Vaginal Hysterectomy as Done 
in France 
BY 
EDGAR GARCEAU, M.D. 
Electro-Therapeutist to the Free Hospital 
for Women, Boston; Visiting Physician 
to Convalescent Home, St. Eliza- 
beth’s Hospital, Boston, Mass. 
amiDTID fKOM 
The American Journal of Obstetrics 
Vol. XXXI. No. 3,1806. 
NEW YORK 
WILLIAM WOOD & COMPANY, PUBLISHERS 
1895 VAGINAL HYSTERECTOMY 
AS DONE IN FRANCE.' 
In 1886 Pean removed the uterus through the vagina from a 
patient who had undergone celiotomy at his hands four years pre- 
viously. The primary operation was done for inflamed appen- 
dages and was unsuccessful in relieving pain. The hysterectomy 
was brilliant in its results. This incident led him to think that 
perhaps too much attention had been bestowed upon the appen- 
dages, and that the uterus might be quite as much responsible 
for pelvic pains as the ovaries and tubes. Reasoning that the 
uterus was diseased as well as the appendages, and frequently 
more so, though perhaps not appreciated as such, he came to the 
conclusion—certainly a logical one—that, in cases of pelvic in- 
flammation involving the female organs of generation, not only 
should the appendages be removed, but likewise the uterus as 
well. As his observations extended and his experience grew 
larger, he found that even in those cases in which the uterus 
was removed and the appendages abandoned a cure resulted 
which proved to be permanent in the vast majority of cases. A 
convincing argument in favor of the new method was that the 
mortality was very much lower than that of celiotomy, ceteris 
puribus. His first sixty cases all recovered ; among them were 
some severe types of pelvic inflammation with dense adhesions 
matting the intestines together to such an extent that celiotomy 
would have been dangerous had it been attempted. 
The new operation met with great disfavor. For a while Pean 
was alone in upholding his views. Segond was the first con- 
1 Read before the Gynecological Section of the Massachusetts Medical 
Society, December 27th, 1894. 2 
vert. He saw Pean operate and cure a patient who had the 
worst kind of pelvic inflammation. It was clearly a desperate 
case: the uterus was flrmly embedded in dense adhesions; the 
induration of the viscera extended almost up to the umbilicus. 
To remove the appendages by celiotomy was not to be thought 
of. To remove the uterus vaginallv under such conditions 
seemed impossible. Pean demonstrated the feasibility of doing 
this and cured the patient besides. 
Gradually the operation gained a foothold, mainly through 
the able writings of Segond, who defended it with extraordinary 
energy, until now even its bitterest opponents are forced to ad- 
mit that vaginal hysterectomy has a place in surgery. 
At the present time the question when to do vaginal hyste- 
rectomy and when to do celiotomy is far from settled. There 
are some who do the vaginal operation in all cases of double sal- 
pingitis, associated or not with purulent collections, and others 
who do it only when celiotomy is contraindicated; still others 
occupy a middle ground. As in all questions of this kind, the 
future will decide. 
The operation.—The instruments should be: three knives 
with long handles, one straight, two curved on the flat with 
edges right and left respectively ; five vaginal retractors of the 
Pean model; two pairs of scissors, straight and curved, with 
blunt points; two three-toothed traction forceps; two bullet- 
traction forceps; a plentiful supply of hemostatic forceps having 
a bite of different lengths—a half-dozen of one and a quarter 
inches, a half-dozen of three inches, a few, curved on the flat, of 
three inches, and about a dozen ordinary small ones; uterine 
sound; needles, etc., in case the bladder is opened; two hooks 
for everting the uterus ; self-retaining catheter ; reflux catheter; 
sponge holders ; uterine curettes and dilators. 
The Pean retractors require special mention. They are long, 
flat blades gently curved at the very end, mounted on strong 
aluminum handles. In the middle of the instument, at the 
junction of the blade and the handle, is a sharp angle which 
increases the efficiency of the instrument, for it makes it easier 
for the assistant to manage. Each blade is four and a half 
inches long and one and a quarter inches wide ; the handles are of 
about the same length. Four of the retractors are of the same 
size and are used to separate the vaginal walls and expose the 
GARCEAU : VAGINAL HYSTERECTOMY AS DONE IN FRANCE. 
3 
cervix. The fifth retractor is only seven-eighths of an inch wide, 
though of the same length; it is very useful to slip into a small 
opening in the peritoneum, and serves as a guide to a larger 
retractor. 
The hooks may also be mentioned ; they are eleven inches long 
and have each two hooks at their extremities, three-eighths of an 
inch apart. They are very useful at times in everting the fundus. 
The self-retaining catheter is very ingenious. It is an ordi- 
nary flexible soft-rubber catheter, having opposite its eyelets 
two rubber shoulders projecting one-quarter of an inch from 
the shaft, one on each side. These prevent it from slipping out 
of the bladder unless considerable traction is made; if this is 
done the rubber shoulders straighten out and the catheter is 
removed. To introduce the instrument a long whalebone sound 
is passed into the canal of the catheter as far as its tip. By 
drawing the mouth of the catheter toward the free end of the 
sound its shoulders straighten out and it can be easily passed. 
Preparation of the patient.— For eight days before the opera- 
tion the patient has vaginal douches of corrosive sublimate 1: 2000. 
The day before she is well purged, and this is followed by a 
rectal enema at least six hours before the operation ; if this is 
not done, and the enema given just before operation, there may 
be great annoyance caused by the discharge of fluid which has 
not wholly escaped. It is unnecessary to comment on the details 
of cleansing and shaving; soap, brush, and corrosive are freely 
used, both externally and in the vagina. The urine is now 
drawn and the limits of the bladder determined by the finger in 
the vagina. 
In these as well as in celiotomy cases the French surgeons 
have their patients’ lower limbs wrapped in cotton wool and 
bandaged ; this remains on three days; it lessens shock. 
The patient being on the back, the operator now examines the 
pelvic organs in order to determine what his line of action shall 
be. In the majority of cases it is most convenient to operate the 
patient in the dorso-sacral position ; it is easier for the assistants, 
the patient remains stationary, her breathing is not interfered 
with, and fewer assistants are needed. When, however, on ex. 
animation the uterus is found to be firmly adherent, surrounded 
by masses, and high up, the left-lateral position of Pean will be 
preferred, for more room will be gained. But this cannot be 4 
GARCEAU : VAGINAL HYSTERECTOMY 
said to be a hard-and-fast rule, for the majority of French ope- 
rators, except Pean, never under any circumstances use the left- 
lateral position, believing that there is no uterus which cannot be 
attacked to advantage in the dorso-sacral position. The left- 
lateral is practically Sims’ position, except that the left limb is 
extended and the right one sharply Hexed on the patient’s chest. 
Simple Vaginal Hysterectomy without Complications, the 
uterus being removed en masse.—Most surgeons, particularly the 
Fig. 1. -The retractors are in position and the bullet forceps draws down the cervix 
Americans, prefer to use ligatures instead of forceps for control- 
ling hemorrhage. This method is certainly much more comfort- 
able for the patient, but when it is necessary to do an operation 
quickly it is perhaps better to employ forceps. The objections 
to forceps are their alleged insecurity, the possibility of wound- 
ing the viscera, and the difficulty of maintaining asepsis. A 
careful operator will avoid all these mishaps. The advantages 
are: they are easily applied; they are easily removed ; they 
control hemorrhage perfectly ; there is no subsequent fistula AS DONE IN FRANCE. 
5 
(from suture); and, lastly, they shorten the operation. In the 
descriptions which follow it will be assumed that forceps are 
used. 
In all cases in which endometritis is present it is well to dilate 
and curette the uterus ; some operators inject it with iodine after 
curetting. 
The operation begins by placing the four large retractors in 
position, one on each side and one anteriorly and posteriorly. 
The assistant on the left of the patient, the more important posi- 
tion, manages the anterior and left-lateral retractors, while the 
right assistant manages the other two. 
The cervix is now seized with traction forceps and the uterus 
lowered as much as possible (Fig. 1). 
Segond’s incision is infinitely the best, for by using it he has 
never clamped the ureter (four hundred cases). It is made with 
a knife. He keeps somewhat close to the os externum anteriorly. 
Posteriorly, however, he allows the knife to cut a little further 
away (about a third of an inch more). Having done this, he 
makes two additional incisions, one on each side, parallel to the 
lower border of the broad ligament; each is two-thirds of an 
inch long. The advantage is twofold : it gives more room and 
it protects the ureter. The distance of the circular incision from 
the os externum varies, of course, with the size of the cervix and 
the attachments of the bladder. Care should be taken not to 
cut too far out for fear of wounding the bladder, nor too near 
the os ; in the latter case, the line of “cleavage” between the 
bladder and the uterus not being hit, the operation would be 
laborious and slow. 
Directly the incision is made the tip of the anterior retractor 
is forced into the wound and pulled upward and backward along 
the cervix (Fig. 2). The sectioned tissue yields a good deal 
—surprisingly so, in fact—and it is just this maneuvre that 
makes the Pean instrument of so great value. While the retrac- 
tor is pulling back the tissue the blunt-pointed curved scissors 
are used to separate the attachments between the bladder and 
the cervix ; the concave curve of the scissors should point toward 
the uterus. Now short snips are taken from left to right, the 
greatest care being taken to keep as close to the uterus as pos- 
sible in order to avoid the bladder. With each snip of the 
scissors the retractor takes a fresh hold, being introduced into 6 
GARCEAU : VAGINAL HYSTERECTOMY 
the part just cut by the scissors. It is truly astonishing to 
witness for the first time the wonderful help given by the retrac- 
tors; without them morcellation would be impossible. Unless 
the attachments between the bladder and the uterus extend 
high up, which is rare, the peritoneal cavity will soon be opened ; 
it may be recognized by its bluish coloration and smooth surface. 
