ception, leading one to believe that with the same relative time and attention given to it that abdominal section has secured, it will be safer. The recovery is more rapid and the after-condition is better, because herniæ and omental and intestinal adhesions are less common. FIG. 1. at time of operation. The pudenda should be shaved; the vagina and cervix should then be cleansed, green soap and water being thoroughly applied with a brush. This measure must never be omitted, but if one case calls for the brush more than another it is the virgin vagina, the vagina with ruga. Of course, FIG. 2. Fig. 1. Vaginal hysterectomy. Fig. 2. Vaginal hysterectomy. Finally, we beg leave to say that, from all that has been said and done in this subject by the various operators, we might as well admit that a revolution is taking place in our methods of dealing with the uterus and appendages, and it is safe to say that most of the operations done now above the pelvis for conditions specified in this article will soon be done from below. It is merely a question of learning how to do it. Operation. The diet should be light the day before, food being taken as late as six hours prior to operation. Twenty-four hours before the operation a brisk cathartic should be given. Six hours before operation the lower bowel must be thoroughly washed out by a copious enema of castile soap and warm water. The bladder should be carefully emptied Initial application of cautery knife. the upper surface of the external genitals, the vulva, the anal regions, and the buttocks must be subjected to the same process of cleansing, the brush being used sparingly on the delicate structures of the clitoris and vestibule. The entire surface, internal and external, must now be washed off with 1: 1000 bichloride of mercury solution, and this in turn washed away with warm sterilized water. When all this has been carefully executed, the patient is ready for any one of the several operations done by the vagina. If the uterus is to be retained, and is to be curetted and packed, this step is now carried out. The débris of the curettage is then removed by washings of I: 2000 bichloride of mercury, and the patient is ready for the next step. Let us suppose this to be an operation upon the appendages-some plastic or conservative procedure. In that event the operation is anterior colpotomy. The body of the cervix is caught with a volsella just below the anterior utero-vaginal junction. Strong traction is then made (Figs. 1 and 2), while with the cautery knife a transverse incision is carried through the vaginal wall from one side to the other about coincident with the above junction. If the uterus is small, this incision need go no further than the sides of the cervix, and by this we mean the line of junction of the anterior and posterior halves of the cervix ; but if it is large, it should be extended thence downward and outward half an inch or more, onto and through the latero-posterior vaginal wall. The bladder is next separated from the uterus, using the index and middle finger for this purpose (Fig. 3), If it be the enucleation of a sub-peritoneal fibroid on the anterior face of the uterus-that is, anterior to the broad ligaments-we proceed to this at once, holding the field of operation against the vaginal incision by pressure from above. If it be the removal, in whole or in part, of an ovary, a tube, or the enucleation of a fibroid at the fundus or on the posterior face of the uterus, posterior to the broadligaments, we antevert the uterus and bring the fundus and body through the vaginal incision into the canal (Fig. 4). This can be best done by bringing through first one of the cornua, after which the remainder of the organ is made to follow. Several instruments have been devised to further this step, which is the most difficult in the operation, but nothing is so good as the two fingers of the operator working through the incision, aided, if necessary, Fig. 3. Vaginal hysterectomy. Enucleating with fingers after preliminary cutting of vaginal wall with cautery knife. Fig. 4. Anterior colpotomy. Fundus uteri and left ovary drawn into vagina. and the utero-vesical fossa is entered. Sweeping the fingers right and left, the bladder and ureters are pressed well aside. Still using the two fingers, the several viscera, including uterus, broad ligament and appendages, intestines and bladder are carefully palpated. Finding the conditions favorable to plastic or conservative operations upon the uterus or appendages, we proceed according to the problem presented. by those of an assistant, placed in the rectum for the purpose of keeping the uterus forward. After the organ is drawn well into the vagina we act in accordance with the problem before us. Fibroids are enucleated upon the same plan as prevails under other circumstances-that is, the capsule is cut through and the growth seized with a volsella, and is worked out of its bed with the aid of the fingers and the scissors. Deep sutures of catgut or fine silk are then passed, for the double purpose of closing the opening left and checking hemorrhage. If the ovary is to be operated upon or removed, it is drawn through into the vagina (Fig. 4), being reduced in size where necessary by aspiration or incision. When in the vagina it is at the command of the operator, and can be removed in whole or part as need demands. These statements are applicable to the tubes, which should also be brought out into the vagina, being previously emptied of fluid contents by aspiration. involved bruising of the vesico-vaginal connective tissue, the cut in the vaginal wall may also be closed. If the contrary has been the case, it is best to leave the cut open. It may be sometimes