Gonorrhea

GONORRHEA. Contents: Historical data..............686 Biology of the gonococcus in the organism........687 Clinical immunity and reinfection.....689 Laboratory diagnosis of G.............690 G. as a general disease............695 General pathology of gonorrheal diseases . . .697 G. in men.-Ways of spread of G.-General symptomatology and prognosis.-Principles of treatment......................698 G. in women.-Ways of spread.-General symptomatology and prognosis.-Principles of treatment.-G. and reproductive function.......70?. G. in children.....................715 Personal prophylaxis...........-..715 Gonorrhea (from Greek gone - seed and rheo - to flow), syn.: tripper, clap, blennorrhea, - an infectious disease caused by Neisser's gonococcus (Neisser) and transmitted, with rare exceptions, directly from person to person. The most frequent mode of transmission of G. is sexual intercourse, as a result of which G. belongs to sexually transmitted diseases (on the spread, social significance, and control of G. - see Venereal diseases). Historical data. G. belongs to the number of diseases whose history is as old as the history of humanity. In one of the chapters of the Bible, in the book of Moses, there is a series of hygienic and prophylactic instructions for persons suffering from this disease, and there is reason to think that King David suffered from urethritis. Herodotus (in the 5th century BC) has a myth explaining the origin of G. The Greeks had two goddesses of Aphrodite - the goddess of ideal love and the goddess of earthly love. The Scythians who invaded Greece offended the former by indulging in earthly love on the threshold of her temple, for which the goddess punished them with a "women's disease", a disease originating from sexual act. Indications of G. are found in Hippocrates, Aristotle, Plato. Epicurus himself not only suffered from G., but even died of urinary retention on the basis of gonorrheal stricture of the urethra. In the 2nd century BC, Galen described the clinical picture of the disease and coined the word "gonorrhea", which in exact translation means flow of seed. In the 8th century, Marcellus (Marcellus Empiricus) describes gonorrheal epididymitis; in the 9th century, Rhazes introduces the method of douches with lead solutions, in the 10th century Avicenna describes urinary retention on the basis of G. and proposes bladder washings. In 1162, the Bishop of Winchester orders the removal of women suffering from leukorrhea from brothels, and in 1347, Queen Joanna I of Sicily issues a decree on periodic inspections of brothels. By the end of the 14th century, the contagiousness of G. is recognized by all, and a number of prophylactic and regulatory measures are prescribed against it. With this, the first period in the history of G. ends. The second begins with the appearance in Europe of another venereal disease - syphilis, from 1493, and lasts almost 300 years. G. is as it were forgotten, it is not written about, then it begins to be confused with syphilis (Ambroise Paré). Although individual voices object (Bulleyn), the vast majority of authors consider gonorrhea to be one of the manifestations of syphilis and treat it with mercury and sarsaparilla. But even in this period of time, one should note the works of Guainer and Paré on the dilation of the urethra with wax candles and metal sounds, Marianus Sanctus - the inventor of the dilator, and Morgagni, who pointed out the significance of the glandular apparatus of the urethra and seminal vesicles in the pathology of G. In 1715 Cockburn, and in 1753 Boerhaave, protest against the mixing of syphilis and G. An opposition school of dualists is formed, and to clarify the question John Hunter in 1767 inoculates himself with pus from the urethra of a gonorrhoeic onto the head of the penis and prepuce. Due to an unfortunate coincidence, the patient from whom the discharge was taken turned out to be simultaneously a carrier of syphilitic infection, and the self-sacrificing experimenter fell ill first with G., and after a corresponding incubation period - with syphilis. Thus it seemed Hunter managed to prove the identity of syphilitic and gonorrheal viruses. In 1793 Bell repeated Hunter's experiment on two doctors, and they fell ill only with G.; in 1812 Hernandez did the same with the same result on 17 prisoners. The doctrine of identity was shaken, but the school of dualists won final victory only thanks to the works of Ricord, who possessed great clinical experience. In the period from 1831 to 1838, he made 667 inoculations of gonorrhea in Paris hospitals, which never once resulted in syphilis, and the medical world of that time bowed to his arguments. The third period of the doctrine of G. began. Unfortunately, through Ricord's own fault, a new confusion arose - he began to deny the contagiousness of G. and even attributed his own successful inoculations of gonorrheal pus to chemical irritation inherent in this pus, which is why he became the head of a new school of avirulists (see). For almost 40 years the dispute lasted; only after the role of microorganisms in the occurrence of inflammatory diseases became clear thanks to the works of Pasteur, the virulists remained the victors. In 1868 Salisbury gave a description of small, well-defined "spores" prone to intracellular arrangement, which he could observe in the pus of gonorrhoeics. In 1872 Hallier observed in a purulent drop cocci that were arranged scattered and in pairs, freely and inside cells. In 1879 Neisser published his classical description of the specific causative agent of gonorrhea - the gonococcus (see). He based his conclusions on the study of 35 patients. He gives exact morphological signs of the gonococcus, describes the method of its reproduction, the typicality of arrangement. Most authors confirmed his discovery, but there were not a few authors who disputed the specificity of the gonococcus (Zeissl, Lustgarten, in Russia - Ge). The work of Bumm and Wertheim (1885-87), who isolated a pure culture of gonococci on blood agar, put an end to all doubts. Bockhart completed the building erected by Neisser by inoculating this culture into the urethra of a paralytic who died a few days later from pneumonia. At autopsy, a gonorrheal ascending lesion of the entire urinary tract was found. In 1886 Roux proposed using the Gram staining method for differential diagnosis. It is interesting to note a few more historical dates. In 1729 the English physician Turner introduced balsam of copaiba into use, the beneficial effect of which on G. was experimentally proven by Ricord in 1854. In 1794 Bell drew attention to the localized nature of inflammation in chronic gonorrheal urethritis and proposed treatment using expanding pressure. In 1876 Otis pointed out the unequal distensibility of the urethra in different places and put forward the requirement of restoring extensibility to the normal limit. In 1853 Desormaux managed to construct a urethroscope, which was subsequently improved by Grünfeld, Nitze, Oberländer, and Valentin, and thanks to which an exact topical diagnosis of G. can be established. Finally, one should note the proposal of Janet, made simultaneously with Reverdin in 1892 - to treat gonorrheal urethritis with abundant washings of a weak solution of potassium permanganate (the latter was first introduced into the therapy of G. in 1864 by Richard and v. d. Corput) and the work of Noeggerath (1872), who proved that in the vast majority of cases inflammation of the uterus and its appendages is a direct consequence of gonorrheal infection, that female G. is difficult to treat and can exist latently for many months, and that finally a significant percentage of female infertility has a gonorrheal disease at its base. In 1909, V. E. Dembskaya first began to use vaccine therapy for gonorrheal diseases in Europe. Despite the significant spread of G. in Russia, its treatment and study stood at a very low level until the very last time; the reason must be sought, among other things, in the fact that there were no special departments in hospitals where those suffering from this disease could receive qualified help. Recently, circumstances have changed dramatically. A mandatory course in minor urology has been introduced into the curriculum of medical faculties, the basis of teaching which is the presentation of the doctrine of G. With the opening of dispensaries everywhere in the USSR, special clinics have also been opened separately for male, female, and in some places children's G. Special departments for the study of gonorrhea have been established in the venereological institutes of Moscow, Odessa, and Kharkov. All this, taken together, if it has not yet lowered the number of cases of gonorrhea, at least in large centers has sharply lowered the number of chronic cases. Biology of the gonococcus in the organism. The gonococcus that has entered the organism causes a reaction on the part of the infected tissues in the form of local inflammation of the mucosa, accompanied by its enhanced secretion and the release of a significant number of leukocytes. Microscopically examining the discharge of patients with G., gonococci are found as a rule inside the protoplasm of leukocytes. On the other hand, examining sections from the urethra affected by an acute gonorrheal process, Jacobi established that in the submucosal layer gonococci are not only found in leukocytes, but also lie freely in interepithelial spaces.

