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The patient's mental condition should be considered. All causes of anxiety from outside sources should be guarded against. Her mind should be occupied as much as possible and she should not be allowed to dwell too much on the approaching operation. Her confidence, not only in the operator but also in the anesthetist, should be sought after. Her physical condition is an exceedingly important factor in the case. Each and every organ should be systematically examined. Her general condition should be improved, if necessary, by rest, by tonics, and by hypodermatic injections of strychnine twice or thrice daily for a week before the operation.

Heart lesions if compensated do not necessarily contraindicate operative measures. If there be slight irregularity in the cardiac function it should be treated. The vessel walls should be examined and if thickened, atheromatous, or calcareous, caution should be used.

In kidney lesion, small amounts of albumin do not necessarily contraindicate but copious amounts do in all cases of complacence. The presence of sugar in the urine, if of appreciable amount, is a contraindication in all such operations of complacence. The urine to be examined should always be catheter drawn from female patients to avoid possible contamination by vaginal secretion or discharge. The urine in any case should be passed just before going into the operating theater, and, if necessary, it should be catheter drawn. The blood should be examined and the percentage of the hemoglobin ascertained. In anemic conditions, it is well to put the patient under treatment for some time before operation, as convalescence is much hindered if the hemoglobin be at a low percentage.

The diet during the period of preparation should be regulated and should be light in character. No food at all should be given for four hours before the operation, with the exception of a cup of beef tea two hours before, and some brandy, if necessary, just before going into the theater. Some surgeons give a nutrient enema of beef tea and brandy just before the operation. The mouth should undergo a very careful course of cleansing. The bowels should be regulated by a course of salines, with a stronger purge on the night before, and an enema on the morning of the operation. Magnesium sulphate and magnesium carbonate may be used for the general purpose of clearing out the intestinal tract. If, in addition, an antiseptic effect is required, phosphate of soda, which increases the flow of bile, may be used. Salol and calomel also may be of service where an antiseptic effect is called for. Effervescing salts, for example the seidlitz powder, are usually inferior to the above, and where there is a gastric or

intestinal lesion high up they may be the source of danger by inflating the gastrointestinal tube.

The skin should be cleansed by a course of warm baths. The vagina should be daily douched with a mild antiseptic lotion in those cases involving the uterus or its appendages. The patient's clothing for the operation should consist of long woolen stockings, reaching up to the trunk, and of a woolen garment covering the thorax and the upper extremities. In cases where sepsis may be feared antistreptococcic serum, used for a few days previous to the operation, may be of service. The preparation of the actual field of operation belongs rather to the technic of the operation itself and, therefore, I will not deal with it here. Of course in cases of emergency one cannot prepare the patient in such an elaborate way, but even in such cases one should take as much time as possible in the preparation. In cases where there has been a recent severe hemorrhage it may be well to give either an intravenous injection of normal saline solution or a rectal injection of similar fluid. Strychnine may be necessary, and, in fact, may be used as a routine treatment. Where a meal has recently been partaken it may be well to wash out the stomach by use of the stomach tube. The bowels should be evacuated by a copious enema. Then, again, the use of antistreptococcic serum may be of importance.

THE TREATMENT AND MEASURES TO BE ADOPTED DURING THE

OPERATION. The temperature of the theater should be kept equable and, in some cases where the operation is likely to be a prolonged one, a hot water operating table is of great service. Though not going into the technic of the operation it is well to mention that antisepsis or asepsis should be rigidly carried out. The handling of important viscera should be minimised; undue exposure of parts should be avoided, and careful hemostatic measures should be employed. As to the anesthetist, one skilled in the art of administrating anesthetics should be employed. If the operation be a prolonged one, strychnine or ether given hypodermatically, or rectal injection of normal saline solution may be of great service.

Syncope may occur during the operation and is revealed by pallor, weak or imperceptible pulse, and very shallow breathing. This condition may improve and often terminates in an attack of vomiting. In extreme cases, however, death is the termination. Syncope is very often seen in patients not completely under the influence of the anesthetic and passes off when anesthesia is complete. It is essentially due to anemia of the brain and, therefore, the treatment consists of lowering the head and stimulating the heart.

THE TREATMENT FOLLOWING THE OPERATION. Under this heading I will not deal with the question of diagnosis but adhere simply to that of treatment. It is a question that requires much skill and sound judgment and often gives rise to grave anxiety on the part of the man in charge of the case. A majority of cases, when the preceding treatment has been thorough, make an uninterrupted and uneventful convalescence. The treatment in such is simple, and the more simple the better for the patient. A brandy and coffee enema may be given before the patient leaves the theater. She is then transferred to the ward and put gently and carefully to bed, keeping the head low and the foot of the bed slightly raised. She is covered with blankets sufficient to keep her warm, hot water bottles are placed at her feet, legs and to the side of the trunk, care being taken that these bottles are covered with flannel and not hot enough to blister. It may be well to mention here that owing to lowered vitality there is greater danger of blistering in the application of heat than normally.

