Hysterectomy 
INDICATIONS AND TECHNIQUE 
BY 
J. M. BALDY, M.D. 
Professor of Gynecology in the Phila- 
delphia Polyclinic; Surgeon to 
the Gynecean Hospital 
REPRINTED FROM 
The American Journal of Obstetrics 
Vol. XXVIIL, No. 5,1803 
NEWYORK 
WILLIAM WOOD & COMPANY, PUBLISHERS 
1893 hysterectomy; 
INDICATIONS AND TECHNIQUE. 
It is not proposed to discuss in this paper the etiology of the 
various conditions for which this operation is performed, nor 
shall the symptomatology and diagnosis occupy more space than 
is incidentally necessary to the consideration of the indications 
for the procedure ; these points are too thoroughly settled to ad- 
mit of further debate. The points which are still in dispute are 
amongst those which will arise during the study of this subject. 
It is not always safe, in forming conclusions, to draw one’s in- 
spiration from a promiscuous collection of statistics, for the rea- 
son that it is well known how loosely many of these are reported, 
and how thoroughly unreliable some of them are on account of 
the desire of the reporter to make as good a showing as his 
neighbor, in consequence of which many essential facts and 
truths are omitted. G-eneral statistics will therefore be ignored, 
and whatever deductions are drawn wall be entirely from the 
author’s personal experience, which has now reached the num- 
ber of seventy-seven hysterectomies. The indications, as taught 
by this experience, are absolute and relative. They are ; 
1. Malignant degenerations of tbe uterus. 
2. Fibroid tumors of tbe uterus. 
3. Pelvic inflammations. 
4. Prolapse of the uterus. 
5. Inversion of the uterus. 
1 Read before the Section on Gynecology and Abdominal Surgery, Pan- 
American Medical Congress, Washington, September 6th, 1898. BALDY t HYSTERECTOMY. 
Malignant Degenerations of the Uterus.—The indications here 
are absolute, both as to the advisability of the operation and as 
to the complete removal of the organ, it matters little how high 
the death rate or how high the percentage of recurrence. The 
disease is incurable and the end certain under any other line of 
treatment. However small the number of cases cured may be, 
yet it is an undisputed fact that a certain proportion regain per- 
manent good health. Should this number of fortunate ones be 
limited even to one or two in the hundred operated ujion, it 
would be sufficient justification. When one considers the great 
relief which follows a simple curettement of a cancerous uterus, 
it can well be imagined how much more thorough and prolonged 
this relief is when the whole organ is removed. The number of 
permanent cures will be in direct ratio to the period at which 
surgery is employed : the earlier in the disease the uterus is re- 
moved the more chance of obtaining a satisfactory result. For 
this reason, when, from a careful study of the symptoms and his- 
tory of a given patient, a reasonably strong suspicion of malig- 
nant disease exists, other conditions being rigorously excluded, 
the uterus should be removed. The justification for acting upon 
such advice will rest largely upon the mortality attendant upon 
the operation, as undoubtedly, under these circumstances, an oc- 
casional non-malignant uterus will be removed. This will mat- 
ter little in comparison with the number of patients saved a miser- 
able death ; and even though the organ prove not to be cancerous, 
it will be a diseased one, giving rise to alarming symptoms, from 
which speedy and permanent relief will be obtained. 
Twenty-five operations have been performed for primary can- 
cer or sarcoma of the uterus; this number does not include those 
cases of malignant changes in uterine neoplasms, all of which 
are considered wfith the fibroid tumors. Of this number three 
have died from the operation. The three deaths were all pre- 
ventable, and would not be likely to occur in another series of 
the same number. Two of them were the first two operations for 
vaginal hysterectomy ever performed by the writer. Single 
clamps on each side of the uterus were used for securing the 
hroad ligaments; in both cases the clamps worked in a faulty 
manner, and one of the ovarian arteries retracted, after being cut, 
from the grasp of the clamp. In one case it was necessary to 
open the abdomen in order to secure the bleeding vessel. 3 
The third death resulted on the fifth day after the removal of 
the uterus by means of catgut ligatures. The patient was ex- 
ceedingly restless, the usefulness of the catgut being destroyed 
by its absorption, the light adhesions gave way and the stumps, 
which had been stitched into the vaginal opening and which at 
this time were sloughing, retracted into the pelvic cavity, set- 
ting up a septic peritonitis which proved fatal in twenty-four 
hours. 
