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Gonorrheal Urethritis in Male Children1
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GONORRHEAL URETHRITIS IN MALE CHILDREN 1 (WITH SOME OBSERVATIONS ON THEIR SEXUAL IMPULSES) LEON M. BEILIN Chi"cago, Illinois
While vulvo-vaginitis in female children is relatively common and has received much attention in medical literature, specific urethritis in male children occurs less frequently and has received comparatively little notice from medical investigators and clinicians. Various forms of gonorrheal infection are fully described in the textbooks of medicine and surgery, but about gonorrhea of the urogenital tract in young boys, little or nothing is said. That this is a definite disease entity, the incidence of which is of much greater frequency than is generally assumed by the medical profession, is conceded by many competent observers. Physicians in the employ of charitable and reformatory institutions, or those connected with clinics and dispensaries for children encounter acquired venereal infections, both gonorrhea and syphilis, in young boys with fair degree of frequency. Specific inflammations of the genital tract in young children, girls and boys, has of late become a subject of renewed study. It has been shown that this condition, seen so often in large clinics in children, is really a gonorrheal one and should be treated from that standpoint. The data upon which such conclusions are based, are identical with those which are brought to bear upon the diagnosis of urethral and vaginal discharges in adults (1). According to Fournier, 15 per cent of all cases of gonorrhea occur between the ages of thirteen and nineteen, and Van Arsdale (4) has estimated that the ratio of gonorrhea in male children to 1
Read before the Chicago Urological Society, December 20, 1929.
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LEON M. BEILIN
that of adults to be one to thirty-five. Fournier's studies in France and Erb's in Germany, show that the first venereal infections are most likely to occur at the onset of adolescence. Madame Alexandra Kollontai, formerly the Commissar for Child Welfare of Soviet Russia, reported an alarming epidemic of venereal infection among young children of both sexes in 1919 and 1920, which she attributed to the aftermath of the war and revolution. The records of the Department of Health of the city of Chicago show that 352 cases of gonorrhea in children of both sexes were reported during the year 1927, and the New York State Department of Health for t he year 1923 shows that, out of the total of 3,346 cases of gonorrhea in males, there were 58 cases of gonorrheal urethritis in boys under the age of fourteen, giving the ratio of gonorrhea of boys to that of adults, as 1 to 57. It is safe to assume, however, that the actual number of venereally infected children in these cities is much larger than the official records of the Departments of Health would indicate. In fact, venereal diseases are present endemically among children of the poor in congested districts of large cities, though by no means are they confined to the lower strata of society. Frank Lydston (2) reported 30 cases of gonorrheal urethritis in young boys of respectable and well-to-do families of Chicago, tracing these infections to a pseudo-hermaphroditic cook in the neighborhood; and Winslow (3) reported an epidemic of gonorrheal proctitis in a school for boys in Baltimore, caused by the practice of sodomy among the children of that institution. Through the courtesy of Dr. Herman Adler, Director of the Institute for Juvenile Research of Chicago, I have caused an analysis of 5,000 cases to be made for incidence of venereal diseases among children examined by this Institute. During a period of twenty-seven months, 600 children under the age of thirteen were treated in the venereal wards of the Cook County Hospital of Chicago, of which 85 per cent had a diagnosis of gonorrhea and 15 per cent of syphilis (5). I had the opportunity to examine these records and to study 83 cases of gonorrhea in boys under the age of puberty.
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GONORRHEAL URETHRITIS IN MALE CHILDREN
The study showed the following: GONORRHEA
SYPHILIS
TOTAL EXAMINED
Question Question Definite of or Definite of or former
- - - - - - - - - -- - - - - - - - - White White Negro Negro
boys ..... ... .. . . . . . . .... . . . .. . . . girls . . .. . . . .. ... ... . . . . ... .. .. . . boys .... · ......... . ......... . ..... girls .... .. .... .... . ........ ... . .
2,853 1,739 245 163
TotaL .. . ...... . . . ... ............ . ...
5,000
5 37 0
former
- - --
8 43 3 5
44
59
105
38
12
103 88 34 163
11 5 --------
47
388
A diagnosis of neurosyphilis, juvenile paresis, or tabes was made in 16 out of 2,853 cases of white boys, 10 out of 1,739 cases of white girls, 2 out of 245 cases of negro boys, and 4 out of 163 cases of negro girls.
This paper is bas;ed on the study of these records and 8 other cases which I have treated in my office and dispensaries. These 91 cases of gonorrhea in young boys, I believe, present the largest series reported heretofore. In a review of medical literature up to the year 1920, Mitchell (6) found only 133 recorded cases, while B. Buckley Sharp (7) in the literature of the last ten years found references to forty-five additional cases. The general opinion to the effect that the etiology in the majority in these cases may be traced to contamination by the use of soiled linen, infected toilet sea1;s) bath-tubs, catheters, thermometers, bed pans, etc. is founded upon unsubstantiated data. Wolbarst (8), Pollack (9), Parrot (10), Epstein (11), a~d others contend that the transmission of the gonococci from any fabric to human beings is very infrequent, if at all possible, occurring probably in less than 1 per cent of all cases. We know that in the moist states the gonococci remain viable for a considerable length of time, but it is practically impossible to recover the organism in culture from the secretions spread upon linen or clothes after a few hours of exposure to the ordinary room temperature. While it is possible that a male child, sleeping with an actively infected mother or other person, may come in intimate contact with the discharge sufficiently soon to permit the transference of infection, we believe this is of relatively infrequent TH E JOU R NAL OF U ROLOGY , VOL. XXV, NO .
