UROGENITAL BLENORRHCEA IN 
CHILDREN. 
BT 
HENRY KOPLIK, M.D. 
REPRINTED FROM THE JOURNAL OF 
CUTANEOUS AND GENITO-URINARY 
DISEASES 
FOR JUNE, 1893. UROGENITAL BLENORRHCEA IN CHILDREN.1 
VULVO-VAGINITIS IN GIRLS—URETHRITIS IN BOYS. 
A Clinical and Bacteriological Study. 
BV 
HENRY KOPLIK, M.D., 
New York. 
CLASSIFICATION and Symptomatology.—Specific gonor- 
rhoeal inflammation of the genital tract in young children, 
girls and boys, has of late become the subject of renewed 
study. It has been pointedly shown in most recent bro- 
chures, Epstein and Cahen-Brach, that the condition seen 
so often in large clinics in young girls and boys, is really 
a gonorrhoeal one, and should be treated from that stand- 
point. The data upon which such conclusions are based, are 
identical with those which are brought to bear upon the diagno- 
sis of urethral or vaginal discharge in the adult. The publi- 
cations of Pott, von Dusch, Spaeth, which first placed the so- 
called vulvo-vaginitis of small children and young girls among 
the gonorrhoeal affections naturally met with a degree of silent 
opposition. It may, in the writer’s experience, be classed 
among the common affections of childhood. The cases which 
are recorded in this paper, are by no means the experience of 
the author, but they are simply the experience of the last six 
months. They record the cases as they come in rotation, and 
give a good picture of what we may learn from a study of this 
affection. During the past six years the writer has seen more 
than two hundred mixed blenorrlioeas of the genitals (girls and 
boys) in children. The present paper will include some inter- 
esting data on contagion. All the authors who thus far have 
studied this affection have, with the brilliant exception of Ep- 
stein, failed to acquaint themselves with the conditions, sympto- 
matic and bacteriological, present in the normal vagina and 
urethra of children who were not suffering from abnormal dis- 
charges. It certainly bears directly upon the understanding of 
the specific catarrh, and justifies a classification of urogenital 
blenorrhceas, which will be adopted in this paper. Epstein 
has shown that in the new-born infant there is a discharge 
which is anatomically and physiologically normal, an 
1 The title “ urogenital hlenorrhcea ” has been adopted as proposed by Cahen-Brach be- 
ing more elegant and correct anatomically than the old term of vulvo-vaginitis. 2 
Original Communication. 
adhesive discharge from the vagina, consisting of epithe- 
lial cells, and micro-organisms. The introitus vaginae in 
these children is not reddened, swollen, or in any way in- 
flamed. In a few days after birth this normal discharge may 
become yellow, or even (in icterus) icteric. If we examine such 
discharge we find no leucocytes. After two weeks the rose color 
of the mucous membrane is restored, and the discharge ceases. 
This he has called desquammative catarrh of the new-born. It 
is a physiological process. Epstein mentions a simple catarrhal 
condition of the new-born urogenital tract, and cases of true 
gonorrhoea of the same tract. Epstein’s material being an im- 
mense number of new-born children only, he has not described 
conditions of later child-life. The author of this paper wishes 
first, to describe a peculiar condition of the urethra and vagina 
in very young female children. The mothers come to the phy- 
sician and relate that the child complains of pain upon urin- 
ation or will cry when passing urine. Here examination will 
reveal a reddened introitus somewhat swollen and exceedingly 
tender, a few red points, apparently erosions, appear around 
the hymen and the urethral orifice. This condition is combined 
with a very slight serous discharge. The surface may be bathed 
with ic or even the labia majora may be moist. This is a pecu- 
liar condition, simple in its nature, not, I think, the result of 
any unnatural interference. Uncleanliness, lithiasis, the adher- 
ence of smegma or dusting powders may cause this condition. It 
is really a primary catarrhal stage, and rarely presents much 
yellow secretion. It disappears as soon as rationally under- 
stood and treated. A second group of cases in young girls are 
the simple catarrhal cases. These children suffer from a scanty 
or profuse, purulent discharge from the vulva. It may, on ex- 
amination, be seen to bathe the introitus. It comes from the 
urethra and vagina, and presents all the features clinically of 
the next group, but is of an innocent, non-specific nature, 
though infectious. The third group of cases in young girls and 
babies are the true gonorrhoeas. In this set of cases we are con- 
fronted with a profuse, yellow or greenish yellow, adhesive, or 
thin discharge from the urethra and vagina. There is swelling 
of the mucous membrane, and the urethral opening is bathed in 
pus, which flows down over the hymenal opening and escapes 
with the vaginal discharge from the vulva, and dries in crusts 
upon the labia majora. 
The simple catarrh of the urethra and vagina in children and 
young girls is not so infrequent, and will be found to present as Urogenital Blenorrhcea in Children. 
3 
stated above, symptoms and physical signs which may con- 
found it with the true gonorrhoeal discharges. The urethral 
opening is swollen and inflamed, the hymenal orifice, the 
fringe of mucous membrane, is also swollen and very sensitive 
to the touch. The discharge appears to have the same physical 
characteristics as the true gonorrhoeal cases. It is yellow, thin, 
greenish or thick and viscid or milky in hue. There is a ten- 
dency of such pus to dry on the labia majora, and the whole 
picture tells of severe local disturbance. The pus examined 
shows, however, the true nature of this affection. It takes but 
careful examination to see that microscopically the discharge 
in these cases is not gonorrhoeal. We have desquammated 
epithelium and leucocytes, bacteria, such forms as rods, cocci 
and diplococci. These rods, cocci and diplococci may exist in 
leucocytes, they may also exist upon epithelium cells, but the 
leucocyte to which our study in this disease is chiefly directed 
shows in its cell substance a mass of bacteria, we find rods, 
cocci and diplococci in the same leucocyte. Leucocytes exist, 
showing isolated diplococci. but with all this we find none of the 
bacteriological peculiarities common to a specific gonorrhoeal 
discharge of the adult male. The history of such discharges 
are almost identical with that of the specific gonorrhoeal one. 
A peculiar persistence even with careful treatment, at most a 
diminution and improvement but still the baffling continuance 
of the disease which lasts almost the same length of time as the 
gonorrhoeal forms. Treatment may diminish as stated, the 
discharge, and the peculiar anatomical structure of the parts in 
the female make this matter easy to understand. I know that 
in the male adult a non-specific urethral discharge is a rarity, 
but this does not invalidate the daily experience that in infants 
and young girls an infectious non-specific discharge is not in- 
frequent. There is in some cases pain upon urination, a 
frequent desire to micturate, and in one case at least, I have 
seen the discharge complicated with inguinal bubo. In the 
non-specific discharge erosions of the introitus also are present, 
but the appearances in the vagina itself are none the less inter- 
esting. Here in the cases I have been able to examine by means 
of a male urethral speculum it will be seen that the mucous 
membrane in its folds and rugae contains a purulent discharge ; 
the cases I have examined did not show erosions in the 
vagina. The collum uteri was a more pinkish red than the 
vagina and in the cervix a drop of pus was distinctly visible. 
The cervix of the uterus itself is therefore the seat of 4 
Original Communication 
disease in many cases. We can thus understand how difficult 
is the treatment and therapeutic disposition of these cases. 
(Spaeth and Cahen-Brach also Bumm report like appearances.) 
