GONORRHEA IN WOMEN. 
ByT. J. WATKINS, M. D. 
GYNECOLOGIST TO ST. LUKE’S, WESLEY AND PROVIDENT HOSPITALS; ASSISTANT PROFESSOR OF 
GYNECOLOGY NORTHWESTERN UNIVERSITY MEDICAL SCHOOL, CHICAGO. 
The number and character of the other papers in this symposium 
make it necessary for me to consider gonorrhea only as it is peculiar 
to women. I will simply review the more important points in the 
subject in order to make the paper brief and in order to open up 
the entire subject for discussion. Great credit is due Noeggerath 
for demonstrating the importance of this subject, which he did years 
before the medical profession were able to realize its significance. 
Fordyce Barker, in opening the discussion on his paper before the 
American Gynecological Society in 1876, said: “If these views 
are true, a modification of this paper should be found in every Sab- 
bath-school library throughout the land.” In the discussion which 
followed, Noeggerath’s views were very severely criticised. Only 
until recently have his teachings been fully appreciated. 
FREQUENCY. 
The frequency of gonorrhea in women varies as regards location 
and social position. The frequency varies in these respects as it does 
in the male, but is not so common in women as in men. Sanger 
states that 25 per cent of his hospital and private patients have 
gonorrhea. Lomen found the diplococcus in fully 60 per cent 
of the cases in Schroeder’s clinic. In A. Martin’s clinic, in 2,078 
cases, 279 were due to gonorrhea. According to E. Werthim, 
gonorrhea is the most frequent cause of suppuration met with in 
gynecological practice. Kopytowrsky finds that 10 per cent of the 
prostitutes whom he has examined still have gonorrhea in the vag- 
inal secretions, after they have been discharged from the hospital 
as cured of gonorrhea; that 7 per cent of prostitutes admitted to 
the hospital for other diseases have gonorrhea in the vaginal se- 
cretions ; and concludes that 8 per cent of all healthy prostitutes have 
gonorrhea. From my observations I would conclude that the per- 
centage must be larger than this in this class of people, as in the 
large majority of them, careful investigation shows redness and dis- 
charge about the urethral glands, the glands of Bartholin and the 
other glands at the vaginal orifice. Dudley says: “The pavement epithelium of the vagina and the presence of the lactic acid bac- 
teria normally found there by Doderlein, make the vagina relatively 
immune.” There can probably be no doubt that immunity to in- 
fection exists, as in all probability all prostitutes are subjected to 
gonorrheal infection. 
LOCATION. 
The gonococcus has been found in all the mucosa of the entire 
female generative organs; and has been found in the musculature 
of the uterus and in ovarian abscesses. In one case of double 
ovarian abscess which I operated, the gonococci were the only 
microorganisms present. The Fallopian tubes were not diseased. In 
this case the gonococci probably passed from the uterine mucosa 
through the uterine wall into the ovary. Bacteriological examina- 
tions made in Howard Kelly’s clinic at Johns Hopkins Hospital, 
of pus from ovaries and tubes in 49 cases, showed the presence of 
gonococci in 7 of them. This, however, does not indicate that only- 
seven of them were due to gonorrhea. Sanger and A. von Rosthorn 
found tubal disease in 33 per cent of women affected with gon- 
orrhea. The statistics of Bumm show that gonorrhea extends into 
the Fallopian tubes in about 10 per cent of cases affected with the 
disease. Gonorrhea is found less frequently in the urethra than about 
the vaginal orifice. A. Martin considers this due to the infrequency 
of glands about the urethra. Penrose thinks that gonorrhea at- 
tacks the different parts in the following order of frequency: The 
urethra, the cervix uteri, the vulva and the vagina. Pryor says 
that gonorrheal endocervicitis occurs five times as often as gon- 
orrheal vaginitis. Gonorrhea seldom extends to the bladder, al- 
though it may do so and may even extend into the ureters and to the 
kidneys. It is not uncommon for gonorrhea to extend into the 
rectum. Baer, in the examination of 191 cases of discharge from 
the bowel in women, found gonococci in 76 cases. Sanger thinks the 
"greater number of rectal strictures are gonorrheal in origin. I have 
observed gonorrheal proctitis in five or six cases. The disease prob- 
ably extends to the rectum from the vaginal secretions, from rectal 
examinations and from use of infected rectal syringe points. Dr. 
A. H. Burr gave the results of an exhaustive study of this subject 
in a paper which he read before this society in November, 1896. 
Bumm states that the development of gonorrhea is never primary 
in the vagina, but that invasion is by way of the cervix, or, more 
rarely, the urethra, where the epithelium is less resistant. This is 
ETIOLOGY. especially true of the cervix where the epithelium is cylindrical. 
According to Steinschneider and Fabay, however, the urethra is the 
more frequently attacked. Schultz’s recent investigations show that 
the urethra and cervix are primarily involved in about the same 
proportion of cases. Bumm has stated that pregnancy will pro- 
voke an excessive development of gonorrhea even in cases in which 
the date of infection has been very remote. J. Veit believes that 
the first attack of gonorrhea usually disappears spontaneously and 
that the Fallopian tubes become involved in the first attack only in 
rare cases of infection, shortly before or after labor. Bumm has 
kept gonorrheal pus in contact with the vaginal wall for twelve 
hours without producing any inflammatory reaction. Menstruation 
favors but does not insure the revival of gonorrhea in latent cases. 
This is due to discharge from the glands and also because blood 
serum is an excellent culture medium for the growth of the gono- 
coccus. This is the reason why gonorrhea is frequently contracted 
during or near the menstrual period. This indicates the advisability 
of the frequent use of antiseptic douches during menstruation. One 
patient under my care had repeated attacks of vulvovaginal gon- 
orrhea following menstruation, as the result of infection from the 
endometrium. By the use of douches during menstruation these at- 
tacks were prevented. The tendency for gonorrhea to extend dur- 
ing menstruation accounts for the fact that attacks of metritis, 
salpingitis and peritonitis so frequently date from a menstrual period, 
or from an interrupted menstruation. Bumm denies that gon- 
ococci lose their virulence and holds that infection from an old case, 
if planted on healthy mucosa, produces an acute attack. Bumm 
believes that gonorrhea is a pure mucous membrane parasite. 
Schultz, after extensive microscopical investigation, concludes that 
gonococci are much more numerous in the urethra than in the cer- 
vix, and consequently that infection most frequently takes place 
from the urethra. 
PATHOLOGY. 
It was formerly believed that gonorrhea was not a pus produc- 
ing microorganism; that when suppuration occurred the infection 
was a mixed one. This has been disproven by finding in large col- 
lections of pus, gonococci as the only microorganism present. In 
gonorrheal inflammation, however, the amount of exudate is greater 
than in most of the other inflammations. Gonorrheal inflammation 
usually extends by continuity of tissue. It may, however, extend 
through the lymphatics and the blood vessels. An illustration of 
extension through the lymphatics is seen in inflammation of the 4 
inguinal glands and in the broad ligaments, during the acute stage 
of the disease. That it may extend through the blood vessels is 
proven by the gonococcus having been found in the blood and in 
the tissues far distant from the primary seat of the disease. 
SYMPTOMATOLOGY. 
The disease may be acute or subacute from the first. In the 
acute cases the symptoms may be similar to any acute vulvovaginitis 
and urethritis. The uterus and adnexa are seldom primarily in- 
volved, although in rare cases there may be present symptoms of 
acute metritis and pelvic peritonitis, probably never general peritoni- 
tis. The fact that the gynecologist is called upon relatively seldom 
to treat the disease in the acute form causes me to believe that the 
subacute is the more common mode of invasion of the disease. In 
the latter variety a leucorrheal discharge is primarily the principal, 
and may be the only symptom. If the disease extends to the 
Fallopian tubes, the symptoms will then be those of salpingitis, 
with probable suppuration. In some cases the disease is excessive- 
ly acute, as the result of either diminished resistance to, or great 
virulency of, the infection. 
