Hysterectomy as an Accompaniment to 
Bilateral Removal of the 
Appendages. 
BY 
Reuben Peterson, M. D., 
GRAND RAPIDS, MICH., 
Member of the Chicago Gynaecological Society, 
Fellow of the American Association of 
Obstetricians and Gynaecologists. 
REPRINTED FROM THE 
American Gynaecological and Obstetrical Journal 
for August, 1896. [Reprinted from the American Gynaecological and Obstetrical Journal 
for August, 1896.] 
HYSTERECTOMY AS AN ACCOMPANIMENT TO 
BILATERAL REMOVAL OF THE 
APPENDAGES. 
By Reuben Peterson, M. D., Grand Rapids, Mich. 
Member of the Chicago Gynaecological Society, Fellow of the American Association of 
Obstetricians and Gynaecologists. 
During the past five years decided changes have taken place 
in the methods of dealing with pelvic inflammatory diseases. Prior 
to 1890 it was the established custom in America to deal with irrep- 
arably diseased appendages by removal solely through an ab- 
dominal incision. Deliberate hysterectomy as an adjunct to ab- 
lation of the tubes and ovaries was not practiced. Pean in 1886 
removed by the vagina the diseased uterus of a patient whom he 
had failed to cure by a previous removal of the appendages. From 
this and similar cases he sought to establish the principle that for 
certain forms of pelvic inflammatory disease hysterectomy, as well 
as removal of the appendages, should be performed. His work 
along these lines, which was reported before the Paris Academy 
of Medicine in 1890, seems to have attracted but little attention in 
this country. Operators of large experience who had carefully 
followed up the history of these cases, subsequent to the opera- 
tion of bilateral ablation of the annexa, were forced to admit that 
many of their patients were not restored to health. Many still suf- 
fered from haemorrhagic and purulent uterine discharges, and the 
reflex symptoms, which had prominently figured among the indi- 
cations for the operation, persisted to a greater or less degree. In 
order to do away with these unfavorable sequelae, portions of the 
uterus were surgically treated. It was urged that in every case 
where the appendages were to be removed for chronic inflamma- 
tory disease the uterus first should be thoroughly curetted and 
drained. Also that the tubes should be dissected out of the uterine 
Copyright, 1896, by J. D. Emmet, M. D. Reuben Peterson, M. D. 
2 
cornua in order that no diseased tissue be left behind. Although 
these procedures were carefully carried out, there still remained 
cases which presented the old train of symptoms. Hence when 
Polk’s paper (i) on Hysterectomy (Suprapubic) for Salpingitis and 
Ovaritis appeared in the latter part of 1893, in which hysterectomy 
was advocated in every case where both appendages had been re- 
moved for serious disease, the idea,- coinciding as it did with the 
clinical observations of many operators was eagerly seized upon 
by prominent gynaecologists throughout the country and immedi- 
ately put into practice. Since that time hysterectomies have been 
done by the score in this class of cases. Is it not well to pause 
after three years’ work in this line and ask ourselves not how many 
uteri have been removed during this period, but how much has 
been learned from careful microscopical and bacteriological exami- 
nations of these removed organs? In other words, do the patho- 
logical lesions found in the ablated uteri confirm the correctness of 
the reasoning of those who, mainly upon clinical grounds, advocate 
hysterectomy in certain inflammatory pelvic diseases. Henro- 
tin (2), at the last meeting of the American Gynsecological Society, 
states that “ the position of advanced, observant gynaecologists, 
who are not hampered by tradition or custom or afraid of their 
own stubborn dogmatic expressions in the past, can be stated as 
follows: ‘ In every operation for septic diseases of the female gen- 
erative organs which demands the removal of the tubes and ova- 
ries hysterectomy should also be performed unless there are contra- 
indications forbidding it.’ ” Now, I consider this a fair statement 
of the present position of surgery upon the subject. The whole 
question will turn upon what interpretation be placed upon the 
phrase “ contraindications forbidding it.” The more carefully the 
removed uteri are studied in connection with the history of the 
case and the condition of the pelvis found at the time of the opera- 
tion, the nearer will we be to determining what will constitute a 
“ contraindication.” If it can be shown that certain pathological 
uterine lesions, either of the mucosa or of the deeper structures, 
are susceptible of cure without removal of the organ, then con- 
siderable advance has been made toward establishing another con- 
traindication. On the other hand, microscopical examination of 
the removed organ may show such decided morbid changes in its 
structure as to render any curative treatment short of ablation in- 
effectual. This line of research may not be the easiest or most Hysterectomy: Bilateral Removal of the Appendages. 
