Venereal Diseases
VENEREAL DISEASES (from " venery," i.e. the pursuit of Venus, the goddess of love), a general term for the diseases resulting from impure sexual intercourse. Three distinct affections are included under this term gonorrhoea, local contagious ulcers, known as chancres, and syphilis. At one time these were regarded as different forms of the same disease. They are, however, three distinct diseases, due to separate causes, and have nothing in common except their habitat. The cause in each case is a definite specific virus, a microorganism. In the case of gonorrhoea the virus attacks the mucous membranes, especially that of the urethra, the vagina and the uterus. Chancres attack the mucous membranes and the skin. In syphilis the whole system comes under the influence of the poison.
Though these three affections are generally acquired as the result of impure sexual intercourse, there are other . methods of contagion, as, for example, when the accoucheur is poisoned whilst delivering a syphilitic woman, the surgeon when operating on a syphilitic patient, the wet-nurse who is suckling a syphilitic infant, and so on. An individual may be attacked by any one or any two of the three, or by all at the same time, as the result of one and the same connexion. But they do not show themselves at the same time. In other words, they have different stages of incubation. In gonorrhoea the disease appears very rapidly. So also in the case of the soft chancres, the first symptoms commencing as a rule three or four days after inoculation. It is different, however, with syphilis, the period of incubation being twenty-eight days, though it may be much longer. The length of the period of incubation, therefore, is of great diagnostic help in the case of syphilis.
For many years the term " venereal disease " was used very loosely, though the writers before the year 1786 had a tolerably clear idea that three distinct diseases were included under the term: the lues venerea, now called syphilis, gonorrhoea, and a condition leading to bubo and associated with a multiple chancre which is known at the present day as " soft sores." John Hunter, as the result of an unfortunate experiment, taught that there was but a single venereal poison which manifested itself in different ways. It took the French school many years of hard work to show that the poison of syphilis was distinct from that producing a soft sore, and that the virus of a soft sore was incapable, when pure, of causing gonorrhoea.
The evidence brought forward by Ricord, by Lancereaux and by Fournier was convincing. It has been confirmed by bacteriology, and it has happened by a remarkable coincidence that the truth of the French teaching about syphilis was first established on the firm basis of experiment in France itself, when Professor Metchnikoff at the Institut Pasteur in Paris gave in his adherence to Schaudinn's work, which showed that the Spirochaeta pallida germ was the cause of the disease.
A. Gonorrhoea.
Gonorrhoea is a specific inflammation of the mucous membrane of the urethra and other passages, by the reception into it of germs known as diplococci (5iirX6os, double; K&KKOS, berry the germs being double, like the halves of a walnut). After the illustrious discoverer, the germ is often spoken of as the gonococcus of Neisser. Gonorrhoea is apt to be a very serious disease, and it sometimes ends fatally.
The germs find entrance during coitus and multiply at enormous rate, spreading to all the glands and crevices of the membrane, and setting free in their development a toxin which causes great irritation of the passage with inflammation and swelling. They remain quietly incubating for three or four days, or even longer; then acute inflammation comes on, with profuse discharge of thick yellow matter, with much scalding during micturition, and there may be so much local pain that it is difficult for the person to move about. Microscopic examination of the discharge shows abundant pus corpuscles and epithelial cells from the membrane, together with swarms of diplococci (gonococci).
The inflammatory process may extend backwards and give rise to acute prostatitis (see PROSTATE GLAND), with retention of urine; to the duct of the testes and give rise to acute epididymitis (swollen testicle); and to the bladder, causing acute cystitis. It may also cause local abscesses, or, by irritation, set up crops of warts.
The treatment of acute gonorrhoea is best carried out if the patient can lie up for a while. He must avoid all fermented drinks and rich foods, and se'xual and other excitement, and he should drink freely of such things as barley-water, in order to dilute, and lessen the irritation of, the urine. Hot baths are comforting. Laxatives should be freely given. The urethra should be frequently washed out with a warm solution of permanganate of potash, a grain to the pint, and, later, a weak solution of one of the zinc or silver salts may be used as an injection.
Capsules of copaiba or oil of sandalwood, and a paste of cubebs pepper, have a beneficial influence, and, later, if the man is depressed, quinine and iron will be found useful.
