GONORRHCEAL IRITIS AND NON-SUPPURATIVE 
GONORRHCEAL CONJUNCTIVITIS, AND 
THEIR PATHOLOGY. 
by 
WILLIAM CHEATHAM, M.D., 
PROFESSOR OF OPHTHALMOLOGY, OTOLOGY, AND LARYNGOLOGY IN THE LOUISVILLE MEDICAL 
COLLEGE, ETC., LOUISVILLE, KENTUCKY. 
Reprinted from the Archives of Ophthalmology, Vol. xxv., No. 4, 1896. GONORRHCEAL IRITIS AND NON-SUPPURATIVE 
GONORRHOEAL CONJUNCTIVITIS, AND 
THEIR PATHOLOGY. 
WILLIAM CHEATHAM, M.D., 
PROFESSOR OF OPHTHALMOLOGY, OTOLOGY, AND LARYNGOLOGY IN THE LOUISVILLE MEDICAL 
COLLEGE, ETC., LOUISVILLE, KENTUCKY. 
MANY of our authors, Stellwag,1 Williams,2 Carter,3 
Juler,4 do not seem to recognize gonorrhoea 
as a cause of iritis. I have had three cases quite recently 
(one a relapsing case, the iris becoming involved at each 
invasion of the urethra), in the first of which there was 
quite a lively synovitis of all the large joints, but in the sub- 
sequent attacks the iris involvement came without the 
synovitis; a permanent posterior synechia may account 
partially for this, as some writers on the subject say a syno- 
vitis must precede the iritis. Nettleship,6 page 444, says : 
" Rheumatic iritis occurring for the first time with gonorrhoeal 
rheumatism is, in my experience, more often symmetrical 
than other forms of arthritic iritis or the later attacks of 
iritis in the same patient. Of 104 cases of iritis with well- 
marked rheumatic symptoms, and 6 with gonorrhoea but no 
rheumatism, in all of which syphilis was so far as possible 
excluded ; (a) In 34 of this series the first attack of iritis 
came on during or very soon after gonorrhoeal rheumatism ; 
in exactly one half of these cases the iritis was double. In 
6 others (making 40 in all) there were iritis and gonorrhoea 
but no rheumatism (gonorrhoeal iritis), and here the propor- 
tions were the same. ($) In the remaining 70 cases the first 
iritis had no relation to gonorrhoea, and in the sub-series the 
attack was single in 56 and double in, at the most, 13 (2 or 
Reprinted from the Archives of Ophthalmology, Vol. xxv., No. 4, 1896. 511 
Gonorrhoeal Iritis. 
3 being doubtful), or about -j-. No corresponding difference 
obtained in regard to the relapses, the vast majority of the 
recurrent attacks in both sub-groups affecting only one eye 
at the time. Some cases of gonorrhoeal iritis have been 
described in which there is iritis due to gonorrhoea without 
arthritis being actually present. Probably in these cases the 
iritis is the first indication of gonorrhoeal rheumatism ; a 
variety of quiet conjunctivitis not due to infection has also 
been described, without pain, and hardly any discharge. 
(Despagnet and others)." 
It will be observed from this that Mr. Nettleship recog- 
nizes gonorrhoea as a cause of iritis; that it can be and is 
present in small numbers of cases without arthritis ; also 
that we have a non-suppurative form of gonorrhoeal conjunc- 
tivitis, a case of which I will report later. 
Max Knies,8 page 312, says: "Gonorrhoea may also be 
the cause of metastatic diseases of the eye, especially of dif- 
ferent forms of iritis. These exhibit marked clinical simi- 
larity with so-called rheumatic iritis in articular rheumatism ; 
they are often associated with spontaneous coagulation of 
the fluid in the chamber (so-called lens-shaped or gelatinous 
exudation, spongy iritis) but exhibit no other peculiarities. 
This form of iritis, which is observed almost exclusively in 
men, is usually bilateral, and often returns with relapses of 
the gonorrhoea, or alternates with inflammation of the joints. 
