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Limits of the Lab:
Diagnosing "Latent Gonorrhea," 1872-1910

One of the most heatedly contested disease entities in turn-of-the-century medicine was "latent gonorrhea," a condition first discussed in an 1872 paper published by the German-born gynecologist Emil Noeggerath. Although none of the bacteriological discoveries of the next few decades—including the isolation of the gonococcus in 1879—provided much evidence of its existence, by the 1890s most Western physicians and medical scientists had nonetheless come to believe that latent gonorrhea was a real, diagnosable disease. While in the wake of its resolution, leading gynecologists contended that laboratory science had cleared up the controversy over latent gonorrhea, in reality it was through more "traditional" diagnostic methods (especially the taking of case histories) that Noeggerath's once-debatable theory gained acceptance. As such, this episode challenges the idea that turn-of-the-century Western medicine witnessed a "laboratory revolution," and that with the rise of bacteriology "the clinic" no longer informed the processes by which doctors defined and diagnosed disease.


latent gonorrhea, Emil Noeggerath, laboratory revolution, gynecology, scientific controversy, venereal disease, Albert Neisser, patients

In early 1876, the German-born gynecologist Emil Noeggerath rose before his colleagues at the inaugural meeting of the American Gynecological Society in New York City to present a paper he had titled "Latent Gonorrhea, Especially with Regard to Its Influence on Fertility in Women."1 [End Page 63] Revolving around the idea that gonorrhea could "persist(s) for life . . . in the organs of generation," Noeggerath's talk "brought forth much opposition," as in the aftermath of his address prominent medical men around the world criticized the suggestion that this venereal disease was an incurable condition, a malady capable of wreaking physical havoc within the body years and decades after its initial contraction.2 Yet although ridicule and rejection characterized their immediate reaction to Noeggerath's theory, within a relatively short period of time Western medical authorities came to treat "latent gonorrhea" as a diagnosable disease entity, reversing their earliest assessments and concluding that this venereal poison could in fact provoke diverse forms of illness after lengthy periods of dormancy. Indeed, whereas words like fallacy, monstrous, and myth dominated the initial discussion of latent gonorrhea, posterity has attached a different label to Noeggerath's 1876 address: "epochal."3

In explaining the causes of this rather sudden about-face, Noeggerath's contemporaries turned to the laboratory, arguing that the discovery of gonorrhea's causative agent in 1879 by German scientist Albert Neisser (only three years after the publication of "Latent Gonorrhea") had resolved the matter in favor of the gynecologist's once-debatable theory. Noeggerath's novel disease entity, one fellow New York City gynecologist exclaimed in 1893, had been "fully established by the discovery of Neisser's gonococcus."4 Across the Atlantic, one year later a German gynecologist echoed this view, asserting that as far as latent gonorrhea was concerned, "it was not until the discovery of the gonococcus that this question was cleared up and Noeggerath's opinions were found in the main to be correct."5 And in 1908, a St. Louis specialist recapitulated what had become the accepted interpretation of this gynecological controversy, reminding his colleagues that the reason for the mass rejection of Noeggerath's [End Page 64] views had to do with the fact that they were "purely clinical," and as such "lacked the necessary proofs afforded later by Neisser in the discovery of the gonococcus."6

The allure and chronological plausibility of such formulations notwithstanding, the relationship between Noeggerath's theory and Neisser's discovery is less straightforward than the recollections of turn-of-the-century gynecologists suggest. For while gynecologists did resolve the controversy over latent gonorrhea's existence in Noeggerath's favor within a decade of Neisser's discovery of the gonococcus, laboratory procedures and bacteriological evidence played only a minor role in the medical profession's eventual embrace of this new venereal condition. The final acceptance of latent gonorrhea came not as a result of proofs derived from the laboratory, but instead from more traditional sources of medical knowledge, especially clinical observations and the taking of patient histories. Thus, instead of serving as an obstacle to the resolution of this turn-of-the-century gynecological debate, an impediment that only more advanced, laboratory-based techniques could remove, the clinic in fact "cleared up" the controversy over latent gonorrhea, bringing practitioners the "necessary proofs" that could not be found in bacteriological analysis.

In recent years, historians have begun to reexamine the relationship between science and medicine in the late nineteenth century, an era marked by bacteriological findings such as Albert Neisser's 1879 isolation of the gonococcus. Prior to this wave of revisionist scholarship, the common view was that this period constituted a watershed moment in the history of medicine, an era in which the methods of laboratory science revolutionized doctors' diagnostic and therapeutic efforts to such an extent that prelaboratory modes of medical practice quickly fell into disuse. Encapsulated in pithy phrases such as the "laboratory revolution," this interpretation presented the late nineteenth century as a great turning point in the history of medicine, as a pivot between the "bedside medicine" of the past and the "scientific medicine" of the future.7 Yet according to more recent studies conducted by L. S. Jacyna, Steve Sturdy, and Charles [End Page 65] Hayter, this interpretation exaggerates the effect novel scientific fields like bacteriology had on medical practice during this "critical period" in the history of medicine; throughout the era of the so-called laboratory revolution, they argue, prebacteriological understandings and modes of practice continued to shape doctors' day-to-day behaviors, especially in the diagnostic arena.8

In showing how clinically derived conclusions formed the basis upon which latent gonorrhea entered the sphere of legitimate medicine, this article illustrates another way in which traditional modes of medical practice held sway in the bacteriological era. The claims of contemporaries notwithstanding, laboratory science was utterly powerless as a means of verifying Noeggerath's ideas; indeed, because bacteriological methods could not prove the disease's existence, opponents of the German-born gynecologist's theory seized upon laboratory (non)-findings in order to challenge the idea of latent gonorrhea. Yet despite a lack of laboratory evidence, these bacteriologically based doubts failed to overturn what by the dawn of the twentieth century had become the conventional wisdom: latent gonorrhea was a real, diagnosable condition. What had fueled Noeggerath's triumph in the debate over this novel venereal malady was a body of evidence rooted in nonlaboratory methods of diagnosis, especially patient testimony. As such, the case of latent gonorrhea represents another instance in which traditional, "bedside" practices continued to influence the ways in which clinicians understood their patients' illnesses in the era of the "laboratory revolution."9 [End Page 66]

In illustrating the "limits of the lab" in the case of latent gonorrhea, this article proceeds in three parts. The first, titled "Introducing Latent Gonorrhea," examines medical authorities' responses to Noeggerath's theory in the three years between his 1876 address and Neisser's discovery of the gonococcus. As it shows, most practitioners in this period reserved judgment on the matter of latent gonorrhea, expressing interest in Noeggerath's ideas while noting the need for further study. The second section, titled "Debating Latent Gonorrhea," examines the critical years in the debate over Noeggerath's proposed disease entity, which encompassed the period 1879-95. It was during this sixteen-year span that the battle lines in the controversy over latent gonorrhea were drawn, as proponents of laboratory science used the lack of bacteriological evidence for Noeggerath's theory to attack the gynecologist's claims while supporters contended that the clinical evidence was sufficient to establish its existence. The third section, titled "Establishing Latent Gonorrhea," looks at the controversy's final phase, the period during which resistance to Noeggerath's ideas withered away. Critically, although the gynecologist's supporters recognized its bacteriological shortfalls, they nonetheless accepted latent gonorrhea as a real medical phenomenon, something that clinical methods of disease diagnosis—physical examinations and (especially) anamnesis—could uncover. Their victory in the debate over latent gonorrhea demonstrates the power these traditional elements of the clinician's art continued to wield in the era of the supposed "bacteriological revolution." [End Page 67]

Introducing Latent Gonorrhea, 1876-1879

Shortly after delivering his address on "Latent Gonorrhea," Noeggerath found himself "criticized sharply" by those specialists in the diseases of women who had journeyed to New York City for the inaugural meeting of the American Gynecological Society.10 However, despite the near universality of opinion aligned against him in the immediate aftermath of his 1876 paper, such condemnation did not characterize the initial response of the entire Western world.11 Indeed, early views on latent gonorrhea spanned a fairly wide spectrum, ranging from hearty denunciation to full-blown acceptance. Yet rather than outright rejection or approval, most appraisals of Noeggerath's theory in the 1870s reflected a more neutral stance, as medical authorities expressed a cautious interest in latent gonorrhea while refusing to definitively state their conclusions on the subject.

