Combined Gynecological Operations. 
GEORGE M. EDEBOHLS, A.M., M.D., 
GYNECOLOGIST TO ST. FRANCIS’ HOSPITAL, NEW YORK. 
BY 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
FROM 
September, 1892. Extracted from 
The American Journal of the Medical Sciences for September, 1892. 
COMBINED GYNECOLOGICAL OPERATIONS. 
By George M. A.M., M.D., 
GYNECOLOGIST TO ST. FRANCIS’ HOSPITAL, NEW YORK. 
The fact cannot be gainsaid that the marvellous progress in the diag- 
nosis and treatment of diseases peculiar to women, attained within the 
past decade, is due almost entirely to surgical as distinguished from 
purely medical gynecology—which, stated in other words, means that 
modern gynecology is essentially surgical. 
Surgical it is, and in a surgical direction its advances in the near 
future are likely to be made: surgery bred of increasing experience and 
knowledge in diagnosis and pathology; surgery based upon clear and 
rational indications and growing ever more exact and skilful in its 
methods; surgery, finally, inspired solely by one consideration, namely, 
the best interests of the patient, all things considered, in the individual 
case. In determining the latter point the personal equations of both 
operator and patient will come largely into play and prove important 
factors in reaching a decision as to the best mode of procedure. 
The uncertainties of other methods of treatment as compared with 
surgical measures are proverbial. Not that for this reason other methods 
are to be discarded. But in proportion as the risks from surgical treat- 
ment can be diminished will surgery steadily gain in favor, both on 
account of its more positive and permanent results, and the shorter 
time required for cure in the very great majority of cases. The latter 
is a very important consideration, and it must be the constant en- 
deavor of the progressive gynecologist to still further reduce the time 
required to lead a case to a successful issue by surgical measures. 
In a line with this thought is the subject of combined gynecological 
operations, by which is meant the performance, at the same sitting and 
upon the same patient, of various gynecological operations heretofore 
usually distributed over several sittings. Not alone are valuable time 
and much bodily suffering and mental anguish thus saved the patient, 
but the results of our procedures are likely to be much more perfect. 
Let us take, for instance, a case of complete procidentia uteri, the cure 
of which is attempted by plastic operations. Let us suppose that curette- 
ment, amputation of the cervix, anterior and posterior colporrhaphy, 
perineorrhaphy, and ventro-fixation of the uterus are all indicated by the 
existing pathological conditions. It will make a world of difference in 2 
EDEBOHLS, GYNECOLOGICAL OPERATIONS. 
the result, as well as in the time required to attain a successful result, 
whether the operator is able to perforin all these operations within a 
reasonable time, at one sitting, or whether he will be obliged to leave 
one or more of them to be performed at one or more subsequent sittings. 
Say, for instance, every operation above named is performed save the 
ventro fixation. It is common experience that plastic operations below, 
however skilfully performed, are in the very great majority of cases 
insufficient to withstand the continuous tendency of the uterus to again 
descend, favored as that tendency is by the relaxation of all pelvic sup- 
ports due to the prolonged prolapsus. As a result, when the time arrives 
at which the ventro-fixation can be added, it will be found that one or 
more of the plastic operations on the vaginal wall and perineum may 
have to be done over. Or if the perineorrhaphy be omitted and the 
ventro-fixation performed at the first sitting, the lack of support below 
will allow the uterus to tear itself away from the adhesions, holding it 
to the anterior abdominal wall. That both of these cases are not supposi- 
titious, my own experience in my first case sadly taught me, just as 
my later experience has demonstrated that when all the above-named 
operations are performed at the same sitting, a good result may be con- 
fidently anticipated. 
Further than this, the cure is complete in from three to four weeks, as 
compared with an indefinite period demanded when the operations are 
performed at different times ; and the patient is spared that unenviable 
frame of mind associated with looking forward to an indefinite number 
of operations to follow each other at indefinite intervals of time. 
The writer firmly believes that the next step forward in gynecological 
surgery will be in the direction of the simultaneous performance of as 
many operations as the patient may require to make her well, and that 
the gynecologist of the highest skill in operative work—which, to my 
mind, almost necessarily presupposes also the greatest skill in diagnosis 
—will consider that he has done justice neither to himself nor to his 
patient, unless, as a rule, admitting of but rare exceptions, he will be 
able safely and well to do all the surgery required in her case at a single 
sitting. It is the purpose of this paper to record some of the efforts 
made by the writer in this direction. 
To do combined operations with safety to the patient, presupposes, first of 
all, perfect asepsis and a not too prolonged anaesthesia. The operator 
must feel almost absolutely sure that no symptom of sepsis can arise after 
operation to harass his mind with doubts as to which of his operative pro- 
cedures has been at fault in this regard. Otherwise his state of mind, 
both, at the time of and after operation, must be far from enviable. 
