[Reprinted from the American Gynaecological and Obstetrical Journal 
for August, 1896.] 
THE VAGINAL VS. THE ABDOMINAL METHOD OF 
DEALING WITH INFLAMMATORY DISEASES 
OF THE PELVIS* 
By A. H. Cordier, M. D., Kansas City, Mo., 
Vice-President of the American Association of Obstetricians and Gynaecologists ; 
Professor of Abdominal Surgery Kansas City Medical College ; 
President of the Tri-State Medical Society, Etc. 
The aim of the surgeon in the application of his methods is to 
obtain the maximum benefit with the minimum sacrifice of struc- 
tures, the least amount of risk to life, and the saving of time and 
pain to his patient. These various results are best obtained by one 
surgeon by the following of a technique to him easy and successful, 
while another is equally successful in obtaining the same results by 
a procedure different wholly or in part. With many surgeons the 
choice of operative procedure determines his success, while others 
possess that rare gift of making a success of any and all methods, 
and are to be congratulated and admired by those of less dexterity. 
Some never make a success of any method, and are constantly scan- 
ning the pages of foreign literature for something new to try. In 
this way much harm is wrought to surgery, and many lives lost. I 
would not be misunderstood on this point, as I do not in the least 
desire to place a depreciative stamp on any good and safe surgery, 
be it foreign or a home procedure; but I do desire to enter a protest 
in the matter of hastily accepting the revival of a class of surgical 
procedures discarded some time ago in this country, and lately re- 
vived in part in Europe. I refer to the draining and partial removal 
of the diseased appendages, and the total removal of the uterus in 
cases of double tubal disease. 
* Read before the Missouri State Medical Society at Sedalia, May 19, 1896. 
Copyright, 1896, by J. D. Emmet, M. D. 2 
A. H. Cordier, M. 1). 
That the reports from a few skilled operators are so favorable 
(in as far as concerns immediate recoveries) that they are seductive 
no one will doubt, and a temptation to accept the theories and follow 
in the footsteps of the advocates of these methods, on first reviewing, 
is often too strong to be resisted by many. 
It is perfect surgery, or as nearly perfect surgery as is possible, 
that all surgeons desire, but, before accepting precepts involving 
human life or comfort, all evidence should be brought to bear on the 
topic, duly analyzed and weighed for its proper worth. 
It is from this standpoint that the writer desires to discuss the 
subject of vaginal hystero-salpingo-odphorectomy, as described and 
practiced by many of the French and a few of our American gynae- 
cologists. Some men in other professions achieve renown by the 
mastership of their art; for instance, Paderewski, whose dexterous 
fingers and delicate touch on the ivory keys of his piano has startled 
and charmed the people of two hemispheres. However, there is 
but one Paderewski. 
The lirrjit and the character of the pathology should form an 
indication as to the character and the extent of the surgical proce- 
dure. A succulent and pus-infiltrated uterus, with possibly numerous 
pus foci, surrounded with pus-laden tubes and ovaries, should be re- 
moved, the choice of operative procedure being the one that, in the 
opinion of the surgeon, offers the greatest chances of immediate 
recovery from the operation, a permanent relief of the constitutional 
(septic) manifestations, the local symptoms resulting from the pres- 
ence of these diseased structures, and the repairing of the damage 
to surrounding organs wrought by their presence. 
A cancerous uterus should always be removed, if seen before the 
disease has extended to surrounding organs. The tubes and ova- 
ries, as a rule, should be taken along with it, thus getting as far be- 
yond the diseased area as possible. 
A uterus known to be tuberculous should be removed along 
with the appendages, as by so doing a systemic infection may be 
averted. The cancerous and tuberculous uterus, as a rule, can be 
removed through the vagina, for, if the disease has advanced so far 
as to involve the viscera, the case is an inoperable one, and should 
be left alone so far as surgery is concerned. The operation that 
promises nothing more than a specimen and a fee is not within the 
domain of legitimate surgery. 
In an old recurring puriform disease of the uterine annexa, where The Vaginal versus the Abdominal Method. 