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LEON M. BEILIN
occurrence. A careful inquiry into the prevailing social and environmental conditions will lead one to the conclusion that in young boys and often in girls the usual mode of infection is per vias naturales. Unfortunately, it is often difficult to elicit the true source of infection in the young in spite of the most minute and painstaking inquiries, as the origin in many cases is kept secret very skillfully at times by either the patient, the parent or by both. The reasons for this secrecy would seem to be apparent. The children, through intimidation or from fear of punishment, will not reveal what has happened to them, while the fear of publicity and its effect upon the child's future deters many parents from disclosing the offenders or from making criminal charges against them. Time was when any allusion to the child's sexual life was considered a heresy. The tendency of medicine in the past has been to treat as pathologic any precocious physical or psychological manifestations of sexual maturity. Now, however, we know that the child brings with him into the world dynamic sexual instincts which are manifested from birth. "We now know," says G. Stanley Hall (12), "that the sex life begins in infancy, long before any localizations i~ the erogenic zones appear." The traditional doctrine that the sex instinct in man does not emerge until the crisis of puberty is manifestly wrong. The individual at puberty is not infused with any new sex powers and there are no latent forces set aside by nature to be abruptly awakened when the child has reached a certain stage of development. On the whole, nature has a great regard for unity, and there is no place in her economy for any violent eruptions. I believe it necessary that physicians recognize this concept of "dynamic unity" in order to comprehend more fully the role of sexuality in the early years of childhood (13). Obviously, sexual incidents in childhood occur far more frequently than is generally assumed. So common are they, in fact, that they cannot possibly escape the notice of any competent physician. The universality of sexual interest and primacy of the genital zone in children has been well established by psycho-analytic
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research that has called to our attention the immature manifestations of sex existant from the earliest years of infancy. Freud maintains that the libido in infants plays the same role in the sexual sphere as does hunger in the nutritive sphere. Watson (14) has frequently observed somatic manifestations of sexual impulse in young boys as early as the age of three, and states that children still in the so-called "period of latency" engage in aggressive acts of a decided sexual nature. I have personally seen a child less than two years old who masturbated and apparently experienced an orgasm or at least some form of nervous cns1s. It is evident, therefore, that the cases of apparent sexual precocity, or as vonKraft Ebing (15) terms it, "sexual paradoxy," when carefully examined will differ from the normal quantitatively rather than qualitatively. The term "a normal child" after all is only a pragmatic one, denoting that the child has made a working adjustment to the realities of life. "One of the most tragic, and unfortunately one of the most frequent occurrences," says Iwan Block in his "Sexual Life of Our Time," "is the premature sexual intercourse on the part of children, resulting from the immature awakening of their sexual impulses." Metchnikoff states that in the remote era children began sexual intercourse at a very early age. We know that, in the south among negroes, children often indulge in various sexual games which are held to be quite natural by the natives and are generally viewed by the populace in the same light as the playfulness of young animals in whom the rutting instinct is developing. It may be of interest to note in this connection that, in the opinion of many observers, the female of the species is usually the instigator of sexual transgressions of children. Along with these sexual transgressions on the part of children themselves, we know that the child may be, and often is, an object of sexual desire to an adult; for in certain men and women the sexual inclinations are directed toward children. This form of psycho-sexual perversion, termed by Kraft Ebing '' a paedophilia erotica," is rather a widely diffused phenomenon among certain individuals with antipathic sexual tendencies. It is known that
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young boys are often utilized for homosexual and sodomistic practices, and it appears that the stimulus of innocence undoubtedly plays an important role in these cases. In this connection, I wish to mention a case of primary chancre of the rectum in a boy aged ten, whom I treated in 1925 at the clinics of the Illinois Social Hygiene League. The patient was an inmate of a well-known home for boys and had acquired his infection through the practice of pederasty with one of the attendants. Several other cases were known to have occurred in the same school from the same source, and were treated in one of the west side dispensaries. Some of these cases of so-called "depravers of children" undoubtedly belong to the sphere of psychiatry, as in many states of mental disorder sexual attacks on children constitute one of the first symptoms of the beginning of moral and intellectual deterioration. Intoxication is another cause, or perhaps an excuse, for many of these crimes. It is also well established that nursemaids, governesses, housekeepers, schoolmasters and schoolmistresses, male and female relatives, etc., have been known to engage in all sorts of sexual acts with children entrusted to their care. Neurotic and hysterical women and those of nymphomanical tendencies, are often sexually attracted by immature boys and engage in sexual contacts with them, believing perhaps that such relations are devoid of the usual (to them) vulgar and sinful aspects or of the dangers of venereal infection or pregnancy. Many young boys are seduced in such a manner and the facts are brought to light only when venereal infections or other complications develop. Havelock Ellis (16) points out that in some of these cases there is undoubtedly a maternal motive involved: the woman seeks to protect the boy from the danger of venereal diseased by training him in coitus, thus influencing him also against the practice of masturbation (17). Freud (18) contends that such attacks on children may give rise in later years to severe neuroses with the danger of inducing sexual perversion. Our attention is called to a well-established superstition that prevails even to this day among certain classes of our foreign
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GONORRHEAL URETHRITIS IN MALE CHILDREN
population, notably among Southern Slavs, Persians, Armenians, even Germans, and also among our Southern negroes, that gonorrhea and syphilis may be cured by means of sexual contact with a child or by passing the disease to "an untouched virgin" of the opposite sex. The origin of this superstition, a relic of the dark ages, is presumably based on the fact that syphilitic parents are usually sterile. In their ignorance they do not attribute the sterility to the disease itself; and so when a child is born, though it be diseased, the parents believe that they are thereby cured and have thus become purified. Similarly, a belief that sick people acquire strength from well ones when sleeping together is very popular among nearly all classes of people; and the hope that the aged may gain vitality from the young is exemplified in the case of King David (see I King, chap. 1, Death of King David.) (9). I have personally encountered cases of bestiality (or zoophilia) among peasants of northern Russia and natives of Siberia, practiced for the same reason. Clinically, gonorrheal urethritis in male children, though analogous in its general aspects to that of adults, presents certain distinguishing variations. A didactic statement of personal conclusions reached would be somewhat as follows: The incubation period seems to be more extended in children on account of comparatively long prepuce; at first there is usually a primary gonorrheal balanitis, which later by extension becomes urethritis. Age incidence.cases
2 5 8 11
years years years years
or to to to
under. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 years ..... · .............................................. 10 years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 years.· . ·.· ............................................
4 26 19 36
The younger children are more susceptible to gonorrheal urethritis, due perhaps to the greater vulnerability of their urethral mucosae. The largest group, thirty-six out of 91 cases or 39.5 per cent, occurred among boys between the ages of eleven to thirteen .
. ~ - - ~ - ~ ...
~,
....
~-~
,
..
~
..
-~~~~~
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LEON M. BEILIN
These boys are at the threshold of puberty with a full awakening of their sex consciousness and ripening of their sexual functions. The next largest number, 26 cases or 28.5 per cent, occurred between the ages of five and seven, the age at which the sexual curiosity and instincts develop hand in hand with the general intelligence of the child. It is in children of this intermediate age that the adult sex perverts are especially interested. The youngest patient was ten months old, and four were under the age of two years. Source of infection. Of the 91 cases recorded in this series, I have found: cases
Definite history with admitted cohabitation ..... . . . ........ . ... . .. . . Doubtful .... .. . . . . .... . ..... . ... . . . ..... . .. .. ... . ... . ...... . ..... . .. (a) Patients slept with infected person but denied any sex contact. (b) Infection present in other members of the family, but no occupancy of the same bed nor sex contact admitted... ... Practice of pederasty. . ... . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Source unknown. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
36 11 8 3 4 40
Of patients who admitted sexual intercourse, or in whom the history of sex exposure was obtained from parents, relatives, or police officers the ages were as follows: AGE
NUMBER OF PATIENTS
years
5 6 7 8 9
10 11 12 13
1 1 5 2 1 2 2 4 18
It may be noted that out of twenty patients, thirteen year old patients, eighteen admitted direct infection through coitus. Symptoms of gonorrheal urethritis in children are similar to those of adults, though on the whole I believe they are somewhat milder in character. Pain, which is the cardinal symptom, may
GONORRHEAL URETHRITIS IN MALE CHILDREN
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be either slight or very severe, and at times out of all proportions to the clinical symptoms present, especially if there be tight prepuce or contracted meatus. Retention of urine is a common occurrence and is due to pain which frightens the child and induces him to delay the act of micturition. Older children are prone to suppress their symptoms for the fear of punishment and their condition becomes detected only by the discharge on their linen, by development of retention or other complication. Of the complications recorded, I find that posterior urethritis occurs more frequently in children than in adults; likewise balaniitis, balanoposthitis, lymphangitis of the penis and inguinal adenitis. Fortunately, children do not suffer from priapism or chordee (24) . The following were the complications: NUMBER OF CASES
AGE OF PATIENT
years
Stricture .. _.. .._. . . .. . .. .. . .. . . ... . .... . .... .. . Epididymitis . . .. . . . . . . . . . . . .. . .. . ... . . . . . .. . . Acute prostatitis . . . ._. .. .. .. . ... . . . .. .. .. . . . . . Paraphimosis . .... . .. . . .............. .. . . . .. . Inguinal adenopathy . . ... . ....... . ... . . .. . . . . Proctitis .. . .......... . ...... . .... .. .. . .... . . . Ophthalmia ........ . .... . .. . ....... . . . ... . . . . Stomatitis ...... . . . . . . ... . .. . . . ...... . . . . . .. . Chancre, hard . . ... . . .. . . . . .. ... ..... . . .... .. .
