The spirit predominant throughout this book is that of an aggressive interference. Yet I have generally laid down also a palliative method of treatment for each disease, to be applied where operation cannot be done I have told what I think and do. The views and methods of others can readily be procured from the medical press. And as I write ex cathedra, quotations and references are unnecessary. Still, it must not be imagined that all herein contained is claimed as original. The contribution of any one of us must nowadays be small as the science progresses, and I take pleasure in acknowledging my indebtedness to Récamier, Péan, Ségond, and Pozzi in Europe, and to Gaillard Thomas, Byford, and Henrotin in America.

I have had great assistance in the pathological work from Dr. F. M. Jeffries, who has been as interested in the work as I; Mr. C. L. Remele has been most painstaking in photographing the specimens; and to Miss Fanny Elkins is due all credit for the illustrations of the operations. I can only hope that I may succeed in directing the attention of the general practitioner to a surgical treatment of the infectious pelvic diseases of women; and if I do so, he will find in these pages some hints which may be of service to him.

WILLIAM RICE PRYOR.

ENDOMETRITIS.

General Considerations.-Believing that the phenomena of inflammation in the female genitals have the same general significance as when occurring in other parts of the body, and that pus produced by such inflammation is caused by the same pyogenic cocci as cause inflammation elsewhere, my conception of its treatment is distinctly surgical. In view of the ravages which these inflammations, when neglected, work in woman's special organs, organs important to her no more than to the community, organs so intimately associated with her mental and social as well as her physical life, I am an advocate of energetic methods of treatment. Pyosalpinx, ovarian abscess, and peritonitis rarely occur except through the medium of the uterus. The excepted cases where the intestinal tract is to blame for the pelvic lesions are so rare that they but emphasize the rule. Such being the case, the importance of properly treating endometritis is apparent.

But while we combat their diseases, the special functions of the organs must be considered, and in our endeavors to check an invasion from without we must so act as to do the least damage to that peculiar membrane, the endometrium, whose function it is to produce the decidual cell. Therefore I advocate the use of large quantities of mild antiseptics as washes, agents which by their bulk ensure cleanliness, and by their innocuousness do not damage the tissues. Conversely, I am opposed to the use of small quantities of powerful escharotic antiseptics, such as carbolic acid, zinc chlorid, etc. The greater the degree of infection within a cavity, the less the indication for strong antiseptics; for these but de- i

stroy tissue in a locality whose vitality is already damaged' by inflammation, and by the slough caused they produce the most propitious culture medium for the germs not removed. Dead tissue must be cast off by suppuration. If after curettage, for example, in chronic purulent (septic) endometritis, the raw surfaces be painted with carbolic acid or even iodin, the intra-uterine packing of iodoform gauze will be followed by temperature. Why? Because the superficial slough produced by the application is not removed by the dressing, retention results, and recovery is accompanied by fever. But if after a clean curettage the uterus be irrigated with boric acid. solution, the gauze dressing protects the uterus while the endometrium is in process of repair, and the convalescence is afebrile. Sterility commonly follows one method, conception can be expected after the other. That is, the function of the uterus is partially destroyed by one, while its return to a physiological state is promoted by the other.

So far as the treatment of endometritis is involved, the physician is concerned clinically with whether it is purulent or non-purulent. If purulent, applications to the endometrium are contra-indicated: if non-purulent, applications may be used. But great care must be exercised lest the innocent form be converted into the virulent type. Whenever pus is discharged from the uterus, the woman's position is just the same as that of any other patient who has a purulent discharge from some other part of the body; it is a surgical case. With our present precise methods of examination, and in view of our ability to do clean work under all circumstances, there no longer exists any excuse for employing the opium, poultice, and douche treatment of a spreading infection. The moment a physician.sees pus escape from the uterus his anxiety must begin, and the instant an extension to the adnexa or peritoneum sets in, his responsibility becomes great. A woman who has once had tubal or peritoneal disease occupies an unfortunate position in society; she has before her all her life a possibly dangerous operation. For