The author in 150 laparotomies did not lose one from external infection. Self-infection arises from the escape of infectious cyst contents, of bowel contents, or of urine into the peritoneal cavity. Sepsis comes on in the form of septic peritonitis. Vomiting sets in after the operation, the belly is tender and distended, the pulse is very small and frequent, the general condition is serious, and the expression of the face is anxious. The temperature rises from the first day onwards, but may be or may become subnormal. The facies hippocratica develops, and the sensorium is dulled, and death occurs within the first three days. According to Runge the treatment is the free administration of alcohol. Only small doses are given during vomiting. When the vomiting is more severe feeding per rectum comes into consideration.

Fever may come on in the later periods as a result of septic inflammation. This leads mostly to circumscribed suppurations of the pelvic walls or the ligatured parts, or to abscesses encapsuled between the bowels. Commonly the pus comes through at the abdominal incision. If not, an opening must be formed upward or into the vagina. The temperature then usually sinks quickly to normal. Hernias of the wound or obstinate abdominal fistulæ are, however, often left behind.

These circumscribed suppurations owe their origin to insufficiently sterilised ligatures, the sowing of not fully virulent bacteria upon the peritoneum during the operation, new infection of the stump from the uterus, blood effusions, and foreign bodies (sponges) left behind in the abdominal cavity.

After a perfectly reactionless course a case of abdominal section may die of embolism of the pulmonary arteries on getting up, or ileus may come on after months. Omental adhesions with the wound scar or the pelvic organs may give rise to very severe discomfort. If the ovaries have been extirpated the troubles of anticipated climacteric arise, such as flushing in the head, nervous excitement, etc. The author has seen excitable conditions,

hallucinations, or blunting of the sensorium just after laparotomy from iodoform intoxication.

For

The cases of death from the injurious action of antiseptics may be avoided by operating aseptically. this gauze compresses sterilised in a current of steam, or sponges dry sterilised, are used within the abdominal cavity. Walthard and Sänger say that dry asepsis leads to stripping of the peritoneal epithelium and to adhesions, and they therefore recommend the damping of the compresses or sponges beforehand with Tavel's solution (2.5 sodii carbonati calcinati, 7.5 sodii chloridi, aquæ distillatæ 1000). The author, however, has found no evil results from using a half per cent solution of lysol for this purpose.

VAGINAL LAPAROTOMY, OR CELIOTOMY.

VAGINAL cœliotomy, an operation described by the author, avoids the disadvantages of ventral laparotomy which have been mentioned, and the author feels compelled to describe it more minutely, because there is nothing about it in the gynecological text-books.

This procedure consists in opening the abdominal cavity from the anterior vaginal fornix. For this purpose the posterior blade of Simon's speculum is passed, the anterior cervical lip is seized with two pairs of volsella and drawn down to the vulva, and the bladder is pushed forwards and upwards with a small catheter.

The operator now makes an incision 1 cm. long at the insertion of the anterior vaginal fornix into the cervix, he seizes the upper margin of the wound with a volsellum and draws it strongly upwards, he deepens the incision with scissors and lengthens it on both sides by 1-2 cm., in doing which the incision must be made quite close to the uterus on account of the ureters. If the vagina is separated from the anterior wall of the cervix by this incision, and the assistant draws the vaginal wound margin strongly upwards, the bladder is pulled away from the cervix (or with slight assistance from the operator's finger) as high as the internal os. It is a mistake to press now with the finger bluntly upwards between the visible bladder and the anterior cervical wall-the plica vesico-uterina is only unnecessarily pushed out of the way, and its opening rendered more difficult. It is much better to place the left forefinger right over the internal os on the anterior

wall of the uterus. One feels the plica then as a thin displaceable membrane lying on the uterus, and can push it down so far with this finger, while keeping the latter constantly pressed against the uterus, that it becomes

visible beneath the transverse mass of the bladder and can be opened with scissors.

If the plica cannot be drawn down in this way, owing to its defective separation from the bladder and uterine body, the first provisional suture is passed at the highest visible part of the anterior surface of the uterus, which

projects clear of the bladder prominence. The bladder may be slightly pushed upward with the dorsal surface of the forefinger, so that the point of the needle when passed appears on the volar side of the finger (Fig. 32). If the assistants pull carefully down on the silk tractor threads

one can open the peritoneum in situ at this time (Fig. 33), unless the plica has been unnecessarily pushed up beforehand-or the opening takes place after passing a second higher provisional suture. The opening of the peritoneal cavity may be safely postponed until the uterus has been anteflexed.