A Text-book of Diseases of Women

by Charles B. Penrose

THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS.

The technique of some of the special gynecological operations, such as perineorrhaphy, and trachelorrhaphy, has already been considered in discussing the treatment of the conditions in which such operations are applicable. The general and local preparation of the patient, the instruments, the dressings, etc., and the technique of the general operations of gynecology that are applicable to a variety of different pathological conditions, such as oöphorectomy and hysterectomy, now demand consideration. The general rules of asepsis that are followed in gynecological operations are the same as those that should be observed in all surgical operations. And although every surgeon should strive to attain perfect asepsis in all operations, yet it is of especial importance for the gynecologist to do so, for he, more often than all others, invades the peritoneal cavity. Of the various structures of the body, the peritoneum is one of the most susceptible to septic influences; and septic infection of the peritoneum, unlike infection of other structures, implies not merely a local disturbance and delay of healing, but general sepsis and death.

Moreover, the gynecologist, operating in the peritoneum, cannot correct any imperfection in his aseptic technique by the use of antiseptic solutions, as can be done in other operations of general surgery. Such antiseptic solutions, if of sufficient strength to be of any value as germicides, are very dangerous in the peritoneum. They may produce fatal poisoning from absorption through the peritoneum; they destroy the delicate peritoneal surface, and thus diminish the very useful power of the peritoneum to absorb blood and serum after the operation; they cause intestinal and other adhesions; and they so impair the integrity of the intestinal walls that septic organisms may be enabled to pass through and infect the general peritoneum.

The gynecologist, thus debarred from the use of antiseptics during a peritoneal operation, must rely altogether upon the perfection of his aseptic technique.

It must not be forgotten that the danger of peritoneal infection, though very much less in the minor gynecological operations on the perineum and the cervix, is yet never altogether absent. The whole genital tract of women communicates directly with the peritoneum, and infection at any point may extend and cause fatal peritoneal sepsis.

The danger increases with the proximity of the infected point to the peritoneum. The danger of salpingitis and peritonitis from trivial intra-uterine manipulations not performed aseptically, such as the passage of a dirty sound, has already been referred to. Fatal peritonitis has followed trachelorrhaphy.

In the various plastic operations of gynecology disastrous results are, of course, not so likely to occur from imperfect asepsis as in those operations that involve opening the peritoneum. In some of these operations, such as closure of a vesico-vaginal or a recto-vaginal fistula, it is impossible to obtain perfect asepsis.

In minor gynecological operations, however, we may use antiseptic solutions which are inadmissible within the peritoneum; and the vascularity of the genital tract is so great that healing is usually rapid and perfect even with very imperfect asepsis. This fact, however, should never justify carelessness on the part of the physician. In every surgical procedure, however trivial, the strictest asepsis should always be observed. The practice avoids, at any rate, a minimum danger; it is a useful training for the physician; and it sets a valuable example to the assistants and nurses. No part of the technique should be “good enough.” It should be as good as it can be made.

The greatest factor in the success of modern gynecology has been asepsis. The doctrine has become so widely spread that the technique, and consequently the results, of careless operators of the present day are much better than those of the best operators before the days of Listerism.

This is not said to justify carelessness. No woman should at operation be exposed to any dangers not inseparable from her condition. The assistants and the nurses should be especially made to feel the responsibility of their positions. A careless nurse or assistant may introduce sepsis and cause death after the most skilfully performed operation. Unfortunately, there is not a distinct realization of this fact. An assistant, though conscious of some carelessness of his own, usually beguiles himself with the belief that death was due to some other cause. If there were a distinct realization of personal responsibility among all concerned at an operation, death from infection through carelessness would be avoided as are other kinds of manslaughter. Unless a surgeon knows that he can furnish the proper aseptic conditions, he has no right to advise a patient to submit to operation unless the disease is such that operation is demanded under any circumstances.

