A practical treatise on genito-urinary and venereal diseases and syphilis

Front matter

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HX64151247 RC871 .T21 1904 A practical treatise

Preface

In preparing this third edition the author has endeavored, as in the past, to present a practical, up-to-date, and compact treatise. His aim has been to avoid both the tediousness of an encyclopaedia and the disappointing brevity of an epitome, and to present a thorough, systematic description of the cognate subjects treated in this volume in a terse and clear manner. Care has been exercised not to overburden the text by describing in detail as morbid entities symptoms and conditions which constitute well-recognized abnormal states. Over-elaboration of rare anomalous conditions, or malformations or unimportant diseases has been avoided, as well as needless repetitions in the various chapters.

The endeavor has been made to present only trustworthy practical information, and to omit surgical and therapeutical procedures of little or doubtful value.

The text has been fully revised and many new sections have been added throughout the work, with the view of presenting the salient phases of progress.

The various genito-urinary affections have received full consideration, and the aim of the author has been so to simplify the subject that their study shall be easy and luminous. Due attention has been paid to the description of the different operations upon the genito-urinary system, and the various new operative procedures will also be found.

In all matters relating to treatment, surgical or medical, the author has aimed at presenting wholesome, conservative, and practical directions ; and while surgery proper has received full consideration, it has been recognized that its performance is but a part, and not the one aim of therapeusis.

The subject of gonorrhoea in all its phases has been exhaustively given, with full, practical, and, it is hoped, judicious treatment. Attention has been directed to the fallacies and dangers in some of the views nowadays advanced in the therapeutics of this disease, and an emphatic protest against them has been made.

Syphilis in all its conditions and relations has been comprehensively considered, and much care has been exercised in the concise presentation of a practical, methodical course of treatment.

With the exception of a few all the illustrations in this volume have

6 PREFACE.

been made under the personal supervision of the author from his own cases, and in this edition twenty-five new illustrations and twelve plates in colors and monochrome have been added.

It is gratifying to mention the rapid exhaustion of the very large second edition of this work, and the appearance of an Italian translation of it issued by the Union Tipografico Editrice of Turin.

I am indebted to Dr. Ward A. Holden for the chapters on Syphilis of the Eye and of the Ear.

In presenting this new edition I venture to hope that it will prove a satisfactory and trustworthy guide for practitioners of medicine and students who desire information upon the subjects therein considered.

ROBERT W. TAYLOR.

142 West Forty-eighth Street, New York, June, 1904.

GENITO-URINARY AND VENEREAL DISEASES, AND SYPHILIS.

Chapter I. Gonorrhoea In The Male

Gonorrhcea, the most frequent of all venereal diseases, and the one essentially of sexual origin, is a virulent process, attended by much suppuration, which attacks chiefly the mucous membrane of the urethra, male and female, and the parts in immediate and more remote anatomical relation. The mucous membrane of the eye is also particularly susceptible to its action. There is no doubt that the rectal and anal mucous membrane may be attacked by this process, but there is much doubt about the existence of gonorrhoea of the mouth and nose. In this work the terms gonorrhoea and urethritis will be used interchangeably.

Gonorrhoea is mostly found in young men ; but instances of children, and even infants, being thus affected are far from uncommon. Toward puberty it is very often found in the male ; while between the twentieth and thirtieth years its frequency of occurrence is greatest. From the thirtieth year onward its occurrence grows progressively less frequent, but it is seen in a goodly number of cases of middle-aged, and even of old, men.

Gonorrhoea occurs much more frequently in the male than in the female. The first attack is usually more acute and severe than are subsequent ones, which are very often subacute in form and chronic in course. When many years have elapsed between two infections, the second may be equally as severe as the first. In very many cases of men who have had in the past an attack of gonorrhoea acute urethral suppuration may be solely due to sexual and alcoholic excesses, which have changed a chronic and dormant localized inflammation of the urethra into a more or less acute condition. This affection is called by some bastard gonorrhoea, and by others simple urethritis.

Gonorrhoea is one of the most persistent diseases which attack mucous membranes. It invades the tissues deeply, and as a consequence it is very often difficult to cure. After a more or less prolonged chronic 2 17

18 GONOBRHCEA IN THE MALE.

stage it often settles down into a latent and dormant condition in a localized form, and may thus cause no symptoms for years. Then, again, this condition of latency may be frequently varied by acute attacks of the disorder.

