Differential Diagnosis of Male and Female Infertility
Infertility resulting from venereal diseases posed many diagnostic difficulties. Doctors were hampered in their ability to diagnose and treat the effects of syphilis and gonorrhoea upon their patients’ fertility. Even with the development of bacteriological and serological testing, the venereal aetiology of a patient’s infertility was difficult to confirm. Venereal diseases did not always result in infertility and doctors found that many infertile patients demonstrated few clear signs of venereal infection.
Comparatively few medical publications addressed the effects of venereal diseases upon male fertility, and even fewer described how doctors might go about diagnosing infertility among their male patients.15 Although gonorrhoeal infection was initially thought to be more serious for men than for women, its detrimental effects upon male fertility were never widely addressed. Likewise, the effects of syphilis upon male fertility were overshadowed by discussion of infertility among women, and by wider concerns over conjugal and congenital infection.
Such an omission was due, in large part, to the belief among doctors that the male reproductive organs were less complex than those of women and therefore less susceptible to complications resulting from venereal infection.16 Although R.A. Gibbons conceded in 1910 that doctors were yet fully to comprehend ‘how much men are to blame for sterile marriages’, he also reminded his postgraduate audience at the Medical Graduates’ College that ‘in many cases of sterility about which you will be consulted it is undoubtedly the fault of the woman’.17 He was not alone in this opinion, which demonstrated prevailing uncertainties and disagreement over the effects of venereal diseases upon male fertility. Doctors devoted considerably less attention to the problem of male infertility (along with its diagnosis and treatment) because it was thought to be such an uncommon condition. Indeed, in 1896, Robert Bell opened the first chapter of his book Sterility with the following observation:
In considering the important subject of sterility in the female, we must not forget the fact that occasionally impotency may exist in the male. This is of such rare occurrence, however, that it may be looked upon almost as phenomenal; moreover, when it does occur, it can generally be traced to the effects of some previous gonorrhoeal or syphilitic attack.18
With few exceptions, medical authors rarely addressed the need to examine and treat both women and men. It may have been increasingly common for infertility or miscarriage to result in a diagnosis of venereal infection among women, but there were few recorded cases where a wife’s apparent infertility prompted the attending doctor to examine her husband or to diagnose him as infertile. The assumption that male infertility was a rare occurrence was, in some respects, a self-perpetuating conclusion. Doctors, convinced that male infertility was uncommon, were less inclined to examine the husbands of seemingly infertile women, and in so doing concluded that the ‘fault’ usually lay with those women.
On the occasions that male reproductive complications were addressed in medical literature, authors usually framed their discussion using the diagnostic category of ‘impotency’. Throughout the nineteenth and early twentieth centuries, medical authors rarely made a clear diagnostic distinction between infertility and impotency.19 As Arthur Cooper, surgeon to the London Lock Hospital, observed in his 1908 book, The Sexual Disabilities of Man,
It not uncommonly happens that, unless the husband is clearly incompetent as regards copulative power, the fault is, as a matter of course, attributed to the wife, and only when the gynaecologist has failed is the husband suspected and submitted to examination [... ] whilst it is quite common for medical advice to be sought respecting the copulative power, it seems to be comparatively rare for a man before marriage to have any sort of doubt or anxiety respecting his procreative power.20
So rare, in fact, that two years later Gibbons had to remind his postgraduate audience that ‘potentia coeundi does not necessarily mean potentia generandi (‘copulative power does not necessarily mean reproductive power’).21 Yet if a man was not impotent, it was very difficult to determine empirically whether he was infertile and whether his infertility was a direct result of venereal infection. Although medical authors occasionally attributed impotency to gonorrhoeal and syphilitic complications, it was more often than not identified as a neurasthenic disorder, or as a consequence of sexual excess or masturbation.22
Throughout the 1880s and 1890s, English doctors remained divided over the American gynaecologist Emil Noeggerath’s (1827-95) assertion that gonorrhoea was the cause of much sterility among women and men.23 Many were also divided over the effects of syphilis upon male fertility. The Austrian urologist Victor Vecki (1857-1938) had claimed in his 1901 book Sexual Impotence that stricture resulting from syphilis could ‘very often cause impotence, and [was] moreover, always a hindrance to fecundation’.24 By contrast, Samuel Gross, like many of his medical contemporaries, believed that venereal diseases did not appear to exert much influence upon male fertility.25 Although Cooper identified gonorrhoea as the primary cause of azoospermia (a zero sperm count), he also maintained that
syphilis may cause azoospermia when the testis or epididymis is affected [... ]. But apart from lesions of the genital organs themselves, syphilis probably does not often prevent fertilisation of the ovum, though it causes immense destruction of life by killing the fetus later on.26
