Gonorrhea in Marriage
Gonorrhea is caused by the gonococcus discovered by Neisser in 1879. The name was given to the disease in the second century by Galen, who supposed that the condition is a spermatorrhea. The infection begins as a surface inflammation and gradually penetrates more or less deeply into the underlying tissues. In the male, gonorrhea may affect any part of the body; and when the disease is chronic it is a source of infection for years. If a man who has had gonorrhea wishes to marry after careful treatment, most physicians will permit him to do so if he passes the customary tests which indicate cure, but he is always dangerous. The tests are: (1) the microscopic and cultural examinations of the centrifugalized morning urine—the washings from the urethra must be negative after repeated trials and over a space of months; (2) the microscopic and cultural examinations of urethral spontaneous and artificial discharges must be negative in the same manner; (3) the microscopic and cultural findings of the secretion expressed from the prostate and seminal vesicles must be negative in the same manner; (4) urethroscopic examinations of the anterior and posterior urethra must show no unhealed lesions; (5) the complement fixation test is to be repeatedly negative. The complement fixation test is like a Wassermann reaction, but the antigen should be polyvalent. This test does not give a positive reaction where no gonorrhea is present, but it is often negative where the gonococcus is present. Hence a positive result has value, but a negative result has little or no value. All these tests are to be tried repeatedly, and if negative for months, the physician may say the man is probably cured, but no physician can guarantee the cure so as to take the responsibility of the decision. Not one physician in five hundred can make these tests himself, because physicians in general lack the special training and the means to make them. As the effects of gonorrheic infection in a woman are so appalling, any woman who wittingly marries a man who has had gonorrhea is very rash, and the man who takes the risk of infecting such a woman is a rascal.
A physician is obliged to let a woman who innocently is about to marry a "cured" gonorrheic know of the man's condition, as in a case of supposedly cured syphilis. Taber Johnson, Noble, and other authorities, say no one can tell when a gonorrheic is absolutely cured.
In women infection of the cervix uteri occurs in about 80 per cent. of the cases of acute gonorrhea, and in 95 per cent. of all chronic cases. The infection may extend up into the uterus at the menstrual period or just after parturition. In the cervix, owing to the histologic formation, the disease tends to chronicity, but the inflammation within the uterus is much more likely to subside naturally. Chronic gonorrhea of the endometrium is usually accompanied by tubular infection. The infection of the uterus may be superficial or it may extend down into the underlying myometrium.
The inflammation extends from the endometrium to the Fallopian tubes and beyond, causing salpingitis, pyosalpinx, hydrosalpinx, tuboövarian abscess, tuboövarian cysts, and pelvic peritonitis. The most frequent form of tubal gonorrhea is pyosalpinx, or pus tube.
In the acute stage of tubal infection the tubes become elongated and swollen, and the mucous surfaces within are covered with a seropurulent exudate. This condition is called salpinx or salpingitis. When the condition advances so far that the external abdominal ostium of the tube is closed, a pyosalpinx forms. The pyosalpinx may be quite large. A hydrosalpinx is like a pyosalpinx, with both tubal ends sealed, except that its content is a serous or watery fluid. When infected material escapes through the distal end of the tube, perioöphoritis develops, and the ovary becomes adherent to the tube and other adnexa. More commonly only the surface of the ovary is affected, but frequently the infection gets into the body of the ovary and causes oöphoritis. The ovary then swells and there is a tendency to the formation of retention and other cysts, or an abscess of the ovary. A tuboövarian cyst is a hydrosalpinx in communication with an ovarian retention cyst, and a tuboövarian abscess is a like formation.
Gonorrhea, especially in women, is likely to be very chronic. Emil Noeggerath, who in 1872 published a book[164] which changed the medical doctrine on the disease, said of women, "Once infected, always infected." Norris[165] reports a case where the gonococcus was latent in a man for twenty years, and he then infected his wife and wished to divorce her until he found that he himself was at fault. Sax[166] reported an infection after fourteen years; MacMunn,[167] one after fifteen years. These are exceptional durations in the male for virulence, though not for continuance of the diplococcus.
