The separation of the bladder from the uterus is accomplished by blunt dis section and the tissues arc pushed off posteriorly in the same manner until the peritoneum is reached. By the dissec tion, we may frequently strip out a good portion of the cervix without the neces sity for ligating vessels. Having reached the peritoneum in front and behind, a fold of the broad ligament is then secured on either side by ligature or a clamp, and incised, which sets free the cervix. We may now proceed to drag down the cervix, ligate and cut the remaining por tions of the broad ligaments on each side in a similar manner, or the cervix may be amputated and the fundus of the uterus rotated downward through the anterior incision. This procedure permits the passage of the finger over the fundus, to follow up the broad ligaments, and ac complish the enucleation of the ovary and tube. The ovary and tube are usually prolapsed backward from their weight, and this manoeuvre renders them tense and enables the operator with the finger to follow more readily the line of cleavage between the tube and ovary and the other tissues.
After the sac is separated and enu cleated, the remaining portion of the ligament is ligated and cut. This is usu ally first done upon the left side, which gives us more room to follow the same procedure upon the right. If ligatures are used they should be firmly tied, and the ends cut to prevent traction, which may pull them from the stump. A re tracted stump is quite difficult to reach, and in dragging it down the ovarian artery may slip back and bleed. The stumps are temporarily held with clamps, so that they may not be retracted be yond our reach when we choose to close the vaginal wound.
With the completion of the operation the surfaces are carefully inspected for bleeding-points, the vagina and the pel vis irrigated with a normal salt solution, by which the hood and discharge are completely removed. In the majority of these cases extensive tearing and denuda tion has been necessary, which will re sult in the escape of the serous effusion or even blood; it is preferable not to close the vaginal wound, but pack the cavity with iodoform gauze. This gauze packing is permitted to remain from six to eight days. When removed, plastic exudation, which has been thrown out around it, will hold up the intestines and prevent their prolapses. The tampon, however, should be replaced by a smaller one, which is permitted to remain for a few days. The sutures may be silk or cat gut, preferably the latter, as the silk is almost certain to become infected, and will prove a source of irritation until they are finally thrown off or disintegrate. The catgut is of much shorter duration and much less likely to cause trouble.
The vaginal operation is not applicable to all cases. It should not be preferred when there is any hope of saving the uterus and the appendages of one side. It is only in those cases in which the ex amination has demonstrated the neces sity for the sacrifice of both ovaries and tubes, that the extirpation of the uterus should be considered. Where a partial operation is done, the preferable route will be by the abdomen, as it permits us the better to inspect the condition of the peritoneal cavity, to break up adhesions, and suitably treat the partially diseased organ, which may remain.
The consensus of opinion from the dications given by the operator- of the widest experience is that conservative operations on the tube and ovaries may be practiced: 1. For new growths of character, for myoma and fibroma of the tube, simple cysts. &molds and fibroids of the ovary, and parova•ian cysts. 2. The tube and ovary ought not to be sacrificed as a matter of ience to the operator. It is cated in malignant or in papillary dis ease. 3. For chronic oiiphoritis and cystic degeneration. 4. For ba•natoma of the ovary and tube (perhaps hardly a consensus of opinion here). .5. For in flammatory diseases of the appendages, where the acute stage has subsided, pro vided that there is no suppuration in the pelvis or in the ovary, that the con tents of the tube are scrolls or luemor rhagie. and prove sterile on immediate cover-slip bacteriological examination (Schauta. Wertheim), and that the inner end of the tube is patent. For con servation to be rational it is essential that part. of the ovary should be capable of function: if both ovaries have to be entirely removed, there is 110 reason for retaining the tube; the state of the ovaries 'mist govern the method of pro cedure. 6. Conservative operations on the tubes should be limited to the child bearing period. Up to the present it is uncertain whether an ovary, the seat of a small eystoma, may be safely resected or whether a tube, dilated by old sterile pus can be safely opened up. Some of the American surgeons show special boldness in the presence of pus. With regard to the tubes, the majority of conservative operations are undertaken when the abdomen has been opened for gross disease of the appendages upon one side, and less advanced tubal disease has been revealed. Jut considering the method to be adopted in dealing with the tubes, certain points stand out: the artificial ostium should lie wide enough to allow of later contraction, if neces sary, by slitting the tube longitudinally. Provision should be made for eversion of the nuicosa in order to obtain, as far as possilde, the conditions present in the normal ostitun andominale. Care should be taken, by suture or otherwise, to leave the new opening in tlw tube in juxtaposition with the ovary. The en ergetic disinfection of the tubes by anti septics practiced earlier, is unnecessary if the eases are suitably chosen, and all measures likely to irritate t he perito 111.11111 to be avoided. It is still unde cided whether resection or ignipuncture of the ovary is the best operation for chronic oUpliorit is and cystic disease. That resection may be followed by ad lees i01) in some cases has been proven by observation. We are not yet in a posi tion to determine how far the technique adopted (i.e., the kind of suture used and the method of suture) is responsible for such adhesions. Florence N. Boyd (Brit. Jour. of Obstet., March, 1903).