comparatively advanced age is by no means rare. From the official statistics of Denmark we learn that among 10,000 women, 465 were delivered at ages between 50 and 55 years. In Sweden, of 10,000 mothers, 300 gave birth to children when more than 50 years of age. In Ireland, the proportion of mothers over 50 was 345 per 10,000. In England the official figures dealing with the delivery of 483,613 women, showed that 7,022 were between 45 and 50 years of age, and 167 over 50 years of age.

The Surgical Academy of Paris, in an authoritative statement regarding the late age at which conception could take place, alluded to the fact that Cornelia, of the family of the Scipios, gave birth to Volusius Saturninus when sixty years of age, that the physician Marsa in Venice recorded the existence of pregnancy in a woman of sixty, that de la Motte recorded pregnancy in a woman of fifty-one, and that he believed it to be true that another Parisian woman had given birth to a girl at the age of sixty-three, and had herself suckled the infant.

In an important case, however, which came before the Court of Chancery in England, the court held that there was no definite evidence of the possibility of pregnancy in a woman sixty years of age; but that the greatest age at which, in England, pregnancy had indisputably occurred, was 54.

Among 4,925 deliveries occurring in the Prague Maternity Hospital, Schwing reports that there were 9 women delivered for the first time when over 40 years of age. Of these:

3 were 41 years of age. 2 were 42 years of age. 1 was 43 years of age. 2 were 44 years of age. 1 was 47 years of age.

Haller reports the cases of two women who gave birth to children, one at the age of 63, the other at the age of 70 years. Meissner delivered a woman of 60 years of her seventh child; Rush attended the delivery of a woman aged 60; Dewees that of a woman aged 61. Mende and Bernstein report cases of delivery at the age of 60. Marion Sims saw, in the state of Alabama, a negro woman 58 to 60 years of age, who gave birth to a child at this age, at an interval of twenty years since her last pregnancy. Nieden reports a case in which the first pregnancy occurred 26 years after marriage. When married, the wife was 18 years of age, the husband 30; during their first twenty-five years of married life there was no sign of pregnancy, but when the wife was 44 years of age, menstruation, hitherto regular, suddenly ceased; the cause of the cessation proved to be pregnancy, and at term a healthy girl weighing nine pounds was born; the mother was able to nurse the child herself. Smith attended a woman aged 52 who was delivered of twins; the youngest of her eight other children, who were then all living, was ten years of age.

Rodzewitsch collected from the Russian literature of the years 1872 to 1881, eleven cases in which women aged 50 to 55 had given birth to children. Talquist reports that in Finland, in the year 1883, a woman 58 years of age was delivered; whilst Ansell records the case of an Englishwoman who became a mother when 59 years of age. John Kennedy records the case of a woman of 62 who was normally delivered at this age; she had begun to menstruate at the age of 13, and since the age of 20 had previously given birth to 21 children, the last five when she was 47, 49, 51, 53, and 56 years of age, respectively. Prior even reports the case of a woman 72 years of age, who not only menstruated, but had an abortion(!)

The ideal of fertility in women is that the first completed act of sexual intercourse should be followed immediately by conception, that the pregnancy should terminate after the normal lapse of time in the birth of a child, and that the same process should be repeated at intervals of about ten months until the end of active sexual life. In actual experience, however, this never occurs. Fertilization as an immediate consequence of the first act of sexual intercourse (which in the lower animals is regarded as the rule) is a very rare occurrence in human beings. Moreover, in no single marriage is the reproductive capacity of the wife utilized to the full, up to the time of extinction of her generative faculty; either because the potency of the male partner undergoes a gradual decline, or, it may be, because, after a while, sexual intercourse becomes less frequent, or because precautions against procreation are taken.

The number of children to which during the three decades of her sexual life, from the menarche to the menopause, a woman might theoretically give birth, is never actually born. If we assume that, during the period of active sexual life, a woman requires a period of fifteen months to two years for each pregnancy, parturition, and lactation, a woman could easily during this period have fifteen or sixteen children, and this figure would represent the normal product of the normal fertility of the human female. There are indeed, women who, it may be in consequence of an exceptionally long period of sexual activity, or through giving birth repeatedly to twins or triplets, or because they have married several husbands in succession, have given birth to twenty-four children or even more. In Berlin, in the year 1901, there lived a woman 41 years of age who had had 23 children; there were three women, aged respectively 40, 43, and 46 years, who had had each 21 children; 246 women with families numbering 13 to 20; and 169 women each of whom had given birth to 12 children. In the very great majority of cases, however, the fertility of the wife of the present day is never fully developed. It is modified in various ways by the conditions of marriage, by social circumstances, by considerations relating to the health of husband or wife, by actual illnesses, and by voluntary limitation of fertility. Generally speaking, according to the investigations of Quetelet, Sadler, and Finlayson, the fertility of women is greatest in marriages in which the husband is as old as the wife, or a little older, but without marked difference in age. Marriages contracted at a very early age are less fruitful; the highest fertility is found in marriages contracted when the husband is 23 and the wife 26 years of age.

Conception does not generally take place until sexual intercourse has been frequently repeated. As the result of a statistical enquiry of my own, relating to 556 fruitful marriages, I ascertained that in these the first delivery occurred:

Within 10 months after marriage in 156 cases. Within 11 to 15 months after marriage in 199 cases. Within 16 to 24 months after marriage in 115 cases. Within 2 to 3 years after marriage in 60 cases. More than 3 years after marriage in 26 cases.

Thus we learn that in 35.5% of the cases the first delivery occurred within 1¼ years after marriage; in 15.6% within 10 months; and in 19.9% within 15 months after marriage; and 11.5% of the cases, the first delivery was more than 1¼ years and less than 2 years after marriage; in 6.0% it was between 2 and 3 years after marriage; and in 2.6%, the first delivery did not occur until more than 3 years after marriage.

From examination of the birth registers of Edinburgh and Glasgow, Matthews Duncan determined the mean interval between marriage and the birth of a living child to be seventeen months. In the majority of cases, the first delivery does not occur until a complete year has elapsed since marriage; in fact, in nearly two-thirds of the instances the first delivery occurs during the second year of married life.

The interval between two successive births is, according to Matthews Duncan, on the average 18 to 24 months, according to Goehlert, 24 to 26 months; the latter, however, points out that in cases in which the child dies very soon after birth, the birth of the next child ensues on the average in 16 to 18 months. In this connection, we must not fail to take into consideration the influence of lactation, inasmuch as mothers who do not suckle their children become pregnant considerably earlier, on the average, than those who undertake this duty. In reigning families, for instance, it is by no means uncommon for the consort to be delivered twice within a single year. The degree to which lactation hinders conception is so widely known, that women often suckle their infant for a very long period, with the definite aim of preventing the speedy recurrence of pregnancy. A high official from the Dutch Indies informed me that for this reason the native women were accustomed to suckle their infants for several years, and that it was by no means uncommon to see a small boy running about smoking a cigar, and then hurrying to his mother in order to be suckled.

The age at which a woman contracts marriage has also to this extent an influence upon her fertility, inasmuch as it appears that those who marry very young are far less fertile than those who marry between the ages of 20 and 25 years; the latter moreover have, on the average, a shorter time to wait for their first conception than women who marry before the age of 20. Women who marry after the age of 25 have to wait longer after marriage for their first delivery; in fact the older the woman after 25, the greater, on the average, the interval between marriage and the first delivery.

Arranging the data already referred to, regarding 556 fruitful women, in relation to this point of view, it appears that the first birth ensued:

═════════════════════╤═════════╤═════════╤═════════╤═════════╤═════════ │ │ │15 months│ │ │ │10 to 15 │ to 2 │ 2 to 3 │More than │Within 10│ months │ years │ years │ 3 years │months of│ after │ after │ after │ after │marriage.│marriage.│marriage.│marriage.│marriage. ─────────────────────┼─────────┼─────────┼─────────┼─────────┼───────── In 163 women marrying│ │ │ │ │ at ages 15 to 20 │ │ │ │ │ years │ 36│ 53│ 46│ 18│ 10 In 313 women marrying│ │ │ │ │ at ages 20 to 25 │ │ │ │ │ years │ 98│ 113│ 56│ 32│ 14 In 70 women marrying │ │ │ │ │ at ages 25 to 33 │ │ │ │ │ years │ 18│ 30│ 12│ 9│ 1 In 10 women marrying │ │ │ │ │ at ages over 33 │ │ │ │ │ years │ 4│ 3│ 1│ 1│ 1 ═════════════════════╧═════════╧═════════╧═════════╧═════════╧═════════

To give percentages, the first birth occurred,

═════════════════════╤═════════╤═════════╤═════════╤═════════╤═════════ │ │ │15 months│ │ │ │10 to 15 │ to 2 │ 2 to 3 │More than │Within 10│ months │ years │ years │ 3 years │months of│ after │ after │ after │ after │marriage.│marriage.│marriage.│marriage.│marriage. ─────────────────────┼─────────┼─────────┼─────────┼─────────┼───────── Women marrying at │ │ │ │ │ ages 15 to 20 │ │ │ │ │ years, in │ 22.0%│ 32.5%│ 28.2%│ 11.0%│ 8.1% Women marrying at │ │ │ │ │ ages 20 to 25 │ │ │ │ │ years, in │ 31.3%│ 36.1%│ 17.8%│ 10.2%│ 4.4% Women marrying at │ │ │ │ │ ages 25 to 33 │ │ │ │ │ years, in │ 25.7%│ 42.8%│ 17.1%│ 12.8%│ 1.4% Women marrying at │ │ │ │ │ ages over 33 years,│ │ │ │ │ in │ 40.0%│ 30.0%│ 10.0%│ 10.0%│ 10.0% ═════════════════════╧═════════╧═════════╧═════════╧═════════╧═════════

Thus whereas in women who contracted marriage between the ages of 15 and 20 years, only 54.5% were confined for the first time within 15 months after marriage, in women who contracted marriage between the ages of 20 and 25 years, in 67.4% the first delivery occurred within 15 months of marriage. And whereas in those who married at the earlier age, the percentage of first deliveries occurring between 15 months and 2 years after marriage was 28.2, in those who married between the ages of 20 and 25, the percentage of first deliveries after the stated interval was only 17.8.

The figures compiled by Whitehead and Pfannkuch give similar results. Of 700 women who married between the ages of 15 to 20 years, there were 306 only who gave birth to a child within the first two years after marriage; whereas of 1,835 women who married between the ages of 20 and 25 years, no less than 1,661 gave birth to a child within two years after marriage—a percentage of 43.7 in the former case, and 90.6 in the latter case. Pfannkuch, as the result of a very large collection of figures relating to this question, found that in women marrying before the age of 20 years, the average number of months before the first delivery was 26; whereas in women marrying after the age of 20 years, the average number of months before the first delivery was 20.

According to Matthews Duncan

═══════════════════════════════════╤═══════════════════════════════════ OF EVERY 100 WOMEN WHO MARRY │ THERE BECOME MOTHERS ───────────────────────────────────┼─────────────────┬───────────────── „ │ In the 1st year │In the 2d year of │of married life. │ married life. ───────────────────────────────────┼─────────────────┼───────────────── Between the ages of 15 and 20 years│ 13.71│ 43.70 Between the ages of 20 and 25 years│ 18.48│ 90.51 Between the ages of 25 and 30 years│ 12.41│ 75.80 Between the ages of 30 and 35 years│ 11.44│ 62.93 Between the ages of 35 and 40 years│ 9.27│ 40.97 ═══════════════════════════════════╧═════════════════╧═════════════════

Sadler examined the relationship between the age at which marriage was contracted and the number of offspring in the case of the wives of English peers. He obtained the following results:

Age at marriage. Births per marriage. 12 to 16 years 4.40 16 to 20 years 4.63 20 to 24 years 5.21 24 to 28 years 5.43

From exact statistical data of births in the Scandinavian countries of Europe (Denmark, Sweden and Norway), Goehlert compiled the following table, showing the percentages of fertility at various ages:

═════════════════╤══════════════════════════╤══════════════════════════ AGES. │ MARRIED WOMEN. │ UNMARRIED WOMEN. ─────────────────┼────────┬────────┬────────┼────────┬────────┬──────── „ │Denmark.│Sweden. │Norway. │Denmark.│Sweden. │Norway. ─────────────────┼────────┼────────┼────────┼────────┼────────┼──────── Under 20 years. │ 1.0│ 1.0│ 0.7│ 9.1│ 7.0│ 4.9 From 20 to 25 │ 13.9│ 12.8│ 11.9│ 43.9│ 35.1│ 37.0 years. │ │ │ │ │ │ From 25 to 30 │ 26.5│ 24.7│ 24.7│ 28.1│ 27.9│ 32.4 years. │ │ │ │ │ │ From 30 to 35 │ 26.7│ 26.1│ 25.3│ 11.4│ 16.8│ 14.9 years. │ │ │ │ │ │ From 35 to 40 │ 21.0│ 21.6│ 21.3│ 5.4│ 9.0│ 7.1 years. │ │ │ │ │ │ ─────────────────┼────────┼────────┼────────┼────────┼────────┼──────── From 40 to 45 │ 9.9│ 12.0│ 13.0│ } 2.1│ 4.2│ 3.7 years. │ │ │ │ │ │ Over 45 years. │ 1.1│ 1.8│ 3.1│ „ │ „ │ „ ─────────────────┴────────┴────────┴────────┴────────┴────────┴────────

From this table it appears that the fertility of married women increases steadily up to the age of 35 years, but after this age it begins to decline. What a marked influence the age at marriage has upon fertility is shown by the comparison of the figures relating to married women with those relating to unmarried women; the fertility of unmarried mothers attains its maximum at the ages of 20 to 25 years. In the countries under consideration the average age of women at the time of marriage is 25 to 27 years.

In order to obtain a still clearer picture of the fertility of women in relation to age, Goehlert has combined the figures relating to the married and the unmarried, and then calculated the percentages, with the following results:

════════════════════════════════════════════╤══════════════════════════ AGES. │ MARRIED AND UNMARRIED │ WOMEN. ────────────────────────────────────────────┼────────┬────────┬──────── „ │Denmark.│Sweden. │Norway. ────────────────────────────────────────────┼────────┼────────┼──────── Under 20 years. │ 1.7│ 1.6│ 1.1 From 20 to 25 years. │ 16.6│ 15.1│ 14.1 From 25 to 30 year │ 26.6│ 25.0│ 25.3 From 30 to 35 years. │ 25.3│ 25.1│ 24.4 From 35 to 40 years. │ 19.6│ 20.4│ 20.0 From 40 to 45 years. │ 9.2│ 11.2│ 12.2 ────────────────────────────────────────────┼────────┼────────┼──────── From 45 to 50 years. │ } 1.0│ 1.6│ 2.9 Over 50 years. │ „ │ „ │ „ ────────────────────────────────────────────┴────────┴────────┴────────

If, finally, we combine into a single table the figures relating to all three of these countries, we obtain the following results:

Under 20 years 1.5% From 20 to 25 years 15.3% From 25 to 30 years 25.6% From 30 to 35 years 24.9% From 35 to 40 years 20.0% From 40 to 45 years 10.9% Over 45 years 1.8%

From these figures it appears that the maximum fertility of married women is attained, in Denmark at the age of 31, in Norway at the age of 31.7, and in Sweden at the age of 32 years. In the case of unmarried women, the maximum fertility is at the ages of 24 to 26 years. In the Austrian Empire, the maximum fertility of women is attained at about the age of 30 years; in England it is attained between the ages of 20 and 25 years.

Divergent results as regards the fertility of married women at different ages were obtained by Goehlert from the examination of 5,290 cases from the reigning families of Europe. In the favourable position as regards means of subsistence occupied by the members of these families, marriage naturally occurs, in most cases, much earlier in life, the mean age at marriage being between 19 and 22 years—the youngest mother (in the Capet dynasty) was only 13 years of age—and for this reason the figures relating to the younger age-classes are larger than in the previous tables. But as a result of this, the reproductive capacity also undergoes an earlier extinction, so that of these women, not one gave birth to a child when she was over 50 years of age. Goehlert gives the following table, compiled from these 5,290 instances:

Under 20 years 8.8% From 20 to 25 years 25.4% From 25 to 30 years 29.4% From 30 to 35 years 21.6% From 35 to 40 years 11.5% Over 40 years 3.3%

In these cases the maximum fertility was obtained at the age of 27.

The physiological fertility of women is much more clearly manifested when we compare the fertility of women who have been married a few years only, with the fertility of women in the later years of married life. In the earlier period, the effective fertility more nearly approaches the physiological fertility, because at this time the various influences by means of which fertility is later so greatly diminished have not yet come into operation. In this connection the following data, published by Körösi, regarding the percentage fertility of recently married women, and that of married women in general, will be found of interest:

═══════════════════════╤═══════════════════════╤═══════════════════════ │Recently-married women.│ All married women. ───────────────────────┼───────────────────────┼─────────────────────── At ages 20 to 35 years.│ 32.9%│ 20.6% At ages 35 to 40 years.│ 32.7%│ 14.7% At ages 40 to 45 years.│ 21.4%│ 5.9% ═══════════════════════╧═══════════════════════╧═══════════════════════

Inasmuch as we learn from this table that in the case of women aged 40 and upward, the newly married exhibit a fertility of four times as great as that of married women in general, in whom pregnancy has already become rare, we can infer the influence upon fertility of abstinence and of artificial measures for the prevention of conception.

On the average, the maximum fertility of woman, that is, the maximum of effective fertility, is attained at the age of 18 to 20 years. Extreme youthfulness, and also the opposite condition, too advanced an age, when marriage is entered on, impair a woman’s fertility; whereas the conditions most favourable to fertility are that, at the time of marriage, the uterus should have attained its fullest development, and the ovaries also should be completely mature; this is not usually the case at puberty, but rather at the age of 20, 21, or 22 years. In Austria-Hungary, of 100 marriages in which the wife’s age at marriage was less than 18 years, the average offspring in the course of a single year were 36 to 38 children; in the case of 100 marriages in which the wife’s age at marriage was 18 to 20 years, the average offspring in a year were 40; this being the maximum fertility, the number of offspring in a year per hundred marriages (i. e., the percentage fertility), now undergoes a regular decline as the wife’s age at marriage increases; at an age of 25, the percentage fertility is 32; at the age of 30 years, the fertility is 24%; at the age of 35, 17%; at the age of 40 years barely 10%; at the age of 45, 7%; at ages 45 to 50, 0.1%. Thus, from the last figure, we see that of a thousand women marrying at the age of 50 years, one only gives birth to a child. Men obtain their maximum fertility (i. e., procreative capacity) at the age of 25 or 26 years; at this age their fertility amounts to 35% (that is, of 100 marriages at this age, 35 children will on the average be born within a single year); at the age of 35 years, the percentage fertility of men falls to 23; at the age of 45 years, it is 9½%; at 55, 2.2%; at 65, ½% (Körösi-Blaschko).

Whereas hitherto we have considered only the monogenous fertility of married women, we must remember that the figures relating to their biogenous fertility are also of interest—that is to say, the changes which a woman’s fertility experiences in married life in respect of the peculiarities of her husband; and of these peculiarities, the easiest to make the object of statistical investigation is the husband’s age. The age of the husband exercises an important influence upon the fertility of the wife, as is proved by the following figures published by Körösi:

════════════════════════════╤════════════════════════════════════════════ AGE OF THE FATHER. │ AGE OF THE MOTHER. ────────────────────────────┼──────────────┬──────────────┬────────────── „ │ 25 years. │ 30 years. │ 35 years. ────────────────────────────┼──────────────┼──────────────┼────────────── 25 to 30 years │ 35.6%│ 25.0%│ 21.2% 30 to 35 years │ 31.2%│ 23.6%│ 19.9% 35 to 40 years │ 27.5%│ 21.8%│ 19.4% 40 to 45 years │ │ 16.7%│ 14.0% 45 to 50 years │ │ 14.4%│ 10.9% 50 to 55 years │ │ │ 10.9% ════════════════════════════╧══════════════╧══════════════╧══════════════

Also:

══════════════╤═══════════════════════════════════════════════════════════ AGE OF THE │ AGE OF THE FATHER. MOTHER. │ ──────────────┼──────────────┬──────────────┬──────────────┬────────────── „ │ 25 years. │ 35 years. │ 45 years. │ 55 years. ──────────────┼──────────────┼──────────────┼──────────────┼────────────── Under 20 years│ 49.1%│ │ │ 20 to 25 years│ 43.0%│ 31.3%│ 16.0%│ 25 to 30 years│ 30.8%│ 27.3%│ 18.5%│ 30 to 35 years│ 33.5%│ 23.7%│ 14.4%│ 8.1% 35 to 40 years│ │ 18.9%│ 11.8%│ 6.7% 40 to 45 years│ │ 6.6%│ 6.1%│ 3.0% ══════════════╧══════════════╧══════════════╧══════════════╧══════════════

We learn from these figures that the maximum fertility is exhibited by a woman 18 years of age, when married to a man 25 years of age; less fertile is a woman 25 to 30 years of age married to a man 28 years of age; still less fertile is a woman 35 years of age married to a man 29 years of age. Neither the age of the mother alone, nor that of the father alone, is determinative of the fertility of the marriage, for the fertility of young wives married to elderly husbands is quite different from that of young wives married to young husbands. Very various age-combinations are possible, and each exhibits an average fertility peculiar to itself.