At the present day the gynecologist advises a woman to submit to a serious—potentially fatal—operation, like celiotomy, for the relief of many conditions which cause suffering, but which do not cause death. He does this conscientiously, because he knows that if the operation is properly performed the danger to life is very small. If he is not certain that the proper operative conditions will be at hand, he cannot conscientiously give this advice, and he had better follow some palliative treatment.

Operations are always better done in a well-equipped operating-room than in a private house. In the operating-room we have better asepsis, better light and mechanical appliances, better discipline of assistants and nurses, and greater opportunity of successfully dealing with unexpected complications.

In an operation which is performed in a private house something is always used which is more or less of a makeshift; and makeshifts should not be used in surgery, especially in abdominal surgery. If we hope to obtain perfect results, we must insist upon perfect surroundings and appliances. Continuous success is the result of scientific accuracy and attention to detail. I say continuous success, because this is the only test of good surgery. We should not be misled by occasional brilliant results obtained under imperfect conditions. In such circumstances the operator admits to himself that his patient was lucky. The element of luck should be entirely eliminated. Nothing should be trusted to luck.

Fortunately, most of the operations of gynecology are performed for conditions of such a character that there is no demand for instant operation. The woman can usually wait until suitable conditions are furnished. In cases of emergency the surgeon can only do his best under the existing circumstances, not his best under the best circumstances.

It cannot be denied that good results, as far as mortality is concerned, are obtained in abdominal operations in private houses. The mortality, however, for a long series of cases of all kinds is greater than that obtained in well-equipped hospitals by operators of equal ability. The number of incomplete and imperfectly performed operations is much greater in private houses than in the hospital, for the operator with imperfect surroundings fears to deal radically with some unexpected conditions which he meets, and is satisfied if the woman’s life is saved, though she be not perfectly cured.

It is not necessary to dwell upon the need of proper training of the operator himself in abdominal surgery. The minor gynecological operations may be performed by any one who is familiar with the ordinary principles of surgery and who understands the special technique of the operation. There is no fear of unexpected complications in such operations. Rapidity of work is not essential, as in abdominal surgery, and the operator may study the condition as he proceeds; moreover, errors arising from inexperience or ignorance are not attended by fatal results.

In abdominal surgery, however, the operator should be specially trained for the work. Except in cases of emergency, he should not perform these operations unless he expects to do so continuously. He should be trained by work upon the cadaver and the lower animals and by watching and assisting experienced operators. He should be prepared to deal, without hesitation, with every pathological condition that may be met with in the abdomen; a glance at works on abdominal surgery will show how numerous such conditions are.

A few successes in simple cases in the hands of an incompetent operator will lure him on with false confidence until he finally meets a condition with which he is unable to cope. Either the patient dies as a result, or, if the operator be conservative, the abdomen is closed over an incomplete operation.

The directions which are about to be given apply especially to those operations in which the peritoneal cavity is entered. They may be modified in obvious particulars in case a minor operation is to be performed upon the vagina or the uterus. In such cases special abdominal cleansing is unnecessary and complete evacuation of the intestinal tract is not so important.

The technique described is that which is followed by the writer. Various equally good modifications are employed by other operators. It seems best, however, to give but one rigid method which experience has proved successful. The experienced operator is able to change it according to his individual preferences.

Operating-room.—The operating-room should be well lighted from the top and at least one side. If a good natural light cannot be secured, an electric drop-light will be found very convenient. For work deep in the pelvis or the abdomen a good light is essential. If necessary, light may be directed to the desired point by means of the ordinary head-mirror.

The floor, walls, and ceiling of the room should be of some non-absorbing material. There should be in the room no appliances whatever that are not essential for the performance of the operation.

The interior of the room should be wiped throughout with a mop or with wet cloths, or, still better, flushed with the hose, in order to remove and lay all dust. The room may be wiped throughout with a solution of bichlorid of mercury (1:2000). At the Gynecean Hospital the operating-rooms are disinfected once a week with formaldehyd gas.

The temperature of the room should be not less than 75° F. Shock from bodily loss of heat and exposure of the peritoneum is diminished if the atmosphere of the room is at an elevated temperature.

