inal vault is opened with the knife, the scissors, or the cautery. The vessels of the broad ligament are secured with the ligature or with the clamp. The uterus is sometimes divided by longitudinal incision and the halves are separately removed.

The following are the general directions for the performance of the operation:

FIG. 215. Vaginal hysterectomy with clamps: first step (Baldy).

The woman is placed in the lithotomy position. The vagina is opened with the Sims speculum and with lateral vaginal retractors (Fig. 214).

If the cervix is septic, it is thoroughly curetted, sterilized with the cautery or by other means, and the sides of the excavation are united by suture.

The cervix is seized by tenaculum forceps and dragged downward and forward.

A transverse incision with knife, scissors, or cautery is made in the posterior vaginal fornix, and Douglas's pouch is opened.

A sponge is introduced into the peritoneum behind the uterus.

FIG. 216.-Vaginal hysterectomy with clamps : second step (Baldy).

Some operators suture the posterior peritoneal layer of Douglas's pouch to the posterior vaginal wall, to control bleeding and to prevent stripping of the peritoneum.

The cervix is now dragged backward and a transverse incision is made across the anterior vaginal fornix.

The bladder is carefully dissected from the anterior

face of the cervix with the knife, scissors, and finger, and the utero-vesical fold of peritoneum is opened. The peritoneum and the anterior vaginal wall may here also be united by suture.

An incision may then be made through the vaginal mucous membrane of the lateral fornices, uniting the anterior and posterior incisions.

FIG. 217.-Vaginal hysterectomy with clamps: third and final step (Baldy). With a finger in Douglas's pouch as a guide, the broad ligaments are then secured in successive portions by ligature or by strong clamp forceps, and the uterus is cut away with the scissors as the ligatures or clamps are placed.

As the upper portion of the broad ligaments is reached the procedure may be facilitated by retroverting or anteverting the uterus, the fundus being dragged through the posterior or the anterior incisions in the vaginal vault.

The tubes and ovaries should be removed when possible, especially in the case of malignant disease.

After the uterus has been removed the vagina may be packed with a gauze drain that reaches upward between the stumps of the uterine arteries; or, if ligatures have been used, the vaginal vault may be closed. The former procedure is the safer. When the gauze drain is used, it is advisable to leave the ends of the ligatures on the uterine arteries long and protruding into the vagina. The ligatures usually become infected, and their removal is facilitated by this procedure. If clamps are used, they should be removed in forty-eight hours.

The treatment after vaginal hysterectomy is the same as that already described after celiotomy.

Combined Vaginal and Abdominal Hysterectomy. A combined vaginal and abdominal operation is sometimes performed in order to enable the surgeon to deal with adhesions and other complications in the upper part of the pelvis.

The operation is usually begun below. The vaginal connections and the bladder are separated from the uterus, and the bases of the broad ligaments are secured with the ligature or the clamp; the cervix is freed from its attachments to the broad ligament.

The abdomen is then opened and the operation is finished from above, the uterus being removed through the abdominal incision.

The writer performs the combined operation in the reverse order, as follows:

The abdomen is first opened. The ovarian arteries and the round ligaments are secured by ligature. The bladder is separated from the uterus and the upper part of the vagina. The broad ligaments are divided to a point somewhat below the level of the internal os.

A gauze pad is then introduced to the bottom of Douglas's pouch, and another to the bottom of the space between the uterus and the bladder. The abdominal incision is then closed.

The rest of the operation is performed through the vagina. The posterior and anterior vaginal fornices are opened by incisions made directly upon the gauze pads. The vaginal mucous membrane is divided over the vaginal fornices by an incision that joins the anterior and posterior incisions in the vaginal vault. The bases of the broad ligaments are secured by strong clamp-forceps, and the uterus is cut away and removed through the vagina. The gauze pads are then removed, and the vagina is drained with gauze introduced as far as the upper end of the forceps.

The following are the advantages of the latter method. of operating:

If sterilization of the vagina and the cervix is not perfect, the cleaner part of the operation is performed first. The bladder is more easily separated from the uterus by operating from above than by way of the vagina. The vaginal vault is quickly and safely opened by incisions. made upon the gauze pads, which keep the intestines out of the way.

The uterus and the infected cervix are removed through the vagina, and not through the abdominal cavity.

If the operation is performed for cancer of the cervix, the incision is made more accurately beyond the limits. of the disease if the vaginal vault is opened through the vagina than if it is opened from above.

Myomectomy.-In some cases of uterine fibroid it is proper to remove the tumor without taking away the This operation-myomectomy-is performed as

uterus.

follows:

The abdomen is opened by a free incision, the pelvis is elevated, and the intestines are displaced from the pelvic cavity in the usual manner. The tumor and the uterus are surrounded by gauze sponges, and, where possible, should be brought outside the abdominal cavity. An incision is made around the pedicle or through the capsule of the tumor, and it is enucleated by dissection with the sharp or the blunt end of the scalpel. During