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.
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;”[49] 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;”[50] 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. Owing to impossibility of fertilization, in consequence of defective formation of spermatozoon or ovum:
b. Owing to impossibility of pregnancy, although semen and ovum may be normal, and fertilization can be effected:
Gonorrhoeal endometritis of atrophic character.
a. Owing to mechanical interference with the conjugation of spermatozoon and ovum:
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.
Occasionally, phimosis offers an obstacle to impregnation, and only after relief of the condition by operation, is the wish for offspring fulfilled. A case of this nature is recorded by Amussat.
In cases of severe stricture of the urethra, sterility may result, although the constitution of the semen is perfectly normal. During erection of the penis, the stricture is completely closed, and the semen accumulates in the urethra above it; when the penis becomes flaccid, the semen flows away, outside the vagina. In some such cases, the semen regurgitates into the bladder, and is not discharged until the patient makes water. Although the supposition is not one in which strict proof is obtainable, it is probable that the man is at fault in cases in which the wives of two or more brothers fail to conceive. I have seen several instances of the kind. Three brothers, all quite healthy, and of virile aspect, were married to women in whom on gynecological examination no significant abnormality could be detected; they had been married respectively for 14, 9, and 8 years; all were childless. Three brothers, two of whom were practising physicians, had lived a number of years (20, 4, and 14, respectively) in sterile wedlock; one of them (a physician) informed me that he ejaculated always a very small quantity of semen, and thought it possible that this was the cause of the sterility. Of four brothers, two had lived long in barren wedlock; the third had no child for 14 years after marriage, when at last his wife became pregnant after a visit to a spa; the fourth brother is a misogynist and a confirmed bachelor.
In our consideration of the various influences by which the contact of ovum and spermatozoon may be prevented, the degree of sexual excitement experienced by the woman during the sexual act must not be overlooked, for this plays a part not to be underestimated, even though it is a matter on which it is difficult to obtain accurate information.
It is extremely probable that an active participation on the part of the woman in coitus has an important influence upon the attainment of fertilization, i. e., that sexual excitement in the woman is a link in the chain of conditions leading to conception. This excitement has a reflex influence, but the influence may be exercised in either (or both) of two ways: first, it may cause certain reflex changes in the cervical secretion, whereby the passage of the spermatozoa is facilitated; or, secondly, it may give rise to reflex changes in the vaginal portion of the cervix, to a rounding of the os uteri externum and a hardening of the consistency of the cervix (changes of an erectile nature) coupled with a slight descent of the uterus—changes which likewise favour the entrance of the semen into the uterine cavity. Theopold goes so far as to say that it is only women who experience erotic excitement who are capable of being impregnated.
My own opinion is that considerable importance is to be attached to voluptuous excitement of the woman during coitus, for the former of the two reasons mentioned above, namely, because such excitement leads to the occurrence of reflex secretion of the cervical glands, the secretion thus produced maintaining or enhancing the activity of the spermatozoa; and contrariwise, in the absence of voluptuous excitement on the woman’s part there is a failure of the reflex secretion, and the passage of the spermatozoa into the uterine cavity is consequently less easily effected. That sexual excitement has great influence upon the production of the first appearance of menstruation, has frequently been shown; and an analogy between such an influence and the suggested effect of sexual excitement in favouring the occurrence of conception, must not lightly be rejected. It is well known that the first menstruation occurs at an earlier age in girls living in towns than in those living in the country; not solely (if at all) in consequence of the better nutriment and easier life of the former, but also, unquestionably, owing to nervous influences. It is, moreover, a familiar experience that factory girls, who from early youth are exposed to sexual stimulation, attain sexual maturity at an extremely early age. Again, from early times it has been the prevailing opinion of the common people that for the impregnation of a woman it was necessary for her to experience voluptuous excitement, or at least, that in the absence of such excitement, conception was rendered difficult. Riedel relates of the indigens of the Island of Buru, that they often have sexual intercourse with foreigners, “but during such intercourse they remain quite passive, in order to avoid impregnation.” It is not an unusual experience in gynecological practice for a sterile woman, in the absence of any prompting, to complain that during coitus she has no “feeling” whatever, and to attribute to this lack of feeling her failure to conceive.
