means of dirty instruments (Fig. 27). The tubercles lie upon the peritoneal surface of the tube, as well as in the cavity, forming miliary tubercular salpingitis. Or the disease may assume either of the two other common tubercular types: caseous infiltration, or chronic fibroid tuberculosis. In one instance, there will be a tube filled with cheesy pus and studded with tubercles; while, in another, the tubercles are few, and the production of connective tissue marked. Tubercular disease constitutes about fifteen per cent. of all inflammatory pelvic disease of a chronic type.

The symptoms and signs are those of pyosalpinx, or other chronic tubal disease, due to other causes.

Treatment. Whenever upon exploratory vaginal section tubercular adnexal disease is found, ablation should be performed. But this statement may be qualified somewhat by excluding operation when general peritoneal tuberculosis coexists.

PELVIC PERITONITIS.

The normal pelvic peritoneum is generally transparent, and through it the color of the underlying tissue may be detected. In certain portions of the pelvis it is thicker than at other points, notably over the rectum and the iliac vessels, and at these points the peritoneum is opaque. Over the uterus the peritoneum is thin, and the peritoneal covering of the tubes is exceedingly delicate.

When inflamed the peritoneum becomes deeply injected. Its color will vary from a delicate pink to a livid hue, according to the severity of the process. At first serum is poured out in a variable quantity. As the circulatory stasis increases the endothelial cells shrink away from each other, and the underlying lymph spaces are exposed. White blood-corpuscles and plasma cells pass out upon the surface of the membrane, where they form

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masses of "lymph." If the process subsides, these lymph masses change into connective tissue bundles or "adhesions," which become supplied with blood-vessels and are covered with endothelial cells. If the infecting agent overwhelms the vital forces, the cells die and produce pus. According to the nature of the result of the infection, we have either a slightly injected peritoneum with serum as a result, or one deeply colored, smooth, and shining generally, but at points unglazed, and covered by lymph; or one livid in hue, rough in appearance, and devoid of endothelium, studded here and there by small lymph masses, and showing frequent spots of purulent lymph. Pus in the pelvic peritoneal cavity may be whitish, yellow, or greenish-yellow. Usually it is odorless, but it may be tainted with intestinal gases without there being an opening into the gut.

Causes. The causes of pelvic peritonitis may be classified as direct and contributing.

DIRECT.-Pelvic peritonitis in women is caused by colon bacilli, gonococci, staphylococci, streptococci, tubercle bacilli, and more rarely by other pathogenic germs. A certain form of peritonitis is also produced by the chemical irritants which are contained in antiseptic dressings, when these touch the peritoneum. According to the nature of the infection the character of the lesions will vary. Where colon bacilli cause the inflammation, there is but little lymph produced, and not much of serum; but it is doubtful if suppurative peritonitis is ever set up by the colon bacillus alone. Peritonitis caused by the colon bacillus is less active than any other, and the local disturbances are slight. It is found most commonly as a result of inflammation of the colon when this is accompanied by bowel distention and retention of feces. Clinically, we meet with it most often after it has produced adhesions, or in its acute stage as a complication in the after-treatment of intrapelvic operations. Very slight toxemia is produced by it, and hence, the rise in temperature and pulse rate may be so slight as to be unnoticed. In cases of adherent retroposed uteri which

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we meet with in young women who have never had uterine or tubal inflammation, the adhesions are probably always due to the colon bacillus. Whenever any organ rests immovable upon one spot of the large gut for a length of time, migration of the colon bacillus is apt to result, causing limited effusion of lymph, and the ultimate formation of delicate adhesions. In the mistaken treatment of abdominal diseases by opiates, the migration of colon bacilli is facilitated.

