Removal of the Uterus and Its Appendages for Pelvic Inflammatory Disease. 1 J., M. BALDY, M.D., Professor of Gyncecology in the Philadelphia Polyclinic ; Surgeon to the Gynecean Hospital. It was supposed when we had all to health and useful lives. So fre- learned the lesson that Mr. Tait quently were these happy results ob- fought so long and valiantly to teach tained and reported to an expectant us, that the question of the treatment profession that sight was lost alto- of pelvic inflammations and their gether, for the time, of certain cases, ravages had been finally settled. The afflicted with these same diseases, on removal of the displaced and adherent whom the same operation had been Fallopian tubes and ovaries, which performed, but who were not blessed contained pus or whose tissues were with the same good results as their hypertrophied and infiltrated with more fortunate sisters. The glamor chronic inflammatory products, soon of success of an entirely new and became a common procedure and the brilliant procedure so greatly over- technique of the operation was so shadowed these poor sufferers that rapidly pushed to perfection that time was necessary before attention many operators arose whose results could be directed towards them. As successfully rivaled those of Tait is often the case the enemies of the himself. Large numbers of women new procedure were the first to point who had formerly been doomed to a out this class, not from any particular hopeless invalidism were now restored desire to aid in the complete solution of the problem, but from a spirit of 1 Read before the Obstetrical Society of Phila- criticism which “ Lo and delphia, October $, 1893. says, behold! 2 J. M. BALDY. thy vaunted remedy has failed.” It are performed for symptoms alone, had failed to a certain extent, it is no disease being found by a physical true, and the taunt sufficed to draw examination and none capable of clear closer attention to the failures and a demonstration even after the organs deeper study as to why they had have been removed. failed. Local applications to the uterus You are all of you cognizant of after a coeliotomy for removal of the patients in your practice on whom an appendages has been tried, with no abdominal section has been performed greater success than the same amount for pelvic inflammatory disease, who of treatment before the surgical pro- consults you for continued bleeding, cedure. Curettement of the womb leucorrhoeal discharges (often pro- has been followed with little more fuse) and pain—women who have encouraging results. I have adopted had the operation performed for these this course in some six or ten cases, symptoms and who complain now, and have not been able in a single three months, six months, a year one to say that I had cured the after the operation, of the same kind woman. The majority of them ceased and the same amount of suffering. coming for treatment long before any You are familiar with such cases, decided result had been obtained. coming both from your own practice During the past winter it was my and that of your neighbor. They misfortune to see a number of these come into the public clinics in consid- women who had been unrelieved or erable numbers complaining of the only partially relieved in spite of the operator and refusing to return to fact that a complete and clean re- him for the reason that they had moval of both appendages had been thought the operation would cure made and that the remaining uteri them, and because it had not their were freely movable. No trouble doctor was to blame, as usual, and as could be detected in the pelvis by a a matter of course. These are the most careful and repeated physical same patients who are held up to us examination. as a proof that our method of treat- After applying local and general ment is wrong and has failed and treatment to several of these women, should, therefore, be condemned in until we were both discouraged and toto. The time has not even yet disgusted, I, in despair, suggested passed when we must submit to just that the womb itself be removed. I such spurious criticism. was led to this decision from the fact But, as a matter of fact, a certain that I had known some months be- too large proportion of our patients fore of a case on whom my colleague, still remain uncured by a simple Dr. Baer, had performed several ab- removal of the uterine appendages; dominal sections in, I think, a neu- and let me emphasize the fact that I rotic case, without obtaining much re- am now discussing a class of patients lief, and upon whom he had finally who have an easily demonstrable performed hysterectomy with an ex- amount of disease of these organs—- tremely satisfactory result. This, in no reference is intended to that too addition to the work being done in numerous class on whom operations France in the way of hysterectomy REMOVAL OF UTERUS AND ITS APPENDAGES. 3 for pelvic abscesses, evidently influ- stration of the truth of this. With a enced my thoughts in this direction. Fallopian tube and uterus, both of The woman to whom I proposed the which are diseased by the same fac* operation had had her original opera- tor and to the same extent, is it tion for suppurating uterine append- rational to suppose that a cure is to ages. Months after her operation be always obtained by the removal of she still had a large uterus, irregular the tube alone? Is it not common bleeding, profuse leucorrhoeal dis- sense to remove the whole of the dis- charges, great backache and pelvic ease, and not only a part ? Theory bearing-down pains. The uterus was and practice both combine in this removed by supra-vaginal amputation matter to force the conclusion. low down into the cervix, and drop- It must not be understood that I ping the stump back into the pelvis. recommend the removal of the uterus Her recovery was an uninterrupted together with the Fallopian tubes and one. The bleeding and leucorrhoeal ovaries in all cases of pelvic inflam- discharges ceased at once, and the matory disease. In many cases the pelvic pains and backache almost en- uterus has succeeded in throwing off tirely disappeared, the little that re- the original infection, and is compara- mained of them being evidently due tively healthy. Under such circum- to the menopause. Encouraged by stances the procedure is not indi- this result, I have continued this line cated. But where an abdominal sec- of treatment up to the present time, tion is performed for the removal of and have now had sufficient experi- the uterine appendages, and the ence to feel warranted in recommend- womb is found enlarged and diseased, ing the procedure to your careful especially if it has been surrounded consideration and trial. In two cases by extensive adhesions, and the free- have I removed the uterus subsequent ing of it leaves large areas o f " °d to a simple removal of the append- peritoneum, hysterectomy should oe ages. Six times have I removed it the operation of choice. But a single at the primary operation. objection can be raised to this propo- It is well known that in pelvic in- sition, viz., the mortality of the opera- flammation the disease first affects tion. Can, then, hysterectomy be the womb, and secondarily invades performed as safely as ovariotomy ? the Fallopian tubes and the pelvic Unhesitatingly I answer in the peritoneum. Not only is the endo- affirmative. My own hysterectomies metrium affected, but the inflamma- now number more than eighty, with tory products invade the deeper seven deaths. These deaths include structures which go to make up the the accidents incident to acquiring uterine walls. If a suppurative pro- the skill and perfecting the tech- cess follows, these infiltrates undergo nique ; in a similar series the results the same changes as do the same ele- will be infinitely better. ments in the walls of the Fallopian Beyond the question of mortality tubes. The ease with which a liga- there can be no doubt as to the ad- ture cuts through uterine tissue, visability of removing the diseased when applied at the cornua in cases uterus. With its appendages gone it of pus tubes, is a well-known demon- is an altogether useless organ, and 4 J. M. BALD Y even the old, familiar cry of mutila- the second one was free. The uterus tion and unsexing the patient has was very large, half as large again as no place. normal. The operation was finished I am free to confess that since by making a clean sweep of both adopting this method of practice the tumors, Fallopian tubes and uterus. field for hysterectomy has greatly The patient is convalescent, and is, I widened. For instance, I assented think, distinctly better without the and assisted in an operation for the womb, which I exhibit to you. removal of the uterus in a woman Looking at this matter as I do, it upon whom seven abdominal sections has been no great matter of surprise had been performed without giving to me to find other operators adopt- her relief. The uterus was enlarged, ing this procedure. Last spring, and was found to contain several while visiting in New York, I found small fibroid nodules, as large as a that Krug had arrived at much the hickory nut, which had undergone same conclusion, and was following calcareous degeneration.