One of those who withheld judgment on latent gonorrhea was George Engelmann. In 1880, Engelmann—who had attended the inaugural meeting of the American Gynecological Society in 1876—published a paper relating the trials of a woman suffering from "habitual miscarriage." In it, the St. Louis gynecologist recounted how he originally believed these difficulties to be the result of syphilis contracted from the woman's husband. But this hypothesis, as Engelmann admitted, proved untenable, as the man showed "no evidence of syphilis" and denied that he had been infected with such a disease. Failing to resolve this medical mystery, Engelmann wondered how a woman could experience repeated miscarriages "at the same stage of pregnancy when no evidence of syphilis of the father can be obtained." "I do not know," he concluded, "unless, indeed, these be the result of latent gonorrhea."12

The English physician Robert Barnes also cautiously endorsed the theory of latent gonorrhea. Noting that Noeggerath's ideas were "difficult to prove or to disprove," Barnes included a section on latent gonorrhea in his 1878 text, The Medical and Surgical Diseases of Women, because he believed that it "has at least an apparent basis in facts."13 In an article published the same year in a New York medical journal, a colleague sounded similar sentiments. The "astonishing" nature of his statement notwithstanding, this physician concluded that as Noeggerath was a "good authority . . . we [End Page 68] must attach some importance to what he says."14 Adding his voice to those of these tentative supporters, a Missouri doctor in 1879 proclaimed his belief that Noeggerath, "if not entirely," was "to a great extent" correct.15

It is difficult to know to what extent these statements reflected the opinions of the medical community at large. Certainly, Noeggerath had his detractors, among them the prominent Philadelphia gynecologist William Goodell. In an 1877 article, Goodell argued that many of those cases of "unfruitful marriage" physicians "attributed to a latent gonorrhea in the woman" were in fact the result not of "an alleged secondary infection of the wife's organs" but of a "primary disorder of the husband's."16 Yet in criticizing Noeggerath's theory, Goodell revealed the extent to which latent gonorrhea had already entered the clinician's diagnostic vocabulary. As the New York City venereologist Freeman J. Bumstead (another critic of latent gonorrhea) quipped in an 1879 text, "Dr. Noeggerath's views [are] so generally known and accepted in America, that one of the first questions asked by the parents of every young lady to whom marriage was proposed by a gentleman, was whether he had ever had the clap!"17 While anecdotal, such comments suggest that Noeggerath's ideas attracted significant support among medical authorities in the years prior to Neisser's discovery of the gonococcus.18

One might expect that before 1879 belief in latent gonorrhea would be based on clinical findings, as it was not until that year that scientists discovered gonorrhea's bacteriological cause.19 Indeed, for early adherents [End Page 69] of latent gonorrhea, evidence of Noeggerath's claims lay in clinical observation and patient interviewing. Thus, in an 1878 testimonial, a St. Louis practitioner buttressed his support of the condition by referencing the cases of six "young ladies" who had recently fallen ill to various pelvic maladies. Subsequent investigations revealed that behind each disease lay a husband who had contracted gonorrhea at some point prior to marriage and who had been "treated and discharged as well." Such evidence "conclusively" proved, he determined, that "latent gonorrhea, as a rule, does set up . . . inflammation" in women.20 The Scottish obstetrician Angus Macdonald similarly based his diagnoses of latent gonorrhea on two chronologically related events: (1) the appearance of a variety of pelvic disorders in women recovering from childbirth (abdominal pains, a "yellowish white discharge," swelling of the genitals, etc.); (2) circumstantial evidence pointing to their husbands' prior contraction of gonorrhea, the symptoms of which had subsided weeks or months prior to delivery. The details on the latter point were hard to assemble with any great degree of certainty, but, despite this, Noeggerath's early supporters believed that the balance of evidence pointed to latent gonorrhea as the culprit.21

As many of Noeggerath's critics noted, the evidence for latent gonorrhea contained within these reports was far from definitive. According to the New York venereal specialist Freeman J. Bumstead, latent gonorrhea's supporters had succumbed to "the fallacy of reasoning on the principle of post hoc ergo propter hoc."22 In a similar feat of logical deduction, the British gynecologist J. L. Milton argued that "had [Noeggerath's] facts been correct, gonorrhea would have long ago depopulated every country into which it had penetrated."23 Yet like their opponents, Bumstead and Milton had recourse only to clinical data and, like others who disputed [End Page 70] Noeggerath's theory, could do little more than report that their personal "experience" called into question latent gonorrhea's existence.24

It is for this reason that caution and restraint dominated the initial reception of latent gonorrhea.25 Reserving judgment, the American Journal of Syphilography and Dermatology counseled "careful investigation" and "extended observations" of the progress of gonorrhea in both sexes.26 Noeggerath's ideas were a subject "worthy of further investigation" echoed the American Journal of the Medical Sciences. "Whether [latent gonorrhea] is so or not," cautioned an author in the Medical Gazette, "I do not pretend to say."27 As these testimonies make clear, if there was a consensus on latent gonorrhea in the three years after Noeggerath's 1876 presentation, it was that the author's ideas needed to be subjected to "careful study," as gonorrhea itself was but a "little understood" disease.28

Debating Latent Gonorrhea, 1879-1895

As has been seen, in the period following the discovery of the gonoccocus, many of Noeggerath's colleagues attributed the gynecologist's triumph in the debate over latent gonorrhea to Albert Neisser's bacteriological findings. However, instead of resolving the controversy over Noeggerath's theory, Neisser's isolation of the gonoccocus—and laboratory science in general—worked only to fan the flames of confusion regarding latent gonorrhea, as bacteriological studies conducted in the 1880s and 90s proved how difficult it was to locate the germs of this venereal disease within the bodies of those suffering from a pelvic and/or reproductive malady (a problem particularly notable among female patients).29 The discovery that [End Page 71] these bacteria were nowhere near as prevalent in long-standing cases of gonorrhea when compared to fresh infections further hampered efforts to put the study of latent gonorrhea on a laboratory footing. Because applying Neisser's findings to the controversy over latent gonorrhea proved nearly impossible, his discovery in fact proved more helpful to the opponents of Noeggerath's theory than it did to its supporters.