As a rule, the iritis is associated with inflammation of the 
joints, especially of the knee and ankle, and the clinical simi- 
larity to rheumatic iritis is thus increased. Forster (Z. 0., 
page 86) mentions a number of cases in which the inflam- 
mation of the joints and the iritis relapsed, but not the 
gonorrhoea." 
It has been my experience to have had more cases of 
iritis in chronic rheumatism, than in acute attacks. 
Noyes,7 page 410, says : " Gonorrhoea occasionally causes 
iritis. The arthritis of gonorrhoea is due to the presence 
of gonococci in the joints, and the same explanation is 
probable for iritis." 
Roosa,8 page 313, says: "Gonorrhoeal iritis occurs oc- 
casionally in the course of urethritis, especially of that which William Cheatham. 
512 
has associated with it inflammation of the joints. It is 
rather a rare disease." 
DeWecker,9 page 176, under the head of blennorrhagic 
iritis, says : " It is peculiar in that it is made up of both 
serous and plastic iritis. It is correlated beyond all doubt 
with the rheumatic form, for we never see an inflammation 
of the urethra followed by iritis without some joint having 
been attacked previously. If I distinguish it from rheumatic 
iritis it is because it does not present the true anatomical 
character of the latter, and because it is a hybrid form, being 
easily cured and leaving no traces, while reappearing very 
readily, whenever the patient has the least tendency to 
urethritis." 
DeWecker says : " We must have the joint involvement 
precede the iritis." In this I am sure he is mistaken ; also 
equally sure that he is in error when he says the disease gets 
well with no damage to the organ. In a sero-plastic inflam- 
mation of the iris there must be some involvement of the 
ciliary body. In a case I have on hand now which was rec- 
ognized and treated early in the disease, there is synechia 
posterior which will not give way. I think the disease runs 
a shorter course and is more easily managed than iritis from 
other causes, but there is often much permanent damage 
resulting. 
Swanzy,10 page 224: " Gonorrhoeal iritis is a mixture 
of the plastic and the serous forms. It does not attend on 
nor immediately follow a gonorrhoea, but an attack of rheu- 
matic arthritis, usually of the knees, always intervenes. 
Gonorrhoeal iritis is extremely rare." 
Schweigger,11 page 342 : " Iritis also occurs in connection 
with articular rheumatism, especially those forms which ap- 
pear to stand in connection with gonorrhoea." 
Juler 4 does not refer to it in the recent edition of his 
text-book, 1893. 
Berry,12 page 132: "Closely allied to rheumatic iritis 
is the rare form which undoubtedly is associated with gon- 
orrhoea. The inflammation is always severe, and the cause, 
owing to co-existing inflammatory changes in the joints, apt to 
be overlooked. Gonorrhoeal iritis always seems to occur in 513 
Gonorrhoeal Iritis. 
both eyes, though not always quite simultaneously, and with 
it may be different degrees of severity in the two eyes. Suc- 
cessive attacks of gonorrhoea are sometimes accompanied 
each time by iritis, and in other cases, although no fresh in- 
oculation takes place, a return of the joint affection may be 
accompanied by a recurrence of the iritis as well." 
Norris and Oliver,13 page 358 : " Notwithstanding the 
prevalence of gonorrhoea and the assertion of Forster that 
if the urethra be habitually inspected in every case of iritis, 
the two diseases would be found more frequently coinciding, 
yet iritis due to gonorrhoea clinically seems to be of com- 
paratively rare occurrence. It does not generally occur as 
an immediate consequence of gonorrhoea, but develops in 
those cases where there are swelling of the joints and rheu- 
matism. In such cases renewed attacks of gonorrhoea are 
frequently accompanied by fresh exacerbation of iritis." 
" Forster asserts that, even where there has been no new 
infection, there may be a fresh attack of iritis whenever from 
any cause there is a recurrence of a thin gleety discharge 
from the urethra." 
