A Text-book of Diseases of Women

by Charles B. Penrose

The presence of the gonococcus is, of course, positive evidence of gonorrhea. But this organism may be present in small numbers and escape detection even at the hands of experienced observers; or it may be present in the tissues of the infected region and fail to appear in the discharge; or it may in time itself disappear altogether. And thus, when the woman begins to suffer from some of the remote lesions of gonorrhea, such as an endometritis or a salpingitis, and is driven to seek medical advice, she may be unable to give any history whatever of the beginning of the disease; the character of the secretions may teach the physician nothing; the gonococcus may have disappeared from the genital discharge; and though a pyosalpinx may be present which had originally been caused by gonorrhea, yet the gonococcus may likewise have disappeared from the tubal pus, and other pathogenic organisms may be found in its place. It becomes impossible to determine the true origin of the disease.

For these reasons, if the physician is accurate in his observations, and classifies as gonorrheal only those cases the specific origin of which he can prove, the frequency of gonorrheal lesions in women will be considerably understated.

Sanger states that in about one-eighth of all gynecological diseases gonorrhea is the underlying cause. Taylor, viewing the condition from the side of the venereal specialist, says that this statement is conservative and probably nearly correct.

It must be borne in mind that gonorrhea is sometimes caused in other ways than by coitus. This is seen in the epidemics of gonorrhea that occur in children. It is without doubt sometimes caused by the use of an infected vaginal syringe. Cases of rectal gonorrhea are not infrequently thus produced.

Gonorrhea in women may attack any part of the genito-urinary tract. It rarely attacks a number of structures at one time, but it usually becomes localized in one or two parts, such as the urethra, the glands of the vestibule, the vulvo-vaginal glands, the vaginal fornices, or the cervix uteri, and runs a subacute course, and may remain quiescent for a long period. It may in time disappear spontaneously, or it may be excited into activity by a variety of causes, such as traumatism, unusual coitus, labor, or miscarriage. The parts of the genito-urinary apparatus that are covered by pavement epithelium are much more resistant to the gonococcus than are the parts covered with cylindrical epithelium. For this reason the external genital surface and the vagina of the woman, and the vaginal aspect of the cervix, are often exempt when other less resistant structures are attacked.

Gonorrhea attacks the different parts in the following order of frequency: the urethra, the cervix uteri, the vulva, and the vagina.

Gonorrhea of the urethra is the most common form of the disease. The great majority of the cases of urethritis in women are of gonorrheal origin. Whenever there is a purulent or muco-purulent discharge from the urethra gonorrhea should be suspected, whether or not the gonococcus is found in it.

The disease may linger in the mucous glands found near the external meatus and in Skene’s glands for a long time. The symptoms of this condition have already been considered. The disease may present all the phenomena of acute urethritis in the male, or it may be subacute from the beginning.

Gonorrhea of the cervix uteri occurs next in frequency. As far as the few accurate observations that have been made teach us anything, gonorrhea of the cervix is but little less frequent than gonorrhea of the urethra. The disease may exist in conjunction with gonorrhea of some other part, or it may occur alone. The infection takes place directly from the discharge of the penis which comes in contact with the external os. Gonorrhea of the cervix usually begins in a subacute or an insidious manner. It is usually unattended by any general or local symptoms sufficiently marked to attract attention. If the woman had been free from a leucorrheal discharge, she may observe a muco-purulent secretion caused by the gonorrhea. If she had a leucorrhea, the alteration in the character and amount of the discharge is usually not sufficient to attract her attention. In some cases the discharge becomes more purulent in character; in others there is no alteration perceptible to the naked eye.

If the disease runs an acute course, the appearance of the cervix will be that characteristic of acute inflammation. The vaginal cervix is congested; the external os is patulous and is surrounded by a red granular or eroded area, while from it is seen escaping a purulent discharge.