That this was the case can be seen in a debate over latent gonorrhea that erupted at an 1889 meeting of the Philadelphia Medical Society. When a gynecologist named Joseph Price sounded his support for Noeggerath's ideas, a colleague interjected that the pathological evidence required to verify latent gonorrhea was "entirely wanting," as no association between this alleged condition and the gonococcus had been demonstrated. Echoing this critique, a third participant in the debate argued that "in order to settle this question, we must have more than mere clinical evidence; we must also have pathological research and experimentation." Discussing his own experiments with Neisser's gonococcus, this aspiring bacteriologist revealed how inoculation in human subjects had failed to spark acute gonorrhea in men: how then could a "little discharge" from a male gonorrheic produce all of the pelvic inflammatory diseases of women claimed by Noeggerath?30

Coming to the beleaguered gynecologist's assistance was a Dr. Hoffman. Acknowledging that the gonococcus was rarely found in the discharges of women suffering from various pelvic disorders ("its place being taken by some other form of micrococcus," he speculated), Hoffman remained untroubled by the diagnostic uncertainties surrounding latent gonorrhea. Instead, he cited as support for Noeggerath's theory an 1857 clinical study published by a European scientist named Bernutz. When attacked again by Noeggerath's detractors, Price held firm. "[W]e possess sufficient clinical material," he repeated in his closing remarks, "to prove that gonorrhea . . . is responsible . . . for the pathological conditions with which [End Page 72] we surgically daily deal." For Price, obtaining "the history of gonorrhea and stricture from the husband" constituted "sufficient" evidence of the disease's role in female pelvic infections. Furthermore, like Hoffman, Price found bacteriological evidence inessential to accurate diagnosis: "[C]linically it is not necessary," he exclaimed, "to determine the presence of the gonococcus to establish the infective virulence of gonorrheal pus." "[P]ersonal knowledge" of a man's contamination with the disease alone proved a "causal relation" to a woman's pelvic sufferings.31

Price and Hoffman were not the only physicians to declare themselves in favor of latent gonorrhea in the absence of firm bacteriological findings. While Philadelphia's leading specialists in the diseases of women debated Noeggerath's teachings, a Missouri doctor signaled his allegiance to the doctrine of latent gonorrhea. Standing before his colleagues at an 1889 meeting of this southern state's Institute of Homeopathy, T. Griswold Comstock dramatically announced that while he had "originally dismissed the statements made by Dr. Noeggerath," "wide experience and observation in the diseases of married women" had caused him to change his mind. Significantly, Neisser's research appears to have played no role in Comstock's conversion experience; acknowledging the difficulties in locating gonococci in women, his acceptance of gonorrhea's latency derived from "several instances" in which young men "apparently" cured of the disease had caused their wives to "suffer greatly" after marriage. Clinical evidence alone had forced Comstock to conclude that "a large per cent of the diseases of the married women that we are called upon to treat in gynecological practice comes from latent gonorrhea."32

So it was with other gynecologists who declared themselves in favor of latent gonorrhea in the aftermath of Neisser's discovery of the gonococcus. 33 Thus, when in 1890 the German practitioner August E. Martin argued in favor of Noeggerath's theory, he admitted that while in the "great majority" of cases no gonococci could be found in the diseased organs of his female patients, these difficulties did not deter his diagnoses of latent gonorrhea, as either "the confessions of the husband" or "the occurrence in immediate connection with cohabitation" counted as "facts which permitted the diagnosis to be established with reasonable certainty."34 For Noeggerath's supporters, it was "clinical experience"—not [End Page 73] laboratory tests—that established latent gonorrhea as a legitimate disease entity.35 While opponents claimed they had "never been able to find the gonococcus in females," Noeggerath's backers remained "convinced from [their] experience that latent gonorrhea is responsible for many distressing pelvic conditions."36 As Angus Macdonald—Noeggerath's first public defender—reiterated in a second paper on gonorrhea published in 1885, "clinical facts" sustained the notion that ovaritis and other gynecological disorders could result from "prolonged connexion with a husband affected with the latent disease," even if bacteriological evidence was wanting.37

Establishing Latent Gonorrhea, 1895-1910

In the final decade of the nineteenth century, laboratory research in Germany strengthened the hands of Noeggerath's supporters. Hoping to resolve the controversy over latent gonorrhea once and for all, a scientist named Ernst Wertheim in 1895 published the results of his experiments with a gonorrheal discharge of "two years' standing." Much to his surprise, Wertheim found that these ancient germs brought about an acute case of gonorrhea when transferred to a "coccus-free urethra." Moreover, when subsequently transplanted back into the original patient, a "fresh gonorrhea" resulted. What this meant was that old, apparently decrepit gonococci could be restored to states of high virulence, and were thus capable of giving rise to "intense gonorrheal inflammation." As one American gynecologist put it in his review of Wertheim's research, "[W]e now understand why the gonococcus, even after years of apparent cure, may regain its full virulence."38 Wertheim's work, another noted, provided a "rational and scientific explanation" of Noeggerath's theory, [End Page 74] going beyond the mere "clinical observation" that had underlay the idea of latent gonorrhea to that point.39

While important, Wertheim's work did not resolve the debate over latent gonorrhea. Interestingly, only a small number of Noeggerath-friendly articles and books published after 1895 mentioned either Wertheim's name or his experiments.40 Second, even those who acknowledged the significance of Wertheim's experiments experienced difficulties—just as they had in the aftermath of Neisser's discovery of the gonococcus— bringing the German doctor's bacteriological research into the clinical realm, as attempts to locate gonococci of any kind (not to mention those of "two years' standing") in the diseased pelvic organs of female patients typically met with little success. Though some practitioners began in the 1890s to incorporate laboratory procedures into their diagnoses of gynecological disorders, most remained satisfied with their ability to diagnose latent gonorrhea without the aid of microscopes and culture plates.41

Indeed, even when laboratory techniques entered the equation, it was clinical evidence that formed the basis of practitioner's diagnoses of latent gonorrhea. In one such case, the New York City surgeon W. R. Pryor wrote of how he diagnosed latent gonorrhea in a woman whose tissue samples, along with those taken from her husband, revealed the presence of gonococci. While pleased to receive bacteriological confirmation of his patient's venereal illness, Pryor determined that laboratory technologies were of no assistance in helping him determine whether or not her gonorrhea was of ancient origin or the result of "fresh exposure." Only after subjecting the woman's husband to clinical examination did Pryor declare himself in favor of the former hypothesis, writing that "at some remote time this man had given his wife a clap of a degree not sufficient to produce symptoms," at least not until "an extra tax was put upon her [End Page 75] system and pelvic organs." Presenting his findings at an 1895 meeting of the New York Academy of Medicine, Pryor announced that such cases occurred "quite frequently," all the while warning his colleagues that latent gonorrhea was microscopically unrecognizable.42

Such deficiencies drew the ire of Noeggerath's detractors, who attacked latent gonorrhea on bacteriological grounds. Just as had the condition's deniers at the 1889 Philadelphia County Medical Society meeting, in 1897 the British obstetrician Frederick J. McCann called latent gonorrhea a hypothesis "contrary to all present pathological dicta." Subjecting the claims of Noeggerath's followers to bacteriological analysis, he complained that "no gonococci [could] be demonstrated in the pus" produced in cases where a "dormant" version of gonorrhea was said to be reactivated by "alcoholic or sexual indulgence." Neither did Noeggerath's theory fulfill Koch's postulates. What latent gonorrhea was, McCann concluded, was merely "a useful cloak for ignorance," a diagnosis uninformed practitioners fell back on whenever it became "difficult to determine the exact causation of disease involving the Fallopian tubes" and ovaries.43

The British gynecologist George Granville Bantock extended this bacteriologically based critique of latent gonorrhea. "Old decrepit gononococcus," he noted in an 1899 address, could not play a causative role in any of the diseases commonly attributed to them, particularly as "it is now well known that the gonococci diminish in number as the disease becomes chronic." Countering the claims of Noeggerath's disciples regarding the role latent gonorrhea played in pyosalpinx, Bantock revealed how gonococci had been found in only "one of every four cases" of the disease, which for him was "a very small proportion on which to establish" such a diagnosis. In all, the idea of latent gonorrhea seemed "as probable as the case of the fatted calf that had been in the family for many years."44

