tic matter"; erudite midwives would probably not be puzzled by the latter expression.

It cannot be said that these pages contain no useful information. That would not be true. The advice to nurses in the opening chapter is excellent and inculcates a modesty and deference to the physician which the later pages do much to destroy. Part VII., on Gynecological Nursing, seems more "up to date" than other portions of the work. Taking the book as a whole, however, it is a question whether such Rip-van-Winkles of medicine would not best be left in undisturbed repose upon the shelves, where they would serve a useful purpose as standards of comparison in the advance of medical knowledge.

A. R. S.

ABSTRACTS.

1. BRÖSE: THE ETIOLOGY, DIAGNOSIS, AND THERAPEUTICS OF GONORRHEA IN THE FEMALE (Zeitschrift für Geburtshülfe und Gynäkologie, Band xxvi., Heft 1).-Bröse's paper is part of a discussion which took place at the last two meetings of the Berlin Gynecological Society; and the importance and interest of the topic, as well as the good points which it contains, warrant its more extensive reproduction.

The author points out Noeggerath's great merit as being the first to draw attention to the frequency of gonorrhea in women and to its great etiological importance in gynecological diseases. He remarks that the frequency of gonorrhea is not easy to state, because it is difficult to decide whether a catarrhal affection of the female genital canal is due to clap or not. A simple microscopical examination of the secretion is not at all sufficient. While the presence of gonococci in the secretion shows the affection to be of a gonorrheal nature, their absence is not conclusive to prove the secretion non-gonorrheal and non-infectious. Lawson Tait is one of the leading opponents of the theory "that gonorrhea must have gonococci as cause." He bases his opinion upon the following points. Says he: "We know that a man can never be cured of a gonorrhea" (in this he takes a far too extreme view) "and that every excess in Baccho et Venere is followed by a reappearance of the clap. Yet the bacteriologists tell us that in the latent state gonococci are absent. Are these industrious little beasts newly formed because a man drinks a glass of beer or indulges in three or four sexual acts instead of one? Why does a woman communicate a clap to one man while six or eight others who have cohabited with her within a few hours escape unharmed? How is it that some men can never have intercourse with a woman, may she be ever so pure, without contracting gonorrhea?"

Using clinical experience as a basis, the author endeavors to dispose of Tait's objections and to bring them into conformity with the gonococci theory. If we make a microscopical examination of gonorrheal secretions, we find gonococci in every fresh case of gonorrhea and also in some chronic cases; but in most chronic cases they are absent, although the discharge is known to be still infectious. Bröse divided his clinical cases into two groups. In the first group cases of the following character are found: A young woman contracts gonorrhea eight to ten days after her wedding. She has urethritis, endometritis cervicis, a salpingitis, and perimetritis. The discharge contains numerous gonococci. We examine the husband and find the urethra to be the seat of chronic inflammatory changes, an endoscopic and urinary examination may demonstrate a discharge, yet in only exceptional cases are gonococci revealed by the microscope. Still we are forced to the conclusion that this young woman has been infected by her husband. A good example of the second group reads like this case: A young man consults his physician and asks him to examine his mistress. He says that he cohabited with this woman only and that he believes he has a clap. The woman claims to be in perfect health. An examination shows that the man has an acute gonorrhea, the discharge contains gonococci. The woman has only remote traces of an old gonorrheal infection, and in many cases no pathological changes can be seen. Repeated and careful examinations prove the absence of gonococci.

How can these perplexing phenomena be explained and the seemingly contradictory statements be proven true?

Bröse mentions that in some cases he found gonococci in the discharge soon after a menstrual epoch. Repeated examinations at other times were not successful. There may also be an obstacle to the discovery of the micrococci in that there are but few in the secretion and thus are overlooked.

