1^C^s Columbia ^mbtrjs^ttp mfteCitjujtBttogotk %(o (daUrgr of ptigaiiians anb S'ttrgrons Spffrftir? ICtbrarg (gtii?n by M^-HjL/y^L c^ JjukM-H^ t / ^' I*. PEA BO by ON GONORRHCEAL INFECTION IN WOMEN. ON GONORRHCEAL INFECTION IN WOMEN. BY WILLIAM JAPP SINCLAIR, M.A, M.D., HON. PHYSICIAN TO THE MANCHESTER SOUTHERN HOSPITAL FOR WOMEN AND CHILDREN AND THE MANCHESTER MATERNITY HOSPITAL; LATE EXAMINER IN MIDWIFERY AND THE DISEASES OK WOMEN AND CHILDREN, UNIVERSITY OF ABERDEEN. LONDON: H. K. LEWIS, 136, COWER STREET, W.C. 188$. PREFACE. The following chapters are, to a large extent, a reprint of papers which appeared in the Medical Chronicle from May to October, 1887. A considerable portion has been re-written, and the substance of the most recent contributions to the subject, which seemed to contain anything of value, has been introduced. The author does not profess to be in any sense a specialist in the Venereal Diseases. His whole aim has been to put before the reader the present state of the question of gonorrhoeal infection from the purely Gynaecological point of view. With that object, while on the one hand performing the function of translator and commentator, he has, at the same time, drawn upon his own experience in the belief that he could thus produce some additional contributions to our knowledge of clinical gynaecology. He has undertaken the work in the hope of doing his part in arousing the profession in England to some interest in a subject which he earnestly believes to be of vast social importance, and full of promise from the point of view both of the social reformer and the practical physician. Manchester, March 6lh, 1888. CONTENTS CHAPTER I. PAGE GONORRHCEAL INFECTION PRODUCES COMPLICATIONS WHICH ARE SERIOUS IN THEMSELVES AND OF FREQUENT OCCURRENCE. Importance to the Gynaecologist i Subject neglected in England — Probable cause of this neglect — Contrasted with German work. Erroneous and Inadequate Views Taught ... 2 Illustration from Holmes's "System of Surgery" — Case illus- trating practical eft'ects — Illustration from Diday's work. Cases Illustrating Phases and Complications . . 6 Case I. Healthy young married woman becomes dys- menorrhoeal sterile invalid — Case 2. Menorrhagia, salpingitis, oophorectomy — Case 3. Puerperal development with remote consequences — Case 4. Puerperal perimetritis, ophthalmia in child — Case 5. Puerperal complications with subinvolution and ovaritis, ophthalmia in child — Case 6. Perimetritis, pyosal- pinx (?), fatal termination — Case 7. Creeping salpingitis and perimetritis affecting two sides in succession — Case 8. Salpin- gitis and perimetritis post abortum, oophorectomy — Case 9. Chronic pelvic complications, treatment and its results sum- marised — Case 10. Gonorrhoeal abscess in breast — neglect of treatment and its consequences. Frequency of Occurrence of Gonorrhoeal Affections 19 Noeggerath's opinion with reference to New York — Alfred Fournier in France — Schwarz, Sanger, Oppenheimer, Lomer, in Germany — Opinion with regard to Manchester — Milton on country districts in England — Differences of opinion reconciled. viii Contents. CHAPTER II. PAGE Historical Retrospect of Views on the Pathology OF Gonorrh(j:a in Women. Before the Time of Noeggerath 25 Ricord's influence — Erroneous views as to seat of disease — Question of criterion of cure in the male sex. Noeggerath's Work and its immediate Influence . 30 Erroneous opinions with regard to his work — His work largely clinical — Meaning of "latent" gonorrhoea — His clinical groups of resulting diseases — Typical history of a case — Case 11. Com- plications with perimetritis — "Recurrent Perimetritis" — Illus- trative case, Case 12, showing consequences of neglected gonorrhoea — Chronic ovaritis and Bartholinitis — Noeggerath's conclusions — His more recent views — Angus Macdonald's work — Cas^ 13. Puerperal gonorrhoeal infection. — Case 14. Late puer- peral complications from gonorrhoea — Dr. Thorburn's inquiry and his conclusions. Neisser's Discovery and its Influence on Research AND Observation ....... 46 Neisser's first publication — His method of observation — His conclusions — Resulting activity in observation — Bokai — Weiss — Haab, and ophthalamia neonatorum — Neisser, second paper — Leistikow — Bockhart, cultivation experiment with the gonococcus — Examination of affected tissues — Sattler — Eklund — Schirmer — Zweifel, experiments with lochial discharges — Arning — Bumm, non-pathogenic diplococci discovered — Kammerer, doubtful observations — Kroner and question of a non- specific ophthalmia of the new-born — Sanger, gonorrhceal disease of the uterine appendages — Frankel, colpitis in children — Cseri — Widmark — French work — Italian work, De Amicis and Giovannini. Contents. ix CHAPTER III. PAGE Contemporary Pathology and the " Gonococcus- Neisser." Examination of a Suspected Secretion .... 58 Appliances required — Rapid method of examination — Bumm's method — What is seen under the microscope — Ilkistrations — Roux's method of differentiation — Allen and Wendt's opinions — Method of working — How to avoid error — Identification of gonococcus in actual clinical work. Presence of the Gonococcus — Its Clinical Significance 66 Proof that the gonococcus is the pathogenic element — Inoculation experiments by Bumm — Fulfil the requirements of proof — Gonorrhoea and simple urethritis discussed — Illustrative case of detection — Gonococcus in ophthalmia neonatorum. 71 Development of the Gonococcus in the Tissues — Its Effects Bockhart's experiment not conclusive — Bumm's observations on the conjunctiva — Details of the process — Application by inference to gonorrhoea in women. Theory of "Mixed Infection" 76 Definition — Example in pneumonia followed by tubercle — In vulvo-vaginal glands — Catarrh of the bladder — Gonorrhceic para- and perimetritis — Comparative rarity of mixed infection of the Fallopian tubes and peritoneum — Tubal tuberculosis as a con- sequence of gonorrhceal mixed infection — Rarity of parametritis. CHAPTER IV. Clinical Phenomena of Gonorrhceal Infection in Women. In the Acute Form Si The urethra and vulvo-vaginal glands— Question of the exis- tence of a gonorrhceal vaginitis — Schwarz's view — Marlineau's X Contents. PAGE view — Uterine gonorrhoea, the rule not the exception — Salpin- gitis — Causes of further advance of disease — Extension to the peritoneum — Ovarian gonorrhoeal disease — Opinions of Bernutz and Goupil — Opinion of Martineau — Extent of ordinary typical attack — Definition of acute attack — Case 15. Illustration of extension of disease during the amenorrhoea of lactation — Case 16. Illustration of an acute attack modified by menstruation. In the Chronic or Creeping Form . . . . -93 Typical case— Variations in form of attack — Explanation of variations in the phenomena — " Latent " gonorrhoea in the male — Its import — Intermittency in progress of disease — Compli- cation of pregnancy — Vitality of gonococcus in cervix uteri — Question of urethral discharge in the male — Noeggerath's expe- rieYice — Permanence of contagium — On what does it depend ? — Effects of neglect of a gonorrhoea by the male — Case. 17. Illus- tration — Case 18. Complicated case showing persistence of contagiousness. CHAPTER V. Consequences of Gonorrhceal Infection to the -Individual. Urethral and Vulvar Gonorrhcea 104 Analogous to disease in male — Cystitis — Acute and chronic Bartholinitis with cases. Uterine Complications . , 104 Changes in uterine mucous membrane — Zeller's research — Bland Sutton's conclusion — Their application — Menorrhagia Illustrations in Case 19, and Case 20. Tubal Gonorrhcea 107 Hydrosalpinx and Pyosalpinx — Lawson Tait on tubal gonorrhoea — Remarks on Dr. Lewers's paper — Sanger's opinions quoted — Reference to polemic— Caj^ 21, in illustration of "de- structive suppuration of the uterine appendages"— A question in treatment of pyosalpinx. Co7itents. xi PAGE Effects upon the Ovaries 115 Production of peri-oophoritis — Olshausen's statement — Nature of the ovarian inflammation — Production of cysts — These a cause of danger in forming abscess — Production of membranous cover- ing and adhesions — Effects on ovulation — Growth of cysts — Causes of pain in ovarian gonorrhceal complications — Ovarian abscess — Dangers in puerperium from old ovarian and tubal disease — Dr. Grigg's paper. Sterility a consequence of Gonorrhceal Infection . 119 Perimetritis the usual cause — How the result follows — Question of other complications as cause of sterility — Stenosis — Sterility primary or puerperal — Gonorrhoea a cause of sterility in the male — Gross's inquiry quoted by Matthews Duncan — Sanger's conclusion — One-sided perimetritis and pregnancy — Perimetritis spreads from one side to the other— Illustrative case from Lawson Tait's "Diseases of Women," Case 22 — Conclusion. Gonorrhceal Puerperal Fever 124 Question still under discussion — Sanger's conclusions — These questioned — Sanger and Angus Macdonald's cases — Kroner's conclusions — Noeggerath's views assented to — Need for further observations. CHAPTER VI. Treatment, Prophylaxis, and Conclusion. Treatment 128 It requires to be chiefly topical —It must be germicide — The urethral and vesical forms as in the male — Oppenheimer's research — His results as to internal treatment — Neumann's opinion as to kidney complications — Malusardi on the thera- peutics of gonorrhoea — Treatment ordinarily too long delayed — Illustrations in Case 23 and Case 24 — How to treat the early stage — Schwarz's treatment — Quotation from his work — Questions as to efiicacy of iodoform — Fritsch's treatment of early stage — xii Contents. PAGE Treatment of uterine form— Schwarz and irrigation — Fritz Levy's proposal — More advanced stages — The secondary vaginitis — Tubal and ovarian gonorrhoea, a separate chapter in gynaecology. Prophylaxis 139 The function of Medicine in relation to the venereal diseases — How are women to be protected? — Question of legislation — Protection of young men — Present state of matters due to ignorance — Duty of the medical profession — Criterion of cure. Conclusion 142 ON GONORRHCEAL INFECTION IN WOMEN. Chapter I. GONORRHGEAL INFECTION PRODUCES COMPLICATIONS WHICH ARE SERIOUS IN THEMSELVES AND OF FREQUENT OCCURRENCE. Importance to the Gynaecologist. /'^ONORRHCEA as it occurs in the female sex is still in ^-^ this country strangely neglected by general practitioner and specialist alike. Its symptoms, its differential diagnosis, and the ravages which are its immediate or remote results, are hardly recognised or understood, and the treatment of it, as ordinarily practised, is contemptible. Yet the virus of this disorder gives rise to a group of diseases, a series of patho- logical conditions, which, by reason of their clinical interest and their social and moral consequences, surpass in impor- tance any other class of affections with which the gynaecologist is called upon to deal. To the reader, cognisant of the eager activity which, now as heretofore, pervades every department of medical research and practice, there must appear to be something extreme or paradoxical in this statement. But the explanation is not far to seek. If gonorrhcea stood alone among the diseases of women that had been neglected for generations by the surgeons, the explanation might be difficult ; but it has only shared what was the common lot with abdo- minal and uterine surgery until the latter was removed from the limbo of neglected subjects by the work of the specialists, B Gonorrhoeal Infection in Women. so recently that many 'of the early reformers are still alive and engaged in the active practice of their profession. Even yet the importance of the part played by the gonorrhoeal virus in the production of disease has received comparatively little attention from the gynaecologists in England and America, whereas in some other countries, especially in Germany, in recent years, a large amount of experimental work has been done, and much clinical evidence has been collected, which must soon work a revolution in the opinions and practice of the profession throughout the world in regard to certain phases of gonorrhoeal disease. So little even of foreign work has been, published in England, that it can be no exaggeration to say that if the whole subject could be put before the practi- tioners of this country in all its fulness of detail, both theo- retical and practical, as it has developed in Germany during the last few years, the knowledge would come as a surprise and a revelation. Writing with this conviction, I need hardly apologise for endeavouring to give an outline of these recent researches and observations, especially as I shall be able to incorporate some observations and illustrative cases of my own, -which can hardly fail to be recognised as corroborative evidence in support of conclusions already suggested in the opening sentences, and ultimately to be stated more explicitly and formally. Erroneous and Inadequate Views Taught. There are few medical practitioners in this country who, when medical students, were not entirely mistaught with regard to the pathology and treatment of gonorrhoea in women. Their teachers were the pure surgeons, and when these taught that the disease was to be considered only a form milder in its course, and more amenable to treatment, when affecting the female sex, there need to be no surprise if the practitioner has carried the ignorance of his teachers into his daily practice, with disastrous consequences to some of his patients. Whether the teaching of Erroneous and Inadequate Views Taught. 3 an old pathology is still carried on, I do not know; but there is no evidence of a change in some of the most recent works on surgery. It would be interesting, if space permitted, to collate a series of quotations on gonorrhoea in women from the older and more recent manuals of surgery, as exhibiting the barrenness of surgical observation until the subject was taken in hand by the specialists. It must suffice, however, to quote from the article "Gonorrhoea" in Holmes's "System of Surgery." This work is selected as one which is looked upon by many practitioners as a complete library of surgical litera- ture, and as I quote from the third edition, published in 1883, it may fairly be assumed that we have here a statement of the orthodox surgical doctrine of the present time, as understood by the average general practitioner; and, having it fresh before us, we shall be better able to see how we stand with regard to the orthodox creed when we have assimilated the newer knowledge. Under the sub-division, "Gonorrhoea in the Female," the author says^: "Gonorrhoea is a much less com- mon affection in women than in men, and when it does occur, the disease is ordinarily much less severe, and hence more rarely comes under treatment. . . . Inflammation, in consequence of gonorrhoea, has been supposed to extend to the cavity of the uterus and to the Fallopian tubes. West mentions two successive attacks of vaginitis, at an interval of eighteen months, in same patient, which were followed by such severe peritonitis as to call on each occasion for the abstraction of blood. . . . Ovarian inflammation, corre- sponding to the epididymitis of the male, occasionally occurs. It has been described by Hunter, Dr. Tilt, and others." There is in this chapter not a single expression to convey to Lhe reader any hint of the serious nature of the complications of gonorrhoea in women, as compared with the corresponding phases of the affection in men. The existence of a "latent" or creeping form of the disease is not so much as mentioned, ' "A System of Surgery, by various Authors." Edited by Holmes; p. 391, 3rd Edition, 1883. Gonorrhceal Infection in Womeyi. and the author is equally silent with regard to dysmenorrhoea, pyo-salpinx, sterility, and other well-recognised results of the disease. It will be observed that the date of this essay is eleven years later than the appearance of Noeggerath's work ; six years later than when Lawson Tait wrote, ^ "Acute ovaritis from gonorrhoea is a common result of the infection;" and four years after Neisser's first publication on the discovery of the gonococcus. It need not surprise us if the practical outcome of such teaching is a very lame method of dealing with the disease in the male, with unfortunate results for the female. The ordinary treatment of the male sex, with its .consequences, is well illustrated by a case at present under my care, which, in its clinical aspect, as aifecting the woman, will be given in more detail in the sequel. It is that of an hospital patient, suffering from acute pelvic inflammation, as I shall call it at present, the special internal development of the disease not having been as yet sufifi- ciently differentiated. She has been married only about two months, and she has a turbid uterine discharge, which has been ascertained to contain gonococci in abundance. In order, if possible, to obtain corroborative evidence, without too closely questioning the wife, I sent for the husband. I told him my object in wishing to speak with him was to learn if he had had clap? "Yes, I had," said he, quite frankly. "When?" " I got it in August last year." " When were you cured?" "In November." "When did you get married?" " In the beginning of February." " When did your wife begin to complain?" "Last month" — that is,' in March, just about a month after marriage. In answer to further questions, my interlocutor informed me that the doctor who treated him first, considered him quite cured in November. There was some uneasiness in the genitals about Christmas, and he consulted another practitioner, with special reference to the question of marriage at an early date. Although the patient was the subject of phimosis, and his glans could not be seen, he was ^ "Diseases of Women," 1877. Erroneous and Inadequate Views Taught. 5 assured that he was all right, and might get married without misgiving. Very soon after marriage he began to have a discharge, and his wife became ill, complaining of intense hypogastric pain, which necessitated her taking to bed. Still another medical practitioner was called in to attend the wife, and he was also consulted by the husband on account of some symptoms which had reappeared. This doctor recommended, and performed, the operation of circumcision on the husband, and is reported to have assured him that there was no sort of connection between his wife's ailment and his own. The final result in this case, so far, is a gleet in the husband, and an ailment which is probably destined to do irretrievable damage to the sexual organs, and perhaps to the general health, of the wife. In further illustration of the practice which may result from an inadequate apprehension of the danger to women arising from gonorrhoeal infection, I shall quote from a comparatively recent French writer on the venereal diseases. Speaking of the case of a young man about to be married, who has had the misfortune to contract a gonorrhoea which there is not time to cure before the wedding day, he says : "In these embarrassing circumstances one sovereign remedy remains, only one — injec- tions of nitrate of silver, . . . Suppose one employs a medium dose of the solution, in an hour and a half or two hours after the injection there appears a discharge, the simple effect of traumatism, accompanied by a little smarting in micturition. This slight inflammation lasts five or six hours. But then, precious result, the canal becomes dry; all morbid secretion is arrested, and this condition persists for eighteen or twenty-four hours — quite sufficient time for the bridegroom to seek his nuptial couch in a healthy, or, at least, noncontagious state. In exact figures, if the newly-wedded pair ought to retire to their room on Friday morning at one o'clock, the preservative injection ought to be made about nine o'clock on Thursday forenoon."^ This is surgery fit only for satyrs; and * " Le p^ril v^n^rien dans les families." Par P. Diday. Paris, 1881. Gonorrhoeal Infection in Women. yet the practical outcome of much of the prevalent treatment is as inevitably the ruin of the health of innocent women, as must be the result of following the coarse advice of this French surgeon. Some who have paid but little attention to the diseases of women may consider the terms here employed to indicate the effect of the venereal poison upon the health of the woman unnecessarily strong. But it will be shown later on that the gonorrhoeal virus may, and does frequently, cause chronic discharges, metritis and endometritis, salpingitis and pyo- salpinx, ovaritis, peritonitis, derangements of menstruation, sterility, and a variety of complications and combinations of these diseased conditions ; and, if this can be proved, any language fails to do justice to the facts. It may be also objected that such severe cases must be rare, and therefore the subject becomes comparatively unimportant. The fre- quency with which the more serious cases occur appears to vary in different countries — that is, as might be expected, according to the habits of the people. The apparent frequency also depends upon the method in which the facts of the history of each gynaecological case are investigated, that is to say, the nature of the cases is overlooked or detected according as the practitioners are ill or well informed on this special theme. That the gonorrhoeal virus and puerperal septicaemia are the great factors in producing the more serious pelvic diseases cannot now be disputed against the weight of evidence ; and there can be no doubt that a large number of the apparently puerperal septic cases are of gonorrhoeal origin. Cases Illustrating Phases and Complications. Without attempting, at present, to give any complete and precise description of a typical case of gonorrhoeal disease in the female sex, including complications, as a guide to diagnosis and treatment, I shall mention in somewhat general terms a few fairly typical cases, with the view of bringing out in con- Cases IlliLstratiyig Phases aiid Complications. 