simple salpingo-oophorectomy. The uterus without the tubes and ovaries is a useless structure. The operation is advisable if the uterus is retroverted and adherent, when the uterus is large and subinvoluted, when the disease of the endometrium is severe and is likely to persist -in any case, in fact, in which the physician fears that the uterus may be a subsequent source of trouble.

SUPPURATION OF THE PELVIC CELLULAR TISSUE.

Pus in the female pelvis, to which condition the vague term of pelvic abscess has been applied, is usually the result of salpingitis producing a pyosalpinx, of ovarian abscess, or of suppuration of an ovarian cyst, very often a dermoid. The disease may also occur from infection of a broad-ligament hematoma or from a pelvic hematocele caused by a ruptured tubal pregnancy.

Following these conditions the cellular tissue of the pelvis may become affected, so that the purulent accumulation may make its way between the layers of the broad ligament or in some other part of the pelvis.

Before the days of modern abdominal surgery these accumulations of pus were evacuated through the vagina, the rectum, or the abdominal wall, according to the direction in which the abscess seemed to point or in which it seemed to be most accessible. The sinuses thus formed often persisted for years or during the remaining life of the woman. There were many theories in regard to the origin of the suppuration, it being impossible to determine its true nature without opening the abdomen. Now we know that the great majority of such pelvic abscesses originated in septic infection of the Fallopian tubes, and that infection of the pelvic cellular tissue was secondary.

There are, however, rare cases in which the suppuration occurs primarily in the cellular tissue of the pelvis, without any involvement whatever of the tubes or ovaries. Such an accumulation of pus is usually found in the cellular tissue of the broad ligaments; it some

times occurs in the utero-vesical tissue, and rarely in the tissue back of the cervical neck.

The cause of such suppuration is usually infection, by way of the lymphatics, from the uterus, or by the passage of septic organisms directly through the uterine wall. The condition is most frequently the result of puerperal sepsis. I have on one occasion seen it occur in connection with extensive venereal ulceration of the external genitals. It seems probable that a pelvic lymphatic gland, becoming infected, may break down and suppurate, forming the starting-point of the abscess.

The symptoms of this form of pelvic abscess are those characteristic of any other kind of suppuration in the pelvis.

The purulent accumulation may be detected by bimanual examination. It usually bulges into the vagina at the lateral fornices or before or behind the cervix. The abscess-mass is in close relationship with the uterus. In this respect it differs from a simple tubal or an ovarian abscess, in which cases a distinct separation of the tubal or ovarian tumor from the uterus may be determined, at any rate, before the pelvic cellular tissue has become involved.

If the abscess bulge in the anterior vaginal fornix, it is very probably of neither tubal nor ovarian origin, as tubal and ovarian abscesses lie to the side of, or behind, the uterus.

The sense of fluctuation is often difficult or impossible to determine. The infiltration of the surrounding structures gives to the mass a dense hard feeling that obscures fluctuation. To the experienced finger, however, this indurated condition of the tissues is characteristic of pelvic suppuration, as is the sense of fluctuation else

where.

The treatment of pelvic suppuration of this nature is evacuation by way of the vagina. The incision should be made into the most prominent part of the mass. When made into the lateral fornices, the operator should

remember the position of the ureters and the uterine arteries. The ureters lie a little over half an inch from the cervix. In every case it is safest to make the incision close to the cervix and to work carefully into the abscesscavity. The pus should be evacuated, and a double drainage-tube should be introduced for subsequent washing.

In most cases, however, the physician cannot determine with any certainty that the abscess is simply confined to the pelvic cellular tissue and did not originate in the Fallopian tube. If there is any doubt of this kind, celiotomy should be performed and the true nature of the condition determined. If a pyosalpinx or an ovarian abscess is present, as is usually the case, the condition. may be dealt with as has already been advised. If the uterine adnexa are healthy, the abdomen may be closed and a subsequent vaginal incision may be made.

Indiscriminate evacuation of collections of pus in the pelvis by way of the vagina has resulted in a great deal of harm. The abscess, being usually of tubal origin, often persists indefinitely. Intestine, ureters, bladder, and blood-vessels have often been injured; and when subsequent celiotomy is performed the operation is attended. with great danger from the presence of the fistulous opening.

CHAPTER XXV.

DISEASES OF THE FALLOPIAN TUBES (Continued).

TUBERCULOSIS.

TUBERCULOSIS attacks the Fallopian tubes much more frequently than any other part of the genital apparatus. The disease may be associated with tuberculosis of the peritoneum or with tuberculosis of the ovaries and the uterus. As has already been said, tuberculosis of the uterus often originates in the tubes and extends thence to the endometrium.

The tubercular Fallopian tube varies much in appearance according to the nature and stage of the disease. The strictly tubercular lesions may be masked by those of ordinary inflammation. There may be peritoneal adhesions, often very dense and widespread, between the tube and adjacent organs, and the ostium abdominale may be closed, as in non-tubercular salpingitis.

In some cases these simple inflammatory adhesions probably existed before the tubercular infection took place, the tuberculosis occurring in an old diseased tube. In other cases it is probable that the inflammatory adhesions and products occurred as a result of the tuberculosis, which attacked a tube previously healthy. In the latter case such adhesions may be viewed as a conservative process.

The tubercular tube is often very much enlarged from infiltration of its walls and dilatation of its lumen. It may be filled with typical caseous material, and when this is removed the mucous membrane will be found the seat of deep, jagged, ulcerated areas.

If the abdominal ostium is not entirely closed, the cheesy material may project into the abdominal cavity.

If the disease has extended to the peritoneal coat, the covering of the tube will be found studded with typical tubercles (Fig. 151). Such tuberculosis of the peritoneum may be confined to that covering the tube, or it may extend to the uterus and throughout the abdominal cavity.

In peritoneal tuberculosis that has originated in the tube the lesions are found to be most widespread in the pelvic peritoneum.

In some cases the ostium becomes closed, and the tubes

FIG. 151.-Tuberculosis of the Fallopian tubes. The disease has extended to the peritoneum, which is covered with tubercles.

are found distended with pus, forming tubercular pyosalpinx. Such tubes sometimes attain enormous size, containing a quart or more of purulent material.

In less extreme cases than those just described the tubercular area may be limited to a portion of the tube, and gives rise to one or more nodular enlargements (Fig. 152). In other cases there is no gross change in the shape or size of the tube, and only a few miliary tubercles are found scattered throughout the mucous membrane.

In a very large number of the cases of tuberculosis of the Fallopian tubes, the lesions resemble in all respects those of ordinary salpingitis, and are not in any way recognizable by the naked eye as characteristic of tuber