Operative gynecology (Volume 2) online

OPERATIVE GYNECOLOGY



VOLUME II



OPERATIVE GYNECOLOGY



BY



HOWARD A. KELLY, A. B., M. D.



FELLOW OF THE AMERICAN GYNECOLOGIC;* L SOCIETY;

PROFESSOR OF GYNECOLOGY AND OBSTETRICS IN THE JOHNS HOPKINS UNIVERSITY,

AND GYNECOLOGIST AND OBSTETRICIAN TO THE JOHNS HOPKINS HOSPITAL, BALTIMORE ;

FORMERLY ASSOCIATE PROFESSOR OF OBSTETRICS IN THE UNIVERSITY OF PENNSYLVANIA

CORRESPONDING MEMBER OF THE SOClfiTi OBST^TRICALE ET GYN^COLOGIQUE DE PARIS,

AND OF THE GESELLSCHAFT FUR GEBUKTSHOlFE ZU LEIPZIG



WITH TWENTY-FOUR PLATES AND
FIVE HUNDRED AND NINETY ORIGINAL ILLUSTRATIONS



VOL. II



NEW
D. APPLETON



YORK

AND COMPANY



Copyright, 1898,
By D. APPLETON AND COMPANY.



COl^TET^TS



•COAPTER PAGE

XX. General prixciples and complications common to abdominal operations . 1

XXI. Care of wound and patient up to recovery 44

XXII. Complications arising after abdominal operations .56

XXIII. Tubercular peritonitis 134

XXIV. Suspension of the uterus 149

XXV. Conservative operations on the tubes and ovaries IQ'S

XXVI. Simple salpingo-ouphorectomv and salpingo-oophorectomy for adherent

TUBES AND OVARIES ............ 193

XXVII. Vaginal drainage and enucleation for pyosalpinx, ovarian abscess, tubo-

OVARIAN abscess, AND PELVIC ABSCESS 209

XXVIII. Hysterectomy, with extirpation of ovaries and tubes — abdominal hystero-

SALPINGO or)PHORECTOMY 236

XXIX. Ovariotomy 246

XXX. Abdominal hysterectomy for carcinoma and sarcoma of the uterus . . 305

XXXI. Myomectomy — hystero-myomectomy 338

XXXII. Operations during pregnancy 403

XXXIII. Cesarean section ' 415

XXXIV. Extra-uterine pregnancy 428

XXXV. The radical cure of hernia 467

XXXVI. Intestinal complications 493

XXXVII. The more remote results of abdominal operations 518

XXXVIII. On the conduct of autopsies, the making of protocols, and the preserva-
tion of tissues for microscopic examination in gynecological practice . 351

V



LIST OF ILLUSTRATIONS.



FIG. PAGE

316. Stricture of rectum due to pelvic inflammatory disease 20

317. V^ermiform appendix adherent to a large papillary ovarian cyst 21

318. Extensive pelvic inflammatory disease with general adhesions 22

319. The clear space 24

320. Encysted silk ligature in the right broad ligament 25

321. Closure of the abdominal wound 42

322. 323, 324, 325. Showing the average charts, or couiposite temperatures and pulse rates

in ten cases in each group 54

326. Introducing normal salt solution under the breasts in case of extreme anemia . . 70

327. Chart showing convalescence complicated by a high pulse rate 72

328. Normal convalescence interrupted by periodical. rises of temperature due to the presence

of the Plasmodium malariie 75

329. Chart of a case of septic peritonitis following myomectomy 86

330. Chart of a case of general sepsis following a perineal operation 102

331. Chart of a case of septicemia from a purulent peritonitis 103

332. Chart showing an abdominal operation complicated by pneumonia 108

333. Stitch-hole abscess chart 115

334. Tubercular left tube with adherent omentum 135

335. Tubercular right tube, with tubercles over a parovarian cyst 135

336. General tubercular peritonitis 136

337. Tuberculosis of tubes and ovaries 144

338. Tuberculosis of the tube 144

339. Diagram showing the relative advantages of closing or of di-aining tlie abdomen in

tubercular peritonitis 146

340. Composite chart, showing course of fever after operation in tubercular peritonitis, with-

out drainage 146

341. Chart showing recovery after removal of tubes and ovaries in tubercular peritonitis . 147

342. Suspension of the uterus, seen from above 150

343. Steps in the reduction of the uterus in the palliative treatment of retroflexion ; anterior

lip of cervix grasped with tenaculum forceps 151

344. Same, traction straightening out the angle of flexion 151

345. Same, the finger in rectum induces slight anteflexion 152

346. Same, forceps carrying the cervix back into the pelvis 153

347. Same, the retroflexion reduced 153

348. Production of an extreme anteposition 154

349. Suspension of the uterus within a year after the operation 155

350. Suspension of the uterus, seen a year after the original operation 156

351. Upper elevator 159

352. Lower elevator 159

353. Suspension of the uterus, showing elevation of the uterus with the lower elevator . . 160

354. Suspension of the uterus 160

355. Suspension of the uterus, as seen from above .......•• 161

356. Suspension of the uterus; outline of operation completed 161



Vlll LIST OF ILLUSTRATIONS.