BALDY : HYSTERECTOMY. 
Experience and a more perfect technique would guard against 
the repetition of a death similar to the first two ; heavier catgut 
and more thorough suturing, together with a judicious restraint 
of a restless patient with drugs, would guard against a repeti- 
tion of the last-mentioned accident. 
Fibroid Growths.—The indications for surgical treatment of 
these conditions are relative. If the tumor be small, is of slow 
growth, and gives rise to no untoward symptoms, it should be 
allowed to remain unmolested, provided the patient may be in 
such a state of life that she is not necessarily exposed to condi- 
tions which predispose to inflammatory complications, and that 
she be not liable to change her place of residence to such quar- 
ters that she will be unable to obtain competent surgical aid 
should there be a future demand for it—a demand which will al- 
most always be made sooner or later. Should the patient have 
advanced to within a few years of the menopause, it may be ad- 
visable to adopt, for the time being, the expectant plan of treat- 
ment. Under all other conditions a fibroid tumor of the ute- 
rus, however small, should be subjected to surgical treatment. 
Surgical treatment having been once decided upon, hysterectomy 
is the proper procedure to adopt. Myomectomy may in rare 
cases be the more desirable procedure, but can only be consid- 
ered where the patient is of such an age as to make it desirable 
and possible for her to bear children, and where the uterine ap- 
pendages are healthy and capable of performing their function, 
the reverse of which is true in the case of the majority of fibroid 
tumors. Under all other circumstances hysterectomy is the 
operation of choice. The withdrawal of ovariotomy from the 
category of operations applicable to the treatment of fibroid 
tumors is based on the fact that it, equally with hysterectomy, 
renders it impossible for the woman to conceive ; it not only al- 
lows the tumor to remain in situ for Nature to absorb, with the 4 
chance, however slight, of this not occurring, hut it usually leaves 
behind a diseased and useless uterine cavity and uterine walls, 
all of which maybe gotten rid of surely and permanently atone 
stroke by the hysterectomy. Ovariotomy is often more difficult 
than hysterectomy, and is not infrequently impossible. 
BALDY : HYSTERECTOMY. 
Hysterectomy as the operation of choice will, as in the case 
of malignancy, depend upon the mortality. The writer has re- 
moved forty-one fibroid uteri by means of this operation. Of 
this number four patients died—three after the supravaginal 
amputation of the stump, and one after complete extirpation. 
In the one case death was inevitable from the previous septic 
condition of the woman, due to electro-puncture. Two of the 
deaths were due to pulmonary complications ; acute congestion 
of both lungs, in the case of one, ending in death within the first 
twenty-four hours, and a double pneumonia of the second re- 
sulting in rapid filling of both lungs and death within several 
days. These two deaths occurred in hospital practice within a 
few days of each other, and at a time when there was an epi- 
demic of pulmonary complications following all kinds of opera- 
tions in the house. At the time of the deaths there were in the 
house six or eight cases with lung troubles, some of whom were 
sick enough to cause considerable anxiety, and on some of whom 
only plastic operations had been performed. The, epidemic 
abated as abruptly as it commenced. The fourth death was 
due to septic peritonitis in a case of complete extirpation, and 
was undoubtedly due to faulty technique, a cause which is 
entirely preventable. 
Pelvic Inflammations.—The indications in pelvic inflamma- 
tions are relative. All operators are having patients, whose 
uterine appendages they have removed for this disease, return 
only slightly or not at all better. The 'women suffer with their 
old pains, leucorrheal discharges, and hemorrhages. In two 
such cases the writer has subsequently removed the uteri with 
complete relief of all the symptoms. In two other cases the 
uterus, together with its appendages, has been removed at the 
first operation, with a perfectly satisfactory result. In no case 
was there a death. 
