magnesium the acids already generated. A thorough search of the literature fails to reveal any evidence of arteriosclerosis following the liberal use of calcium.

DISCUSSION

Dr. Hubbel, of San Francisco, in opening the discussion, said that he had been very much interested in the demineralization theory and believed that Robin was on the right track, although he thought that there was no single route in the treatment of tuberculosis. At the San Quentin prison formerly the tuberculous ward was in a closed portion of the building. After it had been put upon the roof, the death rate was diminished 50 per cent. Diet is of great importance in the treatment, but it cannot be properly carried out with the patient in the home. Overfeeding is productive of much harm. Efforts toward destroying the organism have been futile. Each case must be treated as an individual. He, at the suggestion of a friend, had used the ash from alfalfa, which seemed to benefit the patients. If there really was benefit, he thinks it was due to the mineral content.

Dr. Dulin of North Yakima is of the opinion that if anything can be done in the line of remineralization it must be done through diet. There has been a serious mistake in feeding adults uncooked eggs and large amounts of milk.

Dr. Andrew C. Smith said that he believed the theory of demineralization to be rational and should be taken into consideration in the treatment of tuberculosis. If infection from tuberculosis is so common, then the resistance of the majority of people must be high in order to overcome it, or otherwise the death rate would be much higher.

Dr. Giesy: The overfeeding of a patient is like the giving of too large doses of drugs: instead of obtaining the desired result, detrimental effects are obtained. He is much interested in the individual cell intelligence by which it can functionate without outside influence.

Dr. Geary stated that the veterinarians inform him that the cattle of Jackson County, where there is much lime in the water, are not subject to tuberculosis as are cattle elsewhere.

Dr. Pierce, in closing, said that Robin had demonstrated that the urine of tuberculous patients contained more mineral substance than that of normal individuals, while the tissues of the tuberculous contained less. The problem of remineralization is in reality the problem of preventing demineralization, by avoiding fermentative conditions in the digestive tract. The patient loses his ability to retain the required amount of mineral content by a prolonged acidosis, hence the great difficulty in remineralization. Avid forming foods should be avoided.

GONORRHEA IN THE FEMALE

By Edward F. Ziegelman, M.D., Portland, Ore.

(Read before the Alumni Meeting of the University of Oregon Medical School)

Meetings such as these have primarily two chief objects in view: First, the promotion of good fellowship among the members; second, the acquisition of any practical knowledge disseminated through the reading of papers.

The value of a paper depends upon the author's opportunity, experience and interest in his subject. For this reason I choose the title "Gonorrhea in the Female," a topic which may be open to criticism because of its supposed simplicity of diagnosis and treatment. In my opinion, however, it is one of the most important with which the specialist or general practitioner has to contend-one which has a tremendous bearing upon the happiness and welfare of the general public.

In 1872 Emil Noggerath published a work on gonorrhea which was destined to revolutionize the view of the medical world regarding the clinical significance of the disease, especially of gonorrhea in the female. He was the first man to insist that inflammation of the uterus and appendages was the direct result of gonorrhea and that gonorrhea was extremely intractable to treatment; that it often remained latent for months or years before causing severe complications; and that infection as a result of sexual intercourse might occur after long periods of quiescence. Some authorities interested in the subject are extremely pessimistic in their viewpoints regarding prognosis, and while, personally, I am not of the pessimistic type regarding the treatment of gonorrhea in women, I am extremely careful in making the statement that an individual patient is absolutely cured of her infection. I have come to these conclusions from my work in hospitals, dispensaries and private practice. In institutions and dispensary practice the difficulty is summed up in lack of control, and, whereas we are supposed to have our private patients under greater control than our institutional patients, so far as chronic diseases are concerned, the patient who visits our office will, before a cure is completed, generally lose patience, or the symptoms will be so absolutely nil that she, of her own accord, feels that she is cured and deliberately ceases to make the necessary visits to our office.

The causative organism, as you all know, is the gonococcus, a diplococcus having definite morphological, staining and cultural characteristics which, if remembered and utilized, will overcome any tendency to failure or error in diagnosis. The presence of the organism is proven only when the cocci are

found in characteristic groupings in leucocytes when there is a chance for counterstaining by the Gram method, and when the organism under suspicion corresponds morphologically with the gonococcus. There are numerous bacteria staining Gram negative but only three organisms other than the gonococcus must be differentiated. They are the Micrococcus Catarrhalis, Micrococcus Melitensis and the Meningococcus. The Catarrhalis and Meningococcus are very similar morphologically but fortunately are seldom if ever found in the female genital tract. Nevertheless, when a positive diagnosis is required, either for serological or medico-legal purposes, other means than staining have to be resorted to. For these cases culture offers a method of absolute certainty in diagnosis; but the use of the culture method, unless performed by a skilled bacteriologist is useless, as the gonococcus is an extremely difficult organism to grow.

Gonorrhea is usually contracted through sexual intercourse, though there are numerous authentic cases showing that patients have been contaminated through dirty instrumentation and by way of soiled towels, though, I assure you, this method of infection is in the great minority, due to the fact that if the gonococcus is exposed to room temperature or allowed to dry, it loses its virulence or perishes within a few hours.

