The usual causes of death after celiotomy are peritonitis and hemorrhage. The frequency of hemorrhage as a cause of death is often overlooked. The writer feels confident that many deaths which, without post-mortem examination, are attributed to peritonitis, are really caused by hemorrhage. Without doubt, peritonitis and hemorrhage often occur together; the blood that escapes into the peritoneal cavity may be too great in amount for absorption, and may become septic. The source of the hemorrhage is usually a vessel of the pedicle that escapes from the embrace of an imperfectly applied ligature. This accident should not happen if the operator is careful to see that hemostasis is perfect before the abdomen is closed. Bloody oozing from a surface of adhesion is not sufficient to cause death, and may be removed by drainage; the fatal hemorrhage comes from an arterial vessel that has slipped from its ligature. All ligatured vessels should be finally inspected immediately before the abdomen is closed. If a stump is not perfectly dry, a reinforcing ligature should be applied. Care in this particular will save much subsequent anxiety. If the operator knows that his ligatures have been securely applied, he can exclude the possibility of hemorrhage in case alarming symptoms should arise. If the symptoms of the patient after celiotomy indicate hemorrhage, the abdomen must be reopened and the bleeding vessels secured. The causes of peritonitis after celiotomy have already been discussed. The common symptoms are rapid pulse, abdominal distention and pain with inability to pass flatus or feces, and vomiting, which may finally become stercoraceous. The temperature is usually elevated, though it may remain normal or subnormal. Auscultation of the abdomen reveals total absence of all peristaltic sounds. If these symptoms are not arrested by the use of purgatives, turpentine enemata, and the rectal tube, it is probable that the result will be fatal. Death usually occurs on the third day. The mortality after celiotomy depends upon the condition to be treated, the skill of the operator, and the environment of the operation. Some operations, like ventro-suspension of the uterus, are attended by no mortality. The average mortality after celiotomy for large numbers of gynecological cases of all kinds, in the hands of experienced operators with good operative surroundings, is about 5 per cent. CHAPTER XLII. THE SPECIAL TECHNIQUE OF OPERATIONS UPON THE UTERUS AND THE UTERINE APPENDAGES. A thorough knowledge of the anatomical relations of the various structures in the pelvis is essential for the performance of the various operations upon the uterus and its appendages. A detailed description of such anatomical relations is out of place here. It is especially important to study the distribution of the arterial supply and the relations of the ureters. Fig. 208 will refresh the memory upon these points.