the retrouterine cases, to a higher plane, and remains after the cure in a much more preferable position. At the end of two to three weeks it often has almost entirely regained its mobility, and an examination of several of these patients a number of months later has seemed to me to leave very little to be desired.

In case the inflammatory affection has encroached upon the anterior vesico-uterine cellular pouch, bounded externally by the round ligaments, the same procedure can be used, making the incision in these instances anterior to the cervix and dissecting back between the uterus and bladder until the inflammatory center has been drained.

Allow me to give you a striking illustration of the value of this method. Four years ago a young girl, fourteen years of age, who had apparently had several attacks of appendicitis, developed a pelvic inflammatory affection which resulted in complete fixation of all the organs, the filling of the whole pelvis with large exudative masses, and resulting, after intense suffering and four months of critical illness, in an abscess, which fortunately made its escape by way of the rectum. After remaining well for a year and a half she suddenly developed another acute attack of the same variety. I had failed to examine her in the interval between these attacks, so that I cannot tell how far and completely she recovered, though she was apparently in perfect health. This, then, was a second attack, coming in a girl in apparent health, and ushered in by the most serious symptoms of rigors, fever, painful micturition and painful defecation. Alarmed at the possibility of her having to go through the same ordeal as in the former instance, when her life was in such jeopardy, with the consent of her parents I immediately performed celiotomy, intending, if possible, to abort the threatened destructive process, and if necessary remove the offending organs. The condition of the parts forbade further operative procedures by way of the abdomen. The uterus, ovaries, tubes, and all parts concerned were absolutely fused into one conglomerate mass, which meant that, in a girl of sixteen, I would be obliged to do a complete ablation, with the greatest danger to her life, and the blighting of her future. Closing my abdominal incision, I put her upon her back, and through the little narrow vagina I incised the vaginal roof close to the cervix, anteriorly and posteriorly, penetrated both broad ligaments to their outermost limits, as well as the utero-vesical space, packing as aforementioned with gauze. No pus was encountered, but the disease was stayed. I examined this girl four weeks ago.. She had been

ill in bed only four weeks following the operation, and has now been fifteen months in perfect health. Her uterus is movable, though not to the same degree as you might expect in a perfectly healthy girl; but there is no thickening and no enlargement, and no appearance of disease.

For many years I have opened pelvic abscesses in this manner, never making use of any instruments beyond the first incision and a few nicks of the scissors in the second layer. Making the incision closely upon the cervix, adding to it the secondary incision at right angles down the vagina if necessary, prevents hemorrhage from the vaginal vessels. Once having reached the cellular spaces, the finger can be guided inward within the pelvis. It is to me infinitely safer, and to be preferred to various methods of trocar puncturing, needle exploration and cautery knives. It is simplicity itself, and requires only a few minutes for its performance. But this matter of opening abscesses is an old, old story. It is the application of this method of treatment for the cure of inflammatory pelvic affections in their very incipiency.

Allow me to describe in a few short words my last case, as it represents a perfect type of the value of this method:

A young woman having forgotten herself, and being two days past her expected menstrual time, resorted to the services of an abortionist for the destruction of a supposed pregnancy, which, however, did not exist. Following the introduction of some instrument into the uterus, she suffered for two days very intense pain, accompanied by some fever. She was not, however, confined to her bed. The desired menstruation not making its appearance at the end of six days she returned to the man's office, and a second instrumentation was followed in thirty-six hours by a severe chill, high fever, and excessive pelvic pain. On the sixth day of her illness I saw her in consultation, finding an inflammatory swelling to the left of the uterus in the broad ligaments. On the seventh day, under ether, I made the posterior vaginal buttonhole, penetrated the tissues with my left forefinger, and opened an ovarian abscess containing fully four ounces of pus. Eighteen days later this woman walked two blocks to the street cars and rode home. Her uterus was almost entirely movable. There was no apparent discharge; the woman was to all appearances cured.

Bear in mind the salient points of such history; refer back to cases of that variety which you have seen linger for months in bed, afterward returning for a laparotomy and an ablation of

the appendages. Remember that this woman was sick only seven days, and yet a good four ounces of pus were found in her pelvis, and at the end of three weeks she returned home apparently cured, that is, physiologically, symptomatically, and to all appearances, entirely cured.