We can also regard the question from the standpoint of the difference between the ages of husband and wife respectively. In this connection, Körösi is led by his tables to the conclusion that wives between the ages of 18 and 20 years attain their maximum fertility when married to men 7 years older than themselves; women of 25 years when married to men 3 years older than themselves; women of 29 years when married to men of the same age; women of 30 years and upward attain their maximum fertility only when married to men younger than themselves. Men, on the contrary, always attain their maximum fertility when married to women younger than themselves. The age of maximum fertility differs in the two sexes, and those marriages will be most fruitful in which husband and wife are each of the age most favorable to fertility. This will be the case when the age of the wife is 18 to 20 years, and that of the husband 24 to 26 or perhaps 29 years.

In connection with the question of fertility, we have also to take into consideration the vitality of the children born, that is, what proportion of those born survive. According to Körösi’s interesting papers regarding the fertility of the inhabitants of Buda-Pesth, we learn that for every 100 marriages which have persisted for thirty years and upward, there were born, on the average, 539 children, of whom during this period 241 died, so that the percentage of survivals was 55.28. Parents who have lost one only of several children must, therefore, regard themselves as exceptionally favoured by fortune.

Social position, occupation, and religion, have, according to the last-quoted author, a notable influence on fertility. His investigations showed that the Roman Catholics and the Jews exhibited the greatest fertility; among the Catholics there were 541 children, and among the Jews 557 children, per 100 marriages. Amongst 100 Protestant families, on the other hand, only 479 children had been born. It will be seen that the theory of the comparatively enormous fertility of the Jewish race is not supported by these statistics. The Jews do, however, exhibit a greater power of rearing children, for among them the marriages of more than 30 years’ duration had 61⅔ % of the children still living; among the Protestants 57¾% survived; and among the Catholics only 52–⅗%. It thus appears that the surviving offspring per 100 marriages of 30 years’ duration were, among the Catholics 278, among the Protestants 252, and among the Jews 349.

The question whether, and to what extent, the age of the parents has an influence on the vitality of the children, is answered by Körösi’s mortality statistics in the sense that mothers below 20 years of age give birth to a larger proportion of children deficient in vital power. Where the mothers had married at the age of 16, the mortality of their offspring was, among Catholics 43%, among Jews 33%; married at 17, Catholic mortality 44%, Jewish 30%; married at 18, Catholic mortality 42%, Jewish 32%; married at 19, Catholic mortality 41%, Jewish 29%; married at 20, Catholic mortality 40%, Jewish 26%. Of the children whose fathers had married at the age of 24, 32% had died; of those whose fathers had married at 23, 37% had died; of those whose fathers had married at 20, 42% had died; and of those whose fathers had married before 20, actually 44% had died. It thus appears that the children alike of very young mothers and of very young fathers have a lessened chance of survival.

Inasmuch as the fertility of the wife is a product of two factors, her own peculiar fertility, and that of the procreating male, the question of the fertility of women cannot be accurately treated independently of this second consideration; hereby, however, is introduced a multiplicity of obscure combinations, by which the value of all the statistical data of fertility in women is seriously impaired.

These data give as the measure of fertility, the number of children per marriage actually brought up, embracing fruitful marriages, sterile marriages, and those not yet fruitful. In Berlin, in Copenhagen, and in Buda-Pesth, the average thus attained was slightly less than three births to each family, whilst the number of children actually living averaged two per family. A more accurate representation of fertility is obtained by ascertaining the number of children born, and the number of children living in relation to the duration of marriages reckoned in years, that is beginning with marriages of one year’s duration, and proceeding year by year to the highest recorded duration of marriage. In this way interesting statistics have been obtained; for example, one who has completed thirty years of married life may count on the average that five or six children will have been born to him, but may also reckon on having buried two or three at least of these. (Körösi.)

Fertility is, as many facts indicate, also dependent on nutrition. A distinct proof, says Spencer, writing on the “Coincidence between high Nutrition and Genesis,” that abundant nutriment increases the number of births, and vice versa, is found among the mammalia; compare, for instance, the litter of the dog with that of the wolf and the fox. Whilst the dog’s litter numbers 6 to 14, that of the wolf numbers 5 to 7, that of the fox 4 to 6. The wild cat gives birth to 4 or 5 kittens once a year, the domesticated cat to 5 or 6, twice or thrice annually. The most remarkable contrast, in this respect, exists between the wild and the domesticated breeds of swine. The wild sow gives birth once a year to a litter of 4, 8, or 10 pigs (the number increasing in successive litters); the domesticated sow has often as many as 17 in a single litter, whilst in two years five litters, each numbering 10 pigs, are commonly born.

Darwin also draws attention to the fact that animals under domestication, being fed more abundantly and regularly than their wild allies, procreate at shorter intervals and are markedly more fertile than the latter. He states that the wild rabbit has four litters annually, each numbering 4 to 8 young; whereas the tame rabbit reproduces its kind six to seven times annually, and gives birth to litters numbering 4 to 11. Among birds, analogous phenomena are observed. The wild duck, for instance, lays 5 to 10 eggs in the course of the year, whereas the tame duck lays from 80 to 100; the wild grey goose lays 5 to 8 eggs, the domesticated goose 13 to 18.

It must be added that this exceptional fertility is manifested in animals that are quite inactive in comparison with their wild allies; not only are they richly fed, but they get their food without working for it. Moreover, it is easy to observe that among the domesticated mammals the well-fed are more fertile than the ill-fed.

That in the human species also, fertility is influenced to a notable degree by nutritive conditions, is shown by statistical investigation. After years distinguished by an exceptionally good harvest the number of children born is considerably greater than in normal conditions; whereas after a famine the opposite is observed. Malthus’s law of population states, inter alia, that the population increases when the amount of available nutriment increases, that is, that favourable nutritive conditions cause an increase, that unfavourable nutritive conditions cause a decrease, of population. Hardships and exhausting occupations diminish the fertility of women. The remarkable fertility of the Kaffirs is referred to the fact that this people, possessing large herds of cattle, lead a life comparatively free from care; it is no less true that the Boer women, who lead a life of well-fed leisure, have very large families; whereas the Hottentot women, poor, ill-nourished, and hard working, seldom bear more than three children.

Generally speaking, it may be said that fertility of the soil, in connection with an easily gained livelihood, favours also human fertility, notwithstanding the fact that certain statistical data seem to conflict with this proposition. Sadler, for instance, concludes that an increase in the price of the necessaries of life does not per se check fertility, but, indeed, rather increases it; he considers that the apparent decline in fertility is due to the fact that the number of marriages diminishes, owing to the rise in prices. We must, however, point out, that an increase in price of the necessaries of life is often associated with a rise in wages, and is therefore not necessarily identified with deficient nutrition; when, however, such a rise in prices leads to actual want, a limitation of fertility will certainly result; this has been proved by Legoyt and Villermé with regard to failure of the crops. Famine and disease lower the number of births; a less severe deficiency of nutriment often lowers only the quality of those born. Malthus was of opinion that the population of a country at any time was related to the quantity of nutriment produced or imported therein, on the one hand, and, on the other, to the liberality with which this nutriment was distributed to the individual. In countries where corn forms the principal crop, we find a thicker population than in pasture lands; and where rice is the principal crop, the population is even more abundant than it is in corn growing countries.

Passing to the consideration of the individual nutritive elements, we find that these also influence fertility. Above all, it has been proved that alcohol notably diminishes the fertility of women. Lippich states that of 100 women in Kärnten and Krain suffering from chronic alcoholism, 28.3 were barren. In England, where the abuse of alcoholic beverages is also very frequently observed in women, the same phenomenon has been noted. Matthews Duncan held that alcohol exercised a specific deleterious influence on fertility. Moreover, in addition to the constitutional disturbances produced by the abuse of alcohol, this beverage also exercises a well-known pathogenetic influence upon the female reproductive organs; with especial frequency, chronic oöphoritis may be shown to depend on this exciting cause.

A diet consisting mainly of fish is known to increase the sexual impulse, and is said also to increase fertility. Further, a diet consisting mainly of potatoes or rice is said to favour reproduction; compare, for instance, the fertility of the Hindoos, who abstain entirely from animal food, and of the Chinese, who live chiefly on rice. Davy maintained that the women of races living chiefly on fish were handsomer and more fertile than others: and Montesquieu suggested that there was an association between the abundant population of sea-ports and also of Japan and China, and the large quantity of fish consumed in those places. On the other hand, a diet consisting chiefly of meat is said to have an unfavourable influence in this direction; in support of this view it is pointed out that races living by the chase, and living therefore almost entirely on meat, have very small families. This generalization is invalidated by the fact that Englishwomen, who eat far more meat than the women of the Latin races, are nevertheless distinguished by their great fertility.

In his “History of Civilisation in England” Buckle writes: “The population of a country, although influenced by many other conditions, unquestionably rises and falls in proportion as the supply of nutriment is abundant or the reverse.” Herbert Spencer also states that “every increment in the supply of nutriment is followed by an increment in fertility.”

It must not be forgotten that, in addition to the more or less abundant supply of nutriment, there are always other influences affecting fertility; the general mode of life, race, climatic conditions, etc., may, in various ways, co-operate with or countervail the influence of nutritive conditions. If, with the best possible supply of nutriment, there is associated a luxurious and enervating mode of life, the abuse of alcohol, severe intellectual exertion, or sexual excesses, the general result will be a diminution in fertility. And it is easy to understand why Cros, although perhaps with little justification, goes so far as to regard easy circumstances as an active cause of depopulation. “It is the poor,” he writes, “and the less wealthy departments of France, in which we find the most children.” In estimating fertility, however, we must never fail to take into consideration the more extensive employment of means for the prevention of pregnancy among the upper classes of society.

To a certain extent we can trace the influence of climate and of season upon fertility. Heat appears to favour fertility; Haycraft’s figures for the eight largest towns of Scotland show clearly how the number of conceptions rises and falls pari passu with the temperature. Lower animals also, when brought from a colder to a warmer neighbourhood, exhibit an earlier and more frequently recurring “heat.” In Europe, however, the Northern races appear more fertile than those of the south.

Of the seasons, spring is the one especially favourable to fertility. Quetelet, who proves by numerous statistical data that the maximum of conceptions occurs in May, attributes this fact to a general increase in the vital forces occurring in spring, after the cold of winter. Villermé, however, goes back to the older explanation, that the increase in the number of conceptions in May and June is due to social and economic conditions. The return of spring, especially the end of spring and the beginning of summer, a time of year in which the means of subsistence are provided in exceptional quantity, and of especially good quality, the season also of festivals and social reunion, when the two sexes are brought into more intimate contact and when the majority of marriages occur—these are the conditions associated with the season of greatest fertility. The figures of Wappaeus also confirm the influence of spring in favouring fertility. He found, however, that there were two seasons of maximal fertility. The first at the end of spring and the beginning of summer; the second in winter, especially in December. Mid-winter is for most people a period of domestic amusement and relaxation, one of exceptionally good nutrition, and of social reunion; the spring increase in fertility is a part of the awakening and increase of the reproductive forces of nature at large, which recurs every spring-time.

Every marked and sudden change in the mode of life has an unfavourable influence on fertility. Darwin reports that mares who have for some time been stall-fed with dry fodder and are then put out to grass are at first infertile after the change. Europeans going to reside in the tropics experience a notable decline in fertility as a result of the change of climate. According to Virchow, the fertility of European women who become acclimatized in the tropics declines very gradually, but in the course of a few generations is almost completely annulled.

The marriage of near kin is believed also to diminish fertility. As regards inbreeding in the lower animals, it is well known that when nearly related animals copulate, the number of the offspring is below the average. Nathusius paired a sow with its own uncle, the boar having proved productive in intercourse with other sows; the litter numbered five to six only. This sow, which belonged to the great Yorkshire race, was then paired with a small black boar, which in intercourse with sows of its own variety had procreated litters numbering six or seven; as a result of her first pairing with the black boar, the sow cast a litter numbering twenty-one whilst the second attempt produced a litter of eighteen. Similar results were obtained by Crampe, in his experiments in the inbreeding of rats.

Some authorities declare that the results of inbreeding are similar in the human species, that the marriages of near kin are less fruitful than the average. Darwin writes in this connection: “With regard to human beings, the question whether breeding in-and-in is also deleterious, will probably never receive a direct answer, for man reproduces his kind so very slowly, and cannot be made the object of experiment. The very general disinclination of nearly all races to the marriage of near kin, which has existed from the very earliest times, is of weight in relation to this question. Indeed we appear almost justified in applying to the human race the experience gained by experiment on the higher mammals.”

Darwin’s assumption regarding the effect upon fertility of the marriage of near kin in the human species, cannot, however, be accepted without qualification. In ancient times there was no uniformity of opinion on this topic. It is well known that among the Phœnicians, a son might marry his mother, and a father his daughter; and among the ancient Arabs it was the legal duty of the son to marry his widowed mother. Moses, on the contrary, forbade marriages between parents and children, between brothers and sisters, also marriage with a father’s sister, with a wife’s mother, and with an uncle’s widow.

Darwin considered that the marriage of first cousins was not unfavourable to fertility. Of 97 such marriages, 14 were sterile, whilst of 217 marriages of those not akin, 35 were sterile; the percentage in both cases being almost identical. Mantegazza, who regards kinship in marriage as unfavourable to fertility, found nevertheless that among 512 marriages of near kin, only 8 to 9% were sterile. It is widely believed that the dying out of many aristocratic families is dependent on the inbreeding so common in this class—but it must be admitted that scientific evidence in support of this belief is lacking. Incest in the human species may certainly result in fertilization. Among the Jews, marriages of near kin are very common, and often prove extremely fruitful.

Göhlert made a statistical investigation of the fertility of the reigning families of Europe, in order to throw light on this question. In the Capet dynasty, 118 marriages of near kin took place, and of these 41 were sterile; in the Wettin dynasty (Saxony), there were 28 such marriages, of which 7 were sterile, and 1 produced one child only; in the Wittelsbach dynasty (Bavaria), 29 such marriages, of which 9 were sterile, and 3 produced only one child each. Thus of 175 marriages of near kin, 57, or 32.6% remained sterile. Further, in the Habsburg-Lothringen dynasty, of 110 marriages, 25 were marriages of near kin, and of these 33% remained sterile.

It has been assumed since the days of antiquity that temperament and constitution exercise some influence on fertility. Hippocrates, Soranus, and Diokles, are among the ancient authors who refer to this matter. Soranus says very justly: “Since most marriages are contracted, not from love, but for the procreation of children, it is irrational, when choosing a wife, to have regard, not to her probable fruitfulness, but instead of this to the social position and the wealth of her parents.”

It would appear that a certain dissimilarity in physical constitution and temperament between husband and wife is favourable to the fertility of the marriage. For instance, a vivacious, dark husband, and a lethargic, fair wife, are better suited to one another than a husband and wife both extremely active, or both of extremely phlegmatic temperament.

Toussaint Loua published the following figures regarding the fertility of the women of the various countries of Europe:

══════════════╤═════════════╤═════════════════════════════════════════ │ Number of │ COUNTRY. │ births per │FERTILITY OF WOMEN BETWEEN THE AGES OF 15 │ hundred │ AND 45 YEARS. │inhabitants. │ ──────────────┼─────────────┼─────────────┬─────────────┬───────────── „ │ „ │ Married. │ Unmarried. │ Average. ──────────────┼─────────────┼─────────────┼─────────────┼───────────── Hungary │ 4.94│ │ │ 17.8 Russia │ 4.12│ │ │ 20.5 Austria │ 3.93│ │ │ 16.4 Germany │ 3.77│ 34.8│ 2.9│ 17.7 Italy │ 3.67│ 28.8│ 2.4│ 16.1 Holland │ 3.67│ 35.3│ 1.0│ 16.0 Finland │ 3.63│ │ │ 15.8 England │ 3.58│ 29.7│ 1.6│ 15.5 Scotland │ 3.53│ 32.8│ 2.5│ 15.8 Belgium │ 3.25│ 33.7│ 1.8│ 14.8 Denmark │ 3.12│ 28.5│ 2.8│ 14.4 Roumania │ 3.12│ │ │ 13.5 Norway │ 3.10│ 29.3│ 2.2│ 14.0 Sweden │ 3.05│ 29.1│ 2.5│ 13.7 Switzerland │ 3.04│ 29.7│ 1.1│ 13.1 Greece │ 2.96│ │ │ 13.2 Ireland │ 2.69│ 29.8│ 0.5│ 12.3 France │ 2.63│ 20.3│ 1.8│ 11.6 ══════════════╧═════════════╧═════════════╧═════════════╧═════════════

In towns, conjugal fertility is less, extra-conjugal fertility greater, than in the country. An increase in factory labour gives rise to an increase in the population, but to a decline in the vitality of the offspring; that is to say, it causes a quantitative increase, and a qualitative decrease, in fertility. An increase in agricultural labour has precisely the opposite effect. The influence of war upon fertility is unfavourable both quantitatively, and qualitatively. According to Tschouriloff, the introduction of universal military service, by withdrawing for a time all the most vigorous men from domestic life, tends to diminish fertility. Extensive emigration from a country in which the soil is fertile, and where the vital conditions are generally favourable, is stated by Bertillon to cause an increased fertility in the mother country; he further states that an increase in the number of the proprietors of the soil is followed by diminished fertility, and vice versa.

Prostitutes show as a rule a very low fertility. According to the data of Tarnowskaja, the fertility of prostitutes in Russia is 34%, whilst married women of similar ages in Russia exhibit a fertility of 51.8%. Gurrieri found 60% of prostitutes childless.

The fertility of female criminals was found by Lombroso to be undiminished. On the average, poisoners had given birth to 4.5 children, other murderesses to 3.2 children, child-murderesses to 2 children; thus the prisoners whose crime is commonly dependent on an abnormal eroticism had a fertility above the average.

The diminished fertility of prostitutes depends in part upon frequent venereal infection, in part upon the unfavourable influence of the mercury and iodide of potassium administered for the cure of such infection, also upon the frequency with which they consume excessive quantities of alcohol, upon the excessive frequency of coitus, which exercises a traumatic influence, upon the irregular mode of life, and upon their disinclination to be burdened with children.

Conjugal fertility, that is to say, the ratio between legitimate births and the number of married women between the ages of 15 and 50 years, has declined in Germany during the last decades. It was:

During the years 1872 to 1875 29.7% During the years 1879 to 1882 27.4% During the years 1889 to 1892 26.5%

This decline is small, but it is much more manifest in urban than in rural districts. This fact is shown by the following figures, relating to fertility in Prussia:

1872 to 1879. 1894 to 1897. In all towns 26.9 24.0 In Berlin 23.8 16.9 In other large towns 26.7 23.5 In rural districts 28.8 29.0

This difference depends principally on the fact that in the large towns of Germany (and still more in those of France) the use of means for the prevention of pregnancy is continually increasing, whereas the population of the rural districts is as yet less familiar with the use of these measures.

According to Hellstenius, conjugal fertility, that is, the number of children per married couple, is as follows:

In the Netherlands 4.88 Norway 4.70 Prussia 4.60 Bavaria 4.55 Sweden 4.52 Saxony 4.35 England 4.33 Belgium 4.23 Denmark 4.18 France 3.46

Talquist, who has published a statistical investigation concerning the modern tendency to diminished fertility, arrives at lower figures than Hellstenius. According to him, conjugal fertility is:

In Prussia 4.11 England 4.10 Belgium 4.12 France 2.09 In various States of the American Union 2.5 to 3.0

From the Almanach de Gotha Vacher obtained figures showing that each family of the higher aristocracy has on the average the following number of children.