The large anterior retractor is now discarded and the narrow 
one thrust into the opening made ; the finger completes the 
Fig. 2.—The S6gond incision has been made and a large part of the cervix denuded. 
The anterior retractor pulls up the divided tissue, and the bullet forceps pulls down the 
uterus. The scissors are shown. 
separation. Some operators prefer to use the finger instead of 
the scissors in separating the anterior attachments; this is not 
necessary, for if the retractor is properly used there is no danger 
of wounding the bladder or ureters. However, when the peri- 
toneal cavity is being neared it is well to explore with the finger 
occasionally; if the tissues give at any one point, this point is 
probably nearest the peritoneal cavity. 
Having opened anteriorly, the same process is performed pos- 7 
teriorly; here, however, the linger will prove of greater service 
than the scissors. Sometimes it will be best to work in front and 
behind simultaneously. The hemorrhage up to this stage is 
insignificant and may be disregarded. 
Everting the uterus.—Anterior method. Traction downward 
should be made as much as possible by means of the forceps 
still on the cervix. Now the long-handled hook is dug into the 
anterior wall as high up as possible, and traction made; the ute- 
rus yields and begins to evert; the other hook is placed higher 
up and traction again made. By repeating this process the ute- 
rus suddenly pops out, sometimes unexpectedly. 
Posterior m,ethod. When the uterus is retroflexed, and also 
in cases in which the anterior attachments are unusually high, 
the posterior method is to be preferred. By using this method 
it is not necessary to complete the separation of the anterior 
attachments. The finger introduced into the posterior cul-de-sac 
explores the back of the uterus. Using the finger as a guide, a 
pair of bullet forceps is introduced and seizes the uterus high up 
on its posterior surface. The organ is now pulled down and out 
in such a way as to evert the fundus through the vulva. By 
this movement the broad ligaments are twisted on themselves ; 
their lower borders look up and in front, their upper borders 
down and behind. If the vesico-uterine attachments have not 
been separated entirely, this maybe done now; the finger is 
passed up behind by the side of the uterus over the broad liga- 
ment, and serves as a guide to complete the separation. 
Hemostasis.—A hemostatic forceps is now placed on the left 
broad ligament from above downward (with relation to the pa- 
tient), whether the posterior or the anterior method has been used. 
To do this the index finger seeks the top of the broad ligament, 
and guides the forceps, preventing it from seizing the intestines ; 
when the tip of the forceps strikes the palm of the hand it is 
locked. The ligament is now cut close to the uterus, so as to 
leave some tissue protruding from the forceps, for this might 
slip if this were not done. The same is done on the opposite 
side and the uterus removed. 
Sometimes there is a little oozing from the vaginal wound, as 
well as from the prerectal tissue. It should be controlled by 
clamping the peritoneal and the vaginal edges together with 
small forceps. 
AS DONE IN FRANCE. 8 
GARCEAU : VAGINAL HYSTERECTOMY 
Dressing.—Drainage is not required ; the forceps assure com- 
plete drainage. The dressing consists of small tampons of gauze 
well saturated with iodoform powder; each tampon has a string 
attached to it so that it can easily be removed. Care should be 
taken to place the tampons above the tips of the forceps, if this 
is possible, in order to prevent the intestines from lying on these, 
thus producing pressure necrosis. Other tampons are placed 
between the forceps and the vaginal walls, while a strip of gauze 
is placed between them and the vulva. The patient is cathe- 
terized again, and the dressing completed by covering the 
handles of the forceps with aseptic cotton ; a bandage is then 
applied. The patient is put to bed and her knees flexed and 
supported by a cushion. Pain is controlled by subcutaneous 
injections of morphine. In forty-eight hours tlje forceps are 
removed and the vulva and vagina douched. It is only after 
the sixth day that the upper tampons are removed ; this is in 
order to allow the peritoneal wound opportunity to contract 
down. Fresh tampons are at once replaced after douching. 
The dressing may now be done every day. In three weeks the 
patient is up and about. 
Details.—Many surgeons employ a self-retaining catheter. 
If the instrument is aseptic there is no danger of cystitis; it is 
not, however, absolutely necessary to use one. 
In incising the vagina the greatest care must be taken to keep 
close to the uterus, which serves as a guide. Experiments on 
the cadaver have shown that by using Segond’s incision there is 
less danger of wounding the ureter. If the simple circular inci- 
sion was made it was found that the ureter was one-half inch 
(1.5 centimetres) from the uterus, whereas with Segond’s inci- 
sion the distance was increased to flve-sixths of an inch (2.5 
centimetres). The explanation is perhaps to be found in the 
greater freedom of motion downward accorded the uterus, the 
ureters at the same time slipping outward and upward. 
If a fistula is made it is sewed at once; the natural contrac- 
tion of the tissues will do much to closetese fistulae. 
During the eversion of the uterus a bullet-traction forceps 
should pull down the cervix and prevent it from being carried 
up into the peritoneal cavity ; the uterus is flexed on itself in 
doing this. 
If the uterus cannot be everted, but can be lowered, the fol- AS DONE IN FRANCE. 
9 
lowing maneuvres should be performed: The cul-de-sacs being 
opened, the index finger of the left hand is introduced into the 
anterior opening in front of the uterus and seeks the top of the 
left broad ligament; then taking a long hemostatic forceps, one 
jaw is introduced into the posterior opening and the other into 
the anterior; before locking, the index finger explores behind and 
pushes aside intestines if they prolapse; this has already been 
done anteriorly. The ligament is clamped and cut and the ute- 
rus delivered. It is now a simple matter to clamp the right 
broad ligament. 
If the uterus will not descend progressive clamping must be 
done. The lower part of the ligament is seized with a forceps 
having a bite of one and a quarter inches on each side ; the 
ligament is cut up to the tip of the forceps, and the uterus, thus 
liberated, is lowered ; progressive clamping is done until the or- 
gan is out. If the uterus will not descend, and the operator is 
obliged to introduce his forceps directly into the pelvic cavity, 
the forceps must never be locked until the finger has explored 
anteriorly and posteriorly. Richelot passes his index and mid- 
dle fingers into the anterior and posterior cul-de-sacs respec- 
tively and guides his clamps in the most perfect manner. Care 
should be taken that the forceps do not nip the vagina, rectum, 
or bladder; sloughing would ensue (Mauclaire). 
Vaginal Hysterectomy when the Uterus is Adherent 
{hysterectomy for pelvic suppuration).—This operation is per- 
haps the most difficult of any on the pelvic organs. Various 
expedients have been devised since Pean’s first operation ; they 
bear the names of their originators, but the credit belongs en- 
tirely to Pean, for it was he who took the initiative, and his 
operation to-day is applicable to all cases, even the most diffi- 
cult. The others are merely modifications, and they bear a 
striking resemblance to the Pean operation. Quenu and Muller 
remove the uterus by median section; Doyen removes it by 
hemisection of the anterior wall, and everts it by traction. 
The best operation is perhaps a combination of the Pean and 
the Doyen. Briefly it may be described as having three 
stages : first, removal of the inferior segment of the uterus ; 
second, removal by morcellation of the anterior wall of the ute- 
rus ; and, third, eversion anteriorly of the stump. Probably no 
one operates better than Richelot by this method. He operates 10 
as follows : The patient being on the back, the retractors are 
introduced and the cervix seized (Fig. 1). The Segond incision 
is now made and denudation effected of the cervix proper exactly 
as described in the preceding operation (Fig. 2). As much of 
the anterior and posterior attachments is freed as possible, 
using the retractors to pull back the liberated tissue. The fin- 
ger, as well as the scissors, should be used to separate the adhe- 
sions, which are frequently exceedingly dense, especially poste- 
riorly ; the finger will prove to be quite as serviceable as the 
GARCEAU : VAGINAL HYSTERECTOMY 
Fig. 3 —The lateral retractors have been removed and their places taken by the clamps 
which have seized the uterine. 
scissors, and some operators prefer it to the scissors. 'In most 
instances as much as an inch or more can be liberated anteriorly 
and posteriorly ; every effort should be made to do this, because 
the uterine artery is to be clamped, and to secure it the first 
forceps should seize the broad ligament for at least an inch above 
its lower border. The forefinger of the left hand is now placed 
on the anterior surface of the cervix and glides along outward 
toward the base of the broad ligament; it penetrates between AS DONE IN FRANCE. 
11 
the anterior peritoneal fold and the ligament proper and pushes 
aside the ureter, which is not far distant; the same is done be- 
hind. Then two fingers grasp the broad ligament and serve as 
guides to the first forceps, which seizes the ligament at least an 
inch from its lower border and one-third of an inch from the 
uterus at the level of the external os (Fig. 3). The ligament is 
now cut the whole length of the forceps close to the uterus. 
Fio. 4.—The cervix has been split transversely into two flaps, which are seized by bullet 
forceps. The uterine clamps are shown. 