The many folds of the vagina, the thousands of minute asperi- 
ties of the cervix uteri all contain myriads of micro-organisms 
which cannot be reached by our agencies. The urethra which 
has, I think, erroneously been selected as the point of attack in 
all varieties of vulvo-vaginitis may be said to have a species of 
constant natural irrigation through the passage of the stream 
of urine over the canal. The tendency is therefore in the direc- 
tion of cleanliness of this simple tube in female children. The 
vagina and cervix, the small, undeveloped crypts in the same 
and also the undeveloped crypts (Bartolini ducts) of the in- 
troitus all being infected in the simple as well as the gonor- 
rhoeal blenorrhoea tend to prolong the disease in both forms, 
however the simple catarrhal form of vulvo vaginitis is infec- 
tious ; by this I mean it may be communicated from child to 
child. I have seen this in two sisters who slept together and 
where repeated examination failed to show anything specific of 
gonorrhoea. The non-specific form may last for months, they 
may apparently cease and then recur in greater or less severity. 
I doubt whether any one to-day believes in the scrofulous or 
marasmic theories regarding these affections, but they may be 
favored by bad surroundings which invite a definite infection. 
The methods of infection will be treated of later. 
True Gonorrhoeas.—The next group into which the cases of 
blenorrhoea of the urethra and vagina divide themselves is the 
true gonorrhoea of these parts. Pott, von Dusch, Spaeth, 
Steinschneider have all described these cases, and lately, Ep- 
stein has described gonorrhoea in new-born female infants, and 
lastly, Cahen-Brach has collated some thirty cases of the dis- 
ease. In these cases it is most difficult to trace the origin of 
the disease, which at times becomes epidemic and seems to af- 
fect masses of children (Fraenkel). The authors who have 
busied themselves studying the affection have, with reluctance, 
some of them admitted the gonorrhoeal nature of the affection. 
The little patients are brought to the physician with the his- 
tory that the only thing noticed wrong with the child was a 
discharge from the vulva. All other history is obtained, in 
girls especially, with the greatest difficulty . Examination re- 
veals a thick yellow, or greenish yellow discharge, which ad- 
heres to the labia majora and dries upon them in yellow crusts. 
The children are, some of them, in perfect h ealtli otherwise. Urogenital Blenorrhcea in Children. 
5 
There is sometimes a history of pain upon urination or frequent 
micturition. There are no buboes, as a rule, but in many cases 
the inguinal glands may be very slightly enlarged. An exam- 
ination shows the urethral orifice swollen and reddened, the 
seat of purulent exsudate, the hymen is much swollen and 
bathed in pus ; there may be erosions. When the patient 
cries, or if the perineum be pressed upward, a drop of pus ex- 
sudes from the vagina. If a Tuttle’s urethral speculum be passed 
into the vagina and light thrown into the same by means of a 
head mirror, it is seen to be the seat of an intense inflammation. 
Like the vagina of the adult female in gonorrhoea it may be the 
seat of erosions which easily bleed. The cervix uteri is red- 
dened and bathed in pus, and in the opening of the cervix we 
find a drop of pus. This cervical involvement I have seen in all 
the cases I have examined in this way. The pus when exam- 
ined, either from the vagina or urethra, shows an immense num- 
ber of leucocytes filled with diplococci which answer in form, 
size, grouping and stain reaction to the same forms seen in gon- 
orrhoea of the urethra of the adult male. The course of the 
disease is tedious, and resists most methods of treatment. In 
many of these cases we have, as in the adult, joint complica- 
tions and blenorrhagic conjunctivitis. 
Etiology.—Most authors who have worked upon the etiol- 
ogy of vulvo-vaginitis in children have been struck by the con- 
stant presence of leucocytes in the discharge which are filled 
with micro-organisms, corresponding in size, form, grouping and 
stain to what is found in the discharge from the male urethra 
in true gonorrhoea. The question now is what significance can 
be attributed to these appearances. I need only briefly refer 
here to the discovery of a coccus or diplococcus in 1879 by 
Neisser, its thorough investigation by Bumm with its isolation 
and tests of virulence by the same author. The attacks of con- 
scientious critics, no doubt, have been directed toward proving 
the negative value of these researches, so that lately, 1889, 
Neisser and his pupil, Steinschneider, have taken up the sub- 
ject of the etiology of gonorrhoea anew. The articles of Neisser 
and Steinschneider owe their origin principally to the appear- 
ance of late of the work of Lustgarten and Manneberg upon the 
micro-organisms' of the normal urethra. The authors last 
named showed the presence in the normal urethra in addition 
to other micro-organisms of diplococci which are in form and 
size so much like those of Neisser, that they asserted, should 
inflammation occur, they could invade leucocytes and be easily 6 
Original Communication. 
mistaken for them. They failed, however, to show any real 
examples of this error in diagnosis and all the mass of critique 
and matters published subsequently to (his paper on the liabil- 
ity of error fails to show how these diplococci of the normal 
urethra actually were mistaken in certain cases for the real 
gonococci. Even Bockhard, who published a few cases of 
non-specific urethritis, failed to show that leucocytes might be 
crowded with this diplococcus in the manner seen in the gonor- 
rhoeal pus. Neisser naturally was again put upon the defen- 
sive, and anyone who will study his and Steinschneider’s article 
will admit that both these authors make out a very good case 
for their gonococcus. To sum up the paper of Neisser in 1889, 
he says the non-gonorrhceal urethritis of the male is of so infre- 
quent occurrence as to be practically of little importance diag- 
nostically. The form, size, mode of arrangement against each 
other in pairs, and lastly, the grouping of these pairs in single 
large masses in cells, the peculiarity of stain by Gram (Roux); 
the isolation in exceptional cases if demanded by culture, and 
their capability of producing gonorrhoea when inoculated on 
the healthy urethra, all tend to show a specific micro-organism. 
The inoculation tends to prove the etiological connection. He 
lays stress upon the fact that chronic gonorrhoea, which is con- 
tagious, is so by virtue of the gonococcus. The vulvo-vaginitis 
in small girls, he thinks, is gonorrhoeal. In the adult woman, 
he doubts the existence of gonorrhoea of the vagina and lays 
the existence of the disease in the urethra and cervix. All this 
with the evident conclusion that after examination of thou- 
sands of cases he has come to rely even on microscopic examina- 
tion of a specimen of pus as to its gonorrhoeal nature must con- 
vince the greatest skeptic. Steinschneider also went over the 
ground elaborated by Lustgarten and Manneberg and found 
five varieties of diplococci in the normal urethra. He found 
these so-called or rather erroneously called pseudo-gonococci in 
acute and chronic gonorrhoea, but concludes that in 95 per cent, 
of the cases the Roux stain gives absolutely reliable results. In 
4.6 per cent, other diplococci than Neisser’s decolorize. I think 
most workers who have stained much pus will be inclined to 
side with Neisser when he says that in skilled and tutored 
hands a mistake of identity is not possible. Lustgarten and 
Manneberg picture their normal diplococci on epithelial cells 
and not in leucocytes. I will show also these pseudo-gonococci 
upon epithelial cells in vaginal discharge of two cases of simple 
catarrhal non-gonorrhoeal urogenital catarrh of young children, Urogenital Blenorrhoea in Children. 
7 
yet it would be difficult to mistake them for gonococci. Turn- 
ing now to vulvo-vaginal catarrh or urogenital blenorrhoea 
(Cahen-Brach) of young children and girls, it first struck Pott 
von Dnsch, Spaeth that the cells, leucocytes, in the pus of 
these cases was identical with those found in gonorrhoea of the 
adult male. Since then this pus has been examined by Neisser, 
Fig. 2. 
Simple Vaginitis with pseudo- 
gonococci ON EPITHELIAL CELLS. 