In many cases it passes away and leaves no bad effects. In others it leads to the development in the male of such painful complications as swelled testicle and abscess in connection with the urethra. In the female it may lead to cystitis, inflammation of the os uteri, the tubes, the ovaries, and even to peritonitis. Its long duration in the male urethra frequently leads to stricture, with its distressing and often fatal results from bladder, prostatic, and kidney complications. By the action of the toxins which the. gonorrhoeal process gives forth, and also from the absorption of its virulent microbes from the urethra into the circulation, violent and painful inflammations of joint-structures, joints, tendinous sheaths, bursae, fasciae, and fibrous tissues are produced. In many of these inflammations gonorrhoea seems to produce a true septicaemia through the action of its own virulent microbe. In many cases it is very probable that the morbid action of the gonococcus prepares the tissue for the invasion of pyogenic microbes. By these combined or mixed forms of infection the whole organism may be involved, and severe illness, structural impairment of parts, invalidism, and even death, may be produced. By reason of this action of the gonococcus alone or aided by that of other pyogenic microbes the eyes, the heart and its membranes, the coverings of the spinal cord (and, it is also claimed, those of the brain) may be attacked, aud serious, even fatal results may follow.

When we consider the vast range of pathological conditions which gonorrhoea may cause or lead to, we are certainly warranted in asserting that it is, taken as a whole, one of the most formidable and far-reaching infections by which the human race is attacked.

In the vast majority of cases of gonorrhoea the gonococcus is the infecting agent and in a minority a number of pyogenic microbes, notably the staphylococci and streptococci, are the causative factors.

Predisposing Conditions and Causes. — The size and conditions of the penis are frequently factors in the contracting of gonorrhoea. Thus a very long organ is frequently infected by pus from the uterine neck or fornix vaginae, while a shorter one may escape. A very large and thick organ may give rise to friction and irritation, and in that way become infected. Patients with naturally large meatuses, and particularly those in whom unnecessarily large meatotomy has been practised, are also very susceptible. A meatus which opens on the under surface of the glans resembling hypospadias, and the condition of hypospadias itself, predispose its bearer to gonorrhoeal infection. Then, again, cases

THE GONOCOCCUS. 19

are seen in which this form of the opening exists, and with it shortness and tightness of the frsenum, and perhaps of the prepuce. In such cases there are much redness of the fossa navicularis and a marked tendency to acquire gonorrhoea. In these cases, and in those of hypospadias where the meatus is thus placed low in the glans, it is probable that the secretions of the vagina, which gravitate to its posterior wall, are sucked in by capillary attraction, and find easy entry into the fossa navicularis and urethra, and there produce infection.

In fact, any structural condition that causes hyperemia of the distal part of the penis may render its bearer liable to contract gonorrhoea.

Long-continued copulation, particularly in persons under the influence of alcoholics, is a potent factor of infection. In such cases ejaculation is much delayed, the penis and vagina are much irritated, and gonorrhoea very frequently follows. Indeed, venereal excesses are common and prolific causes of gonorrhoea. Persons who have recently recovered from an attack of gonorrhoea are especially predisposed to subsequent infections.

There can be no question that in some cases of early syphilis the distal parts of the urethra are rendered more prone to the invasion of gonococci and other microbes. This tendency may be brought into action by abnormal conditions of these parts, and may exist in cases where no abnormality is present. An active syphilitic diathesis can undoubtedly be at the root of the persistence of a gonorrhoea, and may also be a factor in the induction of relapses. It must be borne in mind that the disease then is not syphilitic in nature. It is an infective urethritis, due to micro-organisms, occurring in a syphilitic in whom the diathesis is still active and whose tissues are more vulnerable to irritation and microbic invasion than those of a previously healthy person.

THE GONOCOCCUS.

