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.