The only positive diagnosis is made by detecting the presence 
of the gonococcus. This can usually, if not always, be accomplished 
during the acute stage of the disease. In the acute variety, how- 
ever, there is usually no difficulty in making a relatively certain 
diagnosis, without the use of the microscope. In the subacute and 
chronic stages of the disease, the gonococcus is detected with much 
more difficulty. When it is not found, the technique may be faulty 
or the investigation not sufficiently thorough. Absence of the gon- 
ococcus, however, does not prove that the disease is not primarily 
due to gonorrhea. Redness about the openings into the Bartholinian 
glands and into the urethral glands, usually, if not always, means 
that the patient has had gonorrhea. How long the gonococcus 
can be found in the tissues after the date of infection cannot be 
stated. Bumm states that the gonococci may persist and remain 
virulent in the genital tract for five or ten years. Sanger, in dis- 
cussing residual gonorrhea in women, states that after the disappear- 
ance of gonococci in the secretions, certain manifestations of the dis- 
ease may remain, such as redness about, and discharge from, the 
glands at the vaginal orifice, the urethra and the cervix. 
DIAGNOSIS. 
PROGNOSIS. 
The statement frequently made that gonorrhea may remain in 5 
a latent form an indefinite time is probably true. A number of 
cases are on record where gonorrhea has been contracted a number 
of years after the disease was acquired. It is not improbable, how- 
ever, that the subjects may not have subsequently been exposed to 
subacute infections. Spontaneous cures probably result in the male 
and female. The claim made that spontaneous cures are more fre- 
quent in men than in women, if true, may be due to the increased 
number of glands and cylindrical epithelium in the female generative 
organs. From investigations of Doderlein, Kronig and others, 
relative to the destructive nature of the bacteria of the normal vag- 
inal secretions to pathogenic microorganisms, would indicate that 
the contrary would be true. Steinschneider has demonstrated that 
gonococci are often present in the cervix and body of the uterus 
long after they have disappeared from the urethra and vagina. 
Immunity after recovery from the disease does not seem to take 
place, as Klein has found that in chronic gonorrhea the individual 
may become accustomed to the presence of the gonococcus and 
that the microorganism from such a case may cause the virulent 
disease in another person, and then cause reinfection in the orig- 
inal person. Gonorrheal inflammation of the Fallopian tubes, 
probably nearly always results in thickening of the tubal walls, in 
occlusion of the abdominal ostium, in adhesions, or in suppuration. 
Complete spontaneous cures, however, of the tubes probably do 
occur. I recently saw in consultation a patient with acute gon- 
orrhea, involving the pelvic peritoneum; the uterus was large, ex- 
cessively sensitive, and there was swelling in the region of both 
broad ligaments, more marked on the left side. The husband had 
had gonorrhea, and gonococci were found in the discharge from the 
patient. About six months after recovery from the acute attack, 
I made a vaginal fixation of the uterus for retroposition. The 
Fallopian tubes were perfectly normal and the only adhesions found 
were slight ones about the left ovary. It can not be said, however, 
that the tubal mucosa was involved at all. The patient now seems 
to be perfectly well. The literature is meager relative to spon- 
taneous recovery of gonorrheal salpingitis. 
The prognosis as regards sterility has received a great deal of 
attention since Noeggerath demonstrated the importance of the 
subject. Graefe and Kleinwachter have investigated the causes of 
sterility and conclude that gonorrhea is not as prominent an etiolog- 
ical factor as generally supposed. In 648 cases of sterility, Klein- 
wachter found but 80 in which the sterility could be ascribed with 
certainty to gonorrhea; in 12 of these the husband was known to 
have had the disease. TREATMENT. 
In the acute stage I believe in the free local use of nitrate of 
silver, 10 to 30 grains to the ounce of water, to be followed by anti- 
septic gauze tampons, or the frequent use of antiseptic douches. 
Vaginal douches should be given frequently during menstruation 
when gonorrheal vulvovaginitis exists, to diminish the tendency of 
the disease to extend into the uterus. The disease is most liable 
to extend to the uterus at this time, for the reasons already given. 
The douche should be at the body temperature, and only suf- 
ficient in quantity for cleanliness, so as not to interfere with menstru- 
ation. Acute inflammation of the uterus and adnexa should be 
treated entirely by palliative measures, unless large pelvic abscesses 
result, which would require vaginal incision and drainage. 
In chronic inflammation about the glands at the vaginal orifice 
and urethra, the treatment is limited to palliative measures, unless 
they cause sufficient trouble to indicate excision. Suppurative dis- 
ease in the Bartholinian glands and Skene's tubules demand ex- 
cision. Skene’s glands are excised by removing the portion of the 
urethrovaginal septum which includes them and in suturing the 
mucous membrane of the urethra to the vaginal mucous membrane. 
Chronic endometritis is treated by curettage, mild caustic appli- 
cations and by establishing drainage, if necessary. It may be neces- 
sary to repeat the curettage and to continue the treatment for a long 
space of time in order to effect a cure. 
The treatment of chronic gonorrheal salpingitis will vary largely 
with the symptoms which result and with the amount of disease 
present. The adhesions which result from inflammation may, in 
selected cases, be relieved by massage, topical applications, etc. 
The presence of an enlargement in the region of the tubes or ovaries 
does not necessarily require any treatment. To illustrate, I will 
briefly relate two cases that came under my observation seven years 
ago. They both had had gonorrhea and had had slight attacks of 
pelvic peritonitis. When I saw them they had slight backward dis- 
placements of the uterus with enlargement of both uterine ap- 
pendages. I observed these cases for four years and during this 
time they experienced comparatively very good health, much bet- 
ter physically and mentally, I am certain, than if they had been 
subjected to operative treatment. Such cases should not be oper- 
ated, unless symptoms develop which indicate interference, as the 
pus in these cases frequently becomes sterile. When suppuration 
occurs, indicating operative interference, it is nearly always neces- 
sary to excise the affected tube or tubes, as the abscesses are usually multiple, not sufficiently circumscribed, and as the exudate is too 
abundant to make an attempt at incision and drainage justifiable. 
Some conservative surgery has been done upon the tubes af- 
fected with gonorrhea with good success in a limited number of 
cases. The results, however, are not sufficiently numerous as yet 
to enable one to form any conclusions. It may probably be said, 
without exciting contradiction, that tubes affected with gonorrhea 
calling for operation, should be excised, as the danger of recurrence 
of the disease is marked and as sterility, in all events, is almost 
certain. 
In nearly all cases of gonorrheal inflammation, the ovaries, or 
some ovarian tissue, remains healthy. When operating these cases, 
especially if the subject be young, an effort should always be made 
to preserve menstruation, by leaving the ovaries, an ovary, or some 
ovarian tissue. It is my opinion that this can be accomplished in 
from ninety to ninety-five per cent of all cases of gonorrheal inflam- 
mation of the uterine adnexa, where the disease is such as to indi- 
cate operative treatment. When the endometrium is affected, both 
ovaries and tubes the seat of suppuration, and the uterus large and 
adherent, vaginal hysterosalpingoopherectomy is decidedly the 
operation of election. 
REFERENCES. 
J. Whitridge Williams—Am. Journal of Obstetrics, October, 1898. 
Doderlein—Archiv. f. Gynecologie, No. 31, 1887. 
Doderlein—Centralblat f. Gynecologie, 1894. 
Baer—Deutsch. Med. Woch., No. 8, 1896. 
Madlauer—Centralblat f. Gynecologie, December, 1895. 
Pryor—American Gyn. and Obs. Journal, September, 1895. 
Brose—An. De. Gyn. Et. D. Obs., February, 1894. 
Noeggerath—Trans. Am. Gyn. Society, Vol. I., 1876. 
Dudley—Diseases of Women. 
Sanger—Verhand. Der Geselsch. f. Gyn., Leipzig, 1886. 
Loman—Central, f. Gyn., No. 11, 1892. 
C. B. Penrose—Diseases of Women. 
Howard A. Kelly—Operative Gynecologie. 
Pozzi—Treatise of Gynecologie, 2d American Edition. 
A. Martin—Diseases of Women. 
Gould’s American Year Book of Medicine and Surgery, 1896-7-8. 