Observations by a number of authors have shown that in one and the same patient, a microscopic preparation of urethral discharge taken in various ways can reveal a different picture. If one takes a purulent drop flowing freely from the urethra, the overwhelming majority of gonococci will be located inside leukocytes. Conversely, the extra-leukocytic arrangement of gonococci will prevail in those cases when a drop is taken for examination after vigorous expression of pus from the depths of the tissues. On the basis of these observations, it should be thought that the penetration of gonococci into leukocytes occurs not in the depths of the tissues, but on the surface of infected mucous membranes, where the gonococci are carried out by the lymph flow together with leukocytes. Whether the absorption of gonococci by leukocytes occurs here, or the gonococci themselves invade the leukocytes, is a question that remains controversial to this day. Metchnikoff's phagocytic theory apparently encounters serious objections here. No one has succeeded in observing the autolysis of gonococci in leukocytes. On the contrary, gonococci that have penetrated into leukocytes, after a certain period of time, apparently destroy them, which is microscopically manifested by the rupture of the leukocyte and the release of gonococci from the protoplasm to the outside. Gonococci located in the protoplasm of leukocytes [see color table (pp. 679-680), Figs. 1 and 2] continue to develop within it; they divide and increase in number. As a rule, the gonococcus located in the organism causes suppuration, which is clinically manifested by the presence of leukocytes in the discharge and in the mucous membranes of the urinary tract or in the secret of the sex glands. However, Picker showed that in individual cases, albeit rare ones, gonococci can parasitize on mucous membranes and not cause a local inflammatory reaction (bacillary carrier state). The recognition of such cases is extremely important for deciding the question of the termination of treatment of a given person, since the latter are often unconscious spreaders of gonorrheal infection. The gonococcus in the organism differs in its biological properties from the gonococcus in a test tube. It is significantly less sensitive to fluctuations in temperature. At body temperatures of 40.5-41°, even prolonged ones (typhus, pneumonia, etc.), gonococci in the organism as a rule do not die, but their viability and vital activity are greatly weakened, which is clinically manifested by a decrease and often the disappearance of purulent discharge. This circumstance even prompted a number of clinicians to propose hyperthermia—both local and of the entire organism—as a radical method of treatment for gonorrhea. However, special observations have shown that it is impossible to achieve the death of gonococci in this way. This difference in the biological properties of the gonococcus in the test tube and in the organism, the greater temperature resistance of the latter, must apparently be explained by the different living conditions of the gonococci, the difference in the composition of the environment surrounding them in the test tube and in the organism, and the conditions of a certain anaerobiosis existing in the tissues and organs. Furthermore, gonorrheal infection in the organism resists the destructive action of antiseptic agents very well. If in a test tube the weakest solutions of the latter (often plain water) easily destroy gonococci, this is not observed in the organism. The reason must be sought in the fact that, having fallen onto the surface of the mucous membrane lined with columnar epithelium, the gonococcus is already deep beneath the epithelial layer after 24-36 hours, which protects it from the direct action of chemical medicinal substances. It should be mentioned that the continuous partial death of gonococci in the organism causes the constant formation of gonorrheal toxin here. The latter possesses the properties of causing an enhanced development of connective tissue elements and the phenomena of subsequent sclerosis. This explains the density and intransigence of scars, which as a rule are observed in places that were affected by the gonorrheal process. Clinical immunity and reinfection. Gonorrhea is a very widespread disease; it spares neither age nor sex. Not only can a newborn be infected with gonococci, but cases of fetal infection still in the mother's womb have also been described; on the other hand, a case of gonorrheal urethritis has been published even in a 100-year-old elder. It should be considered that there exists neither innate nor acquired immunity against gonorrhea. If individual persons are encountered who have not been infected from a known source of the disease, such cases are explained by sheer coincidence; those who avoided infection are often subsequently infected from the same source. There are a number of individual factors that favor infection. Such is prolonged, repeated, and turbulent sexual intercourse; it is clear that the longer sexual intercourse lasts, the longer period of time healthy mucous membranes are in close contact with diseased ones, and the more the possibility of infection is facilitated. Furthermore, turbulent sexual intercourse causes intensive active contractions of the sex glands, in which the infection nests, and facilitates the expulsion of the latter to the outside. Sexual intercourse during the menstrual period, when the vital activity of gonococci increases, also increases the possibility of infection. Some authors believe that persons who have suffered from gonorrhea become more susceptible to new infection. Two points must be strictly distinguished: reinfection and relapse. Formerly, gonorrhea was considered an incurable affliction; the aphorism existed that from any gonorrhea, except the first one, one can recover. At present, on the basis of prolonged and numerous clinical observations, it is considered that any gonorrhea is curable in the sense that one can achieve the complete disappearance of gonococci from the organism. Cases of "incurable" gonorrhea are encountered singly; the number of "incurable" cases in the practical activity of every doctor decreases in parallel with the increase in his experience. However, it is undoubted that in individual cases such "relapses" of the disease are observed; their cause must be sought in an outbreak of latent infection nesting in organs from which the outflow of discharge is difficult (seminal vesicles, prostate). Sometimes it is important to establish what one is dealing with—a relapse or a reinfection. To resolve this, one usually has to resort to a thorough evaluation of the patient's anamnesis concerning the previous gonorrheal disease and to confrontation. This should also be done in those cases when the infected person categorically denies the possibility of a fresh infection, stating, for example, that the spouse of the person with whom sexual intercourse took place has been living with her for a long time and is completely healthy. There is the so-called "familial" form of gonorrhea: a man not cured of gonorrhea can infect a woman with a weakened gonococcal strain. The weakened virus causes a weak picture of barely noticeable gonorrhea in the woman; both spouses, exchanging gonococci during sexual intercourse, get used to the bacterial race located in their organism, and their mucous membranes acquire as it were a specific immunity to the given race of gonococci. If a third person intrudes into such cohabitation, they can fall ill with acute gonorrhea. Clinical observations have shown that the duration of the incubation period in gonorrhea can range from 1 to 40 days. It depends on the most diverse causes: the toxicity of the gonococcal culture, the penetration of infection not directly into the urethra, but into the paraurethral passage, from where the mucous membrane of the urethra is then slowly and sequentially infected; constitutional features of the organism of a local and general nature also play a known role (according to Zaigraev and Linde, athletic-type patients did not have a prolonged incubation period, while among picnic-type patients, a 10-day duration of the incubation period was encountered in 9%). Upon analyzing individual cases of repeated and primary gonorrhea by the same authors, it turned out that the duration of incubation is the same in both primary and repeated gonorrhea. It should thus be considered a rule to have an incubation period lasting 3-4 days. However, pathologically and anatomically, the incubation period is very short. Experiments on inoculating gonococcal culture into the urethral mucosa have shown that already 12 hours after infection, tissue hyperemia and serous discharge can be observed, after 18 hours—mucopurulent discharge in greater or lesser quantities with gonococci, and after 24 hours—a histologically clear picture of acute gonorrhea. Male patients discover acute gonorrheal urethritis in themselves all the sooner, the more aware they are of the initial picture of the disease.

Fronshtein. Laboratory diagnosis of gonorrhea. As objects for investigation for gonococci, the laboratory receives urine and various pathological discharges of the urogenital system (urethra, prostate, seminal vesicles, vagina, cervix, Bartholin glands), rectum, conjunctiva, as well as from other areas of the body (blood, effusions of synovial membranes, joints, testicles, etc.). For a successful investigation, these materials must be rationally collected: urine is taken in two portions, after preliminary washing of the external genitalia; urethral discharges before morning urination; vaginal and uterine discharges after mechanical cleaning and washing of the external genitalia with an indifferent liquid. With scanty uterine discharge, the latter is obtained by uterine massage. Effusion fluids and blood are obtained by puncture observing the usual rules of asepsis; semen by sexual intercourse into a condom or by masturbation; prostatic secretion by massage of the gland. It is necessary to simultaneously perform a general examination of the urine (physical, chemical, microscopic) to detect other processes that often simulate gonorrhea and depend on improper salt metabolism—oxaluria, phosphaturia, uraturia—or some other nongonococcal infection. For microscopic examination, the urine sediment is centrifuged. The sediment is examined fresh or stained. To detect gonococci in the urine, it is important to examine "threads" and "flakes" visible to the naked eye, consisting of mucus and various formed elements. The threads and flakes fished out of the urine, as well as the urinary sediments, are smeared in a thin layer on glass slides. Smears are fixed in a flame or in formalin vapors and stained by two methods. 1. The double staining method (eosin and methylene blue). 1% eosin in 60% alcohol; stain for two minutes; pour off the stain and remove residues with filter paper or wash off slightly with water (drop by drop). Eosin water-soluble yellowish 1.0; 60% alcohol 100.0 (preparation of 60% alcohol: 95° alcohol 100.0, distilled water 58.0). Saturated aqueous methylene blue; pour on for 7_1/2 min., wash off with water, dry with filter paper. Such staining determines the presence of eosinophils, which, according to Posner, indicates gonococcal intoxication, i.e., the presence of a gonococcal focus somewhere. 2. Another part of the smears is stained to detect gonococci, gonococcus-like and other bacteria according to Gram's method (see Gram's method). When staining smears by Gram's method, the background of the preparation, consisting of formed elements (pus cells, squamous epithelium, mucus, etc.), appears stained in a yellow-pink color (neutral red), gonococci and gonococcus-like ones are also stained in the additional yellow-pink color, i.e., they are Gram-negative; fermentation cocci, staphylococci, streptococci, diplo-streptococci, often accompanying the gonorrheal process, are stained in a dark violet color with gentian violet, i.e., they are Gram-positive; thus, with this method, both typical and atypical gonococci, as well as gonococcus-like and other accompanying flora, are morphologically differentiated (see Gonococcus). To detect atypical gonococci by Gram's method, Finkelstein introduced the following changes: 1) extremely gentle flaming during fixation (2 times through the flame), 2) additional staining with neutral red while heating to light vapors. Bacteriological examination is performed when bacterioscopy does not provide an answer to the question of the presence or absence of gonococci in the pathological material. Material for sowing is taken [after mechanical cleaning of the surrounding external urogenital organs (glans penis, vulva) followed by washing with sterile 0.85% NaCl] with a sterile platinum loop from the urethra and a blunt spoon from the vagina and uterus and sown on the following media. 1. Slant ascites-agar [one part ascites + three parts agar of a certain acidity (pH = 7.2–7.6)]; one tube is sown in the usual way, the other, after sowing, is poured over with sterile oil (vaseline or paraffin) to obtain relative anaerobiosis. 2. Ascites-broth (1 part ascites + 3 parts ordinary broth). This sowing is necessary to weaken the bactericidal properties of the inoculating material. 3. Blood agar (1 part rabbit or ram blood + 3 parts agar); the latter sowing is necessary in view of the occasional presence of gonococci that grow better in the presence of blood (vitamin); in addition, the hemolytic properties of certain microbes accompanying gonorrhea (gonococcus-like, streptococci, diplo-streptococci, staphylococci, etc.) are detected on this medium. 4. Control sowing on simple slant agar (for the presence of gonococcus-like ones). Sowing is kept in an incubator for 24–48 hours; after 24–48 hours, subcultures are made (from liquid media). At the same time, suspicious colonies on agar are examined microscopically. The obtained gonococcal culture, if it is used for the manufacture of a vaccine, is examined for endotoxicity by Jotten's method on white mice. For this purpose, various amounts (1, 2, 3 loops, up to 10 loops inclusive) of a 24-hour gonococcal culture from ascites-agar are injected intraperitoneally into a number of white mice; the result is recorded after 24–48 hours. The endotoxicity of the culture is determined by the minimum amount of it from which the death of the mouse occurs (e.g., 5 loops, 7 loops of culture, etc.). In case of the discovery of gonococcus-like ones, their nature is elucidated by additional sowings on various sugar media (maltose, glucose, etc.). Serology of gonorrhea, serological identification of gonococcal cultures: Sometimes the isolated cultures do not possess sufficiently pronounced and characteristic morphological and physiological properties for the gonococcus and therefore must be subjected to serological identification. For this purpose, it is necessary to have sera of animals (rabbit, goat, horse) immunized intravenously with gonococcal and gonococcus-like cultures. If the test culture is agglutinated by immune gonococcal serum up to half its titer, then this culture must be considered a gonococcal culture. The serological identification of the latter is based on the same specific agglutinating properties of immune sera against gonococcus-like cultures. Sometimes the agglutination reaction proceeds uncharacteristically; then one can resort to the serological identification of cultures using the same immune gonococcal and gonococcus-like sera by the complement fixation method (see Bordet-Gengou reaction). To develop methods for the serodiagnosis of gonorrhea, the agglutinating, precipitating, bactericidal, opsonizing, and complement-fixing properties of serum in people infected with gonococcus were studied. At the same time, it turned out that natural gonococcal infection in humans, unlike artificial immunization of animals in them, is not accompanied by any pronounced serum reactions. Therefore, none of the indicated reactions, except for the fixation of alexin (complement), has acquired practical significance in the serodiagnosis of gonorrhea. The significance of complement fixation, which was first proposed for gonorrhea by Bruck, was soon confirmed by Oppenheim and Müller in gonorrheal arthritis and other gonorrheal processes. In Russia, this method was tested with success by Merkuryev, Dembskaya, Zboromirsky, Romanov, Suteev, and Finkelstein. The complement fixation method in gonorrhea in general terms boils down to the following. The blood of a gonorrhea patient, sterilely taken from a vein, is allowed to settle for 12–24 hours; the resulting serum is aspirated and heated for half an hour at 56–58°. The gonococcal antigen is prepared from a 24-hour ascites-agar culture. It is washed off with 1¹/₂ cubic centimeters of distilled water; 2 cubic centimeters of 4% antihormin are added to it (in the latter amount, active chlorine must equal 0.3%); 4% sulfuric acid is added drop by drop for neutralization according to litmus. Then this mixture is placed for half an hour in a water bath at 54–56° to remove chlorine; a sign of the disappearance of chlorine is the absence of a color change in white starch-iodide paper, which in the presence of chlorine turns black-violet. In the manufacture of antigen, the protoplasm of bacteria must be destroyed (to a certain extent). Of great importance for the quality of the antigen are the freshness of the cultures (no older than two to three weeks), a large selection (not less than 8–10) of cultures of various origins (from men, women and children, acute forms of gonorrhea, chronic, complicated, etc.), as well as a certain degree of their toxicity (Jotten). Many other methods of antigen preparation have also been proposed. Such are the methods of Kohn, Tulloch, MacNeil (on distilled water).

