THE INNOVATOR of a truly scientific and rational therapy. ITS SYNTHESIS is based on established physiologic and chemic laws. IT FILLS THE LONG FELT WANT of the medical profession for a non-toxic, physio logical germicide. OUR CLAIMS for oxychlorine in the treatment of disease are based on the physiologi cal action of chlorin and oxygen, proven on the human and animals, and on scientific deductions drawn by many able members of the profession from clinical results following its use over a period of fifteen years. OXYCHLORINE Is a Powerful PHYSIOLogical Non-poisonous Can be Used Locally, Internally or Intravenously TRY 6% SOLUTION of oxychlorine in continuous wet dressings on a bad case of local infection. TRY 20 TO 30 GRAIN DOSES of oxychlorine dissolved in 6 ounces of water, four times daily in a case of intestinal putrefaction no matter from what cause or in what disease. Continue treatment in both trials for 48 hours and draw your own conclusions. IF YOU ARE INTERESTED and desire literature and enough oxychlorine for trial, write us, state kind of case so we can judge how much oxychlorine you will need, and we shall be pleased to send both. We manufacture Oxychlorine, Oxychlorine Dusting Powder, OXYCHLORINE CHEMICAL COMPANY, The personal claims of a manufacturer may be regarded as partisan, but when a manufacturer makes no claim for his product, contenting himself with presenting the consensus of opinion of thousands of physicians, his statements merit consideration and his product deserves investigation from those members of the profession who have not used it. Clinical Results Prove Therapeutics and clinical results, reported by thousands of successful practitioners, demonstrate that Papers read at the Nineteenth Semi-annual Meeting held in Omaha, Neb., March 21, 22, 1907. PELVIC ABSCESS; ITS ETIOLOGY, PATHOLOGY AND TREATMENT. I W. T. Elam, M. D., St. Joseph, Mo. Professor of Genito-Urinary Surgery, Ensworth-Central Medical College. T is the desire of the essayist with the help of those discussing this paper, to if possible, clearly establish a definite relationship between the etiology, pathology, and treatment of pelvic abscess. By pelvic abscess we mean either localized pus foci in the cellular tissue under the pelvic peritoneum in and around the uterus, between the layers of the broad ligaments, or collections of pus which have formed in the tubes, ovaries, or elsewhere, and have been walled off above the peritoneum in the cul-de-sacs formed by this membrane as it sweeps from the anterior abdominal wall over the pelvic organs. These abscesses, accordingly as they originate above or below the pelvic peritoneum, are, in their beginning, essentially different processes, due, in most instances, to distinctly different causes acting on, or in, markedly different tissues. In their course, on account of this admixture of causes and difference in character and location of tissue, we frequently have a combined pathology to which we are no doubt indebted for the seeming lack of unanimity as regards the surgical measures necessary to bring about relief. A thorough knowledge of the anatomical and physiological characteristics of the tissues and organs here, as elsewhere, is absolutely essential in order that one may have a proper conception of the pathologic possibilities and be able to cope with the surgical problems presenting, to the end that a cure may result with the preservation, when possible, of organs and their function, rather than at the expense of their sacrifice. Important as these basic features are, we must assume the colleagues to be perfectly familiar with them and that a detailed review is uncalled for, especially as such review would be incompatible with the limits and purposes of this paper. If occasion seems to require further reference to important structures, vessels, etc., their relation will then be considered to the point, we trust, of rendering the connection clear. During the past three decades, especially, the female pelvic organs have been the common property of the general and gynecologic surgeon -the one aggressive and a remover of things, the other, at least should have been, though it was not always so, a conservator of the organs under whose banner he has evolved. Excesses have been the history of the former, as a class, while conservatism has been the rule with the latter. Brief reference to the etiology seems warranted, thus enabling us many times when possessed with the knowledge of the character of the infective agent to picture in our mind's eye the pathology and probable end results attending upon, as well as the particular kind of surgical procedure necessary. Taking