necessary to pass from anterior colpotomy to hysterectomy, as where, for instance, we discover that both tubes are purulent and that the ovaries are similarly involved. This can be easily done by carrying the incision around the entire utero-vaginal junction, and then proceeding to the removal of the uterus, as we shall FIG. 5. Vaginal hysterectomy. Forceps applied to lower segment of the right broad ligament and ovarian artery. The ligation and removal of an ovary (which should be done independently) are, in general, simpler than the same operation upon the tube, because of the more extended blood-supply of the latter. In removing a tube tie as much of the mesosalpinx as you can, this generally is all of it; then ligate the uterine end of the distribution of the ovarian artery by including every structure at the cornu, except the tube; hug this closely with your ligature. Next enucleate the tube, and tie such bleeding points as appear. Having completed the operation, the uterus is returned to the abdominal cavity, and the divided peritoneum of the utero-vesical fold is reunited with catgut suture. If the operation has not next describe under vaginal hysterectomy, with evacuation and removal of diseased appendages, such as pus-tubes, ovarian tumors, etc. Posterior colpotomy. This section is resorted to for purposes of simple drainage, as in acute affections involving the cul-de-sac. It is also a part of the operation which looks only to the evacuation of pus-sacs, the removal of small ovarian tumors, the severing of adhesions, and exploration of the pelvis. It consists of a vertical section of the posterior vaginal wall, extending from the utero-vaginal junction to the bottom of the cul-de-sac. It can be made with knife or scissors, as there is small risk of hemorrhage, and, as a rule, can be closed when the work is done, unless pus or some such infecting substance as the | fingers, aided by long forceps, and are then clamped contents of a dermoid has been encountered. or ligated at the attachment to the broad ligament and cut away. If it be an ovarian tumor, this is drawn down to the cut in the vaginal roof, is there tapped, and after the contents have been removed the sac is withdrawn much after the manner which prevails with abdominal section. FIG. 6. Vaginal hysterectomy, with evacuation and removal of diseased appendages, such as pus-tubes, ovarian tumors, etc. It is assumed that the patient has had the usual preparation, that the bladder and rectum have been emptied. A soft rectal bougie should now be carried into the rectum and passed as far as it can be gotten to remain. The vulva and the vagina having been cleansed, as already described, and the cavity of the uterus, and especially the cervical portion of it, having been curetted and washed out with a solution, 1 : 1000, of bichloride of mercury, the removal of the uterus should be the next step. The cervix is grasped back and front with a blunt volsella and drawn forcibly down as near the vulva as possible. The vagina at the uterovaginal junction is then cut through entirely around the uterus (Fig. 1). This accomplished, the enucleation of the cervical portion is next in order (Fig. 2), to be followed by measures designed to control hemorrhage. If it be by ligature, this is passed first on one side, then upon the other, so as to secure the uterine artery, which can be easily palpated. If, on the contrary, the clamps be preferred, one is placed on each side, so as to secure the entire lower half of the attachment of the broad ligament to the uterus, which will include the artery. These clamps are made to hug the uterus as closely as possible, and are guided into position by the thumb and index, or index and middle, fingers, thrust one in front and the other behind the broad ligament, at the uterine attachment. The vessels of the lower segment of the uterus being secured by clamp or ligature, the organ is cut free and the enucleation is carried on with the index and middle fingers (Fig. 3) until the bladder is separated and the utero-vesical space in front and the cul-desac behind have been opened into; the vessels at the sides are not molested, the vaginal wall being The serious difficulties arise in connection with merely pressed back to give easy access to them the conditions of pelvic abscess. We may not be when ligatures or clamps are to be applied. If able to remove the uterus as cleanly as has been dethe case is simple, that is, if there is no extensive scribed, but may be forced to take it out by morcelmatting together of the visceræ, as in bad cases of lation. Cut it out segment by segment, clamping suppurative disease, the peritoneum upon the base the bleeding vessels as they appear. The posterior of the bladder and in the cul-de-sac should be lower half is first removed, then the anterior. In attached with a single stitch (catgut) to the cor- this procedure we may open promptly into a pusresponding vaginal wall. The way is then clear for sac in the cul-de-sac. After cleansing this out, we the application of the clamp or ligature, as one may proceed to the upper half of the uterus. This elect, to about its middle, still applying steady should be cut open antero-posteriorly. After retraction; the upper attachment of the uterus is next moving the two segments, we use the cut ends of brought down; this is clamped (Fig. 5) or ligated, the cornua as guides to the pus sacs, tubes, and after the manner already described, and then ovaries of either side. Feeling one's way carefully, the entire uterus is cut out. The succeeding making traction upon the sacs, which by this time steps depend upon the condition presented. If can be differentiated, first one side then the other it be a simple pyo- or