In ten days or a fortnight the inflammation gradually subsides, a thin watery discharge remaining which is known as gleet. But inasmuch as this discharge contains gonococci it may, though scarce noticeable, set up acute specific inflammation in the opposite sex.
In the case of the female the inflammation is apt to extend to the uterus and along the Fallopian tubes, perhaps to give rise to an abscess in the tube (salpingitis) which, bursting, may cause fatal peritonitis.
A lingering gleet may be due to the presence of a definite ulceration in the urethra, as shown by examination with a slender tube illuminated by electricity the endoscope. The ulcer having been induced to heal by the application of a nitrate of silver lotion, all discharges cease. Chronic inflammation is necessarily associated with the formation of interstitial fibrous tissue, and the contraction of this new formation causes narrowing of the urethra, or stricture. Thus gleet and stricture are often associated, and the occasional passage of a large bougie may suffice to cure both. Often, however, a stricture of the urethra proves rebellious in the extreme, and leads to diseases of the bladder and kidneys which may prove fatal.
One of the most important points in the management of a case of gonorrhoea is to prevent all risk of the septic discharge coming into contact with the eye. It sometimes happens that the patient inadvertently introduces the germs into his own eye by his finger, or that his eye, or the eye of some member of the household, becomes inoculated by the use of an infected towel. If this happen, prompt and energetic measures must be taken to save the eye.
If so be that at the time of delivery a woman be the subject of gonorrhoea, there is great probability of the eyes of the infant being affected. The symptoms appear on the third day after birth, and the disease may end in complete blindness. The name of the disease is ophthalmia neonatorum (see BLINDNESS).
By the term gonorrhoeal rheumatism it is implied that the gonococci have been carried by the blood stream to one or more joints in which an acute inflammation has been set up. It is apt to occur in the third week of the disease, and it may end in permanent stiffness of the joints or in abscess.
In rare cases the germs find their way to the pleura or pericardium, setting up an inflammation which may even end fatally.
For a man to marry whilst there is the slightest risk of his still being the subject of gonorrhoea would be to subject his wife to the probability of infection, ending with chronic inflammation of the womb or of septic peritonitis. Yet it is often extremely difficult to say when a man is cured. That there is no longer any discharge does not suffice to show that he has ceased to be infective. Nothing less than repeated examinations of the urethral mucus by the microscope, ending in a negative result, should be accepted as evidence of the cure being complete. And these examinations should be made after he has returned to his former ways of eating, drinking and working.
B. Local Contagious Ulcers.
Chancroid, soft chancre or soft sore is so named in contradistinction to the Hunterian sore of syphilitic infection, the one characteristic of which is its hardness. The soft chancre is a contagious ulcer of the genitals, due to the inoculation of a distinct form of microorganism, the bacillus of Ducrey; and, provided that the specific germ of syphilis is not inoculated at the same time, the chancre is not followed by constitutional affection. In other words, the disease is purely local, and if some of the discharge of one of these ulcers is inoculated on another part of the body of the individual a sore of an exactly similar nature appears. This reproduction of the sore can be done over and over again on the same individual.
always with the same result. But in the case of the Hunterian sore, inoculation of the individual from the primary sore gives no result, because, as explained below, the constitutional disease has rendered the individual proof against further infection. The soft sore is often multiple. It makes its appearance about three days after the exposure, and as it increases in size free suppuration takes place. It is often of about the size of a silver threepence. Its base remains soft. In individuals broken down in health, the ulceration is apt to extend with great rapidity, and is then spoken of as phagedaenic.
Just as an individual may contract syphilis and gonorrhoea at the same connexion, so also he may be inoculated simultaneously with the bacilli of the soft chancre and the spirochaete of syphilis. In this case the soft chancres may make their appearance, as usual, within the first three or four days, but though passing through the customary stages they may refuse quite to heal, or, having healed, they may become indurated in the second month constitutional symptoms following in due course.
The virulence of soft sores being due to the presence of harmful germs, the surface of the sores should be touched with pure carbolic acid, which has the effect of destroying the germs and converting the sores into healthy ulcers. Or the chancres may be treated by the application of lint soaked in weak carbolic lotion. If the sore happens to be under a tight prepuce, and the germs are of great activity as is apt to happen in such a case ulceration may extend with extreme rapidity. It is advisable, therefore, to remove or to lay open the prepuce, in order that the sores may be effectively dealt with.
