This document discusses the history of accessing the abdomen through the vagina prior to the development of endoscopy. It traces the evolution of speculums and other surgical tools used for vaginal procedures from ancient Egypt and Hebrew cultures through Greece and Rome. Key developments included the speculum, retractors, knives, scissors, advances in pain and infection control, which enabled the transvaginal abdominal access. Knowledge and techniques spread gradually over centuries as connections formed between civilizations through trade, travel, and later the printing press and digital technologies.

1. History
and
the abdominal access
via a natural orifice
before endoscopy.
Dr. Daniel A. Tsin

2. Sir Winston Churchill said
at the Royal College of
Physicians in London on
1944 "The longer you look
back, the further you can
look forward”.

3. The abdominal access via natural orifice was limited to the
vaginal route for a long time prior to endoscopic
procedures.
To do a vaginal approach several elements are required:
 Visualization with the development of the speculum.
 Retractors, knives and scissors for exposure and surgery.
(Clamps and Forceps are mentioned during the evolution of
the above tools).
 Concomitant advances in pain and infection control that
contributed to the transvaginal abdominal access.

4. Sharing of ideas, knowledge, tools,
procedures and experiences was slow in
ancient times.
 As we found, sharing took first centuries, and then years.
 The printing press designed by Johannes Gutenberg around 1450 in
Europe made a pivotal contribution.
 Medical conferences and journals went from years to months.
 Today with digital magazines and the internet, sharing of ideas and
knowledge could be disseminated between days or hours.

5. Connecting some but not all events of this
historical journey is presented in sections.
Speculum.
Retractors, knives and scissors.
Pain Control.
Infection Control.
The transvaginal abdominal access.

6. The Speculum.
 Ancient Egyptians and the Assyrians used vaginal tubes for
enemas.
 The Hebrews from 1300 Before the Common Era (BCE)
used a bamboo vaginal cannula in a ritual to investigate
vaginal bleeding (precursor of the Siphopheroth).
 The Hebrews with their rituals moved by choice or
captivity throughout history.

7. 1200 Before the Common Era (BCE)-970 BCE.
PHOENICIANS WERE MASTER SHIPBUILDERS AND VERY GOOD
SAILORS NAVIGATING AND DEVELOPING CONNECTIONS, CITIES,
DEPOSIT, FACTORIES AND TRADE THROUGH THE MEDITERRANEAN
SINCE 1200 BCE, INCLUDING THE ISLAND OF KOS. THEY REACHED
THE IBERIAN PENINSULA (SPAIN), THE ATLANTIC OCEAN AND THE
WEST COAST OF AFRICA. PHOENICIANS AND HEBREWS WERE
CONNECTED RACIALLY, GEOGRAPHICALLY, BY INTERMARRIAGES, BY
TRADING , TRAVELING TOGETHER IN THE SHIPS OF TARSHIS AND
USING THE SAME LANGUAGE AND ALPHABET FOR MANY
CENTURIES.

8. 970 BCE to 931 BCE
 970 BCE King Hiram of Tyre, a Phoenician, made many trade agreements
with King Solomon of the Hebrews. Among them, was to build the Temple and
participation in Mediterranean trading. The Phoenicians opened land routes
through Hebrew territories to Sheba, Egypt and Mesopotamia. The Phoenicians,
paid by King Solomon, built a fleet at the Hebrew’s Red sea ports. The
components of the ships were made in Lebanon and transported by camels to the
Red sea, where the ships were assembled. The crew was a combination of Hebrew
and Phoenician sailors and merchants. Also known as the King Solomon fleet that
traded in the east coast of Africa and India, where early settlements were formed.
For the first time, there was a documented connection between the
West and East. These connections were not only for maritime route trade but to
share in innovations, culture, rituals and knowledge between three continents.

