SOME POINTS IN THE TREATMENT 
OF 
GONORRHOEA. 
BY 
GARDNER W. ALLEN, M.D., 
Surgeon in the Genito-Urinary Department, Boston Dispensary. 
Reprinted from the Boston Medical and Surgical Journal 
of August 7, i8qo. 
BOSTON: 
DAMRELL & UPHAM, Publishers, 
283 Washington Street. 
1890. S. J. Parkhill & co., Painters 
BOSTON SOME POINTS IN THE TREATMENT OF 
GONORRHCEA.i 
BY GARDNER W. ALDEN, M.D., 
Surgeon in the Genito- Urinary Department, Boston Dispensary 
THE ANTERIOR URETHRA. 
The fact that gonorrhoea, even under favorable 
conditions, has a strong tendency to become chronic, 
and the acknowledged difficulties encountered in treat- 
ing the disease in its later stages, give it an importance 
to the physician perhaps out of proportion to the seem- 
ing insignificance of the symptoms. A slight urethral 
moisture, without subjective symptoms, will sometimes 
keep the patient in a state of worry and depression, 
and the physician at his wits' end, trying one remedy 
after another, for months; yet, if Noeggerath's teach- 
ings are to be followed, and they are apparently gain- 
ing more and more advocates among the gynecologists, 
the importance of absolute extinction of the disease in 
every case can scarcely be exaggerated. 
Various forms of treatment are, from time to time, 
recommended, promising quick and permanent cure 
for gleet; but most of them are disappointing. The 
reports of such brilliant results are probably based on 
too small a number of cases. Chronic urethritis is 
an uncertain as well as an obstinate affection. It 
occasionally happens that a slight chronic discharge 
will stop spontaneously, almost abruptly, and some- 
times a sound passed two or three times, or a simple 
1 Read at the meeting of the Surgical Section of the Suffolk Dis 
trict Medical Society, April 2, 1890. 2 
injection for a few days will check a discharge, and re- 
lieve symptoms that have been going on a long time ; 
but such cases are the exception, not the rule, and 
should not be cited as showing the remarkable proper- 
ties of a particular course of treatment. The slight 
exacerbations to which some men are subject who 
have previously had gonorrhoea, not due to fresh in- 
fection, but following excesses, often yield promptly 
to simple astringent injections; a very few injections 
of a corrosive-sublimate solution will almost surely 
check such outbreaks. Corrosive sublimate (1 to 10,- 
000 or 20,000) also makes a very good, and I think 
the best, injection for chronic discharge. 
Irrigation of the urethra, with a quart or more of 
warm solution, through a blunt nozzle held at the 
meatus, or, still better, through a catheter passed to 
the bulb, often gives satisfactory results in chronic ure- 
thritis ; potassium permanganate (1 to 2,000), corrosive 
sublimate (1 to 20,000), or creolin (1 to 500) may be 
used in this way. The latter is quite irritating, and 
should not be used where there is any active inflamma- 
tion. These irrigations may be repeated two or three 
times a week, an injection being used in the intervals, 
or the patient may irrigate himself every day. A 
sound passed occasionally may be found a valuable 
aid. 
I am convinced, however, that by far the most ra- 
tional method of treating chronic gonorrhoea is by 
means of local applications to the diseased mucous 
membrane through the endoscope. The advantage of 
ocular demonstration of the diseased surface, and of 
being able to observe directly the effect of treatment, 
is obvious. In October, 1887, I reported before the 
Suffolk District Society some cases of urethral endo- 
scopy treated at the Boston Dispensary, and showed 
some of the endoscopes designed by Dr. Hermann G. 3 
Klotz, of New York, and described by him in a very 
interesting article in the New York Medical Journal, 
November 27, 1886. (See 
Fig. 1.) These endoscopes 
are straight, open tubes, of 
different sizes and lengths, 
made of coin silver, which 
allows of their being very 
thin and light, and is not af- 
fected by the solutions used 
in treatment. Any strong, 
steady light, reflected into 
the tube from a head-mir- 
ror, will sufficiently illumi- 
nate the urethra to admit of 
a close study of its patho- 
logical appearances. Hav- 
ing been passed down to the 
bulb, and the conductor 
removed, the endoscope is 
slowly withdrawn, giving op- 
portunity for careful inspec- 
tion of the mucous mem- 
brane and for treatment. 