Neisser, who discovered the cause of gonorrhea, holds that, with the exception of measles, gonorrhea is the most widespread of all maladies. By sterilizing men and women and by abortion it holds down the birth-rate more than any other disease. The number of deaths from the consequences of gonorrhea (pelvic abscess, peritonitis, septicemia, endocarditis, and so on) is enormous. Norris thinks that 12,000 prostitutes die annually from the effects of gonorrhea alone. Woodruff[168] holds that 60,000 is nearer the truth. The estimate, too, is that 50 per cent. of all pelvic inflammatory diseases in women is gonorrheic; and Neisser, Bumm, and Fürbinger hold that from 20 to 50 per cent. of childless marriages are due to gonorrhea. Probably more than 20 per cent. of all the blindness in the world is from the same cause. The Committee of Seven,[169] in 1901, after examining most of the hospital records in New York and hearing from 4750 physicians, estimated that there were more than 220,000 venereal patients in New York City. Bierhoff[170] reckoned that in 1910 there were about 800,000 gonorrheics in that city. In 1906, in Baltimore, there were 3310 cases of the infectious diseases like measles, diphtheria, scarlet fever, and tuberculosis combined, but 9450 cases of venereal diseases. In New York City, in round numbers, there are annually about 41,000 cases of infectious diseases, excluding the venereal group, but 243,000 cases of venereal diseases—over five times more cases of venereal diseases than of all the other infectious diseases together. Of 12,000,000 persons insured in Germany, 750,000 annually are infected with venereal diseases. In the United States navy between 1904 and 1908, with an average of 43,165 men in the navy and marine corps, there were 32,852 admissions to the hospitals for venereal diseases, and of these 11,526 were cases of gonorrhea. This report is far below the actual numbers, as only men incapacitated for work are included in the list. In the English navy in 1906 the daily number of men rendered inefficient by venereal diseases was 867. In the total relative number of venereal diseases the American army and navy, before the present war, were the worst in the world, the Japanese navy next, the English army and navy next.
Sullivan and Spaulding[171] reported on the prevalence and effects of gonorrhea in 522 women and girls in a Massachusetts reformatory for women. Of these women 75.7 per cent. had gonorrhea by positive diagnosis. The average length of time the infection had existed when diagnosed was four years and five months, but one woman had had the disease for twenty-six years, and seven had had it for over twenty years. In 82.7 per cent. there had been no cessation of the clinical symptoms from the time of infection to the time of diagnosis. Of the total number 68 per cent. had pelvic inflammation on one side, and 27 per cent. had it on both sides. There were 41 per cent. of the cases which had had surgical operations or which required such treatment.
Of 63 women committed for alcoholism 52.4 per cent. had gonorrhea, 42.8 per cent. had syphilis, and 9.6 per cent. had doubtful syphilis; but of 400 women who had been at some time prostitutes 98.2 per cent. had gonorrhea, 65.5 per cent. had syphilis, and 9.5 per cent. had doubtful syphilis. Of 119 mental defectives among these women, 90.8 per cent. had gonorrhea, 61.3 per cent. had syphilis, and 6.7 per cent. had doubtful syphilis.
Dr. Thomas Haines[172] reported on 365 cases of boys and girls under eighteen years of age committed to an Ohio reformatory, and of these 20.8 per cent. had syphilis, and it was mostly acquired syphilis, not congenital—over one-fourth of the boys were so affected. McNeil[173] examined 1200 adult negroes in Galveston, Texas, for syphilis and found the disease in 30 per cent. of the 1200.