Apparatus.—All apparatus, such as basins, tables, etc., should be of such a character that it may be sterilized by boiling or by washing with a solution of bichloride of mercury (1:1000). Glass-top tables with painted or nickel-plated frames are preferable. The operating-table should be so arranged that the patient may be placed in the Trendelenburg position ([Fig. 193]). This position permits the intestines to gravitate out of the pelvis, and is very useful in many operations. There are a great variety of tables in use. Before the Trendelenburg posture was introduced the writer used for several years a plain hard-wood plank supported by two wooden horses. The Boldt table is very convenient. With it there is no necessity for a rubber pad for catching fluids. It is applicable for all gynecological operations. Some operators are in the habit of dressing the operating table by placing on it a blanket and sheet. This is unnecessary, unless the patient is in such a condition of collapse that it is essential to preserve all bodily heat. The blanket usually becomes saturated with fluids and serves no good purpose.

The number and arrangement of the basins, tables, stands, etc. used in an abdominal operation are shown in [Fig. 194].

The basins are best sterilized by boiling, or by washing with scalding water (inside and outside) and a solution of bichloride of mercury (1:1000).

The tables and stands are sterilized by washing with the bichloride solution. If wooden-top tables are used, they should be covered with a towel wrung out of a 1:1000 bichloride solution.

Fig. 193.—Trendelenburg position.

Operator, Assistants, Nurses.—Usually one assistant, who stands opposite the operator, and two nurses, are sufficient. A second assistant, standing beside the operator, is useful to thread needles and to hand instruments and ligatures. The operator, assistants, and nurses should possess such general cleanliness as follows a morning bath. They should not attend any patients suffering with a septic or infectious condition upon the day of the operation. If they have done so upon the previous day, they should subsequently take a general bath and change all clothing. Care in this respect is especially desirable on the part of the nurses, whose long hair prevents easy cleansing of the head.

Fig. 194.—View of the sterilizing and operating rooms of the Gynecean Hospital, Philadelphia. The apparatus is arranged for operation. A, flasks of sterile water; B, jar containing silk ligatures in glass tubes; C, instrument-sterilizer containing boiling water; D, tray containing sterile water for instruments at operation; E, basin for washing sponges; F, basin for washing hands of operator during operation; G, tray for sutures, ligatures, and needles; H, jar of cold sterile water; J, kettle of hot sterile water; K, water-sterilizer; L, dressing-sterilizer.

The operator and assistants should wear sterilized outer clothes—cotton shirt and duck trousers. A large sterilized apron put on immediately before the operation is an additional protection. The nurses should wear large sterilized aprons over freshly washed, if not sterilized, dresses.

The hands and forearms of the operator, assistants, and nurses should be bare and especially sterilized. The finger-nails should be short, rounded, and smooth. A long nail is difficult to clean, and in the case of the operator is dangerous, as it may lacerate important structures in the process of enucleation of a tumor. Enucleation of adherent growths is best done with the blunt finger, which passes along the planes of separation. The sharp nail may perforate an intestine or lacerate a blood-vessel, instead of pushing it aside.

The nails, fingers, hands, forearms, and lower part of the upper arms should be thoroughly scrubbed with frequently changed hot water and soap (preferably soft soap) and a large stiff nail-brush. The process should not be done hastily or but once. The soap should be repeatedly washed off and renewed. Five minutes, at least, should be devoted to the scrubbing. The hands and arms should then be similarly scrubbed with alcohol, and finally scrubbed with a solution of bichloride of mercury 1:1000. Immediately before proceeding with the operation the hands and arms should be rinsed in sterile water.

There should be a nail-brush for each solution used. The brushes should be clean and sterilized by boiling or by placing in the steam sterilizer.

After sterilizing the hands, the operator, the assistants, and nurses should touch nothing which is not sterile. If they are obliged to do so, the hands should be again washed.

