Gonorrhea in women has been considered disconnectedly in the preceding pages as one of several pathological conditions that affect the different parts of the genital tract. A more connected discussion of the subject will be of value, in view of the frequency of the disease, its often unsuspected or insidious character, and the serious and fatal lesions that it may produce. Lying between the two specialties of venereal diseases and gynecology, it is often ignored or slighted by both.

Acute gonorrhea in the female is much less frequent than in the male. It is rare in the gynecological dispensaries of Philadelphia to see acute gonorrhea of any part of the genito-urinary tract.

The disease is very often subacute or chronic from the beginning, and is not, as in the male, always preceded by a period of acute invasion, the symptoms of which necessarily attract the attention of the patient and the physician. For this reason gonorrhea in the woman is very often overlooked. We can as yet form no accurate estimate of its frequency. Certain lesions, such as pyosalpinx, which may be the remote result of gonorrhea, are often, especially by gynecologists, indiscriminately attributed to this disease without anything like sufficient evidence of such a causative relation.

The fact that the husband may at some time of his life have had gonorrhea, or even that the woman may have had gonorrhea, is no evidence that a pyosalpinx that appears in later years has been caused by this disease. There are many other causes of pyosalpinx besides gonorrhea. The frequent causative relation of sepsis at labor, miscarriage, or criminal abortion, or during the intra-uterine manipulations of the physician, should always be remembered.

I have no intention of underrating the danger to the woman of coitus with a man who is not entirely cured of a gonorrhea or a gleet. The lives of a great many women have been ruined by marriage with incompletely cured gonorrheal husbands, and but very few men in such a condition would contemplate marriage if they were aware of the danger to the woman that results from such an act. But, on the other hand, men who are at all careful of themselves are, without doubt, usually completely cured of gonorrhea; and there are thousands of men in the community who have had one or more attacks of gonorrhea before marriage, and who have now healthy and prolific wives. Every physician of experience will find such examples in the circle of his own practice or acquaintance. It is very unscientific to lay the responsibility upon such husbands for every pelvic inflammatory condition that may appear in their wives.

The difficulty of proving the presence of gonorrhea in women is often very great. As has been said, the disease may begin and may exist for a long time without attracting the attention of the woman. She often pays no attention to a slight burning or tickling sensation in the urethra, which passes off in a few days. She may have had a leucorrheal discharge for a long time, and she may fail to notice any slight alteration in its character or quantity that may have been caused by gonorrhea.

There is nothing in the gross appearance of the discharge from any part of the genital tract which is absolutely pathognomonic of gonorrhea. The condition may be suspected if there is a purulent discharge from the urethra, because urethritis in women is very generally of gonorrheal origin. But, on the other hand, there may be an innocent-looking mucous discharge from the cervix, such as occurs in health or in mild non-specific conditions, yet in which gonococci may be found.

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

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

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

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

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

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

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

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

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

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

Pelvic pain or discomfort is not usually present unless the body of the uterus is attacked.

All the symptoms of gonorrheal inflammation of the cervix are found in simple non-specific conditions. The only certain diagnosis is made by means of the microscope; and even failure to find the gonococcus will not enable the physician to say with certainty that the disease is not of gonorrheal origin. The gonococcus may be found in any form of discharge from the cervix, even that which to gross examination appears most innocent.

Consequently, in every suspected case a microscopic examination should be made.

The discharge, for examination, should be taken from the cavity of the cervix by means of a sterile platinum loop. If no gonococci are found, a strip of mucous membrane from the cervical canal should be removed with a sharp curette, and it, with the discharge that adheres to it, should be carefully examined.

It may be advisable to examine the discharge immediately after menstruation. A cervical discharge is always increased immediately before, during, and after a menstrual period. This is probably the reason that men are more liable to contract gonorrhea at that time. This fact is so well known that there is a widespread popular belief that gonorrhea may be acquired from coitus, during a menstrual period, with a healthy woman. This is not true. A man cannot acquire gonorrhea from a woman unless she had been previously infected with the disease; otherwise a woman might develop gonorrhea in herself spontaneously, for her discharges come in contact with her own genito-urinary tract.

The greater liability to infection at the time of menstruation is due to the fact that an existing pathological discharge is increased in amount; a subacute disease is rendered more active by the menstrual congestion; and gonococci, quiescent in the superficial cells, are more likely to be thrown off at this time.