1 5
1 1 4 4 2
1 2
13 13, 13, 10, 12, 13 12 13 6, 13, 13, 10 10, 4, 13, 10 10, 13 13 7, 11
One patient (E. W., aged thirteen) had developed a tight, filiform stricture of posterior urethra, which was dilated to size 12 F. Cases are on record (19) in which strictures of urethra in adults have been traced to urethritis during childhood, just as cases of salpingitis and malformations of vagina and uterus are attributed by some. authors (20) to the early vulvovaginitis. Asch and Van Kjelberg (21) state that the so-called primary sterility is usually due to the existence of gonorrhea in the childhood. We find stated in older textbooks, that gonorrheal epididyinitis, orchitis, and prostatitis do not occur in childhood, owing to the incomplete development and functional inactivity of these organs
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LEON M. BEILIN
at that age. However, in this series, 5 cases developed epididymitis. The earliest case of epididymitis recorded ·in the literature was reported by Reinhardt (22) in an infant two weeks old, delivered of a mother having gonorrhea. The infant developed urethritis and in twelve days following, an epididymitis. Acute prostatitis was recorded in 1 case in this series. Acute orchitis, however, is practically unknown during the first two years of life, even as a complication of mumps. Gonorrheal arthritis was not recorded in any of the cases studied, though Holt (23) believes that gonorrheal arthritis is more common in boys than in girls, occurring in nineteen out of 26 cases which he has reported, while Abt (24) states that acute arthritis in children under the age of two is usually gonorrheal in origin. Gonorrheal proctitis was present in 4 cases, all of whom admitted coitus per rectum., In the past, this was considered a rare affection in male children as well as in adults by the general profession, many of whom even did not know of the existence of such a condition (25). This was because this disease often runs an insidious course and escapes detection. With the advent of microscopic diagnosis of gonococcus, its greater frequency has been demonstrated. A gonorrheal stomatitis was present in 1 case, a colored boy (T. S.), aged thirteen. The lesion consisted of yellowish white patches upon the tongue and the hard palate, with a purulent discharge in which the gonococci were demonstrated. He admitted having coitus ab orem, and other abnormal practices. This is the only authentic case of buccal gonorrhea in a boy that I have found recorded in medical literature. Gonorrheal ophthalmia is as uncommon in children as it is in adults, in spite of the ever present ease of digital contamination. This, we believe, is due to the presence of acid lachrymal secretion in contradistinction to its absence in the new born. In this series, 2 cases of gonorrheal ophthalmia were recorded. Out of 187 cases of gonorrhea in male and female children at the Johns Hopkins Hospital, two developed ophthalmia. Duration. Of 83 cases of gonorrhea in boys admitted to the Cook County Hospital, seven absconded and five were taken
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home by the parents shortly after admission. The remaining 71 cases were confined for a total of 1635 days, making an average of twenty-three hospital days per patient. Diagnosis. In the diagnosis of urethral inflammations, it is obvious that not all urethrides encountered in children are of a gonorrheal nature. Simple urethritis is common in young boys and infants, especially among the poor. Among the various causes of non-gonorrheal urethritis in male children are mentioned: Metastatic localizations in the course of infectious diseases, such as mumps, etc.; diathetic influence due to "arthritism" or "lymphatism," similar in type to gouty urethritis in adults (26); tuberculosis of the urethra; dermatoses of the external genital organs; traumatism from foreign bodies introduced into the urethra; masturbation, etc. It must be remembered that organisms morphologically similar to gonococci are sometimes found in the normal urethra and, unless the Gram stain is employed, serious errors are likely to occur. Prognosis in gonorrheal urethritis in boys is generally favorable, although in the absence of treatment or with insufficient treatment cases tend to become chronic. Treatment. Treatment of gonorrhea in boys is similar to that of adults. Thoroughness and regularity of treatment are more important than the selection of a particular gonococcocide. When balsamics are prescribed, children, I believe, tolerate them better than adults. A too energetic local treatment should at no time be attempted, for besides producing a local trauma, the danger of which is greater in children than in adults, such a treatment tends to focus the attention of a young child on his genital organs, thereby stimulating his morbid curiosity and encouraging masturbation. Infected children should not be kept in schools, homes, or asylums; they should be isolated or hospitalized and taught there by special teachers. We may note in this connection that, in Germany and Russia, a wide spread of gonorrhea in children in recent years has led to the establishment of special isolation centers with school and playgrounds, where children under a
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LEON M. BEILIN
rigid superv1s1on are undergoing treatment for their infection while attending school in home-like surroundings. Personally, I had the opportunity of treating 8 cases of gonorrheal urethritis in young boys; two in my private practice and six in dispensary practice. CASE REPORTS
Case 1. Arnold N., aged five, white, well developed, was referred to me for circumcision on account of phimosis and balantis. The prepuce was swollen, red and tender and could not be stripped back. On making a dorsal slit and exposing the corona, the meatus appeared red, with marked ectropion and was plugged by a large crust, upon removal of which a thick purulent discharge was obtained. Several microscopic examinations of the smear showed Gram-negative intracellular diplococci. Hot boric acid dressings were applied to the circumcised area, and in spite of contamination from the discharge, the wound healed within ten days. He was given an alkaline mixture with daily anterior irrigation of potassium permanganate solution, 1: 12,000, which was gradually increased to 1 : 8000 after two weeks, at which time the urine after irrigation was found to contain pus, indicating that the posterior urethra was involved. Gonorrheal (stock) vaccine in doses ranging from two to fifty million were given at weekly intervals for six weeks. At the end of that time urethral discharge ceased and urine became negative. A bougie, size 12 F., was passed as far as the compressor with ease. His prostate, which at this age is very small, when examined with the little finger felt normal throughout t he attack. The history, as to the manner of infect ion in this case, was not obtained. The parents were of average intelligence and lived in very comfortable quarters. The nurse girl, as is usual, was suspected but would not submit to an examination, so was discharged. Case 2. Joseph B., aged seven, complained of burning and painful urination and intense itching about the penis for two days. When seen, he had been unable to urinate for twelve hours. There was pain and swelling in the hypogastrium with the bladder easily palpated 2 inches below the umbilicus. On examination, there was marked lymphangitis extending over both sides of the penis with an inflamed and adherent prepuce which was phimosed. Thick, purulent discharge was expressed from the prepucial orifice. The urethral smear showed intracellular Gram-negative diplococci in
GONORRHEAL URETHRITIS IN MALE CHILDREN
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large numbers. Given a sedative and hot bath, the boy voided his urine. For some time he refused to void unless placed in a tub of warm water. The presence of gonorrhea was not considered a contraindication for circumcision, which was agreed to by the father but objected to by the mother of the child and for a time was abandoned. The child was given daily irrigations of warm permanganate solution of 1 : 10,000, which was gradually increased to 1: 6000, alkaline diuretic internally, also balsamics. He made an uneventful recovery in about two months. This boy slept with his mother who was questioned but denied having vaginal disease. However, subsequent examination of the mother showed a discharge with evidence of an old urethritis and endocervicitis, though smears were negative for gonococci. Her discharge was a year old. It may be, as N eisser pointed out, these cases require repeated examinations to find the gonococci.
