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that they had at some time a pelvic peri- to consider the reasons why we are forced tonitis. If, upon examination of smears to charge such tremendous responsibility from such cases the gonococci are not de- to gonorrhea and its results. To properly monstrable and that they do not yield to appeciate the merits of the situation, we treatment and remain well, but are attended must needs be very plain. In the first by relapses, it is fair to assume that we place, parents are often to blame for alloware dealing with a gonorrheal inflamma- ing children to grow up ignorant of the tion. In order that pregnancy may not take nature of the disease, its frequency and re. place, it is essential that the disease be sults. And here perhaps we should not bilateral. We may not be obliged to look exact of the parent that of which they may as far back as the tubes and ovaries to ac- know little or nothing, but shift the recount for the sterility. Chronic inflamma- sponsibility to the family physician and extion of the otsium uteri, or endometrium pect him to give the necessary information, producing a chronic catarrh may, and, in acting, as he should, not only as adviser in my experience often does, effect a complete time of need, but as a protector of those in impediment to the entrance of the sperma- whom he should have an interest. Too tozoa. Polypi in the cervix, or growths little is known of the nature and harm ariswithin the uterus afford obvious and more ing from gonorrheal infection. This is a easily demonstrated causes of sterility. condition that may be trified with so long The uterus itself may, upon examination, as it is limited to the male, for they can be be found to be a probable cause, especially cured, but it is not so with the female to when found to be undersize, as in infantile the same degree. uteri. While this condition if appreciated in the second place, physicians who treat might readily be ascribed as a cause, we or are consulted in relation to the results of must advert to the fact that the true condi. treatment are not painstaking enough to tion is easily overlooked, for the reason be sure that all danger from inoculation that the cervix presents to the examining has been eliminated before marriage is finger often a practically normal size, which permissible. It is known that men capable if alone taken into account would not reveal of inoculation have married and had chilthe true condition. Bimanual examination dren with no serious results to the mother, might aid and suggest the sounding of its but this is the exception. Some women are depth, which would be found shallow, with more susceptible than others, so frequently thin walls. The endometrium is thin and is this the case and so disastrous may it beunsuitable for impregnation. With this come to them that no small number are uncondition is usually found an imperfect de- sexed by operations thereby made necesvelopment of all of the genital organs, sary. which may be early suggestive of an in- We are not prepared to accept the fantile uterus. Atrophy of the uterus, Negorath theory-gonorrhea once, gonorsimulating the infantile, may result follow- rhea always-in the male; in the female it ing a pregnancy in which some infective may be true, but we do subscribe to the betrouble has been experienced, and from lief that all cases can and should be cured which the patient may recover. Displace- before marital vows are taken. It has been ments and flexions of the uterus have been claimed that a large per cent of married considered by some as prolific causes of women applying for local treatment, are sterility. My observation has led me to re- suffering from a mild form of gonorrhea. gard them as merely factors not acting per Such being found to be the case, should se in any very pronounced degree. The suggest and exact an examination of the conical os has seemed to be often a causa husband, and if he is found to be possessed tive factor, especially when we had a so- of the exciting gonococci, as one in six called pinhole os. According to Sims 85 are, he should also be subjected to treatper cent of all cases of natural sterility” ment and quarantine. have a conical cervix.
The credulity and innate goodness of It is well recognized that long standing women has made it possible for men to catarrhal conditions of the cervix will lead impose upon and endanger their lives withto a stenosis of the canal and must be dif- out turning upon them the inexorable eye ferentiated from the above lesions. Young of investigation. When once they shall bewomen are frequently neglected who suffer come aroused to the full meaning of this for years with a chronic catarrh of the situation, they will, as in other matters, cervix and remain childless after marriage, rise up in righteous indignation and demand often charging it to the husband, sometimes a better and more wholesome state of things properly so.
before they surrender their bodies to the At this juncture we may profit in pausing slaughter. Were the condition reversed, legislative halls would be crying for legal “That it was an imperfection devoid of all protection and a higher morality with pop- perceptible, measurable characteristics." ular acclaim.
