GONORRHEA IN WOMEN.
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.