tarrhal inflammation spread by "continuity of tissue." But this gross statement no longer is satisfactory. After the discovery of Neisser's coccus it was assumed that the spread of the disease to the tubes, ovaries, and peritoneum was due to the invasion of this coccus. The earlier studies of the nature of the gonococcus, especially by Bumm, were opposed to this assumption in its entirety, the exceptions being explained by the theory of "mixed infection." From experiments made by Bumm it was maintained that the gonococcus is incapable of inducing peritonitis, and also that it does not invade the deeper layers of the mucous membrane, the underlying tissues, or the lymphatics. The correctness of this theory is open to suspicion, because it does not explain the conditions found by the clinician, who is inevitably driven to the conclusion that the theory is based upon insufficient or misinterpreted evidence.

Gonorrheal peritonitis, gonorrheal ovaritis and ovarian abscess, and gonorrheal rheumatism involving various joints, have been and are accepted as facts by clinicians; but, according to Bumm's teaching concerning the gonococcus, these conditions are denied or are incapable of explanation. The fallibility of Bumm as an observer is supported by his teaching concerning the frequent relation between gonorrhea and parametritis, the occurrence of which he explains by the theory of mixed infection. Certainly the combined testimony of English and American gynecologists goes to show that parametritis is an extremely infrequent complication of gonorrhea-observers of the widest experience denying its existence apart from the puerperal state.

The more recent studies of Wertheim' have led him to conclusions which agree with clinical experience. He was able to demonstrate that the gonococcus will produce peritonitis in white mice. As the mucous membranes of white mice are refractory to gonorrhea, while those of man are susceptible, he argues that this fact goes far to show that the gonococcus can produce peritonitis in man. He has demonstrated also that the gonococcus can penetrate pavement as well as cylindrical epithelium. He claims that the gonococcus can penetrate the connective tissue and infect the

Proceedings of the German Gynecological Society, 1891.

lymphatics, and thus cause peri-urethral abscess, suppurating lymphatic glands, etc. Moreover, Wertheim has demonstrated gonococci in the pus from ovarian abscess.

These observations of Wertheim are more nearly in accord with the known clinical history of the disease (illustrated in the case reported), and are further supported by the fact that he and other observers, including Sinclair, lay stress upon the statement that other pyogenic bacteria are seldom found in tubal pus (Wertheim has found only the gonococci).

The result of the observations of Wertheim is very gratifying, confirming, as they do, Neisser's claim that the gonococcus is the specific cause of gonorrhea, while harmonizing the experience of clinicians and bacteriologists concerning the disease. If Wertheim's observations are confirmed, gonorrheal ovaritis and abscess, peritonitis, and rheumatism receive a satisfactory bacteriological explanation.

Non-cystic Gonorrheal Salpingitis.-Nothing in the his. tory of gonorrhea is better established than the essential chronicity of the disease. In the urethra, the vulvo-vaginal glands, the vagina, the uterus, and the Fallopian tubes, the general facts are the same-the disease has little if any tendency to undergo a spontaneous cure. The rule is that a chronic catarrhal condition succeeds the acute inflammation (if the disease has not been chronic or "creeping" from the beginning), and that in some fold of membrane, crypt, or follicle enough of the specific poison remains to set up acute inflammation anew. The knowledge of this fact we owe to Noeggerath more than to any other; but each practitioner learns to know it from his own observations. And not only is the dis ease essentially chronic in its nature, but it is very rebellious to treatment. Even where the affected membrane is accessi ble, as in the urethra and vagina, after a long and systematic employment of germicides and astringents the practitioner is chagrined to find a recurrence of acute inflammation. And this is even more true where the comparatively inaccessible endometrium is involved.

The natural history of tubal gonorrhea is still somewhat unsettled. Does gonorrheal salpingitis ever result in a perfect natural cure with a functionally active tube? This is a point of the utmost importance because of its bearing on the

proper treatment of the class of cases in which we have gonorrheal salpingitis with but slight symptoms, and the class who have survived acute salpingitis with peritonitis and who have chronic salpingitis with adherent appendages. The known chronicity of the disease, and its rebelliousness to treatment in accessible regions, offer but little encouragement to expect a perfect cure in an inaccessible tube from which drainage is difficult if not impossible. But the question is of such vital interest that facts, and not mere theoretical considerations, are needed to determine it. Personally I know of no case in which a gonorrheal salpingitis has been perfectly cured. Perhaps this question will be determined definitely by those who are freeing adherent appendages instead of removing them after performing abdominal section. If it can be settled in the affirmative it will enable conscientious men to advise all manner of palliative treatment in such conditions in the hope of effecting a cure. In the meantime I believe that the rule of practice should be to remove all such uterine appendages when the health of the patient is compromised by their presence. At the present time there is no evidence that a Fallopian tube occluded at the fimbriated extremity ever becomes patulous; and there is every reason to believe that gonorrheal salpingitis invariably pro duces occlusion of the tube, except in those cases where the infection spreads quickly to the peritoneum and induces rapidly fatal peritonitis.

Shall both Uterine Appendages be removed when only one is infected with Gonorrhea?—The rule in ovariotomy for a cyst, that the opposite ovary should not be removed if found healthy, has been applied to the operation of removing the Fallopian tube and ovary for inflammation. Tait has called attention to the fact that in a considerable percentage of such cases the inflammation spread subsequently to the opposite side, causing death or requiring a second operation. Confirmatory testimony has been offered by others. Hence the conclusion can be drawn safely that when one uterine appendage has been removed for inflammation the disease is likely to attack the other appendage subsequently. The subject is as yet so new that we have no evidence as to the relative frequency with which this has occurred in cases of

gonorrheal salpingitis, as compared with other varieties of salpingitis; but from what is known of the diseases in question the inference is fair that the healthy appendage is most apt to be infected in gonorrheal cases. Probably our knowledge of the subject is as yet not definite enough to formulate a rule of practice.

In operating upon women, the mothers of families, and who are approaching the menopause, it is certainly wise surgery to remove both uterine appendages, even though one is healthy. With young women desirous of bearing children it seems to me that, the facts being stated, the women themselves should elect whether one or both appendages should be removed, as they alone must suffer the consequences of success or failure.

Probably the percentage in which extension to the healthy side will occur can be materially reduced by appropriate treatment. When life is not threatened, careful preparatory vaginal treatment will do much in this direction by curing a lurking vaginitis. When endometritis is marked, rest in bed until recovery is perfect from the cœliotomy, followed by thorough dilatation, curetting, and disinfection of the endometrium, should likewise lessen the chances of infection by curing the endometritis. Among intelligent people such measures, together with prolonged treatment to restore tone to the pelvic vessels, rational personal hygiene, and the avoidance of exposure, exhaustion, sexual intercourse, and other causes of pelvic congestion, should go far to prevent involvement of the remaining uterine appendage.

IN MEMORIAM.

GILMAN KIMBALL, M.D.

Born December 8th, 1801. Died July 27th, 1892.

WE of a younger generation, who are reaping to the full the triumphs of modern abdominal surgery, cannot realize what those triumphs must have meant to the men who helped to achieve them. The few far-sighted men who were