The treatment of gonorrhea and its complications in men and women, for the general practitioner

Front matter

Glass Book

COPYRIGHT DEPOSIT

THE TREATMENT OF

Preface

Some specialists in venereal diseases say that all patients afflicted with gonorrhea should go to a specialist for treatment, and not to a general practitioner. They say that the general practitioner is not competent to treat gonorrhea properly. Whether these statements are made by the above referred to specialists from purely altruistic motives, exclusively out of consideration for the patient's welfare, is not a question that needs be discussed here. Of course the specialist would be financially benefited; there is no doubt about that; but the patient would also be greatly benefited, and there would be fewer uncured and incurable cases in the land. Be this as it may, granting the desirability of having every case of gonorrhea treated by a specialist, this is a Utopian desire; a hope that will not be realized for fifty or a hundred years to come. There are not enough gonorrhea specialists in the country to treat all the cases of gonorrhea. We are told that next to measles gonorrhea is the most widespread disease; and as all cases of measles could not be treated by pediatrists, so all cases of gonorrhea could not be treated by urologists. And assuming that the number of "gonorrhea" specialists should become adequate to the task of handling all cases of gonorrhea — supply generally follows demand — it would be absolutely impossible for everybody to patronize a specialist: their economic condition would not permit it. We forget

that medicine is greatly influenced by the financial condi-

8 PREFACE

tion of the people. And medical treatment will not become ideal until a radical change has taken place in our social system. And as this is going to take some time, things will run the way they have been running for another century or two, and ninety per cent, of all men unfortunate enough to contract gonorrhea will continue to be treated by the general practitioner. And it is therefore our duty to do our share to make the general practitioner as competent as possible.

The instruction in venereal and sexual diseases given in our medical colleges is disgracefully meager and is responsible for the inadequacy of the average general practitioner in the treatment of these diseases, and for the existence of the quack. A good plain treatise on the treatment of gonorrhea and its complications, intended specially for the general practitioner, seemed to the author as well as to numerous readers of his books and journals, a desideratum. For we have no satisfactory textbooks on gonorrhea. We have a number of books on genito-urinary surgery which contain chapters on gonorrhea, we have a number of quiz compends on venereal diseases, but they are not books which answer the demands of the general practitioner. The books specially devoted to the treatment of gonorrhea, like Wossidlo's, are too technical and are suitable chiefly for specialists. The best book on the treatment of gonorrhea so far is Luys ? "Traite de la Blenorrhagie, ' ' but unfortunately his favorite methods of treatment are urethrovesical irrigations and urethroscopy, and to advise the physician to treat his cases of gonorrhea with irrigations and by the aid of the urethroscope is to do the physician and his patients a very poor service indeed. I shudder to

PREFACE 9

think of the complications and of the number of incurable cases that would result. Even in skilled hands urethroscope treatment is not accomplishing what its zealous advocates claim it does; in unskilled and hurried hands, as must be those of the physician who treats all other ailments of the flesh, it would lead to frequent disaster. The number of damaged urethras would be too great to be counted. Noli nocere is the first requirement of any treatment which we are recommending to the general practitioner, and this motto has been well kept in mind throughout the book.

The style of the book is the plain, non-stilted style, which the author has used in his "Treatment of Sexual Impotence, ' ' which he uses in his Critic and Guide editorials, which he uses in his ordinary conversation. Practically the entire book has been dictated right from the head, without referring to any books. It was considered a fairer way ,to present the present day status of the successful treatment of gonorrhea and its complications than by merely rehashing a dozen textbooks. It was thought that what a specialist with fair abilities and a good memory, who has been treating venereal diseases daily for twenty years, could not say right off, without reference to books, regarding gonorrhea or any of its complications, was not worth knowing, was not necessary for the general practitioner to know. Of course before sending the typewritten manuscript to the printer I gave it some finishing touches, but the book is distinctly a personal book, and represents how Dr. Robinson treats gonorrhea and its complications and not how A., B. and C. treat them. This does not mean that the author has not read and studied the various text-

10 PREFACE

books and papers on gonorrhea; on the contrary, he probably read and studied every one of any significance ; but it does mean that nothing is represented in this book that has not passed through the crucible of his judgment and experience.