Sanger—Arch. f. Dermat. u. Syph., Bd. 37, 1897. 
Bumm—Arch. f. Dermat. u. Syph., 1897. 
Schultz—Central f. Gyn., No. 28, 1896. 
Graefe—Zeit, f. Geburtsh. u. Gyn., 1895. 
Albert H. Burr—Chicago Medical Recorder, Vol. XI. 
93 East Eighteenth Street. 8 
GONORRHEA IN CHILDREN. 
I. A. ABT, M. D. 
Gonorrheal infection of children manifests itself primarily as a 
vulvovaginitis, a urethritis of the male child, a purulent ophthalmia, 
stomatitis or rhinitis of the new-born. 
It is the purpose of this paper to discuss genito-urinary gon- 
orrhea and complications in children. So frequently has the gono- 
coccus been found in cases of vulvovaginitis, that no doubt can be 
felt that gonorrheal infection plays an important role in this dis- 
ease. 
Cahen-Brach (Jahrbuch fur Kinderheilkunde, 1892) examined 
twenty-six children suffering from vulvovaginitis, and in every case 
but one gonococci were found. W. Fisher (Deutsche Med. Woch., 
1895) examined the secretion in fifty-four cases, in fifty of which 
he found gonococci. The disease occurs in children from one to 
twelve years, though it is most frequent in children under six years 
of age. 
As to the constitutional condition of the little girls, it has been 
pretty generally observed that weakly or rachitic children are not 
particularly susceptible; on the contrary, the children, as a rule, 
are well developed and well nourished. 
On the inner surfaces of the thigh and on the perineum one 
usually observes an eczematous condition of the skin covered with 
a dried greenish-yellow pus. The labia majora adhere to one an- 
other. If they be separated, it is noticed that the mucous mem- 
brane of the vestibule is red and swollen, as is also the hymen, and 
a quantity of pus is to be seen. Pressure upon the perineum will 
frequently cause pus to exude from the vagina. In the majority 
of cases the urethra is involved. It is not unusual to find the ducts 
of the Bartholinian glands involved and a small quantity of pus 
can sometimes be pressed out of these ducts. 
THE CLINICAL COURSE AND SYMPTOMATOLOGY. 
Fisher reports a Bartholinian abscess. In many cases the in- 
guinal glands are enlarged, particularly in those cases where eczema 
or excoriation exists. As a rule, the temperature is normal, though 
slight elevations during the first few days of the illness have been 
recorded. As a general thing, the subjective symptoms are trifling 
or absent. The intertrigo may cause itching, or there may be pain 
upon urination or vesical tenesmus. The disease may last for 
weeks or months. The urethritis may persist after the vulvo- 9 
vaginitis has terminated. Exacerbations and relapses are not un- 
common. The endometrium is said never to be involved. 
Aside from gonorrheal ophthalmia, the gonorrheal virus may 
infect the infant at birth upon other mucous membranes. Rosinski 
(Deut. Med. Woch., 1891) describes a stomatitis in new-born chil- 
dren caused by the gonococcus. The lesions develop only when 
the pavement epithelium has been removed. They consist of yel- 
lowish plaques on the roof of the mouth, surrounded by a border 
of pale reddish tissue. These plaques heal without the formation of 
scar tissue. 
Cunier and Ziem (Allgemeine Med. Centralzeitung, 1886) re- 
port cases of gonorrhea of the nasal mucous membrane in new-born 
children. 
PERITONEUM. 
As in the adult female, the tubes or ovaries and peritoneum may 
be involved. Gonorrheal pus in the tubes has been found at au- 
topsy in five cases of girls, from seven to nine years of age.. It 
must not be forgotten therefore that the genitalia of little girls may 
be the point of entrance for the organisms which cause peritonitis. 
The bladder is seldom involved in little girls; a temporary vesical 
tenesmus, or, in rare cases, a temporary vesical catarrh may occur. 
Epidemics of vulvovaginitis have been frequently described; 
they occur particularly in hospitals and institutions and among the 
children of the poor, though none are exempt. Skutch (Inaug. 
Disr., Jena, 1891) describes what is probably the largest epidemic 
which has yet been reported. During the month of August, 1890, 
236 cases were reported in the city of Posen, and probably many 
more occurred that never came to notice. These cases all developed 
in the course of eight to fourteen days in little girls from six to 
fourteen years of age, namely, school children. In a number of the 
children it was noticed that the disease occurred after they had vis- 
ited on one or more occasions a free public bath. The common 
use of towels, soap, and the bath water may have carried the con- 
tagion from one child to the other. In the majority of cases 
gonococci were demonstrated. Purulent ophthalmia developed in 
a number of cases not stated. 
MANNER OF INFECTION. 
The vulva and urethra are most often attacked primarily; the 
vagina, if involved, becomes so secondarily; the gonorrheal virus 
may be conveyed through sponges, towels, bed linen, by manipu- 
lations of the parts with unclean fingers, fever thermometers, or the 
contagion may in rare cases be conveyed by criminal assaults on 
little girls. 10 
Jerome Walker, of Brooklyn, reports in the Archives of 
Pediatrics, for 1886, twenty-one cases of indecent assault and rape 
upon children. Seven children of this series developed a vaginal 
discharge, probably gonorrheal in nature. 
In case VI of Walker’s series a two and one-half year-old child 
was examined at an institution and found suffering from a vulvo- 
vaginitis. The father and mother had both been sentenced to the 
penitentiary for six months for vagrancy; both were found to be 
suffering from suspicious genital discharges. Walker, in comment- 
ing on the case, suspects the father as possibly guilty of indecent as- 
sault on this child. We know, however, from our present knowl- 
edge, that the child could have been infected in various ways other 
than direct infection from the father. If in this case gonococci had 
been actually found, the value from a medicolegal point of view 
would have been of little importance, because it would be neces- 
sary to exclude all the other modes of infection. 
For proof that the disease may be conveyed by fever ther- 
mometers, the experience many years ago of the St. Annen Kin- 
derspital of Vienna is of interest. It was found that nearly every lit- 
tle girl who came to the hospital for treatment suffered in a few 
days from a vulvovaginitis. The cause of the infection was eagerly 
sought for, though the epidemic persisted until the director of the 
hospital ordered that the method of taking temperatures by rec- 
tum be stopped; with this the epidemic ceased. The vulvovaginitis 
may occur in new-born children, though the infection of the vulva 
occurs rarely when compared to the infection of the conjunctiva. 
This is probably due to the protection which the adherent labia 
majora offers to the external genitals, and, moreover, the sojourn 
of the breech in the birth canal is much shorter in most cases than 
is that of the head. It is to be remembered, as has been pointed 
out by Epstein, that a physiological discharge may occur from the 
genitals of new-born children caused by an epithelial desquama- 
tion, similar to the desquamation which occurs on the surface of the 
body. 
PROGNOSIS. 
In a general way, it may be said that the prognosis in little girls 
is more favorable than in adnlts. In a majority of cases the disease 
terminates in about three months, though there are cases recorded 
where a chronic urethritis for a long time resisted all forms of 
treatment. DIAGNOSIS. 
Clinically, great difficulty is frequently experienced in diagnosing 
cases of simple vulvovaginitis from the gonorrheal variety. We 
must rely for an accurate differentiation upon the microscopical ex- 
amination. The pus for examination should be taken from as high 
a point in the tract as possible, preferably from the orifice of the 
urethra. Examination of the pus from a case of simple catarrh 
shows that the discharge is made up of epithelial and pus cells with 
quite a variety of bacterial forms, bacilli, cocci and diplococci. 
These bacteria are found in the pus cells and the epithelial cells, not 
singly, but associated together. The diplococci are few in num- 
ber. In cases of gonorrheal inflammation large masses of diplococci 
are found in the pus cells, usually they are the only bacteria present. 
By staining with Gram’s method, the gonococcus is decolorized, the 
other form of diplococcus is not decolorized. 
TREATMENT OF VULVOVAGINITIS; PROPHYLAXIS. 