Rubber gloves, such as are used in general surgery, are very useful in the operations of gynecology. They may be worn to protect the patient in case the operator or the assistants are not certain of the sterility of their hands, or to protect the operator when working upon a septic patient. Rubber gloves should be sterilized in the steam sterilizer.

Sterilization of Dressings, Towels, etc.—The operating-cloths, aprons, sheets, towels, dressings, gauze pads, etc. are most conveniently sterilized by steam heat. The temperature should be at least 100° C. (212° F.). The dressings and bandages should not be too tightly packed, so that all parts may be exposed to the same temperature.

Several kinds of steam sterilizers have been introduced. The most easily obtained is the Arnold sterilizer. An apparatus like the Sprague sterilizer, in which the steam is superheated, is preferable, but, as it is not portable, it is adapted only for hospital use.

The dressings should be maintained at the elevated temperature for an hour or more. Although this method secures very good sterilization, yet there are certain spores which resist such elevated temperature even after a two hours’ exposure. The method of fractional or discontinuous sterilisation has therefore been introduced. Two or three successive sterilizations are practised at intervals of twenty-four hours. Spores which at first escape destruction will have developed into vegetative forms in the intervals, and are destroyed by the final sterilizations.

At the Gynecean Hospital all dressings are sterilized for three consecutive days for two hours each day. The dressings, towels, etc., after sterilization, should be preserved in sterile glass jars or other sterile receptacle.

Sterilization of Instruments.—Instruments, drainage-tubes, catheters, and any rubber appliance may be sterilized by boiling in water for fifteen to thirty minutes. A dilute solution (1 per cent.) of carbonate of soda is preferable, as the instruments are not so easily rusted, and this solution, when boiling, has greater germicidal qualities than plain water.

Very convenient instrument-sterilizers are made, in which the instruments are contained in a tray that may be lifted out and placed in the receptacle for containing the instruments during the operation. This receptacle or pan should itself be sterilized, and should contain sterile water, or preferably the sterile solution of bicarbonate of soda, in sufficient quantity to cover the instruments.

It is very convenient to keep on hand a saturated solution of carbonate of soda, sterilized by boiling, a small quantity of which may be added to the water in the instrument-tray. Rusting of instruments is diminished by this means.

Appliances that are injured by moist heat or by steam may be sterilized by thorough washing and soaking in a solution of bichloride of mercury (1:1000). It is useful to keep a large vessel of such a solution on hand, in which apparatus that is not injured by the bichloride may be placed.

The Water.—The water used during the operation, for washing the wound, the abdominal cavity, the sponges, and the hands of the operator and assistants, should be sterilized by boiling or by distillation. The water should be boiled for two hours a day on two consecutive days, or it should be boiled under pressure as in some of the modern water-sterilizers. If the water contain a perceptible sediment, it should first be filtered.

Very convenient water-sterilizers are made, from which the water may be drawn of any desired temperature, after having been both filtered and sterilized by heat. There should always be a large quantity of sterile hot water at hand. Water below the temperature of the body should not be introduced in the peritoneal cavity, and pads brought in contact with the intestines should be wrung out of hot water.

About fifteen gallons of sterile water are usually required in an abdominal operation.

The water should be preserved in sterile pitchers, basins, or other receptacles.

Glass flasks are very convenient for containing the water with which the abdomen or pelvis may be washed out. The water may be poured directly into the abdomen from the flask. The flask should be plugged with non-absorbent cotton to prevent the entrance of dust.

Some operators prefer to use a normal salt solution (sodium chloride gr. 90 to water ℥xxxiiiss) for washing out the peritoneum. Such a solution is probably less irritating to the peritoneum than plain water.

If the flasks are used for containing the water, it may be boiled in them, and then preserved by plugging with absorbent cotton until required at the operation. The temperature of the water used for abdominal irrigation should be 100° to 115° F.

