has given us a hundred per cent. of recovery. But by waiting and taking time to determine the character of the laryngeal trouble I have found that I had either syphilis, a benign growth or tuberculosis; so that I have not had occasion to resort to what the doctor has done in these two cases; and so the only thing that I want to do, the only impression I care to make, is to impress upon you the importance of discriminating very carefully in these cases.

I sympathize with what Dr. Keiper has said that the doctors make a mistake when they flee from the specialists. The specialists are assistants to the general practitioner. When we are in our proper sphere we are simply assistants of the general praetitioner; and the general practitioner needs us a great deal more than we need the general practitioner, and I am not immodest in saying that, having been a general practitioner myself for twentythree years before I went into special work; and I feel that I am in a position to realize that; and it has been my desire, in my own special line of work, to be of assistance to the general practitioner, some of whom are here and have been helped by my assistance. And so I say it is very unwise for general practitioners, to flee from specialists as they have done here this morning; and the impression I want to make now is for all of us, specialists and general practitioners, too, to discriminate very carefully in these cases, and don't be in too big a hurry. When you have a case well developed, as these two cases were, do just exactly as the doctor says, don't temporize. I think the diagnosis can be made, if you take time enough, without the microscope. The microscope has been to me a disappointment, very disappointing. I am on record now in the Indiana Medical Journal of having cured four cases of cancer of the nose. I never cured them. I didn't have them. The microscope misled me, mislead us. The subsequent history of those cases, in all those cases, confirms me in the opinion that I didn't have malignant disease of the nose; so we have not yet arrived at the period, at least from my standpoint, that we can rely on the microscope as implicitly as we would like to. As a clinician, I was bred a clinician and possibly I am really more on that than I ought to be, but it does seem to me we may take time enough in these cases, ordinarily, to make the diagnosis without

the use of the microscope. Dr. Dodds smiles. He is keen with the microscope, and with bacteriological work, and he has helped me, and I will call on him again doubtless; but what I mean to say is that we want to be a little careful in plunging around in the larynx too much to make a diagnosis. Let time help us.

Dr. Wm. T. S. Dodds, of Indianapolis: Mr. President, that is a direct attack. Dr. Cook said it was not the gun, but the man behind the gun that did the damage. That may be true of the microscope. The trouble is with some of us we do not know exactly what is required. For instance, a doctor from the northern part of the State brought a pan of milk down to me and wanted to know what was in it. "How soon do you want to know, doctor?" I asked. "I am going back on this afternoon's train; want to know by that time," he replied. I said, "I am sorry; you will have to hunt another bacteriologist." The trouble is we don't know why you send the specimen to the histopathologist. Don't pick out the center or top of an ulcer and expect a differentiation. You can not get it in that case. I simply refuse to make a finding. If you can find a little bit of the disease on some of the healthy tissue, then you can expect to get a diagnosis. Remember that histologists must find the tissue, must have some of the tis sue from which the cancer springs, or the disease springs, and then he can give you an idea; but to take diseased, chaotic cells, which have no relation to the histology of the membrane or the tissue from which these growths spring and give the microscopist no idea, and it is simply a chaotic mass of cells without any association to the structure, he can not do anything. He must have, healthy tissue to enable him to make a finding; and that is probably the reason Dr. Woollen recorded having four cases of cancer of the nose.

Dr. Joseph D. Bryant, of New York: Mr. President, there are many features in this paper and in this subject that appeal to the general practitioner, particularly of surgical interest. I want to say at the outset that I see no reason why early diagnosis should not be made in these cases, the same as in other situations in the