As regards the period of time during which a patient may safely 
remain under the effects of an anaesthetic, individual opinions will prob- 
ably vary very widely. I myself have placed the practical limit in my EDEBOHLS, GYNECOLOGICAL OPERATIONS. 
3 
own work at one and a half hours, and have but on two or three occa- 
sions needed more time than this, no matter how many combined opera 
tions were required. 
Fig. 1. 
Edebohls’ operating-table. Top of table. A, metal frame; A, polished glass plate 
for head and shoulders; C, ditto, for body; D, metal surface ; E, trough ; N, holes for 
foot-supports. 
Fig. 2. 
Table, complete, with foot-supports (It) and ankle-straps (A) 
To do combined operations well within the time limits of safe anaes- 
thesia, requires, in addition to the necessary degree of operative skill 
and dexterity, sufficient and efficient assistance, a perfected technique 
of the various operations attempted, and an instrumentarium suitable to 
rapid work. 
Perhaps, then, I may be pardoned a brief description of the technique 
of the various typical operations entering into combinations, as I have 
practised them, before giving attention to the combinations themselves. 
All of the various operations now to be described are performed upon 4 
EDEBOHLS, GYNECOLOGICAL OPERATIONS. 
the author’s combined laparotomy and gynecological operating-table, a 
description of which may be found in the Medical Record, N. Y., Nov. 
14, 1891. 
Fra. 3. 
J. REYNDERSr-CO. 
HEW YORK. 
Table, showing method of obtaining the Trendelenburg posture. Any position between 
the horizontal and an inclination of 45° may be obtained on the table. 
Fig. 4. 
Table, showing modified lithotomy position, for examination, and for operations upon 
perineum, vagina, uterus, and bladder. D, carrying the buttocks of patient, can be 
raised to any convenient height. EDEBOHLS, GYNECOLOGICAL OPERATIONS. 
5 
Operations upon the uterus, cervix, and anterior vaginal wall are all 
performed with the patient in the dorsal position, and with the aid of 
the writer’s self-retaining speculum, described at length in the Medical 
Record, N. Y., March 7, 1891, p. 283. I have lately somewhat modified 
Fig. 5. 
Fig. 6. 
Self-retaining vaginal speculum. 
Speculum, showing method of use. 
the speculum, making it smaller and more portable, although preserving 
its essential characteristics.1 The modified instrument measures a little 
less than 10 centimetres in its longest diameter and fits into its accom- 
panying pail. The latter is 10 centimetres in diameter, 7.5 centimetres 
deep, and has a capacity of about 6.60 grammes. Any pail, however, 
1 The instrument, as originally made, was hammered out of copper by hand. In the 
further course of manufacture the original design was more or less arbitrarily departed 
from, until the instrument as turned out by different makers often assumed shapes so 
distorted, fantastic, and grotesque that it was with difficulty recognized even by its 
originator. Mr. E. Bocker, 582 Hudson Street, New York, under my supervision, 
finally took a great deal of pains to make an accurate model, and had a mould made of 
the same. The instrument as now turned out by him and by John Reynders & Co., 
being east, has the advantage of uniform correctness of shape. 6 
EDEBOHLS, GYNECOLOGICAL OPERATIONS. 
with a capacity up to a litre, may be used, or an equivalent solid weight 
may be substituted. 
The use of constant irrigation, as facilitated by this speculum, is a 
decided advantage as compared with the use of sponges in the perform- 
ance of combined operations, diminishing the risk of sepsis and contrib- 
uting materially to rapidity of work. Personally I have discarded 
the use of sponges for any and every purpose, using constant irriga- 
tion for plastic work on uterus, cervix, vagina, and perineum, and 
sterilized gauze serviettes for all other operations, including abdominal 
section. 
As an anaesthetic I all but invariably employ ether, administered by 
means of Parkinson’s modification of Ormsby’s inhaler. 
The advantages of this inhaler are its simplicity of construction and 
management, the small quantity of ether required—three to four ounces 
being sufficient for an houi*—and the avoidance of the diffusion of ether 
vapor through the operating-room. After a use of the Parkinson 
inhaler extending back over nearly three years, I have nothing but 
words of commendation for it, and the smoothness of the anaesthesia 
/ 
has been a matter of frequent comment by visitors to my operating- 
room. 
Fig. 7. 
Parkinson ether-inhaler. 
I will now proceed to describe, as briefly as I may, the details of tech 
nique, as I now practise them, in the various gynecological operations. 