The author is convinced that by following the teachings of this volume the general practitioner will become much more successful in the treatment of his gonorrheal patients than he has been in the past.

W. J. R.

12 Mt. Morris Park West, New York.

Contents

chapter page

Preface 7

I The Extent and Seriousness of Gonorrhea . . 13

Chapter I Introduction The Extent And Seriousness Of Gonorrhea

I suppose it would be the appropriate thing to start this book with a disquisition upon the widespread extent of gonorrhea and all the terrible ravages that it works in the individual and in the race. Gonorrhea is a widespread disease and it does cause great ravages in the individual and in the race. Nevertheless neither its extent nor its seriousness must be exaggerated. The writer has always had a great aversion to lurid exaggerations of any kind: first, because an exaggeration is an untruth, or a half-truth, which Tennyson declares to be the worst of lies; and second, an exaggeration usually defeats the very object in behalf of which it is propagated.

The exact or even the approximate extent of the prevalence of gonorrhea no living person knows. All figures or statements in this respect are pure guesses without any solid foundation. We all go by impressions. The general practitioner practicing in a small town, who frequently does not see a case in ten years (because the patients go to neighboring large cities for treatment or are treated by their druggist and barber) is apt to minimize the extent

of venereal disease. The specialist who treats nothing but gonorrhea is apt to judge of all humanity by his patients, and to imagine that everybody has or has had gonorrhea, forgetting that after all he sees only a very small percentage of the population, and that the people who are free from the disease do not go to him at all and he has therefore no means of knowing whether they have or have not the disease.

I have always been fighting against the specialist's tendency to exaggeration and strabismus, and I will say right at the outset that the statements usually made that eighty to ninety per cent, of the male population of every civilized country have or have had gonorrhea are to me absurd. It is the same story of the extreme swinging of the pendulum in the other direction. For a long time gonorrhea was practically disregarded as a disease, and its sequelae in the individual, and its dangers to the welfare and life of the future wives, were not even dreamed of. Noeggerath made himself immortal, and deserves the eternal gratitude of all womanhood, by calling the attention of the profession to latent gonorrhea and its dangers. But I am sure that his statement that eighty per cent, of the male population has gonorrhea, that ninety per cent, of them are never cured, and that they all eventually infect their wives was a wild exaggeration.

I believe that if we say that twenty-five per cent, of the male population suffer with gonorrhea at one time or another, we would rather be overstating than understating the truth. Of course its prevalence varies in different strata of society. In some of the lower strata it may be as high as one hundred per cent., but then on the other hand there are several strata of society in which it does not, in my

SERIOUSNESS OF GONORRHEA 15

opinion, exist to a greater extent than five or ten per cent. As to the curability of this disease I also disagree with the somber estimates of the pessimists. Instead of ninety' per cent, remaining uncured or being uncurable, I believe that the greatest percentage of gonorrheas end in a practical cure. I say ''practical" because a good many cases may show for many years some shreds in the urine or a minute droplet of discharge and still be practically cured, that is, free from gonococci and non-dangerous to their partners. Naturally, I also disagree with the statement as to the frequency with which wives acquire the disease innocently from their husbands. According to the statements of some of our zealous friends practically every woman who marries a man who has had gonorrhea acquires the disease, and as according to their statements eighty or ninety per cent, of men have had gonorrhea at one time or another and ninety per cent, of these cases remain uncured, practically every married woman would be suffering from gonorrhea. Do they know to what absurd conclusions this absurd statement leads? The race would have become practically extinct if the statements just referred to were true. Fortunately they are not. As is well known, Prof. Erb's investigation in his private practice led him to the conclusion that only four per cent, of women who married husbands who had had gonorrhea contracted the disease. Allowing for the fact that his practice was among the well to do, who can afford skillful, prolonged and painstaking treatment, we would be justified in stating that about ten per cent, of married women acquire the disease innocently, a high enough figure as it is, enough to terrify us without any exaggerations! Exaggeration and painting in lurid colors may be permissible for propaganda purposes, but they should be frowned upon by scientists whose only function is to tell the truth.