Whatever the method of preparing the antigen, the latter must satisfy the following requirements: 1) in a definite working dose it must give complement fixation with the serum of a gonorrhea patient or with an immune anti-gonococcal serum (of a rabbit, horse, goat); 2) it must not fix the complement of normal human serum; 3) it must not by itself, i. e., in the absence of the hemolytic system, hemolyze sheep erythrocytes; 4) it must not fix the complement with the sera of patients with non-gonococcal processes (syphilis, skin diseases, colibacillosis). When setting up the complement fixation reaction in gonorrhea, the basic principles applied in the Wassermann reaction are followed (see Wassermann reaction). The main test is set up according to the following scheme. Recent literature concerning studies of various forms of gonorrhea using this method shows that it gives a positive result: 1) in almost 100% of acutely complicated gonorrhea diseases (prostatitis, epididymitis, arthritis, adnexitis); 2) in chronic complicated gonorrhea (40-65%); 3) in uncomplicated gonorrhea, the percentage of positive results fluctuates within fairly wide limits (from 25% to 50%). In general, the clinical value of the Bordet-Gengou reaction mainly reduces to the differential diagnosis (syphilis, tuberculosis, streptococcal processes) of unclear diseases of the joints, prostate, testicles, and appendages (in women). A positive Bordet-Gengou reaction in such unclear diseases undoubtedly speaks for the gonococcal nature of the process. This diagnosis becomes absolute when it is possible to set up the Bordet-Gengou reaction with the effusion fluid of one or another area (e. g., joints, testicular tunics). The technique for setting up the reaction with these fluids is the same as with blood serum. Experimental gonorrhea. In the history of this issue, a whole series of failures is noted that befell the greatest experimenters—Neisser, Kraus, Löffler, Bumm, Leistikow; rabbits, dogs, rats, mice, guinea pigs, horses, and monkeys were tested. Some researchers who worked with cultures on animals saw suppuration, but without the gonococcus (Finger, Kohn, Schlagenhaufer, Christmas). Intoxication with the gonococcus was studied by Etten, Sovinsky, Moskalev, Finkelstein; Molchanov observed changes in the nervous system. Supposedly more successful results were seen by Davis, Heller, Lindström. Dembskaya, to exclude leukocyte activity, smeared the mucosa with guaiac. Reenstierna in recent times injected monkeys with gonococcal cultures grown on media with monkey blood, but without result. Finkelstein performed preliminary anaphylactization of the subcutaneous tissue of the rabbit's scrotum with a toxic dose of gonococcal vaccine, and, injecting thereafter a gonococcal culture grown on a rabbit broth medium, he saw prolonged multiplication of the gonococcus in the tissue (within three to four weeks). Korobkova, Boryu, and Sherishorina in 1925 (by analogy with certain authors: Venulet—paratyphoid in rats, and Zeller—infection of the conjunctiva with dysentery, diphtheria, and pyocyanic bacillus after preliminary sensitization of the organ with bile according to Besredka) did the same thing with respect to rabbits, in which they treated the conjunctiva, urethra, vagina with bile, and then applied the gonococcal culture. Boryu and Sherishorina report that in all cases in their experiments, typical lesions of the mucous membranes were obtained in rabbits with the multiplication of the gonococcus and a general reaction of the organism in the form of an increased temperature, weight loss, an intradermal reaction, and certain immunity reactions; at the same time, the culture used by them was always the same one, isolated from the discharge of a patient with acute gonorrhea (other cultures gave weaker results; the passaged culture sometimes gave infection also without bile sensitization). At the urological congress (Leningrad, 1927), reports were presented on inoculations of the gonococcus into castrated white mice (Sternburg, Schedrovitsky, Rabinovich). Experiments in the same direction on castrated rabbits, as well as with blockade of the reticuloendothelium (trypan blue) and exclusion of cerebral immunity, carried out by Finkelstein, did not yield full results. These data lead to the conclusion that until now no fully convincing experiments on the infection of animals with gonorrhea have been presented.

Test tube | Serum inactivated in cm³ | Test No. 1 | 0.1 | 0.85% NaCl in cm³ | 0.5 | Gonococcal antigen in working dose (0.14) in cm³ | 0.5 | Non-gonococcal | 0.1 | 0.4 | 0.6 | Gonococcal | 0.1 | Test No. 2 | -0.1 | 0.5 | 0.5 | Complement with an addition of 25% in cm³ | 0.5 | 0.5 | --- | 0.5 | a | --- | s | 0.5 | to | 1 | Hemolytic system (hemolytic serum + sheep erythrocytes) | 1.0 | 1.0 | 1.0 | Result | + + + + (no hemolysis) | Hemolysis | + + + + (no hemolysis) | Hemolysis