The gonococcus is clearly revealed to the eye by means of stainingprocesses and by the microscope with a high power and oil-immersion, using at least a y^-inch lens. It is a relatively large micrococcus, nearly always appearing as a diplococcus. It measures 0.8 to 1.6 micromillimetres in length and 0.6 to 0.8 micromillimetres in breadth. The gonococci are usually Fig. 1.

found in pairs, each half of the diplococcus being: f$ ® @& @b €8>

f i-A u a +i + +u ui ^ W ^ W O

oi kidney shape, and the two thus resemble a

no i 171 i 11 /-w ,i • Morphology of the gono-

cotiee-bean or a J* rencn roll. Occurring thus in coccus (after Bumm). pairs, they lie close together, their flattened

surfaces being in close coaptation and their outer margins convex. Between each coccus is a very narrow split which shows as a bright

20 OONORBHCEA IN THE MALE.

line. In these particulars the gonococcus resembles other diplococci. In its multiplication this diplococcus divides by a transverse cleavage or at right angles to the median fissure. By this means of fission each pair of the diplococcus is converted into four diplococci, which are grouped in fours. The mode of division is schematically pictured in Fig. 1. Beginning at the left hand of the figure, the line of cleavage is shown to be more and more distinct until the full development is reached, as pictured in the right-hand figure. In this way these micro-organisms increase and multiply. Other diplococci, however, develop in a similar manner. From this method of transverse fission and growth originates the peculiar grouping of the gonococcus into twos and fours and their multiple derivatives.

In the acute stage of gonorrhoea these diplococci are found in greater or less number encapsulated in masses within the pus-cell. When numerous and thus seated they have been said to present the appearance of a swarm of bees. Under rather low powers they look like little particles of gunpowder. They may be so numerous within a pus-cell as to rupture its wall. Then we find the cocci lying free in the serum, scattered in a disordered manner between the pus-cells, but even then presenting the four and multiple-of-four arrangement. Early in the infection gonococci are seen seated upon epithelial cells.

Under microscopical examination gonococci are readily found and recognized in the pus of acute gonorrhoea. Then the clinical features of the infection and the microscopical picture of the discharge and its pus, epithelium, if present, and diplococci, taken together, are so striking and unvarying that a mistake can scarcely occur. But in later stages of true gonorrhoea, and in many more or less subacute cases of urethral suppuration, it is very often most difficult, and sometimes impossible, to say whether the microbe is the gonococcus or some other form of diplococcus. In all cases the crucial test rests in cultivations and inoculations. '

While, however, there is no single individual sign or mode of distinction of the gonococcus, there are a number of signs which, when taken together, offer strong presumptive evidence that the microbe in question is the one just named. These are —

1. The shape, which is, as we have seen, roundly oval, with its median fissure and its roll-like or coffee-bean appearance, and its lengthwise fissure.

2. The size : they are large diplococci, and in their development are variable and resemble other diplococci.

3. The grouping, as a result of their mode of division, is in single pairs, in fours, eights, sixteens, etc. They never occur in chains.

4. Their intracellular position : the gonococci are found in heaps

THE GONOCOCCUS. 21

within the protoplasm of the pus-cells, and also scattered between the cells in varying numbers. Other diplococci, however, are also found within the pus-cell.

5. Their staining properties : gonococci are readily stained by aniline colors, and they readily lose their staining by Gram-Roux's method. This quality is very characteristic of the gonococcus, but it is also possessed by certain other diplococci, by streptococci, and by staphylococci.

Methods of Staining'. — For general purposes a solution of methyl blue is all that is needed for staining gonococci, but fuchsine, methyl violet, gentian violet, and victoria blue may be used. The technic is as follows : Spread by means of a platinum-wire loop some of the pus, threads, or secretion on a cover-glass in a very thin film, or place a drop of the secretion in the centre of a cover-glass, and then place another cover-glass over this. Then separate the two by sliding them over each other, not by pulling them apart. In this way two evenly-spread specimens are obtained. It is always necessary to wash thoroughly the glans penis and the meatus before taking the secretion, since many microbes are seated on these parts. In taking secretions from the female genitals scrupulous care should be exercised, so that no extraneous or accidental micro-organisms are gathered up. In dispensary work the secretion from the male urethra may be allowed to drop upon a glass slide, and it is then to be spread out over its surface by drawing the edge of a similar slide over it. The specimen may be allowed to dry in the air or it may be passed two or three times (the right side up) through an alcohol or gas flame. The dried secretion is then lightly smeared with the staining fluid by means of a glass rod.