Howard Kelly[174] estimated that venereal diseases cost the United States three billion dollars annually, and Norris thinks this estimate too low. The ravages of the disease are so frightful, physically and morally, that any one who spreads it by infection, especially of an innocent woman, is guilty of the gravest moral injustice. Morrow[175] thinks that 250,000 married women in the United States are suffering from gonorrhea. As most of these unfortunate women are infected by immoral husbands, and as the invalidism and suffering they undergo are indescribable and cure is often impossible, the physician who permits a gonorrheic to marry without a protest is responsible for the evil as an accomplice; and, as has been said, once a gonorrheic, probably always a gonorrheic.
Pelvic inflammatory disease includes in the uterus and its adnexa alone metritis, salpingitis, oöphoritis, pelvic peritonitis, cellulitis, lymphangitis, and perimetritis. Pus may rupture into the pelvic cavity and set up local or general peritonitis or septicemia. It may burrow through from behind the uterus into the vagina, rectum, or other parts of the intestines, or into the bladder, and leave fistulas. Pus has been known to get through the abdominal wall itself. When the disease advances beyond the tubes there is, as a rule, invalidism until after the menopause, although the woman may be cured by surgery. Even skilled surgery does not always cure, because it is practically impossible to get rid of the gonococcus once it has been fixed in the tissues.
In cases where the gonorrheic or other bacterial infection has been chronic in the uterine adnexa, palliative treatment will in a certain percentage of cases make surgical intervention unnecessary, and when such treatment does not avail we must decide between the total removal of organs and the partial removal. Partial removal is called conservative surgery, and the term conservative is used as a synonym of preservative. Prochownick[176] reported 420 cases where pus in the tubes or ovaries was let out extraperitoneally, and no organs were removed. Of these cases, one hundred and sixty, or 38 per cent., were permanently cured. Fourteen of the one hundred and sixty who had received only one treatment subsequently gave birth to children, and three aborted. After a second treatment twenty-seven remained well and three became pregnant, of whom one aborted. Olshausen,[177] a great authority in gynecology, used the palliative treatment, and he commonly waited for nine months after the infection and until the temperature was normal. Goth[178] reported excellent results in seven hundred cases of pelvic disease treated by the palliative method. The chief objections to this method are the time required to get the result, and the difficulty of controlling the patients and their chronically diseased husbands, who reinfect them despite the medical prohibition of marital intercourse.
In cases of chronic pelvic peritonitis the question comes up frequently whether the womb and both tubes and ovaries should be removed wholly or in part. The text-books decide the question without any heed whatever to the notion of the morality of mutilation as such. They take into account the age of the patient, whether she has children or is desirous of maternity, whether or not she supports herself by manual labor, her temperament and character, and the results attained by men who have tried various methods of operating.
The conservative surgery of the uterus and its adnexa in gonococcal pelvic peritonitis was for many years looked upon with disfavor by surgeons. These conservative operations often failed or later required secondary intervention. Preliminary palliative treatment as now used greatly lessened the number of failures. Operations in peritonic conditions are dangerous because they may let loose encysted bacteria and start up a general septic peritonitis, which may be fatal. By delay and palliative treatment the virulence of the bacteria subsides, except where the woman is reinfected by her husband. In any case the blood-count should have been normal for at least a month and a half before any surgical interference is attempted. Olshausen waited nine months to let nature disinfect the pus.
The removal of a part of a tube is called salpingotomy; the taking out of the whole tube is salpingectomy; the opening up of a shut tube is salpingostomy. The presence of pus in a tube is absolute indication for removal according to the gynecologists at present. Howard Kelly and others have succeeded at times in such cases with conservative surgery, yet such treatment is now deemed obsolete—the dangers and failures seem to overbalance the little good effected. The end of conservative surgery is to try to restore function without pain, to preserve menstruation and ovulation, to put the organs in a condition to make pregnancy possible, and to preserve the internal secretion of the ovaries. The ovaries, so far as the woman's health is concerned, are the most important of her generative organs. If a woman is at the end of her child-bearing age there is no reason to preserve the tubes when they are affected, and conservation is likely to fail; but the ovaries should always be preserved, wholly or in part, when possible.
