lapse, should be considered from an operative standpoint only. When a patient has recovered from an attack, with her pelvis filled with inflammatory exudate and numerous adhesions, producing a condition of semi-invalidism, she will have to be operated before health can be restored. Some of these cases are relieved to a limited extent by tampon treatment; but such cases are few and far between. Before tampon treatment is inaugurated in any case of tubal disease, a systematic, pelvic examination should be made in order to ascertain that the case is one suitable for a slow absorption of the exudate by internal medicines and tampon treatment persistently carried out. Such selected cases require several months of persistent treatment to effect permanent relief.

The conservative work performed upon the Fallopian tubes and ovaries is the outcome of long experience by operators in gynic surgery. Total ablation in the treatment of all pelvic disorders requiring surgical interference is justly a thing of the past. Few cases operated at the present day will suffer the regret in future years that inevitably follows such procedures. In rare cases where total ablation becomes necessary the woman often exchanges one condition of suffering for another equally disagreeable, with perhaps the freedom from acute, physical pain, as the solitary, mitigating circumstance. The neurologists have brought our attention to these facts, and they deserve the most careful consideration on the part of all operators. The woman who, by the performance of an operation, has been endowed with hot flashes, dyspnoea, vertigo, rapid taking on of fat, and the loss of sexual desire, remains still a subject for the physician's care. In many cases where the most obstinate and troublesome symptoms have been present, complete relief will be afforded by puncture of an ovary and the liberation of adhesions. Where the Fallopian tubes have been the offending members, conservative work, such as the opening and thorough cleansing of the tube and freeing of both ostia, will be followed by the same prompt relief. I have seen many cases that have required extensive operative measures upon the pelvic organs, where the leaving of a small portion of an ovary prevented an early climaxis.

In every abdominal operation for disease of the Fallopian tube or ovary I have removed all tissue which was diseased be

yond repair, and at the same time have endeavored to save portions of an organ, sufficient to insure the performance of its normal function, even though such function were only partial. In looking over my records I find 87 cases where a part of a diseased ovary or tube was left in situ, and among these cases there were no fatalities. This is mentioned because many operators condemn conservative work upon the tubes and ovaries where a part of the organ has been diseased, asserting that such procedures increase the mortality-rate. Conservative surgery of this character depends upon several factors for its ultimate successful results. Primarily, when part of an organ is left, we must be sure that the blood-supply to that portion is sufficient. When the Fallopian tube has been operated upon and its diseased areas removed, in order to insure ultimate success, the endometrium must be placed in an aseptic state by curettage and the application of antiseptics to its surface if necessary, thus preventing a reinfection of the mucosa of the tube from the cavity of the uterus.

These remarks do not include all cases. A woman who is nearing the menopause will not be benefited by conservative work in the pelvis. The judgment of the operator must decide whether or not an ovary or tube can be saved. In the treatment of salpingitis the fimbriated extremity is found closed, dilated and club-shaped. Under these circumstances the fimbria is opened, the contents of the tube evacuated and the tube thoroughly washed out with a small syringe, using bichloride solution 1: 4000. After this the tube is straightened out and a fine probe gently introduced, to see that the uterine ostia is patulous. Our object is to keep the fimbriated extremity of the tube open; this is done by slitting up the fimbria a distance of about one centimeter, everting the edges and beginning at the cut surface, suturing around the ostia, coming back to the point of starting, so that the edges cannot come together and agglutinate. (See illustration.)

In hæmatosalpinx, which is usually due to a twisting or prolapsus of the tube, which causes a damming up of the blood, with consequent dilatation of the lumen, the condition is not septic, and tubes thus affected should not be removed. If there is an associated displacement of the uterus, with adhesions, these should be liberated and the uterus brought into

On the right is shown method of suturing Fallopian tube, insuring potency of abdominal ostia. The left side illustrates manner of conservative treatment of ovary.

normal position and retained there by shortening the round ligaments. Hydrosalpinx, which is often the result of an old salpingitis, is a dropsical condition of the tube, which should also be treated by evacuation and sterilization of the lumen, leaving the tube in position for future function. If an ovary is found partially diseased the affected area should be removed; even though only a small portion of the parenchyma of the organ be healthy, it should be left in position, noting carefully that it has the proper blood-supply and that raw surfaces are covered over and all bleeding controlled. (See drawing.) This is important, owing to its bearing upon the future function of the tube. In a given case, a history of recent gonorrhoea, or puerperal infection following either abortion or labor, will cause us to refrain from the usual line of conservatism, owing to the septic character of the infection.

ESERIN IN POST-OPERATIVE INTESTINAL PARALYSIS.

BY THEODORE J. GRAMM, M.D., PHILADELPHIA.

(Read before the Homeopathic Medical Society of Pennsylvania.)

THE condition of threatened or existing post-operative intestinal paralysis is one of such serious import in abdominal section cases that operators have long ago learned to dread the symptoms of its advent. They have also learned that its occurrence cannot always be predicted from the character of the case subjected to operation, for this dangerous condition may arise in certain cases in which the pathological lesion is not nearly so serious as in other cases which recovered. The surgeon, therefore, is concerned for his abdominal section cases until the day has arrived upon which the patients' bowels are usually moved, and until that result has been successfully accomplished; for with this evidence of the restoration of the intestinal function we know that the immediate dangers from the operation have largely been successfully overcome. The desire to attain this first step in successful after-treatment has suggested a number of methods of procedure, and has also led to some diversity of opinion as to the choice of the cathartic

drug. This idea of early post-operative catharsis, particularly by means of salines, rests, I believe, upon the suggestion of Lawson Tait respecting the stimulation of the absorptive powers of the peritoneum by catharsis; thus will not only infection within the peritoneal cavity be limited, but the action of the bowels will also be early restored accompanied by all the good results which naturally follow. The time when the cathartic shall be administered has also been much debated, and the tendency, at least in America, has been constantly to diminish the interval for the bowels to move after operation, so that in some instances the cathartic has been given before the operation. Personally, I am thoroughly convinced that in some cases the cathartic may be given too soon. In many instances there is comparatively little difficulty encountered in getttng the bowels to move on the second or third day. But sometimes the attempt is not at once successful, due no doubt to defective absorption and impaired reaction, and then the cathartic may be favorably supplemented by enemata, either simple or compound. Washing out the stomach is also advantageous in overcoming flatulence and allaying vomiting, in removing matters which have undergone fermentation, in counteracting the effects of the excretion of ether through the stomach, and in favoring absorption. But these measures at times fail, and their repetition not only does not succeed, but seems directly to aggravate the general condition of the patient, so that insidiously is brought about a condition of the gravest danger. It is not necessary to dwell upon the distressing details of that awful picture, for every abdominal surgeon has doubtless had occasion to witness the gradually increasing abdominal distention, nausea, vomiting, prostration, restlessness, rapid pulse and rising temperature, sensitive abdomen, and all the while no inclination to stool or the discharge of flatus.

For a long time this condition was believed to depend upon. peritoneal inflammation, but autopsies have repeatedly failed to reveal the evidences of inflammation, and bacteriological examinations have often confirmed the negative finding. It is well known, however, that when not due to sepsis, this distressing picture is most often exhibited by patients who have been subjected to prolonged operation, during which the bowels have been long exposed and have had to endure considerable hand