[Reprinted from The Atlanta Medical and Surgical Journal, August, 1894.] 
THE PATHOLOGY AND TREATMENT OF 
GONORRHCEA. 
By Charles M. Blackford, Jr., Lynchburg, Va. 
Fellow Virginia Medical Society, Member Virginia State Medical Examining 
Board, Secretary Lynchburg Academy of Medicine. 
Gonorrhoea is an acute infectious disease, generally seen in the 
urethra in the male and the vagina in the female. It is character- 
ized by a productive inflammation, leading to the production of 
serum and pus when acute, and to a formation of new connective 
tissue when chronic. 
As stated above, gonorrhoea is usually an affection of the genital 
tract, and, though marked by the same general features in both 
sexes, the difference in seat produces some differences in the re- 
mote effects. Before considering the pathology, it will therefore 
be necessary to understand fully the anatomical and histological 
structure of the urethra and vagina. 
The male urethra consists essentially of a tube of raucous mem- 
brane supported by a submucous layer, which is composed of 
muscular tissue in the prostatic portion and of fibrous tissue in 
the spongy portion, but in this latter there is also found a layer 
of erectile tissue. The urethra being erectile, that is, being of 
varying length and diameter under different circumstances, its 
raucous lining is "too large," and is thrown into folds in the 
flaccid state, so that strictly speaking there is no lumen to the tube 
in its ordinary condition. The existence of these folds must be 
borne in mind, as a serious pathological condition is dependent on 
them. 
The urethra is not a simple tube of uniform caliber. The 
various dilations and contractions should be well known before at- 
tempting operations of any kind, even one so simple as the passage 
of a catheter. The histology of the vagina is simple. It consists 2 
of a tube lined with epithelium, and surrounded by muscular 
coats. In it, as in the urethra, there are openings for gland ducts, 
each of which may become a source of infection. 
This is but a slight glance at the anatomy of these'parts, but it 
is sufficient for our purpose. We pass at once to the symptoms 
and pathology of the disease. After a brief period of incubation 
the preliminary symptoms make their appearance. These are 
tingling and burning in the urethra and at the meatus, increased 
by passing urine, and, on inspection of the meatus, its lips are seen 
to be everted and swollen. A serous discharge commences which 
becomes purulent, and the penis is painful and sore to the touch. 
The amount of discharge varies in individual cases, and may be 
slight or very profuse. After a period which may be a few days 
or may extend over weeks, the discharge may subside and the 
patient get well, or the disease may pass into a chronic condition 
known as gleet. 
On microscopic examination we find evidence of inflammation. 
The epithelium lining the canal is swollen, cloudy and degenerated. 
In places the degenerated cells have been thrown off, and small 
erosions are visible through the endoscopic tube. Within and be- 
tween the cells are diplococci, and the same organisms are found in 
the pus cells. The submucous layers are infiltrated with serum, 
leucocytes, and, should the case be one of severity, pus may be 
formed below the mucous membrane. Should the patient recover 
after a case of short duration, the exuded serum will be absorbed 
and leave no trace of its existence, but should the exudate organize 
the folds of mucous membrane will be glued together and a dimi- 
nution of the lumen at that point result, producing what is called 
a stricture. It is necessary to understand this point fully to have 
a clear conception of the pathology of gleet. A stricture is not 
merely a scar. It is formed beneath the mucous membrane, and 
is the result of the organization of the exudate. It is evident that 
the rugae thus agglutinated form crypts which furnish hiding 
places for the gonococci, almost beyond the reach of antiseptic 
agents. 
The specific cause of gonorrhoea is a diplococcus to which the 
name of gonococcus has been given. It may be stained by any 3 
method, and is readily differentiated from other cocci by the fact 
that, by Gram's method, all other cocci found in the urethra will 
retain the stain, while the gonococci are decolorized. It lies im- 
bedded in the substance of the pus cells, and is consequently diffi- 
cult to reach, except by first using some agent to decompose the 
pus cell. As stated above it lies below the surface of the mucous 
membrane, and is liable to be carried off in the lymph current, 
and to start secondary abscesses in neighboring glands. 
Until very recent times, gonorrhoeal rheumatism, that disagree- 
able sequel that follows some cases, was inexplicable, and even at 
the present day its pathology is far from certain. The study of 
the ptomaines and leucomaines, so carefully wrought out by 
Vaughan and Novy, has given us a hypothetical pathology, which 
further investigation may confirm. It is more than possible that 
this complication may be the result of the absorption of some 
poison elaborated by the micro-organism, and that it is prevent- 
able by the destruction of the cocci. The failure that has attended 
efforts to cultivate the micro-organism outside of the body has im- 
peded experiment in this direction, but when this has been over- 
come it will be possible to test the effects of these by-products. 
It is held by some that the rheumatism is the result of urinary 
absorption from the denuded urethra, and the advocates of this 
view point to the comparative rarity of this complication in 
women, and claim that whenever it occurs in them that the 
urethra, if not the bladder also, is involved. This hardly seems 
to hold good, for were it so the rheumatism would follow any lesion 
of the urinary lining, which we know is not the case. 
When gonorrhea passes into the chronic state it is called gleet. 