If one tube is infected from the uterus many gynecologists are inclined to remove both tubes. When a single tube is affected the cause is seldom the gonococcus, but some other bacteria which are not persistent. When both tubes are affected the cause is commonly the gonococcus, and attempts at preservation then fail, as a rule. Norris, who is a reliable authority, holds that "the only cases in which a salpingostomy is justifiable is on old, non-active hydrosalpinges, and in those cases of tubal occlusion or phimosis resulting from extratubal inflammation, such as sometimes result from appendicitis or ectopic pregnancies."[179] When a tube is shut, if it can be opened the opening tends to close again. A few cases of subsequent pregnancy have occurred after salpingostomy, but such a result is exceptional, because the origin is usually the gonococcus, which destroys tissue and is very persistent.
The ovary corresponds to the testicle, and the Fallopian tube to the vas deferens. Removal of the ovaries, or removal or closure of the Fallopian tubes, renders the woman sterile, but removal of the ovaries has other profound effects beside sterility. Loss of the ovaries brings on suppression of ovulation, menstruation, pregnancy, and ovarian internal secretion, various neuroses, and a tendency to insanity in certain cases.
The testicles and prostate gland produce an internal secretion containing spermin, and the ovaries a similar nitrogenous base called ovarin, which acts like spermin. The suprarenal glands secrete epinephrin; the thyroid gland and the pituitary body also make internal secretions, and these secretions sustain the tone of the blood-vessels and effect immunity against those toxins that arise from metabolic waste substances while these are in the body before elimination. If there is a hypersecretion from one or more of these glands, the excess causes congestion of the cerebrum and cerebellum and of the nerve centres there, and one effect may then be a sexual erethism that leads to masturbation and similar deordination.
Castration in the male or ovariotomy in the female stops all production of spermin and ovarin. In man the prostate gland also ceases its function after castration, and vasectomy lessens the production of spermin. In castration or spaying, again, when we remove the power of producing spermin or ovarin, that function of the testes and ovaries whereby the body is immunized against poisoning by its own effete material is also inhibited, and evil effects arise from this waste material. These toxins act just as would an excess of spermin or ovarin—they congest the cranial nerve centres, excite fever, neuroses, or temporary sexual erethism. This excitement may gradually subside as equilibrium is restored and neutralization effected, through a compensatory overproduction of the internal secretions by the other glands remaining in the body. Cimoroni[180] found after ovariotomy an increase in size of the pituitary body with dilatation of the blood-vessels. Goldstein[181] reported a case of gigantism from overactivity of the pituitary gland after castration. Acromegaly in cases where there was no castration has been accompanied by atrophy of testicles and ovaries. Cecca[182] found like effects in the thyroid, and several have observed these effects in the adrenals. All these results have also been produced experimentally on animals.
Women at the menopause frequently are observed who have become neurasthenic from the irritation of waste material intoxication which is not neutralized because the ovaries are ceasing to function. Ovariotomy in younger women produces this menopause artificially and suddenly; and women from whom both ovaries have been removed, as a rule, become neurotic invalids with a tendency to insanity if they are unstable in character or have a bad inheritance. If the whole thyroid gland is removed, death results from intoxication. Extreme obesity is an effect of undersecretion by the glands and a consequent lack of oxidation. Fat children have deficient glands, as a rule, and eunuchs grow fat as capons do. Removal of the ovaries before puberty arrests or prevents the development of the uterus; removal after puberty stops menstruation, the breasts atrophy, and there is an arrest of general physical growth.
