History

Gonorrhea is the oldest, as well as the most common, of the venereal diseases. An Egyptian papyrus from approximately 3500 B.C. prescribes plant extracts to soothe painful urination. The Hebrew Bible makes reference to treatment of genital exudates, which may well refer to gonorrhea. Hippocrates recognized the venereal nature of transmission at about the beginning of the fourth century B.C., and Galen, in the second century A.D., is believed to have coined the name. In the fourteenth century, a description of the ailment that stressed a major symptom, chaude pisse, or "hot piss," led to the disease's receiving this appellation from the French.

By 1500 or so, interest centered on the distinction between syphilis and gonorrhea. The majority opinion appeared to favor the notion that they were different manifestations of the same disease, particularly because syphilis was so clearly protean in its manifestations. However, in the middle of the sixteenth century, a French physician, Jean Fernel, wrote of gonorrhea as a separate disease from syphilis in his Medicina. The British physician Francis Balfour, writing two centuries later, has also been credited with the belief that syphilis and gonorrhea were distinct.

Confusion set in, however, following John Hunter's argument that the cause of both diseases was the same and that gonorrhea was a manifestation of the disease on a secreting surface (mucosa) whereas syphilis was its manifestation on a nonsecreting surface (skin). To prove this, he infected himself with pustular discharge from a patient he thought had gonorrhea, and developed syphilis instead. The patient may have been dually infected, but at any rate, this was an unfortunate instance of a brilliant and heroic use of the scientific method gone wrong, and it postponed scientific understanding of the two diseases for decades.

It was during this same period (1760-90) that the most lucid literary account of gonorrhea appeared. James Boswell, the biographer of Samuel Johnson, kept a meticulous diary of his own repeated encounters with gonorrhea. The diary details the clinical manifestations and psychological effects of 19 episodes. There is little question of the impact of gonorrhea on his life, and, by extension, on the life of countless others in the era. He is believed to have died of gonorrheal complications.

In the 1790s, Benjamin Bell of Edinburgh, who was in disagreement with Hunter, published several tracts that explored the clinical and epidemiological evidence for gonorrhea and syphilis as separate disease entities. He posed a number of simple questions: Why is gonorrhea more common when the skin of the penis is at greater risk of exposure than the urethra? Why are there geographic differences in the distribution of the two diseases? Why have their manifestations appeared in the same populations at different points in time?

It remained, however, for Philippe Ricord, in a series of clinical observations and direct experiments in the mid-1800s, to provide a definitive distinction between the two diseases. It is of interest that Ricord commented that there is no justification for experimentation with grave diseases in human beings, although he inoculated 17 prisoners with gonorrheal pus, producing occasional ulcers with prompt healing, but no evidence of syphilis.

In 1879, Albert Neisser, an assistant in dermatology at the University of Breslau, Germany, published his preliminary findings which confirmed the conclusions of Ricord by describing the organism that now bears his name. This was probably the second description of a major human pathogen (after Koch's identification of the anthrax bacillus 3 years earlier). In 1882, the organism was first grown in vitro by Ernst von Bumm. The first major preventive action was taken in the following year when Karl Siegmund Crede, at the Lying-in Hospital in Leipsig, recognized the benefit of instillation of 2 percent silver nitrate solution (later reduced to 1 percent) in the eyes of newborns. The occurrence of gonococcal ophthalmia diminished rapidly with the widespread adoption of this procedure.

Unfortunately, advances did not follow in rapid succession. In fact, after the initial diagnostic procedures were established, there were no major improve ments in the understanding of gonorrhea until the sulfonamides (e.g., sulfamidochrysoidine, Prontosil) were introduced in 1937. This success was shortlived, and true antibiosis for gonorrhea appeared only in the 1950s with the general availability of penicillin. The next critical breakthroughs were the description of the different colonial morphologies by Douglas S. Kellogg et al. in 1963 and the development of a selective medium for culturing the gonococcus by James D. Thayer and John E. Martin in 1964. Subsequent events, including the worldwide pandemic of the 1960s and 1970s, and the major advances in immunology and molecular biology, were alluded to earlier. Clearly, it is only in recent times that gonorrhea's effect on us, and in turn, our ability to alter its course, have dramatically changed.

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