vice in making a differential diagnosis between local and general peritonitis. I have seen at ten in the morning a case, apparently, of bilateral pyosalpinx due to abortion, which when operated upon at three in the afternoon was almost moribund. Certain cases of virulent pelvic inflammation will, in a few hours, become general throughout the peritoneal cavity. This is especially true of cases of post-partum and post-abortum infection.

General peritonitis is one of the results to be expected from a policy of delay. The vomiting, rapid pulse, dry tongue, stupor and tympanites, which result from the use of opiates in a grave case of pelvic inflammation will often render a diagnosis of the extent of the infection utterly impossible. The cases where surgeons have opened the belly and found all the disease in the pelvis are many. The surest way to mask the symptoms of pelvic inflammation is to give opium.

Treatment.—OPIATES.—These I rarely use and for a number of reasons. To relieve pain by opiates is to mask the symptoms of extension and complications. The bowels become blocked, and this permits the migration of the intestinal germs; the stomach is deranged, and the bladder function disturbed. Brought to a case of pelvic inflammation, if he contemplates possible operation, the surgeon should withhold opiates. Other means are at his command to ease pain, and the relief afforded by opiates is but a borrowed ease, to be paid back by vomiting, tympanites, and spread of the infection.

INTESTINAL CLEANLINESS. From the first I insist upon this. Placing the patient upon the left side with the hips elevated, I insert a Martin's tube (Fig. 13) and throw into the bowel a quart of tepid normal salt solution. Part of this is retained. To obtain retention the injection should be given at night, or when the bowels do not habitually operate. This cleanses out the colon, flushes the kidneys and allays thirst. I do this each night. The maneuvre is very simple. The outflow tube is corked up, and the fountain syringe is raised four feet

above the bed. The water should be of a temperature of 103° to 105° F. These irrigations, by removing hard fecal masses, and relaxing muscular spasm, relieve pain and prevent tympanites. Purgatives I never use, but mild cathartics, as an ounce of Rubinat water every second morning in a glass of plain water an hour before breakfast, I employ.

There are but two ways of treating these cavity inflammations: the locking-up plan (opiates), and the eliminative. I prefer the latter. No man who has ever

contrasted the two will accept the first.

DOUCHES.-Some patients express themselves as relieved of pain by douches, others dislike to be disturbed.

JOHN REYNDER-CO.

NEW YORK.

FIG. 13.-Martin's tube for rectal irrigation.

But they are demanded where there is much discharge. I prefer to use lysol 4 per cent., at a temperature of 110° F., every four hours.

ABDOMINAL DRESSINGS.-Poultices cause effusions of blood beneath the skin and vary in temperature from 90° to that at which they are put on. I prefer to use an ice-bag over the pubes. It is easier handled and relieves pain, and tends to limit the peritonitis a very little.

FLUIDS. I encourage these women to drink large quantities of water. A good plan is to administer three ounces each hour when awake. Ten drops of lemon juice added will keep the tongue clear. Milk, koumyss, etc., having poor food value, I do not use. Besides, it is difficult to get rid of the cheese left after such preparations. Alcoholics are never indicated. In women deep in infection, and with bad kidneys and thready pulse, I do intravenous infusion. Anesthesia is unnecessary for this. (See Article on TRANSFUSION.) Far better than all drugs is this procedure. It flushes the kidneys, elimi

nates toxins and stimulates the heart. The amount of urea excreted is increased and the albumen diminished. The effect is immediate.

DIET.-Half diet is indicated in mild cases. Farina, hominy, an egg, and a little coffee for breakfast; a little meat, as beef, chicken, chops, etc., with potatoes and cream at midday; chicken soup and toast at four o'clock; and squeezed beef-juice and toast at eight. But all the time an abundance of water.

To those very ill I do not give solids. In the morning, toast, and a very little coffee. Once every three hours after that, either two ounces of chicken broth or one ounce of squeezed beef-juice is given, each time with a little toast. No milk. To those who vomit continuously, I give nutrient enemata. Prepared foods, predigested foods and fermented foods are not to be used.

LOCAL APPLICATIONS.-Pelvic pain, due to inflammation, is diminished by ice-bags over the suprapubic region. Spasmodic pain is eased by poultices. To the vagina, 10 per cent. ichthyol in glycerin, applied by means of a syringe, will reduce pain and act beneficially upon the inflammation at all stages. Local blood-letting, applied to the cervix, is of great value in relieving pain and vascular stasis.

To me, the free purgation used by some is as bad as the opium treatment. All that is needed is a through and through stool once every day or so, but the colon must be kept empty. It is unwise to irritate by strong saline cathartics the thirty feet of intestinal mucosa. Sepsis in the pelvis is not checked by it, and shock is increased. Perfect rest in bed is imperatively necessary. The non-operative treatment of pelvic inflammations seeks the improvement of the tissue-resistance; limitation of the infecting agent; and maintenance of the general strength while the invaded organs are overcoming the infection.

ACUTE GONORRHEAL SALPINGITIS.

The causative germs are gonococci. These may have entered fresh from an acute clap in the male, or from a gleet, or may be the result of a rekindling of the spark which has for some time been dormant and latent in some other part of the genito-urinary tract of the woman (Fig. 14). The disease is usually bilateral, though differing often in severity upon the two sides. The first stage is one of congestion and edema. When the infection reaches the fimbriated end, a local peritonitis results. The peritonitis is secondary to the salpingitis, because the gonorrhea travels through the tubes and not through the lymphatics. The fimbria of the affected tube turn in and their peritoneal surfaces cohere, owing to a circumscribed peritonitis about the fimbriæ. Thus the tubal contents become locked in, and, secretion continuing, a cyst of retention is formed (Fig. 15). Usually this latter is a pyosalpinx, occasionally a hydrosalpinx. Or, the secreted fluids may become almost wholly absorbed and the condition be marked by the production of new connective tissue in the walls of the tube, which, contracting, constitutes tubal sclerosis. Sclerosis with hydrosalpinx, or with pyosalpinx, is very common.

In the first or acute stage, the tube is deeply discolored and easily torn. It may measure as much as an inch in diameter. Upon section the lumen is found not

much distended and the increase in size is due to submucous infiltration.

The tissues are so swollen that the rugæ are almost

obliterated as separate folds. The uterine end of the affected tube is still patent, and the creamy purulent contents of the tube escape into the uterine cavity.