of fluids, eight are led to give the food and milk cold, seven think of hot five of milk, and equal numbers of stimulants and of plain milk; concentrated food, and as many of a liberal diet; liquid diet, eggs and beef tea, are each ordered by four; an increase and "forced each by three; stimulating diet, broths, bovinine, milkand meat extracts, each by two; grape juice, hot coffee and feeding, milk, hot salted milk, egg-nog, malted milk, digested food, Mur punch dock's food, albuminous food, malt, peptonoids, hot rum-punch, kumyss, rennet custard, oatmeal gruel with milk, whiskey hypodermically, "little change" and "stimulants rarely," each by single persons. Two doctors reject stimulants entirely. In phlegmasia alba dolens, twelve direct milk to be given; nine, liquid food; five, ordinary diet; and equal numbers, fruits, gruels and low diet, respectively; four, fever diet; three, broths, and as many, nourishing diet; two, less meats, and equal numbers, each no meats, fruit juices, and dry diet; while no milk, no fruit, no starch, Murdock's food, liberal diet, vegetables, simple diet, bland diet, less liquids, beef tea, bran water, rice water, hot water, gumarabic water, crushed wheat, meat diet, farinaceous foods, vegetable soups, tea and cocoa, find single advocates. In puerperal mastitis, thirteen recommend liquid foods, while twelve direct little fluid shall be used; nine suggest a light diet and eight a bland diet; six prefer farinaceous food, and an equal number, milk; four make no change, but a corresponding number elect a fever diet; three avoid meat, but equal numbers mention respectively ordinary diet, gruels and fruits; vegetables, bread, fruit juices and grape juices, each find two supporters; while liberal diet, crackers, potatoes, beef tea, hot water, vegetable soups, tea and kumyss, receive but solitary mention. In puerperal peritonitis, twenty-one recognize the propriety of a general liquid diet; eighteen think highly of milk, six speak well of gruels, four each of a bland diet and of broths, three each of low det, beef tea, fever diet, farinaceous food and light diet; two each of grape juice, oatmeal, milk diet, the white of eggs, toast, and the avoidance of meats; solitary persons each of chicken broth, liquid peptonoids, fruits, fruit juices, meat juices, vegetables, stimulants, hot water, cocoa, peptonized milk, tea, vegetable soup, milk and egg, kumyss and bovinine. Others suggest less meats, little milk, no milk, “neither fat nor salt," and little fluid. In puerperal cellulitis, seventeen adhere strictly to liquid foods; seventeen specify milk as a dependence; five, gruels; four, each low diet, bland diet and broths; three, fever diet, and the same number, farinaceous food; two direct us to avoid meat; as many forbid milk; while the same number urge respectively nourishing foods, tea, the white of eggs, milk diet, toast, oatmeal and malted milk; single practitioners order no fat or salt, less meats, baked apples, meat juices, vegetables, fruits, stimulants, little milk, hot milk, hot water, fruit juices, cocoa, peptonized milk, crushed wheat, vegetable soups, Mellin's food, little fluid, eggs and milk, bovinine and grape juice. In puerperal fever (generally so-called), milk is recommended by eighteen, liquid food by seventeen, a low diet by six, gruels by five, farinaceous foods, beef tea and bland diet, each by four; soups, toast, stimulants, tea and "no meat," each by three; broths, bovinine, fruit juices, white of eggs, "good feeding," milk diet, fever diet, oatmeal and grape juice, each by two; water, meat juices, “no hearty food," crackers, peptonized milk, baked apple, "little food," hot milk, malted milk, "anything desired," hot water, fruits, vegetables, egg and milk, less meat, crushed wheat, no milk, kumyss and toast water, each by one. In "acute septicemia," milk still leads with seventeen advocates, while those employing a general liquid diet number sixteen. Stimulants are favored by nine, gruels, by five; concentrated food, beef tea and broths, each by four; little food, light diet and generous diet, each by three; bovinine, whiskey, fruit juices, white of eggs, milk diet and farinaceous liquids, each by two; crushed wheat, fruits, toast, vegetables, the avoidance of meat, the disuse of stimulants, soups, sterilized milk, egg-nog, champagne, hot water, cream and water, milk-punch, nourishing diet, egg and milk, little fluid, meat extracts, mush and grape juice, each by one. me. In conclusion I must confess, that when I came to the tabulation of my returns, the difficulty of accurately preserving the practice of each physician presently appalled, and then well-nigh overwhelmed What I had supposed would be an easy task has proved more severe than those of any half dozen previous years combined. I still have a large mass of returns as yet untabulated, but they will not materially affect the figures above given. I shall present a complete report to the Institute at the earliest opportunity-probably next year. BY W. E. GREEN, M.D., LITTLE ROCK, ARKANSAS. In writing upon pelvic surgery it is not my intention to treat the subject in a highly technical way. My object is to touch upon