THERAPY IN GONORRHEA AN HISTORICAL REVIEW By H. L. WEHRBEIN, M.D.

BROOKLYN N. Y.

HIS compilation was under- injections of seawater had been recom- taken in the hope that the mended for the treatment of gonor- polypragmatic method of rheal infections. It is still more treatment which still prevails illuminating that in 1930 a con- at the present time could be showntemporary author extols the use of Tto belong to past centuries and that a 1 per cent sodium chloride solution research into more fruitful fields could as a remedy against gonorrhea in the be stimulated thereby. male. Alzahavarius lived over 900 years ago. A little later Lanfranc Fro m th e Anc ie nt s to i 500 a .d . mentioned epididymitis as a gonor- The general impression from the rheal complication; it occurred to old writers is that gonorrhea was a him that the discharge ceased when nuisance rather than a disease. Other the swelling of the testicle, as he more urgent medical problems claimed thought, took place. The causal con- their attention. However, we shall nection was misunderstood then and give a few excerpts to show the trend. again and again. It led many physi- Moses taught that cleanliness and cians to the belief that any inter- segregation was about all that was ference with the urethral discharge necessary; he was aware of the in- was bound to lead to complications fectiousness of the disease, and it and should therefore be avoided; probably was very common. Its rela- it led others to the belief that the tive importance may be judged from proper treatment of all complications the fact that two pigeons were con- was the reestablishment of the ure- sidered the proper offering to the thral discharge. Many of them used priest. Hippocrates, Galen, and Celsus provocative injections and many mention gonorrhea casually without others, rather recently, tried to rein- deigning it important enough for a fect the urethra with the pus of longer discussion. There was some another case. In the same century, confusion with spermatorrhea at that namely the thirteenth, the famous time and the concern shown referred Petrus Hispanus advises the milk of merely to the possible loss of strength an ass or a goat mixed with the by the constant loss of semen. The juice of plantago to be taken per os Arabs and the later Roman authors as a sure cure of ulcers of the urethra. were more interested; specific thera- It was then the common conception peutic recommendations are being that the amount of urethral dis- made. Alzahavarius (s. Albucasis) pre- charge presupposed an ulcer. This scribed seawater and also salt water misconception was not done away for urethral injections. It is interesting with until Cockburne and Morgagni and illuminating that Eisenmann in made their pathological demonstra- 1830 in speaking about this adds tions. Constantinus Africanus used the remark that recently urethral human milk with barley water for urethral injections and John of Ardern the old and the new disease always improved this by requiring that the associated, who saw the patient with mother should nurse a male infant; gonorrheal symptoms to begin with he also added a little sugar, oil of and then saw him develop chancres violets, and milk of almonds. John of and so forth in due time it was Gaddesden (about 1300) gave a recipe evident that the two went together. for urethral injections containing bar- Paracelsus, a medical Napoleon, al- ley water, honey water, and an iris lowed no more doubt; he declared decoctum; and Joannes Arculanus himself for the identity and that in his discussion of the famous Arabian sealed it. Joannes de Vigo (1513) physician Rhazes, who lived from was the last “dualist” for some time 850-923) stated that the Arab’s pre- to come. Therefore the literature on scription containing antimony, lapis gonorrhea is scarce until the advent haematitis, and acacia met with his of the eighteenth century. However, approval. Enough of this; it is ap- as syphilis became a more lenient parent that since they were expected disease, it became evident to the to do something they lived up to general practitioner that he had to the expectation and tried not to do do something about the gonorrheal any harm. symptoms. They were still classed as syphilitic and many ingenious The Per io d of Syph il is (fr om 1500 to relations were advanced to explain Abo ut 1750) the connection between the early When syphilis became the dread gonorrheal symptoms and the later disease in Europe gonorrhea promptly syphilitic symptoms and it is not and properly was ignored for the time surprising that the fortunate doctor being. There are some statistical re- who treated a case of gonorrhea and ports in the literature which take failed to see dread syphilis in its heed of that old disease gonorrhea, wake took credit for skillful cures. gleet, brenning, droeppert, tripper, That w’as the aim, then, not to let and so forth, but they are unbeliev- gonorrhea degenerate into syphilis. able even for those times. Eight Mercury had been found to be the hundred cases of syphilis—one case supreme healer of syphilitics, there- of gonorrhea; no gonorrhea for several fore the gonorrheics were treated years. The only explanation is that likewise, and since the urethral dis- syphilis went along with gonorrhea, charge was apparently nature’s or rather vice versa, and syphilis method of getting rid of some irritant being the predominant disease, the poison or contagion it was considered gonorrheal symptoms were over- wise not to interfere with the dis- looked. Occasionally only a fortunate charge. A few examples will suffice. male would apply for help when Sydenham is a good one; his recom- there was nothing wrong except dis- mendations were purging, venesec- charge from the penis and dysuria. tion, calomel; injections were harmful. It is not very surprising that the Gideon Harvey in his “Venus Un- great confusion started at that time: masked” wrote in a similar vein: gonorrhea and syphilis were regarded purging, venesection, and demulcents as identical diseases. To the daily to combat the acrimony of the urine. observer who saw his patients with He also used mercury in the form of calomel and added guiac which had the supreme remedy. Astruc disagreed received such warm acclaim in the with the whole lot, but in his dis- treatment of syphilis. Stephen Blan- cussion of Chesneau who