Part 75

Hofmeier rightly points out that whilst gonorrhoeal infection in women may cause sterility, such sterility is by no means an inevitable consequence of the disease.

Other gynecologists are even more reserved in admitting the importance of gonorrhoea as a cause of sterility in women. Fritsch is of opinion that in many cases a casual relation is believed to exist, when in reality there is nothing more than a coincidence. Sterility and slight perimetritis, he remarks, are common in women; gonorrhoea is common in men. But it does not follow that the frequent gonorrhoea of the husbands is the sole cause of the frequent sterility and perimetritis of the wives. “For several years,” he continues, “I have examined all the men I possibly could for evidence of the existence of gonorrhoea, and have enquired for a history of previous attacks of the disease. To my astonishment I discovered that the fathers of many children, whose wives had come to consult me for some quite disconnected condition, had quite as often suffered formerly from gonorrhoea as the husbands of sterile wives.”

M. Saenger is one who very vigorously upholds Nöggerath’s views. He insists that, excluding puellae publicae from consideration, no less than 12% of all gynecological disorders depend upon pathological processes referable to gonorrhoeal infection of the female genital organs. To establish this thesis, it is not necessary to prove that Neisser’s gonococcus is or has been present; the diagnosis must be based principally upon clinical considerations. Chronic vaginitis and urethritis, inflammation of the uterine mucous membrane, tubal suppuration, oophoritis, and perimetritic adhesions (especially those which unite all the lateral pelvic organs into a shapeless knot)—these are conditions thoroughly characteristic of gonorrhoea.

No less unfavourable an influence of gonorrhoeal infection upon fertility is shown by the observations of Glünder. Women numbering 87 were in attendance at the gynecological department of the Policlinik of the University of Berlin, all of them seeking advice on account of sterility. In the case of 24 of these, the husband was also present; 19 of these men admitted having previously suffered from gonorrhoea; the remaining 5 denied such infection, although the wives of all of these had symptoms pointing unmistakably to gonorrhoeal infection; among the other 63 women, there were 8 only in whom the genital organs were found perfectly normal, whilst in 38 of them there were signs of previous gonorrhoeal infection. Thus we see that of these 87 sterile women, 62 (71.3%) had had gonorrhoea; and Glünder, assuming that in these cases the gonorrhoea was the efficient cause of the sterility, and regarding the average percentage of sterile marriages as 12.34 in every 100 contracted, is led to the conclusion that of every eleven or twelve marriages, one is rendered sterile in consequence of gonorrhoea.

To the same opinion, that gonorrhoea is the principal cause of sterility, Lier and Ascher were led by an investigation of numerous clinical histories. Moreover, they believe that in the large majority of sterile marriages, the husband is directly or indirectly responsible. Directly, in so far as a very large percentage of men have their reproductive capacity annihilated by gonorrhoea; indirectly, because, of those who retain their fertilizing powers, so large a number infect their wives with gonorrhoea, and thus render them incapable of conceiving, that chronic gonorrhoea—in the female harder to eradicate even than in the male—must be regarded as the arch-enemy of fertility. Of 80 men affected with azoospermia, all cases observed by Prochownik, in 75 the disease was the sequel of gonorrhoea; of the remaining 5 cases, two were due to syphilitic disease of the testicles, one to tubercular disease of the same, whilst two were due to long continued masturbation, with consecutive atrophy of the testis and epididymis.

But that the obstacle offered to conception by gonorrhoeal infection is by no means so powerful as Nöggerath and his supporters believed, is shown by the investigations of Oppenheimer, who, in Kehrer’s clinique at Heidelberg, examined 108 pregnant women for the presence of gonococci, and found these organisms, pathognomonic of gonorrhoeal infection, in no less than 30 of them, that is, in 27.7%. Thus, in this large number of cases, pregnancy had occurred notwithstanding the presence of gonorrhoea. Lower, again, in Schröeder’s clinique, examined 32 patients during the lying-in period, and detected the presence of gonococci in 26; an experience which also proves that gonorrhoeal infection is no bar to pregnancy. Dunstone has recently recorded 5 cases in which, notwithstanding the existence of gonorrhoea, the women became pregnant once or several times.

In the “Medical Brief” the question was mooted, “Can a woman have children subsequently to being infected with gonorrhoea?” Numerous affirmative answers were received; and among them one mentioning the case of a woman who was infected with gonorrhoea at the age of 18, and subsequently gave birth to 8 children.

The question of sterility in prostitutes has also attracted attention, since these women may be regarded as invariably infected with gonorrhoea. Meissner and Jeannel speak of the infertility of prostitutes as a well-known fact; and the latter states that, whereas, according to Montesquieu, to every 100 women in France, on an average 341 children are born, of which 200 grow up, to 100 prostitutes in Bordeaux there were born 60 children only, and of these but 21 attained maturity. Marc d’Espine affirms that among 2,000 prostitutes not more than two or three will have children in a year. Parent-Duchatelet, on the other hand, regards the sterility of these women as a purely temporary affair, and writes: “les prostituées conçoivent souvent, mais elles avortent fréquement;” and this frequency of abortion he attributes to two causes, in the first place to deliberate induction of abortion, and in the second place, to their mode of life. He continues: “cette fécondité a lieu surtout lorsque, quittant leur mettier, elles se marient ou s’attachent à un seul homme; dans ce cas les grossesses se succèdent, elles sont toujours heureuses et les infants qui en proviennent sont aussi vivaces que les autres;” thus, in his opinion the sterility of prostitutes lasts only as long as they pursue their occupation.

