The ligature should be passed about one-third of an inch up the broad ligament. It is then tied tightly and the ends left long and drawn aside. The segment of broad ligament included in the ligature is divided as near the uterus as is justifiable; in carcinoma of the cervix at least half an inch from the disease should be allowed. Care must be taken at this stage to avoid injury to the ureters; these lie about one inch distant from the cervix; consequently all ligatures must be passed as near the cervix as possible compatible with being clear of the disease.

A second ligature is now passed through the broad ligament above the first and then a third, and more if necessary. The second generally includes the uterine artery, which can always be recognized by its strong pulsation under the finger; the third ligature will control the Fallopian and ovarian arteries. After the arteries on the left side have been secured and divided, attention is directed to the right broad ligament. The cervix is drawn over to the left side, the fundus delivered, and the upper portion of the right broad ligament is dealt with in a similar manner, but from above downwards. If the ovaries and tubes are diseased, they can now be removed by piercing the pedicle and tying the stump in the usual way.

The uterus having been extirpated, the next step consists in dealing with the wound. First, all bleeding is stopped, and the wound is swabbed clean and dry. The ligatures on either side are tied in two bunches and the ends cut off just within the vagina (Fig. 72). The anterior and posterior flaps of peritoneum are united with a few catgut sutures passed by means of Schauta’s needle-holder (Fig. 73); the walls of the vaginal vault are treated in a similar fashion, leaving a circular orifice in the median line into which gauze can be inserted for the purpose of drainage.

   Fig. 72. Vaginal Hysterectomy. Final stage. The uterus has been removed, and the peritoneal flaps are in process of suture. a, a', a'', a'''. Retractors.
f, f'. Spencer Wells forceps attached to the anterior
and posterior vaginal flaps.
p. Circular orifice left open in the peritoneal flaps
for insertion of gauze drain.
sp. Stump of left broad ligament with bundle of
ligatures (l).
cl. Clitoris.
l.m. Labium majus.
u. Urethra.

Fig. 73. Schauta’s Needle-holder.

Some operators prefer to control the vessels in the broad ligaments by means of hæmostatic forceps instead of ligatures. Each broad ligament is clamped in three or more portions and the tissue between them and the uterus cut through. They must be allowed to remain in position for at least forty-eight hours, as recurrent hæmorrhage is possible if they are removed earlier. The only advantages of the forceps appear to be the rapidity with which the operation can be carried out, and the good drainage. The disadvantages are, that it is a somewhat unsurgical proceeding; there is often much pain from the nipping of the broad ligaments, and inconvenience from the presence of the handles between the labia; the intestines may be damaged; sloughing and risk of sepsis must be reckoned with.

After-treatment. The catheter should be used at first four times daily; the author recommends that the gauze should be removed at the end of twenty-four hours, but some operators retain it longer. The ligatures should be pulled upon a little daily after the seventh day, and they gradually cut their way through the tissues in their grasp. No vaginal douching should be administered until after the expiration of a week.

Vaginal hysterectomy for fibroids. This is not often called for. The operation is necessarily limited to fibroid uteri not exceeding in size a fœtal head. Uterine fibroids of such a size can usually be treated in other ways, either temporarily by curetting, or, if submucous, permanently by enucleation through the vagina. The operation is most suitable for uteri containing many small fibroids causing severe hæmorrhage which cannot be controlled by more palliative measures.