If the vaginal incision has been sutured, the sutures are removed in two weeks, and the vagina kept packed until the scar is stout.

I do not give douches until the wound is healed, and forbid intercourse for six weeks after the patient is discharged.

PREPARATION OF PATIENT FOR A

VAGINAL SECTION.

General. The presence of nephritis, of cardiac disease, or of phthisis is no bar to the operation. Where patients have influenza I prefer waiting for a few days until this subsides, lest the narcosis excite a bronchopneumonia. Five days before the operation the patient is given a calomel purge. I prefer triturates of calomel each of gr. 4, given at 7, 8, 9, and 10 P. M., to be followed next morning by a saline purge, like Seidlitz powder. The diet is general and includes everything but the more indigestible foods and luxuries. I exclude everything fried, whether vegetable or flesh; stimulants are withdrawn, and narcotics, if previously used, are not allowed. The patient is made to lie down most of the time, reading periodicals, seeing few friends, and altogether assuming a semi-invalid state. She is encouraged to drink large quantities of water. Each night she is given a high enema of normal salt solution, of two pints. This she is encouraged to retain. The object is to charge the tissues with fluid. This has been shown not only to actually increase the amount of urine, but also to facilitate the elimination of urea. I have the urine analyzed for sugar, albumen, and per cent. of urea, the total for twenty-four hours being carefully measured. If fever has existed before this treatment is instituted, it usually diminishes, and if there is albumen in the urine this decreases. I strive to get the emunctories cleansed out and at the same time store up an excess of fluid for the day following the operation, when the kidneys take away

The fimbria are teased apart with forceps. While holding apart the edges of the V-shaped cut, a running suture of fine catgut is taken from the upper border of the fimbriae down to the angle and up to the fimbriæ of the lower flap. (See Fig. 55.) This suture is so applied as to unite the peritoneal surface with the lining of the tube, and is used for the purpose of preventing closure of the tube. The uterus is packed, and the opening in the cul-de-sac filled with gauze which reaches just within the cut edges. The vagina is packed with gauze. usual after-treatment is employed.

The

Broad Ligament Cysts.-When these are purely pelvic, whether single or multiple, they can be treated through the vagina. When they reach up to the pelvic brim they should be removed by laparotomy.

The uterus is curetted and the cul-de-sac opened. At once the smooth thin-walled cyst is felt. It has no pedicle; therefore, the uterus is held up with a trowel while the posterior vaginal wall is drawn down. Gauze pads are inserted above the cyst and the intestines kept up. With blunt scissors the cyst is split open and emptied. A portion of the flaccid posterior walls of the cyst is torn away with Luer's forceps. The pelvis is wiped dry, and the pads removed. No bleeding of consequence results. The uterus is packed with gauze, the cul-de-sac is filled with the same material which reaches up to lower margin of the cyst cavity, and the vagina is packed. The usual after-treatment is employed.

The After-Treatment in Non-Purulent Cases.-In two days the vaginal dressings are removed and the uterine packing withdrawn. The vagina is again packed. From eight to ten days after the operation the patient is placed in Sim's position and the cul-de-sac dressing taken out. In doing this the uterus must be supported by the trowel. Fresh dressing is inserted and the vagina again packed.

The second dressing is made in a week more, after which the patient is allowed up. The cul-de-sac is kept packed until closed.

If the vaginal incision has been sutured, the sutures are removed in two weeks, and the vagina kept packed until the scar is stout.

I do not give douches until the wound is healed, and forbid intercourse for six weeks after the patient is discharged.

PREPARATION OF PATIENT FOR A

VAGINAL SECTION.