A cultured lady, the mother of several children, assured me, not only that she was always aware, whether an act of intercourse would or would not lead to impregnation, but further, that it was within her power to determine whether the intercourse should or should not be fruitful. If she was passive during intercourse, or if, to use her own expression, her attitude was one of “laisser faire, laisser aller,” conception would not occur; but if, on the other hand, she took an active part in the coitus, so that she experienced a powerful voluptuous sensation, pregnancy would result from the intercourse.
In some cases, the previously described condition of dyspareunia is the cause of the sterility. In fact, the combination of dyspareunia with sterility is so strikingly common, that my own observations have led me to infer that there is a casual connexion between the two states, at least in a considerable proportion of cases.
I append a short note of a few instances of this kind: Mrs. G., aged 27, married 6 years, sterile; an anæmic, delicate lady, who has never experienced the sense of ejaculation. The semen flows away from the vagina immediately after the completion of coitus. No abnormality to be detected on gynecological examination. Mrs. S., aged 24, married 5 years, sterile; during intercourse remains completely cold, and has experienced the sense of ejaculation in dreams only. Gynecological examination disclosed the existence of slight cervical catarrh, but no other abnormality. Mrs. E., aged 30, married 10 years, had a child 9 years previously, a difficult delivery followed by puerperal disease, since then sterile; she states that since her delivery she has not experienced the sense of ejaculation, with which she was formerly familiar; further, since that time she has suffered from profluvium seminis. On gynecological examination the uterus was found to be enlarged and retroflexed. Mrs. K., aged 28, married 6 years, sterile; amenorrhoeic, has never experienced the sense of ejaculation, and finds sexual intercourse so unpleasant that, “in order to be left in peace,” she has herself begged her husband to keep a mistress. Examination showed the uterus to be in an infantile condition.
Whilst I have notes of numerous cases similar to those just quoted, I must also insist upon the fact that I have sometimes had complaints of dyspareunia from wives whose fertility has been proved by the birth of numerous children. And, again, anyone whose position permits him frequent glimpses of what passes behind the scenes of married life, will from time to time have noticed as signs of relative dyspareunia instances in which the faithless wife is far more readily impregnated by her lover than by the husband to whom she is indifferent or whom she actually dislikes.
To relative dyspareunia dependent upon sexual disharmony we must refer also those instances in which a man and a woman prove sterile while living together for a considerable period as man and wife, but after separation both prove fertile in fresh unions. Several such cases have come within my own experience, and similar instances attracted the attention of the observers of antiquity—Aristotle, for example. Haller, for this reason, lays stress on the lack of mutual affection as a cause of sterility; and Virey, also, believes that sterility may often depend upon the absence of the “harmonie d’amour.”
It is possible that the custom, which in certain rural districts has persisted into quite recent times, of a temporary experimental cohabitation of candidates for matrimony, was based on an attempt to discover the existence of such a sexual harmony. Ploss, for instance, reports that in East Prussia, in 1864, he was informed that among the Mazurs this custom of an experimental year of cohabitation was in force. If during this year the woman became pregnant, the young couple were married; but if pregnancy failed to occur, they separated, considering they were not formed for one another.
A well-known historical example of relative sterility is furnished by the two marriages of Napoleon I. His first marriage to Josephine remained sterile, though Josephine had children by Beauharnais; and Napoleon, remarried to Marie Louise, had a son by the latter.
Von Gutceit, a physician of wide experience, points out that “sensitive women, who have a mental or physical antipathy to cohabitation, or who have a secret but ardent affection for some other man, often fail to conceive as a result of intercourse with their husbands; but when, in illicit intercourse, they experience the voluptuous sensations to which they have hitherto been strangers, pregnancy often speedily ensues.” He maintains, further, “that such women, in consequence of the stimulation of the genital organs in the absence of sexual gratification, become affected with all kinds of menstrual irregularities, with fluor albus, prolapse of the uterus, and chronic metritis; they suffer from digestive disturbances and constipation, leading to emaciation; and they are prone to hysterical manifestations.”
