—No such invasion of mucous membrane by septic organisms can take place without active participation of the lymphatics in the region involved. In cases of gonorrheal or even non-gonorrheal urethritis, not merely enlargement of the lymph nodes in the groin may occur, but an active lymphangitis, manifested as a tender, sensitive cord beneath the skin, especially along the dorsum of the penis. The lymph nodes thus become involved and sometimes suppurate, and these abscesses are referred to as suppurating gonorrheal buboes. The suppurative feature is probably caused by contamination with the ordinary pyogenic organisms.
The Testicles.
—Gonorrheal infection seems often to extend along the vas and thus invades the epididymis, where evidences of activity are more frequent than in the vas itself. Epididymitis complicates cases of clap usually after the second week. It is characterized by pain, tenderness, and swelling of the epididymis, which occupies the same position relative to the testis proper that the heel does to the rest of the foot when a person stands in the ordinary military position, i. e., to the rear and inner side. The swelling becomes pronounced, and it is not unusual for a certain degree of swelling to be manifested in the testis proper, with the accumulation of a small amount of fluid in the sac of the tunica vaginalis, thus constituting a mild degree of acute hydrocele. While the inflammation is confined to the epididymis the pain is not intense, but of a dull, heavy character; but when the testis proper is involved there is a true orchitis, the inflammation being confined within the inelastic sclerotic tunic, and the pain then may be severe. Considerable fever accompanies many of these cases, with occasionally some edema of the scrotum and congestion of the testicular coverings. The weight of such a “swelled testicle,” as this condition is called by the laity, is irksome, and occasionally causes extreme discomfort. Under these circumstances physiological rest, i. e., in bed, and the use of a suitable suspensory apparatus are essential.
While resolution of this swelling ordinarily begins early and proceeds satisfactorily, the latter portion of the process is often slow and tedious, and the epididymis thus once involved will for months contain nodules and irregularities of contour. Usually the affection is limited to one side; but both testicles may be involved. If the infection be violent and the treatment inefficient abscesses may result.
This condition calls for early and effective treatment. If seen at the very outset, progress of the lesion may be checked by embedding the affected part in cold, wet compresses, and keeping them cold with ice. Relief later is more likely to be afforded by hot applications, and a hot poultice containing a small amount of fine-cut tobacco has been popular as a local application—the tobacco apparently being anodyne in its effect, although perhaps no more so than belladonna leaves. This may be regarded as a good emergency dressing when it affords the only means of treatment. The greatest relief will be obtained by the application of guaiacol, diluted with three volumes of olive oil or castor oil, well applied over the scrotum, and covered with oiled silk or rubber tissue. This application should be made twice a day. Later, in the more chronic and less painful stages, a reduced mercurial ointment containing a little guaiacol or ichthyol may be used to advantage, resolution being thereby assisted. In quite tedious cases the flying application of the actual cautery is serviceable. Internally tincture of pulsatilla has proved beneficial. It should be given in 1 Cc. doses every two hours. While the benefits accruing from its use are questionable, it has helped to allay fever and subdue pain.
Much has been said about the sterility which results from epididymitis, especially when both sides have been involved. It is easy to understand how the vas may become occluded in many cases, either temporarily or permanently, and yet within my own observation men have suffered from the double lesion and yet begotten children.
Gonococcus Septicemia and Pyemia. Postgonorrheal Arthritis (Gonorrheal Rheumatism).
—Considering the extent of the mucous tract involved, the open port of entry for germs, and the virulence of these organisms in many cases, it is remarkable that there are not more conspicuous illustrations of septic absorption in cases of gonorrheal urethritis. That these do occur and have a widespread, sometimes disastrous, effect has long been recognized. The severe forms are usually the more acute, and if they assume the septicemic type, go on to abscess formation, and in parts which are not always accessible. In rare instances septic disturbance assumes the pyemic type. The writer believes that he was the first to report a case of typical pyemia following gonorrhea, and to recognize it as such.
Aside from these acute manifestations, more chronic and mild affections, especially of the serous membranes, are well known. The most common of these exhibitions occur in the joints, mostly in the knee. A gonococcus peritonitis, pericarditis, or endocarditis are, however, well known. Because of the similarity of the discomfort and the disability resulting from the joint complications of clap to the ordinary joint manifestations of rheumatism, these lesions have long been popularly called gonorrheal rheumatism. The name, however, should be discarded as being incorrect, and for it the best substitute would be postgonorrheal arthritis.
These lesions may be sudden in their onset or may come slowly. They may occur at any time during the acute stage or after its apparent subsidence. The first manifestations involve the serous membranes proper; the fibrous tissues participate sooner or later, and the infiltration resulting from the inflammation thus set up will often permanently compromise their integrity and cause an impairment of their function for the rest of the patient’s life. They are usually confined to one of the larger joints, but may involve several, either simultaneously or consecutively. In acute cases the swelling is somewhat pronounced and the pain and soreness intense. The local symptoms simulate those of acute articular rheumatism. In the fluid drawn from these joints the gonococcus can be occasionally demonstrated. The course of the disease is usually slow, and convalescence may be protracted. Nor is the disability acute only and temporary, but it is often made permanent by the formation of adhesions resulting from the condensation of exudates. Partial or complete ankylosis may result, with considerable deformity. The muscle spasm provoked by the acute joint inflammation will occasion the same distortions and subluxations as are produced by tuberculous and other forms of arthritis, and operations varying in severity from forced motion to joint exsection may later be necessary. (See [pp. 392] and [393].)