Okay, so this is a small disclaimer for this episode, since a lot of you either are kids, high kids, or you listen with your kids. Hi, parents and kids. We are discussing a sexually transmitted disease today, which means we're going to be talking about sex and genitals. So if you want to veto that for your five year old that's listening, put your earbuds in now.
January eighteenth, seventeen sixty three. I this day began to feel an unaccountable alarm of unexpected evil, A little heat in the members of my body sacred to Cupid, very like a symptom of that distemper with which Venus when Cross takes it into her head to plague her votaries. But then I had run no risks, I had been with no woman but Louisa, and sure she could not have such a thing. Away then, with such idle fears,
such groundless, uneasy apprehensions. January nine, eighteenth, the evening was passed most cheerfully when I got home, though then came sorrow to too. Plain was signor gonorrhea. Wait there's more. Thus ended my intrigue with the fair Luisa, which I flattered myself so much with and from which I expected at least a winter's safe copulation. It is indeed very hard. I cannot say, like young fellows who get themselves clapped in a body house, that I will take better care again,
for I really did take care. However, since I am fairly trapped, let me make the best of it. I have not got it from imprudence. It is merely the chance of war. I mean, it goes on and on like there's a much more of it. That's just yeah, Oh my gracious, isn't it so good?
What is that?
What is that? Okay? So that is from James Boswell. So James Boswell was the He was the biographer of Samuel Johnson, who's a literary Okay, yeah, James Boswell throughout his life, throughout his journal entries at least became infected with GONERIEA at least nineteen separate times nineteen So this is merely one of them. I just he really you should take some time and just go and seek out the entirety read his.
Whole journal entry.
Yes, yes, man, Hello, Hello, I'm Aaron Welsh and I'm Erin Almond updyke and put your hands together for hands together for Goneriea, the subject of today's episode.
Of this podcast Will Kill You. Welcome, Welcome, We're gonna have fun today, I can tell.
Oh yeah, I mean if that journal entry is any indication, right, okay, So what are we drinking to talk about GONERIEA.
We're drinking, of course, burning love.
And it is burning because it does Jalipino simple syrup and tequila, lemon juice and a cucumber slice.
Just for freshness.
It's pretty delicious.
I gotta say it is delicious. I'm really enjoying it. And as always, we'll post the full recipe for this quarantine as well as our Placeyburrita, our non alcoholic version on all of our social medias. You can find us on Twitter at TPWKY, on Instagram and Facebook at this Podcast will Kill You, and on our website at this Podcast will Kill You dot com.
And if you ever feel like reaching out to us, you can email us at this Podcast will Kill You at gmail dot com, or go to our website for an entry or a contact form.
Yep. Cool, All right, let's do it right after this short break. All right, GONERIEA, gottareea. Let's get into it. So gonerhea is caused by a bacterium. It's called Nicia gonneriee goner rhea. Ee. I never know how to pronounce all those vowels.
There are so many vowels at the end of that word.
I know it's a lot. Niceria gonerie is closely related to another bacteria that some listeners and you, Aaron, will definitely have heard of. Do you remember what.
It is, meningitis?
Yes, Niceria meningititis, which causes meningitis. So all the Niceria are gram negative diplocoxie, which means that they stain pink when we use stains to look at them under a microscope, and they're just these two little balls gonna yeah, yeah, okay, So let's just I'm just gonna really we're gonna get right into this how all this goes. So we all know how goneria is transmitted.
I think, right, well, maybe you should just do a refresher just in case.
I mean, okay, So goneria is transmitted via sexual relations, so you can get it from all the kinds of sexual intercourse, vaginal, oral, anal and in any direction giving receiving doesn't matter. And for adults that's pretty much the only way that you're going to get goneriea is via sexual intercourse of some design, Okay, in neonates, so in tiny baby infants, it can be passed from mother to baby during delivery, during birth, during passage through the birth canal.
So in general, in this country and in most other countries, we screen pregnant people for gonococcal infection. This is often called ganococcus or ganococcal infection or just gonerrhea, So I'll probably use all those words interchangeably, but yeah, infection in a newborn is actually pretty serious, and so you screen for it during pregnancy and then you treat it and that reduces the risk of neonatal infection. Cool, Okay, so cool. So what happens when you get exposed after a fun
night to gonerhea? Basically, the bacterium which has been deposited into your body will adhere to your epithelial cells, okay, either along the vaginal canal or on the endocervix, or in the anal canal or I wrote penile canal, and then I realized that's just called your your ethra, you're urethra, and it attaches to these epithelial cells. Using pilli, which are basically isn't that fun? I didn't know that until I started researching this. Yeah, so pilli are basically these long,
stringy protein bits that bacteria have. They're kind of like you remember those sticky hands that you used to get from the twenty five cent machines. Oh yeah, you like throw them out and stick them on your wall, and then your mom gets mad at you because you ruin her white walls well.