7 Crete form some of the various phases of the disease under consideration, keeping in mind only that, for the present, the disease has to be shown to be of common occurrence, and important apart from its frequency, and leaving definite con- clusions as to diagnostic points and treatment to be developed in the sequel. Case i. — This patient when first seen was a married woman of 20. She had been married twelve months, and had not become pregnant. She complained of a pain chiefly felt in the left inguinal region, shooting across the hypogastrium, and making her feel sick. She has been worse for the last five or six weeks. IMenstruation has so far been regular, but the last two periods have been scanty. Before marriage, menstruation was almost painless, and she was free from inter-menstrual discharge. Now the pain at the periods, coming on a day or two before and lasting until the flow ceases, is intense. It doubles her up, as she puts it; and she cannot sleep at night for the pain. Her ailment began three months after marriage. She had then some sort of acute abdominal disease, accom- panied with severe hypogastric pain and scalding in micturi- tion. This illness made her keep to bed for a fortnight. There is also mastalgia in the right side, intensified before the periods. Examination per vaginam shows that the uterus is in normal position and movable. Both ovaries are made out enlarged and adherent, and very sensitive to touch. These notes, taken twelve months ago, indicate the patient's condi- tion then ; she is now no J^etter. She has been an in-patient of a hospital for women, and has been subjected to various measures of treatment, with only temporary benefit. She is now a dysmenorrhoeal invalid, and in all probability permanently sterile. Here then is a young, robust girl, whose health is deteriorated, perhaps entirely ruined, by marriage. What is the essential element in the causation of this result? I have not been able to detect the gonococcus, but the husband con- fesses to having contracted gonorrhoea within a year before his marriage, although he considered himself well when the Gonorrhceal Infection in Women. marriage took place. Note the change in the type of men- struation in this case, often one of the most striking features in creeping gonorrhoea. Case 2. — The next patient was, at the time of her mar- riage, three years ago, a robust healthy woman of 22, with- out any record of illness since childhood. A few months after marriage she began to suffer from vaginal discharge, with frequent and painful micturition. Menstruation, which used to be regular, normal in amount, and painless, became painful and profuse, ultimately de^^eloping into menorrhagia, for which medical treatment had to be sought. The first marked menor- rhagic period was ushered in by an illness requiring rest in bed, the chief symptom of which was severe hypogastric pain. From this time the periods varied from one to three weeks, and were accompanied with severe pains, which continued during the whole time of the menstrual flow. An inter- menstrual discharge is described as " running away" from her. The uterus, it appears, was dilated and curetted by the medical practitioner who first attended her, and the result was temporary relief from the haemorrhage, but with no relief from pain at the menstrual periods. When she came under my care, a year and a half ago, I found that she had an enlarged uterus, evidently the result of metritis, and both her ovaries were enlarged and painful. She was submitted to treatment, varied in every way that promised to give relief, but with only temporary advantage. The third time she was admitted as an in-patient of the Man- chester Southern Hospital was after great suffering at a menstrual period, and when she had made up her mind to undergo any operation that might be considered necessary. The state of the ovaries was worse than ever, and accordingly, with the consent of all concerned, the ovaries and tubes were removed. That is six months ago. The tubes were somewhat dilated, and the outer extremities were incorporated with the enlarged and cystic ovaries. The patient recovered without any bad symptom, and is now relieved of her sufferings, and she has regained to a large extent her healthy appearance. Cases Illustrating Phases and Complications. g There can be no doubt, I think, that the direct cause of all this injury to the woman's health was due to gonorrhceal infec- tion : The husband had the disorder the year before he married, and though his statements have varied, he admits to having seen traces of the disease within six months of his marriage. He was and is addicted to drink, and, that being the case, it is easy to understand how the diseased process would be continued indefinitely in the latent form, and be ultimately stimulated by frequent sexual intercourse into such active development as to make it readily contagious. Case 3. — In this case we shall see how the diseased pro- cess may continue indefinitely, while the woman is living under comparatively favourable circumstances, producing symptoms which, under other conditions, might call for operative treat- ment. The patient is 29 years of age, and has been married the second time five years. She came first under my care eight years ago, when her first husband was living. At present the form her ailment assumes is enlargement of the uterus, with retroversion and a tendency to prolapse. On exertion, the dragging of the uterus, when not supported, produces nausea and vomiting, which may come on quite suddenly during any kind of active exercise. The left ovary is enlarged and tender, and bands can be made out behind the broad ligament, which are the result of inflammatory adhesions. Near the vaginal orifice there are tender areas, which make it almost impossible for the patient to wear a Hodge's pessary, and yet a padded Hodge is the instrument which gives most relief to the other symptoms. This difficulty seems to be due to a chronic inflam.mation of the glands of Bartholini. The patient has been so far sterile since her second marriage; she menstruates regularly, but with severe pain, and scanty menstrual discharge. There is a considerable, though not profuse, leucorrhcea. Now, if a physician were being consulted by this patient for the first time, in her present condition, he would probably find it im- possible to make out for certain the state of parts or the cause of the disease. It would be possible to elicit the history of a 10 Conor rh(Eal Infection in Women. very severe puerperal illness over seven years ago ; that illness was of gonorrhoeal origin. I attended the patient during her pregnancy, while she was suffering from an acute attack of gonorrhoea, conveyed to her by her husband, in whom it was clearly of post-nuptial origin. She was only apparently cured by the end of pregnancy. She was delivered of a healthy child, but she was seriously ill for months. The severer symp- toms came on nearly a month after the birth of the child, and arose from inflammation, extending to the pelvic peritoneum and including the ovaries. There followed pelvic abscess, and all the usual train of hectic and emaciation, with adhesions and fixation of the uterus. She made a very slow recovery, and was unfit for any exertion for many months. I have a con- tinuous history of her ailments since then, because I have seen her at intervals during these seven years, and there can be no doubt but that all her troubles began with, and are the direct result of, the gonorrhoeal infection during her first and only pregnancy. Since her second marriage this patient's ailment has been ''latent." Her husband has never suffered from any sort of irritation of the glans or urethra, hence it may be confidently asserted that the wife's leucorrhoea has been entirely non-specific in its effects, although specific in origin. Case 4. — M. N., set. 22, single, strong, healthy-looking woman, complains of a pain in the left inguinal region, and in the thigh. Menstruation is irregular and profuse, sometimes lasting three weeks, and producing extreme weakness. There is intense dysmenorrhoea, the pain continuing during the first two or three days of the period. Much inter-menstrual dis- charge. On examination per vaginam, the uterus is found to be enlarged and fixed, with patulous os; there is a large, hard, not sensitive mass behind the uterus, with the usual accompanying hardness of the tissues round the left side of the pelvis. This patient had an illegitimate child twelve months ago, and she has never been well since. In the latter half of her pregnancy she suffered from swelling of the nymphae and scalding in micturition, and had an extremely Cases Illustrating Phases and Complications. 1 1 profuse mattery discharge. She is convinced it was a venereal disease that she had contracted, although she does not assign the reasons for this belief. The child began to have an inflammation in one eye, with mattery discharge, two days after its birth, and this continued for about a month, although the child was under treatment. This is a common type of hospital case, occurring among women of the same class, both married and single. Repeated examinations of the discharge for the gonococcus gave no result, but the history permits of a confident diagnosis. Case 5. — M. E. M., aet. 24, married six years, and has had four children. Last confinement six weeks ago. Has always had good recoveries until this time. Was confined to bed for three weeks, with pelvic pain after her confinement, and has continued to sufl'er from the pain to some extent since she began to go about. She has been troubled with a profuse yellow discharge since the lochia ceased. On examination, the uterus is found to be enlarged, with open os (subinvolu- tion), and the left ovary is much enlarged and very tender to touch. Discharge from os, yellow, mattery, profuse. For the last two months of her pregnancy she had a slight discharge, which caused some irritation about the vulva, and a slight dis- comfort in passing water. She volunteered a statement which left no doubt that her husband was under treatment for a venereal disease contracted during the wife's last pregnancy. The child was under treatment as an out-patient of the Southern Hospital for ophthalmia ?ieonaioru?n. Examination of the uterine discharge in this case, the matter being taken from the os uteri for the purpose, showed the presence of a micro-organism, having all the characteristic appearances of the gonococcus. Case 6. — This patient was a rather scrofulous girl, of the domestic servant class, aged 19, who, when first seen, had been suffering for about six months from an ailment which was ascertained to be gonorrhoeal in its origin. She had the usual hypertrophied uterus, with great enlargement and pain of the 12 Gonorrhceal Infection in Women. ovaries ; the condition of the Fallopian tubes could not be differentiated. Medical non-manipulative treatment and rest produced much improvement in the course of six weeks, but even then the patient could not walk erect. After other six weeks' treatment by medicated vaginal tampons, without further improvement, I resolved to make a careful exploration of the pelvis with the help of an anaesthetic, and then decide on the question of operation. The careful examination was made, a sound was used, which had been thoroughly disin- fected — which was, in fact, lifted out of a warm antiseptic solution in order to be introduced — and the result of the examination was a decision to operate if a short trial of the then universally favourite hot douche failed to give relief. The hot douche was used for the first time the same day, in the hope of relieving the discomfort caused by the examination, and next day the temperature began to rise. This was one of my early cases of the kind, and I temporised in the hope of giving relief by sedatives ; but the after course was continu- ously downward. There was pelvic peritonitis with fixation of the uterus, and intense pain on touch. She never menstruated again. Ultimately pelvic abscesses formed, one bursting into the bowel and another into the bladder, and continued for months to refill and discharge alternately. The patient slowly emaciated, and ultimately died of exhaustion. My belief with regard to what happened in this case, in the light of later experience, is this : The examination by the sound produced a congestion by its stimulating effect, which, assisted by the hot douche, stirred up into more active deve- lopment the quiescent gonococci, resulting in a further spread of the inflammatory process, probably producing pyo-salpinx, or abscess of the ovary, and other abscesses. It is just possible that the sound may have introduced some pathogenic organism, which brought on a "mixed infection," or the tube may have been stimulated into discharging some of its con- tents into the pelvic cavity. The one thing certain about the case, whatever it may have been towards the end, was that it Cases Illustrating Phases and Complications. 13 was gonorrhoea! in its origin. If the ovaries and tubes had been removed when the temperature began to rise, the result might have been very different. Case 7. — Another domestic servant, in whose case the only ascertainable cause for the lighting up of a fresh attack of ovaritis was passing the sound in examination. She confessed to having become affected with a venereal disease, with ordi- nary symptoms of a mild gonorrhoea, twelve months before. Since then her menstrual periods had become painful, and so profuse that her mistress suspected an abortion at the time I was first asked to see the patient. The girl was so reduced in strength by reason of her losses of blood, and pain from enlarged and tender ovaries, that she was unfit for work. She was admitted, at the request of her mistress, into the Southern Hospital. In the course of examination, a thoroughly disin- fected sound was employed, and in 24 hours there was a distinct rise of temperature with unusual pain in the pelvis. The left ovary became more tender and larger, but in a few days it could not be defined because of a hard exudation in the left side of the pelvis. There was high temperature, with the usual red, dry tongue, but there was never any hectic. The temperature fell in ten days from the first onset of pyrexia, and the exudation could be pressed upon without giving rise to much complaint. All seemed to be going on well for about three days, when the temperature began to rise again, and the right side of the pelvis developed the same train of phenomena as the left. No abscess ever formed, and the patient ultimately recovered after an illness of two months' duration. When last seen her menorrhagia was cured, for menstruation had become scanty, but the dysmenorrhcea con- tinued ; she was still unfit for prolonged exertion of any kind. Case 8. — Mrs. B., set. 29, married seven years, had one miscarriage in the first year of married life, no pregnancy since. She came under my care two years ago, and was under treatment over twelve months without deriving any benefit. She had been always strong and healthy before she 14 Gonorrhceal Infection in Women. was married, and her husband is a well-developed, healthy man. On his side there is the history of gonorrhoea contracted about two years before marriage, but there is no evidence of a gleet continuing after the first apparent cure, and there are no habits of dissipation to make such a continuance or recurrence probable. There is no clear evidence of the conveyance of the disorder to the wife, all her early symptoms being possibly attributable to pregnancy. She aborted at four months without apparent cause, and suffered for a long time from some form of puerperal illness, accompanied with pain in the abdomen. No abscess appears to have formed. From this time men- struation became painful and profuse, and at the time she first came under my care she was entirely laid aside during her periods, suffering what was described as an agony of pain. She appears either to have had at these times short faints or some sort of slight epileptic seizures. She was tolerably well in the intervals. The ovaries were enlarged and painful, and there were some obscure points in the palpation, suggesting adhesions. Dilatation of the uterus before a period gave no relief to speak of. The final resort was oophorectomy. Both the tubes were closed and adherent at the outer ends, the right being greatly distended with turbid serum. The ovaries contained blood-cysts, and were adherent. The omentum had become attached to the extremity of the right Fallopian tube. Tubes and ovaries were completely removed. The operation took place nearly twelve months ago. The patient made a perfect recovery. She is now well, except for some nervous symptoms characteristic of the menopause. This case, taken by itself, would prove nothing with regard to gonorrhceal infection. It requires the experience of many other cases more or less closely resembUng it to bring out the fact that it is a very good typical case, and that we are justified in attaching what might otherwise seem undue importance to the points which make for proof of its gonorrhceal origin. Case 9. — A lady, now 30 years of age, was married twelve years ago, and during the first year of wedlock contracted Cases Illustrating Phases and Complications. gonorrhoea from her husband. She had a miscarriage at seven months, about a year after marriage, and since then she has been a wreck. At present she suffers from enlargement of the uterus, which becomes completely anteverted at times on exertion, making even a moderate amount of walking impossible. Her ovaries are enlarged, especially the right, and they become very painful at the menstrual periods. Menstruation is scanty,. and very painful. There is now hardly any leucorrhoea. The anteversion of the uterus causes much bladder distress at times. She is anaemic and thin, the reverse of what appears to have been her condition before marriage. There is in this case the history of a long serious puerperal illness, necessitating constant medical treatment for over twelve months. The patient has been under treatment for relapses at short intervals almost continuously since recovery from the first serious attack. She has never become pregnant again. She appears to have worn all manner of pessaries, and to have tried internal and external applications of every kind. She has had the uterus dilated once, resulting in a severe illness of some kind; and she used to have several days of suffering every time the sound was passed by any one of the numerous specialists whom she has consulted in the course of years. Among other therapeutic measures that have been tried has been median^ incision of the cervix uteri, the only remaining objective evidence of which seems to be a small notch on the posterior lip of the os. What the anatomical condition is at present and how much of the deviation from the normal is to be ascribed to the original gonorrhoea, and how much to treatment, nobody could now .profess to decide. Twelve months ago she consulted, at my suggestion, a celebrated London gynaecologist, who wrote to me : " She seems to me to have very little the matter," and went on to say that, in his opinion, she was suffering more from treatment than anything else, and he had advised her to give it all up, " to walk and dance and enjoy life." She was not satisfied with the advice given her by this physician, because she believed 1 6 Gonorrhoeal Infection in Women. herself too ill to attempt to follow it, but she took his prescrip- tion to a chemist to be dispensed. The dispenser entered into conversation with her, and at his suggestion she went the same day to another specialist in the neighbourhood whose name she had never heard of till then. This young gentleman wrote to me that he had diagnosed double pyo-salpinx, and had recommended operation. He went on to say : " If you do not care to undertake the operation, I would be very pleased to do it. I have been very fortunate with my cases of abdominal section, and 1 look upon this as a very favourable case.''' I am responsible for the italics. Out of respect for the feelings of earnest and upright gynaecologists, I shall quote no more of this letter, but I must strenuously protest against any one professing gynaecology, whatever his excuse for ignorance, calling a case with a history of ten or twelve years of compli- cations "a very favourable case" for operation. Favourable it could not possibly be, regarding either the immediate consequences of the operation or the remote results. Such cases are always difficult and dangerous because of the firmness and extent of organised adhesions; and they are disappointing in their later results, because the reorganisation of the innervation of the parts is either very slow in following a radical operation, or it remains