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vaginal pack and through one of these tubes the ir- rigations are given at frequent intervals by coupling a douche bag, the latter being placed in a low posi- tion so that the force of the fluid is barely suffi- cient to cause it to flow. Three or four of these ir- rigations are given daily, consisting of some mild antiseptic such as potassium permanganate solution or a weak solution of one of the silver salts. This treatment creates, to a great extent, condi- tions similar to those that exist in urethritis, i. e., adequate passive and occasional active drainage. It involves more than an ordinary amount of work on the part of the physician and attendants but it gives a small percentage of tube infections as compared with the ice bag and douche treatment. I ilo not curette these women, for while at first thought it might appear that if we can remove the en- dometrium, the gonococci having no affinity for the deeper layers would disappear. As a matter of f:ict it is well nigh impossible to comjiletely remove that membrane, and the persistence of even a slight por- tion is sufficient to reinfect the new endometrium that so rapidly forms, also, the manipulation neces- sary in curetting Do You Need A Prescription For Cialis In Canada is extremely likely to force tiie infection into the tube. If for one reason or another the infection spreads to the tubes, it causes violent reaction with symj)- toms of localized peritonitis such as abdominal rig- idity, pain, bowel paralysis and tympanites. There is a decided flow of lymph to the peritoneum around the tubes and the whole pelvic contents soon become fixed in a bed of adhesions. The infected lube soon swells and fills up with pus. It is certain that in manv cases the uterine end of the tube does not I70 irEIL: SEPTIC EX DOMETRII IS. [New York , Medical Journal ' close at this time and it is probable that if it ever does close so early it is only exceptionally. What more likely occurs is that the uterine end finds its calibre inadequate for proper drainage since this portion of the tube is very small and the nature of the lining membrane of the tube is such as to ofifer extended surface for infection with a large quantity of pus formation. Now, if it is true that under good, active, and positive drainage, gonorrhoea tends toward spontan- eous cure, and if it is a fact that in the absence of infection, pus, or other irritants, adhesions tend to undergo absorption, it would seem that if we could create this desirable drainage from the tubes, the infection would sooner or later subside without pyosalpinx formation, just as it subsides without urethritis, under which circumstances the adhesions which formed in anticipation of peritoneal invasion being of no further service would undergo absorp- tion, thus restoring to health and usefulness a tube that otherwise would be a source of considerable trouble, which would be functionally useless and which would eventually have to be removed. There are three ways by which drainage of the tube can be carried out : ( i ) To open up the fim- briated end of the tube through abdominal incision ; (2) to incise the tube either by laparotomy or vag- inal section ; and (3) by maintaining the uterine end of the tube in a patulous condition. Bearing in mind that we are dealing with an acute active infection and that Nature early clo.ses the fimbriated end of tube in order to prevent peritoneal infection, it will be observed that reopening this tube at Do You Need A Prescription For Cialis In Canada the fim- briated end would be acting contrary to Nature in her elTort to dispose or limit the infection. Again gynaecologists have long since learned the futility and dangers of laparotomy in acute pelvic disease. Finally, a procedure of this sort would almost in- variably result in peritoneal infection necessitating drainage with unavoidable consequences. Incising the tube also involves peritoneal contamination and infection, and while this can usually be readily done through the vaginal vault from which point drain- age is good, the operation of itself mutilates the tube, which can never be restored to normal, and finally it is found from experience that vaginal drainage in acute gonorrhoeal pelvic disease is for some reason or other not nearly as successful as the same operation in other pelvic infections. Dudley states (^Gyiicrcology, fourth edition, p. 304) : "The prognosis after incision and drainage is better for hydrosalpinx than pyosalpinx and best for cellular abscess." The problem of approaching a pus tube through the uterine cavity is not a new one. It is mentioned in the American Textbook on Gyncecoloay (i8g8) but only to be condemned as impractical and im- possible. It is undoubtedly a difficult proposition but of much value if it can be successfully carried out, for it is evident that if the tubal approach to the uterine cavity can be maintained in a patulous state, the tube will drain and no tubal Do You Need A Prescription For Cialis In Canada abscess or re- tention cyst Do You Need A Prescription For Cialis In Canada is possible. There is, of course, com- plete tubal connection between the uterus and the Falloppian tube, but it must be admitted that its cal- ibre is small, still, however small it may be. it is still large enough to allow the passage of pus. There is evidence that it possesses dilating power in as much as every structure within the body of that nature' by virtue of its very makeup possesses elasticity, and there is much evidence that extrauterine preg- nancy often becomes uterine by passage through the uterine end Do You Need A Prescription For Cialis In Canada of the tube ( Kelly, Operative Do You Need A Prescription For Cialis In Canada Gyne- cology, p. 441 ), which of course it could not do without dilation, ^^'e have evidence of the ability of this duct to drain in the cases of intermittent dis- charge from pyosalpinx due to intratubal pressure; which discharge relieves the tension for the time I hydrops tubae profluens). Again the treatment of [JUS tube by massage while not recommended is oc- casionally successful in forcing the pus into the uterus. Often after jalpingectomy as a result of faulty technique a fistulous opening through the uterine remnant of the tube remains and is the