ting the suture is by pulling the free end so far out that it can be tied together with the loop carrying the needle. This method of suturing is expeditious, and has the advantage of bringing broad surfaces in contact with each other.

Interrupted sutures may also be placed in tiers above one another -e. g. in closing the abdomen after laparotomy.

FIG. 196.

Second Deep Row of Tier-Sutures (A. Martin).

Chain-suture is used to secure thick pedicles, and will be described under Ovariotomy.

Sponging and Irrigation.-During most plastic operations very small sponges or pads on sponge-holders are needed, and the assistant should press the sponge very gently against the bleeding place, without rubbing it, and he should always keep those points clean where the needle is to be inserted or pushed out. In operations performed in the dorsal decubitus irrigation with some hot antiseptic fluid or hot sterilized water may advantageously be substituted for sponging (pp. 182 and 199); and under all circumstances it is advisable to irrigate the wound before closing the sutures and to remove all clots. The smoother and cleaner the cut surfaces are, the sooner they will grow together by first intention.

How to Clean and Disinfect Instruments.-Instruments should be boiled in a solution of soda before every operation (p. 199). After an operation they should be scrubbed with soap or, better, sapolio and water, and nail-brush, rinsed with clear water, and wiped perfectly dry with at least two towels. During the operation they should be immersed in sterilized water or a 24 per cent. solution of carbolic acid. Selection of Instruments.—In preparing for an operation the operator or his assistant should carefully go through the different steps of the operation in their mind, and take out all instruments that are sure to be used; but, besides, they ought, within reasonable limits, to prepare themselves for the unexpected by having such instruments in readiness as may be required under certain eventualities, and by having more than one of the most indispensable instruments, such as knives, scissors, needles, pressure-forceps, etc.

5. Combination of Operations.-If several operations are needed on one patient, it is, as a rule, best to perform them at different sittings; but as this would sometimes take more time and cost more money than the patient can afford, it may become necessary to perform two or more in one sitting. This ought, however, only to be done when the single operation does not require much time nor cause much shock, for, other things being equal, the danger increases with the length of the operation. A torn cervix, a cystocele, and a lacerated perineum may all be operated on in one sitting; likewise shortening of the round ligaments and perineorrhaphy; but if laparotomy and a vaginal or perineal operation are required, it is better to do the laparotomy first and the other a week later. I prefer to follow the same principle in regard to the cervix, and postpone the other operations until the sutures are removed, for a secondary hemorrhage may occur or menstruation come on prematurely, as happens so often; or, as I have seen once in a very scrofulous patient, the whole cervical portion may ulcerate, and the necessary measures for the diagnosis or treatment may frustrate the operations performed on the walls of the vagina.1

After-treatment.-If there is no danger of shock, the best way is to let the patient sleep after the operation until she wakes of her own account; but if there is shock, it is better to rouse her by aspersion of cold water, shaking, talking, etc.

If she vomits, the measures recommended in treating of anesthesia (p. 204) should be taken.

For the thirst, frequently repeated teaspoonful doses of hot water are often good, but in other cases nothing is like small quantities of ice-water. Ice itself does not quench thirst. An injection of tepid water into the rectum has sometimes proved useful (p. 170).

How far some operators go in combination, and yet get good results, may be seen in a paper by Edebohls, Amer. Jour. Med. Sci., Sept., 1892, p. 262.

No food is given as long as nausea continues. As a rule, a fluid diet of peptonized milk, buttermilk, kumyss, matzoon, beef-tea,' and oatmeal gruel may be begun the day after the operation. Nothing solid should be taken until the bowels have been moved, which in perineal operations is done on the fourth day, and in laparotomies and vaginal hysterectomies on the third, by giving castor oil, laxol, compound licorice powder or sodium sulphate. (See Ovariotomy.)

Pulse, temperature, and respiration should be marked graphically on charts, so that the surgeon may judge of the condition at the first glance. The nurse should also keep a record of food taken, urine excreted, and movements of the bowels.

CHAPTER III.

INTERNAL TREATMENT.

FEW gynecological diseases can be cured by internal treatment alone, but, combined with external treatment, the internal is a valuable and often indispensable adjuvant.

The reader is, of course, supposed to be conversant with general therapeutics. He will ever bear in mind that the body from the ver tex to the sole forms one system, all parts of which are most intimately connected; he will watch for symptoms pointing to disorders in any division of the body; and in his treatment of gynecological cases he will make such modifications as are called for by the conditions of other organs or the constitution in general.

Food and Drink.-Most gynecological patients are suffering from anemia, and often from anorexia at the same time. Attention must therefore, first of all, be paid to their diet. They should be encouraged to eat as much albuminoid food as possible, and, by taking six small meals a day instead of the usual three more copious ones, much can be done to increase the amount of food taken every day. The physician should give as precise orders as possible in regard to time, quality, and quantity of meals, and look to a proper variety in order to avoid disgust. Mild alcoholic drinks, such as beer, Johann Hoff's malt extract, Rhine wine, Moselle wine, French or Hungarian claret, Burgundy, vin Mariani, port, or tokay, should be taken with meals unless especially contraindicated.