hydrosalpinx, these, along is drawn down, enucleated, and withdrawn. It may with the degenerated ovaries, are enucleated by the be that this process of enucleation will have to be Vaginal hysterectomy. Enucleation of uterus with cautery knife without clamp or ligature. done in the depths of the pelvis; if so, one cannot use too much caution, for it is in such cases that visceral injuries are most liable to occur. Patience and intelligent perseverance will enable one to surmount the difficulties, however, so it is rare that one will be forced to call to his aid abdominal section. This, however, should be done if the intestines high up in the pelvis have been injured. Having opened above the pubis, the patient should be thrown into the Trendelenburg posture and the injured intestine quickly found and repaired. If any sacs, or parts of sacs, remain they should be taken out; the pelvis must then be washed out with sterilized water and a loose gauze drain placed in the bottom of the pelvis, extending thence through the vagina. After vaginal hysterectomy of any kind it is wise to leave the vaginal cut open, draining through it by means of a good strip of gauze, which extends from the depths of the cul-de-sac to a proper dressing over the vulva. This precaution may be op. tional in clean cases, but it is an absolute necessity in all pus-cases. If ligatures have been used, they are left long, are tied together, and placed in the vagina. If clamps are employed, they are looked over carefully to see that each is secure, doubtful ones being further guarded by tying the handles firmly together. The handles of the clamps are then encircled with a thick layer of absorbent cotton, which is also in contact with the vaginal drain, whose function it furthers. A soft-rubber retention-catheter is finally placed in the bladder, and the operation may be said to be complete. The catheter is self-retaining, by reason of a bulb or collar at the vesical end of the instrument, but to realize its object it must be plugged or knotted at its free end. By removing this plug or knot at intervals of two or three hours the bladder is properly emptied and the dressings are kept clean. This upper cotton dressing and the catheter are the same for all cases of vaginal section. This article would not be complete were we to omit mention of the method of removing fibroids by morcellation. The preliminaries up to and including separating the vagina from the cervix are identical with the process already described. The departure begins after the cervix has been enucleated, and the lower vessels ligated or clamped. This consists in cutting away, piece by piece, first the cervix, then the body of the uterus, dragging each piece forcibly downward with blunt-toothed volsella; bleeding points are caught as they appear and ligated or left in the keeping of the clamps, as convenience dictates. Working after this fashion, with knife and scissors, protecting the vaginal walls with retractors, the tumor is dragged piece by piece into the vagina, and then cut off. In this way the operation is really performed within the vagina, sparing the cavity above it. As already intimated, the dressing and later treatment of the case coincide with those adopted in other vaginal sections. A word must now be said about enucleation without clamps or ligature. It can be done, but it has its limitations, and should be performed with the cautery. We confess that a ligated or clamped vessel makes us less anxious, and as there is no valid objection which is at all weighty, we prefer to use one or the other. The best cases for this operation are women past the menopause or who have already been rid of their appendages--the uterine vessels being with all such persons more or less atrophied. It is done as follows (Fig. 6): After the usual preparation, seize the uterus at the cervix and burn through the vagina at the utero-vaginal junction. Now keep up forcible and continuous traction upon the cervix, at the same time burning through the attachments to the uterus as they descend. This burning must be made within the true uterine tissue rather, the cautery being driven firmly into it. It is best after each segment has been burned through to relax the traction, to see if the vessels just severed bleed; if they do, sear them at once, and continue it until they are closed. Proceeding in this manner the uterus is quickly peeled from its envelope, and the cornua are brought into view. These are burned through and their stumps seared. In the removal of the tube and ovary it is wiser to use ligatures or clamps. This having been done, the operation is complete. The after-dressing and treatment are the same. Speaking now of vaginal hysterectomy in general, clamps should be removed in from forty-eight to seventy-two hours, after which the patient should receive a night and morning douche of warm boric acid or permanganate of potash solution, for purposes of cleanliness and comfort. Ten days cover the usual limit of convalescence in bed, the patient being permitted, under ordinary circumstances, to take the sitting position in bed at the end of a week. The catheter should be removed when the clamps are taken off. Ligatures should be cut out at the end of two or three weeks. The bowels are treated much as in abdominal section, but there is one comfort the patients with vaginal section can enjoy, that is, morphine for the relief of pain. This drug does not appear to have as troublesome consequences after this form of operation as after abdominal section. With this, Mr. President, I must close. Recapitulation of conditions favorable on the one hand to vaginal section, on the other to abdominal section in diseases of the female pelvic organs: |