The simplest and most expeditious method of staining these specimens is to put a drop of a dilute watery solution of methyl blue upon the cover-glass, allow it to remain two or three minutes, wash off with water, and then examine in water. This may be allowed to dry, and then it may be mounted in Canada balsam. By this method, however, the gonococci are not shown so clearly as by others to be mentioned.

One of the most satisfactory and rapid methods of examination is that recommended by Schiitz. This is founded on the resistance of the gonococcus to acetic acid after being stained with methyl blue. After the cover-glass is covered with a thin film of the suspected material it is passed three times through the flame. It is then brought in contact with a saturated solution of methyl blue in 5 per cent, carbolic-acid water for five or ten minutes. It is then washed with water and placed, for a time long enough to count one, two, three slowly, in a solution of five drops of acetic acid in twenty cubic centimeters of distilled water,

22 GONORRHOEA IN THE MALE.

and immediately washed again in pure water. Everything is then decolorized except the gonococci, which remain distinctly blue. The specimen may be then examined and preserved, or at this stage it may be double stained with a very dilute aqueous solution of safranine. This second staining should be very slight, the cover-glass being washed at once in pure water. By this process the gonococci will be found of a deep-blue color, the epithelial cells of the same color, while the pus-cells and their nuclei will be salmon-colored.

Technic of Gram's Method for Staining Gonococci. — The most reliable means of recognizing the gonococcu* is that known as the Grarn- Eoux method. The procedure is as follows: 1. Make a smear of the suspected discharge on a cover-glass or slide. 2. Pass same three times through the flame of an alcohol lamp or Bunsen burner. 3. Stain for two to four minutes with anilin gentian-violet solution, made as follows : anilin oil, 1 part; distilled water, 20 parts. Shake well. Filter through moistened filter-paper. To nitrate add saturated alcoholic solution of gentian-violet in the proportion of 1 part to 10 of filtrate. This should be made fresh every day. 4. Transfer specimen directly to solution of: iodine, 1 part; potassium iodide, 2 parts; water, 300 parts. Allow it to remain from one'to three minutes. 5. Transfer to absolute alcohol, which should be changed two or three times until decolorization of specimen is completed. 6. Transfer to solution of Bismarck brown (saturated alcoholic solution B.B., 1 part ; water, 10 to 20 parts). Stain for half a minute. 7. Dry and mount in balsam ; or if it is not desired to preserve specimen, it may be examined directly by oil immersion lens with the aid of oil of cedar. By this method the pus-cells are stained a light brown, and the gonococci are decolorized and are shown in marked contrast imbedded in the cells. This method is considered the most reliable for the diagnosis of gonococci in a specimen of urethral discharge. There are a number of other cocci, however, which are decolorized by the use of Gram's method, so that the situation and morphology of the cocci should be taken into account in making the diagnosis.

Roux says that he learned by experiments that Gram's liquid does not sufficiently and firmly fix the basic aniline colors in gonococci, but that as soon as the specimen is treated with absolute alcohol these cocci and the anatomical elements become very difficult to recognize with the microscope. This negative fact therefore constitutes an element of diagnosis, since other micro-organisms do not thus become decolorized. He claims, therefore, that when the presence of gonococci is shown by aniline dyes, and upon the addition of Gram's liquid and alcohol they disappear, it is certain that Xeisser's coccus is present. On the other hand, if the micro-organisms remain stained, they are in all probability not gonococci.

THE GONOCOCCUS. 23

No trouble will be experienced in studying the secretion of acute gonorrhoea even when some weeks old. But the doubt arises in subacute and chronic cases, just the ones in which we are anxious to determine whether the long-drawn-out inflammation is really kept up by the gonococcus, and whether this micro-organism has, as it is claimed it has, an indefinite life as a morbific agent in the male urethra.

