Part 42

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.

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.