Inflammation, abscesses, ulcers, urethritis (inflammation of the urethra) and stricture resulting from venereal infection might all cause either impotency or infertility. Yet most medical authors who wrote about gonorrhoeal and syphilitic infection among men focused on the diagnosis and treatment of these associated conditions without directly addressing their effects upon reproductive health.27
A diagnosis of venereal disease relied upon a physical examination and, increasingly, upon a bacteriological examination. A man’s genitals were examined for signs of infection and any discharge might be subjected to bacteriological examination. However, these examinations were intended to determine the presence of infection, not whether this infection had rendered him infertile. The development of the urethral endoscope allowed doctors to determine the effects of venereal diseases upon the mucous membrane and, by extension, their effects upon a man’s sexual health. However, the health of a man’s spermatozoa could only be established through a microscopical examination of his seminal fluid. In his 1887 treatise on venereal diseases, M.K. Hargreaves had argued that these diseases potentially brought about the degeneration of spermatozoa and that the presence of pus in the semen, whether as a result of abscesses or inflammation, could be indicative of infertility.28 Yet as Gross lamented in that same year, doctors often neglected to test their patients’ seminal fluid and to examine the genitalia carefully.29 Almost 20 years later Cooper made a similar observation that ‘only when the gynaecologist has failed is the husband suspected and submitted to examination’.30 Such omissions on the part of doctors to examine their male patients meant that little was known about the relative frequency of infertility among men and women.31 Only bacteriological examination could conclusively demonstrate a man’s infertility or link that infertility to an underlying venereal infection.32 Without such examinations, doctors could not say with certainty whether a husband, rather than his wife, was infertile.
Yet few medical authors believed that, before automatically diagnosing a woman as infertile, it was necessary to determine through physical and microscopical examination whether venereal infection had rendered her husband infertile.33 Few reminded their readers, as J. Matthews Duncan, lecturer on midwifery at St Bartholomew’s Hospital, had done in 1883, that ‘fecundity [... ] requires the combined matter and forces of two duly developed individuals’.34 Arthur Edis, senior physician to the Chelsea Hospital for Women, was another important exception, arguing in 1890 that
the fact should not be forgotten that [... ] [a woman] may be potentially fertile, conception not taking place from the absence of healthy living spermatozoa on the part of the husband to impregnate the ovum. It has been proved conclusively that men in robust health [... ] may have no living spermatozoa in their spermatic fluid. This may be due to [... ] some antecedent inflammatory condition of the testes, notably from orchitis, the sequel of gonorrhoea.35
However, such views were a minority medical opinion, with many doctors, such as Gibbons, considering it advisable to examine a man’s seminal fluid only if no irregularity could be found upon examining his wife.
By the 1890s the serious consequences of venereal diseases, especially gonorrhoeal infection, for female fertility (and female health more generally) were beginning to be recognized as far more common.36 As we have seen in the case attended by Kenealy, women infected with syphilis often demonstrated a distinctive pattern of infertility that also helped to confirm the medical opinion that women’s reproductive health was more susceptible to complications resulting from venereal diseases. As a result, late-nineteenth and early twentieth-century medical literature focused primarily upon the prevalence, diagnosis and treatment of infertility among women. By 1913, witnesses before the Royal Commission on Venereal Diseases (RCVD) were estimating that up to 35 per cent of married women in England were childless and they attributed a large proportion of these cases to syphilis and gonorrhoea.37
Yet despite such growing certainty about the effects of venereal diseases upon female fertility, there was little guarantee that a woman’s infertility could be conclusively diagnosed as a result of venereal infection. This was especially problematic in the years before and immediately following the identification of the gonococcus and the spirochete (along with the development and wide application of reliable laboratory-based testing). In 1888, the obstetric physician Thomas More Madden had argued that sterility was ‘commonly the result of some structural lesion, malformation [... ] certain morbid constitutional conditions, as well as [ ...] other causes such as sexual incongruity or irrespon- dence of a moral rather than of a physical kind’.38
Although such sexual incongruity might have encompassed syphilis and gonorrhoea, Madden made no specific reference to either disease as a cause of infertility. In that same year, J. Beresford Ryley, Fellow of the British Gynaecological Society, addressed the effects of salpingitis (infection and inflammation of the fallopian tubes) upon female fertility, but only in the context of uterine leucorrhoea (discharge) and hyperplasia (enlargement of the uterus and often an early sign of cancer).39 Although, in 1891, the gynaecologist George Bantock (1837-1913) acknowledged that gonorrhoea could cause salpingitis in some cases, he questioned whether there was any direct aetiological correlation.40 Ryley attributed the cause of leucorrhoea and hyperplasia to, among other things, miscarriage, but did not speculate upon why women might miscarry or why they suffered acute discharge or inflammation in the first place. His only conclusion was that ‘miscarriage during the first six to 12 months of marriage is much more frequent than is supposed, and very much more serious than it is usually regarded’.41 The epidemiology of these miscarriages was not speculated upon.
