Vol. XI.

Original Articles.

CONORRHEA IN WOMEN.

BY F. BYRON ROBINSON, B.S., M.D.*

Gonorrhea is an infectious, progressive catarrhal disease of mucous membrane. It is undoubtedly caused by the gonococcus of Neisser. Neisser's gonococcus is a doubleshaped vegetable organism known as a diplococcus. The gonococcus was seen in gonorrhoeal pus by Haller in 1869, but the coloring methods were not then developed, and so Haller's investigations attracted but Ettle attention. Dr. Neisser, who was an assistant in the Skin Clinic of Breslau, made some investigations by coloring gonorrhoeal pus in 1879. He then published his discovery of what is known as the vegetable germ-gonococcus.

To see the gonococcus in the gonorrhoeal

pas, spread out a tiny drop on a cover-glass,

then dry it, and stain it for a couple of minates in a watery solution of methyl blue; dry it again, and mount it in Canada balsam, and it is ready for inspection. Under the microscope one sees diplococci, or double-shaped organisms. The coccus lies mainly on the surface of the pus corpuscle. The organisms group themselves commonly into colonies. From eight to thirty may be seen in the regularly numbered and formed colonies. I would say that it requires some experience to enable one to properly color and examine with any distinctiveness the gonococcus. The home of the gonococcus is the cylindrical epithelium of mucous membrane.

It may be here noted that I am extending the field for the gonococcus, when it is said that it produces disease in mucous membrane. The author's investigations and publications

*Professor of Gynecology in Chicago PostGraduate Medical School; Gynecologist to Woman's Hospital, to Charity Hospital, to Post-Graduate Hospital, and to Columbian Dispensary.

No. 13.

show that he was one of the first men in this country to demonstrate that the vesiculæ seminales were frequently the seat of gonorrhœal invasion. I next began to write that the strictures of the rectum of women frequently arise from the invasion of the gonococcus. It can therefore be easily observed that the author considers gonorrhoea a very widespread disease. It is vastly more so than syphilis, and also vastly more fatal.

The frequency of gonorrhoea in any community, when carefully studied, will cause the innocent to marvel. The careful study of the disease shows in a remarkable manner how widespread are its advances. It requires the best heads and the finest skill to detect gonorrhoea in unsuspected corners. For example, take the studies of Dr. Sänger, of Leipsic, and note how he found gonorrhoea so much more frequently in his later studies than he did in his earlier ones. In practice, he diagnosed gonorrhoea in 12 per some 2,000 women, in private and hospital

cent. Later he noted 18 per cent. of gonorrhoeal cases among women. More recently he diagnosed 26 per cent. of gonorrhoea among his cases. Observe that his investigations enabled him to more than double his

percentage. Swartze, of Halle, diagnosed gonorrhoea in 18 per cent. of 617 women. Oppenheimer, at Heidelberg, diagnosed gonorrhoea in 27 per cent. of 108 pregnant women. Lomer found the diplococci colonies in 56 per cent. of cases examined in the clinic of Schroeder. By careful study one can find gonorrhoea in about one-half the women who come to the ordinary gynæcological clinics. I feel positive in asserting that 75 per cent. of the cases in which I remove the appendages for pus in the tube or ovary are of gonorrhoeal origin.

It is a common assertion of even general practitioners (who see the ordinary cases of clap) that 75 per cent. of men of the age of 25 acquire gonorrhoea in large cities. Hence it must be borne in mind that the frequency

of clap varies in different communities and different nations.

Gonorrhoea also varies immensely in its virulence in different localities. I have noted that the gonorrhoea of seaboard towns is frequently very fatal. This can be easily verified by noting the kind of cases which arise in New York and Liverpool.

Syphilis varies in the same way.

I noted the appearance of gonorrhoea in Vienna, Berlin, London, Birmingham, and other cities. The most virulent gonorrhoea that I saw was in Birmingham; but in that same town syphilis was absolutely mild.

The variation of gonorrhoea as to locality. is only in accord with other diseases, e. g., scarlet fever, cholera, and puerperal fever.

In Birmingham, gonorrhoea in women was particularly virulent. This may account for the radical statement of Mr. Tait, who told me nineteen cases of pyosalpinx in twenty were from clap. I wish right here to note that I never stated that gonorrhoea was the cause of 95 per cent. of all cases of pyosalpinx, as Mr. Tait did when I was his pupil. But I may say, after studying gonorrhoea in women for a long time, that I do consider it very widespread-much more so than my colleagues in Chicago will admit.

