condition, such as the potassium salts, salicylate of soda, tonics, blisters and counter-irritants. I decided to try Tongaline in the manner above prescribed. By the third day the pain had almost disappeared and the swelling had been reduced two thirds at least. The improvement was uninterrupted and in ten days the patient pronounced himself cured. It is certainly somewhat remarkable to see an old, chronic rheumatic patient, who has been bedridden for months, able to walk comfortably, as if by magic, and due entirely to the effects of Tongaline. On several occasions, when in the company of medical men and the subject of rheumatism was introduced, I have mentioned this treatment, and stated that in my belief we had in Tongaline almost as thorough a specific for rheumatic and neuralgic diseases as quinin was for malaria. Some of the physicians remarked that they had not found Tongaline of so much value, whereupon I replied that the fault was in their manner of prescribing the preparation. I explained to them how Tongaline must invariably be pushed to the extreme in certain obstinate cases and always administered in hot water. Since then I have had the pleasure of hearing one of these physicians state that he is as firm a believer in the efficacy of Tongaline for rheumatism as I am, and that the reason he had never appreciated the preparation so thoroughly was because he had never used it in sufficiently large quantities. In conclusion I would state that if any reader of this article doubts the efficacy that I have ascribed to Tongaline in the more severe forms of the diseases for which it is indicated just let him push the drug until the full physiological symptoms are secured, and I feel assured that he will agree thoroughly with my statements.-[Reprint from the St. Louis Medical and Surgical Journal.

It is the opinion of eminent gynecologists that the surgical treatment of the diseases of women has been largely overdone, and that much useless mutilation has been inflicted in cases which could have been treated more safely and effectively by local applications.

Conservatism is again becoming the watchword, and the medical profession is recognizing the fact that the knife should be resorted to only when medicinal treatment has failed. When it is considered that congestion and inflammation constitute the chief element in many genital diseases, it is easy to understand why Micajah's medicated uterine wafers have effected so many radical cures, and have proved so often an efficient substitute for surgical measures. These wafers exert a specific influence in relieving congestion, reducing inflammation and reestablishing normal conditions of the affected mucous membranes. Under their influence pain and other discomforts are alleviated, discharge caused to disappear, and exudates absorbed. They act safely, efficiently and agreeably in all cases where an antiseptic, astringent and general tonic and alterative action upon the genital organs is indicated.

Their particular sphere of usefulness is in vginitis, leucorrhoea, endometritis, prolapse of the uterus, and menstrual disorders, especially those incidental to the menopause.

Vol. VI.

FEBRUARY, 1898.

No. 2.

ORIGINAL ARTICLES.

THE TREATMENT OF ACCUMULATIONS OF PUS IN THE PELVIS.

By R. C. Coffey, M. D., Moscow, Idaho.

Member of the Idaho Board of Medical Examiners; Vice President of the Idaho State Medical Society.

[Read before the Idaho State Medical Society, September 15th, 1897.]

There is probably no other subject in the realm of gynecoology that demands from the surgeon of to-day more consideration and thought than the best method of dealing with accumulations of pus in the pelvis.

There are three recognized methods of dealing with these cases: (1) assisting nature by simple incision and drainage; (2) removing abscess sac by laparotomy, either with or without hysterectomy; and (3) complete extirpation of the uterus and its appendages, together with the abscess sac, by vaginal hysterectomy While my experience and observations have been limited, I shall briefly report the cases I have treated, with the method used and the results that followed, including some cases treated by Dr. Gritman, which he kindly permits me to report, and afterwards argue the merits of the different methods.

Case 1.-Prostitute, age 18; when admitted to the hospital she was suffering with a temperature of 99o and violent hysterical seizures, which occurred almost daily. She was emaciated and pale, showing evidence of septic absorption. An abdominal section was performed, which revealed a double pyosalpinx. The tubes and ovaries were removed, and the abdominal wound closed with Kelly's mattress suture. Ten days later the external sutures were removed. Some suppuration occurred, which was followed by the formation of fecal fistula that remained open for four weeks, and left a sinus which discharged pus for two months longer. The patient was seen three months after having been discharged, and it was noted that symptoms had disappeared, and the wound had completely healed, but owing to pain resulting from adhesions the patient bent slightly forward in walking.

Case 2.-Age 27, married. She gave a history of an abortion six months previously that was followed by a foul purulent discharge from the uterus. She suffered from pain, which was more intense in the right side, but also existing on the left. Upon opening the abdomen the right ovary and tube were found matted together in a solid mass of inflammatory exudate. They were carefully separated from the intestines and other pelvic viscera, ligated and removed. The left ovary and tube were treated in the same manner. The wound was closed with silk worm gut sutures, leaving a glass drainage tube for thirty-six hours at the lower angle. Patient made a good recovery in four weeks.

