THE TREATMENT OF GONOR- 
RHOEAL INFECTIONS IN THE 
FEMALE BY PERMANGANATE 
OF POTASSIUM. 
Charles Greene Cumston, M.D., 
BOSTON, MASS., 
Instructor in Clinical Gynaecology, 
Tufts College. 
Reprinted from Annals of Gynacology 
and Pmdiatry. 
BOSTON, 1895. THE TREATMENT OF 
GONORRHOEAL INFECTIONS IN THE FEMALE 
PERMANGANATE OF POTASSIUM 
A CLINICAL LECTURE DELIVERED AT THE SUFFOLK DISPENSARY 
BY 
CHARLES GREENE CUMSTON, B. M. S., M. D., 
Instructor in Clinical Gyncecology, Tufts College; Member of the SociSte 
Frangaise lElectrotherapie. 
THE HARVARD PRINTING COMPANY. 
Cambridge, Mass.: 
I^9S* The Treatment of Gonorrhoeal Infections in the Female by Perman- 
ganate of Potassium. 
A CLINICAL LECTURE DELIVERED AT THE SUFFOLK DISPENSARY BY 
CHARLES GREENE GUMSTON, B. M. S., M. D., 
Instructor in Clinical Gynaecology, Tufts College; Member of the Societe Franyaise 
cP Elec tr other apie. 
Gentlemen : —This little girl of 
ten years of age has been brought to 
us on account of vaginal discharge, 
which, according to the child (and in 
these cases you always should be 
prudent in accepting the statements 
of children), came on a week ago 
without any cause. Her health is 
fairly good, but the weak condition of 
her eyes and build lead me to con- 
sider her as lymphatic. She com- 
plains of no pain on urinating and no 
pruritus or burning sensation about 
the vulva. 
preparation stained with Loeffler’s 
methyl blue solution and examined it 
under the microscope, with what 
result ? 
I found the gonococcus in consider- 
able numbers and the diagnosis was 
made. 
This is the course that I strongly 
advise you to employ in these cases, 
as you thus avoid useless questioning 
and arrive at a positive and speedy 
diagnosis of the nature of the affec- 
tion present. 
On examination, we perceive that 
the hymen is intact, that the orifice 
of the vulva is in a condition of 
active hyperemia. A little yellow 
pus is seen coming through the orifice 
of the hymen, but when I ask her to 
cough it gushes out in great quan- 
tity. 
This case is most interesting in the 
pathological and medicolegal point 
of view, but these questions I shall 
leave aside today, as I desire to speak 
to you of a special treatment of 
gonorrhoea, namely by permanganate 
of potassium, which has been put 
forward recently by several French 
physicians, notably by Dr. Janet. 
Now, gentlemen, what did I do in 
this case? I did not push the child 
with questions, for she probably 
would have lied about the cause of 
this condition of affairs and I might 
by so doing put ideas into the child’s 
mind that were not already there, if 
she has not been abused by some boy 
or man. 
J have employed this treatment for 
some time in gonorrhoea of the male, 
and lately since reading the reports 
of its application in gonorrhoeal infec- 
tions in women, I have put it to test 
in several cases with excellent results. 
You are all aware that gonorrhoeal 
infections in women present a very 
considerable gravity. The great 
number of orifices and glands about 
the vagina and urethra make good 
I simply took a drop of pus on a 
platinum needle, made a cover-slip 4 
CHARLES GREENE CUMSTON. 
hiding places for the gonococcus to 
locate and multiply. The communi- 
cation with the peritoneal cavity by 
means of the uterus and tubes from 
the external genital organs exposes 
the patient to extremely serious com- 
plications. 
But the researches of many authori- 
ties in France and Germany have 
established in an unmistakable man- 
ner that in more than 50 per cent, of 
the cases the urethra has been in- 
vaded. 
The chronic form is far more fre- 
quently met with, the proportion 
being, according to Charon, about 
five of the former to one of acute 
urethritis. The external orifice of 
the female urethra is surrounded by 
follicles and minute tubular glands, 
the so-called Skenes glands, and it is 
precisely in these glands that the 
gonococcus becomes established. 
When you are consulted for a 
trouble which you suppose to be 
gonorrhoea, you should make a most 
careful examination in order to deter- 
mine the parts that are invaded by 
Neisser’s organism, for if you intend 
instituting an antiseptic treatment, 
your antisepsis must be complete, or 
else do not undertake it. 
