Lastly, before closing the abdomen the appendix should be examined, and if it has been involved in the inflammation, it should be removed.
In this field of pelvic surgery the method of hypertonic saline treatment introduced by Sir Almroth Wright has materially simplified and bettered the position of the surgeon. In cases where the pelvis has been unavoid ably fouled with pus in the removal of pus-tubes or the treatment of ovarian abscess, I have had excellent results by abdominal drainage, the tube being blocked at the lower end with a strand of gauze, and two or three sodium chloride and citrate tablets being inserted above. Such patients, formerly always an anxiety. have recovered under this treatment without a bad symptom.
It should be remembered that these patients, half poisoned with pus as they are, require very careful nursing, good nourishment and plenty of rest and fresh air to enable them to make a satisfactory recovery after any operation that may have been done.
Tuberculous Pelvic Inflammation.—Tubercle starts as a rule in the tube, and spreads to the surrounding organs. In a case of some standing the tubes are moderately enlarged and filled with caseous tubercular material, the ovaries are superficially involved and tuberculous peritonitis has usually caused more or less extensive adhesions between the original focus and the coils of bowel lying in contact with it. The counsel of perfection in these cases is to remove the affected organs, but operation for this purpose is nugatory or dangerous when the necessity arises to break down firm adhesions with bowel whose wall has been weakened by tuberculous infiltration, since perforations, which it is almost impossible to suture satisfactorily, are practically certain to he made. I should therefore be in
favour of giving a very thorough trial to general antituberculous treatment combined with the injection of small doses of tuberculin in every case before resorting to the aid of surgery. The dose to be injected should be milligramme at first, and if this produces too much reaction and makes the patient worse, half the quantity may be used at the next injection, which should in no case be given at shorter intervals than a fortnight. During the interval, at least for the first month or two of the treatment, the patient should rest absolutely, and afterwards should have absolute rest after each inoculation until the reaction produced by it has passed off.
Non-infective Pelvic inflainination.—Besides the inflammations already described, the practitioner not uncommonly meets with the non-infective adhesive inflammation which is set up in the pelvic cavity around a blood effusion, whether resulting from the rupture of an extra-uterine pregnancy or of a lutein cyst, or from the tearing of an adhesion. Very dense and firm adhesions are formed between the viscera surrounding the blood-clot, and if this should chance to become infected a true suppurative inflamma tion supervenes, which must be treated' on the lines laid down above. Where no infection has occurred, the condition should be treated as described under Extra-uterine Pregnancy and Hmmatocele, Pelvic. R.J.J.