The Practicalities and Limitations of Treatment
Far more information is available regarding the constitutional treatment of syphilis and gonorrhoea, as opposed to specific treatments for venereal disease- induced infertility. There was still much uncertainty surrounding the treatment and treatability of infertility caused by venereal diseases. On the few occasions when specific treatments were discussed, doctors generally agreed that it was first necessary to treat the underlying infection and only then to address the specific problem of infertility.66 This combined treatment could be both localised and constitutional, invasive or non-invasive, according to the therapeutic preferences of the attending doctor and the needs of individual patients.
By the turn of the twentieth century, developing bacteriological understandings of gonorrhoea and syphilis were slowly changing how doctors treated their patients. The effectiveness of treatments such as antigonococcal vaccines and salvarsan were beginning to be thought of in terms of their specificity for isolating and destroying gonococci and spirochxtx. The ability to test for the presence of these microorganisms gave doctors a new benchmark from which to determine the effectiveness of treatments. However, as we have seen, the implementation of these technologies was a slow process. Furthermore, these new methods of microscopical testing were designed to determine the disappearance of the causative microorganism of infection, not whether the disappearance of that microorganism had also restored the patient’s fertility. Although doctors implicitly assumed that the alleviation of physical symptoms would have a positive effect upon the fertility of men, venereal diseases were thought to cause serious and often irreversible damage to women’s reproductive health. New diagnostic technologies could determine the effects of treatment upon constitutional infection but not upon fertility, especially the fertility of female patients.
Although the introduction of salvarsan in 1909 transformed the treatment of syphilis, its use before the First World War was limited to a select few hospitals and infirmaries. The serious side effects from incorrect or wrongly administered doses meant that its administration required a level of skill considerably beyond that of the average general practitioner. it is unsurprising, therefore, that its therapeutic benefits and mode of administration were not widely discussed in pre-war medical writings on infertility caused by venereal disease. Like salvarsan, antigonococcal vaccines developed during the first decade of the twentieth century were designed to combat infection at a microbial level, but were not commonly administered as treatments for, or preventatives against, infertility. The only instance of this treatment being recommended in cases of infertility was by Gibbons, who advised that any vaginal discharge ‘be carefully examined bacteriologically for gonococcus [... and] cultures may be made from the discharge and a vaccine prepared accordingly’.67 On the whole, however, doctors continued to favour more traditional surgical interventions and chemical compounds.
Despite therapeutic developments and despite new understandings of the potentially serious implications of venereal infection for reproductive health, many men and women continued to receive inadequate treatment. Doctors regularly expressed concern about the challenges of persuading patients to persist with their entire course of treatment. As Leedham-Green lamented, patients were likely to wrongly regard themselves as cured and therefore end their treatment prematurely: ‘As soon as the acute symptoms have subsided, and the pain and copious discharge have disappeared, he is likely to consider his complaint to have passed away, or at any rate to be no longer of importance’.68
As historians such as Roger Davidson have argued, fear of mercury’s side effects led some patients to terminate their course of treatment and seek therapeutic alternatives.69 Various doctors also cited cases in which they were called upon to treat the wives of husbands who, anxious to avoid arousing suspicion, were reluctant to persist with lengthy and unpleasant courses of treatment.70 As we have already seen in this chapter, husbands - guided by the medical opinions of their doctors - did not necessarily appreciate the seriousness of their condition or that of their wives, and consequently both received inadequate treatment.71 Such untreated or inadequately treated infections might eventually become acute. Only when serious complications arose would a concerted effort be made to administer a full course of treatment, by which time the patient’s reproductive health was likely to have suffered.
A prevailing diagnostic ambiguity between impotency and infertility meant that there was considerably more ambivalence over available treatments for infertility among men. Since venereal diseases were thought more likely to cause infertility among women, doctors were primarily concerned with the treatment and treatability of female infertility. The treatment of men was not generally discussed in terms of preserving male fertility but rather protecting the health of their wives and any potential children.
As we have seen, infertility was often inseparable from impotency, and it was not until the development of bacteriological testing that doctors were able to determine the effects of treatment upon a patient’s spermatozoa and therefore upon his fertility. Yet even in cases of suspected infertility, the primary concern was the alleviation of physical symptoms such as urethritis through the application of constitutional and local treatments. If a man’s spermatozoa was thought to be affected, it was hoped that the localized treatment of his physical symptoms, along with the constitutional treatment of his venereal infection, would in turn influence the health of his spermatozoa. According to Cooper, gonorrhoea was the chief cause of azoospermia, and in such cases he recommended bed rest together with support and gentle massage of the scrotum, and treatment of the underlying gonorrhoeal infection.72 In difficult cases, he also recommended combination treatments of potassium iodide and mercury. If local applications of mercury were employed, they needed to be diluted with lanolin and almond oil. Hargreaves similarly argued that, in cases where male sterility was a symptom of an underlying venereal infection, the primary concern was to treat that infection through the ‘usual methods’:73
Sterility from syphilis is best cured by resorting to the mercurial and iodide treatment and inunctions of mercury in the groin. When the impoverished semen arises from inflammation and induration of the two epididymis we must insist on rest, purgatives and saline medicines combined with vinum antimonii, and tincture or aconite until nausea is complained of, the scrotum being raised by a suspensory bandage, and cooling lotions used.74
In these discussions about treatment there was an implicit belief that the patient’s fertility would be restored. If venereal diseases could be successfully attacked at a microbial level, and severity of the physical symptoms alleviated, the general health of the patient would improve and so too might the health and number of his spermatozoa.