Sponges.—In the minor operations about the vagina or uterus the field of operation may be kept clean by irrigation with sterile water or by the use of sponges. Small sponges in holders are commonly used. These sponges, after being washed free of sand and bleached if necessary, may be sterilized by soaking for twelve hours in a solution of bichloride of mercury (1:500). They should then be rinsed in warm water and preserved in a 3 per cent. watery solution of carbolic acid, which should be changed every week.

Artificial sponges, or gauze sponges, are the most convenient in abdominal surgery. They are cheap, and may be destroyed after each operation, and they are very easily and certainly sterilized in the steam sterilizer. Good marine sponges are so expensive that but few operators destroy them after they have been once used. The cleansing and sterilization of such sponges are tedious and uncertain. The gauze sponges answer every purpose.

The gauze sponges may be made of various sizes by sewing together about eighteen layers of plain absorbent gauze. The edges of the gauze should be folded in and hemmed to prevent the escape of loose threads in the peritoneum. Some operators use sponges made by wrapping absorbent cotton somewhat loosely in gauze.

The number of sponges used should always be recorded before the operation. It is advisable to preserve the sponges in sets always of the same number, so that in every case the operator knows that this number, or some multiple of this number, of sponges has been used. The writer uses such sets of seven gauze sponges of the following sizes: one sponge 3 by 3 inches; one sponge 10 by 7 inches; five sponges 5 by 5 inches. Usually one such set of sponges is enough for an abdominal operation. In some cases, however, the first set of sponges may become soiled by the discharge from an abscess or a suppurating tumor, and it is advisable to discard these sponges and to complete the operation with a second clean set.

The number of sponges should never be altered during an operation by cutting one in two.

Sponges should never be removed from the operating-room until the abdomen has been closed and the sponges have been counted. If a sponge falls on the floor or in the vessel to receive slops, it should be put aside until the final counting is completed.

When a set of sponges is used, they should always be carefully counted as they are placed in the basin, for the nurse who prepared and put up the set may have carelessly miscounted them.

Accuracy in regard to the sponges is of the greatest importance. There are a number of recorded cases, and many unrecorded, in which sponges have been left in the abdomen. This accident is usually fatal, though there are several cases on record in which the sponge has made its way, by ulceration, into the intestine, and has been discharged from the anus, or has been removed by subsequent incision through the abdominal wall.

Discipline of the Operating-room.—The discipline of the operating-room should be most rigid. Perfect personal asepsis can be obtained only by continuous watching and criticism. The work should be systematically divided among the assistants and nurses, and each should attend strictly to his or her own department, and to nothing else.

The first assistant should assist the operator with sponges, etc. The second assistant should attend to the instruments, ligatures, and sutures. The first nurse should wash the sponges and place them in a basin of sterile water beside the first assistant. She should also attend to the towels and dressings. The second nurse, under direction of the first, should change soiled water in the sponge- and hand-basins, etc.

No one should pick up anything that may have been dropped upon the floor, and no one, unless it is absolutely necessary, should touch anything that has not been sterilized.

Anesthesia.—With the exception of the operator, the anesthetizer is the most important person at an abdominal operation. A careful, experienced anesthetizer is desirable in all operations, but especially so in an abdominal operation. Much more depends upon him than upon the assistant. The custom of trusting the anesthesia to the least experienced man is reprehensible. Many fatal cases after celiotomy may be attributed directly to the anesthesia.

Every operator of experience has observed the difference in reaction between those patients who have been carefully anesthetized and those who have been improperly anesthetized. In a serious case attended by unavoidable shock the superadded depression of ether-poisoning may be enough to cause a fatal result.

The operator should have nothing to do with the anesthesia, and it should not be necessary for him to watch it. The anesthetizer should make a careful examination of the heart, and should be provided with a hypodermic syringe and the necessary stimulants, which he should use at his own discretion.

He should, of course, use the minimum amount of ether. He should be familiar with the steps of the operation, and he should so regulate the anesthesia that the operator will not be impeded by the straining or struggles of the patient at critical moments.

