LATENT GONORRHCEA IN WOMEN M W. R. Pryor, M. D. Visiting Surgeon to the City Hospital (Gynaecological Department); Visiting Gynaecologist to the St. Elizabeth Hospital; Adjunct Professor of Gynaecology in the New York Polyclinic; Fellow of the American Gynaeco- logical Society, reprinted from the Journal of Cutaneous and Genito-Urinarv Diseases for March, 1895 [Reprinted from the Journal or Cutaneous and Genito-Urinary Diseases for March, 1895.] LATENT GONORRHCEA IN WOMEN.* By W. R. PRYOR, M. D., Visiting Surgeon to the City Hospital (Gynaecological Department); Visiting Gynaecologist to the St. Elizabeth Hospital; Adjunct Professor of Gynaecology in the New York Polyclinic; Fellow of the American Gynaecological Society, etc. WE are to consider this latent gonorrhoea in woman in its bearing upon the individualTierself, upon her perhaps in- nocent husband, and upon the offspring. I delivered by forceps a woman who was the mother of six children of a boy. During gestation she presented absolutely no symptoms, subjective or to me apparent, of gonorrhoea. Her labor was followed by vulvo-vaginal abscess, acute gonorrhoeal urethritis, and mastitis. I failed to obtain from her by the closest questioning any history of infection. Her husband, years before marriage, had a clap, but his wife had passed through her labors free from any complication. They had been married fifteen years. The explanation of this case is that the last labor was sufficiently bruising to the tissues to so reduce their resistance as to render them susceptible to the influence of the gono- coccus. Certainly m37 repeated examinations before labor failed to discover any symptom of a gonorrhoea which in a more propitious state of the tissues became active. Quite frequently have I delivered women who have passed through the puerperium without a single complication, and been compelled, after the decidua was cast off and the new endometrium formed, to operate for an acute gonorrhoeal endometritis. One case in particular I recall which infected her uterus no less than three times from a subacute ure- * Read before the Section on Genito-Urinary Surgery, New York Academy of Medicine, January, 1895. Copyright, 1895, by D. Appleton and Company. 2 Original Communications. thritis that produced absolutely no symptoms beyond a slight urethral discharge. Before I began to curette the uterus as an operation preliminary to coeliotomy, I observed several cases which formed a pyosalpinx in a perfectly healthy tube, which I had left after removing a pyosalpinx on one side. I have not and shall not cite any case in which there was any question of a fresh exposure and infection. They are all cases in which I could eliminate any such possibility. A man had a gonorrhoea a year before his marriage. After marriage he had a very blight watery discharge, which he attributed to too faith- ful attendance upon his wife. She bore him four children. At one labor she suffered a severe laceration of the perinseum, and it was for this condition that she came to me a year after her last delivery. I operated and cured her. In due time she returned to her husband, and in ten days developed a most virulent endometritis, with bilateral purulent salpingitis and peritonitis. I curetted her, and in this way removed every trace of her infection. I also examined the husband, and could find no urethritis. In a few months she returned again to her husband, and again had salpingitis and peritonitis. She was not seen by me for ten days, when the tubal trouble had so far progressed as to require a coeliotomy. Now, the interesting incident in the case is just this : The husband I saw two days before his wife’s return the second time, and his urethra was free. I examined him again when he came to report her condition, twenty-four hours later, and after the salpingitis began, and he had no clap. But when I operated upon her he had a profuse purulent urethritis, seven days after 1 first examined him. Dr. Bennet Beach found the gonococcus in the discharges of both husband and wife. At ome remote time this man had given his wife a clap of a degree not sufficient to produce symptoms, or else the symp- toms were masked by those incident to her pregnancies and confine- ments. Until an extra tax was put upon her system and pelvic organs by the perineorrhaphy and consequent detention in bed, she was able to resist the presence of the gonococcus ; but, upon returning to her husband, the vaginal orifice quite tightly closed, coition bruised the urethra. This locality became acutely infected, endometritis followed, and the woman escaped a section then only because of my interference. The second attack of tubal inflammation was not strictly a fresh infection, rather was it a lighting up of a previous one. But it was severe enough to convey gonorrhoea to her husband. With ovaries and pus tubes gone she still has a slight uterine discharge in which the gonococcus is found. We have, then, an unrecognized gonorrhoea in the woman, produc- Latent Gonorrhoea in Women. ing by a strictly auto-in flection acute attacks of gonorrhoeal urethritis, vulvo-vaginitis, endometritis, and salpingitis. I could multiply cases, but these quotations will suffice. In one case only have I been convinced that a husband with clean urethra has been infected by a wife to whom he had previously communicated gonorrhoea, but who was supposed to be free from it—that is, he con- tracted an acute infection from his wife, who had it as a latent disease. My belief is that this latent gonorrhoea in woman can become in her acute with