the dense adhesions, the pus tube was found lying upon the rectum and bulging out the vagina. After its removal a careful examination failed often to reveal multiple pockets but only one large sac with thin walls. Oftentimes the specimen was small compared with the labor and danger of the operation but we persevered and removed the offending organ through the abdominal incision because it smacked of crude surgery, of old pelvic cellulitis days if we aspirated and drained from below. If the removal of every particle of the diseased tube and ovary, if so-called clean and thorough pelvic surgery was necessary for the cure of our patients we were bound to give it to them. While the medical journals were filled with arguments for and against the removal of organs but slightly diseased, the concensus of opinion was entirely in favor of removing pus sacs, their presence being considered a constant source of danger and annoyance to the patient.

In the course of time came a revival of the vaginal route for the surgical treatment of pelvic diseases. The knowledge acquired by an immense number of abdominal operations was utilized to the utmost. Methods were perfected and the results correspondingly improved. History simply repeated itself and radical measures prevailed. It was thought necessary to remove from below the uterus as well as the pus sacs in order that the patient might regain her health. In fact it is against the uterus that the ultraradicalism of the day is directed. The dictum of the French vaginal operators is that in operating for bilateral pelvic suppuration one should remove the uterus together with the pus sacs whenever that be possible. To the objection that anything short of complete removal of the suppurating appendages is not clean pelvic surgery, they reply that experience shows that free drainage being established, the suppurating tubes or ovaries do no damage but are soon rendered innocuous by the absorptive process engendered by the operation.

I believe that there is truth in these assertions. The thickened and distorted tube and ovary are gradually freed from their adhesions and resume their natural outlines. Although this necessitates the establishment of free drainage, the removal of the uterus is by no means always demanded. Again, do the more radical procedures come first, as in the history of all surgical advances. They answer their purpose and in fact are almost indispensable, but are but forerunners of methods which are as effective but far more conservative.

I must confess to having been an unwilling convert to the good results following vaginal incision and drainage in the treatment of pus in the pelvis. I had tried this method in a number of desperate cases in which the abscess had pointed in the posterior cul-de-sac and the patient had been so weak from septic absorption as to preclude any abdominal operation. These cases revived unpleasant recollections of aspiration needles, rubber drainage tubes, a long painful after treatment, tedious convalescence interrupted by frequent relapses and sometimes a resort to the radical operation from above after the patient had regained a portion of her strength. I failed to realize that perfection of the technique of the vaginal operation could so change the results.

This technique consists in a wide incision in the posterior cul-de-sac even greater than that commonly employed in vaginal hysterectomy for nonsuppurative disease. The mucous membrane being cut through with either knife or scissors, the forefinger is carried upward with a boring motion until the pus sac

is reached, the cavity entered and the pus evacuated. This task may be very simple or exceedingly difficult according to the position of the abscess cavity and the density of the adhesions binding down the pelvic organs. It is here that the educated touch obtained by much manipulation of pathological pelvic conditions through an abdominal incision proves invaluable. One is working even more in the dark than when enucleating a pus tube, deep down in the pelvis, through a small abdominal opening. The adhesions binding the pus sac to the uterus and rectum must be freely broken up. A large rent must be torn with the finger in the pus tube or ovary and all suppurating pockets must be opened. According to the predilection of the operator irrigation can be employed or not, the unflushed cases apparently doing as well as those in which irrigation is used. Pus collections on the opposite side of the uterus should be similarly treated. As a final procedure strips of gauze should be carried to all portions of the exposed cavities, their ends projecting into and filling the vagina. Tight packing with gauze should be avoided as it impedes drainage. The strips should remain in position four or five days when they can be withdrawn easily and the cavity repacked. Usually one or two repackings will suffice when the gauze drain may be omitted and the cavity left to close by granulation. A mild antiseptic vaginal douche will be required daily for a while.

If the operator has been fortunate enough to reach and evacuate all pus pockets, the convalescence in these cases is remarkably uneventful. The temperature and pulse usually fall immediately after the operation not to rise again because of the good drainage secured. When the pus sacs are situated low down in the pelvis and only a thin space separates their walls from the vaginal mucous membrane, they can be evacuated usually without the general peritoneal cavity being opened. However, the fear of entering this cavity in our efforts to evacuate the pus, should never interfere with thorough work. It was learned long ago from our abdominal operations that only exceptionally is the pus in the class of cases under consideration very infectious. Moreover, in working from below ideal drainage is secured and the chances of infection correspondingly diminished.