Case 3. Louis A., aged eight, was brought to the dispensary suffering with incontinence of urine, pains and burning in the urethra and some purulent urethral discharge of five days' standing. On examination, discharge was positive for gonococci. The boy was treated with urethral injections of protargol, 0.25 per cent solution, and after three months treatment was discharged as apparently cured. According to the patient's account, a maid employed in the house was in the habit of taking him into her room and, after producing an erection to his organ, having intercourse with him. This occurred frequently. The boy admitted having both the power and desire for intercourse, also he admitted numerous escapades with other females. Case 4. Rufus D., colored, aged nine, had two previous attacks of gonorrhea, one at the age of six and a half, and the other at eight. He was brought to the dispensary by his mother who did not appear much alarmed by his condition and was inclined to view the matter as a huge joke. There was nothing abnormal in the development of the boy's sexual organs, which were much larger than the average for a child of his age. He admitted having a urethral discharge for the past three weeks and was treating himself with injections of argyrol, using his hand syringe with the dexterity of a veteran. Examinations revealed posterior urethritis with some retention of urine. After four visits to the clinic, the patient discontinued his further treatment.
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Case 5. John R., aged six, had dysuria and frequency for four days, urethral discharge for past two days. On examination prepuce was swollen, red and tender, and the preputial canal and meatus were bathed in pus. Microscopically, Gram-negative, intracellular diplococci were found. The usual treatment of protargol, one-fourth of 1 per cent solution, injections with a small B. and D. syringe was given and balsamics prescribed. The patient was irregular in attendance to the clinic and after about four months of treatment absconded, still having urethral discharge with Gram-negative organisms. The mother of this boy could not give any information as to the source of infection at first, but later admitted that the patient slept in one bed with his sister, aged thirteen. The examination of the girl showed a ruptured hymen and free vaginal discharge with Gram-negative diplococci. Case 6. Sanford S., aged six, was referred to the dispensary from the Children's Memorial Hospital. He complained of frequency, dysuria and terminal hematuria for three days' standing. He admitted exposure with a girl of sixteen stating that "all the kids in the neighborhood stayed with her." Two other cases of gonorrhea in somewhat older boys were traced to the same source and were treated at a south side dispensary. The girl was subsequently apprehended by the Juvenile Court and sent to a State institution for the feeble-minded. On account of the acuteness of his symptoms, marked phimosis and contracted meatus, no local treatment was given at first. Later, a circumcision and meatotomy were performed and the usual treatment for gonorrhea was administered. The boy made a good recovery. Case 7. Carville L., colored, aged eleven, was treated at the Michael Reese Dispensary. Had chronic urethritis of six months' standing, also evidence of a healed chancre in the coronal sulcus. The Wassermann reaction was 4+ positive. He admitted a gonorrheal infection two years previously, also a sore on the penis at the same time. On further questioning, he confessed to frequent exposures even while undergoing treatment. His sex organs were well developed; he had no pubic hair and no phimosis. After three visits to the dispensary, he did not report for any further treatment. Case 8. Tony M., aged six, was brought to the Michael Reese Dispensary by a school nurse on account of frequency. Examinations
GONORRHEAL URETHRITIS IN MALE CHILDREN
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showed a purulent discharge, negative diplococci; also phimosis and pin-point meatus. The mother of the boy was instructed to give him three daily injections of 5 per cent solution of argyrol with a small dropper. This boy was very reluctant to answer any questions as to the source of his infection, simply saying that he got it "from a boy at school." When I last saw him, after three months of treatment, he still had a urethral discharge with a Gram-negative diplococci.
I CONCLUSIONS
1. Gonorrheal urethritis in boys is not a rare condition, though it is far less common than in female children. 2. Infection usually results by direct method, due to precocious sexual activity. 3. Children of all classes of society are subject to this infection. 4. All urethral discharges in young boys should be regarded with suspicion and examined microscopically. 5. Should the gonococci be found, the possibility of the case assuming a medico-legal phase should be recognized. 6. Non-specific urethritis may occur. It is generally milder in character, shorter in duration, and is usually not accompanied by any complications. 7. Clinically, gonorrheal urethritis in male children is analogous to this disease in adults, though it presents certain distinguishing variations. 8. The course of this disease is usually milder in children with few constitutional symptoms; complications are less frequent, occurring chiefly after the period of early childhood. 9. Essential points of treatment are: local cleanliness, free action of all emunctories, administration of alkalies, with or without the use of urinary antiseptics and local employment of similar gonococcidal agents as in adults, though in considerably weaker dilutions. 10. Thoroughness of treatment is more important than selection of a particular gonococcide. 11. Proper isolation and hospitalization of infected cases with adequate social service is all important. 12. These cases emphasize the importance of closer cooperation between pediatrician and urologist.
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I am greatly indebted to the Warden of Cook County Hospital for permission to study and report these records. 185 North Wabash Avenue, Chicago, Ill. REFERENCES (1) (2) (3) (4) (5) (6) (7)
(8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26)
KoPKIK, H.: Diseases of Infancy and Childhood, Lea and Febiger, 1918. LYDSTON, G. FRANK: Sex Hygiene for the Male, Riverton Press, 1912. WrnsLOw: Cited by KoPLIK. VANARSDALE, W.W.: N. Y. Med. Jour., 1890, 667. Report of the Chicago Vice Commission, 1908. MITCHELL, A. G.: Cited by L. E. SCHMIDT in Abt's System of Pediatrics, iv, 1201-64. SHARP, B. BucKLEY: Gonorrheal urethritis in male children, Lancet, 1927, 653. WoLBARST, A. L.: Acute urethritis in children, Med. Rec., New York, 1910, 768. POLLACK, F.: Maryland Med. Jour., August, 1906. p ARROT: Cited by POLLACK. EPSTEIN: Ibid. HALL, J. STANLEY: Adolescence, i, 1916. GIBBS, TRAVERSE: Criminal aspect of venereal disease in children, N. Y. Med. Rec., 1907, 643. WATSON, JOHN : Behaviourism, Appleton Co., 1924. KRAFT EBING BON: Psychopathia Sexualis, Rebman Co., 1906, 413. ELLIS, HAVELOCK: Psychology of Sex, III. STALEY, W.: Jour. Ment. Sciences, January, 1916. FREUD, SIGMUND: Psychopathology of Everyday Life, Macmillan Co., 1914. FISCHER, A. : Gonorrheal urethritis in boys under puberty, Munch. Mediz. Wochenschr., 1902, No. 46. VLASOVA, V. A. : Gonorrheal urethritis in children, Pediatria, 1928, 55. AsHANDKJELBERG: Cited by VLASOVA. REINHARDT, A.: Cited by MITCHELL, A. C., AND QurnN, N . I. in Arch. of Pediatrics, 1915. HALT, E.: Gonorrheal infections in children, N. Y. Med. Times, July, 1905. ABT, I.: Gonorrhea in children, Jour. Amer. Med. Assoc., xxx, 1474. LANGER, ERIK: Geschlechts krankheiten bi K inder, Munich, 1925. GENEvorx, M.: Les Uretrites des les petit garcons, Theses de Paris, 1904.