complications bv any process which will decrease the resistance of the infected tissues; and my experience has shown such a condition propitious to the development of the gonococcus to follow confinement, operations, and violent coition. But I can not conceive of these cocci, attenuated, old, and degenerate, starting an infection in the male urethra unless they have become rejuvenated by a sudden de- velopment into reproductive activity. Still, one case I have seen which would rather point to the possibility of such a coincidence. Upon the offspring the following effects I have noticed : Specific vulvo-vaginitis I have seen once in a baby ten months old. The mother was infected, but supposed cured, and washed the child with a sponge which she handled after taking her douche. Three times have I treated for vulvitis children of between three and four years who had bathed with gonorrhoic mothers. Not one of tfiese women had the least idea that she was infected, and in not one could I find a suspicion of any symptom of gonorrhoea, beyond a very slight cervical milky leucorrhoea. Of the husbands I can give no reliable history ; they all indignantly negatived every compromising question. In one case, already quoted, the mother had a vulvo-vaginal abscess and urethritis. She presented her baby with the most typical gonor- rhoeal oral ulcers (Rosinski’s) I have ever seen, the child in return giv- ing her a mastitis which went on to suppuration. It is almost needless to call your attention to the frequency of gon- orrhoeal conjunctivitis in the newborn. The matter is being quite widely discussed with a view to preventing blindness. For myself, I have seen women who presented not one symptom of clap, giving birth to children which had most virulent conjunctivitis. I have not yet seen a male or female newborn which had contracted gonorrhoea of the genitals from its mother ; but a case is on record of a child born with gonorrhoeal conjunctivitis, contracted in utero. Regarding the aetiology of this disease, our position seems to be this : Every case of acute gonorrhoea will show the typical gonococcus, and also very many cases of chronic infection. Where the gonococcus 4 Original Communications. is not found by staining, gonorrhoea may be present. Hut we can safely say that if we fail to cultivate, in achl media, the gonococcus and can not find it by staining, there is no gonorrhoea. One hundred and ninety-seven prostitutes taken at random fur- nished the following results: The urethra, vagina, and cervix uteri were examined in all. The microscope alone was used, no cultures being made, and six hundred specimens were made from the one hun- dred and ninety-seven women. Cervix uteri.—Gonococci were found in 31*3 per cent. The re- sult was doubtful or negative in sixty-eight per cent. In those cases having the gonococcus there was a marked purulent discharge in two only, redness in one case, and in seventeen cases no clinical symptoms whatever. I wish to draw your attention to the importance of these examinations. The absence of clinical symptoms is most suggestive. In eighteen cases the gonococci existed once only with staphylococci; and in forty-six cases where no gonococci were found, staphylococci were present in but two. Clinically, of those forty-six cases two pre- sented a thick secretion and one blood. The absence of staphylococci and other cocci in the very class where we would expect other pyo- genic cocci as well as gonococci is worthy of note. Vagina —Out of the one hundred and ninety-seven women one hundred and eighty presented a vaginal discharge. Many forms of bacterial life were present, but in one case only was the pure gono- coccus found alone, and in six other cases it existed in conjunction with other germs. Of course, in these six cases it is reasonable to suppose that the gonococci leaked from the cervix or urethra into the vagina in several. In one hundred an’d seventy-three of these one hundred and eighty women no gonococci were found in the vagina, and in seventy-four no micro-organisms at all. Staphylococci were found in three cases. Urethra.—One hundred and twelve of the women showed gono- cocci. Of these women, in twenty-one the disease was apparent by ocular inspection, but in ninety-one cases the gonococcus was found with no pus discharge. Indeed, six had that very day been discharged from hospitals as cured. In sixty-one cases there was not the least suspicion of trouble. Seventy times a follicular urethritis with dis- charge existed, but gonococci were not present. When it was thought sufficient to take the discharge from the cervix of gonorrhoics, the gonococcus was found in but 9*5 per cent of cases; but scraping with a Volkmann’s spoon shows that the gonococcus can be found in even fifty-four per cent of the cervices of gonorrhoics. It is my l>elief that in an overwhelming percentage of cases puru- Latent Gonorrhoea in Women. 