And then they get covered in fuzz and they don't stick anymore. Yes, just like that.
But so you know, like if you throw that out and stick it and then you let it go, it like flings towards the wall, right, So that's kind of what these pill i do. They reach out, they grab onto the epithelial cells and then they contract and that sucks the bacteria up against the epithelial cells.
That's so cool.
It's very cool. And it's great if you're in something like a urethra or up against the cervix, because you're probably gonna have fluid rushing through those tubes and so you want to be able to stick on and grab on real type. Yeah, so ganeria is good at that, and once it sticks on it starts to replicate basically right then and there, it doesn't it's not a virus, so it doesn't have to infect your cells. It just
grabs a hold and then starts replicating. Oh pretty fun. Yeah, and then once it colonizes, once it starts growing, it stimulates the release in your body of a whole bunch of pro inflammatory molecules. So this basically stimulates your immune response. So then a whole bunch of immune cells, especially neutrophils and macrophages, which are kind of the first line defense
against bacteria. They come in and in normal bacterial or other bacterial infections, they'd be able to pagosatize, which means swallow up, essentially eat the bacteria and then help clear the infection. But Gonnerrhea are sneaky little suckers and they can actually survive inside of neutrophils.
Oh that's amazing, I know.
So when you look at like a swab from someone who has a goneriinfection, if you stain it, you'll actually see neutrophils just full of Gonnerhea bacteria.
Oh my gosh, it's very cool. Like a trojan horse. Yeah, yeah, maybe sure.
The neutrophils normally kill bacteria by using reactive oxygen species, but the niceria can actually what sort I'm looking for, neutralize those because they have an enzyme called catalase which helps to neutralize that. So they can just survive inside of the neutrophils, which I think is very cool. That's awesome, And because they're recruiting a bunch of neutrophils and macrophages, that is also what kind of results in the symptoms
that we see. So if you get a genito urinary infection, let's talk about what kind of symptoms you'll actually have. First of all, most of the time you won't have any Most infections are straight up asymptomatic, which is part of why it can spread so easily, because anything that's spread by sexual contact in certain populations is going to be pretty easy to spread. And if it's asymptomatic, then it never gets detected or treated, so you just keep
sharing the burning love. So for a genito urinary infection, if you get infected in the urethra, you're going to see dysurea, so that means painful urination because you've got basically inflammation going on along the lining of your urethra. And then you'll also get a discharge, and that discharge will be either white or yellow or greenish, okay, CoRIS and it's mostly neutrophils. It's mostly neutrophills, dead cells, and bacteria.
And then even those neutrophils are often full of gonococcal bacteria as.
Well, So all of the stuff that you are secreting is full of it's like packed with Gottrhea bacterial cells.
Absolutely, yeah, yeah, so that discharge is super infectious.
Okay.
You also can get infection of the epidymus. So if it travels through their urethraat and back down into the epididymus, which is the tubes that surround the testis where the sperm actually have to travel through. Then you can get what's called epididymitis, which is infection inflammation of the epidymus, and that can be very very painful, So you can have testicular and scrotal pain on top of painful urination
and urethral discharge. If you get an endocervical infection, so an infection of the vaginal canal and the cervix at the top there, it's even more likely to be asymptomatic. Than a urethral infection. Okay, if you do get symptoms, they're often mistaken for a bladder infection or aaginal infection like a yeast infection or a bacterial vaginosis or something. So you might have some dysyria, you might have some
vaginal discharge or some bleeding in between periods. But more often there are no symptoms in people with an endocervical or a vaginal infection.
And when you say more often, like can you give me a pee, put in number to the percentage of cases.
I don't have a number. I was trying to find solid numbers. And it's just like most of the time in endocervical infections it's asymptomatic, and most of the time in your reath roll. In penile infections, it is symptomatic or it's more likely to be symptomatic, though in both cases it can be asymptomatic. The problem with endocervical infections
is that they can spread. They're asymptomatic, so they're less likely to be detected, and they can spread from the endocervix to the uterus or the fallopian tubes, which causes what's called pelvic inflammatory disease. Or pid pid is a very serious disease. It can cause abdominal and pelvic pain, fever, abscesses.
It kind of is considered a more systemic infection and it can lead to infertility because it can really severely damage the filipian tubes and the uterus itself, and it also can cause scarring on the filippian tubes that can increase the risk for future ectopic pregnancy, which is when an embryo implants outside of the uterus, and that can
be very dangerous in rare cases. Epididymitis can also lead to infertility, but it's more common that in people with a uterus or ovaries you end up with infertility as a complication of a gonococcal infection. You can also get rectal infection all holes here. It's usually asymptomatic, but you kind of do have the same symptoms discharge, anal itching, soreness, bleeding. You can also get a pharyngeal infection, an oral infection.