Since women were more likely to be diagnosed with infertility, discussion of treatment was tailored to the needs of infertile women. Despite accounts of mistreatment or neglect on the part of husbands and doctors, and despite Kenealy’s actions in the case of her own patient, it was increasingly accepted that venereally diseased women required immediate treatment, especially if their reproductive health was to be preserved. Kenealy’s decision to withhold treatment from a syphilitic mother lest it save a potentially degenerate foetus was extreme, and vehemently criticized in the medical press.75 Some letters to the Editor of the BMJ were supportive of her general concerns for the health of mothers and the problems of infertility caused by venereal diseases. However, few countenanced her decision to withhold mercury in the hope of inducing a miscarriage. Kenealy’s professional contemporaries criticised her for acting on her eugenic principles. Her actions were, at best, unprofessional, and, at worst, criminal. They maintained that, rather than relying on the discretion of ‘Nature’, Kenealy should have employed her scientific knowledge and clinical skill to provide the best possible care to restore her patient’s health.
Doctors may have asserted the importance of swift and thorough treatment but they also understood that available treatments for venereal diseases had limited therapeutic effect and were often messy, protracted, and the cause of much discomfort.76 If administered too regularly or in overly concentrated doses, mercurial treatments could have a variety of dangerous side effects. Kenealy withheld mercury in an attempt to induce a miscarriage. Yet some doctors suggested that the administration of compounds normally used to treat syphilis could have potentially detrimental effects upon foetal development and could themselves induce miscarriages.77
By the early twentieth century, doctors such as Watson were asserting that, in cases of gonorrhoea, ‘the antiseptics chosen should have at the same time the greatest penetrating and the least irritating action on the tissues as well as the highest specific bactericidal effect on the gonococcus’.78 As with the new combination mercury-salvarsan treatments, these chemical solutions were designed to attack venereal diseases at a microbial level. However, as will be seen, the application of these various chemical solutions was intended primarily to alleviate the symptoms of constitutional infection. They were rarely administered to counteract the specific effects of venereal infection upon a woman’s fertility. Mercurial compounds might reduce the possibly of a child being born with signs of congenital syphilis, and the application of strong antiseptics might prevent a child from developing gonorrhoeal ophthalmia neonatorum. These treatments might even have prevented a woman from becoming infertile. However, once infection had become so acute as to impede conception, these treatments had little therapeutic effect.
Compared to infertility among infected men, the damage inflicted upon a woman’s reproductive organs was commonly thought to be irreversible.79 Unlike cases of male infertility, where specific local treatments were thought to have a positive influence upon the quality and quantity of a man’s spermatozoa, corresponding treatments for women could only alleviate the genitourinary symptoms of an underlying venereal infection. Watson concluded that ‘whether a woman is rendered sterile or not depends on the areas involved and the amount of damage inflicted’.80 He lamented that
it is, in fact, a hopeless task to attempt to abort gonorrhoea in the female. Cases at a stage of infection sufficiently early to make this procedure feasible rarely come under observation, and although the cervical and uterine tissues may be subjected to a much more energetic treatment than is possible in the male urethra, no line of radical treatment short of hysterectomy promises much hope of success.81
If infection was so acute as to render a patient infertile, there was little that could be done to reverse the tissue damage. The treatments most commonly called upon were those that alleviated inflammation or targeted a build-up of pus in or around the fallopian tubes and ovaries. These treatments offered little guarantee, and doctors could do little more than hope that they would have a positive influence upon a woman’s fertility.
Whatever treatment was deemed to be most appropriate, doctors generally agreed that it needed to be administered swiftly before serious and irreparable damage was inflicted. In order to treat inflamed and pus-filled organs, doctors recommended a number of invasive and non-invasive practices. Watson recommended bed rest to ‘promote uterine drainage and to assist in localising the inflammation in the pelvis’, and ‘hot application to the abdomen’ to alleviate pain and assist with the absorption of antiseptic solutions such as tincture of iodine, formalin or strong silver nitrate that were to be applied internally.82 Hargreaves similarly used localised vaginal injections of permanganate of potash, but also recommended a ‘change of air’ and temporary sexual abstinence.83
Although infertile women were more likely to have been subjected to invasive surgical procedures than infertile men, there was a growing understanding that surgical intervention was only advisable as a last resort in the most serious cases. Such procedures were to be limited to the ‘late separation of adhesions, and plastic operations to restore the parts to a condition in which they may be enabled to perform their physiological functions’.84 Madden may not have explicitly linked salpingitis to gonorrhoea, but he was reluctant to employ surgical techniques to alleviate inflammation of the fallopian tubes and ovaries.85 Only when vaccine therapy proved unsuccessful in curing vaginal discharge did Gibbons recommend curetting as a means of facilitating fecun- dation.86 Although Watson recommended the use of sterilized probes and tubes to apply one of several antiseptic solutions in early stage infections, he was adamant that ‘intrapelvic manipulation’ and invasive treatments were inadvisable in most cases.87