A New Stain for Gonococci in Chronic Gonorrhoea. — It is well known that the secretion of chronic gonorrhoea is very difficult to stain, and that the basic aniline dyes are not convenient for this purpose, as they fade quickly and stain gonococci and nuclei alike, v. Wahl therefore suggests a mixture of auramine and thionin, consisting of 15 c.c. of a saturated alcoholic solution of " auramine II." (1:10) and from 8 to 10 c.c. of a saturated alcoholic solution of thionin (1 : 20), to which 30 c.c. of distilled water are added after shaking. If a bright staining of the cellular elements is aimed at, it is advisable to add a little watery solution of methyl-green (1 : 50) and a corresponding amount of thionin. The nuclei are then stained bluish-green and the gonococci deep violet. The mixture without these additions stains (in from ten to fifteen seconds) the cellular elements a light green and the gonococci a dark violet.

Fig. 2. i

Showing on the left half some groups of gonococci obtained by culture, and on the right half some groups of a so-called pseudogonococcus cultivated from a specimen derived from a normal urethra virgin to gonorrhoea.

This micro-organism outside of the human body has little vitality. Its culture media are blood-serum, and blood-serum and agar-agar, and urine and urea, in acid solution.

It is well to emphasize the following facts : In the normal urethra are found innocuous and virulent microbes of whose history and pathogenic power we as yet know little. Whether these organisms play any part in urethral inflammation we do not now know. One of them termed a pseudogonococcus so much resembles the gonococcus that it is a source of error in 5 per cent, of cases of the recognition of the latter (see Fig. 2).

Chapter II. Invasion Of The Tissues By The Gonococcus

The process of the invasion of the tissues by the gonococeus may now be considered. Owing to the great difficulty, and at times impossibility, of obtaining a urethra the seat of active gonococci invasion, Bumrn studied the subject upon the conjunctiva of infants inoculated with gonococci-containing pus. As the mucous membrane of the eye resembles that of the urethra, and as the two membranes react similarly to gonorrheal infection, it is fair to assume that the morbid processes and appearances are similar in each instance. It is this want of pathological material on my own part which forces me here to make use of Bumrn's observations and results.

Having gained a foothold on the superficial epithelial layers, and there having greatly increased in numbers, the gonococci penetrate between the epithelial cells, which have become swollen and succulent, into the soft protoplasm substance. It is interesting to note that in the infective process the cocci themselves are the active agents in attack and penetration, and that they are not enclosed in pus-cells. Indeed, active participation of the pus-cell is not observed. The spreading of the micro-organisms onward is thought by Bumm to be due to their growing more actively on one side — a condition caused by the difference in soil and probably by an increased supply of oxygen. In all cases the road traversed by the gonococci is through the cement-substance between the cells. Sometimes they penetrate in single rows; then again they advance in a larger body; and when the tissues will admit, they form a roundish colony, and from that nidus make further incursions into the tissues. "When they have got well down toward the subepithelial connective-tissue layer, reaction on the part of the tissues occurs. Then great numbers of white blond-cells escape from the dilated capillaries, together with much serum. This stream of pus, pouring out, breaks through the epithelium or even carries it away in small or large plates. The removal of the epithelium then permits further invasion of the gonococci even to the papillary layer, but there it stops. Pus-cells with the gonococci may now be seen, but free gonococci are much more numerous. Coincidently with this cocci invasion and multiplication the inflammatory process increases in intensity, and a dense round-cell infiltration is formed beneath the surface of the mucous membrane. This is the transition to the purulent

PLATE I.

INVASION OF THE TISSUES BY THE GONOCOCCUS.

stage of gonorrhoea. In some cases, as early as the twelfth day regeneration of the epithelium begins and rapidly progresses, and then the further invasion of the micro-organism may be stopped. During this reparative process the pus-cells escape unhindered, and rows and clusters of gonococci may be harbored between the cells of the uppermost layer of the epithelial strata. Under some circumstances there may then be a new invasion by the gonococci. An outpouring of pus destroys more or less of the epithelial layer, and this opens the way for a second invasion. This condition is what occurs in relapses of acute and moderately acute gonorrhoea. The cocci may develop between the superficial connective tissue and the tunica propria, but they do not luxuriate. It seems probable that they do not find in the deep parts of the mucous membrane the conditions necessary for development, or that they are unable to withstand the influence exercised by the tissue-elements. They are most at home in the superficial layers of the connective tissue and between the epithelial cells.