3 
the adhesions are well organized and where the intestinal bladder 
and omental attachments are firm, the vaginal method would be 
fraught with more danger than the abdominal. These cases have 
established in part a peritonitic immunity by a prolonged and grad- 
ual process of auto-sero-therapy; consequently, the abdominal 
method is not so liable to inaugurate an acute dangerous peritonitis 
or septicaemia, as is often the case in the acute or primary attacks 
if operated on. 
Some of the advocates of the vaginal method only a short time 
ago maintained that it was an admission of incomplete operation to 
use drainage, yet they advance the good drainage by the vagina 
as an argument in favor of the vaginal route. 
It has long been an established and demonstrable fact that, in 
the great majority of instances, the uterrts is capable of taking care 
of itself, and that it does not give rise to any trouble by its presence 
after the diseased appendages have been removed. I do not under- 
stand why an organ with a good and free natural drainage should 
not recover, and yet (as is claimed) an ovarian abscess or parts of dis- 
eased tubes, with walls as thick and as shaggy as a cocoanut, get well 
with only an opening into the vagina. 
To remove the uterus and a part only (as is admitted in many 
cases) of a diseased tube and ovary, and leave a filthy sequestrum 
in the pelvis, and expect Nature to cure the case, is not good surgery, 
and a larger percentage will be found to have imperfect recoveries, 
fistulae, and continuance of the pain than if the work had been com- 
pleted. This it is possible to do, and it is done by good surgery 
when operating suprapubically. 
The Trendelenburg position and vision surgery took possession 
of the minds and technique of many operators a few years ago, and 
numerous articles were written lauding the advantages of that posi- 
tion while doing abdominal and pelvic surgery. The pathology is 
rarely confined to the pelvis, but its effect and extension are often 
found at the umbilical level. Some of these operators (and many 
of them are skilled and successful in every surgical sense) are now 
practicing and teaching the dark-route (vaginal) method, where 
strong instruments, the sense of touch, much muscle, and adhesive 
or staying qualities are factors in the make-up of the surgeon and 
his surgical outfit, and essential to getting the specimen or part of it. 
The vaginal-route operation is not an easy one, neither is it as 
quickly performed as the suprapubic. 4 
A. H. Cordier, M. D. 
Pus is not always found in the tubes and ovaries where their re- 
moval is demanded. Firm and well-organized adhesions are often 
found binding the omentum, bladder, uterus, tubes, and ovaries 
firmly together. These adhesions were at one time Nature's breast- 
works thrown out for the protection of surrounding organs, but, 
like Nature's work in many other localities, she here fails to undo 
her imperfect work. The vascularity or limit of these adhesions is 
only determined at the time of the operation. An omental adhesion 
to the fundus may be torn across in the beginning of an operation, 
and scarcely a drop of blood escape, while in another the haemor- 
rhage may quickly prove fatal. A bleeding of this character is best 
controlled by a good ligature, such as it is only possible to apply in 
all cases correctly by the suprapubic method. 
A prolapsed uterus surrounded by inflammatory diseased tubes 
and ovaries can best be treated by a vaginal hysterectomy, remov- 
ing appendages'at the same time. In this condition the uterus is 
not removed because of a fear that its infected state would preclude 
the possibility of a relief of the symptoms, but to relieve the symp- 
toms induced by the procidentia. Some of these cases are cured by 
the removal of the appendages, a ventral fixation of the uterus, and 
a repair of the vaginal tears. 
Occasionally a gynaecologist is called to see a case in the first 
attack, and finds the general state of the patient such that to attempt 
the major or curative operation would be fraught with a danger of 
such magnitude that it would be bad surgery to do otherwise than 
simply to make an incision into the mass in the vaginal vault and 
drain, with the idea of completing the operation at some future time. 
All are agreed upon the course to pursue in such a case. 
If the case should prove to be a true pelvic abscess, one of those 
extremely rare cases in which the pus is extraperitoneal-or, in 
other words, between the layers of the broad ligament-this seem- 
ingly minor procedure will be found, in the majority of instances, 
all that is necessary to effect a cure. These cases are rarely met 
with in practice, and not so often in the literature of to-day as in that 
of former years. To remove the uterus in such a case would be a 
sacrifice unwarrantable, as there is nothing to be removed but 
the pus. 