SERIOUSNESS OF GONORRHEA

Gonorrhea is a serious disease, serious to the individual male, potentially serious to his wife and to his children. But even here we must not exaggerate. One writer says we must tell our young men that gonorrhea may end in death. But so may measles, so may a pinprick, so may the paring of a corn or the extraction of a tooth. It is all a matter of the frequency of such an eventuality. It is true that gonorrhea may end in an endocarditis or a general septicemia leading to death, but these results, are extremely rare, and we gain nothing by using these possible but extremely rare sequelae as specters to frighten our young men. In the vast majority of cases gonorrhea is a perfectly curable disease, leaving few or no sequelae.

Gonorrhea is a serious and dangerous disease, but its seriousness and dangerousness do not reside in the gonorrhea per se, but in our social-economic conditions, which do not permit the individual the proper rest and the proper treatment. If our patients attacked with gonorrhea could at once obtain the same care and treatment as do patients attacked with typhoid fever or pneumonia, ninety per cent, of them would be perfectly well by the end of two or three weeks.

But because gonorrhea is a " shameful " disease, because the young man must hide its existence from his parents, because there are no hospitals which accept venereal patients, because the patient must keep on working, perhaps

SERIOUSNESS OF GONORRHEA 17

running up and down stairs and lifting heavy weights, because he is unable to go to skillful specialists, but is obliged to treat himself with nostrums or be treated by the hurried and not always competent general practitioner, or in the frequently worse than useless dispensaries ; because of these things gonorrhea becomes in many cases such a serious disease, dangerous to the individual himself (arthritis, endocarditis, etc.), to his wife (endometritis, salpingitis, ovaritis), to the child (ophthalmia neonatorum) and by his becoming sterile or by rendering the wife sterile, to the race. To emphasize and to recapitulate: Skillfully treated from the beginning, under proper hygienic and dietetic conditions, gonorrhea is a benign affection; neglected or maltreated gonorrhea becomes an intensely dangerous disease. Which again brings us to the point emphasized by the author so many times, that if we wish to be successful in the treatment of our patients we must demand an improvement or a radical change in the social-economic conditions of the people.

Chapter II The Classification Of Urethral Inflammations

Urethritis is an inflammation of the urethra accompanied by pain, swelling and discharge. Not all urethral discharges and inflammations are due to the gonococcus. Of course gonorrhea is so much more frequent and serious that it overshadows all other urethral troubles. Nevertheless if we wish to avoid blunders, blunders which may prove extremely serious to the patient, we must bear in mind that a discharge from the urethra may be of other than gonococcal origin, and I therefore give at the outset a classification of urethral inflammations. Bearing this classification in mind may help one to avoid gross errors in diagnosis.

We divide them first into two large classes:

I. Bacterial.

II. Non-bacterial.

In the bacterial class we have the following varieties:

1. Gonococcal or Gonorrheal;

2. Common or simple bacterial;

3. Chancroidal;

4. Syphilitic;

5. Tubercular;

6. Neoplastic (?)

The non-bacterial or aseptic urethrites may be classified

as follows:

CLASSIFICATION 19

7. Chemical;

8. Traumatic;

9. Toxic;

10. Diathesic.

To class urethrorrhea among the urethrites is incorrect, for urethrorrhea can hardly be considered an inflammation of the urethra. Still more incorrect and utterly without excuse is to class prostatorrhea and so-called spermatorrhea among the urethrites.

Chapter III Gonorrheal Urethritis In The Male

Gonorrhea or gonorrheal urethritis is an inflammation of the urethra caused by a germ which was discovered by Neisser in 1879 and named by him the gonococcus, or the gonococcus of Neisser.

Taking the word gonorrhea in its pre-Neisserian sense, as synonymous with urethral discharge, the disease is one of the oldest known. It is mentioned in the Bible, and it has been described by Greek and Roman writers. Of course we have no means of knowing whether the urethral discharge spoken of by the ancients was specific in character and due to the gonococcus, or whether it was due to some other germ, or altogether non-bacterial; but we are justified in assuming that at that time, the same as now, most of the cases were due to the gonococcus. The description given by the ancients tallies very well with our gonorrhea.