I would venture that if those who decry the idea of the wide extension of gonorrhoea among all classes, would more vigorously study the disease, they would end as Dr. Sänger did; and that Dr. Sänger himself will increase his percentage by his more extended and recent studies.

The time will come when most men will recognize the terrible disasters of gonorrhoea. The time will no doubt soon be here when expectant fathers-in-law will not merely inquire into the financial standing of the sonin-law, but will carefully investigate the condition of his mucous membrane. The student of gonorrhoea in women doubts the propriety of a man with gonorrhoea hastily marrying. But the general practitioner will deliberately (but ignorantly) tell such a man to marry before the penis stops secreting. The amount of study by the general practitioner given to gonorrhoea is still very limited in this country. The wide range of the pathology of gonorrhoea is yet very inadequately impressed on the medical student.

No doubt the reason for the indifference of general practitioners in regard to the magnitude of gonorrhoea is that its immedi ate results are not severe. The remot effects of clap are the disasters which tel the story of a long course of pathology. Th practitioner only sees the effect. He ha forgotten the cause. The pathology o gonorrhoea will run a course of forty year and even then kill-e.g., by stricture.

In this article I will consider the organs o a woman affected by gonorrhoeal poison, and attempt to show some of the morbid effect which I have so many times witnessed.

In the first place, it may be generally understood that a woman is infected from her husband, who may have contracted gon orrhoea from one to ten or more years previ ously. ously. The gonorrhoea has stuck to him fo all these years, and when it is deposited or the fresh mucous membrane of the wife i will in all probability pursue a similar chroni (and sometimes acute) course with her. man who has had latent clap for years may and does frequently, induce a penile discharg by the sexual excesses indulged in immedi ately subsequent to marriage. The irritation produced on the woman's genital organs, b enticing extra blood and exalting the glandu lar secretion, peculiarly fits her to become suitable culture-medium for the gonococcus

The evil effect of gonorrhoea on women i mainly chronic trouble, and the chronicall diseased mucous membrane induces untol reflexes. The continued irritation from th mucous membrane, by reflexes flashed t every viscus, induces indigestion, malnutri tion, anæmia, and neurosis. The reason tha gonorrhoea is worse in woman than in man, i because of the peculiar periodic function of woman's genital apparatus. The tube an uterus have exalted activity every month, an this extra action brings extra blood and ex tra nutrition to the parts. The consequen extra glandular secretion gives splendid cul ture-media for any germs.

A woman may contract gonorrhoea an never know it, or she may know it from th start from changed conditions of the gen tals. The gonorrhoea may declare itself: (4 in the eyes; (b) in the mouth and throat; ( in the rectum; (d) in the genital canal.

1. A typical gonorrhoeal attack will b

best described by noting the morbid condition of the genital tract. The first observable condition is that the vulvar mucous membrane is reddened. Vulvitis exists. The membrane is swollen, and an excessive amount of secretion exists on its surface. From the congestion and pressure on the periphery of the nerves ending in the vulva (pudic, small sciatic, and ileo-inguinal), she may complain of pain. The parts have a burning sensation. This redness so far confines itself to the vulva, and if one opens up the vagina it will appear normal.

2. Next, the gonorrheal virus spreads in two different directions: (a) in the urethra, and (b) into the vulvar glands. The urethral trouble arouses the woman by inducing painful and frequent urination. It may be asserted, honestly, that sudden burning and scalding in urination of a young woman is always suspicious of gonorrhoea; and it is almost certain, if the trouble endures for any length of time, that she has contracted a *local specific disease" which is almost incurable and ten times more dangerous than syphilis. Now the urethral irritation will last, generally, for some three weeks, more or less. It may exacerbate at the next monthly. But the woman is very conscious that she has had something she never had before, and she will give a very vivid account of it, especially if she acquired it innocently. The urine will be varied in color; it will contain extra mucus, and very often pus can be squeezed from the urethra by placing the index finger into the vagina an inch above the mouth of the urethra, and then slowly drawing the finger outward, all the time pressing on the urethra. The pus is broken-down epithelial cells.

Now the gonococcus thrives well in the trethra, as there are both cylindrical and glandular epithelia in this canal. The glandalar epithelium lies in depressions or crypts the urethral wall.

A most significant thing in gonorrhoea is the vulvo-vaginal gland situated near the junction of the lower end of the labium minor with the labium majus. When one can see a little red circle around the mouth of Bartholini's duct, it is suspicious; and when one can squeeze some yellow pus out of the duct, it is almost certain to be gonorrhoea.