Gordon[183] reported on 112 cases of oöphorectomy. Of these thirty-four had had before operation various symptoms of neurasthenia, hysteria, or psychasthenia, and vague abdominal disturbances. Surgeons in each of these thirty-four cases blamed the ovaries for the symptoms; and although these organs were not diseased in any degree, the surgeons removed them. In twenty-five of these cases there was no improvement whatever; in the remaining nine there was improvement for a few weeks, but complete relapse later, and finally their symptoms grew worse. The obsessions became permanent and expanded. Those women in the group who had hysterical paroxysms began to have stronger and more frequent attacks. Several psychasthenics had to be confined in asylums for the insane. Three of the women who had complained merely of vague nervous symptoms, as pain in the abdomen, head, or back, or of constipation or diarrhea, after oöphorectomy grew irritable, highly nervous, quarrelsome, fickle, restless, showed a tendency to travel about, to complain of others; finally there was insomnia, and loss of appetite or voracity. In the remaining seventy-five cases one or both the ovaries were diseased, but both ovaries were completely removed. All these women developed symptoms like those described above, but several grew much worse in their mental condition than the psychasthenics among the first thirty-four women. The generally observed symptoms are: restlessness with a tendency to move from place to place; loss of self-control; dissatisfaction with all persons and things; want of interest in work; indolence; pessimism. Sometimes there are outbursts of anger, with a tendency to attack. The mental conditions do not, as a rule, become clearly developed melancholias or manias, although a few do grow definitely insane. The morbid symptoms, however, persist obstinately. After ten years' observation Gordon found no improvement in some of these psychasthenics.
When the ovaries must be removed for diseases like cystic degeneration or abscess, the surgeon leaves, if possible, part of an ovary, or he engrafts part of an ovary in the abdominal wound, under the skin, or elsewhere. This grafting is beneficial in many cases, but it has little or no effect in many others. The graft is absorbed and it disappears in a year or two, but before it is absorbed it makes the onset of the surgical menopause gradual and thus prevents much suffering. In thirty-two cases reported by Chalfant[184] the graft gave evidence of functioning in five of seventeen women from whom the uterus and ovaries had been removed; in others it acted for months and then failed; in others it lessened the unfavorable symptoms; in others it had no effect at all. Stocker[185] reported two successful implantations of ovarian grafts and one testicular graft.
Giles[186] says that in his series of 157 cases of double oöphorectomy severe mental depression occurred in various groups in from 10 to 33 per cent., and two women became insane. Sex instinct was abolished in 16 per cent. Dickinson[187] found, in 200 cases where one or both ovaries had been removed, that not more than 20 per cent. fell into the surgical menopause even when the uterus had been taken out; but Giles, in 50 removals of one ovary, found irregularity, diminution, or cessation of the menses in 16 per cent. Carmichael, Valtorta, and McIlroy[188] discovered in animals a compensatory hypertrophy of the remaining ovary after one ovary had been removed. The internal function and nutrition seem to depend upon the ovarian secretion, as atrophy occurs after bilateral oöphorectomy. In all operations upon or near the ovaries there is likelihood of interference with the blood supply of the ovary, either by including ovarian arteries in the ligatures, or by tension of these vessels, which occludes them, or by malposition and prolapse of the ovary, which kinks them: these accidents result in degeneration or retention cysts. In most cases of pelvic peritonitis the uterus is retrodisplaced, and this position prevents cure until it is corrected.
When there is pus in the ovary, resection, in the opinion of gynecologists at present, is not an advisable operation; the ovary should be removed. Watkins,[189] however, says he resects small ovarian abscesses in young women with good results. In resection the blood supply is, as has been said, usually disturbed, and the cause for the operation is, as a rule, the gonococcus, and both these circumstances make the prognosis bad. The stitches necessarily used in resection operations are an additional source of irritation. Turetta[190] speaks in favor of resection in certain cases. A single retention cyst may be resected, especially when pedunculated. Boldt[191] had only one bad result in forty-five resections where a part of the ovary was saved. If the blood supply after the resection is evidently to be poor, resection is useless. Skill in surgical technic has much to do with success in all these cases. When the uterus is removed because of tumors, even near the time of the menopause, if one or both ovaries can be left in, this should be done. In such conservative operations Dickinson found 80 per cent. of the patients free from nervous disturbance at the time of the menopause.