The etymology of the word gonorrhea is barbarous in the extreme, if we consider its significance. Literally it means a running of semen, from : gonos=&emen and rheo=I run. The ancients thought that the urethral discharge was due to running out of spoiled, poisoned semen. We know better, but all attempts to change the word have proved and will prove fruitless. It is difficult or impossible to change

an incorrect but thoroughly established word for one sci-

GONORRHEAL URETHRITIS 21

entifically correct. Nor is it necessary. Language was made for man, not man for language, and as long as the word stands for something definite and gives rise to no confusion in anybody's mind, it is a good word, and all attempts to change it must prove quixotic. The name which Neisser gave to the specific germ of gonorrhea is not any better, for what does gonococcus mean? It means sernencoccus, which is of course absurd. But we know what it stands for, and it is useless to attempt to change it. 'Gonorrheal urethritis " or "gonococcal urethritis" are not much better, nor are the terms blenorrhea and Menorrhagia, used in Germany and France respectively, a great improvement. We will therefore adhere to the old term gonorrhea, it being understood that when we use the term without any other qualification, we refer to an inflammation of the urethra caused by the diplococcus of Neisser. When speaking of the complications we will use gonorrheal prostatitis, gonorrheal epididymitis, gonorrheal vesiculitis, etc.

The infection takes place almost exclusively during sexual intercourse. But note that I said almost. I do not at all deny the possibility of non-venereal infection, from soiled linen or infected instruments; and it will not do to sneer at the possibility of infection from a bathtub or the seat of a water-closet. In a Berlin clinic I watched an acutely gonorrheal patient go into a privy. When he got up there was about half a teaspoonful of thick creamy pus on the seat, at the point touched by the meatus. A person sitting down on that seat within an hour or two would be very apt to get some of the pus transferred to his urethra and to develop a gonorrheal urethritis. That gonorrheal vulvovaginitis in little girls — which however seems to be of a different character from the gonorrhea of adults — may and often does assume the character of an epidemic, the infection being carried by soiled linen, by the nurses, etc., and is often contracted in the water-closets of the school, is of course well known.

But the histories of my patients alone would be sufficient to make me refrain from being dogmatic about the nonpossibility of extra-venereal gonorrheal infection. As I stated elsewhere, I know that my patients do not lie to me ; they certainly do not all lie. They know that I am not a hypocrite, that I am not going to pass sanctimonious judgment upon them, and they have no reason whatever to lie about the manner in which they acquired their gonorrhea or syphilis. They also fear that deceiving the doctor about any detail in their history may lead to different treatment and that thus they may not be benefited or may even be injured. When, therefore, an intelligent patient assures me that he had never had sexual intercourse, or had not had any for several months, that he knows no cause for his urethral discharge, which shows the presence of gonococci, except perhaps that he visited a toilet in a railway or subway station, or slept in a second rate hotel in which the bedding was not of immaculate purity, I see no reason whatever for doubting his — or her — story.

Of course the eases of extra-venereal gonorrheal infection are few in number in comparison with those contracted during sexual intercourse; but it is important that their possibility be not denied altogether. Admitting their possibility may prevent unjust accusations, and occasionally the breaking up of a home.

Chapter IV The Germ And The Diagnosis Of Gonorrhea

The gonococcus, the little germ or micro-organism which is responsible for so much human misery, is exclusively a human parasite. It can live and thrive in the human body only. All attempts to inoculate the gonococcus in any animal have failed ; no animal can be infected with gonorrhea. Perhaps it was sent to the human race to keep it from promiscuity. It is about half the size of a red blood corpuscle, about 1-50 fi in length and 0.7 /x in width. It is a diplococcus, that is, it occurs always in twos or in multiples of twos. This is due to its method of division. Under the microscope in good preparations they appear like a coffeebean which has been opened and laid out flat. They are found both in the cells and outside of the cells, and we speak of them as extra-cellular and intracellular, but the intracellular position is the characteristic one, and a microscopic specimen which contains many extra-cellular but no intracellular cocci would not be typical and would not give us the right to make the diagnosis gonorrhea.