It is not only the application of the old surgical principle to evacuate pus as early as recognized, but this operation strives to go further. It shows to us that pus or no pus, the character of exudative material of the variety that is usually found in the pelvis is susceptible of absorption when broken up and drained. In some way, as happens within the peritoneal cavity when a drain is introduced, septic material from within seems to be drawn toward the breach that has been made, and if sufficient outlet has been provided, and if the parts are kept sufficiently aseptic to prevent mixed forms of infection at that site, the bacteria are usually destroyed and expelled, the exudative material is replaced by granulating tissue, and a cure results. No matter what success a man may have as a skillful enucleator of large and old pus sacs, he must indeed be bold who would deny the advantages of an early incision through the vagina if it can be followed by such good results as are apparently shown by cases as they have come to my notice. The objections that hold good against the vaginal incision in old pyosalpinx and other cavities. which have destroyed, to a great extent, the organs in which they originate, have but little weight when applied to the procedure which I advocate. We are here simply incising, irrigating, draining localities permeated with recent lymph. The more I see of this work the more I have reason to believe that it is of value, and probably it will soon be determined that the earlier the operation is done the more striking its benefits. a question with me whether it will not be recognized in the future that an incision in the Douglas sac, performed at the very incipiency of a pelvic peritonitis, establishing a drainage for the primary serous effusion that occurs, will not prove an invaluable means of aborting and controlling these nefarious processes. It means the elimination of the noxious material as soon as it becomes palpable.

I had almost forgotten to say that in every single instance when this operation is performed the uterus is to be carefully, thoroughly and intelligently curetted. Failure to cure incipient.

septic diseases of women arises most frequently from an inability. to exactly locate and reach the exact seat of the affection. If a

woman suffers from endometritis, pure and simple, she can be cured by an intelligent and thorough curetting, if every vestige of the diseased tissue can be reached and removed. Here we have facing us the frequent inability to reach the cornua of the uterus, at the opening of the Fallopian tubes. In some cases, without our knowledge, the disease has already encroached upon the tubes. themselves, and to a certain extent, beyond our reach. In other varieties, some of which also we are not able to diagnosticate, the virulent microorganisms have penetrated through some of the aforementioned channels, beyond the uterine body, in one or the other direction, and my contribution to your understanding of this subject is an attempt to point out another method of combating these unfortunate affections according to reasonable indications. The demonstration of the value of my suggestions will probably fall within the province of the consulting man whose practice brings him face to face with these diseases in the first part of their course. The great hospital operator will probably see but few of these cases at a sufficiently early stage to verify the value of the proceeding. It has seemed to me to be a most valuable adjunct in the treatment of the septic diseases of women, and is presented to you with the hope that it may become a respectable addition to the methods in vogue for the conservative surgical treatment of these affections.

353 LA SALLE AVENUE.

RENAL INSUFFICIENCY IN GYNECOLOGICAL CASES.

BY J. H. ETHERIDGE, M. D., CHICAGO.

Any one writing to-day on gynecology and failing to take up for consideration some operative procedure is extremely liable not to find many readers. To read all of the current gynecological literature impresses one with the conviction that the surgery of pelvic diseases comprises about all that is good and worth knowing of the recent advance in this field of research. It is deplorable that appearances warrant such an inference, yet it is a fact that they bear no other interpretation. At no distant day there will be a reaction against this furor operativus, and then more attention will be paid to the legitimate sphere of remedies in gynecology. The vast majority of physicians are incapable, from environment and lack of training, of performing surgical operations on women, and are compelled to limit their gynecological exploits within the range of remedies. To such men the writer hopes these pages may commend themselves.

Every successful gynecologist takes into consideration each and every organ and function of his patient before he lays out a plan of treatment. He knows superlatively well that each patient has disorders outside of the pelvis. He knows furthermore that it is the exception for a woman to present herself for his consideration who is sound in every other organ and has disorder only in her pelvis. Whenever a practitioner says his gynecological patients never or rarely have any other derangement than pelvic disorder, we all understand that he rarely sees anything but the generative organs, and that, therefore, he has mental nystagmus; consequently he is an unsafe leader.

Many years ago, while the writer was attending to a large indoor dispensary practice, he was impressed by the numerous general symptoms given by gynecological patients. He therefore began a system of case records which included every symptom given by 100 consecutive patients. The result was interesting and extremely instructive. Those 100 case records led to absorbingly interesting investigations into the various kinds of dyspepsias, headaches, backaches, and neuralgias. During these investigations the interdependence of disorders and their symptoms was brought out so clearly and simply that the wonder is that its universal recognition does not obtain.

American Gynecological and Obstetrical Journal, June, '95.