The gonococcus is a diplococcus which seems to be injurious only to the tissues of the human being, as inoculations in animals have produced no definite or reliable result. Like syphilis, it is spread by direct or indirect contagion, and usually in the same way. It is generally found in the genito-urinary mucosa of both sexes, but it has been accidentally and even innocently conveyed by immediate and mediate transfer to the mucous membranes of the eye, the rectum, and even to the mouth, although here, as in the nose, the mucous membrane is but little susceptible to its activity. It is generally stated that 20 per cent. of the blindness occurring in the young is due to gonorrheal conjunctivitis. Those membranes covered with cylindrical epithelium are more liable to succumb to infection by this parasite than are those covered with squamous epithelium. The more the epithelial cells conform to the former type, the more difficult it is to get rid of the infection; hence the disease lingers in the cervical canal longer than in the vagina.
The disease always commences as a contagious catarrhal discharge from the mucous membrane. It may spread much farther than this, invading deeper tissues by continuity, or tissues at a distance by the lymph stream, or producing even metastatic expressions of infection in distant tissues and organs. Under these circumstances the serous membranes are likely to suffer, and the peritoneum, the endocardium, the pericardium, the pleuræ, the meninges, and particularly the serous linings of some of the joints, as the elbow and knee, show unmistakable evidences of infection; while through the medium of the venous and then the arterial systems typical representations of pyemia following gonorrhea may occur.
The disease as it usually appears is seriously and often obstinately complicated by the structure of the membranes which it involves. The mucous membranes throughout the body are more than mere mucous surfaces; they are dotted with openings for the escape of glandular secretions, and nowhere is this more conspicuous than in the urethra, where many minute follicles, so called, empty tiny drops of secretion into the mucous canal. Infection may easily travel along these routes and lurk within such minute recesses long after it has apparently disappeared from the surface; and so it often happens that in the male not only the urethral follicles but the ducts leading to Cowper’s glands and prostate become involved, while in the female the follicles around the meatus, the urethra, and the vulva rarely escape. The clinical importance of this statement is of interest, as by it may be explained many of those cases where an old infection seems to have been lighted up, or where the contagion has been conveyed to another after an attack which was supposed to have been entirely cured. Nothing seems to favor outbreaks of this kind as do alcoholic and sexual excesses.
The gonococcus may be scarcely regarded as an obligate pyogenic organism by itself, but the parts most often involved in this disease may be regarded as never free from the presence of other germs of greater or less activity, and by association, if not by actual symbiosis, such an intense reaction is provoked that the resulting products do not differ from true pus, save by the added presence of the specific organism most at fault. Under these circumstances abscesses may form in any tissue infected. Another expression of this fact would be the establishment of a pyarthrosis after involvement of one or more joints. Gonococci may be found in almost every abscess of truly gonorrheal origin; on the other hand, in some of the serous cavities it is possible, at least for a time, that gonococci may be present in the serous fluid without producing in it more than a disturbing effect, the fluid now appearing turbid rather than puruloid.
The amount of toxemia which may be produced by gonococci without reference to formation of pus has not yet been established. It is, moreover, a difficult thing to estimate in cases of mixed infection. Occasionally there are cases of metastasis and gonorrheal invasion which are free from evidences of suppuration, and yet there may be anemia and cachexia of profound type; these can only be explained on the theory of an intoxication.
Besides the serous tissues of the body the fibrous structures may suffer seriously, not only in an acute manner, but also in a chronic and obstinate form.
It has been the custom to speak of urethritis as a synonym for gonorrhea, and to divide it into the specific and non-specific forms, including under the former expression cases where the gonococcus can be demonstrated, and under the latter term those which do not seem to show it. There is no doubt but that urethritis may be set up by the introduction of a foreign body, such as a sound or catheter, as well as by some irritating discharge from the vagina, and also as the result of excess of uric acid in the system, perhaps even of alcohol. These, if occurring in a previously uninfected urethra, may be regarded as distinctly non-specific lesions. It is also supposed that under certain circumstances inflammation may be set up by other organisms than the gonococcus; nevertheless almost all cases of so-called clap are positively gonococcus infections, simple or mixed, and have but one origin.
Diagnosis.
—Diagnosis can be made positive only with the microscope. A recognition of the gonococci by staining them and then watching the effect of iodine in their decolorization will be of great importance and reliable. The affinity of these germs for basic aniline dyes, and the fact that they do not take the iodine stain of Gram, will serve to differentiate them from the numerous other organisms with which they may be found mixed. By staining a cover-glass preparation first with methyl blue or other basic color, then placing it in Gram’s solution, and finally in a solution of Bismarck brown, the true gonococci which have been made visible by the methyl blue will have disappeared under the influence of the iodine, while other bacteria will be stained by it. It has been mentioned that the germ is a diplococcus of rather ovoid form, met in clusters but not in chains, and in groups of four or multiples of four; it may be attached to epithelium and pus corpuscles, or found within them, and is rarely found free in fluid except when present in large numbers. These organisms are capable of cultivation, growing best upon a mixture of human serum and neutral agar, at a temperature of 36° C.
The urethra may be infected from without and from within, and this infection may be either of a truly specific type (gonococcus) or of the pyogenic type; as between these forms information may be gained by the history and the clinical course, but the minute diagnosis is only to be made with the microscope. This is of more than theoretical value, inasmuch as it substitutes a certainty for a working hypothesis. It is, moreover, sometimes of great value, as when the question of infection of one of the opposite sex comes up, or it may have at times even an important medicolegal value, as in cases of rape.