Currettement of the Uterus. —With the patient in the dorsal position 
and after thorough disinfection of the vagina with creolin-mollin, 10 per 
cent., followed by irrigation with 1: 2000 sublimate solution, the speculum 
is introduced and the anterior lip of the cervix seized and drawn down by 
the double tenaculum forceps herewith illustrated. The tenaculum for- 
ceps has two teeth on one point, and a single tooth, fitting between these 
two, on the opposite point. 
The points as well as the ratchet lock on the handle are kept in true 
working order by means of the improved antiseptic lock which I have EDEBOHLS, GYNECOLOGICAL OPERATIONS. 
7 
elsewhere described. (Medical Record, N. Y., March 15, 1890, p. 310.) 
It has proved to the writer a most valuable and practical instrument in 
almost all his plastic and abdominal work. A few additional instances 
of its utility will be alluded to further on in the paper. 
Tenaculum forceps. 
After seizing the anterior lip, the cervix is dilated, if necessary, by a 
simple dilator (I prefer the ordinary two-branched, glove-stretcher form, 
Sims’ or Wylie’s modification thereof); a double-current catheter (Boze- 
man, Fritsch, or Kelly) is introduced and the uterine cavity washed with 
a 1: 2000 sublimate solution. A sharp . curette is next introduced and 
the entire mucous membrane of the uterus systematically scraped out 
until the harsh grating sound and feel of the curette as it passes over 
the tissues informs us that the submucous and muscular layers have 
everywhere been reached. A curettement of the uterus, as may be 
gathered from the above, to me means an abrasio mucosae totalis—an 
entire removal of the mucous membrane. Nothing less than this do 
I consider satisfactory or sufficient. The curettement can be still more 
satisfactorily accomplished by having an assistant draw lightly on the 
tenaculum forceps grasping the cervix. This releases the operator’s left 
hand, the index finger of which can be passed up the vagina along the 
outside of that portion of the uterus we are curetting. This finger 
forms an excellent point d’appui to the curette within the uterus, and 
thus aids materially in rapid and thorough work. One or twice during 
the progress of the curettement, and again at its close, the uterus is 
thoroughly washed out with 1 :2000 sublimate solution. There are very 
few combinations of gynecological operations into which curettement 
does not with advantage enter. 
Fig. 9. 
Double-edge lance-shaped knife. 
Trachelorrhaphy.—My method of performing this operation differs 
in no wise from that usually employed, except that I use a lance- 
shaped knife instead of the scissors, to remove such tissue as may be 8 
EDEBOHLS, GYNECOLOGICAL OPERATIONS. 
required both in this operation and in amputation of the cervix. I find, 
however, that where combined operations are called for, amputation of 
the cervix is much more frequently indicated than trachelorrhaphy. 
On consulting my records for the past two years I find that I have 
performed three times as many amputations of the cervix as trachelor- 
rhaphies. 
Amputation of the Cervix.—The modification of Simon and Marck- 
wald’s operation adopted by Skene of Brooklyn, and so well described 
and pictured by the latter in his treatise on the Diseases of Women, 
1889, page 345, leaves little or nothing to be desired, and I practise it 
strictly as there depicted, with only one exception. Instead of embracing 
the cervix above the seat of amputation with an elastic ligature to 
control hemorrhage, I secure the latter object by passing a curved needle 
armed with a catgut ligature around the circular artery high up on 
each side of the cervix. The ligatures are drawn tight and allowed to 
remain until removed by absorption. I was led to adopt this procedure 
after two or three unpleasant experiences with secondary hemorrhage 
after the employment of the elastic ligature, and have since had no 
further trouble in this direction. When perineorrhaphy enters into the 
combination with trachelorrhaphy or amputation of the cervix, I prefer 
to use sutures of absorbable chromicized catgut (Doederlein, “ Resorbir- 
bares Chromsaureskatgut,” Centralbl.f. Gyn., 1890, p. 534), or those 
prepared from the tendon of the tail of the kangaroo, for the latter two 
operations. Otherwise, I prefer to sew the cervix with silkworm-gut. 
In work on the cervix the Hagedorn needle and the tenaculum forceps 
above described have been found especially serviceable, the latter in lieu 
of the tenaculum ordinarily used. It never slips its hold until released 
by the operator. 
Anterior and Posterior Colporrhaphy.—The limits of the vaginal wall 
to be removed are fixed by four toothed sponge-holders; the tissue to be 
Toothed sponge-holder. 
removed is rapidly circumscribed and cut at the same time by a sharp- 
pointed scissors, one point of which, after piercing the mucous membrane 
of the vagina, is made to traverse along the connective-tissue plane be- 
tween the vagina and the bladder or rectum. The segment of vaginal 
wall thus circumscribed is now peeled entirely from the underlying 
bladder or rectum, following tbe connective-tissue plane as a guide. In 
this lies the secret of success in both operations, as by doing so we reach 
vascular parts which will unite firmly after suture. The timid or inex- EDEBOHLS, GYNECOLOGICAL OPERATIONS. 