incomplete. Palliation, not cure, is the best that can reasonably be expected. Enough has been said to call attention, in passing, to these extremes of treatment for some of the complications arising from gonorrhoeal infection, and to call up in imagination the effects upon the patient of such advice. In the case under consideration the patient, wisely, I think, has adopted as much as she could of the advice "to give it all up," and is certainly no worse, probably a little better, than she was last year. Case io, — Two years ago I had occasion to open a mammary abscess in a hospital patient, and I took some of the matter to the Pathological Laboratory at Owens College with the object of trying some cultivation experiments, which I had the opportunity of making under Professor Dreschfeld's Cases IlliLstratiyig Phases and Complications. ly friendly instruction and guidance. The pus was full of micro- organisms, some of which looked like gonococci. Tube culti- vations produced a development like that obtained by Bumm from the gonococcus. No pure cultivation was carried out with this specimen. When the patient was next seen she was asked about her symptoms during pregnancy, and it then came out that she must have been infected with gonorrhoea while pregnant. The infant at the breast was suffering from ophthalmia neonatorum, and was also an out-patient of the hospital. The patient had so far no symptoms suggesting the existence of any pelvic complication. Her only ailment was the mammary abscess, which must have been produced by the extension of the inflammation along the milk ducts, and that inflammation must have originated in the implantation on the nipple of colonies of gonococci from the child's eyes. To go back a step further, the purulent discharge from the child's eyes originated in infection from the genital tract of the mother. The state of matters here described may have been a result of "mixed infection;" but without going into the discussion of that subject, I may claim, provisionally, this case as also an illustration of the consequences of gonorrhoea. Cases might be multiplied indefinitely, but sufficient have perhaps been given for the present object, which is to convey a general impression of the importance and the frequency of occurrence of this class of disorders. It may seem strange to some to whom such observations are the mere commonplaces of practice, that so much is said about the importance of these disorders as a group of diseased conditions. But there can be no doubt that the subject is, as a rule, treated too lightly. It will be seen that a point common to all the cases cited is the absence of treatment in the early stages of the disease. The only apparent exception is the case which was under my care while in the acute stage ; but even in this case the disease was thoroughly established before treatment was begun, and, besides, the treatment was of the ordinary inefficient routine sort which was in vogue eight years ago. How little success c 1 8 Gonorrhoeal Infection in Women. attended it has been made manifest. As a rule, the disorder in women excites so little attention that the doctor is called in only to deal with complications when they arise. The reasons for this are probably the absence in most cases of severe urinary troubles ; the want of an evil conscience, which is usually present with the man ; the comparative difficulty with which women can minutely inspect their pudenda when slight discomfort begins, and their natural shyness about submitting to the inspection of other eyes; and the comparative frequency with which some plausible reason for a discharge or discomfort can be assigned; it is, for example, the effects of intercourse soon after marriage, a derangement of menstruation from some supposed "cold," or some one of the disorders of early pregnancy. No doubt one active influence in preventing the detection of gonorrhoea in the woman, while it is yet in the curable stage, is the conviction on the part of the husband that the thing is of no importance if the wife can be kept in ignorance of its nature. Matters will assume a very different aspect when all concerned awaken to the importance of prevention, and the difficulty of cure when the disease has reached the stage of compUcations. It is necessary to guard against exaggeration, for there is a danger that in rousing from long ignorance and neglect of the subject, the professional mind may sway to the other extreme, and, amidst the phenomena of disease obscure in their nature and as yet inexplicable, be tempted to accept gonorrhoeal infection as an easy and sufficient explanation of morbid processes with which it has no kind of causal relation. Still, as yet, the actual facts with regard to opinion are all the other way, and the danger which exists is not too strongly stated by a recent writer on the subject, who says^: — "The danger of gonorrhoea in the woman lies especially in this fact, that the infection from the urethra or vulva, vagina or cervix, may extend over the mucous membrane of the uterus, and thence further on to the tubes, the ovaries, and ' Dr. Fritz Levy (Copenhagen) : " Om den ' latente ' Gonorre hos Kvinden." Hospitals Tidefide, Nos. i, 2, and 3, 1887. Frequency of Gonorrhoeal Affections. 19 peritoneum, where it may give rise to a series of the gravest abdominal ailments. These may end fatally in acute peritonitis, resulting from the escape of pus from the tubes into the peritoneal cavity, or from the bursting of an abscess of the ovary, or of a pyo-salpinx ; or they may give rise to a condition of chronic peritonitis with adhesions of the uterus, tubes, and ovaries to the adjacent organs, or to recurrent attacks of pelvic peritonitis with the ultimate development of a 'gonorrhoeal cachexia,' and general breakdown of the health." Frequency of Occurrence of Gonorrhceal Affections. I have not seen any statistics worth quoting which could guide us to a definite conclusion as to the frequency with which gonorrhoea is to be met with in men and women in this country. Every medical practitioner in the large centres of population knows that it is one of the commonest ailments among men, but with regard to women the case is different. The disease, as it occurs in the female sex, varies so much in its features, that from the signs and symptoms alone it is usually looked upon as impossible of diagnosis. As the cases are not definitely diagnosed, there appears to be a general belief that the disorder is-not nearly so common among women outside the classes of professed or clandestine prostitution as it is among men. We must, therefore, for the present, rest satis- fied with little more than looking at the views of some foreign authorities, keeping in mind that most of the facts are of foreign origin, when we come to draw conclusions from them. Noeggerath,^ whose small work on " Latent Gonorrhoea in the Female Sex " marks the beginning of a new era in our clinical knowledge of the disease, says : " I do not know what the state of matters is in other cities ; I did not know how we stood in New York until I questioned the husband of every woman who came under treatment. And I believe we may ' " Die latente Gonorrhce im weiblichen Geschlecht." Bonn, 1872. 20 Gonorrhoeal Infection in Women. apply here the dictum of Ricord that in every i,ooo men, 800 have had gonorrhcea." In another place he says : " I believe I do not go beyond the mark when I assert that gonorrhoea in 90 per cent, of the cases remains uncured. Of every hundred women who have married men formerly affected with gonorrhoea, scarcely ten remain healthy, the others suffer from some of the ailments which it is the object of my essay to describe." Coming more into detail with regard to these affections, he says that his experience in New York, which he supposes to be a type of all the cities of the first rank, leads him to conclude that " after catarrh, chronic perimetritis is the most common ailment of the female sex." Alfred Fournier, who writes the article " Blennorrhagie," in the Nouveau Dictionnaire de Medecine, 1866, says: "Blen- norrhagia is perhaps the most common of all diseases. In the great centres of population, in the cities, where the people are facile in their habits and fond of pleasure, there are few men who escape it, and there are many who have had it again and again." In another place he says : "La blennorrhee est vulgairement connue sous les noms de goutte militaire^ de goutte matinale, de suinternent habituel ou chro?iique. EUe est d'une excessive frequence, et cela a tous les ages, dans toutes les classes de la societe." Some German gynaecologists have noted the frequency with which the diseases of gonorrhoeal origin occur in their practice, and the results strongly support the once much derided statements of Noeggerath. E. Schwarz,^ of Halle, in a lecture published last year, says that in 617 cases, carefully observed since the end of 1885, there were 112 which excited the suspicion of previous gonorrhoeal infection, and in which the patients' statements and the still existing symptoms made the diagnosis more or less probable. Of these 112 there were 33 = 5*3 per cent, who proved to be the subjects of acute gonorrhoea, and of that ^ "Die gonorrhoische Infektion beim Weibe." — Sammlung klinischer VortrcLge, Leipzig, 1886. Frequency of Gonorrhoeal Affections. 21 number 19 were either unmarried or widows. In the whole of these cases, diagnosed by appearances and symptoms alone, the diagnosis was further demonstrated by the presence of the gonococcus. Of the remaining 79 cases the gonococcus was found in its characteristic groups in 44 cases, although in some it had to be searched for several times. Thus gonorrhoea was proved to be present in 77 out of 617 cases, that is, in 12-4 per cent. Schwarz is of opinion that many of the remaining 35 cases had been infected at some time or other, and that the gonococcus would have been found if examination had been made at the most favourable times (Pradilektionszeiten), shortly before or after menstruation, during pregnancy, or in the puerperium. Several of them suffered from perimetritic affections with fixation and dislocation of the uterus, purulent endometritis, or showed other suspicious signs, and with several there was a history of purulent ophthalmia in their new-born infants. Sanger,^ of Leipsic, who is perhaps the principal champion in Germany of views approaching to those of Noeggerath, gave the latest results of his observations in a paper read before the German Gynsecological Society at Munich last year. He does not consider that the diagnosis of gonorrhoea is established except by the clear statements of the man or woman, by the occurrence of ophthalmia in the new-born chil- dren, or by the presence of affections of the urinary tract and the vulvar glands. The last especially he considers patho- gnomonic. Out of 1,930 gynaecological cases which came under his notice, in private and hospital practice, in the previous year, Sanger found 230 cases of gonorrhoeal disease, equal to 12 per cent., or one-eighth of all the cases. More recently still, of 161 cases he had found 29, or 18 per cent., of gonor- rhoeal origin. In 389 cases of pregnant women, he found that 100 had a purulent discharge, 26 per cent., and 40 of the children ultimately born suffered from ophthalmia neonatorum, ' " Ueber die Beziehungen der gonorrhoischen Infektion zu Puerperalerkrank- ungen." — V erJiatidlungen der detttschen Gesellscha/t f&r Gynllkologie, Leipzig, 1886. 22 Gonorrhceal Infection in Women. O. Oppenheimer,! of Heidelberg, working upon the mate- rial of Professor Kehrer's Clinic, endeavoured to establish the relative frequency of gonorrhceal infection in women, partly by direct examination of the vaginal discharges, and partly by the occurrence of ophthalmia neonatorum. In io8 pregnant women, he found 30 in whose vaginal secretion the specific diplococcus was undoubtedly present; that is, in 277 per cent. Ophthalmia neonatorum occurred in from 12 to 13 per cent, of the cases. Lomer,2 of Berlin, examined some of the patients of Schroder's Clinic, just as they came, without any selection on the ground of previously existing catarrh of the uterus, and he found in nine out of 32 lying-in women the characteristic diplococcus enclosed in pus cells, that is, in 28 per cent. The cases in which diplococci in colonies were observed, leading to the suspicion of gonorrhceal infection, amounted to 56 per cent, of all examined. The frequency of the occurrence of the disorder varies so much in different localities that it is, and perhaps always will be, impossible to formulate any statement which will be of general application even to cities. A curious example of this diversity is quoted by Noeggerath in a recent paper. ^ He refers to Winckel's statement that when he was at Dresden he was never able to demonstrate a single fatal case of acute gonorrhceal salpingitis in 400 female bodies examined, whereas soon after his transference to Munich he met with many cases of acute gonorrhceal salpingitis and peritonitis, and among them one fatal case. *' In Dresden in eleven years not a single fatal case, in Munich in three years and three quarters three cases." With regard to the material on which my experience in Manchester has been acquired, I am not prepared to hazard 1 " Untersuchungen iiber den Gonococcus (Neisser)." — Archiv /iir Gyiiiikologie, 5d, XXV., Hft. I. * Deutsche wed. Wochensckrift, No. 43, 1885. 3 " Ueber latente und chronische Gonorrhoe beim weiblichen Geschlecht." — Deutsche med. Wochenschri/t, Dec. 8, 1887. Frequency of Gonorrhoeal Affections. any definite statistical statement at present. In private prac- tice the occurrence of some of the gonorrhoeal diseases of women, now that they are diagnosed as a rule, is common enough ; but they are by no means the most ordinary ailments which one is called upon to treat. In the current list of patients the disease is never without two or three unequivocal witnesses to its existence. In hospital practice, among the class of women who are not very particular in their notions of personal cleanliness, it is a very common disease. Married men of the operative class, when out of work, appear to con- tract some form of venereal disease in amazingly large propor- tion, and to take little or no precaution to save their wives from the misery resulting from the contagion. It is a social question which it would be hard to settle, whether the poorer married women of the working class suffer most from the effects, including sterility, produced by the venereal diseases conveyed to them by dissolute husbands, or from the con- stantly recurring child-bearing and lactation, which fill up the burdensome prime of life for the healthy wives of the more virtuous or fortunate. Among the purely gynaecological cases, as they occur in my hospital practice, the proportion of cases of gonorrhceal origin is about i in 15. Of the cases of pelvic peritonitis, in any of its forms or phases, gonorrhoea is the cause in an overwhelming proportion, the fraction of the whole next in amount to the gonorrhceal being that made up by neglected cases of abortion. From the contemplation of such facts as these it is a relief to turn to the other extreme. Milton,^ speaking of a small town in Cumberland, says : " Having had the opportunity of tracing this disease for many years back, in what was then a very small town in the North of England, where gonorrhoea is now rather firmly established owing to the growth of the place, I was able, by means of the books of a successive line of surgeons, kept for a long time, to make out pretty certainly ' " On the Pathology and Treatment of Gonorrhcea." By J. L. Milton. 5th Edition. London, 1883. 24 Gonorrhceal Infection in Women. that in their practice it had, till about forty years ago, only been very rarely seen and sometimes not heard of for years together. All the inquiry I could make tended to fortify this opinion : the general experience seemed to be that gonorrhoea always died out soon after it was acquired." In another place he says : "During a four years' apprenticeship to a surgeon, who, though living in a very small town, had one of the largest practices in Cumberland, I saw but very few cases of gonor- rhoea, certainly not a dozen, though every instance of such a disease must have come to my knowledge. Of these I know that some were caught from sources foreign to the place." With regard to the prevalence of these disorders, we can readily infer that between their frequency of occurrence in the cosmopolitan cities and dense centres of population, and their rarity in sparsely populated rural districts, there may be every grade of proportional frequency. Consequently, if the pro- fession as a whole is to arrive at a just comprehension of the facts, the conclusions reached by each individual as the result of his experience must be modified and corrected by the experience of those practising under every degree of difference in circumstances. If this fact were kept in mind, we should find the history of the discussion of the subject under con- sideration less embellished with sneers and triumphant re- joinders than it is. For example, we find Milton discussing Noeggerath's conclusions without having acquired any clearer notion of them than could be obtained second-hand from a review, and with mildly sarcastic superiority brushing them aside. " It does not seem to have struck Dr. Noeggerath," he says, " that, had his facts been correct, gofiorrhosa would have long ago depopulated every country into which it had pene- t7'atedy^ It will be seen, however, on reference to Noeggerath's words, which I have been careful to give literally, that he explicitly states that his allegations do not apply to the state of any community in respect of this matter except New York, with which alone he is familiar. If we had only our crowded » op. cit., p. 53. Before Noeggerath. 25 world-cities to trust to for the continuance of the race, the world would soon be depopulated, or worse, from more potent causes than gonorrhoea. If the statements on either side of the question of frequency of occurrence are a little strong, the conclusion of the whole matter only amounts to this : that for the physician in the large city, gonorrhoea is a disease of primary, practical importance; for his contemporary in the rural district it is more a matter of speculative scientific interest. Chapter II. HISTORICAL RETROSPECT OF VIEWS ON THE PATHOLOGY OF GONORRHCEA IN WOMEN. Ix order to obtain a clear view of our present position with regard to the pathology of gonorrhoea and the effects of the disorder, it seems to me expedient to give a short historical retrospect of the path by which our present position has been reached. We shall then be better able, without the need for repetitions, definitely and concisely to consider the special phases of the disease with which we are at present concerned ; to examine the phenomena of the affection as it occurs in the female sex, the consequences which infection may entail, and the prophylaxis and treatment, and any medico-legal, moral, and social questions which may naturally arise out of the whole case. For our present purpose the past may most conveniently be divided into three periods — (i) Before Noeggerath's treatise appeared; (2) Noeggerath's work and immediate influence; (3) Neisser's discovery. Before Noeggerath. (i) The first period takes us back, according to the ordinary fashion in medical histories, to the time of Hippocrates. For practical purposes we may rest satisfied with looking to the 26 Gonoi'rhoeal Infection in Women. more modern epoch when Ricord flourished. Ricord's views as to the non-specific nature of gonorrhoea dominated the profession in his time, and do to a large extent still prevail. There was always a strong minority who held the opinion that the disease was specific, but they were in the position of mere agnostics, who could not accept the "frivolous anecdotes" on which their opponents seemed to ground their faith, rather than a school of scientific opinion founded on research and observation. The successive failures of the specificists to demonstrate the presence of an organic virus in the form of a micro-organism was claimed as still stronger support of the antagonistic views. Several investigators, each in turn, claimed to have discovered the specific organism. Donne's trichomonas vagitialis, for example, held the field for a considerable time as the organism whose presence produced the phenomena of vaginitis ; but the anticipations of its discoverer and those who accepted his opinions were doomed to disappointment. But the existence of a micro-organism to carry the disorder was not a necessary part of the belief of those who held to the specific nature of gonorrhoea. The position taken up by Sigmund and Auspitz of Vienna, Durkee in America, and perhaps also by ]\Iilton and other authorities in this country, was that gonorrhoea can develop only from gonorrhoea, and some of these certainly held to the view that the specific virus resided in pus as compared with any other form of secretion. On this opinion depended some important practical conclusions, and we shall see that with regard to the precautions to be taken to prevent the spread of the contagion the believers in specificity were as faulty as the opposite camp. Ricord, Fournier, and Diday were the chief authorities from whom orthodox writers, in this country and elsewhere, drew inspiration, and confidence in the correctness of their theoretic views. Mr. Henry Lee, in the article in Holmes's *' System of Surgery" already referred to, under "Causes of Blennorrhagia," mentions, in addition to the usual direct con- tagion, the action of irritating substances and constitutional Before Noeggerath. 