In France 2.0 Italy 3.0 Germany 4.8 England 4.9 Russia 5.1

According to the figures we have published, the fertility of women suffices for the production during the sexual life of a small number only of children, averaging, in fact, 4 to 5 children per marriage. Many mothers, however, give birth to a very large number of children. Among 73,000 families inhabiting Buda-Pesth, Körösi found 300 mothers who had had 15 children or more; 7 mothers who had each had 21 children; and 3 mothers who had given birth respectively to 22, 23 and 24 children.

A newspaper report states that the wife of a citizen of Buda-Pesth, during the 43 years of her married life, gave birth to 32 children. In the year 1902, a Bohemian woman gave birth to her twenty-fourth child. Stieda reports the cases of two mothers, one of whom had 21, and the other 23 children. The wife of the German Emperor, Albrecht I, and the wife of Prince Jost of Lippe-Biesterfeld, each bore 21 children.

The so-called two-children-system obtains most commonly in France.

It is true that even in France there are on an average nearly three children born per marriage; but if we take into account surviving children only we find an average per family of 2.1 children only. Similar conditions obtain in New England, and in Transylvania; and the same practice is spreading throughout the United States. Another way in which the attempt is made to keep down the population is that customary in Alsace, where, if there are several children in a family one only marries, in order to avoid a division of the family property. It cannot be denied that in France, doubtless in consequence of the two-children system, a somewhat widely diffused prosperity exists, a prosperity which is lacking in the rare districts in France, such as Brittany, in which limitation of the family is not practised. What a disastrous influence the general use of measures for the prevention of pregnancy exercises on the military power and political status of a nation has, however, in recent years been made especially manifest in the case of France. In that country, of ten million families, two million are absolutely childless, and two million have only one child each, so that two-fifths of the French families are as good as inactive in maintaining the population of the country. The injury thus done to France is shown still more clearly by a tabular comparison of the excess of births over deaths in the German and French nations, respectively, during the two decades 1874 to 1894 (from G. von Mayr’s Population Statistics).

Year. Germany. France. 1874 +13.4 +4.8 1875 13.0 2.9 1876 14.6 3.6 1877 13.6 3.9 1878 12.7 2.6 1879 13.3 2.5 1880 11.6 1.7 1881 11.5 2.9 1882 11.5 2.6 1883 11.7 2.6 1884 11.2 2.3 1885 11.3 1.4 1886 10.8 1.5 1887 12.7 1.3 1888 12.9 2.5 1889 12.7 1.2 1890 11.3 –0.3 1891 13.6 –0.5 1892 11.7 +0.1 1893 12.2 –1.2 1894 13.6 –0.4

To what an extent in all times, and among all peoples, the fertility of women was esteemed, is shown by religious writings and traditional customs which aimed at enabling a wife who had had no children by her own husband, to seek other conjugal embraces. Among the Jews, it was the duty of a man to marry his widowed and childless sister-in-law; if he were unwilling or unable to perform this duty he was compelled to take a part in a ritual termed “chaliza,” in which his foot was bared and the bereaved woman spat upon him, because he was unwilling to maintain his brother’s house. In the law book of the Hindoos of Manus, we read, “If husband and wife have no children, it is proper for them to obtain the desired offspring by a union between the wife and the husband’s brother, or some other relative;” the child obtained in this way was legally regarded as the child of the husband. Confucius wrote: “If your wife is barren, take a second wife; she must be subordinate to the first wife, for her only duty is the bearing of children.” An analogy to this ordinance is to be found in the Bible; Abraham’s barren wife Sarai says to Abraham: “Behold now, the Lord has restrained me from bearing: I pray thee, go in unto my maid; it may be that I may obtain children by her. And Abraham hearkened unto the voice of Sarai.” In the same way the barren Rachel speaks to her husband Jacob, “Behold my maid Billah, go in unto her; and she shall bear upon my knees, that I may also have children by her.”

Luther, in his treatise on marital love published in the year 1522, bases, doubtless on the above biblical precedents, the following statement regarding fertility: “If a sexually potent woman is married to an impotent man, if she is unable to take any other man openly, yet is unwilling to do anything dishonourable, she should say to her husband, “Dear husband, you cannot fulfil your duty to me, and you have deceived my young body, you have endangered my honour and my happiness, and in the eye of God our marriage is null, forgive me therefore if I form a secret union with your brother or with your nearest friend; the fruit of this union will be yours in name, thus your possessions will not fall to strangers, and you will willingly allow me to deceive you, because involuntarily you have deceived me.””

In ethnography, the term endogamy is used to denote a law or custom by which marriage is allowed only within the limits of a specified race, tribe, or caste; thus, in the Old Testament, Jews are forbidden to marry women of other races. The ethnographical term exogamy indicates the prohibition of marriage between persons who are more closely allied, as, for instance, the Mosaic prohibition of marriage within certain degrees of blood-relationship. Such exogamic prohibitions persist even in the legislation of the present day. In many ecclesiastical and national laws we find the marriage of first cousins and of uncle or aunt with niece or nephew forbidden; and even a prohibition of the marriage of a man with his deceased wife’s sister.

Hegar considers the danger of inbreeding to be very great in the human species; for whereas in the lower animals breeders employ a methodical and carefully considered selection of the best specimens, nothing of this kind occurs among human beings; and the health of modern civilized man is such that there are few families without a skeleton in the closet. “Not only in families, but also in villages, in small and large towns, even in classes, and in entire nations, certain peculiar qualities, morbid tendencies, and predispositions, are handed down from generation to generation. We have, for instance, the tendency of the Jews to nervous disorders and diabetes, that of the English to gout, that of the Germans to myopia.” Strahan has therefore employed the term “social consanguinity,” to indicate that by means of common customs, environment, occupation, and mode of nutrition, a similarity in type is produced, leading to a similar predisposition to disorders and diseases transmissible from father to son.

The dangers of inbreeding are believed by Hegar to be, under present-day conditions, so considerable that he would allow the marriage of near kin in exceptional cases only, and where the circumstances are peculiarly favourable—for instance, where both parties to the projected marriage are in excellent health, and where there is no great similarity between them in feature or mental type. Certain anomalies transmitted from remote ancestors, dependent on deeply-marked peculiarities of the germ cells, may be so developed by inbreeding as to become absolutely fixed characteristics. If the morbid manifestations can be traced back for several generations, if the bodily defects and disturbances of development (the so-called stigmata of degeneration), are well marked and numerous, if the functional disorders of the nervous system and of the sense organs are pronounced, leading to idiocy, insanity, epilepsy, congenital deafmutism, blindness, instinctive criminality,—there is in such cases little or no hope of the regeneration of the family. It dies out, because the members are sterile; because they are confined in prisons or asylums; or because the children, if any are born, are deficient in vitality, and fail to reach maturity.

According to the brief summary of the subject given by Hegar, the peculiarities of the offspring at the time of birth depend upon:

Factors which give rise to peculiarities of the germ-cells:

I. Germinal rudiments derived from the ancestors;

II. Influences acting on the germ-cells within the parent organism;

a. Owing to peculiarities of the fluids and tissues of the parental body;

b. Owing to substances which penetrate the parental body and reach the germ.

Germinal rudiments altered by the conjugation of the male and female reproductive cells:

I. On the mother’s side;

a. Owing to peculiarities of the fluids and tissues of the maternal body;

b. Owing to substances which penetrate the maternal organism and reach the fertilized ovum.

II. On the father’s side, owing to substances which adhere to the paternal reproductive cells, or are enclosed within these.

The number of consanguineous marriages at the present day is not less than 5½ to 6½ per 1,000; the fertility of these marriages appears to be identical with the fertility of ordinary marriages. Mayet has made a statistical investigation to determine the influence of consanguineous marriages in the pathogenesis of mental disease. He finds that the number of those congenitally affected with mental disorder is twice as great in the offspring of consanguineous marriages as in the offspring of crossed marriages; in the case of simple mental disorder, of paralytic dementia, and of epileptic dementia, the ratio is actually greater than two to one (the actual figures are 218, 257, 208 : 100). Thus we see that when there exists any cause of inheritable mental disorder, blood-relationship of the parents more than doubles the danger to the children. In the case of imbecility and idiocy the danger is less in this respect (the ratio is 150 : 100); the factor of inheritance plays a less prominent part than in the case of other psychoses.

It was remarkable that among the offspring of marriages of nephew and aunt, cases of mental disorder were almost entirely lacking. Among the offspring of marriages of uncle and niece, the inheritance of mental disorder was more prominent than among the children of first cousins. It is interesting to determine the influence of blood-relationship in cases in which the existence of inheritable predisposition could not be proved. In these cases, as regards simple insanity, paralytic dementia, and epileptic dementia, the number of cases among the offspring of consanguineous marriages was only one-half as compared with the offspring of crossed marriages; whereas in the case of imbecility and idiocy this ratio was reversed. In idiocy, where inheritance generally speaking plays a small part, the origination of the disease would often appear to depend directly on the blood-relationship of the parents; whilst as regards other forms of mental disorder, if there is no inheritable predisposition, blood relationship in the parents appears to be a positive advantage; where, however, a family predisposition to insanity exists the likelihood of actual insanity appearing in the offspring is notably enhanced by a consanguineous marriage.

The Restriction of Fertility and the Use of Means for the Prevention of Pregnancy.

As we have already pointed out, a restriction of the fertility of women occurs in the majority of marriages, to this extent, that the potential reproductive powers of the wife are not fully utilized. In recent times, however, the restriction of fertility, by the deliberate use of measures for the prevention of pregnancy, has become so widely diffused, that it appears unwise from the scientific standpoint simply to ignore the question, and it has become indispensable to study how the practice developed, and to consider what are its actual results. From our own point of view, it is the more necessary to do this, for the reason that the use of preventive measures has come to play an important part in the sexual life of woman, and therefore deserves the fullest attention, not merely from the standpoint of the sociologist, but in addition from the purely medical point of view.

In many divisions of the population, and even in entire nationalities, the prevention of pregnancy, not merely in illicit intercourse, but also in married life, has become so general a practice that the fertility of the nation as a whole has been profoundly modified. Thus, in France at the present day, the average number of children per marriage is less than two; and the two-children-system is almost universally practised in Transylvania and Norway, whilst it is very rapidly spreading in North America. In the principal towns of the whole of Europe, this system is largely on the increase among the upper classes of society. The marriages of the poor, partly owing to ignorance, and partly to indolence, are as yet comparatively little affected by this depopulative principle.

In the days of antiquity, many lawgivers endeavoured to set bounds to excessive fertility, and artificial abortion was methodically practised by those who wished to avoid an inconveniently large family. Even among savage peoples, we find that certain preventive measures are occasionally employed in sexual intercourse. Among civilized peoples, however, until the beginning of the nineteenth century, religious and moral ideas derived from the Bible continued to dominate the sexual life. It is well known that Old Testament law and Christian morality alike forbid any artificial restriction of human increase. “Increase and multiply” was the command given in Genesis to the first parents of the race; and the psalmist exclaims, “Happy is the man that hath his quiver full” of children.

A remarkable revolution in thought was initiated toward the beginning of the nineteenth century by the great philanthropist and powerful thinker, Thomas Robert Malthus, founder of the doctrine of the propriety of checking the increase of population, author of the work “An Essay on the Principle of Population,” London, 1798, whose Law of Population soon attracted world-wide attention. Modern civilization having greatly increased the cost of bringing up a family, while simultaneously there has been a general rise in the price of the necessaries of life, there has resulted an extraordinary diffusion of Malthusianism; in comparison with the causes just alluded to for the use of preventive measures, diseases which render renewal of pregnancy dangerous to the mother’s life have comparatively little to do with the causation of voluntary sterility.

In his “Essay on the Principle of Population,” Malthus indicates, as the cause which has hitherto hindered mankind in the pursuit of happiness, the unceasing tendency of all organic life to increase in excess of the means of subsistence. In the case of plants and of unreasoning animals, the natural process is a very simple one. Both animals and plants are impelled by a powerful instinct to reproduce their kind, and the operation of this instinct is quite undisturbed by any anxiety regarding the livelihood of their offspring. The reproductive function is thus exercised at every available opportunity, and the superfluous individuals of the next generation are destroyed by lack of space and nutriment. In the human species the restriction of population is effected by a more complex mode of operation. Man is impelled to reproduce his kind by an instinct not less powerful than that of other animals; but the gratification of this instinct is checked by reason, which makes him ask himself whether he is not about to bring into the world beings for whom he will be unable to provide the means of subsistence. If he is influenced by this consideration, the resulting restriction of population may often entail serious consequences; if, on the other hand, he gratifies his instinct, regardless of the appeal of reason, the human species will inevitably tend to increase more rapidly than the means of subsistence.

Malthus declared that population, when its increase was unrestricted, doubled itself every twenty-five years, and therefore increased in a geometrical progression; he considered that in the most favourable circumstances the means of subsistence could not possibly increase more rapidly than in an arithmetical progression. The contrast between these two modes of increase will be more striking if we write out the actual figures. According to the theory of Malthus, the increase of human population would be represented by the figures 1, 2, 4, 8, 16, 32, 64, 128, 256, whereas the simultaneous increase in the means of subsistence would be represented by the figures 1, 2, 3, 4, 5, 6, 7, 8, 9. Such an increase in population is, however, always prevented by certain checks, classed by Malthus as of two kinds, preventive checks and positive checks.

A preventive check, in so far as it is voluntary, is peculiar to the human species, and originates in the intellectual faculty which enables man to foresee the consequences of his actions. A man who looks around him, and sees the poverty into which those with large families so often fall, who reckons up his present property or earnings, which barely suffice to provide for his own personal necessities, cannot fail, when he considers how hardly they would suffice for seven or eight additional persons, to doubt whether it would be possible for him to provide for the offspring he might bring into the world. Such considerations as these are likely to lead a large number of persons of all civilized nations to resist their natural instincts, and to refrain from early marriage. If abstinence entailed no serious consequences, it would be the least of all evils resulting from the principle of population.

The positive checks to increase of population are manifold, and embrace all the causes which are competent to lessen the natural duration of human life. Among these we may enumerate: all unhealthy occupations, severe toil, climatic conditions, poverty, errors in the rearing of children, town life, excesses of all kinds, the whole army of illnesses and epidemics, war, pestilence, and famine. In all countries, preventive and positive checks are more or less powerfully operative, and yet there are few in which the population is not continually tending to increase beyond the means of subsistence. As a further consequence of this tendency of population to increase, we observe the wider diffusion of poverty among the lower classes, so that any permanent improvement in their condition is rendered impossible.

After Malthus had carefully stated his thesis, he gave a summary record of the conditions of population in nearly all nations of the past and of his own time, in order to show how in all alike the three principal means of limiting population, moral restraint, disease, and poverty, had been in continuous operation.

He showed, for instance, how the population of the South Sea Islands had been limited by certain conditions, cannibalism, castration of the males, infibulation of the females, late marriages, the sanctification of virginity, contempt for marriage, etc.

In ancient Greece, Solon’s laws permitted infanticide. Plato, in “The Republic” asserts that it is the duty of the Government to regulate the number of the citizens, and to prevent an immoderate increase; men and women should be allowed to procreate only during their period of maximum strength, all weakly children should be killed. Aristotle advised that men should not be allowed to marry before the age of 37, and women before the age of 18; the women should give birth to a limited number of children only; if, after this, they again became pregnant, abortion should be induced. He maintained that if all were at liberty, as was the case in most countries, to bring into the world as many children as they pleased, poverty, the mother of crime and insurrection, must inevitably ensue.

Among the Romans war was as a positive check unceasingly operative: in this time of the Empire, preventive methods came into general use, in the form of various kinds of sexual perversity. Juvenal complains of the skilled methods employed in the induction of abortion; during the later period of the Roman Empire, sexual morality became so degenerate that marriage was hated and despised.

Passing to the consideration of the checks on population among the nations of modern Europe, Malthus examined the registers of marriages and deaths, and came to the conclusion that in few countries is the mass of people sufficiently capable of self-restraint to postpone marriage until they are reasonably assured of being able to provide for all the children they are likely to have; still, he ascertained that at the present day positive checks on population were less active, and preventive checks more active, than in earlier times and among savage races.

Malthus did not base upon his conclusions the advice that in sexual intercourse means of preventing pregnancy should be employed, as the modern “Malthusians” advise; in his eyes, moral restraint, that is to say, sexual abstinence, was the only remedy for the prevention of poverty and the other evil consequences of the principle of population. Moral restraint was in his opinion the only virtuous method of avoiding the evils of excessive fertility. It was a man’s duty not to marry until he had a definite prospect of being able to maintain his children; the interval between puberty and marriage must be passed in strict chastity. Man’s duty is not the mere reproduction of his species, but the reproduction of virtue and happiness, and if he is not able to do the latter, he has no right whatever to do the former. Malthus lays great stress on educating the people in this matter; “in addition to the ordinary subjects of instruction, it is necessary to explain the principle of population, and the manner in which it gives rise to poverty.” In the nature of the case, no lasting and general improvement in the condition of the poor is possible without an increase in the preventive restriction of population.

The Malthusian doctrine of the law of population gave rise to an enormous sensation, and some of his disciples soon proceeded to translate his conclusions into practice; such authorities as James Mill and Francis Place recommended measures by means of which, “without any injury to health, or to the feminine sense of delicacy, conception can be prevented:” the avowed aim of these measures was to prevent the increase of population beyond the means of subsistence. Physicians and physiologists joined the ranks of these innovators; among others Raciborski, Robert Dale Owen in his “Moral Physiology,” Richard Carlile in his “Book of Woman,” the first work to give an exact description of the means to employ for the prevention of conception, Knowlton in his “Fruits of Philosophy.” In the year 1827 in the Northern counties of England leaflets were for the first time distributed among the working classes to instruct them in the use of preventive measures. Bradlaugh founded the Malthusian Society, which aimed at the dissemination of instruction in the use of preventive methods. There is now in England a “Malthusian League,” numbering leading physicians among its members; this supplies to all classes the means by which the family can be artificially limited. A new edition of the above-mentioned book, “The Fruits of Philosophy,” was circulated in London in an edition of several hundred thousand copies, and prominent persons spoke at congresses on the subject of Neo-Malthusianism. In Germany, also, a “Union of Social Harmony” was founded, for the free distribution of a hand-book on the use of measures for the prevention of conception, and for an investigation regarding the results of these.

We do not propose here to subject the teaching of Malthus to a critical examination; he has found formidable opponents, who have endeavoured to prove that his fundamental assumption is false; they maintain that work or the power of work increases in direct ratio with the population; and they also assert that population tends to increase, not, as Malthus maintained, in a geometrical, but simply in an arithmetical progression. We shall merely quote Liebig’s reply to the law of Malthus, “when human labour and manure are provided in sufficient quantity, the soil is inexhaustible, and will continue to yield unceasingly, the most abundant harvests;” and Rodbertus’ remark that “agricultural chemistry will ultimately be competent to create nutritive materials; this will some day be just as much within the power of society, as it is at present to provide any requisite quantity of textiles, given the necessary amount of raw material.” The celebrated socialist Bebel, is a strong opponent of Malthus. He writes: “The earth is doubtless thickly populated, but none the less only a small fraction of its surface is occupied and utilized. Not merely could Great Britain produce, as has been proved, a far larger supply of nutritive materials than at present, but the same is true of France, Germany and Austria, and in a still higher degree of the other countries of Europe. European Russia, were it as thickly populated as Germany, could support, instead of ninety millions, as at present, a population of four hundred and seventy-five millions. For the purposes of the higher civilization, toward which we are striving, we have to-day in Europe, and shall have for a long time to come, not an excess of population, but an insufficiency, and every day brings new discoveries and inventions whereby the means of subsistence are potentially increased. In other parts of the world, the insufficiency of population and the superfluity of ground are even more noticeable. Carey is of opinion that the single valley of the Orinoco, fifteen hundred miles in length, would suffice to provide nutritive material in sufficient quantities to feed the whole existing population of the world. Central and South America, and more especially Brazil, have a soil of extraordinary fertility, but are as yet practically unutilized by the world. To increase, not to diminish, the numbers of the human race, that is the appeal made by civilization to mankind!” A similar position on this question was recently taken by Roosevelt, the President of the United States, himself the father of six children, in a letter to two American women, Mrs. J. and M. Van Vorst, authors of the book “Woman Who Toils (Factory Life in America).” In this book, the writers prove that in the United States the average size of the family is now less than in any other country of the world, France alone excepted. President Roosevelt, in his letter, declares himself an ardent supporter of the biblical injunction, “increase and multiply!” He writes: “Whoever evades his responsibilities, through desire for independence, convenience, and luxury, commits a crime against the race to which he belongs, and should be an object of contempt and horror to a healthy nation. When men avoid becoming fathers of families, and when women cease to regard motherhood as the most important career open to them, the nation to which these men and women belong has cause for uneasiness about its future.” President Roosevelt continues: “To the American woman marriage is no longer a life-duty, a profession, as it is to her sisters who are members of the older civilizations. A woman who manages an extensive business, who supervises her own landed property, or who plays her own part in the world of finance,—for such as these, the ‘lottery of marriage’ is naturally something they dread rather than desire.” President Elliott, of Harvard College, has expressed similar views in a speech on this subject. He deplores the late marriages and small families of the cultured Americans. According to the last census, an American family has on the average less than three children; twenty years ago the average number was from four to five children.