Bubo. The bacilli from the soft sore are apt to find their way into the lymphatic vessels, and so to reach the glands in the groin, when they set up destructive inflammation. Under the influence of rest the inflammation may subside, but if it continues and suppuration threatens, the gland had better be laid open and scraped out. If a speck of the contents of the abscess be inoculated on to the skin, a soft chancre is again produced.
C. Syphilis.
The cause of syphilis, whether inherited or acquired, is the presence in the blood and tissues of the same organism, which can be demonstrated in the various secondary lesions, in the blood and in the internal organs. The name of the germ is Spirochaeta pallida; 1 it is a protozoon of spiral form, from 4 to 20 n in length and i n in diameter, with a flagellum at either extremity. It possesses motility of three kinds a lashing, a corkscrew and a to-and-fro movement. It stains pale pink with Giemsa's fluid. At the time of writing (1910) it has not been found practicable to make an artificial cultivation of the spirochaete. But it may generally be found in primary and secondary syphilitic lesions by the aid of a ^ in. oil-immersion lens and abundant patience. The pale, spiral, hair-like germ is also found in children who inherit syphilis. Inoculations of the spirochaete in monkeys have produced the characteristic primary (Hunterian) sores, which have proved infective to other monkeys. And in the reproduced primary sores, as also in the secondary lesions following them, the same specific micro-organism has been demonstrated.
Syphilis is an infective fever, and its life-history may well be compared with that of vaccinia. A child is vaccinated on the arm with vaccine lymph for two or three days nothing is observed; but on the fourth day redness appears, and by the eighth day a characteristic vaccine vesicle is formed, which bursts and sets free a discharge which dries into a scab. If on the eighth day the clear lymph in the vesicle is introduced at another point in the child's skin, no characteristic local effect follows. The system is " protected " by the previous inoculation; this protection will last for some years, and perhaps for life. There is, then, exposure to a poison; its introduction locally; a period of incubation; a characteristic appearance at the seat of inoculation; a change in the constitution of the individual, and protection for a variable period. So with syphilis. The syphilitic poison is introduced at the seat of an abrasion either on the genital organs or on some other part of the surface of the body. The poison lies quiescent for a variable period. The average period is four weeks. A cartilaginous, button-like hardness appears at the seat of inoculation. If this is irritated in any way, an ulceration takes place; but ulceration is an accident, not an essential. From the primary seat the system becomes infected. The virus, passing along the lymphatic vessels, attacks the nearest chain of lymphatic glands. If the original sore is in the genital organs, the glands in the groin are first attacked; if in the hand, the glands of the elbow or armpit; if on the lip, the glands below the jaw. The affected glands are indurated and painless; they may become inflamed, just as the primary lesion may, but the inflammation is an accident, not an essential. In due course the poison may affect the whole glandular system. The body generally is so altered that various skin eruptions, often symmetrical, break out. Any irritation of the mucous membrane is followed by superficial ulcerations, and in the later stages of the 1 From xatri), long hair, on account of the waving, hair-like appearance of the germ.
disease skin-eruptions, scajy, pimply, pustular or tuberculous in type, appear. These eruptions do not itch. The individual is as a general rule protected against a second attack of syphilis, although there have been rare cases recorded in which individuals have been attacked a second time. In weakly people, in severe cases, or in cases that have not been properly treated by the surgeon, syphilitic deposits termed gummata are formed, which are very apt to break down and give rise to deep ulcerations. Gummata may attack any part ; the skin, muscles, liver and brain are the favourite sites.
It by no means follows that because the infecting sore is small, unimportant or quickly healed, the attack, of which the sore is the first (primary) symptom, will be mild. The most serious train of symptoms may follow the healing of a primary sore which has been so unimportant as scarcely to have attracted the attention of the individual, or actually to have escaped notice. Indeed, it not infrequently happens that the most serious forms of secondary or tertiary symptoms succeed a sore which was regarded as of such trivial nature that the individual declined to submit himself to treatment, or quickly withdrew himself from it to enter a fool's paradise. The advisability of ceasing from treatment should always be determined by the surgeon, never by the patient; mercurial treatment must be continued long after the disappearance of the secondary eruptions. It is the disease which the surgeon has to cure, not the symptoms. The patient is apt to think only of the symptoms.
