Hot water is used in vaginal injection (p. 171 et seq.) before operations in order to diminish bleeding during them (T. A. Emmet). It is also used to check hemorrhage during operations. Thus a stream of some hot antiseptic solution may be kept continually flowing over the field of operation or may occasionally be directed against the bleeding surface. At the end of laparotomy hot water is often poured by the pitcher or through a finger-thick glass tube right into the peritoneal cavity. Hot-water injections are also used as a hemostatic independently of operations, both in the vagina and in the uterus (pp. 172, 173).

Styptics, especially alum, tannin, and chloride, persulphate or subsulphate of iron (Monsel's solution), are used as applications (p. 170), on tampons (p. 177), or in injections (p. 172). The undiluted liq. ferri chloridi or subsulphatis may be applied with cotton to small bleeding surfaces. Diluted with 10 parts of water, it may be used in injections or left in on a tampon. A very convenient way of using styptics on small wounds is in the shape of dry styptic cotton as sold in the drug

stores.

Cauterization is an excellent hemostatic and, at the same time, an antiseptic, but as it leaves an eschar, it can, as little as styptics, be used where healing by first intention is aimed at. The dry heat of the actual cautery is so powerful a hemostatic that it may even be used to sever the pedicle of an ovarian tumor without using any ligature. A very convenient apparatus is Paquelin's thermo-cautery (Fig. 156), in which a tip of platinum may be kept at different degrees of heat by a more or less abundant supply of benzine vapor.

Independently of its hemostatic effect, cauterization is often used as an antiseptic to sear a wound surface, and thus make it impenetrable to bacilli. Thus, some use it on the stumps left after removal of the ovaries or the uterus.

Cauterization by means of the galvano-cautery will be described under Electric Treatment.

Ligature.-Spurting arteries, or more rarely bleeding veins, may be ligated with silk or catgut, according to the general rules of surgery, but in gynecological practice we are oftener than in other departments obliged to tie, not the isolated bleeding vessel, but a more or less considerable mass of the surrounding tissue with it (mass ligature). Arteries may be tied where they are severed or in continuity.

Ligature of the Uterine Artery.-The uterine artery may be tied from the vagina. According to Martin, the patient is placed in the dorsal posture with raised knees. A broad, short, and flat speculum is introduced. The operator, sitting in front of the table, tries to locate the artery by its pulsation. The cervix is pulled well over to one side with a volsella. A middle-sized, strong, curved

1 Geo. Engelmann of Boston, Trans. Amer. Med. Assoc., 1885.

needle is introduced into the anterior part of the fornix of the vagina, a finger-breadth [?] from the cervix and on a line with its anterior circumference. The needle is carried deep in, and pushed out on a line with the posterior wall of the cervix. Next, the ligature is tied very tightly. If needed, the same may be done on the other side.1

FIG. 156.

Thermo-cautery.

There is danger of comprising the ureter in the ligature; and, since the ureter lies about half an inch outside of the cervix (p. 81), a finger-breadth, as advised by Martin, would be a particularly dangerous distance. In the opinion of the writer, one-third of an inch is the proper distance.

2

Fritsch is opposed to methods by which the uterine artery is tied by means of a mass ligature applied through the vaginal roof. He says by so doing we do not know what we tie, and even if the uterine artery is included in the ligature, it is not sure that it is made impervious. He makes an incision an inch and a quarter long in the posterior roof of the vagina on the right and left sides. This incision divides, as a rule, first the two vaginal branches. Next he cuts deeper until he has severed the uterine artery, which is then seized and tied or surrounded by a mass ligature. Then the same is done on the other side. The wounds are filled with iodoform gauze in order to prevent rapid healing and the formation of a collateral circulation.

The safest procedure is to make a transverse incision in front of the cervix, just below the bladder, separate this from the uterus, carry the bladder and ureters forward with a retractor, ligate the artery by carrying a silk ligature around it with Schroeder's or Polk's needle (see Uterine Fibroids) from the front backward, cut the ligature short, and close the vagina with a running suture of catgut.

The uterine artery may also be tied from the abdominal cavity after performing laparotomy (see Uterine Fibroids).

Ligature of the Internal Pudic Artery.-As a rule, this artery should be cut down upon where it bleeds and both ends tied, but it

A. Martin, Pathologie und Therapie der Frauenkrankheiten, Leipzig, 1885, p. 22. 'H. Fritsch, Billroth und Luecke, Handb. der Frauenkrankheiten, Stuttgart, 1885, vol. i. p. 949.

may also be tied in continuity by cutting through the skin and fascia in an oblique line running downward and outward a little above the spine of the ischium, separating the fibers of the gluteus maximus, holding them apart with retractors, and tearing the deep fascia.

FIG. 157.

Sometimes sutures are used for hemostatic purposes-e. g. a running catgut suture may be put over a bleeding tear in the broad ligament; or an artery imbedded in tissue may be made to stop bleeding by passing a needle with thread under its course and tying; or a bleeding surface of the abdominal wall may be excluded from the abdominal cavity by folding the wall, so as to press one-half of the bleeding surface against the other, and put sutures through from side to side as in a mattress (mattress suture). These sutures may be made more efficacious by using quills, a couple of lead-pencils or pen-holders serving as such.

