324 BOYINE OBSTETEICS 



ent iu the uterus. In doubtful cases an incision is made and 

 the parts explored with the hand. 



The operation consists in ligating the prolapsus as a 

 whole. For that purpose a broad ribbon is employed, placed 

 around the cervix uteri with a surgical loop; a good-sized 

 strong rubber tube may also be used. 



Many empirics in Holland used a silk necktie for this pur- 

 pose, tightening it around the cervix. 



Two points must be observed : 1, the site of the ligature ; 

 2, the tightening of the ligature. 



Most operators ligate a few centimeters posterior to the 

 palma plicata; only a few ligate the vagina. The first place is 

 preferable, as there is no danger of including the urethra. 



In order to tighten the ligature properly it is necessary 

 that it be strong, so that two men can pull on it with all their 

 power; and, on the other hand, that it is sufficiently broad to 

 prevent cutting through the uterus. 



The mass enclosed by the ligature is so large that it is 

 somewhat difficult to out off the entire circulation, which at the 

 same time is absolutely necessary. 



To accomplish this the two ends, of the ligature are fast- 

 ened one each to a stick, one man pulling on it steadily; some 

 time being required before the parts are firmly constricted. 



Traction ought to be exerted upon the cord steadily for 

 one minute to squeeze out all the liquid from the uterus wall 

 and to cut off the circulation completely. 



Some suggested to circumcise the entire mucosa before 

 applying the ligature, which would then include only the mus- 

 cularis and serosa. This is not necessary, provided the liga- 

 ture is tightened gradually and firmly, thus depriving the parts 

 of any blood supply. 



The elastic ligature may also be used to advantage. The 

 rubber tube is wrapped around the parts several times and 

 fastened in the ordinary way. 



After ligating the uterus it is cut off 4 to 6 cm. from the 

 ligature. Some practitioners wait twenty-four to thirty-eight 

 hours before amputating it. This is only indicated when 