So I have heard stories from people who work at the student health clinics of kids coming in they think they've got sore throat and it turns out it's gonnerrhea.
Oh gosh, oh I got a kick out of it. So it causes the same symptoms as like sore throat.
Yeah, it's basically just a sore throat. It's a pretty minor infection, and even in your throat, it's usually asymptomatic.
Okay, So that's.
Why gonerrhea is so easily spread is because in so many cases it's just completely asymptomatic. So yeah, but gonerhea, while it can cause these symptoms, and this type of infection just kind of right away right after it attaches and starts to colonize, it can also pass through that epithelial cell border, which is essentially your body's protection against bacteria. It's like first line defense. So it can make its way past that epithelial cell border and then make it
into your bloodstream. And if, yeah, if nicia makes it into your bloodstream, it's very, very bad. It's called a disseminated ganococcal infection because it's disseminated amongst your whole body through your bloodstream, and it most often will then go to your joints and your synovial fluid around your joints and your skin, and it'll cause dermatitis and arthritis and in very rare cases. It can infect your meninges just
like its cousin. I don't know, do you call bacteria in the same genus cousins relative, just like it's relative Niceria meningititis, which is a very common cause of meningitis. Niceria gono rhea can also cause meningitis if it infects your mininges, of your spinal cord or your brain. Wow. Yeah, so that's bad news bears. In neonatal infections, when an infant gets infected, it most commonly results in an ocular infection. It'll get into their eyes as they pass through the
birth canal, and this can cause blindness. It's really, really, really bad. Yeah, So that's why we screen pregnant women and most neonates when they come out, they give them erythromycin eye drops just in case. Yeah, so that's just to cover all the bases, because that would be terrible.
It also can infect babies. It can go pass through their eyes and get because that's a mucous membrane where there's a lot of blood flow, it can get into their bloodstream and cause disseminated infection in babies as well, which can be life threatening, especially because babies have basically no immune system to help protect them. Also bad, Yeah, also bad. It's not a great disease.
Nope, they never are.
They never are. It is preventable, though, which is cool. Condoms work, right, so that's great.
What about uh treatment?
Treatment? Great question. It is still treatable today. So yeah, as of now, there is one recommended treatment, and that's recommended by the CDC and the WHO. If you get diagnosed with gonorrhea, you will get an injection of CEF triaxone, which is an extended spectrum cephalosporin antibiotic. You get an injection of that, and then you also get a single dose of a whole gram of azethromycin and you pop that oral and then that will take care of the gonerrhea.
It also takes care of chlamydia because it's extremely common to have coinfection. I was trying to find one solid number on how common gonerrhea and chlamydia co infections are and I couldn't find one solid. But in some studies I found it was like up to forty percent of people who were diagnosed with gun we're also diagnosed with chlamydia.
That's really interesting. Do they colonize the same areas. Is there competition or is it facilitation or what.
That's a really good question. I don't know specifically. I don't know if it's just because it's they're transmitted in exactly the same way and have the exact same risk factors, so if you have one, it's really likely to have the other, yeah, Or if there's any kind of interactions that go on between the two bacteria, I'm not sure.
Interesting.
It's a great question though. Yeah, but it's super common as if thromycin will clear both a resistant gonereal infection that's resistant to the sef triaxone, but it will also additionally take care of the chlamydia. So that's why we give both. Okay, So if you've ever been diagnosed and been like, why do I need this giant horse pill and a shot in my butt? I assume they put it in your butt. I'm not positive though, that's why. Yeah, okay,
So yeah, that's that's the bio. It's a pretty it's a pretty straightforward bacteria as far as they go.
I feel like, yeah, it seems it goes there to do the job that it came there for. It does the job, and then you treat it. Yeah, fully hopefully.
Yeah, so how did we get here? Eron, where did this bacteria come from?
Okay?
And oh my gosh, tell me how it got its name? I can't wait. Okay, right after this break.
Ganorrhea is an oldie, and we've got the Holy Trinity of ancient Egypt, the Bible, and Hippocrates to back that up.
The Holy Trinity, I like that.
There's a papyrus from thirty five hundred BCE and ancient Egypt that recommends some certain plant extracts for painful urination. There's a passage in Leviticus in the Old Testament that declares that men with runny penises are unclean, not in those words, but more or less in those words. And Hippocrates describes genital ulceration and how it is sectually transmitted. We've also got Abubakar Muhammad ebn Zakaria al Razi, so again yeah, yeah, he's everywhere. And even Senna, so Avicenna
also is the okay Latinised name. They seem to describe urethrilled discharge and urine retention, both which are characteristics of ganarrhea. Now any I mean, any one of these could be referring to many other sexually transmitted infections. But goneria is definitely old, as is its name, which was given by the Greek physician Galen in the second century CE, so likes, it's a long time ago. For a long time it was tied in with syphilis and so and it had.