Another explanation is given in a recent publication by Wertheim,' and this is undoubtedly the strongest point made. Wertheim shows that only young gonococci are stained by watery solutions of aniline colors, while old cultures do not imbibe the staining fluid. He says "old gonococci lose their typical forms, and thus changed we no longer recognize them as gonococci. They become granular spheres, variable in size and indefinite in outline." Wertheim further writes that this change of form occurs if the culture medium is exhausted and no longer nutritious; and he thoroughly proves the correctness of his hypothesis, because he succeeded in raising typical gonococci by transplanting the aforementioned altered forms into fresh culture media.

In doubtful cases we must make cultures of the suspected dis"Die ascendirende Gonorrhoea des Weibes," Archiv für Gynäkologie, Band xlii.

charge; this is the only way to arrive at an absolutely certain diagnosis. The objections of Tait to the specific action of the gonococci, because gonococci are absent in so-called latent cases of clap, can therefore be satisfactorily explained.

The author next investigated the statements of Tait and Noeggerath, who claim gonorrhea in man to be an incurable disease which always continues to exist in a latent state. Bröse examined the husbands whose wives showed marked or suspicious symptoms of gonorrhea, and he found in nearly every case a circumscribed or diffused urethritis, strictures, abnormal secretions, rarely gonococci. From these investigations he concludes that latent gonorrhea is a myth, and that if a man infects a woman his urethra must be the seat of chronic inflammatory processes. These pathological changes may be very minute, but an endoscopic or urinary examination will, as a rule, reveal their presence. The chronic urethritis may continue for many years, which seems plausible if it is remembered that strictures are often noticed years after the existence of a believed cured clap; but it should also be known that not every clap follows a chronic course, and that most cases of gonorrhea are cured by the usual treatment. Whether a clap is completely cured can only be determined through the endoscope and repeated and careful examinations of the urine. While the genital canal of man or woman is the seat of a chronic gonorrheal inflammation, gonococci in one form or the other are surely harbored in the tissues, at times mingling with the secretions, causing and spreading new infection. Therefore persons who have a chronic gonorrhea are capable of infecting others. But in gonorrhea, as in other infectious diseases, there exists a peculiar predisposition in different individuals. If an individual once has gonorrhea, this attack increases his liability to successive attacks, and we therefore frequently hear that men who have had gonorrhea always suffer from a fresh outbreak whenever they have intercourse with a puella, nearly all of whom are afflicted with chronic gonorrhea. However, the author does not agree with Tait's view that a man can contract a gonorrhea from a pure and uninfected

woman.

This variable disposition to clap also explains Tait's objections to the gonococci theory, based upon the fact that a woman may infect one man while others who cohabit with her within a few hours escape unharmed. The cervix is the point most frequently infected. Here the few scattered gonococci, because infection is generally spread through chronic gonorrhea, are deposited mingled with the ejaculated semen. From the cervix the infection spreads to the vagina and vulva. A primary infection at the introitus vaginæ is only produced by a very acute clap. As has been mentioned before, Bröse says we cannot easily distinguish a simple cervical catarrh from a gonorrhea, and that neither microscopical nor macroscopical examinations of the

secretion are sufficient to form definite conclusions. Gonorrheal disorders of the uterus are very frequent, and every cervical catarrh, especially if found in nulliparæ, should arouse suspicion. He believes most cases of so-called puerperal catarrh gonorrheal in nature; and the fluor albus of virgins often due to the same cause, which, however, does not of necessity indicate that a coitus impurus has taken place, for there are other ways by which gonococci may gain an entrance to the genital canal.

The diagnosis "cervical catarrh" should therefore never be accepted as satisfactory. It is, indeed, more rational to prove a cervical catarrh non-gonorrheal than gonorrheal in character.

To arrive at a correct diagnosis, bacteriological experiments, while always desirable, are not necessarily demanded. A gonorrheal infection is accompanied by certain symptoms which, combined with other observations, are sufficient to diagnose most cases and differentiate them from non-infectious catarrhs.