The same is done on the opposite side. The forceps now take 
the place of the lateral retractors, which may be discarded, but 
they must be handled with care. As a matter of fact, the late- 
ral retractors have but little to do. The cervix is now split 
transversely from side to side, through and through, up to the 
point of the forceps; two flaps are thus made, an anterior 
(pubic) and a posterior (rectal) (Fig. 4). The posterior flap is now 12 
GARCEAU : VAGINAL HYSTERECTOMY 
amputated obliquely from below upward, in order to remove as 
much as possible ; strong forceps seize the anterior flap and pull 
it downward ; the uterus begins to roll anteriorly, thanks to the 
void which has been made behind ; at the same time the scissors 
denude and separation is effected between the uterus and blad- 
der ; the retractor holds the ground gained; some progress is 
made. The anterior flap is then amputated, but before cutting 
it off entirely a bullet-traction forceps is fastened into the stump 
above, because it might retract; there would be some difficulty 
in getting it again. If the uterus is not very adherent and will 
descend somewhat it may be possible to make two more flaps, 
which are amputated in the same way after preliminary hemo- 
stasis of the broad ligament. But if the uterus is very adherent 
the rest of the operation deals with the anterior wall of the 
organ. Placing a bullet forceps on each side of the canal, the 
stump is pulled down as much as possible and liberation effected 
between the bladder and the uterus. After separating as much 
as possible, the anterior uterine wall is morcellated in the me- 
dian line in small pieces with scissors and knife in the manner 
shown in the diagrams (Fig. 7). The sections should be either 
vertical or oblique, according to the case—oblique if the uterus 
does not yield. The part removed should include all the tissue 
down to the uterine cavity. Two more bullet forceps are now 
inserted on the upper parts of the edges of the excavation ; 
renewed traction is made, more denudation effected, and mor- 
cellation carried higher up. By repeating the process the peri- 
toneal cavity is reached ; at this point all embarrassment ceases, 
for the bladder is definitely protected. 
Central excavation or morcellation is a quick process. The 
uterine cornua incline toward the median line ; the fundus de- 
scends in the form of a Y, which allows of its being hooked 
with the finger and pulled down* and out. If there are adhe- 
sions behind the uterus they may be separated under the eye 
with the greatest ease. Having done this, a strong clamp seizes 
the upper part of each ligament down to the clamp which has 
been placed in position from below (Fig. 6), and the rest of the 
stump amputated. Should there be any difficulty about evert- 
ing the organ when once the peritoneal cavity has been reached, 
the uterus is bisected antero-posteriorly in the median line and 
each half clamped separately. AS DONE IN FRANCE. 
13 
In all these procedures there is little hemorrhage and it may 
be disregarded. 
Details.—Very rarely is it impossible to remove all of the 
uterus by this method. When there are numerous extensive ad- 
hesions the operation is laborious and slow, requiring extraordi- 
nary patience ; the uterus is immovable and refuses to descend ; 
in these cases it is necessary to proceed with care, for the tissue 
is friable and is apt to tear. Sometimes the long knife will 
prove of greater service than the scissors. Very seldom does the 
Fig. 5.—The cervix has been amputated. The uterine clamps are seen on the sides. 
A cone has been morcellated from the anterior uterine wall. Two bullet forceps should be 
shown as seizing the upper edges of the excavation. The two lower ones are not absolutely 
necessary. This figure illustrates S6gond's morcellation. 
fundus of the uterus have to he abandoned. The final result, 
however, is said to be quite as good, provided the stump does 
not offer an obstruction to the flow of the pus, if there should be 
any. 
It is absolutely necessary to apply at least four forceps to the 
broad ligaments, one for each uterine and one for each ovarian. 
Some operators neglect this if these arteries do not bleed; it is 14 
GARCEAU : VAGINAL HYSTERECTOMY 
unsafe to do so, on account of the possibility of secondary hem- 
orrhage. Sometimes the adhesions may temporarily occlude 
these arteries and they bleed afterward. 
Segond’s method of rnorcellation is worthy of description be- 
cause it is so easy. It commends itself to one who has had little 
experience with the operation. He calls it central conoid exca- 
vation (“evidement conoide central”). Since he has used this 
method he has never had to leave the fundus behind. The ex- 
cavation begins after the cervix has been amputated, the ute- 
rines having been clamped. The next denuded portion is now 
removed in the following way: A curved knife cuts a cone, the 
base of which corresponds to the traction forceps below, the 
apex being in the anterior median line and up to the point of 
denudation. Before completely detaching the cone, bullet-trac- 
tion forceps are inserted into its upper edges ; the cone is then 
removed (Fig. 5). Pulling down again, fresh denudation is ef- 
fected and a new cone removed. By repeating this process the 
fundus is reached. The point is to operate in the anterior me- 
dian line. Little by little, thanks to the removal of the anterior 
uterine wall, thus removed by successive conoid morsels, the 
organ is everted (bascule) forward, dragging with it the supe- 
rior border of the broad ligaments. At this moment only, the 
operator thinks about hemostasis. As a matter of fact, there is 
but very little hemorrhage during anterior rnorcellation. 
The secret of the operation is never to apply forceps before 
seeing and feeling exactly where they are going and what they 
are going to clamp, and never to cut anything without being 
sure of the ground. The large retractors give unhoped-for room, 
and, well managed, protect the tissue from injury. 
There should never beany hemorrhage. The operator should 
always see what he is doing. It is not a blind operation. 
When it seems easier to do rnorcellation of the posterior wall 
of the uterus, as in retroversion, it should be done. The conoid 
excavation or Doyen’s median section (to be described later) 
should be employed, or simply Iiichelot’s method of morcella- 
tion. 
The management of pus pockets.—The operation described 
is applicable not only to cases in which there are no pus pockets 
—i.e., to cases in which there are simply inflammatory adhe- 
sions—but likewise to cases in which there are one or more pus 
cavities around the uterus. If, during the operation of mor- AS DONE IN FRANCE. 
15 
cellation, such a cavity is opened, the operator is not disturbed. 
He waits until the flow of pus ceases, enlarges the opening 
with his finger, washes out the cavity with the reflux catheter, 
and proceeds exactly as though nothing had happened. 
These pockets are situated in the broad ligament, in the tubes, 
in the ovaries, or in cavities formed by adhesions (encysted peri- 
tonitis) ; in the latter* case they may be in close connection 
wTith the uterus. Large pockets need not be considered form d 
able; Pean has done vaginal hysterectomy in a casein which 
Fig. 6.—Showing the clamps seizing the broad ligaments ; two above and two below 
The uterus has been removed. 
the abscess reached lip to the umbilicus. When it is evident, 
before operation, that pus exists on one or both sides of the ute- 
rus, it is well to proceed cautiously. It is possible in these cases 
that the uterus is fairly movable, and there is a temptation to 
remove the organ entire ; this should not be done, because in 
placing a long clamp on the broad ligament a pocket might be 
opened, and if this should happen the operation field would be 
obscured. But in morcellation the operator sees exactly what 
is being done, step by step, and there is no embarrassment 
(Segond). 16 
GARCEAU : VAGINAL HYSTERECTOMY 
If the cavities have not been opened during the operation 
they may be searched for now after the removal of the uterus. 
Sometimes the tubes appear as large, congested coils filled with 
pus. They should be incised methodically, in order not to soil 
the peritoneum. A mounted sponge or two are placed beside 
and above the tube ; these steady it and make it bulge into the 
vagina, at the same time shutting off the serous cavity. Then a 
cut with the knife opens the tube and the contents fiow into 
the vagina, while a pair of forceps at the same time seizes 
the mouth of the incision and prevents the sac from retract- 
ing upward. The cavity is washed out with corrosive and the 
tube sac now removed in so far as possible with the fingers, 
taking care not to tear the viscera. 
If the pus has escaped during the operation, search should be 
made for the opening; it will usually be found under the ute- 
rine cornu. 
Sometimes all the pus sac is not enucleable. After opening 
one or two pockets it is found that the cul-de-sac of Douglas is 
entirely obliterated and the pelvic cavity divided into two sacs, 
back to back against each other, and so firmly adherent that it is 
impossible to remove them. They have been opened and their 
contents drained. These are cases of double pyosalpinx and all 
of the pus is in the tubes. Here simple drainage suffices; the 
pockets are washed out, and care is taken that there shall be a 
free exit. Their subsequent behavior is like that of an abscess 
cavity anywhere else in the body ; they contract and become 
obliterated, thanks to the free drainage afforded by the removal 
of the uterus. 
In some cases there are multiple abscesses on one or both 
sides. The greatest care should be taken to search for them with 
the finger and open and drain them ; if left behind they will 
cause further trouble. To be sure, it is possible, and quite prob- 
able, that they will open spontaneously in a day or two, but it 
is not safe to count upon this event. 
The treatment of adhesions and the appendages.—The mat- 
ter may be summed up in a few words. When the appendages 
can be separated from the adhesions it is proper to remove 
them, otherwise they may remain behind. They will atrophy 
and give no further trouble. The inflammatory deposit disap- 
pears in an incredibly short space of time. The following case 
which came under my personal observation illustrates this 17 
point : M. J., 29, Ilpara, was admitted to the Broca Hospital 
(Pozzi’s) August 12th, 1891. Ever since her last confinement, 
three years before, she had been suffering from inflammatory 
pelvic trouble which had confined her to bed most of the time. 
The longest period of quiescence was three months; the rest of 
the time she had been practically bedridden from pain and pros- 
tration. She had had four attacks of pelvi-peritonitis, which had 
been severe, the last one eight days before entering the hospital. 
Examination showed a uterus which was fixed, immovable, and 
surrounded by inflammatory adhesions ; on the right a mass the 
size of a good-sized fist filling the pelvis and impinging on the 
rectum, on the left a smaller mass. Vaginal hysterectomy was 
done by Dr. Jayle, Pozzi’s first assistant. No pus was found. 
There was no shock to speak of, although the operation lasted 
over an hour. In three weeks the patient was completely well, 
suffering no pain, and walking about. I had examined the woman 
before the operation and easily made out the large masses ; when 
I examined her again, three weeks after the operation, I was 
astounded to find that on the left side almost nothing remained, 
and that on the right side there was only a mass the size of a 
small hen’s egg. She told me that she was perfectly well, and 
she looked so. And yet both ovaries and tubes were left behind ! 