It went by many different names in different places and so on, so it's interesting that this one was the one to make it through the whole way. But Goneriea is from Ghanos for seed and row for flow, so it's just sort of flow seed flow.
Yeah, it's kind of yucky.
I mean. By at least the tenth and eleventh centuries, goneria seemed to be pretty prevalent, or at least prevalent enough to lead to the creation of laws that were to prevent any activity that spread the disease of burning pea. It also may have had a hand in secularizing medicine in some places, because physicians were ordered to treat everyone whip the disease without being able to refuse based on moral objections. Oh interesting, So yeah, along with like leprosy
and some other sort of stigmatized diseases. But even so, no one really paid much attention to gonarrhea alone for another few hundred years. But before I get into that, where did it come from?
Yeah?
And I couldn't find a ton of good info on its evolutionary origins, but according to one of my sources, there are two possibilities, and neither of which is particularly exciting. But one is that it came from an a virulent strain in the vaginal and rectl mucosa which mutated into a virulent strain. Okay. Another was that it came from the naso pharynx and mutated into a virulent strain via
oral sex. So yeah, I don't know when this occurred or where, but it would have required a decent pipe ulation density to be sustained and then spread throughout medieval times, though not as big of a population as something like measles. And that's because the long duration of infectivity and the possibility of sort of these latent infections.
Yeah, probably helped symptomatic Yeah yeah, Okay.
Around the fifteen hundreds is when it began to be called the clap, which it's colloquial, one of its colloquial names.
I had no idea that it was gonorrhea that was called the clap oh.
Yeah, well, because I think a lot of people think it's uh, chlamydia because.
C yeah, that's what makes sense, chlamydia.
Yay, yeah, okay, So why did Why was it called the clap There are a couple of hypotheses, One which is the most likely one is that it refers to less clapiers c L A p I e r s clapiers there we go, which is the French word for brothels reallyble source of infection, that's what they were called. Yeah, I never knew that. Another I read somewhere is that
it causes a clapping sensation when you pee. And the most horrifying one I found was that it refers to a common treatment for gannere infections in men, where you were supposed to clap the penis hard to get the pea flowing again, maybe using your hands, maybe using a book and a hard surface, Oh no, yikes. Yeah. But for much of its history, ganerrhea was overshadowed by syphilis, which we will definitely be doing an episode on some time.
Absolutely, syphilis is major.
It's huge, Yeah, But syphilis had settled down enough around the fifteen sixteenth century for people to start taking note of this other disease and describing it. And one of the tracing this early history, of course, relates to that where goneria and syphilis were assumed to be the same disease, with goneria to be more the mild precursor to full blown pocks of syphilis.
That makes sense.
One guy in the seventeen hundreds decided to settle this once and for all. He wanted to prove that they were the same, and that gonorrhea was the secreting form and syphilis was the skin form. So he took the postular discharge from an infected person and then smeared it onto himself, onto his yeah, onto his genus. Unfortunately, he came down with syphilis, so he didn't really prove anything, but I guess so, yeah.
He he swabbed somebody's like ulcer or something and then or what did he.
What it seemed like is that he took the discharge. So the direct quote was pustular discharge. Okay, So I don't know if it was from the like, from the urethra, or if it was from a sore apox. Yeah, in any.
Case, I mean, yeah, you get discharged with ooh that's so yucky.
Yeah. Well, Anyway, the path of physiology of ganerrhiea was still under debate. Maybe the discharge was caused by ulcers in the urethra, maybe it was from the seminal vesicles. No one really knew, but as was the root of transmission. One popular view, as you might imagine, is that it came from women. Of course, originated in women. I should say it.
Would only originate in women. It's the only logical explanation.
Yep. One surgeon said, quote this thing resteth in their secret places, forming therein pretty little sores full of venomous poison, being very dangerous for those who unknowingly meddle with them.
That's our title, resteth in your secret places.
Other theories acknowledge that intercourse was a likely source of infection, along with non sexual things like gout or rheumatism. Eventually, though, goneria and syphilis got their separate entries and as result, separate cures. I think you know that one of my favorite parts of doing this research for the history is coming across the old treatments that were used.
I think this is one of everyone's favorite parts.
Okay, are you ready for goneria?
I can't wait.
Let's start with the easy ones. Rest, avoid alcohol, avoid sex.
Yeah, okay, okay, seems reasonable.
Inject some mercury into the head of your penis. It worked for syphilis, why not, conneriea. It didn't work for goneria. It did not atropine. Throw back to Belladonna. Yeah, whyden, that urethra. All right, Let's let's take it up a notch. Maybe some bleeding and purging, maybe some leeches.
Yeah, it seems right on your ween or what?
Uh huh? Yeah okay, yeah, so uh let's see, where's another one. Take the milk of a woman, like breast milk, milk, a little sugar, oil of violets, and barley water, and administer it with a syringe. I mean, that could have been our quarantini.