It stains readily with the ordinary basic anilin dyes, such

as methylene blue, bismarck brown, methyl violet, saffronin,

fuchsin, etc., and if the smear is properly prepared can be

easily identified under the microscope. Numerous stains

have been invented, giving us very pretty microscopic specimens, but the general practitioner needs know but one or at most two stains, and if he only learns to apply them properly he will get for every practical purpose results as good as does the expert bacteriologist with the very complicated and refined stains. But the smear must be prepared properly.

HOW TO PREPARE A PROPER SMEAR

One of the common errors to which the beginner is liable is to make the smear too thick. This is an error which must be guarded against ; the thinner the layer of pus the better. Take a clean glass slide, take a wooden stick or a toothpick and wind around it a small wisp of cotton, dip the cotton in sterile water and shake off the excess. If the pus is gushing from the urethra, wipe off the meatus with some cotton or wash it off with sterile water to prevent contamination with germs which may abound on the glans and meatus. Insert the cotton carrier into the fossa navicularis, and with the pus thus obtained make several narrow smears over the glass slide. This distributes the pus very evenly and very thinly, and for this reason I prefer this method to the platinum loop or to squeezing the pus between two slides. Where the pus is very scanty and we have to go deep into the urethra to obtain some, there the platinum loop may be used. We then allow the thin layer of pus to dry on the slide, which takes a minute or two, then pass it three times lightly and quickly over the flame of an alcohol lamp or Bunsen burner. This fixes the preparation. With a glass dropper we then drop one or two or three drops of Loeffler's solution of methylene blue, allow it to remain two minutes, then wash off in running

ACUTE GONORRHEAL URETHRITIS

NON-GONORRHEAL URETHRITIS

DIAGNOSIS OF GONORRHEA 25

water. We then dry it with blotting paper (this step may be left off) put on a cover glass, put a drop of cedar oil in the center of the cover glass, and examine with a 1-12 oil immersion lens. And if the typical diplococci are present, the patient presents the ordinary history and symptomatology of gonorrhea, the diagnosis is settled and no further investigations are necessary.

We hear of the danger of making a diagnosis of gonorrhea by the microscope alone, of the possibility of confusing gonococci with the pseudo-gonococci and the micrococcus catarrhalis, etc., but these are all academic points, and in the vastest majority of cases the general practitioner will not be confronted with them. The general practitioner can never hope to become an expert bacteriologist, and where a medico-legal question comes up, or where a man wants a final authoritative judgment as to his complete cure and permissibility to enter matrimony, the decision will have to be put into the hands of a specialist.

In the vast majority of cases the patient comes to the doctor with unmistakable signs and symptoms of urethritis. The decision to be made then is only: Is it a gonorrheal or a non-gonorrheal urethritis? — and to decide that question the methylene blue test is sufficient in the vast majority of cases.

It occasionally happens that either because the gonococci have undergone a degenerative morphologic change, or on account of contamination with other germs, it is impossible to decide definitely whether the cocci that we see in the field are gonococci or not. In such a case we must use the well known Gram stain, which was elaborated for us by Roux of the Pasteur Institute.

Germs can be divided, according to the manner in which they behave toward the Gram stain, into Gram-positive and Gram-negative. The Gram-positive take the Gram stain and are stained by it a deep bine-black. The Gram-negative do not take the Gram stain, or if they have been stained by some of the anilin dyes are decolorized by the procedure involved in making the Gram test. The gonococcus is a Gram-negative germ. So then if we stain a specimen with one of the anilin dyes, examine it under the microscope and see clearly a number of cocci, then we subject the specimen to the Gram stain, and examine again the specimen under the microscope and find that the cocci have become decolorized, we know that we have to deal with gonococci, while if the cocci which we saw before remain stained they are not gonococci.