Case i.-The patient was a woman. She had just returned 
from her bridal tour when she came to see me concerning an in- 
flammation of her eyes. I found she had double iritis ; on look- 
ing for the cause she spoke, after some questioning, of having a 
severe attack of the " whites," attended by great pain on urina- 
ting ; she said during her trip her modesty prevented her attend- 
ing to the calls of nature as regularly as she should have done, 
and attributed the symptoms to that. She had some pain in her 
limbs with some swelling of the joints. I put her on the usual 
local treatment, and gave her internally oil of gaultheria and po- 
tassium iodide ; recovery was quite prompt. I afterwards learned 
that her husband had gonorrhoea at the time of his marriage ; 
that he had delayed the wedding on this account as long as 
possible. 
Case 2 is in a gentleman. Both eyes are involved, the left much 
worse than the right. This case has been much more obstinate ; 
it was of the sero-plastic form. It is undoubtedly a case of 
gonorrhoeal iritis. This case was a very violent one in which 
leeches had to be used. It has been on hand now six or eight weeks. William Cheatham. 
514 
Case 3 was in the person of a young married woman. I found 
her suffering but little pain, except when exposing the eye to light. 
She had the room darkened, and had been using cold cloths 
locally. She had gonorrhoea acquired from her husband, who 
thought himself well. She had three relapses, each preceded by 
an exacerbation of her gonorrhoea and an arthritis. Atropia 
would not at first dilate her pupil • cocaine muriate and hot 
fomentations followed by atropia finally gave her a round pupil; 
this case was sero-plastic in form. As soon as her pupil was 
dilated, and oil of gaultheria given a few days, her recovery was 
quite rapid. The relapses were several weeks apart. Each re- 
lapse was, as I stated before, preceded by an exacerbation of her 
gonorrhoea and an arthritis ; each relapse was less severe than 
the preceding one. The patient finally made a good recovery. 
I have recently had under my care for the third time a gentle- 
man with conjunctivitis ; both the ocular and palpebral conjunc- 
tivae are involved ; vision is perfect ; there is considerable burning 
and pain, with little or no secretion ; some photophobia; no 
rheumatism ; no involvement of any of the other tissues of the 
eyes. He has had two previous attacks of gonorrhoea, with each 
of which he had similar attacks of conjunctivitis. I gave him an 
eye-bath of saturated solution of boric acid, to be used hot every 
two hours, with salicylates internally. Recovery was very rapid. 
There was some tendency to relapses when there was from any 
cause an exacerbation of the urethritis. The peculiarities of this 
case of conjunctivitis was the severe burning and pain, the diffuse 
character of the congestion, with the small amount of secretion. 
Dr. Knapp calls my attention to a most excellent paper 
on this subject by G. Haltenhoff, page 169, vol. xv., 
Archives of Ophthalmology. Dr. Haltenhoff reports a 
series oF cases of his own and many by other authors, 
among them, Hirschberg, who mentions a case of benign or 
abortive form of gonorrhceic ophthalmia. Other cases of 
abortive gonorrhceic ophthalmia have been reported, so says 
Haltenhoff in the article referred to above, by Grima, Gep- 
ner, Tarizot, Hecker, Lippert, and Haab. Haltenhoff calls 
our attention to the fact that, " the internal clinicists, more 
especially venereologists, have remained, up to this day, be- 
lievers in a non-inoculated gonorrhceic conjunctivitis in 
opposition to ophthalmologists." Haltenhoff also gives us 515 
Gonorrhoeal Iritis. 
cases from Cullerier, Mauriac, and Icard, the latter calling it 
ophthalmic purulente arthritique. " Alf. Fournier, though," 
Haltenhoff says, " gives us the most explicit and minute 
information on this subject. He considers the subject 
under two heads, ophthalmic de contagion and ophthalmic 
rheumatismale,-the latter of which he divides into serous 
iritis, iritis simplex, and conjunctivitis, generally accom- 
panied by slight irritative symptoms, scanty catarrhal 
secretion, limited at times to the caruncle and palpebral 
conjunctiva." 
This form of conjunctivitis may be present occasionally 
without joint involvement, and the latter may precede or 
follow the eye trouble. Haltenhoff says: "Prof. White 
of Philadelphia likewise distinguishes as absolutely distinct 
inoculated gonorrhoeal ophthalmia from the benign form of 
double conjunctivitis generally accompanied by gonorrhoeal 
rheumatism, besides the more common sclerotitis, and iritis. 
