if I remove one tube and the opposite ovary, conception, although rendered more difficult, is by no means impossible. I had such a case in the wife of a doctor who conceived soon after returning home, the ovum necessarily passing from the right ovary up the left uterine tube, and so into the uterus. The right uterine tube and the left ovary were removed. She bore a healthy child at term, and again conceived an extrauterine foetus.

If, now, I remove both the upper blocks (the uterine tubes), conception goes, but menstruation, ovulation, and internal

secretion are retained; if I remove the top blocks and the next below (the uterus), I still retain, with the ovaries, ovulation and internal secretion.

If, on the other hand, I remove both lower blocks (ovaries), the whole falls, for with the ovaries go not only ovulation and internal secretion, but menstruation and conception as well. So I take it, as a rule, when the ovaries are sacrificed it is best to remove with them the uterus and the uterine tubes.

Let me now illustrate the various ways of removing these structures, using simple diagrams. I leave out the round ligaments with the understanding that, though small and

insignificant in the course of the operation, they must yet always be tied to avoid a slow, persistent hæmorrhage.

The classical method or methods of removal, inspired by Freund and rendered more precise by Stimson, by the express ligature of the large vessels (uterine and ovarian), consists in tying of, first, one ovarian and uterine artery, then the opposite ovarian and uterine, and then amputating the uterus through the cervix (Fig. 2, p. 243). This is immaterially modified by tying both ovarian vessels first, then tying the uterine, and then amputating (Fig. 3, p. 244).

Removal by a transverse incision in order from left to right-1, 2, 3, 4, 5—or from right to left.

Another method of removal is this (Fig. 4), which may be called the Pryor-Kelly method-the enucleation by a continuous tranverse incision from side to side. The ovarian vessels of one side are tied, then the uterines of the same side; the cervix is then divided above the vaginal vault, and the uterine vessels of the opposite side exposed and caught. Last of all, as the severed uterus is lifted out of the abdomen, the remaining ovarian vessels are caught.

Another method of removal is Faure's (Fig. 5, p. 246). The uterus is pulled well up and forwards, exposing the cervix

behind in the region of the utero-sacral ligaments. The first step in the operation, then, is to divide the cervix completely; as the uterus is pulled up the uterine vessels are exposed and caught, or the finger is pushed through between the divided portions of the cervix and the broad ligaments, first on one side, then on the other, hooked up in the tinger and clamped,

Removal of uterus by first dividing cervix posteriorly, and then clamping one broad ligament and then the other, or by ligating the vessels as shown in the figure.

and the uterus removed, with or without the ovaries, in one piece. This differs from Doyen's method in not opening the vagina, and in leaving the cervix, being a sub-total operation. Again, we can pull the uterus up and backwards, exposing the cervix anteriorly and dividing it as the first step in the operation, and exposing the uterine arteries in this way.

After clamping the uterines, the uterus is pulled up and further detached, when the ovarian vessels are clamped

P

FIG. 6A.

་་་་

FIG. 6B.

4

Horizontal transverse section of the cervix anteriorly exposing the uterine vessels. This may be followed by bisection from behind up to fundus.

(Figs. 6A and 6B). This is Kelly's sub-total anterior extirpation, differing from Richelot's operation in not opening the

FIG. 7.

Clamping off the broad ligaments close to the uterus to effect the removal of the uterus without hæmorrhage. This is then followed by the removal of the ovaries and of the uterine tubes.

vagina, and in the particular limited class of cases for which it is designed.

Again, I can take two long clamps and thrust one down

each side of the uterus, from cornu down to and including uterine vessels, and then, after removing the uterus, I have more light and room to attack and remove the uterine tubes and the ovaries (Chaput's method) (Fig. 7, p. 247).

Lastly (Faure-Kelly-Kroenig's method), I can catch the uterus by its cornua, and, pulling it up towards the abdominal cavity, bisect it down into the cervix. Then, by dividing the

7

必

3

FIG. 8.

Bisecting the uterus, following the order 1, 2, 3, 4,; then removing the opposite side in order 5, 6, 7, or vice versa.

cervix on one side, I expose and control the uterine vessels, then pulling up that half of the uterus so that the cervix lies uppermost, the ovarian vessels of that side are exposed and caught. With a similar treatment of the opposite side, the pelvis is emptied of uterus, ovaries, and uterine tubes (Fig. 8).

I will not speak at length here of such an anomalous procedure as the incision of the anterior face of the uterus, into