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extension by continuity of tissue. As a result we have salpingitis, ovaritis, and peritonitis the complications, and never see primary broad ligament abscess result. In view of the ravages which unchecked gonorrhea works in a woman's pelvis, the very first symptom must be vigorously met. The joint complications sometimes. seen in men, I have never seen in women, but they do occasionally occur. Women who have had true gonorrheal endometritis and in whom it is not radically cured are always sterile. Those cases which do not produce some complication result in a chronic condition. My belief is that gonorrhea of the endometrium is never cured except by surgical means.

CHRONIC GONORRHEAL ENDOMETRITIS.

Symptoms.-Chronic gonorrheal endometritis is about the happiest result to be expected from an acute attack. I do not find the chronic state other than as a result of the acute. There is slight enlargement of the uterus in some cases; but old cases who have had repeated attacks, have usually small, hard uteri. The cervix in all is usually the seat of folliculitis with erosions. There is always a purulent discharge. The condition may exist without pelvic complications, but I have never seen it. Uterine pain is not present, but where the uterus is persistently enlarged there is a sense of weight in the pelvis. Whenever in such cases there is marked pelvic pain, it is an absolute indication that the causative acute attack has resulted in damage to the periuterine tissues. As a result of the aggressiveness of pelvic surgery a godd many supposed conditions have been properly eliminated from our pathology, and many apparently innocent states of the uterus have been found to be accompanied by pronounced disease in the adnexa. As I said above, I do not find chronic corporal gonorrheal endometritis without complications. It is these complications so difficult to detect which produce the distressing symptoms and not the chronic inflammation in the uterus. These women are generally sterile.

Diagnosis. For clinical purposes chronic inflammations of the uterus are characterized by one prominent symptom-a purulent discharge. There being no evidence of adnexal disease, we may put the case down as not due to gonorrhea. But far more difficult is it to determine whether the cervix alone or the entire endometrium is involved. To settle this the endocervicitis must first be cured. If this is easily accomplished, the flow of pus checked, and relapses without apparent cause do not occur, we can be sure that the pus did not come from above the os internum. But where the cervix remains inflamed under persistent treatment, or where the purulent discharge continues after the cervix is brought to a normal condition, we may know that the eudometrium is involved. The persistence of the discharge despite energetic measures applied to the cervix convinces us that the corporal endometrium is inflamed. The patient's word cannot be relied upon in determining this, for she probably douches and washes away discharges. A piece of cotton large enough to fill the vaginal vault is wrung out in Thiersch solution and applied over the cervix. It is kept there by vaginal taınpons. In twelve hours it is removed and the amount of pus discharged in that time can be determined. Treatment.—The presence of bar to the methods of treatment. ciently open for the purpose, the out (see Septic Endometritis). But as all the cases of chronic general gonorrheal endometritis which I have met have some degree of adnexal disease, I advocate curettage and the cul-de-sac operation (see Cul-de-Sac Operation). A curettage alone undoubtedly checks the source of infection, and, following it, some repair ensues in the inflamed adnexa. But we must consider both intra-uterine washings and curettage as merely palliative. If a radical cure is to be effected, the adnexa must be directly treated through the cul-de-sac. For a long time it has been my belief that chronic gonorrheal endometritis is never found except as a result of an acute pro

adnexal disease is no If the cervix be suffiuterus may be washed

cess, and in this respect gonorrhea of the uterus differs from septic endometritis which may from the first be devoid of acute symptoms.

In no form of purulent endometritis do I ever make applications. These, while destroying pyogenic cocci, also kill the superficial cells of the endometrium and furnish no means for the escape of the destroyed tissue. The history-books of all of us bear many cases where acute pelvic inflammations have resulted from intrauterine applications.

TUBERCULAR ENDOMETRITIS.

Tubercular disease of the cervix is exceedingly rare, the disease being usually limited to the body of the organ. But it is occasionally met with, and then is secondary to vaginal tuberculosis. Occurring in the cervix the disease is either miliary or ulcerative, and is not often diagnosticated without the aid of the microscope; the miliary tubercles being mistaken for small cervical cysts and the ulcers for carcinoma.

It is rare to find the cervix and corpus uteri involved in the same individual; the uterus being affected secondarily, the cervix from the vagina, the endometrium from the peritoneal face of the uterus.

Symptoms.-Tubercular endometritis produces profuse leucorrhea which may contain caseous masses. The uterus is enlarged. Where menstruation occurs it is irregular or profuse, but the concomitant cachexia generally produces amenorrhea in the later stages. Otherwise the symptoms are those of chronic endometritis, plus the general symptoms of general tuberculosis where

that exists.

Diagnosis. Without finding the tubercle bacillus, a positive diagnosis is impossible. It is not necessary to excise portions of ulcerating tissue; the discharge will show the bacillus.

Treatment.--Whenever a diagnosis can be made, exsection of the affected portion is indicated if it possibly

can be done. The cervix without a tendency for the disease to extend upwards, may be amputated. But palliative treatment can not be applied to the corpus uteri, and curettage alone will not check the disease. Total vaginal extirpation of the uterus and adnexa is indicated, both because the uterine disease is commonly secondary to adnexal tubercular disease, and because extirpation of the tubercular uterus works such marvellous changes in the metabolism of the blood as to hold in abeyance for years tubercular lung disease. Because of local and general reasons, if I may so term them, hysterectomy is indicated in corporal tuberculosis. Any other operative procedure but plays with the disease, opening new channels for its extension. Local treatment is useless. Excision is the treatment for tubercular disease of the genitals. I have seen a phthisical woman gain thirty pounds in two months after this operation. No one who has not estimated the quantity, often ounces a day, of discharge coming from these women can have any idea of the drain upon their systems.

The failure of agents lauded as corrective of tuberculosis to even modify the disease when the organ is within easy access and the treatment applied under the eye, is a commentary upon the methods of reasoning of those who advocate them.

Sequelæ. When occurring as a primary disease, uterine tuberculosis will surely extend to the peritoneum and adnexa, to be followed by general tuberculosis.

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PELVIC INFLAMMATION.

Up to a few years ago it was undoubtedly the practice with most surgeons to remove through the abdomen all ovaries and tubes which presented evidences of inflammation, whether these were diseased primarily, or as the result of a lymphatic infection in the pelvis. So long as this remained the established rule of procedure in dealing with tubo-ovarian disease, precise differentiation of the various lesions was not necessary. But a more careful study of the manner in which the gross lesions were produced, together with the application of those general surgical principles which govern the treatment of inflammatory lesions elsewhere, has taught us the necessity for carefully separating those lesions which necessitate the removal of the diseased organs from those which are relieved by conservative measures. It therefore becomes our duty to enter into a thorough analysis of each case. To do this it is not essential to a proper conclusion that a bacteriological examination be made, but the correct treatment can be reached by studying the clinical history of each case. Although the ovaries and tubes, as well as the pelvic peritoneum, will probably suffer in most cases where the infection passes outside the uterus, yet all the structures will not be equally damaged. The manner in which the infection reaches the pelvic structures as well as its nature will indicate somewhat the organ we will find most affected. In all infections, for instance, occurring in the uterus pregnant after the third month, those lesions which result from pelvic peritonitis are to be expected, for in such a uterus the lymph streams and not the tubes are the chief carriers of the infecting agents. And inasmuch as the poison of gonorrhea travels not through the lymphatics, but through direct continuity of tissue along the uterus