Owing to the fact that the gonorrheal virus is readily conveyed to 
little girls, children should avoid sleeping with persons suffering 
from gonorrhea. The child should have its exclusive bed, and have 
for its exclusive use towels, sponges and wash-rags. In hospitals, 
asylums and public bathing houses similar precautions should be 
taken. Children suffering from suspicious vaginal discharges should 
not be admitted to the general wards of children’s hospitals and 
asylums. 
TREATMENT. 
The treatment consists of cleanliness, antisepsis and rest to the 
parts. The vulva should be kept scrupulously clean; in severe cases 
it should be irrigated three or four times daily with a saturated 
boric acid solution or a solution of 1-10,000 bichloride. Cassel ad- 
vises (Berlin. Klin. Woch., 1893) that after the preliminary cleansing 
of the vulva the child be placed in the lithotomy position with 
the pelvis elevated. A soft rubber catheter, or the tubing of a soft 
rubber balloon syringe is introduced into the vagina, and the same 
irrigated. He uses 1-1000 or 1-2000 bichloride solution. Later, if 
the condition persists he uses one or one and a half per thousand 
nitrate of silver solution. The bichloride irrigation is extensively 
used, though not in as strong solutions as advised by Cassel; solu- 
tions of one to five or one to ten thousand answering the same pur- 
pose. Permanganate of potassium or of zinc in solutions of the 
strength of 1-3000 are extensively used. Many other antiseptic so- 
lutions are advised. In obstinate cases irrigation with astringent 
solutions, such as the sulphate of zinc or tannic acid, may be used. 12 
A pad of sterilized cotton well dusted with boric acid and starch 
may be placed between the labia to prevent the irritation caused by 
the purulent discharge. 
Experience teaches that the irrigation of the urethra with strong 
antiseptic solutions, or the introduction into the urethra of bacilli 
of iodoform or thallin, or any similar procedure does not do any 
permanent good. The administration of salol and boric acid in ap- 
propriate doses are recommended for the urethritis. 
GONORRHEAL URETHRITIS IN MALE CHILDREN. 
The symptoms present much the same picture as is seen in the 
adult. Koplik has seen children in arms suffering from this 
condition. Bokai observed 109 cases of urethritis in children, many 
of whom, he points out, suffered for weeks or months from a 
urethritis. Most of these were probably gonorrheal. Twenty-seven 
occurred during the first year, thirty-six from the first to the third 
year, thirty-two from the third to the seventh year, and fourteen 
from the seventh to the fourteenth year. 
Holmes (Surgical Treatment of Diseases of Children) devotes 
a special chapter to this subject. He says he has not infrequently 
seen cases of gonorrhea in male children. Rona reports fifteen cases. 
He says the process was in every case a urethritis totalis, the disease 
becoming chronic, and usually lasting for months. Moncorvo has 
seen many cases of gonorrhea in small boys. Von Arsdale has 
frequently observed gonorrheal urethritis in young boys. One case 
was in a child ten months old; two cases were in children from one 
to four years. I have notes of two cases. 
Case 1. P. I., a boy aged two years and three months, was seen 
in private practice for the first time January 7, 1898. The parents 
are of average intelligence and live in very comfortable quarters. 
The previous health of the child was good. The child was pale, 
had a temperature of 100.8 degrees, and was suffering from a 
urethral discharge, which the mother had noticed for two days. 
The meatus was red and swollen; the penis was swollen, showing 
the presence of lymphangitis. The child experienced great diffi- 
culty in micturition, and cried with pain at each attempt. He uri- 
nated frequently, and small quantities at a time. Some of the time 
he suffered from incontinence. The urine, which was collected in 
two portions, showed both portions to be cloudy. A thick, yel- 
lowish pus oozed from the urethra. A microscopical examination of 
the pus showed the presence of gonococci. At the end of about two 
weeks the mother directed my attention to a purulent discharge 
from the rectum. The child complained of pain with each evacu- 13 
ation of the bowels, and intense itching about the anus. Examina- 
tion showed the anus reddened, the margins slightly swollen. Upon 
causing a dilatation of the anal orifice, a purulent discharge was 
observed. Some of this pus was collected for microscopical exami- 
nation, which showed the presence of gonococci. The child suf- 
fered from rectal irritation and tenesmus. The stools did not appear 
abnormal in color or composition, though they were small, fre- 
quent, and at least twice were streaked with blood. 
The treatment consisted in the regulation of the diet, and for 
the first few days in the administration of one-drop doses of fluid 
extract of hyoscyamus four times daily for the relief of pain and 
vesical tenesmus. At the end of the first week urethral injections of 
about one per cent solution of ichthyol were ordered once daily; 
later, permanganate of potash solution in the strength of 1-5000 
was used. For the rectal infection three ounces of peroxide of 
hydrogen diluted one-half was injected three times daily, followed 
by a suppository of bisulphate of quinine and ichthyol. At the end 
of about seven weeks the urethral and rectal discharge disappeared, 
and the little patient, who up to this time had been weak and 
anemic, improved rapidly, and has not suffered any relapse. The 
source of infection in this case could not be ascertained. The nurse 
girl, as is usual, was suspected, and was dismissed. While we have 
not very far to seek for the source of rectal infection, the exact man- 
ner in which it took place could not be learned. The mother had 
been previously cautioned regarding the infectious nature of the 
purulent discharge. She said that she exercised great care, and 
could not throw any light on the rectal infection. 
Case II. A colored boy, aged nine years, who was seen at the 
dispensary of the Northwestern University Medical School during 
the summer of 1898. He had been sick for five weeks with painful 
urination and a purulent discharge from the urethra. There was 
phimosis. Microscopical examination showed the presence of 
gonococci. In this case it was elicited that shortly before the pa- 
tient was taken ill his cousin, a young woman, nineteen years of 
age, came to make a prolonged visit to the family. During her stay 
she occupied the same bed with the patient. The boy was reticent 
and denied any immorality on his part or that of his cousin, though 
the circumstances were suspicious. 
In private practice, as well as in hospital and dispensary prac- 
tice, it is in most cases difficult to elicit accurately the mode of 
infection, though it cannot be doubted that most cases are due to 
MODES OF INFECTION. 14 
actual sexual contact, a lesser number to manipulations of the parts 
with infected hands, linens, and the like. The recorded cases show 
that the majority of children acquire the disease from servants, or 
from little girls suffering from vulvovaginitis. 
Strictures occur the same as in adults. Kammerer reports a 
case in a child two and a half years old, who, six months after an at- 
tack of gonorrhea, developed a stricture which did not permit the 
finest catheter to pass. A suprapubic puncture was made to empty 
the bladder. Two strictures were found in the anterior urethra, and 
one impermeable in the membranous portion. The deep stricture 
was treated by performing an external urethrotomy. The anterior 
strictures were relieved by dilatation. 
Cystitis has been observed by Viger and Moncorvo. Rona en- 
countered the complication in two cases. In one case it continued, 
and persistent hemorrhage occurred. 
It has been supposed that epididymitis and orchitis do not occur 
as complications, owing, perhaps, to the functional inactivity of the 
organs. True, the condition has been seldom observed, though 
Rona reports a child fifteen months old suffering from a urethritis 
totalis. In about twelve days after the beginning of the disease it 
was observed that the scrotum was swollen, and both testicles were 
painful. After fourteen months the patient was dismissed as cured, 
though a little hard nodule, the size of a pea, remained in the left 
epididymis. 
Lymphangitis of the penis, balanitis and balanoposthitis occur 
commonly. Rectal gonorrhea has not been observed in any of the 
cases previously reported. 
The diagnosis presents but few difficulties, and differs in no im- 
portant detail from that of adults. The specific must be differen- 
tiated from the non-specific variety. This differentiation depends 
on the presence or absence of the gonococci, and also upon the dura- 
tion of the disease and the occurrence of complications. The gono- 
coccus must be found in considerable number, and arranged in 
groups within the leucocytes. It must decolorize readily by Gram’s 
method of staining. The best culture medium is made from the 
blood or serous fluid of man. 
COMPLICATIONS. 