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GONORRHEAL URETHRITIS IN MALE CHILDREN 1 (WITH SOME OBSERVATIONS ON THEIR SEXUAL IMPULSES) LEON M. BEILIN Chi"cago, Illinois
While vulvo-vaginitis in female children is relatively common and has received much attention in medical literature, specific urethritis in male children occurs less frequently and has received comparatively little notice from medical investigators and clinicians. Various forms of gonorrheal infection are fully described in the textbooks of medicine and surgery, but about gonorrhea of the urogenital tract in young boys, little or nothing is said. That this is a definite disease entity, the incidence of which is of much greater frequency than is generally assumed by the medical profession, is conceded by many competent observers. Physicians in the employ of charitable and reformatory institutions, or those connected with clinics and dispensaries for children encounter acquired venereal infections, both gonorrhea and syphilis, in young boys with fair degree of frequency. Specific inflammations of the genital tract in young children, girls and boys, has of late become a subject of renewed study. It has been shown that this condition, seen so often in large clinics in children, is really a gonorrheal one and should be treated from that standpoint. The data upon which such conclusions are based, are identical with those which are brought to bear upon the diagnosis of urethral and vaginal discharges in adults (1). According to Fournier, 15 per cent of all cases of gonorrhea occur between the ages of thirteen and nineteen, and Van Arsdale (4) has estimated that the ratio of gonorrhea in male children to 1
Read before the Chicago Urological Society, December 20, 1929.
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LEON M. BEILIN
that of adults to be one to thirty-five. Fournier's studies in France and Erb's in Germany, show that the first venereal infections are most likely to occur at the onset of adolescence. Madame Alexandra Kollontai, formerly the Commissar for Child Welfare of Soviet Russia, reported an alarming epidemic of venereal infection among young children of both sexes in 1919 and 1920, which she attributed to the aftermath of the war and revolution. The records of the Department of Health of the city of Chicago show that 352 cases of gonorrhea in children of both sexes were reported during the year 1927, and the New York State Department of Health for t he year 1923 shows that, out of the total of 3,346 cases of gonorrhea in males, there were 58 cases of gonorrheal urethritis in boys under the age of fourteen, giving the ratio of gonorrhea of boys to that of adults, as 1 to 57. It is safe to assume, however, that the actual number of venereally infected children in these cities is much larger than the official records of the Departments of Health would indicate. In fact, venereal diseases are present endemically among children of the poor in congested districts of large cities, though by no means are they confined to the lower strata of society. Frank Lydston (2) reported 30 cases of gonorrheal urethritis in young boys of respectable and well-to-do families of Chicago, tracing these infections to a pseudo-hermaphroditic cook in the neighborhood; and Winslow (3) reported an epidemic of gonorrheal proctitis in a school for boys in Baltimore, caused by the practice of sodomy among the children of that institution. Through the courtesy of Dr. Herman Adler, Director of the Institute for Juvenile Research of Chicago, I have caused an analysis of 5,000 cases to be made for incidence of venereal diseases among children examined by this Institute. During a period of twenty-seven months, 600 children under the age of thirteen were treated in the venereal wards of the Cook County Hospital of Chicago, of which 85 per cent had a diagnosis of gonorrhea and 15 per cent of syphilis (5). I had the opportunity to examine these records and to study 83 cases of gonorrhea in boys under the age of puberty.
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GONORRHEAL URETHRITIS IN MALE CHILDREN
The study showed the following: GONORRHEA
SYPHILIS
TOTAL EXAMINED
Question Question Definite of or Definite of or former
- - - - - - - - - -- - - - - - - - - White White Negro Negro
boys ..... ... .. . . . . . . .... . . . .. . . . girls . . .. . . . .. ... ... . . . . ... .. .. . . boys .... · ......... . ......... . ..... girls .... .. .... .... . ........ ... . .
2,853 1,739 245 163
TotaL .. . ...... . . . ... ............ . ...
5,000
5 37 0
former
- - --
8 43 3 5
44
59
105
38
12
103 88 34 163
11 5 --------
47
388
A diagnosis of neurosyphilis, juvenile paresis, or tabes was made in 16 out of 2,853 cases of white boys, 10 out of 1,739 cases of white girls, 2 out of 245 cases of negro boys, and 4 out of 163 cases of negro girls.
This paper is bas;ed on the study of these records and 8 other cases which I have treated in my office and dispensaries. These 91 cases of gonorrhea in young boys, I believe, present the largest series reported heretofore. In a review of medical literature up to the year 1920, Mitchell (6) found only 133 recorded cases, while B. Buckley Sharp (7) in the literature of the last ten years found references to forty-five additional cases. The general opinion to the effect that the etiology in the majority in these cases may be traced to contamination by the use of soiled linen, infected toilet sea1;s) bath-tubs, catheters, thermometers, bed pans, etc. is founded upon unsubstantiated data. Wolbarst (8), Pollack (9), Parrot (10), Epstein (11), a~d others contend that the transmission of the gonococci from any fabric to human beings is very infrequent, if at all possible, occurring probably in less than 1 per cent of all cases. We know that in the moist states the gonococci remain viable for a considerable length of time, but it is practically impossible to recover the organism in culture from the secretions spread upon linen or clothes after a few hours of exposure to the ordinary room temperature. While it is possible that a male child, sleeping with an actively infected mother or other person, may come in intimate contact with the discharge sufficiently soon to permit the transference of infection, we believe this is of relatively infrequent TH E JOU R NAL OF U ROLOGY , VOL. XXV, NO .