When, however, the appendages can be removed it is proper 
to remove them. The contents of the pelvis, when inflamed, 
may be compared to an arch the keystone of which is the uterus ; 
this being removed, it is in most instances easy to remove the 
sides of the arch, for they can be undermined, as it were, and 
attacked from below. The forceps on the cornu of the uterus is 
pulled gently and the ovary and tube appear in the vaginal 
vault; care should be taken not to pull too hard. When the 
ovary and tube appear the finger is passed in and explores ; ad- 
hesions are separated and the appendages pulled into the vagina ; 
the pedicle is clamped and they are excised. This is a simple 
case. Sometimes the tubo-ovarian mass is high up and strongly 
adherent; the finger scarcely touches it and traction on the cornu 
effects nothing. The index and middle fingers are now passed in 
and explore ; the tactile sense tells what is ovary, what intestine, 
what omentum, and what tube wall; the line of “ cleavage is 
found and efforts made to free the mass. Things are very much 
as in a difficult celiotomy. There are cases in which the fingers 
do not suffice to pull down the ovaries ; in these cases a fenes- 
AS DONE IN FRANCE. 18 
GAKCEAU : VAGINAL HYSTERECTOMY 
trated forceps is often useful to seize the organ and cause it to 
descend. Gentleness is requisite for success, and no harsh mea- 
sures should be adopted. When persistent, careful efforts have 
been made without avail, the appendages must be abandoned and 
Nature allowed to complete the cure (Richelot). 
Dressing.—This is the same as in simple vaginal hysterectomy, 
except that the pus pockets should be filled lightly with iodoform 
gauze, which is removed with the tampons six days later. Care 
must be taken at this first dressing to place the fresh tampons as 
high as possible in the vaginal vault, because if placed too low 
the contraction of the wound might shut off the openings of the 
pus pockets and a secondary abscess result. Should such an 
occurrence happen it is easy to open the abscess per vaginam. 
The forceps are removed in forty-eight hours. It is extremely 
rare* that a hemorrhage occurs on their removal. If it should 
happen the patient should be taken to the operating room and 
placed in Sims’ position. The tampons are removed, the re- 
tractors inserted, and the bleeding points seized with forceps 
again (Richelot). 
During the days following the operation it is wonderful to 
witness the change in the patient. The temperature drops, the 
pulse becomes steady, the bladder and rectum regain their func- 
tions, and the patient makes rapid strides to recovery. The 
peritoneum has not been handled except in the pelvic cavity, 
and that very little ; the intestines have not been touched ; 
everything has been done in the vagina outside the peritoneal 
cavity. There is really not more shock than after an operation 
for a bad perineal laceration. 
After-treatment.—The patients take nothing by mouth for four 
or five hours after the operation, then they may have iced 
champagne in teaspoonful doses ; this and other stimulants is the 
only nourishment taken until the forceps are removed. The 
vomiting ceases now and the patients may have milk and Yichy 
water or cold bouillon. They may have nourishing food from 
the third day. 
An ice bag is to be placed on the lower abdomen immediately 
after the operation ; it diminishes pain and may be allowed to 
remain four to six days. Severe pain is controlled by subcuta- 
neous injections of morphine. On the third day a rectal injec- 
tion of glycerin one part and wine two parts is given (Pozzi), 
a few hours after the removal of the forceps. On removing the AS DONE IN FRANCE. 
19 
upper tampons on the sixth day no immediate vaginal injection 
should be given ; it is best to wait a few hours before doing so, to 
avoid violent colic which has sometimes been caused. Now the 
patient may have a daily injection of carbolized water, one per 
cent. A strip of gauze may take the place of the tampons from 
this moment. In ten to fifteen days, in non-suppurative cases, 
the liquid returns clear. The patients sit up in bed toward the 
eighth day, and get up on the eighteenth or twenty-first day. 
Sexual relations should not be resumed until cicatrization is per- 
fect ; it generally takes two months. 
Other methods of Vaginal Hysterectomy. Pearts ori- 
ginal method.—The patient being in the left-lateral position (or 
dorso-sacral), the retractors expose the cervix, which is seized 
and pulled down. The circular incision is made, the ligaments 
clamped and cut, and the two flaps, pubic and rectal, made and 
amputated, care being taken to fasten bullet forceps into both 
flaps before amputating them. Securing a good hold again, 
denudation is effected anteriorly and posteriorly for as great a 
distance as possible. Two fresh pairs of hemostatic forceps now 
grasp more of the ligaments above the first ones ; the ligaments 
are cut, new flaps are made, and the process continued until the 
uterus is removed. Each stage comprises four maneuvres : 1st, 
liberation of the anterior and posterior surfaces of the uterus; 
2d, section of the broad ligaments ; 3d, division into two flaps of 
the portion of the uterus liberated ; 4th, excision of the two flaps 
thus obtained. The whole organ is removed without losing a 
drop of blood, and seeing exactly what is being done. The first 
principle of the operation is never to apply forceps, nor to cut 
anything, without having seen the region on which the forceps 
are to be applied or the knife carried. 
The solution of the operation is to be found in the retractors 
and in the division of the uterus into flaps. The retractors give 
unhoped-for room and, well managed, protect the tissues from 
injury. The division into segments allows the uterus to descend, 
even when it seems at first sight impossible for it to do so. 
This method is applicable to all cases, and has been employed 
with success when other methods have failed. It is the parent 
operation and has held its ground well. 
The rules already given in regard to the management of pus 
and the appendages apply to this method as well as to those 
about to be described. 20 
GARCEAU : VAGINAL HYSTERECTOMY 
Doyen’s method of hemisection and eversion, patient on the 
back. This process is applicable to cases in which the uterus is 
not too firmly adherent and can be somewhat lowered ; also to 
cases in which the uterus is not more than twice its normal size. 
It is particularly to be selected when the uterus is very mov- 
able. 
The great advantage of the method is that preliminary hemo- 
stasis of the broad ligaments is unnecessary. The ligaments are 
not clamped until the uterus is everted through the vulva. 
Figs.17 and 8.—Diagrams showing the Richelot vertical or oblique morcellation of the 
anterior uterine wall. 
Fig. 7. 
Fig. 8. 
The anterior lip of the cervix is seized with two pairs of 
bullet-traction forceps, one on each side, to the right and left; 
they remain here until the end of the operation. The circular 
incision is made and as much denudation effected as possible with 
scissors, retractor, and finger, both in front and behind. Now 
the anterior wall of the uterus is split in the median line between 
the two pairs of bullet-traction forceps, with the straight scissors, 
up to the point where denudation ceases (Fig. 9). Two more 
pairs of traction forceps seize the upper edges of the incision 
near the angle; traction downward is made, fresh denudation AS DONE IN FRANCE. 
21 
effected, and the median splitting carried higher up ; two more 
pairs of traction forceps are inserted as before and the process 
continued until the uterus is everted. The anterior cul-de-sac 
has been opened during the operation of hemisection. 
The central section is a very quick way of reaching the peri- 
toneum. The cornua incline toward the median line; the fundus 
descends in the form of a V and can be seized with the finger 
and pulled down. If necessary the median section is carried 
over the fundus to the posterior wall, splitting the uterus in two 
halves. Adhesions behind are easily attacked and separated. 
The appendages are separated and drawn out. If possible a 
single large clamp seizes the broad ligament from above down- 
ward and external to the appendages, thus controlling the hemor- 
rhage (Fig. 11). Doyen applies a lighter forceps, just inside 
the large one, in order to be more sure; the uterus is then 
amputated. In cases in which the appendages cannot be lowered 
enough to be included in the large clamp, it is necessary to clamp 
them higher up with another pair of forceps. When the uterus 
is retroverted the hemisection may equally well be performed 
on the posterior wall. 
The advantages of the method are : first, preliminary hemo- 
stasis of the broad ligament is unnecessary; second, the opera- 
tion field is not obstructed by clamps; third, removal of the 
appendages is easier, there being no clamps in the way. 
The median incision is not attended with much hemorrhage ; 
it may be disregarded. 
The method of Muller and Quenu, patient on the back.— 
The steps are the same up to the completion of the cervical de- 
nudation. The uterines are either ligated or clamped. The 
essential feature of the operation is the splitting of the uterus 
antero-posteriorly into two lateral halves progressively from be- 
low upward, denuding as the operation proceeds; otherwise it 
does not differ from Doyen’s, and, like his, it is applicable to 
cases of fairly movable uteri, or to cases of only moderate en- 
largement of the organ. 
The choice of methods.—As to the choice of methods, this 
must be left to the operator ; what is simple for one is difficult 
for another. Personal equation must be considered. Everything 
depends on the skill of the operator and his readiness to take 
advantage of circumstances as he finds them. To formulate 
special rules which would be applicable to special cases is impos- 22 
GAKCEAU : VAGINAL HYSTERECTOMY 
sible. In general, Richelot’s method, which is really a combina- 
tion of methods, will give the best results. I have never seen 
Segond operate, but I believe that his central conoid excavation 
is a most excellent procedure, because it preserves the relation of 
the parts more perfectly, perhaps, than the vertical or oblique 
excavation of Richelot. 
There are three possibilities in vaginal hysterectomy: either 
the uterus descends easily, or descends with difficulty, or not 
at all. ~In the first instance any method is applicable; perhaps 
Fig.JO.—Doyen’s method of hemisection. Preliminary hemostasis 'not required. A 
bullet forceps to'the right and left below, and others above on the edges of the median 
section near the angle. / 
Doyen’s hemisection is the best. A cautious surgeon will per- 
haps prefer to clamp his uterines first. In the second instance 
the cervix is amputated first and the body removed next, either 
by anterior eversion after hemisection or conoid excavation of 
the anterior wall, or by posterior eversion after similar treat- 
ment of the posterior wall. If the uterus is absolutely immov- 
able there are but two methods, the flap method of Pean and 
the central excavation. Sometimes a combination succeeds—i.e., 
of the flaps and the central excavation. Here the operator takes 23 
advantage of circumstances; if the uterus cannot be everted, 
both anterior and posterior walls are attacked by the Pean flap 
method, and it is most exceptionally the case that the skilled 
operator is obliged to consider himself vanquished. 
