Part 74

Recently, Neugebauer has made as complete a collection as possible of all the recorded cases of hermaphroditism.

Secretions of the Genital Organs.

The constitution of the secretion of the vaginal mucous membrane, or of the secretion formed in the cervical canal, or both of these in combination, may constitute hindrances to the normal contact of spermatozoon and ovum.

The secretions of the female genital organs are manifold. The outer surface of the labia majora is covered with skin, containing sebaceous and sweat glands; but the inner surface of the labia majora and the rest of the external genital organs are covered with mucous membrane, the outer stratum of which consists of stratified pavement epithelium; this epithelium contains sebaceous glands and mucus glands. The intermixture of the secretions of these glands with the epithelial scales which are constantly being cast off in large numbers, constitutes the whitish material with which this region is smeared, known as “smegma.” A mucus secretion of a fluid consistency is discharged from the vulvo-vaginal glands known by the name of Bartholin’s glands.

The mucous lining of the vagina is poor in glands; it contains very numerous papillæ, which do not, however, project from the surface of the membrane, since the depressions between the papillæ are filled in by the stratified epithelium with which the entire extent of the vaginal mucous membrane is covered. The secretion of the vaginal mucous membrane is a fluid of thin consistency with an acid reaction; the admixture of numerous morphological elements, in the form of epithelial cells cast off from the superficial layers of the stratified epithelium, often, however, makes the vaginal secretion thick and opaque. The epithelial lamellae are frequently covered with heaps of lepthothrix granules, and among the granules are seen vibriones and bacteria and also numerous lepthothrix threads of varying length.

The same stratified epithelium extends on to the neck of the uterus to a distance which varies in different individuals; gradually, however, the number of layers diminishes, the flattened cells give place to thicker, prismatic cells, until we have a single-layered prismatic epithelium; finally the cells become columnar and ciliated, and this columnar ciliated epithelium covers the whole of the interior of the uterus. The mucous lining of the cervical canal contains numerous mucous glands, some of which are simple tubular glands, whilst others are racemose; they are lined with columnar ciliated epithelium, and secrete a dense, gelatinous, alkaline mucus, containing a few epithelial cells and occasional leucocytes. The mucous membrane of the uterine cavity is beset with simple tubular glands, lined with a single layer of prismatic epithelium; these glands secrete a grayish alkaline fluid. The secretion formed in the uterine cavity is thinner in consistency than that formed in the cervical canal.

Normally, the secretion of the vaginal mucous membrane is not more than is sufficient to keep the surface of the canal moist and slippery; it is a thin fluid of an acid reaction, and almost as clear as water. Shortly before and after menstruation, the secretion of the vaginal mucous membrane becomes more abundant; it is even thinner than at other times; the reaction remains acid. The secretion of the cervical canal is normally, in the absence of sexual intercourse, small in amount, so that a free flow of secretion from the os uteri externum is by itself sufficient to indicate that the mucous membrane of the canal is in an abnormal condition. The vitreous, gelatinous, alkaline mucus secreted by the glands of the cervical canal is normally retained within the canal, and is seen on examination with the speculum to fill the os uteri externum. In consequence of the congestion of the uterus that occurs during menstruation, and for the same reason during sexual excitement, the secretion of the cervical canal is more abundant, it also becomes less tenacious, and flows out through the os into the vagina. But this evacuation of the cervical secretion through the os is a normal occurrence only during menstruation and as a result of sexual intercourse; in these circumstances it appears in the form of a clear or somewhat yellowish drop of fluid exuding through the os uteri externum.

In catarrhal states, the secretions of the genital passage, like those of other mucous membranes, become abnormal. There is an increase in the number both of epithelial elements and of leucocytes; and in very acute catarrhs, erythrocytes also mingle with the secretion. On microscopical examination we find that the catarrhal secretion differs in its characters according to the part from which it is derived: the mucus from the cervical canal forms gelatinous accumulations; that from the vaginal mucous membrane forms thick opaque masses; and in the mixed secretion which exudes from the vulva, we find also smegma from the external genital organs. In addition to cells from the laminated epithelium, we see often young cells, somewhat oval or polyhedral in form, with granular protoplasm, and a vesicular nucleus. In some inflammatory states, pus corpuscles will also make their appearance. Various micro-organisms are in addition to be found in the catarrhal secretions.

