The methods of controlling hemorrhage by means of the cautery and the tampon we will speak of later. After careful co-aptation, the surface should be wiped dry by means of absorbent cotton. In case there is oozing or pockets, then drainage should be resorted to, as is described under the various operations. After operations on the vagina or the cervix, the surfaces are best kept dry by sprinkling with iodoform and then tampouing with 50 per cent. iodoform gauze. Of course the tampons should not be pressed so tightly as to strain the sutures. In the same way salicylic acid, or bismuth, or thymol gauze may be used. The iodo forw gauze may rdtnain in situ at least forty-eight hours, or if there is no oozing from five to six days. After its removal, the surface is douched, and fresh gauze is inserted. In case of plastic operations, where rest of the parts is an essential matter, the dressing should not be removed, but the douche ordered in case of much secretion. In case the operation has been performed in the cavity of the uterus, then this is either tamponed with iodoform gauze, or else an iodoform pencil is inserted, which is re newed from time to time.
In general too active means interfere with the aseptic treatment. In the thoroughly disinfected vagina asepsis is obtained because of the shut ting off of the air. Injections in cases which'are pursuing a normal course do more harm than good, for mechanical injury may readily be done, the united edges may be separated by the point of the syringe, and, further, the use of much fluid may interfere with union by first intention.
• Pure air, cleanliness, and rest, are the essential factors in the after treatment. Special rules as regards rest in bed must be formulated for the individual case. Generous, but non-irritating diet enters also greatly as a factor in the after-treatment, and strong tea, coffee, spirits, etc., are to be strictly forbidden. In case of badly nourished anemic women, in particular after major operations, this rule is inoperative, and coffee, tea and rhum, wine, champagne, etc., must be ordered. Pain, which is fre quently present for some time after operation, must be allayed by narco tics, subcutaneously, locally, or by the vagina or rectum. Small, frequently repeated, rectal injections of opium, are particularly to be recommended. This agent should not be used too sparingly, since sleep of some hours is of great benefit to the patient. In case of purely nervous patients, where pain is not a factor, chloral hydrate, and the bromides, etc., are indicated.
In case all of the detailed rules have been rigidly adhered to, it will be exceptional that convalescence is not undisturbed, and union by first intention does not result. As yet, however, it is not in our power to keep infection absolutely at a distance, and here and there we meet with septic affections. Owing to the site of many of our operations we are unable
to detect local changes in the wound, as is possible with the general surgeon. In case of wounds of the uterus and vagina direct inspection after operation is generally not possible, and we have to depend on the sensations of the patient, and on the nature of the wound secretion.
The state of the temperature and of the pulse are of the highest•im portance. The thermometer should be used frequently and at regular intervals. In case of plastic operations, the slightest rise of temperature may mean interference with union by first intention. In regard to elevation of the temperature, we must take into account the nervous irritability of the patient, the influence of the dressing (iodoform), inter current affections, (such as catarrh of the bladder from infection by the catheter). In case these factors are eliminated, then an examination of the secretions may give us a hint as to the nature and site of the cause at the bottom of the fever.
Septic affections early manifest themselves by disturbance of the sub jective state of the patient. Listlessness, loss of appetite, restlessness, alteration of the facies, etc., tell the careful observer of impending in fection. The determination of these factors necessitates, of course, thorough knowledge of the patient, and where such is not the case; care ful inquiry into her antecedents may assist us.
Serious septic infection is readily recognized, but we must always bear in mind the possibility of the symptoms being due to the development of one of the exanthemata, such as typhoid. The appearance of the wound, and thorough examination of the secretions,will assist us in differentiation.
In case in this way the presence of infectious matter is determined, then our first aim should be to provide for as free removal of the secretion as is possible. Tampons, clots, portions of tissue, sutures which are involved in necrosing tissue, these should be at once removed; the uterine cavity, in which there is frequently a flexion, may be cleansed and emptied by injections.
The second indication is the removal of the necrosed masses, to pre vent renewed absorption. Injections of disinfecting fluids will not accom plish this, but the masses must be removed with cotton or instruments, under the guidance of the eye, of course, to prevent new injury whence fresh absorption might take place, and the more readily since we might open occluded lymph vessels or veins as well as interfere with the pro tective granulations. It is far preferable, hence, to thoroughly cauterize these masses down to sound tissue, although in case of wounds in gyneco logy this is not always possible. In case we can readily expose the diseased parts, then we may apply one or another of the caustic agents to be described further on.