Fig. 1. 
Simple Vaginitis showing 
RODS, COCCI AND DIPLO- 
COCCI IN LEUCOCYTES. 
Steinschneider (four girls) Widmark, Ollivier, Hirschberg 
(blenorrhoea and vulvo-vaginitis), Fraenkel, Lober, Kratter, Ep- 
stein, Parrot, Deutschman, Martin, Comby, Cseri and myself, 
all with the uniform presence in the discharge from the vagina 
and urethra of leucocytes which contain diplococci answering 
Schematic drawing to illustrate forms. 
Fig. 3. 
1. Group of pure serum culture diplococci of the normal vagina. 
2. Group of diplococci from simple vaginitis, pure potato culture. 
in every way to the descriptions of the diplococcus of Neisser. 
No author has, as yet, to my knowledge, made any attempts to 
cultivate the gonococcus Neisser, from the vaginal or urethral 
discharge of these children suffering from gonorrhoeal vulvo- 
vaginitis. Steinschneider has only examined the pus micro- 
scopically, as also Epstein and Cahen-Brach. I have made 8 
Original Communication. 
several attempts, I think, interesting ones, to isolate the gono- 
coccus Neisser from the discharge in children, and beg to direct 
attention only to the diplococci in the normal vagina of chil- 
dren and also the abnormal condition, which are apt to be mis- 
taken for the gonococcus. In the normal vagina of the female 
child we have a diplococcus which, when stained, resembles 
closely the pseudo-gonococcus pictured by Lustgarten. It 
grows upon blood serum in a whitish layer in small, white, 
beaded colonies. In agar the surface growth is a whitish moist 
layer and in puncture of gelatin tube there is a white non-char- 
acteristic growth. In colonies upon gelatin we have small, 
round, granular, olive colored by transmitted and yellow-white 
by reflected light. Some colonies of these diplococci are su 
perficial and golden-yellow by transmitted light, whitish by 
reflected light. It will thus be seen that it might be called a 
diplococcus albus, and is stained and retains stains by Gram. 
Turning our attention to the catarrhs of the vagina in children, 
we have a diplococcus which I have found existing alone and in 
almost pure culture in two cases of non-specific non gonorrhoeal 
vulvo-vaginitis. This vulvo-vaginitis, as I have cited in the 
early part of this paper, is infectious, though not gonor- 
rhoeal ; see Cases IY. and Y. (simple). This diplococcus does 
not decolorize by Gram, it is about the size of the gono- 
coccus. Sometimes it appears slightly larger or smaller. In 
gelatin we find it grows in superficial and deep light straw 
colored colonies, whitish by reflected light. The puncture in- 
oculation in tubes is a whitish nail-like formation which, after 
a time, fluidifies the gelatin slowly. In agar plates the colonies 
are not characteristic. They are oval, deep or superficial, 
round and spreading, the deep have a projection on one side. 
On the surface of agar the growth is enamel white, moist 
layer, no tendency to luxuriant spreading. In bouillon it 
causes a general turbidity after twenty-four hours, and after 
a few days a membrane forms on the surface of the bouillon. 
On potato we find a luxuriant white creamy layer, moist, 
raised, no great tendency to spread at sides. In appearance it 
looks identical with the pseudo-gonococcus pictured by Lust- 
garten and Manneberg, and in my own cases was seen an epithe- 
lium of the vagina. The cases in which it was present will be 
referred to again. The above diplococcus is also a white diplo- 
coccus. 
A third diplococcus is a micro-organism which I think has, 
with its fellow, a yellow diplococcus, been mistaken by many Urogenital Blenorrhcea in Children. 
9 
enthusiasts for the gonococcus Neisser and so published. It is 
always in vulvo-vaginitis to be found in the discharges and 
grows so luxuriantly that I think it has been the principal agent 
in baffling my attempts at least to completely isolate the true 
Neisser coccus. This diplococcus is almost the exact counter- 
part in form to the true gonococcus. The first diplococcus is 
white, another is yellow and corresponds to what Bumm has 
described as the diplococcus flavus. These two diplococci I have 
isolated from gonorrhoeal vulvo-vaginitis. The white diplococ- 
cus grows upon potato in a creamy layer almost indentical 
with the pseudo-gonococcus previously described. This creamy 
layer has a moist appearance, no tendency to spread at the sides. 
On agar this diplococcus grows in a pearly white layer and the 
stick in agar is not characteristic. It grows also in gelatin in a 
whitish non-characteristic stick—fluidifying the same slowly 
from the top. The yellow diplococcus grows, according to my 
notes on agar in form of a raised growth with wavy edges at 
first white and subsequently turning yellow in tint. 
I have not used human serum in my attempts to isolate the 
gonococcus, not having even to-day any free access to human 
material, but the cow’s serum was used, and it is well-known 
that the diplococcus Neisser grows sparingly on this medium 
and not as well as upon the serum and agar of Hueppe or hu- 
man serum. It is not surprising that I only obtained what I 
think were very restricted gonococcus growths. If we inocu- 
late drops of pus of a vulvo-vaginitis, according to Bumm’s 
method, upon cow’s serum, we find after twenty-four hours a 
fluidification of the serum, a sinking of the area of inoculation 
into the serum. In these excavations of serum tubes a diplo- 
coccus is found which is the exact counterpart of that seen in 
the crude pus sewn in tubes. If a needle is introduced into 
these excavations a thin, adhesive tenacious material can be ex- 
tracted, and in this we find the diplococci mixed with other 
micro-organisms. By transferring several excavatious contents 
to several tubes we sometimes are fortunate in obtaining a 
growth in yellow, white or creamy white layer on the serum 
composed of diplococci most of which decolorize with Gram. 
Not having used the plate method of agar serum of 
Hueppe (Werthheim), these growths were not pure gonococci, 
and in a few days, generally the fourth serum tube, they were 
outgrown by the diplococci last described above and lost. The 
remaining tubes showed diplococci which grewT upon agar and 
gelatin and what was more discouraging did not decolorize with 10 
Original Communication. 
Gram. These attempts at culture were begun as I stated, in in- 
tervals of other work as far back as 1889. This past two years 
I have again attempted their isolation always using bullock’s 
serum, the result was the same. I think I can say that I had 
before me the gonococcus upon serum for it decolorized by 
Gram, but I could not hold it because it was contaminated by 
the rapidly growing diplococci always growing with it which I 
think are not specific. I did not use the methods so successfully 
adopted by YVerthlieim lately, but none the less it appears to 
me I would still have greatest difficulty in isolation and selec- 
tion from this pseudo-diplococcus. Authors and workers have 
grown so skeptical to-day that if what is true as stated by 
YVerthlieim (which Bumm and Neisser do not agree to), that the 
gonococcus grows upon agar simple and mixed with human or 
cow’s or sheep’s serum, only inoculation experiments will in 
the future convince the critical reviewer that the coccus isolated 
from any case was the true Neisser coccus and not a pseudo 
variety. This discouraging outlook, for I could not persuade 
myself to try such inoculation for simple verification sake, has 
deterred me from further attempting the more complete isola- 
tion of the Neisser micro-organism from urogenital discharges 
of a gonorrhoeal nature in children, while the apparent lux- 
uriance of growth of the above pseudo-gonococci is an as- 
tonishing result of culture attempts and the difficulty of isola- 
tion of the true micro-organism responsible for the affections 
of the genito urinary tract of a gonorrhoeal nature in children 
has baffled many observers notably Fraenkel. There can be no 
doubt of its active part in the etiology. Fraenkel has been 
successful in certain inoculations and lately Werthheim has 
been able to isolate the gonococcus in female subjects suffering 
with affections of the tubes and cause gonorrhoea in the 
male with pure culture. The various diplococci other than 
those isolated by myself, have in other hands proved non-path- 
ogenic and incapable of producing gonorrhoea. Epstein at- 
tempted inoculation of gonorrhoeal pus from his cases upon 
healthy children with negative results, and concludes from this 
that there must be peculiar conditions present of the mucous 
membrane to favor inoculation. To recapitulate in children we 
find diplococci in the normal vagina, in the simple catarrhal 
forms of urogenital blenorrhcea and lastly in the gonorrhoeal 
forms of urogenital blenorrhoea. 