3 
enticing-. One would far rather have a universal rule for guidance, 
such as is laid down above, but conservative surgery does not ad- 
vance along these lines. For example, it is much easier to adopt 
a universal rule to operate for appendicitis in every case as soon 
as the diagnosis be made. Yet those who advocate and observe 
this rule are in the vast minority, and ever will be so long as it 
can be proved that a certain percentage of cases recover by adher- 
ing to other modes of procedure. The technique of hysterectomy 
has been so perfected that in the hands of the skilled operator the 
mortality is increased but little if any over that resulting from re- 
moval of the tubes and ovaries alone. This fact, however, does 
not justify one in removing the uterus in every case. While clinical 
experience has shown me that a certain percentage of my cases 
were not cured after their pus tubes were removed, on the other 
hand it has also demonstrated that certain cases did recover after 
this treatment. It seems to me it is plainly the surgeon’s duty 
under these circumstances to endeavor to solve the problem why 
one set of cases recovered and the other did not. The reason must 
lie, other things being equal, in the condition of the uterus at the 
time of the operation. How can these different conditions be 
studied and definite rules of procedure be established except it be 
upon both pathological and clinical grounds? Yet a perusal of the 
literature emanating from our gynaecologists upon hysterectomy 
for inflammatory affections will show that their conclusions have 
been arrived at mainly from a clinical consideration of the subject. 
That this is a dangerous mode of studying any surgical question 
and one liable to lead to grave errors is demonstrated by the abuse 
of ovariotomy when it was performed for symptoms and not for 
demonstrable pathological lesions. I fail to see the line of reason- 
ing adopted by Polk. He—the advocate par excellence of conserva- 
tive surgery, who would leave in an ovary or part of an ovary with 
everything else removed—advocates the removal of the uterus in 
every case of bilateral ablation of the appendages because some 
cases fail of cure without this additional procedure. What right 
has he or any one else to justify his position by claiming that the 
“ emasculated uterus ” is a useless organ and hence should be 
sacrificed? It should be sacrificed if it is so diseased that no known 
procedure can effect its cure, and that should be the only justifiable 
ground for its removal. One who claims so much for thorough 
dilatation and curettage of the uterus, in the way of depletion and Reuben Peterson, M. D. 
4 
drainage, should surely obtain better results than are shown by his 
advocacy of the proposition to perform hysterectomy in each and 
every one of these cases. 
I am making a plea against the adoption of a universal rule in 
regard to these cases as if it were for all time settled. I claim that 
the surgeon has no right to remove the uterus after ablation of 
the appendages unless he is convinced that the organ is diseased 
beyond the hope of cure by less radical methods. Krug, in the 
discussion of Polk’s paper, said he had “ never found a healthy 
uterus when there had been such inflammatory disease in the tubes 
and ovaries as would warrant bilateral salpingo-oophorectomy.” 
It is not a question, it would seem to me, of the uterus being always 
found diseased in these cases. As most inflammatory diseases of the 
annexa arise from some form of intra-uterine affection, it would 
be remarkable if the uteri were perfectly healthy. The question 
is, how much are they diseased and how can this disease be cured. 
I would not belittle the work of those who were the first to advo- 
cate hysterectomy for inflammatory disease. I consider it a great 
step in advance, and for certain conditions it is the only procedure 
which should be adopted. But I do believe that the prediction of 
Baldy (3), made two years ago in a paper on this subject, that uteri 
might be removed which might safely be left behind, has proved 
true to a far greater extent than any one could have predicted. 
Even if the uterus be a functionless organ after bilateral sal- 
pingo-oophorectomy, I do not think that the most radical opera- 
tors would urge that it be removed for this cause alone if he could 
determine in what cases it could “ safely ” be left within. 
The investigations of Wertheim (4) have thrown considerable 
light upon gonorrhoea of the uterus. They would tend to show 
that the deeper uterine structures are affected to a greater degree 
than formerly supposed. There is in many cases infiltration of the 
muscle with hyperplasia of the vessel walls. That the gonococci 
can penetrate into the muscularis is considered highly probable 
by Wertheim, though he has never, bacteriologically, demonstrated 
their existence (5). That a metritis with sensitiveness and a general 
enlargement occurs in gonorrhoeal disease of the uterus is a well- 
known clinical fact, but that it is due to the gonococcus has never 
been proved, because the muscular tissues being an unfavorable 
soil for the germs, they either perish or pass on through the uterine 
wall to the peritonaeum. Madlener (6) claims to have actually dem- Hysterectomy: Bilateral Removal of the Appendages. 
