[Reprinted from the American Gynecological and Obstetrical Journal 
for February, 1895.] 
UTERINE FIBROIDS. HYSTERECTOMY. TREATMENT 
OF THE PEDICLE.* 
By A. H. Cordier, M. D., Kansas City, Mo., 
Lecturer on Abdominal Surgery,-Kansas City Medical College. 
As we learn more and more of the pathology of uterine fibroids, 
we limit the application of the removal of the appendages (Tait's 
operation) to relieve the symptoms produced by their presence, and 
to check their further development. The pathologist and clinician 
have repeatedly demonstrated that it is of not infrequent occurrence 
for fibroid tumors to undergo sarcomatous degeneration. This is es- 
pecially true of that form of uterine neoplasm known as a fibro-myoma, 
or as Mr. Tait terms them, myomata. This form of growth develops 
like sarcoma, at any age, but is most likely to appear before the age of 
thirty, and is usually a single growth, soft, semi-fluctuating, rapid in 
its development, and unattended by the usual hemorrhages so often 
accompanying the multinodular or hard fibroid. These growths 
(myomata) do not cease their development at or after the menopause, 
but may grow with increased rapidity after this period is past. They 
are liable to undergo mucoid, colloid or sarcomatous degeneration. 
They are composed principally of muscular tissue. They may grow 
rapidly for a few months, then remain quiescent for a number of years, 
start up from their lethargy and develop rapidly. Owing to the rich 
blood supply of this form of uterine tumor they are not as likely to 
suppurate as the hard, compact, fibrous growths, but let this nourish- 
ment be cut off by the ligation of the vessels leading to it (Tait's 
operation) or the ligation of uterine from below (Dorsett-Martin 
operation) and the danger from necrosis is real, not imaginary. Any 
small tumor of the uterus may become an enormous growth filling the 
abdomen, hence all small tumors that show a disposition to become 
* Read by title before the Mississippi Valley Medical Association, at Hot Springs, 
Ark., November 20, 1894. 2 
A. H. Cordier, M. D. 
steadily larger should be dealt with surgically. Electricity, ergot, etc., 
are agents that have been tried and discarded in most instances for 
some procedure that is reasonably certain in its results, and that is 
some form of surgical operation, removal being by far the most exact, 
and in the aggregate, safest. 
Chicago-St. Louis has given us a new procedure (ligation of the 
uterine arteries per vaginam) that to the unwary and inexperienced 
seems reasonable, safe and certain, but to one who understands the 
pathology and clinical behavior of these growths, the Dorsett-Martin 
operation is a most inexact, dangerous and incomplete piece of surgery. 
The blood supply is not alone the sole supporter of the growth and 
development of any structure, and this is as true of uterine growths, 
as of any other part of the body. The nerve supply is of much im- 
port to the vitality of any structure, and in the uterus, Mr. Tait long 
since called attention to the necessity of the ligature including a nerve 
(Johnson's nerve) near the cornu in the broad ligament, in order that 
the menopause be completely brought about. Some one up in the 
Northwest, recognizing this fact, ligated both uterine arteries, then 
opened the abdomen and ligated both ovarian and included this 
nerve (?) and his case was a success, as the growth ceased its develop- 
ment, as did the woman her earthly existence. Uterus sloughed. 
The appendages have been found diseased in my cases with a fre- 
quency to warrant the conclusion that there exists a causal relation 
between inflammatory diseases of the appendages and the develop- 
ment of uterine fibroids. If this fact is recognized by the surgeon, I 
am sure he would be neglectful of his duty, and unsurgical in his 
methods should he resort to any procedure that had not for its object 
the removal of the diseased appendages, breaking up of adhesions, 
the liberating of sound imprisoned surrounding organs, and the re- 
moval of the growth, if large or of that variety liable to continue its 
growth after the appendages are removed. 
Many growths produce by their presence, pressure on the bladder, 
rectum and ureter. Such a growth should always be removed by the 
surgeon, and not left for Nature to absorb (?) or for its presence to 
produce irreparable injury to surrounding organs. 
I do not desire to be misunderstood in my position as regards the 
removal of these growths. I would not operate on dying patients, be- 
cause they will continue to die in spite of the surgery, and not as a re- 
sult of the surgery. Operations on dying people bring reproach to 
this class of life-saving work. 
I mention this fact to impress some one, possibly, who may hear Uterine Fibroids. Hysterectomy. Treatment of the Pedicle. 
3 
this read or see it in print, of the necessity of early surgery in all 
cases where past experience has demonstrated that at some time in 
the progress of any given case surgery becomes necessary in order to 
save the life of the sufferer. Early surgery means completed and 
satisfactory work. I am no advocate of abandoning a procedure when 
once begun, for any surgical operation that is done in an imperfect 
manner must of necessity, in most instances, beget disaster and dis- 
appointment. 