Case 3.-Age 22; occupation, domestic. She gave a history of gonorrhea eight months previously. On opening the abdomen a tubo-ovarian abscess was found, and as its walls were very thin, gauze was packed well around the tube before enucleation was attempted. The sac was ruptured during the operation, but was thoroughly removed. After the removal of the other ovary and tube the pelvic cavity was irrigated with a large quantity of salt solution, and the wound was closed with drainage. The patient died on the sixth day from peritonitis.

Case 4.-Prostitute, age 24. She gave a history of having had gonorrhea two years prior to the time I first saw her. An examination revealed a tumor in both ovarian regions. A double oophorectomy was performed. The abdominal wound was closed with silk worm gut sutures, without drain

age. Sutures were removed on the tenth day and patient was discharged cured in three weeks.

Case 5.-Prostitute, age 19. She gave a history of having suffered from both gonorrhea and syphilis. Both tubes and ovaries were easily removed, but despite the use of great care one abscess ruptured into the peritoneal cavity. After the cavity was carefully sponged and dried the wound was closed and a strip of iodoform gauze was placed in the lower angle for drainage. This was removed on the third day and a smaller piece inserted. The wound closed in a few days and the patient was discharged cured in four weeks.

Case 6. Age 30, married. Examination revealed a hard mass in the region posterior and to the right of the uterus. On opening the abdomen a large inflammatory mass, which included both ovary and tube and extended into Douglas's pouch, was brought to view. Sponges were packed around the tumor and an attempt made to remove it en masse. During the operation of enucleation a small abscess in the wall of the exudate was opened. The pus was removed as thoroughly as possible and the operation completed. No difficulty was experienced in the removal of the left ovary and tube. A small glass tube was used for drainage, and around this iodoform gauze was packed into the pelvis. As there was little discharge from the wound, the glass drainage tube was removed in thirty-six hours, and the gauze was removed on the third day. Symptoms of peritonitis developed and the patient died on the seventh day after the operation. Case 7.-Age 24. She was suffering from a double pyosalpinx. Celiotomy was performed and the tube removed. The wound was closed with silk worm gut sutures without drainage. Patient made an uneventful recovery, and was discharged in three weeks.

Case 8. Prostitute, age 19. This was a double pyosalpinx, with right ovary and tube bound down in Douglas's cul de sac by adhesions. They were removed with some difficulty, owing to the density of the adhesions, but no difficulty was experienced in the removal of left ovary and tube. The pelvic cavity was thoroughly dried and the wound closed without drainage. There was some elevation of temperature for a week, but the patient made a good recovery.

Case 9.-A double pyosalpinx, with severe edometritis, was diagnosed. A vaginal hysterectomy was performed and the abscess walls with both tubes and ovaries were removed. One tube was ruptured during its removal, thereby soiling

the peritoneal cavity, but it was thoroughly irrigated with normal salt solution, and the operation continued until the uterus and all the diseased tissue were removed. The pelvis was then packed with gauze, which was partially removed on the third day, the remaining portion being removed on the fifth day, and the cavity irrigated with salt solution. There was some pus at each dressing, and the temperature reached 100° for ten days after the operation. The cavity soon began to grow smaller, and in four weeks nothing but a small cicatrix marked the opening from which the uterus had been removed.

Case 10.-Prostitute, age 24. Tube and ovary of right side very much enlarged and prolapsed, forming a solid mass just back and to the right of the body of the uterus. An incision was made just posterior to the uterus and the removal of the diseased organs was accomplished with some difficulty. After a careful examination the other tube was found to be enlarged, so a total extirpation was performed. Catgut sutures were used instead of the clamps to control the hemorrhage. The cavity was then packed with gauze strips, care being taken to cover all the denuded points. It was partially removed on the second day and completely so on the fourth, and the cavity irrigated with normal salt solution. As there were no stumps to slough, the opening closed very rapidly, so that the patient was entirely well in three weeks.

Case 11.-Seamstress, age 26. An enlargement of both tubes and a distinct tumor on the left side could be elicited. Vaginal hysterectomy was performed, heavy silk being used for ligatures, (our cat gut at the time being unreliable). Besides a double pyosalpinx we found a dermoid cyst the size of a turkey's egg attached to the left ovary. The pelvic wound in this case was packed as in the others. The patient made an uneventful recovery; and was able to go home in four weeks.

Case 12. The uterus was fixed, and the ovary and tube could not be defined on the right side on account of an inflammatory exudate involving the entire right side of the pelvis. A vaginal hysterectomy was performed, and on opening the solid mass on the right side it was found to be a large pelvic abscess, which included the ovary and tube, and consisted of three pockets. An incision was now made both anterior and posterior to the cervix, clamps placed on the broad ligaments, and the uterus with the left appendages removed. The sac on the right side was now carefully separa