Placing sterility, as he did, as a law of Perhaps no symptom has been so fre- nature, it failed to gain any lasting hold quently charged with being the cause of upon the profession. sterility as dysmenorrhea, being encouraged After a careful review of the subject, and largely by no less an authority than Sims, bringing it down to date, we are forced and yet it has been proven that a large per more and more to recognize the most potent cent of dysmenorrheas are unexplainable cause to lie in the results of a gonorrheal and are often associated with conditions infection, either in the male or female. which when relieved and fertility estab- Rougy, in the Medical Record of February lished, still suffer from a dysmenorrhea. 18, 1911, reports 120 cases of sterility seen Not all dysmenorrheas, as was thought by in which the husbands were also examined Sims, are due to a stenosis of the cervix; and found 70 per cent due to gonorrheal inindeed, a large per cent are never under flammation. Dysmenorrhea was present in stood. The reaction of the vaginal secre- 84 per cent. Displacements not a great tion is of considerable importance in reach- factor, nor does obstruction seem to be a ing a diagnosis or the cause of sterility frequent cause. Leucorrhea in 95 per cent. The normal vaginal secretion is faintly Acid reaction in 20 per cent, all of which acid, if it should from any cause become is in full accord with our observations as strongly acid, the life and movement of the herein set forth. spermatozoa are jeopardized and sterility It is not necessary to advert to the treatresults. The cervical mucus is alkaline ment, as that inust conform to the findings. naturally, and favors the inward movement The sole object of this paper was to atof the spermatozoa, but if from catarrhal tract the attention of the physician to a processes it becomes acid, it, too, checks all closer observation of these unfortunate palikelihood of impregnation :
tients. Atrophied conditions of the ovaries, re
819 Gloyd Building. sultant upon such diseases as rickets, phthisis, diabetes, syphilis, tuberculosis, or
DISCUSSION. other toxic affections, should not be forgot- DR. LESTER HALL: Dr. Crowell's paper ten. The long continued use of morphine treats the subject thoroughly and leaves little to lessens the probability of fecundation, as
be added to what has been said. Personally I
find most of my cases due to obstruction. By realso does quinine, in the opinion of some. peated dilation until the os becomes patulent, Repeated ovarian congestions at the time many of these cases become pregnant. The part of puberty from various causes, now well that gonorrhea plays is recognized yet the gonoappreciated results in follicular cysts of the
coccus travels so slowly that the disease is often
cured before the infecting organism reaches the ovary and sterility.
endometrium. While we have essayed to indicate some I have dealt with a class of women not exposed of the etiological factors in the production to gonorrhea and have had good results as menof sterility suggestive of the necessity for a
tioned. Gonorrhea may be a remote cause. In
clinical practice it may be the most potential painstaking consideration in order that we cause, but I doubt if it is in the general practice may the more intelligently deal with such of most physicians. cases, we are not unmindful of the fact that
I would rather think the habit of not having we are not fully clear in regard to all the
babies is a more potential cause, fighting against
conception for years for a more suitable time to intricacies of fertility. We must admit
have their children. This brings on nervous disthat not every case of sterility will reveal turbances and a sympathetic endometritis results a cause, however carefully we may work to from cheating nature. There are many ways elicit it. On the other hand, we have,
this is done and the fact that men often with
· draw from the copulation act before the woman with apparent reason, given an unfavorable has experienced her orgasm may be a potent prognosis, to be in due time greatly sur cause. True, many times, the man is at fault prised, if not chargined. We feel con rather than the woman. There are many of the strained to caution gynecologists against a
modern ways of cheating nature out of her just
reward and, it seems to me, are more potential in preformed notion as to the usual cause of causing sterility even than gonorrhea. sterility, as was Sims when he claimed that the majority were due to mechanical causes,
DR. GEO. M. GRAY: Sterile women often are
desirous of having children, but are unable to do or of others who claim that it was due to a so. I cannot agree with Dr. Hall that the majorfunctional defect of the uterus, although it ity of these cases are due to stenosis of the cerwill be admitted that it may be either or a vix. In most of them the uterine sound passes combination of both. Matthews Duncan
easily. Many of them have an inflammation of
the cervical endometrium, causing a mucous plug brought out the theory that sterility was
to obstruct the canal very often. I think we are due to a “deficient reproductive energy.". justified in assuming that there is some obstruct
ion in the passage of the ovum to the uterus, or read several articles stating that very few peoan obstruction at the cervix, either from plugs or ple understood the art of perfect copulation, and due to the inflammation. I think beyond any while that may be true, yet it has nothing to do question, the majority can be attributed to the with pregnancy. Healthy normal women do beobstruction in the tube, due to some infection, come pregnant when spermatozoa find their way and there is no question but what gonorrhea is to the proper place. I knew one woman who the most frequent of all. In this country we are raised a family who has never had a satisfactory handicapped for full statistics, giving some idea copulation. Her husband is one of those rare as to the prevalence of this condition in the dif specimens, excitable, and usually ejaculates beferent nationalities. In Jewish women sterility fore entering, and if he did enter properly, she furnishes grounds for divorce yet they are as never experiences an orgasm, yet she has been free from gonorrhea as any people we see, though pregnant several times. I think there is freunable to conceive. If the obstruction is not at quently a condition existing in the ovum, or, the cervix or at the tube, we must look to the where the corpus luteum is not developed propmale for causes of sterility, such as gonorrheal erly and, when the ovum encounters the spermaepididymitis, mumps, and other infective condi- tozoa, the endometrium is not stimulated propertions. I have observed several young men af- ly by the corpus luteum to perform the product flicted with a double gonorrheal epididymitis who of conception. I have had several women tell me married and have never had children. It is not of passing a small clot a number of days after always the fault of the woman, but probably is copulation, which it seems to me may be in this most often in the woman due to the closure of type of cases. This is a complex subject and, the tubes.