9. 931-605 BCE
The Hebrews in 931 BCE were divided into two kingdoms. In the north the
Kingdom of Israel and in the south, the kingdom of Judah with the city of
Jerusalem. The Phoenicians and Hebrews came under Assyrian rule
from 883–605 BCE. The conquerors, aware of the Phoenicians mastery of
sailing, were able to make tax agreements to include the navy and
establish trading routes. The Hebrews did not have such luck, near 740
BCE the Assyrians took part of the Kingdom of Israel and began the
diaspora of Hebrews to other parts of the empire. In 722 BCE the last
city was taken, and the deportation to the Assyrian empire ended the
Kingdom of Israel. Many Hebrews fled to Judah avoiding captivity. The
kingdom of Judah, like the Phoenicians, became part of the Assyrian
empire.

10. 605-539 BCE
 The Phoenicians were then ruled by the Babylonian empire 605 BCE,
with a similar outcome to the previous conqueror. The kingdom of
Judah also became part of the Babylonian empire around the same
time, but they rebelled against the conquerors. In 586 BCE,
Nebuchadnezzar II destroyed the kingdom of Judah and the city of
Jerusalem including the temple, and deported the Hebrews to
Babylon. They remained in captivity until the fall of Babylon by the
King of Persia, Cyrus the Great in 539 BCE. The Hebrews were then
freed in Babylon or able to return to Judah.

11. India 600 BCE . Yoni-Vraneksana.
Sushruta described the lithotomy position and
ancient metallic instruments, forceps, clamps
,cautery, retractors, knives and lancets, tubular
instruments with side openings for operating and
the Yoni- Vraneksana, a vaginal speculum with a
lever scissor type of mechanism for opening and
closing. This happened three centuries after the King
Solomon Fleet reached India.

12. Thales of Miletus.
 Thales (634 BCE – 546 BCE), a mathematician
and philosopher, and son of Phoenicians
born In the Greek city of Miletus where he
had connections with Egyptians and
Babylonians.
 Thales influenced Pythagoras of Samos (570
BCE - 495 BCE).
 Pythagoras influenced Hippocrates of Kos.

13. Hippocrates
(The father of western medicine)
Hippocrates, from the Greek island of
Kos, in 400 BCE described the
treatment of illness of the uterine
cervix and the dilatation of the uterus
procedures that required visualization.

14. 400 BCE – 332 BCE : Greece
 Greek tools.
 Some historian used the name of Katopter for an instrument with a lever type of pivot
, similar to the Hindus tools (600 BCE) that uses a lever system as a vaginal speculum
 Other historians mentioned that the Katpopter was two separate spoon shaped single
blade speculum working as vaginal retractors or limited the Katopter as a rectal
speculum.
 Diopter or Dioptra, a vaginal speculum. The dioptra has a nuts and bolts
mechanism for opening and closing. The advantage of the dioptra is that it allows the
speculum to be set steady in place. When set, no additional handling of the speculum is
required. The name dioptra was used by Greeks, but it is possible that this instrument
was developed later and was used in the 1st century.
 Ancient Greeks also had forceps , clamps , scalpels and lancets for punctures and
surgical procedures.

15. 332 BCE – 323 BCE
Alexander the Great: 356 BCE-323 BCE
 332 BCE: Alexander enters Jerusalem .
Hebrews began, by choice, the Hellenistic
diaspora mostly to the west.
 Alexander the Great founded the city of
Alexandria in 331 BCE. He invaded India in
326 BCE, the connections among Asians and
Europeans increased even further.

16. 323 BCE-80 BCE
 Ptolemy I, a successor of Alexander, established in 288 BCE the
Ancient Library and Medical Schools of Alexandria. In time it
became a universal library, a center for connections, research,
publications ,collections and copies of Greek manuscripts and
translations from, Assyria, Buddhist, Egypt , Hebrew, Persia, Sumerian
and others scriptures.
 China connected with India by the sea in the 2nd century BCE.
 146 BCE: the city of Corinth is taken by the Romans. Most of the
Greek territory became the Roman Province of Macedonia.
 80 BCE: Alexandria was under roman jurisdiction. Greek remained the
most common language at the library.
 Alexandria was the largest city of the world during the 2nd and 1st
century BCE.