A third scientifically grounded critique of latent gonorrhea published in the final decade of the century flowed from the pen of Robert W. Taylor, clinical professor of venereal diseases at the College of Physicians and Surgeons in New York City. In the 1895 edition of The Pathology and Treatment of Venereal Diseases, Taylor offered a scathing critique of "so-called latent gonorrhea." Like Bantock and McCann, Taylor lambasted the "easy-going method" by which practitioners diagnosed many female pelvic disorders. "It is so easy and convincing in the case of a wife suffering [End Page 76] from pelvic disease," Taylor sneered, "to ascertain that at a more or less remote period the husband has had gonorrhea, and to fix upon that infection as the origin of the wife's trouble, that some men by routine come to make these diagnoses." But when weighed on the scales of science, Taylor declared, the legitimacy of such shoddy diagnoses quickly crumbled. To prove the errors of the Noeggerath school, Taylor pointed to the studies of British gynecologist J. Thorburn and German bacteriologists Albert Doederlein and L. Menge. While Thorburn's study (conducted in 1877) had shown that the fertility rates of gonorrhea-stricken women did not differ greatly from those free of the disease, the latter's revealed the frequency of streptococci and staphylococci in various maladies of the female reproductive organs, contending that it was these bacteria—not the gonococcus—that caused the majority of pelvic inflammations. Based on this research, Taylor concluded that "we are warranted in throwing out of consideration the mythical and fanciful latent gonorrhea in women."45

Noeggerath's supporters too recognized this lack of laboratory evidence. As the century turned, specialists in gynecology and venereology continued to note the need for more "bacteriological work" regarding the subject of gonorrhea. When it came to this condition, one practitioner complained, there existed "great difficulties in the way of getting decisive evidence as to the identity of organisms found" in the discharges of suffering patients. What particularly troubled E. Solly, a British specialist, was the lack of knowledge regarding latent gonorrhea. "How long it can remain thus latent and yet retain its potential virulence," Solly confessed in an article published in 1900, "is a subject which demands further research." "We do not know under what conditions a latent and possibly degenerate gonococcus may re-acquire virulence," he concluded.46

Yet such difficulties did not shatter Solly's faith in latent gonorrhea. In his 1900 article, the practitioner mentioned the case of a man who suffered a "severe attack" of gonorrhea some years into marriage. As in the aforementioned cases, Solly recorded the man's admission of having contracted gonorrhea earlier in life. "The case is incomplete," he concluded, "in that no bacteriological examination was made, but there was some evidence that the husband might, after all, have had a latent gonorrhea, [End Page 77] infected his wife, and then re-infected himself from the new 'culture.'" The credibility of such a hypothesis for Solly lay in his observation that "there did not appear to be the slightest possibility of either party having contracted infection from another source." Solly's defense of latent gonorrhea derived from the clinical and biographical, not the bacteriological.47

Perhaps the best assessment of the state of diagnostic techniques regarding latent gonorrhea in the 1890s came from a Milwaukee professor of pediatrics named Julius Noer. "One of the most important questions for us to consider," Noer wrote in a 1900 article addressed to general practitioners, "is, have we any certain, positive means or data upon which we can depend for a diagnosis of chronic or so-called latent gonorrhea? Clinically," he continued,

We admit that there is always room for doubt and it does not appear that up to the present time even the skilled microscopist can always furnish us with a positive diagnosis. The existence of involution forms of cocci closely resembling the gonococcus makes the microscopists' findings uncertain. The difficulty encountered in hunting for gonococci in a mass of debris of old cases where gonococci are not abundant must always be considered.

Yet despite his doubts, Noer found no trouble in diagnosing latent gonorrhea, which fell along the same grounds as that offered by Solly.48

Supporters and critics of latent gonorrhea in the 1890s agreed on one point: the gonococcus was an elusive entity, especially when it came to women.49 Yet despite these diagnostic difficulties, most medical elites publishing in the century's final decade accepted the validity of Noeggerath's theory. Tellingly, in his 1899 attack on Noeggerath, Bantock characterized himself as a "heretic," as someone who deviated from the orthodox view on latent gonorrhea.50 As a number of leading lights in the medical [End Page 78] world reflected, by the 1890s there was very little debate over the accuracy of Noeggerath's views. "It is coming to be believed by gynecologists," observed one Indiana practitioner in 1898, "that very many, or perhaps most, of the pelvic diseases of women are the result of a latent gonorrhea in the husband."51 For the majority of medical authorities active in the 1890s, latent gonorrhea was simply "a well-known fact."52

The first decade of the twentieth century witnessed the decaying of the last vestiges of resistance to Noeggerath's theory; of forty publications on latent gonorrhea printed between 1900 and 1910, none opposed the gynecologist's idea. Significantly, the final triumph of latent gonorrhea had little to do with advances in diagnostic techniques or novel laboratory experiments. Just as in the 1890s, a smattering of medical authorities cited Wertheim's experiments as having provided the ultimate proof of Noeggerath's theory.53 Like their late-nineteenth-century counterparts, early-twentieth-century practitioners continued to note the diagnostic difficulties involved in latent gonorrhea's detection. Above all, they continued to articulate the necessity of clinical observations and patient interviewing in any cases involving women suffering from postmarital pelvic maladies.

When dealing with cases of suspected latent gonorrhea, noted the British physician Thomas Clifford Allbutt in the 1906 edition of his A System of Gynaecology, "inquiry should always be made as to the starting-point of the affection." Defending the vital role of the case history in such diagnoses, he declared that female pelvic pain coming on soon after marriage suggested "latent gonorrhea on the part of the husband as a cause." Interviewing the husband in such cases was essential, he argued, cautioning [End Page 79] that "history must . . . never be pooh-poohed, but receive its due value although at first its significance may not be seen."54 Others agreed with this assessment, especially as the man's urethra might not contain a single gonococcus.55 While the microscope offered an unparalleled capacity to diagnose gonorrhea, noted the German physician Reinhold Ledermann in a 1910 article, it remained "particularly difficult" when it came to the "latent stage . . . when the gonococci are encapsulated in crypts and glands or in deep-seated inflammatory recesses and are only temporarily admixed with the secrets of the diseased mucous membranes."56

In a 1902 article on the "Signs and Treatment of Gonorrhoea in Women," the New York homeopath L. L. Danforth discussed what he viewed as the typical case of latent gonorrhea, which involved an "innocent" woman who entered the physician's consulting room "only a few weeks" after her wedding. "A vaginal examination reveals suspicious signs," Danforth began, which microscopic work confirmed. Supplementing these came "the confessions of the husband, who states that he had suffered from an attack of gonorrhea, of which he was pronounced cured before marriage." For Danforth, this trifecta (clinical findings, bacteriological analysis, and a case history) confirmed the diagnosis of latent gonorrhea. Yet in his remarks, Danforth noted that this scenario was less realistic than the typical case, for "we do not always find the gonococci after repeated trials." Untroubled, Danforth concluded that bacteriological findings were the least significant of his three-tiered approach: "[I]f we get a confession and no gonococci," he counseled, "we may be sure of our ground."57

Danforth's beliefs regarding the importance of laboratory science in the diagnosis of latent gonorrhea were far from the fringes of acceptable practice. Indeed, in a 1905 article, the Chicago gynecologist G. Frank Lydston—perhaps the most eminent specialist in the diseases of women [End Page 80] in the United States at the time—articulated the same position. Admitting that "we [have] no tests at the present time which would enable us to give a positive opinion of the infectiousness of a given case of suspected latent gonorrhea," Lydston declared the superiority of nonbacteriological methods of diagnosis. "The clinical history in many cases," he informed his colleagues, "[is] more important than the laboratory study of the case, and a careful combination of both methods of study [is] always essential."58

The Role of Patient Testimony

That practitioners such as Danforth and Lydston should attach such importance to "clinical history" in cases of suspected latent gonorrhea suggests that patients played a significant—though passive and indirect— role in the controversy over Noeggerath's theory. While they did not participate in debates over latent gonorrhea conducted by medical societies, publicly lobby the medical establishment on Noeggerath's behalf, form an advocacy group, or perform any of the other actions typical of the modern-day patient, these laypersons nevertheless had some impact on this turn-of-the-century gynecological debate's outcome. Their part in the controversy over latent gonorrhea can be seen in the words of Noeggerath's defenders, who attached great diagnostic significance to things they learned from interviews and discussions with patients. Indeed, because medical professionals could not create a bacteriological identity for latent gonorrhea, its existence owed almost entirely to the testimonies and histories provided by patients, who drove doctors' understandings of this venereal condition.

