TWENTY CONSECUTIVE CASES OF ABDOMINAL 
SECTION, WITH ONE DEATH. 
BY 
J. M. BALDY, M.D., 
OF PHILADELPHIA 
FROM 
THE MEDICAL NEWS, 
June i, 1889. [Reprinted from The Medical News, June i, 1889.] 
TWENTY CONSECUTIVE CASES OF ABDOMINAL 
SECTION, WITH ONE DEATH} 
By J. M. BALDY, M.D., 
OF PHILADELPHIA. 
This paper embraces the report of twenty abdom- 
inal sections taken from the surgical experience of 
the writer, and are reported simply as a basis for 
some general remarks on this class of surgery. The 
cases are taken consecutively, and include the only 
death I have as yet met with. No case has been re- 
fused for operation where there seemed a possible 
chance for life, and several of them were in such a 
condition that this chance seemed very small indeed. 
The general mortality is fully as low as that obtained 
by Lawson Tait, as reported in his last one thousand 
cases. Of the operations themselves I have little to 
say. They have been neither harder nor easier than 
those of a similar character done by other operators. 
The fact becomes daily more and more apparent to 
me, that all abdominal operations, with complica- 
tions, are difficult; in fact, each new one seems 
more difficult and delicate than the last. It is im- 
1 Read before the Philadelphia County Medical Society, May 
22, 1889. 2 
BALDY 
possible to lay down any definite rule of procedure 
in any class of cases, for the reason that no two are 
alike; it is simply surprising to find how differently 
even two apparently similar cases will result. At 
times one has need of all his courage and skill, to 
meet the requirements and complications of the case. 
Seventeen of the list were complicated by adhe- 
sions, more or less dense, and the difficulty, nay, 
almost impossibility at times of breaking these adhe- 
sions, have convinced me of the folly of even 
attempting to cure such cases by either electricity or 
massage. In some cases, the electricity would have 
destroyed the surrounding tissues much sooner than it 
would have even made an impression on the adhe- 
sions themselves, so extensive, dense, and organized 
were they. It is simple unadulterated nonsense to 
tell me that I could have done with safety, through 
the thickness of the tissues of the abdominal wall 
and vagina, that which I was barely able to do with 
my fingers directly on the disease, and the patient 
fully anaesthetized ; and massage, if carried to the 
extent advocated by some of its votaries, loses even 
the merit of being harmless, but becomes extremely 
dangerous. If the patients of the gentlemen who 
use this remedy (or say they do) will submit to the 
pain necessarily incident to this treatment, they 
must be dealing with a much less serious type of 
cases than it has been my fortune to handle. 
In eleven of these cases I have used the drainage 
tube; nor in any case have I ever regretted its use. 
On several other occasions I should have used it, but 
that the after-treatment was conducted by another ABDOMINAL SECTION. 
3 
than myself, the patient residing in the country. In 
one case the tube was accidentally displaced by the 
patient, before she was completely from under the 
influence of the anaesthetic. In this case the adhe- 
sions and hemorrhage had been particularly severe, 
and I was considerably worried over its loss for 
several days; the convalescence progressed, how- 
ever, without any incident worthy of note. I have 
since then several times done without a tube and 
depended on purgatives for drainage, with a greater 
ease of mind, especially in the out-of-town cases. 
Irrigation with boiled distilled water, and when 
that has become exhausted, simple boiled water, has 
been a constant resource and of the utmost benefit. 
There is absolutely nothing which will take its place 
for cleaning the abdominal cavity of clots and 
debris, as well as for its stimulating effect upon the 
patient. Of late, however, two surgeons have ex- 
pressed the opinion that the flushing is decidedly 
dangerous, and base that opinion, each upon one 
case. Both the patients died after the operation in 
which warm-water irrigation had been used. The 
rest of the profession seem to be unanimous in the 
opinion that irrigation is safe and beneficial. 
In the fatal case of M. Polaillon, a French sur- 
geon : 
“ The patient took chloroform badly, the excited stage 
was long and she readily came to, though plenty of 
chloroform, out of a new bottle, was administered on a 
piece of lint. He employed distilled water, previously 
boiled, and containing one part of carbolic acid to a 
hundred. 