1
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LEON M. BEILIN
occurrence. A careful inquiry into the prevailing social and environmental conditions will lead one to the conclusion that in young boys and often in girls the usual mode of infection is per vias naturales. Unfortunately, it is often difficult to elicit the true source of infection in the young in spite of the most minute and painstaking inquiries, as the origin in many cases is kept secret very skillfully at times by either the patient, the parent or by both. The reasons for this secrecy would seem to be apparent. The children, through intimidation or from fear of punishment, will not reveal what has happened to them, while the fear of publicity and its effect upon the child's future deters many parents from disclosing the offenders or from making criminal charges against them. Time was when any allusion to the child's sexual life was considered a heresy. The tendency of medicine in the past has been to treat as pathologic any precocious physical or psychological manifestations of sexual maturity. Now, however, we know that the child brings with him into the world dynamic sexual instincts which are manifested from birth. "We now know," says G. Stanley Hall (12), "that the sex life begins in infancy, long before any localizations i~ the erogenic zones appear." The traditional doctrine that the sex instinct in man does not emerge until the crisis of puberty is manifestly wrong. The individual at puberty is not infused with any new sex powers and there are no latent forces set aside by nature to be abruptly awakened when the child has reached a certain stage of development. On the whole, nature has a great regard for unity, and there is no place in her economy for any violent eruptions. I believe it necessary that physicians recognize this concept of "dynamic unity" in order to comprehend more fully the role of sexuality in the early years of childhood (13). Obviously, sexual incidents in childhood occur far more frequently than is generally assumed. So common are they, in fact, that they cannot possibly escape the notice of any competent physician. The universality of sexual interest and primacy of the genital zone in children has been well established by psycho-analytic
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GONORRHEAL URETHRITIS IN MALE CHILDREN
73
research that has called to our attention the immature manifestations of sex existant from the earliest years of infancy. Freud maintains that the libido in infants plays the same role in the sexual sphere as does hunger in the nutritive sphere. Watson (14) has frequently observed somatic manifestations of sexual impulse in young boys as early as the age of three, and states that children still in the so-called "period of latency" engage in aggressive acts of a decided sexual nature. I have personally seen a child less than two years old who masturbated and apparently experienced an orgasm or at least some form of nervous cns1s. It is evident, therefore, that the cases of apparent sexual precocity, or as vonKraft Ebing (15) terms it, "sexual paradoxy," when carefully examined will differ from the normal quantitatively rather than qualitatively. The term "a normal child" after all is only a pragmatic one, denoting that the child has made a working adjustment to the realities of life. "One of the most tragic, and unfortunately one of the most frequent occurrences," says Iwan Block in his "Sexual Life of Our Time," "is the premature sexual intercourse on the part of children, resulting from the immature awakening of their sexual impulses." Metchnikoff states that in the remote era children began sexual intercourse at a very early age. We know that, in the south among negroes, children often indulge in various sexual games which are held to be quite natural by the natives and are generally viewed by the populace in the same light as the playfulness of young animals in whom the rutting instinct is developing. It may be of interest to note in this connection that, in the opinion of many observers, the female of the species is usually the instigator of sexual transgressions of children. Along with these sexual transgressions on the part of children themselves, we know that the child may be, and often is, an object of sexual desire to an adult; for in certain men and women the sexual inclinations are directed toward children. This form of psycho-sexual perversion, termed by Kraft Ebing '' a paedophilia erotica," is rather a widely diffused phenomenon among certain individuals with antipathic sexual tendencies. It is known that
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LEON M. BEILIN
young boys are often utilized for homosexual and sodomistic practices, and it appears that the stimulus of innocence undoubtedly plays an important role in these cases. In this connection, I wish to mention a case of primary chancre of the rectum in a boy aged ten, whom I treated in 1925 at the clinics of the Illinois Social Hygiene League. The patient was an inmate of a well-known home for boys and had acquired his infection through the practice of pederasty with one of the attendants. Several other cases were known to have occurred in the same school from the same source, and were treated in one of the west side dispensaries. Some of these cases of so-called "depravers of children" undoubtedly belong to the sphere of psychiatry, as in many states of mental disorder sexual attacks on children constitute one of the first symptoms of the beginning of moral and intellectual deterioration. Intoxication is another cause, or perhaps an excuse, for many of these crimes. It is also well established that nursemaids, governesses, housekeepers, schoolmasters and schoolmistresses, male and female relatives, etc., have been known to engage in all sorts of sexual acts with children entrusted to their care. Neurotic and hysterical women and those of nymphomanical tendencies, are often sexually attracted by immature boys and engage in sexual contacts with them, believing perhaps that such relations are devoid of the usual (to them) vulgar and sinful aspects or of the dangers of venereal infection or pregnancy. Many young boys are seduced in such a manner and the facts are brought to light only when venereal infections or other complications develop. Havelock Ellis (16) points out that in some of these cases there is undoubtedly a maternal motive involved: the woman seeks to protect the boy from the danger of venereal diseased by training him in coitus, thus influencing him also against the practice of masturbation (17). Freud (18) contends that such attacks on children may give rise in later years to severe neuroses with the danger of inducing sexual perversion. Our attention is called to a well-established superstition that prevails even to this day among certain classes of our foreign
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GONORRHEAL URETHRITIS IN MALE CHILDREN
population, notably among Southern Slavs, Persians, Armenians, even Germans, and also among our Southern negroes, that gonorrhea and syphilis may be cured by means of sexual contact with a child or by passing the disease to "an untouched virgin" of the opposite sex. The origin of this superstition, a relic of the dark ages, is presumably based on the fact that syphilitic parents are usually sterile. In their ignorance they do not attribute the sterility to the disease itself; and so when a child is born, though it be diseased, the parents believe that they are thereby cured and have thus become purified. Similarly, a belief that sick people acquire strength from well ones when sleeping together is very popular among nearly all classes of people; and the hope that the aged may gain vitality from the young is exemplified in the case of King David (see I King, chap. 1, Death of King David.) (9). I have personally encountered cases of bestiality (or zoophilia) among peasants of northern Russia and natives of Siberia, practiced for the same reason. Clinically, gonorrheal urethritis in male children, though analogous in its general aspects to that of adults, presents certain distinguishing variations. A didactic statement of personal conclusions reached would be somewhat as follows: The incubation period seems to be more extended in children on account of comparatively long prepuce; at first there is usually a primary gonorrheal balanitis, which later by extension becomes urethritis. Age incidence.cases
2 5 8 11
years years years years
or to to to
under. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 years ..... · .............................................. 10 years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 years.· . ·.· ............................................
4 26 19 36
The younger children are more susceptible to gonorrheal urethritis, due perhaps to the greater vulnerability of their urethral mucosae. The largest group, thirty-six out of 91 cases or 39.5 per cent, occurred among boys between the ages of eleven to thirteen .
. ~ - - ~ - ~ ...
~,
....
~-~
,
..
~
..