I pass now to consider the medical point of view of this question of the prevention of pregnancy. It is my opinion that the physician as such should intervene in the matter, not in any case for the relief of the dominant economic parental dread of insufficient means for the upbringing of children, but only on account of the purely medical consideration of the physical dangers of motherhood. That is to say, the physician should lend his skilled assistance toward the attainment of facultative sterility, only when his own special scientific knowledge leads him to consider this urgently necessary; it is not his province to assist in preventing the birth of an immoderate number of offspring; his intervention is justified only when deliberate reflection has convinced him that his patient’s health or life would be endangered by pregnancy or childbirth. A woman’s life and well-being must appear to him of greater importance than the existence or non-existence of a possible infant. That this view is morally sound, is shown by the fact that public opinion justifies the accoucheur in the destruction of an already living child, when the mother’s life is endangered. In this connection we may recall the words of the great Napoleon; the physician Dubois, attending Marie Louise in a difficult confinement, asked Napoleon whether, if matters came to an extremity, he should save the mother or the child; Napoleon, notwithstanding his strong desire for the birth of an heir to his dynasty, replied, “The mother, it is her right.”

In isolated cases, which deserve always very serious consideration, some pathological condition in the wife may justify the prevention of pregnancy. In certain very serious general disorders, in diseases of the heart or of the lungs, in pelvic deformity, and in pathological changes of the female reproductive organs, it may be right to employ means for the prevention of pregnancy—not merely sexual abstinence, but actual measures to prevent fertilization.

The misuse of medical knowledge for the recommendation or employment of preventive measures, on the ground of humanitarian sentiment or social and economic considerations, must, however, be strongly resisted. Even leading gynecologists have erred in this way. Saenger writes, “Scientifically-trained accoucheurs will do much more to promote the health and well-being of women, and to protect them from sexual and other diseases, than the humanitarian efforts of the Neo-Malthusians, who transfer a purely scientific question, such as the disproportion between the number of births and the supply of nutritive material, to the sphere of medicine, regarding themselves as justified in preventing conception whenever they please, independently of considerations relating to the health of the mother * * * * * * * * A woman exhausted by frequent child-bearing, anæmic and suffering, is certainly a figure to arouse everyone’s sympathy; in so far as she is ill in consequence of injury received in childbirth, it is our duty to prevent further injury, and to relieve to the best of our ability that which has already occurred; in so far, however, as she is not suffering from any affection of the reproductive organs, but is ill owing to the lack of sufficient food, or from overwork, it is the duty of society to render assistance. Here we have to do with the social problem; the solution of which will be brought no nearer by the use of the occlusive pessary.” Fehling also maintained that a text-book of gynecology is not the proper place in which to pass judgment on so important a socio-political question. The business of the gynecologist in this matter is merely to say a word of caution against the use of various measures which are so often recommended as harmless, but are in fact dangerous to the woman who uses them.

Kleinwächter, who declares that he is far from recommending the use of preventive measures when a healthy woman wishes to save herself the trouble of child-bearing, gives as legitimate indications for their use: 1, the various forms of severe pelvic deformity; 2, certain tumours in the pelvic cavity; 3, after the removal of malignant tumours of the reproductive organs, certain general disorders, recently arrested pulmonary tuberculosis, organic heart disease, etc. Regarding these cases, Kleinwächter writes: “The wife’s life would be endangered by pregnancy, which must therefore be prevented without forbidding coitus, and avoiding the practice of coitus interruptus, which endangers her health, or of any mode of intercourse repugnant to the feelings of wife or husband.”

The most trustworthy, but unquestionably at the same time the least practicable method, for the prevention of pregnancy, is that of Malthus—permanent sexual continence. This recommendation, to which Tolstoi in “The Kreuzer Sonata” gives his adhesion, has recently found an advocate in a modified sense in a distinguished gynecologist, Hegar, who considers that the great fertility of the modern civilized countries of Europe entails many disadvantages—inferior physical development, increased general mortality, emigration, an unfavourable distribution of population in relation to dwelling and occupation, occasional famine—and who sees the only effective remedy in a “regulation of reproduction,” whereby the tendency to marriage and the number of births are to be diminished. The question “when is the number of children in a family too large?” is answered by Hegar as follows “A maximal limit is easy to establish. The most suitable age for child-bearing is from twenty to forty. At an earlier and a later age than this, both the mother and the offspring are liable to suffer. Between two successive births there should be an interval of about two and a half years; this would leave time for the birth of eight children. If we assume that pregnancy lasts nine months, that lactation is continued from nine to twelve months after delivery, (and if the mother does not herself nurse the child, artificial feeding or careful supervision of the wet-nurse will occupy her for a like period), to devote an additional period of six months to nine months to the complete restoration of the mother’s health cannot be regarded as excessive. For this maximum family we assume a perfect state of health on the part of the mother, a pure atmosphere, and a sufficient supply of all the necessaries of life. Illnesses, weakness, or infirmity of the mother, often indicate that the number of children should be further limited. It is easier to provide a suitable dwelling and a pure atmosphere for a small family than for a large one. The same thing is true as regards the means of subsistence.

“If the reproductive function is to be intelligently controlled,” continues Hegar, “above all it is necessary to devote attention to the age and health of the parents; but occupation, dwelling, and general environment, must also not be overlooked. Among the cultured classes of our Fatherland, people are gradually learning to form sound opinions about these matters. Among the working classes, on the other hand, especially among those engaged in factory labour, the heedless gratification of the sexual impulse is responsible for untold misery.” Hegar’s advice may be summarized as follows: If the marriage takes place after the attainment of complete maturity, in the wife at twenty and in the husband at twenty-five, and if procreation is discontinued in the wife at forty and in the husband at forty-five to fifty, if between successive deliveries the intervals necessary for the wife’s restoration to health are maintained, if illness and states of debility are taken into account, if sickly, hereditarily-tainted individuals are forbidden to marry—the excessive increase in population, as far as Germany is concerned, will cease to give cause for anxiety. The regulation of reproduction will, however, still be incomplete, unless we enforce a selection too rigorous for our present views. Moderation and continence must aid as far as may be necessary in preventing an undue increase in population. Hegar does not fail to point out the evil effects of an excessive limitation of the family. In a marriage when one child only is born, this child is the object of unceasing anxiety and attention, and real or imaginary dangers assume an excessive importance in the morbidly excited imagination of the parents. Hence we find a continuous excess of watchfulness and over-education in the case of the only child, to whom independent thought and action are entirely unknown. Boys become milksops, girls nervous and hysterical. In the two-children-system, again, one or both of the children may die when the age of the parents is already considerably advanced. Still in those districts of France in which this system obtains the population is well-to-do, and an exceptionally large proportion of the males are fit for military service. The use of various measures for the prevention of conception is considered by Hegar to be harmful, at any rate in the case of young women; this practice gives rise to anæmic conditions, and to nervous weakness and irritability, seldom, however, to more serious disorders, as indeed is apparent from the fact that the mortality of married women as compared with unmarried women is lower in France than in other countries.

Gräfe, with reference to the view that if for any reason conception must be prevented, this should be done by abstinence from sexual intercourse, remarks: “Doubtless an ideal demand, but one which even those with exceptional strength of will are unlikely to satisfy. And the worst of it is, that even a single indiscretion will often result in impregnation. Moreover, it is distinctly contrary to natural conditions, that a healthy married couple united by an intimate affection should live together abstaining completely from sexual intercourse. The question has already been much discussed, both in speech and writing, and this will continue in the future, without altering the fact that the physician will be asked, and will be compelled to give, advice regarding the use of means of the prevention of pregnancy.”

Ribbing writes, “Although the sexual impulse is the product of a powerful natural developmental force, still the temporary, and sometimes even the permanent, control of this impulse is a moral civilizing force of enormous importance.” This writer is opposed to the use of artificial preventive measures; he considers them untrustworthy and dangerous to health. Untrustworthy, for the reason that nature has endowed living organisms with a strong impulse toward conjugation and has equipped with very powerful forces the processes by which fertilization is effected. Every physician is familiar with cases in which preventive measures have proved ineffective. This fact is proved also by the statistics of prostitution. Although prostitutes are fully instructed in the use of preventive measures, which they almost universally employ, nevertheless every year a smaller or larger number of prostitutes become pregnant. These measures are dangerous to health, partly because of their interference with natural functions, because many of them are clumsy and ill adapted; and partly, again, because owing to their use the woman fails to enjoy the natural periods of repose which are entailed by pregnancy, parturition, and lactation. Noteworthy also are the psychical considerations adduced by Ribbing against the use of preventive measures. The majority of well-bred women feel deeply wounded if they believe themselves to be regarded merely as a means of enjoyment, not as individuals, as persons with inalienable rights. For the man also there is danger, for it is easy for him to acquire a dislike to the wife who, even though on his own initiative, occupies herself with the technique of the sexual life in a manner which he feels instinctively to be opposed to the chastity and puremindedness demanded by every man from his wife. Ribbing therefore advises a certain measure of sexual abstinence in married life.

Max Nordau also insists on the moral disadvantages of the wide diffusion of the use of preventive measures. “If a race or nation has reached this point in its downward career, the individuals of which it is composed lose the capacity of loving in a healthy and natural manner. The sense of the family disappears; the men will not marry, because they find it inconvenient to burden themselves with the responsibility for another human life, and to care for any other creature than themselves; the women dread the pains and inconveniences of motherhood, and if they marry, they endeavour, by the employment of the most immoral means, to ensure barrenness. The reproductive instinct, of which reproduction has ceased to be the aim, is in some annulled, whilst in others it degenerates into the most peculiar and irrational perversities. The act of sexual union, the most sublime function of the organism, is degraded into a profligate act of lust; it is no longer undertaken in the interest of the perpetuation of the species, but exclusively for the pleasure of the individual, and without any relation to the needs of the community.”

Alfred Russel Wallace has advocated sexual continence as a preventive measure during the period of maximum vitality and strength; he advises that the age of marriage of women should be considerably advanced, in order to diminish their fertility. If woman’s average age at marriage were 29, instead of 20 years, the fertility of marriages would be reduced in the ratio of 8 : 5.

The desired goal of artificial sterility will not, however, be reached through the advocacy of moderation and continence. The numerous additional measures employed for this purpose may be classified as physiological and artificial; the latter class may be further subdivided into mechanical and operative.

By physiological means for the prevention of conception, we understand measures which aim at producing sterility by reducing the number of acts of intercourse and by restricting these acts to certain defined periods of time. The physiological preventive measures, apart from the higher ethical value they possess in comparison with artificial measures, have the advantage that they may be regarded as harmless to the general health of the woman and to the integrity of her reproductive organs in particular; they have, however, this very serious disadvantage, that the results of their use are very uncertain, so that they offer no more than a probability, and often a very moderate probability that conception will be prevented.

As a physiological measure for the attainment of facultative sterility “without breaking any moral law,” Capellmann advised abstinence from coitus during a period of fourteen days after menstruation and three to four days before the commencement of the flow. Without laying too much stress on the fact that by following this recommendation the period during which the intercourse is permissible would be extremely restricted, it is necessary to point out that, whilst in this way the occurrence of conception may be rendered less probable, its prevention is by no means guaranteed, for it is an established fact that a woman may be impregnated by intercourse on any single day of the intermenstrual interval. Capellmann’s advice, embodying, as he expresses it, the “only morally permissible” means for the prevention of conception, was not original, for the same recommendation was given at an earlier date by Raciborski, who, however, regarded the measure as very uncertain. Capellmann is of opinion that it is sufficiently trustworthy for practical purposes.

Bebel, who is a declared opponent of Malthusianism, none the less lays down positive rules for the diminution of procreative capacity and of fertility by regulation of the diet. He refers to the example of the bees, which, by a change of nutriment, can produce a new queen-bee at will. “Thus the bees,” he says, “are in advance of human beings in their knowledge of sexual development. Presumably they have not been compelled, for a couple of thousand years, to listen to sermons informing them that to occupy themselves about sexual matters is ‘improper’ and ‘immoral.’ There is no doubt whatever that the mode of nutrition has an influence on the composition of the male semen, and also on the susceptibility to fertilization of the female ovum; hence the increase in population must to a very important extent depend on the mode of nutrition. If this could be definitely established, we should have, in the supply of nutriment, a means of regulating the population. As an example of the effect, in this connection, of the mode of nutrition in the human species, it is reported that in consequence of the fatty and nutritious diet of the old Bavarian peasants, who lived chiefly on very rich puddings, the marriages of the well-to-do peasants were frequently childless. However, it must not be forgotten that pre-conjugal intercourse, which was customary in that part of the world, and was somewhat promiscuous in character, may have contributed to cause this sterility.” Finally, Bebel points out that the woman of the future “will be unwilling to bear a large number of children. She will wish to enjoy a measure of personal freedom and independence, and will not consent to pass half or three-quarters of the best years of her life either pregnant, or with a child at her breast. From this it will result that the population will be regulated, without unwholesome sexual abstinence, and without the employment of unpleasant preventive measures.” However, Bebel gives us no details as to the precise manner in which this regulation is to be effected.

Tolstoi, in his widely celebrated book “The Kreuzer Sonata,” condemns absolutely the gratification of the sexual impulse. He demands the recognition of the fact that “sexual congress, in which a man either avoids the natural consequences—the birth of children,—or else throws the whole burden of these consequences on the woman, is opposed to the simplest demands of morality, is in fact utterly base.” To render possible the sexual abstinence he regards as morally necessary, men must not only endeavour to live in a natural way, but they must consume no alcohol, eat with great moderation, abstain from meat, and not be afraid of hard work. Tolstoi even demands that men and women shall be so brought up “that both before and after marriage they may regard love, and the sensual passion associated therewith, not as they do at present, as a sublime and poetical state, but as a bestial condition degrading to humanity.” Tolstoi is, however, utterly opposed to the use of preventive measures: “first, because they liberate men from the cares and sorrows entailed by having children, which must be regarded as the penance to be paid for sensual love; and, secondly, because their use is closely allied to the crime most repugnant to the human conscience, the crime of murder.” Chastity is no less a duty after marriage than before; after marriage man and wife must “continue to pray to be delivered from temptation, and must endeavour to replace sensual love by the pure relationship of brother and sister.”

Eulenburg regards the modern diffusion and the continuous increase in the use of preventive measures as signs of decadence; Löwenfeld, on the other hand, regarding the social conditions of the present day as the principal source of the use of preventive measures, sees therein no moral decay, but on the contrary rather a rise in the moral standard of life.

Another physiological means of prevention is to be found in avoiding cohabitation in that season or month in which, judging by the woman’s previous deliveries, she would appear to have been peculiarly susceptible to impregnation. Cohnstein maintained that in woman, as in the lower animals, the capacity for conception was associated with a particular season of the year, that there was, in fact, an individual time of predilection for impregnation. The assumption that there is such a time of predilection is, however, traversed by the fact, familiar to all who have recorded the birthdays of children in large families, that these occur in the most diverse months of the year. It has, indeed, been statistically proved that certain months and seasons are especially favourable to conception, that a maximum of conceptions occurs in the spring, and a second much smaller maximum in the winter; but these variations in the number of conceptions depend mainly on social factors, as, for instance, upon the customary season for marriage, opportunity for intercourse between the sexes, common labours in the house or in the open, etc. This alleged time of predilection for conception cannot, therefore, seriously be considered in the discussion of measures for the prevention of pregnancy.

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.

All these mechanical occlusive pessaries are open to the objection that they are apt to give rise to irritative conditions of the genital organs, causing offensive discharges, pruritus, etc. (Recently in order to diminish this drawback, the pessary has been constructed of vulcanized cambric, instead of rubber, and appears then to have a less irritating effect.) Still worse is the injury to the uterus and to the cervical mucous membrane caused by certain intra-uterine instruments which have been recommended for the prevention of conception. The latest of these is an “obturator,” consisting of a silver or silver-gilt tube, which is passed through the os uteri into the interior of the uterus, and left in situ. It is claimed for it that “it allows the menstrual discharge to flow freely away, but renders the entrance of the spermatozoa extremely difficult.” Biermer reports five cases in which serious injury to health followed the use of one of these obturators. In one of these cases in which there were very severe pains and a discharge from the uterus, Biermer removed from the interior of the uterus a broken wing of the obturator; the patient died, however, and the autopsy disclosed perforation of the uterus. In another of the cases the apparatus was also broken.

Less dangerous is the recently invented tampon-speculum. This is passed into the vagina by the woman herself, in order that through it she may, by means of a special introducer, insert a tablet of boric acid, hydrochlorate of quinine, citric acid, or some other substance lethal to the spermatozoa. Without some such instrument, the introduction of these “ovals” to the proper place is often found difficult by women.

A very remarkable means of bringing about artificial sterility, one resembling the operative procedures sometimes adopted in western countries, is employed in various parts of the world, and notably in the East Indies and in the Sunda Islands, namely, the induction of an artificial malposition of the uterus, more especially of anteversion. Thus, van der Burg writes from the Dutch Indies: “In the girls the sexual impulse develops very early, and is gratified without fear of consequences, when the services of certain skilled elderly women have been requisitioned.” These women appear, in fact, to understand, by means of pressure, rubbing, and kneading, through the abdominal walls (not by the vaginal route), how to induce anteversion or retroversion of the uterus, to such an extent as to prevent the occurrence of conception. It is said that the only inconvenient consequences of this procedure are trifling pains in the lumbo-sacral and inguinal regions, and some trouble in passing water during the first few days after the manipulations have been effected. Later, when a girl who has been treated in this way wishes to marry and become a mother, by a reversal of the manipulations the uterus is restored to its natural position. It is said that these skilled women have been called in by European women in the Dutch Indies, who did not wish to have many children; but it appears that in a woman who has once given birth to a child, the result of the manipulations is less to be depended upon, than in the case of a virgin.

A means of ensuring artificial sterility, which in all civilized states is punishable as a criminal offence, and which is nevertheless very frequently practised, is the artificial induction of abortion. Especially in North America it would appear that there exist regular professional abortionists. In this connection, Thomas, the well-known American gynecologist, writes as follows: “Statistics showing the frequency of criminal abortion are not, and probably never will be, available, for this crime cannot be adequately controlled by human society, and commonly eludes legal punishment. It seems a hard saying, but it is a true one, to assert, that the law pursues unremittingly him who has killed his fellow-man, while it leaves immune him who has killed the embryo in the mother’s womb. On my table there lies at this moment one of the most widely circulated, most respected, and most carefully edited daily newspapers of New York—a paper which finds its way into the best circles of society, and also into the hands of girls and women throughout the country. In its columns I find fifteen advertisements which emanate beyond all question from professional abortionists—from men and women who gain their livelihood by child-murder.”

O. Reyher remarks also that in American newspapers advertisements such as the following are of every-day occurrence: “Pills for the regulation of the periods. Ladies expecting to be confined are warned not to use them on any account, for if they do so abortion will infallibly ensue.”

Emmet, in his “Textbook of Gynecology” also complains of the terrible frequency of criminal abortion, so that “every day we see more unhappiness and misery result from the misuse of conjugal relationships than we see in an entire month as a result of births which take place in a natural manner.”

Pomeroy also says that “The prevention of conception and the destruction of the unborn life are pre-eminently American sins;” and he adds that if no bounds are set to their spread, “they must, sooner or later, lead to universal misfortune. In the course of our practices we come into contact with women who would hesitate to kill a fly, but who think nothing of having destroyed half a dozen or more of their own unborn children.”

