until the cul-de-sac opening closes and the post-cervical scar has contracted. The operation leaves the corpus uteri perfectly free. Pregnancy resulting after the operation is uninterrupted, and labor is normal. Lacerations and disease in, the cervix and perineum are to be cor

rected after the patient has recovered from the replacement operation, and are made purely to supplement the first operation. The rules governing these plastic operations are the same as apply after hysterorrhaphy, etc.

The operation in my hands takes the place of all other

operations. It has a wider range of application than any other procedure, and can be used in all cases not presenting pus. When the retroposition is accompanied by occluded tubes, by hydrosalpinx, by cystic ovaries, etc., this is the preferable operation. But when pus is present in either ovary or tube removal of this and replacement can only be accomplished by laparotomy.

BROAD-LIGAMENT ABSCESS.

This rare condition almost invariably follows labor or abortion. The infection passes along the lymph streams between the folds of the broad ligament, and causes suppuration there. The pus forms very slowly usually. In the epidemic of puerperal fever which occurred in New York in 1881-82, the author saw a great many of these cases, but they are now comparatively rare. I have met with but six in the last 1,000 clinic cases. As the pus accumulates, it separates the folds of the broad ligament. The bladder in front prevents much bulging anteriorly, so the greater part of the distention of the broad ligament is posteriorly. As this grows larger, the peritoneum is stripped from the posterior surface of the uterus and is lifted up; the peritoneum of the pelvic floor behind. the broad ligament is also lifted, and the masses may be so large as to reach Poupart's ligament. The fluid is essentially extraperitoneal. It is suppuration in continuity of tissue, and is far different in all its bearings from suppuration in a preformed sac (pyosalpinx). Coexistent with this formation, there is a great amount of peritonitic effusion about the broad ligament. There may also be a pyosalpinx or ovarian abscess present. After the abscess reaches a large size, the gross lesion presented is of an abscess cavity lying upon the pelvic floor, to one side of which is the displaced uterus, and above which lies the matted mass of omentum and intestines. In rare cases the abscess is bilateral. In such the pus may extend

in front of the uterus and between the bladder, so that the two abscesses communicate.

Symptoms.-These are at first not suggestive of broad ligament abscess. After a long attack of continuous pelvic inflammation, in the course of which there have been many rigors and violent fluctuations in temperature, this condition may be suspected. Upon examination, the uterus is found crowded up high and to one side. It is sometimes so displaced that the cervix cannot be felt. Extending from the side of the uterus to the lateral pelvic wall is a large mass, tense and fluctuating. This mass is sessile upon the uterus, i. e., there is no sulcus between the mass and the uterus. It is immovable

and fixes the uterus. It projects in all directions when large, and can be felt behind the bladder, above Poupart's ligament and deep in the pelvic floor. There are evidences of a severe type of pelvic inflammation. The bladder is capable of holding but a few ounces of urine. when the abscess is large, and the lumen of the rectum is almost closed. Upon rectal examination, the mass is found apparently attached to the rectum if it has stripped up the pelvic floor. About the only conditions simulating this are, dermoid cysts, ectopic gestation ruptured and septic, and broad ligament cyst. But the history of a labor or abortion, long-continued sepsis, and a gradually enlarging tumor, which is always sessile, even when small, and which undoubtedly occupies the broad ligament, will render the diagnosis clear. When the accumulation is small, the finger readily enters the incised cul-de-sac. The enlargement is found to be upon one side of the uterus, and the posterior wall of the broad ligament bulges backwards. A slight pressure against the mass suffices to evacuate the pus, rendering the diagnosis clear. With this pus formation, there has been much peritonitis, and the examining finger evacuates the lymph and serum produced by this. The pelvic viscera, where they can be reached, are found matted together. The ovary and tube upon the affected side are raised high in the pelvis. When the abscess is large, the

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finger cannot be made to enter the cul-de-sac at all; and upon incising the vaginal mucosa, the finger enters a cavity of loose cellular tissue which bleeds freely. This is produced by the abscess lifting the peritoneum from the pelvic floor. After inserting the finger behind the uterus up to the level of the internal os, it will enter the pus sac at once, or will find it if turned laterally toward the fluid mass.

This lifting of the pelvic peritoneum is characteristic of all large broad ligament accumulations.

stant.

Treatment.-All these accumulations should be treated through the vagina. They should be opened through the posterior cul-de-sac and evacuated. For this purpose the fingers alone are to be used after the vaginal wall is incised, as the position of the vessels is not conIf the cul-de-sac is entered before the abscess is emptied, it, as well as the abscess cavity, must be packed with gauze. If the examining finger enters at once into the pus cavity, it is to be widely stretched and packed. The after dressings are governed by the amount of discharge and the temperature. It is wise to curette the uterus before opening the cul-de-sac. After dressing the abscess cavity the uterus is to be packed with iodoform gauze, which in two days is withdrawn.

DIFFUSE PELVIC SUPPURATION.

This must not be confounded with primary purulent peritonitis. There has been suppuration in either the ovary, the tube, or the broad ligament. Accompanying this there has been a virulent form of peritonitis, and a great outpouring of plastic lymph has ensued. Sometimes this lymph breaks down into pus; in other cases the original pus focus leaks into the lymph masses. a result the pus has ceased to be confined in either tube, ovary, or broad ligament, but has wormed its way between adherent lymph planes, omentum, and intestines.

As

More lymph is produced, and wider burrowing of pus ensues, thus presenting a picture of indistinguishable organs within and between which are pus pockets and connecting sinuses. This is diffuse suppuration.

Symptoms. The history is usually one of prolonged suffering, recurrent attacks of peritonitis, emaciation, and hopelessness. The woman is practically bed-ridden. Upon examination the uterus is found firmly imbedded in a mass of exudate. The uterus, ovaries, tubes, and other pelvic organs form one dense conglomerate mass. The diagnosis from small fibroid or ruptured ectopic pregnancy with pus is impossible. Broad ligament cysts, ovarian tumors, simple fibroids, etc., do not present the immobile sensitive uterus, profound sepsis, emaciation, and mal-nutrition which accompany diffuse suppuration. Nephritis and phthisis are common accompaniments. I have usually found the rectum permanently distended in these cases. It cannot contract.

Very often sinuses form between the bowel and the pus foci, affording a temporary relief when the pus escapes into the gut, followed by great increase in the lesions from contamination by bowel filth.

Upon opening the cul-de-sac, the finger at once evacuates pus lying free in the pelvis. The exploration is purely digital, and as the finger maps out the various organs it enters pocket after pocket of pus. The livid lymph-covered intestines are found low down usually, pressed down by tympanites, and tend to protrude into the vagina when freed. Above the uterus and adnexa is an impenetrable dome of matted intestines and omentum.

Treatment. Many of these women are so critically ill that a radical operation is contraindicated. The first step is usually to inject a quart of sterile and filtered normal salt-solution into the elbow vein. The uterus is curetted. The cul-de-sac is opened, and all pus pockets emptied. The pelvis is wiped dry with gauze. Irrigation should never be employed for this purpose, lest the pus be washed into the higher pelvis and abdomen. After evacuating all the pus cavities and thoroughly