1. Normal vagina, a white diplococcus not decolorized by 
Gram. Urogenital Blenorrhoea in Children. 
11 
2. Simple catarrhal vulvovaginitis, a white diplococcus not 
decolorized by Gram. 
Gonorrhoeal vulvo-vaginitis. 
3. White diplococcus, not decolorized by Gram. 
4. Yellow diplococcus (diplococcus liavus Bumm). 
All the above diplococci have a form and size apt to be mis- 
taken for true Neisser diplococci, but in the material of over 
two hundred cases I have not met any case in which these so- 
called pseudo-diplococci existed in lucocytes alone exactly in 
the arrangement and disposition of true gonococci. They are 
found as a rule in pairs of two or four at most, in company with 
baccilli and simple micrococci or with streptococci in the leu- 
cocyte. In a small proportion of cases we find that long expos- 
ure of the crude pus spread on cover glass to the Gram method 
may even decolorize these diplococci as found also in the adult 
by Steinsclineider, but the arrangement and disposition is so 
different from the true micro-organism as to guard against erro- 
neous conclusions. The modes of staining these micro-organ- 
isms has given some workers difficulty, notably Fraenkel. The 
method pursued by the writer consisted in overstaining with 
gentian violet in anilin solution, decolorizing with alcohol lightly 
to find the presence of the coccus and reserving several glasses 
for Gram stain. At the same time to give good pictures the 
most satisfactory method has been to spread the pus thinly on 
cover glasses, heat for some little time on the Ehrlich plate be- 
low the 100° C point; after complete drying stain first with a 
dilute aqueous solution of crystalized eosin and then wash and 
transfer to a dilute solution in water of Loeffler’s menthyl blue 
alkaline solution. Beautiful pictures can thus be obtained. 
If stained first with blue and then eosin, the eosin is apt to de- 
colorize the blue stained diplococci, giving very erroneous pic- 
tures. I have mentioned these points, having worked them out 
in many cases. Baumgarten’s method of staining intensely 
with methyl violet and slightly decolorizing with alcohol, also 
gives good results. I have not tried safranine being so well 
pleased with the blue and eosin stain. The Gram stain is the 
differential stain only, and pictures obtained with gentian ani- 
lin solution are apt to be overstained and confused. I have ob- 
tained with the eosin-blue stain beautiful pictures of the eosin- 
ophile leucocytes mentioned by Ehrlich as evidence that we here 
deal with leucocytes directly emigrated from the blood vessels. 
Ehrlich has found these leucocytes in cases of gonorrhoea in the 
adult. I obtained them in my cases of gonorrhoeal urethritis of 12 
Original Communication. 
boys, also in simple and gonorrhoeal vulvo-vaginitis. They are 
simply diagnostic of the truth maintained by Ehrlich, that 
the eosinophile cells are not artifacts. I have elaborated the 
simple stain methods in order that others may be aided thereby. 
Measurements. The measurements of the true gonococcus 
are 0.8/* to 1.6/* (micro-millimeters) in the long diameter, average 
1.25/i and 0.6 to 0.8/* in the line of the interspace. 
The pseudo-gonococci found in the normal vagina of the 
child measure 0.8 to 1.24/* (micro-millimeters) in the long diam- 
eter, and have a breadth of 0.8/* in the interspace. 
The pseudo-gonococci found by me in cases of simpler uro- 
genital blenorrhcea, have a diameter of 0.9/* (micro-millimeters) 
to 1.28/* (micro-millimeters) in long diameter, and 0.9/* (micro- 
millimeters) in breadth at the interspace. 
The pseudo-gonococci found by me in the gonorrhoeas of 
female children measure 1.24/* (micro-millimeters) to 0.9/* (micro- 
millimeters) long diameter, and in the interspace the same as the 
previous pseudo-gonococci. 
It will be seen as above, that all these diplococci, when care- 
fully measured, are not only much the same size, but all the 
measurements are for practical purposes, identical with those of 
the true gonococcus. It will be also noted that in growth the 
pseudo-gonococci act much the same in artificial media, and it 
would be difficult to diagnose them apart from their particular 
form of disease. 
Urethritis in boys and young children.—1. There is a sim- 
ple non-specific inflammation of the meatus urinarius in male 
children, which is manifested by an eroded condition of the 
meatus. The child suffers in passing water, because the slight 
secretion of pus dries on the orifice of the glans penis, and pre- 
vents the passage of urine. The urine, when voided, also causes 
pain. In some cases the meatus alone is eroded, in others, if the 
glans is pressed, a small drop of pus can be expressed from the 
anterior part of the urethra. This condition, which might be 
called simple erosion of the meatus and catarrh of the fossa 
navicularis, is obscure in its origin. I have often thought it 
might be caused by an infection in children who crawl about on 
the ground and thus get filth over the organ, infection being 
favored by a slight scratch or wound. I confess, however, that 
this is unsatisfactory, as it has occurred to me to see this condi- 
tion in babes who cannot crawl about alone. It must be caused 
by some unnatural interference with the by nurses or par- 
ents, though not, however, with bad intent. Urogenital Blenorrhcea in Children. 
13 
I have often examined the drop of pns in the cases of simple 
anterior urethritis, and never found anything but what is found 
in simple catarrhal processes. Nothing characteristic of gonor- 
rhoea was ever found by me. 
2. True gonorrhoea has occurred in a number of male children 
in my service, and some of the children quite young, one a baby 
in arms. The symptoms of urethritis in male children give 
much the picture seen in the adult male, with the excep- 
tion that the constitutional disturbances are almost nil. Rona 
has lately recorded some fifteen cases of gonorrhoea in boys of 
various ages. He has never observed orchitis in any of his cases, 
but has had balanoposthitis and severe lymphadenitis or even 
lymphangoitis as complications. In a baby 15 months old, there 
was severe epididymitis of both sides, of weeks’ duration. Rona 
has seen a case of real stricture of the urethra in a boy 11 
years old. Bokai has seen some cases of true gonorrhoea in 
boys, but has never seen a stricture. It may be mentioned here 
that the cases of my first group, though not complete and typi- 
cal urethritis, do not find their counterpart in the adult, at least 
not frequently. Within the past six months alone I have seen 
three cases of true gonorrhoea in boys -3 years, years, and 
9 years old respectively. The histories of the cases are much 
the same. The boys in the primary stage had much swelling 
of the body and glans of the penis. There was a profuse, thick 
green discharge from the urethra, frequent micturition, and very 
little pain complained of. In one case I was able to watch until 
no discharge, not even serous discharge was apparent. This 
boy, I think, was really cured ; it is now a month, and he has not 
returned. The disease ran its course—a very mild one—in about 
seven weeks. The other boys disappeared from observation. 
In 1889, I saw a baby, 18 months old, with the same symptoms. 
Here, also, swelling of the glans was severe, and the baby 
seemed to suffer very much. 