10. Finkelstein. Gonorrhea as a general disease. In the majority of cases of gonorrhea, the infection occurs sexually. In cases of sexual perversion, gonorrheal infection may penetrate through the rectum or oral cavity. Extragenital infection through infected linen, sponges, and irrigators undoubtedly occurs, but is extremely rare in adults (much more frequently in women than in men). This rarity is explained by the instability of gonococci outside the organism, as they lose their virulence upon drying. In exceptional cases, medical manipulations performed with poorly disinfected instruments serve as the source of infection. Until very recently (Gramenitsky, 1916), there was a debate as to whether gonorrheal disease represents a local process that gives rise to complications and leads to metastases only as an exception, or whether it is from the very beginning an infectious disease of the entire organism. Having at present significant serological material, we can state with certainty that gonorrhea is a general infectious disease. A number of numerous clinical observations, a series of cases of in vivo diagnosis of gonococci in the blood, in the endocard, and in organs remote from the primary focus also serve as unquestionable proof of this theory. The penetration of gonococci into the general bloodstream is observed apparently in all cases of gonorrheal infection without exception (gonococcal bacteremia), but it entails typical sepsis (see Gonococcemia) only in an insignificant number of patients. In the majority of cases, the bloodstream serves for gonococci merely as a convenient pathway for dissemination throughout the organism. At the same time, they usually quickly disappear from the blood, which explains the significant difference in quantitative relation between the frequency of positive serological reactions and the positive finding of gonococci in the blood by culture. The penetration of gonococci into the general blood stream is favored by their inherent ability to rapidly penetrate into the deep layers of tissues, from where they are washed out by the venous blood flow and carried throughout the organism. In those cases where the protective power of the blood serum is weakened, gonococci will develop in a suitable medium, which blood is for them, and in the course of the gonorrheal process a number of complications will be observed on the part of organs remote from the primary focus of the disease. In those cases where the body's protective power is sufficient, the destruction of gonococci in the blood occurs, along with their disintegration with the formation of toxins, and only phenomena of general intoxication of the organism are observed without separate metastases. The great importance of constitutional factors in the spread of gonorrheal diseases is confirmed by the observation that in some individuals, repeated infections are as a rule accompanied by metastases in the same organs as in the first infection. Mkrtychyants and Levant pointed out that asthenics and individuals with lymphatic-hypoplastic anomaly are distinguished by a decreased production of antibodies against gonorrheal infection and are predisposed to metastases of gonorrheal infection. The toxicity and virulence of individual gonococcal strains apparently do not play a significant role in this matter, since even in cases where the local process is accompanied by an apparently minimal reaction, significant general phenomena can be observed. More important is the local weakening of individual organs as a result of their mechanical trauma or general fatigue, chilling, excesses in venere et in baccho, or as a result of a previously suffered disease of another etiology. A clinical symptom of the general gonorrheal disease is an increase in temperature, sometimes sharp with fluctuations, sometimes insignificant, accompanied by general malaise and body aches. These phenomena pass quickly without any therapy or end in metastases in one or immediately in several organs. The penetration of gonococci into the general bloodstream can occur from any focus of infection (e.g., cases of general infection of the newborn from the placenta). But there are certain organs from which the generalization of the process is greatly facilitated due to their significant vascularization. These are the posterior urethra and seminal vesicles in men, and the uterine appendages in women. There seems to be no organ in the human body where gonococci could not penetrate via the blood pathways and cause inflammatory changes there (joints, ligamentous apparatus, skin, muscles, bones, individual lymph glands, endocardium, nerve trunks, irises of the eye, etc.). The spread of infection from the primary focus of the disease can occur, apart from the blood pathway, via the lymphatic pathway or per continuitatem. Tanton expressed the opinion that leukocytes stuffed with gonococci are carried away by the lymph flow and thus serve as disseminators of the contagion. Histological studies by Ehrmann, Wolf, and Rost confirmed this theory. General pathology of gonorrheal diseases. The fundamental law of gonorrhea is the selective affinity of the gonococcus for mucous membranes, especially for cylindrical epithelium. Therefore, those organs that are lined with such epithelium (urethra, cervix of the uterus, conjunctiva of the eye) are most frequently affected by the gonorrheal process. Upon reaching the cylindrical epithelium, the gonococcus not only spreads along its surface, but quickly and easily penetrates between the clefts of the epithelium into the subepithelial layer, into the submucosal connective tissue stroma, causing an inflammatory reaction on the part of the mucosa by its presence and the products of its disintegration (endotoxins). Stratified squamous epithelium is a certain barrier to the penetration of gonococci deep into the tissues, and they vegetate on its surface as saprophytes, without causing local inflammatory phenomena until they come into direct contact with cylindrical epithelium. A necessary condition for the gonococcus to manifest its effect in full volume is the presence of trauma to the mucous membrane, which opens access for the gonococcus deep into the organ, whether this trauma is instrumental, medicinal, or depends on the irrational behavior of the patient. In the anamnesis of the majority of patients "with complications of gonorrhea," i.e., those suffering from the involvement of not only the urethra but also other organs in the inflammatory process, one can almost always establish (as the immediate etiological moment) one of the enumerated factors. Under the influence of the inflammatory process caused by the gonococcus, the death and shedding of the cylindrical epithelium occur. The healing process is accompanied by its metaplasia (its replacement by stratified squamous epithelium). A large and important role in the recovery process is attributed to this metaplasia by a number of authors (Bumm, Finger). Falling onto the surface of the newly formed squamous epithelium, gonococci encounter a natural barrier to their further development; on the other hand, the gonococci that have penetrated deep into the tissues, covered by the newly formed epithelial layer, find convenient conditions for their development there and, being as it were isolated from the external environment, unimpededly carry on their destructive work. After a certain period of time, the duration of which is purely individual, one can observe the disappearance of the metaplasized squamous epithelium and the complete or partial regeneration of the cylindrical epithelium of the mucous membrane. For a long time it was believed that the gonococcus causes inflammatory phenomena and suppuration exclusively on mucous membranes. However, the study of its biology and the accumulated clinical material show that mucous membranes are merely those tissues that are most susceptible to gonorrheal infection, but there is no tissue in the organism where gonococci could not manifest their vital activity. Gonorrhea in men. Pathways of dissemination. It should be considered established that the rapidity of the spread of infection along the male urethral mucosa is caused not by the gradual involvement of the surface of the mucous membrane in the specific inflammatory process, but by the infection of it by lymph flowing from previously infected peripheral segments along the dense-meshed lymphatic plexuses of the urethra (Panizza). Only in this way is it possible to explain such facts as the spread along the urethral mucosa of immobile gonococci against the urine flow, their spread from the anterior urethra of the man into the posterior, despite the hermetic separation of the latter, and the greatest intensity of gonorrheal lesions in the bulbous urethra, i.e., in the part of the latter especially rich in lymphatic vessels. Finally, histological studies by Nakano and partly by Ilyinsky have shown that in the presence of acute gonorrheal inflammation of the epididymis, the most sharply expressed foci of inflammation can be located in the intertubular connective tissue and in the vicinity of lymphatic vessels. For certain individual organs, one must also admit the possibility of the penetration of gonorrheal infection due to antiperistaltic movements of the excretory ducts. Clarification of the mechanism of the pathways of dissemination of gonorrheal infection in each individual case is also of purely practical interest. In infection per continuitatem or via lymphatic pathways, one must first of all strive to affect the primary source of infection in the organism.

In hematogenous infection, our therapeutic efforts must be directed toward increasing the defensive forces of the organism in the fight against the penetrated infection. General symptomatology and prognosis. Two forms of the disease should be distinguished: acute and chronic. By acute gonorrhea is meant the form proceeding with abundant discharge from the urethra and painful sensations, by chronic the same picture, but in a milder form. In the latter cases, only scanty discharge from the urethra is observed in the form of a purulent drop in the mornings or in the form of purulent threads in the urine containing gonococci. The disease manifests itself in men with symptoms on the part of the urethra. In the course of the disease, regardless of its stage, a number of complications of the primary process in the urethra may be observed, which consist in the fact that both the sexual glands and individual organs of the human body, sometimes far removed from the primary focus of the disease, are involved in the inflammatory process (this is detailed in the description of the corresponding organs). In the majority of patients with gonorrhea, the concept of «chronic gonorrhea» is associated with the idea of an incurable form of the disease. At the present time, on the basis of clinical observations, one should hold the point of view that gonorrhea is a curable disease, regardless of its form—acute or chronic. The cure of acute gonorrhea, however, is significantly easier and requires less time than the cure of chronic gonorrhea. By the cure of gonorrhea should be understood the persistent (forever) disappearance of gonococci from the discharge of the urogenital organs. The mere disappearance of purulent discharges is not sufficient to consider the patient recovered from gonorrhea. Under the influence of treatment, the discharge usually disappears earlier than the gonococci can be destroyed. It is enough for the patient to violate the diet, to have sexual intercourse, for the gonococci to begin to multiply intensively and for the purulent process to flare up with the same force. The decision on whether the gonococci have persistently disappeared, whether the patient should be considered finally recovered, and whether he should stop treatment is a difficult task. Microscopic and bacteriological examination of the discharge of the sex glands and urine is the only reliable criterion currently available for the cure of gonorrhea. However, the analysis has value only when it is performed systematically and in connection with a methodical, comprehensive clinical examination of the patient and is considered as one of the main links of objective research data and the evaluation of subjective sensations and the patient's anamnesis. It is necessary to produce repeated control examinations not only of the first portion of urine, after artificial chemical and mechanical irritation of the urethral mucosa, but also a bacterioscopic examination of the discharge of the sex glands. If, after repeated methodical clinical examination of the patient and the indicated bacterioscopic examination of the urine and secretion of the sex glands, no foci of inflammation are found either in the urethra or in the glands, and in the analyzes not only gonococci are not detected, but leukocytes are not found either, or these are single ones, the patient can be told that he is healthy. It is easy not to sin against the truth even in the case of diagnosing «healthy» even in the presence of individual threads of a mucopurulent character in the first morning portion of urine. In this case, the diagnosis of «healthy» should be made only after a control examination of the patient over a certain period of time, during which the patient should not be treated, but lead a normal lifestyle. A number of authors (Vossidlo, Oberländer) indicate that the diagnosis of «healthy» after suffered gonorrhea can be made only with the complete and long-term disappearance of threads containing leukocytes from the morning urine. The indicated requirement is maximal and of course an unconditionally justified requirement. However, one should not forget that leukocytes and threads in the urine can always be observed in individuals who have suffered gonorrhea, once it is impossible to achieve a complete restoration of the anatomical integrity of the urinary tract. Especially in cases of gonorrhea complicated by a disease of the accessory glands, it is never possible to achieve the complete disappearance of leukocytes from the urine. If one were to be rigoristic and give a conclusion on the possibility of marriage only in the complete absence of leukocytes in the urine, then more than half of the patients should be forbidden to have sexual intercourse forever. On the other hand, everyone is well aware of cases where such individuals entered into marriage and did not infect their wives. Based on this consideration, it is not always necessary to strive for the disappearance of leukocytes. By persistent treatment aimed at destroying individual leukocytes in the urine, one can sometimes not only fail to bring benefit to the patient, but also cause him significant harm. Prolonged treatment of chronic urethritis contributes to the complication of the process due to mechanical and chemical irritations. Secondary urethritis arising thus can proceed as intensively as gonorrheal ones. It is best therefore in those cases where (in the absence of gonococci and other bacteria, as well as infiltrates in the urethra) there is only a slight discharge of a mucous character and only slight turbidity in the urine, to abandon any treatment. After a careful methodical examination of the discharge of the urethra itself, the ejaculate and the sex glands, after repeated provocation with a negative result, the patient should be indicated that he does not require treatment. Cure in gonorrhea is a consequence of the reverse development of inflammatory phenomena caused by gonococci, and occurs by scarring, which sometimes causes deep changes in the affected tissues, especially if the disease lasted a long time and the inflammatory phenomena were very stormy. These changes in turn affect the functions of those organs where scars have formed. The formation of dense scars in the mucosa of the urethra entails a modification of its lumen, its compression—a stricture, and affects the freedom of urination. The formation of scars in the thickness of the prostate gland can lead to a change in its function and affects the sexual act in the direction that sexual power falls. Finally, the formation of scars in the epididymis causes their overgrowth, impermeability for spermatozoa and serves as the cause of male infertility. The easier the disease proceeded, the fewer scars are formed, the less they will affect the functions of the urogenital organs. Therefore, one should proceed to the treatment of gonorrhea as soon as possible and carry out the latter if possible in such a way that, striving to destroy gonococci, not to disrupt the integrity of the tissues. It must be said that lately, when the treatment of gonorrhea has taken on a completely different character, the development of deep scars in the affected organs is observed much less frequently than before. Principles of treatment. The most common method of treatment of acute gonorrhea until recently consisted in the fact that the patient was given a Tarnowsky syringe in his hands and this or that medicine for injection into the canal (protargol, Arg. nitr., sublimate). It was believed that the liquid introduced into the canal would destroy, kill gonococci and this would destroy the disease. This was the period of antiseptic treatment of gonorrhea, based essentially on a principle that is undoubtedly correct. However, when applying this treatment principle, it was not taken into account that already 24 hours after getting onto the mucous membranes, the gonococcus penetrates into the deep layers, and the antiseptic agents used to act on the gonococcus do not penetrate so quickly and so deeply. As a result of the treatment of gonorrhea by injection into the urinary canal of disinfecting, bacteria-killing solutions, a rapid decrease in discharge is usually observed (sometimes its complete disappearance). This is due to the fact that gonococci located on the surface of the mucosa are destroyed, and the suppurating surface of the mucosa heals. Those gonococci that managed to penetrate deep into the tissues, finding no way out, continue to live, and a small inflow of blood to the genital organs as a result of drunk wine or a minor violation of their integrity, as a result of sexual intercourse, or even excitement, is enough for the picture of the disease to appear in full again. Therefore, the glory of an incurable disease has taken root for gonorrhea. At the present time, another method of treatment is widespread, which can be called aseptic, and the treatment results have become significantly better (gonorrhea has passed into the category of curable diseases). The method consists in the fact that they strive not to kill gonococci, but to put them in such conditions as to make their development in the organism impossible. They strive to remove gonococci from the organism; for this purpose, the suppurating surface of the mucosa is washed with large amounts of liquid. A KMnO₄ solution is taken for washing, which has the ability to cause local tissue edema (see Janet method). Due to this edema, the secretion of the mucosa is enhanced, gonococci from the depth are carried out by the current of blood serum and removed from the organism by washing or urine. When the gonococcus penetrates into organs hidden from direct action (prostate, epididymis, joints), they strive to act on gonococci through the blood, which has the ability to kill gonococci; for this purpose, a vaccine is injected under the skin.

