Course.
—The period of incubation generally varies within wide limits, as mentioned above under classification of the various types; it may be as short as a few hours or may extend to ten days, or possibly even longer. Usually it is from two to five days. The early symptoms consist of discomfort along the course of the urethra, chemosis or edema, and swelling of the meatus. Within a short time after these symptoms the characteristic discharge appears. It may at first be viscid, but soon becomes purulent, and then more or less profuse, while urination gives rise to great discomfort. By the end of the first week the discharge is usually grayish in color, thick, continuous, and so profuse as to equal in volume 20 to 50 Cc. in twenty-four hours. The lesion is not confined to the urethra, and soon spreads to the peri-urethral tissues and thence to the lymphatics. A peri-urethritis with venous engorgement is added to the urethritis, and there is such an obstruction of the return circulation as to produce swelling and edema of the prepuce; this not only makes access to the urethra difficult, but conceals any excoriation and ulceration which may be going on beneath it. Sometimes this tumefaction proceeds to a degree where gangrene results.
All these local disturbances will be accompanied by more or less lymphatic involvement in the groins and in the perineum, with great soreness and tenderness throughout the entire genital tract. Chordee (painful erection) is a common and painful complication of this stage of the disease. Finally a well-marked degree of auto-intoxication, with its ordinary febrile and septic manifestations, may ensue. As the disease spreads farther back into the deep urethra there is irritability of the bladder, while in severe cases the frequent attempts at urination thus excited, with the accompanying pain during the act of expelling a few drops of urine, are distressing features of the disease. The pains are not limited to the organs involved, but are often referred to the back, to the perineum, and down the thighs. The symptoms above referred to belong to a well-marked case of acute specific type. There may be milder manifestations of each kind, and occasionally a case will run its course with but a minimum of the difficulties and discomforts above mentioned. Sometimes by the end of the third week, usually before, the disease will show a tendency to subside, even if inadequately treated. The inflammatory symptoms become less marked, the discharge thinner and less voluminous, until perhaps by the end of the seventh week there is noticed only a small amount when the patient rises in the morning. With all this apparent and spontaneous improvement there may be present, nevertheless, a serious and distressing amount of peri-urethral infiltration, which will soon be followed by cicatricial contraction and the formation of a stricture, the most frequent sequel of gonorrhea.
Complications.
—Complications may occur along any portion of the genito-urinary tract. These will be considered in their anatomical order.
Balanitis.
—Balanitis signifies an inflammation of the mucosa covering the glans. When the mucous surface of the prepuce is also involved, as it usually is when the orifice is contracted, then the condition is known as balanoposthitis. In the absence of ordinary cleanliness of the parts this may go on to erosion or extensive ulceration. It is sometimes complicated with chancroid or chancre. When such a condition exists, and the glans cannot be sufficiently exposed for purposes of cleanliness, the dorsum of the prepuce should be slit up sufficiently to permit of complete exposure, while in some cases the edema and the infiltration will be such as to justify circumcision. When needed these operations should be practised even if raw surfaces are thereby left exposed to infection. Such possibility may be usually obviated by cauterizing a fresh surface, as soon as exposed, with pure carbolic acid or one of the stronger caustics, or operation may be made with the thermocautery.
Folliculitis.
—Folliculitis implies the extension of the infection to the follicles and lacunæ which abound within the urethral canal. As long as their orifices do not become occluded they easily discharge their contents into the urethra, but when so swollen as to become occluded they lead to the formation of abscesses, which, beginning in a minute way, may sometimes give relatively extensive disturbance. These discharge internally; sometimes they so present that they may be opened externally, as they should be under these circumstances. They form a communication between the urethra and the exterior, and in this manner the majority of the ordinary urinary fistulæ are produced. These often occur in the perineum, but sometimes even in the pendulous portion.