The American Medical Congress offered a prize for a brief and readable essay, suitable for diffusion among women, showing the criminality and the physical harmfulness of artificial abortion. The prize was awarded to Storer’s essay, entitled “Why Not?”

Among the ancient Greeks, the fear of over-population led to the practice of homosexual intercourse. The states of ancient Greece were in most cases of a very small area, so that a very moderate increase in population would render the means of subsistence insufficient. Hence intercourse with women was avoided, and the sexual impulse was gratified in unnatural ways. Inspired by this fear of over-population, Aristotle urged upon men that they avoid women, and should indulge in the love of men and boys, and at an earlier date, Socrates had celebrated the love of boys as a mark of higher culture. The most notable men of classical Greece practised homosexual intercourse; authors and poets celebrated the love of boys. Stimulated by their example, Sappho of Lesbos became the inspired poetess of the love of women for members of their own sex (Lesbian love).

Among the Romans it was rather satiety in consequence of sexual excesses which led in that country to the diffusion of the Greek love of boys; the consequent childlessness diminished to such an extent the numbers of the Roman burghers and patricians, that Augustus, in the year 16 B. C., enacted the Julian law, by which the procreation of children was rewarded, whilst celibacy became a punishable offence.

At the present day the fear of an excessively large number of children, in relation to the property possessed by the parents and in regard to nutritive possibilities, has led among whole classes, and even among entire nations, to the adoption of preventive measures in sexual intercourse; these measures have, in fact, been developed into a system, which finds adherents among all strata of the population, but more especially, as it is easy to understand, among certain well-to-do sections of the community. In France this system has been adopted to such an extent as to amount to a national calamity.

In few countries of the civilized world, remarks Bebel, are marriages so frequent, relatively to the population, as they are in France, whilst in no country is the average number of children per marriage so small, or the increase of population so slow. The French bourgeoisie long ago adopted this system, and the peasantry and the artizan classes are following their example. In many parts of Germany the same causes have led to the same results. In France, in addition to the prevention of pregnancy and the practice of artificial abortion, infanticide and the exposure of children are also actually employed to keep down the population.

Operative measures for the production of artificial sterility have been practised from very ancient times, and by civilized and savage peoples alike. According to Strabo, the ancient Egyptians and Lydians were acquainted with the art of removing the ovaries from girls and women. The kings of Lydia, Andromytes and Gyges, had the women of their harems castrated, ut iis semper ætate et forma florentibus uteretur. Von Micklucho-Mackay reports that in some parts of Australia the indigens remove the ovaries of certain girls, in order to provide their young men with hetairæ who cannot possibly become pregnant. M. Gillirray saw at Cape York a native deaf and dumb woman whose ovaries had been removed, to prevent her procreating deaf and dumb infants.

We cannot refrain from reference to the astounding proposal of C. A. Weinhold, contained in his work upon the over-population of Central Europe and its consequences to the countries concerned and to civilization in general. He advises, “as a general and urgently required measure, the widespread practice of a sort of infibulation, which is to be undertaken at the age of fourteen and preserved until marriage, and is to be performed in the case of all those individuals who can be proved not to possess sufficient property for the upbringing of an infant, if they should become pregnant as a result of extra-conjugal intercourse. And in those who never attained a financial position in which they might be able to bring up a family, the infibulated condition should be allowed to persist throughout life!”

This proposal is, in fact, no novelty, inasmuch as the bringing about of an artificial adhesion of the labia with a view to the prevention of conception—the operation of infibulation—is practised by many savage peoples. According to the detailed account given by Ploss-Bartels, this operation, in which the inner surfaces of the labia majora are freshened, stitched together, and allowed to adhere, is practised by the Bedschas, the Gallas, the Somalis, the inhabitants of Harrar, at Massaua, etc. The purpose of this practice is to preserve the chastity of the girls until marriage, when the reverse operative procedure is undertaken. If the husband goes away on a journey, in many cases the operation of infibulation is once more performed upon his wives. Slave-dealers also make use of this operation so as to prevent their slaves from becoming pregnant. It is reported, however, that the operation does not invariably produce the desired effect. Hartmann informs us that in Nubia, in Senaar, and in part of Kordofan, the præputium clitoridis or the entire clitoris is cut away, and the margins of the nymphæ are then freshened and stitched together, so that the only aperture left is one sufficiently large for the outflow of the urine.

Brehm states that the operation is performed by old women, who make the necessary incisions with razors; shortly before marriage, the bridegroom sends the girl’s relatives a model of his penis, carved in wood, according to the size of which an aperture is made between the adherent nymphæ; when the woman becomes pregnant, the incision is still further enlarged. In the kingdom of Darfur, the labia majora as well as the nymphæ are freshened and stitched together. In the Berber country, Werne became acquainted with a young widow whose husband had had her submitted to the operation of infibulation no less than seven times. Another somewhat less brutal method of performing infibulation is described by Ploss, as being practised by many Eastern races; a ring is fastened through the labia in such a way as to guard the introitus vaginæ In Europe, during the Middle Ages, such and similar apparatus (“girdles of chastity”) are said to have been employed for the protection of the honour of an absent husband.

Of gynecologists who have advised operative measures for the prevention of pregnancy, in women in whom that condition involved serious dangers, the first, as far as I know, was Blundell. As a result of experiments made on rabbits, he suggested division of the Fallopian tubes as the best way of attaining this end. Later, Froriep and Kocks also endeavoured to induce artificial sterility in women by occlusion of the Fallopian tubes. Froriep’s idea was to bring about obliteration of the lumen of the tubes by means of cauterization with nitrate of silver; Kocks constructed for the same purpose a galvano-caustic uterine sound. But, in the first place, both the methods advocated are too uncertain to be relied upon; and, in the second place, their application is neither easy, nor devoid of serious risk.

Much more effective, however, is the method recommended by Kehrer for the sterilization of women, namely, division of the Fallopian tubes by the vaginal route. Kehrer considers that the physician is justified in preventing the occurrence of pregnancy in a number of morbid conditions—incurable nervous, cardiac, pulmonary, gastric, and renal disorders; various constitutional affections; and, finally, in cases of pelvic deformity of such a degree that the delivery of a living child is impossible except by means of Cæsarean section, but the patient does not wish to be exposed to the risks of this operation. He believes, moreover, that all the methods commonly recommended for the prevention of pregnancy are untrustworthy. So powerful, however, is the sexual impulse, that, as experience shows, the mere prohibition of sexual intercourse, however earnestly made, invariably proves ineffectual. For coitus interruptus to be effective, the interruption must occur at the right moment; and this does not always take place. Cold water douches after coitus are unhygienic; douches of warm water, medicated with sublimate, alcohol, and other drugs lethal to the spermatozoa, are indeed rationally conceived, but often fail of their effect, either because they are deferred until too late, or else because they fail to irrigate all parts of the vagina. Plugs of cotton wool, sponges, etc., are not always introduced in such a way as effectually to occlude the vaginal passage. A suitable and properly introduced occlusive pessary is, indeed, a relatively trustworthy preventive apparatus, but if worn continuously it is apt to become very foul. A thorough douching of the genital passage with an antiseptic solution, performed by the skilled hand, immediately after coitus, would doubtless destroy the spermatozoa with the like certainty with which the same procedure destroys micro-organisms when performed prior to a gynecological operation—but when carried out by the layman, the value of the method is more than doubtful. The operation, for a time actually fashionable, of extirpation of the uterine annexa, certainly gives rise to sterility, but entails the serious disadvantage that the consequent premature menopause is attended by the same disturbances as the natural change of life. On the other hand, section and ligature of the Fallopian tubes is considered by Kehrer to induce sterility without in any other way disturbing the functions of the female reproductive organs. By means of anterior colpotomy we obtain a suitable route for the ligature and section of both tubes at the isthmi. When carried out with the proper antiseptic precautions the operation is almost entirely free from risk; and when the organs are healthy the closure of both the upper and the lower segments of the tubes is effected, and no retention of secretions need be feared as a result of the operation.

With regard to the indications for the performance of this operation, Kehrer insists that it should be undertaken only in cases of serious disease, and when the pros and cons have been conscientiously weighed. A consultation is also indispensable. Moreover, it is essential that husband and wife should both fully understand the nature of the proposed operation, and should form an unbiassed judgment regarding its advisability. To avoid any possibility of subsequent reproaches, Kehrer advises that a written report should be drawn up, giving the reasons for undertaking the sterilization, and that this should be subscribed by the physicians in consultation, by the patient herself, and by her husband.

Arndt considers that in cases in which there already exists serious constitutional disease, the performance of this operation may lead to fever, severe hæmorrhage, injury to adjacent organs, and even death. He holds, therefore, that in such cases the physician should advise the use of some of the more ordinary methods of preventing conception (if simple abstinence from intercourse cannot be practised). Only in women with pelvic contraction of the second or third degree, in whom previous children have been still-born, or subjected to craniotomy, is operative sterilization by Kehrer’s method justifiable. But in preference to anterior colpotomy, as recommended by Kehrer, he prefers the longitudinal incision in the posterior vaginal fornix advised by Boileux. If the uterus is drawn down firmly, and the portio vaginalis then pushed forward against the pubic symphysis, it is easy, at any rate with the assistance of a little abdominal pressure, to draw part of the Fallopian tubes into the vaginal incision.

Recently Pincus has recommended the cauterization of the uterine cavity with superheated steam (atmocausis, castratio uterina). He advises it only in women who are incurably ill (tuberculosis, morbus Brightii, hæmophilia), so that pregnancy and parturition would involve almost certain death.

Kossmann considers that when pregnancy and parturition will endanger a woman’s health and life, it is the physician’s duty to acquaint both husband and wife with this fact; but having done so his duty is fully discharged. “If, after being warned, the married pair choose to indulge in sexual intercourse, they have knowingly and voluntarily run into danger, and for this the physician is in no way responsible.”

As indications for facultative sterility Levy enumerates tubercular disease of the lungs, mental disorders, severe organic or functional diseases of the central nervous system, active syphilis (in certain circumstances), pernicious anæmia, hæmophilia, diabetes mellitus, severe heart disease, chronic disease of the kidneys or liver, certain pelvic deformities, and the tendency to habitual abortion.

I have myself before now stated my opinion that it is the duty of the physician, in the case of a married woman suffering from heart disease, with due regard to the danger which pregnancy will entail upon her, to give needful advice in the matter of the prevention of conception. In women affected with valvular heart disease, and in whom there are serious disturbances of compensation, conception is absolutely to be avoided; also in conditions of marked cardiac degeneration, and when there are distinct symptoms of insufficiency of the heart muscle. When, on slight exertion, palpitation, increased frequency of the pulse, and respiratory need (“air-hunger”), ensue; when there is extensive œdema of the lower extremities which persists even after confinement to bed; when the pulse readily becomes arhythmical both in respect of the strength and the temporal succession of the beats; when the urine is scanty and contains varying quantities of albumen; when there are frequent attacks of heart-weakness, with a small irregular pulse, coldness of the extremities, a cyanotic tint of complexion, nausea, dyspnœa, sense of faintness, or actual syncope—in all such cases, whether dependent upon valvular disease, on pathological changes in the arteries, or upon disease of the myocardium, the occurrence of pregnancy is a true disaster, giving rise in most cases to a grave aggravation of the heart trouble and often enough costing the patient her life. I further regard it as a sound medical axiom that in cases of cardiac disorder of a less severe type than that just described the woman thus affected should not have more than one or two children. This is the more necessary because with each successive pregnancy the functional capacity of the diseased heart decreases in geometrical progression and the danger to life proportionately increases. But in such cases of heart disease the prevention of pregnancy must never be effected by the interruption of coitus by the man before ejaculation, for the reason that this procedure gives rise to manifold reflex cardiac troubles, and especially to paroxysms of tachycardia, with simultaneous diminution in vascular tone, vasomotor disturbances, and states of mental depression—and these entail exceptional dangers in women suffering from heart disease.

THE DETERMINATION OF SEX.

The problem of the determination of sex in the human species is one which has occupied natural philosophers from the very earliest times, and has always greatly interested all classes of the population.

The interest awakened by the subject depends principally on the fact that female children have usually been less desired than male in all periods of history and among almost all races. In the uppermost circles of society the truth of this statement is manifested by the fact that the birth of a prince is announced by a salute of 101 guns, that of a princess by a salute of 35 guns only.

It would serve no useful purpose to transcribe here the opinions, or rather guesses, which were ventured on this topic in earlier days when the very nature of the reproductive process was still entirely unknown, and we shall merely mention that the curious will find various references to the determination of sex in the works of Hippocrates, Aristotle, Plutarch, Soranus, Susruta and Galen.

Broadly speaking, the earlier theories may be said to diverge in two main directions, some holding that the sex of the infant was in some way determined by the mode of intermixture of the male and the female elements in the act of generation, and others maintaining that sex was already inalterably predetermined at the time of intercourse either in the male or in the female sexual elements.

Pari passu with the modern development of the theory of evolution, and with the enormous increase in recent days in anatomical and physiological knowledge, the theory of the determination of sex has been very widely extended. The rival views may be briefly arranged in the four following categories:

I. That sex is already inalterably predetermined in the ovum, upon the constitution of which it solely depends; there are therefore male and female ova, and the process of fertilization exercises no influence whatever upon the determination of sex. The alternative theory to the above, that sex is determined solely by the constitution of the fertilizing spermatozoon—i. e., that the spermatozoa, and not the ova, are male and female, respectively—is one which in recent years has tended more and more to disappear from the field.

II. That sex is determined in the moment of fertilization by the reciprocal interaction of male and female, of zoösperm and ovum. One variant of this theory maintains that each reproductive element strives for the reproduction of its own sex; that a struggle takes place and that the victor in the contest stamps its own sex-likeness upon the fertilized product. According to another view, however, sex is not directly transmitted in this manner; it is supposed that the more powerful the proper reproductive element (according to this theory the ovum) the more strongly does it tend to determine the reproduction of a stronger, i. e., a male organism; thus the greater potency of the female element in the act of reproduction tends to favour the determination of the male sex.

III. That sex is not determined until after fertilization, during the early stages of the development of the embryo; the determining causes are supposed to be various factors capable of influencing the developing organism during this period, and more particularly the nutritive conditions of the mother.

IV. That the determination of sex is not dependent solely upon the action of any single one of the factors above enumerated, but arises as a resultant effect of the operation on the germ of all three of these acting in temporal succession.

Modern physiology has endeavoured to solve this problem by statistical investigations, by anatomical demonstration, and finally by experiment.

I. Statistical Investigations.

Statistical data have been collected showing the ratios between male and female births in the most varied conditions possible, and from these data the attempt has been made to draw valid conclusions regarding the causes of the determination of sex. Now in the first place it is above all necessary to bear in mind that such statistical data cannot possibly have any value unless they relate to very numerous instances, and even then they are liable to be invalidated by various sources of fallacy. We may with advantage quote in this connection the remarks of Hensen in his work on the “Physiology of Reproduction:” “Each individual instance is rendered unique in kind by the interaction of certain incommensurable elements; for instance the state of health of the individual organs in their innumerable combinations, variations in the general health of the parents, the frequency of coitus and the time at which it took place, the desire of the parents to have a son and then no more children, their social position—in these ways innumerable complications are introduced into the problem, and the difficulty of drawing valid conclusions is rendered almost insuperable, unless the number of instances dealt with is enormously large.”

One fact definitely established is that more boys are born than girls, the proportion between the two, known as the sexual ratio, being 106 : 100. Statistics relating to the half of Europe (Oesterlen) and dealing with 59,350,000 births, showed a ratio of 106.3 male to 100 female births; in individual countries variations from this mean are found to occur, but these are not very extensive, the highest ratio being 107.2 : 100, and the lowest ratio 105.2 : 100.

From the works of Hofacker (“Ueber die Eigenschaften welche sich bei Menschen und Tieren von den Eltern auf die Nachkommen vererben”—Concerning the Qualities transmitted from Parents to Offspring in Men and Animals—Tuebingen, 1828) and Sadler (“Law of Population,” London, 1830) conclusions have been drawn regarding the effect of a variation in the age ratio of the parents on the determination of sex. The deductions in question, known as Hofacker and Sadler’s law, are as follows:

1. If the husband is older than the wife more boys are born than girls.

2. If husband and wife are the same age somewhat fewer boys are born than girls.

3. If the wife is older than the husband the excess of female births is larger still.

Hofacker’s actual figures were the following:

Father younger than mother 90.1 boys to 100 girls. Father same age as mother 93.3 boys to 100 girls. Father 4 to 6 years older than mother 108.8 boys to 100 girls. Father 6 to 9 years older than mother 124.7 boys to 100 girls. Father 9 to 12 years older than mother 143.7 boys to 100 girls.

Sadler’s results were closely similar:

Father younger than mother 86 boys to 100 girls. Father same age as mother 94 boys to 100 girls. Father 1 to 6 years older than mother 103 boys to 100 girls. Father 6 to 11 years older than mother 126 boys to 100 girls. Father 11 to 16 years older than mother 147 boys to 100 girls. Father 16 years and more older than mother 163 boys to 100 girls.

Goehlert found that the offspring of marriages in which the husband was younger than the wife were 71 boys and 86 girls; of marriages in which husband and wife were of the same age, 263 boys and 282 girls; and of marriages in which the husband was older than the wife, 2,017 boys and 1,865 girls.

Wappaeus, combining the data supplied by these three investigators, Hofacker, Sadler and Goehlert, obtained the following sexual ratios for the entire 8,000 cases (i. e., the number of boys born to each 100 girls born): When the husband was younger than the wife, 88.2; when husband and wife were of the same age, 93.5; when the husband was older than the wife, 113.0.

It will be observed that the mean sexual ratio of these 8,000 cases is 109.6; whilst, as we saw above, when a sufficiently large number of instances is taken, the sexual ratio always closely approximates to 106.3. From this it appears that the numbers dealt with by Hofacker, Sadler and Goehlert in their investigations were too small for the deduction of trustworthy averages.

The same criticism is applicable to the observations of Ahlfeld, Breslau and Noirot, whose results conflict with those just given. According to Ahlfeld, in the case of 1,376 births where the father was at least 10 years older than the mother, the sexual ratio was only 98.2. According to Noirot’s data, in cases in which the father was older than the mother, this ratio was 99.7.

Oesterlen gives the following brief summary of the researches made for the establishment and confirmation of the law of Hofacker and Sadler:

═══════════════╤══════════╤══════════╤══════════╤══════════╤══════════ │ Father │Father and│ Mother │ Sexual │Number of AUTHOR. │older than│ mother │older than│ ratio. │instances. │ mother. │same age. │ father. │ │ ───────────────┼──────────┼──────────┼──────────┼──────────┼────────── Hofacker │ 117.8│ 92.0│ 90.6│ 107.5│ 1,996 Sadler │ 121.4│ 94.8│ 86.5│ 114.7│ 2,008 Goehlert │ 108.2│ 93.3│ 82.6│ 105.3│ 4,584 Noirot │ 99.7│ │ 116.0│ 103.5│ 4,000 Legoyt (Calais)│ 109.9│ 107.9│ 101.6│ 107.9│ 6,006 Legoyt (Paris) │ 104.4│ 102.1│ 97.5│ 102.9│ 52,311 Breslau │ 103.9│ 103.1│ 117.6│ 106.6│ 8,084 ═══════════════╧══════════╧══════════╧══════════╧══════════╧══════════

The law of Hofacker and Sadler cannot be regarded as possessing universal validity, although the figures on which it is based seem to show pretty clearly that we are justified in regarding the mutual interaction of the male and female reproductive elements at the moment of fertilization as effective in the determination of sex. In the investigations to which we have hitherto alluded it is only the relative ages of husband and wife that have been taken into account; but other researches have shown that the absolute age alike of the husband and of the wife has an influence in the determination of sex.

The influence of the absolute age of the mother in the determination of sex has been very clearly established. Ahlfeld was the first to draw attention to the fact that among the children of elderly primiparæ there was always to be found an excess of boys, and that there was an increase in this excess proportionate to the greater age of the mother. Among 102 children born to primiparæ over 32 years of age the sexual ratio was 137 : 100; and a later investigation made by the same author in conjunction with Schramm showed that among 1,038 children born to primiparæ over 28 years of age the sexual ratio was 124 : 100.

Hecker obtained similar results. Among 432 children born to primiparæ over thirty years of age the sexual ratio was 133 : 100. Winckel, dealing with primiparæ of the same ages, found a sexual ratio of 136.8 : 100.

