pelvic diseases, but may be used to advantage toward the end of a cure begun on other lines.1

O. Operations in General.-1. Time for operating. If we have a choice, operations should be avoided in this climate during the hot season. It is no small discomfort for the patient to lie in bed for weeks, when not even the nights bring coolness, and it is rather trying for the operator to work when the thermometer is in the nineties in the shade. But I have had hospital-service during the hottest time of the year, and performed both laparotomies and plastic operations without the slightest disturbing influence on perfect success.

In general, operations should not be performed on pregnant women, on account of the danger of producing miscarriage. It would seem that interference with the rectum is particularly liable to have this effect. As to the genitals, we may say that the farther the seat of operation is removed from the uterus the less is the danger of provoking abortion. Sometimes the very presence of pregnancy may call for operative interference. Vomiting in pregnancy, which may lead to the patient's death, may be treated successfully by applying nitrate of silver in substance or in solution to a granular os, or by stretching the os and lower part of the cervical canal (Copeland's method) with the index-finger. Large polypi hanging from the cervix may be the source of hemorrhage or become an obstruction during labor. It may, therefore, be wise to remove them with the galvanocaustic wire. Ovarian cysts should be removed if discovered early. If the patient is far gone or in labor, tapping may be preferable. If a cancer of the cervix can be removed, it is better to do so even with the risk of causing abortion, as the cancer, as a rule, grows rapidly during pregnancy, and may cause an obstruction during labor that may cost the life of both mother and child."

As a rule, we avoid operations during or near menstruation, on account of the great congestion of the pelvic organs. Most operators prefer to operate eight or ten days after menstruation has ceased, but since we have seen (p. 118) that the menstrual process is finished even in the uterus itself eight or nine days after the beginning of the flow, there is no occasion to wait more than four or five days after it has stopped. As the removal of the ovaries, or probably rather the tying of the pedicle, very commonly brings on a menstrual flow, even if the patient has just gone through her menstrual period (p. 119), it may be preferable in anemic patients, in order to avoid this extra loss of blood, to operate immediately before or during menstruation. H. P.

The value of gymnastics as preventive of and cure for pelvic disorders has been inculcated by John H. Kellogg, Med. News, November 8, 1890, No. 930, p. 468.

Further information may be found in a paper by M. D. Mann of Buffalo, N. Y.: "Surgical Operations on the Pelvic Organs of Pregnant Women," Trans. Amer. Gyn. Soc., 1882, vol. vii. p. 340.

C. Wilson' of Baltimore even prefers, in regard to laparotomies, to select the "uterine flood" rather than the "uterine ebb," during which he thinks patients are more liable to passive hemorrhages, the absorption of septic poison, and the deadly influence of shock, than when the system is under the stimulus of the uterine flood. Moreover, he believes that the local bloodletting from the uterine mucous membrane is a healthy derivation from many of the dangers of laparotomy. Tait, Goodell, and Thomas-Mundé do not care whether the patient menstruates or not. Operators may, therefore, be warranted in not paying much attention to the time of menstruation in regard to the performance of laparotomies, and sometimes even in preferring the approach or the presence of the flow. If the patient menstruates, her vagina, after having been disinfected, should be filled with a tampon of iodoform gauze. Goodell recommends curetting during menstruation or metrorrhagia, but to avoid this time in myomectomy or hysterectomy.

Plastic operations ought always to be performed shortly after menstruation, as the occurrence of this flow might be mistaken for hemorrhage or interfere with proper after-treatment.

Lactation need not interfere with operations. It is only necessary to discontinue nursing for twenty-four hours, on account of the effect of the anesthetic on the child, and press or pump out the milk of the breasts.

The time of the day most suitable for serious operations is the morning, when the operator may be sure not to have come near any case from which pathogenic germs might be brought to the patient, and his own nerves are refreshed by rest and sleep. But other considerations often prevail, and many operate in the afternoon. Daytime should always be preferred, as no artificial light but the electric can replace a good daylight. If it is necessary to operate at night, care should be taken to obtain as perfect an illumination as possible. 2. Preparation for Operations.-The more thought the operator and his assistants bestow beforehand on every detail of a contemplated operation, the more smoothly it will come off, and, other things being equal, the better the result will be.

Room.-If we have the choice, we should select a large room with a good light for operating, and, if possible, this should be another room than the one in which the patient shall lie after the operation, but contiguous with it. The best room should be reserved for the after-treatment. According to the season this should either be cool or have a southern exposure. For an important operation, especially

2

3

Amer. Gyn. Trans., 1889, vol. xiv. p. 45.

Tait, Diseases of Women, p. 212.

Wm. Goodell, Med. News, Nov. 29, 1890, p. 560.

Thomas, Diseases of Women, 6th ed., p. 718.

a laparotomy, all superfluous furniture should be removed, the carpet should be taken up, the bedding aired, the floor and, if they are oilpainted, also the walls should be scrubbed, not only with soap and water, but thereafter with a solution of bichloride of mercury (1:1000). No curtains should be allowed round the bedstead. Every object should be carefully dusted. The room should be pleasantly warm, about 70° F., or, if the abdominal cavity is to be opened, even a little more than that.

The bed should have a horse-hair mattress and blankets. If possible, it is a great advantage to have two beds. With proper precautions even a very sick patient may be moved from one bed to another, and it contributes much to her comfort.