5 
onstrated the gonococci in the muscular tissue in one case where 
the uterus was removed seven weeks after confinement. 
Gonorrhoeal disease of the uterine deeper structures offers, then, 
an explanation of the poor results obtained by treatment through 
the curette and drainage. Removal of the endometrium leaves the 
deeper structures still diseased, and in a short time the old symp- 
toms will again appear. For this reason Werth (7) claims that, in- 
asmuch as it is impossible clinically to distinguish the forms of 
endometritis in which the deeper tissue is involved, a thorough 
cauterization after curettage should always be employed. He 
recommends liquor ferri, and shows that after its use a regeneration 
of the epithelium is delayed. 
These conclusions were arrived at from a careful microscopical 
examination of uteri removed after curettage performed some days 
previously, and are therefore more valuable than mere theoretical 
conjectures in the matter. In another article (8) he shows that the 
endometrium is never entirely removed, patches untouched by the 
curette always remaining. The cornua were most likely to be 
spared. 
Just what percentage of cases of inflammatory disease of the 
annexa are due to gonorrhoea it is hard to say. Probably twenty- 
five per cent, would be a conservative estimate. It is generally 
conceded that Noeggerath’s (9) picture of latent gonorrhoea and 
its frequency was exaggerated. Yet no one can question the im- 
portant role played by the gonococcus in the production of pyo- 
salpinx. Apparently gonorrhoea of the uterus is especially diffi- 
cult of cure, and this should have weight in deciding whether hys- 
terectomy should follow removal of pus tubes. 
Schauta (10) takes a very decided stand in this matter. From 
the results of his observations he finds that only fifty-nine per cent, 
of cures result when both appendages are removed, and only twenty- 
three per cent, where one side was removed. When this lesion is 
due to gonorrhoea, he, like Tait, claims that when one side is re- 
moved the other should be also together with the uterus. This 
recommendation is not based, it seems to me, upon sound scien- 
tific principles, and is not advocated by the majority of gynaecolo- 
gists. If this dictum be followed, then we practically concede that 
we are powerless in the presence of gonorrhoeal disease to effect 
a cure short of hysterectomy. While the investigations referred 
to above have shown us why frequent failures result from our 6 
Reuben Peterson, M. D. 
efforts to cure gonorrhoea of the uterus, still I do not believe that 
every case of gonorrhoeal endometritis is incurable. A certain pro- 
portion of the twenty-five per cent, will no doubt fall under this 
category, and in time we shall be in a position to recognize these 
cases and act accordingly. Much will depend upon the wishes of 
the patient in cases where one side is unaffected (n). She may 
demand the most radical operation if there exist a possibility of 
the other side becoming affected. On the contrary, she may be 
desirous of children, and be willing to risk the possibility of a sec- 
ondary operation from the failure of intra-uterine treatment. 
Schauta makes every exertion to establish the diagnosis of gonor- 
rhoea prior to operation, and during the progress of the latter has 
the contents of the pyosalpinx examined for the gonococci. If 
gonorrhoea is found to exist, both annexa and uterus are removed, on 
the ground that the gonococci work irreparable change in the uterus, 
while the inflammation of the appendages due to streptococcus and 
staphylococcus infection is usually one-sided, and the uterine lesion 
usually heals, and consequently the uterus can safely be left. As 
more than fifty per cent, of the cases of inflammatory disease of the 
annexa are considered to arise from infection after abortions or the 
puerperal state, it will readily be seen that, if Schauta’s claims be 
true, there are many cases where the uterine lesions will either be 
cured or be amenable to treatment after the removal of the annexa. 
More such investigations should be made, and, by the collec- 
tion of both bacteriological and clinical data, rules can be formu- 
lated which will be of inestimable value to the surgeon in deciding 
what should be done in a given case. Whatever may be said to 
the contrary, hysterectomy is a much more radical procedure than 
bilateral removal of the annexa, and should never be performed 
except when demanded for the cure of the patient. 
Some advocate hysterectomy on the ground that twelve per 
cent, of chronically diseased annexa requiring removal are found 
to be tubercular upon microscopical examination, and that the 
uterus may be affected also (12). This position is strengthened 
by the observation of Cullen (13), who thinks tubercular disease 
of the uterus is usually secondary to that in the tubes. But tuber- 
cuar uterine disease is usually demonstrable by the examination 
of scrapings, and hence it is possible to have a fairly clear idea of 
the condition of the uterus prior to the operation. Where the uterus Hysterectomy: Bilateral Removal of the Appendages. 
7 
is found to be tubercular, it should always be removed, because 
of the difficulty of curing it by intra-uterine treatment. 
