then, from regarding casts and albumin in the urine as a contraindication for operation, I think the operation in large tumors should be looked upon as the only means of relieving that condition. If I mistake not, a certain operator on the Continent did a hysterectomy, and for some good reason left one of the ovaries behind. The woman recovered, conceived again, had an abdominal pregnancy, and was delivered by laparotomy. This case caused me to consider the advisability of entirely closing up the cervix by Emmet's operation, and thus prevent possible accident. In closing, if I may be allowed to mention the idea most forcibly impressed upon my mind by this history, I would say that, while the extraperitoneal method of dealing with the stump may be unavoidable at times, it gives rise to grave accidents, which a secure intraperitoneal method does not engender, and that it will not be the method of the future. Discussion postponed until next meeting. TRANSACTIONS OF THE GYNECOLOGICAL SOCIETY OF CHICAGO. Meeting, Friday Evening, February 19th, 1886. The President, DANIEL T. NELSON, M.D., in the chair. DR. A. REEVES JACKSON opened the adjourned discussion of the treatment of pelvic abscess by the presentation of the following paper, entitled: LAPAROTOMY FOR PELVIC ABSCESS. Owing to Dr. Jackson's absence, the paper was read by the Secretary, Edward Warren Sawyer, M.D. At the December meeting of this Society, a discussion arose upon the subject of pelvic abscess and its treatment. It was based upon the report of a case by Dr. H. T. Byford, which had been treated by favoring discharge of the pus by way of the rectum, and placing within the abscess-cavity a portion of sulphate of copper to promote granulation. The discussion seemed unfinished, and was withal of so interesting a character that I have thought well to reopen it by the relation of the following case. Whether the operation performed in the treatment of the case should be termed a laparotomy will depend upon what significance we attach to the term. Upon this point, opinions will doubtless differ. If we understand by the word laparotomy the opening of the abdominal cavity in its largest sense, the term is here correctly used; but if, on the other hand, we mean the opening of the abdomen for the relief of an encysted intraperitoneal abscess non-adherent to the abdominal wall, the term would not be properly applicable, for here there was complete adhesion, and, possibly, in the course of time, the abscess might have pointed and opened in that direction, although I do not believe that such result would have occurred. Without active interference, I think the disease would have resulted in death from pyemia in a very few days. On March 9th, 1885, I visited Anna N., in consultation with Dr. Louis Braun, of this city. She was 24 years old, had been married six years, and had one child 18 months old. On February 1stfive and a half weeks prior to my visit-she had miscarried, producing a fetus 4 months old. A few days after that event, Dr. Braun found the patient suffering from symptoms of pelvic inflammation, which had since continued with varying severity. He informed me that the pelvic swelling, which he detected on examination, appeared to involve all the periuterine structures, but to a greater extent on the right side, that during the past few days, however, it had seemed greater on the left side. From the onset of the attack, the pulse had been rapid and the temperature elevated the former ranging from 110 to 130, and the latter being persistently over 102° F., reaching, on one occasion, 104° F. Pain had been severe, but controllable by morphia. The appetite had failed utterly, and the stomach finally rejected all food. At the time of my visit, the patient was pale, extremely emaciated, and her visage showed marks of prolonged suffering. On examination, I found on the left side of and behind the uterus a swelling as large as a medium-sized orange, with rather indistinct outlines. Its lower portion was in a plane with, or somewhat below, the os uteri, and bimanually its upper margin could be felt extending above the fundus, which was pushed strongly to the right. Both uterus and tumor were immovable. The latter had a slightly elastic feeling in some places, although I was unable to detect any certain fluctuation through the vagina, rectum, or hypogastrium. Through the posterior vaginal wall, at a point about an inch above the lower portion of the swelling, I fancied I received a sensation of bogginess, and this, taken in connection with the history of the case, gave me the belief that pus was present. Accordingly, I thrust a curved trocar and canula into the swelling by way of the vagina to the depth of about two inches, with no other result than the emission of a few drops of blood. It was then concluded that the patient