27 causes. He then, in support of his position, quotes from Ricord a passage which I transcribe as well adapted to our present purpose : — " If we investigate with the greatest care the exciting causes of gonorrhoea — and I am now speaking of characteristic cases of the disease — we cannot help admitting that a gonorrhoea! virus is absent in the majority of cases. Nothing is more common than to find women who have occasioned gonorrhoea unsurpassed in intensity and persistency, and attended by the most serious complications, and who are yet only affected with uterine catarrh, which is sometimes hardly purulent. In many cases, intercourse during the menstrual period appears to be the only cause of the disease ; while in a large number we can discover nothing, unless, perhaps, errors in diet, fatigue, excessive sexual intercourse, the use of certain drinks, as beer, or of certain articles of food, as asparagus. Hence the frequent belief of patients, which is very often correct, that they have contracted their gonorrhoea from a perfectly sound woman. I am most assuredly familiar with all the sources of error in such investigations, and I will presume to say that no one is more guarded than I am against the various forms of deceit which are strewn in the path of the observer; yet I confidently maintain the following proposition: Gonorrhoea often arises from intercourse with women who them- selves have not the disease. Anyone who studies gonorrhoea without preconceived notions, is forced to admit that it often originates from the same causes that give rise to inflammation of other mucous membranes." When the masters in this peculiar field of science felt the need of strong language to bolster up such flabby opinions on causation as this passage implies, we need hardly feel surprise at any vagaries of the ordinary disciple. After reading a series of the stories by which the non-specific view is main- tained, one hardly feels the absurdity of the suggestion made by a surgeon, mentioned by Milton, that a certain case of gonorrhoea might have originated from making water in the night air. 28 Gono7'rhceal Infection in Women. With regard to the phenomena of the disease in women, the predecessors of Noeggerath held the erroneous view that the vagina was the chief seat of pathological change. If the urethra and bladder were not involved, producing the charac- teristic symptoms, and if no coarse changes had occurred in the vagina, the surgeon was not in a position to decide with confidence whether or not he had to deal with a venereal disease. A discharge from the uterus was to him the product of a uterine catarrh, a condition quite separate and distinct from any venereal affection, and in only a very few severe cases had the observer confidence to allege any causal relation between the venereal virus and the uterine or pelvic disease. It followed from such loose notions as these with regard to the chief seat of the malady, its superficiality in an anatomical sense, and its non-specific nature, that the surgeon felt himself justified in pronouncing, from mere inspection, any suspected female clean or otherwise. It re- quires little imagination to grasp the vast social importance of this mistaken view of the pathology of so common a disorder; and that it was a mistaken view it is the chief object of this essay to emphasise, because all the rest depends upon it. If a concrete example of the social results of a pathological error be demanded, it should be remembered that the Contagious Diseases Acts, now repealed, were passed and administered in the United Kingdom, partly on the basis of this discredited pathology. Yet the medical profession is so indifferent to revising its opinions on this subject, and so confident in its old prepossessions, that it is probably not going beyond the mark to say that, if the re-enactment of these statutes depended upon a plebiscite of the qualified practitioners in this country, taken without further discussion, the laws would at once again come into force. With regard to the disease, as affecting the male sex, the crux of the position was the belief that the pus cell was the pathological unit. The pus was the morbific agent, but inasmuch as any pus cell, whatever its origin, might be Before Noeggerath. 29 sufficient, the disease was not specific. The practical result of this belief was that men, just recovering from gonorrhoea, were assured that if only the remaining discharge was clear and glassy they might indulge in sexual intercourse without fear of conveying the contagion. With some it was a difficult ques- tion to decide when the discharge became sufficiently clear to be innocuous, and, for safety, many surgeons stuck to the rule, that there must be an entire disappearance of the discharge before they could sanction sexual intercourse. " So long as any discharge ^.r/i'/i' sexual congress is unsafe,"^ is a dictum containing the most advanced opinion of this school. This expresses by no means the general opinion and practice. " But not only does the medical world believe that a so-called cured gonorrhoea is actually cured, but they are even of opinion that a man who has a gleet (Nachtripper) may not infect his wife. It is usual at the present time with the best informed practitioners (non-specialists) to sanction marriage in the cases of men who still continue to observe adhesion of the urethral orifice and staining of the linen, as beaux restes of a gonorrhoea. Even the highest authorities, as Professor A. Geigel, permit the cohabitation with his newly-married wife of a man, the subject of gleet, so soon as the urethral discharge appears perfectly clear. "^ Such was the state of practice and of doctrine with regard to gonorrhoea, when a specialist in diseases of women began to comprehend and explain the meaning of certain pathological conditions of the female sexual organs which he had long observed. The establishment of the relation of cause and effect between the neglected, ap- parently trifling and innocuous, chronic gleet in the male, and inflammation of the pelvic peritoneum in the female sex, is one of the most important and interesting chapters in modern gynaecology. ' Mr. Henry Lee, in Holmes's " System of Surgery." - Noeggerath, p. 2. 30 Gonorrhoeal Infection in Women. (2) Noeggerath's Work and its Immediate Influence. The work which I am specially desirous of doing justice to, because of its originality and intrinsic merits, is that of Dr. Emil Noeggerath, a German physician, formerly practising in New York. His "grand idea" is expounded in a treatise, a mere "opuscule" in respect of physical proportions, published in German in 1872. The peculiar mode of publication has been a misfortune to English readers, and it has largely detracted from the influence which the book ought to have exercised. It has never been translated into English, and this fact seems to justify me in drawing largely upon the words of the original in support of the views which I am seeking to advocate. When it first began to dawn upon me in the course of gynaeco- logical practice that many of the unexpected mishaps, and the whole course of many of the most intractable cases, were due to the gonorrhoeal virus, I naturally turned to the literature in order to learn what was already known on the subject. Com- paratively late in the search I had the opportunity of reading Noeggerath's monograph, which, until then, I had known only by hearsay. Like every other man I have hitherto met, I knew of Noeggerath as a German doctor who had actually pubUshed the outrageous doctrine that clap is an incurable disease, and as nothing more. It was, therefore, surprising to find, on perusal of the work, that only the undeniable exaggerations had been seized upon and noised abroad; the admirably clear exposition of the fruits of clinical work of the highest excellence, and the great idea which inspired the whole and formed an advance on all that had hitherto been written on the subject, appeared to have fallen, for the most part, as seed on stony ground. Noeggerath's work was largely clinical, and in this respect it contrasts with much that is to follow, which is mainly the work of pathologists and bacteriologists, engaged in research and observation without such close relation to the actual phenomena of disease. He, however, clearly Noeggerath's Work and Its Influence. 31 enunciated the microbiotic nature of the disease, and indeed he almost believed, like some of his predecessors and contemporaries of the specific school, that he had dis- covered and succeeded in cultivating the special organism. " There is hitherto awanting," he says, " a so-called direct proof. If it were already proved in which form-elements the gonorrhceal contagion is exclusively bound up, if it were demonstrated that the pus corpuscles, and the pus corpuscles only, were the carriers of the contagion, then perhaps elements might be discovered in the secretions of the woman by careful microscopic examination which would throw light upon the origin of the affection." ..." The whole meaning and importance of micrococci and of the fungi derived therefrom bear as yet so clearly the stamp of incompleteness, and are viewed with distrust by so many distinguished men of science, that I cannot expect any of my readers to attach very great importance to the presence of a fungus in forming their conclusions on the question. The subject must be further investigated by the mycologists in co-operation with one or other of the gynaecologists." Although it would be an exaggeration to call upon the reader to admire these sentences as a prophecy from the remote past, or as bearing the evidence of far-reaching scientific vision, still they show a very clear appreciation of the state of contemporary knowledge, and of the course that future research must take in order to be successful. It is evident that if Noeggerath had enjoyed the advantage of knowing Koch's methods of investigating the life-history of micro-organisms, that the missing link in the chain of evidence which he sought for would soon have been found, and the discovery of Neisser might have been antici- pated by seven years at least. Let us now examine Noeggerath's clinical work. He says that his object in publishing his observations is '* to depict in their characteristic features a group of diseased conditions peculiar to the female sex, and to prove that certain phenomena observed in the sexual organs, which have hitherto been looked 32 Gonorrkceal Infection in Women. upon and treated as distinct, possess a common basis from which, collectively and separately, they are derived." For this common basis he selected the name " latent gonorrhoea," because "it may be present for weeks, months, and even years, in the affected individual before it displays itself by any of its characteristic phenomena." In explaining further the nature of latent gonorrhoea, he says : " I have undertaken to show that the wife of every man, who at any time of his life before marriage has had gonorrhoea, with very few exceptions, becomes affected with latent gonorrhoea, which sooner or later shows its existence by some one of the forms of disease about to be described. The reason why this fact has not hitherto been brought under discussion in a radical fashion is grounded on several circumstances. In the first place, we physicians have hitherto believed that a gonorrhoea in a man, after it has once ceased to exhibit any signs of its existence, such as occasional moistening or adhesion of the urethral orifice, even itching, or discomfort in micturition, is actually cured. Such is, however, in the great majority of cases, not the fact, and I believe I am not going beyond the mark when I say that 90 per cent, of cases of gonorrhoea remain uncured. Of 100 women who have become the wives of men who have formerly been affected with gonorrhoea, scarcely 10 remain healthy; the rest suffer from one of the ailments which it is the task of this treatise to describe." In order to prove his theses, Noeggerath gives the notes of fifty selected cases, which are so arranged as to illustrate the various heads under which he discusses his subject. These clinical groups, under which he classifies his observations, are : (t) Acute perimetritis; (2) recurrent perimetritis; (3) chronic perimetritis ; and (4) ovaritis. All the four varieties of diseased processes are complicated with catarrh of distinct portions of the mucous membrane of the sexual organs, and this catarrh, in a few cases, is found to be the only sign of disease. Although this classification may now be considered obsolete, if even it could be considered originally established by the NoeggeratJi's Work afid Its hifliience. 33 author's own material, it did good service by calling attention to the extreme frequency of perimetritis as a consequence of the gonorrhoea! infection. It may be a question whether it is possible clinically to distinguish between the three varieties of perimetritis, or whether every attack of perimetritis is not necessarily always more or less acute, ultimately becoming more or less gradually chronic, and liable at any time, under favouring conditions, to become recurrent. In any case we may accept that which is implied in the classification as some- thing which clinical experience since Noeggerath's time tends more and more to establish, viz., that there is always catarrh, and in the great majority of cases perimetritis. " Inflammation of the female sexual organs, as it occurs in consequence of latent gonorrhoea, whether acute or chronic in its course, is in every case periuterine, that is to say, it affects the serous covering of the pelvis, and of the organs contained in it." In ICO cases of this disease, occurring in the author's practice, not one can be recalled to memory in which the morbid process began in the parametrium. After a criticism of the views of Matthews Duncan and the statistics of Bernutz, he concludes that, provisionally setting aside the cases which are said to have originated in the puerperal state and from menstruation, Bernutz also supports the opinion that gonorrhoea and syphilis are the most prominent causes of perimetritis. "But not only does the florid, acute gonorrhoea supply the principal contingent of this class of disease, but the so-called latent gonorrhoea is quite as important as the acute form. And I may add (i) that a woman who, at any time of her life, has had an acute gonorrhoea, has to expect some time, it may be after months or years, one or more attacks of acute, sub- acute, or chronic perimetritis; (2) that the wife of a man who, at any time of his life, before or during wedlock, has suftered from gonorrhoea is, with regard to ^n attack of perimetritis, in the same position as if she herself had had an acute gonorrhoea. " Under these two groups of circumstances a woman must expect at some time or other in her life to become the subject D 34 Gonorvhoeal Infectio7i in Women. of a pelvic inflammation, sometimes ending only at death. If it comes to an acute manifestation of the affection, the case usually takes something like the following course. "The man, either already a dweller in a large city, or in his capacity as traveller, student, etc., has become initiated into the mysteries of modern civilisation by contracting gonor- rhoea. This disease, although it may have apparently disap- peared without leaving a trace behind it, makes him for many a day capable of conveying the contagion. The young, hitherto healthy, wife begins to complain a few weeks after marriage; attention to her domestic duties becomes a burden to her, and pedestrian exercise which could formerly be taken without the least effort now gives rise to signs of fatigue; menstruation becomes more profuse than formerly, and there are pelvic pains during the first days of the periods ; a little vaginal discharge follows each period, and this, gradually increasing, ultimately continues without intermission until the next menstrual period begins. After a few months, really severe pains come on either in the left or the right half of the pelvis, and the sufferer is ultimately compelled, on account of feverishness and unbearable burning in the abdomen, with increased discharge, to take to bed and send for medical help. According to the severity of the attack she remains confined to her bed for weeks or perhaps for many months, with exhausted strength, struggling for life, ultimately slowly recovering, but remaining sterile and invalid for the rest of her days. " It not unfrequently happens that the woman who is married under such circumstances soon becomes pregnant, and during her pregnancy she suffers from pelvic pains which are supposed by herself and the doctor to be necessary draw- backs of her condition, and so she receives no particular atten- tion. It sometimes happens that the symptoms become so urgent as to call for active treatment in order to prevent mis- carriage. Labour ultimately comes on, and is followed by a severe endometritis with perimetritis, the former or the latter Noeggerath's Work and Its Influence. 35 being the more prominent feature of the case. The develop- ment of this inflammation may begin either immediately after the birth, or, as is more frequently the case, it may come on eight to fourteen days, or even six to eight weeks after." It is a peculiar fact that some women directly after marriage with a man who has formerly had gonorrhoea begin to exhibit symptoms of serious inflammation, whilst others may be years before they emerge from the latent period, and others again show such trifling departures from the normal condition that it is difficult to say whether they are aifected or not. It may be set down as a law of this disease that " the earlier the first cohabitation occurs after the time when the gonorrhoea was pronounced to be cured, the shorter is the period of latency in the woman, and the acuter are the symptoms." Space will not permit me to transcribe all Noeggerath's interesting cases, and it must suffice to select one from the first series. Case ii (Noeggerath's Case 5^). — "Mrs. M., a native of Boston, had been, when I first saw her, married for five years to an advocate in New York, who about one year before his marriage had undergone two months' treatment for gonorrhoea. The wife, who before marriage was a type of robust health and beauty, began soon after marriage to have ailments; she remained sterile, and suffered from Dain at the besrinning of her menstrual periods, and, what had never before occurred to her, began to have a slight fluor albus shortly before the periods. After a year she consulted Dr. Marion Sims, who performed on her his operation of incision of the cervix, with the object of curing the sterility. This proceeding was followed by such severe haemorrhage as to necessitate tamponade of the vagina. On the following days pain began, and gradually increased to an enormous severity. The doctors in attend- ance found that the cause was an acute perimetritis. The patient was confined to bed for two to three months, and since » op. cii., p. 18. 36 Gonorrhceal Infection in Women. that time she has never had a day's good health. She con- sulted one after the other the principal gynaecologists of New York and Boston; by one she was cauterised for ulcer of the cervix ; another applied a large blister to the hypogastrium on account of chronic metritis ; and a third made her wear an intra-uterine pessary for two months. A careful examination revealed the following facts : the uterus was anteverted and but slightly movable ; the left ovary was small, hard, and firm, and fixed in the pelvis by adhesions ; whilst the right ovary, lying deeper, seemed to be greatly swollen, rounded, and softened. Both ovaries were intensely painful to touch. The vagina was reddened, and bathed in a muco-purulent discharge, and there was catarrh of the glands of Bartholini. This lady had suffered inexpressibly during the last four years, not only at the men- strual periods, but during the intervals. The sleep was broken. . . . . I gave a very doubtful prognosis, and as soon as I saw that neither narcotics nor absorbent medicines produced the least effect upon her condition, I advised her to visit a German watering-place. My advice was concurred in by a gynaecologist in Paris, and the patient on my strenuous recom- mendation spent two seasons at Kreuznach. On her return she felt in many respects better, but by no means completely restored to health." This patient ultimately left New York on account of symptoms of commencing tuberculosis, and the author could learn nothing of her subsequent history. . The chapter on " Recurrent Perimetritis" contains some passages which cannot fail to arrest the attention even of those familiar with the literature of the subject. The author has never seen a case of recurrent perimetritis in which he failed to prove the former existence of gonorrhoea either in the woman or in the man. He cannot understand how the phenomena of the disease are to be explained, except by the occasional emptying of the irritating contents of one or other Fallopian tube into the pelvic cavity, but as to the reason why this accident should occur in only a few women he cannot offer any suggestion. He thinks that any stimulus capable of producing Noeggerath's Work and Its Influence. 