17. 47 BCE Alexandria.
Historians mentioned a fire at the library in
47 BCE during the siege of Alexandria. Yet the
library and the schools of medicine survived
and was considered the most famous Library
and Medical Schools of that age.

18. August 24th of the year 79: Pompeii.
 Mount Vesuvius erupted on August 24th of the year 79, and
covered Pompeii with ashes.
 A definitive connection was established with a Dioptra described
by the Greeks in 400 BCE and Magnum Matricis in Latin that
was later found in the excavation that began in 1763.
 Other connections were made with similar speculums found in
Greece and in Mediterranean cities from Lebanon to Spain.
 Other instruments recovered were forceps and clamps.

19. 1st to 6th Century: Alexandria
 Claudius Galenus studied for several years in a school of medicine in Alexandria. In
the year 391 BCE, a deliberate act of destruction resulted in the loss of a significant
amount of documents at the library under the excuse of eliminating paganism. The
Library gradually deteriorated after this event, while the medical schools were
working until the 7th century.
 There were multiple books of anatomy and surgery with descriptions of surgical
instruments like clamps , forceps, surgical knives, operations, abortions, removal of
dead fetus’ and drainage of the uterus. Possibly, I can only guess that we lost a
connection to early evidence of a puncture for vaginal drainage of abdominal fluid
or abscess or an earlier version of a colpotomy among the destroyed books of the
Library of Alexandria.

20. Claudius Galenus of Pergamum 130
- 210
Influenced by Hippocrates.
Influenced by Aulus Cornelius Celsus on hemostasis.
Multiple contributions in the field of medicine.
Major contributions in the field of surgery, clamping,
and ligature of vessels to stop bleeding .

21. 2nd to 5th Century: Babylon
The rabbis of Babylon began writing the Talmud
based on ancient and New Hebrew laws. Among them
is the prohibition of sexual relations for seven days
after the beginning of the menstruation or while the
blood flowed from the uterus. When abnormal
bleeding occurs after seven days, in order to localize
the origin of the bleeding, either from the womb or
the vagina, a metallic cannula called a siphopheroth
was placed in the vagina.

22. Siphopheroth
 The siphopheroth, a blunt end metallic cannula, was used to place
a wooden rod called the mechul . The presence of blood on the
mechul meant it was of uterine origin and no sex was allowed.
Blood outside the siphopheroth was vaginal instead.
 This ritual evolved from the bamboo cannula used in 1300 BCE.
 Connecting the siphopheroth as a potential first description of an
instrument used to inspect the vagina and as a precursor of the
speculum makes sense even though this cannula was more of an
inspection tool than a visualization tool.

23. Greco-Roman Empire
3rd to 6th Century:
 Administrative changes divided the Empire.
 A Single State.
 Separate Imperial Courts.
 Greek to the East.
 Latin to the West.
 The Eastern Roman Empire also known as the
Byzantine Empire.
 Alexandria became a Byzantine City.

24. 6th -7th Century
 The library of Alexandria was completely destroyed during the Muslim
conquest of Egypt in the year 642 and some books were kept by the
conquerors that later were translated from Greek to Arabic. Previously,
some books were saved and had Syriac translations, some of which were
taken to the Imperial Library of Constantinople and some taken by the
Sasanians that were in Alexandria from 619 to 629.
 The Muslims transferred some of the Schools or knowledge of Medicine of
Alexandria to Antioch and Harran.
 Sasanians opened Academies and Medical Schools in Persia. Most
of the medical books were written in Syriac.

25. 8th and 9th Century
 The Muslim invade the Iberian peninsula. They called it Al-Andalus.
 The Muslims fought with China in the 8th century and learned about
paper technology from war prisoners. They made, an Arabic
version of the Library of Alexandria using Sasanian academies as
additional sources. It was called the House of Wisdom (Bayt
Al-Hikma) in Baghdad, in the 9th century it functioned as a cultural
center and for translating books to the Arabic language
using paper and ink.