Vaginal Hysterectomy when there is Enlargement of 
the Uterus.—The operation may be divided into two heads, 
cases in which the uterus is not more than twice its normal 
size, and cases in which the uterus is much larger. Richelot 
has removed tumors which have weighed three and a half 
pounds (thirteen hundred grammes). Pean removes all fibroids 
vaginally which do not extend above the umbilicus, or even 
higher. 
Gases in which the uterus is not more than twice its normal 
size.—Here any of the preceding methods already described is 
applicable, the choice being determined, to some extent, by the 
shape of the tumor and the preference of the operator. Doyen 
always employs his method of hemisection without special regard 
to shape. If the tumor refuses to come down he morcellates in 
the anterior median line by the oblique method (Fig. 10). He 
does not clamp his uterines, relying on the downward traction to 
stop hemorrhage by compression ; the hemorrhage is never con- 
siderable in any event. 
The method of Muller and Quenu is also a good one. As the 
uterus is bisected the uterine cavity is touched with a solution 
of chloride of zinc (1:10) as an antiseptic precaution. If the 
uterus is not adherent this method is perhaps as quick as any. 
The operation is begun by preliminary hemostasis of the uterines 
by clamps or ligatures. 
But the best of all is the method of Richelot. Again it is 
merely a combination of methods. Richelot seems to have taken 
the best features of all the processes and to have combined them 
in such a way as to give the most satisfactory results. His skill 
is wonderful. He makes the circular incision, denudes the 
cervix, and endeavors at once to enter the posterior cul-de-sac, 
generally an easy matter in the absence of adhesions. In incis- 
ing the vagina he takes care to cut not far distant from the ex- 
ternal os, because the bladder frequently descends well down on 
the cervix in fibroids. The anterior cul-de-sac will probably be 
opened later for the same reason. The uterines are now clamped, 
the ligaments cut, flaps made, the posterior one amputated, trac- 
tion forceps applied to the anterior one, and renewed efforts 
AS DONE IN FRANCE. 24 
GARCEAU : VAGINAL HYSTERECTOMY 
made to enter the anterior cul-de-sac. Having entered this, the 
anterior flap is in turn amputated. Now the rest of the broad 
ligament is seized with a single clamp, which is guided in such a 
way, by the index and middle fingers, as to avoid clamping the 
intestines. The hemostasis being assured, the uterus is removed 
by morcellation in pieces of varying size, no special care being 
taken about making flaps. The forceps used in morcellation of 
fibroids are of a special type (Fig. 13). In the process of 
morcellation care should be taken to secure the stump of the 
uterus with forceps before removing a morsel. The appendages 
are removed in the usual way. But the operation does not 
Fig. 10.—Oblique morcellation of the anterior uterine wall in a case of fibroid 
always proceed as smoothly as this. Sometimes the uterus re- 
fuses to descend and the ligaments cannot be clamped in toto. 
In these cases, if the flap method of morcellation is attempted 
(Pean’s), it will be found that the stump gives a poor hold 
owing to the size of the uterus and its height in the pelvis. It 
is better to do median or oblique morcellation of the anterior 
wall; Segond’s central conoid excavation is particularly to be 
recommended. The uterines have been clamped and there is 
no fear of hemorrhage. Having reached the fundus, the organ 
is everted anteriorly and the ligaments clamped from above. 
Details.—The relations of the uterine arteries, whatever the AS DONE IN FRANCE. 
25 
volume and the position of the tumor, always remain the same 
with regard to the cervix ; the same procedures are always to 
be followed in securing them. Sometimes there are dilated 
vessels, branches of the uterines, in the vicinity of the main 
artery; occasionally an extra pair of forceps will be required 
to secure these. Even if the cervix is partially effaced by the 
hypertrophy of one of its lips or hidden behind the symphysis, it 
Fig. 11.—Doyen's method of hemisection. The uterus has been everted and a clamp 
seizes the broad ligament. 
is generally possible to seize it and bring it down gently. Only 
once has Richelot had to attack the body of the uterus in the 
posterior fornix before making the circular incision; it was a 
large tumor. If suppuration of the appendages complicates the 
fibroid the operation is rendered more difficult. Here the rules 
already given apply. 26 
GARCEAU : VAGINAL HYSTERECTOMY 
Cases in which the uterus is of quite large size.—The ope- 
ration begins as usual by clamping the uterines and cutting 
the ligaments up to the points of the forceps. The cervix is 
now split transversely and the mouth of the uterus laid wide 
open ; uterine tissue in the way is removed by morcellation. 
The cervical flaps must be preserved, if possible, for they serve 
as traction points; if they cannot be saved they must be ampu- 
tated and forceps put higher up. The anterior retractor often 
has a hard part to play, because the peritoneum is reflected higher 
Fig. 12.—Morcellation of tumors of large size. The tumor is removed before attacking 
the uterus. Also illustrates the method of morcellating a simple submucous fibroid, 
sparing the uterus. 
than usual and is opened later; besides, the bulging of the fib- 
roid in front may hinder its progress and even prevent it from 
entering deeply when the anterior cul-de-sac is opened. The 
object now is to empty the fibroid contents of the uterus by 
morcellation. Tumors of small size may be met with, which are 
gently enucleated, cut out with the knife or scissors, or simply 
torn out with the forceps or hooks (Fig. 12). Some uteri are 
literally crowded with these small fibroids. After some prog- 
ress has been made, the uterus, already much diminished in size, AS DONE IN FRANCE. 
27 
may be seized right and left by its muscular walls (the flaps 
have been amputated) while the operator attacks the main tu- 
mor; this is removed in the same way by morcellation, until 
finally the uterus is transformed into a flabby sac, which is in 
turn morcellated or which can be everted with ease. Should the 
tumor be very large it may be necessary to do progressive clamp- 
Fig 13. —1Traction forceps used in morcellating fibroid tumors of the uterus. 
ing of the broad ligaments and remove the lower portions of 
the muscular walls, so that the upper parts of the tumor may 
be made accessible. Almost all the work, long and tedious, has 
been done outside the peritoneal cavity, which is opened at the 
end. It will be seen that the object is, not to remove uterus and 
tumor at the same time, but to morcellate the tumor before at- 
tacking the uterus. Sometimes the operation is exceedingly dif- 
ficult, and profound conviction and great coolness are requisite 28 
GARCEAC : VAGINAL HYSTERECTOMY 
for success. The white, rounded tumor appears in the depth of 
the wound. Traction is made on the cervical flaps to make the 
tumor more accessible ; but the anterior surface of the organ is 
arrested by the beak of the retractor, which cannot be dispensed 
with as it prevents the anterior vaginal wall from falling on the 
forceps. Between the retractor, which elevates, and the forceps, 
which pull, there is a struggle, and if the edges of the cervix 
or uterus are thin and friable the operator has a premonition 
that the forceps are about to slip. As quickly as possible a bul- 
let forceps grasps the uterine tissue by a few fibres, and another 
seizes the tumor. If the assistants now make the slightest move- 
ment to hold the retractor better, or if they “ change their grip ” 
at critical moments like these, the forceps are torn out and the 
tumor disappears. The situation is worse. An assistant de- 
presses the tumor by pressure on the abdomen, and at the same 
time the operator introduces bullet forceps on his finger as a 
guide, which steers it among the coils of intestines. The tumor 
is seized and drawn downward, care being taken not to open 
the jaws of the forceps very wide for fear of wounding the 
intestines. The whole difficulty comes from the fact that the 
surface of the tumor, not having been cut into yet, cannot be 
seized by a good bite of the traction forceps. It is well now to 
make a small incision into the mass with a knife and to intro- 
duce another pair of bullet forceps on its edge. The incision 
is now enlarged and strong traction forceps applied. The ope- 
rator is now master of the situation, and morcellation proceeds 
without difficulty. In every case it is possible to succeed with 
patience. Finally the last fibroid mass makes its exit in a lump, 
frequently dragging with it the fundus of the uterus. Some- 
times, however, there is a second fibroid, and even a third ; in 
these cases the operation is prolonged to an hour and a half or 
even two hours. The ureter has not been injured, even if it is 
displaced by the fibroid of the lower part of the uterus, because 
morcellation proceeds from the centre to the periphery (Riche- 
lot). In conclusion it may be said that Segond attacks even 
these large fibroids by his process of central conoid excavation. 
The most remarkable feature of the operation, which has 
been long, is the little degree of shock attending it. The peri- 
toneum has not been touched. The day after the patient has no 
pain and is comfortable. She does not look like a person who 
has undergone a severe operation the day before. (The descrip- AS DONE IN FRANCE. 
29 
tion of the operation for large fibroids has been copied almost 
word for word from Richelot’s book.1) 
Incision of the vagina to gain room.—In certain cases when 
the vagina is small it is necessary to incise the perineum. On 
the external surface the portion sectioned is represented by a 
line which begins about half an inch from the middle of the 
fourchette and extends down and out toward the ischium for 
about an inch and a half. In the vagina the incision has the 
same direction and is of the same length. The cut is best made 
by transfixion with a sharp-pointed knife, cutting from below 
upward. Hemorrhage is arrested at once. Generally enough 
room will be gained by cutting one side only, but there are 
cases which may require bilateral section. The incisions are 
sutured at the end of the operation. It may be said that the 
most skilful operators never find it necessary to resort to cut- 
ting the perineum. 