To overlook the treatment of an 
orifice is to put yourselves in the 
unhappy position of seeing all those 
that you have treated reinfected by 
this remaining neglected focus. 
In 1864 Guerin had already de- 
scribed the inflammation of the peri- 
urethral glands, and of late quite a 
number of memoirs have appeared 
regarding this pathological condition. 
Your treatment should be method- 
ically applied, and, following Tixeron, 
you will proceed as follows : firstly, 
disinfection of the urethral ,and peri- 
urethral glands; secondly, disinfec- 
tion of Bartholinis glands; thirdly, 
disinfection of the vagina and uterus. 
In making a differential diagnosis 
of these various affections, micro- 
scopical examination of the dis- 
charges is of greatest value, as the 
gonococcus will be discovered if it 
be present in the slightest secretion ; 
consequently I think it would be 
well for you to carry out my plan as 
you have seen me do in the case of 
our little patient. 
Up to within a short time, gonor- 
rhoea in the female was considered as 
very infrequent. The older writers 
thought that the malady resided in 
the vagina, and on account of the 
considerable discharge from this cav- 
ity the accompanying discharge from 
the urethra was overlooked. The 
urethritis was not noticed because 
the acute symptoms are not com- 
plained of by the patient, probably 
on account of the little urethral sur- 
face in the female and also because 
the duration of the acute stage is 
always of short duration in the 
weaker sex. 
The symptoms of gonorrhoeal uri- 
thritis are well known to you, as they 
are practically the same in women as 
in men, with the exception of a much 
less intensity and general reaction in 
the former. Now, I have told you 
to examine microscopically the dis- 
charges, and my reason, among others, 
is, that by this means you will cor- 
rectly determine the stage at which 
the affection has arrived. For ex- 
ample, in the first stage you will find 
the gonococcus, in the second there GONORRHOEAL INFECTIONS IN THE FEMALE. 
5 
will be various organisms present, 
while in the third you will only find 
altered anatomical elements. Con- 
sequently your treatment will vary 
according to the stage of the disease, 
and I will now trace it out for you. 
sent in the resulting discharge a cure 
may be considered as obtained. 
We now come to the treatment 
of the second stage, in which many 
varieties of organisms may be present 
in the discharge. On account of the 
proximity of the vagina with the 
urethra, the latter is continually 
bathed in the mucous secretions of 
the genital organs, and, as you prob- 
ably know, these secretions afford a 
most excellent culture media for in- 
fectious bacteria; consequently it 
frequently happens that it is infected 
by this means, the infection showing 
itself by a slight discharge, in which, 
microscopically, you will be able to 
make out a number of varieties of 
bacteria. 
Treatment of the stage with the 
gonococcus. When you have found 
the organism in question, a urethral 
and vesical irrigation should be made 
with a solution of permanganate of 
potassium. The strength of the solu- 
tion must vary from 1 per 1000 to 1 
per 2000, according to the given case, 
and the quantity at each irrigation 
should be at least one litre. The 
irrigation should be practiced every 
day, the usual duration of treatment 
being from ten days to two weeks or 
thereabout. 
This form of urethral infection is 
easily controlled by a 1 in 20,000 solu- 
tion of bichloride of mercury, with 
which the bladder should be irrigated. 
You will notice that the discharge 
passes through successive changes 
before completely disappearing. Dur- 
ing the first few days it becomes 
opaline and more watery, while the 
gonococcus generally is no longer to 
be found after the fourth or fifth 
irrigation. 
The third and last stage is, as I 
have already said, that in which the 
microscope reveals only anatomical 
elements, such as round epithelial 
cells, leucocytes, glandular dSbris, 
iodophile cells, etc. 
The patient should then be care- 
fully watched for the week following 
treatment, as is recommended by Dr. 
Janet, and after this lapse of time he 
advises testing the cure by a slight 
reaction on the mucous membrane 
of the urethra, in order to ascertain 
if the gonococcus has entirely dis- 
appeared. 
In this case the object of your 
treatment must be to modify the 
mucous membrane of the urethra, and 
I consider, with Tixeron, that a 1 
per cent, solution of ichthyol is the 
best preparation for accomplishing 
this. It should be used in the form 
of injections, a glass syringe being 
used. 
