4. Incision through the vesico-uterine peritoneum from the severed round liga ment across to its fellow, freeing the bladder, which is now pushed down with a sponge, so as to expose the supravagi nal cervix.
5. Pulling the body of the uterus to the opposite side to expose the uterine artery low down on the side opened up. The vaginal portion of the cervix is lo cated with thumb and forefinger, and the uterine artery, seen or felt, is tied just where it leaves the uterus. It is not always necessary to tie the veins.
6. The cervix is now cut completely across just above the vaginal vault, sev ering the body of the uterus from the cervical stump, which is left below to close the vault.
7. As the last fibres of the cervix are severed or pulled apart, while the body of the uterus is being drawn up and 9. Ligatures are now applied in place of the forceps holding the uterine artery, round ligament, and ovarian vessels; if the surgeon prefers, these may be tied, as they are exposed, without using for ceps.
10. After the enucleation the opera tion is now finished in the usual way: (a) by closing the cervical tissue over the cervical canal, and then (b) by draw rolled out in the opposite direction, the other uterine artery comes into view, and is caught with artery-forceps about an inch above the cervical stump.
S. Rolling the uterine body still far ther out, the right round ligament is clamped, and cut off, and lastly the ovarian vessels are clamped at the pelvic brim, and the removal of the whole mass, consisting of uterus, tubes, and ovaries, is completed.
ing the peritoneum of the anterior part of the pelvis [vesical peritoneum and anterior layers of broad ligaments] over the entire wound area, and attaching it to the posterior peritoneum by a continu ous catgut suture.
The continuous transverse incision should always be started on the side where the ovarian vessels and the ovary and tube are most accessible. If the case is one of a fibroid uterus, and the tumors are developed under the pelvic peri toneum or in the broad ligament of one side, this side should be opened up last, from below upward, whereupon the tumors can be rolled up and out with surprising facility.
The abdominal incision is always closed without drainage, by using a continuous catgut suture for the peri toneum, interrupted silver-wire sutures for the fascia, a buried continuous cat gut suture for the subcutaneous fat, and the subcuticular catgut suture for the skin. II. A. Kelly (Texas Med. News,
Slay, '96).
Various operations that have been performed for fibromyoma of the uterus. At first these were restricted to fibrous polypi and, as htemorrhage was feared, they were often strangulated by a liga ture and allowed to become necrotic, thus giving rise to serious danger to the patient. Later enucleation was prac ticed, and, finally, when ovariotomy be came a popular operation, they were re moved through an abdominal incision. Porcelini suggested morcellement, the danger of which consists in the subse quent necrosis of the stump of the cer vix. Hegar improved the treatment of the stump in this operation, and as far as life is concerned the results were fairly good. Intraperitoneal and extra peritoneal methods of treating the stump were then employed. Hegar then suggested castration in tumors of mod erate size, and the results were very good. _1nother method is enucleation through the abdominal incision. This can only be employed in certain favor able cases. The latest operation is total extirpation through the abdomen. The operation is rapid; often the COUVR leseenve is protracted. It can be ren dered even safer by doing the first part of the operation through the vagina, but the results are not always very success ful. Vaginal °nucleation and total ex tirpation is pa rtieularly recommended by Duterssen. This can only be done when flu; tumor does not extend above the umbilicus. If the tumor is large it is not advisable to attempt to preserve the uterus. When possible, the best operation is total extirpation through the vagina. Ilegar (AItinchener med. Woch., Nov. 25, 1902).
Abdominal total hysterectomy is per formed in the same way as supravaginal hysterectomy until the uterus is ampu tated at the cervix. Then the entire anterior cervical wall may be divided in the median line, or the anterior vaginal wall may be grasped just in front of the cervix by forceps and the vaginal canal opened between the forceps and the cervix. An incision is then carried laterally around the cervix guided by the finger passed through the opening made. The vaginal wall is caught by a forceps wherever vessels spurt. When the cervix is cut out catgut sutures and ligatures are put on the vaginal edges, and if pos sible all raw tissues drawn together. If this is impossible, the unapproximated surfaces should be packed with gauze that extends into the vagina, and the peri toneum be united over it.