The applications are made 
by means of a cotton tam- 
pon on the end of a wire, 
and as large an endoscope as will pass the meatus 
should be used. 
A more or less deep or livid congestion, with cede- 
matous swelling of the mucous membrane, dilated cap- 
illaries here and there, and a granular appearance in 
places, is the commonest condition. It may be nearly 
evenly diffused over the whole surface of the anterior 
urethra, but is generally more circumscribed, notably 
in the bulbous portion, but especially about the peno- 
Fig. 1. Klotz's Endoscope. 4 
scrotal angle, where it is most marked, as a rule, ac- 
cording to my experience. The latter situation, or 
just anterior to it, is a common seat of stricture of 
large calibre, recognized by a rigid state of the mucous 
membrane, which is often associated with inflammation 
of the mucous glands of the urethra. When this con- 
dition is present, the inflammation is apt to linger here 
after it has subsided in the bulbous portion and else- 
where ; and, when the general congestion has been par- 
tially reduced, the mouths of the glands may be seen 
as small points, each surrounded by a dark red or red- 
dish-brown areola. In these cases of stricture recov- 
ery will almost surely be retarded, and it makes but 
little difference of how large calibre the stricture is. 
In one case a 38 (French) sound passed easily; yet 
a stricture was distinctly defined by a bougie a boule, 
and it proved a very troublesome complication. 
Other abnormities described by authors on endo- 
scopy include variations in color and smoothness of 
the mucous membrane, thickening of the epithelium 
in stripes, erosions and ulcerations, polypi, papilloma- 
tous growths, etc. The latter, constituting the rare 
affection described by Oberlander, of Dresden, as 
papillomatous urethritis, I have had an opportunity 
of seeing, through the kindness of Dr. F. M. Briggs, 
whose very interesting case is reported in the Boston 
Medical and Surgical Journal, October 24, 1889. 
In endoscopic examination the light reflexes, mi- 
nutely described by Griinfeld, sometimes a hindrance 
and sometimes an aid to the clearness of the view, 
should be carefully noted and taken into account, also 
the effect on the color of the mucous membrane - 
paleness - produced by pressure of the end of the 
tube and of the cotton tampon. 
In treatment, I have used nitrate of silver almost 
exclusively, and generally begin with a one per cent. 5 
solution and increase the strength gradually to ten per 
cent., if well borne. The cases which tolerate the 
stronger solutions seem to do better, as a rule. The 
applications are, of course, limited to the parts actually 
diseased, whereby the healthy parts are spared un- 
necessary irritation, and the stronger solutions, the 
quantity being small, may be safely used. A slight 
discharge for twenty-four or thirty-six hours, with 
moderate pain on micturition, is the only reaction to 
be expected. It would evidently be impossible to use 
an injection of anything like the same strength with- 
out setting up acute inflammation. The applications 
should be made every four to seven days, and, if 
thought advisable to use injections in the intervals, 
ordinary astringents may be prescribed, or a solution 
of corrosive sublimate (1 to 10,000 or 20,000) ; and 
sounds may be passed occasionally with advantage. 
A narrow meatus should be cut, strictures cut or di- 
lated, and other complications treated according to 
indications. 
The cases of stricture complicated with glandular 
disease are slow in their progress toward recovery, 
but generally do well in the end. The silver solution 
seems to work gradually into the mouths of the glands, 
and may help to promote absorption of the stricture 
tissue; this, I think, I have observed in one case. 
Klotz uses sulphate of copper where these glands are 
involved. These strictures are so resilient that very 
little can be accomplished by dilatation, and many 
patients object to being cut. Oberlander 2 treats them 
by forcible dilatation by means of his dilator, in which 
spreading blades may be opened to any extent. The 
2 See " A Resume of the Views of Dr. Oberliinder, etc.," by J. A. 
Fordyce, M.D., in Journal of Cutaneous and Genito-Urinary Dis- 
eases, January, 1889. There is also a detailed description of the 
treatment in Volkmann's " Sammlung Klinischer Vortrage," No. 