should have prolonged hot-water vaginal douches daily, rectal feeding, and appropriate anodyne and tonic medicines. On April 18th-five weeks later-I saw the patient again, with Dr. Braun, who reported that after my former visit the symptoms had all become gradually ameliorated; the stomach resumed its functions, pain subsided, pulse and temperature became normal. No menstrual or other discharge had appeared. This improved condition had continued until two days before, when, without apparent cause, the patient had a chill, followed by rapid pulse, high temperature, pelvic pain, and irritability of the bladder. Under anesthesia, I examined the abdominal and pelvic organs. The pelvic swelling had undergone no marked change, except that it seemed to have increased in an upward direction, extending now to a point about an inch above the symphysis pubis. At this place, I thought I detected obscure fluctuation. The swelling as felt per vaginam was hard at every accessible point. All operative measures were declined by the patient and her friends, and the treatment advised consisted in the administration of morphia and quinine, and peptonized milk for diet. April 19th, the patient was much worse. The pelvic pain was controlled only by large doses of morphia given hypodermically, and the stomach retained almost nothing. The pulse was 130, temperature 102° F. It was decided that laparotomy should be performed the following day. April 20th. There were present as assistants Drs. Steele, Braun, Sterl, Dickerson, and Mascheck. A spray of carbolized water had been kept playing in the room for several hours. The patient was etherized, and the bladder emptied by catheter. She was the thinnest person I ever saw placed upon an operating table. Immediately before the taking of ether her pulse was 124, temperature 103° F. The hair of the pubis was shaven off, and the skin of the abdodomen washed with soap and carbolized water. An incision three inches long, ending below at the upper portion of the mons veneris, was made in the middle line of the hypogastrium. Deepening the cut, I came upon the peritoneum, which, however, could not be separated from the parts beneath. Proceeding inward through dense structures, the knife suddenly entered an abscess cavity, which at once gave exit to a stream of pus to the amount of two or three ounces. Passing my finger through the opening, I found that the cavity extended downward, behind and to the left of the uterus, about three inches. The abscess walls proper could not be accurately defined. The inflammatory processes had matted together the upper part of the uterus, the left broad ligament, tube, and ovary. The cavity was washed out, and a rubber drainage tube passed to the lower end, the outer portion of the tube being stitched to the edge of the wound at its lower extremity. The remainder of the wound was closed with sutures, and dressed in the usual manner. The night following the operation the patient slept fairly well without an opiate. When I saw her the next day, she had taken milk and limewater with relish; her pulse was 108, and temperature 100° F. In brief, the relief of the symptoms was immediate, and the recovery uninterrupted. Pus continued to discharge for more than six weeks in constantly diminishing quantity. The tube was then removed. Menstruation appeared July 20th, and has been regular since. I examined the patient September 25th. The uterus was still in a position of right latero-version, but movable in a slight degree. The parts about the left broad ligament were thickened, and somewhat tender. An irregularly shaped mass occupied Douglas' space, and extended upward and to the left. The patient had gained greatly in weight, was ruddy, and doing her own housework. In a letter dated December 29th, she states, "I have no pain, and feel better than I have for four or five years." Dr. Jackson appended the following note from Mr. Lawson Tait: 7 THE CRESCENT, BIRMINGHAM, January 4th, 1886. MY DEAR SIR:-I have performed now thirty-two operations for pelvic abscess, in every one of which a cure has resulted. Yours very truly, LAWSON TAIT. · DR. CHRISTIAN FENGER.