This reaction is obtained by the 
instillation of a few drops of a T per 
cent, solution of nitrate of silver into 
the urethra, or by allowing the 
patient to drink several glasses of 
beer. If the reaction which takes 
place shows the gonococcus to be ab- 
The treatment of infection of the 
peri-urethral and Bartholini’s glands 
should be directed in such a manner 
that the antiseptic will penetrate 
inside the gland. In order to attain 
this result you should begin by press- 6 
CHARLES GREENE CUMSTON. 
ing out with the fingers the contents 
of the gland. When this is accom- 
plished, you introduce the needle of 
an Anel’s syringe, such as is used by 
oculists, into the orifice of the gland, 
and the solution of permanganate of 
potassium, which should be strong, 
say 1 per cent., is to be quickly and 
forcibly pushed in. The quantity of 
solution for each gland is one cubic 
centimetre. 
the urethra at each coitus, ultimately 
results in a more or less complete 
infection. I have many personal 
cases of this description, mostly occur- 
ing among the better class of people, 
which I have carefully examined, 
both as to the condition of the hus- 
band as well as the wife. 
The spreading of the disease to the 
tubes and pelvic peritoneum should 
always be present in your mind when 
making your prognosis, and the treat- 
ment of a gonorrheal metritis, which, 
when the lesions are not advanced, is 
not very difficult, may become ex- 
tremely so, when the adnexa are 
invaded, because the gonococcus from 
the tubes may reinfect the uterus 
when this organ has been cured of 
the disease. Thus the infection after 
being ascendant becomes descendant. 
If after a few trials the gonococcus 
does not disapper from the secretions 
the gland should be destroyed by a 
galvano-cautery, as advised by 7 Dr. 
Janet. To do this, a small platinum 
needle is inserted in the gland and 
the current turned on. 
I have now finished with the treat- 
ment of urethritis and will now pass 
to the important chapter of gonor- 
rheal infection of the uterus. 
This organ possesses many glands, 
which are especially deep seated in 
the cervix and beside the endome- 
trium in rich infolds. All these 
anatomical conditions offer excellent 
soil for Neisser’s organism to develop 
in. 
This possibility must not discour- 
age you in your treatment. Continue 
your disinfection of the uterus, for 
the tubes do not contain glands and 
the gonococcus cannot live long in 
them, at least in most cases. 
As the uterus communicates freely 
with the vagina, which is always the 
home of many infectious organisms, 
the uterus may be reinfected from 
this canal after treatment by the per- 
manganate of potassium. You will 
consequently watch closely the con- 
dition of things for a few days after 
completing your treatment. 
Gonorrhoeal metritis may develop 
without a preexisting vaginitis or 
urethritis, by direct inoculation in the 
cavity of the cervix. This is an 
important fact for you to bear in 
mind, as this form is met with often 
in young married women, and, from 
my personal experience with gonor- 
rheal metritis, I am inclined to 
believe that it is produced by gleet in 
the husband, so that although his 
urethral discharge may amount to 
only a drop or two in the twenty-four 
hours, the constant inoculation of 
perhaps only a trace of mucus from 
Now, there is no doubt in my mind 
that intra-uterine irrigations of per- 
manganate of potassium have an 
effect on gonorrhoeal infection that is 
to be had with no other antiseptic. 
But the great point is to have a flow 
of sufficient quantity and. force, and 
this can be accomplished with the GONORRHOEAL INFECTIONS IN THE FEMALE. 
7 
Rotunda Hospital douche. This in- 
strument may be adapted to any 
pitcher or bowl that is at hand, and 
its value in surgery and obstetrics is 
without compare. 
din or Reynolds are perhaps the best. 
If, however, you employ the latter 
instrument, I think it well to give it 
the necessary curve for the uterus 
you are treating. 
There are very few physicians or 
nurses that know what a good douche 
is. I even know of the ordinary 
enema syringe being used for intra- 
uterine irrigation. To say the least, 
this a is most barbarous practice, and I 
trust that none of you will ever be 
guilty of such unsurgical technique. 
Not only is there danger of pumping 
up air into the cavity of the uterus, 
but the force and quality of the jet 
leave much to be desired. Then you 
have the fountain syringe, which is a 
decided improvement over the former 
douche, but which does not permit of 
a sufficient flow of liquid, owing to 
the small diameter of the rubber tub- 
ing and also no stop-cock allowing 
the quantity of liquid to be regulated. 