FIG. PAOB

357. Conservative operation on the ovary 174

358. Parovarian oyst removed from left broad ligament ' . . . 175

359. Parovarian cyst extirpated without removing either tube or ovary 176

360. Hypertrophy of the ovary, with cystic degeneration â– , . . 178

361. Hemorrhagic corpus luteum cyst and cystic Graafian follicle in same ovary . . . 179
363. Cyst of the corpus luteum 180

363. Pedunculate corpus luteum cyst of the left ovary 181

364. Cysts of corpora lutea in both ovaries 181

365. Velamentous adhesion of the right uterine tube to itself and to the uterine cornu . . 183

366. Angular attachment of the left uterine tube to the cornu of the uterus .... 184

367. Adhesions of the outer free extremities of both uterine tubes to the ovaries . . . 185

368. Conservative operation to preserve the right ovary and left tube 188

369. Diagram of same after removal of the right tube and left ovary 189

370. Double hydrosalpinx 200

371. Large left hydrosalpinx, with numerous adhesions â– . . . 201

372. Double hydrosalpinx, with adhesions 201

373. Hydrosalpinx 202

374. Hydrosalpinx, with few convolutions 202

375. Same, in longitudinal section 202

376. Hydrosalpinx containing a nodular S-shaped calculus 203

377. Hydrosalpinx, with congenital deficiency in the tube 203

378. Right tubo-ovarian cyst 204

379. Same, laid open 205

380. Tubo-ovarian cyst, from right side 205

381. Same, divided 205

382. Outline of the torsion of the pyosalpinx shown in the colored plate 209

383. Large abscess of the right ovary 214

384. Abscess of the ovary, laid open 215

385. Nodular salpingitis 215

386. Opening a retro-uterine pelvic abscess by puncture 224

387. Stout curved, saw-toothed traction forceps 225

388. Conservative treatment of abscess of both Fallopian tubes 228

389. Same, showing gauze drain behind uterus and extending down into vagiiui . . . 229

390. Ovarian abscess 234

391. Double pyosalpinx, with carcinoma of the cervix 235

392. Extirpation of myomatous uterus, ovaries, and tubes, with a left ovarian cystoma . . 237

393. Hystero-salpingo-oophorectomy for large double hydrosalpinx 240

394. Outline showing extirpation of the uterus, tubes, and ovaries by a continuous incision . 241
.395. Extirpation of uterus, tubes, and ovaries for pelvic peritonitis 243

396. Diagram showing the relations of an ovarian cyst to the peritoneum of the pelvic floor

and broad ligament 248

397. Long pedicle of a papillary ovarian adeno-cystoma 249

i398. -^^iagram showing the relations of an intraligamentary cyst to the anterior and posterior