COMPLICATIONS COMMON TO CHILDREN OF BOTH SEXES. 
Gonorrheal rheumatism has been reported as occurring after 
vulvovaginitis and purulent ophthalmia. The gonococci has been 
found in these joint effusions. It is an interesting observation that 
the arthritis which occurs in children is never of so severe a type as that which occurs in adults. There is usually little or no fever. 
Ankylosis, which is so frequent a sequel in the adult cases, is un- 
known in the child, and is approached only in a few cases by tempo- 
rary stiffness in the joints. 
Endocarditis as a complication of gonorrhea such as occurs in 
the adult has not been recorded in children. 
Cases of secondary purulent ophthalmia are- not so frequently 
reported in the literature as one would be led to expect. Pott 
(Specific Vulvovaginitis im Kindesalter Jahrb. f. Ivinderheilk., 1883) 
and Cahen-Brach (Jahrb. f. Kinderheilkunde, 1892) report such 
cases. 
4008 Grand Boulevard. PATHOLOGY OF GONORRHEA AND TREATMENT OF 
SOME SURGICAL COMPLICATIONS. 
PATHOLOGIST TO ST. LUKE’S ANI) MICHAEL REESE HOSPITALS. 
D. N. EISENDRATH, M. D. 
The history of the gonococcus dates from 1879, when Neisser 
first found it in gonorrheal pus. It is a coccus occurring in pairs 
usually in the interior of leucocytes with a clear interspace between 
with adjacent sides flattened, biscuit-shaped. Its size varies from 
0.8 ;j.. to 1.0 i>.. in length, and from 0.6 to 0.8 //. in width. In the 
tissues and pus its size is uniform; in cultures it varies. It is neither 
a strepto- nor a staphylococcus, but has a grouping of its own which 
is quite characteristic. It is nonmotile, and divides longitudinally. 
It is best stained with an alkaline methyl blue or gentian violet so- 
lution. It is decolorized by Gram’s method. This serves to dis- 
tinguish it from all other cocci except the so-called pseudogonococci, 
and the meningococcus of Welchselbaum. Lustgarten and Manna- 
berg described the former, pseudogonococci, as occurring in healthy 
and gonorrheal cases. It is a lemon yellow diplococcus, decolor- 
ized by Gram and occurring in about five per cent. If all of the well- 
known points, as to the morphology, staining reactions, enclosure 
and arrangement within cells be observed, a mistake in diagnosis 
is possible in only a small number of cases. The meningococcus in 
its morphology, intracellular position, appearance in culture media, 
decolorizing with the Gram stain, more completely resembles 
the gonococcus, but in this case as with the pseudogonococci, the 
culture test is the only reliable one in doubtful cases, namely, the 
gonococcus will only grow on media in which some albumin taken 
from the human body is present and will not grow upon ordinary 
media; whereas the other cocci spoken of will grow well on all 
media. Bumm was the first to obtain successful results in the culti- 
vation of the gonococcus by using human blood serum. On ac- 
count of the difficulty of obtaining this serum Wertheim suggested 
a far more practicable medium in the shape of human blood serum 
agar. Some human serum seems necessary, but ovarian, pleuritic, 
ascitic and hydrocele fluid can be substituted for the blood serum. 
Many other media have been suggested, but none have proven sat- 
isfactory. If none of the above fluids can be obtained a convenient 
method is that of Pfeiffer, namely, to allow a number of drops of 
blood from a previously sterilized finger to flow over the surface of 
a tube of nutrient agar. Surface colonies are pale, grayish, translu- cent, finely granular, with finely notched borders. The gonococcus 
is exclusively aerobic, and is very sensitive to temperature. When 
inoculated with bits of agar into the anterior chamber of a rabbit’s 
eye it causes the greatest irritation. A nonfatal peritonitis can be 
produced by injecting pure cultures in rats and guinea pigsj and in 
white mice and guinea pigs. Veillon and Grosz caused a fatal per- 
itonitis by injecting large amounts of the pure culture. Sterilized 
gonococci cultures had the same effect. Finger caused transient 
redness, swelling, and pain of the knee-joint in animals. Inocula- 
tions upon the urethrae of animals always prove negative. 
One of the most interesting contributions to our knowledge of 
the gonococcus since its discovery by Neisser and cultivation by 
Bumm and Wertheim has been made by De Christmas, published 
last year in the Annals of the Pasteur Institute. Time will permit 
of only a resume of his work. He isolated the toxin of the gono- 
coccus from pure cultures growing in rabbit serum-bouillon con- 
taining glucose, which he found better than the Wertheim medium. 
The injection of the toxin obtained from filtered cultures produces 
the same results as the cultures themselves. This toxin placed upon 
the human urethra caused, after one hour had elapsed, a drop of 
thick yellow pus, which contained no gonococci, but a large num- 
ber of mono- and polynuclear leucocytes and epithelial cells, but 
no gonococci. The toxin acts first upon the epithelial cells and the 
leucocytic emigration is secondary, because in the first drops taken 
the former greatly exceeded the latter in number. This artificial 
urethritis was accompanied by pain and the other typical symptoms 
and disappeared gradually. It resembles the true gonorrhea in the 
fact that the secretion continues long after the inflammatory symp- 
toms have disappeared. In cases in which there is a doubt as to the 
nature of the process the injection of such a toxin would clear it 
up. In animals the injection of the toxin causes rapid loss of 
weight and high fever. Locally it causes abscesses, with thick 
sterile pus, no tendency to spread and which heal by resorption. 
There are no lesions to be found post-mortem. Heat has no effect 
upon the toxin; it can be precipitated by alcohol and extracted with 
glycerine. The toxin is formed in the bodies of the gonococci 
themselves. Injected into the anterior chamber of a rabbit's eye 
it produces great irritation and early pus formation. Injected into 
the pleural cavity, it produces rise of pulse and respiration and all 
of the evidences of a pleuritis with the formation of thick yellow 
pus. Animals can be immunized by intravenous injections of the 
toxin in thirty days, so that injections of pure cultures or the toxin 18 
have no effect. This may have a future in the treatment of some in- 
ternal complications of gonorrhea. 
In man the favorite ground for the gonococcus is upon mucous 
membranes and preferably those lined by cylindrical or transitional 
epithelium, not excluding squamous, as Bumm claimed. It read- 
ily penetrates between the cells into the connective tissue and be- 
tween muscle fibers. It grows most luxuriantly, however, upon the 
surface, and it is probably through the destructive action of its toxin 
as Christmas has shown, upon epithelial cells and leucocytes, that 
pus is formed. It can easily be comprehended how the posterior 
urethra, bladder, seminal vesicles, vas deferens, and epididymis can 
be invaded by contiguity of tissue. It has been proven to be the 
cause of suppuration in the pelvic connective tissue in both male 
and female. In the female the urethra with its crypts and glands, 
the cervix uteri and Bartholinian glands are the favorite seats. Its 
etiological relation to endometritis and salpingitis, as wrell as to 
ovarian abscesses, can no longer be questioned. By continuity it 
may invade the peritoneum and cause a suppurative peritonitis. In- 
fection of the rectum and conjunctiva are instances of inoculation 
infection. In severe cases it gives rise to a pyemic condition; the 
metastases in the joints, tendon sheaths and bursae ; on the 
pleura, pericardium, endocardium, meninges, having been observed 
and proven to be caused by the gonococcus by a number of ob- 
servers, microscopically and by the culture as well as reinoculation 
of the microorganisms upon healthy urethrae, again producing gon- 
orrhea. Wertheim found the gonococci in thrombi in the blood 
vessels of the walls of the bladder in a case of gonorrheal cystitis, and 
other authors have proven their presence in the circulating blood; 
others again have cultivated them from the various above-named 
metastases, so that the chain of evidence is complete beyond all 
doubt to prove that the gonococcus may cause general as as 
local infection. This will be taken up more in detail in another 
paper. The treatment of several of the metastatic complications in- 
terests us greatly, especially that of the joints and tendon sheaths. 