The reaction of the vaginal secretion is normally faintly acid; should it become strongly acid, the movements of the spermatozoa are immediately suspended. The mucus of the cervical canal, the alkaline reaction of which is extremely favourable to the onward movement of the spermatozoa, may, owing to catarrhal processes, be so altered that it becomes acid; it then destroys the spermatozoa, and gives rise to sterility. This fact can sometimes be proved by microscopical examination. In several cases in which endometritis existed in sterile women I made a microscopical examination of the cervical mucus shortly after the completion of sexual intercourse; and in a number of these, no living spermatozoa were to be seen, but only dead, motionless spermatozoa (Fig. 82). I had, of course, in these cases, previously assured myself that the husband’s semen was normally active.

FIG. 82.

Mucus from the Cervical Canal, taken one hour after sexual intercourse, from a woman suffering from chronic endometritis.

Among the epithelial cells, pus cells, and finely granular masses, we see a few motionless, dead spermatozoa. ]

According to Nöggerath, in cases of uterine catarrh, we may find one of three different varieties of secretion. In some cases it is small in amount, and very thin in consistency; in others, it is moderate in amount, very thick, non-transparent, bright yellow, and gelatinous in consistency; in the third class of cases, we have numerous degrees of variation, starting from the normal, purely mucus, transparent secretion, mixed with yellow flocculae, up to a secretion which has almost the aspect of pure pus. The first described variety is, according to Nöggerath, met with chiefly in women whose uteri are small, with indurated tissues, and its discharge seems to depend upon commencing atrophy of the mucous membrane. The second form is the most obstinate, the catarrh being situated chiefly in the cervical and probably also the uterine glands; whereas the first variety of secretion is rather a serous transudation, and contains very few formed elements. The third form is characterized by extensive denudation of the superficial epithelium, and is mixed with a smaller or larger quantity of pus.

Levy, who made microscopical examinations in sterile women (39 cases), gives it as a “constant fact” that when the cervical secretion contains epithelial and pus cells in large quantities, the spermatozoa never retain for long their power of movement. Whereas in examinations made repeatedly on healthy women 25 hours after sexual intercourse, he found numerous spermatozoa still in active movement, in women having a catarrhal discharge with the characters just mentioned, five hours after intercourse the movements of the spermatozoa had almost entirely ceased.

Not only may the secretions of the genital passage be injurious to the spermatozoa by their quality, but further a very abundant secretion may interfere with fertilization. In the first place a very abundant secretion is apt to be very dilute, and if the spermatozoa are immersed in a fluid of which the specific gravity is too low, they swell up from imbibition of water, and their movements are suspended. But excessive secretion, such as is sometimes met with in cases of cervical catarrh, may also have a purely mechanical deleterious action, by washing away the semen out of the vagina. If, again, the quantity of the ejaculated semen is unusually small, contact with the normally acid vaginal mucus may suffice to render the spermatozoa speedily motionless. Finally, when the cervical secretion is of a too tenacious consistency, so that it fills the os as with a plug, the upward passage of the spermatozoa may be barred.

Such tenacious cervical mucus will give rise to sterility especially in women who have not previously born children; whereas in parous women, owing to the more patulous condition of the os, the entrance of the spermatozoa is not so effectually prevented. The same distinction between nulliparous and parous women must be made, as von Scanzoni has pointed out, also as regards the production of sterility by hypersecretion of uterine mucus. Women who become affected with uterine blenorrhoea only after having had one or more children, will readily become pregnant again; but when such blenorrhoea affects a woman who has never been pregnant, sterility almost invariably results.

Von Grünewaldt has drawn attention to a somewhat rare form of chronic endometritis with tenacious secretion, leading to sterility. The shape, size, and consistency of the uterus appear normal, the organ is often virginal, but with the speculum we see exuding from the os a greyish green, extremely tenacious secretion, which is wiped away with difficulty. He saw 24 women affected with this disease; 10 of these had lived in marital intercourse for many years without ever having become pregnant; in 10 others there was acquired sterility, i. e., they had at first borne children after marriage, but had subsequently ceased to be fruitful; in the remaining 4 it was not possible to ascertain whether they were fruitful or sterile, since two of them were living apart from their husbands, whilst in the case of the other two only two years had elapsed since the birth of the last child. In any case, not one of the women thus affected had ever become pregnant subsequent to the time at which she acquired this form of endometritis, notwithstanding the fact that in several of the cases the symptoms were alleviated by treatment.