An example of the patient's indirect influence can be seen in an 1899 article published by the Scottish obstetrician R. M. Murray. Titled "Notes of a Case Bearing on the Latency of Gonorrheal Infection," the article recounted the travails of a married couple whose third child showed signs of ophthalmia soon after birth. Believing that the disease's origins were gonorrheal in nature, Murray asked the child's father during "a private interview" whether he had recently contracted gonorrhea through an extramarital affair. After witnessing the man's stringent denials of these allegations, Murray concluded that it was instead latent gonorrhea that provoked his child's ophthalmia. Tellingly, the Scottish physician admitted that the results of his "private interview" were inconclusive, and that it was [End Page 81] "open to anyone to say that it is more likely that in spite of the asservation of the husband the infection was quite recent."59 Thus, despite his suspicions, Murray allowed his patient's testimony to govern the condition he diagnosed, and a case of latent gonorrhea entered the medical record.60

Murray was far from the only turn-of-the-century medical specialist to note the ways in which patients influenced their doctors' diagnostic determinations. In his influential manual The Irrigation Treatment of Gonorrhoea, the New York City practitioner Ferdinand C. Valentine admitted that in many cases of latent gonorrhea, gonococci might be found in such abundance that the physician "might believe . . . that a new gonorrhea has been recently contracted." Accepting the possibility of fresh infections, Valentine nevertheless dismissed such notions, concluding that in most cases "it is better to err on the side of charity and give the patient the benefit of the doubt."61 Numerous other medical writers accepted Valentine's directive, concluding in their cases either directly or indirectly that the "veracity and integrity" of their patients could not be besmirched, that they had "every reason to believe that their statements were true."62 In their published case histories, a single thread ran through doctors' diagnoses of latent gonorrhea, whether implied or explicitly rationalized: "I know this man is honest."63

As statements like this indicate, it seems that doctors' diagnostic dependency redounded primarily to the benefit of male patients, who in the late nineteenth and early twentieth centuries served as the principal underwriters of the medical profession. Such was certainly true in the case of Genevieve Pendergurt, an Iowa woman who in 1910 filed for divorce from Tom Pendergurt—her husband of five months—on the grounds of "cruel and inhuman treatment." As evidence of this, the plaintiff alleged that she had "contracted from [her husband] a venereal disease." Although she was initially granted a divorce, an appellate judge later overturned this verdict, ruling that Pendergurt did not have sufficient evidence to prove [End Page 82] that her illnesses—which had required several surgical operations—were the result of her husband's gonorrhea. What appeared more likely to this judge, especially after hearing a local medical expert pronounce upon "latent gonorrhea or chronic gonorrhea as some call it," was that the plaintiff's illnesses instead represented the flaring up of a long-standing, "dormant" case of gonorrhea that had been only "seemingly cured."64 Though a single case, available evidence—especially the contention of physicians that improved means of diagnosis would "exonerate many an innocent woman from the suspicion of guilt"—suggests that diagnoses of latent gonorrhea often served to protect men from allegations of marital infidelity.65

Interestingly, though the divorce trial of Genevieve and Tom Pendergurt saw a number of physicians take the stand, none of them made reference to any bacteriological examinations they had performed on either the plaintiff or the defendant. The conclusion that Ms. Pendergurt's disease was the result of latent gonorrhea rested on a number of questionable claims, namely the defendant's insistence that he had not recently contracted a venereal disease. That medical experts involved in this case felt confident diagnosing Ms. Pendergurt with latent gonorrhea is not surprising; as has been seen, medical authorities during the late nineteenth and early twentieth centuries attached enormous diagnostic importance to patient testimony when considering Noeggerath's novel venereal malady. Subsequent generations of venereologists would look askance upon such diagnostic methods, arguing that "patients' statements" were often "of doubtful reliability when venereal disease is in question." "The possibility of reinfection," mid-twentieth-century writers contended, was a factor much ignored in the earlier literature on latent gonorrhea.66 Yet during this period, in which no surefire test for gonorrhea (especially in women) existed, clinicians found it necessary to delve into the "personal history" of their clients in order to diagnosis venereal [End Page 83] maladies, which in turn necessitated "fall[ing] in line with the patient's own point of view."67


In the end, patient testimonies and physical examinations proved much more crucial to resolving the controversy over latent gonorrhea than did laboratory science. Though the tools and methodologies of the laboratory increased the medical profession's knowledge of venereal diseases, when it came to Noeggerath's theory of latent gonorrhea, bacteriology played second fiddle to the more-established techniques of clinical observation and biographical investigation. The homeopath T. Griswold Comstock put it best when he observed that "in our clinical experience in a number of cases that we have treated . . . we have found microbes in the discharge which were evidently attributable to the contagion of a previously existing gonorrhea."68 "Evidently attributable" was the best laboratory science could do; when it came to confirming latent gonorrhea, more than a display of gonococci was required.

As this study has shown, laboratory science played a minor role in the medical world's reversal of opinion regarding latent gonorrhea.69 Examining the process by which Noeggerath's novel disease entity gained acceptance within Western medical circles reveals, as has much of the recent literature on the nature of the "bench-bedside" relationship in turn-of-the-century medicine, that this period is best seen not as a "revolutionary" epoch, but instead as one in which older, clinically oriented approaches powerfully informed the ways in which medical doctors went about diagnosing and treating their patients' illnesses. Like those portraits of turn-of-the-century [End Page 84] practice painted by Jacyna, Sturdy, and other revisionist scholars, what an analysis of the debate over latent gonorrhea illustrates is the power the clinic continued to wield throughout this allegedly pivotal period in the history of medicine. Unlike most revisionist accounts, however, which have been primarily concerned with providing evidence of the clinic's role in determining the shape and character of modern "scientific medicine," this study aims to incite a broader investigation of the sources of its strength. In the case of latent gonorrhea, it appears that the heart of the clinic's power lay in doctor-patient relationships, and in particular on physicians' reliance on patient testimony. Ultimately, it was the trust doctors invested in their clients' statements (along with the cultural attitudes and social norms upon which that trust rested) that worked to transform latent gonorrhea from a controversial disease entity into a real, diagnosable malady. [End Page 85]

Elliott Bowen

Elliott Bowen, a Ph.D. candidate in the history department at Binghamton University, is currently at work on a dissertation titled "Mecca of the American Syphilitic: Doctors, Patients, and Disease Identity in Hot Springs, Arkansas, 1890-1940." This article, which speaks to his interest in the history of sexually transmitted diseases, emerged out of a research seminar conducted by Prof. Fa-ti Fan during the fall 2011 semester.

In addition to acknowledging the anonymous reviewers at the Bulletin, each of whom offered incredibly useful comments on this essay's various drafts, the author would like to express his gratitude to Prof. Jerry Kutcher and Prof. Fa-ti Fan. Simply put, without the guidance, assistance, and encouragement provided me by these two individuals, this article would have never reached its present form. From the bottom of my heart, I thank you both.


1. Biographical information on Emil Noeggerath can be found in Herbert Thoms, Classical Contributions to Obstetrics and Gynecology (Springfield, Ill.: Charles C Thomas, 1935); Francis R. Packard, History of Medicine in the United States, vol. 2 (New York: Hafner, 1963); and J. D. Oriel, "Noeggerath and 'Latent Gonorrhea,'" Sexual. Transm. Dis. 18, no. 2 (1991): 89-91. For Noeggerath's address, see Emil Noeggerath, "Latent Gonorrhea, Especially with Regard to Its Influence on Fertility in Women," Trans. Amer. Gyn. Soc. 1 (1876): 268-300.