The etiology of the cases in two of the boys is interesting as 
tending to prove in an almost absolutely conclusive clinical way 
that the vulvo-vaginitis gonorrhoeica of girls is really sudh and 
capable of causing urethritis in the male. These two boys set 
5 and 9 years, had attempted intercourse with a small girl living 
in the same tenement. They sent the girl to me and the girl (case 
III gon.), was suffering from a vulvo-vaginitis which was gon- 
orrhoeal. It would be difficult, I think, to find three more con- 
vincing cases in the literature of contagion. They go also to 
prove Epstein’s supposition to be correct that peculiar condi- 14 
Original Communication. 
tions of the sexual concours favors contagion, for, as stated, his 
inoculations from gonorrhoeal babies to the urethrae of babies 
were negative. 
Examination of the pus of non-gonorrhoeal cases of anterior 
urethritis gives pus cells which are the seat of isolated diplo- 
coccus forms, but in no way resembling gonococci, proving that 
in the male urethra in children as in the adult there are also so- 
called pseudo-gonococci. 
Examination of pus of the gonorrhoeal cases in boys and 
babies gives true diplococcus (Neisser) pictures in all their ex- 
quisite and absolutely convincing detail of form, arrangement 
in groups and masses filling up the leucocytes, size, reaction to 
stain tests. I have also in these cases found the leucocytes 
filled with eosinophile granulations. The methods of stain were 
as detailed with the female children. 
Mode of Infection.—The theories of Pott and others who 
wrote upon the gonorrhoeal form of urogenital blenorrhoea 
(vulvo-vaginitis), in young children presupposed that many of 
these cases originated in an indirect way from the use of utensils 
by the children in families whose adults were the sufferers from 
gonorrhoea, male or female. There are, of course, examples of 
gonorrhoea being conveyed to children in this indirect way but 
this does not account for a large proportion of cases. In my 
own experience I have never treated cases which could be legally 
construed as those in which children had been dealt with by 
adults in a forcible manner and thereby contracted gonorrhoea, 
These cases are all carefully weeded out of my service and re- 
ferred to the surgeons in. charge of the police precinct station. 
They are of no interest to the author of this paper. But the 
great mass of my cases are true gonorrhoeas and those in which 
the origin has been kept secret very skilfully by parents, chil- 
dren or both. I believe many of them originate in actual sexual 
contact either accidental or with intent. This may occur acci- 
dentally among the poor where, as in case, XIII, there was 
a history of a man sleeping in the same bed with the child. The 
mother protested though not even questioned, that the man was 
not to blame. It was probably some one nearer than a stranger to 
the child. In another case (IX. gonorrhoeal), the mother told 
me in great distraction that she had slept with the child. Had 
been ill for weeks with a discharge. Examination of the mother 
showed salpingo-oophoritis with also urethritis and endocer- 
vicitis. In the urethra of the mother I found gonococci. In 
another acute case in a child I obtained the same history but Urogenital Blenorrhoea in Children.« 
15 
though the mother had a discharge (urethritis and vaginitis and 
endocervicitis), I did not find gonococci. Her discharge was 
six months old and it may, as Neisser has pointed out in these 
cases, have required repeated examinations to find the gonococ- 
cus. I have spoken of the mode of infection in two of the 
boys. In the third case of a boy the gonorrhoea was contracted 
from an older boy with whom he had had relations. 
I have also shown, I think, conclusively, that the simple 
catarrhal vulvo-vaginitis is an entity as real as the gonorrhoeal 
form. How do they originate in face of the fact that in the 
male simple typical urethritis is so great a rarity (Neisser 
Bockhardt) % I think in girls everything is favorable to infec- 
tion. The parts are not protected as the male urethra is. The 
mucous membrane is peculiarly favorable to reaction under ir- 
ritants. The mothers are constantly interfering with these parts 
in children. In the exanthemata the vagina and vulva react 
as does any other organ, the nose, ear, glans, etc., to mixed 
infections. But where no history of exanthemata exists, the 
tracing of infection is difficult. Among the poor the herding 
together of parents and children in the same bed may favor 
contagion from the mothers who suffer from simple vaginitis. 
I have shown that the simple vulvo-vaginitis in children is con- 
tagious also. I have purposely recorded a case in my collec- 
tion of gonorrhoeal ophthalmia in a child of mild type in 
which the swelling and chemosis of the conjunctiva was not so 
extreme. One eye only was affected, gonococci were found in 
the pus. I had treated the mother before the delivery of this 
babe for what I thought was gonorrhoeal disease of the genitals. 
This child recovered with simple cloudiness of the cornea. I 
have simply noted this case in order to point out modes of 
contagion Epstein does not believe in indirect contagion and 
Parrot has also come to the conclusion that contagion from 
clothes, towels, sheets of the mother is difficult if possible. He 
has never seen a vulvo-vaginitis result from a gonorrhoeal con- 
junctivitis. I have noted a case in which I think pustular ec- 
zema of the labia majora caused simple catarrh of the urethra 
and vagina and also suppurating inguinal bubo (III. of simple). 
In case VII. of the simple forms I have not the slightest 
doubt that the simple vaginitis of the mother caused the dis- 
ease. The pus may have been conveyed from the fingers of the 
mother to the parts of the infant. 
The seat of disease. In vulvo-vaginal catarrh, simple and 
gonorrhoeal, most authors, even recent writers (Cahen-Brach) 16 
Original Communication. 
are inclined to place the primary infection in vnlvo-vaginal 
catarrh in the urethra, and look upon the infection of the hymen, 
vagina and cervix uteri as secondary. However this may be, I 
have never seen in all my large material a case in which I could 
say that the urethra alone was affected. When the cases come 
to me the urethra, hymen and vagina are found all the seat of 
disease in all forms of intensity in both simple and gonorrhoeal 
cases with the exception of case VII of simple form. Neisser 
and Bumm, believe that the vagina in children can be the seat of 
gonorrhoeal disease, whereas in adults, as is well known, they still 
believe gonorrhoeal vaginitis is not an actuality. Werthlieim’s 
work, if it is further corroborated, will tend to explode the old 
theory that the gonococcus can only flourish upon columnar 
epithelial surfaces. Werthheim showed that not only the 
peritoneum could be invaded by the gonococcus solely and 
purely, but that the planes of connective tissues could be subject 
to invasion and this in actual inoculation experiments. Thus 
many infections formerly thought to be due to mixed infections, 
will come under the heading of true gonorrhoeal diseases caused 
by the gonococcus wholly. The cases of vulvo-vaginitis which 
I have seen, have, if gonococci were present, yielded this abun- 
dantly in the discharge of pus from the vagina as well as that 
of the urethra obtained directly by first cleaning the parts and 
then squeezing a drop of pus from this tube. In those cases in 
which the urethral pus was examined, the gonococci cells were 
not so numerous, though a purer secretion of gonococci exists in 
the urethra. I have come to believe that the urethra, nymphm 
and hymen, the vagina and uterine cervical canal are all the seat 
of gonorrhoeal disease, and one of the chief causes of the in- 
tractible nature of the various forms of vulvo-vaginitis is the fact 
of the involvement of the vagina and cervix, the latter especially 
difficult to treat in small children. I know that Cahen-Bracli 
intimates that infection of the vagina by urethral pus can be 
avoided by means of tamponade. Infection of these parts 
spreads rapidly, and when we see them, at least in my own 
material, the mischief to the vagina has been done and seems to 
play a leading role. 
