While twisting the forceps back and forth gentle traction is made upon the instrument. No force must be used. If the forceps does not slip out readily, either the stumps are stuck to it and must be freed by repeated twisting of the instrument, or else the gauze has become stuck to the forceps and must be liberated by introducing a blunt, flat instrument of some sort between the gauze and the forceps. In this manner each forceps is removed.

Time in Bed-Cases of cul-de-sac exploration and replacement are allowed out of bed after the third dressing. This is true also of hysterectomy cases, unless the vagina be widely opened and the perineum gaping. Inasmuch as the third dressing is usually made on the seventeenth day, the patients are out of bed generally before the expiration of three weeks. I make no attempt to hasten their discharge, but allow the surfaces to heal without much physical effort by them, and their minds to recover from the disturbance incident to facing and enduring so serious an operation.

Dressings.—In hysterectomy cases, on the eighth day, I put the patient in Sims' position. While the woman is in this position and perfectly still a careful removal and renewal of the dressings are made. In removing the gauze strips the centre ones are first taken out, so as to loosen those next the vessels. At the top of the cavity will be seen the lymph-covered rectum red and oozing, and upon each side the dead stumps already beginning to blacken. The instruments used in this first dressing are a long-bladed Sims' speculum, my trowel depressor, and a dressing forceps. Sims' tampon screw is a valuable instrument in all these dressings. The second dressing is made a week later.

The method of dressing cul-de-sac and replacement cases is described under the proper chapter.

Behaviour of the Wound.-The sloughs produced by the forcipressure smell badly. There are two ways of removing this: one by douching, after the first dressings are removed; the other, by ample, repeated dressings. I prefer the latter. There is no odor about my

patients, although I do not dress them more often than once in a week. The sloughs are blackened shreds and masses at each side of the vaginal incision. They should not be pulled off, but should be allowed to separate gradually. Healing does not really begin until the sloughs have separated, after which it is very rapid. I renew the dressings whenever discharges escape through them, and prefer Sims' position in doing this.

Sometimes in healing there will be produced at the vault of the vagina a knob of granulation tissue. It is better not to make application to this, but to pull it off with Luer's forceps.

Occasionally gonorrheal urethritis is aggravated, and a coincident cystitis induced by the operation and catheterism. Repeated irrigations of the bladder by saturated boric acid solution will correct the latter, and silver nitrate, grs. v. to f3i once a day, will cure the former.

ACCIDENTS AND COMPLICATIONS.

Bladder. The bladder is wounded more often than any other viscus. There are two ways in which the bladder may be injured. In the digital separation of the bladder from the uterus, the finger may enter the bladder cavity. Carelessness in making the separation between the two viscera leads to this. The rent is usually transverse. Upon suspecting such an injury the catheter is passed, and if the mucosa vesicæ is even bruised bloody urine will be withdrawn. Further dissection is effected by the use of mouse-tooth forceps and scissors, as manual violence will but enlarge the opening. Transverse rents in the bladder do not require suture, as they close if the bladder is kept empty.

In that method of separating the bladder from the uterus which is accomplished by progressively dividing the anterior uterine wall and dissecting away the bladder in stages, a vertical rent may be made by the scissors. The contracting bladder tends to keep such an opening

permanent. Here, therefore, continuous sutures of fine chromicised catgut should be employed to close the rent and the bladder should be kept empty. The aftertreatment is modified by this accident in but one particular, namely, that the bladder should not be allowed to distend. The catheter is left in place a week and is opened every hour. Each day the bladder is irrigated with a saturated solution of boric acid, but at one time no more than an ounce of the solution is to be injected. After the stationary catheter is removed, catheterism is done every two hours and the intervals progressively lengthened. The nurse should be instructed to notify the attending surgeon if no urine flows, for clots may block the catheter. The injection of a little boric acid solution will clear the tube.

The rubber catheter may be pressed so snugly against the pubes that flow of urine through it will be stopped. This condition will be differentiated from stoppage due to clot by rotating the catheter and pushing it up a half inch. If it be pressure obstruction the urine will then flow.