The after history of these cases is remarkably good. They not only regain their health and resume their occupations, but bimanual examination in a surprisingly short time subsequent to the operation will reveal but little pelvic sensitiveness and thickening. When I have adopted the method because of the exigencies of the case, fully expecting to be obliged to perform a subsequent radical operation, oftentimes I have been happily disappointed. I recall one case in particular of a desperately sick woman in whom the abdominal incision would have caused death on the table. Over a pint of pus was evacuated by the method just described and the patient made an uninterrupted recovery. Examination seven months after the operation failed to reveal the slightest tenderness or thickening at the seat of the former abscess.

I would not wish to be understood as considering the radical removal of hopelessly diseased appendages by the abdominal route to be without a place in pelvic surgery. On the contrary there are cases in which this procedure is the only one which will restore the patient to health. The disease may be so high up in the pelvis and the relations of the diseased structures may be so situated in regard to the rest of the pelvic contents that the abdominal route is clearly

indicated. A consideration, however, of the various pathological pelvic conditions and the proper operation to be instituted for their relief would far exceed the limits of this short paper.

Time, with its failures and successes, will do much toward solving still unsettled questions. The vaginal incision operation is not as enticing or as brilliant as a celiotomy, but that, with the proper technique, it is destined to save many a tube and ovary which would otherwise be sacrificed, is, to my mind, beyond question.

903 COLUMBUS MEMORIAL BUILDING.

HYDROSTATIC IRRIGATION OF URETHRA AND BLADDER.*

BY FREDERICK W. ROBBINS, M. A., M. D., DETROIT, MICHIGAN.

ADJUNCT PROFESSOR OF GENITO-URINARY DISEASES IN THE DETROIT COLLEGE OF MEDICINE.

[PUBLISHED IN The Physician and Surgeon EXCLUSIVELY]

NOTWITHSTANDING many physicians have for years treated urethral inflammation by means of the urethral syringe, it has been well understood by those giving special attention to these cases, that the treatment is in most cases not only useless but pernicious. This fact, and the reasons for it, I attempted to emphatically state in a paper read before the Detroit Medical and Library Association in 1896, entitled "The Use and Abuse of the Urethral Syringe." Irrigation of the urethra and bladder under pressure is a very different procedure, and has been practiced a sufficiently long time to give us well defined ideas as to its value and limitations, and it is to present my own ideas derived from experience and also to hear yours that I venture a few words on this subject tonight.

I would speak with due consideration, and not from the standpoint of the optimist or pessimist. Frankly, however, I wish to state that I cannot, with FRED C. VALENTINE, say that every case of muco-serous discharge with gonococci I have cured in thirty-six hours, and acute cases with purulent discharge in ten days.

The irrigation method was first, I believe, presented to us by JANET something over five years ago, and succeeding him by quite a number, especially in France, so that by some it has been designated the French method. Not until within the past two years have we adopted the method in this country to any great extent, and we owe much to FRED C. VALENTINE, of New York, for his clear and forcible presentations of the subject. We want forcible presentations of this and kindred subjects until no physician will dare to lazily and ignorantly prescribe for patients suffering from urethral disease. These cases require care, both in making a diagnosis and in carrying out treatment.

I will not enter into an explanation of the technique of hydrostatic irrigation, except in so far as will make clear the general idea to any, if there be such present, not familiar with it. The patient sits or half reclines on the edge of a chair or couch while a reservoir holding one or two pints hangs from two to six feet above him. To the bottom of this reservoir is attached about eight feet of rubber tubing, into the distal end of which is inserted a glass or hard rubber nozzle which fits into or against the meatus, but does not enter the *Read before the DETROIT ACADEMY OF MEDICINE.

urethra. Besides these necessities there is a bell glass to protect the surgeon's hands and clothing and a thumb stopcock to regulate the pressure.

In the instrument stores of today I find a number of metal nozzles which are made to be introduced into the urethra, and through openings back of the bulb the urethra is to be irrigated from behind. To introduce any instrument into an inflamed urethra produces increased irritation, and is in itself an injury. Moreover, one often is obliged to treat acute inflammation of the urethra in which the meatus will not allow the introduction of any instrument of any size, and, lastly, it is the height of short-sightedness for one to imagine that he can pass an instrument into the urethra, irrigating from behind, and escape any real or imaginary dangers resulting from irrigating from the meatus. Not only does he, by his instruments, push the germs farther in, but they close the door so that medication cannot reach them. In a word, then, the use of any instrument in an acutely inflamed urethra should meet with our firm condemnation.