2. Thoms, Classical Contributions (n. 1), 245. See also Victor Robinson, The Story of Medicine (New York: New Home Library, 1943), 424-25; Theodore Cianfrani, A Short History of Obstetrics and Gynecology (Springfield, Ill.: Charles C Thomas, 1960), 316-18; Sarah Stage, Female Complaints: Lydia Pinkham and the Business of Women's Medicine (New York: Norton, 1979), 83-84; Harold Speert, Obstetric and Gynecologic Milestones Illustrated (New York: Parthenon, 1996), 365-67.

3. Freeman J. Bumstead, The Pathology and Treatment of Venereal Diseases (Philadelphia: Henry C. Lea, 1879), 210; Angus Macdonald, "Latent Gonorrhoea in the Female Sex, with Special Relation to the Puerperal State," Trans. Edinburgh Obstet. Soc. 3 (1873): 164-89, quotations on 185; J. L. Milton, On the Pathology and Treatment of Gonorrhoea (London: Hardwicke and Bogue, 1876), 44; Packard, History of Medicine (n. 1), 1129.

4. D. Berry Hart, Manual of Gynecology, 4th ed. (New York: J. H. Vail, 1893), 669.

5. Ernst Finger, Gonorrhea (New York: William Wood, 1894), 272-73.

6. Palmer Findley, Gonorrhea in Women (St. Louis: C.V. Mosby, 1908), 40.

7. For works in this vein, see John Duffy, A History of Public Health in New York City, vol. 2 (New York: Russell Sage, 1974); Morris J. Vogel and Charles Rosenberg, eds., The Therapeutic Revolution: Essays in the Social History of American Medicine (Philadelphia: University of Pennsylvania, 1979); John Harley Warner, The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America, 1820-1885 (Cambridge, Mass.: Harvard University Press, 1986); Andrew Cunningham and Perry Williams, eds., The Laboratory Revolution in Medicine (New York: Cambridge University Press, 1992). For more on the various "germ theories" circulating through late-nineteenth-century medical culture, see Michael Worboys, Spreading Germs: Disease Theories and Medical Practice in Britain, 1865-1900 (Cambridge: Cambridge University Press, 2000).

8. For earlier formulations of this thesis, see Vogel and Rosenberg, Therapeutic Revolution (n. 7). The first work to seriously question the "laboratory revolution" was L. S. Jacyna, "The Laboratory and the Clinic: The Impact of Pathology on Surgical Diagnosis in the Glasgow Western Infirmary, 1875-1910," Bull. Hist. Med. 62, no. 3 (1988): 384-406. For more recent revisions of the "laboratory revolution" thesis, see Charles Hayter, "The Clinic as Laboratory: The Case of Radiation Therapy, 1896-1920," Bull. Hist. Med. 72, no. 4 (1998): 663-88; Christiane Sinding, "Making the Unit of Insulin: Standards, Clinical Work, and Industry, 1920-25," Bull. Hist. Med. 76, no. 2 (2002): 231-70; Gayle Davis, "The Cruel Madness of Love": Sex, Syphilis, and Psychiatry in Scotland, 1880-1930 (New York: Rodopi, 2008), esp. chap. 4. Some of the most up-to-date scholarship on the nature of the relationship between the lab and the clinic in turn-of-the-century medicine has recently been published in Soc. Hist. Med. 24, no. 3 (2011); see in particular, Steve Sturdy, "Looking for Trouble: Medical Science and Clinical Practice in the Historiography of Modern Medicine," 739-57; Morten Hammerborg, "The Laboratory and the Clinic Revisited: The Introduction of Laboratory Medicine into the Bergen General Hospital, Norway," 758-75; Rosemary Wall, "Using Bacteriology in Elite Hospital Practice: London and Cambridge, 1880-1920," 776-96; Mirjam Stuij, "Explaining Trends in Body Weight: Offer's Rational and Myopic Choice vs. Elias' Theory of Civilizing Processes," 796-812.

9. In arguing that "patient testimony" played such a critical role in determining the outcome of the debate over latent gonorrhea, I do not mean to suggest that patients themselves were important in resolving this medical controversy. The distinction is an important one to make; though many scholars have convincingly shown the power turn-of-the-century patients wielded in their relationships with physicians, they played almost no role in resolving debates among medical authorities of the time. For an excellent analysis of the impact of patients on these matters in more recent times, see Steven Epstein, Impure Science: AIDS, Activism, and the Politics of Knowledge (Berkeley: University of California Press, 1996). For scholarship on patient power in earlier periods, see Jill Harsin, "Syphilis, Wives, and Physicians: Medical Ethics and the Family in Late-Nineteenth Century France," French Hist. Stud. 16, no. 1 (1989): 72-95; Nancy Theriot, "Diagnosing Unnatural Motherhood: Nineteenth-Century Physicians and 'Puerperal Insanity,'" in Technical Knowledge in American Culture: Science, Technology, and Medicine since the Early 1800s, ed. Hamilton Cravens, Alan I. Marcus, and David M. Katzman (Tuscaloosa: University of Alabama Press, 1996), 73-90; Regina Morantz-Sanchez, "Negotiating Power at the Bedside: Historical Perspectives on Nineteenth-Century Patients and Their Gynecologists," Fem. Stud. 26, no. 2 (2000): 287-309; David G. Schuster, "Personalizing Illness and Modernity: S. Weir Mitchell, Literary Women, and Neurasthenia, 1870-1914," Bull. Hist. Med. 79, no. 4 (2005): 695-722; Sally Wilde, "Truth, Trust, and Confidence in Surgery, 1890-1910: Patient Autonomy, Communication, and Consent," Bull. Hist. Med. 83, no. 2 (2009): 302-30. Interestingly, one of the only studies to connect lay and patient interests to debates between bacteriologists and clinicians is on gonorrhea; see Michael Worboys, "Unsexing Gonorrhoea: Bacteriologists, Gynaecologists, and Suffragists in Britain, 1860-1920," Soc. Hist. Med. 17, no. 1 (2004): 41-59.

10. "Excerpta," Atlanta Med. Surg. J. 14 (1877): 631-32.

11. "Physicians of all nations united in denouncing him," said one historian of the early reaction to Noeggerath's ideas. Robinson, Story of Medicine (n. 2), 425.

12. George Engelmann, "Induction of Miscarriage in Case of Placenta Praevia," St. Louis Courier Med. Collateral Sci. 4 (1880): 377-85.

13. Quoted in "Reviews," Amer. J. Med. Sci. 77 (1879): 168-76, quotation on 175.

14. John T. Darby, "Clinical Remarks on Gonorrhoea in the Female," Med. Gazette 3 (1878): 392-94, quotation on 394.

15. J. M. Richmond, "Remarks on a Few of the Surgical Diseases of the Pelvic Organs," Trans. Med. Assoc. State Missouri 22 (1879): 39.

16. In his 1877 report, Goodell spoke of a case of sterility that he attributed to a woman's husband, particularly to the lack of sperm in his semen. Based on this, he concluded that "I am also led to think that, in the majority of these cases of unfruitful marriage which have been attributed to a latent gonorrhea in the woman, it is reasonable to attribute the sterility less to an alleged secondary infection of the wife's organs, than to the primary disorder of the husband's." William Goodell, "Case of Sterility," Obstet. J. Great Britain Ireland 4 (1876-77): 171-72, emphasis added.

17. Bumstead, Pathology and Treatment (n. 3), 210. "Clap" was a popular euphemism for gonorrhea.

18. For more support of latent gonorrhea in the period 1876-80, see E. Cross, "Latent Gonorrhea," St. Louis Clin. Rec. 4 (1878): 205-6; Elizabeth Griselle, "Peri-Uterine Cellulitis and Its Sequelae," Trans. Session Med. Soc. State California 9 (1879): 236-41; "Reviews," Amer. J. Obstet. Dis. Women Child. 13 (1880): 223-28; "Reviews and Book Notices," North Carolina Med. J. 3-4 (1880): 41-50.