In pelvic inflammatory disease in women the infection has first 
invaded the uterine cavity. In very many cases the endome- 
trium remains permanently diseased and the uterine wTalls have BALDY : HYSTERECTOMY. 
5 
become invaded by inflammatory products, even with pus. In 
many cases of pyosalpinx the tissue is so diseased that the liga- 
ture cuts through like a knife, even when it is placed well up on 
the uterus. It is no more to be expected that uterine walls dis- 
eased to such a decree will reg-ain their normal condition than 
e? O 
to expect the same of the tubal walls under like circumstances. 
The mortality of hysterectomy under these circumstances should 
be no greater than after the removal of the appendages alone. 
This procedure should therefore be the operation of choice in 
all cases where the uterine walls are infiltrated with pus and 
the uterus materially enlarged. 
Prolapsus Uteri.—The indications are relative. All cases in 
which the usual surgical means have been tried and failed 
should be subjected to hysterectomy as a sure means of cure. 
Women who are suffering from old complete prolapse, near, at, 
or past the time of change of life, are proper subjects for this 
procedure. Future child-bearing need not here be taken into 
consideration. The only questions to be considered are, first, 
whether or not the usual plastic operations give promise of a 
cure; second, the mortality of the operation. As to the first, it 
is well known to all operators that jfiastic operations, even when 
accompanied by a ventro-fixation, at times fail. As to the mor- 
tality, the uterus has been removed six times by the writer by 
vaginal hysterectomy without a death, and with complete suc- 
cess in each instance. Cases which are particularly applicable 
for this treatment are those with greatly enlarged and hyper- 
trophied uteri, measuring five and six inches in depth, accom- 
panied by profuse uterine discharges and hemorrhages. These 
uteri are not infrequently found to be cancerous, such being so 
in the case of two of the six reported. The operation should 
always be followed by plastic operations on the anterior and 
posterior vaginal walls for a repair of the relaxation of the 
vagina. 
Inversio Uteri. —The operation is only applicable to old, chronic 
cases, and only then when judicious attempts at replacement 
by taxis and elastic pressure have failed. Taxis should not be 
tried longer than half an hour, with the patient under ether. 
If at the end of this time there is no sign of beginning return, 
elastic pressure should be resorted to either by the colpeurynter 
or Aveling’s repositor. Should these fail after several days’ 6 
BALDY : HYSTERECTOMY. 
trial, vaginal hysterectomy is a proper and safe procedure. One 
case has been successfully treated in this manner by the writer. 
The methods of performing hysterectomy are abdominal, va- 
ginal, and the combined methods. 
Abdominal hysterectomy is performed by— 
1. Supravaginal amputation. 
(a) Treatment of the stump by the extraperitoneal 
method, 
(b) Dropping the stump. 
2. Extirpation. 
Fig. I.—Vaginal hysterectomy with the ligature. First step: ligation of uterine arteries 
Yaginal hysterectomy is performed by— 
1. Clamp operation. 
(a) Single clamp. 
{b) Multiple clamps. 
3. Ligature operation. 
All cases of prolapse and inversion of the uterus, all malig- 
nant uteri sufficiently small, and very small fibroid tumors of 
the uterus are proper subjects for the vaginal operation. 
Fibroid tumors, excepting the very small ones, large malignant BALDY : HYSTERECTOMY. 
uteri, and all cases of inflammatory uteri should be subjected to 
the abdominal operation. 
The combined method is superfluous and more dangerous 
than either of the other two alone. 
In the hands of the writer vaginal hysterectomy by means of 
the catgut ligature has proven the safest and most satisfactory 
of the vaginal operations. With the clamps there were four 
operations with two deaths, with the catgut ligature there were 
Fig. 2.—Vaginal hysterectomy with the ligature. Second step. 
twenty-seven operations with one death. Where the operation 
is performed for prolapse, the ligature operation, and stitching 
the stumps in the opening in the vaginal fornix, is absolutely 
necessary to success. The broad ligaments are thus made to 
act as guy ropes from above and give infinitely better support, 
with less chance of stretching, than would be the case if ventro- 
fixation or Alexander’s operation had been relied upon. 