On the one hand, women with venereal diseases could be rendered completely or partially infertile. They might be unable to conceive or they might conceive and then miscarry or suffer stillbirths. On the other hand, gonorrhoea and syphilis could produce many troubling physiological conditions in the children that infected women were able to carry to full term. Venereal infection did not necessarily prevent conception. David Watson, surgeon to the Glasgow Lock Hospital, was among numerous doctors who conceded that gonorrhoeal infection could precede, coincide with, or follow conception. He argued in 1914 that pregnancy appeared to ‘furnish the gonococcus with the conditions which favour its growth, the symptoms are more marked, exacerbations more frequent, and complications more liable to supervene’.42 As we have seen in the case attended by Kenealy, the same was also true of syphilis and its effects upon female fertility and infant health.
Children might be born with characteristic signs of congenital syphilis or with gonorrhoeal ophthalmia neonatorum, while other children might demonstrate no discernible signs of infection.43 For example, Bantock had criticized Noeggerath and his supporters, including William Japp Sinclair (1846-1912), professor of obstetrics and gynaecology at the University of Manchester, who argued that gonorrhoea caused innumerable cases of sterility among men and women. Bantock denied having seen ‘a single instance’ of male sterility caused conclusively by gonorrhoea. He also challenged Noeggerath and Sinclair’s argument about gonorrhoeal infertility among women by calling attention to the large numbers of newborns who developed ophthalmia neonatorum following the transmission of gonococci from their mothers.44 Indeed, in cases of latent gonorrhoea, the birth of such infected children was often the best, and perhaps the only, indication of infection among their mothers.45
The fact that many infertile women did not demonstrate clear signs of venereal infection and the fact that other women with diagnosable symptoms were able to carry children, infected or otherwise, to full term meant that the venereal aetiology of infertility remained a subject of medical debate for many decades. This complex and seemingly inconsistent correlation between venereal infection and infertility created problems when attempting to understand and anticipate the effects of venereal diseases upon women’s reproductive health. A focus on complications resulting from venereal diseases during pregnancy meant that the problem of infertility was comparatively overlooked. The unpredictable effects of venereal diseases upon individual women meant that the aetiology of their reproductive complications was not necessarily diagnosed or even diagnosable.
Historians have suggested that standards of modesty prevented doctors from thoroughly examining respectable female patients, instead taking them at their word that they had never suffered from the characteristic symptoms of venereal infection.46 Certainly, mid-century doctors were often performing female genital examinations by touch, with eyes averted for the sake of modesty. By 1886, with the repeal of the Contagious Diseases Acts, the speculum had become synonymous with ‘intrusion’ into the female body and its use in genital examinations was a source of much disagreement among doctors.47 Cursory examinations and reliance upon patient accounts of health and illness undoubtedly impeded the development of knowledge about the effects of venereal diseases upon female fertility.
Yet available sources furnish us with detailed descriptions of genital sores and discharges, suggesting that at least some women, respectable and unrespectable alike, were being carefully examined.48 Arthur Edis (1840-93) claimed that ‘whenever we are consulted in a case of sterility, the patient [... ] comes prepared to submit to a careful investigation’.49 These investigations included thorough physical examinations in which the hymen, vagina and uterus were checked for signs of inflammation, discharge, ulceration and any other irregularities. However, as doctors such as James Ernest Lane (18571926), surgeon to the London Lock Hospital, increasingly acknowledged, such physical examinations could not detect latent or asymptomatic infections.50 In many cases there were simply too few clear signs of syphilitic or gonorrhoeal infection to determine the aetiology of a woman’s infertility.
