In women infection of the cervix uteri occurs in about 80 per cent. of the cases of acute gonorrhea, and in 95 per cent. of all chronic cases. The infection may extend up into the uterus at the menstrual period or just after parturition. In the cervix, owing to the histologic formation, the disease tends to chronicity, but the inflammation within the uterus is much more likely to subside naturally. Chronic gonorrhea of the endometrium is usually accompanied by tubular infection. The infection of the uterus may be superficial or it may extend down into the underlying myometrium.
The inflammation extends from the endometrium to the Fallopian tubes and beyond, causing salpingitis, pyosalpinx, hydrosalpinx, tuboövarian abscess, tuboövarian cysts, and pelvic peritonitis. The most frequent form of tubal gonorrhea is pyosalpinx, or pus tube.
In the acute stage of tubal infection the tubes become elongated and swollen, and the mucous surfaces within are covered with a seropurulent exudate. This condition is called salpinx or salpingitis. When the condition advances so far that the external abdominal ostium of the tube is closed, a pyosalpinx forms. The pyosalpinx may be quite large. A hydrosalpinx is like a pyosalpinx, with both tubal ends sealed, except that its content is a serous or watery fluid. When infected material escapes through the distal end of the tube, perioöphoritis develops, and the ovary becomes adherent to the tube and other adnexa. More commonly only the surface of the ovary is affected, but frequently the infection gets into the body of the ovary and causes oöphoritis. The ovary then swells and there is a tendency to the formation of retention and other cysts, or an abscess of the ovary. A tuboövarian cyst is a hydrosalpinx in communication with an ovarian retention cyst, and a tuboövarian abscess is a like formation.
Gonorrhea, especially in women, is likely to be very chronic. Emil Noeggerath, who in 1872 published a book[164] which changed the medical doctrine on the disease, said of women, "Once infected, always infected." Norris[165] reports a case where the gonococcus was latent in a man for twenty years, and he then infected his wife and wished to divorce her until he found that he himself was at fault. Sax[166] reported an infection after fourteen years; MacMunn,[167] one after fifteen years. These are exceptional durations in the male for virulence, though not for continuance of the diplococcus.
Neisser, who discovered the cause of gonorrhea, holds that, with the exception of measles, gonorrhea is the most widespread of all maladies. By sterilizing men and women and by abortion it holds down the birth-rate more than any other disease. The number of deaths from the consequences of gonorrhea (pelvic abscess, peritonitis, septicemia, endocarditis, and so on) is enormous. Norris thinks that 12,000 prostitutes die annually from the effects of gonorrhea alone. Woodruff[168] holds that 60,000 is nearer the truth. The estimate, too, is that 50 per cent. of all pelvic inflammatory diseases in women is gonorrheic; and Neisser, Bumm, and Fürbinger hold that from 20 to 50 per cent. of childless marriages are due to gonorrhea. Probably more than 20 per cent. of all the blindness in the world is from the same cause. The Committee of Seven,[169] in 1901, after examining most of the hospital records in New York and hearing from 4750 physicians, estimated that there were more than 220,000 venereal patients in New York City. Bierhoff[170] reckoned that in 1910 there were about 800,000 gonorrheics in that city. In 1906, in Baltimore, there were 3310 cases of the infectious diseases like measles, diphtheria, scarlet fever, and tuberculosis combined, but 9450 cases of venereal diseases. In New York City, in round numbers, there are annually about 41,000 cases of infectious diseases, excluding the venereal group, but 243,000 cases of venereal diseases—over five times more cases of venereal diseases than of all the other infectious diseases together. Of 12,000,000 persons insured in Germany, 750,000 annually are infected with venereal diseases. In the United States navy between 1904 and 1908, with an average of 43,165 men in the navy and marine corps, there were 32,852 admissions to the hospitals for venereal diseases, and of these 11,526 were cases of gonorrhea. This report is far below the actual numbers, as only men incapacitated for work are included in the list. In the English navy in 1906 the daily number of men rendered inefficient by venereal diseases was 867. In the total relative number of venereal diseases the American army and navy, before the present war, were the worst in the world, the Japanese navy next, the English army and navy next.
Sullivan and Spaulding[171] reported on the prevalence and effects of gonorrhea in 522 women and girls in a Massachusetts reformatory for women. Of these women 75.7 per cent. had gonorrhea by positive diagnosis. The average length of time the infection had existed when diagnosed was four years and five months, but one woman had had the disease for twenty-six years, and seven had had it for over twenty years. In 82.7 per cent. there had been no cessation of the clinical symptoms from the time of infection to the time of diagnosis. Of the total number 68 per cent. had pelvic inflammation on one side, and 27 per cent. had it on both sides. There were 41 per cent. of the cases which had had surgical operations or which required such treatment.
Of 63 women committed for alcoholism 52.4 per cent. had gonorrhea, 42.8 per cent. had syphilis, and 9.6 per cent. had doubtful syphilis; but of 400 women who had been at some time prostitutes 98.2 per cent. had gonorrhea, 65.5 per cent. had syphilis, and 9.5 per cent. had doubtful syphilis. Of 119 mental defectives among these women, 90.8 per cent. had gonorrhea, 61.3 per cent. had syphilis, and 6.7 per cent. had doubtful syphilis.
Dr. Thomas Haines[172] reported on 365 cases of boys and girls under eighteen years of age committed to an Ohio reformatory, and of these 20.8 per cent. had syphilis, and it was mostly acquired syphilis, not congenital—over one-fourth of the boys were so affected. McNeil[173] examined 1200 adult negroes in Galveston, Texas, for syphilis and found the disease in 30 per cent. of the 1200.
Howard Kelly[174] estimated that venereal diseases cost the United States three billion dollars annually, and Norris thinks this estimate too low. The ravages of the disease are so frightful, physically and morally, that any one who spreads it by infection, especially of an innocent woman, is guilty of the gravest moral injustice. Morrow[175] thinks that 250,000 married women in the United States are suffering from gonorrhea. As most of these unfortunate women are infected by immoral husbands, and as the invalidism and suffering they undergo are indescribable and cure is often impossible, the physician who permits a gonorrheic to marry without a protest is responsible for the evil as an accomplice; and, as has been said, once a gonorrheic, probably always a gonorrheic.
Pelvic inflammatory disease includes in the uterus and its adnexa alone metritis, salpingitis, oöphoritis, pelvic peritonitis, cellulitis, lymphangitis, and perimetritis. Pus may rupture into the pelvic cavity and set up local or general peritonitis or septicemia. It may burrow through from behind the uterus into the vagina, rectum, or other parts of the intestines, or into the bladder, and leave fistulas. Pus has been known to get through the abdominal wall itself. When the disease advances beyond the tubes there is, as a rule, invalidism until after the menopause, although the woman may be cured by surgery. Even skilled surgery does not always cure, because it is practically impossible to get rid of the gonococcus once it has been fixed in the tissues.