The Gram test is performed as follows. Prepare and fix the slide as before, pour over it some anilin-water-gentianviolet dye and leave on for two minutes, then shake off the excess and dip in Lugol's solution. Now dip the slide in absolute alcohol. This decolorizes the gonococci. If we examine the specimen at this stage we will find that the Gram-positive cocci, if there are any there, are of a blue-black color, while the gonococci have disappeared from the field, so to say, for being unstained they can be seen but with difficulty. If we wish, however, we can use a double stain, and after removing the slide from the absolute alcohol we dip it in or pour over it some bismarck brown solution. Examining the specimen then, the gonococci will appear of a light brownish color, while the pseudo-gonococci will be blue-black.

DIAGNOSIS OF GONOKRHEA 27

CULTURES

The gonococcus is a difficult germ to cultivate. It does not grow on ordinary culture media, such as agar-agar, glycerin-gelatin, etc. The medium must contain some human serum, blood serum, ascitic fluid, etc. The general practitioner cannot possess the facilities nor can he acquire the skill necessary for making cultures of gonococci. Nor is the procedure of very much use. We often hear it stated by some genito-urinary specialists that we cannot make a diagnosis of gonorrhea from microscopic examinations alone, that we must always make a culture. This is a fatuous statement, often made I fear for the sake of personal aggrandizement. And again, first of all, even a properly made culture in the hands of an expert bacteriologist is not absolutely conclusive evidence, errors can occur even there. Second, the cultures as made by the average laboratory are very often worse than useless, because misleading. Thirds the cases where with the history, clinical symptoms, and bacteriological findings we are unable to make our diagnosis, are so rare as to be negligible. In over twenty years' practice, treating patients with I believe a fair degree of intelligence and success, I have not found it necessary once to have recourse to a culture. Fourth, it is not so important. I mean just what I say, that the differential diagnosis between the gonococcus and some other coccus is not such a life and death matter as some of our confreres would unwittingly make us believe. One would think that the gonococcus is the only deadly bacillus and that if the symptoms of which the patient complains are due to some other germ the case is of no importance. This is far from being true. Other bacteria flourishing in the urethra may give rise to as much trouble as the gonococcus. We can have very severe epididymitis, prostatitis, or vesiculitis from the coli bacillus, staphylococcus, etc.; and cystitis, pyelitis, and pyelonephritis are much more apt to follow infection by other germs than they are to be the result of gonococcal infection. So what's the difference? "Whether the urethritis and its various complications are due to the gonococcus or to other germs they have to be treated, and the treatment is practically the same whatever the infecting agent is. Fifth, the complement fixation test is more reliable, gives us more information, takes less time and is less troublesome to perform. The complement fixation test, similar to the Wassermann test for syphilis, is now performed by all serologic laboratories. All the general practitioner has to do is to draw a dram or two of blood from one of the veins in the elbow, put it in a sterilized bottle and send it to the laboratory.

Chapter V The Course And Symptomatology Of Acute Gonorrhea

The course of acute gonorrhea, or more specifically speaking, acute gonorrheal urethritis in the male may be divided into five stages: (1) the stage of incubation, (2) prodromal, (3) acute or ascending, (4) subacute or stationary, and (5) declining or subsiding stage.

The stage of incubation is the period from the moment of infection to the moment of the appearance of subjective symptoms. When the gonococci get into the urethra they do not cause symptoms at once (it would be better if they did) . It takes them some time to ' ' settle down, ' ' to increase and multiply, to get into and between the epithelial cells of the urethral mucous membrane, and cause inflammatory symptoms. The time required for this development, in other words the length of the incubation stage r varies in different cases; but the usual length is between three to five days. In other words it takes three to five days from the moment of an infectious intercourse until the patient becomes aware that there is anything the matter with him. During that time the patient is perfectly well. The incubation stage may only last twelve hours, and may last as long as two weeks; but this is exceptional. The shortest incubation stage in my personal experience was twenty-four hours, the longest twelve days. The reported incubation stages of four to eight weeks may be taken with a grain of salt. Or perhaps it is possible that the gonococci are deposited on the glans under the prepuce, and only later on, after several weeks, become accidentally transported to the urethra. At any rate, it is well to remember that in the vast majority of cases of gonorrhea the incubation stage lasts from three to five days; the less common, but still not excessively rare, limits are: one to seven days.