275, May 31, 1886, p. 14. 6 
dilatation is carried a little farther at each sitting, 
until the stricture is ruptured and the diseased glands 
split open, when applications of nitrate of silver (two 
to five per cent.) are sufficient to complete the cure. 
Other diseased conditions are to be treated accord- 
ing to indications, and I will not go into details here. 
Ulcerations generally require strong applications or 
cauterization, polypi should be removed with the snare, 
and papillomata by means of the curette. 
Fortunately, however, in most cases we have to do 
with a simple inflammation of the urethra. As a rule, 
they do well, and it is very satisfactory to see the 
mucous membrane gradually fading and assuming a 
normal appearance, and to hear the patient's expres- 
sions of gratification as he feels his disagreeable sensa- 
tions passing away. The duration of treatment, of 
course, varies in different cases. In an ordinary un- 
complicated case, a dozen sittings, covering a period 
of about two months, would probably suffice. Here 
is an average case : 
Case I. E. C., age twenty-one, began treatment 
with the endoscope August 13, 1888, after some pre- 
liminary treatment to diminish the discharge. First 
gonorrhoea a year and a half ago ; duration six months. 
Second attack six months ago; discharge continues to 
date. Mucous membrane highly congested in the 
bulbous portion, gradually shading off anteriorly; 
quite oedematous in the middle portion. Solution of 
nitrate of silver, one per cent., applied. The history 
is simply that of gradual improvement in the appear- 
ance of the mucous membrane, the intense congestion 
fading out and leaving a nearly normal condition with 
simultaneous amelioration of subjective symptoms. 
A two per cent, nitrate of silver solution was applied 
August 17th; three per cent. August 20th, 24th and 
27th; four per cent. August 30th; five per cent. 7 
September 5th; seven per cent. September 8th; and 
ten per cent. September 11th. The patient here sud- 
denly broke off the treatment against my advice, and 
immediately plunged into excesses which he kept up 
almost uninterruptedly, without the least apparent dis- 
advantage, until the following summer, when he had 
a slight exacerbation, which was easily controlled by 
a few injections of corrosive sublimate. 
THE POSTERIOR URETHRA. 
In passing the endoscope beyond the bulb into the 
deep urethra, great care should be observed to avoid 
injury to the delicate and inflamed mucous membrane 
held down against the end of the instrument, as it is, 
by powerful muscular contraction. Griinfeld recom- 
mends a hard rubber tube for this purpose, the edges 
not being as sharp as those of the metallic instrument; 
he passes it without a conductor, and is thereby en- 
abled to keep the visceral end, under control of the 
eye, constantly in the axis of the urethra. A smaller 
endoscope should be used than in the anterior urethra, 
not larger than 24 F., according to Klotz. 
The color of the mucous membrane is normally of 
a deeper red than in the spongy portion. With some 
practice and carefully guarding against expulsion of 
the tube by sudden and convulsive contractions of the 
external sphincter, the caput gallinaginis may be rec- 
ognized as a bright-red rounded prominence in the 
lower part of the field with a crescent of dark-red 
mucous membrane above it. Bleeding is very easily 
excited in the deep urethra, which obscures the view 
and renders treatment less effective. 
Pathological distinctions are less easily recognized 
through the endoscope than in the anterior portion. 
Griinfeld describes hypermmia, catarrhal swelling and 
hypertrophy of the caput gallinaginis, but Klotz thinks 8 
that differences in size of this organ may be due to 
individual peculiarity. Applications 
are made as in the anterior portion, 
but the solutions used should gener- 
ally be milder. 
Three years ago, Dr. E. L. Keyes, 
of New York, read before the Ameri- 
can Association of Genito-Urinary 
Surgeons a valuable paper on " Deep 
Injections of Nitrate of Silver."8 
He uses for the purpose a modifica- 
tion of Ultzmann's deep urethral syr- 
inge, the essential feature of which 
is a long, curved nozzle of pure sil- 
ver with a pinhole opening in the end. 
