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.
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.