Düsing, examining the records of the lying-in hospitals of Leipzig, Dresden and Jena and thus obtaining a very large number of instances whereon to base his conclusions, confirmed the view that elderly primiparæ give birth to an excess of boys, and further that the older they are the larger the excess of male births. He drew up the following table:

══════════╤════════════╤════════════╤════════════╤════════════╤═══════════ Age of │ Leipzig. │ Dresden. │ Jena. │ Total Nos. │ Sexual primiparæ.│Boys. Girls.│Boys. Girls.│Boys. Girls.│Boys. Girls.│ ratio. ──────────┼────────────┼────────────┼────────────┼────────────┼─────────── 15 │ 1 : −│ 1 : 2│ 1 : −│ 3 : 2│} 549 : 494 │ │ │ │ │ = 111.1 16 │ 4 : 4│ 6 : 10│ 2 : 2│ 12 : 16│ „ 17 │ 23 : 13│ 20 : 15│ 9 : 7│ 52 : 35│ „ 18 │ 67 : 55│ 103 : 100│ 17 : 13│ 187 : 168│ „ 19 │ 110 : 103│ 152 : 141│ 33 : 29│ 295 : 273│ „ ──────────┼────────────┼────────────┼────────────┼────────────┼─────────── 20 │ 148 : 147│ 187 : 185│ 32 : 45│ 367 : 377│} 807 : 781 │ │ │ │ │ = 103.3 21 │ 157 : 145│ 241 : 201│ 42 : 57│ 440 : 404│ „ ──────────┼────────────┼────────────┼────────────┼────────────┼─────────── 22 │ 120 : 133│ 191 : 207│ 48 : 53│ 359 : 393│} 903 : 962 │ │ │ │ │ = 93.9 23 │ 106 : 108│ 168 : 149│ 51 : 51│ 325 : 308│ „ 24 │ 71 : 105│ 111 : 118│ 37 : 38│ 219 : 261│ „ ──────────┼────────────┼────────────┼────────────┼────────────┼─────────── 25 │ 79 : 57│ 73 : 72│ 35 : 27│ 187 : 156│} 531 : 469 │ │ │ │ │ = 113.2 26 │ 45 : 35│ 30 : 43│ 20 : 20│ 125 : 98│ „ 27 │ 31 : 35│ 52 : 55│ 10 : 12│ 93 : 102│ „ 28 │ 32 : 33│ 26 : 33│ 19 : 16│ 77 : 72│ „ 29 │ 19 : 10│ 26 : 18│ 4 : 13│ 49 : 41│ „ ──────────┼────────────┼────────────┼────────────┼────────────┼─────────── 30 │ 9 : 15│ 30 : 13│ 9 : 6│ 48 : 34│} 155 : 104 │ │ │ │ │ = 150.0 31 │ 3 : 8│ 15 : 11│ 3 : 3│ 21 : 22│ „ 32 │ 5 : 6│ 12 : 9│ 7 : 3│ 24 : 18│ „ 33 │ 2 : 2│ 5 : 5│ 5 : 2│ 12 : 9│ „ 34 │ 4 : −│ 8 : 5│ 2 : −│ 14 : 5│ „ 35 │ 2 : −│ 9 : 3│ 2 : 1│ 13 : 4│ „ 36 │ 1 : −│ 3 : 3│ 1 : 1│ 5 : 4│ „ 37 │ 4 : 1│ 4 : 3│ 1 : −│ 9 : 4│ „ 38 │ − : −│ − : 1│ 1 : −│ 1 : 1│ „ 39 │ − : −│ 4 : −│ 1 : −│ 5 : −│ „ 40 │ 1 : 1│ 2 : 1│ 1 : −│ 4 : 2│ „ 41 │ − : −│ − : 1│ − : −│ − : 1│ „ ──────────┴────────────┴────────────┴────────────┴────────────┴───────────

As an explanation of this statistically proved fact, that elderly primiparæ gave birth to a large excess of boys, Düsing suggests that these women who conceive for the first time comparatively late in life, are, prior to the conception, in a state corresponding with that of a lower animal species suffering from a deficiency of males, and for this reason exhibit a tendency to procreate a larger number of individuals of the deficient sex. In multiparæ also it is possible to trace the influence of a deficiency of male individuals. When there is such a deficiency the interval between successive births is unduly protracted. Düsing found (once more from the records of the lying-in hospitals of Dresden, Leipzig and Jena) that the longer the interval between one parturition and the next the longer, that is to say, the mother has had to wait for her next conception, the greater is the excess of male births. Düsing therefore lays down the law: “Delayed impregnation gives rise to an excess of male births.”

═══════════╤════════════╤════════════╤════════════╤════════════╤═══════ Age of │ Leipzig. │ Dresden. │ Jena. │ Total Nos. │Sexual primiparæ. │Boys. Girls.│Boys. Girls.│Boys. Girls.│Boys. Girls.│ratio. ───────────┼────────────┼────────────┼────────────┼────────────┼─────── 1 │ 162 : 158 │ 194 : 178 │ 58 : 45 │ 414 : 381 │ 108.6 2 │ 366 : 307 │ 374 : 361 │ 168 : 145 │ 908 : 813 │ 111.6 3 │ 198 : 196 │ 207 : 194 │ 116 : 94 │ 521 : 484 │ 107.7 ───────────┼────────────┼────────────┼────────────┼────────────┼─────── 4 │ 127 : 109 │ 132 : 106 │ 59 : 45 │ 318 : 260 │} 115.7 5 │ 59 : 54 │ 55 : 54 │ 38 : 38 │ 152 : 146 │ „ ───────────┼────────────┼────────────┼────────────┼────────────┼─────── 6 │ 61 : 62 │ 52 : 49 │ 49 : 24 │ 162 : 135 │} 121.9 8, 9 and 10│ 18 : 16 │ 41 : 23 │ 16 : 24 │ 75 : 63 │ „ 11 and more│ 5 : 15 │ 12 : 9 │ 4 : 6 │ 41 : 30 │ „ ───────────┴────────────┴────────────┴────────────┴────────────┴─────── Totals: 4,903 births, 2,591 m.; 2,312 f.; sexual ratio = 112.06.

Bidder considers that his own observations entitle him to modify Ahlfeld’s dictum regarding the influence of age in primiparæ in giving rise to an excess of male births. He tabulates his results as follows:

═════════════════╤═════════════════╤═════════════════ AGE OF MOTHER. │Number of cases. │ Sexual ratio. ─────────────────┼─────────────────┼───────────────── 17 to 20 │ 80│ 122.2 20 to 22 │ 405│ 130.1 22 to 24 │ 369│ 109.9 24 to 26 │ 1,138│ 104.6 26 to 30 │ 2,049│ 105.5 30 to 32 │ 878│ 112.5 32 to 36 │ 1,120│ 119.6 36 to 39 │ 676│ 123.1 40 and upward │ 215│ 131.5 ═════════════════╧═════════════════╧═════════════════

and formulates the following thesis: Very young primiparæ give birth to an excess of boys; primiparæ in the first bloom of womanhood give birth to an excess of girls; later, however, as the age of the primiparæ increases the excess of male births soon reappears and rapidly increases.

Hofacker’s data and the researches of Hampe agree with those of Bidder in showing that to very young primiparæ, as well as to elderly primiparæ, an excess of boys is born. Among the offspring of 363 mothers, at ages varying from 16 to 26 years, Hofacker found the sexual ratio to be 121; among the offspring of 1,056 mothers, at ages 26 to 36, the ratio was 101; and among the offspring of 567 mothers at ages 36 to 46, the ratio was 111. Hampe tabulated 5,992 instances as follows:

═══════════════════════╤═══════════════════════╤═══════════════════════ AGE OF MOTHER. │ Number of instances. │ Sexual ratio. ───────────────────────┼───────────────────────┼─────────────────────── Below 20 years │ 56│ 107.7 20 to 25 years │ 871│ 90.6 25 to 30 years │ 1,633│ 114.9 30 to 35 years │ 1,631│ 108.3 35 to 40 years │ 1,185│ 117.1 Over 40 years │ 616│ 124.0 ═══════════════════════╧═══════════════════════╧═══════════════════════

We learn, therefore, that if the age of the progenitors is to be regarded as one of the causes by which sex is determined, we must take into consideration not only the relative ages of husband and wife but, in addition, the absolute age of the wife.

Goehlert undertook a statistical investigation in which the absolute age of the husband was taken into consideration as well as that of the wife. From this it appeared that the maximum sexual ratio was exhibited when the father was between the ages of 30 and 35 years. When the age of the mother is treated as the determining influence, we find the maximum sexual ratio in the offspring of mothers between the ages of 25 and 30 years. Goehlert believes, however, that the paternal influence is more powerful than the maternal in the determination of sex. The respective influences are compared in the following table:

══════════════╤═══════════════════════════════════════════════════════ AGE OF FATHER.│ AGE OF MOTHER. ──────────────┼─────────────┬─────────────┬─────────────┬───────────── „ │ 20 to 30 │ 30 to 40 │ Over 40 │ Totals. │ years. │ years. │ years. │ ──────────────┼─────────────┼─────────────┼─────────────┼───────────── 25 to 35 years│ 105.76│ 107.87│ 109.14│ 106.6 35 to 45 years│ 102.8│ 105.1│ 105.3│ 104.7 Over 45 years │ │ 104.3│ 103.9│ 109.1 In general │ 105.25│ 105.97│ 104.9│ 105.5 ══════════════╧═════════════╧═════════════╧═════════════╧═════════════

Geissler, studying the data obtainable regarding the sexual ratio during a 10–year period in the Kingdom of Saxony, ascertained that in families possessing two children or more there was a very definite distribution of the possible sex-combinations. Where there was an even number of children those families were in the majority in which the number of boys and girls was identical. If the number of children in the family is an unequal one, those combinations are most frequent in which the number of boys exceeds the number of girls by one; next in frequency are those combinations reversed to this, i. e., in which the number of girls exceeds the number of boys by one. All other combinations are comparatively infrequent in proportion as the discrepancy in number between boys and girls is larger. Rarest of all are families in which the children are all of the same sex; and among these, again, the most unusual are those consisting of boys only.

This distribution of the sex-combination is believed by Geissler to depend upon the fact that in the first birth and all the subsequent births there is generally speaking a slight advantage in favour of the male sex. It has not been proved that the sex of the first-born exercises a determining influence on the sex of the subsequent children. It does, however, seem clear that in the case of parents who have given birth in succession to several children of one sex only, there exists some definite obstacle to the procreation of children of the opposite sex. Putting these exceptions out of consideration, there seems to exist a tendency in the later births of a series toward the procreation, more especially of that sex which has been absent or deficient in the earlier births of the series. The strength of this equalizing tendency increases as soon as it has for the first time manifest itself. It is always greater when the sex deficient in the earlier births of the series has been the male.

I have myself undertaken a statistical investigation of the births occurring in the reigning families of Europe and in the families of the leading members of the aristocracy. The necessary particulars are to be obtained from the genealogical court calendars; and it is my belief that the data obtained regarding these uppermost strata of society are comparatively free from many sources of error by which the ordinary statistics of the subject are apt to be invalidated. For 556 marriages there were 1,972 births, comprising 1,023 boys and 949 girls, and thus exhibiting a sexual ratio of 107.7.

In relation to the relative ages of the parents, the following table was drawn up:

══════════════════════════════════════════════════╤══════╤══════╤══════ │ │ │Sexual │Boys. │Girls.│ratio. ──────────────────────────────────────────────────┼──────┼──────┼────── Husband older than wife by one to five years │ 294│ 283│ 103.8 Husband older than wife by more than five and less│ │ │ than ten years │ 327│ 306│ 106.8 Husband older than wife by more than ten and less │ │ │ than fifteen years │ 190│ 167│ 113.7 Husband older than wife by more than fifteen years│ 138│ 113│ 122.1 Husband same age as wife │ 34│ 42│ 80.9 Husband younger than wife │ 40│ 38│ 105.2 ══════════════════════════════════════════════════╧══════╧══════╧══════

From these figures we may deduce the following conclusions, which are not wholly concordant with the law of Hofacker and Sadler: When the husband is older than the wife the excess of male births among the offspring is greater than it is in the case of an average drawn from the offspring of all marriages (in my cases the difference was 111.8 as compared with 107.7). But a closer analysis shows the difference to be less simple than at first sight appears. If the husband is older than the wife by one to five years, the excess of male births among their offspring (103.8) is less than in the average of all marriages (107.7); the same is true of the offspring of marriages in which the husband is more than five and less than ten years older than the wife, though the difference here is very trifling (106.8 as compared with 107.7). It is not till we come to the offspring of marriages in which the husband is from ten to fifteen years older than the wife that the increase in the excess of male births becomes notable (113.7 as compared with 107.7); and when the husband is more than fifteen years older than the wife the excess of males is higher still (122.1).

If we arrange these data so as to show, in cases in which the husband is older than the wife, the additional influence of the absolute age of the wife, we obtain results which partially conflict with those of Bidder, as follows:

══════════════════════════════════════════════════╤══════╤══════╤══════ HUSBAND OLDER THAN WIFE. │ │ │Sexual │Boys. │Girls.│ratio. ──────────────────────────────────────────────────┼──────┼──────┼────── Wife’s age, 15 to 20 years │ 280│ 287│ 97.6 Wife’s age, 20 to 26 years │ 595│ 513│ 116.0 Wife’s age, 26 to 33 years │ 74│ 69│ 110.1 ══════════════════════════════════════════════════╧══════╧══════╧══════

Thus we see that when the wife is very young, i e., less than twenty years of age, even though the husband is older than the wife, there is among their offspring no excess of male births, but the contrary—a sexual ratio of 97.6 only. Most marked is the excess of boys in cases in which the husband is older than the wife, and the age of the wife is from twenty to twenty-five years. When the husband is older than the wife, and the wife’s age lies between twenty-five and thirty-two years, the excess of male births is not so great, though still considerable.

Hence it appears that the law of Hofacker and Sadler, which cannot be regarded as fully valid in the terms in which it was originally expressed, must be modified as follows: If the husband is at least 10 years older than the wife, and the latter is at an age when her reproductive capacity is at its maximum (twenty to twenty-five years), the offspring exhibit a notable excess of male births. There is still a considerable excess of male births in the offspring of marriages in which the husband is at least ten years older than the wife, and the wife is more than twenty-five years of age. On the other hand fewer boys are born than girls as the offspring of marriages in which, although the husband is older than the wife, the wife has not yet attained the age of maximum reproductive capacity—i. e., is less than twenty years of age. The excess of female births is most marked when the husband and wife are of the same age. When the wife is older than the husband there is a moderate excess of male births.

I admit, however, that the figures upon which I have based these conclusions are, like those of Hofacker, too few in number for the foundation of trustworthy inferences. The instances in my computation number 1,972; those in that of Hofacker, 1,996; but, as I have already remarked, there are reasons for believing that the data I have employed admit of the introduction of fewer sources of error.

The influence of the absolute age of the mother in the determination of sex having been statistically proved, many have inferred that this determination is not effected during the instant of fertilization, but occurs at a later stage of intra-uterine life, and is influenced by the manner in which the embryo is nourished by the maternal organism. It is suggested that elderly and immature mothers are unable to furnish the embryo with nutriment so well as those mothers who are at the age of maximum reproductive capacity, and that upon this fact depends the excess of male births in the latter case. (We shall return to this matter—the influence of deficient nutrition in relation to the excess of male births). But the proof of the fact that the absolute age of the father has also an influence in the determination of the sex of the offspring offers a ground for opposing this assumption that the sex of the embryo is determined during intra-uterine life subsequent to fertilization, and suggests that the father also exercises a determining influence in the origination of sex during the act of fertilization.

The absolute age of the husband seems also to have some influence upon the sexual ratio. The absolute age, like the relative age, of the father appears favourable to the procreation of a greater excess of boys. Thus, Hofacker found in 1,193 cases, in which the age of the father was from twenty-four to thirty-six years, that the sexual ratio was 100; in 683 cases in which the age of the father was from thirty-six to forty-eight years, the sexual ratio was 114; and in 105 cases, in which the age of the father was from forty-eight to sixty years, the sexual ratio was 169.

In investigations based upon larger collections of cases Schumann and Düsing have endeavoured to determine the variation in the sexual ratio according to the absolute age of the father.

Düsing examined the statistics of births in Norway, Alsace-Lorraine and Berlin, and from the data thus obtained he compiled the following table:

════════╤════════════════════╤════════════════════╤════════════════════ AGE OF │ 30 TO 35 YEARS. │ 25 TO 30 YEARS. │ 20 TO 25 YEARS. MOTHER. │ │ │ ────────┼──────┬──────┬──────┼──────┬──────┬──────┼──────┬──────┬────── AGE OF │Boys. │Girls.│Sexual│Boys. │Girls.│Sexual│Boys. │Girls.│Sexual FATHER. │ │ │ratio.│ │ │ratio.│ │ │ratio. ────────┼──────┼──────┼──────┼──────┼──────┼──────┼──────┼──────┼────── 15 to 30│ 8,525│ 7,887│ 108.1│27,389│25,843│ 106.0│21,560│20,330│ 106.0 years │ │ │ │ │ │ │ │ │ 30 to 35│23,283│21,823│ 106.9│23,394│23,486│ 103.9│ 7,954│ 7,469│ 106.5 years │ │ │ │ │ │ │ │ │ 35 to 40│17,885│17,070│ 104.7│10,272│ 9,838│ 104.2│ 2,426│ 2,416│ 100.4 years │ │ │ │ │ │ │ │ │ ────────┼──────┼──────┼──────┼──────┼──────┼──────┼──────┼──────┼────── 40 to 45│ 7,972│ 7,681│ 103.8│ 3,165│ 3,058│ 103.5│ }│ 1,100│ 105.0 years │ │ │ │ │ │ │ 1,154│ │ Over 45 │ 4,220│ 3,997│ 105.6│ 1,734│ 1,525│ 113.8│ „ │ „ │ „ years │ │ │ │ │ │ │ │ │ ────────┴──────┴──────┴──────┴──────┴──────┴──────┴──────┴──────┴──────

In this table we find the births arranged in relation to varying ages of the fathers and in relation to mothers whose ages are tabulated in three classes, the ages of the latter being those at which they are most prolific. The table shows clearly that the excess of boys is larger at the beginning and at the end of each column. Thus, the age of the mother remaining constant, young fathers and elderly fathers procreate a larger proportion of boys than do fathers of intermediate age.

But I find in this table, which is based upon a very large number of instances indeed, a confirmation of the thesis which I stated above, for the highest sexual ratio of 113.8 is in this table found in the case of fathers over forty-five years of age who are married to mothers of ages twenty-five to thirty years; this is, as I said, the case in which “the husband is at least ten years older than the wife, and the latter is at the age at which her reproductive capacity is at its maximum.”

From such figures as these, which seem to show the influence of the absolute age of the father upon the determination of sex, it has by many been inferred that the man exercises a preponderating influence upon the determination of the sex of the embryo, impressing his own sex upon it, and that the greater the sexual potency of the begetter the more powerful also is the influence exercised by the latter; that the point of first importance in this connection is the sexual capacity of the man; and that the excess of male births increases pari passu with the increase in the potency of the procreating male.

Two additional considerations have been adduced to demonstrate the influence of the father in determining the sex of the offspring. The first of these is a comparison of the ratio between male and female births in towns and in rural districts, respectively; and the second is a comparison between the ratio of males to females in the offspring of married and of unmarried parents, respectively.

In towns the excess of male births is smaller than it is in the country. The average sexual ratio in Prussia during the five-year period, 1875 to 1880, is given by Düsing as follows:

In Berlin 105.70 In other large towns 105.72 In medium sized towns 105.44 In small towns 106.17 In rural districts 106.62

The indisputable fact that in towns more girls are born than in rural districts is referred to the fact that in the country the husband usually enters on marriage with his virile powers completely unimpaired, whereas in towns many men only marry after they have for many years expended their best forces in irregular sexual intercourse, and thus reserve for their wives only the dregs. But, as we shall show presently, the difference between town and country in this respect is susceptible of a different interpretation.

It has also been asserted (Horn) that extra-conjugal sexual intercourse is favourable to the procreation of boys, the suggestion being that the greater sexual vigour in the former case determines a preponderance of males in the offspring; but this assumption is invalidated by the statistical evidence which now accumulates, that among illegitimate offspring there is a smaller excess of boys than among legitimate offspring. Babbage, for instance, came to this conclusion as a result of the comparison of 1,000,000 illegitimate births with 14,000,000 legitimate births. On the other hand, the following utterance of Ploss appears extremely artificial: “In a country in which illegitimate births are very numerous, in which the illegitimate children are for the most part begotten by enervated debauchees, the excess of male births is smaller; but in a country in which the illegitimate births are less numerous, and in which the illegitimate infants are for the most part the fruit of love and are begotten by youthful lovers, the excess of male offspring is larger.”