The vaccine itself does not kill gonococci, but when administered subcutaneously, it enhances the defensive forces of the blood. In order to bring a greater amount of blood to the affected organ and affect the gonococci, local blood supply is increased through the application of heat in the form of hot baths, enemas, and compresses. Cauterizations, usually applied during the period of the disease known as the chronic stage, also aim not to directly kill the gonococci, but to induce an increased influx of blood to their location, which in turn will act upon the gonococci.

R. Frenshtein. Gonorrhea in women. Routes of transmission and localization. In adult women, primary gonorrheal infection primarily affects the urethra, the major and minor glands of the vestibule of the vagina, and the cervical canal. As a rule, the vagina itself is not primarily affected by gonorrhea. Even secondary involvement of the vagina in the gonorrheal process is a rather rare occurrence (Bumm, Mandl, and others). Disease of the vagina due to gonorrhea is usually observed in children, owing to the delicate, moist, and non-keratinized epithelium of the mucosa, then in pregnant women, and finally in cases of genital hypoplasia. The primary localization of gonorrhea in women is greatly influenced by the mode of transmission. In non-venereal infection, the urethra and the glands of the vestibule of the vagina are affected first; the same occurs during incomplete coitus, when those parts of the female genital apparatus that come into direct contact with the male organ are affected first. The localization of the infection in women is also greatly influenced by the stage of the inflammatory process of gonorrhea in the man. In an acute inflammatory process in men, the discharge flowing from the external opening of the urethra infects the entrance to the vagina, the vestibular glands, and the external opening of the female urethra at the very beginning of the sexual act. In the presence of chronic urethritis in the man, gonococci enter the female genital organs only at the end of the sexual act along with glandular secretion and semen, as a result of which the cervix uteri is infected first in such cases. The possibility of introducing a primary gonorrheal infection into the uterine cavity and fallopian tubes is also not excluded. Wertheim succeeded in proving the presence of gonococci on the uterine mucosa as early as five days after infection. The experiment of Rotter deserves great attention, as he proved that spermatozoa easily transport gonococci with them, and that consequently the so-called ascending gonorrhea of women arises through the assistance of spermatozoa. As for the frequency of involvement of the urethra, cervix uteri, and vestibular glands by the gonorrheal process, Menge, taking into account the possibility of simultaneous involvement of these organs, gives the following statistical data. 70% Acute gonorrhea.

Chronic gonorrhea. Urethra 95%

95% Vestibular glands .... 20%

25 % The spread of the gonococcus along the mucous membrane of the urethra, the cervical canal, and the vagina proceeds, among other things, apparently according to the law of capillarity. In the urethra, the upward spread of gonococci is limited at the beginning of the bladder, where urine with its acid reaction is an unfavorable environment for the reproduction of the microbe. But even if the gonococcus is unable to penetrate the bladder, it paves the way thither for pyogenic microbes—staphylococci, Escherichia coli, and streptococci. Along the cervical canal, the spread of gonococci also proceeds according to the law of capillarity. Among the cells lining the cervical canal, the columnar epithelium is insignificant, and one cannot speak of any counteraction on its part to the process of capillarity. In the canal of the uterine cervix, the lower segment is most frequently affected by the gonorrheal infection (the lower zone of Walthard). The upper segment of the cervical canal (the second and third zones of Walthard) is affected by the gonorrheal process to a significantly lesser degree than the lower one. Gonorrhea of the urethra, vulva, vagina, and cervix uteri is usually called open gonorrhea, in contrast to gonorrhea of the endometrium, tubes, ovaries, and peritoneum, which is called closed or ascending gonorrhea (see also the corresponding organs). When speaking of ascending gonorrhea, it is generally accepted that it spreads very rapidly throughout the endometrium, further along the tube, the ovaries, and the pelvic peritoneum. However, Menge and Asch believe that endometritis should be classified under the open form of gonorrhea and that ascending gonorrhea can only be spoken of if the gonorrheal process has passed to the Fallopian tubes and above. Furthermore, they assert that endometritis, like endocervicitis, is a prolonged gonorrheal affliction, a constant source for the ascending process. Recently, R. Schröder and his school have put much effort into studying endometritis from the standpoint of the modern doctrine of the cyclical changes in the uterine mucosa. On the basis of these studies, it should be noted that gonorrheal endometritis is in most cases a short-term disease, usually ending in self-cure within 2–3 ovarian-menstrual cycles. During menstruation, a greater or lesser amount of blood from the uterine cavity also enters the tubes (Sampson, Gauss, and others). In the presence of a gonorrheal infection of the endometrium, in the case of patency of the Fallopian tubes, the infection from the uterus, as a result of the antiperistaltic movements of the latter, must penetrate during the very first menstruation together with blood into the lumen of the tubes, and from there onto the ovaries and the pelvic peritoneum. The onset of endometritis marks the beginning of the ascending process, and endometritis should thus be classified under the closed form of ascending gonorrhea. If endometritis were a constant companion of endocervicitis, as some authors think, then in that case every woman infected with gonorrhea would inevitably contract ascending gonorrhea as well. Meanwhile, only 30% of all infected women suffer from the latter form, and consequently gonorrheal endometritis is not encountered in 60–80%, as Menge believes, but only in 30%. It is believed that menstruation, like the puerperal period, contributes to the transition of gonococci from the cervix uteri to the mucosa of its cavity and that in the intermenstrual period the penetration of gonococci into the uterine cavity is hindered by the internal os uteri. Meanwhile, as Rotter's observations have shown, the internal os uteri cannot serve as an obstacle to the penetration of gonococci into the uterine cavity. One of the reasons preventing the penetration of gonococci from the cervix uteri into its cavity is the direction of fluid flow in the upper genital tract from top to bottom due to the direction of action of the ciliated epithelium in the tube and on the endometrium. Under normal conditions, the boundary of two currents lies in the region of the internal os: the lower vulvo-cervical current, acting according to the law of capillarity, and the upper tubal-corporal current, acting in the opposite direction thanks to the centrifugal action of the ciliated epithelium. But this boundary may turn out to be disrupted in cases of antiperistaltic movements of the uterus, during coitus, or at the moment when the normal action of the ciliated epithelium current is disturbed (menstruation, postpartum period). Endometritis should be classified as a closed form of gonorrhea. But there is an exception to this rule concerning the postpartum period, when the uterine os remains open for a long period, and the ovulatory-menstrual cycle in 50% of all cases is restored only with the end of the lactation period. The penetration of the gonorrheal infection in the postpartum period from the cervical canal into the uterine cavity entails the development of endometritis, usually ending in self-cure thanks to the free outflow of the discharge from the uterine mucosa. When the first menstruation occurs, an unhealed gonorrheal endometritis can give a complication in the form of pelvioperitonitis. Thus, the open form of gonorrhea in the postpartum period shifts its upper boundary from the internal os uteri upwards to the uterine opening of the Fallopian tubes. In the usual form of ascending gonorrhea with the penetration of the gonorrheal infection onto the uterine mucosa, its further spread upwards, i.e., to the tubes, ovaries, and pelvic peritoneum, proceeds without any special leaps. The blood that has escaped from the menstruating uterus into the tube is expelled along with the gonococci by antiperistaltic movements into the abdominal cavity and here gets into Douglas' pouch and the ovary. A certain interval of time elapses between the penetration of gonococci into the uterine cavity and their further penetration into the tubes. But after the gonococci have penetrated into the tube, they immediately penetrate per continuitatem onto the peritoneum and the ovaries. Thus, the gonorrheal process in the tubes, ovaries, and peritoneum usually begins almost simultaneously. 70 General symptomatology and prognosis. The course of gonorrhea in women is acute and chronic. The gonococcus that first hits the mucous membrane of an organ causes an acute inflammatory process here, expressed in the desquamation of the epithelium and a strong local leukocytosis. The exudate flowing from the surface of the mucous membrane in the acute stage usually contains a large amount of the infectious agent, located both intracellularly and extracellularly. Some gynecologists hold the view that female gonorrhea in certain cases takes on the character of a chronic process from the very beginning. The course of the gonorrheal infection in the acute stage is quite varied. In the so-called open form of the gonorrheal process, one can observe, according to some authors, complete self-cure in 50%. According to Menge, such a self-cure can occur already 3–4 weeks after the onset of the infection. Gradually, all clinical phenomena begin to disappear, the discharge becomes less and less, and both the pathogens of the disease and pus cells disappear from the mucosal discharge. In other cases, one can observe a prolonged course of the acute period, gradually passing into a subacute stage. But even in these cases, the subacute period can end in complete recovery. In a small percentage of all cases, namely in 25%, the subacute form of female gonorrhea after several acute flare-ups passes into a chronic state. The discharge in the chronic form of the gonorrheal process is scanty, seropurulent or mucopurulent, and gonococci are detected in it with difficulty and in very small quantities. In the so-called open form of female gonorrhea, i.e., where the discharge can flow out unimpeded, the chronic form of gonorrhea can proceed either as an overt process or as so-called latent gonorrhea (Noeggerath). The first, overt form of chronic gonorrhea is characterized by the fact that in the scanty discharge of the genital organs the infectious agent is easily detected even without the help of special provocative methods. As for the latent form of chronic gonorrhea, in it the infectious agent lies in an insignificant amount in the depths of the mucosa and comes out together with the discharge only in exceptional cases. In the overt form of chronic gonorrhea, a woman infects a man very easily; in the latent form, only under special conditions (e.g., during stormy coitus, during coitus during menstruation, etc.). But the enumerated forms of the gonorrheal process nevertheless end in recovery, which can be biological or only bacteriological. In biological recovery, not only does the pathogen disappear, but the secretion of pathological exudate, i.e., purulent discharge (leukorrhea), also ceases. In bacteriological recovery, the pathological exudate (leukorrhea) remains, but gonococci disappear from it. Thus, in fact, the inflammatory process of the mucosa remains, but of a non-gonococcal character. As for the closed or ascending gonorrheal infection, an acute and a chronic form of its course are also distinguished here. (The characteristic feature of gonorrheal endometritis has already been mentioned above.) In infection of the appendages and peritoneum, depending on the strength of the infection, the acute form of gonorrhea can proceed either as a serous pelvioperitonitis or as a seropurulent inflammation of the peritoneum and pelvic organs.