This is proven in most cases very distinctly by making the 
vagina the point of attack in treatment. If this is done as will 
be detailed, the symptoms rapidly subside quicker than by any 
means known to the author. The irrigation and local treatment 
of the vagina results in most acute cases in a rapid diminu- 
tion in the amount and change in character of the discharge. Urogenital Blenorrhcea in Children. 
17 
Even those cases in which Cahen-Brach said he prevented infec- 
tion of the vagina (and no doubt he did prevent marked disease 
of this tube) it will be noticed he- always, at each sitting, irri- 
gated the vagina with sublimate before tamponading the same, 
preparatory to treatment of the urethra. 
In simple urogenital blenorrhcea we may have the vagina 
affected without the urethra being in the remotest way dis- 
eased. This is shown in case VII of the simple group where 1 
do not doubt the infection was conveyed from a simple vaginitis 
of the mother to the infant in some way. In this case I took 
great pains to examine the urethra of the child by scraping the 
secretion in the long diameter out of the tube, no leucocytes 
were found and only isolated bacterial forms, while the vagina 
was markedly infiammed. The broad expanse of mucous mem- 
brane presented by the vagina and hymen as compared to 
the urethra would naturally prepare one for more disturbance 
here, and also a more convenient place for infection than the 
urethra. Thus far my studies convince me that in both forms 
of urogenital blenorrhcea the vaginal process plays as much 
a role as that of the urethra. I grant, however, that my 
studies have convinced me that the urethral mucous mem- 
brane is a more favorable abiding place for the gonococcus. 
Even in children (vide case wherein gonococci existed after 
six months). In the vagina the gonorrhoeal process, after a 
time, in old cases, is replaced by a species of desquamative 
catarrh in which all traces of gonorrhoeal diagnostic ele- 
ments may be obliterated or scanty in number and difficult 
to find. 
Complications.—The only complication which I have had 
any experience with and of which I shall treat, are in the female 
children, ophthalmia, arthritis and bubo. Ophthalmia is a 
much more frequent complication in children than in the adult. 
I have observed it in the gonorrhoeal cases alone, and in 1890 
published such a case in a child three years old, in tire New 
York Medical Journal. The blenorrhcea affected both eyes ; in 
this patient there was also the complication of arthritis. It has 
been asserted that the eye of the child is especially susceptible 
to contagion, hence the frequency with which we meet blenor- 
rhoea in these children. The cases of blenorrhoea which I have 
had, showed the same leucocytes filled with gonococci in the pus 
of the eye as in that of the vaginal discharge. In 1890 I pub- 
lished two cases of arthritis complicating gonorrhoeal urogenital 
blenorrhoea in young girls. In both these cases I have found 18 
Original Communication. 
the gonococcus in the vaginal dischargeand published microphoto- 
graphs of the same. Hartley in 1887, New York Medical Journal, 
also published some cases similar to these. Deutschman, an oph- 
thalmologist, observed arthritis in children suffering from gon- 
orrhoeal ophthalmia ; he found what he thought was the gono- 
coccus in the joint effusions. Petrone, Kammerer and Hartley 
publish cases in which they have found what they accept as the 
gonococcus in joint effusions. Brieger and Ehrlich, on the other 
hand, are equally conlident in asserting their non-existence and 
attributing the joint affections complicating gonorrhoea, as due 
to a so called mixed infection However this may be, we see 
that in these small children the joints are liable to react in much 
the same way as in the adult gonorrhoeal cases. Brieger, Ehr- 
lich, Baumgarten, Sanger doubt the presence of the gonococcus 
in the blood, lymph channels or in joint effusions. Werthheim, 
however, contends, as already stated, that the gonococcus can 
invade the lymph channels. Thus the isolated cases of periton- 
itis, joint affection, endocarditis would be regarded from such 
a standpoint as really caused by the gonococcus. These points 
remain still to be more fully studied. The joints which I have 
seen most frequently affected have been the knee joint, the an- 
kle, the wrist joint. I have not as yet seen cases of involve- 
ment of the very small joints. This, perhaps, is a matter of de- 
tail. Gerhardt has published cases of gonorrhoeal arthritis in 
older girls above eighteen years of age. I refer to the article 
on arthritis complicating vulvo-vaginal inflammation in children 
by me for more detailed literature. 
Relapsing cases, and the presence of gonococci in old cases. 
—The author has found the gonococcus persist in cases of 
vulvo-vaginitis in girls, after eight weeks, or nine weeks, or six 
months (case XVII). In these cases the cells containing the typi- 
cal pictures of gonococci will be found to be very few. The pus 
in these cases should be collected from the urethra or deep vag- 
inal fornix. In old cases it should be a routine to examine pus 
from the urethra or vaginal fornix repeatedly for gonococci, if 
we are in any way desirous of fixing an exact diagnosis. Neis- 
ser has called especial attention to this in the adult and in 
children it holds good that a discharge may be pronounced 
simple which is really gonorrhoeal, especially in old cases, if 
fortune and perseverance does not favor in discovering the few 
leucocytes with typical gonococci. 
There is also a distinct class of cases which should always be 
looked upon with suspicion. These are the relapsing urogenital Urogenital Blenorrhoea in Children 
19 
blenorrhceas. The history obtained in these cases is that the 
child has suffered for months from a discharge which had ceased 
being thought cured, in a few weeks or months such a dis- 
charge will reappear. Many of these cases are gonorrhoeal. 
Neisser lias dilated upon such a class of cases in adults, and in 
children we have their distinct counterparts. The gonococcus 
nested in the myriads of rugae and asperities of the female- 
urogenital tract will apparently lie dormant to regain energy 
and cause renewed symptoms at favorable moments. Sparse 
discharges of recurrent cases should be repeatedly examined, if 
possible, to tind the gonococcus. More especially so, if there is 
a history of conveyance of the disease from one child to another. 
Among the cases of old gonorrhsea, I refer the reader to case 
XVII. (gonorrhoeal), especially where for the past six months 
previous to visit, the child had a discharge, which at first profuse, 
was finally very spare. At first examination it seemed it might 
be simple catarrh, but subsequent careful search in the minutest 
quantity of urethral pus revealed diplococci (Neisser.) 
Treatment.—In order not to repeat the literature upon treat- 
ment, I will simply say that all the new methods recommended 
for the treatment of this affection, thalin, iodoform bougies, 
injections, siiver applications, have been used by me with the 
same degree of success as that obtained by others. They have 
failed to effect what we may call a shortening of the disease. 
The discharge ceases, under the above treatment, to be profuse, 
but the patients complain that small amounts of secretion are 
found on the vulva every morning. The disease drags on a 
course of six, eight, or even twelve weeks. Being convinced 
that this prolonged discharge from the parts is in part aided by 
the anatomical nature of the vagina and cervix uteri, I have 
adopted the following course in all cases. 
The parts being cleansed with 1-5000 sublimate, externally, 
a Tuttle’s urethral speculum is introduced into the vagina, and 
the same is thoroughly douched with sublimate, 1-5000. The 
parts are then dried with a uterine applicator and cotton, and a 
10 per cent, solution of nitrate of silver is carried upon a cotton 
applicator into the vagina up to the cervix, and the parts 
thoroughly painted with the same. The vagina is again 
douched with 1-5000 sublimate, and the speculum withdrawn. 
In acute cases the applications cause some bleeding, due to 
erosions in the vagina ; this soon ceases after a few applications, 
and further treatment.is not attended with any stains of blood 
on the applicators. The silver is at first applied daily, and then 20 
Original Communication. 
every other day. Under this treatment the discharge ceases to be 
profuse within a few days, but I am not in a position to give 
exact data. I can recommend it as being the most satisfactory 
mode of treatment, and the most rational method to employ. 