26. 10th Century: Al-Andalus.
 Translated books reached Libraries and Medical Schools in
the Arab held land from Persia in the east to the Iberian
Peninsula and North Africa in the west. Arab physicians, like
Albucasis, benefited from these connections and
contributed by describing ectopic pregnancy and writing
Al-Tasrif.
 The Islamic golden age included the Libraries and Medical
Schools of Cordoba in Al-Andalus, and was the most
important European cultural center of that century.

27. 11th to 13th century.
During the Spanish Reconquista of Al-
Andalus, Toledo is taken in 1085 and
Cordoba in 1236 from the Muslims. The
Arabic books are then translated to
Castilian and Latin and influenced the
medical renaissance in Europe.

28. Renaissance - 18th Century.
(Renaissance 14th to 17th Century)
 Diopter, Dioptra or Magnum Matricis.
 The Greco-roman type of speculum was in use until
the 1800’s.
 Dr. René-Jacques Croissant de Garengeot in 1727
designed a similar type of speculum.
 Ambroise Paré. Describe the Bec de Corbin (crow's
beak) for clamping and tying vessels.

29. 19th Century Speculums.
 Madame Marie Anne Boivin a French midwife
in 1825, invented a bivalve speculum, and was
later improved by others using this concept with
a combination of levers and ratchets, or nuts
and bolts.
 Dr. Edouard Gabriel Cusco introduced a bivalve
speculum in 1859.
 Dr. T W Graves introduced his own version of a
speculum in 1878.

30. Modern Speculums after 1901.
 Today, connections exist among bivalve metallic speculums
like the Collin and Pederson. Most plastic speculums are
transparent modified versions.
 There are lighted and some specially designed speculums for
laser or other uses.
 Different types of speculums which are not frequently used
include, inflatables speculums and a vaginal air pump dilating
speculum with a colposcope. The application of these
speculums is mostly diagnostic and for procedures outside
the peritoneal cavity.
.

31. Ancient Retractors, Knives
and Scissors.
 The retractor and the obsidian knife evolved from rudimentary tools of the
Stone Age and used for exposure and cutting. Scissors evolved possibly
during the Bronze Age and probably during the Iron Age, and appeared in
Egypt around 1500 BCE. Surgical retractors were described in 600 BCE by
Sushruta. Spoon like retractors were found in Egyptian excavations but
documents of its use are not clearly available and in some cases the antiquity
is difficult to establish. The use of this type of exposure was done in
Hippocrates’ time.
 Forceps and Clamps appeared in Egypt around 1500 BCE.

32. Retractors. 19th Century.
 Dr. Marion Sims in 1845 used his single blade speculum in the USA.
 In 1879, Dr. August Breisky used his retractor.
 Dr. Doyen, in 1885, described his retractor.
 Dr. Pierre-Victor Alfred Auvard, in 1896, presented the weighted
speculum.
 Dr. William Rice Pryor introduced several vaginal retractors in his
publication in 1899. Retractors, surgical and gynecological, and
single blade speculums are mostly used for transvaginal and
intraperitoneal operative procedures. The concept for self-retaining
vaginal retractors evolves from the Dioptra. Recently, elastic
retractors were used in transvaginal NOTES and NOTES transvaginal
hysterectomy.

33. Pain Control BCE.
 Historic simultaneous connections occurred between the evolution of the
speculum and the fields of analgesia and anesthesia. The Babylonians and
Egyptians used the mandrake as analgesic around 4000 BCE. There are records
from ancient Sumerians that prove cultivation of opium since 3000 BCE. The
Bible refers to the wine of the condemned dating to 700 BCE during the time of
Amos. Sushruta used analgesic made from cannabis and other herbs around 600
BCE. Manuscripts from the Ancient School of Medicine of Alexandria mentioned
herbal concoctions for sedation and analgesia. There could be a connection
with a wine called morion, the wine of the condemned (drank or sponged), and
the herbal concoctions. There is also a connection with the soporific sponges
moistened with herbal concoctions. Soporific sponges were used until the
middle ages.

