[Reprinted from the American Gynaecological and Obstetrical Journal 
for September, 1895.] 
HYSTERECTOMY FOR SUPPURATIVE DISEASE OF 
THE PELVIC ORGANS* 
J. M. Baldy, M. D., Philadelphia, Pa. 
When on the evening of October 5, 1893, I read before the Ob- 
stetrical Society of Philadelphia a paper entitled Removal of the 
Uterus and its Appendages for Pelvic Inflammatory Disease, and for 
the first time proposed this procedure as a matter of election, my re- 
marks met with a strong protest and almost universal disapproval. At 
almost the same time Polk made a similar proposition in a paper read 
before the New York Obstetrical Society, which was received by an 
equal amount of condemnation. 
During May, 1894, I read a paper on the same subject before the 
American Gynsecological Society at its Washington meeting, and it 
proved to be a matter of considerable surprise that in the short in- 
terim so large a number of the members had already practiced and 
approved the new procedure, as was developed by the discussion. 
Since that time I have had many opportunities of demonstrating the 
feasibility and advisability of this operation to many physicians visit- 
ing Philadelphia from all sections of the United States, and find that 
many of them on returning home have adopted the method. To-day 
the operation is established on a sure and firm basis, and many women 
who were before doomed to a partial recovery are now blessed with a 
complete return to health. My object of again encroaching upon the 
time of the profession with this subject is not that I believe anything 
is needed to establish its feasibility, but rather to again freshen the 
minds of those who may feel that hysterectomy is either a more diffi- 
cult or more dangerous operation in these cases than salpingo-obpho- 
rectomy. For this purpose it may not be out of place to once more 
review certain general considerations arising in this connection which 
were formulated in my paper before the American Gynsecological 
Society one year ago. I there propounded the question, “Is the 
* Read before the Section of Obstetrics and Diseases of Women of the American 
Medical Association, Baltimore, May 8, 1895. 
Copyright, 1895, by J. D. Emmet, M. D. 2 
J. M. Baldy, M. D. 
uterus essential or useful after the ovaries have been removed ? ” At 
that time I assumed and still assume that this query can only be an- 
swered in the negative. If it is granted that the uterus deprived of 
its appendages is a useless organ in the human economy, as far as its 
relation to this matter is concerned, four questions are pertinent : 
i. Are all patients cured after an operation, requiring double sal- 
pingo-obphorectomy ? 
2. Are patients cured after hysterectomy when double salpingo- 
oophorectomy has failed ? 
3. Does the operation of hysterectomy increase the mortality over 
that of double salpingo-oophorectomy ? 
4. Is the retention of the uterus of any disadvantage or danger to 
the patient ? 
As to the first and fourth questions nothing can be added in answer 
other tnan was advanced in the paper to which reference has already 
been made. There is no one who has practiced gynaecological surgery, 
to even a limited extent, but knows that patients suffering from chronic 
pelvic inflammatory disease are not always cured of their symptoms 
by the removal of the tubes and the ovaries alone. The matter is so 
notorious that it is hardly necessary to more than call attention to the 
fact to quiet any criticism from this direction. As to whether or not 
patients are cured after hysterectomy, when double salpingo-oopho- 
rectomy has failed, as stated in my former paper, experience must de- 
cide. I there said :“In my paper read before the Philadelphia Ob- 
stetrical Society, October 5, 1893, two cases are reported in which the 
uterus had been removed subsequent to a simple extirpation of the 
appendages. After the primary operation these patients had con- 
tinued to suffer from leucorrhoeal discharges, bleeding, and pain. 
The secondary operation for removal of the uteri proved that the ap- 
pendages had been thoroughly and completely extirpated at the first 
operation, and that no such cause as incomplete removal existed to 
account for the continued suffering. The removal of the uterus in 
both cases cured the patients, and at the present writing they both re- 
main in good health. Two other similar operations have been per- 
formed since that time with like results.” 
It may be stated that these four patients, now a year and a half 
later, remain in good health without any return of their old symptoms. 
I am at this time able to add two cases to this list with like results, 
making a total of six patients who have been rescued from chronic 
invalidism by a hysterectomy subsequent to a double salpingo-oopho- 
rectomy. During this period from fifteen to twenty patients have Hysterectomy for Suppurative Disease of the Pelvic Organs. 
3 
passed through my hands on whom the salpingo-oophorectomy had 
failed to relieve the symptoms, but whom I was unable to persuade to 
try the hysterectomy on account of their sufferings at their former 
operation and a sentiment against losing the womb, which many women, 
by reason of false professional teaching, appear to consider a vital 
organ. These facts seem to answer my second question most em- 
phatically and in the affirmative. 
