Notwithstanding these facts, it must not be forgotten that many cases are recorded in medical literature of women conceiving after intercourse effected against their wishes, as by rape, or when they were in a state of intoxication, or asleep, or in the entire absence of all voluptuous sensation. Moreover, the erection of the vaginal portion of the cervix, and the reflex movements and secretory changes in the uterus, may also occur independently of sexual desire and voluptuous sensation; but such cases are certainly exceptional, and their credibility is frequently open to suspicion. In numerous instances in which conception is stated to have followed intercourse in a state of unconsciousness, judicial proceedings have elicited the fact that the intercourse was not entirely involuntary on the woman’s part, and that the alleged force was no more than a vis grata. Von Maschka reports a case in which a girl asserted that she had been violated whilst in a condition of epileptic unconsciousness, but she remembered every detail of the act with precision. Casper, again, in a case in which it was asserted that defloration had been forcibly effected whilst the girl was in a state of alcoholic coma, showed that there had been no more than moderate intoxication combined with great sexual excitement. Assertions that pregnancy has resulted from intercourse effected during sleep, in a state of unconsciousness, or in the “magnetic” or “hypnotic” state, should always be accepted with reserve.
It is interesting to note in this connexion that the Chinese physicians enumerates among the causes of sterility the practice of “congfou” by the man, this name being given to a manipulation analogous to hypnotism, whereby the voluptuous sensation during intercourse is diminished or abolished by distracting the attention elsewhere.
A proof of the importance of specific sexual sensation for the attainment of conception is afforded by the fact that in the majority of women voluptuous excitement is absent at the first act of intercourse, and only gradually develops thereafter; in correspondence with this, we find that the first conception does not usually occur until some time after marriage, and that the period of its occurrence frequently coincides with the full development of voluptuous sensation during intercourse. Thus, even in the woman fully fitted for conception, the actual capacity for impregnation is only developed gradually, and after a sufficient experience of intercourse.
This transient incapacity for conception may, indeed, also depend upon the fact that at first coitus is apt to be incompletely effected, and for this both husband and wife are to blame; but unquestionably in many cases the reason is the one first mentioned.
In some cases, certain psychical influences which affect the intensity of the voluptuous sensation, manifest its significance. Thus, in some instances, the influence of stimulation of the clitoris in leading to conception has been clearly shown; in others, the performance of coitus in some unusual position, varying with the woman concerned, is alone competent to arouse sexual sensibility to its full extent, and to bring about the orgasm. One occasionally receives confidential information from a husband that his wife experiences a voluptuous sensation only when coitus is performed in the lateral posture, or more bestiarum, or in the situs inversus, etc., etc.
Excessive frequency of intercourse, prolonged and repeated sexual excitement, on the other hand, induce sterility, as is well seen in prostitutes, who rarely become pregnant.
Finally, perverse sexual impulse must be mentioned as a possible cause of sterility. This may be an acquired perversion, due to the fact that at the epoch of the menarche, the commencement of puberty, owing to the strength of sexual desire whilst intercourse is an impossibility, or simply from evil example, the girl has become a confirmed onanist, and continues the habit even after marriage. In other cases we have to do with a psychopathic state, a form of mental degeneration due to very various causes, or in some cases inverted sexual sensibility exists in a person whose mind is in other respects normal. In women with sexual inversion, ordinary copulation with the male is insufficient to arouse the sexual orgasm, and for this reason, as well as because persons thus affected avoid coitus as much as possible, sterility commonly ensues.
In sterile homosexual women, and equally so in women addicted to masturbation, gynecological examination may disclose no abnormality whatever; but in other cases of the kind we may find a contributory cause of sterility in the fact that the internal genital organs are imperfectly developed, or even completely absent. In sterile women, if on gynecological examination we find certain characteristic changes in the reproductive organs, a strong suspicion will be aroused that the sterility is due to abnormal modes of sexual gratification. The changes in question are: hypertrophy of the clitoris, enlargement and a bluish colouration of the labia minora, retroversion of the uterus, neuralgia and displacement of the ovaries, leucorrhoea, and menorrhagia.
The question has been mooted by Cohnstein, whether, as is commonly assumed, a woman is capable of becoming pregnant at any time during the year, or whether, as in the lower animals, the reproductive capacity can be exercised only at certain seasons, or again, whether there may not be individual moments of predilection for the occurrence of conception. He found that in the great majority of women there were such seasons of predilection, and only in a minority could conception be effected indifferently at any time of the year. As a proof of this assertion, he appends the following case: A married woman, 33 years of age, had several years before been delivered prematurely of a still-born child, and since then had not again been pregnant. Her reproductive organs were normal. The husband’s semen was examined, and also found to be quite free from abnormality. In the course of the three following years an attempt was made to cure the sterility by dilatation of the cervical canal, suggestions for the proper regulation of sexual intercourse, etc., but all without effect. Cohnstein now calculated the date at which the full term of the previous pregnancy would have fallen, and found that this was the middle of February; he therefore inferred that intercourse effected at the beginning of May would result in impregnation. As a fact, the woman conceived at this time, and at full term gave birth to a healthy girl. The assumption that such a time of predilection for the occurrence of conception exists is, however, contradicted by the well known fact that in the case of large families the children’s birthdays are irregularly distributed throughout the year.
Baker-Brown describes a special form of sterility due to “sympathetic or reflex action.” It depends upon diseases of the organs adjoining the uterus, such as vascular tumours of the urethra, bleeding piles, fistula, fissure, and prolapse of the anus, schirrus of the rectum, ascarides. “These diseases produce sterility in consequence of the loss of blood, the menstrual disturbances, the morbid congestion of the uterine system, and the reflex neuroses, to which they give rise.” Courty reports a case belonging to this category in which in a young married lady sterility was due to fissure of the anus, which had long existed without recognition; after the fissure had healed, conception occurred. Palmay recently reported a case in which “taenia solium was the cause of sterility. In a woman 20 years of age, who had lived in sterile wedlock for three years, the presence in the intestine of a tapeworm, which she had harboured for many years, gave rise to dysmenorrhœal troubles. The complete expulsion of the worm relieved the dysmenorrhœa, the woman became pregnant, and gave birth to a child at full term; since then menstruation has been painless.” The presence of the tapeworm may have had an unfavourable influence upon the blood-supply and the innervation of the uterus. But cases of this nature do not constitute a special form of sterility; they must be classed, either with cases due to interference with ovulation, or with those due to prevention of the contact of ovum and spermatozoon.