(See Fig. 2.) He begins with a very 
weak solution, one grain to the 
ounce, and gradually increases the 
strength, rarely going above two per 
cent. Keyes thinks that most of the 
disagreeable results of this treatment, 
which have limited its popularity in 
the past, are due to passing the in- 
strument too deeply into the prostatic 
urethra, and considers it important 
that the point of the syringe should 
just enter the membranous portion. 
Two or three minims of the solution 
deposited here will diffuse themselves 
backward over the mucous membrane 
and penetrate into the prostatic 
urethra. He prefers to inject before 
micturition, because otherwise the 
nitrate of silver is decomposed by 
the urine with which the urethral walls are bathed, 
B 
A 
Fig. 2. Ultzmann's 
Deep Urethral 
Syringe. 
8 New York Medical Record, May 28, 1887. 9 
but he allows the patient to urinate soon after, and 
then has him hold his water as long as possible and 
avoid straining. When there is much pus, however, 
he has the patient urinate first, and then injects a 
larger quantity (five minims), which will not be de- 
composed. 
Keyes reports cases, successfully treated by this 
method, of acute and sub-acute gonorrhoeal cystitis; 
acute and chronic deep urethral inflammation ; double 
relapsing epididymitis due to the latter; irritability 
of the bladder; the same due to enlarged prostate; 
oxaluria, prostatic neurosis and sexual weakness. He 
also recommends it in prostatorrhoea, spermatorrhoea, 
nocturnal emissions, and nervous impotence. 
The results obtained by these deep injections are 
certainly, in many cases, among the most satisfactory 
in the treatment of urethral disease. Although not 
uniformly successful, they are generally so, and, if 
the patient is to be benefited, he will show signs of 
improvement after the first or second injection, as 
a rule. The treatment may be repeated every three 
or four days, and in inflammatory trouble a very few 
injections are generally sufficient. Impotence requires 
more and stronger injections. 
I usually inject after micturition, and use five or 
six minims of the solution, beginning with one-half 
per cent, and increasing the strength gradually to two 
per cent. With a finger in the rectum, in the sulcus 
between the bulb and the prostate, the tip of the syr- 
inge may be felt as it enters the membranous portion, 
and a too deep insertion of the instrument thereby 
guarded against. It seems to me that this method of 
treatment is best adapted for gonorrhoeal cystitis and 
other inflammatory affections of the prostatic urethra. 
A few cases will best illustrate the effects of the treat- 
ment. 10 
Case II. M. B.. aged thirty-three, came to the dis- 
pensary August 6, 1887, with acute gonorrhoea, which 
was treated in the usual way, with diuretics and injec- 
tions, until August 30th, when the discharge was dimin- 
ished ; but he reported that he had been seized a day 
or two before with frequent, painful and bloody mic- 
turition. In great distress at time of visit; it was 
impossible to hold water more than an hour, and a 
small quantity of purulent, bloody urine would then 
be passed with great pain, and followed by severe vesi- 
cal tenesmus. A deep injection of nitrate of silver, 
one-half per cent., was given. 
September 1st. Urinary symptoms entirely relieved, 
but he has pain in testicle; September 3d, testicle 
greatly swollen. 
The patient had an acute epididymitis, which ran 
the usual course. He considered it a trifle, however, 
compared with the suffering he had endured with cys- 
titis. There was no return of urinary symptoms ; the 
relief was prompt, complete and permanent. Whether 
the epididymitis in this case was the result of the in- 
jection, the nozzle of the syringe having been inadver- 
tantly pushed too far in, or whether it occurred in the 
ordinary course of the disease, it is impossible to 
say. 
Case III. J. H., aged twenty-four, on October 22, 
1887, had gonorrhoea of six weeks' duration, with a 
copious, thin discharge, and for a week had been suf- 
fering with frequent micturition with blood at the end 
of the act, and followed by severe tenesmus. Deep 
injection of nitrate of silver, one per cent. 