White says whilst in seven to eight hundred cases of gonor- 
rhoea there occurs only one case of ophthalmo-blennorrhoea, 
he counts one case of rheumatic ophthalmia in fifty or sixty 
cases of gonorrhoea, a relative frequency, therefore, of 13 or 
14 to 1." 
With these facts before us can any one doubt the exist- 
ence of a non-inoculable conjunctivitis depending upon 
gonorrhoea? We see but few cases, comparatively, because 
with our cases of conjunctivitis we seldom look so far for a 
cause, and because the disease yields so readily to treatment 
and needs no special medication. The disease seems to be 
very rare in women, all the cases reported being in men. 
As to pathology, Haltenhoff, in this same article I have 
quoted from so much, says: "To modern pathologists those 
theories appear to be the most acceptable which suppose an 
absorption of certain products from the diseased urethral 
mucous membrane into the blood,-products endowed with 
phlogogenic influence upon a certain class of tissues. Benign 
gonorrhoeal conjunctivitis might thus naturally be classed 
with well-known exanthematous forms of conjunctivitis." 
The older writers, as mentioned in this article of Haltenhoff, 
seem to have given considerable attention to this form of William Cheatham. 
516 
conjunctivitis, while the more modern ones, or such as I 
have been able to consult, with the exception of Nettleship, 
in his edition of 1890, on Diseases of the Eye, page 444, where 
he gives a line or two to the subject, say nothing whatever 
about it. 
A recent paper in the April number, Bulletin of the Johns 
Hopkins Hospital, by Drs. Thayer and Blumer of the Johns 
Hopkins Hospital staff, on " Ulcerative Endocarditis due to 
the Gonococcus and Gonorrhoeal Septicaemia," has in it much 
of interest bearing on this subject. Drs. Thayer and Blumer 
say: " In the majority of cases in literature when the direct 
association of endo- or pericarditis with gonorrhoea has been 
made out clinically, an arthritis has also existed." Morel 
(" Des Complications Cardiaques de la Blennorrhagie," These 
for 1878, No. 269), however, in his conclusions asserts that 
" rheumatism is not a necessary intermediary, though the 
co-existence of these two lesions is the usual condition. A 
particularly interesting case of this nature, endo- and peri- 
carditis appearing on the fifteenth day after the beginning 
of the urethral discharge without co-existing arthritis, has 
recently been reported by Prevost {Arch. MTd. Beiges, 1895). 
Wertheim (Z. c.) showed clearly that in the female direct 
infection (per continuum) of the uterus, tube, ovary, and 
peritoneum may occur." 
" The power of the gonococcus to cause suppuration is 
now undoubted. The ophthalmia is also clearly an infection 
by direct transmission of the virus; but if entrance of the 
gonococci into the tubes and ovaries can be traced per con- 
tinuum, and into the eyes by direct transmission, the same 
cannot be said of the iritis, which has been observed without 
a coincident conjunctivitis, nor of the commonly observed 
arthritis, nor of the various processes which have been ob- 
served in the nervous system. Indeed there are relatively 
few of the numerous complications of gonorrhoea, such as 
conjunctivitis, cystitis, metritis, salpingitis, epididymitis, 
arthritis, periarthritis, peritonitis, pleurisy, local foci of 
suppuration, myocarditis, indeed general pyaemia, various 
cutaneous affections, iritis, neuritis, meningitis, meningo- 
myelitis, albuminuria, etc., which we can clearly trace to an 517 
Gonorrhoeal Iritis. 
extension per continuum or, however much we may suspect 
it, to a direct transmission of the infective agent. Even in 
epididymitis, where until recently the extension per con- 
tinuum has been generally accepted, the entire freedom 
from disease of the tracts connecting the urethra and epidi- 
dymis has compelled us to seek another explanation." 
