the use of any pessary, means marked structural lesions of that organ, together with the presence of many strong peritoneal adhesions round about, forcibly fixing this abnornal position. These cases ought to have surgery; otherwise they drag out a miserable existence of pain and physical disabilities. An Alexander operation of shortening the round ligament, or a vaginal fixation of the uterus, in such conditions is unreasonable. A section wherein the peritoneal adhesions are broken up, and the dislocated organ put into a better posture, enables us at the same sitting to detect, by actual inspection, in what way and how much the appendages are diseased. Almost always they are; their removal, in whole or in part, should then come.

We encounter one of the most difficult and serious problems in the whole question at issue, when we approach the consideration of the morbid conditions of the ovaries and tubes making an oophorectomy or salpingectomy, one or both, expedient and justifiable.

No one hesitates as to the propriety of the removal of an ovarian cyst-the sooner the better. No one for a moment will contest the advisability of the exsection of the uterine appendages seriously and hopelessly involved in disease. Spencer Wells' experiences have taught us valuable lessons. Out of his 1,000 ovariotomies (some 228 living under 40), 120 had 230 children; only 2.6 per cent had recurrences on the opposite side. Then always look to, and carefully examine, the appendage of the opposite side, for macroscopical evidences of disease, in order to determine what best there to do.

He who has witnessed, on section, the ravages of gonorrheal salpingitis, ovaritis, and pelvic peritonitis; noticed the pelvic pain, the febrile disturbances, the threatened death, the inevitable relapses, must say naught else can be done. Some localized sepses, puerperal or non-puerperal, do as much damage. Beyond these there are several morbid entities, less pronounced, which need shed on them all the light we have. In the present chaotic state of indications the authorities are by no means clear.

Salpingitis, in some form, is a very common affection. Surgical relief for it depends largely on its type and duration.

Purely catarrhal forms of salpingitis-the most frequentnever need section; the watery encysted (hydrosalpinx) usually

do; the bloody and purulent (hemato- and pyosalpinx) almost always. Unmistakable evidences of the special variety are not always clearly defined. We may reasonably infer the presence of the purulent variety, by the existence of a boggy mass posterior and lateral to the uterus (possibly increasing slowly in size), by the febrile movements, and by the sensible depreciation of the general health.

It is thought that salpingitis and oöphoritis of the saccated form is worse when the streptococcus has been the source of infection.

While slight purulent accumulations may be disposed of by Nature and general treatment, a large one (distinctly encysted pyosalpinx) never can.

I have witnessed marked improvement in a few cases which had had repeatedly free discharges of pus through the uterine end of a distended tube. These cases were all septic, not specific. The spontaneous relief in these cases, by the evacuations of pus, was always preceded for a few days by increased pelvic pain and some elevated temperature. The fimbriated ends of the tubes were absolutely, probably permanently, closed. It is fortunate that Nature so protects herself. Patients, of course, are sterile.

A Fallopian tube slightly distended with water, mucus, or pus may recover itself, if well emptied after abdominal section. The evacuation of the same can be effected in one of two ways-(a) aspiration; (b) the passage of a probe into the ampulla, followed by finger compression. The contents thus squeezed out, a partly diseased tube may recover itself.

When a pyosalpinx follows in the wake of a catarrhal salpingitis there are always more or less interstitial changes in the tube. It becomes thickened, adherent, closed at both ends. Coexisting and resulting pelvic peritonitis is constant. A seriously distended tube from pus may burst.

Now that we understand the modus operandi of periuterine inflammations, by the route of endometrial infection, single or mixed, we can comprehend the extreme vulnerability of the female peritoneum to disease, bearing, as it does, the brunt of many indiscretions, puerperal and non-puerperal, moral and professional.

Probably a majority of women after 35 would, on an autopsic examination, show structural lesions of the peritoneum to some degree. Pelvic peritonitis in the female is even more common than its kindred affection of the chest-pleurisy-in the male.

These peritoneal adhesions, when more marked, are very tender, hinder normal mobility, and displace structures. In the female repeated attacks of an acute kind from trifling causes are very common.

Dr. Polk, of New York City, in the Transactions of the American Gynecological Society for 1887, with a conservative effort to save, not sacrifice, parts, speaks of the advantage of relieving accidentally imprisoned pelvic organs after section, without any mutilation. Pure adhesions never constitute a rule for the removal of organs. These taken away, normal function may be resumed.

How and to what extent can we give a betterment to conditions referred to without any abdominal section?