layers of the peritoneum of the broad ligament 250

399. Adherent cyst of the ovary showing the mimicry of the intraligamentary cyst . . 250

400. Parasitic ovarian cyst of left side, with general peritoneal carcinosis .... 250

401. Left ovarian cyst with a twisted pedicle 251

402. Same, pedicle untwisted to show its anatomical elements 251

403. The relations of the parasitic multilocular ovarian cyst shown in inset Fig. 400 . . 251

404. Ovarian cyst showing natural perforation, with discharge 252

405. Large multilocular ovarian cyst in a negress 253

406. Typical polycystic ovarian tumor, with long twisted pedicle 259

407. Multilocular ovarian cyst, in which smaller cysts project into the cavity of the large one . 200

408. Polycystic ovarian tumor and parovarian cyst existing on the same side .... 261

409. Multiple adeno-cystomata of the ovary 262



LIST OF ILLUSTRATIONS. IX

FIG. PAGE

410. Wall of a miiltilocular ovarian cyst magnified 170 times ....... 263

411. Papillomata of both ovaries, seen m situ from behind 265

412. Inner surface of a papillo-adeno-cystoma of the left ovary 268

413. Cysto-papilloraa of the ovary 270

414. Solid or fibroid papillary adenoma of the ovary 272

415. Adeno-carcinoma (colloid carcinoma) of the ovary 274

416. Cysto-carcinoma of the ovary of unusual form 275

417. Flat carcinomatous metastatic nodules on the intestines 276

418. Large adeno-carcinoma (colloid carcinoma) of the omentum 276

419. Adeno-carcinoma of the omentum, seen in section 276

420. Rudimentary jaw from a dermoid cyst containing molar teeth, and with a wisp of hair

growing from its extremity 277

421. Contour of the abdomen in the case of an unusually large dermoid cyst .... 277

422. Left dermoid cyst of the ovary with a long pedicle 278

423. Complicated dermoid cyst of the right ovary 279

424. Right dermoid cyst with extensive adhesions 280

425. Parovarian cyst situated between the ampulla of the tube and the outer end of the ovary . 281

426. Parovarian cyst, showing its translucency and the uterine tube spread out on its surface . 281

427. Parovarian cyst, with subsidiary cysts lying beneath the tubo-ovarian fimbria . . 281

428. Parovarian cyst bulging out on both sides of the tube 282

429. Cyst of the parovarium 283

430. Parovarian cyst 284

431. Parovarian cyst with twisted pedicle . . - 285

432. Subperitoneal cyst developed entirely from the peritoneum 286

433. The pedicle of the hydatid tied about the free tubal fimbria at its base .... 287

434. Same, enlarged, showing appearance of the degenerated fimbria . . . . , 287

435. Fibroid tumor of the ovary 288

436. Calculus of the ovary 288

437. Partially calcified fibroma of the right ovary 289

438. Angio-sarcoma of the left ovary, with metastasis in the uterus 290

439. Monocystic tumor of the left broad ligament 296

440. Suppurating adhei-ent ovarian cyst 297

441. Suppurating adherent ovarian cyst 298

442. Same, cross-section of the intestinal and mesenteric attachment 298

443. Diagram from a case of intraligamentary cyst, seen from above 299

444. Same, showing closure of wound after enucleation of cyst 299

445. Intraligamentary Graafian follicle cysts, in situ 300

446. Same, removed 301

447. Multiple dermoid cysts of both ovaries .......... 302

448. Left dermoid cyst and right multilocular ovarian cyst with twisted pedicle . . . 302

449. Fibroma of the left ovary with large myomata of the uterus 303

450. Adeno-carcinoma of the cervix, with hydroureter of both sides 305

451. Carcinoma of the cervix 307

452. Extensive epithelioma of the cervix 308

453. Inoperable epithelioma of the cervix ........... 309

454. Adeno-carcinomatous nodule entirely concealed within the cervix 310

455. Adeno-carcinoma of the body of the uterus, growth stopped at internal os . . . 311

456. Adeno-carcinoma of the body of the uterus 312

457. Same, cut through the anterior wall 313

458. Adeno-carcinoma of the uterine body, with metastatic nodules in the lymph cliannels of

the left broad ligament 313

459. Limited area of carcinoma of the fundus of the uterus on the left side .... 314

460. Operation for carcinoma of the uterus 316

461. Carcinoma uteri 317

4()3. Double hydroureter due to advanced cancer of the cervix uteri 318



X LIST OF ILLUSTRATIONS.

FIG. PAGE

463. Autopsy on a case of caroinoina of the cervix ; liydroureter, with (louble ureter on the

• left ai9

464. The upper half of a liydroureter, with liydrouephrosis from compression due to a can-

cerous cervix 320

465. Eelations of the ureter and bladder to the uterus and vagina 323

466. Diagram showing stojipage of bougie in the ureter in the operation for carcinoma of the

cervix 324

467. Outline diagram of the steps of the radical operation for cancer of the cervix . . 325

468. Hysterectomy for carcinoma of the cervix ; left broad ligament opened up . . . 326

469. Same, the left uterine artery tied and cut off 327

470. Same, bladder freed and vaginal vault opened anteriorly 329

471. Same, in sagittal section, showing the left side of the pelvis, with the operation completed. 330

472. Epithelioma of the cervix in grapelike mass 331

473. Uterus enucleated per vaginam, in contrast with this method 333

474. Small sarcoma in the right horn of the uterus 333

475. Sarcoma of the body of the uterus 333

476. Sarcomatous nodule in the vagina 334

477. Sarcoma of the uterus and right ovary 335

478. Same, uterus cut open in front 336

479. Greatly enlarged right ovary removed with a myomatous uterus 340

480. Uterus with extensive myomatous involvement 343

481. Myomatous uterus, showing interstitial and su])peritoneal masses 343

483. Diagram of Case J. S. S., San. 107 344

483. Globular myomatous uterus presenting form of pregnant uterus at term .... 345

484. Myomatous uterus, exhibiting a perfect cast of the pelvis 846

485. Large subperitoneal myoma, seen from behind 347

486. Pedunculated myoraata, giving a perfect ballottement 350

487. Large globular myoma choking the pelvis 352

488. Same, lifted up into the abdomen 358

489. Uterus after extirpation of a myomatous tumor, showing great muscular hyjiertrophy . 356

490. Myomatous uterus, conservative operation 358

491. Conservative treatment of the myomatous uterus 358

493. Same, after removal of the tumors 359

493. CuUen's myoma enucleator 359

494. Myomatous uterus from which eight myoma were enucleated by seven incisions . . 361

495. Same, showing incisions closed by interrujited catgut sutures 361

496. Ijarge submucous myoma 363

497. Schematic diagram, showing incision from left to right in extirpating the myomatous

uterus 30!)

498. The operation of hystero-myomectomy 371

499. The last step in the enucleation of the myomatous uterus 373

500. Complicated hystero-myomectomy (hydrosalpinx and ovarian cyst) 375

501. Complicated hystero-myomectomy (intestinal and omental adhesions) .... 376
503. Globular myomatous uterus complicated by dermoid cysts of the left ovary . . . 379

503. Myoma and carcinoma in a negress 3S0

504. Myoma with cystic degeneration 3S1

505. Large fibro-cystic tumor of the uterus attaclied to a muUinodular mydinatous ulcrus . 3