[Reprinted from The American Journal of Obstetrics and Diseases of 
Women and Children, Vol. XXXIV., No. 4, 1896.] 
WITH COMPLIMENTS OF THE AUTHOR. 
VAGINAL HYSTERECTOMY BY THE CLAMP METHOD,1 
BY 
B. SHERWOOD DUNN, M.D., 
Lately attached to Prof. Pozzi, Broca Hospital for Women, Paris, France; Member of 
the SociStS Clinique des Praticiens de France; Fellow of the American 
Association of Obstetricians and Gynecologists. 
(With ten illustrations.) 
One year has passed since I had the honor to address this 
Association upon the subject of this paper. 
The views expressed and active discussion of this operation 
by the members at that time persuaded me that this paper, 
which should cover more fully the history, technique, and 
statistics, would be as useful and as acceptable as any I could 
present. 
I have found that this particular operation is not favorably 
received in the United States and is but little employed, espe- 
cially in the West. I am a fixed partisan of the clamp method, 
believing it immeasurably superior to the method by ligature, 
and therefore ask your attention to the points I shall emphasize 
in support of my opinion. 
Vaginal hysterectomy is a new operation in its perfected 
technique. It was first performed, I believe, by Sautier, of 
Constance, in 1822, and again by Recamier in 1829. From 
1829 to 1879, because of the multiplied failures, it was done but 
rarely, and then only for cancer. With the advent of antisep- 
tic surgery it again was brought into public notice in the pub- 
lication by Czerny of a resume of cases in a Vienna medical 
journal. Between 1880 and 1885 the operation gained ground, 
and successful operations were published by Pean, Terrier, and 
Richelot; but active interest in this procedure dates from the 
celebrated discussion before the Surgical Society of Paris in 1888, 
when Verneuil, that old war-horse of the French school of sur- 
gery, arose in that distinguished body of savants and declared 
himself absolutely opposed to the advent of this new procedure, 
and presented a favorable array of cases treated by the chain 
1 Read by title at the annual meeting of the American Association of 
Obstetricians and Gynecologists, Richmond, Va., September, 1896. 2 
DUNN: VAGINAL HYSTERECTOMY 
ecraseur. So strong was his influence, and his opinion was 
held in such high regard, that it must have required a great 
deal of moral stamina to permit of the expression of opposition 
to this fiat, which was limited to a few younger men-notably 
Richelot, Bouilly and Terrier, and, I think, Segond. These 
gentlemen had the courage of their convictions, and particularly 
M. Richelot, who in 1891 excited anew the animated discussion 
■of this operation by presenting before the Surgical Society again 
a resume of twenty-five new cases operated upon for cancer, 
with ten relapses of the disease and fifteen without relapse, the 
shortest of which was then one year and five months. Emi- 
nently successful results were at this time presented by the 
other surgeons I mentioned in connection with him, and from 
this date vaginal hysterectomy has steadily grown in favor 
with gynecologists, until now it is performed for a variety of 
conditions other than cancer. 
I look upon an uncomplicated vaginal hysterectomy as one 
of the simplest of the capital operations in gynecology, and 
with very little practice, in the hands of an experienced ope- 
rator, less dangerous to a patient than a laparatomy. But I 
would not be understood to advocate indiscriminate hysterec- 
tomy. I am intensely conservative by nature, and believe in 
capital operations only after the exhaustion of tentative mea- 
sures ; but where hysterectomy is indicated I think it preferable 
to any other procedure. On account of the complete control 
which is had over patients in European hospitals, especially on 
the Continent, the knife is used more freely than in this coun- 
try ; and I am satisfied that vaginal hysterectomy is practised 
to excess in Europe. 
Certain elements in the operation should be made prominent. 
The danger increases in proportion to the length of the opera- 
tion. The shorter the duration of the operation, within certain 
limits, the less the patient suffers from shock and from the 
effects of the anesthetic. I should consider fifteen or twenty 
minutes the average duration of time for an uncomplicated 
case. With a view to shortening the operation, Prof. Richelot 
in 1885 first employed the clamp method, and although Pean 
at about the same time claimed priority for this procedure, yet 
it is to Richelot that surgery is indebted for the present perfec- 
tion of the technique of this operation, and he is, I think, uni- 
versally conceded by his compeers to be the "king of vaginal 
hysterecto mists." I have seen him do this operation in four 
and one-half minutes, and he reports having done one hundred 
and forty-four vaginal hysterectomies between February, 1894, 
and May, 1895, without the loss of a single case. BY THE CLAMP METHOD. 