Preparation of the Patient.—It is always desirable, when possible, to have the patient under observation for several days before operation. As I have already said, a more accurate diagnosis may be made by repeated examinations, and opportunity is afforded for the administration of medicines to improve the general condition. A weak woman about to submit to a serious operation is benefited by the administration of 1/20 grain of strychnine three times a day, for several days before the operation.

During this period the patient should receive a daily bath, a laxative when necessary to produce a daily movement, and a vaginal douche of one gallon of hot water every morning and evening.

The special preparation of the patient is directed to sterilizing the abdominal surface, the external genitals, and the vagina, and to emptying the gastro-intestinal tract. This preparation should begin twenty-four hours before the operation. During this time it is best to confine the patient to bed.

Thorough evacuation of the intestinal tract is very desirable in abdominal surgery. When the intestines are empty and collapsed, the various intra-abdominal manipulations are most easily performed. If the intestine is injured and it becomes necessary to repair it, or if any other intestinal operation is required, it may be performed most easily and with the greatest cleanliness if the gut is empty.

Though it is impossible to sterilize the intestinal tract, yet we most nearly approach the condition of sterilization by thorough evacuation of the bowels.

Twenty-four hours before the operation purgation should be begun by the administration of 1 dram of Rochelle salts, dissolved in half a tumblerful of water or soda-water, every hour until the bowels begin to move freely. Five or six doses are usually sufficient. The lower bowel should finally be emptied thoroughly by an enema of soap and water administered three or four hours before operation. During the twenty-four hours preceding operation the diet should consist of light, easily digested, concentrated nourishment, such as milk, buttermilk, soft-boiled eggs, rare beef, soups, beef-tea, coffee, tea, and whiskey if necessary.

Unless the patient is very weak, no food should be given on the morning of the operation. If her condition does not warrant such abstinence, she may have a glass of milk, buttermilk, coffee, or milk-punch. Such food is required if the operation is performed late in the day.

In very feeble patients a nutrient enema may be administered about two hours before the operation.

A hypodermic injection of 1/20 grain of strychnine is often useful upon the morning of the operation when the patient is in poor condition.

Preparation of the External Genitals and Vagina.—The pubis and the external genitals should be shaved. The woman should be drawn down to the edge of the bed, and the anus, the external genitals, and the vagina should be scrubbed with green soap. The vagina should be washed throughout. The nurse may do this by inserting one or two fingers, or she may retract the perineum with the Sims speculum, and scrub the vagina, the fornices, and the vaginal cervix with cotton held in forceps.

The scrubbing should be followed by a vaginal douche of a gallon of hot water to wash out the soap, and then by a douche of two quarts of bichloride solution (1:2000). One hour before operation the vaginal douche of bichloride should be repeated, and the nurse should introduce in the vagina as far as the cervix a light vaginal tampon of gauze wet with the bichlorid solution. In every abdominal operation on women it is desirable that the external genitals and the vagina should be clean. It may be necessary to pass the catheter or to perform some vaginal manipulation, or the vagina may be opened during the operation.

If the vagina is small or virginal, or if the woman is nervous, the nurse may be unable to perform the method of cleansing just described; and it is then necessary for the operator or the assistant to clean the vagina after the woman is anesthetized. Such cleansing should always be performed, in addition to the cleansing by the nurse, whenever a vaginal operation is performed or it is expected that the vagina will be opened from above. Thorough vaginal sterilization is most easily accomplished when the patient is under the influence of ether, as the perineum is easily retracted and the vagina becomes more patulous. The woman should be placed in the lithotomy position, and the washing should be performed with two fingers or with a soft brush like a jeweller’s brush, or with cotton in forceps. If necessary, the perineum should be retracted with the speculum. Green soap should be used, and the vaginal walls, the fornices, and the cervix should be thoroughly scrubbed. The soap should then be carefully washed out, and the scrubbing should be repeated with bichloride-of-mercury solution (1:2000).

The cleansing of the external genitals and the vagina is best done by the nurse after the final movement of the bowels and immediately before the woman has her general bath.