all forms of pus collections, acute and chronic, including those of the tubes and ovaries, free, or walled off by adhesions, we find therein, the following pathogenic organisms: gonococcus, streptoand staphylococcus pyogenes, and bacillus coli communis. Other germs, especially the tubercle bacillus, and as well numerous saphrophitic organisins are frequently found. Their implantation and propagation upon and into the tissues is brought about, or favored, by gonorrheal infection, abortion, labor at full term, manual or instrumental examination, and surgical interference. Andrews (Statistical Notes on Causes of Salpingitis; A. J. . O. and D. W. and C., Vol. XLIX, No. 314, Feb., 1904, p.181) found germs occurring in the following order of frequency; number of cases examined 684 compiled from the work of twenty-eight different authors-cases presumed to include acute, subacute and chronic pyosalpinx: Robb and Smith (Am. J. O. and D. W. and C., Vol. L., No. 320, August, 1904, page 190, "The Streptococcus in Gynecology") found the streptococcus in 16 out of 137 cases or about 8.5%. Other investigators substantiate these claims. Abscesses developing in the uterine walls, in the cellular tissue around this organ, or between the layers of the broad ligaments, are almost always due to strepto- or staphylococcic infection, or both, usually following delivery, at, or near, full term. The bruising and tearing of the tissues of the uterus and pelvic floor furnish the necessary rent and soil for germ implantation and development. These extra-peritoneal pus formations may burrow along the normal lines of cleavage upward and backward behind the peritoneum along the psoas muscle, or upward and forward to the anterior abdominal wall along and above the outer twothirds of Poupart's ligament, or rupture into the peritoneal cul-de-sacs (adhesions having previously been established), and occasionally into the bowel or bladder. Their most frequent disposition however, if allowed to pursue an unmolested course, is to point or rupture into the posterior, anterior, or lateral fornices. They are most frequently an accompaniment or sequel of an. acute cellulitis which is ushered in within from twenty-four hours to ten days after infection with a chill, and, if uncomplicated by peritoneal involvement, a rapid, full, bounding pulse, dull throbbing pain, dry hot skin, and a temperature ranging from 100 to 103 or 104 F. In fact the picture is one of a typical sthenic inflammation. Physical examination reveals an enlarged, edematous, hot, tender uterus, or a painful, hot swelling, or doughy mass, in one or more of the fornices. If peritonitis coexists or supervenes, the symptoms will then reflect the character of the tissue bearing the brunt of the infectious process. Treatment. It perhaps will best preserve the connection between cause, pathology, and treatment, to take up the treatment of extra-peritoneal or cellulitic abscess at this point. These abscesses are essentially acute, as we have in connection with the local infection acute inflammatory exudates, together with more or less profound systemic involvement due to the absorption of toxines, or the activity of the germs, or both, in the blood. In either instance, the indication is, to my mind, clear. The general surgical rule, "when pus is present, evacuate it," applies most pertinently here, even though a septicemia or septico-pyemia co-exists. This indication is plainly for the evacuation of the pus, and it should be done extra-peritoneally through an incision into the posterior, anterior, or lateral fornices, or along the outer upper border of Poupart's ligament, the location being determined by the point of fluctuation. In no instance should the patient be subjected to an abdominal celiotomy for the purpose of drainage or removal of pus in the cellular tissue. When multiple abscesses occur, all of the compartments involved should be freely opened, and the pus pockets carefully searched for by finger dissection, evacuated, cauterized, and drainage instituted by means of ten or twenty per cent iodoform gauze. When multiple abscesses form in the uterine wall the incision should extend entirely around the cervix and into the anterior and posterior peritoneal cul-de-sacs. After packing the incised areas with iodoform gauze, the patient should be returned to her bed and, if temperature falls and improvement occurs, she should be returned to the table in from seven to ten days for a complete hysterectomy, either per vaginum or via the abdominal route as best meets the views and experience of the individual operator. The following selected case illustrates this point: |