advised the card in his “Besieged Venus” de- use of calomel he agreed heartily viated a little. Of course, he also used saying that he had seen marvelous mercury purges, but he asked his results from the use of small amounts colleagues not to weaken the patient of it. by too many venesections. While We should not leave this period he feared the suppression of the dis- without pointing out the fact that charge greatly (it may bring on the the sufferer from a venereal disease pox) he still thought that urethral at that time received full punishment injections of tea were of advantage. for his indiscretions; most therapeutic He gave many case histories which endeavors were designed to give him served no purpose except to extol some thing additional to worry about. his standing as a therapeutist. And We have mentioned the large doses as a last member of this group let of cantharides already, but the large us mention Jean Astruc, who ap- doses of mercury were probably still parently was of better caliber. He more harmful. The theoretical atti- wrote an elaborate treatise on venereal tude concentrated on the amount of diseases and made a sincere effort salivation produced and the saliva to evaluate the work done so far. was often measured very much in His own regime of treatment was the same way as we measure the given in detail, but it will be sufficient patient’s urinary output today. It to say that after the usual purges, is also significant that the attitude venesections, and mercury intoxica- of the various authors left no doubt tions he came to the use of balsamics in the mind of the reader as to the and bland urethral injections. He value of the advice given; it was was critical of many prescriptions put forth with an assurance which given by others, but only after he must have been in reciprocal relation had made a trial. He particularly to his security as a therapeutist. attacked the use of cantharides which Apparently not one of them came were recommended in grain doses out with the pessimistic story of the and which caused frequently unbear- facts; yet all of them could have able bladder pain and hematuria, done so, if they had thought it wise. and he did not think much of lime water mixed with calomel for urethral Fro m 1750-1830; Astru c to Ric ord injections. This period is mainly interesting Then as now publications appeared on account of the struggle to establish which contained the great secret of a gonorrhea as an independent disease sure and rapid cure. Lead in the once more. We are mainly interested form of a bolus mixed with turpentine in William Cockburne, who was the and camphor was highly praised by first to make marked improvements Mayerne who promised a cure in a in the conception of the disease. few days. Musitanus said that one Among his many contentions was could cure gonorrhea in three days one that the discharge from the with plantago extract and calomel, urethra came from the lacunae which and Martin Lister thought cochineal he described and illustrated. Morgagni finally got credit for this but there is be the best informed and the most no doubt that Cockburne had found convincing. He pointed to the fact them independently. He also showed that syphilis could not be cured without that the so-called “carnosity” of mercury, while gonorrhea could; he the urethra, namely a caruncle, which also made inoculation experiments had been held responsible for the with gonorrheal pus and showed that urinary difficulties following gonor- a chancre did not follow. Johann rhea, was an erroneous conception Clemens Tode in Copenhagen made and that the difficulty was due to a the same contention in 1774 but did thickening of the mucosa and a not have any experiments. At the narrowing of the lumen. He still same time mercury became less impor- thought that there was some con- tant as a remedy, but the antiphlo- nection between gonorrhea and syph- gistic apparatus, vensections, muci- ilis, but he contended that either laginous decoctions, and balsamics disease could exist without the other. were used. Local treatment was A small quantity of corruption would frowned upon by the majority, but cause gonorrhea, a large quantity a few claimed quick and regular would cause syphilis. In his methods success by the use of their method. of treatment he did not deviate The time is also known through markedly from his contemporaries. its belief, which was then almost He still used purges and he still was universal and which persisted for greatly afraid of stopping the dis- almost a century, that a gonorrheal charge too quickly. There were injec- complication could be ameliorated tions, he claimed, which would kill if the discharge could be reestablished. the corruption and the running with- The method in vogue was the intro- out endangering the patient with duction of pus from another patient the pox and there were other methods into the urethra of the sufferer from of treating gonorrhea, namely by ophthalmia, epididymitis, or whatever increasing the discharge, which then the case might be. would remove the corruption. He We should not leave this particular has an interesting chapter on the period, in which progress had been “Algedo,” namely the early stoppage made but in which the therapy of of the discharge; he considered this gonorrhea was in such a confused a dreaded complication causing great state, without mentioning Bernard pain in the bladder and in the anus. Peyrilhe who evaluated the status of From his case histories it is apparent contemporary knowledge correctly by that at least some of these patients stating that gonorrhea was a self- suffered from prostatic abscesses. limited disease, that therapeutic ef- Almost at the same time there forts were silly and in many cases appeared in England a number of harmful. publications which contended that John Hunter’s famous experiment, syphilis and gonorrhea were caused which took place in 1767, is well by two different contagions. Francis known. In a lesser man it would not Balfour (1767) was the first and he have meant much, but coming from was quickly followed by Charles Hales such an excellent physician and being (1770) and W. Ellis (1771). Ellis, argued with such skill it was enough who was an apothecary, appears to to delay clarity for almost seventy years. Hunter’s own therapeutic tech- Eisenmann in his two volume work nique as