Polak[192] describes an operation for the preservation of the menstrual function in double suppurative disease of the tubes and chronic metritis. He maintains that even if only one tube is infected, both should be removed because this apparently sound second tube will later, almost as a rule, show infection—probably by extension from the fundus of the uterus inside. Ordinarily inflammation of the tubes happens to be bilateral. Owing to the persistence of the gonococcus in the uterine muscle, surgeons are inclined to the removal of the whole uterus and both tubes. After such an operation menstruation ceases, and in the removal of the uterus the blood supply to the ovary is interfered with so that the ovaries degenerate. The consequent artificial menopause has a decidedly injurious effect on the woman's general physical and mental health. The parts of the uterus permanently infected by chronic gonorrhea are the cervical region, the fundus and the partes interstitiales of the Fallopian tubes. Polak advises that in cases where surgeons usually remove the tubes and the whole uterus they should instead cure the cervical infection by the cautery and take out the tubes, but in place of the removal of the whole uterus they should cut out a wedge including the fundus and the partes interstitiales of the tubes. This leaves the body of the uterus and does not injure the circulation to the ovaries. In the last seventeen cases thus operated upon by him he had success.
When it is necessary to remove both ovaries and tubes an opinion very common now is that it is better to take out the uterus also, because in such cases the uterus and vagina atrophy and this condition later causes trouble. Giles came upon such trouble in 11 per cent. of sixty-two cases. As the uterus is useless after the removal of the ovaries and tubes, there is no reason why it should not be removed. The danger of atrophy is sufficient reason for the mutilation. In operations for pelvic peritonitis it is well to remove also the appendix, because it is nearly always diseased, or it will give trouble from adhesions later and cause a secondary operation. It has no function we know of at present.
In conservative surgery of the uterus and adnexa for pelvic inflammatory diseases, the results attained by four skilled surgeons are: Giles cured 90 per cent. of 132 cases; Polak cured 35 per cent. of 300 cases; Robins cured 100 per cent. of 20 cases; Norris cured 73 per cent. of 191 cases. Polak's patients became pregnant after operation much oftener than those of the other operators. Seventeen per cent. of his patients, from whom he removed one ovary and resected the other, became pregnant. Giles found that of his married patients under fifty years of age at the time of the operation 25 per cent. became pregnant and went to term. They bore twenty-five children. Five of these also miscarried. In sixty-eight of Morris's cases seventeen were delivered of living children after the operation; three had two children each, one had three children, and there were seven miscarriages. In one of his cases where he removed one ovary and both tubes, the woman bore a healthy full-term child two years after the operation. Dudley[193] found that about 10 per cent. of 2168 cases of resection became pregnant after operation. Ectopic gestation is likely to occur in a few cases after conservative operations. Giles had seven such cases in his series of 132 operations, Polak one, and Norris two.
When it is necessary to remove the uterus, the choice between supravaginal hysterectomy, where the cervix is left in after the destruction of its mucosa, and panhysterectomy, where the cervix and the body of the uterus are removed, offers no moral problem except the necessity of deciding upon what will be best for the woman. Rupture of a pus tube is a very dangerous accident—all the patients suffering from such a rupture die if not operated upon, and fifty per cent. die even after operation. A physician may do this damage by ignorant or careless examination, and he may be morally responsible for the death. The accident happens not unfrequently from marital congress, and if the husband has been warned by a physician but does not heed this warning, he is guilty of murder if the woman dies after rupture of the pus tube.
Pregnant women are more liable to infection by the gonococcus than non-gravid women, because of the increased blood supply to the generative organs in gestation, and the softening of these organs. For the same reason, latent gonorrhea is likely to become active and to spread during pregnancy. A like activity and extension of latent gonorrhea often occurs during menstruation. Women with gonorrhea are commonly sterile—this is the chief reason why prostitutes are usually sterile. In married women gonorrhea may cause dyspareunia; it may bring on abortion through endometritis; it may shut the tubes and prevent conception; it may destroy the ovaries.