Next to the taking of a complete history, a careful examination of the husband, if the case in question concerns a married woman, is of the greatest importance. The husband should be examined in every case of fluor albus. This will prove many cases to be gonorrhea which at first did not look at all suspicious. Another important link in the chain of circumstantial evidence is a history of ophthalmia neonatorum. Small ulcers at the introitus vaginæ, condylomata, changes in the glands of Bartholin or their ducts, a vulvitis, and last, but not least, a urethritis and an inflammatory condition of the lacunæ of the meatus, are all symptoms pointing to gonorrhea. The chronic urethritis is one of the most constant symptoms, yet, as it is accompanied with but little discomfort, it is easily overlooked. The urethritis is diagnosed by trying to express the discharge in the usual manner and through the endoscope. A catarrhal inflammation of the lacunæ near the orificium urethræ externum is typical. Inflammatory affections of the joints and diseased pelvic adnexa should also draw our attention to the fact that an existing leucorrhea is probably of a gonorrheal character. This is especially the case if the pathological changes in the pelvis are not easily amenable to treatment. Regarding the prophylaxis, the author believes the regular inspection and examination of prostitutes to be insufficient. He rightly says nearly all puellæ publicæ are afflicted with chronic gonorrhea, and their cure is problematic. A far better prophylactic measure is to warn all men who believe themselves cured, because the acute symptoms have passed, of possible consequences. Whether a man is really cured can only be determined through a careful endoscopic and urinary examination; and every man suffering from chronic clap, no matter whether gonococci are found or not, should be cautioned not to marry until he is really cured.

When treating a woman for gonorrhea we must bear in mind what we wish to attain in a given case, whether we only

desire to relieve the symptoms, such as pain and leucorrhea, or if we can hope to cure the patient, which is, of course, the ideal. In the latter case we must, if she is a married woman, also treat the husband. Should the husband prove to be incurable, which is not at all infrequent, energetic treatment must be avoided, as otherwise the symptoms may be aggravated. In such cases disinfecting douches are prescribed, which, however, will not effect a complete cure.

Acute gonorrhea Bröse treats only symptomatically, ordering vaginal injections of chloride of zinc or sublimate. The urethritis is combated by injecting one- to five-per-cent solutions of nitrate of silver.

About four weeks after the onset of acute symptoms a more energetic local treatment is carried out. Strong solutions of chloride of zinc are applied to the cervix, but the cavum uteri is let alone, except when we feel sure that the disease has already extended thus far. Disease of the tubes and a history of repeated miscarriages point to this. As a rule a gonorrhea does not extend above the os internum.

Intra-uterine therapy is not free from danger in acute or chronic gonorrhea. Curetting Bröse considers a very hazardous procedure, and hardly less dangerous and of but little utility is intra-uterine irrigation. If intra-uterine treatment is indicated the author recommends medicated bougies or direct applications by means of Playfair's probes. The inflamed Bartholin glands generally undergo spontaneous resolution; extreme cases may demand extirpation. The chronic urethritis is best treated by applying strong solution of AgNO, through the endo

scope.

A catarrh of the lacunæ is not amenable to treatment, and cauterization with the Paquelin will be necessary. The treatment of the diseased adnexa the author does not discuss in this paper; this topic will be fully gone into at some future date. His final conclusions he sums up as follows:

1. That the gonococci are the true cause of gonorrhea is settled beyond all doubt, but a microscopical examination is not always successful in demonstrating their presence, because they may have assumed other forms. Bacteriological investigation by the making of cultures is a reliable and absolutely certain method.

2. Latent gonorrhea, as described by Tait and Noeggerath, does not exist. A careful examination of the urethra will always reveal inflammatory changes.

3. A diagnosis of gonorrhea can generally be made by a close observation of the clinical symptoms. The careful examination of the husband is very important.

4. Both the husband and the wife must be treated simultaneously. If the husband is incurable the treatment should be shaped accordingly.