The whole subject must, after all, hinge upon the answer to the 
third question, “ Does the operation of hysterectomy increase the 
mortality above that of double salpingo-oophorectomy ? ” If the 
mortality be increased and the relief be not. commensurate, the pro- 
posed procedure must fall and we must return to the old one of 
double salpingo-oophorectomy or seek for a substitute in some other 
direction. That much greater and surer relief of symptoms are ob- 
tained has already been demonstrated. In my paper of last May 
there are reported twenty-two patients who were suffering from chronic 
pelvic inflammatory disease upon whom I had performed hysterec- 
tomy. In that report I said : “Of this number, all recovered from 
the operation and the great majority have been cured. My highest 
mortality in the past has always followed removal of the appendages 
in this same class of patients. At no time have T been able to pick 
out anything like twenty-two successive successful double ovarioto- 
mies in cases of the same character as those upon whom I have found 
it advisable to perform hysterectomy. Not only has hysterectomy in 
my hands lessened the mortality very markedly, but it has rendered 
the convalescence infinitely smoother, easier, and more satisfactory.” 
At the present writing I have twelve more to add to the list, making 
in all thirty-four cases without a death. 
In addition to my own cases I may submit in evidence the work 
in this same direction by other operators to date : 
Cases. 
Deaths. 
Baldy 
Kelly (hospital cases) 
Polk. 
Krug 
65 
Pryor 
4 
Penrose 
1 
223 
6 
Making a grand total of 223 cases with 6 deaths, a mortality in the 
hands of six operators of 2.68 per cent. 4 
J. M. Baldy, M. D. 
What better argument can one possibly offer in favor of any new 
procedure ? A greatly lessened mortality, a surer and more thorough 
relief of symptoms, an easier and shorter convalescence, a freedom 
from any possible future disease of the womb ! Can there be any 
who are yet skeptical ? 
Hysterectomy being determined to be the proper procedure in 
certain chronic pelvic inflammations, it remains to determine in what 
cases to choose this operation. In this connection I can not do better 
than quote verbatim from my last paper on the subject ; 
“It is well known in pelvic inflammation that the disease first 
affects the mucous membrane lining the womb, and secondarily invades 
the Fallopian tubes and pelvic peritonaeum. In many cases not only 
is the endometrium affected, but the inflammatory products invade the 
deeper structures which go to make up the uterine walls. These infil- 
trates undergo the same changes as do the same elements in the walls 
of the Fallopian tubes; whether it be suppuration or partial organiza- 
tion, in either case the process is apt to become a permanent one. 
“With Fallopian tubes and uterus, both of which are diseased by 
the same factor and to the same extent, is it reasonable to suppose 
that a cure is always to be obtained by the removal of the tubes 
alone ? Theory and practice both combine in this matter to force 
the conclusion. 
“ It must not be understood that the removal of the uterus together 
with the Fallopian tubes and ovaries is recommended in all cases of 
pelvic inflammatory disease. I am forced to dissent at this point 
from the views of some other surgeons with whose opinions in other 
respects lam thoroughly in accord. In many cases the uterus, possi- 
bly on account of its anatomical relations which are so favorable to 
good drainage, has succeeded in throwing off the original infection 
and is comparatively healthy, if not entirely so. Under such circum- 
stances hysterectomy is not indicated. But where an abdominal 
section has been performed for the removal of the uterine appendages, 
and the womb is found enlarged and diseased, especially if it has 
been surrounded by extensive adhesions, the destruction of which 
leaves large areas of denuded peritonaeum, hysterectomy should be 
the operation of choice. Even when the uterus is not greatly diseased, 
if during the course of the operation it be largely denuded of its 
peritoneal covering, it is best to complete the operation by its re- 
moval. The sole objection which could be urged against this pro- 
cedure is an increased mortality; but since this has been proved 
fallacious, opposition from any standpoint must necessarily be with- Hysterectomy for Suppurative Disease of the Pelvic Organs. 
5 
drawn. It is freely granted that in accepting this practice, uteri will 
often be removed which might safely have been left behind. Even in 
the face of this possibility the procedure is fully justified, in view of 
the possibility of future-harm on the one hand and the certainty of 
no extra risks on the other. 
“ The decision pro or con is at times a difficult one at the time of 
the operation, in which case the patient should be given the benefit 
of the doubt and the uterus should be removed. In all cases it is, of 
course, assumed that both ovaries must of necessity be sacrificed. 
Except in the presence of malignant or tubercular disease the womb 
should never be disturbed if even a portion of one ovary and a Fallo- 
pian tube can be preserved. Nor is an operation to be extended to 
the performance of hysterectomy where the double salpingo-oophor- 
ectomy will even temporarily answer the purpose, should the patient 
be in such condition that the prolonged manipulation might render 
the result of a given case doubtful. Common sense must be used in 
the application of this principle, as in all surgical procedures.”