In this infective process, therefore, we see a violent invasion of a mucous membrane by large masses of gonococci which penetrate between the cells. There is always to be observed a connection between the multiplication and activity of the micro-organism and the intensity of the inflammatory process. The reaction on the part of the tissues corresponds to the intensity of the irritation excited in the soft and sensitive epithelium. So long as there is secretion present on a mucous membrane, the gonococci may remain in it and multiply, for it offers a favorable culture-soil. The great mass of gonococci in the uppermost strata of tissues perish there from simple dissolution. Final healing is caused not so much through the elimination of the micro-organisms as by the development of a protective covering of squamous epithelium in several strata which closes all gaps, cracks, and inlets to further invasion. The infective process is therefore brought to an end by the energetic development of epithelium, which forms a barrier which the gonococci cannot break through. (Plate I.)

It is very probable that when gonorrhoea is caused by the staphylococcus and the streptococcus the pathological processes and changes are similar to those produced by the gonococcus. Clinical and microscopical study shows that different individuals are affected in different ways.

Explanation of Plate I.

a, epithelial layer covered with pus-cells and gonococci. b, penetration of tissues by colonies of gonococci. c, diffuse superficial development of gonococci. d, superficial colonies invading epithelial layers, e, further penetration of the colonies into the tissues. /', still further penetration of the colonies, g, penetration into superficial portions of a papilla. h, penetration of gonococci into the intrapapillary layer, i, recurrent invasion with development of squamous epithelium.

In some the attack, as shown by the discharge, comes on briskly and promptly, while in others the morbid process develops slowly and insidiously, and often with much halting. In the very earliest period of gonorrhoea much can be learned as to the mode of invasion of the disease, and as to the pathological conditions in a given case, by the microscopic examination of the secretion. This scientific examination should be made in every case, since from its results indications of a practical nature may be derived. Not only in the very earliest stage does the microscope give much aid and broad enlightenment in pathology and treatment, but throughout the whole course of gonorrhoea its teachings are invaluable.

As will be shown farther on, the number of gonococci in the serous discharge of the first day or two shows very great differences in individual cases. In some periods, the earlier as a rule, there are enormous numbers of gonococci in the discharge, while during the latter stages of the attack there are frequently so few of them that but one or two pus-cells can be found in the entire field containing gonococci. So a drop of discharge at one stage of the attack may contain, estimating it roughly, but two or three or several . hundred gonococci, while at another time the drop holds enormous quantities of the cocci — a million or more.

Thus when gonorrhoea is contracted, as a result either of the duration of the exposure to the infecting pus or according to the stage of development of the discharge in the donor, the number of gonococci received may vary within very wide limits. This numerical variability, then, in the gonococci seems in a measure to determine the period of incubation and the character of the onset of the discharge. The vulnerability of the tissues and the conditions favorable to inflammation also have much to do with the promptitude of the onset of the inflammation.

In some cases, where a very few gonococci englobed in the pus-cells are received, the discharge does not become visible for some days, although during this time there is an exudation, but it is so scanty and colorless that it escapes attention. In such a case as this it would seem that so few gonococci entered the urethra that some days are requisite for them to proliferate extensively enough to produce a widespread chemotaxis or attraction of the leucocytes from the blood-vessels of the urethral mucosa, or that the tissues were not particularly vulnerable. After the gonococci have proliferated and become more extensively distributed over the urethra, a widely-spread and severe exudative inflammation of the canal takes place more or less suddenly. An attack of gonorrhoea would be liable to begin in this slow, mild way if the infection originated from a similar discharge, such as fairly old gleet or declining

INVASION OF THE TISSUES BY THE GONOCOCCUS.

gonorrhoea, in which it takes considerable searching with the microscope to find a pns-cell here and there containing gonococci.

In other cases a severe discharge, purulent from the beginning, occurs suddenly within forty-eight or seventy-two hours after the exposure. In such a case as this we may suppose that a very large number of gonococci enter the urethra and proliferate extensively. The initial cocci are not localized, but become rapidly distributed — perhaps at the exposure — over a large surface of the urethra, and exert chemotaxis, or, in other words, produce inflammation simultaneously at many points over a large segment of the urethra.