A failure to discriminate between this rare disease and the more 
common tubal disease until in the midst of a vaginal hysterectomy 
is extremely unfortunate, as it is then too late to retrace, while, if the The Vaginal versus the Abdominal Method. 
5 
incision was made suprapubically, the error would not be so expen- 
sive, and the correct course to pursue would be pointed out. 
It may be claimed that through a posterior vaginal opening the 
appendages can be examined, and the same deduction arrived at as 
though the abdomen was opened; but the fact must not be lost 
sight of that in these cases (true pelvic abscess) the pelvic perito- 
naeum is clean and uninfected, and that a posterior opening endan- 
gers the safety of this structure. A safe rule to apply here would 
be to cut into the bulging part where the pus is nearest to the mu- 
cous membrane. 
In the midst of a prolonged and difficult operation for the re- 
moval of the uterus and pus-bearing tubes an alarming haemor- 
rhage sets in, the exact source of which can not be found. The 
patient's abdomen is opened in the quickest possible time, with an 
imperfect asepsis, and the bleeding controlled; but three days later 
the patient dies from a peritonitis. 
The operator can not take the necessary time and precaution 
in preparing his instruments, his patient, and himself to do a clean 
abdominal operation when the question of most importance is to 
quickly save his patient from haemorrhage. The above remarks 
applicable to bleeding are of equal force in most instances where 
an intestine has been opened through the vagina. Very few opera- 
tors, I am sure, would feel competent or able to put in a row of Lem- 
bert sutures, and make a closure of an intestinal rent that could be 
trusted to keep in liquids and gases. 
The mesentery, in cases where many adhesions are present, will 
be found thickened and shortened at the time of operation to such 
an extent that it would be impossible to pull a coil of bowel down 
into the vaginal opening, already filled with a dozen, more or less, 
pressure forceps. 
In comparing the relative ease with which the manipulation 
can be carried on through an abdominal incision and an opening in 
the vaginal vault, it must be remembered that the bony resistance 
met with by the impinging of the hand against the pubes is unyield- 
ing, differing very much from the pliant muscle of the abdomen 
under anaesthesia. 
A small percentage of post-operative herniae is found following in 
a large series of abdominal incisions, but these are discovered by 
the patient and not by the surgeon, and are not of such frequent 
occurrence as to be used as an argument against the suprapubic 6 
A. H. Cordier., M. D. 
incision. Time and close investigation of the vaginal cases will re- 
veal an equal or a larger number of vaginal bowel protrusions. 
The length of the mesentery precludes, in most instances, the 
possibility of the intestine reaching the outer entrance to the vagina, 
and many vaginal intestinal herniae will not be discovered by the 
surgeon owing to the return of the bowel when the patient is in the 
usual position for vaginal examinations. In examining for a,vaginal 
hernia, the examination should be made with the patient standing. 
It is not sound argument to advance that the woman with a 
vaginal operation can get up and be about in ten days, as it is not 
probable that the vault has healed so much more quickly than a 
smaller, clean, incised wound in the abdominal walls. 
One writer says: " The abdominal scar is a source of great worri- 
ment, especially to the Frenchwomen, who are great admirers of a 
fair complexion and unblemished skin." A suprapubic scar and a 
low-necked dress may be incompatible in Paris. Even some who 
held other views are made converts to this idea after visiting the 
French metropolis. 
Very few cases in abdominal surgery die from shock if the work 
of the operator is decisive and quick. " Chronic surgery " and pro- 
longed anaesthesia kill many patients, regardless of the character or 
location of the pathology or route of surgical approach. Septic 
patients endure anaesthetics and slow surgery badly. 
One writer, and, by the way, a good operator, in praising the 
vaginal system, says: " Landau has done good work, but in a great 
many cases he opens the abdomen to finish." (Italics mine.) Landau 
is regarded as an expert surgeon, yet in a large number of cases he 
is compelled, in the midst of an already prolonged vaginal operation, 
to open the abdomen to finish his work, thus making two incisions 
instead of one, opening the pelvic and abdominal cavities. This 
work can always be completed by the suprapubic route. 
Not a week ago, in breaking up universal adhesions, the appen- 
dix (which was diseased) pulled off at its caecal end, leaving a ragged 
opening into the caecum. The discovery and closure of the bowel 
injury saved my patient. Others have had similar experiences.