37 sudden powerful contractions of the uterus and Fallopian tubes may produce in that way expulsion of the contents of the tubes into the pelvic cavity, and among these causes, which have been illustrated by cases of specific tubal catarrh in his own practice, he mentions : coitus after long absence of the husband, introduction of the uterine sound even in cautious and experienced hands, the application of bland intra-uterine medicaments, the wearing of intra-uterine pessaries, incision of the external or of the internal os, dilatation by sponge tents, and other manipulations. And such results he has observed only as the consequence of manipulations in women who were the subjects of latent gonorrhoea. " At least the presence of this affection explains, in by far the largest number of cases, the occurrence of the so-called 'accidents,' which, to the astonishment of the much-cutting uterine surgeon, sometimes come upon him Hke a thunderbolt from a cloudless sky. . . . I am far from saying that every fatal result of these minor operations is the result of perimetritis due to tubal catarrh, and I am persuaded that phlebitis and lymphangitis supply their contingent. This last, however, is the exception, the first the rule." The notes of a case of recurrent perimetritis make, as a rule, a long story, and it would be tedious if I were to quote any of Noeggerath's cases in full. We are concerned at present only with the relations of supposed gonorrhoeal infection to the after-history, and the author's evidence in proof of such relations can be exemplified by extracts from a few typical cases. His eighth case is that of Mrs. R, a well-developed and beautiful Englishwoman, who was married to a young merchant in 1 86 1. The gentleman had been under treatment for a rather obstinate gonorrhoea by a friend of Noeggerath's, but for three months before his marriage not a trace of the disease was to be seen. He was assured that it was quite safe for him to get married, and he acted on the advice. All went well for about six weeks, and then the lady began to complain 38 Gonorrhceal Infection in Women. of a pain in the side, which at last increased to such a pitch that she had to take to bed. The husband's doctor was consulted, and diagnosed pelvic peritonitis, which he treated energetically. The patient was confined to bed for two months, and has been ailing ever since — 1861 to 1872. All the symptoms are referable to the condition of the pelvic organs, which is given in detail. Then follows the history of ten years of bad health, varied with periods of more acute suffering. The next case is that of a lady who was brought to New York in the beginning of 1872 to be under the author's care. When a bachelor the husband had suffered from gonorrhoea, which required many months for its cure ; but it had disappeared for two years before marriage. In answer to the question whether every trace of it had disappeared, he admitted having noticed, after his marriage, an adhesion of the urethral orifice, and to have experienced occasional discomfort in micturition. Ten^ months after marriage the wife was confined of a healthy child, and since then (18 years) she has never become pregnant again. Soon after her confinement she began to complain of pain in the left side, and a sense of weakness in the pelvis. Then follows a history of wanderings in search of health from one European health-resort to another, and back to America. There were six distinct attacks of pelvic inflammation. Digital examination proved the existence of a mass of exudation in the pelvis, enlargement of the ovaries, and matting together of the pelvic organs generally. Noeggerath evidently despaired of doing any good, and recommended her to visit a Canadian watering-place. These are fair examples of the half-dozen cases given as illustrations in this portion of the work. They have all these two points in common, that they are incurable ailments, entirely destroying the health and happiness of women who were healthy before marriage, and that they all show a history of gonorrhoea in the husband, which is brought out in a more or less convincing fashion as the cause of the wife's sufferings. Noeggerath's Work aJid Its Influence. 39 One more case may be quoted, chiefly for the sake of illustrating a point to which attention must be called later on, viz., the import of 7ieglected gonorrhoea in men in relation to the gonorrhoeal infection in women. Case 12 (Noeggerath's Case 19). — "Mrs. V., an American lady, married six years before, as a healthy girl, to a man who suffered from a neglected gleet until shortly before marriage. The husband assured me that for two months before marriage he was quite well. Directly after the marriage the wife began to complain, had a leucorrhceal discharge, and suffered from pain in the right side, and sacralgia. Menstruation also became irregular and painful. She was treated by a series of doctors without any lasting benefit. On examination, I found a very sensitive 'succulent' uterus dislocated to the left, both ovaries very painful, especially the right, which was enlarged and fixed close to the uterus in an exudation mass. There were large ulcerated areas on the labia, and catarrh of the glands of Bartholini. After two months' treatment the patient had a slight attack of acute perimetritis." . . . In the chapter on chronic ovaritis and catarrh, the author calls attention to the importance of inflammation of the glands of Bartholini as a sign of previously-existing gonorrhoea. It has been usual to rely on the presence of an inflammation of the urethral mucous membrane as a diagnostic mark, but this is comparatively evanescent ; the reddening of the orifices of the vulvo-vaginal glands, on the contrary, remains for years. " In the natural condition the openings of the ducts of both glands are seldom visible to the naked eye. When, however, you examine a woman who in former years has suffered from gonorrhoea, it is the rule that if you pull the labium minus away from the remains of the hymen, you see, between the upper and lower caruncula myrtiformis, a deep red point, covered with the glassy mucus. From this point, as a centre, there extends upwards and outwards a streak, which gradually becomes paler, and ultimately fades into the colour of the surrounding mucous membrane." These appearances are said 40 Gonorrhoeal Infection in Women. to be characteristic of catarrh of the glands of Bartholini. That such an inflammation is caused by gonorrhoea, and that it is persistent, there can be no doubt, but whether it is characteristic of gonorrhoeal inflammation alone, or may result from inflammatory conditions set up by other causes, yet remains to be settled by further clinical observation. On the subject of sterility as a consequence of latent gonorrhoea, Noeggerath carries his conclusions further than the evidence produced seems to justify. He maintains that gonorrhoea is a common cause of sterility in the man, producing azoospermia, and he gives cases in proof. He is more con- vincing in dealing with the analogous effect on women, and he makes out a better case, though here also he leaves an impression of going beyond the record in the statement of opinions. His treatment calls for little notice, not because of any deficiency in its merits, but because for our present purpose it is irrelevant. It is the treatment pursued by a judicious, scientific, and most patient physician, yet the most striking thing about it, perhaps, is its inefficacy. Noeggerath never hints at operative treatment, except to condemn it, but it is probable that few chapters have ever been written in more eloquent and telling support of surgical interference in this class of ailments than the portion of his short work which is devoted to treatment. Neither is this the place to deal with any conclusions which may suggest themselves from consider- ing Noeggerath's work in the light of later experience, or to discuss wide-reaching questions which arise out of the subject and to which he himself explicitly calls attention. His more definite conclusions are perhaps best given in a nearly literal rendering of his own words : — (i) " Gonorrhoea in the man, as well as in the woman, persists for the whole life-time, in spite of apparent cure. (2) "There is a latent gonorrhoea in the man as well as in the woman. (3) "Latent gonorrhoea in the man as well as in the Noeggerath's Work and Its hifliience. 41 woman, may evoke in a hitherto healthy individual either a • latent gonorrhoea or the symptoms of an acute attack. (4) "Latent gonorrhoea in the woman manifests itself in course of time by perimetritis, acute, chronic, or recurring ; or by ovaritis, or as a catarrh of some definite portions of the genital mucous membrane. (5) "The wives of men who at any time of their lives have had gonorrhoea are, as a rule, sterile. (6) " Such women, if they do become pregnant, either abort or bear only one child. Exceptionally three or four children are born. (7) " From the discharge of a woman affected with latent gonorrhoea a fungus may be cultivated, which is exactly analo- gous to that obtained from the discharge of acute gonorrhoea in the man." jMuch of this is now merely matter of historic interest ; as the expression of opinion which first attracted serious atten- tion to the subject, and led to the further observations which have brought about an entire revolution in the professional estimation of the importance of this class of disease. Noeggerath has lived to greatly modify his first impressions. In the paper already referred to (p. 22) he states that he has given up his pessimistic standpoint, viz., that gonorrhoea is incurable, and that ninety per cent, of all married men who have had this disease infect their wives. He admits that if you ask ten men, eight or nine may say they have had gonor- rhoea, yet it would be unjustifiable and arbitrary to assume that any disease of the organs of generation occurring at a later time in the wife is due to gonorrhoeic infection. When husbands deny that they have retained traces of gleet or a gonorrhoea until just before marriage, Noeggerath's rule is to thoroughly examine the urethra. Some of the worst cases of acute and recurring perimetritis which he has seen have occurred in the wives of husbands who had been dismissed as cured from gonorrhoea shortly before marriage. Of 24 patients suffering from acute and recurring perimetritis 12 were married 42 Gonorrhoeal Infection in Women. to men who were cured one to three months before marriage, one man had been cured 5 J months, another a year, six had been healthy two years before marriage, two married 2 J years after stoppage of the gonorrhoea, one had had no symptoms of disease for 10 years, and one for 11 years. These are the opinions formed by 15 years' further experience. His views with regard to puerperal infection will be mentioned in the proper place. Noeggerath's first work was more an influence than an extensive addition to the sum of knowledge; a fruitful idea, under whose inspiration other men saw in a fresh light the facts of daily experience, and could recognise in them the material suitable for building up the required superstructure of new knowledge. We can only look at the work of the most important contributors, those who by observation and research have added the largest amounts to our knowledge, or \yho have modified in some important respect the general views by the contribution of influential ideas. The first fruits of Noeggerath's work in Britain appeared early, if the crop has not been extensive since. In 1873 Dr. Angus Macdonald^ read a paper before the Obstetrical Society of Edinburgh, which contained a report of some striking cases in support of Noeggerath's position, and an expression of opinions which might almost be called prophetic. In the course of his remarks he says that Noeggerath "really seems to prove his positions well, strong and strange though they appear to be. I must confess, however, that I cannot help feeling convinced that he proves too much. . . . That, however, Dr. Noeggarath has got hold of a grand idea, and one which possesses a large amount of evidence in its favour, no one, I think, can deny who reads the recorded cases fairly." The author then proceeds to give the details of seven cases, in which gonorrhceal infection had given rise to more or less severe puerperal illness. The gonorrhoeal ^ " Latent Gonorrhoea in the Female Sex, with Special Relation to the Puerperal State," By Dr. Angus 'i,l2s:d.ovi2\A.— Edinburgh Medical Journal, June, 1873. Noeggerath's Work and Its Influence. 43 puerperal fever was in one sad case fatal. The whole of Dr. Macdonald's cases go to disprove a point that Sanger has recently insisted upon, viz., the constantly late onset of the gonorrhoeal form of puerperal fever as compared with the early appearance of symptoms in cases originating otherwise. That some gonorrhoeal puerperal cases are late in developing their severer symptoms, there is little room for doubt, but the cause of variation in this respect is still in obscurity. For the sake of calling attention to this point, which is obviously important, and interesting inasmuch as it is still unexplained, it may be worth while to insert here Dr. Macdonald's first case, and place by it for comparison one which came recently under my observation. Case 13 (Dr. Angus Macdonald's Case i). — "Mrs. S., aged 24, was delivered of a female child after an easy labour, on the 15th of April, 1869. Previous labours two, and had been quite normal. Both mother and child did well until about the fourth or fifth day, when the mother was seized with severe pain in the abdomen, accompanied with great tenderness on pressure, and a considerable amount of fever. This pain and tenderness, however, disappeared in about a week or ten days, under the influence of opiates internally, and the application of poultices externally. About the same time as the mother became ill, the baby's eyes were noticed to be affected with severe conjunctivitis of a suspiciously specific character. On inquiry, I ascertained that the husband of my patient had, during the time she was carrying this child, been affected with discharges of a gonorrhoeal character, but that she herself had not suffered in consequence, except that she had some leucorrhoea before her confinement She had had no pain on micturition, nor any swelling of the parts, as far as she could remember. The child's eyes were treated." . . . The mother made a slow recovery, but was able to be out of bed by the end of five weeks. "About this time, after being at church getting her child baptised, my patient was suddenly seized with excruciating pain in the left side of the pelvis, 44 Gonorrhceal Infection in Women. about the situation of the left ovary, accompanied with quick pulse and fever. This, on physical examination, gave all the usual signs of a perimetritis originating near the opening of the left Fallopian tube, and spreading forwards and towards the right, so as to involve the anterior half of the pelvis, and fix the uterus in position. For this attack she was treated by poultices and opiates, as well as, latterly, with the bromide and iodide of potassium, and other remedial agents. She made an exceed- ingly slow recovery, and was more than six months almost entirely confined to bed. . . . Since then I have ascertained from her that she suffers more or less severely at each menstruation from pain in the left groin, and that when she menstruates she is usually ill for nearly three weeks at a time, though not very much blood comes away at any one time. Since I attended her, in 1869, she has given birth to two healthy children. . . . She is now in tolerably good health." Case 14. — B. J., set. 24, married two years and a half Had one child a year after marriage. She came under my care owing to a chronic ailment, which was ascertained to be perimetritis, with double laceration of the cervix uteri. The anamnesis supplied the following facts : — The patient was well until her confinement; she had copious leucorrhoea during her pregnancy, but no urinary trouble. Two weeks after her confinement some severe inflammatory illness, affecting the abdomen, came on, and she was in bed several weeks. She has suffered from pain in the left iliac and inguinal regions more or less ever since. The child suffered from an inflamma- tion of the eyes, with discharge of matter, for which it was successfully treated by the doctor in attendance on the mother. There have been several relapses since the patient's recovery from the first acute illness, the last dating from a fortnight before she came under my observation. In an interview with the husband, I learned that he had a gleet for over a year before his marriage, but considered himself quite cured for Noeggerath's Work and Its Influence. 45 two months at least before the marriage took place. He observed, however, for a long time, that after sexual intercourse there used to be a moistening and adhesion of the meatus. This patient is still under treatment, and other facts of the case may have to be referred to in illustration of points which would at present seem irrelevant. There can be no doubt that the case is one of late gonor- rhceal puerperal fever, and the course of the disease is that of a recurrent perimetritis. This is a fairly typical case, and the present purpose is served by placing it in juxtaposition to Dr. Angus Macdonald's typical case of early development of the inflammatory symptoms. But the relation of gonorrhceal infec- tion to the puerperal diseases is too important to be treated only incidentally. The late Dr. Thorburn, of Manchester, paid some attention to gonorrhoea in its relation to gynaecology, but soon concluded that it was unimportant. At the meeting of the British Medical Association held at Manchester in 1877, he read a paper on "Latent Gonorrhoea as an Impediment to Marriage," of which a too concise summary is given in the British Medical Journal^ of August 25th, [877. Dr. Thorburn denied the possibility of Noeggerath's conclusions being correct, and *' appealed to the statistics of 81 private families, carefully collected by him. He showed that there had been 33 per cent, of male gonorrhoeic infections previous to marriage, 26 in all; and taking all the cases of abortion, sterility, uterine, and pelvic inflammations, and living births that had occurred in these eighty-one fami- lies, he showed conclusively that there had been the merest fractional difierence in their proportion between the previously and not previously infected classes. As regards inflammatory pelvic aff"ections, the balance was fractional in favour of the free gonorrhoeic cases ; in other respects equally fractional in favour of the non-gonorrhoeic." The conclusion was that the latent gonorrhoea of Noeggerath is mythical; and is not, as it otherwise would be, an imperative barrier to marriage. It is not for me to go behind the statements here quoted and try to 46 Gonorrhceal Infection in Women. explain them away or minimise them. They do not seriously affect the question whether or not gonorrhoea may be an impor- tant factor in the causation of the diseases with which the gynaecologist has to deal. It mast at once strike the reader, possessed of local knowledge, that Dr. Thorburn's statistics would be drawn from a class of people, exceptional to some extent in this respect that they would be specially careful and cleanly in their habits, and specially careful of their own health and that of their families, reducing to the minimum both the chances of contagion and the consequences of contagion, if perchance it did occur. However, I am concerned at present only in giving illustrations of the clinical work done under the influence of Noeggerath's " grand idea," and before the dis- covery of the gonococcus. We come now to the work of Neisser. Neisser's Discovery and its Influence on Research AND Observation. So early as 1869, Hallier^ had discovered and described the cocci which occur in gonorrhceal pus, but in the absence of sufficient means of magnifying, colouring, and illuminating the objects examined, his work attracted little attention. In 1879, Dr. Albert Neisser,^ at that time assistant in the University Clinic for Dermatology at Breslau, pubHshed an account of his observations. Whatever suggestions may have been thrown out by previous investigators, there can be no gainsaying the fact that it was Neisser's publication which gave the stimulus and guidance to workers in the same field, and has led to an ever increasing and widening process of research and experiment, by both clinicians and biologists. Neisser found that when he prepared the pus of gonorrhoea in a certain way, he could see, in and about the corpuscles, micrococci, which he concluded must be characteristic of the ' Zeitschrift /iXr Parasitenkioide, 1869. Bd, I., p. 179. 2 " Uber eine der Gonorrhoe eigentumliche Micrococcusfonn." — Centralblatt Jur die 7nedicinischen Wissejischa/ien, 1879, No. 28. Neisser's Discovery and Its Influence. 