Part 58

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.