Also, I wish to point out the utter worthlessness of this return current nozzle pictured in some of our recent text-books. When introduced into the meatus either the inlet or outlet is sure to be covered with mucous membrane, making our work without effect. On the part of many there prevails an idea that usually a gonorrhea is confined to the anterior urethra, but unfortunately this is not the case. By far the larger majority of cases not treated by irrigation have posterior urethritis, and when this occurs there are only four plans of treatment to choose from, namely, internal antiseptics, posterior urethra instillation, intravesical injection with a catheter, which being removed the fluid is passed out naturally, and, lastly, intravesical irrigation without a catheter, or, as we speak of it tonight, hydrostatic irrigation. There can be no question but that gentle continued hydrostatic pressure is much less liable to cause injury to the urethra than the passage of any instrument. The anterior urethra can be irrigated with perfect ease, and by pressure upon the urethra at any portion with the little finger passage of septic material backward may be prevented. It is highly desirable to prevent mixed infection, and for this reason the penis should be thoroughly washed, preferably with antiseptic soap, before irrigation and the nozzles having been boiled should be taken from an antiseptic solution.

Now, as to the question, In what cases do you irrigate and with what results? I would answer, (1) in all cases of simple acute anterior urethritis; (2) in all cases of uncomplicated posterior urethritis; (3) in all cases after instrumentation; (4) in most cases of cystitis not due to tuberculosis or malignant growths. Folliculitis, stricture and gonorrheal arthritis do not contraindicate irrigation. Of the cases in which I have methodically irrigated, by far the greater number have passed through other hands and were complicated. A sufficient number of acute cases have been treated to show that much good can be accomplished by irrigation. A few cases I will briefly report.

Case I.-MR. S., was seen on the sixth day after exposure, and had a mucopurulent discharge. Gonococci were present. I irrigated the anterior urethra with a 1-8000 solution of permanganate of potash, applied a solution of nitrate of silver, twenty grains to the ounce, through urethroscope and again irrigated with potassium permanganate solution. For four days I irrigated twice a day,

then once a day. There was never any increase in amount of discharge, and he was sent home well on the sixteenth day.

Case II.-MR. W., had gonorrhea six years ago, from which he recovered. Now, six days after exposure, he has a distinct gonorrheal discharge. I irrigated with a 1-2000 solution of potassium permanganate morning and night. The first irrigation made him feel faint. On the second day the urethra was sore and urine thready,.but there was no discharge. Two treatments were given. On the third day only one treatment. On the fourth day the urine was perfectly clear. Only one treatment given. On the seventh day patient was discharged well.

Case III-MR. Y., had never been diseased. On the fifth day after exposure a slight discharge began, in which gonococci were present. I irrigated the anterior urethra with a solution of the bichloride of mercury, 1-20000, and then wiped out through the urethroscope with a solution of nitrate of silver, twenty grains to the ounce, and irrigated with a 1-4000 solution of potassium permanganate. I irrigated with a 1-4000 solution of potassium permanganate daily for the next five days. The. discharge never became free, nor was there any pain, but a very few gonococci could be detected in the threads. I ordered him to irrigate himself twice a day, and in about a week he reported himself cured.

Case IV.-A. L., three days after exposure, noticed slight discharge. On the fourth day the discharge was yellow, and gonococci were present. I irrigated with potassium permanganate solution and twice a day for four days. After the second day there was no discharge or discomfort, and on the eleventh day, both portions of urine being perfectly clear, the patient was discharged.

In these cases I have not entered upon full details of treatment. Occasionally a weak solution is used, and sometimes I have given as high as 1-1000. Intravesical irrigation, while usually performed after the second day, is not always done. In these cases what do we find? In the first place there is no medicine to buy or derange the stomach. Secondly, there is no discharge to foul the clothing. Thirdly, there is no chordee or swelling of the penis. In short, in the most successful cases there is immediate cessation of discomfort. Ordinary exercise, even bowling or riding a bicycle, may be allowed, nor is it necessary to restrict the diet.

Keeping the urethra well washed out, as may be done by means of diuretics, does not lessen inflammation or the number of gonococci, but irrigation as we have explained it does cure, and the reasonable explanation, according to VALENTINE, is that the hydrostatic pressure causes the tissues to become edematous with the antigermicidal fluid producing a field not adapted to growth of the gonococcus, which, it must be always remembered, rapidly develops, not alone on the surface of the mucous membrane but in the epithelial and subepithelial structures.

Now, lest you think me an optimist, I wish to relate a case or two in which, although having had the patients under observation from an early stage of the disease, the results were not brilliant. In some of these cases the cause of delay can be explained and avoided, in the others failure is no more marked than is that under any other known method of treatment.