The children struggle with every mode of treatment, but with 
good table and appliances, less harm is done by the above 
modes than by singly trying to introduce bougies, which give 
pain and cause no end of trouble. I have refrained, in all my 
cases, from treating the urethra of girls. The parts are so small 
that the pain resulting from interference with the urethra by our 
present methods does not justify persistence in efforts of treat- 
ment. The eye and joint complications I generally have referred 
to the surgeon for treatment The bubo presents nothing pecu- 
liar. - 
ILLUSTRATIVE CASES. 
I. Simple non-gonorrhoeal urogenital blenorrhceal vulvo- 
vaginitis.—L. G., aged 6 years, suffering for the past four 
weeks from a vaginal and urethral discharge. The discharge 
from the urethra shows only isolated diplococci not character- 
istic of gonorrhoea. 
II. Simple relapsing form.—S. Id., aged 6 years, has three 
months ago had a discharge from the vagina. It had appar- 
ently ceased and now has returned. The vagina shows a gleety 
yellow discharge, slight redness of the nymphse, no gonococci in 
urethral or vaginal secretion. 
III. Simple form with bubo.—Ida L., aged 5 years, has 
had a discharge from the vulva now of twenty-four hours’ dura- 
tion. On the vulva there are pustules anti in the introitus 
aphthous ulcerations. The vagina and urethra show a purulent 
discharge and there is an impetigo upon the vulva (labia 
majora.) The vaginal discharge is green and thin. The right 
inguinal lymph nodes suppurating. 
Examination of urethral and vaginal discharge shows no gono- 
cocci. Two cases of non-gonorrhceal discharge repeatedly ex- 
amined and nothing found but pseudo-gonococci which were 
also isolated and cultivated. 
IV. R. M., aged 7 years, has for past two weeks suffered 
from a yellow discharge, no urinary symptoms, no redness of 
parts. This child has had a discharge a year ago. 
Pus from vagina and urethra shows pure examples of pseudo- 
gonococci. (Lustgarten.) 
V. Annie M., sister to above, suffers from a urogenital 
blenorrhcea, two weeks duration. The discharge is not great but 
whitish, purulent, no urinary symptoms, no redness of parts. 
Repeated examination of urethral and vaginal pus shows the 
above pseudo-gonococci. Urogenital Blenorrhoea in Children. 
21 
YI. Healthy child years old has been sick a week with 
painful and frequent micturition. Mother lias noticed that 
mornings the child has discharge from the vulva adherent in 
crusts, not abundant. Parts are swollen but not markedly so. 
Discharge is greenish yellow fluid and just moistens the parts. 
The urethral orifice bathed with drop of pus. Nymphse 
swollen and tender. Child has slept with mother who has 
a babe eight weeks old. Urethral and vaginal pus carefully 
and separately examined; no characteristic gonococci. The 
bacilli, and pseudo-diplococci (as in Y and Yl cases), did not 
decolorize with Gram. 
• YII. Simple non-gonorrhoeal vaginitis without any signs of 
urethritis.—S. G., infant aged 12 months well nourished. Has 
for the past week shown a discharge from the genitals There 
are no other symptoms. Examination shows that the vulva is of 
normal hue, not eroded, no crusts or discharge visible, urethra 
also perfectly normal but the hymen is somewhat swollen but 
not reddened in hue. The orifice is bathed in pus ; squeezing 
the perineum causes the appearance at the hymenal orifice of a 
thick viscid creamy yellow discharge. Child sleeps with its 
mother. The mother is six months pregnant but examination 
shows nothing abnormal. The leucorrhoea of mother is normal 
in quantity and what we would expect in a woman at this 
period. 
The pus of vagina of child was examined but absolutely noth- 
ing found but pure pus, in a few of the leucocytes isolated single 
pseudo-diplococci, these even were rare. The infant’s urethra 
was scraped but absolutely no pus cells were obtained showing 
it was not inflamed. 
The mother’s urethra examined, no leucocytes indicating- 
inflammation present, only epithelium, pseudo-diplococci and 
other bacteria. 
I. Gonorrhoeal vulvo vaginitis or urogenital blenorrhoea.— 
L. R. aged 4 years. Mother has noticed discharge for the past two 
days from vulva. Patient complains of pain on passing urine 
and when walking. She has yellow crusts of dried pus on 
labia majora, a thick greenish yellow discharge from the vag- 
ina. The nymphse are much swollen as also hymenal structure. 
Hymen imperforate, meatus urinarius red and swollen. 
Pus contains gonococci. 
II. S. F. aged 4 years. The discharge from vagina thick and 
greenish hue, has yellowish crusts on labia majora, has been ill 
six days. Has been in a leading hospital for tubercular disease 
of jaw and returned home with the discharge. 
Pus shows gonococci. 
III. C. S., girl who has commuicated gonorrhoea to two boys. 
Examined in the seventh week of the disease. There is a urethral 
and vaginal discharge and the vulva is reddened and eroded. 22 
Original Communication. 
The discharge is spare and gleety ; when examined very char- 
acteristic gonococci found. 
IV. S. D., aged 2 years. For past three days there has been 
a thick yellowish green discharge from vulva. Discharge is 
abundant about the urethra and dries upon the labia majora in 
crusts. 
Pus contains abundant gonococci. 
V. C. M., aged 10 years. Pale and anaemic child has had a 
thick greenish yellow discharge from genitals for the past eight 
days, no other history, denies symptoms of any kind. 
Pus examined, gonococci. 
VI. Jenny S., aged years, has for the past six days suffered 
from a discharge from the genitals, which is thick, greenish and 
dries in crusts upon the labia majora. Parts are swollen and 
painful at the introitus, no inguinal adenitis. 
Pus examined gives gonococci. 
VII. D. R., 6 years old. Has for the past three days com- 
plained of painful and frequent micturition. She has had a 
thick yellow discharge from genitals which dries in crusts on 
the labia majora. There is great swelling of the nymphse. 
Gonococci in pus. 
VIII. Gonorrhoeal vulvo-naginitis with pains in the joints. 
—M. W., sick with vaginal discharge for past two weeks. A 
week ago complained of pains in the ankles and the right wrist. 
The discharge is a profuse greenish one and the nymphm and 
hymen are sensitive, swollen. Crusts on the vulva, no tempera- 
ture, no bubo. 
Discharge shows gonococci. 
IX. F. B., aged 4 years. Four weeks before visit had measles. 
A week before consultation mother noticed a greenish yellow 
discharge on clothes. This has continued since. There have 
been no urinary symptoms. Child is intelligent and robust. 
There is erosion of vulva ; introitus and urethra painful and 
swollen, the discharge is thin and fluid. That from the vagina 
contains abundant gonococci. The mother of this child has, for 
the past three days, complained of painful and frequent mictu- 
rition but secretion from urethra of mother shows nothing defi- 
nite. Mother sleeps with child. 
X. M. R., aged 6 years, has been in a leading metropoli- 
tan hospital. Six days before visit was discharged from the hos 
pital when mother noticed the vaginal discharge. The discharge 
from the vagina dries in crusts on the labia majora, no symp- 
toms referable to bladder. The labia majora are eroded, 
the vaginal and urethral discharge is thick and yellow, parts 
about the introitus infiammed and much swollen and painful. 
* Pus from vagina contains gonococci which persisted after eight 
weeks, when patient returned to begin treatment anew. Then 
discharge very small in amount but a few gonococci present. Urogenital Blenorrheea in Children. 