47 disease. He put the thinnest possible speck of pus upon the object glass, and allowed it to dry; he then stained the pus with a watery solution of methyl violet, and allowed it to dry once more. It was then ready for examination. In his inves- tigations, Neisser used a Zeiss's microscope with Abbe's illu- minating apparatus, ^^h oil immersion lens, with ocular No. 4 or 5. On bringing the object into focus, besides the nuclei of the pus cells, varying in form and deeply stained, while the protoplasm took on the dye but slightly, there could be seen more or less numerous groups of micrococci. Single indi- viduals were seldom to be seen ; almost always there were two micrococci so close to each other as to give to the observer the impression that they were one organism. He described each double individual as forming a figure-of-eight, or as a pair of dinner-rolls placed with the flattened surfaces close to each other. He believed that they developed by a process of divi- sion, each half of the double organism gradually dividing and forming a fresh double organism. This process is shown in diagrammatic form in the accompanying illustrations taken from Bumm's work (Fig. 2c). The micrococci for the most part formed colonies of 10, 20, or more individuals, and they were surrounded by a mucous envelope, which could be dis- tinctly seen under a more subdued light. The micrococci were found chiefly on the surface of the pus corpuscles, rarely on the epithelial cells. In some pus corpuscles which were beset with micrococci, the nucleus was wanting or diminished in size. Neisser, at the time of publishing his first essay, had found the micrococcus in 35 cases which he had examined. In every case examined this was the only sort of micro-organism found in the gonorrhoeal pus, with the exception of a case which was suspected from the first of being complicated with soft chancre of the urethra. On the other hand, this particular micro-organism was not present in the pus from every other form of venereal disease or complication. Nor could it be discovered in any one of thirteen cases of simple fluor vaginalis submitted to examination without selection. 48 Gonorrhceal Infectioji in Women. Exactly the same typical micrococci of gonorrhoea in the male were found in nine cases of purulent urethritis in women. In the seven cases of purulent ophthalmia of the new-born, which had so far come under examination, the same charac- teristic micrococcus was found in great abundance. In all cases of simple conjunctivitis, which were examined for the sake of comparison, the micro-organism was looked for in vain. It was present in the only two cases of gonorrhoeal ophthalmia in the adult which had come under observation: The presence of the micrococcus consequently appeared to Neisser to be a constant mark of a gonorrhceal affection of the urethra, and of the eye; and even at the time of pubhshing his observations, he had repeatedly made use of this fact in order to diagnose the specific gonorrhoeal character of pus. The publication of this discovery in Germany, at a time when Koch's countrymen were full of confident expectation as to the future of the new bacteriology, attracted to it universal attention, and brought a host of workers into the field. It was not to be expected that the results of all observers would agree, and the history of seven years' industrious observation and experiment shows a good deal of difference of view on even essential features of the subject. Neisser himself has been constrained to modify his original opinions, but, upon the whole, his work has been only supplemented and established by subsequent observers. The reader to whom the subject is comparatively new, when endeavouring to get at that which is acquired and added knowledge, amid a good deal of conflict of evidence, even in matters of fact, should not be discouraged into relinquishing the quest. He should remember that while most of us look upon Jenner's discovery as one of the greatest boons ever conferred upon mankind by medical science, there are still not a few who denounce it as a curse ; and among these there are to be found men who have had the opportunity which a medical education offers of acquiring scientific modes of thinking, and so subordinating their emotions to their Neisser's Discovery and Its Influence. 49 intellect when discussing scientific questions. Similarly, it will be possible, I think, to trace in the work of some contributors to the elucidation of the questions arising from Neisser's discovery, the influence of fixed and rooted opinions, and perhaps also of bias of even less creditable origin, in judging of new facts. As Neisser's discovery emanated from a clinic for der- matology, the dermatologists and syphilologists were among the first to publish observations. The presence of the micro- organism in the ophthalmia of the new-born interested the ophthalmologists and obstetricians, and other inquirers soon followed suit. It seems to be the custom for the specialists in Germany to publish their results, for the most part, in their special journals, and so the literature of a subject such as that under consideration, which claims the attention of several specialists, is almost inaccessible to the foreigner. Bumm, of Wiirzburg, whose work we must chiefly draw upon, mentions fifty-two contributions up to the beginning of 1886, and I find forty papers on ophthalmia neonatorum alone abstracted in the Centralblatt fiir Gyndkologie^ in the six years 1881-86, some of them, like Crede's, being considerable treatises. It is only possible, therefore, in trying to get a clear view of the present state of opinion on all that relates to the gonococcus, to select merely the contributions which have added something to our knowledge and have stood the assay of criticism and later experience. In 1880, A. Bokai^ published the results of attempts to cultivate the micro-organism. He succeeded in obtaining pure cultivations, and in two cases he believed that he was success- ful in producing acute gonorrhoea in men by transferring a few drops of the fluid containing the crop of pure gonococci to the urethra. In the same year F. Weiss, ^ of Nancy, prepared a thesis, under the guidance of Prof. Spillmann, in which he ^ " Ueber das Contagium der acuten Blennorrhoe."— ^//^^w«^r med. WocJunschrift, 1885, Nos. 22 and 23. 56 Gonorrhceal Infection in Women. cases of colpitis in children has been long well-known to the staff of the Stephanie Children's Hospital, in Pesth. Since October, 1883, the discharges in 26 female children, varying in age from two to ten years, had undergone microscopic examination, and in every one a large diplococcus bearing a striking resemblance to Neisser's gonococcus had been found. Biologically both cocci appear to be identical. The contagious- ness of the discharge is very great, and contact of it with the conjunctiva may lead to serious results. Cseri mentions the case of a short-sighted nurse, who, in syringing a child with colpitis, got her eye infected by accident, and lost it in conse- quence of conjunctival blennorrhoea. Further observations on this subject were published by J. Widmark^ in the same year. He merely states that he has found the gonococcus in eight cases examined, but he does not seem to have proved the identity of the micrococcus present with Neisser's gonococcus. The most recent French literature on the subject of the gonococcus is summed up in Martineau's^ work. The author has worked at the subject alone, and in company with Goguel, and is perfectly satisfied as to the existence and pathogenic nature of the gonococcus. He claims for Bouchard precedence of Neisser, by one year, in the discovery and description of the micro-organism. The observations and experiments made by the French physicians have been the same in kind, though not so extensive, as those carried out in Germany, but no one is referred to as having failed to satisfy himself of the importance of Neisser's discovery. This fact is in marked contrast to the import of the contri- butions from Italy. In that country several workers have submitted the results of their German contemporaries to a destructive criticism, and have sought to prove that the gonorrhoea diplococcus of Neisser, considered as the patho- ^ "Gonococci in eight cases of vulvo-vaginitis of children." — Archiv fur Kinder- heilkiijtde, VII. 2 " Logons cliniques sur la blennorrhagie chez la femme." Paris, 1885. Cojiteinporary Pathology. 57 genie element in blennorrhagia, does not exist. ^ The last of these, Giovannini, merely gives categorically a summary state- ment of conclusions derived from work in the Pathological Institute of Bologna. Until he has described the method by which his results have been obtained, we may suspend our judgment. Chapter III. CONTEMPORARY PATHOLOGY AND THE "GONOCOCCUS- NEISSER." We have now passed in review the history of Neisser's discovery, and the chief episodes in the course of the evolution of our knowledge of the subject which have modified the original conclusions with regard to the morphology and functions of the gonococcus. Setting aside in the meantime the objections which have been raised on the basis of more or less complete and mature investigations, and accepting pro- visionally the broad conclusion that the gonococcus is the active agent, the pathogenic element, in the production of the gonorrhoeal diseases, whether they affect the sexual organs of the adult or the conjunctival mucous membrane of the new- born, we may now proceed to look at the organism more closely, and consider how we are to detect its presence, and how we may bring our knowledge to bear upon the diagnosis and the treatment of disease. Some refinements with regard to morphologically similar micro-organisms, and the mode of differentiating them from the true pathogenic gonococcus, can be considered when we have become more familiar with the ordinary methods of looking for the bacterium. In order to save frequent repetitions and references, I ought to state explicitly here that in writing this chapter I have constantly drawn upon the work of Dr. Ernst Bumm, of ^ De Amicis : Revista clinica terapeutica, March, 1884 ; and Giovannini : Central blattfilrdiemed. Wissensdiaften, No. 28, Nov. 27, 1886. 58 Gonorrhoeal Infection in Women. Wiirzburg, whose treatise^ is by far the most important and original that has so far appeared upon the pathology of the gonorrhoeal infections. Examination of a Suspected Secretion. In a case of alleged simple urethritis in a man, of suspicious purulent discharge from the pudenda of a woman, or of conjunctival inflammation in a new-born child, how can the practitioner decide whether he has to deal with a simple catarrh or an inflammation of specific origin ? He must look for diplococci in colonies or groups within the leucocytes or pus cells of which the discharge is composed. How is he to look ? In order to be available as a practical clinical procedure, any method of investigation must be simple and rapid, like the process of testing urine for the presence of albumen or sugar. A difficulty in the way of popularising any process, is the cost of the apparatus, and the care required to keep it in good working order. A good microscope, with a y^^^h homogeneous immersion lens, is an essential provision. My observations have been carried on or verified with a Zeiss's microscope, provided with Abbe's illuminating apparatus ; the objective is a Powell and Lealand's y^^^h oil immersion, and the eye-piece almost always Zeiss's No. 2. or No. 4. The ordinary apparatus and re-agents for microscopic work are supposed to be at hand in carrying out the following rapid clinical method of looking for a diplococcus in a suspected discharge. A thin cover-glass, carefully cleaned, is held ready in a pair of suitable forceps, and a minute drop of the suspected pus is spread over a small area of its surface. This is quickly dried by holding it in the current of hot air high above the flame of a spirit lamp. Over the dry matter on the glass a drop of a concentrated alcoholic solution of methyl violet is let fall and allowed to spread. After a momentary pause, the superfluous solution is got rid of by turning the cover glass on edge and ^ "Der Mikro-Organismus der Gonorrhoischen Schleimhaut-Erkrankungen 'Gono- coccus-Neisser.'" 2nd Edition. Wiesbaden: J. F. Bergmann, 1887. Examination of a Suspected Secretion. 59 bringing it in contact with some clean blotting paper. The glass, now covered with a thin film of the dye-solution, is again raised for a few seconds above the spirit lamp, not long enough for it to dry. The dye is next washed away, as well as it can be, by bringing the cover-glass under a stream of distilled water from a wash-bottle. The cover-glass with the adherent stained film of discharge has now to be dried. The drop of water which adheres to it can be got rid of by bringing the object edgewise on to a piece of blotting paper as before, but still the glass remains wet, and even in the heat of the spirit- lamp it will take perhaps a minute to dry. This time may be saved, without drawback to the preparation as far as rapid clinical inspection is concerned, by immersing the wet cover- glass momentarily in absolute alcohol, which should be kept in readiness in a suitable vessel, such as a small wide-mouthed stoppered bottle. When the water is replaced by the alcohol, the drying above the flame of the spirit-lamp takes only a few seconds. A small drop of Canada balsam, dissolved in benzol, is now let fall upon the centre of the cover-glass, which is at once applied to the slide, previously cleaned and warmed. The preparation is now complete and ready for examination. With a little experience of this method, and when the appli- ances are all held in readiness, the practitioner will find that this method of looking for diplococci takes little more time than the ordinary testing of urine. There are obvious objec- tions to the process if it be looked upon as a method of scientific research, but that is not its object. A quantitative analysis of the sugar in urine by even the shortest process requires time, but a qualitative analysis can be, and has often to be, made in the course of a consultation. So it may be desirable to know, in the course of a consultation, whether a discharge contains diplococci, and if it does, the overwhelming probability will be that the case is gonorrhceal, the anamnesis and the clinical features being available to perfect the diag- nosis. For the purpose in view the method of examination which I have described is sufficient. 6o Gonorrhoeal Infection in Women. Bumm, in the monograph already referred to, says that at the Wiirzburg Clinic for Obstetrics and Gynaecology, they take only two or three minutes to make the preparations. For staining a watery solution of magenta (fuchsin) is used : the secretion is spread upon the slide and prepared in nearly the same way as that just described. When it is finally dried, the examination is made without a covering glass direct in the oil for the immersion lens. Neisser's original method of examination could not be finished in one day because of the slow process of drying and staining, and Eschbaum's rapid method takes twenty minutes or half-an-hour. No process requiring such a length of time for its completion is suitable for the consulting-room, however admirable results it may afford in the pathological laboratory. If it be desired to retain specimens for repeated examination and reference, all that is further required in the preparation of them is to employ a saturated solution in aniline water of the dye-material selected, and to take plenty of time in drying. Now the next question is : What do we see in the examina- tion of an object prepared as described ? If there are gono- cocci in the field they will be distinctly seen. When absolute alcohol is used to promote rapid drying, the staining material may be found to have spread a fittle.into the intercellular spaces, but not so as to mterfere appreciably with the efficiency of the process. In Fig. i we have an attempt to represent the field of view, in a slide prepared from a real case, that of a young man who had been declared cured of a gonorrhoea a month before he came under examination. He was exactly in the condition in which men used to receive, and perhaps do still receive, medical sanction to marry. In consequence of *' taking a glass of beer," he had the slightest possible return of discharge, and a speck of sero-purulent fluid supplied the object which the figure is intended to represent. It will be seen that the leucocytes are for the most part merely stained, and free from diplococci, the neuclei taking on a deeper coloration than the protoplasm. One epithelial cell occurs in t > t IC. Examination of a Suspected Secretion. 6i the field. The diplococci appear only as black dots, for the most part double, but not uniformly so. Some observers see a good deal more of detail in the individual organisms, but no refinements are to be expected from the rapid mode of preparation of the object. The appearance is, however, characteristic and unmistakable. In addition to the groups in or about the cells, it will be seen that two larger diplococci are visible with the epithelial cell as a background. These have probably fallen away from some disintegrating group ; but, whatever be their origin, they are a common enough feature in the field of view in the ordinary course of searching a prepara- tion for the gonococcus. The illustrations in Fig. 2 are intended to show the relation of the micro-organisms to the other elements that come into view in the field during examination, and also to show some Fig. 2. -This group contains : i, a normal pus corpuscle ; 2, a pus corpuscle partly surrounded with cocci ; 3, a pus corpuscle with cocci in the protoplasm ; 4, a pus corpuscle com- pletely filled with cocci, and 5, a free colony or group of cocci, b. — Gonococci from a pure cultivation, c. — A diagrammatic representation of the development of gonococci. d. — Section from the conjunctiva, showing the presence of gonococci in the discharge before penetrating the epithelial covering. 62 Gonorrhceal Infection in Women. of the details which should be made out by the observer after employing more careful modes of preparation than that just described. They are taken from Bumm's work, and are, as he explains, mostly diagrammatic. The explanatory notes sufficiently indicate the various relations of the micro-organism to the tissue elements, which may be seen in preparations of gonorrhceal pus. It may now be asked : If in examining a discharge by the method described, the observer finds diplococci in groups or colonies, such as those figured above, is he justified in giving a decided diagnosis of gonorrhoea ? Unfortunately the subject is not so simple as this, and a definite unassailable conclusion is not to be reached by such a summary process. In a suspected case, the discovery of diplococci arranged in the manner which has been described, makes it almost, but not altogether, certain that the disease is gonorrhceal. How then can we be certain ? This brings us to the consideration of the diagnostic value of the presence of the gonococcus, and of a method by which it can be infallibly differentiated from any other micro-organism. There can be no doubt that Bumm has proved the existence of micro-organisms which cannot be distinguished by the indi- vidual form alone from Neisser's gonococcus. He describes five different varieties of diplococci obtained by pure cultivation, only one of which, producing a yellowish-white film in the culti- vation medium, is pathogenic. It is obvious that cultivation experiments cannot become a clinical method of differentiating micro-organisms which are identical or very similar in form, and we must therefore look for some more practical method. Such a method appears to have been discovered by Dr. Gabriel Roux,^ of Paris. It depends upon the effect of Gram's staining fluid upon micro-organisms in general, in- cluding the diplococci resembling the gonococcus, as compared with its effect upon the gonococcus itself. Roux's application of Gram's method of staining consists in first colouring the ' Le Concours Medical, Nov. 13, 1886. Exavtifiation of a Suspected Secretion. 63 dried film of secretion which is to undergo examination with methyl-blue or gentian violet, fixing the colour, if it is fixable, with Gram's iodo-iodide solution, and then washing with absolute alcohol, so as to decolorise the pus or leucocytes in the secretion. Gram's liquid fixes the colour in all micro- organisms, as far as is known at present, excepting the gono- coccus. Hence it follows that if the cocci, which have been observed in a specimen of discharge prepared in the ordinary Jitay, completely disappear after the application of Gram's solution and washing with alcohol, they are Neisser's gono- coccus. If on undergoing the same treatment they remain visible, that is, retain their colour, then they are some other form of diplococcus ; and the case from which they are derived cannot be pronounced gonorrhoeal on the strength of the microscopic examination alone. Roux's method has been submitted to a severe trial by Dr. Charles W. Allen ^ and Dr. Edmund C. Wendt,^ of New York, and they both express confidence in it as an exact test. These observers have worked together, and though writing in different journals they practically give identical reports. Dr. Allen says: "We have examined pus containing a great variety of forms of bacteria, and find that, while the double coloration method brings out all: other micro-organisms more beautifully than any other process we have employed, decolorisation removes the staining from the gonococci and causes them to disappear, while other micro-organisms are not decolorised. Here, then, we have a method which, when carefully carried out, appears never to fail, and has the great advantage of simplicity." The process of examination, as practised by himself and Dr. Wendt, is thus described : " A drop of pus is spread into a thin layer by pressing between two glass slides, and allowed to dry in the air. A drop of a solution of methyl- ' " Practical Observations on the Gonococcus, and Roux's Method of Confirming its Identity." — Jour7tal of Cutaneous atid Genito-Uritiary Diseases, March, 18S7. ' " A New Colour Test (Roux's) for the Detection of the Gonococcus." — Medical News, April 23, 1887. 