applied to gonorrhea revived on gonorrhea devotes almost the whole mercury again. He not only used it second volume to postgonorrheal com- internally but also locally in the form plications; he is also a good historian of bichloride injections (1:2000). He and merits attention on account of also used sugar of lead (1:300) for his honesty and impartiality. Treat- injections and cantharides and turpen- ment at his time was mostly by tine internally. internal medication. Injections were John Howard, who followed im- used of course, but he did not approve. mediately after Hunter, showed the We are now almost up to Ricord, latter’s influence in all of his writings. but we should not miss a glance at a He was convinced that the same statistical compilation which was pub- virus caused syphilis as caused gonor- lished in the Edinburgh Medical and rhea and his treatment of the latter Surgical Journal in 1818. The compila- employed the whole medieval arma- tion came from two army physicians ment: venesections, purging, mercury and was accepted as a true indication and antimony. He did not think of the value of certain drugs. We may much of local treatment, but thought assume of course that the duration of that it was permissible in some cases. disease is identical with the duration The best injection consisted of calomel of the discharge. Fifteen patients in water. Treatment with his internal who were treated by rest and fasting method cured in six weeks; injection were cured in an average of eight treatment took much longer. and one-half days; 8 treated with Shortly afterwards cubebs were in- cubebs in five and one-half days; troduced as the supreme remedy. 4 with camphor in nine days, 8 with They were given in dram doses. A capsicum in thirteen and one-half few days’ medication was considered days, and 20 treated locally with sufficient in most cases. injections of a 4 per cent (!) solution With the beginning of the nine- of silver nitrate were cured in seven- teenth century the dualists came teen and one-half days. again to the fore but another con- Ricord has become immortal fusion arose which did not do much through his decisive experiments damage but which is interesting to which showed that Hunter was wrong. note. Since stricture of the urethra He did little for our problem. Silver was a fairly common after-effect of nitrate was his supreme remedy and gonorrhea the notion became popular he used it in unbelievably strong that other strictures and narrowings solutions in the urethra as well as of the hollow viscera were due to in the vagina. He also recommended gonorrhea. The pathology of syphilis camphor highly as a sedative. with its many deferred phenomena made a chronic, even incurable, gonor- From Ric or d to th e Pre sen t Time rhea understandable. So when a pa- The literature on gonorrhea after tient was found with a rectal or Ricord contains little of interest on esophageal stricture and a history of therapy. Slowly the new bacterio- gonorrhea in his early life was elicited, logical knowledge occupies the stage. the conclusion was drawn that these From Donne who thought that the strictures were gonorrheal in nature. trichomonas was the causative or- ganism of gonorrhea (1837) to Neisser it, he may make it more toxic, he who found the diplococcus in 1879 may use live organisms, he may use all sorts of organisms are described 50 strains, or what not, but he will and claimed. Bumm succeeded in find a group of physicians who will be isolating the gonococcus and in infec- favorably impressed and another step ting a female urethra. Since then forward has been taken. it has been more or less a therapeutic The only explanation for these battle with antiseptics. The silver many successes is the fact that salts led the host of chemicals which gonorrhea is a mild disease, a disease were invented, praised, and discarded, which will respond to the admonitions and at the present moment the stage of Moses as well as to an organic is still the same. Every year brings silver preparation. However, it is a forth a number of new compounds mild disease to the average patient and every year we loose a like number. and to the casual observer, but not The gonococcus too has become a to the epidemiologist. The statistical helpmate against its ravages. The data collected in Europe before the number of vaccines, sera, extracts, war indicate that every male in the etc. almost outnumber the silver salts. large cities, as in Berlin, has to expect Even as in the sixteenth century a gonococcus infection once in his gonorrhea is still a rich field for life and that every poor mariner in quacks. In the last decade alone cities like Hamburg and Bremen has we have been advised that a 1 per cent to suffer twice in a life time. saline solution is a most efficient We may also mention its com- therapeutic agent, that pure ether plications and so be assured that it is a injected into the urethra will cure, problem worthy of great efforts. But that formaldehyde vapors will do it the efforts must be less primitive; too and that tincture of iodine is highly the disease is not known well enough. effective but of course a little painful. Its course without treatment cannot It seems that there is something even be approximately stated with wrong in our approach. In spite of statistical figures; even with treat- the rather good knowledge we have ment we do not know yet if the about the bacteriology of the gono- average case may be expected to coccus and the pathology of the last two months or six months. Our organs affected we still behave like pathological knowledge of the disease the primitive experimenters of cen- is still deficient. Where are the gono- turies ago. Some clever chemist syn- cocci, how long do they last in near thetizes a new organic silver salt. or remote foci, how are they slain or His medical associate uses it on if this is too much what are their men afflicted with gonorrhea. He is living conditions in vivo? impressed favorably and says so. Until some of these questions are Others concur and the new compound solved it will be an accident if we is a success until another chemist find the means of shortening a gono- brings out something else. Or a bac- coccus infection materially and it teriologist makes a new vaccine; he will be a miracle if we find a specific may add bile salts, he may detoxicate treatment.