“ During the flushing, respiration became rapid, then 4 
BALDY, 
grew feeble and ceased; the face became blue. The 
heart continued to beat regularly. The alarming symp- 
toms began at a quarter past ten o’clock. Artificial 
respiration was continued till eleven. Then a few feeble 
respirations began, and continued for a quarter of an 
hour; the pupils were then half contracted. The heart 
beat regularly and quickly. The patient continued un- 
conscious. In spite of stimulants, spontaneous respira- 
tion could not be permanently maintained. Phlebotomy 
resulted in the escape of a few drops of very dark blood 
from the left arm. Gradually the heart’s action became 
more and more feeble, the face grew pale, flatus escaped 
from the anus, and the pupils dilated. She was thirty- 
five minutes under chloroform, and about an ounce and 
a half of the anaesthetic had been used.” 
Of course, the case died of the chloroform ; the 
history is too complete to admit of any other inter- 
pretation, nor do I think for a moment that any one 
but the operator could think otherwise. 
The second case was a patient of Dr. Weir, of 
New York. Of this case, Dr. Jacobus says : 
■ “ How the death of this patient can be, even indirectly, 
attributed to hot douching, I cannot understand, for it 
was a case of recurring appendicitis, with several per- 
forations, general peritonitis and partial collapse, operated 
upon on the fifth day, after having been treated by other 
physicians, then removed to a hospital and examined 
under ether, the day previous to the operation.” 
This is the flimsy evidence on which the objection 
to irrigation is founded. If surgeons will overdose 
their patients with chloroform or wait until the 
eleventh hour to operate, they must expect them to 
die. I have repeatedly flushed the abdomen to the 
diaphragm and have yet to see anything but good 
results. My observations and inquiries amongst my ABDOMINAL SECTION. 
5 
friends have disclosed the same experience without 
an exception. 
A number of these cases were confined to bed with 
a peritonitis at the time of the operation. All sorts 
of complications have been met with. In three 
cases the vermiform appendix had to be freed and 
then removed on account of its diseased condition. 
In one, when torn loose, it was found perforated in 
two places; the appendix was simply ligated and 
cut away. In none of these cases did any unpleas- 
ant symptom arise from this procedure. 
The patients have for the most part been operated 
on at their own homes and in several instances were 
nursed by their friends. This has, of course, neces- 
sitated an enormous amount of extra work for my- 
self; but otherwise they would not have been 
operated on, having absolutely refused to go to a 
hospital. The result only helps to emphasize the 
fact that hospitals are more luxuries than necessities 
for these operations, notwithstanding the opinion 
of some operators to the contrary. 
In two of these cases there have resulted ventral 
hernias. In three fistula tracks have followed. A 
ligature has recently come away from one of these 
fistulas and it will now probably close. The other 
two fistula tracks both followed supra-vaginal hys- 
terectomies. 
The after-treatment has been practically, in many 
cases, nothing. Unless special indications arise 
they recover without having had a single dose of 
medicine, excepting sulphate of magnesium, which 
is generally given on the third day. Until the third 6 
BALDY, 
day they get nothing to eat. Solid food is given 
by the fourth or fifth day, if they wish it. If thirst 
is great, it is relieved by rectal injections, at inter- 
vals, of about half a pint of warm water ; otherwise 
tablespoonfuls of soda water are depended on. 
Opium I have never used and never expect to. 
The simpler the details of the operation the better. 
In ordinary cases my whole armamentarium con- 
sists of two ligature needles, two or three suture 
needles, a knife, a pair of scissors, a sponge- 
holder, half a dozen haemostatic forceps, a drain- 
age and an irrigating tube. Pure silk is used 
both for ligatures and sutures. The dressing con- 
sists of a few strips of gauze, a pad of absorbent cot- 
ton and a six-tailed bandage. My bag stands near 
by and contains all other necessary instruments, but 
it is exceedingly rare that I have to resort to them. 
The less work done with instruments and the more 
with the fingers the safer it is for the patient. One 
often sees operators with six, eight, or even ten pairs 
of forceps hanging to the sides of the incision. These 
instruments are not at all desirable and where it is 
necessary to use them to control hemorrhage, they 
can safely be removed by the time the peritoneum 
is opened. It is exceptional that I have a single 
pair hanging to the vessels when my fingers enter 
the peritoneal cavity. They crush and bruise the 
tissues and only tend to prevent good union. In all 
the details of the preparation for the operation and 
of the operation itself, the most perfect and rigid 
attempts at cleanliness have been observed. All in- ABDOMINAL SECTION. 