We must here consider also the effect of gonorrhoeal infection in giving rise to sterility in women. Sterility may arise from gonorrhoea in women in various ways. Sometimes the abundance of the cervical secretion is alone sufficient to prevent the entrance of the spermatozoa into the uterus; in other cases the hindrance to fertility depends upon the inflammatory conditions in the pelvis that so frequently result from gonorrhoeal infection—perimetritis and parametritis; it may be catarrhal changes in the tubes—salpingitis, hydrosalpinx, and pyosalpinx—by which the contact between spermatozoon and ovum is prevented. Chronic gonorrhoeal endometritis may give rise to such changes in the uterine mucous membrane as to unfit it permanently for the implantation of the ovum, even should there be no obstacle to fertilization. Finally, double gonorrhoeal oophoritis may result in rendering the formation of mature ovum an entire impossibility—bringing about a condition analogous to azoospermia in the male, and causing absolute sterility. Although in many cases the detection of the gonococcus affords indisputable evidence of the existence of gonorrhoeal infection, it must be remembered that it is often difficult, and sometimes entirely impossible, to make the diagnosis with certainty; and for this reason it is possible that gonorrhoeal infection plays a much larger part in the causation of sterility than has until lately been believed.

The observant physician will in cases of sterile marriage frequently find in husband or wife or both, evidence of previous or still existent gonorrhoea; but he will cautiously weigh all the circumstances before deciding that such gonorrhoeal infection is the efficient cause of the sterility. In many cases, however, the etiological relation is too obvious to be overlooked, and we can trace all the distresses of the unfortunate wife to the injury she unwittingly received upon the momentous wedding night.

Still, we have to remember how extraordinarily common, more especially in the so-called upper classes of society, is gonorrhoeal infection, and what an enormous percentage of men entering upon married life have previously experienced one or more attacks of the disease—so that were sterility a frequent sequel of such infection, fertility would be the exception rather than the rule. By inquiry among friends and patients as to whether when they married they had previously suffered from gonorrhoea, in conjunction with information regarding the fruitfulness of their marriages, I have been led to the conclusion, which appears to me to be one of considerable importance, that the proportion of sterile to fruitful women among the wives of men who have suffered from gonorrhoea before marriage, is about the same as the proportional fertility of all marriages considered independently of gonorrhoeal infection, viz. 1 : 10. This depends, as it appears to me, not only upon the fact that very frequently in men gonorrhoea is completely cured, but also upon the fact that in women gonorrhoeal infection does not necessarily cause sterility. It may indeed be regarded as definitely established that women actually suffering from gonorrhoea may become pregnant, and that the pregnancy may proceed to its natural termination. The recent investigations regarding the frequency with which gonococci may be detected in the genital secretions of pregnant and parturient women—and they are to be found in a surprisingly large percentage—suffice to prove that gonorrhoeal infection offers no insuperable obstacle to conception. That the discovery of gonococci in a man’s urethra does not justify us with apodictic certainty in forbidding the man thus affected to marry is in fact proved by the following remarkable case, which came within my own experience. A young man who had had several attacks of acute gonorrhoea, wishing to marry, had himself examined by two specialists in genito-urinary disease. Both detected gonococci in his urethra, and both forbade him to marry. The patient, however, would not be advised, and married the lady of his choice; now, six years after marriage, he is the happy father of four blooming children, and his wife is in perfect health.

Gosselin, in an elaborate work published in 1853, was the first to point out the serious consequences as regards a man’s future potentia generandi which are entailed by an attack of gonorrhoea followed by epididymitis. He insisted that the inflammation might lead to the obliteration at some point of the vas deferens, whereby the secretion of the testicle was prevented from mixing with the secretions of the prostate, Cowper’s gland, and the seminal vesicle; and hence the ejaculated sperm was lacking in its principal constituent. In such cases, either in the epididymis (usually in the globus minor of that organ), or else in the course of the vas deferens, somewhere between the epididymis and the vesicula seminalis, some relic of the former inflammation is usually to be detected, the globus gonorrhoeicus, and this usually represents the seat of strangulation of the excretory duct of the testicle.

In the year 1872 Nöggerath published his book, written with flaming fiery zeal, entitled “Latent Gonorrhoea in the Female Sex.” In the most startling colours he depicted all the misery and distress which formed the wedding gift of the gonorrhoea-infected husband to his wife; when sowing his wild oats, such a husband is preparing for the crop by which his young wife’s happiness is destroyed, her health ruined, her life endangered, and her hopes of offspring annulled. While we may admit that Nöggerath’s motives were of the noblest, we cannot but wonder that the wickedness of the male sex has not yet entailed the destruction of the whole human race, overwhelmed as by a new fall of Sodom and Gomorrah.