23 
XI. C. H., 8 years old, lias had a discharge for two weeks 
from the genitals. Has never had such an illness before. There 
are no urinary symptoms. The pus is white, creamy,,and does not 
excoriate the labia. The child has slept with her mother who, 
for some time past has suffered from a profuse vaginal discharge, 
frequent and painful micturition. Mother’s discharge is thick, 
ropy and yellow. Mother volunteered statement that child may 
have contracted the disease from her. 
Examination. Pus of vagina of child shows abundant gono- 
cocci. The pus taken from urethra of mother contains a few 
leucocytes giving typical gonococcus pictures. 
XII. A L., aged 4 years, has for a week been ill with a 
yellow discharge from the vagina and urethra. There is no his- 
tory of urinary symptoms. The introitus vagina painful, red 
and somewhat swollen. Pus from the vagina showed gono- 
cocci. 
XIII. A. Gf., aged 4 years. Two weeks ago the child had 
developed a discharge from the vagina, frequent, but no history 
of painful micturition. There has been some malaise, no buboes. 
Urethral opening, nympha? and hymen all red, painful, swollen; 
pus taken from the vaginal opening contains abundant gono- 
cocci. The mother volunteered statement that child had slept 
in same bed with a man who she asserted was sick (?). 
XIV. C. M., well nourished child aged 8 years, has for the 
past two weeks suffered from a purulent discharge from the 
genitals. There is frequent micturition but no marked pain ; no 
other history. 
Examination shows erosions around introitus; same is 
painful and swollen. The pus discharged from the urethra and 
vagina is thick and greenish in hue ; no enlarged inguinal 
glands. 
Pus contains abundant gonococci. 
XY. S. B. No previous history. Child is 5 years old 
and well nourished. The vaginal discharge is of one day’s 
standing ; no other symptoms ; no buboes ; no pain on urina- 
tion. The child sleeps with mother who for five months has 
suffered from a vaginal leucorrhcea. 
Examination. Pus from child, gonococci. 
Examination. Pus from mother, no gonococci. (Cervix 
and urethra examined.) 
XYI. A. W., 5 years old. Has suffered for five days from 
a discharge from the genitals. No history of painful micturi- 
tion or frequent desire to pass urine. Child is very robust and 
well built for its age. Has a very profuse discharge from the 
urethra and vagina, which show abundant gonococci. 
XVII. Old gleety form in which urethra showed gonococci 
six months after onset of disease. 
M. K., 6 years of age, has for the past six months had a 24 
Original Communication. 
vaginal discharge which at times was profuse at others scanty. 
There has been burning pain upon passing urine. Introitus 
is red and spongy with a very scanty vaginal discharge of a 
thin consistence and greenish in hue. Urethral orifice swollen 
and reddened. 
Pus taken from urethral canal shows gonococci. 
I. Simple erosions and catarrh of the anterior urethra in 
boys.—Boy 9 years old suffers from an erosion or impetiginous 
condition of the meatus urinarius. By squeezing the glans a 
small drop of pus can be expressed from the urethra. This pus 
contains cells the seat of isolated diplococci, but they do not 
have the arrangement of gonococci. No other history as to 
origin of affection. 
II. Boy aged 5 years. For the past week has had an ulcer- 
ated and sore condition of the meatus urinarius. When the 
glans penis is pressed a small drop of pus exsudes from the 
urethra. 
Cover glasses show no gonococci. 
I. Gonorrhoeal urethritis in boys.—S. B. Intelligent boy 
aged 5 years, not abnormal in physique. Has for several days 
had a urethral discharge. Thick yellow. The glans, penis and 
body of penis much swollen. Makes statement that he has 
played with child in same house (history related elsewhere). 
This child was small girl 7 years old suffering from gonorrhoeal 
urogenital blenorrhoea. 
Pus from boy’s urethra showed gonococci. 
Case sent to me by Dr. W. W. Van Arsdale. 
II. Boy aged 9 years came to me with a gleety, milky dis- 
charge from the urethra. Penis somewhat swollen, the boy 
has no other symptoms and denies that there is painful or fre- 
quent micturition. States he contracted the disease from same 
girl as case I. 
III. P. B. Boy aged years, intelligent, robust, brought 
to me with a creamy white discharge from the urethra. There is 
much oedema of the glans, and penis and this condition said to 
have been worse. Is sick now fourteen days. States that 
another boy gave him the trouble (?). The boy cured appar- 
ently after 7 weeks of treatment. Urethral pus shows gonococci. 
IV. A specimen in my collection, dated August 1889, taken 
from the urethra of a babe 18 months old, who, for two weeks, 
had an abundant discharge from urethra, the glans, penis and 
body of penis is much swollen, child is very restless and 
evinces signs of pain when organ is examined. No history. 
Pus of urethra contains gonococci. 
LITERATURE. LEADING NOTICES ONLY. 
1. Patt. Jahrbuch. f. Kindheilk, Bd., XIX, 1883, s. 7. 
2. E. Fraenkel. Virch. Archiv. Bd., 99, 1885, s. 251. Urogenital Blenorrhoea in Children. 
25 
3. Widmark. Archiv.f. Kind. Heilk., Bd., VII, s. 1. 
4. Spaeth. Miln. Med. Wochen., 1888. 
5. Ollivier. Le Concours Med., 1888, Nov. 3. 
6. Bouchout. Treatise Diseases Children. 
7. Hirschberg. Berlin. Klin. Wochen., 1884. 
8. Epstein. Archiv.f. Dermatol, u. Syph. Bd. 23, 1891. 
9. Lober. La Semaine Med. 1887. 
10. Hartley. N. Y. Med. Jour., 1887. 
11. Kratter. Berlin. Klin. Wochen., 1890, No. 42. 
12. Vibert and Bordas. La Medicine Moderne, 1890, No. 47, 1891, No. 1. 
13. Parrot. Jahrb. f. Kindheilk. Bd., XVIII, p. 346 
14. Suchard. Rev. 31ens des. Enfance. 
15. Deutschman. Archiv.f. Ophthalmol., 1890. 
16. Werthheim. Archiv.f. Gyntec., Bd. XLII, 1892. 
17. Martin. Jour. Cutaneous and Genito-Urinary Diseases, Vol. X, No. 11. 
18. Comby. Rev. des 3Ialad. des Enfance, Jan. 1892. 
19. Dusch. Internat. Rundsch, Wien II, 647. 
20. Cs6ri. Wien 3Ied. Wochensch., XXXV, 703. 
21. S. Loven. Centralbl. f. Gyntec. No. 10, 1887. 
22. Neisser, A. Naturforsclier Versammlung, Straasburg, 1889. 
23. Giovanni. Centralbl. f. 3Ied. Wissen., 1886, No. 48. 
24. Bockhard. Monatsheft f. Prakt. Dermatologie, Bd. V, 1886. 
25. Steinschneider. Same as Neisser. 
26. V. Dutsch. Deutsch. Med. Wochenschr, 1888, No. 41. 
27. Touton. Archiv.f. Dermatol, u. Syph., 1889. 
28. P. Roux. Archiv. f. Dermatol, u. Syph. 1893. 
29. Cahen-Brach. Jahrb. f. Kindheilk. Bd., XXXIV, hft. 4. 
30. John A. Wyeth. Kansas City Med. Index, 1892. 
31. H. Koplik. N. Y. Med. Jour., 1890, June 21. 
32. Sanger. Die Tripper ansteckung beim Weiblichen Geschlecht, Leipzig, 
1889. 
33. Lustgarten and Mannaberg. Verteljahrschrift f. Derm., 1889.