The disease is extremely frequent during pregnancy. Gurd[194] isolated the gonococcus in 52 of 113 pregnant women who came to his dispensary service because of pelvic pain. Leopold, Stephenson, Fruhinholtz, and many others estimated that about 20 per cent. of all pregnant women have gonorrhea, but more recent observers think that from 5 to 10 per cent. is nearer the truth.
When a pregnant woman has gonorrhea great care must be taken in treatment to prevent abortion. Powerful antiseptics in the cervix, or dilatation of the cervix, are not permissible, and operative interference is to be delayed as long as possible—in each instance to avoid abortion. The vaginal douche as a routine treatment is not used now by obstetricians in these cases. When the gonorrhea is in the uterus douches of hot bichloride solution, 1 to 10,000, are used twice daily during the last few weeks of gestation, with the intention of saving the infant's eyes from infection during delivery. After delivery the cavity of the uterus should not be entered with instruments lest infection be carried in, unless absolute necessity requires this instrumental procedure. Post-partum gonorrheal sepsis is differentiated from other septic conditions chiefly by the history of gonorrhea in the husband, by bacteriological examinations, and by the technical differentiation of symptoms.
The moral guilt of a person who infects another with gonorrhea is affected by the extent of the physical injury done. Gonorrhea causes, besides the effects already described: (1) chronic cystitis, with all the suffering, loss of work, and danger of renal infection in such a condition; (2) lymphadenitis of the inguinal canal, and rarely of other places; (3) proctitis, or inflammation of the rectum, especially in women and young children; (4) ophthalmia, vaginitis, and proctitis in infants and children, and metastatic conjunctivitis; (5) stomatitis or inflammation of the mouth in adults and children; (6) nasal gonorrhea (a doubtful condition); (7) gonorrheal septicemia, bacteremia, or toxemia, which may affect any organ in the entire body; (8) bone and joint lesions: (a) gonorrheal arthritis in any joint in the body (this condition may be fatal, or it may leave permanent disability, or it may disappear); (b) tenosynovitis, or pain, swelling, and edema along affected tendon sheaths; (c) gonorrheal periostitis, where the bone and periosteum near a joint are affected; (d) perichondritis and chondritis, a rare condition, where cartilage is attacked; (9) endocarditis, or inflammation of the lining membrane of the heart (one of the most frequent secondary lesions of gonorrhea); (10) pericarditis, or inflammation of the sac which contains the heart; (11) myocarditis, an inflammation of the heart muscle itself, usually as an extension of endocarditis; (12) aortitis, or inflammation of the aorta—a rare condition; (13) phlebitis, an inflammation of the veins—a very rare condition; (14) thrombosis, or blocking of a blood-vessel by exudate (this may be fatal); (15) skin lesions, as erythema, erythema nodosum, bullous and hemorrhagic eruptions, hyperceratosis, and ulcers; (16) gonorrhea of the lungs in septicemia; (17) gonorrheal pleurisy in septicemia; (18) gonorrheal nephritis, which is frequent in gonorrheal septicemia—the condition is often fatal; (19) perinephritis, a very rare condition; (20) gonorrhea of the nervous system, as neuritis or neuralgia, or neuroses, which vary from slight melancholia to severe mental disturbances; (21) parotiditis, a very rare condition; (22) otitis, or inflammation of the middle ear, a very rare condition; (23) suppuration in muscles, or under the skin; (24) wound septicemia; (25) venereal warts; and (26) epididymitis, which often causes not only sterility but impotence.
Campbell[195] reported a gonorrheal infection of a compound fracture at the ankle—it required four months to get the wound free of the infection. Gonorrheal obliterating epididymitis is quite common. Delbet and Chevassu[196] found 114 cases of male sterility in 131 cases of epididymitis. More than half of such cases are left permanently sterile, and if the function of the testicle cannot be restored by the surgeon the patient is impotent, and any marriage he would make, ... is rendered void. These two surgeons have restored function in six such cases by uniting the vas with the epididymis by Martin's operation. It is much easier to restore function after vasectomy than after obliterating epididymitis.