The operation cf Mr. Tait is applicable to a few cases, to check 
haemorrhages and cause the growth to cease its development. The 
growth must be small, of the hard variety, and in a patient near the 
natural menopause, and unaccompanied by any polypoid growths with- 
in the uterine cavity. Enucleation is applicable in a very limited 
degree to small, single, hard fibroids in the front wall of the uterus. 
The appendages must be normal, or should be removed at the same 
time. Any extensive enucleation is attended with more danger than a 
hysterectomy, and leaves behind a poor piece of surgery, and a useless 
uterus, in most instances. It is possible for some fibroid uteri to be- 
come impregnated, and a recognition of this fact should form an 
operative indication, in these cases, for the mortality to both child and 
mother is very high. 
We have arrived at a period in the history of pelvic surgery where 
we can not yield to the plea for ideal surgery, as far as a theory is con- 
cerned, but must submit to the more intelligent entreaty for good re- 
sults and low rates of mortality-really the goal of truly ideal surgery. 
If a skilled operator has a preference, or is partial to a particular 
method, he is certainly entitled to do his favorite operation, provided 
his results are equally as good as those of others doing the same work 
in another way. If a large series of cases be reported with a mortal- 
ity of five per cent, after a given method by one surgeon, and on com- 
paring this percentage with the work of another doing the operation 
with some modifications, you find a death-rate of twenty per cent., you 
may rest assured that the fault, in the majority of instances, will not 
be found in the operator so much as in the faulty principles underlying 
the procedure of his choice. I find many operators who are constant- 
ly changing their technique, trying a new stitch here, and a buried 
ligature there ; or a different instrument is applied, all, possibly, at the 
expense of the abandoning of an old, faithful and efficient procedure. 
Usually the old have been abused, hence the seeking of something 
new to try. All that is necessary, in the majority of instances, for a 
procedure to receive their unqualified indorsement, is a foreign stamp, A. H. Cordier., M. D. 
4 
or a so-called conservative imprint by some illustrious and superan- 
nuated book writer, or professor. Unfortunately, the outlines of much 
abdominal surgery are mapped out by turning a revolving bookcase, 
while the topography is dictated to the office stenographer. 
The surgery of some abdominal operators reminds me very much 
of the rapid transformation of a piece of butcher's meat, in an aver- 
age boarding-house-roast to-day, soup to-morrow, and hash the next 
day, not recognizable at all ; a species of surgical omelet, so to speak. 
While my comparison may seem a little absurd to some of my hearers, 
I am sure others will agree with me, in the main. I am fully in ac- 
cord with any surgical advances, but do not believe in abandoning a 
good procedure, one that is all that could be desired, for an uncer- 
tainty. 
Pean's method being the one of my choice is one I shall describe 
in full. Mr. Tait, Drs. Price, Bantock, Keith and McMurtry all per- 
form the Pean operation. 
Operation.-The preparation of the patient for a suprapubic 
hysterectomy is one of much import, and too much care and atten- 
tion can not be given the details of the same. Cleanliness should be 
the watchword, and the eyes of the operator the sentinel, that no un- 
clean nurse, sponge, instrument, or assistant, cross the aseptic halo. 
A larger number of instruments are necessary in doing a supra- 
vaginal hysterectomy than is required in an ordinary "section." The 
operation itself demands a variety of instruments, and to be ready to 
meet unexpected complications requires more to be added to the list 
-one dozen haemostats, two hysterectomy pins, Koeberle serre-nceud, 
with delta metal wire, (this wire may be obtained from Krohne & 
Sessemann, London,) an extra Koeberle, in case of a break, should be 
on hand, a knife for the abdominal wound, a large scalpel to cut away 
the tumor, four large tissue forceps to clamp the broad ligaments 
while making the pedicle, strong straight needles to sew the abdomi- 
nal incision ; silkworm-gut sutures, silk two siJes, for ligatures-blad- 
der and intestinal injuries require a fine silk suture-a strong, straight 
needle to sew through the pedicle to reduce its size and keep the peri- 
tonaeum from retracting ; large flat sponges, smaller round sponges ; 
irrigator, drainage-tubes, piston syringe to empty tubes; dressing ma- 
terial, iodoform gauze, etc. I prefer ether as an anaesthetic in all 
abdominal operations. 
Time is an important item in the performance of a hysterectomy, 
and the operator who recognizes this, and completes his work quickly 
will, everything else being equal, have the lowest mortality. Uterine Fibroids. Hysterectomy. Treatment of the Pedicle. 