When the abdominal operation is performed in the presence 
of malignant disease complete extirpation is necessary. In all 8 
BALDY : HYSTERECTOMY. 
other cases the supravaginal amputation is preferable. Extirpa- 
tion is a longer and somewhat more tedious operation, and in 
addition the subsequent condition of the vagina is that of a con- 
siderable shortening; the advantages of this procedure over 
the amputation do not compensate for these disadvantages. The 
uterus was removed by complete extirpation five times with one 
death. 
Fig. B.—Vaginal hysterectomy with the ligature. Third step : the fundus inverted into 
the vagina, and the final ligatures in place. 
As between the two methods of treating the stump, dropping 
it back into the pelvic cavity is preferable to treating it by the 
extraperitoneal method. The mortality is much the same, but 
other considerations all turn the balance in favor of the intra- 
pelvic method. The extraperitoneal method is not applicable 
to intraligamentary growths. Twenty-eight operations w7ere 
performed and the stump treated extraperitoneally ; of these UALDY I HYSTERECTOMY. 
9 
two died. Thirteen cases were operated npon and the stump 
allowed to retract back into the pelvis ; of these patients one died. 
The supravaginal amputation accomplishes all that extirpa- 
tion does; is applicable, with the exception of malignant uteri, 
to all conditions and diseases; is less difficult and tedious of per- 
formance ; has less danger of septic infection, due to the smaller 
opening of the cervical canal than of the vagina; and, finally 
has less mortality. After the ovarian and uterine arteries are 
ligated and the uterus amputated, the cervical canal should be 
cauterized by means of the Paquelin cautery, closed by catgut 
or tine silk sutures, and the edges of the cut peritoneum closed 
over the stump. 
Hysterectomy is a difficult operation, however performed, 
Fig. 4.—Vaginal hysterectomy with the ligature. Final step : uterus removed and 
stumps drawn down into the vagina; sutures in place ready for closing the vaginal opening. 
and should never be undertaken by an incompetent operator. 
The mortality following the operation when properly per- 
formed should to-day be much less than is indicated by seven 
deaths in seventy-seven operations. It must be borne in mind 
that this mortality includes the accidents incident to gaining 
the requisite experience in manipulation, as well as those neces- 
sary to perfecting the technique. 
The convalescence following hysterectomy is, in the majority 
of cases, as easy and uninterrupted as that following ovariotomy. 
A few more years will see the field of applicability of this operation 
greatly widened, the more so as the mortality decreases. The 
uterus is a useless organ in all cases where the ovaries or Fallo- 
pian tubes have been removed, and is only too frequently a source 
of discomfort, invalidism, and death. 10 
BA.LDY HYSTERECTOMY". 
The technique of vaginal and the two varieties of abdominal 
hysterectomy—complete extirpation, and the intrapelvic treat- 
ment of the stump after supravaginal amputation—have many 
points in common. In each operation the important point is to 
secure in separate ligatures the two ovarian and two uterine 
arteries; everything else is subordinate to this. Rigid anti- 
sepsis is absolutely necessary. 
Vaginal Hysterectomy.—The patient being placed in the dor- 
sal position, the perineum is well retracted with a Sims specu- 
lum. The cervix uteri is grasped with a pair of tenaculum forceps 
and drawn down. The vagina about the posterior portion of 
the cervix, from broad ligament to broad ligament, is cut loose 
Fig. s.—Supravaginal amputation of the uterus. First step; ovarian arteries ligated 
with a few strokes of a knife, and its peritoneal and mucous 
coats quickly whipped together by a continuous suture, to pre- 
vent bleeding. The vaginal mucous membrane is now incised 
on the anterior aspect of the cervix, from broad ligament to 
broad ligament, well below the attachment of the bladder. The 
connective-tissue attachments of the bladder to the cervix are 
loosened by forcing the finger between them and the uterus un- 
til the peritoneum is reached. This membrane is quickly pene- 
trated by forcing a pair of blunt hemostatic forceps through it 
into the peritoneal cavity, and withdrawing them after having 
first widely separated the blades. Where it is possible the 
mucosa and serosa are stitched together, as was done posteriorly. 