But yeah, good God, don't have any source of breast milk around here?
Sure not, why craigslist exists. And if that doesn't work, you can always resort to urinating with your penis in warm cow's milk.
Just PLoP it into cow's milk and ye pee. That's a very interesting idea, you know, I'm I'm not opposed to that idea in concept.
Yeah, yeah, Well, Eventually the treatments became a bit more tame, with levage or washing out of the urethraa as the most common treatment. Often, the symptoms of virulent gonorrhea would disappear after a few weeks. Can't really say cured because microbial confirmation was not possible, and something called gleat g l e e T was left in their place. Ooh, a new word for me too. What is gleat is basically the post gonerrhea clear or cloudy discharge without any
other symptoms such as pain or urination problems. It's also probably what gave goneria its other nickname, the drip. Ah.
Yeah, gleat, that's a good word for that. I can imagine exactly. Yeah it is.
Yeah, I'm never gonna forget it. Gleat was usually treated with a stringence, which probably didn't do anything because gleat usually disappeared around the same time that the person stopped using the astringents. It's probably just irritating your penis more. Yeah, but wait, there's more.
Of course there is.
So the word bougie. Have you come across bougiees in med school?
I don't know how to answer this question.
Okay, so then doesn't sound like you have Okay, bougie didn't always mean bourgeois. Okay, no, no, no. Sometimes after male became infected with gonnerrhea and recovered, his urethra would remain obstructed and urination was difficult, maybe from the gonnerhea itself, maybe from the treatment. Physicians didn't really know. But to treat this, bougies were used. Bougie meaning a thin, flexible
instrument made of silver, lead or wax. They're still used today, by the way, like bougies are still around like a sound, but not really a sound anyway. After giving the person a painkiller, the bougie would be inserted into the urethra. Sometimes it would be left there for days, only removing it when you needed to pee.
Other times, I'm sorry, So this is like you said, silver lead or whacks.
Yeah, it's got to be a little flexible.
Okay, And it's like a rod, the flexi wire rod, and you just poke it up there, yeah and leave it.
Yeah. We will post some pictures of bougies.
Excellent.
Oh yeah, there are some great old illustrations of like the variety of bougies, especially once once they became more popular in like throughout the eighteen hundreds and things, and then there was like electro something bougie, and then there were oh no, and then there were ones that were like linked together with tubing and yeah, okay, but one of the most horrific ones is that there were some bougies that would have a corrosive crystal at its tip
which was designed to clear the passage by like eroding whatever the inflammation was. So people actually died from that. Uh yeah, yeah, But a surgeon's reputation could be made or destroyed on how well he could work his way around a urethroat with a bougie.
Yeah, aweso.
And so we don't really see throughout history, we don't really see a lot of descriptions of gonorrhea in females. We just get sort of this male specific thing, and as such we also don't get very many women's specific treatments right. Treatments for female patients, though the ones that are listed weren't much better. Most included a frequent and thorough cleaning of the volva and vagina and treatment with
silver salt or the chemicals. Irrigation of the urethrow was also done, sometimes with a treated solution, and finally, sometimes the cervix was cauterized with silver nitrate or a medicated wick was inserted. Mm yeah. More often than not, though, the prescribed treatment was just weighted out, which often led to infertility.
Mm hmm yeah.
If these early venereologists had anything to say about gonnerhea and females, it was that they were surprised at how much milder the infection seemed. Diagnosing gonnerie in females was more difficult because physicians had a tough time distinguishing between normal vaginal discharge and gonerrhea discharge. So doctors often relied
on the next best thing, patient history, but not firsthand. No. No, doctors took the word of quote, those whom we look upon as men of veracity, meaning a dude could say, I up with her and now I have gonerhea, so she must have given it to me, and that would be basically the diagnosis.
Wow, yeah, awesome. Cool.
In the case of gonorrhea, it was pretty much always a one way street from vagina to penis. That was how it was perceived throughout most of history. Some physicians did note other signs of goneriea infections and females, including inflammation of the labia and clitterists, but there wasn't a lot of attention paid to any internal indications of the disease.
Shocking right.
The cervix, which is recognized today as a principal side of infection, was rarely mentioned. And that's because up to the nineteenth century, physicians who were almost without exception male, pretty much never performed vaginal exams.
They're never going to be looking up there.
No no God forbid. They take a speculum and peek inside, and if the woman was unmarried, forget about it. In the eighteen hundreds, people finally started talking about where gonerhea came from and how to prevent it. Was it a
specific infectious particle, was it just random inflammation? According to someone named Sweetear, I don't know how you pronounced that, sweet Hour, it was the latter, and he set to prove this by injecting an aqueous solution of ammonia strong enough to give it a quote burning taste into his urethra twice. What yeah, He said that the second injection
caused the most pain he had ever experienced. So the next morning, no surprise, he had some seepage, a considerable evacuation of purulent matter of the same yellow green color as that of a virulent child piss aka hot hot pea goner rhea. So he concluded. His conclusion was that Goneriel was nothing more than simple irritation of the urethra.