The results of vaginal hysterectomy performed for pelvic in- 
fiammation.—The statistics of Jacobs and Riclielot are the lat- 
est published. Both of these men are skilled operators, and 
their results may be considered as fairly representing the merits 
of the operation. 
Jacobs’ statistics include all cases up to the 1st of March, 
1894; Richelot’s, up to the 1st of January, 1894. 
Jacobs has done hysterectomy for double inflammatory affec- 
tions of the appendages 166 times ; he had 162 recoveries and 
4 deaths, a mortality of 2.4 per cent. Analyzing these cases 
we find that in 113 there were double purulent collections, 
which were due to salpingitis, ovaritis, or encysted peritonitis ; 
there were 111 recoveries and 2 deaths, a mortality of 1.8 per 
cent. The 2 deaths were due to cardiac complications. The 
bladder was perforated twice, the intestines once ; the opening 
was sutured immediately aud no fistula resulted. In 98 of 
these recoveries the patient was followed for a period varying 
from 1 to 4 years; the others were lost sight of: 5 or 6 com- 
plained of vesical pain due to adhesions; 1 died from demen- 
tia 8 months after the operation ; 1 had an incurable intestino- 
vaginal fistula ; 2 have had and now have severe pelvic pains, 
which, however, are intermittent; 88 of these cases were ab- 
solute cures. Analyzing the 43 cases of non-purulent inflam- 
“ L’Hysterectomie vaginale contre le Cancer de l’Uterus et les Affections 
non-cancereuses.” Paris, 1894. O. Doin, lSditeur. 30 
GARCEALT I VAGINAL HYSTERECTOMY 
matory troubles, we find that 1 died during the operation (re- 
nal case); 35 were absolute cures; there were some rebellious 
gastritis complications ; the rest were lost sight of. In 10 cases 
of tumor complicated with bilateral inflammation of the appen- 
dages, 1 died from embolism soon after the operation; 7 were 
followed for a year and were completely cured. 
He gives his abdominal work by way of comparison. There 
were 165 cases with 4 deaths, giving a percentage of 2.4, the 
same as by the vaginal method ; yet it is to be remarked that 
in 56 of these cases the lesion was unilateral, and it is to be taken 
into consideration that many of the cases operated on vaginally 
were desperate ones and inoperable by the abdominal route. All 
of these patients had inflammatory affections of the appendages. 
The distant results of his celiotomies are as follows: Out 
of his 10 unilateral pyosalpinx cases there were 4 permanent 
cures; the remaining 6 had subsequent inflammation on the op- 
posite side. The results in the cases of bilateral pyosalpinx are 
especially noteworthy: there were 3 deaths and 28 operatory 
recoveries; 25 were seen later; 17 of them had uterine or peri- 
uterine affections which required curetting in 11 instances, with 
or without amputation of the cervix ; 4 of them had to have a 
hysterectomy performed to relieve them of their pains; in 5 
there was rebellious parametritis. Among the 44 cases of non- 
purulent bilateral salpingitis many suffered from chronic ute- 
rine affections; vaginal hysterectomy was required once; in 
many other cases some kind of local treatment was needed. He 
had 34 cases of bilateral ovaritis; many of these had some kind 
of local treatment subsequently. The unilateral affections of 
the ovary (46) in general did well. In many instances operation 
for hernia following the celiotomy was required ('number not 
given). 
Richelot had 103 cases of strictly inflammatory diseases of the 
appendages, 61 of which were associated with pus ; there were 
7 deaths, a mortality of 6.7 per cent. Analyzing these cases we 
find that cures were obtained in almost all. In some there were 
heat flashes and nervous symptoms of various kinds, which dis- 
appeared in a short while ; a few had a tender vagiual cicatrix, 
but it was temporary. Richelot states, however, that in some 
instances when the appendages are left in situ subsequent in- 
flammation may be possible from the lighting up of the smould- 
ering fire. Sexual appetite was not diminished. AS DONE IN FRANCE. 
31 
Landau’s work is remarkable. He regards celiotomy as the 
operation of choice, but in certain cases he thinks vaginal hyste- 
rectomy infinitely superior. He says : “ There is a category of 
cases of suppurative disease of the pelvic cavity which are not 
amenable to the usual forms of treatment; in these celiotomy 
is extremely dangerous and puts the life of the patient in peril. 
These cases are those which are complicated with rupture of the 
tube into the bladder, rectum, or intestine ; reference also is made 
to multiple abscesses which are intra- or extraperitoneal. In 
these the best treatment is that inaugurated by Pean—vaginal 
hysterectomy with removal of the appendages.” He has had 30 
cases of this kind without a single death. 
Pean’s results are phenomenal. From the time of his first 
operation until December 31st, 1892 (later statistics not found), 
he had done the operation 150 times with 1 death. He states 
that 145 were completely cured. The patient who died was 
exhausted at the time of the operation and succumbed on 
the sixth day; of the remaining 4, who died during the year 
following the operation, death in 2 was caused by pulmonary 
phthisis, in 1 by cerebral hemorrhage, and in the remaining 
1 by syphilis. Most of the cases were serious and of long 
standing ; life was insupportable from suffering ; almost all were 
pale and wretched-looking. In two only were there post-opera- 
tory symptoms referable to the bladder ; they were finally cured. 
In almost all the disease was bilateral. 
The following table shows at a glance the results of various 
operators: 
Cases. 
Deaths. 
Jacobs 
4 
Landau 
30 
0 
Pean 
150 
1 
Segond 
11 
Routier 
0 
Terrier 
7 
Pozzi 
0 
Michaux 
2 
Richelot 
7 
Rouaffert 
21 
1 
Dewandre 
3 
0 
Sutton 
0 
Henrotin 
1 
724 
34 
This gives a mortality of 4.6 per cent. Considering the nature 32 
GARCEAU : VAGINAL HYSTERECTOMY 
of the disease—inflammation of the appendages—the mortality 
is not high. In cases of pelvic suppuration Jacobs’ results have 
hardly been excelled by any celiotomist; it is questionable if 
they have been equalled. He had 113 cases of double purulent 
tubes with 2 deaths, a mortality of 1.8 per cent! 
The results of vaginal hysterectomy performed for fibroids of 
the uterus.—The table is striking. The benignity of the method 
is apparent when it is considered that the cases represent the 
first efforts of the individual operators in almost every instance. 
The low mortality is to be explained by the insignificant shock. 
The tumors were of all sizes, some reaching to the umbilicus. 
Forceps were always used. 
Cases. 
Deaths. 
Mayer 
0 
Pean 
4 
Jacobs 
22 
2 
Mangiagalli 
8 
0 
De Ott 
100 
0 
Carle. 
22 
0 
Calderini 
1 
0 
Bockel 
0 
Routier 
0 
Riclielot 
1 
400 
7 
This gives a mortality of 1.7 per cent. 
In Richelot’s case of death the circumstance was due to his 
removing the upper tampons too soon. The woman had some 
irritation of the stomach ; he feared iodoform poisoning and 
removed the dressing on the fourth day ; she died the next day 
of peritonitis. lie always waits until the sixth day before dis- 
turbing the tampons. 
The claims of superiority of vaginal hysterectomy in cases of 
inf ammatory diseases of the appendages.—In the first place, the 
statistics are favorable. They are, on the whole, better than 
those of celiotomy. Jacobs’ results are wonderful. Landau’s, 
Pozzi’s, and Pean’s speak for themselves. Landau’s were all 
difficult, as well as Pozzi’s. Celiotomy is always preferred by 
Pozzi when he thinks there is a chance for success. All his 14 
cases recovered; they were desperate and inoperable by the 
abdominal route. As Jacobs says, the statistics of vaginal hyste- 
rectomy are derived from desperate cases. To quote Jacobs: 
“ Let us now review the indications for vaginal hysterectomy, 
beginning with the most difficult cases of suppuration com- AS DONE IN FKANCK. 
33 
plicated with adhesions. There is pus in the dilated tubes, in 
the ovaries, in the adjacent cellular tissue. The uterus is fixed 
and the coils of intestines are glued together above these lesions 
like a solid roof. In such a case celiotomy displays the adhe- 
sions, which cannot be separated without opening the bowels, 
with a chance that we may reach the purulent focus limited by 
them, open, empty, and drain it; and the result may be a slow 
recovery or an intractable fistula. Often we are confronted 
by a similar condition in which the pelvis is occupied by adhe- 
sions, in the middle of which the uterus is imprisoned, and yet 
without the presence of purulent foci. In such cases, owing 
to fear of accident, the surgeon is induced to relinquish the 
operation as an exploratory incision. It is of course always 
possible to finish the operation, but we have to consider the life 
of our patient. In just these cases vaginal hysterectomy gives 
results little short of marvellous—not wholly without danger, 
but with a security far greater than the abdominal. The col- 
lections of pus are opened into the vagina without infecting 
the peritoneal cavity ; the adhesions are severed, if possible, 
but should the finger encounter too great resistance they are 
abandoned, and in a few days they will soften and become ab- 
sorbed. In pelvic suppuration and with extensive complicated 
adhesions, both equally formidable for the celiotomist, vaginal 
hysterectomy is triumphant.” 
The most wonderful result after these operations is the im- 
mediate disappearance of the inflammatory masses. There is no 
doubt whatever about this. The explanation is probably to be 
found in the excellent drainage and in the removal of the cause. 
There is no reason why cicatrization should be any different 
from that in any other part of the body. An almost analogous 
condition is to be found in appendicitis. Before operative 
methods were in vogue in treating this disease, its frequent re- 
currence was its most distressing feature. The appendix removed, 
the patient got well. 