Rest in the recumbent posture is of primary importance. At the start of any acute attack free saline purgation is always beneficial. Repeated doses of the same in diminished quantities are useful to maintain daily alvine evacuations. Counterirritation with small fly blisters, repeated at times, does good in the chronic forms of the disease, but cold or hot applications, according to the season of the year, are best for the acute. Very sthenic cases require minute doses of aconite or veratrum viride as antiphlogistics. Generally no internal medicine equals quinine in doses of grs. ij.-x., according to the temperature range. Opium is to be avoided as much as possible; if given, it is best administered as the aqueous extract made in suppositories for the rectum. The long-continued hot vaginal douche, usually grateful, sometimes provokes pain. Specific cases call for the hot sublimate douche, otherwise choice is given to the boracic acid solution. A nutritious diet prevents undue. inroads of the disease on the general health.

For chronic cases no local medicament is superior to ichthyol diluted with boroglyceride. The stronger tincture of iodine. (Churchill's) applied to the vaginal vault is an active resolvent and counterirritant. But not a few cases are positively aggravated by the use of any vaginal speculum.

Iron as a tonic is almost always contraindicated, although the patients are anemic and menstruation is suppressed. Minute doses of the bichloride of mercury are much more desirable. That the bromides do diminish pelvic congestion and are sexual sedatives must not be forgotten. Menorrhagic states of ovarian origin are best combated with the sodium bromide. Electricity, in the form of the faradic current of tension, and better

still the galvanic current, is to be considered in old cases to resolve pelvic exudates, abate pain, and control local neuroses. In this way most cases can be ameliorated or cured. No operation is considered, none is entertained, unless fair trial has been made of these milder measures for from a few days to three months.

Relapses are oftentimes milder.

Certain indications are afforded by a careful microscopical examination of the blood. Says Cabot: "Increasing counts of leucocytes usually point to need of an operation; stationary leucocytosis to a well walled-off abscess. The size of the count is a rough measure of the size of the abscess, and cases without leucocytosis rarely need operation, usually recovering under palliative treatment; also many with leucocytosis. Pelvic pain and soreness may be as great in various non-suppurative conditions as when abscess is present, but the leucocyte count is raised in none of the pelvic diseases of woman, except abscess, septicemia, and hemorrhage. Endometritis and cystitis cause no leucocytosis. The application of these rules will not infrequently help in the diagnosis of pelvic disease, and in deciding how much importance to attach to the complaints of pain and tenderness in doubtful cases. The absence of leucocytosis makes us rightly confident that no abscess of any considerable size exists."

Can naught else be done, in some pronounced and confirmed cases, to forego the possibility or probability of an abdominal section?

Salpingitis is very rarely indeed a primary disease; almost invariably an outcropping of an endometritis. Both tubes are usually attacked, the left the more frequently. How far it is possible to arrest the morbid movement and check the progress of the extending disease seriously concerns us. Intrauterine interference is not to be dreaded now, as it was in days prior to antisepsis. As long as the infecting area remains in the uterine cavity, so long will the pelvic peritoneum throw out lymph. The septic forces removed, the lymph effusion ceases, further extension stops. To anesthetize the patient, to dilate, to curette and to pack and medicate the uterine cavity are correct in theory and positive in results. Physical evidences of the remnants of pelvic exudation may not be effaced for months, still a decided improvement comes.

A previously occluded uterine end of a Fallopian tube may be made patent by this minor surgical step. Endosalpingitis is less amenable to treatment than is endometritis, but it is reasonable to believe that a betterment will follow, if the endometrium, anatomically and physiologically much like and connected therewith, has its disease annihilated.

The tubes exsected, there is, of course, less danger of any reinfection, but this implies a step which we should studiously attempt to avoid.

As not a few diseases of the ovaries are resultant on tubal infections, we are again forcibly reminded of the importance of preventing and controlling the morbid action at its fountain head.

The ovary when first attacked is injured on its peritoneal layer. There is a localized pelvic peritonitis-a perioöphoritis. Probably in most instances the structures beneath the periphery are implicated. The whole organ becomes congested, enlarged, adherent, and may suppurate. Parenchymatous hyperemia leads to interstitial hyperplasia, which in time may develop into cirrhosis or sclerosis. Then the ovaries are hardened, shrivelled, scarred. The gland tissue is replaced, in whole or in part, by a fibrous material; its follicles disturbed, destroyed. The function of the whole organ is always hindered, hence sterility.

Some forms of menorrhagia are observable in the stage of ovarian parenchymatous hypertrophy; but when contraction and condensation follow, the amenorrheic states are experienced, though the menstrual molimina may be quite severe. Always there is an array of annoying and painful symptoms. The disease is never fatal per se, hence the symptoms are protracted until Nature gives relief, after a complete arrest of menstruation and ovulation.

An ovary smaller than normal, quite pale, a condition expressive of local torpidity and general depreciation of health, may simulate after section a cirrhosis, but should not be taken for it.

It is very easy to understand why ovarian abscesses are more frequent than uterine, for the tissues are different in kind and formation. Localized pus formations of the ovary (one drachm to one ounce) are in my experience not rare.

Follicular ovaritis with cystic degeneration is a very common affection. We hear very often of ovaries being removed for cystic degeneration. What is cystic degeneration?