Oh dear, uh huh. And he did this by to himself.
Weirdo, man, I mean, do you not like I am amazed at the self experimentation that went on? Yeah, that's fold. These are precious parts. Yeah, I mean, don't worry. There is some human experimentation for prisoners, and people will care who can't advocate for themselves.
Just wait for our syphilist episode for plenty of that. Yeah.
Others attribute it to something female specific, like if you had sex the woman who had a certain vaginal discharge or maybe she was on her period, and then there were predisposing factors too much sex, sex that goes on too long, and unnatural sizes of the male organ I don't know which direction, which direction, alcohol or rich diet, et cetera, et cetera. By the late eighteen hundreds, we're finally getting to the age when the mysteries of so
many infectious diseases are revealed. The age of microbiology, or the beginning, and gonerhea is no exception, and the name that you might most associate with gonerhea is nicer. It's nicer Goneree. But there was another mostly forgotten physician who made huge contributions to the understanding of the disease. His name was Emil Nogath, and he was a German physician who was especially interested in pelvic inflammatory disease.
Hmm, he was.
I wanted to put this tidbit in here. He was a workaholic who spent hours and hours at his desk, keeping himself awake with tons of coffee and putting his feet in a bowl of cold water under his desk.
Just to keep him awake. Yeah, so funny.
I feel like we could have used that when we were finishing our dissertations. Anyway, After many clinical examinations, of which the majority of subjects for female, he announced his findings that one goner rihe was likely a latent infection and that gleek could still cause infection in women. Two Goneriea did affect females and that it was a common cause of infertility in both sexes, and three Goneriea was
extremely prevalent. He estimated that sixty percent of men in large cities in the US had had gonerhea at some point, and that sixty percent of those men would infect their wives, and that men could give the disease to women was itself kind of a revolutionary thought, but unfortunately his conclusions were not well received at the time, primarily because American physicians took those prevalence estimates as a direct attack on
the morality of American males. But the suggestion of goneriea as a latent infection made it more difficult to treat clinically. How could you tell when an infection was over if you couldn't use gleek to guide you. Fortunately, in eighteen seventy nine, just a few years after no Garrath announced his findings, Albert Nisser, the namesake of Niceria gunoia, isolated the bacterium, making it possible to identify exactly when a person was no longer cape of transmitting the infection.
WHOA, which is pretty cool.
Yeah, Gonerhea had been fairly well described in adult males and very poorly described in adult females. But as you mentioned, there is another group that is commonly affected by the disease, infants. Gonerhea can cause this conjunctivitis in newborns, which can lead
to blindness if left untreated. Like you said, and despite the fact that GUNNERIEA and females was so poorly characterized, the link between the infection and this outcome and infants was discovered in the early nineteenth century, helped along by more horrific experiments in which the eyepuss of one of these infants was inserted into a male urethra, producing goner
rhea within a few days. WHOA. Yeah, Still, it wasn't necessarily conclusive because sometimes babies were born to mothers who did not appear to have gonerrhea, but the discovery of asymptomatic infections would clear that up over time. But even though the lane between gonorrhea infection and a mother and ie infection and the newborn was discovered, it was still not able to be treated, and that was a huge
problem because cases were growing. So by the mid eighteen hundreds, up to twelve percent twelve percent of neonates and European hospitals developed the eye infection WHOA. Twenty percent of those developed corneal ulceration, and thirty percent of those became blind.
Oh my goodness.
So that's huge numbers.
That is huge numbers. Twelve percent of babies infected. Good gracious.
