The sutures may be soiled by the hands of nurses and a.s.sistants, or the fingers of the surgeon. All these things may be safeguarded, but the operation may have been required for the removal of infected cysts, or pelvic peritonitis: in these cases it is wise not to bury sutures.

Troublesome buried sutures should be removed. In many instances this is easy of accomplishment, and in others it requires patience and often perseverance, even when the patient is under an anaesthetic. The simplest implement for removing a buried suture is a crochet-hook.

The disadvantage of st.i.tch-abscesses, apart from the inconvenience they cause patients during their convalescence, is that they often cause the scar to yield at that spot, and necessitate the wearing of an abdominal belt. If the hernia is of small extent, and especially when it is situated near the lower angle of the scar, it is difficult to fit a belt which will restrain it without the use of perineal bands or straps. In such cases a truss, on the principle of those employed for inguinal hernia, is more satisfactory than a belt.

Occasionally a scar forms a raised hard red keloid band, and causes some anxiety to the patient. These keloid scars shrink and whiten in the course of a year or eighteen months.

=Cancer of the cicatrix.= Several cases have been recorded in which, after the removal of an ovarian adenoma, a new growth, described as 'cancer of the cicatrix', has formed in the scar. These growths are probably due to the soiling of the wound at the time of operation with epithelial fragments from the tumours.

After abdominal hysterectomy for cancer of the body of the uterus, or its cervix, the abdominal wound may become infected with this disease, and in cases where exploratory cliotomy has been performed for diffuse cancerous disease of the peritoneum the cicatrix is liable to become permeated by malignant disease also.

REFERENCES

BALDY, J. M. The Mortality in Operations for Fibroid Tumour of the Uterus. _Trans. Am. Gynaecological a.s.sociation_, 1905, x.x.x. 450.

BARTLETT, W., AND THOMPSON, R. L. Occluding Pulmonary Embolism. _Annals of Surgery_, 1908, xlvii. 717.

BLACKER, G. F. _Lancet_, 1909, i. 395.

BLAND-SUTTON, J. Hunterian Lecture on Thrombosis and Embolism after Operations on the Female Pelvic Organs. _Lancet_, 1909, i. 147.

BLAU, A. Ueber die in der Klinik Chrobak bei gynakologischen Operationen beobachteten Nebenverletzungen. _Beitrage f. Geb. u. Gyn._, 1903, Bd. vii. 53.

BUCKNALL, R. The Pathology and Prevention of Secondary Parot.i.tis (with Literature). _Med.-Chir. Trans._, 1905, lx.x.xviii. 1.

DEAVER, J. B. Hysterectomy for Fibroids of the Uterus. _Am. Journ. of Obstetrics_, 1905, lii. 858-74.

HASTINGS, S. A Preliminary Note on Embolism in Surgical Cases. _Archives of the Middles.e.x Hospital_, 1907, xi. 78.

JONAS, E. Temporary Uretero-v.a.g.i.n.al Fistula after Panhysterectomy for Fibroid of the Uterus. _Am. Journ. of Obstetrics_, 1907, lvi. 731.

LEQUEU. Sur les parotidites post-operatoires. _Bull. et Mem. de la Soc.

de Chir. de Paris_, 1907, T. x.x.xiii. 1044.

LUTAUD, P. _Sur un procede d'uretero-cysto-neostomie dans le traiment des fistules uretero-v.a.g.i.n.ales et uretero-cervicales._ Paris, 1907.

LYLE, RANKEN. A Series of Fifty Consecutive Abdominal Sections. _Journal of the British Gynaecological Society_, 1906-7, xxii. 120.

MALLET, G. H. _Am. Journ. of Obstetrics_, 1905, li. 516.

MORRIS, H. Lectures on the Surgery of the Kidney. _British Medical Journal_, 1898, i. 1039.

n.o.bLE, C. P. Clinical Report upon Ureteral Surgery. _American Medicine_, 1902, iv. 501.

---- Myomectomy. _New York Medical Journal_, 1906, lx.x.xviii. 1008.

OLSHAUSEN, R. Veit's _Handbuch der Gynakologie_, 1907, 2nd Ed., Bd. i.

715.

PURCELL, F. A. The Risks to the Ureters when performing Hysterectomy, &c. _Journ. Brit. Gyn. Soc._, 1898-9, xiv. 174.

ROBINSON, B. Sudden Death, especially from Embolism, following Surgical Intervention. _Medical Record_, 1905, lvii. 47.

SPENCER, H. R. Discussion at Exeter on Uterine Fibroids, &c. _British Medical Journal_, 1907, ii. 452.

TEBBS, B. N. Symptomatic Parot.i.tis. _Med.-Chir. Trans._, 1905, lx.x.xviii.

35.

TRENDELENBURG, F. Zur Herzchirurgie. _Zentralbl. fur Chir._, 1907, No.

44, 1302.

---- Ueber die chirurgische Behandlung der puerperalen Pyamie.

_Munchener Med. Wochenschr._, 1907, x.x.xiv. 1302.

WEIBEL, W. Das Verhalten der Ureteren nach der erweiterten abdominalen Operation des Uteruskarzinoms. _Zeitsch. f. Geb. u. Gyn._, 1908, lxii. 184.

SECTION I

OPERATIONS UPON THE FEMALE GENITAL ORGANS

PART II

v.a.g.i.n.aL GYNaeCOLOGICAL OPERATIONS

BY

JOHN PHILLIPS, M.A., M.D. (Cantab.), F.R.C.P.

Professor of Obstetric Medicine, King's College, London Obstetric Physician and Gynaecologist to King's College Hospital

CHAPTER XII

PREPARATION OF THE PATIENT FOR PERINEAL AND v.a.g.i.n.aL OPERATIONS: OPERATIONS FOR INJURIES TO THE PERINEUM AND PELVIC FLOOR

PREPARATION OF THE PATIENT

In operations upon the perineum and v.a.g.i.n.a, the same scrupulous precautions against sepsis should be taken as in abdominal section.

Before proceeding to practical details, it will be useful to consider a few points regarding the distribution of bacteria in these parts. Not only the ordinary bacteria of the skin, but also those from the r.e.c.t.u.m, and, under certain conditions, from the urine and the v.a.g.i.n.al secretion abound on the perineal and v.u.l.v.al surfaces. The healthy virgin v.a.g.i.n.a may be considered free from pathogenic organisms, harbouring only the harmless v.a.g.i.n.al bacillus of Doderlein. After s.e.xual congress the v.a.g.i.n.a contains pathogenic organisms, and in conditions such as carcinoma of the cervix and body of the uterus, and in all forms of vaginitis, many varieties of bacteria are present in great numbers.

The normal uterus is germ-free; in fact the external os uteri may be said to divide the bacteria-free from the bacteria-containing area of the genital ca.n.a.l. But in carcinoma and in the various forms of septic endometritis, the uterus not only contains many pathogenic bacteria, but acts also as a continual source of infection to the v.a.g.i.n.a and external genital organs. It follows, therefore, that this area may be exceedingly difficult to render sterile, and in certain conditions this is indeed impossible. None the less, every effort should be made to attain this object; for even if the organisms cannot be entirely removed, yet their numbers can be considerably reduced, and it must be remembered that the action of septic organisms is, to a great extent, directly proportionate to their numbers.