S.KEY575] PATHOLOGY 5
violence and gradually dies out altogether with the final exclusion of the
gonococci. On the other hand, in an important proportion of cases
there are left below the surface foci of infection which communicate
with the surface only imperfectly or intermittently. It is these foci which
are responsible for the comparative intractability of gonorrhoea. In
some men and an important proportion of women the tissue reaction
is by no means violent. In fact sometimes a woman is found to be
harbouring gonococci in the cervical canal without showing any sign of
local inflammation. The importance of the tissue reaction is shown by
the fact that in men who react only mildly the disease seems usually to
run a more protracted course, whereas in those with particularly violent
inflammation of the parts the attack often clears up quickly and com-
pletely.
The gonococcus is believed by most workers to spread to other parts Methods of
of the urogenital canal and its adnexa along the surface, but Kenneth
Walker has produced evidence of spread along lymphatics. In the male
the disease spreads very frequently into the prostatic follicles and
seminal vesicles, from which it may invade one or both epididymes.
In the female similarly the Fallopian tubes are often invaded, with
consequent obstruction of the affected tube and inflammation of
neighbouring pelvic tissues of various degrees of severity.
Invasion of the blood-stream probably occurs far more often than Metastases
metastatic complications. Apart from the evidence of blood culture it
would be difficult to explain those cases in which a joint, a tendon
sheath, or a bursa which has been injured or overworked has been the
only one in which a metastatic complication has occurred.
Of all the parts that are invaded via the blood-stream the joints, tendon
sheaths, and bursae are much the most often affected and after them
the iris and conjunctiva, Gonococcal ulcerative endocarditis is rare, and
isolated cases only have been reported of pleurisy, pericarditis, neuritis,
meningitis, and encephalitis. Gonococcal osteomyelitis and osteoperi-
ostitis have been reported by Finger, Ghon and Schlagenhaufer,
Bardenwerper, and others. Nephritis and pyelonephritis may be the
result of ascending infection, as in the case recorded by Dourniashkin
and Cohen, or of infection through the blood-stream, as may have been
the explanation of a case reported by Bianchetti. Purpura has been
traced to gonococcal infection by finding the gonococcus in the skin
lesion and by blood culture. Two cases of gonococcal septicaemia
reported by Tebbutt and one byChevallierand his colleagues were proved
by blood culture; all had purpura and proved fatal, but metastases were
not found. Two others, reported by Wheeler and Cornell and by
Garlock, were cured by operative removal of the genital foci. There
does not appear to be any record of isolation of gonococci in the skin
affection called keratodermia blennorrhagica, which sometimes com-
plicates gonococcal arthritis. Subcutaneous and subfascial abscesses
containing gonococci which must have arrived by the blood have been
reported by Randall and Orr and others. Randall and Orr quoted