Mild forms of serous pelvioperitonitis, after a brief acute period, pass into a subacute stage, which ends in so-called post-gonorrheal perimetritis, periadnexitis, and adhesions between individual intestinal loops, or else, after repeated flare-ups, the disease turns into a chronic form of inflammation of the appendages. In serous-purulent inflammation of the peritoneum, almost as a rule, following the acute and subacute periods, a chronic stage of inflammation of the appendages sets in with frequent relapses. The chronic form of ascending gonorrhea can eventually end in recovery. In contrast to the open form of gonorrhea, ascending gonorrhea in women rarely yields a complete biological cure: anatomical-pathological changes usually remain both in the genital organs and in other organs of the lesser pelvis, which are difficult to influence therapeutically. These post-gonorrheal changes lead not only to sterility, but are a source of constant abdominal pain and difficulties in the functional discharges of other pelvic organs. A major role in the course of the gonorrheal process, especially the ascending one, is played by the so-called mixed, or rather supplementary infection (superinfection). Schottmüller and Barfurth performed studies of punctate from the posterior fornix in fresh cases of pelvic peritoneal inflammation and found the following microflora: sterile pus in 15%, streptococci in 16%, Escherichia coli in 10%, gonococci in 7%, staphylococci in 2%, anaerobic strepto- and staphylococci in 50%. Heynemann obtained approximately the same results. Thus, in the ascending inflammatory process, it is no longer gonococci that come to the foreground, but anaerobes, which find the best conditions for their development in closed cavities. This circumstance explains the seriousness and duration of the course of the ascending process. Diagnosis. When diagnosing female gonorrhea, the physician must solve the following tasks: 1) whether the leukorrhea of which the patient complains is gonorrheal; 2) if the woman has no leukorrhea, whether she has a so-called latent form of gonorrhea; 3) whether there is involvement of only the lower urogenital tract or the so-called ascending gonorrheal process; 4) finally, the physician always has to solve the difficult problem of the "cure" of gonorrhea. Thus, the diagnosis of gonorrhea falls into two parts: the diagnosis of the open gonorrheal process (clinical and bacteriological) and the diagnosis of ascending gonorrhea. The bacteriological diagnosis of gonorrhea in the acute period of the disease presents no particular difficulties. In the chronic course of the disease, however, the detection of gonococci can turn out to be an extremely difficult matter. When taking smears, it is necessary to take discharge from the urethra and cervix uteri; in doubtful cases, smears should also be taken from the ducts of Bartholin's glands, from paraurethral passages, from the sulcus clitoridis, from the vagina, and from the rectum. Under no circumstances should discharge be taken from the uterine cavity, as Asch and Bocura suggest doing. The introduction of a probe, catheter, or other instrument into the uterine cavity leads to contraction of the uterine muscle and to antiperistalsis of the organ, the consequence of which may be an ascending gonorrheal process where there was none before. In the chronic gonorrheal process of the lower section of the urogenital tract, due to the scantiness of the discharge, gonococci are not washed out to the outside by the secretion, but nest in isolated groups on individual epithelial islands or deep within the glands. To extract gonococci from here, it is necessary to scrape the epithelium itself slightly. In view of this, it is recommended to take material from the cervix uteri using a curved dressing forceps or tweezers. From the urethra, a smear is taken two to three hours after the last urination using Asch's blunt spoon. From the duct of Bartholin's gland, the secretion is extracted with the end of an eye cannula, which is made rough with a file (Wolff). Kritzler recommends inserting a cotton tampon rolled in the form of a stick into the urethra for 3–4 hours. Smears and cultures are then made from this tampon. All these methods of obtaining material do not always lead to positive results, and to detect gonococci, it is often necessary to resort to so-called provocation. The principle of provocation consists in disrupting the equilibrium established during gonorrhea between the macro- and microorganism. During provocation, local damage to the mucosa is produced or a so-called negative phase is created in the organism, thanks to which gonococci obtain better conditions for their multiplication, the amount of discharge increases, and gonococci are washed to the outside. Methods of provocation are divided into local and general. Local provocation is subdivided into chemical, mechanical, and thermal. For chemical provocation, Neisser proposed a 1% solution of silver nitrate, Blaschko a 25% dilution of Lugol's solution, and Scholz a 10% hydrogen peroxide. For thermal provocation, Gauss proposed a glowing probe, Neufeld ultraviolet rays, and other authors diathermic bougies, etc. For mechanical provocation, Schulz uses Hegar dilators in the urethra. For general provocation, in which a negative phase is created or, according to other authors, oxidative processes in the organism are lowered, the subcutaneous administration of gonococcal vaccine, adolan, caseosan, etc., is used. Methods of general provocation also include so-called alimentary provocation, i.e., the ingestion with food of spicy substances irritating to the mucosa: beer, herring, etc. Mixed (or combined) provocation is also used. Orlovsky and some other authors speak out against local chemical provocative agents, as well as against general provocation with vaccine. It must be admitted that provocation sometimes makes it possible to detect gonococci where they were not detected without it. In the female gonorrhea department of the State Venereological Institute, the following combined method of provocation is used. The patient is injected with 400 million killed gonococcal bodies intramuscularly, and the urethra and cervix uteri are lubricated with the following solution: Iodine 1.0, Potassium iodide 2.0, Glycerin 100.0. In addition, the patient is given herring with vinegar and beer. Thereafter, the discharge of the urethra and cervix uteri is examined for 3–4 days. In Gauss's clinic, the examination of discharge after provocation is carried out for 10 days. An excellent biological provocative agent is menstruation, upon the termination of which it is recommended to examine the discharge of the cervical canal. Of great importance in the bacteriological examination of genital discharge is the so-called multiplicity of smears. According to Ziehl, in 50% of all cases gonococci are detected upon the first examination of smears, in 40% upon the seventh examination, and in 10% only upon the tenth examination. Therefore, it is customary to perform up to ten examinations of smears from each organ for a final diagnosis. Examinations are best performed twice a week. In doubtful cases, one has to resort to culturing the discharge, to which Jadassohn's clinic attaches great importance. In the diagnosis of ascending gonorrhea, bacteriological examination has only relative importance. Of course, upon finding gonococci in the discharge of the lower genital tract and simultaneous disease of the uterine appendages, the probability of a gonorrheal etiology of the latter will be obvious. However, it should be borne in mind that often with the onset of the ascending process, gonococci disappear from the lower sections. Bacteriological examination of punctate from the posterior fornix has relative importance, since in the ascending gonorrheal process one is often dealing with a mixed infection in which anaerobes predominate. Of significantly greater importance in the closed form of female gonorrhea is the so-called biological and serological diagnosis. Biological diagnosis of the gonorrheal process consists in the organism's reaction to the introduction of gonococcal vaccine. In the presence of gonorrhea, the organism responds to the introduction of the vaccine with a local, focal, general, and equivalent reaction. The entire process of these reactions is apparently explained by so-called "hyperergic inflammation" (Gerlach). The equivalent reaction (Hauser) consists in the onset of uterine bleeding (menstruation) following the introduction of the vaccine. According to the observations of some authors (Wagner), this reaction is observed in 30% of all cases. Herrold's reaction, in which a filtrate of a broth gonococcal culture is injected intradermally, should also be classified as a biological reaction. Among other laboratory-diagnostic methods, morphological examination of the blood should be mentioned. A number of authors attach great importance to hyperleukocytosis. Very sensitive and very important in many respects in ascending gonorrhea is the erythrocyte sedimentation reaction. As studies at the State Venereological Institute have shown, it serves not only as a diagnostic, but also as a good prognostic method. One of the most difficult and responsible questions in the doctrine of female gonorrhea is the diagnosis of cure. The clinical picture undoubtedly plays a major role in solving this question; however, clinical diagnosis alone is insufficient in the so-called latent form of chronic gonorrhea and in so-called post-gonorrheal leukorrhea. The main criterion for the presence or absence of infection is the so-called bacteriological diagnosis, but a single examination is absolutely insufficient.