Nöggerath maintained that 90% of men infected with gonorrhoea remained uncured; and that of the women married by men thus permanently infected with gonorrhoea, barely 10% remained free from the disease. It is gonorrhoeal infection, of which this author gives so gloomy a picture, which is, in his opinion, the principle cause of sterility in women. According to his observations, of 81 women thus infected, 49 remained absolutely sterile; only 31 became pregnant; 23 were delivered at full term, 3 had miscarriages, and 5 premature delivery. Thus, not so many as 1 in 3 of these women had a full-time child. Of the 23 who were delivered at full term, 12 never had more than 1 child each; 7 had 2 children each; 3 had 3 children each; 1 only had 4 children, the normal average fruit of healthy marriages. In all, the 81 women had only 39 children. If we take 4 to be the average number of the offspring of a healthy married pair, there was but one normal woman among the whole 81. Forty-nine were absolutely sterile; 11 of the remainder had 1 child, and did not again conceive during periods ranging from 3 to 18 years after the recorded delivery; thus there were 60 sterile women among 81.

Nöggerath’s doctrine regarding the relation between gonorrhoeal infection and sterility obtained at first little credence—perhaps for the reason that he drew such far-reaching conclusions from so limited a material—Schröder mentions Nöggerath’s opinions only to dismiss them as extravagant; but the idea that the husband was mainly to blame for the occurrence of sterility in marriage continued to form the topic of scientific discussion. The indignation which Nöggerath’s assertions, unquestionably too sweeping, had aroused in gynecological circles, gradually subsided, as every gynecologist devoted his attention to supporting or refuting Nöggerath’s conclusions.

It soon became evident, that gonorrhoea in the male had a deleterious influence upon the fertilizing quality of the semen, and this far more frequently than had previously been supposed. Fürbringer, as a result of the examination of 124 cases, laid down the important proposition, that when epididymitis or funiculitis gonorrhoeica duplex had been observed to occur, the probability that the patient would be an azoospermist was expressed by the ratio of 9 : 1, and this in direct opposition to the views of Zeissl, who had maintained that in this respect the consequences of gonorrhoea were trifling.

Seeligmann conducted a pathologico-anatomical investigation which led him to conclude that in cases of gonorrhoeal epididymitis, in addition to the inflammation of the epididymis, phlebitis and periphlebitis of the plexus pampiniformis occurs, and also lymphangitis of the extensive system of lymphatic vessels which pass through the spermatic cord from the testicle; the changes left in the blood and lymphatic vessels by the inflammation, result in the testicle being for the future imperfectly nourished, and often therefore lead to impairment of the functions of this organ; thus the oligospermia so frequently seen as a sequel of gonorrhoeal epididymitis (the ejaculated semen containing but few spermatozoa, and these with little or no vitality), is not always due to a complete obliteration of the vasa deferentia by the inflammation, but in many cases to the functional derangements of the testicle brought about in the manner above described. It is probable also that lues may give rise to azoospermia as a result of endarteritic processes. The remarkable result of Seeligmann’s investigations was that in as many as 75% of the sterile marriages that came under his observation, the husband was the one to blame.

Latterly, the view that gonorrhoeal infection plays a very considerable part in the etiology of sterility in women, has been widely accepted. Among German gynecologists, Olshausen, a man of enormous experience, considers that Nöggerath’s book, notwithstanding much exaggeration, is substantially accurate in its main conclusions. A similar view of Nöggerath’s work is taken by E. Schwartz, Bandl, A. Martin, and Hofmeier.

According to the exhaustive work of E. Schwartz, gonorrhoea is in women one of the commonest causes of sterility. Sterility due to this disease may be either primary or secondary. In some cases no ovum can find its way into the uterus, either because the ovaries are completely enveloped in masses of exudation and pseudo-membranes, or on account of dislocation of the ovaries and the Fallopian tubes, or because the tubes have been rendered impermeable by inflammatory stenosis or flexion, or by loss of their ciliated epithelium; in other cases the ovum, indeed, enters the uterus, but fails to be implanted upon the diseased mucous membrane; again, it is conceivable that even when ovum and spermatozoon are properly formed and encounter one another in the normal manner in the tube or in the uterine cavity, and when the uterine mucous membrane is in a condition suitable for the implantation of the fertilized ovum, contact with gonorrhoeal secretions may have impaired the vitality of the ovum or of the spermatozoon, or of both, to such a degree, that either fertilization fails to occur, or the fertilized ovum is incapable of further development. In some instances, sterility dates from the first infection of the wife; but more commonly it does not develop until after the completion of one or more pregnancies.