As regards the former, Nasse, who has written an extensive mono- 
graph on this subject, proved by culture the presence of the gono- 
coccus alone in nineteen out of thirty cases. The localization of the 
gonococcus in the joints, tendon sheaths and bursae may take place 
almost from the very beginning of the disease, and not necessarily 
from the time the posterior urethra is invaded, as was formerly 
thought, depending more upon the invasion of the deeper layers 
of the tissues of the urethra and bladder. They are greatly fa- 19 
vored by trauma, excesses, or irritating therapeutic measures. It 
is a frequent complication of the gonorrhea of pregnancy, or of 
the puerperium, of ophthalmia neonatorum, or of the vulvovagin- 
itis of children. No joint can be said to be free from it. It does 
not generally involve one joint, but wanders from one joint 
to another as acute articular rheumatism, though does 
not seem to be as polyarticular. In men the knees 
are most frequently affected, in women the wrists and finger-joints. 
The disease in the joints may be acute, subacute or chronic. Of the 
former there are three varieties, the acute gonorrheal hydrops, in 
which there is a serous or sero-purulent effusion, a second variety 
in which in addition to the effusion there is extensive thickening of 
the capsule and involvement of the paraarticular tissues. In this 
variety the exudate may at times be purulent, cause perforation 
of the capsule and periarticular abscesses. A third variety resembles 
the ordinary pyemic arthritis with destruction of cartilage and cap- 
sule. The second variety is the most deplorable because, in spite of 
all treatment, it leads frequently to ankylosis. In general, the ten- 
dency of gonorrheal arthritis is through the early adhesions and 
capsular thickening as well as periarticular infiltration to lead to 
stiffness, subluxation and contractures. Examination of gonorrheal 
joints shows as the principal changes loss of endothelium and un- 
der this formation of granulation tissue, it is the change to con- 
nective tissue of the latter which leads to the above results. 
Gonorrheal tendovaginitis and bursitis are not at all rare af- 
fections. The former occurs most frequently in the tendon sheaths 
of the extensors in the hand, and of the tibial muscles in the lower 
extremity. The latter in the bursa between the insertion of the tendo 
Achilles and the bone. The treatment of acute hydrops should be 
rest and compression with or without the application of some local 
remedy like guaiacol carbonate. The internal administration of 
salicylates and so forth is of but little avail. In the second variety 
with extensive capsular and paraarticular involvement, if a cast or 
a splint does not succeed within a short time, an early puncture oi 
the joint, with washing out with some antiseptic solution, e. g., bi- 
chloride of mercury or lactate of silver with injection of iodoform 
emulsion, followed by massage, active and passive movements, will 
give the best results. If these latter means are not employed fairly 
early even in cases in which the joint is not washed out, ankylosis 
is almost certain to result. When the exudate is purulent, with high 
temperature and threatened destruction of the joint, arthrotomy is 
frequently necessary. The treatment of gonorrheal tendovaginitis is comparatively simple. It is rarely necessary to open the tendon 
sheaths in order to evacuate the pus, but even here the tendency 
to stiffness of the fingers and toes must not be forgotten, and early 
massage and movements insisted upon. 
20 
103 State Street. 21 
WHY IS GONORRHEA STILL A MUCH DREADED 
F. KREISSL, M D., Chicago. 
DISEASE? 
PROFESSOR OF GENITO-CRINARY SURGERY, CHICAGO CLINICAL SCHOOL. 
“Gonorrhea of the male urethra is, perhaps, one of those diseases 
which the practitioner encounters most frequently. He starts his 
practice with it, and it is the one which causes him many sorrowful 
hours up to the end of his days. 
“He is vei;y often reproached by his patients, either by reflections 
or in plain language, of being incompetent of curing even a gonor- 
rhea, and the specialist, too, can hear it of his colleague, the 
practitioner. To be sure the patient and our social life are, to a cer- 
tain extent, to blame for the failure, but the physician himself is 
also responsible. We dare say, there is no chapter in medical 
science in which we act so irrationally and superficially as in gonor- 
rhea. A rubber, glass or tin syringe, a collection of a half a dozen 
prescriptions for injections; that forms the whole armamentarium 
of most physicians against this scourge.” 
These are the introductory words of E. Finger to the chapter 
on gonorrhea in the second edition of his book, “Blennorrhea of the 
Sexual Organs,” published in 1891. The close observer of to-day 
will hardly find much to change in this statement, although many 
volumes on the same subject have been published since. To-day, 
as then, the therapy of gonorrhea is a much neglected child; to-day, 
as at that time, the practitioner feels himself helpless facing the 
much dreaded disease, and but a limited circle of the “initiated” 
comes out victorious in the fight against it. If this were not so 
I would not have the honor to read this paper before you to-night; 
there would not be so much discussion on the serious complications 
and sequelae of gonorrhea, and one would not so frequently hear 
questions from colleagues such as these: “Doctor, is there any 
remedy at all which cures gonorrhea?” or, “Doctor, do you really 
believe gonorrhea can be permanently cured?” or, “What do you 
prescribe for gleet?” and the like. 
The time allotted is too short to discuss the subject in ques- 
tion from all the points of interest and importance, consequently 
I have to confine myself to a few facts, which, I think, ought to 
be first mentioned, alluding to others only in a passing way. I 
might run the risk of provoking opposition, as is always the case 
when an attempt is made to break from time-honored methods or 22 
prejudices; but I will be satisfied if it should assist in clearing the 
situation of the questions involved in the subject. 
Asking for the cause of failure in successfully dealing with 
gonorrhea, we find the answer in the following points. Super- 
ficial diagnosis, incorrect conception of the gonorrheal process, 
improper selection of remedies, and the almost universal tendency 
to start in with an effective treatment too late and to discontinue 
it too soon, and, last but not least, the lack of individualizing cases. 
I say this with the presumption that the patient follows all of 
our instructions in every detail and that he is not afflicted with 
any of the constitutional diseases which frequently favor the appear- 
ance of complications and prolong the gonorrheal process. A 
urethral secretion is quite often pronounced gonorrhea or gleet, 
while there has never existed a gonorrhea or where this process 
came to an end—leaving only the sequelae in its track. 
Hard and soft chancroidal ulcers, and the presence of mucous 
patches in the urethra during the secondary stage of syphilis fur- 
nish a secretion which is mistaken for gonorrhea and is treated as 
such, until the appearance of local symptoms on the skin and 
other parts of the body call the attention to the real character 
of the discharge. The same applies to herpetic eruptions and 
tuberculosis of the urethra, leading to tubercular ulcerations, which 
may, in rare instances, be a partial symptom of more or less gen- 
eralized urogenital tuberculosis, or, in far rarer cases, start pri- 
marily in the urethra.. In parenthesis I desire to state that simul- 
taneous infection with gonorrhea and syphilis is not a very rare 
occurrence, and the same is true of a urethra affected with sec- 
ondary syphilis in which the gonococcus may become implanted. 
Traumatic urethritis and secretions in acute exanthematic dis- 
eases should hardly lead into errors, which is not to say that the 
latter precludes the possibility of a gonorrhea. Another condi- 
tion, which in its initial symptoms most closely resembles specific 
urethritis and therefore occasionally may be mistaken for it, is 
the so-called pseudogonorrhea. It would better be called acute 
nonspecific urethritis, including all kinds of infectious urethritis 
which cannot be otherwise classified, and which were first described 
by Bockhard, who observed about fifteen cases of the kind. The 
whole process lasted, as far as my recollection goes, about ten days, 
and the microscopical examination for gonococci was negative. 
Finger and Neisser recorded similar cases, produced by bacilli, 
streptococci and staphylococci. 
It should also be remembered that small concrements, polypoid or papillomatous growths in the canal produce symptoms of ure- 
thritis, but a urethroscopical investigation should promptly reveal 
the real condition. 
Urethrorrhea and prostatorrhea, folliculitis and periglandulitis, 
simulate chronic specific urethritis. They all might be complicated 
by the presence of gonococci, but very often they are not, and yet 
they are described as gleet. A thorough microscopical examina- 
tion, notwithstanding all the other auxiliary methods of diagnosis, 
would prove the presence or absence of gonorrhea in a given case. 
