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.”
Fig. 56.—Ovum of Asterakanthion ten minutes after fertilization.
Fig. 57.—Fusion of male pro-nucleus and female pro-nucleus to form the segmentation nucleus of the fertilized ovum.
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.
Fig. 58. —Passage of spermatozoon through the zona pellucida of the ovum of asterakanthion.
Fig. 59.—Ovum of scorpæna scrofa thirty-five minutes after fertilization.
Fig. 60.—Male pro-nucleus and female pro-nucleus in fertilized ovum of frog, prior to the formation of the segmentation nucleus.
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.
Fig. 61.—a. b. c. Prostatic calculi from normal semen. d. Spermatozoa. e. Large and small cells, some containing granules, as morphological elements of semen. f. Spermatozoon distorted by imbibition of water. g. Crystals. (After Bizzozero.)
Fig. 62.—Normal semen.
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.
Fig. 63—Semen consisting chiefly of sperm-crystals, cylindrical epithelium and small granules exhibiting molecular movement—but containing no spermatozoa.
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.
Fig. 64.—Oligozoöspermia. a. Living spermatozoa, b. Dead spermatozoa, c. Pus corpuscles, d. Erythrocyte, e. Seminal granules.
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.