Infection from without, so far as the male urethra is concerned, is a question of the venereal origin of the disease. Infection from within, in the specific form, is a matter of recrudescence of a formerly active lesion supposed to have disappeared. Infection of non-specific type from without affects the introduction of germs either by venereal contact or by the medium of an unclean catheter, sound, or some other instrument, or from within by the extension forward of an inflammation higher up in the genito-urinary tract, such as may be due to stone in the bladder, cystitis, enlarged prostate, or uric acid or oxalic acid crystals. Urethritis, usually of mild type, is not infrequent in old men from either of these causes. It may also be produced by the infection of a too strong or irritant injection, whether used either for prophylaxis or for ordinary treatment.

Classifying them we may then have urethritis of the following four types:

A. The period of incubation is short, usually two to six days, and the resulting inflammation is severe; the consequences are often remote and sometimes disastrous. Gonococci will be found in the pus and epithelial debris.

B. This has been described as “bastard clap.” It is really an auto-infection, with an incubation period of a few hours, and is practically the reawakening of a quiescent stage of A. It is characterized by abundant purulent discharge; this latter is thin and mucilaginous, more like that of so-called gleet, with an abundance of pus threads, or “clap threads,” in the urine. In this form gonococci are also found, but less frequently.

C. Much like A in its clinical course, but less violent, and with less widespread reaction. Its period of incubation is rarely over thirty-six hours. This type is most common after alcoholic and sexual excesses; the latter especially with one already suffering from vaginal discharge, particularly so when near the time of menstruation. Here the microscope will show few if any true gonococci, but a profusion of pyogenic organisms.

D. This form of disease is of non-venereal origin, and is susceptible of easy explanation and of satisfactory treatment if the cause be properly treated. No case of urethral discharge which does not seem to fall easily into one of the above categories should be treated without a search of the anterior urethra, especially the fossa navicularis, for possible chancre or chancroid, as well as for stricture.

Among the laity the idea is prevalent that gonorrhea is a disease of more or less trifling import, while many of the profession regard it as rarely worthy of serious consideration. This is an unfortunate notion regarding this disease, and those who have had largest experience unite in expressing the opinion that gonorrhea reckons more victims in the death list than does syphilis—not because it is more common, but because of its complications and the ravages, especially in the kidneys, resulting therefrom. It has been shown that the specific organism producing it may linger for years in the follicles of the urethra, whence it may issue forth, unexpectedly, to produce vaginitis, perhaps in the most innocent of women, and thus bring on a train of pelvic disorders which may involve the ovaries, the tubes, and the peritoneum. Doubtless gonorrhea has made in this indirect way many more victims than syphilis.

Regarding gonorrhea thus seriously, it is well to treat it cautiously and to inculcate vigilance in the daily life and habits of the patient. There are no arbitrary limits during which danger exists and then passes; peril lurks about such a case for an almost indefinite time. There is danger not alone to the individual, but to all with whom he may have sexual or even other relations. This advice pertains not alone to the urethral discharge and the care of the urethra, but especially to the avoidance of all possible contamination of the conjunctiva. One of the saddest spectacles in the domain of medicine is to see one or both eyes of an innocent victim injured or ruined by gonorrheal infection.

There is no denying the clinical fact that individuals vary considerably in their susceptibility to this disease; moreover, individual susceptibility varies at different times. Alcoholic and sexual indulgence seem to materially lower this susceptibility. Thus from the same individual, and within twenty-four hours, one may acquire the disease while others escape. In some instances immunity seems to be afforded by repeated attacks; in other individuals repeated attacks seem only to enhance the liability to the disease. The gonococcus grows best in alkaline media. Prolonged sexual excitement diminishes the acidity of the urethral fluids, and this favors the growth and development of the germ. No credence should be given to popular notions concerning the possible avoidance of infection after exposure. Even a careful toilet is usually inefficient for this purpose, while the use of prophylactic injections is to be reprehended. They do more harm than good. If strong enough to be bactericidal, they should be extremely irritant; if weak enough to be tolerated, they will prove useless. The patient should also be warned concerning possible transfer of the disease without sexual contact, and all toilet utensils, towels, etc., should be kept by themselves, and all syringes and instruments used in the treatment of the case should be carefully sterilized.