Table.-A strong narrow table should be placed with one end in front of a window. A common kitchen table four feet long and two wide is very convenient. It should be covered with a folded blanket or quilt, a muslin sheet, and a rubber sheet or oil-cloth. The latter should be pinned together, so as to form a funnel leading at the lower end of the table, down into a slop-pail. Instead of the latter arrange

FIG. 167.

Inflatable Surgical Rubber Cushions.1

ment inflatable rubber cushions (Fig. 167) may be used to advantage. A towel or sheet may be rolled so as to form a hard cylinder, which is bent so as to form part of a circle or the three sides of a square, and in the latter case tied with strings at the corners. This frame is covered with a rubber sheet. The first part of this arrangement may be improvised, and the latter is easily carried in a satchel. A pillow is placed at the head of the table, and this end is slightly raised

Howard Kelly, Amer. Jour. Obst., 1887, vol. xx. p. 1030, but H. O. Marcy of Boston claims many years' priority (Trans. Amer. Association of Obstetricians and Gynecologists, 1893, reprint, p. 13.

so that fluids may gravitate down into the pail. For laparotomy it is better to have the table level with drainage to the side where the operator stands.

In hospitals tables are preferably used that can be thoroughly disinfected. Good tables for this purpose, and with facility for Trendelenburg's position (p. 138), have been constructed by Cleveland, Edebohls, Foerster, and Boldt.

Leopold uses for Trendelenburg's position an apparatus that has the advantage of being inexpensive and so simple that any carpenter can make it. It consists of a frame 50 inches long and 20 inches wide, with a hinged flap that can be raised up. The shorter, lower part of the flap, upon which the legs rest, can be bent downward, so as to form a right angle with the upper part, upon which lie the thighs and the pelvis, and which is a yard long. By means of a support the flap can be raised as much as 20 inches above the frame, so that the support forms an angle of about 30° with the upper part of the flap. The frame is fastened with iron clamps to a table (see Fig. 112, p. 139).

McNaughton has had made of galvanized iron a portable attachment that also can be used on common kitchen tables. In hospitals two long wooden foot-stools, about six inches high, should be in readiness to be used when the patient is brought into Trendelenburg's position.

Most tables are of a convenient height for the operator to stand at, but not only are perineal and vaginal operations performed sitting, but some prefer also to perform laparotomies in the sitting posture. Then the table should be rather low, and the operator seated on a high chair between the legs of the patient.

Assistants. For most operations three, four, or even five assistants are needed, and each of them should have his part distinctly allotted and explained to him beforehand. One should exclusively be charged with the anesthesia, and as the patient's life in most cases depends much more on him than on the operator, this function should be confided to the most experienced man available. In operations with the patient in the lithotomy position one assistant should hold either knee under his axilla, thus keeping both hands free for sponging, holding speculum or tenaculum, or for such other assistance as may be needed. In laparotomies one stands opposite the operator and the other at his left. A fourth assistant may be used to hand instruments, which saves time and allows the operator to keep his eyes uninterruptedly on the field of operation; but, in order to limit the possible sources of infection as much as possible, some operators prefer to place their instruments within reach and dispense with this assistant.

As a

McNaughton's attachment is sold by H. A. Kaysan in Brooklyn, N. Y.,

$12.00.

for

rule, the assistance of a nurse is required to hand and clean sponges, and attend to fluids, basins, pitchers, syringes, dressing-material, etc.

Spectators. There can hardly be any doubt that the fewer persons are present in the operating-room, the better, other things being equal, are the chances of the patient. Particularly in laparotomies the presence of persons coming from a case of erysipelas, scarlet fever, diphtheria, typhoid fever, or other zymotic disease constitutes an element of danger. On the other hand, nobody can learn to operate by reading descriptions of operations. The accumulated experience of mankind in this line can only be acquired by seeing others at work. And it is, therefore, in the interest of humanity in general that operators admit students and fellow-practitioners to witness their operations. To what extent and with what restrictions this should be done depends on many circumstances which cannot be considered here. Fortunately, experience has shown that when those who come in contact with the field of operation follow all the rules of antiseptic surgery the mere presence of other persons in the room has little or nothing to do with the result of the operation.

Patient. The patient's urine should be examined with special reference to the presence of albumin in the same, as it may be deemed necessary to postpone the operation or desist from it altogether if the kidneys are in a bad condition, or at least to prefer chloroform to ether as an anesthetic, the latter having proved particularly dangerous in patients with inflamed kidneys,' or to use opium or cocaine, or operate without an anesthetic. If there is albumin in the urine, it should also be examined microscopically for casts. If there is an excess of pigment and salts in the urine, it is well to prepare the patient for an important operation by the use of Vichy or lithia water. If the urine contains sugar, the patient would not be a fit subject for any plastic operation until she had been properly treated for glycosuria. The presence of pus or many epithelial cells may likewise call for special preparatory treatment before an operation is undertaken.

The heart and the lungs should also be examined. If the heart is diseased, chloroform is particularly dangerous. Advanced phthisis is a counter-indication for nearly all operations; in lighter pulmonary

affections ether should be avoided.

On the day preceding that of the operation the patient should have a warm bath and be scrubbed with soap all over, in order to have the skin in as good a condition as possible. To move her bowels she should toward evening take a heaping teaspoonful of compound liquorice powder or another suitable aperient, and after that she should receive no other food than a little coffee or beef tea.

Six hours before the operation she should be given an enema of a quart of soap-suds.

1 T. A. Emmet, l. c., p. 745.