34. Pain Control in Pre-Columbian
America
 The pre-Columbian south-American natives used
coca around 1000 BCE. Some other analgesic and
hypnotics used by American natives include
coaxihuitl , datura , peyote , pulque, nanacatl as
well as the paralyzing curare before the connection
and subjugation by the Europeans that started in
earnest in the 16th century.

35. Pain Control. 2nd - 18th Century
 Hua Tuo in China used anesthesia during surgery in the
2nd century.
 Analgesia was done by putting opium in an alcoholic
solution in the 16th century, whichwas improved in the
17th century and used extensively in the 18th century.
 Dr. Joseph Priestley in 1775 developed Nitrous Oxide
and Dr. Humphry in 1800 discovered its capacity as a
pain killer and mild anesthetic.

36. Pain Control 19th to 20th Century
 Dr. Friedrich Sertürner first isolated morphine from opium in 1804, an effective
painkiller. Doctor of dentistry, Horace Wells, used it in 1844 for tooth extraction.
 The first successful use of general anesthesia in surgery using ether was in 1846
by Drs. Williams T G Morton and John Collins Warren. Anecdotally, it had been
used before by Dr. Crawford W. Long in 1842 and later published in 1849.
 Chloroform another anesthetic was independently discovered in 1831 by Drs.
Samuel Guthrie, Eugène Soubeiran and Justus von Liebig . Dr. James Y.
Simpson was the first to use it in humans in 1847. There are more and better
types of anesthetics after the era of endoscopy that began in 1901.

37. Infection Control BCE.
Prevention and treatment of infections
of wounds are mentioned by Egyptians
and Sumerians since 2000 BCE.
Sushruta and Hippocrates advised
cleansing of the wound.

38. Infection Control: antiseptics and
asepsis.
Dr. Thomas Watson suggested the use of surgical
gloves in 1842, yet it took almost 50 years for it to
become universally accepted.
Dr. Ignaz Philipp Semmelweis made a major
contribution in asepsis in 1847.
Dr. Joseph Lister’s contributions to antiseptics and
asepsis were done between 1865 and 1867.

39. Infection Control : Sterilization.
 Dr. Charles Chamberland in 1881 invented sterilization
with steam, also known as the autoclave.
 Dr. Ernst von Bergmann in 1890, invented the sterilizer
for gauze and gowns.
Sterilization techniques evolve after 1901 with new
methods to accommodate new instruments and
requirements.

40. Infection Control: Antibiotics
 The era of antibiotics began after 1901 with a Sulfonamide in 1932. A
few years later, hundreds of manufacturers produced thousands of
tons of sulfas, which was the first and only effective antibiotic
available in the years before penicillin. However, it was not useful in
prophylaxis or treatment for the transvaginal approach since it was
not effective on anaerobic infections.
 The discovery of penicillin in 1928 and the mass production in the
late 1940’s is another important connection since it brought in a safe
era for medicine and surgery including colpotomy. New generations
of antibiotics will then follow to improve effectiveness and spectrum
in prophylaxis and treatments.

41. The Transvaginal abdominal access:
Paulus Aegina
Historians give credit to Aetius of Amida, a 6th
century Byzantine Greek physician, or another
Byzantine Greek physician, Paulus Aegina or
Paulus Aegineta of the 7th century for the
treatment of pelvic abscess that rupture in the
vagina.

42. The Transvaginal abdominal access:
Recto-uterine pouch.
 Several publications were done after 1730, when Dr. James
Douglas published “A description of the peritoneum and
that part of the membrana cellularis which lies outside”. This
anatomical description gave the information needed for the
rational access to the lowest place in the pelvic cavity. Using
this knowledge as a connection, began a series of
procedures to reach the abdominal cavity via the pouch of
Douglas.