The starting point of pelvic inflammatory disease is the uterus. 
Endometritis is the first lesion. Pathological changes may 
reasonably be supposed to take place in the uterus. A paren- 
chymatous metritis enlarging the organ and giving rise to pain 
and leucorrheal discharge, or a chronic interstitial metritis with 
hypertrophy of the fibrous tissue, certainly demands as much 
attention as a purulent ovaritis or salpingitis, To neglect the 34 
GARCKAU : VAGINAL HY6TERKCTOMY 
uterus in such a condition is not logical. Once removed, even if 
the appendages are left behind, the reservoir of germs is no 
longer present to cause reinfection. Whether or not leaving be- 
hind the appendages, when they cannot be extracted, influences 
the final result has not yet been definitely determined. The 
question is perhaps sub judice. Those who have had most ex- 
perience with the operation say that only exceptionally is there 
any further trouble. At all events, there can be no fresh infec- 
tion. It is, however, rarely the case that they have to be left 
behind. One thing is certain, the immediate results are most 
excellent. 
Another point greatly in favor of the operation is the manage- 
ment of pus. The drainage is perfect. The pus and secretions 
flow down a natural incline and the peritoneal cavity is not con- 
taminated. In celiotomy the pus tubes frequently burst and 
the contents spread over the peritoneum. In case the pus is 
foul and fetid, such as is met with after abortions and childbirth, 
the accident is alarming and gives the operator great uneasiness. 
In cases in which pelvic suppuration iscomplicated with rectal, 
vesical, or intestinal fistulse, vaginal hysterectomy is the opera- 
tion of choice. A celiotomy under such circumstances is fraught 
with danger. But by the vaginal method the peritoneum is not 
soiled, the discharges flow into the vagina, and the fistula closes 
of itself. The conditions are favorable for such a result, the 
natural healing being aided by cicatricial contraction of the pelvic 
contents en masse; it is rare that a secondary operation is needed. 
The post-operatory shock of vaginal hysterectomy is infinitely 
less than that of celiotomy. The reason is apparent. The intes- 
tines have not been manipulated. Special emphasis must be 
made on this point, for it is one of the strongest arguments in 
favor of the operation. The pelvic cavity seems to have far 
greater tolerance for operative measures than the great serous 
cavity. 
The cicatrix, which is often tender, to say nothing of hernia, 
is not a factor in the vaginal operation; nor does the patient 
have to wear an abdominal support, so disagreeable to sensitive 
women. 
Vaginal hysterectomy removes the possibility of subsequent 
cancer of the uterus. Tubercle bacilli are found in twenty per 
cent of all cases of pus tubes; the inference is that they may b« 
present in the uterus. AS DONE IN FRANCE. 
35 
The ob jections made against vaginal hysterectomy are: the 
danger of hemorrhage daring the operation; the danger of 
secondary hemorrhage; the possibility of wounding the bladder 
and ureter and intestines; the difficulty of maintaining asepsis. 
The same accidents may happen in celiotomy, probably not 
less often. Statistics on celiotomy show this. As to the fre- 
quency of clamping the ureter, it may be said that Segond 
in 400 consecutive cases never clamped it once. Segond has 
never lost a patient from hemorrhage (up to 1893) ; lie has 
had secondary hemorrhage five times, which was in every case 
easily controlled—it happened on removing the forceps; he 
opened the bladder three times—it was sutured and the patient 
recovered ; he opened the rectum nine times—three times it was 
accidental, six times there was a pre-existing fistula: of these, 
two died several months after the operation from pulmonary 
tuberculosis; a third still had a small fistula, but it was a recent 
case; the other six recovered spontaneously without interference, 
notably a woman who had passed all the feces per vaginam be- 
fore operation. Richelot in 219 cases opened the rectum twice, 
the bladder once. In the first case of opening the rectum the 
fistula closed in a year—it was small and gave little trouble ; in 
the second the closure was accomplished in two years—it had 
given little trouble during the second year; in his bladder case 
the wound was sutured and the patient got well at once. He 
has had one case of severe hemorrhage on removing the clamps ; 
the patient recovered, but she came near dying. He has had 
three secondary hemorrhages which took place several days 
after removing the clamps; tamponing controlled it. Never, 
with Richelot, did the clamps become unclasped. As to the 
question of asepsis, with proper care it can be maintained. 
Sutton has taken pains to make examinations for bacteria in 
the dressings removed seventy-two hours after vaginal hysterec- 
tomy. In his five cases no germs were found. 
The greatest objection to the operation is the difficulty of 
making a correct diagnosis before operation in doubtful cases. 
The celiotomist who sees what he is doing has a great advantage 
in feeling as well as seeing. Pean, however, says that in such 
cases, which must in most instances be simple ones, it is easy to 
open the posterior cul-de-sac and explore with the finger. In 
severe affections involving both sides it is seldom that the dia- 
gnosis cannot be made beforehand. Another objection is the dif- 36 
GARCEAU : VAGINAL HYSTERECTOMY 
ficulty of performing tlie operation. This is certainly valid. It is 
difficult, and sometimes very difficult. A mere description, how- 
ever well presented, gives but an imperfect idea of the details 
which are absolutely requisite for success; a verbal description 
is not much better. As Segond says, “ one must see the opera- 
tion performed a number of times by a skilled operator who has 
done it many times himself, in order to learn it and be able to 
do it afterward.” It is unique in its way and cannot be com- 
pared with anything in surgery. The instruments, too, must be 
suitable; the Pean retractors are almost a sine qua non of success. 
It has been said that removal of the uterus induces nervous 
troubles. Segond has never seen this result, and he follows all 
his cases (400 up to November, 1894). 
The indications for vaginal hysterectomy.—It is natural 
that American surgeons who have not, perhaps, witnessed the 
results of vaginal hysterectomy should be somewhat sceptical 
about it. But here it may be said that Pean’s most bitter oppo- 
nents are to be found in France, and that they have been forced 
to admit that in selected cases it is the operation of choice. This 
admission has not been brought about by theoretical reasoning, 
but by actual results obtained in desperate cases. It is easy to 
understand opposition to vaginal hysterectomy. Abdominal 
methods have been perfected to such an extent that celiotomy 
to-day may be said to be at the very acme of perfection ; to re- 
place it by a method which at first sight seemed blind and 
hazardous appeared out of reason. But the way to convince is 
by logic and fact. Yaginal hysterectomy has come to stay. 
In Paris there are two camps, the hysterectomists and the 
celiotomists; the former never do celiotomy if they can help 
it, the latter never do vaginal hysterectomy under any cir- 
cumstances. But there is likewise a middle camp, that of the 
unbiassed surgeon who is ready to accept an innovation provided 
it can be proved to merit recognition. To this Pozzi belongs. 
His views appeared in Annales de Gynecologie et d? Obstetrique, 
1893, page 504; they have not changed since then, for vaginal 
hysterectomy was repeatedly done at his hospital last summer. 
Pozzi does vaginal hysterectomy for the following conditions: 
1. ‘‘Diffuse suppuration of a chronic nature involving all the 
tissues around the appendages and giving rise to such disorders 
that ablation of a limited pocket would seem to be of little 
value or impracticable.” AS DONE IN FRANCE. 
37 
2. “ Non-suppurative, very adherent, chronic conditions form- 
ing a mass in the pelvis. In these instances the chronicity of 
the affection, as well as the exacerbations of pelvic peritonitis, 
should be considered. The surgeon should not diagnosticate 
invincible adhesions without due reflection. It is perfectly pos- 
sible that an erroneous idea of the condition may be obtained 
from examining the patient during an acute attach; here the 
edema of the deeper tissues deceives the examiner.” 
3. “Continually discharging fistulse of the abdominal wall or 
vagina succeeding celiotomy (with or without drainage), and 
not yielding to curetting, to dilatation, nor to operation, with a 
view of finding the suture which causes the fistula. This must 
not be construed into an argument against celiotomy, for I have 
had to open the abdomen to extirpate appendages in a suppura- 
tive state, complicated with fistula, after vaginal hysterectomy.” 
4. “ Persistence of adnexial tumors which are painful, existing 
after celiotomy. I have had to do the same thing after vaginal 
hysterectomy.” Pichevin practically admits the same, but ad- 
mits as an additional reason, 
5. Fistulm opening into the rectum or bladder and communi- 
cating with a pus cavity. 
To complete the list we might add : 
6. Incurable disease of the uterus persisting after removal of 
the appendages by celiotomy. 
We might even add to these conservative indications that of 
Landau, which is, 
7. Extensive disease of the uterus, such as parenchymatous 
metritis, etc., complicated with double purulent salpingitis. He 
insists on removing the appendages, however, even if he is 
obliged to do a celiotomy at the same sitting to accomplish this 
result. 
These, then, are the indications which are recognized by the 
conservative surgeons. Perhaps it would be better to say by 
surgeons who prefer to do celiotomy when this method seems to 
offer any chance for success. 
Bat there are many operators, and their number is rapidly 
increasing, who think vaginal hysterectomy has a far wider range. 
Among them Richelot stands pre eminent. Ilis book, which has 
lately appeared, contains a most excellent resume of the indica- 
tions for vaginal hysterectomy. The whole subject is treated in 
a masterly way, and there is an absence of theoretical discussion 38 
GARCEAU : VAGINAL HYSTERECTOMY 
which, added to the simplicity of the style, makes the book most 
readable. All his cases (219) are given in full. He speaks from 
profound conviction, and such is his eloquence that one is im- 
pressed by what he says. 
Richelot, Segond, Pean, and others operate all cases by vagi- 
nal hysterectomy in which the bilaterality of the inflammatory 
trouble can be demonstrated. This includes the lighter forms of 
salpingitis and ovaritis, provided operation is imperative. They 
believe the results are better than in celiotomy. When, however, 
the bilaterality of the affection has not been demonstrated, and 
particularly if the patient is young, celiotomy is to be preferred. 