The asymptomatic presence of gonorrhoea meant that infection frequently went unregarded or misdiagnosed until it became acute. As the historian Michael Worboys has demonstrated, Sinclair was initially the only doctor in Britain to accept Noeggerath’s claims that innumerable women were being infected by husbands who, guided by their doctors, did not appreciate the seriousness of their gonorrhoeal condition. Many of these women consequently went undiagnosed and untreated until they presented acute symptoms, potentially resulting in infertility and requiring surgical intervention.51 In 1909, Frances Ivens (1870-1944), medical officer for diseases of women at the Liverpool Stanley Hospital, reiterated concerns that doctors without adequate gynaecological knowledge or experience would fail to comprehend the prevalence and severity of gonorroheal infections among women patients. As a result, ‘cases may be regarded as simple leucorrhoea, cystitis or pelvic inflammation, unless a searching inquiry is made into their aetiology’.52 Such inquiries having been neglected, a woman would enter an acute stage of infection. In 1906, Charles Leedham- Green, senior surgeon to Queen’s Hospital and lecturer on bacteriology, concluded that, in such cases, the gonococcus did not remain localized but rather ‘spreads insidiously to the uterus, tubes, ovaries and peritoneum, giving rise to grave trouble and danger’.53 Women in this acute stage of infection often experienced pelvic inflammation and pain, vaginal discharge, painful micturition and menorrhagia (a collection of symptoms now classified as pelvic inflammatory disease).54 By the turn of the twentieth century, doctors were increasingly aware that women suffering from these symptoms of acute infection, as well as a variety of associated conditions such as endometritis (inflammation of the lining of the uterus) and salpingitis, were also likely to be rendered infertile.55
Empirical practices were central to the diagnostic process. But how could doctors confidently diagnose patients who demonstrated few clear signs of venereal infection? Before the development of bacteriological and serological testing, women presenting obscure symptoms were exceptionally difficult to diagnose. Although not applicable in cases of gonorrhoea, a woman’s pattern of infertility was often a key indication of suspected syphilitic infection. This distinctive pattern of neonatal and antenatal complications was defined by Kassowitz’s Law (1875), which stipulated that the severity of congenital transmission decreased with each new pregnancy.56
In 1887, Jonathan Hutchinson wrote of one case brought under his care in which the wife of a fellow doctor, supposedly having escaped infection from her husband, demonstrated a clear pattern of syphilitic infertility.57 His patient demonstrated no clear signs of infection, but she had experienced two stillbirths, and had then given birth to another two children who had died in infancy ‘with the usual symptoms of inherited disease’. Although the next seven children lived, each displayed clear signs of congenital syphilis. ‘Thus’, Hutchinson concluded, ‘it would appear that eleven conceptions have in succession been tainted’. Florence Willey (1867-1945), assistant physician for diseases of women at the Royal Free Hospital, was still drawing upon this empirically based principle of diminution in 1914. It enabled her to determine whether, in the absence of clear physical symptoms, her patients were suffering from syphilis. These ‘were cases in which the woman had miscarried two or three times, or had had one or two miscarriages, a stillbirth, or possibly then a child dying within the first four weeks of life’.58 As James Sequeira (1865-1948), physician to the skin department of the London Hospital, observed when discussing this phenomenon before the RCVD, ‘there would [otherwise] be no possibility of treating them because they have had no symptoms to treat’.59
With the identification of the gonococcus in 1879 and the spirochete in 1905, as well as the development of new diagnostic technologies such as Gram staining and the Wassermann reaction that allowed these microorganisms to be detected, doctors were better able to determine whether infertile women were suffering from a venereal infection and whether that infection might have caused infertility. For example, witnesses before the RCVD cited various cases in which seemingly asymptomatic women gave birth to congenitally syphilitic stillborn children. Following the identification of the spirochete and the development of serological testing, these children were often examined pathologically in order to confirm the presence of syphilis in their mothers. Thomas Barlow (1845-1945), President of the Royal College of Physicians, described one infant case in which ‘the interior of the body [was] swarming with spir- ochaetes’.60 Such children were a ‘more virulent source for cultivating that organism than any acquired case could be’.
When determining the effectiveness oftreatments, doctors were increasingly reminded of the necessity to follow up empirical observations with bacteriological or serological examinations ofurethral or cervical smears to determine the disappearance of the causative microorganism. In many cases of suspected gonorrhoea encountered at the Liverpool Stanley Hospital, Ivens first checked for a history of pelvic inflammation following the first menstruation after marriage, painful micturition, sterility or the presence of ophthalmia neonatorum if a woman was able to conceive and give birth to a living child. She then confirmed her observational diagnoses by bacteriologically examining discharges from the urethra, cervix, Bartholini’s ducts or pelvic abscesses.61
However, in many cases this was an ideal rather than a realistic practice. Doctors may have been motivated by the prospect of professional advancement to remain abreast of new medical ideas and practices. Yet many were slow to acquire the up-to-date knowledge, skills and laboratory facilities necessary to employ new diagnostic tests, to use the results of such tests to determine the reproductive health of their patients and to implement treatments based upon those results. As Szreter demonstrates, doctors - especially older generations of general practitioners - were also reluctant to abandon traditional diagnostic practices in favour of new technologies that they did not wholly understand and in which they had limited confidence.62 In 1891, Bantock had asserted that the test for the gonococcus was ‘so delicate and complicated that it [was] practically of little use’, and therefore doctors should ‘fall back on rigid clinical observation in order to arrive at definite and exact results’.63 The cost of these new technologies, especially the Wassermann test (at between 10s.6d. and ?2.2s. per reaction), made them impractical tools for most doctors working outside of the larger general hospitals.64 Diagnostic practices reliant upon the presence of a collection of observable symptoms were not quickly displaced or modified by new understandings of micrococcal causation or by developments in bacteriological or serological examination.65