The gonococcus has penetrated the duct and attacked Bartholini's gland.

We have no better guide to gonorrhoea than Bartholini's gland. I have now examined so many, with confessions and non-confessions, and noted results, that I would say that if pus can be pressed out of both ducts, ninety-nine cases in a hundred are gonorrhoea.

So chronic catarrh of Bartholini's glands is pathognomonic of clap.

3. Now we must pass over the vagina, as it is almost always free from visible symptoms due to gonorrhoea, Vaginitis is a rare affection. The reason the gonococcus does not attack the vagina is because its surface is not lined with cylindrical epithelium. It is lined with squamous epithelium, and possesses scarcely any glands-only the semblance of glands, known as mucous crypts. The vaginal lining is not far removed from real skin, and the gonococcus does not attack skin.

4. The great home of the gonococcus is the endometrium (endocervicitis and endometritis). In the cervix and endometrium it thrives and exists indefinitely. It has here requisite conditions, which are: (a) cylindrical epithelial (and glandular) cells; (b) heat; and (c) moisture. This may be considered the palatial home of this aristocratic germ. It causes leucorrhoeal discharges, due to breaking down of the uterine epithelium-both cervix and body. The discharge is nearly always yellow or tinged with yellow. Such women are ill at menstruation, and abort easily. At abortion they are frequently seriously ill.

This gonorrhoeal endometritis often lasts years, with varied results. Modern gynæcological methods of inspecting and treating the endometrium are the only possible way of eradicating the gonorrheal disease.

5. We now come to the endosalpinx-in other words, the lining membrane of the fallopian tube. It is simply a continuation of the endometrium, as I have frequently shown by the microscopical sections of fetal tubes and uteri at their junction. They gradually merge one into the other. In fact, only for the round ligament as the inviolable landmark between uterus and tube, we would not always be able to distinguish uterus from tube.

The tubes have been the fighting-ground for gonorrhoea for some time. The general practitioner often denies that the terrible disasters of gonorrhoea in women are brought about by the presence of the gonococcus in the endosalpinx. I have now treated so many women with gonorrhoea in the tubes, and have also operated and removed the gonorrhoeal tubes so often, that I feel convinced beyond all reasonable doubt that the great majority of all pyosalpinges are from gonorrhoea. A few, it is to be admitted, acquire pyosalpinx from puerperal sepsis, uterine cancer, actinomycosis, tuberculosis, and from dirty instrumental examination by tinkering doctors.

For some eight years I have been watching carefully diseases of women in Germany, Austria, England, and the United States. I should think that during that time I have examined six thousand women and have witnessed, assisted in, or operated myself, in hundreds of laparotomies. I am fully convinced that 80 per cent. of all pyosalpinges result from gonorrhoea. I also wish it understood that I consider that pyosalpinx may get well or end in a hydrosalpinx; i. e., the pus in the pyosalpinx may be absorbed, and fluid or hydrosalpinx result-the startingpoint of the pathological state having been, as in most cases of chronic pyosalpinx, gonorrhoea.

The most constant condition left in the tube after it has been infected with gonorrhoea, is adhesions. Adhesions are the remnants of peritonitis. Another remnant of changed conditions is hydrosalpinx.

The course of gonorrhoea in a fallopian tube is generally definite. First we have catarrhal endosalpingitis. The endosalpinx of the isthmus suffers least, but that of the ampulla (the outer two-thirds of the tube) suffers mainly. As the inflammation of the endosalpinx approaches the fimbriated extremity of the tube, it comes to a new membrane having squamous epithelium covering it. Now, it was shown that the gonococcus only grows well on cylindrical epithelium; but the peritoneum has not got cylindrical epithelium-so here ends the facile and rapid progress of the gonococcus.

But if the gonococcus does not thrive on peritoneum, it does another and a fortunate

thing for the woman. The gonococcus irri tates the peritoneum so that it throws out ar exudate which soon closes up the fimbriated end of the tube so that the contents of the tube (pus, serum, mucus) cannot go into the peritoneal cavity. The fallopian tube a the abdominal ostium closes in two ways It closes by slowly contracting and entirel turning all the fimbriæ back into the tube itself, where every fimbria lies coiled and platted like the petals of a rose. process hermetically seals the tube; and the contents (infectious or non-infectious) ar safely imprisoned unless the tubal wall bursts This is the kind of pyosalpinx which get well by absorption of the pus and leaving the serum (hydrosalpinx), which may finall become absorbed, leaving a functionles tube.