in a large number of cases, after we have gone DR. HOWARD HILL: I do not care to discuss
over the entire category of troubles, eliminating the whole question of sterility in women. Is it
gonorrhea, we find they are still sterile. I would not a possibility that this is a complicated process?
not be surprised if they might have an atrophic Ovulation out of time without proper conditions
condition. We dislike to admit that gonorrhea of the uterus, alone, with the irregularities in
plays so important a part here, but I think it is menstration is a factor. We notice some of these
true. cases flowing once in two weeks, then sometimes
During the past few years shortness of the in a month, then twenty-one days and so on. This
vagina has been emphasized. If a woman is sort of a thing might bear an important relation
healthy, and the canal is open and if the endoto sterility it seems to me. There may also be
metrium is in proper condition, there should be conditions of the ovary interfering with the re
conception. lease of the ovum at the right time, as for instance a thickened tunica albuginia. It seems to me we must think of some of these other things
CASE REPORTS OF SYPHILIS. besides simply a mechanical obstruction.
(a) Clinical report, Dr. V. W. McCarty. DR. FROEHLING: There are two in the con (b) Pathological report. Dr. A. L. Skoog. tract to blame for sterility. Professor Case, of Heidelberg, made extensive investigation in sey
Male, white, American; 52 years; musi. eral thousand cases of sterility. He examined cian. the men and women too, and found the cause in Family History.-Two brothers dead of two-thirds of the cases in the women and onethird in the male, Inflammatory processes inside,
tuberculosis and one has attacks of vertigo outside, or in the neighborhood of the sexual or- and diplopia. One child dead of tuberculogans of the woman no doubt produces much of sis. the sterility. I agree with Dr. Hall in seeing more Personal History. - Thirty years ago had cases where gonorrhea did not figure, or, any abnormal condition of the sexal organs, and where
venereal sore diagnosed as chancre. Had I could demonstrate spermatozoa in the male yet
secondary sore throat and eruption over the woman was sterile.
body. Twenty years ago patient had cough DR. BELOVE: I have but one thing to say
with some bloody expectoration. A very relative to causes of sterility and that is that heavy drinker most of his life. Drunk ocsome cases of sterility may be due entirely to the casionally now. fact that the posterior part of the vagina, the Present Illness. -Patient complains of culdesac of Douglas, is shallow and due to the fact that it takes some time for the spermatozoa
growing more ''nervous" for fifteen years to travel to the cervix and the spermatozoa are
and of having difficult and frequent micturnot retained for a sufficient time for conception ition. Vague shooting pains with numbto take place. This is entirely a mechanical trou- ness of extremities the past three years. ble.
Ten months ago patient lost control of DR. H. C. CROWELL (closing): There are so many causes we cannot decide as to the cause
urinary sphincter; six months ago of of sterility. The shallow culdesac referred to by
sphincter ani. At the same time he began Dr. BeLove has been talked of a great deal dur having trouble with his legs, tired easily, ing the last year. As to this I do not know, I and could not walk steadily. Difficulty in have never had a case of that kind. The arrest of the ovum in passing is an impor
speaking, and in playing the violin and tant consideration.
coronet developed. Walking, lifting his Relative to flexions I do not think there are many left leg and descending stairs became diffithat produce sterility. Spermatozoa will find
cult. Two weeks ago he had a severe attheir way through a small opening and as for the particular peculiarities of certain individuals in
tack of vertigo, with diplopia, lasting five egard to copulation I question whether this has minutes with similar attacks daily; anything much to do with the subject. I have later he became quite deaf. He is now
anemic, shows a loss of weight and some fication. A positive Wasserman is not only suggesatrophy of leg muscles, especially on the
he tive of syphilis by itself but is suggestive of a slight
or a considerable degree of a continued syphilitic left side. He is clear mentally. Pupils
activity. respond sluggishly to light and accommo Again the high lymphocytosis linked to the clini. dation. Tongue has slight fibrillary tre: cal history is significant; in this relationship it mor. Motor power generally impaired.