Forcipressure.-Much time is saved by substituting a temporary strong pressure with Koeberle's clamp (Fig. 157), a kind of arteryforceps with catch that has been modified by many other operators, and therefore goes under different names (Péan's, Spencer Wells's, Tait's, etc.). When made of proper size and left for twenty-four hours, such forceps may be made to secure even the uterine and the ovarian arteries in the extirpation of the uterus; but in most operations small clamps, five or six inches long, are used temporarily, and removed toward the end of the operation when the bleeding is stopped. If, exceptionally, a vessel yet bleeds, it may, of course, be seized again with the forceps and secured with a ligature. F. Dilatation and G. drainage are so intimately connected that we will treat of them together. In regard to dilatation of the cervix the reader is referred to what has been said on the subject in the chapter on Examination (pp. 154–156).

Koeberle's Artery-
Clamp.

Dr. Outerbridge of New York has constructed an ingenious instrument for permanent dilatation of the cervix and drainage of the uterus. It consists of a silver- or gold-plated steel wire (Fig. 158), made so as to form an anterior and posterior blade, with a slight eversion at one end and bent at right angles at the other. It is selfretaining, and varies in length and curvature. For its introduction the patient may be in Sims's or in the dorsal position. The univalve or bivalve speculum is introduced, the cervix steadied with a tenaculum, and the dilator put into the grasp of a carrier made for the purpose (Fig. 159). It consists of a fork with a movable ball and spiral

spring sliding up and down a metal rod with handle. The dilator is introduced five or six days before expected menstruation, left in

FIG. 158.

FIG. 159.

π

Outerbridge's Permanent Dilator of Cervix.

during, and at least from five to eight days after the same, unless conception takes place and menstruation does not come on. The instrument may be removed with a finger or by means of speculum and tenaculum or a blunt hook.

Sometimes a perforated glass or hard-rubber stem is introduced into the uterus, and on the same principle I have had a glass vaginal plug made with an opening at the top.

Sometimes an opening is made with knife or trocar in the vaginal roof, behind the uterus, with or without laparotomy. This opening is enlarged by means of a diverging uterine dilator and a soft-rubber drainage-tube inserted. The same may be carried through the abdominal wound. If it is only introduced through an opening in the vagina into a space shut off from the peritoneal cavity, the drain should have

a T shape, the upper bar of the T serving as wings to retain the tube in situ.

In laparotomies often a glass tube (Fig. 160) is left leading from the bottom of Douglas's pouch or of a cyst which can

Carrier for Outerbridge's
Dilator.

FIG. 160.

G.TIEMANN & CO.

Abdominal Glass Drainage-tube.

not be entirely removed to the lower end of the wound, where it is

1 P. E. Outerbridge, Med. Record, April 20, 1889, vol. xxxv. p. 430.

held, between the lips of the incision, by the sutures. The tube is closed with a stopper of iodoform gauze, and the accumulating fluid pumped out at short intervals-in the beginning every hour-by means of a small glass syringe and attached rubber tube. It is still better to utilize the capillarity of iodoform gauze and fill the tube loosely with a strip of this material, through which the fluid will trickle out.

Great diversity of opinion obtains among leading gynecologists as to the frequency with which abdominal drainage should be used and the length of time the tube should be left in. The more strictly antisepsis is carried out during operations the less drainage becomes necessary, and the absorbent power of the peritoneum may to a great extent be relied upon to remove blood and serum from the abdominal cavity.

We have already spoken of the use of iodoform gauze for drainage of the uterus and the abdomen (pp. 179-181). For further particulars, see Ovariotomy.

H. Bloodletting.-Leeches, from two to four in number, may be applied through Fergusson's speculum to the vaginal portion. In order to prevent them from entering the uterus a small cotton plug should be placed in the cervical canal. This method is little used here. The artificial leech may be substituted with advantage (Fig. 161).

Reese's Uterine Leech. It consists of a glass cylinder with scale. By pressure on the plate, 4, a lance-shaped knife is pushed into the tissue of the cervix to a depth regulated by screwing the disc, 7, along the piston, B, and then withdrawn. By pulling the piston out a vacuum is created, into which the blood enters. The metal fitting, C, can be unscrewed, so as to allow the removal of the piston and the cleaning of the tube.

Scarification. In most cases no sucking apparatus is needed. A small spear (Fig. 162) is pushed to the depth of three-quarters of an

FIG. 162.

Buttle's Uterine Scarificator.

inch into the vaginal portion in three or four places, and from half an ounce to two ounces of blood are withdrawn twice a week. The posterior lip is less sensitive than the anterior. If the flow does not stop of itself, the small openings are pressed together with a pledget of cotton dipped into cold water, or if that does not suffice liquor ferri is applied or a hot douche is administered.