5 
The abdominal incision should be (to begin with) a little nearer 
to the umbilicus than is usually made in a " section " for the re- 
moval of diseased appendages. This precaution is made necessary 
to avoid wounding the bladder in the first incision, as this viscus is 
frequently pulled up by the growth of the tumor. Having entered 
the peritoneal cavity and settled the error or correctness of the diag- 
nosis, proceed to sweep the fingers or the whole hand over the 
growth, going first above, then to either side, finally examining very 
closely for the location of the bladder ; satisfying yourself that the 
growth can be removed (it is very rarely that one can not be removed) 
your incision is carried downward to the full limit of safety, and if 
need be, upward above the umbilicus. The growth is now brought 
forward through the abdominal opening. If omental adhesions are 
present they are "sponged" off, or double-ligatured, and cut until 
freed from the growth. In delivering the growth be careful that no 
undue force is used with the fingers in the region of the broad liga- 
ments, where you will find enormously enlarged and tortuous blood- 
vessels. The same precautions should be exercised posteriorly, for 
here in many cases you will find large and vascular adhesions, which 
if torn across bleed profusely, and are found and ligated with diffi- 
culty. 
In the globular oedematous myomas you will often find that it is 
with much difficulty that they can be removed from their snugly fit- 
ting pelvic mold. They can be easily dislodged if you can succeed 
in getting air to the bottom of the pelvis by pressing the finger or a 
clean catheter alongside of the tumor to the bottom of the pelvis. If 
you fail in this, then the'' corkscrew of Mr. Tait will be of much 
assistance to you. This instrument is screwed into the "fundus" of 
the growth, and traction made slowly and steadily until the tumor is 
delivered. Examine again closely for the location of the bladder, 
which is usually marked by a difference in color and the course of 
blood-vessels, and a faint line may be seen marking its limit when 
made out. If still in doubt, have an assistant quickly introduce a 
catheter, and its limit is then easily made out. If the bladder is 
pulled up too high to admit of the wire bring applied, carefully dis- 
sect it from the walls of the tumor, and permit it to drop out of the 
way. If the pedicle is small the wire can now be applied, the pins 
having been placed in position before the wire is tightened. The 
pins should be placed parallel and exactly across the abdominal in- 
cision and on a level with the surface of the body. 
If the pedicle is too large to admit of being constricted by the 6 
A. H. Cordier, M. D. 
wire and fastened in the lower angle of the wound, pass a large tissue 
forceps on either side on broad ligaments, two to each ligament, and 
cut between them down to the tumor, and from side to side in front 
and behind, having previously caught the peritonaeum with haemostats, 
in many places around the tumor, just below the proposed line of in- 
cision in the capsule, and above the bladder attachment. This last pre- 
caution guards the bladder and prevents the peritonaeum and capsule 
retracting beyond the proposed location of the wire. Having divided 
the capsule, rapidly dissect it down to just above the location to 
which the wire is to be placed. You have almost practically enu- 
cleated the tumor, and have reduced the pedicle from the size of the 
thigh to that of the wrist, and that, too, with very little loss of blood 
and time. The pins are now pushed through the capsule and tumor, 
and the wire tightened by the noeud and the remains of the tumor 
and capsule are cut away an inch from the pins, and the wire tight- 
ened again until all oozing stops. At that stage of the operation 
when the tumor is delivered, a large flat sponge should be placed 
over the intestines, and two or three sutures passed through the pari- 
etes and grasped by heavy forceps and crossed over the line of the 
incision. This protects the intestines, and keeps them in place. 
The haemorrhage being controlled by the wire, the cavity of the 
cervical canal is cleansed, and a piece of gauze packed in it to pre- 
vent infecting the peritonaeum during the completion of the opera- 
tion. The peritonaeum is washed or cleaned by sponging, if it needs 
it, especial care being given the location of the bladder, as here blood- 
clots are liable to be left behind. Two strong strings are placed 
around the pins to be used in pulling the stump into the lowrer angle 
of the incision, and to hold it steady while the peritonceum is being 
stitched to the pedicle below the wire. Fine antiseptic sdk is used for 
the sewing. 
Union takes place quickly between the parietal and pedicle peri- 
tonaeum, and soon seals that cavity from any outside source of infec- 
tion. You now introduce your sutures, then remove the large flat 
sponge and irrigate or clean out the recesses of the peritonaeum, es- 
pecially the pelvis, and, if the tumor is a large one, in the " flanks " 
also. Silkwrorm-gut sutures should be used in closing the abdominal 
incision. You now take a strong, straight needle, armed with stout 
silk, and sew back and forth through the pedicle to reduce its size, to 
aid in controlling haemorrhages, should the wire break during your 
absence, and to pievent the peritonaeum retracting below the wire 
(not likely to occur) and to reduce the size of the stump. Uterine Fibroids. Hysterectomy. Treatment of the Pedicle. 