There are frequent cases of arthritic rheumatism in which the source of the infection is a chronic gonorrhea of the seminal vesicles. Fuller[197] has done 101 vesiculotomies for this condition, and of these twenty-three were gonorrheal. In these twenty-three the excision of the infected vesicles cured the rheumatism. In vesiculotomy great care must be taken not to cut the vas deferens. If it is cut the man is impotent until the vas is restored, and it would be a very difficult operation to reunite the vas if cut near the vesicles.
Of all the gonorrheal affections of the body the most dangerous and important are the cardiac inflammations and ophthalmia neonatorum. This ophthalmia is a purulent infection of the external parts of the eye in infants. It may be caused by many kinds of toxic bacteria, but the worst cases are from the diphtheria bacillus (a very rare condition) and the gonococcus (a very frequent condition). Before 1881, when Credé introduced prophylactic treatment for ophthalmia neonatorum, every maternity hospital had a department isolated for the care of babies suffering with this disease. At the present day, however, despite the precautions taken, this disease is quite common. Pennsylvania and New York alone spent $242,000 annually for the support of asylums for the blind, and about 40 per cent. of the children in these institutions were blinded by gonorrheal ophthalmia. The United States spends $1,800,000 yearly on victims of ophthalmia neonatorum. Stephenson[198] tells us that in the practice of forty-one oculists who reported to him the gonococcus was found in 67.14 per cent. of their 1658 cases of ophthalmia. Mayou found the gonococcus in 63.5 per cent. of 1483 cases.
There is an infection of the child's eyes by gonococci possible even while the child is in the womb, but this is very exceptional; the infection happens in the vagina during delivery, as a rule. When the child's head is born its lids and eyelashes should be cleansed with vaseline, or 1 to 5000 bichloride, or carbolized oil, before the eyes are opened to put in the silver nitrate solution. This solution should be made from a pure drug or it will injure the eyes. A one per cent. solution is strong enough for routine work, but if the gonococcus is suspected, or if it is known that the mother has gonorrhea, then the lids of the infant must be everted and touched everywhere with a five per cent. solution of silver nitrate. This is neutralized with a salt solution and washed out before the lids are turned back. It is rash to trust any of the albuminoid preparations of silver, like argyrol, silvol, or protargol, in gonorrhea or suspected gonorrhea of the eyes.
If the child develops ophthalmia the treatment should be turned over to an oculist when possible. When a child can have a day and a night nurse, this method should be adopted, but ordinarily there is no nurse except some woman about the house or the mother. In such cases one eye, commonly the right, does better than the other because the first eye treated is opened readily, but after the infant has been irritated it shuts the eyes so strongly that it is difficult to open them at all. The first eye treated is habitually the same. The nurse should begin to treat the eyes alternately on this account, or wait to treat the second eye until after the baby has quieted down. Iced compresses should be used, but not so long as to chill the eye very much—five to ten minutes at a time is enough. If the physician himself makes the applications of silver nitrate, the nurse should use some silver salt like argyrol. Three to eight grains of zinc sulphate to eight ounces of boric solution is a good regular eye-wash in these cases. Atropine must also be instilled to protect the iris. If only one eye is affected, the other eye should be protected under a watch glass sealed over it. All persons who have gonorrhea, or who treat gonorrhea, must be warned of the danger they are in of infecting their own eyes.
A new treatment of gonorrhea is described by Weiss.[199] The gonococci are killed by a temperature of 107.6 degrees Fahrenheit, and in eleven cases Weiss subjected men to a hot bath for forty to fifty-five minutes, with the temperature of the water gradually increased from 104 to 110 degrees Fahrenheit. In one instance the body temperature was raised to 108.5 degrees F. in a forty-minute bath and the gonococci disappeared at once. In the other cases the body temperature did not go up so high, but the vitality of the gonococcus was evidently reduced, and under a few local injections they all disappeared.