After the clinical symptoms of gonorrhea have subsided, all patients should be subjected to a thorough bacteriological examination. In private practice I insist on three negative smears, to be followed by two negative smears after the next menstrual period. In children, five negative smears must be obtained. In the case of unmarried women, instructions are given, to return for urethral examination when contemplating matrimony or on the first appearance of any symptom suggesting a recurrence of the original condition. In the case of married patients, the greatest care should be exercised to obtain a complete cure before the marital relation is resumed.

Those genito-urinary men of the present day who limit their practice almost exclusively to the treatment of gonorrhea in males are very much in advance in their methods over those practitioners to whom the women come for treatment of their gonorrhea and its complications. Unfortunately the treatment of gonorrhea in the female is confined almost entirely to the general practitioner. This condition of affairs has not led to much advance in our treatment of their troubles.

Treatment depends entirely upon the stage of the disease. In acute stages practically all that is demanded is absolute rest, light diet, particularly about the time of the menstrual period. Great care should be exercised in preserving cleanliness not to transfer the infection along the genital tract beyond the point of origin. Chronic cases require much patience on the part, both of physician and patient. The silver salts are the favorites of most authorities. In the treatment of the urethra the endoscope is invaluable. I have found that Skene's glands are best treated by the actual cautery. The glands of the vestibule also yield much more readily to this form of treatment. Infection of Bartholin's glands can usually be satisfactorily treated by injection of silver salts, using a bluntpointed needle-one similar to a hypodermic-and inserting same into duct. There are cases requiring a dissection of the gland-a procedure not so simple as one might think. Linear cauterization, after the method of Boldt, has proven very satisfactory in treatment of the cervical canal at intervals of every two weeks, though I believe in the hands of experienced plastic operators a resection of the cervical mucosa after the Schroeder method gives the most satisfactory results.

Accordingly, to the best authorities, a gonorrheal endometritis seldom if ever occurs. I am frank to say I have never seen such condition. I draw this conclusion from the microscopic study of uteri removed from women who have had a gonorrheal infection. Numerous sections have been stained for the gonoroccus in situ and I have yet to see an endometrial

section showing the same or evidence of an endometritis. On the contrary, there are authorities who contend such conditions. exist and they advocate curettage and application of silver preparations. I have always held that such procedure was unwarranted, not to say dangerous, because of the great liability of lighting up a previous infection or adnexal disease. If a true gonorrheal endometritis ever does exist, it can be treated in conjunction with the tubal condition.

Treatment of the tubes and ovaries should be conservative: by rest in bed, light diet, hot vaginal douches, hot and cold applications over the pelvic region. I have occasionally found the use of stock vaccines to be beneficial-contrary to the statistics of most men. Operative procedure on acute gonorrheal pus tubes either salpingectomy or scalpingostomy-is unwarranted, first, because it is against one of the basic principles of surgery, i. e., the conservation of tissue, and, second, the drainage procedure must necessarily tend to increase one of the most dreaded sequelae of abdominal surgery-adhesions. If drainage in gonorrheal tubes must be done, the most logical procedure and route, in my opinion, is per vaginam.

Regarding conservative or complete surgery in these cases, one must be guided by the particular conditions which he meets. He should explain to the patient that conservative surgery may mean future pregnancies, or perhaps future operative procedure.

Whether one should, in radical surgery, do a supra-vaginal or a pan-hysterectomy will depend on the condition of the cervix at the time of operation. I personally believe that conservative surgery on the tubes and radical surgery on the cervix is the ideal proceedure.

To impress upon you the importance of the subject and the difficulty of making a relatively positive cure based upon bacteriological and serological examinations, I call attention to the following case reports:

Number of cases reported under hospital care 10, of which 4 or 40 per cent reported cured, all under social restriction.

Number of cases reported under dispensary care 10, of which 2 or 20 per cent reported cured, both under social restriction.

Number of dispensary cases uncured 8 or 80 per cent, all without social restriction.

Number of office cases reported 10, of which 4 or 40 per cent reported cured, two of which were under social restriction.

Total number of cases reported cured 10, or 33 1-3 per cent of total number treated, of which 8 or 80 per cent were under restriction and 2 or 20 per cent without restriction.

Total number of cases reported uncured 20 or 66 2-3 per cent of total, of which 18 or 90 per cent without restriction and 2 or 10 per cent under restriction.

CONCLUSIONS

(1) Gonorrhea in women, contrary to the belief of many, is one of the most difficult of diseases to cure.

(2) It requires unlimited perseverance on the part of the physician and the explicit confidence of the patient.

(3) It requires in many cases surgical skill and judgment. (4) If we hope to control this disease and obtain results, all infected women must be under civil jurisdiction, or subject to same, and, if necessary, public clinics with salaried attendants should be provided.

(5) A cure must be determined only on bacteriological and serological examination, not on the amelioration of symptoms.

(6) Do not fail to insist that the husband (or paramour) consult a competent genito-urinary man, since it is useless to treat a female gonorrheic who persists in having intercourse with an infected man.

RENAL TUBERCULOSIS

Albert E. MacKay, M.D., F.A.C.S.,

Professor Genito-Urinary Diseases, University of Oregon Medical School

In reviewing the literature on renal tuberculosis, it would appear that the subject of diagnosis and treatment had become quite universally settled. It may be so by the expert urologist or skilled surgeon, but on considering the history of ten comparatively recent cases occurring in our own community and seen by men who are successful practitioners of medicine, it also seems quite apparent that further discussion of the subject before a medical society would be productive of much good.

The statement is made because in all these cases when presented for final consideration, while the diagnosis was made quite readily and promptly, the destruction of the kidney was far advanced and the bladder involvement was pronounced and severe. In one case, bilateral involvement of the kidneys had occurred, while the X-ray showed a large stone shadow in one kidney and a chain of glands involved along the opposite ureter. This man had shown marked bladder symptoms for at least two years, was treated many months and even cystoscoped during the past year, yet no sugges tion was even made to him that the disease was possibly tubercular. Nephrectomy was done in nine cases, with apparent complete symptomatic recovery in six.

In another case, operated upon May 12, 1916, improvement was only noted for a short time, but poor environment and inability to receive decent hygienic treatment might be responsible for the poor result, but an earlier diagnosis would undoubtedly have afforded an opportunity for complete re

covery.

Still another case operated upon September 7, 1916, has made a splendid recovery except for a persistent vesical irritation which at the present time is slowly yielding treatment. This case is a marked instance where an earlier diagnosis would have obviated a long, tedious bladder treatment.

Mr. W., seen with Dr. McDaniel and operated upon February 19, 1917, is making an apparent clear recovery. His condition was diagnosed a year before by Peterkin in Seattle. Nephrectomy recommended and refused, but the continued exacerbation of bladder symptoms finally precipitated radical treatment. The lessons in diagnosis presented from a review of these ten cases, show a marked disregard for the early significance of bladder symptoms as a clue to renal tuberculosis, resulting in a hopeless condition in one case, a most un