The question as to what influence, if any, gonorrhoeal secretion has per se upon the semen, has often been asked, but not yet satisfactorily answered. We have no certain knowledge whether the gonococci, the pus cells, or one of the toxins of the secretion, exercises a deleterious influence upon the vitality of the spermatozoa; it is certainly possible that this may be the case, for the diplococci, just as much as streptococci and staphylococci, are found not only within the cells, but also in the intercellular fluid and in the detritus, and so must be brought into intimate contact with the spermatozoa; but inasmuch as quite a number of persons who are at the time actually suffering from gonorrhoea beget children, we are compelled to assume that for the harmful influence, if any such exists, to be exercised, a prolonged contact of the semen with the gonorrhoeal pus is necessary. In cases of gonorrhoeal epididymitis and prostatitis, and also in gonorrhoeal urethritis, no such prolonged contact occurs; but when the vas deferens or the vesicula seminalis is inflamed, the contact is more prolonged, and may suffice to destroy the vitality of the spermatozoa, which are extremely sensitive to chemical stimuli. In 8 cases observed by Kroner, the fruitful coitus was unquestionably effected when the husband was suffering from still active gonorrhoea; in all the cases the children were born at full term, and all suffered from conjunctival blenorrhoea. That gonorrhoea often fails to induce sterility, is shown by the familiar fact that a woman frequently has one child after another, all infected with this conjunctival form of gonorrhoea, showing that the mother remains fertile notwithstanding the persistency of the gonorrhoeal infection.

Upon the investigation of 60 carefully written clinical histories, dealing with the relation between proved gonorrhoeal infection and a sterile marriage, Grechen has drawn up the following table, showing the various ways in which chronic gonorrhoea may give rise to sterility:

A. Absolute Sterility.

a. Owing to impossibility of fertilization, in consequence of defective formation of spermatozoon or ovum:

I. In the male: 1. Aspermatism. 2. Azoospermia. II. In the female: Oophoritis glandularis.

b. Owing to impossibility of pregnancy, although semen and ovum may be normal, and fertilization can be effected:

Gonorrhoeal endometritis of atrophic character.

B. Relative Sterility.

a. Owing to mechanical interference with the conjugation of spermatozoon and ovum:

I. In the male: 1. Epididymitis duplex. 2. Strictura impermeabilis urethrae. II. In the female: I. Perioophoritis and perimetritis, and their results, viz., adhesions and displacements of the reproductive organs. 2. Tubal catarrh, pyosalpinx, kinking and other forms of obstruction of the tubes.

b. Owing to extension of the gonorrhoeal process to the decidua, causing abortion in the early period of pregnancy:

Endometritis gonorrhoeica chronica, and endometritis decidualis.

Benzler has endeavoured to elucidate the problem of the relations between gonorrhoea and sterility by a collective investigation in the army. The investigation was concerned with 474 men who during their period of service with the colours had been treated for gonorrhoea, and who subsequently had married. Dealing with all cases alike, without regard to complications which had been observed in some cases but not in others, of the 474 wives, there were 64 who never became pregnant = 13.5%; 78 who had one child only = 16.5%; total, 142 = 30%.

Leaving out of consideration the cases in which epididymitis had been observed, there remained 363 cases of uncomplicated urethritis; of the 363 wives of these men, there were 38 who never became pregnant = 10.5%; 63 who had one child only = 17.3%; total 101 = 27.8%.

Thus, in the cases in which the husbands had had uncomplicated urethritis, the percentage of absolute sterility was only 10.5; while in the unselected cases of gonorrhoea, it was no more than 13.5. The figures show clearly that the influence of uncomplicated gonorrhoea is but trifling; indeed, it is obvious that this must be the case, for it is probable that not less than 80% of men experience at least one attack of gonorrhoea, and did this give rise to sterility, either directly by its influence on the men themselves, or indirectly by transmission to their wives, the human race would soon die out. Moreover, the frequent occurrence of ophthalmia neonatorum is a sufficient proof that notwithstanding gonorrhoeal infection in all these cases, pregnancy and delivery have taken place.

To sum up, it is my opinion that in recent years the influence of gonorrhoeal infection in inducing sterility in women has been painted in far too gloomy colours, and it is time that these extreme views should be abandoned.

This is a convenient place to insist upon the fact that in cases which are by no means rare, in the absence of aspermatism and azoospermia, and altogether independently of gonorrhoeal infection, it is the husband who is responsible for the occurrence of sterility; in such cases the sterility is due to failure of conjugation between spermatozoon and ovum, dependent upon congenital or acquired defects of the penis. The great majority of cases of this kind are due to hypospadias.

A case of sterile marriage is reported by Lier and Ascher, in which the husband had suffered from hypospadias and had been operated upon for the relief of that condition. Although erection of the penis was normal, and coitus terminated in the usual orgasm, with sense of ejaculation, the semen did not find its way into the vagina; it accumulated in the artificial cul-de-sac between the former abnormal urethral orifice and the artificially constructed meatus, and after coitus the semen had to be expelled from this region by digital pressure.

Miclucho-Mackay reports that among the Australian aborigines, hypospadias is artificially induced, in order to prevent fertilization. In young boys, an incision is made through the lower wall of the urethra from the meatus as far up as the scrotum, and care is taken that the several surfaces do not reunite. During coitus, the semen flows away without entering the vagina. This mutilation is practised, not only in South and Central Australia, but also by the indigens of Port Darwin.

That hypospadias does not in all cases offer an insuperable obstacle to impregnation, is, however, shown by a striking case which came under the notice of Labalbary. He saw a hypospadiac who, in micturating, had to crouch down in the feminine posture, because he was unable to project the stream of urine forwards; in coitus, he deposited his semen only on his wife’s vulva. But his wife gave birth to two sons, about whose paternity there could be no reasonable doubt, since both exhibited the same malformation as their putative father.