7 
struments, sponges, dressings, etc., used about an 
operation are prepared by myself, when possible. 
It is daily becoming more apparent that inexperi- 
enced and untrained men should not be tempted 
lightly to enter into the abdominal operation. An 
alarmingly large number of operations have lately 
come to my notice, by men who have presumably 
never attempted the procedure before, and who have 
been assisted by men equally inexperienced and in- 
capable of dealing with possible complications. A 
considerable number of these cases have, of course, 
ended fatally—cases which should have all recovered 
had a skilled operator undertaken them. I do not 
mean to say that a physician with only a limited 
experience should never attempt an abdominal oper- 
ation, because I am very decidedly of the opin- 
ion that every surgeon in the land should be pre- 
pared in an emergency to open the abdominal cavity 
and attempt to deal with what he finds. Our coun- 
try is so large, and the different settlements and 
towns so wide apart, that it is an impossibility always 
to obtain skilled assistance; even where it could 
be obtained there are times when physicians have 
no moral right to wait long enough for its arrival. 
If a tubal pregnancy has ruptured and the patient is 
bleeding to death, that belly should be opened at 
once, and by the first man with any respectable 
amount of surgical experience who may first see the 
patient. Any physician attending a case of labor, 
perhaps in the country, may meet with a ruptured 
uterus, and will give his patient a much better chance 
for life if he open the abdomen immediately. And 
so it is with many cases of intestinal obstruction, 8 
BALDY, 
gunshot and stab wounds. A delay of even a few 
hours in these cases is responsible for their terrible 
mortality, and it would be better for any one with 
good general surgical judgment and skill to open the 
abdomen, than to leave it unopened or even to 
delay. It is full time that members of the profession 
had learned the importance of this and realized their 
own individual responsibility in allowing such pa- 
tients to die, without an effort to save them. 
But excepting as an emergency and life-saving 
procedure, I am just as decidedly of the opinion 
that men without special experience should never 
open the abdominal cavity, both for their patient’s 
sake and for that of their own reputation. If a sim- 
ple ovarian cyst is found the operation is easy enough 
and any tyro could finish it successfully; but just as 
surely as serious complications are met with both the 
patient and doctor are in trouble. 
I may mention some of the more recent cases of 
which I am cognizant, which will serve to illustrate 
some of the points. 
Case I.—A young married woman with a good-sized 
cystic tumor of the abdomen; in good general health; 
within one hour's ride of Philadelphia. Operation 
undertaken by several young men, but without even a 
good knowledge of general surgery. A long time was 
wasted in obtaining entrance into the peritoneal cavity. 
The cyst was found adherent and adhesions bled on 
being freed. Operation lasted over two hours, and finally 
ended by leaving it only half finished, with part of the 
cyst in situ. Death on the following day. 
Case II.—Young healthy married woman with cystic 
disease of abdomen. Operator’s first case. Cyst adhe- 
rent. Bleeding profuse, and large haemostatics plunged 
blindly into pelvis in hopes of controlling it. Operation 
over three hours. Death in a few days. ABDOMINAL SECTION. 
9 
Case III.—Young healthy married woman. Unrup- 
tured tubal pregnancy diagnosed. Patient lived in a 
town which could have been reached in a short time by 
an expert. The ambitious attendant put the woman to 
bed, took several days to prepare for the operation, and 
together with four friends opened the abdomen. Opera- 
tion lasted for five hours ; not finished; patient bled to 
death on the table. 
This is the only case of tubal pregnancy I have 
ever known to be killed by an operation. I could 
relate many more equally as distressing, but these 
cases tell all that is necessary and will justify the 
remarks I have already made. 
There are two complications in abdominal surgery 
constantly met with, and in dealing with which men 
show their skill and judgment or display their total 
unfitness for such work: these are adhesions and 
hemorrhage. They are, moreover, constant com- 
panions ; where there are adhesions to be dealt with, 
there is also nearly always, of necessity, bleeding. 
Adhesions are not things to be blindly torn loose. In 
dealing with them, the utmost care and judgment 
must be constantly exercised, and the almost instinc- 
tive knowledge of when to break and when to ligate 
them, must be ever present. Nor are adhesions 
things to be afraid of. It matters not how dense 
they are, it is exceptional that they cannot be suc- 
cessfully disposed of. The man who loses his head 
and becomes frightened because of tight adhesions, 
had better never attempt this class of surgery, as 
they are almost sure to be met with in greater or 
less degree. 