In examining a suspected case of gonorrhea in the female, anamnesis is of particular importance. Especial attention should be directed to the menstrual history, inquiries being made concerning changes in the character of the flow and the development of a dysmenorrhea. Inquiries should be instituted concerning the existence of vesical irritability, frequency of urination, dysuria and cloudiness of urine, as frequently a gonorrheal cystitis is present. The possibility of previous attacks of pelvic peritonitis as well as dyspareunia and painful defecation should be inquired into, and to impress upon you the importance of this, let me refer you to the chart where you will see two cases of gonorrheal proctitis as sequelae. If the patient be a married woman, great tact must be used, and the questions entirely free from all suggestion of marital contamination, though under no circumstances should the patient be left in ignorance of the infectious nature of her disease. On the other hand, care must be taken not to arouse a suspicion of marital infidelity in a case that might possibly be the result of an extra-genital infection. No rule can be laid down to govern all cases; common sense is a prime requisite, and an endeavor should be made to have the husband consult a genito-urinary man, as it is absolutly futile to attempt to cure a gonorrhea in a woman whose husband is afflicted with a neglected or chronic urethritis or other form

of Neiserian infection and who is continually reinfecting his wife.

Accurate statistics relative to the period required for the incubation of the gonococcus in women are obtained with difficulty, as the initial symptoms of this disease in the female are often so slight and of so insidious or transitory a character that the actual date of onset is difficult of definite determination. As a further hindrance, the onset is, as a rule, so mild that the physician is rarely consulted until the disease has made considerable progress; in fact, when the infection is confined to areas below the internal os it is not uncommon for patients to be in ignorance of the existence of the disease.

The anatomical structures in the female most frequently involved which can be reached by treatment other than operative are the urethra, Bartholin's glands, the glands about the vestibule, the cervix, and, less often than the others, the vagina, unless the patient is a child.

The

In an extension of the disease above the cervix it extends by direct continuity along the endometrium and along the mucosa of the tube. The most frequent pathological condition produced by a gonorrheal infection of the tube is a pyoendosalpingitis. Gonorrhoeal lesions of the Fallopian tubes possess certain characteristics which, while not sufficiently absolute to prove the etiology of the infection, are pronounced enough in the great majority of cases so that we may be moderately certain of the type of infection present. extension of the gonococcus along the surface mucosa produces certain microscopical pictures that are more or less characteristic, whereas pyogenic micro-organisms reach the tubes by way of either the blood or lymph vessels of the broad ligament, and the mucosa is not primarily involved. In these infections various ulcers and cellulitis are common, while from the very nature of the gonococcal infection these structures are far less frequently involved. When the end of the fimbriated extremity of the Fallopian tube has not been closed through the inflammatory result of the primary gonococcal infection, which is rarely the case, the ovary may become infected secondarily, a perioophoritis resulting. When the substance of the ovary itself is infected, the most frequent route of infection is through a recently ruptured follicle. Such ovaries are rarely larger than a hen's egg and are often but slightly increased in size. During the chronic stage sclerotic changes are common, and the ovary may be even smaller than normal. As a rule, multiple retention cysts are present, and a frequent terminal result of a gonorrheal infection of a tube is a hydrosalpinx.

The symptomatology, when you see your patient early, is

that of an acute inflammation, depending upon the anatomical structures involved, and as we often have only Bartholin's glands, the vagina and cervix involved, many women have no symptoms of a urethritis. The type known as the honeymoon gonorrhea, when the gentleman, out of courtesy to his young wife, does not wish to cause her pain and does not rupture the hymen at the first intercourse, is usually the most extensive infection we find in women, as the infectious semen is deposited at the orifice of the urethra and at the opening of Bartholin's glands. As a result, we have an acute vestibular gonorrheal urethritis and Bartholinitis. This condition, of course, causes considerable pain and intercourse ceases. If a woman were seen in this condition by a competent physician she could easily be treated and the spread of the disease prevented. But nine out of ten of these patients do not consult a physician on account of a sensitive modesty. As a rule, they employ douches and carry the infectious material in this way from the outside into the vagina and thus transfer the disease to the cervix with subsequent great possibility of internal tubal trouble.

The diagnosis is usually suspected by the clinical symptoms and visual pathology, but should be corroborated by examination of smears, especially in the subacute cases. Personally I find that collecting the material from the urethra, right and left Bartholin's glands, the vagina and the cervix with a medicine dropper gives a greater percentage of positive results than either with a cotton swab, platinum loop or glass rod. In chronic cases, obtaining smears from Skene's ducts and from the cervix after the use of a dull curette is most important. These smears are all stained according to the Gram method. The usual pelvic examination is made to determine any adhesions or disturbances of the tubes. Should the smears prove negative, I believe the complement fixation test in a great many cases gives a clue to the causative factor if a definite pelvic pathology is present, and where bacteriological examination has failed. In virgins, the use of an endoscope has proven invaluable as a means of obtaining a smear from the vagina or cervix.

It is a well-known fact that a female gonorrheic can transmit infection at one time and not at another. She is more likely to produce an infection directly after a menstrual period. The reason for this has never been satisfactorily explained, but my belief is that since the ideal culture media is blood serum, a natural growing media is produced during the menstrual period. At least this seems plausible. This most likely causes a multiplication and, possibly, an increased activity of hidden organisms.