Whatever has been published against the fact that the gonococcus, 
discovered by Neisser in 1879, is the cause of the disease in ques- 
tion, is not strong enough to disprove its exact etiological signifi- 
cance and value. In 1885 Bumm examined the vaginal and urethral 
secretion in women and discovered, besides the gonococcus Neis- 
ser, various forms of cocci which he called diplococcus flavus, diplo- 
coccus citreus conglomeratus and diplococcus albicans. Lust- 
garten and Manaberg subjected the normal urethra to a bacterio- 
logical examination in 1887 and succeeded in isolating eleven va- 
rieties of bacteria. The statement that they found a diplococcus 
which displayed no difference from the gonococcus N. regarding 
size, shape and relation to the staining process has not been in- 
dorsed by a great many others, especially by Petit and Wasser- 
man. 
Legrain in his publication, “Les microbes des eculements de 
l’uretre,” 1888, with good reason censures the imperfect way in 
which the authors communicated the results of their research. In 
1896 E. Tano in Tokio published a very thorough paper on his 
examinations of the urethral filaments in chronic urethritis. He 
succeeded in cultivating twenty-six kinds of bacteria from them, 
ten different bacilli and sixteen varieties of cocci, only one of 
which, called micrococcus II g., closely resembled the gonococcus 
N. in shape, size and relation to the aniline dyes and which appar- 
ently was the gonococcus Neisser associated with other micro- 
organisms, as is often the case in chronic gonorrheal urethritis. 
But what do all these publications prove? Hardly more than 
the relationship between the gonococcus and gonorrhea, and that 
other bacteria inhabit the apparently healthy urethra, or that cer- 
tain microorganisms inoculated upon the healthy urethra are also 
capable of provoking more or less severe and profuse secretions. 
It is commonly believed that only the presence of the gonococci 
in the pus cells permits the diagnosis gonorrhea. But are pus cells 
always found in the gonorrheal secretion? Certainly not. We find hardly any on the first and second day of the disease and 
usually none when the secretion has assumed a mucoid character. 
At that time we see but flattened epithelium and occasionally on 
its border or scattered between the epithelial cells a few gonococci. 
And the secretion will again assume purulent character within a 
few days when at this time we discontinue treatment, and then we 
will again find the typical gonococci inside of the numerous pus 
cells. What conclusions are to be drawn from the above facts? 
Since it is established beyond any doubt that gonorrheal urethritis 
is an infectious disease we will have to break with the antiquated 
principle of the expectant treatment as it was taught in former 
years, especially by the Vienna school, and whose present repre- 
sentative, Finger, still adheres to it. This principle is based upon 
false presumptions as to the pathology of the gonorrheal process 
and therefore untenable from the bacteriological standpoint and 
against the fundamental laws of modern surgery. Does any sur- 
geon, taking charge of an infected wound, advise to delay the appli- 
cation of antiseptics for a week until the disease has reached the 
acme, or does a gynecologist in a case of puerperal fever prescribe 
sandalwood oil and plenty of seltzer and milk for ten days and more 
before he dares to resort to local interference? And the same rules 
should apply to the treatment of gonorrhea. It must be effective 
and should begin as early as possible to prevent the gonococcus 
from penetrating the tissues, and it should be kept up until we are 
satisfied that all the gonococci are annihilated. In a paper read 
before this body about twro years ago, I presented my views upon 
this subject in detail; neither time nor your patience would allow 
of reiterating them to-night. I only state briefly that the silver- 
salts still rank highest among the antigonorrhoics and that their 
value in destroying the vitality of the gonococcus is daily more 
appreciated. 
For the past fourteen months I have used protargol, a silver- 
salt, which was highly recommended by Neisser and which favor- 
ably compares with argonin in its prompt effect and total lack of 
irritation of the tissues. It has a strong penetrating power and 
is therefore also applicable in the more chronic cases. But in 
using any of the silversalts we must not forget that more or less 
reaction will follow each application, which manifests itself by a se- 
cretion lasting for from four hours to several days, according to the 
concentration of the solutions used. In applying the nonirritat- 
ing silver solutions in very mild concentration, we make a grave 
mistake by only injecting during the day for say fourteen hours, 25 
while nothing is done at all during the night. What we gain 
during the day we lose again in this way, forgetting that our reme- 
dies are not a permanent antiseptic dressing. This is of the greatest 
importance for the acute stage of the disease, in which the gono- 
coccus is at the height of its energy and vitality, and multiplication 
takes place rapidly, while in the stadium decrementi more concen- 
trated solutions may be used and at longer intervals. 
It should further be an absolute rule not to apply an irritating- 
silver solution to the tissues before the acute reaction has passed 
off. The oculist will not treat the conjunctiva with a few drops of 
a one per cent nitrate of silver solution oftener than once in forty- 
eight hours, and yet there are men who advise daily brushing of 
the whole acutely inflamed urethra with ten and twenty per cent 
solutions of this salt through the urethroscope until the submucous 
tissue, denuded of the protective epithelium, offers an open gate 
for the invasion of the system by the gonococcus. 
Another point of importance is that the silversalts in a cer- 
tain concentration do not check the catarrh, and they ought there- 
fore not be expected to dry up the canal after having annihilated 
the gonococci. To do this and do it at the right moment is left 
to the astringents, which accomplish the desired result within a 
very short time. Wherever this does not take place, when even a 
scanty secretion appears at the meatus or only as filaments in the 
urine, we will have to search for complications. The most com- 
mon are strictures or their forerunners, glandulitis and periglandu- 
litis, or the disease has invaded the posterior urethra, the seminal 
vesicles and Cowper’s glands. By stripping these parts and by 
a microscopical examination of the stained specimen obtained in 
this way, we gain valuable information as to the nature of the secre- 
tion, and remove any doubt of the case being one of urethrorrhea, 
prostatorrhea or gonorrhea. But many a case of posterior ure- 
thritis of the final type is indiscriminately treated with injections in 
the anterior urethra for months, and from these quarters you will 
often hear the complaint that the silversalts do not give any better 
results than other applications. And in many a case of chronic 
or subacute anterior urethritis deep injections into the healthy 
posterior urethra, and even into the bladder, are made or bougies 
passed, unnecessarily irritating and injuring the parts not con- 
cerned in the disease. 
Altogether, we will rarely have occasion to see posterior ure- 
thritis in those cases of acute gonorrhea which are treated from 
the start with the silversalts, provided the patient observes our in- 
structions in regard to diet and habits. 26 
On the other hand, this complication and others like cystitis, 
epididymitis, prostatitis and prostatic abscess will hardly ever fail 
to appear in the course of a gonorrhea, if we do not understand that 
the gonococcus can be killed by the steel sound. Now, if this is 
the correct and scientific procedure, why is it not adopted by the 
surgeon? Why doesn't he poke a piece of steel into an infected 
wound or into a septic peritoneal cavity? But I understand the 
effect desired in passing heavy steel sounds in gonorrhea is not 
only mechanical, but also absorptive. Now, what do we wish 
absorbed in acute or subacute gonorrhea? In this stage of the 
disease there are no plastic infiltrations or indurations, and the 
only product which might possibly become absorbed is the gono- 
coccus. I hope I do not exaggerate when I say that some cases 
of general infection are started from lesions in the urethra caused by 
the steel sound. Many cases are reported and I have seen some 
in which these symptoms rapidly followed a forcible instrumenta- 
tion in an infected urethra. 
We will find many pages in the text-books filled with theories 
and discussions regarding the question whether posterior urethritis, 
cystitis and epididymitis appear at the end of the second or 
third week after the first alarm at the meatus, and some cases are 
recorded in which these complications were noticed after eight days. 
I can only say that these complications appear within forty-eight 
hours after a steel sound is passed into the healthy posterior urethra 
through an infected pars anterior. 
Where this does not occur the patient had incidentally washed 
out the gonococcus from the surface of the canal by urinating 
before the manipulation. 