The room should be dark, well ventilated, kept at an equable temperature, and all noise should be avoided. No food should be allowed for the first twenty-four hours. If the patient complains of thirst, dry tongue and mouth, the latter may be swabbed with a mixture of glycerine and honey. Another efficacious method is to allow the patient to suck a slice of lemon and cracked ice bound up in a bag of thin muslin. If she complains of pain and cannot sleep, a hypodermic of morphine may be allowed. If the bandages are too tight they may be loosened or snipped at the discretion of the surgeon. At the end of twentyfour hours feeding may be started, commencing with very small quantities and gradually increasing in amount, but kept liquid in character until after the bowels have been opened. This may be done by giving an aperient on the second or third night, followed by an enema the next morning. They should then be kept regular thereafter by salines or enemata.

Once the bowels are acting well and regularly the diet may be more generous in character and amount. The bandage when soiled should be changed, care being taken that the dressings are undisturbed. If, however, the dressings are also soiled they should be promptly changed as well. The wound should be dressed on or about the ninth day and at the same time the stitches should be removed. In the above I have not mentioned the drainage tube, but if such has been used the dressings must be changed to meet the requirements of the case. The same may be said if gauze packing has been used.

The patient should be kept in bed for about three weeks, avoiding all unnecessary movement, but not necessarily remaining in one position. The back, buttocks and shoulders should be kept under careful observation. At the end of about three weeks she may be allowed to sit up, but should pass the greater part of the next week on a couch or wheel chair. For the next six months she should avoid doing any heavy work, especially the lifting of any heavy weight. The bowels should be kept regular to avoid any undue straining at stool, and it may be advisable to make use of a low commode, for in so doing the thighs are well flexed on the abdomen.

COMPLICATIONS OR DEVIATIONS FROM THE NORMAL. Those cases not making such an exemplary recovery are best discussed, I think, under the separate heading of the complications or deviations from the normal. We may classify these as follows: (1) shock; (2) hemorrhage; (3) vomiting ; (4) pain; (5) temperature and pulse variations; (6) thirst; (7) flatulence; (8) intestinal paresis; (9) intestinal obstruction; (10) sepsis ; (11) pulmonary complications; (12) pulmonary embolism; (13) phlebitis and thrombosis; (14) fistulæ ; (15) bedsores.

Shock.—I have stated in the first part of this paper what I consider shock to be, and I have also discussed the prophylactic measures to be adopted in order to avoid the appearance of such a condition. When these measures have been fully carried out shock does not usually play a very important part in the question of after-treatment. In cases where shock was to be feared, either from the gravity of the operation or from its prolonged length, I have found a systematic course of saline rectal injections of great service. The course may be mapped out as follows: a pint and a half of normal saline solution, to which is added one ounce of brandy, are injected immediately on the completion of the operation. The patient then should be put to bed with all the care which I have already described, but the foot of the bed should be raised to a greater height than in the preceding treatment. One pint of normal saline is injected hourly for the next four hours; then every two hours until the pulse is of good volume and tension; and finally every four hours until there are signs of rectal irritation. At the end of twenty-four hours the pulse will usually be nearly normal in rate, volume, and tension. If signs of rectal irritation show themselves early, a suppository of morphine and belladonna usually has the desired effect.

In cases of shock unless the collapse is immediate it is generally delayed for some four to six hours or even more, and under the above regime it usually does not appear at all. If, however, the shock is so great that it appears at once, hypodermic injections of strychnine or ether, or both, may be used, and these may be supplemented by rectal injections of normal saline solution, or by an intravenous injection of saline solution into one of the superficial veins, or by a subcutaneous injection of normal saline into the loose tissues of the breast. In addition to having the foot of the bed raised it is well to bandage the lower extremities with a warm flannel bandage from below upward.

Hemorrhage.—This may come on immediately after the operation or, as most frequently, some few hours later when reaction has well set in, or, again, it may be secondary in nature, and may appear at any time after the second day up to the fifth or the sixth day. The reactionary hemorrhage is best prevented by careful technic during the operation, seeing that each and every bleeding vessel is securely tied; the secondary hemorrhage is best prevented by careful asepsis or antisepsis during the operation. Hemorrhage, whenever it does occur, should be carefully watched and if of any magnitude the only treatment is to reopen the abdomen, and secure, if possible, the bleeding point.

Vomiting.–This may be due to the anesthetic. Then it is usually simple in character and passes off in a few hours. It is best prevented by careful preparation of the patient before the operation, and by careful and skilful administration of the anesthetic during the operation. It may be relieved by a few doses of iodine, two, minims in two drams of water, every two hours. The fumes of vinegar inhaled from a napkin soaked with the liquid are often very efficacious in relieving this early vomiting. When due to the want of proper preparation, washing out the stomach by means of the stomach tube is often of great service. Later on, vomiting may be due to one of the following: (a) intestinal paresis; (b) intestinal obstruction; (c) peritonitis. The treatment of vomiting in each of these complications is essentially that of the condition itself.

Pain.—This is sometimes a troublesome complaint especially in neurotic patients, when slight moral suasion may be tried. but when troubling the patient very much morphine may be used hypodermatically at first, and afterward by suppository. The use of morphine, however, should be restricted as much as possible on account of the danger of starting the morphine habit, which often dates from the accidental discovery of the stimulo-sedative power of the drug. I may mention that much discomfort

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