No

But this fortunate ending of gonorrhoea salpingitis (pyosalpinx) is far from being th only one. The chief course of gonorrhoea salpingitis is where the closure of the fimbri ated end is not accomplished by turning a the fimbriæ back into the tubal lumen, bu some few accidentally become strangled an left outside in the abdominal cavity. we have part of the fimbriæ inside the tuba lumen, and part inside the peritoneal cavity This fact, makes the great disaster in pyosa pinx of gonorrhoeal origin. The fimbriæ le outside of the tube have a mucous mem brane, and it is mucous membrane-not per toneum that perpetuates the gonococcu These fimbria in the peritoneal cavity an the cause of the wide and extensive adhesion found in operating. The adhesions are pr duced by recurrent attacks of peritonitis du to the infection of the fimbriæ left in th peritoneal cavity. Generally the peritonit recurs by invasion of infection from the al dominal ostium due to traumatic rupture; during the monthly menstrual rhythm an e acerbation of the peritonitis takes place. I such cases the woman's pelvis is filled wit exudate; she is a partial or complete invali for years.

It must be borne in mind that abortion while the woman suffers from gonorrhoea a very disastrous. The virus seems to violent exacerbate, and dangerous peritonitis r sults. Again, the trauma arising from abo tion may rupture some pathogenic cyst due

previous gonorrhoea, and death may thus suddenly occur.

The wall of the tube must be studied to know what the effect of gonorrhoea is on it. The peritoneum of the tube is nearly always thickened and covered with flocculent, stringy adhesions in all stages of organization. Flakes of lymph or solidly organized bands may be observed. The muscular wall is not much altered, unless it be atrophied from the pressure of exudate.

The inflamed mucous membrane is where the exudate arises, so the tubal wall is thickened from the inside. The tube will often attain the size of a thumb or a broomstick. It remains convoluted and sacculated. | The chief pathology lies in the ampulla. Such tubes are friable, and so easily broken that I have broken them from the uterus in enucleating them from their bed.

The mucous membrane is in most cases entirely destroyed by pressure. I had one gonorrhoeal pyosalpinx where it could be demonstrated after removal that the tubal wall had previously ruptured three times, and it had made extensive peritoneal adhesions.

6. The ovary is the next structure that the gonococcus attacks. Ovarian disease is almost always secondary to tubal disease. I will give the result of my own investigations, worked out over a year ago. When the gonococcus in its journey has reached the abdominal ostium, it has come to the end of mucous membrane. But the germ thrives on cylindrical or glandular epithelium. The Ovary is, unfortunate enough to be covered by glandular or cylindrical epithelium, known as the "germinal epithelium" of Waldyer; so the gonococcus simply passes from the endosalpinx to the germinal the germinal epithelium. covering the ovary.

The next step is the one which I especially offer as explaining cystic degeneration of the Ovary. After the gonococcus has invaded the cylindrical or glandular epithelium of the ovary, it simply passes on to another group of germinal epithelial cells known as the membrana granulosa. The membrana. granulosa is both glandular and cylindrical, and the gonococcus can thrive indefinitely in such a medium. The result is that the Graafian follicle does not ripen naturally. It

does not rupture, but the membrana granulosa simply expands so that we get an ovary crowded with abnormally enlarged cysts or unruptured ova.

I am thoroughly convinced that this description fits gonorrhoeal tubes, for I have examined large numbers. It is easy to demonstrate positively that the virus passes from the end of the tube to the ovary or peritoneum, for degenerate ovaries exhibit the course of the degenerative process, and old adhesions start at the abdominal ostium and spread through the pelvis. I have also made post-mortems where the tubal end was not closed and the yellow gonorrhoeal pus would drip from the abdominal end of the tube as I held it up. In one of those very cases the woman died in four hours from leakage of pus into the peritoneal cavity, and the friends thought the doctor had killed her with hypodermatic injections of morphine. I could in this case easily exonerate the attending physician from all blame.

I have demonstrated in gonorrhoeal disease that the tubes were fairly normal in appearance, but that deep in the interior of the ovary one or two teaspoonfuls of pus could be found. I have shown this in cases where gonorrhoea existed beyond the shadow of a doubt (and by confessions), by opening the ovary after I had removed it by laparotomy. In one such case I did laparotomy simply because the woman had continual recurrences of pelvic peritonitis; she would be almost clear from exudates at the intervals of the attack. But at one recurrence, when the ovary felt enlarged, I did laparotomy, and found considerable pus in the interior of the ovary. Her husband had had gonorrhoea five years before.