Analogous phenomena have been noted, and with much greater distinctness, in the animal world. Darwin, writing on this subject, remarks: “It is by no means a rare occurrence, that certain males and females will not be fruitful in intercourse together, whilst the same individuals prove perfectly fertile in intercourse with other members of their species—and this in cases in which there is no evidence that the subsequent fertility is due to any change in the conditions of life. The cause is probably to be found in an innate sexual disharmony between the infertile pair. A very large number of instances of this kind have been reported to me by well-known breeders of horses, cattle, pigs, dogs, and pigeons. Sometimes a breeder will fail to obtain offspring from a male and a female of known fertility whom he wishes to couple for some special reasons. The most celebrated living horse-breeder informed me that frequently a mare, which in other seasons with other stallions has proved fertile, may be coupled with a stallion likewise of proved reproductive potency, and will fail to be impregnated; yet this same mare will shortly afterwards be impregnated by another stallion.”
Pflüger reports that he has often seen a thoroughbred stallion, which was fully prepared, at a moment’s notice, to serve a thoroughbred mare, prove extremely unwilling to serve a common mare on heat, and only induced to do so with the greatest difficulty, and indeed by a trick. The stallion is placed in the central one of three stalls, on one side of him is the thoroughbred mare, whilst in the third stall is the common mare, covered with a cloth. The stallion’s head is turned to show him the thoroughbred mare; immediately his appearance undergoes a change. Every muscle of his body appears to quiver, and never does a fine animal appear more beautiful than at such a moment, full of pride, fire, and vitality.[51] As soon as the stallion makes ready to serve the mare, he is rapidly led to the other stall, and suitably assisted to the actual commencement of intercourse with the substituted mare. But it sometimes happens, as Pflüger himself has seen, that the stallion becoming aware of the deception, refuses to complete the coitus, withdraws his penis, and immediately turns to the mare of his choice.
Matthews Duncan, among 191 sterile women, found that 39 had no sexual appetite, and 62 had no voluptuous sensations during coitus. He regards abnormal sexual appetite as one of the principal causes of sterility.
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.
The fertilization of the ovum is, as previously described, probably effected in man, as in other mammals, in the upper third of the Fallopian tube. The fertilized ovum is then swept down into the uterus by the action of the cilia which line the tube, assisted by the peristaltic movement of the muscular wall of the canal. The uterine mucous membrane at this time is thickened and thrown into folds, and in these latter the fertilized ovum is entangled; by its presence the ovum now exerts a reflex stimulus leading to a still greater proliferation of the cells of the uterine mucous membrane, which grows up over the ovum and soon shuts it off completely from the uterine cavity. Thus the ovum comes to be entirely imbedded in the substance of the mucous membrane.
Thus for the implantation of the ovum, it is first of all necessary that the uterine mucous membrane should be in a normal condition; pathological changes in this membrane, and indeed any morbid structural alteration in the uterine tissues, may prevent the implantation and incubation of the ovum, and may thus give rise to sterility.
The uterine cavity is normally lined with ciliated epithelium, the cells of which have an elongated elliptical form. The movement of the cilia is directed downwards. The epithelium is perforated by the orifices of the uterine glands; these glands are simple tubular glands, passing through the mucous membrane with an S-shaped or corkscrew curve; between the glands lies a rich germinal tissue, made up of rounded cells. The rounded connective tissue cells have processes which build up the scaffolding of the mucous membrane. Among the connective tissue cells of the uterine mucous membrane, wandering leucocytes are almost always to be seen. Menstruation is characterized by a swelling of the mucous membrane, and by enlargement of the uterine glands. At the same time, blood extravasations appear between the more superficial layers of the membrane, and on its free surface, and various portions of the surface of the membrane are cast off.
Very numerous are the morbid states of the uterus and its annexa whereby the implantation and incubation of the ovum are prevented; and incapacity of the uterus for the fulfilment of these functions is therefore a common cause of sterility in women.