" Is the disease curable? " This is the question constantly put by the patient on his coming for treatment. The answer is: " Yes; beyond doubt." But the individual must be made to understand the necessity of his submitting himself trustfully and patiently to a prolonged course of treatment. A second question is as to whether, in the course of the disease, his hair will fall out, his body will be covered with sores and his face with blotches, and if his bones will be attacked. Here, again, the answer will be that prompt submission to treatment will render all such calamities extremely improbable. Another question often put is as to whether the disease is contagious or infectious. Obviously, if a man has a primary sore or a secondary eruption upon the lip or tongue he should use his own glass, cup or spoon, and should refrain from kissing any one. If due care thus be taken no danger is likely to ensue.
The diagnosis of syphilis is often difficult. The first appearance of the sore about four weeks after exposure to the risk of infection, its hardness, the indolent enlargement of the associated lymphatic glands, and the occurrence of rash or of sore throat, are all helpful. But when the primary sore occurs on the finger, the face or, indeed, in any extra-genital region, it is apt to be lacking in the usual characteristics, and so the diagnosis may for a while be missed. In the case of doubt, the blood of the patient should be submitted to the delicate test known as the Wassermann reaction.
The General Treatment of Syphilis. It is impracticable to lay down a hard and fast line for the treatment of the disease, for no two individuals are exactly alike, neither does the disease follow a strict path in all cases. But experience has amply shown that in the early stages of the disease, mercury, at least for the present, is the only drug on which reliance can be placed. Guaiacum was at one time extensively used, and somehow or another sarsaparilla acquired a bubble reputation; but the practical surgeon of to-day ignores these drugs in the treatment of syphilis. Still, mercury must be prescribed with great judgment. For a man worn out by alcoholic or other excesses, or with health broken down by tuberculosis or other exhausting disease, mercury must be given with great caution. In times past, its reckless administration until profuse salivation was set up, or until the teeth fell out and the very jawbones became diseased, deservedly brought the mercurial treatment into disrepute. " Better the disease than the remedy," said public opinion, and not without reason. But this miscarriage of treatment is absolutely a thing of the past. Before placing a patient under mercurial treatment it ought to be seen that there is no unwholesome condition of his gums, and that his teeth are put in a satisfactory state; unless this is done, the administration of small doses of mercury may have the effect of producing salivation, and, in consequence, a temporary cessation of the treatment. In any case the gums must be watched, and the treatment stopped if tenderness occurs.
There are several ways of giving mercury: (a) by the mouth; (6) by rubbing a mercurial ointment into the skin; (c) by injection into the muscles; (d) by inhalation of mercurial vapour. Inunction is especially suited for those whom mercury given by the mouth causes diarrhoea or other disturbance; in a private house, however, it is found " dirty " and objectionable.
The fumigation-treatment is carried out by seating the naked man on a cane-bottomed chair and covering him over with a blanket; calomel being volatilized, its fumes are carried under the blanket along with steam.
Treatment by intra-muscular injections is increasing in popularity, but in carrying it out, great care must be taken that no septic germs are introduced. The preparation of mercury is given in solution or mixed with oil, and is usually injected about once a week into the muscles of the buttock or loin. The "grey oil," which is much used for injections, consists of finely divided metallic mercury in some fluid fat. Calomel is also used suspended in olive oil. After a few months of weekly injections there should be some weeks of rest from treatment.
But the most usual, and, perhaps, the most satisfactory method of administering mercury is by the mouth, in the form of pills or mixtures. The pills generally contain metallic mercury finely divided, as in " blue pill" and as in pills made of "grey powder, or as calomel, or some other salt of mercury, such as the bichloride or tannate. The preparation given in a mixture is usually a solution of perchloride of mercury.