"Are these secondary processes purely gonorrhoeal? If 
so, what is their relation to the primary lesion? As Finger 
{Arch, filr Dermat. und Syph., Wien und Leipzig, 1894, 
xxviii.) well says : ' There are various possibilities in this 
connection : («) The complication is produced by the gono- 
coccus alone-purely gonorrhoeal. The disease of the 
mucosa furnishes the opening through which the pyogenic 
cocci enter and give rise to the complication-mixed infec- 
tion. (f) The gonococcus produces the complication, into 
which, however, the pus-cocci enter later; both exist to- 
gether until the gonococcus, dying, is succeeded by the 
pyogenic coccus-secondary infection, (d} The complica- 
tion is essentially not of a microbic nature; it is produced 
by the products of the growth of the gonococcus in the 
urethra, and absorbed-toxic nature.' Finger then says: 
' By entrance into the blood current, distributed by this, the 
gonococcus may be the cause of the most varied articular,, 
periarticular, and perichondric metastases, and entering into 
the connective tissue the gonococci may succeed in causing 
a genuine suppuration.' 
" The proof, however, that many of the secondary suppu- 
rative processes are genuine gonorrhoeal metastases is not 
enough to justify the assumption that all are of the same 
nature. The fever and constitutional symptoms, the albu- 
minuria so commonly present, all point to a general intoxi- 
cation, while the unsuccessful efforts to demonstrate bacteria 
in the lesions of the nervous system suggest strongly that 
these changes may be due to a soluble toxine. We must 
probably recognize in genorrhcea a general disease, one 
which from a local starting-point may cause severe general 
symptoms, fever, chills, albuminuria, while in other instances 
grave secondary lesions may follow. In some instances 
including conjunctivitis, epididymitis, metritis, etc., local William Cheatham. 
518 
suppurative processes, it has been definitely shown that the 
gonococcus itself may be the exciting cause, the coccus 
reaching the affected areas doubtless through the blood 
current; in other instances, including neuritis, myelitis, cu- 
taneous manifestations, iritis, the negative results of micro- 
scopical and cultural researches suggest that the local lesion 
may be due to a toxine alone." 
From these articles then of Drs. William Sydney Thayer, 
Geo. Blumer, and Haltenhoff, I think we can say that the 
so-called gonorrhoeal iritis is more probably toxic, than the 
result of the gonococcus in the blood ; the iritis always being 
non-suppurative appears to me another argument of the 
toxic origin of the disease; that a certain form of non- 
suppurative conjunctivitis occasionally associated with 
gonorrhoeal urethritis is the result of toxines also. In these 
few pages it has been my endeavor to report a few cases of 
gonorrheal iritis mainly to give its more recent pathology, 
and to call the attention of the profession to a form of con- 
junctivitis the etiology of which is not often recognized, 
modern authors paying it little or no attention ; claiming 
for it (which is not new) its dependence, as does that of 
gonorrhoeal iritis, upon toxines. 
BIBLIOGRAPHY. 
1. Roosa's, Bull's, and Hackley's edition of Stellwag On the Eye, 1873. 
2. H. W. Williams, Diseases of the Eye, 1882. 
3. Robert Brudenell Carter, Diseases of the Eye, 1875. 
4. Henry E. Juler, Ophthalmic Science and Practice, 1893. 
5. Diseases of the Eye, by Edward Nettleship, 1890. American edition. 
6. H. D. Noyes, English edition of: Relation of Diseases of the Eye to 
General Diseases. By Max Knies, M.D., 1895. 
7. Diseases of the Eye. By Henry D. Noyes, M.D., 1890. 
8. Diseases of the Eye. By D. B. St. John Roosa, M.D., 1894. 
9. Lytton Forbes, English edition of L. de Week er, Ocular Therapeutics. 
10. Diseases of the Eye. By Henry R. Swanzy, A.M., M.B., F.R.C.S.I., 
1892. 
11. Porter Farley's edition of Ophthalmology by Prof. C. Schweigger, 1878. 
12. Diseases of the Eye. By Geo. A. Berry, 1889. 
13. Ophthalmology. By Drs. William F. Norris and Chas. A. Oliver, 
1893. Ube IRnicfcerbocfier press, HAew Uork