Bowel Wounds.—I have never wounded the gut. But in several cases I have found pus tubes opening into the rectum. After the operation of ablation is completed a continuous suture of fine chromic catgut closes the bowel opening. These openings also tend to close spontaneously, and even an awkward method of suturing will be effective. The rectum should be rendered incontinent in these cases by paralyzing or dividing the sphincter ani.

If the pus sac opens into a coil of small gut, or this latter be wounded, the rules governing the treatment of this accident during laparotomy will apply here. If resection is to be done the attempt should be made to use Murphy's button, but the general rule is that laparotomy and careful suturing are needed to properly close wounds in the small gut.

Wounds of the Ureter.—These are not recognized when made. In fact, ureteral fistulæ commonly occur

late as the result of sloughing produced by improperly protected forceps. As the lower half of the pelvic ureter is nourished by vesical arteries, when slough occurs it commonly involves at least an inch of the ureter if produced by grasping the ureter in the forceps; and no method of anastomosis can be applied later on. If such an accident is detected during the operation, laparotomy should be done at once and the severed ends of the ureter be either sutured or the ureter implanted into the bladder. If the ureteral fistula occurs during convalescence, the case should be let alone until no lesion remains other than an uretervaginal fistula. Then the case should be treated as though the accident resulted from laparotomy. At first, attempts are made to close the fistula through the vagina. These usually fail and the surgeon must resort to implantation into the bladder or to nephrectomy. This accident has not befallen me.

Pneumonia.—This occurs not infrequently, as we often operate upon those with phthisis or influenza. The pneumonia commonly develops on the second day, and is of the lobular type. I look with suspicion upon every rise in temperature on the third day and carefully examine the lungs. For this pneumonitis catarrhalis— usually due to streptococcus--I give potassium iodid only, 5 grains q. I h. to three doses; stop three hours, and then 5 grains q. 1 h., three doses as before. resolution becomes complete, I give 10 grains a day. I have not seen a fatal result from pneumonia following vaginal ablation. The general treatment embraces strychnin hypodermatically and other heart stimulants as needed. So soon as possible the posture of the patient must be changed from the dorsal to the lateral, to check the tendency to hypostatic congestion.

Until

Nephritis.-The method of preparing the patient very much lessens the liability to this complication. For three days after operating all urine is measured and each day an analysis is made. Upon the appearance of symptoms of nephritis, I at once give a high saline enema of three pints. If this is retained, I shall expect to repeat

it in eight hours. I also order large draughts of Buffalo Lithia water in hourly administrations. In aggravated cases I give glonoin hypodermatically and use either subcutaneous or intravenous injections of normal salt solution. Digitalis is indicated in cases properly demanding it and should be given as infusion by the rectum. But it is so slow in its action that the diluent normal salt solution must be employed first.

Intestinal Paralysis.—From the first the vomiting is severe and frequently gets worse. Blood may be vomited. The bowels can not be moved and tympanitis becomes marked. The temperature rises, and the pulse becomes quick and weak. The patient is pale, anxious, and in great distress. Neither she nor the physician can detect intestinal peristalsis. This condition I have seen three times, and only in women who had the most firm and extensive adhesion of the small gut to the uterus and adnexa, requiring careful dissection to remove them.

The stomach should be kept absolutely empty. Once every three hours one pint of normal salt solution at a temperature of 100° should be injected into the descending colon through a Wales tube (Fig. 110).

Hypodermatically strychnin is indicated, gr. s q. 6 h. The first fluid administered by mouth should be a little chicken broth, but should not be given until the stomach has been at rest for twelve hours. In a severe case lasting four and a half days, no food was given, but the patient was kept alive by the salt solution enemata alternating with nutrient enemata. The old treatment of attacking the stomach with cerium, cocain, belladonna, calomel, etc., is irrational. The stomach is normal, and the vomiting is due to intestinal paralysis, regurgitation of bile into the stomach, and reversed peristalsis. Morphia but aggravates the trouble.

Convulsions.-Epileptics and hystero-epileptics will have repeated convulsive attacks. These are best controlled by very minute quantities of morphin, gr. 12 occasionally. These are the only cases in which I employ morphin, and it is indicated because the seizures are due