Gonorrhea of the cervix very often stops at the internal os. It may, however, extend to the body of the uterus and to the Fallopian tubes, as has already been described. The diagnosis of gonorrheal endometritis can be made only by microscopic examination of the discharge or of a strip of the endometrium removed with the curette.

The gonorrheal discharge of the cervix may infect, secondarily, local areas of the vagina. The most usual position of secondary infection is the posterior vaginal fornix. A red eroded area, caused in this way, is often found. The prolonged contact of the pus produces a localized vaginal gonorrhea.

Primary vaginal gonorrhea is rare in the adult woman, in whom there is the usual resistant power of the epithelium. The mucous membrane of the vagina becomes tough from coitus and childbirth, and is usually impregnable to the gonococcus. Bumm has kept gonorrheal pus in contact with the vaginal wall for twelve hours without producing any inflammatory reaction.

In girls and in young women, in whom the mucous membrane of the vagina is soft and hyperemic, vaginal gonorrhea is more likely to occur. Like gonorrhea in other parts, the disease may be acute or chronic. It may involve the whole vaginal tract or it may be restricted to local areas.

The disease sometimes involves only the lower portion of the vagina, and is most severe on the posterior wall. In other cases it is limited to the posterior vaginal fornix, where it has a tendency to become localized and to persist. In the very early stage the mucous membrane is dry and red. It later becomes covered with a purulent or muco-purulent secretion of a milky color.

If the disease is extensive, severe symptoms may be present. The woman will suffer with burning pain in the pelvis, the pain being increased by any movement.

Acute inflammation of the vagina is usually of gonorrheal origin. A thorough examination of the condition can be made only by placing the woman in the knee-chest position and by exposing the vagina by retracting the perineum with the Sims speculum. The whole vaginal tube, especially the posterior wall near the ostium and the fornices, should be carefully inspected.

Gonorrhea of the vulva may arise primarily, or it may be caused by infection from discharge from the vagina or the cervix. Like gonorrhea of the vagina, it is rare in the adult woman. It is usually seen in girls or in young women. Its occurrence in children has already been referred to.

The disease may extend to the small glands of the vestibule and the fourchette and to Bartholini’s glands; in these situations it may lurk for many years, forming a source of infection to men and a great element of danger to the woman. Suppuration of the glands of the vestibule may result in small urethral fistulÆ.

In making an examination of the external genitals the parts should always be thoroughly exposed and the physician should attempt to express the fluid from the orifices of the glands. Microscopic examination of the discharge should be made.

Inflammation of any of the glands of the external genitals is usually the result of gonorrhea.

When the physician examines a woman suspected of gonorrhea, she should not prepare herself beforehand by vaginal douches and washing the external genitals. The urine should not have been voided for some time. Prostitutes, fearing that gonorrhea will be discovered, often remove all discharges as much as possible before they submit to examination. Other women do the same from motives of cleanliness. As the diagnosis depends upon observation of the origin and character of the discharges, such preparation should be avoided.

As has already been said, it may be advisable in doubtful cases to make the examination immediately after a menstrual period, when the discharges are more profuse and perhaps more virulent than at other times. The examiner should always proceed methodically, and should inspect every portion of the external genitals, the vagina, and the cervix. The vestibule, the external meatus, the urethra, the fourchette, the glands of Bartholini, the vaginal walls, the external os, and the cervical canal should in turn be examined. Discharges obtained from these structures should be saved and submitted to microscopic examination.

Though the gonococcus is by no means always found in cases the specific character of which is proved by infection of the man, yet it would escape observation much less often if such thorough examination were made.

If the gonococcus is not found, the diagnosis must be made from the consideration of the lesions that we know occur but rarely except in gonorrhea. Thus, urethritis is a strong diagnostic point in favor of gonorrhea; so is inflammation of the glands of the vestibule, of the fourchette, and of the vulvo-vaginal glands. Vaginitis not caused by the degenerations of old age, by traumatism, or by the discharge from a cancer of the cervix or from a vesico-vaginal fistula is usually of gonorrheal origin. This is especially true of vaginitis localized in the vaginal fornices.

Gonorrhea in women should be most carefully treated until all signs of the disease are eradicated. The treatment has already been discussed under the consideration of the different structures that may be attacked. Gonorrheal cervicitis and endometritis are the most difficult to cure, and it may be impossible to determine with certainty that the disease has been eradicated from these structures. If milder measures fail, the cervical canal and the body of the uterus should be completely curetted, and the raw surface should be treated with pure carbolic acid. The physician should never discharge the patient until she is thoroughly cured.