43. The Transvaginal abdominal access: Some highlighted
contributions in chronological order.
 1784: Dr. Henry Watson presented: A case of ascites in which the
water was drawn off by tapping the vagina. Med Communications.
London RE 1784, Vol 1, p. 162.
 1812: Several reports of vaginotomy used to remove dead fetus
from an abdominal pregnancy appeared in the medical literature.
 1822: Dr. J N Sauter did a vaginal hysterectomy using an anterior
colpotomy approach.
 1825: Dr. J C M Langenbeck did a vaginal hysterectomy using a
posterior colpotomy. Previously he performed a vaginal
hysterectomy in 1813 but without opening the peritoneum.

44. More contributions in chronological
order: Colpotomy.
 1829: Improved vaginal hysterectomy techniques were
performed in France and Germany by several physicians.
 1831: Dr. J. Alfred Recamier performed a posterior colpotomy to
evacuate a possible abscess, yet it is not clear if the evacuation
was an abscess or a hematocele.
 1864: Few unsuccessful reports of transvaginal puncture of
ectopic pregnancy.
 1867: Dr. Robert Greenhalgh did a successful puncture of the
tubal sac in an ectopic pregnancy.

45. More contributions in chronological
order: Vaginotomy.
 1870: Dr. T. G. Thomas performed a vaginal ovariotomy.
 1875: Dr. T. G. Thomas used transvaginal galvanocautery to remove an ectopic
pregnancy.
 1884: There were several publications on the transvaginal treatment of tubal
ectopic pregnancy.
 1890: Dr. S Pozzi published the: Traité de gynécologie clinique et opératoire were
he described the vaginal approach into the abdominal cavity in detail.
 1890: Jules-Émile Péan performed a vaginal hysterectomy for carcinoma. He also
invented the Pean hemostat.

46. More contributions in chronological
order : Vaginal Section.
 1895: Dr. A. Duhrseen described the transvaginal approach for female
sterilization.
 1883-1886: Howard Atwood Kelly performed a postmortem transvaginal kidney
removal (During his residency at The Episcopal Hospital. Philadelphia)
 1896: Dr. Howard A Kelly reported a series of 10 cases of ectopic pregnancies
managed via the vaginal route. He also Invented the Kelly clamp.
 1899: Dr. William Rice Pryor in his book “The Treatment of pelvic inflammations
through the vagina” used the term vaginal section for diagnosis and treatment of
several pelvic conditions, and also described several vaginal retractors.
 1901: Dr. Dmitry Oskarovich Ott presented Ventroscopia.

47. The Era of Endoscopy.
 Dr. Philipp Bozzini of Mainz, Germany in 1806 described the
Lichtleiter, considered for many the first endoscope.
 1901: The first intraabdominal endoscopy in humans was
Ventroscopia (Ventroscopy) using a vaginal access.
 Ventroscopia is a transvaginal endoscopic technique that
evolved in Colpolaparoscopy, Culdoscopy, Fertiloscopy,
Culdolaparoscopy and Natural Orifice Transvaginal Endoscopic
Surgery.

48. The Era of NOTES.
 Female patients could benefit from the new speculums, methods, instruments,
anesthesia, antibiotics, technology, and rigid and flexible new tools for minimally
invasive surgery.
 Many surgeons have already overcome cultural barriers, taboos and
misconceptions and chose to team up with expert gynecologists to share,
connect, and learn the experience and knowledge they need to feel comfortable
performing and offering this option to their patients.
 Continue the Era of Notes on slide share: History of Natural Orifice Transvaginal
Endoscopic Surgery.
 https://www.slideshare.net/tsin/history-of-natural-orifice-transvaginal-endoscopic-surgery
 Thank you for your attention www.culdoscopy.com