its salient points, and draw out a discussion that will obtain from our pace ablest operators the most advanced and practical thoughts. The progress in all the departments of abdominal surgery during the past decade has been so rapid that it seems hardly possible to keep with its teachings. The brilliancy of achievements is equalled only by the boldness of its advocates. What was authority yesterday is, as it were, obsolete to-day. The methods of former years are now not only worthless but, we might say, pernicious. The old routine practice, the dilatory measures of the theorist in the treatment of many serious conditions of the pelvic viscera, when viewed by the light of recent investigations, are absolutely murderous. A knowledge of pelvic pathology is essential to a proper understanding and appreciation of the diseases of this region, and to this factor more than any other in a physician's acquirement depends his success in their management. The range of pathological possibilities is more extensive, the consequences of inflammatory products are more serious, and the disintegrating influence of pus is more devastating here than in almost any other part of the body. Infection of the pelvic structures is usually of uterine origin, the sepsis passing along the Fallopian tube ultimately reaches the pelvic cavity; an inflammation of the tissue here, in many respects, pursues the same course as elsewhere. The involved tissue becomes congested and effusions and cellular infiltration follow. In the tubes the irritated mucous membrane pours out a serous discharge, which becomes muco-purulent and quickly infects all adjacent structures. If the distal end of the tube remains patulous, the purulent matter is discharged into the pelvic cavity, infecting the ovary and peritoneum with varied consequences, the seriousness of results depending largely upon the virulence of the poison. If the sepsis is mild in character the inflammation is slow and circumscribed in its extension, the effusion of serum into the areolar tissue is limited, and the vitality of the circulation is not greatly impaired, reaction may follow, and the exudations are carried away by absorption. On the other hand, if the infection is virulent there is a more violent inflammation and a rapid pouring out of morbid products, the deeper structures become involved, the tissue becomes over-distended, the capillary circulation destroyed, and suppuration results. If the accumulation of pus is not early evacuated the most serious consequences follow. When the inflammation invades the Fallopian tube, the mucous membrane becomes swollen and plastic lymph often occludes the passage; in such cases the accumulation of serum dilates and enlarges its cavity, resulting in a hydro- or a pyo-salpinx, according to the nature of excreted fluid. The inflammatory exudations into the connective tissue of the tube renders dense and thickens its walls, which often leaves the tube in a greatly hypertrophied condition, and more or less infiltrated with pus corpuscles. At times the uterine extremity of the tube remains patulous; when this occurs the secretions may be discharged into the womb and recovery may result. Occasionally a more important feature of pelvic infection than disorganization of the tubes and ovaries, one that is often caused by delay in operating, is the bowel, bladder, and omental complications. Adhesions and contractions, resulting from the exudation of inflammatory products, cause a distortion and dislocation of organs and tissue that may be productive of the most severe and uninterrupted suffering, the relief of which is at times of more importance than is a cure of the original trouble. Since the laws of morbid anatomy apply alike to all regions, so also should the broad principles of surgery govern here as elsewhere. Who would, in this day of surgical progress, aspirate an abscess of the liver, leave an empyæmic pleuritis to a spontaneous evacuation or a gangrenous limb to nature's amputation? Yet, if we are to believe what we read, there are those who would treat a pelvic abscess by the expectant method, a disorganized ovary by electricity or a pus tube by dilating and curetting the uterus. These conditions. are to the pelvic surgeon what the former are to the general surgeon, and the evil consequences resulting to the general organism from their mismanagement are not less deleterious. There is a consensus of opinion among those most competent to speak, experienced operators, that diseased and occluded tubes with retained secretions and degenerated cystic or suppurating ovaries never return to a state of physiological health and that the consequent inflammatory changes, adhesions and contractions are not amenable to any form of therapeutical treatment. A verification of this fact is demonstrated in almost every specimen removed. There is a sentiment against the removal of the tubes and ovaries that is not based upon knowledge or sustained by rational reasoning. Limited knowledge of the subject and small opportunities are largely responsible for this. It must be remembered, when dealing with the subject, that the purpose of surgery is not always to establish |