[Reprinted from the American Gynecological and Obstetrical Journal 
for August, 1895.] 
THE VAGINAL ROUTE FOR OPERATIONS ON THE 
PELVIC VISCERA.* 
D. Tod Gilliam, M. D., Columbus, Ohio, 
It is not many years since all, or nearly all, operations on the 
supravaginal pelvic structures were done per vaginam. 
In this category were operations for the removal of the submucous, 
uterine fibroid, the evacuation of pelvic abscesses, hsematoma, and 
other fluid collections, and later those for ectopic gestation. Follow- 
ing this came the craze for abdominal section. 
The peritoneal cavity, so long the hobgoblin of surgeons, could 
now, thanks to aseptic methods, be invaded with comparative im- 
punity. This gave a wonderful zest to the work, and it was prose- 
cuted vigorously along all the lines. A flood of light followed the 
knife into the abdomen and pelvis, mooted questions were set at rest, 
false theories abandoned, and pathology revolutionized. 
Brilliant surgical achievements followed each other in bewildering 
profusion, and the infatuation spread. The knife was in every hand, 
and many women carried on the most prominent part of their anatomy 
the private mark of their favorite surgeon. 
At this time the gynaecologist who was not an abdominal surgeon 
was clearly in disfavor. Did he attempt to remove a submucous 
fibroid, eliminate the uterine appendages, tap a pelvic abscess, or in 
any manner deign to interfere surgically with supravaginal structures 
through the vagina, he was ridiculed and characterized as a fossil. 
This more especially among English-speaking peoples. Meanwhile 
the Germans devised and perfected a technique for vaginal hysterec- 
tomy which slowly but surely made its way into general favor. 
One of the cardinal rules governing the selection of cases for this 
operation was that the uterus should be freely movable—so movable, 
indeed, as to be easily drawn down to the vulva. An attempt to oper- 
* Read before the Ohio State Medical Society, May~i6, 1895. 
Copyright, 1895, by J. D. Emmet, M. D. D. Tod Gilliam, M. D. 
ate under other circumstances was regarded as reprehensible. Pean 
then conceived the idea of removing the immovable uterus. It was a 
bold thought and well worthy the genius of the great French surgeon. 
He succeeded. His success was the signal for a storm of antagonism. 
The operation was denounced as a wanton and wicked mutilation. 
To remove the womb for pelvic inflammation was treason to all the 
better instincts of humanity. “ If,” say they, “we remove the tubes 
and ovaries, open and drain abscess cavities, curette, cauterize, and 
pack the uterus, we have done all that is justifiable. Then, again, 
the mortality of Pean’s operation must be appalling. Pean, it is true, 
with his marvelous skill, may meet with a measure of success, but the 
operation is not feasible and will die with him.” 
Pean replies : “A womb without tubes or ovaries is of no value. 
From it emanates poison that permeates and disrupts the pelvic struc- 
tures. The Tait operation and curettage can not remove the trouble.” 
A portion of the tube remains. It is infected. The ligatures that 
surround it are infected and the infection spreads again. The woman 
remains an invalid. Look at the anatomy of the parts. Observe how 
the blood-vessels and lymphatics center in and are distributed from 
the uterus. Observe, furthermore, how the natural drainage of the 
pelvis converges to the same point. If this organ be removed it will 
have the effect of removing a plug from the bottom of a basin. From 
a physiological standpoint the uterus is simply a nest for the recep- 
tion and maturation of the egg—without appendages it is of no more 
account than a deserted bird’s nest. From a pathological standpoint 
it is a hotbed of infection, distributing its deadly virus not only to 
the adjacent pelvic structures, but at times by way of the blood and 
lymph channels, scattering it broadcast through the general system. 
As a diseased organ in the midst of diseased tissues, it blocks the way 
to a free and natural drainage, and retards or renders futile Nature’s 
efforts to eliminate peccant matter. 
As to the mortality, I find that it is even less than the best results 
in the hands of the best abdominal surgeons. In time Pean was 
joined by Richelot, Segond, Jacobs, and others, and, backed by such 
spirits the operation was lifted to such prominence as to demand 
favorable recognition. 
Let us look a little further into its claims. General pelvic infil- 
tration and multiple pelvic abscess as the result of sepsis has always 
been the bane of the abdominal surgeon. He knows when he meets 
such a case that he is to grapple with difficulties sometimes insuper- 
able. He knows that he must reach tubes and ovaries and pus cavi- The Vaginal Route for Operations on the Pelvic Viscera. 
3 
ties through coils of agglutinated intestines and jumbled viscera. He 
knows that the adhesions are often dense, that the tissues are often 
soft and friable, and that rents in the bowel or bladder are likely to 
occur. He knows that the evacuated pus frequently inundates the 
peritoneal cavity and wells up through the incision ; that in draining 
he must drain against gravity. He knows that the immediate mor- 
tality is great, that convalescence is tedious with its loathsome ac- 
companiment of discharging sinuses, that many cases never recover, 
but lapse into a state of hopeless invalidism. He knows that ventral 
hernia is almost a common sequence, that painful scars are even more 
so. He knows that the intrapelvic structures are often matted and 
disturbed in their relations, that intestinal embarrassment or obstruc- 
tion is very frequent. He knows all this and much more. In the 
transvaginal operation the pelvic viscera other than the uterus and 
appendages are not disturbed. There is no handling of intestines, 
consequently but little shock. No breaking up of adhesions (except 
in so far as to liberate the uterus and appendages), no contamination 
of the peritonaeum with purulent matter, but simply an elimination of 
irreparably diseased parts. These are taken from the central and 
under surface of the arch, and there is natural, free, and uninter- 
rupted drainage. Under this all peccant matter is discharged, exuda- 
tions absorbed, adhesions dissolved, resolution and restoration com- 
plete. The patient is well. The mortality is less than by any other 
method. There is no hernia, no painful scar, no sense of insecurity, 
no languishing to a long-hoped-for death. 