Yeah, okay, So let me introduce you now to a German obstetrician named Karl Siegmund Franz crid Creede, Crede, I don't know, Craid who in the eighteen fifties founded one of the first gynecology departments in Europe at our favorite, one of our favorite historical hospitals, Charitay, still in existence today,
and featured on that amazing show that we have talked about. Anyway, So when he was at this hospital, he noticed the high rate of eye infections born to mothers infected with gnarrhea, and he tried all manner of things to try to lower the cases. He tried to douche the vagina prior to delivery. Didn't work. He tried to wash the eyes of the infant with a borax solution, didn't work. He yeah, Finally he tried wiping the eyes with cotton wool and plain water and then adding a drop of two percent
silver nitrate, and that worked like a charm. And the technique was picked up all over the continent. Okay, and then we've got finally the isolation of the bacterium itself, which happened in eighteen seventy nine by the twenty four year old Albert Nisser. Unfortunately, there was no suitable animal model for ganerrhea, so because this is an exclusively human bacterium,
so what remained but to conduct human experiments? Oh dear, human volunteers were produced, inoculated and subsequently found to have gonerrhea volunteers volunteers in quotes. Ye, So finally it was accepted that this bacterium caused gonorrhea. Even though a lot of progress had been made towards identifying the causative agent of gonerhea and describing its clinical symptoms, treatment still had a really long way to go. And this was a problem because gonerhea can be fatal, and frequently was in
the eighteen hundreds as a result of bacterial endocarditis. But fortunately goneriea reached a turning point when antibiotics were developed. In nineteen thirty seven, clinical trials of sulfonamides were shown to be moderately effective against the disease, but the victory was short lived. By nineteen forty four, only seven years later, only twenty five percent of people with gonerrhea were being cured due to the emergence of resistant strains, and doctors
had to dust off their bougies. Fortunately, penicillin took over as a primary and very effective treatment for the disease, and by the late nineteen forties was widely used. Initially, because goneriea was so sensitive to penicillin, doctors were like, well, we don't foresee any resistance occurring, but within yeah, right, I mean, come on, history repeats itself, people, But within ten years resistant strains had emerged and become obviously a
major problem. Then streptomycin was introduced and resistant strains emerged once again. Blah blah blah. It's been this continual struggle to find one drug to effectively treat gonorrhea. So, and I'm sure you'll tell me all about the oh yeah,
the horror show that's going on today. You might expect that the prevalence of gonerhea would decline over the twentieth century with the availability of antibiotics, but if you look at a figure of rates over time for certain countries, you actually see a huge increase starting in the sixties and that increase actually represent sense what is called a gonerhea pandemic that peaked in the mid nineteen seventies, occurring in places like the US, Sweden, Canada, and the UK.
Epidemiologists point toward a few things that could have caused a huge increase, and it was probably a combination of things like changing perceptions and sexual practices. People were having a lot more sex with a lot more partners, a huge population boom as the baby boomers became sexually active young adults, and the greater availability of contraceptives such as the birth control pill, which did not protect against STIs.
In any case, the disease began to decline again. And I don't really know why and if there were certain public health campaigns that went on, but goneria today continues to make headlines as these super bug resistance strains have totally gotten out of control. So Aaron, tell me more about those guys and about where we stand with gonerhea today.
I don't wait too So let's talk quickly just about the status of how how many people are we talking when we talk about gonorrhea, and then we'll talk a little more in depth about the antibiotic resistance because that is sort of the main part of the current story of gonohea. Okay, okay. So in the US, according to the CDC, they estimate about eight hundred and twenty thousand
new infections of gonorrhea every year twenty thousand. It is the second most commonly reported communicable disease in the US after chlamydia. Wow, which is the number one, goes hand in hand, seems to makes sense. So in twenty seventeen there was over five hundred and fifty five thousand cases that were actually reported, and so the number eight hundred
and twenty thousand is the estimate. So that means that it's estimated that two hundred and seventy thousand people each year are getting infected with GONERIEA and just don't know it. So that's a bummer.
That's a lot of people.
It's a lot of people. Worldwide, the World Health Organization estimates seventy eight million people are newly infected with GONERIEA every year. Seventy eight million. Wow, that's a lot.
This is much more prevalent than I realized.
Me too, let me I talk about it that much. I knew that it was one of the most common STIs, but I had no idea that it was. Yeah, So the US Public Health Task Force currently recommends screening only for certain populations of people. Recommends screening for any women with vaginas who are sexually active under the age of twenty five, in any kind of sexual relationship, women who are over the age of twenty five if they have multiple partners every year, and any men who have sex
with men. That is the US Public Health Task Force recommendations. And a study that I found that looked at whether this type of screening protocol, so screening every year regardless of if you're in a monogamous relationship or not, just if you're sexually active. I found a paper that looked at from two thousand to twenty fifteen whether this type of screening actually reduced the incidents of gonorrhea, and it found that it did. But what's interesting is that they
also looked at other screening scenarios. So what if we did universal screening of everyone of a certain age group, regardless of their sexual practices, just whether or not they're sexually active, and you can actually reduce incidents even more, is what they found. If you did more universal screenings.
That makes complete sense people who are in monogamous relationships. Maybe one person doesn't realize they're in a monogamous relationship or exactly what.
They are, right, yeah, yeah, so yeah. So overall, it's a very common disease, so screening in general makes a lot of sense, especially because there's such high rates of asymptomatic infections. But the big story with gonerrhea is antibiotic resistance. It's definitely the most important part of the story. Antibiotic resistance has been detected in basically every country that has gonerrhea on its reportable diseases list, so everywhere where there
is gonerrhea, there is antibiotic resistance. There's resistance to all of the drugs that you mentioned that used to be used to treat gonorrhea, so the penicillins or the betaalactams, streptomycin, and all of the floral quinolones as well. In addition, there's also resistance to some cephalosporins, which is why now the only drug that's recommended that is still considered effective are the extended spectrum cephalosporins like cef triaxone, which is
what we treat with. The scary thing is that in over fifty countries they have reported resistance to these drugs as well. Ooh yeah, that's.