5 lent urethritis and endocervicitis are due to gonorrhoea; and, unless I can discover some very plausible reason for these two conditions, I attribute them to gonorrhoea. Fifty-three gonorrhoic women were kept under observation for five months. At the end of that time the gonococcus was found in the cervix in seventy-five per cent. The gonococcus seeks the racemose gland for its habitat. The lymphatic tissues and lymphoid endometrium it occasionally invades. Therefore we find gonorrhoea as a latent disease in women in the com- pound racemose glands of the cervix, the vulvo-vaginal glands, and of the urethra. Dormant gonorrhoea may produce absolutely no macroscopic changes and microscopically be unrecognized. In such a state.it may become acutely virulent at any moment, so as to be communicated to other tissues of the woman, or to the male, or her child. When latent, it is the more dangerous, because producing no symptoms and thus not recognized. The complications due to latent gonorrhoea, such as cysticis, peri- tonitis, and salpingitis, I will not discuss. The causative agent is insig- nificant in view of the importance of the complication. But I can not refrain from expressing my view of the prevalence of pyosalpinx. Cer- tainly, in the lower walks of life and among prostitutes, gonorrhoea plays a prominent role in the causation of pyosalpinx ; but in the mid- dle and upper classes I believe most pelvic inflammation is the result of too much minor gynaecology. Ignorant of the anatomy and physi- ology of the uterus, every practitioner has provided himself with specula, sounds, and applicators, and treats the inside of the uterus. I am perfectly aware of the importance of this statement, and I make it advisedly and as the result of my experience. No case is to be considered cured when the discharge from any pelvic organ contains the gonococcus developed by staining or culture. Clinically, any purulent discharge from the urethra or cervix is sus- picious; for pyogenic cocci other than gonococci do not remain for any length of time in the compound racemose gland. It is exceedingly difficult to cure, and I will mention my method in the chronic cases. Chronic gonorrhoeal urethritis in the female I treat by means of nitrate of silver—twenty to thirty grains to the ounce —applied through a urethral speculum. If the infection be seated in one or both vulvo-vaginal glands, ex- cision alone will suffice. Incision is efficacious temporarily only. Gon- orrhoeal endocervicitis is a most intractable affection. In dealing with the infection we must not lose sight of the possibility of cervical steno- ( )riginal Communications. sis. Therefore chloride of zinc I do not advise. The weaker chlorides, as of mercury, and carbolic acid, I do not find equal to the condition ; I use a double-strength tincture of iodine. Iodine, as yon know, is more powerfully germicidal than chlorine, and applied in this volatile state it is a most valuable remedy. At the same time it is less injuri- ous to the tissues than other equally good remedies. A chronic vul- vitis I treat by means of nitrate of silver. Chronic vaginitis I treat the same way, but always keep the vagina packed with iodoform gauze. This latter material straightens the folds of the mucous membrane and prevents invasion of the vagina by any one. Indeed, I plug up the vagina in cases also where I treat the cervix. Thus reinfection during treatment is guarded against. Our cervical applications should never extend beyond the inter- nal os. In very young children who have gonorrhoeal infection of the geni- talia in a chronic form, I have been compelled to abandon very often every means except frequent irrigations with the weak antiseptic super- saturated solution of boric acid. Why the gonococcus affects the racemose gland and not the tubular, I can not tell you. The endometrium is not propitious to its presence, it being found here in only about fifteen per cent of cases. Certainly it does not occur as a latent gonorrhoeal endometritis. Pyogenic infec- tions of the endometrium give rise to very prominent symptoms, and we do not see the infection here as a latent condition. The prevalence of gonorrhoea I do not believe due so much to the neglected gleet in the male as to the uncured latent form in woman. It is so extremely seldom that women are cured where once the infec- tion has reached the cervical glands, that we are almost warranted in saying that it rs never cured. Women who contract gonorrhoea usually stop treatment the moment disagreeable symptoms disappear, and for very obvious reasons. This is especially true of prostitutes, they being indifferent to conditions not painful, and wholly rebellious to routine treatment of symptoms which do not appeal to them as important. Gonorrhoics of a better class, deceived wives, or too trusting sweethearts, are prompted in their dis- obedience to our orders by modesty only. So it is that we gynaecolo- gists, while recognizing the danger of turning loose upon society these symptomatically cured yet virulent cases, are unable to compel their attendance upon our private and public clinics. And it is because there are so many unrecognized cases in the community, and the com- plications due to gonorrhoea are really becoming one of the problems of our social life, that I deem the subject worthy of vour attention. Latent Gonorrhoea in Women. There being no way of controlling even our private patients, I do not see what good segregation and inspection of prostitutes will do. Syphilis may be limited by this means, but not gonorrhoea. I com- mend to you particularly the strong iodine preparations and vaginal tampon of iodoform gauze in all cases where the cervical canal is infected. We are to handle this condition in women in the light of its com- municability to others and the very grave complications to which it gives rise in woman herself. It will not be limited in its ravages very much until we are able to educate women to the belief that every purulent discharge is pathologi- cal and never natural. We have got them to that point as regards intermenstrual bleedings, and hope to persuade them to look upon pus from the genitals as having the same signilicance as pus from other localities.