1 Monsquera's beef-jelly is excellent for the purpose.

2 Where economy is an object the strong California wines, such as port, sherry, angelica, and tokay, are to be recommended. Good wines can be obtained for 50 cents a bottle, and superior kinds are sold for $1. These wines are certainly much to be preferred to the cheap mixtures often sold as imported wines. I have been particularly pleased with the "Sunset" wines.

Weir Mitchell's rest cure, in which the patient is removed from her friends, put to bed, fed by a nurse to the limit of her digestive powers, and treated with massage and electricity,' may be indicated in exceptional cases, but, as a rule, gynecological patients should be encouraged to take as much exercise in the open air as they can without increasing their sufferings.

If the patient cannot digest her food, she should take pepsin and hydrochloric acid after each meal :

Sig. Shake well. A tablespoonful after meals.

I have also found Parke, Davis & Co.'s pepsin cordial very beneficial.

In severe cases of indigestion rectal alimentation may even become

necessary.

Very commonly gynecological patients suffer from constipation and need some aperient. A heaping teaspoonful of Carlsbad salts or sulphate of sodium, dissolved in a tumblerful of hot water and taken on an empty stomach in the morning, often effects a cure in the course of six weeks. A heaping teaspoonful of compound licorice powder, taken in the evening, gives a passage the next morning, and many like that powder. As a rule, I combine the aperient with a tonic by giving Blaud's pills with aloes:

Ft. pil., No. Ix.

āā zij ;

gr. v to xv;

q. s.

Sig. Three pills three times a day, after meals.

Sometimes nausea or vomiting call for symptomatic treatment. They should be treated with bismuth, for instance:

R. Bismuthi subnitr.,

Magnesiæ carb.,
Sacchari,

zij;

āā. 3ss.-M.

Sig. A heaping teaspoonful three times a day, between meals;

1S. Weir Mitchell, Fat and Blood, and how to Make them, 2d ed., Philadelphia,

1878.

An important paper on this subject, by Henry F. Campbell of Augusta, Ga., is found in Trans. Amer. Gyn. Soc., 1878, vol. iii. p. 268, et seq.

The artificial salt seems to be just as good, and costs only one-fourth of the imported.

or Liq. iodi co. (mj every two hours); creasote (mj every three hours); ac. hydrocyan. dilut. (miij every one to three hours); tinct. nuc. vom. (miij every three hours), each diluted with a tablespoonful of water; or cocaine hydrochlorate (gr. every two or three hours); or cerium oxalate (gr. iij to v, t. i. d., in pills).

Tonics are nearly always needed, especially iron, quinine, strychnine, arsenic, and phosphorus. I do not know of any better tonic than the solution of ferrous malate (American Pharmaceutical Manufacturing Company) and the compound tincture of cinchona, equal parts.— M. Sig. A teaspoonful three times a day.

Another valuable combination is the following:

R. Strychninæ sulph.,
Ferri et quininæ citrat.,

Syr. aurant.,
Aquæ,

gr. j;

zij;

3ss;

ad 3iij.-M.

Sig. A teaspoonful in a wine-glass full of water, three times a day, after meals.

Plain Blaud's pills are also excellent. If a malarial element is present, full doses of quinine and other antiperiodics are required. In carnogen, the extract of red bone-marrow, given in teaspoonful doses, we have a new and powerful remedy against anemia.

In tympanites, so often accompanying gynecological diseases, strychnine answers an excellent purpose.

Anodynes are sometimes indispensable, but they should only be used for a short time and in as small doses as will suffice. Magendie's solution of morphine, 4 to 8 drops three times a day; tincture of opium, 15 drops; or suppositories with 1 grain of opium every three hours, are the most common anodynes. Hydrobromate of hyoscine, gr., has been much praised of late. I find phenacetin, in doses of vii ss grains, repeated after one hour, and if needed a second time after three hours, has an excellent effect in relieving pelvic pain.

Extract of conium in the dose of 1 or 2 grains, t. i. d., is also good. Iodoform or aristol, 5 grains, in suppositories, t. i. d., often dulls pain. Among sedatives, the bromides of potassium, sodium, and ammonium, single or combined, are often required. An embrocation with chloroform (1 part) and olive oil (3 parts) gives at least temporary relief in the troublesome backache so generally complained of.

If the patient is troubled with insomnia, it has to be met with one of the many hypnotics chemistry has offered us in late years. I have been particularly pleased with sulphonal (gr. x), chloralamid (gr. xlv), or trional (gr. xv).

Resolvents are often called for in chronic inflammations. The most important are iodine, gold, and mercury. We have spoken in another