General. The presence of nephritis, of cardiac disease, or of phthisis is no bar to the operation. Where patients have influenza I prefer waiting for a few days until this subsides, lest the narcosis excite a bronchopneumonia. Five days before the operation the patient is given a calomel purge. I prefer triturates of calomel each of gr. 4, given at 7, 8, 9, and 10 P. M., to be followed next morning by a saline purge, like Seidlitz powder. The diet is general and includes everything but the more indigestible foods and luxuries. I exclude everything fried, whether vegetable or flesh; stimulants are withdrawn, and narcotics, if previously used, are not allowed. The patient is made to lie down most of the time, reading periodicals, seeing few friends, and altogether assuming a semi-invalid state. She is encouraged to drink large quantities of water. Each night she is

given a high enema of normal salt solution, of two pints. This she is encouraged to retain. The object is to charge the tissues with fluid. This has been shown not only to actually increase the amount of urine, but also to facilitate the elimination of urea. I have the urine analyzed for sugar, albumen, and per cent. of urea, the total for twenty-four hours being carefully measured. If fever has existed before this treatment is instituted, it usually diminishes, and if there is albumen in the urine this decreases. I strive to get the emunctories cleansed out and at the same time store up an excess of fluid for the day following the operation, when the kidneys take away

at least from half a quart to a quart of urine and no fluids are ingested. The shock, both surgical from hemorrhage, and vasomotor from traumatism to these important pelvic structures, is much diminished.

Local. Two days before operating I prepare the patient. The pubes and vulva are shaved, the abdomen is covered by a wet dressing of 1⁄2 per cent. lysol solution, and the vagina is packed with gauze wet in bichlorid solution. These dressings are changed twice more before the operation. The day before operating I give meat once, potatoes, bacon, eggs, tea, soup, as much as needed. All the time the patient is instructed to drink two quarts of water a day. I do not like milk. In the first place it has poor food value for an adult, and its digestion results in the formation of "bullets" in the bowels. Furthermore, the intestinal gases are increased by it. For the same reason I do not use koumyss.

After the first purge of calomel and salts, it is rarely necessary to use another laxative; but if needed, one pil. rhei. comp. may be given two days before operating.

The day I operate I give no food or drink after midnight, if the narcosis is to be in the forenoon. If I operate in the afternoon, I give coffee and toast for breakfast and a pint of water at II A. M. I do not give stimulants either before or during the operation. Certain very desperate cases are met with: those with nephritis and prolonged suppuration. In such cases I perform transfusion into the elbow vein, using c. p. normal salt solution, and introducing as much as sixteen to sixty ounces at the time of operating. To old drunkards and to women with fatty hearts, I sometimes give a hypodermic of strychnia, gr. 36, before beginning the narcotic. But I do not do this often.

Cleansing the Patient.-The position is that for lithotomy, with the coccyx hanging over the table. The thighs and vulva are scrubbed with lysol solution 2 per cent. The packing is withdrawn from the vagina, and the latter is scrubbed with 1 per cent. lysol solution, using for this purpose a long brush (jeweller's,

(Fig. 56). The perineum is depressed and the brush moved up and down and rotated within the vagina while an assistant pours the solution into the vagina. After

JOHN REYNDERS-CO, NEW YORK.

FIG. 56.-Brush for scrubbing the vagina.

using the lysol the external parts and vagina are scrubbed gently with Thiersch solution. The legs and all parts of the field of operation are covered by sterilized towels or stockings. The operator then proceeds.

VAGINAL ABLATION.

General Considerations.-The vaginal mucosa and peritoneum only are severed in vaginal hysterectomy; whereas, in laparotomy, the skin, fat, fascia, muscle and peritoneum are cut. In vaginal hysterectomy no vessels are cut by the incisions which require ligation, but many small arterial trunks must often be secured in making an abdominal wound. It is not necessary to sever the peritoneum in performing vaginal ablation, for sufficient space may be secured without that. It is necessary to dissect the uterus from the bladder in both vaginal and abdominal ablation, but in the former the advantage is present of having the cervix as a guide. The uterus and adnexa to be removed are not masked by the viscera which lie above them when vaginal ablation is done.

Separation of Adhesions.-It is usually necessary to work through a mass of adherent intestines before the organs we seek are seen in laparotomy, while the work in vaginal ablation proceeds below the matted intestines which lie above the uterus. This attribute of the vaginal operation is worthy of a moment's discussion. We find two kinds of adhesions: Those which have formed