Sterilization of the Abdomen.—The patient should have a warm bath from head to feet upon the morning of the operation. The abdomen, from the ensiform cartilage to the pubis, should be scrubbed with a nail-brush. Special care should be devoted to cleansing the umbilicus. After this bath the patient should be dressed in a clean flannel undershirt and night-gown and should be placed in a clean bed.

The nurse should then wash the abdomen, from the ensiform cartilage to the pubis and from flank to flank, and the upper third of the anterior aspect of the thighs, first with turpentine, second with green soap, and finally with ether, devoting special care to the umbilicus. The abdomen should then be covered with a large wet bichloride dressing (1:2000), which should not be removed until the patient is upon the operating-table. A towel wrung out of the bichloride solution and held in place by a bandage or binder will answer the purpose. A second cleansing of the abdomen by the operator or the assistant should be done after the patient is upon the table. The surface should be washed with green soap and sterile water, then with ether, and finally with the solution of bichloride of mercury. The washing should not be restricted to the central abdomen, but should extend over the upper parts of the thighs and the flanks, which may be exposed during the operation.

Fig. 195.—Tait’s hemostatic forceps.

Fig. 196.—Spencer Wells’ forceps.

The bladder should be emptied by the catheter immediately before the patient is placed upon the operating-table.

The patient should be placed upon the operating-table by clean nurses or assistants.

The legs should be strapped to the table. The hands should be held out of the way by the anesthetizer. They may be retained very well by a safety-pin passed through the lower sleeve and the shoulder of the night-gown or the pillow-case.

The undershirt and night-gown should be drawn well up behind, to prevent wetting. If the clothes become wet, they should be changed immediately after operation.

The legs and the chest should be covered with clean blankets. The field of operation should be surrounded by sterilized towels. One large towel with a hole of suitable size in the center is convenient. A pocket may be made immediately below the hole, to retain the instruments when the Trendelenburg position is employed.

Fig. 197.—Knife.

Instruments.—The number and the variety of instruments used by the gynecologist in abdominal operations depend a good deal upon the taste of the individual operator. The list given here comprises all the instruments that are found useful by the writer in abdominal work:

Small hemostatic forceps ([Fig. 195])	12
Medium-sized forceps	2
Large forceps ([Fig. 196])	4
Knife ([Fig. 197])	1
Scissors—two pairs of long scissors, one straight and one curved on the flat.
Pedicle-needles ([Fig. 198])	2
Cyst-trocars ([Figs. 199] and [200])	2
Straight, spear-pointed needles, 2½ inches in length,for closing the abdominal incision by the mass-suture.
Curved needles for suturing within the abdomen.Fine straight and curved needles for the repair of intestinalinjuries.
Large curved needles for catgut, etc.
Abdominal retractors (blunt)	2
Needle-holder ([Fig. 201])	1
Long dressing-forceps	2

Three sizes of twisted silk are used for suture and ligature: heavy silk for ligature of the large arteries; medium silk for ligature of smaller vessels and for various suturing in the abdomen; fine silk for peritoneal and intestinal suture.

Fig. 198.—Pedicle-needle.

The silk should be as small as is consistent with secure ligature. The heavy silk is necessary for the ligature of pedicles in which a large amount of surrounding tissue is included with the artery.

Fig. 199.—Small curved trocar.

The silk is rolled on glass spools or on cores of gauze, contained in glass tubes plugged with cotton, and is then sterilized in the steam sterilizer by fractional sterilization. It is advisable always to use, for heavy ligature, silk of a uniform size, because the operator becomes accustomed to the strength of the silk and knows just how much strain it will bear. Silkworm-gut is the best material to use for suture of the abdominal incision in case the “through-and-through” or interrupted mass-suture is employed.

The silkworm-gut should be of the heaviest and the longest size. It may be sterilized by boiling with the instruments before the operation.

Fig. 200.—Large cyst-trocar.

