he then cuts the uterus free on the left side. Having done this, he introduces a pair of forceps close to the uterus upon the right side where the adnexa have not been freed, and removes the uterus and adnexa of the left side, leaving in the tissues which embarrassed him. It will now be found that he will have room for removing the remaining adnexa under the guidance of the eye. To do this the operator will secure the ovarian artery outside the ovary and tube. This will render the forceps which was applied between the uterus and right adnexa unnecessary, so it may be removed. This is in reality but a form of morcellation or removal in fragments. While the removal of the uterus en masse is more generally accepted than any other method, I am pursuaded that it is responsible for many of those ill results which lend arguments to the opponents of the vaginal method. In certain cases it is utterly impossible to remove the uterus and adnexa entire. Such cases are those where the uterus is much enlarged, where the pus foci are enormous or attached high at the pelvic brim, and cases of advanced genital sclerosis. It may be found impossible to free the adnexa before applying forceps, and equally so after forceps have fixed the tissues. Appreciating the difficulty of ablation en masse, I have for several years practised exclusively ablation by hemisection. This I sometimes supplement by morcellation, but the morcellation is employed merely as a step preliminary to the hemisection. ABLATION BY HEMISECTION. "I divide my difficulties by splitting the uterus." This is the operation which I always employ. It is the operation of election in all cases, whether associated with fibroid degeneration or not. In such cases it is sometimes associated with, but never supplanted by morcellation. By means of this procedure, the time consumed in operating is rarely twenty minutes, and the operation is always complete. Remembering his anatomy, the operator recalls that both upon its anterior and posterior surfaces, the uterus is comparatively sparsely supplied with vessels, along the middle line. Therefore, an absolutely median section produces but little hemorrhage. The time of operating is short, for, by means of the hemisection, each set of adnexa and its corresponding half of the uterus are rendered movable. Further, as one-half of the severed uterus is shoved up into the pelvis, out of the way, the hand is enabled to work high in the pelvis to the side of that half of the uterus which is drawn down, and the fingers have all the space to one side in which to work, from the bladder to the perineum. One other advantage is that, as each half of the uterus is liberated and drawn down, it is swung outside the vaginal outlet, giving an unobstructed orifice in which to work. Operation.-First Stage.-The patient is on the back and in the lithotomy position. A short Jackson speculum draws down the perineum. The uterus is curetted and swabbed out, but not packed. The intra-uterine traction-forceps is introduced, and the posterior cul-desac is opened (Fig. 72). All adhesions posterior to the uterus along the middle line are severed by the examining finger up to the fundus. No attempt is made to further separate the adherent organs at this stage. It can not be now properly done and is a waste of time. The posterior incision is carried around the cervix, almost to the middle line. Drawing down the uterus and holding up the bladder, the anterior cervico-vaginal juncture is severed by means of the scissors. This cut is not to be made close to the external os, but is above the dense cervical structure, and in the loose pericervical tissue. The fold at which the incision is made is easily seen when the uterus is shoved up. This incision is carried laterally toward the posterior cut, but stops one-eighth inch from it on each side. As this incision is made, a few fine arterioles spurt. They are not important, being but small anastomotic branches between the uterine FIG. 72.--Showing the method of incising the vagina at the point in Fig. 62. The intra-uterine traction forceps is shown pulling the uterus down. The second step in all vaginal ablations (from a photograph of an operation by the author). |