The uterus is now entirely free from all its attachments except- BALDY : HYSTEKECTOMY. 
11 
ing the broad ligaments. A succession of ligatures are placed 
upon these on each side, beginning from below and cutting the 
uterus free from the ligaments as each successive ligature is 
placed and tied. Three ligatures usually suffice for each broad 
ligament. The first one secures the uterine artery ; the second 
includes the balance of the ligament up to the ovarian artery, 
which, after being tied and cut away, frees the womb sufficiently 
to allow of inverting the fundus into the vagina; it is thus a 
simple matter to place the final ligature, which, on each side, in- 
cludes the ovarian artery. The ligature should be placed on the 
outer side of ovary and Fallopian tube, so as to allow of cutting 
Fig. 6.—Supravaginal amputation of the uterus. Second step ; ovarian and uterine arte 
ries ligated and uterus amputated. 
between them and the pelvic wall; in this manner both tubes 
and ovaries are removed with the womb. The uterus being 
removed, the three stumps on both sides should be drawn well 
down into the vagina and the vaginal opening closed about 
them, the sutures being so placed as to pass through the stumps, 
thus fixing them in their drawn-down position. When the ope- 
ration is finished, nothing is seen in the vagina but the protrud- 
ing stumps. The vaginal canal is douched with mercurial solu- 
tion, well dried, and lightly packed with iodoform gauze, which 
is to be removed in the course of a few days. Catgut ligatures 
are used throughout. BALDY : HYSTERECTOMY. 
Supravaginal Amputation, with Intrapelvie Treatment of the 
Stump.—The abdomen is opened in the median line, the patient 
being in Trendelenburg’s position, with the intestines well back 
in the abdomen and the pelvis empty. A ligature is placed on 
each side of the uterus, close to the pelvic wall, including as 
much of the broad ligament as possible; a ligature to tempo- 
rarily prevent bleeding from the uterus is placed close to that 
organ. After cutting between these ligatures and drawing the 
womb up, a second ligature is placed, if necessary, on each 
-side, so as to include any remaining broad-ligament tissue, to 
Fig. 7.—Supravaginal amputation of the uterus. Closure of the cervical canal with 
sutures. 
the level of the pelvic floor. These attachments are also 
severed. The uterus being well drawn up, the uterine artery 
on either side is located by the finger and a ligature placed 
under it close to tire uterus. After securing this vessel on both 
sides the uterus is removed as low down on the neck as possible, 
the amputation being made wedge-shaped. As soon as this is 
accomplished the cervical canal is cleaned with the knife or a 
Paquelin cautery, and the cut surfaces of the neck are brought 
together by several sutures. The peritoneal edges are now 
whipped together by a running suture from side to side of the 
pelvis, burying under it the cervix and all the stumps but the 
ones including the ovarian arteries. Even these may be cov- 13 
ered by doubling the loose peritoneum over tbera from side to 
side by the aid of a few sutures, thus completely covering up 
all raw surfaces. 
BALDY ; HYSTERECTOMY. 
Complete Extirpation.—The steps of this operation are the’ 
same as the preceding up to the point of amputation of the ute- 
rus. Instead of this procedure the attachments about the cer- 
vix are freed and the uterus removed entire. The peritoneal 
reflection between the uterus and bladder is incised from side 
to side, and the bladder connective-tissue attachments gently 
sundered with the finger or the handle of the knife. The va- 
ginal sheath, being reached, is opened, and with a finger in the 
Fig. B.—Supravaginal amputation of the uterus. Suture of the peritoneum over the 
cervix and stumps. 
vagina it is no very difficult matter to free the attachments 
from the complete circumference of the cervix. This being ac- 
complished, the edges of the vagina are brought together by a 
continuous suture. Thus any danger of infection getting into 
the raw surfaces from that canal is obviated. The peritoneal 
edges are sutured in a similar manner as in the preceding ope- 
ration, all the stumps but the topmost ones being turned into the 
space between the vagina and peritoneum. Silk is used for the 
ligatures on the arteries, catgut for all suturing. 
Drainage in any of these three operations is superfluous. MEDICAL JOURNALS 
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