Whilst the individual is undergoing mercurial treatment his diet must be regulated. Plain meat, roast and boiled, and vegetables which cannot cause indigestion or diarrhoea, will form his chief food. Spirits and liqueurs should be absolutely forbidden, but a glass or two of wholesome wine or beer may occasionally be allowed. If there is any secondary eruption of the tongue, mouth or throat, smoking must be forbidden. The dress must be warm, and there should be no exposure to extremes of cold or heat, nor should excessive work or amusement be undertaken. Briefly, it may be said that the subject of syphilis should live low and think high. It has been said by an English physician who delighted in epigrams, "Syphilis once, syphilis ever"; but this is not true. If the individual places himself unreservedly and continuously under the treatment of a trustworthy practitioner, he may confidently look forward to a cure; and, if so be that he is eventually married, may depend upon his children showing no sign of his unfortunate infection.
Unlike whooping-cough, smallpox or pleurisy, syphilis is not a disease which, left untreated, cures itself in the course of time. Syphilis is a disease which peculiarly calls for treatment, and that treatment, to be effectual, must be prolonged. To promote the healing of an ulcer, or to get rid of a cutaneous eruption, the result of syphilis, is not to treat syphilis. It is merely to free the patient of a symptom of the disease. To cure syphilis and the disease is curable the treatment must be patient and prolonged. And it must be for the surgeon to say to the individual that he may consider himself as cured, not for the patient to take upon himself the assumption that, because no secondary or tertiary symptoms have been seen for a certain number of months, he is cured.
In the midst of the uncertainties which surround the subject of syphilis, the question sometimes arises as to whether the treatment by mercury, for instance, is of the importance which is ascribed to it. Two instances may be given in proof of its undoubted value. First, a woman who has been infected and never properly treated, becomes pregnant, and though, perhaps, showing signs of good health in every other respect, has a miscarriage; pregnancy and miscarriage follow each other at short intervals, four, six or eight times. Then, at last, she is put upon mercurial treatment, and, going to her full time, bears a healthy infant. Second, an infected but healthy-looking woman, who has not been properly treated, produces a child who, in the course of a few weeks, becomes shrivelled and wan. His food does him no good, and daily he becomes more miserable. At last some mercurial ointment is spread upon his " binder," and he quickly becomes healthy and happy, and, in due course, if the treatment is persevered in, is entirely cured.
When should the Treatment of Syphilis be begun? The answer to this important question is: " As soon as the disease is diagnosed." As soon as it is seen that the primary sore is hard, and that the glands in anatomical association with it are swollen, mercury should be administered. It may not prevent the outbreak of the secondary symptoms, but it may greatly modify them. But if a surgeon is in doubt as to whether a sore is truly an infecting one, he should wait before condemning the individual as syphilitic, and placing him under the necessity of submitting himself to perhaps a two years' treatment, which, after all, may not have been necessary. Time would quickly clear up doubt.
Abortive Treatment. When it is remembered that the germs of syphilis have been incubating at the seat of inoculation for a month more or less, before the primary sore or chancre makes its appearance, it may be taken for granted that the removal of the sore by wide dissection, or its destruction by cautery, will not prevent the occurrence of secondary symptoms. For during those weeks the germs were finding their way into the lymphatics and the blood vessels and were producing a general infection.
When the disease has undergone a sufficient treatment by mercury, or when a patient presents himself with lesions which denote the fact that the disease has passed into the tertiary stage, a solution of iodide of potassium is given in combination with that of perchloride of mercury, or the iodide is given by itself. In these conditions the effect of the potassium salt is often most remarkable. It is a drug of the greatest value, and, recognized as such, is apt to be found an important ingredient in popular " blood mixtures." If given, however, in doses larger than can be borne by the patient, its poisonous effects are manifested by a metallic taste, by watering of the eyes and by the breaking out on the back and shoulders of scattered pimples.
Thus, mercury in some form is the recognized and proper treatment for syphilis in the secondary stage, and iodide of potassium in the tertiary. And, for as much as one cannot say where the secondary stage ends and the tertiary begins, it is a common practice to com- bine the mercuric with the potash salt in the treatment of certain phases of the disease.
In 1910 attention was hopefully directed towards Professor Ehrlich's treatment of syphilis by a complex preparation of arsenic, conveniently spoken of as " 606.