Where peritonitis is caused by gonococci, serum and lymph are produced. Under ordinary conditions gono-f cocci do not produce purulent peritonitis. Suddenly flooding the pelvic cavity by a large quantity of virulent gonorrheal pus will set up a purulent peritonitis. Pelvic peritonitis due to gonorrhea may be caused by the gonococci reaching the peritoneum through the uterus and Fallopian tubes, through the bladder, or through a ureter. By far the greater number of cases of this form of peritonitis are produced by the infection coming through the uterus and tubes. Gonorrhea causes peritonitis by extending directly along the continuity of the, tissue, and not through the medium of the lymphatics. As a consequence we have the peritonitis secondary to a salpingitis. The first effusion of plastic lymph occurs at the fimbriated end of the affected tube, effectually closing it, and causing it to unite to any adjacent organ. As the infection progresses, lymph is thrown out upon the surface of the uterus as well as on the tube. The production of serum is slight, and altogether the tendency of the peritoneal inflammation is to localization. A characteristic of gonorrheal peritonitis is its tendency to recurrence. The younger the subject infected, the more pronounced the peritonitis. The puerperal state after the third month appears to grant a certain immunity against this form of infection. It is generally seen in unimpregnated women. For the lesions induced in the ovaries and tubes by this infection the reader is referred to "Salpingitis" and "Ovaritis."

Pelvic peritonitis due to staphylococci usually results in

the limited production of both serum and lymph. I do' not believe that primary purulent peritonitis is ever caused by staphylococci. The infection may reach the peritoneum through either the medium of the tubes or through the lymphatics, or by both channels. In the former case the peritoneum at the fimbriated end of the tube is first affected, resulting in the closure of the tube. Here the pelvic peritonitis is limited. Where the infection passes to the peritoneum through the lymphatics, the peritonitis occurs as a primary disease. According to the extent of the infection the severity of the peritonitis will vary. The passage of an unclean sound which bruises a slight area of endometrium will cause but a limited degree of infection and a small amount of lymph will be poured out upon the broad ligament or uterine wall. The same kind of infection occurring at the site of a recently detached placenta may result in an infection which will be the cause of a general plastic pelvic peritonitis. The degree of the peritonitis will correspond to the number of lymphatics which are involved. If this infection occurs in the puerperal state, and results in the production of a broad ligament phlegmon, this may be the means of starting a suppurative type of peritonitis. But this suppurative peritonitis will be secondary to a plastic form, and the pus will be locked in. Diffuse suppuration in the pelvis will result, but not primary purulent peritonitis. There is a vast difference, both in the local lesions and danger to life. The tendency of infection by the colon bacillus is to produce lymph-effusion at the point of migration of the bacillus, and this will result in attaching that point to any organ which rests upon it. Primary tubal and ovarian diseases are not produced by the colon bacillus.

The tendency of infection by the gonococcus is to produce primary suppurative salpingitis with secondary peritonitis about the tubal orifices. This focus of suppuration in the tube becomes the agent by which other attacks of peritonitis are produced. Recurrent plastic peritonitis is characteristic of gonorrheal infection. The

tubal lesions are more marked than those of the peri

toneum.

Staphylococcus infection tends to produce: (a) tubal inflammation with secondary peritonitis; and, (b) pelvic lymphangitis with primary peritonitis. The extent of the peritonitis is greater than where the gonococcus is the infecting agent.

None of these pathogenic germs tends ordinarily to produce primary purulent peritonitis. They are usually local in their activity and produce but mild toxemia.

Such is not the tendency of the streptococcus. From its first introduction into the system this germ produces the greatest amount of septicemia relative to the degree of the local disturbance. Introduced into an unimpregnated uterus, it produces either tubal inflammation with peritonitis secondary to that, or primary peritonitis by extension through the lymphatics. Occurring in the absence of a recent gestation it results in the liberal outpouring of serum and the widest effusion of lymph by the peritoneum. As a result, there is suppuration in the tube or ovary, or both, which is surrounded by large masses of lymph. There is never intermission, however, in an inflammation produced by the streptococcus. It never becomes strictly a local disease, but there is a continuation of acute manifestations with marked exacerbations. After a time the pus leaks into the lymph planes. and the gravest form of diffuse pelvic suppuration is produced. The streptococcus is found in the products of inflammation in such pelves, but there are such marked differences in the gravity of the symptoms in various cases, that we are forced to believe that there is a great variability in the virulence of this germ.

Occurring in a uterus recently aborted or delivered, this form of infection may result in primary purulent peritonitis. This is the gravest form of peritoneal inflammation. Large quantities of serum are produced; the peritoneum is livid in color; the effusion of plastic lymph is limited, and as a result, there is little or no tendency to localization of the disease. Death may occur before