October 25th. Great relief for thirty-six hours, 
then return of symptoms. Injection repeated with a 
two per cent, solution. 
October 27th. Much better. Injection repeated. 
October 29th. Continued improvement. Micturi- 11 
tion scarcely more frequent than normal. No tenes- 
mus. 
Case IV. B. A., aged twenty-seven, August 21, 
1888. First gonorrhoea four years ago ; duration, a 
year and a half. Present attack of three months' 
duration ; copious, purulent discharge. Very frequent 
and urgent micturition, with vesical tenesmus by day; 
no trouble at night. First half of urine passed is 
cloudy, second half slightly turbid. Deep injection of 
nitrate of silver, one per cent. 
August 28th. Marked improvement. Micturition 
much less frequent. Injection repeated. 
September 1st. Micturition normal. Discharge 
has stopped. 
September 11th. Discharge has reappeared. No 
return of urinary symptoms. 
In the treatment of various affections of the deep 
urethra I have obtained good results from irrigating 
the neck of the bladder with a solution of permangan- 
ate of potash. This is a perfectly safe operation, and 
subject to none of the risks associated with the deep 
injections of nitrate of silver. Ultzmann advises com- 
plete emptying of the bladder after irrigation; and in 
cases of acute inflammation, or when other solutions 
are used, it is probably a wise precaution; but I do 
not believe that any harm can come from leaving be- 
hind a small quantity of a mild permanganate solution. 
Moderate tenesmus, lasting a short time, is the only 
disagreeable symptom I have observed with mild solu- 
tions, and this is the exception. It has been my prac- 
tice, at the suggestion of Dr. H. W. Cushing, to leave 
part of the solution in the bladder, and I have come 
to regard this as an important factor in the success of 
the operation. The fluid settles down into the neck 
of the bladder, as the patient walks about, and has an 12 
opportunity to exert its stimulating influence on the 
mucous membrane for a con- 
siderable time before it is 
decomposed by the freshly 
secreted urine. Potassium 
permanganate is rapidly de- 
composed in the presence of 
organic matter, and herein lies 
the safety of leaving this sub- 
stance in the bladder, for the 
astringent and stimulating ef- 
fect, which might become irri- 
tating if prolonged, is checked 
as soon as enough urine is 
secreted to decompose the 
solution. 
The treatment is conven- 
iently carried out by means 
of Ultzmann's large irrigating 
syringe and catheter. (See 
Fig. 3.) The syringe holds 
about five ounces of fluid ; the 
catheter is a short metallic 
instrument, intended to reach 
only as far as the back part of 
the membranous portion. A 
fountain syringe or siphon 
with an ordinary gum-elastic 
or soft rubber catheter may be 
used, but means should be pro- 
vided for accurately measuring 
the amount injected The cath- 
eter, having been filled with 
fluid and the air expelled, is 
passed just beyond the external sphincter, and four to 
six ounces of the solution, or as much as the bladder 
B 
C 
A 
fig. 3. Ultzmann's Syringe- 
Catheter. 13 
will comfortably hold, are slowly injected and allowed 
to run out again. This is repeated until the solution 
comes away with as bright red a tinge as it went in ; 
then two or three ounces are injected into the bladder 
and left there, the catheter being removed. The pa- 
tient is then allowed to go, being told to hold his 
water as long as he can without positive discomfort. 
I usually begin with a 1 to 4,000 or 5,000 solution, 
and gradually increase the strength. Solutions stronger 
than 1 to 2,000 are not as a rule well borne, and 
those weaker than the first-mentioned are so rapidly 
decomposed as to accomplish little. Solutions of a 
strength of 1 to 3,000 and of 1 to 2,000 are the most 
useful. 
After employing this method in two or three cases 
of prostatorrhoea with success, it was tried in several 
cases of cystitis and in one case of spermatorrhoea. 
Like every other treatment it sometimes fails, but 
improvement may be expected and entire relief of 
symptoms has followed in many cases. If good is to 
result it is soon apparent and a few injections only are 
necessary, as a rule, to bring about the desired effect. 
The following are a few illustrative cases. 
