and pelvic contents. If bleeding points are seen, they are grasped; but if the operator has done his work properly, four pairs of forceps are all that will be needed. The gauze pads are removed, and the pelvis is carefully

FIG. 83. Application of clamps from below. Faulty method, as the ovarian forceps projects too high.

FIG. 84. Application of clamps from above and from below. Faulty method, as the forceps will not lie loosely when dropped, and will tear the liga

ment.

cleansed by gauze swabs, particular attention being paid to the cul-de-sac. This completes the third stage.

Fourth Stage.-Dressings.—“The pelvic Mikulicz." A piece of iodoform gauze is inserted between the forceps and the vagina upon each side. Each set of forceps is then drawn toward the lateral pelvic wall by means of a

FIG. 85. The application of the pelvic Mikulicz dressing. The method of holding the dressing to one side while successive pieces of gauze are introduced is to be noted.

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long, narrow retractor. Between them enough strips of gauze are inserted to fill the space. These strips project up above the points of the forceps (Fig. 85). The patient is lowered to the horizontal position, and a self-retaining

catheter is introduced on a sound. The sphincter ani is dilated thoroughly. This is done to allow of the easy escape of intestinal gases, and to allay spasm of the levator ani muscle. The opposing muscle to the levator ani is the sphincter. Under the bruising and stretching to

which the levator is subjected, it is apt to spasmodically contract if held down hard by the undilated sphincter. Patients who have the sphincter dilated are more comfortable than are those in whom this is not done. A piece of plain gauze is wrapped around the forceps and tied. The operation is completed (Fig. 86).

The method of making these dressings is radically different from that employed elsewhere. I consider it an essential feature of my method. The Mikulicz dressing is employed here to absorb all discharges. It should be of sufficient volume to do this during the week in which plastic union is taking place between the rectum and bladder. But there is another reason why I pack these cases so snugly. It is to avoid an accident which not infrequently happens to those who use the gauze in slender strips only. When the latter dressing is used, at the time the forceps are removed, the sloughing ovarian stumps very often snap back into the pelvis, causing secondary infection. The pelvic Mikulicz dressing holds these stumps immovably fixed at the vaginal vault, and I have never seen such secondary infection.

In a case of what I supposed was a secondary hemorrhage from an ovarian vessel, when I removed the forceps on the second day, I made a rapid section of the belly. There was even at this early day found firm plastic union between the bladder and rectum, and the field of my vaginal operation was found completely shut out from communication with the general pelvic cavity The after treatment usual after vaginal hysterectomy is employed.