Bad and it's what you'd expect.
Right, And we're also seeing increasing resistance to a zythromycin, which is what we give as a backup in case gunnerhiea is resistant to CEF triaxone. So now it's our main line of defense and our backup line of defense that is becoming resistant. So the reason or one of the reasons that we see such high rates of antibiotic resistance is that there's a lot of different mechanisms by
which bacteria can evolve antibiotic resistance. They can evolve ways to inactivate drugs, so just sort of attacking the drug itself and inactivating it. They can alter their cell membranes that the antibiotics use as targets so that the antibiotics can no longer bind and actually do their job. They can also evolve new mechanisms to export the drugs out of the bacteria once they make it in or to prevent the bacteria from getting in sorry, to prevent the
antibiotic from getting into the bacteria to begin with. And all different classes and groups of antibiotics that we've developed so far have different mechanisms of action, and some bacteria are good at developing resistance against maybe one class of antibiotics, so they can change their cell membrane so that penicillins can't bind as well, But then maybe they can't figure out a way to export it, so they can't be resistant to all antibiotics.
Gotcha.
It turns out that Nicia gonnerihe has shown the ability to develop resistance in basically all of the ways that bacteria can develop resistance.
Cool.
Yeah, so it's really good. They're really good naturally at uptaking and recombining, so shuffling around DNA from the environment, and because they have those pili which they use to grab onto the walls, they can also use pili for what's called conjugation, which is kind of like bacteria sex, where they transfer DNA from one bacteria to another, and what they often transfer are plasmids, which are those little round pieces that usually or very often have antibiotic resistance
genes on them. So Niceria are really good at that. So that's why we see such high rates of antibiotic resistance, and very quickly, because you can have like a single Nicia bacterium just giving its gene to all of the other bacteria around them.
Yeah, it's great, that's amazing.
Yeah. So obviously there's a lot of interest in developing better methods of treatment. Unfortunately, from what I found on the World Health Organization website, there's only three candidate drugs in the pipeline in development for treatment of resistant gonorrhea. Uh oh, yep, there's only three new drugs in the pipeline. One of them is I think either in or just
finished phase three trials. I don't know if those trials went well, and then the other two are still in phase two clinical trials, so they've still got a long way to go before they're on the market. Okay, So then the next natural question is if we can't develop better antibiotics vaccine, what about vaccines. There's a lot of discussion about this. There's nothing very close on the horizon, Okay. Progress for a gonerial vaccine in general has been very
very slow. So we have seen development of vaccines for other STIs like HPV, which is excellent. There's also a vaccine in development for HSV so Herpes simplex virus GONERIEA. Not so much gonneria and syphilis are proving to be very,
very difficult to try and develop vaccines for. However, I did find one paper that was very interesting that was just looking at a mouse model that suggests that at least in theory, it should be possible to stimulate the right kind of immune response that you would need to
even be able to develop a vaccine. Because we'll talk more about this in the Vaccine's episode, But basically, for a vaccine to be able to work, whatever bacteria or virus you're trying to fight has to stimulate an immune response that creates a memory response, right, And so if the bacteria don't do that to begin with, then your body never develops memory, and so your body can't just
fight them off every time you get infected. Right, So it does seem that at least in theory, it's possible to generate that type of response with some Gonerihea antigens, which are the surface proteins of goneriea.
Why does it not create a memory?
Goneriea have huge amount of anagenic variation, like massive anagenic variation, So there's tons of different strains and there's tons of variation in those cell membrane proteins, and so they're really good at evating our immune system. And then on top of that, they're really good at fighting off our body's first line defenses, which are those neutrophils and macrophages, because they can just live inside of those cells.
So okay, yeah, that makes sense.
So people are working on it. It seems it's definitely far in the future. Sure it's nothing that's going to be happening in the next few years or anything like that. But yeah, that's gonorrhea. Wow.
Yeah, that was a good one.
Yeah it was. I had fun.
I did too. I learned a lot, me too.
One clap, clap, clap, to.
Get ourselves around of applause.
That's another good title it is. I really like that. I like that a lot. Well, should we do sources?
Yeah, sources, Okay. I read sections of a book called The Scars of Venus, A History of Venereology by jd Oriole, and I'm sure I'll be going back to that for future episodes. I also use the Cambridge World History of Human Disease edited by Kenneth Kipple, and some papers that I will put on the website.
Awesome, and I have several really interesting papers, mostly about the current epidemiology of gonorrhea. So, as always, we will post our full source list on our website This Podcast will Kill You dot com. Just go to the episodes tab and you can find every source that we used in all of our episodes. Yep.
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