body. I want to say also that I believe that the microscope should verify always the opinion of the surgeon or physician based on his own observation. I want to say, at the same time, that I believe that in a large majority of cases, to one who has experience in observing these things, perhaps the eye or the touch may be quite as reliable as the microscope. I wish to illustrate distinctly what the gentleman who has just preceded me spoke of, the importance of the point of derivation of the specimen to be examined. I think myself that if the specimen be taken by the average surgeon, or possibly by any surgeon without directions from the microscopist, he may not perhaps get the specimen that permits of a satisfactory examination. To illustrate: Some five years ago a case of the throat and somewhat of the larynx was referred to me for diag nosis and treatment-I will not name the disease as it came to me except to say it was malignant; at least, the physician who brought it himself said he thought it was. I asked him if previous examinations had been made of the growth, and he said yes, and mentioned the microscopists who had examined it and pronounced it in every instance nonmalignant. I was satisfied from the looks of it that it was malignant; but I called the microscopist on the telephone, and I said you have examined, haven't you, repeated specimens from this case, this disease? He said he had. I said, "What is your recollection of the nature of it?" He said nonmalignant. I said, "I will tell you what I will do with you; I will bring the patient to your laboratory, and I will allow you yourself to cut the specimen from the growth, and then we will wait and see what you have to say; because I regard it as malignant." I took the patient to him, and he removed the piece himself as he saw fit, and in the course of the requisite amount of time he returned to me the fact that the disease was malignant; I know it, he said, because of the relation the diseased tissue bears to the healthy tissue. I am very glad the point was made by the gentleman, because I wish to say that I think when possible, at least when convenient, the microscopist should have the opportunity of making his own selection, and then no question can arise as in the three or four cases which may be wrongfully recorded.

Now, personally, I haven't removed the larynx. I, personally, have been asked to remove the larynx more than once, but have declined. I have performed thyrotomy several times for the purpose of reaching growths in the larynx. I want to say that I regard laryngectomy for intrinsic diseases as an operation not to be encouraged for two reasons: First, it never gets to one in the proper time; and, second, I do believe that thyrotomy, early diagnosed, should be done. I believe it should be promptly done. I believe the diagnosis should be promptly and early made. I do not believe that cutting away a portion of the questionable growth in the larynx necessarily causes general infection, not in the sense certainly of sepsis, nor do I believe in the sense of extension and disturbing; if in such cases the malignancy is hastened, asume that it is hastened, we have then at our command the means of diagnosis which promptly hastens action, and in that way relieves the patient and the surgeon from responsibility. In other words, I believe that thyrotomy done promptly as the result of equally prompt diagnosis, resulting in the removal of the diseased tissue, is just as important in disease of the larnyx and certainly of greater avail than it is of the soft tissues of the body, outside of the cartilaginous environment that characterizes these growths; and I want to say another thing. I agree fully with the statements of the gentleman that when the general practitioners leave when we are considering a question like disease of the larynx they make a great mistake; because it may give them wisdom which will cause them to sooner realize the presence of disease in their patients' larynges as signals of importance. I believe, as was said, that each should work with the other, and work promptly, and not with the exclusion of the specialist, but along with the specialist. The general practitioner should consider sarcoma, even though it was one which had heretofore given way repeatedly, which in this instance involved the patient in great distress, a calamity. I can see no other course by which the rate of mortality, down to eight per cent., can be much bettered except by honest, earnest, early and prompt co-operation between the general practitioner and the specialist.

GONORRHEA IN WOMEN.

BY A. S. JAEGER, M. D., OF INDIANAPOLIS, IND.

It is with great temerity that the writer approaches this subject, appreciating full well his own limitations and the vastness and importance of the condition to be considered, both from a medical and sociological standpoint. It is a subject indeed worthy of one's best efforts, and he trusts you will bear with him while in a limited way it is presented to you for consideration.

It is surprising that a condition such as this, conducive as it is, not alone in its immediate but also in its remote results, to so many of the serious and at times fatal derangements of the female genitourinary tract, pernicious in its effects both physically and psychologically, should receive such superficial treatment in the American text-books of the present day. Of numerous books on gyneacology referred to, while all of them mention in a general way gonorrhea as an etiological factor, only few give more than scant space to the subject of acute gonorrhea and its proper treat

ment.

Let us consider for a few moments the frequency of this disease as a causative agent in female troubles. McNaughton-Jones, quoting Alexander Foulerton, states: "He collected the statistic results in 459 cases of salpinitis and found the gonococcus had been identified in 85 cases, or about 19 per cent. In about 60 per cent. no micro-organism of any kind had been identified in the contents of the tube. He accounted for the absence of the microorganism in so large a percentage of cases by the fact that many of them did not come under observation until such a late time in the duration of the affection that the causative bacteria had died out from some cause, after starting the pathological process. Many cases of pyosalpinx owed the presence of certain bacteria to secondary infection from some other cause than the specific inflam