A careful survey of the whole field should first be 
taken by the surgeon, for the most part with his 10 
BA LDY, 
fingers, and a decision carefully arrived at as to 
whether or not it will be possible and safe to remove 
the disease. The decision once made in the affirma- 
tive and the enucleation once begun, it should 
never, but under very exceptional circumstances, 
be stopped. The worse results obtained in abdom- 
inal surgery are in these unfinished operations. The 
great danger of this half work was sounded some 
years ago by Lawson Tait, and is to-day accepted 
as sound teaching by all who have a right to an 
opinion on the subject. There is constant danger 
attending the breaking up of adhesions. One may 
at any time open an intestine and have the ques- 
tion of a resection to decide ; a ureter may be torn 
out at any moment and a nephrectomy must of 
necessity follow. I have known of the whole cir- 
cumference of the sigmoid flexure of the bowel 
being torn away and a closure of the two ends of 
the gut necessitated ; often the coats of the intestine 
are torn away down to the mucous lining, and a 
perforation may occur some days subsequently. The 
bladder has been opened a great number of times. 
With these dangers ahead, it can readily be seen 
why untrained men should keep their hands off, 
unless absolutely necessary. 
In addition to all this, bleeding is constant, as I 
have said, and may be of two kinds, either venous 
or arterial. Fortunately, the vast majority Of it is 
simply venous or a general oozing. Where an artery 
of any size is torn, is must be at once secured and 
ligated, but otherwise the bleeding had better be left 
alone or controlled by skilful handling of sponges; 
it will not be often that this cannot be done.* But ABDOMINAL SECTION. 
whether controlled in this manner or not, there is 
no time to be wasted over it. The very best chance 
of stopping it is to finish the enucleation quickly 
and apply the ligature to the pedicle, then there is 
time and room enough to deal with what may be 
left, which does not often amount to much. It 
has lately been proposed and found necessary to 
throw a ligature around the uterine artery on each 
side, by passing a threaded needle deep through the 
sides of the uterus and thus include the artery. I 
have never seen a case where I even had to think 
of this procedure, and I have seen some very free 
bleeding ; surely it would take very rough and care- 
less handling often to necessitate a resort to it. 
However, an uncontrollable case may at times occur, 
and it is a point well worth bearing in mind. Often 
the mere bringing together of torn peritoneal edges 
over a denuded and bleeding surface is sufficient to 
control an otherwise troublesome point. Much of 
it may safely be left to the drainage tube. I never 
like to use s'yptics when it can be avoided. It is the 
premature attempt to control bleeding which is often 
so disastrous. Men find a pretty free flow of blood, 
and, not being accustomed to it, become frightened 
and stop everything in the endeavor to control it. 
This they find oftentimes impossible ; the indication 
then is to finish quickly and stop the bleeding at its 
root. The pedicle ligature will stop it all, or what is 
still left is not alarming. Had such been the course 
pursued in the tubal pregnancy case mentioned, the 
operation would most probably have been finished 
and the patient survived. The one redeeming 
feature of that case is, that the same men and their 12 
ABDOMINAL SECTION. 
friends will never be tempted into another such 
operation; but, unfortunately, the woman’s friends 
and acquaintances will also never be tempted into 
one. And so indirectly that one case will probably 
be responsible for the death of half a dozen or more 
others, who might be saved did they not refuse 
assistance. 
Abdominal surgery, of necessity, has enough 
legitimate deaths to answer for, without being loaded 
down by such unnecessary and frightful examples. 
Note.—Since the above was written I have had a 
patient die of apoplexy,- on the seventeenth day 
after operation. The case was one of intra-liga- 
mentous papillomatous cyst. Second operation. 
Had done well from the first. Small quantity of 
pus from tube. Tube had been perfectly dry and 
clean for some days, pulse and temperature normal. 
Said she never felt better in her life. Had slept 
soundly all night, ate a good breakfast and was talk- 
ing and joking with nurse when she suddenly had 
a convulsion ; became unconscious and died within 
twenty minutes. Post-mortem revealed a calcareous 
condition of the mitral valves of the heart. At the 
bifurcation of two vessels in the fourth ventricle, a 
piece of the calcareous plate was found lodged, one 
of the vessels was ruptured and the ventricle half 
full of blood-clot. Everything else in the body 
was healthy. A full report of the case will be 
shortly published. Of course, I do not consider 
this a death from operation, but have thought it 
proper to speak of it in connection with this paper. 