2'echnique.—The instruments needed are a knife, two pairs of long- 
handled scissors slightly curved on the flat, three bullet forceps, a 
set of Pean’s retractors, four broad-ligament and several haemostatic 
forceps. The retractors being introduced, the cervix is seized with 
bu let forceps and a semicircular incision made in front from side 
to side, being careful to avoid the vesical wall. A similar incision is 
made behind but not so close to the cervix. From the junction of 
these incisions a linear incision three fourths of an inch in length is 
carried outward on either side along the face of the broad ligament. 
This imparts greater mobility to the uterus, and increases the distance 
between it and the ureters. With finger and scissors the cervix is 
freed from the bladder, a retractor being inserted into the opening 
and materially facilitating the process. 
In like manner the cervix is freed behind. Forceps are now ap- 
plied to the broad ligament on either side so as to include the uterine 
arteries, and the portion thus secured cut through, keeping close to 4 
D. Tod Gilliam, M. D. 
the uterine wall. The side retractors may now be dispensed with, the 
forceps taking their place. The cervix is next split up on either side, 
and the posterior half amputated. The anterior half is also ampu- 
tated, but before complete severance a new hold must be taken by the 
forceps on the anterior uterine wall above. From this time on the 
operation consists in dissecting off the bladder, splitting the anterior 
uterine wall longitudinally in the middle line, seizing the same on 
either side and cutting it away piece by piece until it is destroyed and 
the fundus reached. 
The anterior retractor should continually follow the finger into the 
depths of the dissection, and the traction forceps should always secure 
a new hold on the tissues above before a piece is cut away. When 
the peritoneal cavity is reached the narrow retractor should be sub- 
stituted for the anterior one, and should be pushed up into the cavity. 
Traction on the fundus will now cause it to roll forward and out into 
the vagina. Forceps are now applied to the upper half of the broad 
ligament from above downward, and the uterus cut away. Should it 
be practicable, the annexse are removed at the same time ; otherwise 
they may be left. Pus deposits, whether in the tubes or elsewhere, 
are opened, washed out, and drained, care being taken to protect un- 
infected parts by gauze packing. Adhesions to the uterus can usually 
be separated under the eye after its inversion into the vagina. A pad 
of iodoform gauze is placed over the tips of the forceps, to protect the 
intestines from injurious pressure, and between the forceps and vag- 
inal walls, to protect the latter. The forceps are removed at the end 
of forty-eight hours, and after gentle irrigation the dressing replaced. 
The gauze pads above the vaginal vault are not removed for six 
days. 
Notwithstanding the manifold advantages of the vaginal operation, 
as detailed above, it is not, as I believe, applicable to all forms of 
pelvic inflammation or all degrees of the same. There are limitations 
to its range of usefulness, as also its feasibility. For some years, un- 
der the domination of a passion for salpingectomy, every tube that 
could be made out to have undergone any pathological change was 
condemned to the knife. As a result there was a woeful and wanton 
unsexing of women, to the incalculable detriment of society. For the 
last two or three years we have been gradually coming back to our 
senses, and we find that under favorable conditions many of these 
ailments pass away entirely, while very few indeed pass on to a con- 
dition absolutely demanding operative interference or the sacrifice of 
the appendages. Ido not think it proper, therefore, to remove the The Vaginal Route for Operations on the Pelvic Viscera. 
5 
annexa in many instances, and certainly not to remove the uterus 
except in the most aggravated cases. The danger is that this, like all 
other popular movements, will be carried to extremes ; and in the 
eager chase for notoriety, and ofttimes through self-imposed blind- 
ness, there will ensue such a rage for vaginal hysterectomy as will do 
irreparable damage. 
It was the dread of multiple pelvic abscess, the fearful mortality 
attending the operation for the same, and the very unsatisfactory 
results ensuing, that impelled the coeliotomist to attack the diseased 
appendages at an early period, in order to forestall such dire conse- 
quences. 
It is in this connection that the great value of the Pean operation 
is manifested. 
Relative to this, it may be said that the coeliotomist’s extremity is 
the vaginal surgeon’s opportunity. In other words, when the de- 
structive changes of pelvic inflammation have gone to such an extent 
as to be practically beyond the reach of the coeliotomist, Pean steps 
in and, by removing the uterus per vaginam, makes possible a perfect 
recovery. Knowing this, the conscientious surgeon will keep hands 
off. As a result, thousands of women who have hitherto been sacri- 
ficed to the misguided zeal of the surgeon will resume the functions 
of life and maternity, and tens of thousands of children elsewise un- 
born will add to the strength of nations.