19. At least one of Noeggerath's early supporters conducted microscopical analyses aimed at uncovering gonorrhea's microbial origins. Despite his failures in this regard, the Scottish obstetrician Angus Macdonald heartily endorsed Noeggerath's views, concluding that clinical and biographical evidence was sufficient to the diagnosis of this disease. See Macdonald, "Latent Gonorrhoea" (n. 3), 164-89.

20. Cross, "Latent Gonorrhea" (n. 18), 206.

21. Explaining a typical case, Macdonald wrote of how after "careful inquiry" he was able to verify a husband's history of "gonorrheal discharges for several months before the labour took place." But there was much uncertainty in his claims. "As to the number of months" before labor, he conceded, "it was impossible to gain an absolutely correct statement. On the most close and anxious inquiry, I was unable to make out whether the patient was infected just before labour, or had previously suffered from latent gonorrhea." Macdonald, "Latent Gonorrhea" (n. 3), 173.

22. Bumstead, Pathology and Treatment (n. 3), 210.

23. Milton, Pathology and Treatment (n. 3), 34.

24. "Let any specialist in diseases of the male genital organs inquire of married men coming to [their] office whether they ever had the clap, and, if so, if their wives have since been healthy and borne children," Bumstead declared, "and he will find the answers not corroborative of Dr. N's views." Bumstead, Pathology and Treatment (n. 3), 210. Macdonald, "Latent Gonorrhoea" (n. 3), 188-89.

25. It might be thought that physicians' reticence with regard to latent gonorrhea was also a result of their belief that this venereal disorder did not affect women, as Worboys's article on "Unsexing Gonorrhoea" (n. 9) suggests. As a matter of fact, both supporters and opponents of Noeggerath's theory believed that gonorrhea was a disease of both sexes, though several likely agreed with Bumstead that "[G]onorrhoea is a much less common disease in women than in men." Bumstead, Pathology and Treatment (n. 3), 186. For more on this, see Darby, "Clinical Remarks" (n. 14), 392; Richmond, "Remarks" (n. 15), 39.

26. "About Books," Amer. J. Syphilography Dermat. 4 (1873): 187-88.

27. Darby, "Clinical Remarks" (n. 14), 394.

28. "Recent Literature," Boston Med. Surg. J. 156 (1877): 589.

29. See "Gonorrheal Infection in Women," in The Year-Book of Treatment for 1886 (Philadelphia: Lea Brothers, 1887): 207-11, esp. 209; "Gonorrheal Infection in Women," Practice: J. Busy Doctor 2 (1888): 130-32; "Abstract and Selections," Obstet. Gazette 11 (1888): 659-60; Leslie A. Phillips, "Gonorrheal Infection in Women," New Engl. Med. Gazette 25 (1890): 13-19; William Pepper, ed., A System of Practical Medicine by American Authors 4: Diseases of the Genito-Urinary and Cutaneous Systems (Philadelphia: Lea Brothers, 1886), 229; August Eduard Martin, Pathology and Therapeutics of the Diseases of Women, trans. Ernest W. Cushing (Boston: E.W. Cushing, 1890), 220; Woodward D. Carter, "Diagnosis of Gonorrhea of the External Generative Organs of the Female," Hahnemannian Monthly 35 (1900): 453-54; Chalmers Watson, ed., Encyclopedia Medica, vol. 4 (New York: Longmans, Green, 1900), 194; George Granville Bantock, "The Modern Doctrine of Bacteriology, or the Germ Theory of Disease, with Special Reference to Gynaecology," Brit. Gyn. J. 15 (1899): 18-50, esp. 23.

30. Joseph Price, "Gonorrhoeal Diseases of the Uterine Appendages," Med. Surg. Rep. 60 (1889): 328-34, quotations on 328-29, 332.

31. Ibid., 330, 333, 334; emphasis added.

32. T. Griswold Comstock, "Infection of Gonorrhoea and Its Serious Consequences to Females," Clin. Rep. 2 (1889): 350, 353.

33. See E. Teichelmann, "Gynaecology," Birmingham Med. Rev. 25-26 (1889): 111.

34. Martin, Pathology and Therapeutics (n. 29), 220.

35. Kate Lindsay, "Avoidable Causes of Female Pelvic Disorder," Trans. Michigan Med. Soc. 13 (1889): 222-36, esp. 228.

36. "Report of the Committee on Gynaecology: Gonorrhoeal Infection in Women," in By-Laws, Lists of Members, and Statistics of the Massachusetts Homoeopathic Medical Society (Brookline, Mass.: Chronicle Press, 1890), 46-47. Admitting that existing technologies were "entirely unreliable" in determining a definitive link between "gonorrhea and the many pelvic disorders supposed to result from it," they concluded that "suspicion," the opinions of experienced practitioners, and "the absence of other causes" had decisively settled the matter. See "Significance and Diagnosis of Gonorrhoea in Women," Physician Surg. 8 (1886): 346-48; J. C. Hoag, "Modern Views of Theoretical and Practical Obstetrics," Chicago Med. J. Examiner 58 (1889): 46-60.

37. "Whether such a catarrh may be capable of being diagnosed by finding a special gonococcus," Macdonald said of a typical case, "I do not say here to inquire." Angus Macdonald, "Gonorrheal Ovaritis," Edinburgh Med. J. 31 (1885): 514-18, quotation on 516.

38. "New Observations in Gonorrhea," Buffalo Med. & Surg. J. 34 (1895): 551; Joseph Taber Johnson, "The Curse of Gonorrhea," Amer. Gyn. 1 (1902): 599-609, quotation on 603;

39. "New Observations in Gonorrhea" (n. 38).

40. Examination of twenty-six Noeggerath-friendly articles or books published between 1895 and 1900 reveals only five that mention either Wertheim's name or his experiments.

41. See George Granville Bantock, "On the Importance of Gonorrhoea as a Cause of Inflammation of the Pelvic Organs," J. Gyn. 1 (1891): 97; Orren B. Sanders, "Gonorrhea— Clinical Suggestions," Proceedings of the Massachusetts Homeopathic Medical Society 13 (1900): 218. Recognizing it as "a condition which at present cannot be explained," most of Noeggerath's supporters remained satisfied with their ability to diagnose latent gonorrhea without the aid of laboratory science. W. J. Mayo, "The Various Causes of Pus in the Pelvis," Trans. Minnesota State Med. Soc. 28 (1896): 53-55, quotation on 53. Or as another prominent practitioner put it, "[T]he manner in which [latent gonorrhea] is brought about is not clearly known. In many of these discharges from the male urethra, no gonococci can be found. Very probably in such instances the discharge may act by modifying the vaginal or cervical secretion." John Clarence Webster, Diseases of Women: A Textbook for Students and Practitioners (New York: Macmillan, 1898), 156.

42. W. R. Pryor, "Latent Gonorrhea in Women," J. Cutan. Genito-Urinary Dis. 13 (1895): 89-91.

43. Frederick John McCann, "The Aetiology of Gonorrhoea," Trans. Obstet. Soc. London 38 (1897): 250-53.

44. Bantock, "Modern Doctrine" (n. 29), 23.

45. Robert W. Taylor, The Pathology and Treatment of Venereal Diseases (Philadelphia: Henry C. Lea, 1895), 287-89.

46. For more on diagnostic difficulties, see E. C. Dudley, Diseases of Women (New York: Lea Brothers, 1899), 157; Webster, Diseases of Women (n. 41), 156; Lewis Wheat, "Latent Gonorrhea in the Male as a Factor in Diseases of the Female Organs of Generation," Gaillard's Med. J. 72-73 (1900): 977-81; E. Solly, "Septic Rheumatisms," J. Balneology & Climat. 4 (1900), 269-78, quotation on 275.