points to a specific or para-specific pathology. The
essayist's statement of the lateral pyramidal tracts Rhombreg sign marked. Ataxia well de
being the seat of the lesion is true only in part in as veloped. Intention tremor slight. Babin. much as his further clinical descriptives indicate ski and Oppenheim's signs positive. All ten- even more damage to the ingoing or sensory route. don reflexes increased. Abdominal and
This would indicate a previous or present spinal cord
syphilis, leading again to Dr. Skoog's question as to skin reflexes absent. Cremasteric reflexes
whether we now have a para-specific condition; I sluggish. Tactile sense normal. Lynıpho- think we have. cytes, uncentrifuged specimen, 70 to cu. DR. MILLER: Another point. The Wasserman mm. Wassermap reaction negative. No- both in the cerebro-spinal fluid and in the blood was guchi butyric acid reaction prompt and negative, while the Nouguchi test was positive, positive. Nonne-Aplet test prompt, cloud
showing these cases of late syphilis can be detected
by the Nouguchi and butyric acid tests; they being ing and curding. Luetin test mildly posi- of more value than the Wasserman in either blood or tive.
spinal fluid. Differential Diagnosis. -1. From heredi- DR. SOPHIAN: If I may be permitted, I should tary spastic. paraplegia, by lack of history, like to call attention to the cerebro-spinal fluid in, by ataxia, sphincter and cerebral symptoms. these cases referred to. A lymphocytosis in these 2. Combined scleroses by vagueness of cases is not diagnostic of syphilis, because lympho
cytosis is commonly seen in other types or condientity.
tions. First, tubercular meningitis often shown up 3. Diffuse myelitis, by the symptoms re to 99 per cent lymphocytes. Another common conferable to the brain.
dition is infantile paralysis, making as high a differ4. Tabes dorsalis, lack of Argyll-Robert
ential count practically as tubercular meningitis.
The other type is syphilis of the central nervous son pupil, by increase of deep reflexes, lack
system. A point to bear in mind is that lymphocy. of optic atrophy and crises.
tosis is not diagnostic, but only suggestive. 5. Paralytic dementia, lack of character Nouguchi's test referred to also is simply signifiistic mental disturbances as changes in
cant of an increased proteid element, which simply character, delusions of grandeur, cerebro
means an inflammation in the central nervous sys
tem, so I think the only positive examination of the spinal fluid findings against.
fluid present in syphilis of the central nervous sys. 6. Multiple Sclerosis.-Of extreme diffi- tem, not present in other conditions, is the positive culty to differentiate. Against it is age of
Wasserman. The Wasserman in these cases is often
negative, but a positive Wasserman is more than patient, 52, and the definite history of lues.
suggestive and means something. Increased proFor such a diagnosis is a mild, not classical teid content only, is what the other tests show. intention tremor, a speech defect, hardly They are not of absolute diagnostic significance. I scanning, hystagmoid movements with ver
saw a case several years ago where diagnosis of in
fantile paralysis was made before the paralysis aptigo, spastic weakness, sphincter involve
peared. One of the earliest diagnoses was made by ment and lost abdominal reflexes.
Dr. Flexner. Paralysis appeared later, and Dr. Diagnosis. - Late cerebrospinal lues, Flexner had already predicted infantile paralysis. para-specific in type; on history of lues,
He found positive Nouguchi test, high lymphocytocerebrospinal fluid findings and reflexes so
sis, the inflammation coming on with general con
stitutional symptoms. With fever and high lymoften found in late specific lesions of the phocytosis, one is warranted in suspicioning infanspinal cord; the multiplicity of symptoms tile paralysis. I saw a case, with acute onset, and and the regions involved; spinal cord, lat
with the same picture in the spinal fluid, and I made eral columns, particularly pyramidal tracts,
the diagnosis before the paralysis appeared. In the
cases of syphilis of the central nervous system, the but not the anterior horn cells. The brain
Wasserman is necessary it seems to me to make a changes limited to base, may be meningeal positive diagnosis. or nuclear changes.
DR. LYLE: Notwithstanding the results of these in other things than syphilis of the nervous system. The relation between love and sexual de. For instance in infantile paralysis before paralysis
tests in diagnosis, their reliability, etc., I would (b) Pathological report, Dr. Skoog. like to ask what are we to do with these cases? One (Dr. Skoog read notes on pathological
we see treated with 606 may make a recovery, an
other, treated with mercury makes a recovery, specimens from two patients. Then Dr. while in other cases, both fail. What are we to go Skoog showed slides projected.)
by? What is the general practitioner going to do?