Case V. A. C., age forty-six, in very poor general 
health, came to the dispensary September 18, 1888, 
with gonorrhoea of two weeks' duration ; thin, purulent 
discharge, chordee, and frequent, urgent, painful mic- 
turition with vesical tenesmus. He was treated with 
diuretics and tonics, with only temporary relief of the 
urinary symptoms, until October 2d, when the bladder 
was irrigated with a solution of potassium permanganate 
1 to 4,000, two ounces being left in. 
October 6th. Relief for a few hours after irrigation, 
but vesical symptoms have now returned. Irrigation 
repeated with a 1 to 3,000 solution. 
October 9th. Improvement. Irrigation with a 
1 to 2,000 solution. 14 
October 13th. Urinary symptoms entirely relieved. 
October 20th. Micturition normal. 
Case V I. A. R., age seventy, with no venereal 
history, complained, September 27, 1888, of frequent 
micturition with severe tenesmus and blood at the end 
of each act. Urine nearly clear. Small amount of 
residual urine. Prostate moderately enlarged. He 
was treated with diuretics until October 9th, when 
there was no improvement and he was irrigated with a 
permanganate solution, 1 to 3,000, two ounces being 
left in the bladder. 
October 13th. Great improvement. Irrigation with 
a 1 to 2,000 solution. The patient did not return, but 
was seen a year later and said that he made a rapid 
and complete recovery after the last visit. The cause 
of the vesical symptoms in this case is obscure. 
Case VII. L. E., age twenty-two years, no vene- 
real history. 
October 18, 1888. For six weeks has been troubled 
with frequent and painful micturition with vesical 
tenesmus ; occasionally passes a small amount of blood. 
Urine turbid; when passed in two glasses the last half 
is slightly tinged with blood and contains whitish clumps 
which, under the microscope, prove to be only fibrin. 
A few days later the urine contained a heavy sediment 
of pus, most of which was passed toward the end of 
micturition, and a little blood ; albumen one-quarter 
per cent. Prostate slightly enlarged and moderately 
sensitive. Was treated with diuretics with some im- 
provement in subjective symptoms and in character of 
urine, but none as to frequency and precipitancy of mic- 
turition, until October 27th, when the bladder was 
irrigated with permanganate solution 1 to 3,000 and 
some fibrinous shreds washed out. Two ounces of the 
solution were left in the bladder. 
October 30th. Marked improvement. Can hold 15 
water longer. Urine clearer. Irrigation repeated 
with the same strength of solution. He improved 
rapidly after this without further local treatment. He 
was seen a year later and said that his recovery was 
complete and permanent. 
Case VIII. F. G., age twenty-one, tall, well built 
and apparently in perfect health, was first seen Febru- 
ary 29, 1888, and gave the following history. First 
gonorrhoea a year ago ; second, three months ago, dura- 
tion six weeks. Ever since this last attack he has had 
a discharge after micturition and defaecation of a 
whitish, ropy substance. He says that sexual desire 
and power are diminished, but does not feel in the least 
nervous or anxious about his condition. General 
health perfect. 
The patient urinated in my presence and immediately 
afterward passed, with very slight effort, about a tea- 
spoonful of the substance described above which, under 
the microscope, proved to be pure semen. He was 
given pills of iron, ergotin and strychnia and was not 
seen again until September 12th. 
He then reported that he had taken the pills only 
three weeks and the discharge of semen had continued 
uninterruptedly, although he could sometimes prevent 
it by avoiding straining after evacuating the bladder 
or rectum. His general health continued good and he 
had regained sexual power and desire. He again pro- 
duced some semen for examination, although not quite 
as much as before, and it showed the same character- 
istics under the microscope. He was directed to resume 
the pills and the neck of the bladder was irrigated with 
a solution of potassium permanganate 1 to 5,000, two 
ounces being left in. The irrigation was repeated as 
follows, with a gradual diminution in the amount and 
frequency of the discharge : September 17th, 1 to 3,000 ; 
September 21st, 1 to 2,000; September 24th, 1 to 
1,500; September 28th, 1 to 1,000. 16 
October 3d. The last injection was followed by 
severe pain and urgent desire to urinate which was 
resisted for an hour, and then micturition was very 
painful, especially at the end, and accompanied with 
the discharge of a thick reddish substance in clumps 
(permanganate). Very little pain after this. No 
seminal discharge. Local treatment suspended. Pills 
continued. 