64 Gonorrhoeal Infection in Women. blue in aniline water is now placed upon it for a moment, and washed off with a stream from a wash-bottle ; a few drops of Gram's iodo-iodide liquid is then poured on, and allowed to remain for several minutes. This fixes the colour on micro- organisms in general. Gram's liquid is now washed off, and while the specimen is still wet, a cover glass is placed upon it, and it is examined with an oil immersion lens. If micro- organisms resembling the gonococcus are found, we proceed to test them by decolorisation. The cover-glass is removed, and the specimen treated with absolute alcohol, until the colour is as completely removed as possible. The cover-glass is replaced, and the specimen again examined, when all gonococci will have been found to have disappeared. All other organisms, however, which may have been present will be distinctly visible. If desirable, the pus cells may be brought out again by applying a solution of eosin. By this method we have been able to exclude all cases which would have been of necessity left doubtful, without some confirming test." It has yet to be seen whether the experience of other observers will confirm Drs. Allen and Wendt in their confi- dence in Roux's test. Bumm is satisfied, from his experience of the behaviour of the various organisms under staining processes, that the pathogenic diplococcus which he found in puerperal cystitis and in mammary abscess has its colour fixed by Gram's staining fluid, while the gonococcus has not. But if Bumm's contention is well founded, there is still room for further evidence with regard to the behaviour of the four other non-pathogenic varieties of diplococcus. Practically, in dealing with the discharges from the female genitals every source of error in identifying the gonococcus may be considered eliminated. If in a suspected case the particle of matter to be examined be carelessly taken from the lower portion of the vagina, there is a whole " fauna" of that region usually brought into the field of the microscope. But in every actual case for investigation, during the most characteristic and prolonged Exaniinatio7i of a Suspected Secretion. 65 stages, the discharge for examination may be best taken direct from the orifice of the urethra or from the os uteri, and the fluid taken from either site is comparatively free from bacteria other than the gonococcus. I have constantly applied Roux's test for the last few months, and though as a test it seems satisfactory, I doubt whether, clinically, its application is not a mere counsel of perfection, only valuable in hushing quibbling and pedantic objections to the sufficiency of the clinical and ordinary microscopic methods of differentiation. Instead of examining the same film of mucus or pus first with the ordinary stain and again after the application of Gram's fluid, I have usually made six complete and permanent preparations from each specimen of discharge to be examined, and have labelled them so that they could be repeatedly compared, if necessary. Three of these preparations are made with the ordinary stain, one rapidly done, the other two more carefully ; two others are prepared with Gram's fluid, washing in absolute alcohol, and mounting in Canada balsam as described ; and the sixth is re-stained with eosin in order to make the pus and other cells again visible, as recommended by Roux. Without exception, in the cases ascertained to be gonorrhceal by independent evidence, when diplococci have been seen at all, they have disappeared under Roux's process, and this has been so whether the pus has been taken from the cervix uteri and been free from other bacteria, or from the vagina when the diplococci were associated with myriads of other bacilli and cocci which persisted in the preparation after the washing with absolute alcohol In old standing cases of gonorrhceal origin, and in doubtful cases, diplococci have hardly ever been seen in the uterine discharge, and when they have occurred in non-gonorrhoeal cases they could never be mistaken for the gonococcus, if the grouping of the gonococcus be characteristic. With regard to the identification of the gonococcus in the actual clinical work of gynaecology, we are now in a position to collect the points of the complete process. They are : — F 66 Gonorrhoeal Infection iji Women. (i) The presence of some clinical sign or symptom to suggest the existence of comparatively recent infection. (2) The collection of the secretion to be examined from the cervix uteri, from the orifice of the urethra, or exceptionally from the orifices of Bartholini's glands. As there is, strictly speaking, no vaginal blennorrhagia, the collection of the dis- charge from the vagina is merely inviting the risk of error. (3) The presence of a diplococcus in the protoplasm of the pus corpuscles, or other elements of the fluid, and its arrange- ment in the groups or colonies which have been proved to be characteristic. A single group in the field of the microscope is sufficient to settle the question. In the absence of such a group, however numerous separate diplococci or groups of diplococci apart from the cells may be, we cannot pronounce the case to be gonorrhoeal, even though we know that separate individuals and groups are very numerous in the acuter stages. (4) Roux's test may be applied to complete the proof: {a) When all the other conditions of the proof are already fulfilled, in order to observe the disappearance of the gonococci, and {h) when some diplococci are present, but not in the characteristic groups, in order to see whether the persistence of the micro-organisms will prove the negative. Presence of the Gonococcus — Its Clinical Significance. The whole subject is in too inchoate a state to make it safe to allege that these conditions are sufficient to satisfy the requirements of medico-legal investigation. Clinically, so far as my experience goes, the fulfilment of the first three condi- tions has justified me in stating that a disease was gonorrhoeal when such a possibility was denied by the patient or by one of the parties to its production, and, without exception, the confident statement of the opinion has elicited information that was previously withheld. But this is anticipating what we have next to consider, viz., the diagnostic value of the Clinical Significance of tJie Gofiococctis. 6y presence of the gonococcus in a discharge. All experience goes to show that the presence of the gonococcus settles the question ; it is the pathognomonic sign of the disease. Even the apparent exceptions support this conclusion. If gonococci are present in the discharge from an inflamed mucous membrane^ the discharge is of gonorrheal origin. Apparent exceptions to this rule have already been referred to. On the one hand, there are the reported cases of vulvo-vaginitis of young children, in which diplococci were observed, which could not by any means be differentiated from the true gonococcus. The later observations of Cseri, during an epidemic in Budapest, point, however, strongly to the conclusion that the virus of that disease and of the gonorrhoea of adults is identical. On the other hand, we have Kroner's observations on cases of ophthalmia neonatorum, in which the gonococcus could not be found in the discharge. Bumm's experiments, however, prove that the discharge from such cases is not infectious, and the inflammatory process is not followed by the same results as are seen in the genuine infectious ophthalmia of the new- born. Further inoculation experiments by Bumm with the discharge from the cervix uteri left as an effect of a former gonorrhoea, and with other discharges of gonorrhoeal origin, but free from gonococci, the experiments of Zweifel with the vaginal discharges of puerperal women upon the eyes of the new-born, and a host of other experiments with every variety of discharge, lead us inevitably to the further conclusion that a secretion containing gonococci, 7C'he?i brought into contact with a mucous me?nb?'ane capable ofiffectiofi, gives rise with certainty to a gonorrhoeal inflammation; and conversely, a secretion^ 7uhatever its origin may be, tuhich does ?iot contain gonococci, is incapable of giving rise to a gonorrhoeal inflammation. The portion of the proof of these propositions, which consists of inoculation experiments with gonococci, derived from pure cultivations, is worthy of more detailed statement. The successful inoculations on the human subject have been, from the nature of the case, very few; attempts to inoculate the 6S Gonorrhoeal hifection i?i Women. lower animals have been uniformly unsuccessful. Gonorrhoea seems to be a purely human development. We have seen under what circumstances Bockhart's inoculation experiment was carried out ; let us examine one of Bumm's more satisfactory experiments. The original virus was obtained from a case of blennorrhoea neonatorum, and the inoculation was effected with gonococci of the second generation of pure cultivation in blood-serum. A speck from the cultivation area, along with a little clot of the serum, was conveyed by means of the platinum wire into the urethra of a woman, measures having been taken to prevent the spread of the disease, should it arise, to the internal sexual organs. The greatest care had been taken to ascertain that the genitals of the subject were entirely free from gonococci. Two days passed after the inoculation without any symptom.s. On the third day the patient complained of a burning pain in micturition, and a small amount of yellowish watery secretion could be pressed from the urethra. This discharge contained separate gonococci as well as groups upon the epithelium. The other numerous pus corpuscles present were quite free from cocci. Next day the urethral mucous membrane, which had become red and swollen, bulged out from the orifice. The secretion was now thin, purulent, and small in quantity, and it contained numerous free cocci, epithelium cells beset with cocci, and also some pus cells filled with them. The further course of the disease was that of a rather severe attack of urethral gonorrhoea. The acute stage lasted three weeks, and the discharge required other three weeks of treatment to bring it to a complete cessation. No complications occurred. The discharge was regularly examined during the whole course of the attack, and the presence of the gonococcus in the characteristic manner was as regularly demonstrated. An almost exactly similar experiment was made with the twentieth generation of a pure cultivation of the gonococcus with a similar result. These inoculation experiments of Bumm's fulfil all the Clinical Significance of the Gonococcus. 69 requirements of a complete proof that the micro-organism is the cause of the disease. We have in them (i), a distinct type of disease in gonorrhoea; (2) the isolation of the organism developed in that disease, and its cultivation in artificial media apart from the tissues in which it originally developed ; (3) the inoculation of the organism into tissues capable of taking on the diseased action, and the production thereby of a disease characterised by all the phenomena of the original disease ; and (4) the identification of the micro-organism in its characteristic relation to the tissues undergoing the diseased process set up as the result of inoculation. If the proof, as stated so far, has done justice to the available material for proof which exists, we should now be in a position to accept the dictum — without the gonococcus there is no gonorrhxa ; and, conversely — without gonorrhoea there is no g07iococcus. The truth of these propositions is far-reaching in its influence. Gonorrhoea is the only disease which produces an infectious catarrh of the female genitals. All the various other diseased conditions and irritations producing catarrh of the genital tract in the female, which have been alleged to give rise to urethritis in the male, must be admitted to be innocent; they cannot produce a specific blennorrhoea. What then, it will be asked, becomes of the cases with which we are all familiar? We have all seen men who have had the alleged misfortune to contract a urethral inflammation from their wives; they have indulged too imprudently in sexal inter- course; the wife has a chronic discharge from general bad health, or from the mechanical irritation of a pessary; she had not quite ceased menstruating, and so forth. It is an ancient and convenient superstition, which has been almost universally accepted as fact. For such facts so much the worse if they do not square with the well-established modern doctrine. That a simple urethritis, simulating gonorrhoea, is not possible, it would be illogical and absurd to allege ; but that few of us ever see such a urethritis, whose origin is above suspicion, the universal experience must admit to be the fact. When we JO Go7iorrhceal Infection in Women. consider, on the one hand, how rare alleged simple urethritis is, and how common the specific form ; and, on the other hand, how frequently, one might almost say universally, some amount of uterine or vaginal catarrh is found among parous women, who have never run the risk of specific catarrh, we must admit that there exists a discrepancy which is inexplicable on any hitherto accepted theory. If simple urethritis in the male could be produced by any form of non-specific catarrh in the female, then urethritis would be one of the commonest of ailments among continent married men, just the class among whom it is seldom or never seen. No case of alleged simple urethritis need, however, cause more than a momentary difficulty. Such cases are always seen in the acute stage ; if the discharge contains gonococci, it is specific ; if it is free from gonococci, the inflammation is not gonorrhoeal. This facility for learning the truth may be sometimes embarrassing to some patients, and, occasionally to the practitioner ; but the existence of an exact criterion in the early stage cannot fail, in the long run, to conduce to the morality and to the physical well-being of the community. A case which well illustrates these points has recently been under my care. It was that of a lad of sixteen, a member of a highly-respectable family, who was brought to me by his mother. He had recently come home from school, and he had not been able to conceal the fact that he was suffering from a discharge from the penis. On examination I found that he was the subject of marked phimosis, and the orifice of the urethra could not be brought into view. The purulent discharge from the opening of the prepuce was copious enough. Not so long ago I might have been satisfied and silenced by the explanation which was given me as to the cause of the disorder. But I made a microscopic examination of the pus, and found typical gonococci. The possibility of my view, as stated to the patient alone, being correct was at first strenuously denied, but while he was under treatment I ascertained the origin of the malady. There was nothing unusual about it. Developnent of the Gonococais. yi The occurrence of ophthalmia in a new-born child should also lead to an examination of the discharge. If the matter contains gonococci, the disease is gonorrhoea!, and in the absence of proof of post-partum infection, it is to be presumed to have originated in gonorrhoeal infection of the mother. This is now a universally accepted opinion, and the fact calls for no further notice. Development of the Gonococcus in the Tissues — Its Effects. The immediate dependence of the phenomena of the gonorrhoeal inflammation upon the presence of the gonococcus brings us to this conclusion, that the pathology and patho- logical anatomy of this disease are described in any satisfactory account of the life-history of the gonococcus and the changes which its development produces in the tissues which harbour it. We have seen incidentally the result of Bockhart's experiment on the urethra of a dying paralytic, and the pathological investigation of the condition of the mucous membrane. Bockhart's conclusions have been warmly contested, especially with regard to the extraordinary penetrative power of the gonococcus, and its capacity for migration. But from the nature of the case there are few in a position to speak with confidence on the subject. Very few opportunities occur of submitting to sufficiently searching examination the urethral mucous membrane when it is in the condition to throw light on the pathology of gonorrhoea, and no opportunity at all of observing the progress of the disease in the urethra from day to day. The principal work of pathological investigation has been carried out upon the conjunctiva of the new-born; and here Bumm's^ contribution stands out pre-eminent. Bumm had the opportunity of snipping out a small portion of the conjunctiva in a large number of cases of ophthalmia neonatorum at different stages of the disease. These portions ' Loc. cit. 72 Gonorrhoeal Infection in Women. of tissue were prepared and submitted to careful microscopic examination ; and the observations thus made cannot fail to throw much light upon the minute anatomy of the disease- process in the genital tract. His observations extend from the first to the thirty-second day of the disease, when the gonococci could no longer be found either in epithelium or in connective tissue. The knowledge derived from a short summary of Bumm's conclusions may be advantageously applied ana- logically to the phenomena of the disease as observed in the female sexual organs. It will be found to explain some clinical features otherwise obscure or inexplicable, and to suggest a reasonable explanation of some symptoms of whose causation we have at present no direct knowledge. Along with the infecting secretion at the outset of the purulent ophthalmia infection, there comes in contact with the conjunctival sac a small number of the micro-organisms. These find in the superficial moist layer of the conjunctiva an excellent soil, and proceed at once to proliferate, so that in twenty-four hours from the first contact they may be found in great abundance. While other micro-organisms which may have been brought incidentally into the conjunctival sac, amidst the infecting secretion, are rapidly eliminated by the movements of the eyelids and the flow of tears, the gonococcus holds its ground. "Endowed with an eminent invasive force," it penetrates between the superficial epithelial cells, and also into the soft protoplasmic substance of the same elements, continues to proliferate between the layers of the epithelium, and ultimately reaches the papillary layer of the mucous membrane. There is no evidence that the micro-organisms possess any power of locomotion to carry them against the outward stream of fluid. They develop • superficially and inwards, probably owing to something in the nature of the soil. The time taken by the process varies to some extent, but usually in two days the micro-organism has penetrated and taken complete possession of the whole epithelial sheath. The way in which it marches forwards is always the same — by Development of the Gonococcus. 