3 
The clamp method has the advantage over the ligature of 
shortening the duration of the operation more than fifty per 
cent, and the fear that is felt, by those not familiar with it, of 
post-operative hemorrhage is groundless. By a series of ob- 
servations made at the autopsies of Broca Hospital, Paris, part 
of which were made by myself, it was demonstrated that from 
the point of impingement of the forceps on an artery the blood 
clot extended from three-fourths to a centimetre in its lumen, 
and that within twenty-four hours after the operation that part 
of the clot nearest the instrument, and consequently furthest 
from the blood current, began to organize itself, and the fibrin, 
by the natural inflammatory action set up by the traumatism, 
would, before forty-eight hours, assume a consistence that ren- 
dered its dislodgment practically impossible. I have more than 
Fig. 1.-Scheme. A, volsella first applied and maintained; B, C, D, successive posi- 
tions of the second pair of volsellse ; E, anterior peritoneal cul-de-sac. 
once been asked the question by surgeons visiting Paris how we 
managed to control hemorrhage from the uterus in splitting it 
up or after amputation of the cervix. The answer is simple. 
By forcibly drawing the uterus downward the traction on the 
blood vessels and their displacement seems to close them, for 
all hemorrhage is arrested. 
Now as to the indications for this operation. Where you 
have an enlarged uterus showing endometritis, perimetritis, 
and probably diseased parenchyma, even though the adnexa 
are but slightly involved, hysterectomy gives the best results. 
Bilateral disease with suspected pus, with perimetritis and 
possible pus pockets in the adhesions ; purulent pelvic abscesses 
following neglected and long-standing diseases ; uterine fibroma 
when found in the median line and the size of the organ has 4 
DUNN : VAGINAL HYSTERECTOMY 
not rendered its abstraction too difficult through the vagina, 
although I have seen Paul Segond extirpate a fibroma weighing 
sixteen pounds through the vagina by the morcellement method 
(Fig. 2). 
There is considerable opposition to this operation in the pre- 
sence of purulent disease, although of late the concourse of 
European opinion favors hysterectomy in double pyosalpinx, 
and also very firm adhesions are by some looked upon as a con- 
traindication. My experience in the latter has been that in 
seizing a firmly adherent uterus with the Richelot improved 
Fig. 2.-Scheme showing the morcellement method for removal of a flbromatous uterus 
through the vagina. A, volsella first applied ; 1 to 6, successive portions removed from 
anterior wall; B to I, successive positions of volsella. 
five-toothed volsella forceps, you can always draw it down, 
after making the incision around the cervix, sufficiently to 
reach and clamp the uterine and ovarian arteries, and then 
the rest is a matter of patience and careful manipulation. In 
the case of pus tubes and general purulent abscesses I think it 
will appeal to you as reasonable that your chances for success- 
ful drainage are far superior by the vagina, which gives you 
drainage downward, than by the suprapubic route, where 
your drainage must be 'upward. The vaginal operation also 
affords you the opportunity to daily flush out the field of disease BY THE CLAMP METHOD. 
5 
more thoroughly and fearlessly than you can do through an 
abdominal incision. 
It is important that your patient should be carefully and 
properly prepared for this operation. The previous evening 
the vagina should be thoroughly scrubbed with soap and water 
by aid of a hand brush, and then flushed out with a 1:2000 
bichloride solution and packed with iodoform gauze. Bind the 
lower extremities to midway between the knee and hip libe- 
rally with cotton wadding held on by gauze bandage, and leave 
it on for two days after the operation. It will materially lessen 
the shock by keeping the feet and legs warm. In the morning, 
just previous to operating, the vagina should again be scrubbed 
as before and then flushed out thoroughly with a 1:2000 solu- 
Fig. 3.-Showing the manner of seizing the cervix with the five-toothed volsella, and 
the circular incision around the cervix at the vaginal insertion. (The anterior and 
perineal retractors, which should be in place, are not shown.) CU, cervix uteri; SV, 
line of incision. 
