Chronic Pelvic Inflammation.—Cases of chronic pelvic inflammation may be divided into two classes. In one, the presence of pus and visceral adhesions causes a constant aching and pain with menstrual exacerbations; in the other, extensive adhesions and large collections of pus may be present without causing any marked discomfort. Tn both, however, the general health suffers and loss of weight, anaemia, and a more or less hectic appearance show that septic absorption is taking place. In addition to this a patient with tender adhesions or collections of pus is always liable to an acute recrudescence of the inflammation, so that even where symptoms are practically absent and the disease has been discovered almost by accident, measures should be taken for its cure.
A thorough trial may be given to the remedies suggested in the last paragraph on subacute pelvic inflammation. In addition an attempt should be made to eradicate any chronic endometritis that may he present by swabbing out the uterus with Iodised Phenol, pure Carbolic or Formalin (40 per cent.). In doing so the practitioner should avoid anything but the most gentle traction upon the uterus, and he will be well advised to leave curetting, if indicated, to a specialist, as rough handling of the uterus is very likely to induce a return of acute inflammation and may possibly cause rupture of a pyosalpinx or pelvic abscess into the peritoneal cavity. A change of air either to the seaside or to a hydro where pelvic hydrotherapeutics can be carried out is often very serviceable.
Operative Treatment of Chronic and Subacute Pelvic Injlanin1ation.—In most cases the question of operation arises sooner or later. It may he postponed while symptoms are improving or are in abeyance and if the patient is improving in general health or maintaining her improvement. It arises at once if there is no improvement or if the patient is losing ground after a fair trial of non-operative measures; if it is important that she should be put in a position to resume active life as soon as possible, and if her circumstances are not such as to permit of her receiving the careful nursing and the opportunities for rest that can alone make non-operative measures successful. It need scarcely be said that when an abscess or pyosalpinx has ruptured into the peritoneal cavity operation is urgently indicated to save the patient. As regards the question of operating while rise of temperature and pulse-rate show that the infection is still active it 43 may be laid down as a general principle that if a collection of pus is present and is in such a situation that it can be easily reached and easily drained it should be opened at once. This condition is most commonly fulfilled in the case of pelvic abscess arising in the connective tissue or in Douglas's pouch. On the other hand, where operation means an extensive separation of adhesions leaving large raw absorptive surfaces, as in the removal of a pus-tube, all signs of active inflammation must have ceased for some time if the operation is to be safely undertaken. An excellent method of
judging on this point is to make a careful bimanual examination in the morning and take the temperature the same evening. If it is raised, operation should be postponed. The two methods may sometimes be combined with advantage; a large pus-tube or pelvic abscess may be incised through the posterior fornix and drained, and when the temperature and pulse-rate have come down to normal, the radical removal of the infected pus-tube may be undertaken.
\Vhat the actual operation should be in a case of pelvic inflammation depends so much on the condition actually present, which is often only disclosed when the pelvic viscera are in view after the preliminary incision, that nothing like definite rules can be laid down for its performance. One or two general questions may be briefly discussed.
Should operation be carried out by the abdominal or by the vaginal route ? It may be broadly stated that where the opening and drainage of an abscess cavity is alone aimed at the vaginal route is best, except in the case of an abscess in the iliac fossa, which must be opened above Poupart's ligament. Where the, aim of operation is to break down adhesions, to remove disorganised ovaries or tubes distended with pus or when there is a suspicion that the appendix may be implicated, it is better to operate through the abdomen, as adhesions can be dealt with under the guidance of the ey e and injuries to bowel or ureter can be more easily dealt with. Should the abdominal route be chosen, drainage through the posterior fornix should be secured, otherwise then:, is grave risk of disaster.
Should an attempt be made to save ovaries and tubes ? If at all possible it should be the aim of the operator to save at least one ovary, or, if that be not possible, a portion of one ovary, and this can usually be accomplished. If there is one moderately healthy tube it should be saved, even if upon the opposite side from the ovary that is kept. If both tubes arc diseased, there is little use in attempting to save one, as even if it does not give rise to trouble afterwards it is unlikely to become capable of per forming the function of an oviduct. Speaking generally, the younger the patient and the more easy her circumstances the farther may one justifiably go in the direction of conservatism, while in a patient approaching the menopause or under the necessity of working for her living it is foolish to imperil the success of the operation from a sentimental desire to save an organ which will probably remain functionless. If both ovaries or tubes have to be removed it is wiser to remove the uterus as well, as in nearly every case it is already diseased and will probably give rise to further trouble, while its function under the circumstances is gone.