-Before entering into the discussion of the paper which has been read here this evening, I wish to remark that I came here under the impression that the entire subject of suppurative pelvic inflammation was to be dealt with; I now see the subject is limited to the treatment of pelvic abscess by laparotomy. The operation performed in Dr. Jackson's case I should not call a laparotomy at all, but simply an oncotomy. An abscess was opened, and the operation does not differ materially from the opening of a deep-seated abscess in any other region of the body,e. g., in an extremity. As I understand the term laparotomy, and I am not aware that it is ever used otherwise, it means that section of the abdominal parietes is followed by an operation, performed within the peritoneal cavity. If the wall of an abscess situated in an abdominal organ has become adherent to the visceral surface of the abdominal parietes, the peritoneal cavity is of necessity obliterated to the extent to which adhesions have formed. An incision made over such adhesions does not open the peritoneal cavity, and consequently the operation cannot be spoken of as a laparotomy. In the paper which I published on "Laparotomy for Periuterine Abscess," it is distinctly stated that the only way by which it seemed possible to get at the abscess was by opening the peritoneal cavity, it is also mentioned that omentum and intestines were found between the walls of the abscess and the walls of the abdomen. Concerning the etiology of pelvic abscess, I should like to call attention to the literature of the subject. Sänger,' whose statements regarding etiology I have found to be the most complete, says that one out of nine of all gynecological affections is of gonorrhoic character. He further says that fifty per centum of these are diseases of the uterine appendages; although, of course, any part of the genital tract may be primarily invaded. In the Fallopian tubes, he finds that disease most often has its principal focus, where it begins and whence it spreads. He distinguishes six kinds of salpingitis: (1) septic, puerperal, and non-puerperal; (2) tuberculous; (3) syphilitic; (4) actinomycotic; (5) gonorrhoic (6) a mixed form. The gonorrhoic is the most common form of the disease, and it produces the most severe cases of pelvic inflammation. It has as yet not been proven that the gonococci of Neisser can, of themselves, produce abscesses; but destruction of the surface of the mucous membrane is sufficient; an entrance is thus given to the septic, pus microbes, the staphylococcus aureus and albius and the streptococcus pyogenes, which are probably always present. The invasion having taken place, we must ask ourselves, By what channel does the inflammation travel? Where should we expect finally to find an abscess in case one should form? The Fellows will remember the beautiful experiments of Bitas, Koenig,2 Schlesinger;' experiments which about three years ago I repeated in the dead-house of the Cook County Hospital, although the purpose I had in view at that time was a different one. These gentlemen injected, by means of fine canulæ, fluids, such as colored glue, into the periuterine tissues of puerperal and non-puerperal bodies. Koenig found (a) that fluids, injected in the region around the fundus uteri and uterine portion of the Fallopian tubes, first pass upwards into the iliac fossa to reach the crest of the ilium, then downwards towards Poupart's ligament, and finally into the pelvis minor or true pelvis; (b) fluids injected into the periuterine tissues in the neighborhood of the internal os first fill the extra-peritoneal connective tissue of the pelvis minor, then follow the round ligament as far as Poupart's ligament, and ascend in a backward direction into the iliac fossa; (c) that when the injection is made near the lower portion of the posterior surface of the uterus, the fluid first flows into the cul-de-sac of Douglas, and thence rises into the iliac fossa. Schlesinger, although in the main agreeing with Koenig, differs with him in the following two points: He says, (a) when fluid is injected into the neighborhood of the fundus uteri, it first passes into the iliac fossa, but thence it does not descend into the true pelvis, as Koenig observed, but it ascends, running up the anterior abdominal wall; (b) from the broad ligament the fluid finds its way into the iliac fossa and thence upwards towards the kidney, running in the mesentery of either the ascending or descending colon. Schlesinger further makes the interesting statement that his pericervical injections filled the pericervical tissues, but that they never produced a tumor which could be felt above the symphysis pubis. As far as my experience goes, the results of these experiments correspond well with the clinical facts. The puerperal abscesses which I have opened were situated, two over the crest of the ilium, one on Poupart's ligament, and one on the anterior abdominal wall, about three inches above the ligament. As before mentioned, about three years ago I made similar experiments; the fluid I employed was milk. My object, at the time, was to ascertain the exact relative position of such an artificial exudate, representing an abscess, with regard to the anterior wall of the abdomen, especially of an exudate in one of the broad ligaments. I wanted to see for myself what difficulties I must be prepared to encounter in uniting the walls of a pelvic abscess, after having opened it, to the edges of the abdominal wound. As |