Richelot operates complicated cases of retroversion by the 
vaginal method. By complicated cases are meant those in which 
the uterus is firmly bound down in Douglas’ cul-de-sac and gives 
rise to severe metrorrhagia; in these conditions the ovaries are 
prolapsed and diseased. The symptoms calling for the operation 
are severe pains in the thighs and back, and a condition of 
nervous debility which makes the woman unfit for anything. 
He has operated 21 times under these circumstances, with com- 
plete cure in all cases. 
The social condition of a patient has to be taken into consider- 
ation in deciding the question of radical operation. A woman 
who has to work for a living, and who perhaps has been under- 
going so-called treatments at various hospitals and receiving 
absolutely no benefit from them, will frequently accept an opera- 
tion which will free her from the pains from which she has suf- 
fered months and months. On the other hand, a woman who 
has nothing to do, and who can devote a proper amount of time 
and care in following out a course of treatment which is intended 
to be palliative only, may by so doing be made so comfortable 
that it would be unwise to recommend any radical procedure. 
Richelot does not hesitate to do vaginal hysterectomy under 
circumstances like the following: The woman belonged to the 
working class; she was 42 years old and had had thirteen 
children at term. Ten months before entering the hospital she 
had a miscarriage. She was curetted one month after this mis- 
hap, and four months later Schroder's operation was performed. 
The hemorrhages continuing and becoming grave, vaginal hys- 
terectomy was done in November, 1893 ; three months later she 
was seen and was in perfect health. 
In cases of pelvic neuralgia resisting all forms of treatment, AS DONE IN FRANCE. 
39 
vaginal hysterectomy gives remarkable results. Ilichelot’s de- 
scription of this disease is concise. He says: “ The surgeon 
should operate with extreme caution. The severe forms of pelvic 
neuralgia are to be called manifestations of true hysteria with- 
out painful localizations in the pelvis. There is pain, hut there 
is no pathological lesion. The diagnosis is to be made as follows : 
Local examination should be negative; the uterus should be 
normal in position, the cervdx of normal size ; the cul-de-sacs 
should have preserved their normal suppleness and should not be 
hard or indurated; but there is, with rare periods of lull, an 
exquisite sensitiveness on touching the cervix and cul-de-sacs 
and on moving the uterus while palpating bitnanually ; pressure 
on the iliac fossae is also painful, and sometimes the surface of 
the abdomen can scarcely be touched even lightly without excit- 
ing exquisite pain. The patients suffer horribly ; they walk bent 
double ; some have to stay in bed all the time. During an acute 
exacerbation all the symptoms of pelvic peritonitis may be 
present, but on examination after the attack is over nothing 
abnormal is found. The length of the disease may be from one 
to thirty years or more. These patients are miserable and go 
from one gynecologist to another without receiving benefit. At 
last they become bedridden and they die” It has been said that 
simple celiotomy without doing anything whatever will cure 
these cases, the cure being mental. Richelot cites a case in 
which he did this without the least effect; nothing was done 
but simple exploratory incision. He has also met with cases in 
which the appendages were removed, there being slight lesions ; 
in these, also, the neuralgic pain persisted after the operation. 
He now treats both conditions by vaginal hysterectomy with suc- 
cess. The following case happened in Ilichelot’s practice : The 
woman was 38 years old. She had had three children and had 
been married twenty-one years. She had been ill twenty years. 
Her second confinement, seventeen years before, during which 
she was taken care of by Budin, proved to be severe. She had 
a rheumatic history and often suffered pains in the arms and 
shoulders. Her children were all nervous and had neuralgias. 
She had never had any hysterical attacks. Her stomach was ir- 
ritable and she had to be careful about her food. For seventeen 
years she had attacks of severe pains in the pelvis ; the accom- 
panying symptoms were excessive tympanites, nausea and vom- 
iting, anorexia, constipation, and filiform pulse—in fact, all the 40 
GARCEAU : VAGINAL HYSTERECTOMY 
symptoms of pelvi-peritonitis. The last attack lasted five 
weeks. When seen by Richelot she was in a moribund con- 
dition. Ifis diagnosis was double pyosalpinx with peritonitis. 
When the attack subsided, however, a movable uterus slightly 
anteverted was found, and small appendages which could be 
easily felt; there was no induration whatever. She had been 
through an attack of pelvic neuralgia with a condition of peri- 
tonismus. Vaginal hysterectomy was done. The uterus was 
somewhat large, but the appendages normal. Seen five months 
later she reported herself perfectly well. Richelot has had 
sixteen similar cases, which were all cured with but one ex- 
ception. 
In cases of prolapse of the uterus vaginal hysterectomy is 
gaining many adherents, even though in many cases it proves to 
be a preliminary operation, a plastic one being required sub- 
sequently. 
If a mistake in diagnosis has been made, and the operator finds 
a hematosalpinx or a cystic ovary when he expected to find 
tubal inflammatory disease, no embarrassment need be occasioned, 
for it is quite easy to treat these affections by the vaginal method. 
Hydrosalpinx and extrauterine pregnancy come under the same 
heading. Jacobs and Pean have reported many such cases. 
Chronic endometritis deserves special mention. Reference is 
made to those cases which have resisted all forms of treatment, 
electrical and other. The patient suffers pain, constant leucor- 
rheal discharge, and is exhausted by repeated hemorrhages. 
Curetting has been tried without avail. In such cases vaginal 
hysterectomy is justifiable. Sutton has done it for a suppurative 
endometritis. The uterus was infiltrated with pus, but the ap- 
pendages were not involved. The case was gonorrheal. She 
recovered. During the past nine weeks Sutton has done the 
operation twice in eases in which a celiotomy with removal of 
appendages was unsuccessful in curing the patient. Ilehasdone 
it in another instance in which there was general inflammation 
of the uterus and appendages, and in still another in-which the 
inflammation was complicated by cataleptic convulsions—all with 
success. 
The operation has not been received with universal acclama- 
tion in America, and will doubtless meet with much resistance at 
first. But Sutton, Thomas, Engelmann, Lusk, and Coe, as well 
as others, believe that it is a decided advance in gynecology. AS DONE IN FRANCE. 
41 
Mann, of Buffalo, believes that it is “ the question of the day in 
gynecology, and its decision demands our best thought and our 
closest observation.” 
Illustrative cases.—Picque :x A case of vaginal hysterectomy 
done for pelvic abscess with dense inflammatory adhesions filling 
the pelvis. The patient was 34 years old. She entered the 
Broca Hospital November 11th, 1891. Married at 19; eight 
months after marriage had a miscarriage, which was followed by 
pelvic pain in the region of the appendages. This subsided 
and for fourteen years she was well. Intrauterine instrumen- 
tation for sterility brought on chills and fever, and an abscess 
on the left side of the uterus which discharged into the vagina. 
She then had an extension of the inflammation on the right side. 
Yaginal examination showed a uterus which was impacted in the 
pelvic cavity and surrounded by inflammatory masses. Yaginal 
hysterectomy on November 19th, 1891. Twenty-five days later 
was discharged well. Seen January 20th, 1893, she reported her- 
self perfectly well. The appendages were not removed. 
Picque :3 Yaginal hysterectomy done subsequent to celiotomy ; 
removal of the appendages did not cure the patient. The 
woman was 24 years old, and entered the Broca Hospital (Pozzi’s) 
June 5th, 1891. She had gonorrhea at 16 and an abortion six 
years later. Pozzi examined her and found on either side of the 
uterus a mass, that on the left as large as a small hen’s egg, 
on the right as large as a mandarin orange. On June 20th the 
appendages were removed by celiotomy. On the right there 
was a simple non-purnlent inflammation ; on the left there was 
a little pus. Discharged July 29th. Returned in November 
of the same year on account of profuse leucorrhea. Curetting 
done twice without result. Yaginal hysterectomy performed. 
Discharged well in December. 
Teril1on:% A case of vaginal hysterectomy done eight days 
after celiotomy, it not having been possible to complete the 
latter operation owing to dense adhesions. The patient was 23 
years old and had been sick three years following abortion. 
The uterus was immobilized by adhesions which extended up to 
the umbilicus. A celiotomy was done, but no attempt was made 
to remove the appendages, as it seemed impossible to remove 
them. Eight days later vaginal hysterectomy was done and the 
1 Annales de Gynecologie et d’Obstetrique* 1893, p. 176. 
4 Id., p. 176. 3 Id., 1891, p. 381. 42 
GARCEAU : VAGINAL HYSTERECTOMY A8 DONE IN FRANCE. 
patient got well. She had no more pain. The lesions were 
tuberculous. 
DewandreA case of vaginal hysterectomy done for general 
purulent inflammation involving uterus and appendages. The 
woman was 34. Married at 26 and pregnant eight times. Last 
confinement April 20th, 1893. In 1891 had a child at eight 
months. Since then has been ill. The uterus is imprisoned and 
immovably held between two masses. Vaginal hysterectomy 
June 3d, 1894. Uterus, tubes, and ovaries removed ; all puru- 
lent; adhesions between tubes, omentum, and intestines separated 
with ease by the fingers. The cure was perfect. 
22 Highland street. 
No references have been given in this paper, because it was thought unneces- 
sary. The statistics have been gathered from the leading French medical 
journals, notably Annales de Gynecologie et d'Obstetrique. The operation is a 
new one, and the references may be easily obtained from the “ Index Medicus.” 
The most prolific writers on the subject are Richelot, Segond, Pfean, Quenu, 
and Doyen. 
1 Bulletin de la Societe Beige, 1894, No. 5.