Gauss pointed out the necessity of repeated examinations. He suggests performing 21 examinations of the discharge from each organ, of which 9 examinations should be without preliminary provocation, and 12 with various preliminary provocations, both general and local. Albrecht and Funk perform 30 examinations, of which 2 are done with preliminary provocation (one with a 25% Lugol solution and the other with a 10% hydrogen peroxide solution). Abraham requires observation over the course of a whole year, at two, four, and six months, and corresponding bacteriological examinations. Prognosis. According to Pincus, systematic treatment of urethral gonorrhea in stationary conditions yields 97% cures. According to the data of the State Venereological Institute, Janetization and subsequent instillation according to Guyon (disregarding accompanying complications) yield the same percentage of recovery. As for endocervicitis, it as a rule passes into a chronic state. But nevertheless, endocervicitis also responds well to treatment. According to the data of a number of American and European authors, women suffering from endocervicitis and treated for longer than three months yield 80-90% recoveries. This fact shows that the pessimistic view of the curability of female gonorrhea, widespread even among physicians, has no proper foundation. According to the State Venereological Institute, in patients with open female gonorrhea who were treated regularly for an average of 5 months, bacteriological recovery occurred in the significant majority of cases. One of the most serious moments in the course of open gonorrhea is the transition of the infection from the cervix to the endometrium and higher up to the tubes and peritoneum (on average in 25-30% of all cases). According to Kahn, among patients working in factory industries, this percentage reaches 46. In closed gonorrhea, just as in open, the prognosis in general is not all that bad. In the overwhelming percentage of cases, ascending gonorrhea is cured. A patient can be considered cured after an ascending gonorrheal process when three main complaints have disappeared, namely—leukorrhea, pain, and hemorrhages. From this point of view, the ascending gonorrheal process yields a rather large percentage of recovery. In 70% of cases, ascending gonorrhea ends in post-gonorrheal perimetritis, often complicated by backward displacement of the uterus or a tumor of the appendages. In the remaining 30%, the gonorrheal process in the appendages proceeds chronically in the form of pyosalpinx, producing flare-ups, hemorrhages, etc. Of these 30% of severe forms of ascending gonorrhea, after one or another period, sometimes even 4-5 years, they nevertheless end in recovery, if not in the biological sense of the word, then clinically. Only in 10% does the process in the appendages remain for the whole of life until the onset of the climacteric. In some cases, especially with mixed infection, the patient may develop gonorrheal cachexia. Principles of treatment. The therapy of gonorrheal infection in women must be causal, i.e., strive for the rapid and definitive removal of gonococci. But in addition, a "biologico-symptomatic-prophylactic" therapy is also required. The latter strives to eliminate distressing symptoms (pain, hemorrhages, etc.), and then restore the status quo ante in the tissues, return to the affected organs their former normal function, and finally prevent the spread of the infection to other organs. Therapy of gonorrhea strives to achieve this task through so-called general and local measures. Measures of a general character have the purpose, firstly, of eliminating all irritating factors from the diseased organism, secondly, of intensifying metabolism in the diseased organism, and thirdly, of helping it to destroy the causative agent of the disease. As general measures are used: 1) physical methods of treatment, 2) dietary measures, 3) internal drug therapy, 4) internal therapia magna sterilisans, 5) passive and active immunization, and 6) so-called nonspecific parenteral therapy. Of all types of physical methods of treatment, physical rest stands in the first place, especially in the acute stages of open and closed gonorrhea. Further, physical methods include hydrotherapy in the form of sitz baths, compresses, etc., then the mountain sun, as well as treatment with diathermy, to which some authors attribute not only an analgesic but also a bactericidal significance. In the acute stage of gonorrhea, diathermy should be considered contraindicated. Diathermy gives good results in so-called post-gonorrheal cicatricial changes (perimetritis and perivisceritis). Therapeutic muds (peat and mineral) should also be considered an excellent physical method of treatment for post-gonorrheal changes in the genital organs, reducing the phenomena of dysmenorrhea, menorrhagia, leukorrhea, and pain localized usually in the lower abdomen and sacrum. Dietary measures and the internal use of medicinal agents are of very important significance for the purpose of eliminating mainly antiperistaltic movements of the genital organs and the spread of the process to the overlying genital organs. Therapia magna sterilisans in the sense that Ehrlich conceived it was and is used in gonorrhea; recently in the form of the intravenous use of acridine series dyes (Trypaflavin, Acriflavin, Gonoflavin), as well as quinone derivatives, Rivanol.

Gonorrhea

Passive and active immunization. This includes the use of serum from immunized animals, which has not become widely used. Dembskaya notes the effect of this therapy in pediatric gonorrhea. As for active immunotherapy or vaccination in gonorrhea, this method has recently become very widespread; the preparation of the vaccine and its application are quite diverse. Non-specific parenteral therapy. This includes parenteral protein therapy in pure form or in combination with vaccine therapy or with local therapy. This type of therapy includes treatment with colloidal substances (electrargol and collargol), as well as autohemotherapy or autoserotherapy. This also includes treatment with parenteral administration of sulfur and turpentine, as well as the treatment of gonorrhea with malaria; Ziller spoke out against the use of the latter, pointing out that the high temperature inherent in malaria treatment leads to the ascent of the gonorrheal process. Local therapeutic measures boil down to antiseptic, i.e., bactericidal and astringent, and aseptic (i.e., Janet's irrigations) measures. The question of local treatment of female gonorrhea is somewhat more complex than the question of the treatment of male gonorrhea. As far as gonorrhea of the urethra is concerned, there is no fundamental difference in the therapy of male and female urethritis. But the question of the treatment of gonorrhea of the cervical canal stands entirely differently. It is quite understandable that treatment of the cervix according to Janet is impossible, and therefore until the present time gonorrheal endocervicitis has been treated with antiseptic-bactericidal and astringent agents. But even on the question of the method of applying these bactericidal and astringent agents for the therapy of gonorrheal endocervicitis, there is still no complete unity. Some authors (primarily gynecologists) stand for conservatism in this direction and use bactericidal agents per vaginam, relying on the fact that the introduced medicinal substance in the posterior vault of the vagina, according to the law of capillarity, will rise through the cervical canal and there develop its bactericidal action. Other authors (primarily venereologists, and recently some authoritative gynecologists) stand for active therapy, which consists in introducing the medicinal substance into the cervical canal. Some gynecologists (Menge, Asch) also use active intrauterine therapy. Good results in the open form of female gonorrhea are given by combined treatment consisting of local therapy of the urethra and cervical canal and general therapy consisting of the use of vaccine and protein therapy. Local therapeutic measures also include instrumental treatment (dilation, cauterization), massage, and surgical treatment consisting of the removal of scars (peritoneal adhesions) and the removal of inflammatory tumors (pyosalpinx). Gonorrhea and reproductive function. The effect of gonorrhea on a woman's reproductive function can be of two kinds, depending on whether the infection occurred before the onset or already during the established pregnancy. If the gonorrheal infection occurred before the onset of pregnancy, the consequence of this is usually so-called primary sterility. According to the studies of a number of authors (Bumm, Schenk, Lier-Ascher), among the etiological factors of female sterility, gonorrhea accounts for 30-40%. According to Seitz's calculation, sterile marriages in 50% of all cases are due to gonorrhea. Gonorrheal infection can lead to sterility in three cases: 1) in the case of the acute form of open gonorrhea, 2) in gonorrheal endometritis, and 3) in gonorrheal lesions of the tubes. In the acute stage of open gonorrhea, i.e., in gonorrhea of the urethra, vagina, and cervix, conception apparently does not occur because spermatozoa, failing to enter the lumen of the Fallopian tubes, perish in the purulent discharge of the infected organs. In the chronic stage of the open form of gonorrhea, the onset of pregnancy is entirely possible. In the acute period of gonorrheal endometritis, conception is excluded for the same reason as in the acute form of open gonorrhea, and also because the implantation of the fertilized ovum into the inflamed endometrium is very difficult. In chronic endometritis, in which there is usually small-cell infiltration in the so-called basal layer, as a result of which the functional layer is poorly developed, the possibility of implantation of the ovum in the thickness of the mucosa is not excluded, but under such conditions the nutrition of the ovum is unsatisfactory, and pregnancy often ends in abortion. In those cases when pregnancy is preserved, the woman suffers throughout the entire period of pregnancy from cramping pains in the abdomen and aching and pulling pains in the sacral region. These pains are explained by the presence of small-cell infiltration in the myometrium and peritoneal adhesions in the lesser pelvis. The third and main factor in sterility on the basis of past gonorrhea is salpingitis, in which the patency of the Fallopian tube is impaired. However, cases of normal pregnancy have been described even after past pyosalpinx. As for the gonorrheal infection that followed during an already established pregnancy, clinically it manifests itself as follows: the frequency of gonorrhea during pregnancy, according to some authors, is determined at 15-20%. According to Elkin's observations, gonococci in pregnant women are found in 1.5% of all cases. The open form of gonorrhea that followed during pregnancy or was acquired even before that proceeds differently than in non-pregnant women. Due to the strong looseness and edema of the tissues, as well as the strong hyperplasia of the cervical glands (Stieve), the gonococcus finds extremely favorable conditions for its development in the genital organs of a pregnant woman, and the gonorrheal infection retains its acute form for almost the entire period of pregnancy. Clinically, this manifests itself by abundant purulent, corrosive leukorrhea, which often causes colpitis granularis (Bumm, Menge) and acute condylomas. Gonorrheal lesions of Bartholin's glands during pregnancy apparently occur no more frequently than outside of pregnancy. The principles of treatment of the open form of gonorrhea during pregnancy are the same as outside of pregnancy. To avoid possible disruption of pregnancy, intracervical therapy is contraindicated here. Labor in the acute period of open gonorrhea is very painful, and the expulsion period is prolonged. Painful contractions can also occur in cases of chronic gonorrhea if there are inflammatory changes in the myometrium. According to some authors, gonorrhea plays a certain role in the etiology of placenta previa, its accretion, and the formation of infarctions in it. Schottmüller found the gonococcus in the lochia of septic patients in only 1.9% of all cases, Ilkevich in 0.92%, and Kaplan in 3.7%, and even then not in pure culture. According to Seitz's calculations, the gonococcus is the cause of puerperal infection also in only 1%. Gonorrheal infection in the postpartum period is characterized by three types of course. If gonococci penetrate the uterine cavity immediately after birth, which, according to Menge's research, occurs in 50% of all cases of open gonorrhea, then gonorrheal endometritis develops, proceeding without special clinical manifestations and giving rise to the so-called late ascending gonorrhea only by the time of the first menstruation after birth. The second type of endometritis, the so-called early gonorrhea, is discovered when the puerpera gets out of bed and thereby worsens the outflow of lochia. The third type of puerperal gonorrheal infection is its mixed form, which usually leads to pelvioperitonitis shortly after birth.