That developmental defects of the uterus, even when they are not such as render conception impossible, may yet often give rise to sterility, has been already explained in writing of the conditions of the uterus which prevent the contact of ovum and spermatozoon; for defects of development which are not sufficiently severe to prevent this contact, may yet suffice to render the uterus unfit for the implantation and incubation of the fertilized ovum. Inflammatory disorders, such as perimetritis and the formation of exudations in the parametrium, may render the uterus unable to undergo the enlargement necessary to pregnancy. Tissue changes in the uterine musculature may likewise prevent the implantation of the ovum, or the proper development of the uterus during pregnancy. New-growths of the uterus or its neighbourhood may bring the development of the fertilized ovum to an untimely conclusion. Above all, however, it is diseases of the uterine mucous membrane which unfit the organ for the implantation of the ovum, and thus give rise to sterility. All those inflammatory states which lead either to softening or to induration of the uterine parenchyma, or to swelling and thickening of the endometrium or parametrium, may offer a hindrance more or less serious to the normal incubation of the ovum.
The diagnosis whether in an individual case we have to do with sterility dependent upon impotentia gestandi, is often difficult, because the conditions which cause it are frequently associated with those which cause sterility by preventing the contact of ovum and spermatozoon. In any case, a careful examination of the pelvic organs must be made, not only to determine whether there is any displacement or enlargement of the uterus, chronic metritis or perimetritis, parametric exudations, or new growths of the uterus or of neighbouring organs, but also, if necessary by dilating the cervical canal, to ascertain the condition of the uterine mucous membrane, and whether there is hyperplasia or atrophy thereof. In this connexion, examination of the uterine secretion is of especial importance: a purely mucous, transparent, vitreous, tenacious secretion in the os and in the cervical canal, indicates the existence of catarrhal endometritis; a markedly haemorrhagic secretion signifies hyperplastic endometritis; profuse purulent secretion containing gonococci, indicates gonorrhoeal endometritis; the discharge of pieces of membrane shows that there is exfoliative endometritis; the discovery of fragments of carcinomatous tissue indicates the breaking down of a malignant tumour of this nature; etc.
Finally, it is necessary to obtain a careful history of the case, asking whether there have been menstrual irregularities, or miscarriages, and the characters of previous labours (in cases of acquired sterility); any pathological conditions in other organs should be investigated; and the condition of the blood and the state of general nutrition should receive attention. Chlorosis, anæmia, and scrofula often give rise to catarrhal endometritis; severe disease of the heart may lead to congestive troubles of the genital organs; after abortion or difficult labour, chronic metritis or endometritis are common. Further, the differential diagnosis between erosion and carcinoma of the portio vaginalis, must often depend upon consideration of the patient’s age and general health, and upon the nature and duration of the haemorrhage. Pain on micturition, appearing soon after marriage, and lasting often a few days only, will indicate the probability of gonorrhoeal infection, etc.
Von Grünewaldt has vigorously insisted upon the fact that the notion of sterility, i. e., impotentia generandi in women, is not coincident with the notion of impotentia concipiendi, and there is an important distinction between cases in which it is impossible that fertilization should be effected, and cases in which, though fertilization may take place, the implantation and incubation of the ovum fail to ensue. In this author’s opinion, the only absolute mechanical hindrance to the entrance of the semen is to be found in atresia of the genital passage, and the role of impotentia concipiendi is of quite minor importance as compared with incapacity on the part of the uterus for the implantation and incubation of the ovum, an opinion, which, notwithstanding the record of exceptional cases in which pregnancy has occurred in spite of the existence of mechanical obstacles to conception, I must regard as altogether beyond the mark. On the other hand, it is indisputable that for the occurrence of pregnancy it is necessary, not only that contact of ovum and spermatozoon should be possible, but further, that the uterus should be in a condition favourable for the implantation and further development of the ovum subsequent to fertilization. For this reason, diseases of the uterine tissues must play an important part in the causation of sterility, though we cannot go so far as to admit with von Grünewaldt that these diseases are the principal cause of reproductive incapacity in women.
Various metritic processes, and also venous hyperaemia consequent upon heart disease, may lead to atrophy of the uterine mucous membrane, which then appears thin and smooth, whilst the uterine glands are destroyed, or transformed into small cysts. The same condition may result from retention of secretions in the uterine cavity—hydrometra and haematometra. In all these cases, the epithelium probably loses its cilia. The process has a serious influence antagonistic to the reproductive capacity inasmuch as the implantation of the chorionic villi is rendered difficult (Klebs).