-~~~~~
76
LEON M. BEILIN
These boys are at the threshold of puberty with a full awakening of their sex consciousness and ripening of their sexual functions. The next largest number, 26 cases or 28.5 per cent, occurred between the ages of five and seven, the age at which the sexual curiosity and instincts develop hand in hand with the general intelligence of the child. It is in children of this intermediate age that the adult sex perverts are especially interested. The youngest patient was ten months old, and four were under the age of two years. Source of infection. Of the 91 cases recorded in this series, I have found: cases
Definite history with admitted cohabitation ..... . . . ........ . ... . .. . . Doubtful .... .. . . . . .... . ..... . ... . . . ..... . .. .. ... . ... . ...... . ..... . .. (a) Patients slept with infected person but denied any sex contact. (b) Infection present in other members of the family, but no occupancy of the same bed nor sex contact admitted... ... Practice of pederasty. . ... . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Source unknown. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
36 11 8 3 4 40
Of patients who admitted sexual intercourse, or in whom the history of sex exposure was obtained from parents, relatives, or police officers the ages were as follows: AGE
NUMBER OF PATIENTS
years
5 6 7 8 9
10 11 12 13
1 1 5 2 1 2 2 4 18
It may be noted that out of twenty patients, thirteen year old patients, eighteen admitted direct infection through coitus. Symptoms of gonorrheal urethritis in children are similar to those of adults, though on the whole I believe they are somewhat milder in character. Pain, which is the cardinal symptom, may
GONORRHEAL URETHRITIS IN MALE CHILDREN
77
be either slight or very severe, and at times out of all proportions to the clinical symptoms present, especially if there be tight prepuce or contracted meatus. Retention of urine is a common occurrence and is due to pain which frightens the child and induces him to delay the act of micturition. Older children are prone to suppress their symptoms for the fear of punishment and their condition becomes detected only by the discharge on their linen, by development of retention or other complication. Of the complications recorded, I find that posterior urethritis occurs more frequently in children than in adults; likewise balaniitis, balanoposthitis, lymphangitis of the penis and inguinal adenitis. Fortunately, children do not suffer from priapism or chordee (24) . The following were the complications: NUMBER OF CASES
AGE OF PATIENT
years
Stricture .. _.. .._. . . .. . .. .. . .. . . ... . .... . .... .. . Epididymitis . . .. . . . . . . . . . . . .. . .. . ... . . . . . .. . . Acute prostatitis . . . ._. .. .. .. . ... . . . .. .. .. . . . . . Paraphimosis . .... . .. . . .............. .. . . . .. . Inguinal adenopathy . . ... . ....... . ... . . .. . . . . Proctitis .. . .......... . ...... . .... .. .. . .... . . . Ophthalmia ........ . .... . .. . ....... . . . ... . . . . Stomatitis ...... . . . . . . ... . .. . . . ...... . . . . . .. . Chancre, hard . . ... . . .. . . . . .. ... ..... . . .... .. .
1 5
1 1 4 4 2
1 2
13 13, 13, 10, 12, 13 12 13 6, 13, 13, 10 10, 4, 13, 10 10, 13 13 7, 11
One patient (E. W., aged thirteen) had developed a tight, filiform stricture of posterior urethra, which was dilated to size 12 F. Cases are on record (19) in which strictures of urethra in adults have been traced to urethritis during childhood, just as cases of salpingitis and malformations of vagina and uterus are attributed by some. authors (20) to the early vulvovaginitis. Asch and Van Kjelberg (21) state that the so-called primary sterility is usually due to the existence of gonorrhea in the childhood. We find stated in older textbooks, that gonorrheal epididyinitis, orchitis, and prostatitis do not occur in childhood, owing to the incomplete development and functional inactivity of these organs
78
LEON M. BEILIN
at that age. However, in this series, 5 cases developed epididymitis. The earliest case of epididymitis recorded ·in the literature was reported by Reinhardt (22) in an infant two weeks old, delivered of a mother having gonorrhea. The infant developed urethritis and in twelve days following, an epididymitis. Acute prostatitis was recorded in 1 case in this series. Acute orchitis, however, is practically unknown during the first two years of life, even as a complication of mumps. Gonorrheal arthritis was not recorded in any of the cases studied, though Holt (23) believes that gonorrheal arthritis is more common in boys than in girls, occurring in nineteen out of 26 cases which he has reported, while Abt (24) states that acute arthritis in children under the age of two is usually gonorrheal in origin. Gonorrheal proctitis was present in 4 cases, all of whom admitted coitus per rectum., In the past, this was considered a rare affection in male children as well as in adults by the general profession, many of whom even did not know of the existence of such a condition (25). This was because this disease often runs an insidious course and escapes detection. With the advent of microscopic diagnosis of gonococcus, its greater frequency has been demonstrated. A gonorrheal stomatitis was present in 1 case, a colored boy (T. S.), aged thirteen. The lesion consisted of yellowish white patches upon the tongue and the hard palate, with a purulent discharge in which the gonococci were demonstrated. He admitted having coitus ab orem, and other abnormal practices. This is the only authentic case of buccal gonorrhea in a boy that I have found recorded in medical literature. Gonorrheal ophthalmia is as uncommon in children as it is in adults, in spite of the ever present ease of digital contamination. This, we believe, is due to the presence of acid lachrymal secretion in contradistinction to its absence in the new born. In this series, 2 cases of gonorrheal ophthalmia were recorded. Out of 187 cases of gonorrhea in male and female children at the Johns Hopkins Hospital, two developed ophthalmia. Duration. Of 83 cases of gonorrhea in boys admitted to the Cook County Hospital, seven absconded and five were taken
GONORRHEAL URETHRITIS IN MALE CHILDREN
79
home by the parents shortly after admission. The remaining 71 cases were confined for a total of 1635 days, making an average of twenty-three hospital days per patient. Diagnosis. In the diagnosis of urethral inflammations, it is obvious that not all urethrides encountered in children are of a gonorrheal nature. Simple urethritis is common in young boys and infants, especially among the poor. Among the various causes of non-gonorrheal urethritis in male children are mentioned: Metastatic localizations in the course of infectious diseases, such as mumps, etc.; diathetic influence due to "arthritism" or "lymphatism," similar in type to gouty urethritis in adults (26); tuberculosis of the urethra; dermatoses of the external genital organs; traumatism from foreign bodies introduced into the urethra; masturbation, etc. It must be remembered that organisms morphologically similar to gonococci are sometimes found in the normal urethra and, unless the Gram stain is employed, serious errors are likely to occur. Prognosis in gonorrheal urethritis in boys is generally favorable, although in the absence of treatment or with insufficient treatment cases tend to become chronic. Treatment. Treatment of gonorrhea in boys is similar to that of adults. Thoroughness and regularity of treatment are more important than the selection of a particular gonococcocide. When balsamics are prescribed, children, I believe, tolerate them better than adults. A too energetic local treatment should at no time be attempted, for besides producing a local trauma, the danger of which is greater in children than in adults, such a treatment tends to focus the attention of a young child on his genital organs, thereby stimulating his morbid curiosity and encouraging masturbation. Infected children should not be kept in schools, homes, or asylums; they should be isolated or hospitalized and taught there by special teachers. We may note in this connection that, in Germany and Russia, a wide spread of gonorrhea in children in recent years has led to the establishment of special isolation centers with school and playgrounds, where children under a
80
LEON M. BEILIN
rigid superv1s1on are undergoing treatment for their infection while attending school in home-like surroundings. Personally, I had the opportunity of treating 8 cases of gonorrheal urethritis in young boys; two in my private practice and six in dispensary practice. CASE REPORTS
