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.
[164] _Die latente Gonorrhoea in weib. Geschlect._ Bonn.
[165] _Gonorrhea in Women_, p. 123. Philadelphia, 1913.
[166] _Trans. Amer. Urological Assoc._, vol. iii.
[167] _Lancet_, November 24, 1906.
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.
[168] _Expansion of Races._ New York, 1909.
[169] _Medical News_, December 21, 1909.
[170] _New York Med. Jour._, November 12,
1910.
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.
[171] _Jour. Amer. Med. Assoc._, January 8, 1916.
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.
[172] _Jour. Amer. Med. Assoc._, January 8, 1916.
[173] _Jour. Amer. Med. Assoc._, September 30, 1916.
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.
[174] _Jour. Amer. Med. Assoc._, October 6, 1912.
[175] _Social Diseases and Marriage_, 1904.
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.
[176] _Monatschrift f. Geburt. u. Gynä._, 1909, n. 20.
[177] _Zeitschr. f. Geb. u. Gyn._, 1907, vol. lix, n. 1.
[178] _Archiv. f. Gyn._, vol. xcii, n. 2.
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.
[179] _Gonorrhea in Women_, p. 285. Philadelphia, 1913.
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.
[180] _Policlinico_, 1907, p. 16.
[181] _Münchener medizinische Wochenschrift_, April 8, 1913.
[182] _Soc. Med.-Chir. de Bologne_, 1904.
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.
[183] _Jour. Amer. Med. Assoc._, October 17, 1914.
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.
[184] _Surgery, Gynecology, and Obstetrics_, November, 1915.
Chicago.
[185] _Correspondenz-Blatt f. Schweizer Aerzte_, February 12,
1916.
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.
[186] _Jour. Obstet. and Gynecol. of Brit. Empire_, March and
April, 1910.
[187] _Trans. Amer. Gyn. Soc._, vol. xxxvi, p. 324.
[188] Norris, _Gonorrhea in Women_, p. 289.
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.
[189] _Jour. Amer. Med. Assoc._, January, 1913.
[190] _Il Policlinico_, January 3, 1919.
[191] _Trans. Amer. Gynecol. Soc._, vol. xxxiv, p. 327.
Philadelphia, 1909.
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.
[192] _Jour. Amer. Med. Assoc._, December 8, 1917.
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.
[193] _Jour. Amer. Med. Assoc._, vol. xli, n. 24.
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.
[194] _Montreal Med. Jour._, vol. xxxvii.
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.
[195] _New York Medical Journal_, February 22, 1908.
[196] _Canadian Presse Médic._, July, 1908.
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.
[197] _New York Medical Journal_, May 30, 1908.
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.
[198] _Ophthalmia Neonatorum._ London. 1907.
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.
[199] _Münchener medizinische Wochenschrift_, November 2, 1915.