Gummata. The most characteristic form of the generalized syphilitic infection, which may not manifest itself for several years after the reception of the virus, is a new growth in various organs the liver, testes or brain, the muscles (tongue and jaw-muscles especially), the periosteum, the skin and the lungs. The deposits are called gummata from the tenacious appearance of the fresh-cut surface and of the discharge oozing from it. The structure consists of small round cells among thin fibres; it closely resembles granulation-tissue, only that the cells are smaller and the intercellular, substance (fibres) denser. Molecular death, or necrosis, overtakes this ill-organized, new formation at various central points, owing to the inadequacy of the blood supply. One remarkable feature of the process is the overgrowth of cells in the inner coat of the arteries within the affected area, which may obliterate the vessel. Gummata, and the ulcers left by them, constitute the tertiary manifestations of syphilis.
In a large proportion of cases only the secondary symptoms occur, and not the tertiary, the virus having presumably exhausted itself or been destroyed by treatment in the earlier manifestations.
Inherited Syphilis. In the syphilis of the offspring it is necessary to distinguish two classes of effects there are the effects of general intra-uterine mal-nutrition, due to the placental syphilis of the mother; and there are the true specific effects acquired by inheritance from either parent and conveyed, along with all other inherited qualities, in the sperm-elements or in the ovum. These two classes of effects are commingled in such a way as not to be readily distinguished; but it is probable that the ill-organized growth of bone, at the epiphysial line in the long bones (sometimes amounting to suppuration), and on the surfaces of the membrane-bones of the skull (Parrot's nodes) is a result of general placental mal-nutrition, like the corresponding errors of growth in rickets. The rashes and fissures of the skin, the snuffles and such-like well-known symptoms in the offspring are characteristic effects of the specific taint; so also the peculiar overgrowth in the liver, the interstitial pneumonia alba of the lungs and the like. As in rickets, it is in many cases some months after birth before the congenital syphilitic effects show themselves, while other effects come to light during childhood and youth.
It must be remembered that the moist eruptions and ulcerations about the mouth and anus of the infant, as well as the skin affections generally, are charged with the spirochaetes and are highly contagious.
From the second to the sixth year there is commonly a rest in the symptoms that are regarded as characteristic, but the tibiae may become thickened from periostitis, or a joint may become swollen and painful, and resolve under mercurial treatment.
The characteristic physiognomy gradually manifests itself if the child is not treated with mercury-^ the flattened nose, the square forehead, the radiating lines from the mouth, the stunted figure and pallid face. During the second dentition, the three signs, as pointed out by Jonathan Hutchinson, may be looked for the notched incisor teeth of the upper jaw, interstitial corneitis and syphilitic deafness. Perforation of the soft or hard palate may occur, and ulcerations of the skin and cellular tissue. Destruction of the nasal bones, caries of the forehead and skull, of the long bones, may also take place.
Colics' Law. A woman giving birth to a syphilitic infant cannot be inoculated with syphilis by the infant when she is suckling it; in other words, though the mother may have shown no definite signs of syphilis, she is immune; whereas the syphilitic infant put to the breast of a healthy woman may inoculate her nipple and convey syphilis to her. This is known as Colles' Law, and it is explained by the theory that, the mother's blood being already infected, her skin is proof against a local cultivation of germs in the form of a Hunterian sore.
Syphilis and Marriage. The question as to how soon it would be safe for a person with secondary syphilis to marry is of extreme importance, and the disregard of it may cause lasting mental distress to the parent and permanent physical injury to the offspring. A man who finds himself to be the subject of secondary syphilis when he is engaged to be married would do well honourably to free himself from responsibility. But should a person who has been under regular and continuous treatment desire to marry, consent may be given when he has seen no symptoms of his disease for two full years. But even then no actual promise can be made that his troubles are at an end.
The transmission of syphilis to the third generation is quite possible, but it is difficult of absolute proof because of the chance of there having been intercurrent infection of the offspring of the second generation.
REFERENCES. A. Fournier, Treatment of Syphilis, trans. C. F. Marshall (1906); R. Clement Lucas, Brit. Med. Journal (1908); A Manual of Venereal Diseases, by Sir Alfred Keogh and others (1907) ; Power and Murphy, A System of Syphilis (1908). (E. O. *)
Note - this article incorporates content from Encyclopaedia Britannica, Eleventh Edition, (1910-1911)