This patient has been recently seen and reports that 
there has never been the least return of the seminal 
discharge and he has remained well in all other 
respects. 
Gonorrhoea in women has been a good deal written 
about in recent years and there is great difference of 
opinion as to pathology, especially in regard to the 
relative frequency with which different parts are in- 
vaded. Some authorities think that urethritis is pres- 
ent in every case of gonorrhoea, others consider it as an 
occasional complication only. Bartholini's glands are 
commonly, or rarely, involved, according to the views 
of one writer or another. Some maintain that the 
disease rarely extends beyond the cervix, while others, 
Sinclair for instance, of Manchester, Eng., following 
Noeggerath, regard implication of the uterus and its 
appendages as the great danger and believe that it will 
almost surely follow if the progress of the disease be 
not promptly checked. 
As for the vagina, it probably always has been and 
still is commonly looked upon as a favorite seat of 
gonorrhoea. Yet Sigmund4 and Steinschneider6 of 
Neisser's clinic in Breslau, declare that gonococci do 
not settle upon the mucous membrane of the vulva or 
GONORRHCEA IN WOMEN. 
4 Annual of the Universal Medical Sciences, 1888, vol. ii, p. 441. 
B Berliner klinische Wochenschrift, April 25, 1887. 17 
vagina ; and Sinclair says " it is still a question whether 
there is any such thing as gonorrhoeal vaginitis. The 
vagina seems to be the last portion of the genital 
tract, from the uterus downwards, to become affected, 
and the first to get well under any suitable cleansing 
process."6 He thinks, however, that the vagina in 
children and young girls may provide a more favorable 
breeding ground for the micro-organisms. Bumm's 7 
researches furnish strong evidence of the non-existence 
of vaginal gonorrhoea. He cut out bits of suspected 
mucous membrane and examined them microscopically 
with negative result, and also kept gonorrhoeal pus in 
direct contact with tlyj vaginal wall twelve hours with- 
out setting up vaginitis. The discovery of gonococci 
in the secretion about the vulva or in the vagina, of 
course, does not prove that the vulvar or vaginal 
mucous membrane is affected, for they may have come 
from the urethra or cervix. 
In most that has been written on treatment, a good 
deal of space is taken up in detailed descriptions of 
elaborate and more or less severe methods of treating 
the vagina - scraping, scrubbing, cauterizing and 
packing. It seems to me that we should satisfy our- 
selves that gonorrhoeal vaginitis really exists before 
resorting to measures, as routine treatment, so heroic 
and so difficult to thoroughly carry out. I believe 
that frequent douching with fairly strong antiseptic 
solutions will be found efficient, as far as the vagina 
is concerned, in a large majority of cases. 
The urethra should be carefully attended to, for 
here the disease is apt to linger. Copaiba and other 
internal remedies used in the male may be employed. 
Skene 8 advises injections of nitrate of silver and sul- 
6 On Gonorrhoeal Infection in Women, London, 1888, p. 82. 
7 Ueber gonorrhoische Mischinfection beim Weibe. Wiesbaden, 
1887. 
8 Diseases of Women, p. 821. 18 
pbate of zinc, with suppositories of iodoform or bis- 
muth. Finger,9 of Vienna, applies, through an endo- 
scope, tincture of iodine or solution of nitrate of silver, 
two to five per cent. Aubert,10 of Lyons, gives injec- 
tions of nitrate of silver, or passes the solid stick 
rapidly into the urethra. Eraud,11 of Lyons, curettes 
the urethra, and then applies nitrate of silver. Cul- 
lingworth,12 of St. Thomas' Hospital, London, passes 
into the urethra a sound wound with cotton and dipped 
in strong carbolic acid. 