47. Solly, "Septic Rheumatisms" (n. 46). See also R. Milne Murray, "Notes of a Case Bearing on the Latency of Gonorrheal Infection," Trans. Edinburgh Obstet. Soc. 24 (1899): 12-15; H. R. Holmes, "Gonorrhoea as an Etiological Factor in Diseases of Women," Med. Sentinel 3 (1895): 341-45.

48. J. Noer, "What Are the General Practitioners' Duties Regarding the Prevention of the Spread of Venereal Diseases?," Clin. Rev. 12 (1900): 293-94. See also Mayo, "Various Causes of Pus" (n. 41); C. C. Carmalt, "The Immediate Causation of the Diseases Peculiar to Women," Boston Med. Surg. J. 130 (1894): 68-70.

49. See especially, Finger, Gonorrhoea (n. 5). A supporter of Noeggerath's, Finger pointed out that the diagnosis of latent gonorrhea was "more difficult" than that of the acute variety of the disease, as "the absence of gonococci in these cases does not exclude gonorrhea." This was because in latent gonorrhea, the practitioner dealt with "secondary infections in which the gonococci were finally overcome," he hypothesized. Finger, Gonorrhoea (n. 5), 277.

50. Bantock, "Modern Doctrine" (n. 29), 23.

51. Frank Glenn, "The Treatment of Gonorrhoea," Indiana Med. J. 16 (1898): 234. "The conservative belief of recent times," one writer observed in 1899, "is that a very large number, a majority, of old gonorrheal patients of both sexes continue to harbor gonococci within their genito-urinary spheres for months or years, and sometimes for a lifetime, unless they have received very intelligent treatment which the most skillful specialists alone are able to give." James Foster Scott, The Sexual Instinct: Its Use and Dangers as Affecting Heredity and Morals (New York: E.B. Treat, 1899), 377. Noting that Noeggerath's theory about female inflammatory affections had been "disbelieved" in his day, the prominent New York gynecologist D. Berry Hart wrote in 1893 that his views were "now in great part held by most." Hart, Manual of Gynecology (n. 4), 669. See also H. W. Longyear, "Some of the Recent Advances in the Treatment of Intra-Peritoneal Diseases," Trans. Michigan State Med. Soc. 17 (1893): 275-89, esp. 278; Thomas M. McIntosh, "Observations Abroad," Southern Med. Record 22 (1892): 337.

52. "Editorial: Gonorrheal Infection," Med. Adv. 25 (1890): 135.

53. See Prince Albert Morrow, Social Diseases and Marriage: Social Prophylaxis (New York: Lea Brothers, 1904),129; Johnson, "Curse of Gonorrhoea" (n. 38): 599-609; Findley, Gonorrhoea in Women (n. 6), 39; M. Thorner, "Endometritis," Indiana Med. J. 25 (1907): 299-312; E. E. Reininger, "Chronic Gonorrhoea," Proc. Internat. Hahnemannian Assoc. 25 (1901): 281-300.

54. Thomas Clifford Allbutt and W. S. Playfair, eds., A System of Gynaecology (London: Macmillan, 1906), 51.

55. "In the chronic cases," a Dr. J. G. Sherrill noted in a discussion on latent gonorrhea held at the 1902 gathering of the Southern Surgical and Gynecological Association, "we frequently find gonococci absent, in other words, we cannot get them out of their inferior connection with the tissues and demonstrate them by the microscope." Johnson, "Curse of Gonorrhoea" (n. 38), 80. See also Henry Jacques Garrigues, Gynecology, Medical and Surgical (Philadelphia: J.B. Lippincott, 1905), 8.

56. Reinhold Ledermann, "Gonorrhoea and Expert Testimony," Amer. J. Dermat. 14 (1910): 517. See also Florence N. Ward, "Surgical Treatment of Gonorrhea in Women," Pacific Coast J. Homeop. 19 (1908): 43.

57. L. L. Danforth, "The Physical Signs and Treatment of Gonorrhoea in Women," Trans. Homeop. Med. Soc. State New York 37 (1902): 152-55.

58. G. Frank Lydston, "Some of the Fallacies in the Clinical Diagnosis of Gonorrhoea," Surg. Gyn. Obstet. 1 (1905): 439-40, quotation on 440, emphasis added. See also George Armstrong, "Gonorrhoea as a Cause of Disease of the Uterine Appendages," Massachusetts Med. J. 29 (1909): 43-54.

59. Murray, "Notes of a Case" (n. 47), 14.

60. "From my own knowledge of the man and of his habits of life," Murray concluded, he had "no difficulty in believing" his patient's testimony. Ibid., 13.

61. Ferdinand Charles Valentine, The Irrigation Treatment of Gonorrhoea (New York: William Wood, 1900), 169.

62. Charles C. Norris, Gonorrhea in Women (Philadelphia: W.B. Saunders, 1913), 124.

63. George R. Livermore, "A Plea for the Education of the Public to the Seriousness of Gonorrhea," Memphis Med. Monthly 30, no. 9 (1910): 463. See also "Double Pyosalpinx," Amer. J. Dis. Women Child. 40 (1899): 415; J. B. Greene, "Gonorrheal Peritonitis," Progress 2 (1888): 58-61; W. E. Fitch, "The Remote Effects of Latent Gonorrhea in the Female," Trans. Med. Assoc. Georgia 54 (1903): 370-80.

64. "Wiley v. Wiley," Northwestern Rep. 151 (1915): 205-10.

65. T. M. Reade, "Gonorrhea and Marriage," Lancet-Clinic 99 (1904): 29-32, quotation on 30. For more examples, see S. Jervois Aarons, "Leucorrhea—Its Causation and Treatment," Med. Brief 26, no. 1 (1898): 521. At times "latent gonorrhea" seems to have benefited women; for examples of this, see Valentine, Irrigation Treatment (n. 61), 169-71; Almo De Monco, "Non-Specific Urethritis," California Eclectic Med. J. 4 (1911): 258-61. For a case in which latent gonorrhea helped a wife obtain a divorce, see "Stella Winifred Holmes v. Frank A. Holmes," in American Law Reports Annotated 8, ed. Burdett A. Rich and M. Blair Wailes (Rochester, N.Y.: Lawyers Co-operative, 1920), 1534-40.

66. Charles M. Carpenter and Robert S. Westphal, "The Problem of the Gonococcus Carrier," Amer. J. Pub. Health 30 (1940): 537-41.

67. "Clinical Notes," Med. Council 6 (1901): 198. For more examples of patient's influence, see H. J. Boldt, "Gonorrheal Pyosalpinx," Ann. Med. Pract. 15 (1902): 166-68; August A. Hussey, "Gonorrhea in Women," Brooklyn Med. J. 17 (1903): 171-74; Palmer Findley, "Gonorrhea in Women," Amer. Med. 11 (1906): 387-95.

68. T. Griswold Comstock, "Chronic Endometritis, Leucorrhea, and Uterine Catarrh," Clin. Rep. 3 (1890): 162.

69. Just as late-nineteenth- and early-twentieth-century gynecologists subscribed to the view that Neisser's gonococcus provided "proof" of Noeggerath's theories, so have some modern-day authors acceded to the view that latent gonorrhea's truth was "unknown until the day of bacteriological study" (Lavinia L. Dock, Hygiene and Morality: A Manual for Nurses and Others, Giving an Outline of the Medical, Social, and Legal Aspects of the Venereal Diseases [New York: Putnam, 1910], 41). According to physician-historian Ira Rutkow, although Noeggerath's 1876 address was initially "met with much skepticism," the gynecologist "was proved correct a few years later when the gonococcus was discovered." Ira Rutkow, The History of Surgery in the United States, 1775-1900, vol. 2 (San Francisco: Norman, 1992), 115.