M. Kushpir. Gonorrhea in children is a not uncommon disease, occurring more frequently in girls than in boys, which is explained by the different structure of their genital organs. The vulvar cleft in girls, lying openly, extremely favors the penetration of infection into it, whereas in boys, due to the presence of the foreskin, the urethra is protected. A number of pediatricians (Bachinsky, Filatov in 1892) denied, even many years after the discovery of the gonococcus, the possibility of gonorrheal urethritis in boys. However, at the present time in the literature there are a number of reports on undoubtedly gonorrheal infection of boys, and it can arise, just as in girls, by sexual and non-sexual routes. In cases of sexual infection, it is usually a matter of so-called crimes against morality. Sources of infection are also sleeping in the same bed with adults infected with gonorrhea, the use of night vessels, sponges, baths, and linen contaminated with gonococcus. Non-sexual infection also includes eye infection in newborns (see Blennorrhea). Entire epidemics of gonorrhea in girls in educational institutions and orphanages have been described. The significant spread of children's gonorrhea observed in large cities is apparently explained by the crowding of the population as a result of the housing crisis. The course of gonorrhea in boys differs from that in adults in that the disease process is usually limited to the anterior urethra and does not produce complications in the form of disease of the sex glands, because sexual excitations, physical exertion, the use of alcoholic beverages, and other factors that predispose to the spread of the gonorrheal process in adults are absent. The course of the disease is also more favorable. This is explained by the peculiarity of the structure of the children's urethra (Tsvinev) in the form of a small volume of mucous glands and weak development of elastic tissue. The course of gonorrhea in girls has peculiarities in localization, in course, and in prognosis. They usually observe phenomena of vaginitis, which is extremely rare in women. The explanation for this should be sought in the difference in the structure of the vaginal epithelium in girls and women—more delicate, loose, favoring the penetration and development of infection in the former. As for the transition of open gonorrhea in girls into ascending and closed, such cases are rare. The course of the disease usually from the very beginning has a sluggish, chronic character and is often overlooked by the parents of the patient. The diagnosis of gonorrhea in young girls presents considerable difficulty. Of course, here we are not talking about those cases where intracellularly located Gram-negative diplococci are found in the abundant purulent discharge, but about those when no microorganisms are found at all in the abundant purulent vaginal discharge, or Gram-positive or Gram-negative but atypically shaped diplococci are found in the scant purulent or mucous discharge. Purulent discharges from the genital organs of girls are far from rarely caused by non-gonorrheal infection. Constitutional anomalies, diatheses, anemia, scrofula, worms, prior general children's infectious diseases (measles, diphtheria, scarlet fever), masturbation, urine retention, lack of cleanliness—these are a number of factors that can be the producing moment for the appearance of purulent discharge from the genital organs of girls. The children's genital organs are sterile only during the first hours after birth. Having before oneself "sterile" (bacterioscopically) purulent discharges from the genital organs of girls, it is necessary to repeatedly perform analyses for gonococci. Of considerable value here is eosinophilia, which, with worms excluded, speaks for the presence of latent infection. The presence of diplococci atypical in shape for the gonococcus, with significant purulent discharge, speaks for gonorrhea; in all other cases, the diagnosis must be confirmed by culture. The prognosis of gonorrhea in girls is quite poor. The small size of the genital organs, on the one hand, and the insufficiency of the outflow of purulent discharge (due to the presence of the hymen), on the other hand, hinder therapeutic measures, which, along with local treatment by irrigations with antiseptic and astringent agents (e.g., potassium permanganate), have as their goal the raising of the defense forces of the sick child's organism. The lack of radically acting agents along with the difficulties of local treatment of gonorrhea in girls is the reason why the disease usually takes a chronic and prolonged course. Most cases, however, end in complete recovery, and this apparently occurs not as a result of one or another method of local treatment, but as a result of the destruction of the gonococcus by the forces of the organism itself. The criterion of cure should be considered the absence of clinical symptoms and repeated negative bacterioscopic and bacteriological analyses for 6 months (see also Vulvovaginitis). Personal prophylaxis, if correctly organized, is a means that can almost 100% guarantee a man against contracting gonorrhea. The significant growth of venereal diseases during the last world war forced a number of states to pay close attention to measures of personal prophylaxis, giving their application an organized and systematic character. Pugh reports that in the British troops, out of 5,342 cases in which personal prophylaxis was applied, there was not a single failure, and all authors draw attention to the necessity of applying preventive agents within the first hour after sexual intercourse. There are two methods of personal prophylaxis: the first is the isolation of the mucous membrane of the man's genital organ from the infected organs of the woman, and the second is the destruction of the infection that has already gotten onto the mucous membrane. The first method consists of putting a condom on the penis before sexual intercourse. The use of the latter guarantees against infection with the gonococcus, provided, of course, that the integrity of the condom is preserved during sexual intercourse. As regards the second method of prophylaxis, the most widespread advice is to urinate immediately after sexual intercourse and wash the external genitalia with soap, thereby achieving the mechanical removal of the gonococci that have gotten onto the mucosa. In 1885, Hartmann proposed dropping several drops of a 2% silver nitrate solution into the navicular fossa immediately after suspicious sexual intercourse; other authors experimentally showed that silver nitrate applied in this way, even 5 hours after sexual intercourse, is able to destroy the gonococci that have penetrated here and prevent the development of the disease. It must be said, however, that this method causes severe irritation of the mucous membrane and pain sensations, which caused its insufficient dissemination. In 1888, Frank proposed using a 20% protargol solution in glycerin for personal prophylaxis; the bactericidal action of protargol is no less than the action of silver nitrate, and meanwhile it does not cause pain sensations and chemical inflammation. This method of prophylaxis has become quite widespread in Germany, where pocket pipettes with a mixture of glycerin and various protein silver preparations are produced for sale by the pharmaceutical industry; in the German navy, every sailor given shore leave receives several similar tubes with instructions on how to use them, which sharply reduced the incidence of gonorrhea in the navy. In England, in the troops, washing of the anterior urethra with potassium permanganate (1:3,000) is used as a prophylactic agent. In essence, this method is already a transition to abortive treatment, i.e., to the treatment of infection in a single session. The latter method of prophylaxis deserves the greatest attention, because it does not irritate the mucosa, can be repeated an infinite number of times, which cannot be said about silver preparations, and contains two principles—mechanical removal of the infection by a jet of liquid and the creation of local unfavorable conditions for the development of gonococci.

R. Froshtein. Personal prophylaxis plays a lesser role in women than in men. The folding of the mucous membranes of the woman's genital organs, the multiplicity of orifices and blind tracts make the treatment of these organs to such an extent as to destroy all gonococci that have penetrated there completely impossible. In view of this, many authors consider individual prophylaxis for women impossible and believe that it is exhausted only by the personal prophylaxis of the man.