Hyperplasia of the uterine parenchyma, affecting either the whole organ or a large part, and characterized either by enlargement of the entire organ, or only by thickening and elongation of the cervix, may hinder the incubation of the ovum. It may be due to endometritic catarrhal processes; to venous hyperaemia, especially in cases of valvular heart disease; to subinvolution; and sometimes to excessive sexual stimulation, as in prostitutes. Both the change in the shape of the cervix, and the changes undergone by the uterine mucous membrane in cases of extensive uterine hyperplasia (it commonly becomes atrophic and discharges a watery secretion), interfere with the reproductive capacity.
In all cases of chronic metritis, the hyperaemia and hyperplasia of the uterus may give rise to haemorrhages; these sweep away the ovum, and thus lead to impotentia gestandi. And the nutritive changes in the mucous membrane that occur in chronic metritis also interfere with the implantation and incubation of the ovum. Moreover, it is well known that in these cases, even if conception is effected, abortion is extremely apt to occur, owing to the pathological state of the endometrium, which interferes with the normal development of the decidua. Haemorrhages occur in the decidua, and are followed by abortion. And further, the replacement of portions of the muscular tissue of the uterine wall by fibrous tissue, a change which is apt to occur in long continued metritis, interferes with the proper expansion of the uterus during pregnancy, and thus leads to abortion.
On the other hand, it cannot be denied that frequently enough patients with well marked chronic metritis nevertheless conceive in a normal manner, and give birth to a healthy child; and this not once only, but again and again.
As sterility due to mesometritis, von Grünewaldt classes the numerous cases in which sterility ensues upon a confinement in which the patient reports that inflammation followed delivery—or sometimes in which nothing abnormal was noticed. The results of local examination are negative: there is no displacement, no exudation or swelling, and no relevant affection of the endometrium. But the characteristic feature of these cases is, according to von Grünewaldt, that after her last full-time delivery, a woman has had a miscarriage or a premature delivery, and subsequently has been completely sterile. The degenerative process is at first partial, so that it does not prevent conception, but renders it impossible for the pregnancy to go on to full term; subsequently it extends throughout the mesometrium, and conception is no longer possible.
Cole of San Francisco regards as the most frequent cause of sterility ensuing upon a single delivery, subinvolution of the uterus, most commonly due to rising too early after delivery. He therefore considers it of especial importance after a first delivery that the physician should satisfy himself that no serious injury has been effected by the process.
Chronic endometritis is a very frequent cause of sterility: in the first place, the catarrhal swelling of the mucous membrane, which often extends from the os uteri externum to the ostium abdominale of the Fallopian tubes, offers an obstacle alike to the downward passage of the ovum and the upward passage of the spermatozoa; and secondly, in long standing cases, the large size of the uterine cavity and the smoothness of the surface of the atrophied mucous membrane, render the lodgment of the ovum in the uterus very unlikely. A further powerful obstacle to impregnation in cases of endometritis is offered by the profuse muco-purulent secretion which usually, though not invariably, accompanies that disease. This secretion, in some cases flowing freely over the surface of the membrane, but in others adhering to it with tenacity, whitish-yellow in colour, rendered cloudy by admixture of pus, or tinted red by admixture of blood, sometimes of a gelatinous consistency with a strongly alkaline reaction, contains globules of mucus, ciliated and cylindrical epithelial cells, pus corpuscles, bacteria and cocci,—and, if the endometritis is of gonorrhoeal origin, the gonococcus of Neisser. This secretion, when profuse and thinly fluid, pours out through the os, and sweeps away the semen; when tenacious and gelatinous, it fills up the dilated cervical canal above the constricted os uteri externum, and constitutes a powerful barrier to the upward passage of the spermatozoa; when purulent, it is destructive to the vital activity of the spermatozoa. The changes in the mucous membrane in cases of long standing endometritis whereby the uterus is rendered unfit for the implantation and incubation of the ovum, are the following. The epithelial cells, as usual in cases of continued catarrh, change in form, the ciliated cells disappear, and are replaced, first by cylindrical cells, later by polymorphic cells, approaching in type those of pavement epithelium. The mucous membrane is swelled, the vessels are dilated, there is hyperplasia of the glands, with a moderate amount of small-celled infiltration of the interglandular tissue (Fig. 83). Ultimately the mucous membrane undergoes atrophy, its glands disappear, it comes to resemble a thin stratum of connective tissue.