Looking for an explanation why this remainder of our former 
misapprehension of the infectious character of the disease still 
enjoys the favor of so many followers, we will have to turn back 
to the time when we knew little or nothing of the etiological signifi- 
cance of the gonococcus and of the pathology of the process. 
There have been cases in which the gonococcus had exhausted its 
own vitality, as do other microorganisms, leaving behind infiltra- 
tions around the follicles and with them scanty seromucoid or 
mucopurulent discharges; in others the secretion was so scanty that 
it did not appear at the meatus, but remained glued to the urethral 
mucosa until the stream of urine washed it out, rolling it up and 
giving it the shape of filaments or shreds. This was the place where 
the steel sound victoriously dominated. There was occasion to 
crush infiltration, stimulate circulation and further the absorption, 
and the urethra became dry. 27 
But this, unfortunately, induced the misconception that the steel 
sound had cured chronic gonorrhea, and, consequently, led to the 
conclusion to apply it in the earlier stages in order to prevent 
gleet. How disastrous the conclusion was will only be appre- 
ciated by those who, blindly following the teaching, caused so 
much harm and still see it done by others. Recognizing this de- 
plorable fact, one might almost wish that the real advantages of 
the steel sound had never been discovered, or at least not until 
fifty years later. 
I do not expect to be understood that the steel sound and 
bougies are exclusively responsible for the many complications 
in the course of a gonorrhea; they quite often follow treatment 
by internal medication alone and more yet frequently injections 
with the four sulphates, resorcin, thalin, tannic acid, alum, bismuth 
and many other preparations. If anybody would tell me to-day: 
“So and so many cases have been cured by these remedies,” I 
would only answer that those which really got well did so not 
because of, but notwithstanding, the treatment, and then almost 
invariably at the expense of the normal condition and function of 
one or the other of the main or accessory genital organs. Other- 
wise we would not see so many cases of stricture, indurating pros- 
tatitis, perivesiculitis adhesiva, azoospermy, aspermatism, and 
sexual neurasthenia. But in the vast majority of the so-called cured 
patients a thorough examination would have revealed the gono- 
coccus, alone or associated with other microorganisms, in the fila- 
ments of the morning urine, in the secretions of Cowper’s glands, 
prostate, and seminal vesicles, obtained by stripping, and in the 
discharge expres'sed from the follicles and adhering to the probe- 
pointed bougie after passing the latter up and down the anterior 
urethra. 
These are just the cases which largely contribute to the surgical 
work of the gynecologist. They are responsible for the repeated 
question: “When may a person, once afflicted with gonorrhea, 
safely be permitted to marry?” This question will find its answer 
at the close of this article. I only desire to say here that I do not 
indorse the common expression, “Once a gonorrhoic, always a 
gonorrhoic.” 
Another source of unduly prolonged urethral gonorrhea is the 
infected paraurethral ducts, which should be looked for in cases 
in which the discharge appears time and aeam after every symp- 
tom of the disease had disappeared, or when, excluding a new 
infection or a posterior urethritis, the persistence of the symptoms 
points to some abnormal condition in the pars anterior. Touton was the first to call attention to this congenital mal- 
formation. Diday first observed paraurethral blenorrhea, and Otis, 
in analyzing three of his cases says: “The foregoing cases, taken 
together, appear to me to warrant the inclusion of follicular sinuses 
among the possible causes of persistent urethral discharge. 
Most frequently I have occasion to see paraurethral ducts asso- 
ciated with congenital malformation, such as hypospadias and epi- 
spadias, in which cases they can hardly be overlooked, being located 
either in the groove shaped open part of the canal, or in the raphe 
penis, the limbus preputii, and around the blind urethral excava- 
tion at the apex glandis. But they are more frequently overlooked 
when situated inside and near the orifice of a normal urethra. Con- 
servative treatment in these cases is not very satisfactory, better 
and more speedy results could be obtained by division and cauter- 
izing, or as Ehrman on the basis of twenty-three cases advises, 
electrolysis. The same is true of chronic gonorrhea of Cowper’s 
glands, extirpation being the most reliable expedient. Extirpa- 
tion, in chronic cases of perivesiculitis, was also advised by Eugene 
Fuller in a very able paper in the Journal of Cutaneous and Genito- 
urinary Diseases some two years ago. Persistent massaging, hot 
rectal injections and local applications of silver solutions have 
given me satisfactory results in most desperate '"ases, and should 
therefore be fully exhausted before the certainly effective, but seri- 
ous operation is resorted to. 
Time does not allow me to dwell long on the merits or demerits 
of various other methods used in gonorrhea; I have to confine my 
very brief remarks to Valentine and Danet’s irrigations and the 
Oberlander-Kollman treatment with dilating and flushing of the 
canal, either successively or simultaneously. The reports as to their 
efficiency in acute gonorrhea are contradictory. I would not recom- 
mend either. They might perhaps, by simply washing out, do good 
in a very mild case at a moment when comparatively few 
gonococci appear on the surface of the urethra, but they do much 
traumatic harm in an acutely inflamed canal. In chronic cases, 
where the process is confined to a limited number of follicles, the 
combined treatment of cauterizing through the urethroscope or 
dilating and irrigating in experienced hands will be gratifying. 
It is hardly necessary to emphasize the hopelessness of a cure 
by an abortive treatment, and wherever such a result is obtained 
by the application of highly concentrated solutions it is done at the 
expense of the tissues, which break down and cicatrize, and I would 
not call such a result a cure. 29 
The cure of gonorrhea by internal medication exclusively will 
always remain an ideal, because it can not be realized, and those who 
believe in it are happy in the delusion, which the patient does not 
share quite as long. 
It remains to discuss the most important point in this subject— 
“When may the gonorrheal process be pronounced extinct?” This 
question is unfortunately raised at a very late moment, usually a 
week or so before the inquirer secures his marriage license, instead 
of at the end of treatment. 
The answer is short and decisive: When no gonococci exist 
or may be suspected as existing along the urethral canal and in 
the neighboring organs related to it. But, how are we going to 
find this out? What means do we have to decide whether a scanty 
mucoid or seromucoid secretion at the orifice, or one or more 
shreds in the urine are of gonorrheal origin or ordinary urethror- 
rhea, prostatorrhea, or urethral catarrh? 
We know that, for longer or shorter intervals, secretion and 
shreds do not appear in the urine and, nevertheless, the gonorrheal 
processus still in existence, although latent, because the diseased 
Littre glands are temporarily closed, or because a mutual adaptation 
between the gonococcus and the tissues has taken place. It is not 
necessary to discuss this well-known fact in detail, or that this 
amicable relation does not mean more than a truce until a sexual 
excitement, an exposure, indulgence in alcohol or physical over- 
work occurs as a disturbing element. In remembrance of this, 
we will always be in a position to provoke a secretion, in which at 
least a few specimens of the gonococcus can be found, or if this 
should not be the case, we may get the final answer from a culture 
test. When it comes to decide such subjects or to the more chronic 
and aggravated cases it is evident that only a specialist or a very 
few especially versed general practitioners can deal with problems 
requiring special appliances and extended experience. But it is the 
province of the general practitioner to deal with acute gonorrheal 
urethritis, because it is he to whom as a rule the patient applies 
first for advice and in his hands rest the management and final 
development of the case. 
If the rules on this matter should become uniformly adopted, 
if we all could agree as to the modern principles of diagnosis and 
treatment of gonorrhea, there would not be much left of the “rav- 
ages of gonorrhea,”\here would not be any need to call for “leg- 
islation against the spreading of gonorrhea,” and gynecological so- 
cieties could afford to turn attention to more fruitful subjects than 30 
discussion as to the advisability of police control of prostitutes. 
Then the time will have arrived to place on the shelves of the med- 
ical curiosity museum, next to the steel sounds and sandalwood oil 
the sentence, attributed to the great French syphilologist, Ricord, the 
honor of whose birthplace belongs to this country: “Une chaude 
pisse commence, Dieu le sait quand elle finira!” Or, in our own 
language: “Gonorrhea a disease which starts as a slight burning 
urination, but only the Lord knows when and how it will end.” 
Schiller Building.