73 breaking down the cementing substance between the epithelium elements. Sometimes the gonococci are seen pressing forward in thin streaks, sometimes spreading out into rounded colonies or thinly scattered groups of fungi, according to the resistance of the tissues to be penetrated. In every case the reaction on the part of the tissues is at this time very energetic and complete. Great swarms of white blood-corpuscles migrate from the capillary network which comes close down to the epithelial sheath, penetrate into the superficial layers of the connective tissue, and thence find their way through the epithelial layers to the surface. Owing to the disintegration of the strata of epithelium by the development of the fungi, it gets carried away in the stream of fluid and of cellular elements, either as individual epithelium cells or in flakes, a breaking up to which capillary haemorrhages between epithelium and connective tissue and the movements of the eyelids contribute. At the verge of the transition-epithelium of the limbus corneas and of the edges of the eyelids, the invasion by the fungi breaks off suddenly. This epithelium, as well as the pavement epithelium of the cornea, retains its regular stratifi- cation and normal appearance. It resists the invasive force of the gonococcus. When the epithelial sheath is broken through, the papillary portion of the mucous membrane lies exposed to the ravages of the micro-organisms. But their invasive force appears to be broken ; they penetrate only the most superficial sheath of the sub-epithelial connective tissue. Usually the gonococci lie in small groups in the interspaces between the strains of fibres which run parallel to the surface. More rarely they may be seen in streaks penetrating perpendicularly, and these possibly reach the capillary lymph-spaces. While the micro-organisms are thus invading the superficial layers of the conjunctival connective tissue, the inflammatory process appears to have increased in intensity; the infiltration of round cells reaches finally as nmch as 2 mm. under the free surface of the mucous membrane, and the individual cells are 74 Gonorrhoeal Infection in Women. crowded upon one another. This process gives direct origin to the purulent stage of the blennorrhoea. The process of repair begins usually within four days, but it varies according to the severity of the attack. It starts from the remnants of the original epithelial covering, proceeds rapidly, and soon brings to an end the further development of the cocci in the tissues. The new epithelial sheath consists of a layer of cubical or slightly elongated elements, which becomes rapidly covered with two or three layers of flatter cells. The most superficial of these layers becomes further modified, and the whole sheath forms an impenetrable protection to the underlying tissues against the micro-organism. By the time the process of repair is well advanced, viz., the tenth or twelfth day, the gonococci are no longer present in the connective tissue, only in the superficial portion of the epithelial sheath, where whole ranks and groups of the micro-organisms still hold their ground. Occasionally there is a re-invasion of the deeper strata, when the new protective layers are broken through at points by the outward stream of debris from the surface of the connective tissue, and then there is a fresh invasion by the cocci, a repetition of the process, and, to some extent, of the appearances resulting therefrom. Such relapses hinder the process of repair, but do not prevent the complete development of the new kind of epithelium. The process of epithelium formation is usually complete in the third week of an attack of ophthalmia of the new-born, and the epithelial sheath remains intact during the subsidence of swelling and proliferation of elements in the papillary layer behind it. The force of the invasion by the fungi and the duration of its difterent phases vary greatly in different cases. When the processes in the ophthalmia of the new-born were compared with the stages of the gonorrhoeal ophthalmia in the adult, it was found that the process of repair was longer in beginning in the latter, and the invasion of the connective tissue of the mucous membrane was deeper, more extensive, and of longer duration. As late as the fourteenth day of the disease in an Developmeyit of the Gonococcus. 75 adult no trace of an epithelial sheath could be seen ; the papillary portion lay completely exposed, and contained, to a considerable amount, colonies of gonococci, partly free and partly in the cell protoplasm of the pus corpuscles. When we see the invasion by gonococci giving rise to such different phenonema according to the age of the individual attacked, we cannot reject, without further consideration, the view that when implanted upon such a suitable soil as the urethral mucous membrane of the adult, the gonococcus may develop more vigorously and penetrate more deeply than it has been shown to do in the conjunctiva of the new-born. It is not improbable, ' though there exists no direct proof except in the single case of Bockhart, that the invasion may extend to the lymph-vessels and even into the capillary blood-vessels, but such an occurrence must be the exception, not the rule. Bumm maintains that he has proved that the gonococcus can only invade and destroy cylindrical epithelium, it cannot enter the pavement epithelium, and it can penetrate only the most superficial layers of the connective tissue of a mucous mem- brane. ^Vhethe^ there is any essential difference in the mode and extent of invasion when the gonococcus develops in the mucous membrane of the urethra, of the cervix uteri, or of the Fallopian tube, remains to be proved by direct observation. As far as our knowledge of the process in the conjunctiva is concerned, we see that the reaction of the tissues in the acute stage corresponds exactly to the violence of the onset and the rapidity with which the micro-organism is developed ; and in the later stages, when the tissues have become protected by the development of epithelium due to the reaction of the tissues, and the gonococcus disappears, the remaining pheno- mena of the disease are just those which may be produced by any chronic irritation. The final process of healing depends, not so much upon the elimination of the micro-organisms, as upon the closing of the tissues against their further invasion, by the development of thick layers of pavement epithelium. The application of these conclusions to the phenomena of ^6 Gonorrhoeal Infection in Women. the gonorrhoeal process in the genital tract is so obvious that any attempt at an explicit statement would be superfluous. The reaction of the tissues leading to the development of a special modification of epithelium, which will ultimately become in some sense cicatricial, explains at once the modified symptoms of second and subsequent attacks of gonorrhoea ; and there are other equally striking points in the fitness of the results of Bumm's observations to explain clinical features of the disease, as we must trace them in the sexual organs. Theory of " ]\Iixed Infection." No account of the pathology of gonorrhoeal infection would be complete up to the present time without mentioning in some detail Bumm's theory of mixed infection, which has been already hinted at. His most recent contribution is a paper^ published in December last, which, we may take for granted, contains the most mature experience on the subject. Mixed infection is defined as the invasion of the organism by two or more kinds of bacteria. When these mixed in- fections are accidental they deserve no further notice. But that kind of mixed infection in which there exists a causal connection between the invasion of the two germs is most important. In such a case the bacterium possessing the greater power of invasion precedes and, as it were, prepares the soil for the second germ. These forms of mixed infection are distinguished by a certain constancy of occurrence, and the possibility, and even probability, exists that if one germ has settled another will follow. Ordinary croupous pneumonia with its after diseases is a typical example. The bacteria of pneumonia deprive the alveoli of the lungs of their epithelium, and fill them with an exudation, which is a soil in which secondarily tubercle bacilli or pyogenous germs settle, and which may lead to the termination of the illness in phthisis or ' "Ueber gonorrhoische Mischinfectionen beim Weibe." — Deutsche medicmische IVochenschrift, No. 49, 1887. Theory of ''Mixed I?ifectio7ir 77 formation of abscesses. The gonococcus, too, by its growth on the mucous membrane of the female genital tract, is capable of so altering its substratum that other fungi which are usually present there without doing harm, or which, favoured by suppuration, find their way from the air, obtain an entrance into the tissues, and then on their own behalf exert their specific effects, which are totally different from those of the gonococcus. This fact is well illustrated in the gonorrhoeal infection of the vulvo-vaginal glands. These and their ducts are tolerably frequently the seat of gonorrhoea in women. The ordinary course is this : an acute purulent stage is followed by a chronic mucous discharge, which may continue for months. The secretion gradually ceases, part of the gland becomes de- stroyed, and finally cure supervenes. The course, however, is totally different if, during the course of the acute blennorrhoea, pyogenous micro-organisms find their way into the inside of the gland. The previously only tolerably tender gland be- comes painful and swells, the skin covering it becomes red, and soon the appearance of purulent Bartholinitis is produced. Such a gland, excised and examined, shows no traces of gonococci. The pus inside the gland only contains pyo- genous staphylococci ; these have overpowered the gonorrhoea microbes, have penetrated into the gland-sac, and from there into the periadenitic connective tissue. This is covered thickly with heaps of cocci, and shows the first commence- ments of purulent liquefaction. The great majority of all abscesses of the vulvo-vaginal glands are due to this kind of gonorrhoeic mixed infection. Other fungi possessing no pyogenous properties may invade the gland without giving rise to any characteristic tissue reaction. Similar processes occur in the mucous follicles of the female urethra. Catarrh of the bladder is another form of gonorrhoeic mixed infection. Gonorrhoeic cystitis does not exist in the sense that the specific cocci of gonorrhoea attack the epi- 78 Go7torrhceal Infection in Women. thelium of the bladder, as they do that of the urethra, and then cause it to suppurate. Bumm has isolated the active agent in cystitis — a special kind of coccus which is very similar to the ordinary gonococcus. Returning to the genital tract, the inflammatory processes which, after cervical and uterine gonorrhoea, usually develop in the pelvic connective tissue and pelvic peritoneum are extremely frequent. Bumm says : " It is astonishing with what frequency here (Wiirzburg), in gonorrhoea patients, in whom indeed excesses of all kinds, continuous mechanical insults, &c., but often also a too heroic (eingreifende) treat- ment tend to help, para- and perimetritic processes are found." The microbes of gonorrhoea do not directly invade the lymph tracts and the connective tissue about the uterus, and cause inflammation and exudation. The territory of the gonococcus is fortunately limited to the superficial layers of the mucous membrane. Gonorrhoeic para- and perimetritis cannot be explained by the action of gonococci; there must therefore be another agent, which, under the influence of the infection of the mucous membrane, passes into the parametric tissues and there causes disturbance. It is not very common for that exudation to break down into pus ; if it does so, the occur- rence is due to mixed infection. Bumm has had two such cases: in one he demonstrated the staphylococcus pyogenes aureus; in the other, the noxious agent was a chain micro- coccus. In both cases the formation of pus was doubtlessly due to the pyogenous micro-organisms, which found admission through the infected and eroded cervical mucous membrane, and settled and multiplied in the lymph spaces of the broad ligaments till they were eliminated by the purulent inflamma- tion. Bumm thinks himself, therefore, justified in saying, " Purulent parametritis with gonorrhoea of the cervix is due to a mixed infection with pyogenous bacteria ; it is the analogue of the acute gonorrhoeic bubo in the male, which likewise owes its origin to pyogenous germs." The further the gonorrhoeal infection advances upwards Theory of ^^ Mixed hzfectiott." 79 from the cervix, the fewer admixtures occur in the gonorrhoeic pus. In gonorrhceic uterine secretion besides the gonococcus but very few other bacteria are found, and they are scarcely ever found in the Fallopian tube. The gonococci advancing along the mucous membrane ultimately reach the tube, while other germs remain behind. The proper character and the results of the pathogenous activity of the gonorrhoeic microbes is therefore seen — pure and unadulterated — in the tube. They cause purulent inflammation of the mucous membrane, but the surrounding connective tissue remains free from them. The gonorrhceic tubal pus is evacuated into the peritoneum, and whereas in other conditions the bursting of an abscess into the abdominal cavity is followed by the gravest consequences, in this case the whole process ter- minates with a circumscribed inflammation, encapsuling the exuded pus. The cause of this difference is the varying pathogenic value of the organisms which are contained in the pus. A puerperal pelvic cellulitic abscess bursting into the peritoneum causes general peritonitis, because it contains pyogenous streptococci, which rapidly multiply in serous cavities, and are capable of exerting the most deleterious effects. Gonorrhceal tubal pus cannot do this; its microbes do not find in the peritoneum conditions for their increase; the pus, therefore, acts as an aseptic foreign body, becomes encapsuled, and is finally absorbed. It may, under special circumstances, be possible for pyo- genous cocci to get mixed with gonorrhoeal pus, the result being a dangerous peritonitis. But such cases are as yet unknown or unreported. Bumm then mentions another form of gonorrhceal mixed infection, viz., that with tubercle bacilli. Statistics, which are, however, few and therefore not to be quite relied upon, seem to show that in the etiology of localised genital tuber- culosis, gonorrhceic processes, especially epididymitis, play a role. The question arises whether the cases of isolated tubal tuberculosis are not due to an old tubal gonorrhoea. The 8o Gonorrhceal Infection in Women. thickened tubal pus, in which the gonococci gradually become disintegrated, might be a good soil for the tubercle bacilli, and so, by means of mixed infection, a tubal gonorrhoea might be changed into a tubal tuberculosis. He mentions the facts of a case which seem to support this opinion. In the paper of which the above is a summary, Bumm frequently refers to parametritis as a result of gonorrhoeal infection. It may be as well to take this opportunity of stating that hitherto my experience has not brought me a single case of parametritis in which there was the slightest evidence that gonorrhoeal infection, pure or mixed, had anything to do with its production. While perimetritis is one of the com- monest of complications, if indeed it is not part of the normal course of the disorder, parametritis must be among the rarest. Chapter IV. CLINICAL PHENOMENA OF GONORRHCEAL INFECTION IN WOMEN. Coming now to the clinical phenomena of the disease, we shall see how far our modern doctrine of the pathology furnishes a feasible and sufficient explanation of the clinical signs and symptoms, and also to what extent our knowledge requires to be supplemented. It is not intended to reproduce here a description of an attack of gonorrhoea in the female such as might be suitable for a systematic treatise on the subject, but rather to describe and call attention to some features which are of value in relation to the diagnosis and treatment of the disease, but which, as a rule, do not attract sufficient attention. At this stage the description of subjective symptoms is purposely omitted to prevent repetition when we reach the illustrative cases which will be introduced. There are two distinct types of the gonorrhoeal disease in women : (i) the acute, and (2) the chronic or "creeping." In the Acute Form. 8i In the Acute Form. The acute form, as affecting the urethra, does not differ materially from the gonorrhoeal urethritis of the male. There is the same reddening, swelling of the mucous membrane, itching and burning, and finally the same discharge and scalding in micturition. The troubles in the female are less, as a rule, than in the male, and the complications of the urethral form less serious. Hence the comparatively little notice the disease received while the urethral affection was believed to be the most important part of the series of phenomena which ordinarily result from infection. In most of the cases to which I shall have to draw attention, the urethral troubles passed away spontaneously, and at an early period in the course of the disease. In the female the urethral form never occurs without other portions of the genital tract becoming involved, but the converse proposition is not true; the uterus may be affected, and the most serious complications may develop in the pelvis, without the patient ever having noticed any discomfort in micturition, and without the medical prac- titioner who may be called in to treat the complications being able to satisfy himself that any change in the mucous membrane of the urethral meatus has occurred. As a rule the vulva becomes next affected. The nymphae become thickened and stiff, the mucous covering becomes eroded, and the exposure of the underlying tissues thus produced gives rise to much of the suffering in micturition. At the same time the orifices of the glands of Bartholini become inflamed, and similar tissue changes take place in those about the urethral orifice. In the ordinary Bartholinitis the disease spreads inwards and the glands become painful and swollen, but if the ducts do not become obstructed the swelling subsides, and a discharse from the mouths continues for some time in much the same way as from the urethra. Although the ostium vaginae becomes red and inflamed in an acute attack it is never so deep red as the orifices of the ducts of Bartholini's glands. In every stage G 82 GonorrJiccal Infection in Women. of the disease the peculiar reddening, sometimes with erosion, at and near these orifices, is always distinctly visible. The reason of this appears to be that the mucous membrane about the ostium vaginae, especially that within the remnant of the hymen, does not readily take on a diseased action ; it is not a suitable soil for the development of the gonococcus. In women who are fastidious as to personal cleanliness you can hardly ever see any marked signs of vulvitis. In the careless, on the contrary, you not only find vulvitis, which may be due to the development of the gonococcus, but you find an erythema of the external surfaces of the labia and of the perineum which cannot possibly depend in any way upon the specific micro-organism of gonorrhoea, except inasmuch as the increased discharge due to the presence of the micro-organism becomes acrid and irritating, even to the external integument when left in contact with it. It stands to reason, therefore, that much of the tissue change which occurs in many cases of vulvitis depends more upon filth than upon anything specific. It is not unusual to hear the acute form of gonorrhoea referred to as vaginitis, by a sort of euphemism, and yet it is still a question whether there is any such thing as gonorrhoea! vaginitis. The vagina seems to be the last portion of the genital tract, from the uterus downwards, to become affected, and the first to get well under any suitable cleansing process. Why should this be ? Anyone who has seen the uterus when a state of prolapse has been for long its usual position, cannot have failed to be impressed with the similarity of the vagina to the external integument. It has no genuine mucous membrane, merely a comparatively slight modification of the outer skin, and its surface is covered, like the outer skin, with a more or less horny epithelium. Such a surface is not easily invaded by the disease-process, and, indeed, in even well marked cases of urethral and uterine gonorrhoea, it is sometimes hardly possible to detect any changes in the vagina. Schwarz^ ^ "Die gonorrhoische Infektion beim y^7&\\i&"—Samtnlung klinischcr VortrUge, No. 279. In the Acute Form. 83 maintains that a vaginal gonorrhoea is not rare in the acute form, and he says he has seen it in cases where the uterus remained intact, and the vaginal changes could not therefore be attributed to contact of irritating discharges. But the discharge which produces the erythema may come from outside, from beneath. If a woman is suffering from an extensive urethral and vulvar inflammation, with oedema and erosions of the nymphae, the discharge will be copious, and flow into the vagina when she is lying in certain positions, unless the ostium vaginae be very firm and contracted, which is not its usual state in the class of case under consideration; and in this way the infection may be set up and the symptoms increased by the production of an erythema from irritation, such as has just been alluded to as affecting the skin near the genitals under certain favouring circumstances. The younger the female affected the softer is the vaginal lining, and the more readily does a true gonorrhoea! invasion result; we may therefore consistently maintain that a true gonorrhoeal vulvo-vaginitis of the adult is rarely or never seen, and yet accept the evidence with regard to the specific nature of the vulvo-vaginitis of young children. Schwarz says that gonococci are to be found in and under the deeper epithelial layers of the vaginal lining, but he does not express himself so as to imply that he has found them. If, however, this turns out to be a true observation, corroborated by capable observers, it follows that a genuine gonorrhoeal vaginitis does exist. On the other hand, and the fact may be referred to only as showing the difference of opinion which perhaps still exists, Martineau^ does not look upon vaginitis as a directly specific disease. He describes the appearance of the vagina as seen through the speculum — the intense redness, the prominence of the plicae, the layer of greenish pus covering the mucous surface, the small erosions, "superficial, red, and readily bleeding, which result from the desquamation of the epithelium produced by ' " Le 16 Periodical Works. PERIODICAL WORKS PUBLISHED BY H. K. LEWIS. THE NEW SYDENHAM SOCIETY'S PUBLI- CATIONS. Annual Subscription, One Guinea. 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