The Rotunda douche leaves nothing 
to be desired. With it you can 
obtain a very considerable or very 
small jet of liquid, and, above all, it is 
easily kept clean and is portable. So 
much for the douche. 
When the cervix is sufficiently per- 
meable to admit of an easy introduc- 
tion of the catheter, which should be of 
small calibre, it is better to irrigate 
without dilating, so as to avoid all 
traumatism to the uterus, which is 
most important. The end of the 
sound is pushed gently up to the 
fundus and the stop-cock is slowly 
opened. The strength of the solution 
of the permanganate should be from 
1 to 3000 or 2000, while the level of 
the solution should be about four feet 
above the patient. 
You must watch carefully to see 
that the liquid runs out as fast as it 
enters, and, if it does not, you must 
stop the flow and find out where the 
obstruction is. The first irrigations 
are rather painful, but the last do 
not trouble the patient much. 
When the uterus will not admit 
the easy introduction of the catheter, 
dilatation becomes necessary. To 
obtain this you may employ Hegar’s 
sounds or laminaria. After dilatation 
is sufficient, the technique of the 
irrigation is the same as I have just 
described. There are also here three 
stages of discharge the same as I 
pointed out in the commencement of 
this lecture, and I will not repeat 
them again. To each of these three 
stages corresponds a treatment. 
With abundant irrigation (and here 
I differ from Dr. Janet, for I employ 
from two to three litres at each 
seance, the former only uses about 
one litre, if I am not mistaken) you 
clean the surface of the endometrium 
of the mucous debris and fibrous 
coagulations which are excellent 
culture media for the gonococcus, 
and the antiseptic comes directly in 
contact with the infected tissue. 
While the gonococcus is present, 
the strength of the solution of per- 
manganate will vary from 1 to 2000 
or 3000, according to the patient, 
and in cases where the reaction is 
As to the intra-uterine catheter to be 
employed I have no particular choice, 
those of Fritsch, Collin, Budin, Rever- 8 
CHARLES GREENE CUMSTON. 
not intense, you may even employ 1 
to 1000. The duration of the treat- 
ment cannot be set down, but it 
varies from eight to fourteen irriga- 
tions, one being made daily. 
If the discharge persists in spite of 
the vaginal douching, a few applica- 
tions of a 10 per cent, solution of 
ichthyol should be made to the endo- 
metrium. 
Microscopical examination of the 
discharge should be made daily, and 
this will furnish you with the most 
important indications as to the 
strength of your solution and the 
length of time that the douching is 
to be kept up. 
In closing, I would say that the 
curette has its indications, and that 
the above treatment I only advocate 
in the more recent infections. In 
old cases of metritis, Neisser’s organ- 
ism has disappeared and the perman- 
ganate would have no action. 
If the metritis is very acute with 
considerable abdominal pain, you 
must wait a few days until the acute 
symptoms have subsided, and to ob- 
tain this I know of nothing better 
than the application of' equal parts 
of the mercurial and belladona oint- 
ment over the abdomen, with absolute 
rest in bed. 
There are many other methods of 
treating gonorrheal metritis, by appli- 
cations of carbolic acid, nitric acid, 
chloride of zinc either in solution or 
in the form of a paste made up into 
a cayon to be introduced into the 
cavity of the uterus, but these 
methods are as dangerous as they are 
useless. 
It is quite safe to say that after 
fourteen irrigations the gonococcus is 
destroyed and the treatment can be 
discontinued, after which the patient 
should be carefully watched for four 
or five days. 
In the case of our little patient I 
have ordered daily irrigations of per- 
manganate of potassium at the 
strength of 1 to 2000, and I trust that 
I can show you the remarkable effect 
of the treatment. 
During this time a slight discharge 
may appear, containing a number of 
varieties of bacteria. The best means 
to avoid this discharge is to order a 
disinfection of the vagina morning 
and evening, with a 1 in 10,000 solu- 
tion of bichloride of mercury. 
(The patient was seen one week 
later, the discharge had disappeared, 
and examination of the urethral and 
vaginal secretions could reveal no 
trace of the gonococcus. The child 
did not complain of any pain produced 
by the permanganate.)