The three surgeons last mentioned treat the cervix 
as they do the urethra, that is, with solid nitrate of 
silver, curette, and strong carbolic acid respectively, 
carrying the applications up to the fundus, if necessary. 
Sinclair injects pure tincture of iodine into the uterus. 
Within the last year improved facilities have been 
provided for the treatment of women in the Genito- 
Urinary Department of the Boston Dispensary, and 
more attention has been paid to patients of this class 
than before. The treatment has been more or less 
experimental, but many of the cases have shown 
marked improvement. It has been found difficult, 
however, to induce the patients to come regularly and 
to persevere in treatment after they have improved so 
far as to be free from actual discomfort. The scien- 
tific value of the records, therefore, is not as great as 
could be wished. By way of giving an outline of the 
treatment I have followed, and in the hope of exciting 
criticism and discussion, I report the following case: 
Case IX. Julia B., age twenty-eight, on Septem- 
ber 12, 1889, had a discharge of two months' duration. 
She had had more or less leucorrhoea for ten years. 
9 Die Blennorrhoe der Sexual-Organe. Leipzig und Wien., 1888, 
p. 247. 
10 Journal of Cutaneous and Genito-Urinary Diseases, March, 1889. 
11 Journal of Cutaneous and Genito-Urinary Diseases, November, 
1889. 
12 Braithwaite's Retrospect, January, 1890, p. 196. 19 
Physical examination showed the following condition : 
Considerable purulent, urethral discharge; also a 
vaginal discharge and a copious, glairy, muco-purulent 
discharge from the cervix uteri, with erosion of the 
os. Microscopic examination, by Dr. E. M. Greene, 
showed numerous gonococci in the urethral and cer- 
vical discharge, but none in the vagina. 
The following method of treatment was adopted: 
The vagina was first thoroughly irrigated with a solu- 
tion of corrosive sublimate 1 to 5,000, and the vulva 
carefully cleaned with the same solution. Then, a 
speculum having been passed, the ropy discharge 
clinging to the os was wiped away, and the cervix 
cleaned out as thoroughly as possible. An application 
of carbolic acid (95 per cent.) was then made to the 
cervical canal as far as the internal os, by means of a 
sound wound with cotton, and also to the erosions 
about the external os. The speculum was then slowly 
withdrawn, and any secretion seen on the vaginal walls 
was wiped off with a swab wet with the sublimate solu- 
tion. An ordinary, small-sized, soft rubber catheter 
was next passed into the urethra, and this canal was 
irrigated with the 1 to 5,000 corrosive sublimate solu- 
tion. A suppository, or short bougie, of iodoform was 
then inserted into the urethra and held there until it 
melted. At home the patient used as a douche, twice 
daily, a solution of zinc sulphate and alum, two grains 
of each to the ounce. This was changed later to a 
four per cent, solution of boric acid. 
The local treatment was repeated three times a week, 
and at the seventh visit there was still a slight urethral 
and cervical discharge, but the gonococci had disap- 
peared. The treatment was then interrupted by 
menstruation, and at the next visit was suspended, 
the urethral discharge having stopped and the pus 
having disappeared from the cervical discharge. The 
erosions about the os were entirely healed. 20 
The patient was seen again January 2, 1890, and 
was found to have a slight urethral discharge contain- 
ing gonococci. There was also some vaginal discharge 
or leucorrhoea, and a moderate amount of colorless, 
transparent, ropy, cervical discharge. The os looked 
perfectly normal. There were no gonococci in the 
vagina or cervix. 
Corrosive sublimate irrigation of the vagina and 
urethra was resumed. The gonococci disappeared 
from the urethra in a short time, but the irrigations 
were kept up, at irregular intervals, for several weeks. 
When occasionally a slight, thin secretion could be, 
with difficulty, pressed from the urethra, it was exam- 
ined under the microscope, but always with negative 
result. At the last visit there was no trace of dis- 
charge. 
It is probably a wise precaution to keep up the irri- 
gation, at more or less frequent intervals, for some 
time after the urethral discharge disappears. The 
patient should be directed to hold her water as long 
as possible before the visit, in order that any trace of 
discharge may be discovered. THE BOSTON 
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