Case 1. Arnold N., aged five, white, well developed, was referred to me for circumcision on account of phimosis and balantis. The prepuce was swollen, red and tender and could not be stripped back. On making a dorsal slit and exposing the corona, the meatus appeared red, with marked ectropion and was plugged by a large crust, upon removal of which a thick purulent discharge was obtained. Several microscopic examinations of the smear showed Gram-negative intracellular diplococci. Hot boric acid dressings were applied to the circumcised area, and in spite of contamination from the discharge, the wound healed within ten days. He was given an alkaline mixture with daily anterior irrigation of potassium permanganate solution, 1: 12,000, which was gradually increased to 1 : 8000 after two weeks, at which time the urine after irrigation was found to contain pus, indicating that the posterior urethra was involved. Gonorrheal (stock) vaccine in doses ranging from two to fifty million were given at weekly intervals for six weeks. At the end of that time urethral discharge ceased and urine became negative. A bougie, size 12 F., was passed as far as the compressor with ease. His prostate, which at this age is very small, when examined with the little finger felt normal throughout t he attack. The history, as to the manner of infect ion in this case, was not obtained. The parents were of average intelligence and lived in very comfortable quarters. The nurse girl, as is usual, was suspected but would not submit to an examination, so was discharged. Case 2. Joseph B., aged seven, complained of burning and painful urination and intense itching about the penis for two days. When seen, he had been unable to urinate for twelve hours. There was pain and swelling in the hypogastrium with the bladder easily palpated 2 inches below the umbilicus. On examination, there was marked lymphangitis extending over both sides of the penis with an inflamed and adherent prepuce which was phimosed. Thick, purulent discharge was expressed from the prepucial orifice. The urethral smear showed intracellular Gram-negative diplococci in
GONORRHEAL URETHRITIS IN MALE CHILDREN
81
large numbers. Given a sedative and hot bath, the boy voided his urine. For some time he refused to void unless placed in a tub of warm water. The presence of gonorrhea was not considered a contraindication for circumcision, which was agreed to by the father but objected to by the mother of the child and for a time was abandoned. The child was given daily irrigations of warm permanganate solution of 1 : 10,000, which was gradually increased to 1: 6000, alkaline diuretic internally, also balsamics. He made an uneventful recovery in about two months. This boy slept with his mother who was questioned but denied having vaginal disease. However, subsequent examination of the mother showed a discharge with evidence of an old urethritis and endocervicitis, though smears were negative for gonococci. Her discharge was a year old. It may be, as N eisser pointed out, these cases require repeated examinations to find the gonococci.
Case 3. Louis A., aged eight, was brought to the dispensary suffering with incontinence of urine, pains and burning in the urethra and some purulent urethral discharge of five days' standing. On examination, discharge was positive for gonococci. The boy was treated with urethral injections of protargol, 0.25 per cent solution, and after three months treatment was discharged as apparently cured. According to the patient's account, a maid employed in the house was in the habit of taking him into her room and, after producing an erection to his organ, having intercourse with him. This occurred frequently. The boy admitted having both the power and desire for intercourse, also he admitted numerous escapades with other females. Case 4. Rufus D., colored, aged nine, had two previous attacks of gonorrhea, one at the age of six and a half, and the other at eight. He was brought to the dispensary by his mother who did not appear much alarmed by his condition and was inclined to view the matter as a huge joke. There was nothing abnormal in the development of the boy's sexual organs, which were much larger than the average for a child of his age. He admitted having a urethral discharge for the past three weeks and was treating himself with injections of argyrol, using his hand syringe with the dexterity of a veteran. Examinations revealed posterior urethritis with some retention of urine. After four visits to the clinic, the patient discontinued his further treatment.
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LEON M. BEILIN
Case 5. John R., aged six, had dysuria and frequency for four days, urethral discharge for past two days. On examination prepuce was swollen, red and tender, and the preputial canal and meatus were bathed in pus. Microscopically, Gram-negative, intracellular diplococci were found. The usual treatment of protargol, one-fourth of 1 per cent solution, injections with a small B. and D. syringe was given and balsamics prescribed. The patient was irregular in attendance to the clinic and after about four months of treatment absconded, still having urethral discharge with Gram-negative organisms. The mother of this boy could not give any information as to the source of infection at first, but later admitted that the patient slept in one bed with his sister, aged thirteen. The examination of the girl showed a ruptured hymen and free vaginal discharge with Gram-negative diplococci. Case 6. Sanford S., aged six, was referred to the dispensary from the Children's Memorial Hospital. He complained of frequency, dysuria and terminal hematuria for three days' standing. He admitted exposure with a girl of sixteen stating that "all the kids in the neighborhood stayed with her." Two other cases of gonorrhea in somewhat older boys were traced to the same source and were treated at a south side dispensary. The girl was subsequently apprehended by the Juvenile Court and sent to a State institution for the feeble-minded. On account of the acuteness of his symptoms, marked phimosis and contracted meatus, no local treatment was given at first. Later, a circumcision and meatotomy were performed and the usual treatment for gonorrhea was administered. The boy made a good recovery. Case 7. Carville L., colored, aged eleven, was treated at the Michael Reese Dispensary. Had chronic urethritis of six months' standing, also evidence of a healed chancre in the coronal sulcus. The Wassermann reaction was 4+ positive. He admitted a gonorrheal infection two years previously, also a sore on the penis at the same time. On further questioning, he confessed to frequent exposures even while undergoing treatment. His sex organs were well developed; he had no pubic hair and no phimosis. After three visits to the dispensary, he did not report for any further treatment. Case 8. Tony M., aged six, was brought to the Michael Reese Dispensary by a school nurse on account of frequency. Examinations
GONORRHEAL URETHRITIS IN MALE CHILDREN
83
showed a purulent discharge, negative diplococci; also phimosis and pin-point meatus. The mother of the boy was instructed to give him three daily injections of 5 per cent solution of argyrol with a small dropper. This boy was very reluctant to answer any questions as to the source of his infection, simply saying that he got it "from a boy at school." When I last saw him, after three months of treatment, he still had a urethral discharge with a Gram-negative diplococci.
I CONCLUSIONS
1. Gonorrheal urethritis in boys is not a rare condition, though it is far less common than in female children. 2. Infection usually results by direct method, due to precocious sexual activity. 3. Children of all classes of society are subject to this infection. 4. All urethral discharges in young boys should be regarded with suspicion and examined microscopically. 5. Should the gonococci be found, the possibility of the case assuming a medico-legal phase should be recognized. 6. Non-specific urethritis may occur. It is generally milder in character, shorter in duration, and is usually not accompanied by any complications. 7. Clinically, gonorrheal urethritis in male children is analogous to this disease in adults, though it presents certain distinguishing variations. 8. The course of this disease is usually milder in children with few constitutional symptoms; complications are less frequent, occurring chiefly after the period of early childhood. 9. Essential points of treatment are: local cleanliness, free action of all emunctories, administration of alkalies, with or without the use of urinary antiseptics and local employment of similar gonococcidal agents as in adults, though in considerably weaker dilutions. 10. Thoroughness of treatment is more important than selection of a particular gonococcide. 11. Proper isolation and hospitalization of infected cases with adequate social service is all important. 12. These cases emphasize the importance of closer cooperation between pediatrician and urologist.
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LEON M. BEILIN
I am greatly indebted to the Warden of Cook County Hospital for permission to study and report these records. 185 North Wabash Avenue, Chicago, Ill. REFERENCES (1) (2) (3) (4) (5) (6) (7)
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