Catgut is sometimes employed for ligature and suture. The difficulty of securing certain sterilization makes it advisable to avoid using this material within the peritoneal cavity. Sterilized silk is so certainly absorbed in all cases and is so easily employed that the writer has altogether given up the use of catgut within the peritoneum. It is useful as a buried suture for the muscle and fascia of the abdominal wall. Silk is not so certainly absorbed in this position, and if the catgut should happen to be imperfectly sterilized, no worse result than suppuration of the incision will occur.

Fig. 201.—Reiner’s needle-holder.

Various methods of sterilizing catgut have been introduced. The writer uses the following method, which bacteriological experiments and clinical experience have shown to be good: The catgut is soaked in juniper oil for one week. The oil is then washed out with ether and the catgut is soaked in ether for forty-eight hours. The gut is then rolled on glass spools and is placed in a glass jar containing pure alcohol. The alcohol is boiled in the jar for an hour at a time on several successive days. The gut is used directly from this jar, and is always boiled in the alcohol for an hour before each operation. In this way, if a considerable amount of gut is prepared at one time, it is subjected to many boilings before it is used up. The alcohol is boiled by placing the glass jar in a vessel of hot water.

The following methods of sterilizing catgut are also good:

The Claudius or Iodin Method for the Sterilization of Catgut.—Cut the catgut into the desired lengths and wind on glass slides or spools. Place in a wide-mouth jar with a glass stopper containing a solution composed of iodin and potassium iodide, each one part, and distilled water 100 parts. In making this solution the iodin and potassium iodide should first be pulverized in a mortar, the distilled water should be added, and stirred with the pestle until solution is complete.

At the end of eight days the catgut is sterile and ready for use. It may be kept indefinitely in the solution without deterioration. Before using take the catgut from the jar with sterile forceps and rinse in sterile water.

The Cumol Method for the Sterilization of Catgut, employed at the Johns Hopkins Hospital.—1. Cut the catgut into the desired lengths, and roll 12 strands in a figure-of-8 form, so that it may be slipped into a large test-tube.

2. Bring the catgut gradually up to a temperature of 80° C., and hold it at this point for one hour.

3. Place the catgut in cumol, which must not be above a temperature of 100° C., raise it to 165° C., and hold it at this point for one hour.

4. Pour off the cumol, and either allow the heat of the sand-bath to dry the catgut, or transfer it to a hot-air oven, at a temperature of 100° C. for two hours.

5. Transfer the rings with sterile forceps to test-tubes previously sterilized as in the laboratory.

The cleanest specimens of the crude catgut should be obtained for surgical purposes. There is no doubt that some specimens of crude catgut are more difficult to sterilize than others. A special apparatus has been introduced for sterilizing catgut which renders the process safe and certain.

The writer uses catgut only for suture of the abdominal fascia and muscles. Large-sized gut is employed.

The Dressing.—The dressing of the abdominal wound consists of ten or twelve layers of sterilized gauze, covered by a large sterilized abdominal pad about 1 inch thick, 13 inches long, and 9 inches broad. The pad is made of absorbent cotton enclosed in a layer of gauze. The dressing is retained in place by a six-tailed sterilized abdominal binder of flannel.

If no drainage through the abdominal incision is employed, the use of celloidin with the gauze dressing is of advantage. It retains the dressing securely in position for an indefinite period, and, if used liberally, it acts as a splint for the abdominal wall. Either of the two following formulæ given by Robb may be used:

℞.	Ether (Squibb’s),
	Absolute alcohol,	āā.	℥viss;
	Of a solution made of 15 grains of bichloride crystals dissolved in 11 drams of absolute alcohol,		♏xvj.

Mix, and add of Anthony’s “snowy cotton” enough to give the solution the consistence of simple syrup.

℞.	Absolute alcohol,		℥viss;
	Iodoform powder,		ʒxiiss;
	Mix, and add ether,		℥viss.

Mix, and add of Anthony’s “snowy cotton” enough to give the solution the consistence of simple syrup.

The celloidin should be poured over the edges of the first layers of gauze that are placed upon the wound.

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