Next to the age of the progenitors, their nutritive condition is shown by statistical investigations to exercise an important influence in the determination of sex. The following proposition has, in fact, been established: Where the supply of nutriment is deficient, the offspring contains an excessive proportion of boys.

Ploss, in an article on “The Causes of Variations in the Sexual Ratio,” published in twelfth volume of the “Berliner geburtsh. Monatsheft,” has collected a number of statistical data to demonstrate that the determination of sex is principally dependent upon the nutritive condition of the mother. In his opinion the determination of the sex of the embryo depends neither upon the quality of the ovum nor upon that of the spermatozoon, nor again upon the reciprocal influences exerted by ovum and spermatozoon on one another. During the earliest time after fertilization the embryo is sexually neutral and only later, as a result of some new influence acting upon it, does it receive an impulse toward the formation either of the male or of the female sex. Among all the external conditions which are capable during this period of exercising a determinative influence the most important are the nutritive conditions, for nutrition is the most important factor in determining the form of the young animal, and most of the other outward conditions, such as light, heat, and chemical changes, affect the embryo in a mediate manner only, through the changes they are respectively capable of inducing in its nutrition and metabolism. But Ploss is not content with asserting that the nutritive condition of the mother is of great importance in determining the sex of the embryo; he goes further than this, and declares that it is scanty nutrition of the mother which especially gives rise to the birth of males, whereas abundant nutrition of the mother tends to give rise to the birth of females. He refers to observations made in respect of other animals than man. St. Hilaire observed that among the underfed animals in menageries there was an excess of male births. Hofacker and Girou de Bazarcingues have noted similar phenomena in the case of domestic animals; they found that when these were richly fed they gave birth to an excess of females, but that when they were poorly nourished they gave birth, on the contrary, to an excess of males. Among sheep, with whom the number of male and of female births is approximately identical, Martegoute found that those animals which had given birth to female lambs had on the average a greater weight than those ewes which had given birth to male lambs. During the period of lactation, also, the former lost weight more than the latter.

When Ploss had further ascertained that among those engaged in the fur-trade it is the established belief that from fruitful regions the skins chiefly of female animals will be obtained, but from barren regions, on the other hand, among the skins obtained those of male animals will preponderate, it appeared to him that he was justified in drawing the conclusion that among the mammalia a well-nourished mother, one capable of providing abundant nutriment for her offspring, is, on the whole, more likely to give birth to a female than to a male, and conversely. He then endeavoured, by reference to the statistics of population, to show that in the case of human beings also, when the mother is exceptionally well nourished, there is especial likelihood of a girl being born; whereas when the mother is ill nourished she is more likely to give birth to a boy—odd as it may seem, at first sight, that a rich diet should determine the production of the so-called less powerful sex, the female; and conversely. (Ploss, be it noted however, denies that male new-born infants are more powerful than female.) The fact that in the country, comparatively speaking, many more boys are born than in towns (vide supra) is explained by Ploss as dependent on the fact that townswomen are on the whole better nourished than the countrywomen, owing to the greater consumption of meat by the former.

The circumstance again (likewise alluded to above), that in the case of illegitimate births almost always the excess of male births is less marked than in the case of the offspring of legal unions, is regarded by Ploss as offering further proof of the influence of nutritive conditions upon the determination of sex. Illegitimate mothers are on the average women at the very best age for child-bearing, women who have worked vigorously, are themselves well nourished, and are therefore better able to nourish their unborn offspring than (on the average) married women. Further, it is a remarkable fact that in Saxony, regions of which the elevation above the sea-level is less than 1,000 feet, produce comparatively more girls than regions at an altitude of 1,000 to 2,000 feet above the sea. This Ploss refers to the worse nutrition of the women living at the higher altitude, for the fact is well known that the higher we go above the sea the less fertile is the soil and the more limited is its produce.

Starting from the view that the lower classes of the population are in good years better nourished than they are in bad years, Ploss compared statistically the rise and fall of the prices of foodstuffs, in Saxony, with the variations of the sexual ratio in the same kingdom; and he found, in correspondence with his theory, that in bad times there was a greater excess of male births than there was during periods in which food was cheaper. Moreover, the consumption of meat appeared to have more influence upon the variations in the sexual ratio than was exercised by the consumption of vegetable foodstuffs. Ploss endeavoured to show graphically that with an increase in the price of provisions there corresponded an increase in the excess of male births, and vice versa.

That after times of great wars, pestilence, and emigration, in which the male portion of the population has been decimated, there occurs a notable increase in the excess of male births, is explained by Ploss by the assumption that in consequence of the deficiency of male labour, the general supply of provisions is deficient, just as it is after years of bad harvests; hence, in consequence of the scanty nutrition of the mothers, the number of female births is depressed and the number of male births increases. Those countries which in general possess a more thriving population, such as Saxony, England, Belgium, Prussia, etc., exhibit a smaller excess of male births when compared with those countries in which a more widespread poverty exists, such as Russia, Lombardy, Bohemia, and even France. With increasing prosperity, fruitfulness increases, and there is an increase also in the proportion of female births.

These views of Ploss’s are, however, rightly contested by Breslau and Wappaeus.

Breslau (“The Causes of the Determination of Sex”) offers in the first place theoretical objections to the view that nutritive conditions in the mother are determinative in the production of the sex of the offspring; and he then proceeds to quote statistical data which are opposed to any such theory. He rightly insists, in the first place, that, inasmuch as it is unquestionable that in the act of fertilization the spermatozoon induces in the ovum certain changes, the effect of which is manifested in days far later than those of intra-uterine life, by the production of the most manifold and various somatic and psychical resemblances to the father, it is obvious that this single occurrence of the fusion of the spermatozoon, the bearer of the paternal influences, with the ovum is competent to induce in the ovum a molecular arrangement upon which the determination of sex may be supposed to depend—it is not necessary to suppose that for this determination, repeated actions, or a prolonged period of time, is requisite.

In this connection a reference to birds is instructive, for in this division of the animal kingdom we seem absolutely compelled to assume that the sex of the offspring is irrevocably determined in the moment of fertilization. “In birds, who lay an egg every day, eggs which are kept all at the same temperature during the period of incubation, and some of which develop into cock and others into hen birds—how is it possible to imagine that the nutritive condition of the parent is determinative of the sex of the offspring, since this nutritive condition cannot reasonably be supposed to change to any notable extent from one day to the next and then back again?”

The paternal influence in the determination of sex is regarded by Breslau as likely to be at least as important as that exercised by the mother. Unquestionably the semen is subject to certain variations in quality and in quantity, and it is possible that these variations may make themselves felt in the subsequent development of the embryo. Of the semen, as of all secretions, we can assume with some probability that in certain conditions (conditions which are, indeed, but little understood), it may exhibit a greater or less intensity in its stimulating qualities, and that in this way it may be subject to changes, according to which it will tend to influence the development of the embryo, now in the female, and now in the male direction. Again, in view of the continued interchange of nutritive materials between the embryo and the maternal organism, it is probable enough that the constitution of the maternal organism and likewise that of the ovum, at the moment of fertilization, are not matters of indifference to the determination of sex. But to attribute to the nutritive condition of the maternal organism the sole or even the principal influence in the determination of the sex is an unjustifiable assumption.

The proofs alleged by Ploss from the animal world in support of his thesis, viz., that in the case of poorly nourished animals there is a marked excess of male offspring, are justly controverted by Breslau with the remark that the observations on animals are but few in number, and further that we know nothing whatever regarding the normal sexual ratios among the offspring of such animals as lions, tigers, hyænas, bears, etc., in the free state.

If, again, domestic animals when well nourished give birth to an excess of female offspring, and when ill nourished and overworked to an excess of male offspring, in the former case we can only regard the excess of female births as a pathological phenomenon, inasmuch as a superabundant supply of nutriment is not that which furnishes the highest powers or is most suited to the preservation of life. Again, the accounts given by fur-dealers are quite untrustworthy, since these men commonly obtain their goods at third and fourth hand; moreover, most of the animals whose pelts form articles of commerce, are beasts of prey, such as the otter, the lynx, the bear, the wolf, the fox, etc.—and these animals have no “pasturage.” Among vegetable-feeding animals the females are no doubt found on the pasturage more often than the males, for the reason that the females have to nourish both themselves and their young, whereas the males, which have themselves only to provide for, are contented with less food and inhabit chiefly more retired and less fertile regions; they are also shyer and are less easily shot and trapped. Regarding statistical data relating to the influence of nutrition on the production of boys, Breslau shows, from the figures of the Canton of Zurich, that with few exceptions, the years in which the price of corn was lowest were the years in which the production of boys was greatest, and vice versa—the exact opposite of the results obtained by Ploss from his examination of the figures relating to births and the price of provisions in Saxony.

Wappaeus contests the conclusions of Ploss even more vigorously, and adduces the statistics of Sweden in the 20–year period 1770 to 1790, in which period this kingdom repeatedly suffered from famine in consequence of failure of the crops, so that the births and deaths were largely affected. It appeared, however, that the more abundant or more scanty nutrition of the inhabitants of Sweden during this period had no marked influence upon the sexual ratio.

If scanty nutrition of the mother had, in fact, any influence upon the determination of the sex of the embryo in the direction alleged by Ploss, viz., so as to bring about the birth of a greater excess of boys, this influence should be manifested with exceptional clearness in the case of twins, for it is obvious that the nutriment that is insufficient for one embryo would be still scantier for two. Hence various statistical investigations have been undertaken to determine the sexual ratio in the case of twin births. Ploss found that in Saxony, in the case of 23,420 twin births, the sexual ratio was 106.7 boys to 100 girls; Moser gives the sexual ratio in the case of twin births as 106; Meckel von Hemsbach gives it as 105.4; Hecker, 116 and 122; Sickel, 112.3. Düsing combined the figures relating to twin births in various lying-in hospitals, published by Hecker, Sickel, Baillarger, Siebold, Elsässer, and Levy, respectively, and thus obtained a sexual ratio of 121.5 boys to 100 girls. This excess of boys is notably greater than among births in general.

But other statistical data are available which show a reversed condition, viz., that in the case of twin births the sexual ratio is lower than usual. According to von Frick’s collection of twin births in Prussia, the sexual ratio was 104.7 boys to 100 girls; whereas in the case of single births in the same country the sexual ratio was 106.35 to 100. Riecke, in Württemberg, in the case of 60 twin births found 58 boys and 62 girls. In the case of twin births observed by Braun, Chiari, and Späth, 94 in all, the children were in 64 of these of identical sexes, namely, in 30 instances boys, and in 34 instances girls. According to Breslau, in the case of twin births in the Canton Zurich, the sexual ratio was 104.1 to 100; whereas in the case of single births the sexual ratio was 106.2 to 100.

As regards triplets the reports of the sexual ratio vary from 111.76 : 100 (Meckel von Hemsbach) to 104.55 : 100 (Neefe).

It is obvious that the statistical data at present available regarding the sexual ratio in the case of multiple births are far too variable for it to be possible to base upon them any valid conclusions as to the influence of the nutritive condition of the mother upon the determination of the sex of the offspring. And taken as a whole the statistical data hitherto available do not enable us to infer with confidence that nutritive conditions, and more especially the nutritive state of the maternal organism, exercise any effect upon the determination of the sex of the offspring.

Another attempt at the utilization of statistics has been to ascertain whether the time of fertilization in relation to menstruation, (in the first days after the flow, or later in the intermenstrual interval) has any influence upon the determination of sex. The starting point in this investigation was the earlier view that sex depends upon the state of the ovum, and the belief that a very favourable state of ovum and sperm favours the production of the female sex. The ovum, after its discharge from the ovary, like the spermatozoon after its discharge from the testicle, tends sooner or later toward death, and the only thing that can save either from this ultimate fate, is for the two to unite to form a new organism. Precisely what moment in the history of the detached ovum is the most favourable, is a matter regarding which we have no exact information, but it is probable that at the moment of its discharge from the ruptured follicle, it is at the zenith of its vital powers. On this theory the determination of sex depends upon the period at which, after its liberation from the follicle, the ovum encounters a spermatozoon; the ovum which is fertilized early in its career becomes a female embryo; the ovum, on the other hand, which is not fertilized until it has become comparatively old, becomes a male embryo. But, as Hensen points out, a spermatozoon, according to its condition, may either fail sufficiently to fortify an ovum which itself is in good condition; or, on the other hand, a powerful spermatozoon may fortify an ovum of deficient vitality. But it is difficult to say precisely on what considerations the greater or less vitality of the spermatozoon depends—or, to speak more in accordance with the terms of the theory, we do not know exactly what makes it a good spermatozoon or the reverse. It may be “bad,” either because it has remained too long in the testicle or because it has been discharged too quickly, is too recently secreted; moreover, a long sojourn of the spermatozoon in the uterus will doubtless suffice to lower its vitality.

The Jews, more especially, whose religious ordinances forbid them to have sexual intercourse either during or shortly after menstruation, and among whom there is a great excess of male births, have been adduced as a proof of the thesis that sexual intercourse during the later part of the intermenstrual interval tends to favour the procreation of boys. In Leviticus xv. 19, we read: “And if a woman have an issue, and her issue in her flesh be blood, she shall be put apart seven days.” From the commentary in the Talmud it appears that these seven days are to be reckoned from the commencement of the flow. Statistical reports from various countries show that among the Jews there is a greater excess of male births than among the other inhabitants of the respective countries. The overplus of male births exhibited by the Jews varies from 1 to 15%, the difference probably depending on the fact that the number of instances under consideration is too small for uniform results to be possible. In Prussia, during the period 1820 to 1834, the sexual ratio among the Jewish births was 111 : 100; during the period 1849 to 1852 it was 106 : 100; in Hungary during the period 1835 to 1855 it was 117.1 : 100; in Sweden, 1851 to 1855, it was 108 : 100. Among illegitimate children of the Jewish community the sexual ratio was, in Austria, 123.9, in Prussia, 118.6.

Fürst, examining the cases in von Braun’s clinic, and making a statistical collection of the days of conception and of delivery, has endeavoured to prove that “there is an excess of boys when conception occurs during the period of post-menstrual anæmia.” His figures show, in fact, a very notable excess of boys in cases in which conception has occurred during the five days immediately following the cessation the menstrual flow; and an excess of girls when conception has occurred during the later part of the intermenstrual interval. Thus, in the former case the excess of boys is represented by the figures 37 : 12; in the latter case the excess of girls is represented by the figures 79 (girls) : 65 (boys). These figures are explained by Fürst on the theory that in the human species conception during the period of post-menstrual anæmia probably leads to an enormous excess of male conceptions (owing to the fact that the unfertilized ovum is badly nourished during the days just before conception); whereas in the later part of the intermenstrual interval the better nourishment of the ovum probably leads to the procreation of an excess of girls—hypotheses which are based on a quite inadequate number of instances. Fürst gives the following table:

═════════════════╤═════════════════╤═════════════════╤═════════════════ NUMBER OF DAYS │ Number of boys │ Number of girls │ Boys and girls BETWEEN REPUTED │ born. │ born. │ together. END OF │ │ │ MENSTRUATION AND │ │ │ REPUTED │ │ │ OCCURRENCE OF │ │ │ CONCEPTION. │ │ │ ─────────────────┼─────────────────┼─────────────────┼───────────────── 1│ 7│ 1│ 8 2│ 6│ 3│ 9 3│ 9│ 5│ 14 4│ 15│ 3│ 18 5│ 3│ 6│ 9 6│ 5│ 6│ 11 7│ 6│ 5│ 11 8│ 2│ 8│ 10 9│ 4│ 5│ 9 10│ 6│ 4│ 10 11│ 6│ 5│ 11 12│ 3│ 6│ 9 13│ 4│ 5│ 9 14│ 6│ 5│ 13 15│ 1│ 2│ 3 16│ 2│ 5│ 7 17│ 2│ 3│ 5 18│ 3│ │ 3 19│ 1│ 3│ 4 20│ 1│ 2│ 2 21│ 1│ 1│ 2 22│ 4│ 1│ 5 23│ │ 1│ 1 24│ 1│ │ 1 25│ │ 2│ 2 26│ 2│ │ 2 27│ │ 1│ 1 28│ 1│ 1│ 2 31│ 1│ │ 1 ─────────────────┼─────────────────┼─────────────────┼───────────────── │ 102│ 91│ 193 ═════════════════╧═════════════════╧═════════════════╧═════════════════

Baust gives a report, based, he says, upon “thoroughly trustworthy data,” furnished by personal friends, regarding 14 cases, which show, in his opinion, that every conception occurring in a week after the cessation of the menstrual flow leads to the birth of a girl; but that when conception occurs on the fifth or sixth day after menstruation the result varies as regard sex. Swift, from a report of 20 cases, draws the conclusion that in the intermenstrual interval, boys, in the latter part of the interval girls are conceived.

The influence of the strength of menstruation upon the determination of sex has also been studied by the statistical method, starting with the idea that menstruation, in proportion to its strength, affords on the average a measure for the subsequent nutrition of the embryo, and this nutrition is further supposed to determine the sex. Düsing therefore arranged the births occurring in the lying-in hospitals of Dresden, Leipzig and Jena, according to the information given regarding menstruation in the clinical history of each case; it appeared that when menstruation was comparatively scanty, there was a greater excess of boys than when menstruation was comparatively abundant. The actual figures were the following:

═══════════════╤═══════════════════════════╤═══════════════════════════ │ Abundant menstruation. │ Scanty menstruation. ───────────────┼─────────────┬─────────────┼─────────────┬───────────── Dresden │ 902│ 847│ 495│ 431 Jena │ 66│ 69│ 56│ 45 Leipzig │ 21│ 22│ 239│ 211 ───────────────┼─────────────┼─────────────┼─────────────┼───────────── Totals │ 989│ 938│ 790│ 687 Sexual ratio │ 105.4 │ 114.7 ═══════════════╧═══════════════════════════╧═══════════════════════════

Here also we may append the figures obtained by Düsing regarding the births of foals at the Prussian stud-farms, which he regards as supporting his view that by natural selection all animals have acquired the faculty, whenever stronger demands are made upon their sexual capacity, of procreating a larger number of individuals of their own sex. In the tables we learn how many mares on an average a stallion had covered in each year, that is, we learn how great were the demands made upon the sexual capacity of the stallion in that particular breeding stable in that year. The figures relating to the years 1859 to 1892 were tabulated and averages were drawn with the following results:

═════════════════╤═══════════════════════════════════╤═════════════════ NUMBER OF MARES │ NUMBER OF FOALS BORN. │ Sexual ratio. SERVED. │ │ ─────────────────┼─────────────────┬─────────────────┼───────────────── „ │ Colts. │ Fillies. │ „ ─────────────────┼─────────────────┼─────────────────┼───────────────── 60–70 │ 42,445│ 41,933│ 101.22 55–59 │ 56,511│ 66,226│ 100.49 50–54 │ 59,940│ 61,096│ 98.18 45–49 │ 57,077│ 59,216│ 96.39 40–44 │ 59,967│ 62,007│ 96.71 35–39 │ 38,348│ 40,181│ 95.44 20–34 │ 26,354│ 27,069│ 97.35 ═════════════════╧═════════════════╧═════════════════╧═════════════════

From these figures, which relate a very large number of instances indeed, we learn that when greater demands are made upon the stallion, more males are procreated. In fact, except for two slight divergencies, the rise in the sexual ratio proceeds strictly pari passu with the increase in the number of mares covered.

I must, however, draw attention to the fact that this assumption when applied to the human species, that the man on whom whose sexual capacity especially extensive demands are made, procreates an especially large number of male children, is not confirmed by the sexual ratio among the offspring of polygamous marriages in which unquestionably greater demands are made upon the husband’s sexual powers than is the case in monogamic unions.

