come still further into view. The grooved guide is now inserted behind the uterus and the organ split in two parts. The further steps of the operation are described under Hemisection, third and fourth stages. In reality morcellation is not a very important factor in the removal of inflamed uteri. In fibroid extirpation it is an invaluable essential. In these pus cases the morcellation is useful only as a step preliminary to hemisection. Without it in certain cases hemisection is difficult. If there be absolute fixity of the cervix, such as we see in bilateral broad ligament abscess, it will be necessary to secure the uterine arteries and cut the cervix loose at the sides before beginning with the hemisection and morcellation; but I consider it a misfortune when I am compelled to apply hemostasis before the adnexa are free (Fig. 89).

Sometimes the operator will find that even after he has removed all the visible portion of the anterior uterine wall he can not turn down the cornua beneath the pericervical ring. Either the adhesions above the uterus are so dense that the cornua are fixed, or else there is a mass behind the lower zone of the uterus which prevents descent of the organ. When he comes to a standstill in his anterior morcellation he proceeds as follows: The uterine arteries are clamped by two forceps and the cervix is freed with scissors. The cervix is then amputated at the level of the internal os. A firm grasp is taken of the stumps, and the posterior uterine wall is morcellated as was the anterior. After proceeding half way up the uterus in this manner it may often be found that the uterus is so shelled out that it may be partially inverted, or that one cornu may be brought so far into view that forceps may be applied to the ovarian artery close to the cornu. If this can be done it is an easy matter to cut the uterus loose upon one side and to swing the mutilated organ out of the vagina. The enucleation of the adnexa attached to this large portion of the uterus is then made as though the uterus had been split in half, and it is removed with the adnexa of that side as in hemisection. Then the adnexa outside the forceps

which was first placed on the ovarian artery of the opposite side is freed and brought out; the ovarian artery secured outside the ovary and the adnexa together with

FIG. 89.-Showing the effect of morcellation as outlined in Fig. 88. The traction forceps draw the cornua together so that the fundus is made to roll out beneath the bladder.

the provisional forceps are removed. By this method of irregular morcellation very large uteri can be taken out through the vagina with the use of only four forceps

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(Fig. 90). All through such an operation as described. repeated palpations must be made of the arterial anastomoses at the sides of the uterus, and the utmost care must be exercised not to wound them either by scissors

FIG. 90.-Symmetrical morcellation of the fibroid uterus. The uterus reached the level of the umbilicus. Miss L., aet. 42. Vaginal Ablation. Four pairs forceps used. Recovery.

or traction forceps. I employ for morcellation very stout scissors curved on the flat, one blade blunt and the other pointed (Figs. 91 and 92). The pointed blade can

JOHN REYNDERS & CO.

FIG. 91.-Sharp heavy scissors, especially useful in morcellation. Either point can be driven into the tissues, however hard.

be driven into the tissue. I am further careful always to cut from without in.

An assistant can lend material aid by pressing down above the pubes, employing the closed fist for this pur

pose. Such support prevents the uterus being drawn up in case the traction forceps tear through. The operator should strive to avoid lacerating the uterine tissue by pulling his traction forceps through it. This may happen to him once, but the one experience should teach him the degree of traction the tissues will tolerate without tearing.

JOHN REYNDERS & CO.

FIG. 92. Stout blunt scissors used in vaginal hysterectomy.

Like all very technical manœuvres pages of description of the various steps do not become mental pictures until applied. But one operation upon a difficult case will suffice to make clear the necessity for all I have written. If the operator meets fibroid nodules within the uterine walls they are shelled out of their beds. The removal of each of such isolated growths aids in the progress of the operation.

VAGINO-ABDOMINAL HYSTERECTOMY IN THE PUERPERAL STATE.

Indications. It is supposed that a possible malarial paroxysm has been eliminated by cinchonizing the patient by means of a rectal injection of quinin solution (see formula). Faithful trial of intra-uterine irrigations (see septic endometritis) have failed to subdue the symptoms of septicemia, and the operator determines to open the posterior cul-de-sac. This he does after performing curettage. When the cul-de-sac is open the propriety of performing hysterectomy may be settled, but it is impossible before. Upon inspecting the

uterus it is found livid and usually studded with isolated flakes of lymph. The curettage has shown the inside of the uterus to be necrotic, and after the cul-de-sac is opened slight pressure with the examining finger will break the uterine wall. The uterus is in a necrotic condition. The fluid evacuated from the cul-de-sac may be muddy serum containing more or less lymph, or seropus may be present in large quantities lying free in the pelvic cavity. Almost any one of the various lesions of the ovaries and tubes may be found. But the indications for ablation are the necrotic or gangrenous condition of the uterine walls, and a septicemia which will not yield to curettage and cul-de-sac evacuation. The presence of pus in the pelvis with a firm uterus does not call for ablation. A sufficiently effective evacuative operation can be made through the cul-de-sac without removing the uterus; and the presence of enormous amounts of recent lymph not only does not call for the ablation, but rather contra-indicates it, if the uterus be firm. If by bacteriological examination of the discharge streptococci have been found, this is but another reason for hastening the operation. I wish to be clearly understood as opposed to this formidable operation for septicemia where there is absence of signs of uterine necrosis. Streptococci may be present and large quantities of pus produced, and yet the cul-de-sac evacuation will suffice to effect a cure. If the uterus is beyond saving, so long as it remains it feeds the lymphatics with septic material. These women die, not from the peritonitis and pus foci, but from septicemia.

Operation.-Rapidity in operating is essential. The uterus is curetted, irrigated, and packed with gauze. The posterior cul-de-sac is opened, and the bladder is partially separated from the cervix by incising the vaginal mucous membrane. Into the posterior incision iodoform gauze is stuffed. While he cleanses his hands, the operator has the patient placed in Trendelenburg's position and prepared for laparotomy. The abdomen is opened from the umbilicus to the pubis. As soon as it is entered