Where the microscopical appearances of the annexa show tuber- 
cular deposits, it would seem advisable to remove the uterus, be- 
cause of the serious nature of the disease, the possibility of the 
uterus being affected, and the difficulty of curing tubercular uterine 
disease by the curette. If the microscope shows tubercular dis- 
ease in the appendages unsuspected before, the uterus can be re- 
moved by a secondary operation. 
At the last meeting of this Association, a former chairman of 
this section, Dr. Eastman, remarked, in speaking of hysterectomy 
for fibroids, that he was not at all sure of what the after-effects of 
complete removal of the uterus would prove to be; that he found 
vaginal prolapse, cystocele, and rectocele following some cases, and 
that he would be obliged to suspend judgment until he had operated 
on more cases by this method. This by a man who has probably 
performed as many if not more complete hysterectomies than any 
operator in the country. It would seem as if the lesson to be 
learned from the remarks of such a man was to go a trifle slow in 
urging that the uterus be removed. It is generally conceded that, 
when we are obliged to remove an organ, it is a practical acknowl- 
edgment of defeat. Starting from this defeat, our surgical efforts 
involving removal may end in victory as regards the health of the 
individual. 
We must continually keep before our minds the two great 
classes of cases calling for bilateral removal of the annexa, and it is 
only necessary to recall our past cases to find examples of each. 
The first is where there is advanced disease, usually chronic, 
involving both annexa. The tubes and ovaries, either filled with 
or free from pus, are bound down in the posterior cul-de-sac and to 
the omentum and bowels by dense adhesions. Much labor must 
be expended in enucleating these masses, and much injury may 
be done the uterus in separating it from the pus sacs. Repeated 
infections, with resulting metritis and endometritis, have also 
greatly impaired its integrity. Here the indications are clearly for 
removal of the uterus. Its peritoneal covering may be so injured 
that if left it will be firmly bound down by dense post-operative 
adhesions, and give rise to great suffering. These are the cases 
where hysterectomy will give brilliant results as compared to the 8 
Reuben Peterson, M. D. 
older methods. But these are not the usual but the severe cases, 
and fortunately the exceptions. 
The second class is the one which we are considering in this 
paper. Here the recurrent attacks of pelvic peritonitis have been 
fewer, hence the adhesions less. The tubes and ovaries may be the 
seat of purulent collections, or their contents may have become 
changed to a cheesy material, with thickening of the walls. The 
fimbriated extremities of the tubes are closed, and no conservative 
operative procedure can be entertained. The uterus is enlarged 
but fairly movable. The masses on either side having been re- 
moved without much difficulty, the operator is then confronted 
with the question of whether or not hysterectomy shall follow. 
His decision will depend largely upon the condition of the uterus 
and the possibility of its being cured by treatment directed to 
its interior, aided by the atrophy resulting from the removal of 
the appendages. Careful recorded observations, both pathologi- 
cal and clinical, will result in rules which will guide the surgeon 
in his choice of procedure. 
Pythian Temple. 
References. 
1. Polk: Hysterectomy for Salpingitis and Ovaritis. N. Y. Journal of Gyn. and 
Obs., vol. iii, 1893, pp. 1053 and 1088 ; vol. iv, 1894, p. 61. 
2. Henrotin : Conservative Surgical Treatment of Para-uterine and Peri-uterine 
Septic Diseases. Am. Gyn. and Obs. Journal, vol. vi, 1895, p. 769 ; N. Y. Journal of 
Gyn. and Obs., vol. iv., Jan., 1894, p. 72. 
3. Baldy : Extirpation of the Uterus in Disease of the Annexa. Transactions 
of the Am. Gyn. Society, 1894. 
4. Wertheim : Central, f. Gyn., 1895, No. 26. 
5. Wertheim: Deut. Med. Woch., No. 27, July 4, 1895. 
6. Madlener : Central, f. Gyn., Dec. 14, 1895. 
7. Wertii : Archiv f. Gyn., Bd. xlix, Heft 2. 
8. Werth : Central, f. Gyn., 1895, No. 29. 
9. Noeggerath: Transactions of the Am. Gyn. Society, 1876. 
10. Schauta: Central, f. Gyn., 1895, No. 29. 
11. Noble: Certain Aspects of Gonorrhoea in Women. Am. Gyn. Trans., vol. 
xvii, 1892. 
12. Williams: Johns Hopkins Hospital Reports, 1892, vol. iii. 
13. Cullen : Johns Hopkins Hospital Reports, vol. iv, Nos. 7 and 8.