7 
A drainage-tube can be used if the usual indications for its use 
are present, such as oozing from adhesions, free fluid in the peritonae- 
um at the time of the operation, or escape of pus from a pyosalpinx. 
(A complication of frequent occurrence in fibroids of the uterus.) 
Care must be exercised in approximating the cut surfaces about 
the pedicle, for fear too much tension is placed on the integument 
surrounding the stump and cause stretching of the skin. Pledgets 
of iodoform gauze are applied under the edges of the stump and 
under the pins to prevent pressure on the skin, and the stump is cov- 
ered with iodoform to hasten the drying process. The usual dressing 
should be applied with gauze, and the many-tailed bandage. * The 
Koeberle is permitted to project from the dressings that it may be 
tightened as often as may be necessary without disturbing the patient 
or her dressings. 
If the pedicle is a large one, the dressings will soon be soiled by 
the discharge. There should not be a large one. The nurse is in- 
structed how to tighten the wire if oozing of blood is detected. The 
wire is tighter ed by a turn or two of the clamp each day until the 
stump drops off, which usually occurs from the eighth to the twenti- 
eth day. The dressings are changed as often as it is necessary. 
Every aseptic precaution should be carried out in its fullest detail in 
doing the operation, and in the treatment of the pedicle afterward. 
If suppuration about the stump takes place, it is due to want of asep- 
tic care on the part of the surgeon or nurse. If this accident has 
occurred it is best treated by keeping the groove around the stump 
lightly packed with iodoform gauze saturated with pure listerine or 
■campho-phenique. After the pedicle drops there remains a shallow 
cavity that is soon filled up by healthy aseptic granulation tissue. 
'This description of the technique of a supravaginal or suprapubic 
hysterectomy is one applicable to all uncomplicated cases. The in- 
ventive ingenuity of the surgeon will find here a broad field in which 
to extend in meeting unlooked-for complications. 
If I have succeeded in making the various steps of this, the choice 
operation for the removal of uterine myomata, clear and plain to those 
unacquainted with its technique, the object of writing this paper has 
been attained, and my desire gratified. 
I beg to submit to your consideration the following deduc- 
tions : 
1. All rapidly growing fibroids of the uterus should be removed. 
2. Procrastination, tinkering, and electrical darts convert many a 
simple case into one of great magnitude, with many complications, 8 
A. H. Cordier, M. D. 
making the work of the operator very difficult, and hazardous to the 
patient. 
3. Small, stationary, hard fibroids, without dangerous symptoms, 
may with safety be allowed to remain, especially in women nearing 
the menopause. 
4. Rapidly growing oedematous myomas may not present any dan- 
gerous symptoms, may occur at any age, may and do continue to grow 
after the climacteric, removal of the appendages does not check their 
growth. 
5. CEdematous myomas should be removed by a hysterectomy as 
the entire uterus will usually be found taken up in the body of the 
neoplasm. 
6. Fibroids undergoing mucoid or colloid degeneration should be 
removed by a hysterectomy. 
7. Suppurating fibroids, when not extruded into the vagina, should 
be removed by a hysterectomy. 
8. Pediculated fibroids, if the pedicle is small, may be removed 
with safety by taking all due precautions to guard against haemor- 
rhage. 
9. All hysterectomies (with Dr. Price's qualification) should get 
well. 
10. Oophorectomy or salpingo-oophorectomy, as a means of relief 
for tumors of the uterus is being more and more limited in its sphere 
by a more thorough understanding of the nature of these growths. 
11. Medicinal agents and electricity may in many instances re- 
lieve the symptoms for a short time, but the uncertainty and the 
dangers attending their use more than outweigh the expectations for 
good. 
12. The operation of Bantock as described is quick, safe, effi- 
cient and is followed by the lowest mortality. 
13. The liability to post-operative hernia is not increased by the 
ventral-fixation method. 
14. I'he convalescence is of very little if any longer duration than 
that following the other procedures. 
15. The "drag on the pedicle" and unsightly cicatrix are objec- 
tions raised by some to the wire method, that disappear after a short 
time and actual experience in handling these ca««9S. 
16. The suppuration about the pedicle so much dreaded by those 
who have never performed the operation, is an objection that is easily 
set aside in the face of a recognition of the fact that when it does 
occur it never kills and that the same objection may with justice be Uterine Fibroids. Hysterectomy. Treatment of the Pedicle. 
9 
raised against the other procedure-i. e., suppuration in the vaginal 
vault. 
17. Fistulas in the Bantock operation are of rare occurrence and 
are due in most instances to a faulty technique during the operation 
or want of surgical cleanliness and good judgment in managing the 
case afterward. 
18. In the Bantock operation there is less danger of ureteral and 
bladder injuries, the dangers from sepsis are reduced, the likelihood 
of secondary haemorrhage minimized and time of operative procedure 
shortened.