Are we to use the arsenical preparation to treat these, DISCUSSION.
or should we use the old mercury treatment, and
hope for results? These are some of the things I S. GROVER BURNETT: There is not much to would like to be enlightened on. add to Dr. Skoog's definite, detailed clinical findings, leaving little mystery as to the diagnosis, notwith DR. SKOOG (closing): I did not rely on any of standing a negative Wasserman. A negative Was- these things as diagnostic. We have to consider serman does not exclude syphilis but it does sup- every factor, and that is what I tried to do here. I port the doctors contention of a para-specific classi- am cognizant of the fact that we have lymphocytosis
sire is dual and in its better phase is little appears, in tuberculosis and I had one case of multiple sclerosis with active lymphocytosis.
understood. Sexual desire does lead to atI have classified this man as a para-syphilitic. tachments between man and woman. On While we so classify tabes and paretics it is a ques. the other hand, love for a man instinctively tion of whether we have a right to do it here, or is this a plain case of syphilis. Some rely too much,
prompts a normal woman to wish to mother I think on 606 for these cases. This patient has
his child. never had 606. He is better today than six to eight From all this generalization I desire to weeks ago. He received mercury, and is now on an report a case of an entirely different kind, iodid preparation.
one in which the woman desired motherhood for financial reasons. After corres
pondence I met her at a hotel in IndianSOME CHILDLESS WIVES. apolis. She had written for me to meet her
at a certain date, in her home city, but had SECOND PAPER.
fixed a time when I would be in attendance G. HENRI BOGART, M. D., Paris, Ill.
on a convention, and I so wrote her. The
morning of the convention, I had not been Barrenness was once woman's most in the lobby of the hotel where our associadreadful fate, back in those days when "Go tion foregathered, for fifteen minutes until ye forth and replenish the earth" was I was paged out. She was in the city, waitspoken, and thence to the pioneer days ing me at another hotel. Angered, I sent when the family greeting to the bride and her messenger back with a note making an groom, as they turned from the altar was appoinment for 8:30 in the evening. My "May you live long, prosper, and have big cavalier treatment resulted partly from rebabies.” And the big babies were an ele. sentment that she had presumed to come on mental part of the prosperity, for each boy for consultation regardless of my conveniand girl was a valuable asset in the earlier ence, and partly because of disgust for her days of the pioneer. It was a disgrace, or mercenary reasons for desiring maternity. at least a misfortune, not to have children. A childless uncle wished to make her But the old order changeth, and instead of husband his heir, provided there were chil. a dozen or more olive branches the family dren to perpetuate the family,otherwise anof une and two became more frequent than other nephew was to inherit it. She was greater numbers.
anxious that the money should come to her At the same time the long rows of tiny husband. When I came to her room, I found tombstones in family burial lots are no her a magnificent jewess married at sixteen longer common.
and now thirty. She had brought written Prevention of pregnancy became more reports from examinations of both herself common and by the crudest methods. Va. and her husband. ginas were tanned into leather by astrin- A careful reading of these reports congent douches and washes. Fallopian sec- vinced me that neither partner should be tion as a preparation for marriage was re- sterile. sorted to. It was to this illicit operation, for a long time I talked with her hoping indeed, that the world is indebted for the to stumble on to a solution. Finally I boon of sterilization by vasectomy.
learned that orgasm occurred much more Thus was repeated the truth of that age quickly and forcibly with her than with the old truism told in Samson's riddle, “Out of husband. This, with a sharply acid reacthe eater came forth meat, but of the tion of the vaginal secretions offered a pos strong came forth sweetness.” Some of sible answer. At orgasm the uterus after these women have later come to know the its usual suction action, would close firmly holy desire for maternity, and have come and exclude the semen ejaculated later, begging oh, so piteously that the severed while the acid secretions would kill the tubes be reunited, but I have never known spermatozoa, before admission to the uterus the operation successfully performed, either was possible. in the male or the female.
I explained this to her and advised that There are some of these women who had she procure a bivalve speculum and a long contracted loveless marriages, mere sexual smooth syringe. Before coition thoroughly partnerships for reasons of finance, social cleanse the vagina with borax solution. position, or other conventional cause, who Then after intercourse the speculum was have later developed love and affection to be introduced, the semen taken up in the strong as their nature will admit. These syringe then injected into the uterus. I inwomen, invariably desire to bear a child sisted upon the speculum, and also that in for the husband who later became a lover. the first instance the husband should have