tion of bichloride. Catheterize the bladder, shave the pubes, 
and protect the neighboring parts with gauze wrung out in 
1:1000 bichloride. Curette the uterine cavity and inject a solu- 
tion of ferrum perchloride or other antiseptic astringent; then 
seize the cervix firmly with a five-toothed forceps ; draw it 
forcibly toward you and down upon the perineal valve (Fig. 4) 
previously inserted ; with curved scissors or the bistoury make 
a circular incision completely around the cervix just below the 
vaginal insertion (Fig. 3) ; with the aid of the finger press the 
tissues progressively upward until you pass the uterine artery 
(Fig. 5) ; with the finger and thumb placed each side of this 
organ you feel exactly its pulsations, and with the straight 6 
DUNN : VAGINAL HYSTERECTOMY 
hemostatic forceps (Fig. 10) seize and compress it, and sever it 
by cutting between the forceps and the uterus (Fig. 6). You 
should be careful to direct the point of the forceps toward the 
uterus, to avoid comprising the ureter in its grasp. When the 
uterine arteries of both sides are severed continue the separation 
of the tissues upward anteriorly and posteriorly until you enter 
the peritoneal cavity ; then advance the anterior retractor, with 
which your assistant has steadily elevated and protected the blad- 
der in front, into the peritoneal opening and maintain it there. 
By splitting the uterus upward in the median line from its 
Fig. 4.-Perineal retractors. Width, 0.060 millimetre. Length, 0.06, 0.09, 0.12 centimetre 
cavity outward, anteriorly, you can from time to time seize the 
organ higher up by each lip of this incision with your volsella 
forceps (Fig. 1) and more surely control it in the different 
maneuvres (Fig. 7). The point now is to clamp and section the 
ovarian arteries, and you will find this materially favored if you 
can antevert the fundus toward you (Figs. 8 and 9). Sometimes 
the abnormal size and length of the organ renders this difficult 
or impossible. In this case amputate the cervix to shorten the 
uterus, and then, if it still refuses to revolve forward, split it 
into two halves upon the index placed behind the organ to pro- BY THE CLAMP METHOD. 
7 
tect the intestine from injury, and bring successively each half 
forward and clamp the arteries either in front or behind the ovary, 
as the case may permit. If strong adhesions prevent your draw- 
ing the appendages forward to clamp behind the ovary, do not 
hesitate to leave them. I have seen them abandoned in many 
cases with no evil results. Be careful to never let go with one 
pair of volsella forceps before placing another pair in position ; 
and also it is important that the points of the hemostatic forceps 
placed on the uterine and those placed on the ovarian should pass 
each other, so the broad ligament shall be comprised fully in the 
two pairs, otherwise you are liable to considerable hemorrhage. 
Fig. 5.-Separating the tissues upward with the Anger. VG, vagina ; R, rectum ; 
U, uterus ; V, bladder. 
In a non-adherent, uncomplicated case you will ordinarily 
have four pairs of forceps in situ after having extirpated the 
uterus, but the operation is by no means complete. The pos- 
terior section of the vaginal wall, that corresponding to the cul- 
de-sac of Douglas, always bleeds copiously, and by aid of the 
small hemostatic T-forceps of Pozzi you should bring the 
sectioned peritoneum and that of the vagina together ; with the 
aid of three or four pairs the hemorrhage here will be fully 
arrested. Then you should spread out the border of the broad 
ligament and place a pair of small forceps on every bleeding 
point. The aim is not to leave the slightest oozing, not for fear 8 
DUNN : VAGINAL HYSTERECTOMY 
of any danger to the patient from hemorrhage, but to protect 
her from the danger of infection, as blood is one of the best 
of culture mediums for germs. 
If the case is one demanding drainage, place two or three 
strips of iodoform gauze together and with dressing forceps 
carry these ends just beyond the sectioned border into the peri- 
toneal cavity ; then pack the centre of the vaginal opening 
between the forceps clear down to the vulva with iodoform 
gauze, and also around between the forceps and vaginal walls, to 
protect the tissues from erosion. Place a rubber T-self-retain- 
ing catheter in the bladder, cover all over with cotton and a 
Fig. 6.-Showing tissues pushed up and the straight hemostatic forceps clamping the 
uterine artery of each side. 
T-bandage, and place the patient in bed, putting a round bolster 
just below the thighs, upon which to rest the projecting ends of 
the forceps to relieve the parts and the patient of their weight. 
The forceps are removed at the end of forty-eight hours, and 
the patient's bowels should be moved by enema the third day. 