328 South Seventeenth Street. No. 
Pathological condition or symptoms. 
Drainage. 
Adhesions. 
Result. 
Effect of ope- 
ration. 
Remarks 
I 
Pelvic inflammatory disease; ovarian 
cyst. 
No. 
Dense and 
universal. 
Recovery. 
Great relief 
from symp- 
toms. 
Adhesions so great that it was impossible 
to reach pelvis; nothing removed. 
Ventral hernia. 
2 
Constant local pain ; convulsions dur- 
ing menstruation; impossible coition 
frpm pain ; chronic salpingitis ; small 
cirrhotic ovaries. 
No. 
Yes. 
Recovery. 
Only gradual 
relief; not yet 
complete ; 
convulsions 
seldom; 
coition pos- 
sible and 
easy. 
From being a chronic almost bedridden 
invalid, is now able to attend to her 
household and marital duties. 
3 
Left puerperal pyosalpinx. 
Yes. 
Dense and 
universal 
Recovery. 
Cure. 
First case of the kind ever operated on 
in which life was saved. 
4 
Pyosalpinx. 
Yes. 
Universal 
and dense 
Recovery. 
Cure. 
Three weeks in bed with peritonitis ; 
disease seven years’ standing 
5 
Cirrhotic ovaries, prolapsed and ad- 
herent. 
No. 
Yes. 
Recovery. 
Cure. 
Relief gradual but complete; convulsive 
attacks, which were cured. 
6 
Ovarian cyst; retro-peritoneal cyst; 
enlarged cirrhotic ovary. 
No. 
Yes. 
Recovery. 
Pelvic ab- 
scess. 
Fourth day walked to kitchen and ate 
her dinner, sitting at table ; out of bed 
frequently. 
7 
Pelvic abscess. 
Yes 
Yes. 
Recovery. 
Cure. 
Ventral hernia. 
8 
Fibroid uterus; enormous distention 
from ascites; hysterectomy, extra- 
peritoneal. 
Yes 
No. 
Recovery. 
Cure 
Fistula track ; ventral hernia; had been 
tapped eight times. 
9 
Ovarian cyst; ventral hernia. 
No. 
No. 
Recovery. 
Purulent 
peritonitis. 
IO 
Purulent peritonitis. 
Yes. 
Yes. 
Death. 
Same as Case 9. Lived six days. An 
earlier operation would have saved her. 
II 
Double pyosalpinx. 
Yes. 
Dense and 
universal. 
Recovery. 
Cure. 
Almost died of hemorrhage on the table. 
12 
Right pyosalpinx and ovarian abscess ; 
left hsematocele. 
Yes 
Universal. 
Recovery. 
Cure 
Peritonitis at time of operation. 
13 
Prolapsed and adherent ovaries, four 
times natural size. 
No. 
Yes. 
Recovery. 
Cure. 
For a few months complete cure ; lately 
some pain, probably from adhesions. 
14 
Fibro-cystic uterus; supra vaginal hys- 
terectomy. 
Yes. 
No. 
Recovery. 
Cure. 
Fistula track; had been diagnosed and 
treated for hernia. 
is 
Extra-uterine pregnancy 
Yes. 
Universal. 
Recovery. 
Abscess. 
Of a month’s rupture and commencing 
gangrene. 
l6 
Multiple abscesses. 
Yes. 
Yes. 
Recovery. 
Cure. 
Fistula track; ligature recently came 
away, and track will probably close 
17 
Left ovarian cyst; right pyosalpinx 
and ovarian abscess. 
Yes. 
Universal 
but light. 
Recovery. 
Cure. 
Had severe attack of peritonitis during 
convalescence. 
18 
Right ovarian cyst; left cirrhotic ovary 
No. 
Yes. 
Recovery. 
Cure. 
Peritonitis at time of operation. 
19 
Ovaries greatly enlarged, prolapsed, 
adherent, and painful. 
No. 
Yes. 
Recovery. 
Cure. 
Inversion of uterus had been reduced, 
but constantly tended to re-invert; 
operation to correct this tendency. 
20 
Pyosalpinx and chronic salpingitis. 
No. 
Yes. 
Recovery. 
Cure. 
Right tube adherent to uterus from over 
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