As indications for facultative sterility Levy enumerates tubercular disease of the lungs, mental disorders, severe organic or functional diseases of the central nervous system, active syphilis (in certain circumstances), pernicious anæmia, hæmophilia, diabetes mellitus, severe heart disease, chronic disease of the kidneys or liver, certain pelvic deformities, and the tendency to habitual abortion.
I have myself before now stated my opinion that it is the duty of the physician, in the case of a married woman suffering from heart disease, with due regard to the danger which pregnancy will entail upon her, to give needful advice in the matter of the prevention of conception. In women affected with valvular heart disease, and in whom there are serious disturbances of compensation, conception is absolutely to be avoided; also in conditions of marked cardiac degeneration, and when there are distinct symptoms of insufficiency of the heart muscle. When, on slight exertion, palpitation, increased frequency of the pulse, and respiratory need (“air-hunger”), ensue; when there is extensive œdema of the lower extremities which persists even after confinement to bed; when the pulse readily becomes arhythmical both in respect of the strength and the temporal succession of the beats; when the urine is scanty and contains varying quantities of albumen; when there are frequent attacks of heart-weakness, with a small irregular pulse, coldness of the extremities, a cyanotic tint of complexion, nausea, dyspnœa, sense of faintness, or actual syncope—in all such cases, whether dependent upon valvular disease, on pathological changes in the arteries, or upon disease of the myocardium, the occurrence of pregnancy is a true disaster, giving rise in most cases to a grave aggravation of the heart trouble and often enough costing the patient her life. I further regard it as a sound medical axiom that in cases of cardiac disorder of a less severe type than that just described the woman thus affected should not have more than one or two children. This is the more necessary because with each successive pregnancy the functional capacity of the diseased heart decreases in geometrical progression and the danger to life proportionately increases. But in such cases of heart disease the prevention of pregnancy must never be effected by the interruption of coitus by the man before ejaculation, for the reason that this procedure gives rise to manifold reflex cardiac troubles, and especially to paroxysms of tachycardia, with simultaneous diminution in vascular tone, vasomotor disturbances, and states of mental depression—and these entail exceptional dangers in women suffering from heart disease.
The Determination of Sex.
The problem of the determination of sex in the human species is one which has occupied natural philosophers from the very earliest times, and has always greatly interested all classes of the population.
The interest awakened by the subject depends principally on the fact that female children have usually been less desired than male in all periods of history and among almost all races. In the uppermost circles of society the truth of this statement is manifested by the fact that the birth of a prince is announced by a salute of 101 guns, that of a princess by a salute of 35 guns only.
It would serve no useful purpose to transcribe here the opinions, or rather guesses, which were ventured on this topic in earlier days when the very nature of the reproductive process was still entirely unknown, and we shall merely mention that the curious will find various references to the determination of sex in the works of Hippocrates, Aristotle, Plutarch, Soranus, Susruta and Galen.
Broadly speaking, the earlier theories may be said to diverge in two main directions, some holding that the sex of the infant was in some way determined by the mode of intermixture of the male and the female elements in the act of generation, and others maintaining that sex was already inalterably predetermined at the time of intercourse either in the male or in the female sexual elements.
Pari passu with the modern development of the theory of evolution, and with the enormous increase in recent days in anatomical and physiological knowledge, the theory of the determination of sex has been very widely extended. The rival views may be briefly arranged in the four following categories:
I. That sex is already inalterably predetermined in the ovum, upon the constitution of which it solely depends; there are therefore male and female ova, and the process of fertilization exercises no influence whatever upon the determination of sex. The alternative theory to the above, that sex is determined solely by the constitution of the fertilizing spermatozoon—i. e., that the spermatozoa, and not the ova, are male and female, respectively—is one which in recent years has tended more and more to disappear from the field.
II. That sex is determined in the moment of fertilization by the reciprocal interaction of male and female, of zoösperm and ovum. One variant of this theory maintains that each reproductive element strives for the reproduction of its own sex; that a struggle takes place and that the victor in the contest stamps its own sex-likeness upon the fertilized product. According to another view, however, sex is not directly transmitted in this manner; it is supposed that the more powerful the proper reproductive element (according to this theory the ovum) the more strongly does it tend to determine the reproduction of a stronger, i. e., a male organism; thus the greater potency of the female element in the act of reproduction tends to favour the determination of the male sex.