Few subjects in the domain of pathology have been so misunder- 
stood as this, nor have many been more fully explained by modern 
investigation. The statement made above as to the mode of for- 
mation of a stricture must be remembered. A stricture is formed 
by the fastening together of the rugse in the mucous membrane and 
its subjacent tissues by the organization of the lymph poured out, 
in and around them. This forms pockets in which the secretion 
from the membrane is retained, and in which the gonococci can 
thrive unmolested. The caliber of the stricture has no effect, for 4 
however slight the elimination of the normal lumen be, the saccu- 
lation of the membrane is present, and so long as this persists, and 
so long as the bacteria can live in the pockets, so long will the 
gleet remain. 
A stricture opposes a mechanical obstruction to the flow of urine, 
and behind it some of the urinary sediment will be deposited. This 
is composed of desquamated cells from the bladder and deep urethra, 
mucus, and perhaps pus. This debris furnishes a moist, warm 
breeding place for gonococci, and owing to the covering of muco- 
pus, the position is almost impregnable. 
It is this specific nature of the disease that makes the great dif- 
ference between it and the other forms of urethritis and catarrh in 
other organs. The treatment of gonorrhoea differs from that of 
other catarrhal affections on account of its seat, and the impossibility 
of giving functional rest to the part. It is a tractable disease when 
properly treated, and the most annoying that we encounter when 
such is not the case. 
In the female the lesions are similar to those of the male, though 
the larger size of the canal renders the disease more easy of access, 
and diminishes the danger of its becoming chronic. The stricture 
exists, but this is not so serious as in the male. The lurking 
place for the disease is the cul-de-sac behind the neck of the uterus, 
and a knowledge of this fact will go far towards obviating its 
danger. 
The treatment of gonorrhoea is a matter of importance to every 
physician, for like the poor, we have it with us always. A few 
points must be borne in mind. The first is that we have a narrow 
tube filled with a muco-purulent secretion, not readily miscible with 
water, and behind this liquid plug is a sphincter muscle closing the 
channel. If an injection be made it will but play on the end of 
this plug, and will not affect the diseased portion of the urethra. 
Again, this secretion is actively contagious, and if forced into the 
bladder will extend the disease to that organ. It is therefore nec- 
essary to remove the secretion from behind, and treat a clean 
membrane. 
This may be done in several ways. If the patient be told to 
urinate immediately before the administration of the treatment the 5 
urethra will be fairly clean, but irrigation is far better. A 
small, flexible catheter should be lubricated with glycerine and in- 
troduced as far as the triangular ligament. It is important to use 
glycerine, for any oil will leave a water-proof coating on the 
urethra, and defeat the desired object. Through this catheter about 
a quart of warm solution of sodium bicarbonate (ten per cent.) 
should be run, allowing it to return outside the catheter so as to 
wash the sides of the urethra. The pus will be dissolved by the 
alkaline wash and will be entirely removed. By raising the foun- 
tain syringe any desired pressure may be obtained, and it is well 
to use enough pressure to dilate the tube so that the follicles may 
be well washed. 
When the water returns clear and free from " tripper-faden," the 
antiseptic wash should be substituted.- In my own practice, I use 
the following: 
R Hydrarg. chlorid. corros gr. J. 
Sodium chlorid gr. v. 
M. Sig. Dissolve in one pint of warm water. 
Still using a fountain syringe, I attach a Lindenschmidt dilating 
irrigator to its tube, and run the whole pint through the urethra 
bathing its clean walls thoroughly. Using this treatment three 
times daily I find the inflammation to subside, the secretion to di- 
minish, and the case to end in nine or ten days, as a rule. 
I cannot insist too much on the importance of an alkaline wash. 
Without it the sublimate is useless, for in most cases the antiseptic 
will not reach the membrane at all, or if it docs, it will be precipi- 
tated by the albumen in the secretion. 
The treatment of gleet may be summarized in three words: cut 
the stricture. Until that be removed, all means will be useless, for 
it furnishes a constant source of irritation. It may be destroyed 
by dilation, or still better by cutting. After this, under antiseptic 
irrigation the gleet will rapidly disappear. This statement must 
be somewhat qualified. Every long-continued discharge from the 
urethra is not a gleet. After an attack of gonorrhoea, the mucous 
membrane may remain in an atonic condition for some time, during 
which there is a glairy discharge, but this has no tripper-faden nor 
gonococci. In these cases all treatment directed to the urethra 6 
should be stopped, and the general health of the patient improved. 
Tonics, surf-bathing, or other exercise, will be of advantage. Of 
course, excessive exertion of any kind must be discouraged, and 
sexual rest insisted on. Steel sounds cautiously used will often aid 
recovery, whether by obliterating strictures in course of formation 
or by some pressure effect on the membrane, I am unable to say. 
Experience teaches the sad lesson that there is no treatment that 
is unfailing, but in a fairly large practice among such cases, I have 
found that alkaline irrigation, followed by weak antiseptics, gives 
more satisfactory results than any method in common use. 
A word as to internal medication. Except the alkaline diuretics 
and laxatives, internal medication is of little use. The employ- 
ment of balsams is hallowed by long usage, and patients expect 
them, but aside from the mental effect, little or no good will follow 
them. Rest, alkaline washes, and antisepsis are the great pillars 
on which we rely.