The reports of travellers of earlier days, to the effect that in Oriental countries more girls are born than boys, have recently been confirmed by several observers. Campbell states that in the harems of Siam the number of boys and girls born is equal. Clarke states that among the Mohammedan Indians more girls are born than boys. According to McLennan Indian experience teaches us that where polyandry prevails male offspring predominate in numbers; but where polygamy prevails there is, on the contrary, an excess of female infants. The following data collected by Goehlert from historical reports and from genealogical writings, regarding the progeny of notable persons living in polygamous unions, show certainly a large excess of female offspring over male:

═════════════════╤═══════════════════════════════════╤═════════════════ │ CHILDREN. │ Sexual ratio. ─────────────────┼─────────────────┬─────────────────┼───────────────── „ │ Male. │ Female. │ „ ─────────────────┼─────────────────┼─────────────────┼───────────────── Morocco: Muley │ 24│ 124│ 19.4 Scherif │ │ │ Palestine: │ │ │ Rehoboam, King │ 28│ 60│ 46.6 of the Jews │ │ │ Arabia: Imon of │ 14│ 74│ 18.9 Sana │ │ │ Turkey: nine │ 110│ 128│ 85.9 sultans │ │ │ ═════════════════╧═════════════════╧═════════════════╧═════════════════

According to Tousenel, love marriages give rise to more daughters than sons, whereas among the offspring of conventional or compulsory marriages, male children predominate. Further, among the offspring of legitimate unions, the excess of males is greater than among the offspring of illegitimate unions. A physician, V. J. Cook, maintains that boys are procreated in the evenings (before midnight), but girls during the early morning hours—at which latter time women are less “impressionable” than during the evening hours.

Düsing, starting from the common belief that all animals have the faculty, when there is a lack of individuals of one sex, of procreating an excess of offspring of the sex which is deficient and thus of restoring the balance between the sexes, maintains that numerous factors, through the co-operation of which the sexual ratio is regulated, act in temporal succession. He shows that the individuality of the mother has an influence upon the sex. But this finds expression through the qualitative constitution of the ovum; hence already before fertilization there must exist a tendency toward the development of one sex or the other—for example, younger ova tend to become females; older ova, on the contrary, to become males. It has further been shown that the individuality of the father, that is to say, the qualitative constitution of the sperm, has an influence in the determination of sex. Thus, by means of the influence of the sperm, the already-mentioned pre-existing tendency of the ovum can in some instances be counteracted and overpowered. The influences in the personality of the father and of the mother, which during fertilization find expression in the qualitative constitution of the sperm and of the ovum, respectively, can thus bring about a resultant tendency, acting in one direction or the other with varying force. Thus, after fertilization, we have this resultant tendency toward the formation of a male or female embryo.

But, Düsing continues, at this time the sex is not definitely determined. The influence of the nutritive condition in which the fertilized ovum finds itself has yet to make itself felt. This influence on the determination of sex through the maternal nutrition, continues (in the human embryo) for as long as three months, but even when the reproductive organs of the embryo have definitely begun to diverge in the direction of the masculine or the feminine type, as the case may be, some nutritive influence, if it is sufficiently powerful, may yet turn the balance in the other direction, so that a partial or complete hermaphrodite results, a being uniting the characteristics of both sexes.

Actual inheritance of sex, of which people used to speak, cannot, in Düsing’s opinion, possibly occur. The mode in which one sex or the other develops is indeed inherited; but the decision which sex shall develop does not depend upon inheritance, but is determined by the co-operation of several outward influences. The qualities by which this is effected are acquired by adaptation to general or special vital conditions.

Wilckens (“A study of the Sexual Ratio and of the Causes of the Determination of Sex in Domestic Animals”) opposes the views of Düsing, on account of the results of his own investigations, relating to the births of 30,000 domestic animals. He formed the following conclusions:

1. Locality (soil and climate) has an influence upon the sexual ratio and upon the determination of sex in domestic animals, but this influence is probably indirect only, being exerted through the intermediation of the nutrition of the embryo in utero.

2. The season in which the domestic animal is conceived affects the sex; the hot season favours the production of males, the cold season that of females; in the hot season, in general, the appetite and nutrition of domestic animals diminish, whereas in the cold season these increase.

3. Regarding the male progenitor, neither his age, nor his sexual energy, nor the demand made upon that energy, nor the age of the semen, has any influence upon the sexual ratio or the determination of the sex of the offspring.

4. The age of the female progenitor influences the sexual ratio and the determination of the sex of the offspring in this way, that in general, primiparæ and young mothers conceive a larger number of female offspring. This influence of age may be referred to the fact that in general young mothers nourish their offspring in utero better than older mothers.

5. The nutrition of the fruit in utero influences the determination of sex, speaking generally, in the following way, that better nutrition favours the determination of the female sex, worse nutrition favours the determination of the male sex.

6. In addition to the influence of nutrition of the fruit upon the determination of sex, other influences, whose nature still remains obscure, must also co-operate, because one and the same progenitor in similar nutritive conditions does not always procreate offspring of the same sex.

7. Owing to the operation of these unknown influences, prediction of the sex of the offspring, and voluntary determination of the sex of the offspring, remain impossible. All we can say is that there is some probability that young and well-nourished mothers will procreate a comparatively larger number of female offspring, whilst elderly and ill-nourished mothers will procreate a comparatively larger number of male offspring.

II. Anatomical Investigations.

Of anatomical investigations and discoveries, those more especially relating to the sex-relationships of twins and triplets have been applied to the elucidation of the problem of the determination of sex.

The first and most important fact in this connection, one that is not merely a rule confirmed again and again by anatomists and gynecologists, but is further, as Mayrhofer has demonstrated as a result of his researches in von Braun’s clinic, a “natural law,” is this, that twins and triplets enclosed in a common chorion are invariably of the same sex. The sex-identity of such twins has been referred to the similarity of their nutritive conditions (Leuckart, Ploss), and more especially to the communication between their bloodvessels; and an intimate connection between these relationships and the determination of sex has been believed to exist.

Mayrhofer, however, opposes this assumption by the following deductions (“The Determination of Sex in the Human Species”); “Fœtuses enclosed within a single chorion always possess a common placenta, in which the blood-channels from both umbilical cords frequently, in the case of twins perhaps invariably, communicate. It might therefore be supposed that the sex-identity of embryos enclosed within a single chorion is due to the intermixture of their blood in the placenta. Hyrtl, however, describes a triplet’s placenta, in which, though all three fœtuses were enclosed within a single chorion, the vessels passing to the umbilical cord of one of the fœtuses were entirely distinct from the vascular area common to the two other fœtuses; it is therefore probable that in the case also of twins enclosed within a single chorion there is not necessarily any communication between their bloodvessels in the common placenta. But even if it were proved that in the case of twins enclosed within a single chorion their bloodvessels always do communicate in the common placenta, we could not therefore infer that the intermixture of the blood of the two fœtuses is the cause of their sexual identity.

“For the intermixture of the blood of the two fœtuses in the common placenta could never lead to a complete identity in the composition of the blood of the two; it could only lead to a diminution of the differences which would exist between the bloods if their placental circulations were entirely distinct, and the similarity in the bloods thus established could not be expected to do more than make it a general rule that such twins or triplets should be of the same sex; but to this rule exceptions might be expected to occur in certain cases, as when hæmatopoiesis in the two (or three) fœtuses was very different, or when the circulation through the intercommunicating bloodvessels was interfered with through the pressure of fibrinous deposits—differences between the bloods would then arise sufficient to cause differences in sex (if identical composition of the bloods is presumed to be the cause of the sexual identity).

“Experience teaches us that the existence of communicating vessels in the placenta does not suffice to induce a close similarity of growth and of the formation of the organs in twin fœtuses; nor does it prevent the illness and death of one fœtus leaving the health of the other undisturbed, although the communicating channels remain open; so that, if we except acardiac monsters, it is correct to say that each fœtus pursues a secluded life, uninfluenced by the life of its neighbour. Acardiac monsters, on the other hand, always receive blood which has already served for the nutrition of the normal fœtus, and the result of this is an arrested development and a striking preponderance of connective tissue in the acardiac twin. But notwithstanding the fact that the failure of its own proper circulation (which is indeed rendered possible by the existence of the communicating vessels in the placenta) leads to its defective nutrition with a blood inferior to that supplied to the normal fœtus, the acardiac monster is always of the same sex as the normal twin.”

From these considerations Mayrhofer rightly infers that the identity of sex of two fœtuses contained in a single chorion, since it does not depend upon the existence of communicating vessels in the placenta, must arise from a developmental tendency already existing in the two germs at the time of conception—or, in other words, that at the time of conception their sex is already inalterably determined.

This conclusion with respect to the sex of twins contained in a single chorion may very readily be extended to the inference that in the case of all human fœtuses the sex is already determined at the time of conception.

Another anatomical fact is that many twins are contained in a single chorion for this reason, that they originate from two germinal vesicles within a single ovum. It is an open question whether it is not possible for two embryos contained in separate chorions to come to lie in a single chorion through atrophy of the intermediate wall. If this is indeed possible, the invariable identity of sex in the case of fœtuses lying in a single chorion must lead us to agree with Mayrhofer in inferring that two ova lying within a single follicle, simultaneously fertilized, give rise to embryos of identical sex.

B. S. Schultze and Ahlfeld, as a result of the investigations regarding twins, also came to the conclusion that the sexual identity of twins depends upon their derivation from a single ovum. If, in accordance with what has been said above, an explanation of the sexual identity of certain twins is to be found in the fact that for such twins there has been a single conception only, and hence the influence, whatever it may be, by which sex is determined acts on both germs at the same time—still the sexual identity of twins in general is remarkable and has not yet been fully explained. The sexual identity in fact occurs much more frequently than appears to correspond to the percentage of twins derived from a single ovum. Von Fricks examined the data relating to multiple births in Prussia during the period of 1826 to 1879 and compiled the following table:

══════════════╤═════════════╤═════════════╤═════════════╤═════════════ Per Cent. │ Twins. │ Triplets. │Quadruplets. │Quintuplets. ──────────────┼─────────────┼─────────────┼─────────────┼───────────── Boys only │ 32.6│ 24.5│ 14.3│ 33.3 Girls only │ 30.3│ 22.5│ 19.4│ Boys and girls│ 37.1│ 53.0│ 66.3│ 66.7 ──────────────┼─────────────┼─────────────┼─────────────┼───────────── │ 2 B. 1 G. │ 28.5│ │ │ 1 B. 2 G. │ 24.5│ │ ──────────────┼─────────────┼─────────────┼─────────────┼───────────── │ │ 2 B. 2 G. │ 23.4│ │ │ 3 B. 1 G. │ 19.5│ │ │ 1 B. 3 G. │ 23.4│ ──────────────┼─────────────┼─────────────┼─────────────┼───────────── │ │ │ 4 B. 1 G. │ 33.3 │ │ │ 3 B. 2 G. │ 33.3 ══════════════╧═════════════╧═════════════╧═════════════╧═════════════

According to Ahlfeld, of twin births in general, the ratio of those with a common chorion to those with separate chorions is 1 : 8.15. If, however, we wished to explain the frequency with which twins are of identical sex from the occurrence of such twins derived from a single ovum, we should expect to find a very different ratio, namely, 1 : 3.84; that is to say, twins with a common chorion would have to be nearly three times as common as they actually are. From these facts Düsing endeavours to draw the conclusion that external conditions have an influence upon the determination of sex, for very many external conditions are identical in the case of twins; as, for instance, the age of the father, the age of the mother, the nutritive conditions of the ova and of the spermatozoa, the nutrition of the embryo, etc.—all of these would influence both the twins in the same direction. A difference in the sex of twins, on the other hand, might be due to two successive fertilizations.

B. S. Schultze has been led by his embryological studies to the conclusion that there are male and female ova. Thus he believes that sexually identical twins originate from a single ovum with two germinal vesicles, thus assuming that a double fertilization of such ova is possible. But since in such cases the sexes of the resulting twins are always identical the spermatozoon can have no influence upon the determination of sex, but the conditions leading to the development of one sex or the other must pre-exist in the ovum—i. e., there must be male and female ova.

That as a matter of actual fact in some cases the female progenitor exercises an overwhelming influence on the determination of sex, and that the opinion held by so many that this determination depends upon the mother alone is sometimes supported by facts, is shown by the incident recorded by Darwin (“Descent of Man,” Vol. I.), that an Arab mare was delivered seven times successively of a filly, never of a colt, although she was covered by seven different stallions. On the other hand, the circumstance, if it is not to be attributed to pure chance, can also be explained by the constitutional vigour of this mare (Hensen) without adopting the above hypothesis.

Recently Upjohn has maintained that there are two kinds of spermatozoa, male and female; the latter are the commonest, but the former are the more energetic.

An interesting anatomical fact bearing upon this question has been discovered by M. Nussbaum, namely, that in ascaris megalocephala the reproductive glands are indicated already before the separation of the germinal layers; and Nussbaum suggests that this is also the case in all animals, although the proof cannot be obtained in every instance.

Semper has shown also in the case of some of the plagiostomata that long before the beginning of the definitive development of the reproductive organs, the apparently hermaphrodite embryo already possesses at least the tendency toward the constitution of one sex or the other. For in these animals, at a time so early that as yet the reproductive glands exhibit no sexual differentiation whatever, the sexes can nevertheless be distinguished by what appears to be a secondary sexual character. In the female, namely, one ovary only is developed; and very early indeed in the embryos destined to become females we can observe an asymmetrical development of the two germinal furrows. By this characteristic the two sexes can be distinguished far earlier than it is possible to do so by the recognition of a histological differentiation of the reproductive glands.

According to Mayrhofer the prepotency of the male gives rise to the procreation of an excess of males in this way, that physical prosperity of the male probably leads to the generation of boys, whereas prosperity of the female tends to give rise to the generation of girls. Moreover, economizing of the semen by infrequent sexual intercourse tends to originate offspring of the male sex. In this connection Hensen remarks, apropos of the greater excess of male offspring among the Jews: “We might ask whether, in consequence of the comparative sexual continence of the Jews which demands a definite power of endurance on the part of the ova, there may not be effected a certain selection of the ova; and thus we may perhaps explain how it is that in this race an exceptional vigour is somewhat more often to be observed than in other races.” Bock assumes that “thinner semen,” such as results from more frequent sexual intercourse, favours the procreation of the female sex, whereas when intercourse is less frequent a larger number of boys is likely to be born. Janke indicates as two important fundamental principles of scientific physiology that, (1) sexual intercourse represents as it were a contest between the two parties to the sexual act as to which shall transmit his or her sexual influence to the child, the victor in the contest determining the sex of the offspring, and (2) that a crossed inheritance occurs, inasmuch as whichever progenitor proves stronger in this contest transmits to the child the sex other than his or her own. He therefore advises women who long to have a boy to drink a glass of champagne before fulfilling their conjugal duties in order to gain increased sexual vigour.

Fiquet also expresses the opinion that when a vigorous, passionate, and sanguine male progenitor has intercourse with a frigid and phlegmatic woman there will be a preponderant tendency for the offspring to be female; whereas, when the conditions are the opposite of these, the male progenitor being phlegmatic and cold, the female on the contrary sanguine, passionate, and ardent, the offspring will probably be of the male sex.

In opposition to these opinions of Fiquet and Janke, to the effect that the temperament and the sexual vigour of the progenitors have a determining influence in the origination of the sex of the offspring, Düsing insists that the quality of the reproductive products are alone influential. Düsing lays down the following proposition: “The greater the scarcity of individuals of one sex is, the more extensive consequently the demands made upon the sexual capacities of the individuals of that sex, the more rapidly their reproductive products are employed; and the younger these products therefore are when employed the more individuals of their own sex will appear among the offspring.”

Richarz believes, on the contrary, that the prepotency of the male gives rise to the procreation of more girls; a mother of high reproductive capacity will have more boys, one of less reproductive capacity, on the other hand, more girls.

Starkweather (“The Law of Sex,” London, 1883) states his view in the proposition: “The superior parent produces the opposite sex;” and he holds the quaint view that this superiority is displayed in certain anatomical characters of the face of the progenitor. He endeavours from the shape of the head and from the facial expression to deduce the superiority of the male and the female progenitor respectively. A high, square forehead, with prominent supra-ciliary ridges, constitutes, according to Starkweather, one of the principal symptoms of this superiority; important also are a strongly developed middle third to the nose, narrow lips, etc. He declares that in families known to him the possession of this Roman nose in the father is signalized by the possession also of a large number of daughters, while a Roman-nosed mother has many sons. The more the parents’ noses resemble each other the more equal will be the distribution of the sexes among the offspring. He connects this fact (!) also with the fact that the possessor of the aquiline nose is the ruler of the family. Men of great strength of character procreate chiefly daughters; women, on the other hand, with a powerful character and a firm will bring into the world a notable excess of boys. In the Southern States of the American union Starkweather found confirmation of his theory, since he observed there that among the offspring of white fathers and coloured mothers there was an excess of girls amounting to 12 to 15 per cent. Among the half-castes of Java, the so-called Lipplapps, in the third generation girls only are born, and these are sterile. The excess of girls in these cases depends upon the superiority of the white father; this superiority is transmitted to the few sons of the second generation, and these therefore procreate girls only to constitute the third generation; the latter are not powerful enough to bear children at all.

Roth has revived the old view that one ovary provides the germs for the male offspring, the other those for the female offspring. He believes further that in the process of cohabitation the mechanical impressions and stimuli received by one-half of the external genital organs, reinforced by contact with and pulling on the pubic hair, are transmitted through the pudic nerve and the hypogastric plexus to the corresponding half of the vagina and the uterus, to the Fallopian tube of that side and to the corresponding ovary. If, now, we can consider it as established (?), that in the human female one ovary discharges male ova only and the other female ova only, it seems to him that it is the corresponding half of the external genital organs, when specifically stimulated in sexual intercourse, and the consequently increased vital activity in the pudic nerve and its connections with the hypogastric plexus, that must be regarded as the organ by means of which sex is determined. Roth has also been informed by laymen that when for some time they have procreated daughters only they subsequently procreated sons, “when, having been accustomed to sleep on one side of their wife, they adopted the practice of sleeping on the other.”

Ricardi reports that in Modena the peasants say that a man whose wife has hitherto had daughters only, must, if he wishes to have a son, assume some other posture than usual in the performance of coitus.

III. Experimental Investigations.

A considerable number of years ago, Thury attacked the problem of the determination of sex by the experimental method. In his series of experiments he ascertained, using 29 cows, that in the case of 22 of these, which were served early in their heat, the calves were without exception heifers, while in the case of the remaining 7, which were served late in their heat, the calves were equally without exception bull-calves (Thury, “The Law of the Determination of the Sexes,” Leipzig, 1863); in the record of these experiments no mention is made of the age of the cows. Thury concluded that the sex was determined according to the fertilization of the ovum soon or late after its liberation from the ovary; namely, that an ovum fertilized soon after its discharge produced a female, whilst an ovum which had become comparatively old before it was fertilized became a male.

Thury’s sensational experiments gave rise to a succession of similar experiments, made mostly by cattle-breeders, above all in agricultural colleges and in stud-farms.

Some of these experiments were made in the agricultural colleges at Proskau and Eldera. The cows, which according to Thury’s views should have been delivered of heifers, were served as soon as their heat was observed (the heat lasted as a rule from 24 to 30 hours); these were delivered of 5 heifers and 5 bull-calves (in Proskau) and of 3 heifers and 5 bull-calves (in Eldera); the sexual ratio in these cases was therefore normal. On the other hand, cows which were not served until their heat had lasted for 20 hours were delivered (in Proskau) of 1 heifer and 4 bull-calves.

Further experiments (in Waldau) gave the result that cows served early were delivered of 1 heifer and 1 bull-calf. In another series (in Eldera) 9 cows served as soon as heat was observed (or, speaking strictly, in from ½ to 1½ hours of this), gave birth to 7 heifers and 2 bull-calves.

Experiments made at the Royal Friedrich Wilhelm Stud-Farm gave the following results: In the case of 20 mares, which if Thury’s theory had been correct should all have given birth to fillies, 11 only fulfilled this expectation; but 10, on the other hand, were colts. Touchon, in his experiments at Hohenhau, obtained 11 calves and 2 foals, exhibiting the sex expected in accordance with Thury’s theory.

Düsing made a compilation of the figures given in all the experiments made to test Thury’s theory, with the following results: Cows fertilized early were delivered of 13 bull-calves and 29 heifers; mares fertilized early were delivered of 10 colts and 13 fillies; cows fertilized late were delivered of 5 bull-calves and 2 heifers.

Gerbe made experiments on rabbits, putting the buck to some doe-rabbits soon after the beginning of their heat, but to others as late as possible in their heat. On examining the young in the horns of the uterus, from the ovary downward, the distribution of the sexes was found to be approximately equal.

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