The patient is kept rigorously in the recumbent position for 
twenty-one days with daily dressing of the parts. The wound 
contracts and cicatrizes completely, pushing a stump of cicatri- 
cial tissue inward which acts as a sort of pessary support to the 
abdominal contents. 
I have yet to see the first case of hernia following this opera- 
tion. BY THE CLAMP METHOD. 
9 
As might naturally be inferred from the animated discussion 
Fig. 7.-Splitting the uterus upward. A, first pair of volsellse, which remain until 
uterus is removed ; B, second pair of volsellse, for seizing progressively higher up on the 
median incision, to antevert the fundus toward the operator. C, opening into the 
peritoneal cavity. (The clamps which have been placed on the uterine arteries are not 
shown.) 
cited in the Paris Society of Surgery, there is a set of eminent 
Fig. 8.-The fundus anteverted. B, C, D, progressive points of seizure along the median 
incision ; F, fundus. (The clamps on the uterine arteries are not shown.) 
surgeons in France who are opposed to this operation, as against 10 
DUNN: VAGINAL HYSTERECTOMY 
a greater number of equally celebrated advcoates of it, and 
then the conservative men who take the middle ground and do 
both ; of this last my eminent master, Prof. Pozzi, is one of 
the leaders. In an article1 he declares the following as his 
indications for the operation : 
1. Diffuse, chronic suppuration involving the periuterine tis- 
sues and appendages, where the ablation of a limited pocket 
would result in little benefit or is impracticable. 
2. Multiplied adhesions resulting from chronic disease, form- 
ing a mass of the organs, but non-suppurative. 
3. Abdominal fistula which resists cure by curettement, dila- 
tation, or operation seeking to find the suture that caused it. 
4. Painful tumors of the adnexa following celiotomy. 
Fig. 9.-Applying the clamp on the ovarian artery from above downward. (The clamps 
on the uterine, which should appear, are not shown.) U, uterus ; O, ovary ; Tr, Fallopian 
tube ; Pc, first pair of volsellae ; LL, broad ligament; Ps, second pair of volsellae. 
Prof. Richelot, in addition to the above, advocates vaginal 
hysterectomy for bilateral pus tubes ; retroversion with firm 
adhesions and prolapsed and diseased ovaries ; long-standing 
metrites with double ovaritis; pelvic neuralgia resisting all 
other treatment. In his book published in March, 1894,2 he de- 
scribes most happy results in certain selected cases of this kind. 
In Richelot's communication before the Congress at Brussels, 
September, 1892, he reports 134 operations for lesions other 
than cancer, with 9 deaths (6.7 per cent); Segond, at the same 
Congress, 102 with 11 deaths (10.7 per cent); Pean, at the same 
1 Annales de Gynecologie et d'Obstetrique, 1893, p. 504. 
2 " L'Hysterectomie Vaginale," Paris, 1894, O. Doin, editeur. 11 
BV THE CLAMP METHOD. 
Congress, 90 cases with 1 death. Doyen published in 1893 a 
resume of 61 cases with 3 deaths. Jacobs published 166 cases 
in March, 1894, with 4 deaths. Pozzi, up to January, 1894, had 
14 cases with no deaths. In my own experience I have ope- 
rated upon 21 cases with 2 deaths. The most remarkable sta- 
tistics are the 144 cases of Richelot spoken of, with no deaths. 
It may be safely said that vaginal hysterectomy for lesions 
exclusive of neoplasm, in the hands of the well-known operators 
of to day, gives a mortality of four per cent. 
When I first entered the hospital service in Paris I was con- 
stitutionally opposed to vaginal hysterectomy. It appeared to 
Fig. 10.-Model of clamps for vaginal hysterectomy. 
me to be an inhuman and brutal operation. My opposition was 
fostered by being attached to one of the most celebrated lapa- 
ratomists in Europe, Prof. Pozzi, who is justly celebrated as 
being one of the most expert operators of the present day. It 
is only natural that the personality of such a man, who is wor- 
shipped by those around him, should render difficult an un- 
prejudiced consideration of the methods of other men; but the 
more I have seen of this operation in the hands of such masters 
as Richelot, Terrier, Bouilly, Segond, Le Dentu, Quenu, Pean, 
Lucas Championniere, and Aubeau, as well as Pozzi, the more 
I have been compelled to recognize its utility, until I now look 
upon it as one of the most benign procedures known to gyne- 
cology for certain limited conditions. 
Bradbury Building, Los Angeles, Cal.