9 
perienced operator will fail right here, removing the vaginal wall in part 
of its thickness only, the deep layers of the vagina presenting raw sur- 
faces ill adapted to firm union. I prefer to close the denuded surface 
thus made with buried kangaroo or chromicized catgut suture in tiers, 
and have thus far never failed to secure full primary union. I have 
tried and abandoned the Stoltz or purse-string method described by 
Munde (Am. Journ. of Obstet., 1890, p. 268) as the “ best ” for cystocele. 
It is theoretically and practically incorrect, in that it shortens the 
vagina in its length as well as in its circumference, a thing it is rarely, 
if ever, desirable to do. 
Perineorrhaphy.—The method invariably employed is that described 
by the author in a paper entitled “ A New Method of Suture in 
Perineorrhaphy,” published in the Am. Journ. of Obstet, October, 
1890. I there reported ten cases, all of incomplete laceration. Since 
then I have operated upon twenty-seven cases more, five of which were 
complete tears into the rectum, making thirty-seven cases in all. In 
every single one of them I obtained primary union and a perfect result 
at the first operation. 
Shortening of the Round Ligaments—is performed after the author’s 
method as described in the New York Medical Journal, October 11, 
1890. After an experience with the method now embracing fifty-one 
cases, I am more pleased with it than ever, both as regards the 
immediate and ultimate anatomical and therapeutical results. The 
only modification in the operation as described is a slight one in 
the method of suture. I now close the canal and secure the ligament 
by buried silkworm sutures embracing the cut fascia of the external 
oblique muscle and the ligament; uniting the superficial fatty layer and 
skin by a running suture of catgut. I would here like to emphasize 
one point only, a disregard of which will surely lead to disappoint- 
ment : shortening of the round ligaments is neither alone nor in com- 
bination a suitable operation for prolapsus uteri. The sole indication 
for the operation is a non-adherent retroverted uterus with normal-sized, 
non-adherent tubes and ovaries, and then only when the symptoms are 
plainly referable to the retro-displacement. I have within the past six 
months, however, in two cases of adherent retroversion with normal-sized 
appendages, released the uterus from its adhesions under narcosis, after 
the method of Schultze (without a laparotomy), and secured the uterus 
in anteversion by shortening the round ligaments. 
Ventro-fixation of the Uterus.—I will describe the operation as I per- 
form it in adherent retroversion, and in combination with other opera- 
tions for prolapsus uteri, leaving out of account those cases in which it 
is performed in the course of laparotomy for other conditions—diseased 
adnexa, and so forth. 
An incision four or five centimetres long is carried through the abdomi- 10 
EDEBOHLS, GYNECOLOGICAL OPERATIONS. 
nal wall in the median line anteriorly between the umbilicus and pubes, 
the patient being in the Trendelenburg posture. Two fingers are then 
introduced, the pelvis is explored, and the uterus, if adherent, is lib- 
erated. The anterior surface of the uterus is next grasped with the 
tenaculum forceps at a point on a line with and midway between the 
origin of the Fallopian tubes, and the uterus brought forward to and 
sustained behind the abdominal incision. Three silkworm sutures are 
next passed embracing fascia, muscle, peritoneum, and a section of the 
anterior uterine wall two or three centimetres wide and six to eight milli- 
metres deep. One suture passes on a level with the origin of the tubes, 
the second below, and the third above that level. Two or three silk- 
worm sutures embracing fascia, muscle, and peritoneum are inserted to 
close the balance of the deep parts of the abdominal wound. The 
tenaculum forceps is removed and the anterior face of the uterus 
between the points of entrance and exit of the three sutures is scarified 
by scraping off its peritoneum. All the silkworm sutures are now tied, 
cut short, and buried by closing over them, with running catgut suture, 
the skin and superficial fat. The author has performed ventro-fixation 
as above described for retroversion and prolapsus twenty-one times, exclu- 
sive of nearly an equal number of cases in which it was performed in 
the course of laparotomies undertaken for the relief of other conditions. 
All have recovered, and I know of none in which the uterus has again 
become retroverted or prolapsed, although a number of my cases are 
over three years old. 
Nephrorrkaphy.—An incision extending from the twelfth rib to the 
crest of the ilium is carried through the posterior abdominal wall along 
the outer edge of the quadratus lurnborum and erector spinse muscles 
until the peri-renal fat is reached. This is drawn out of the wound until 
all slack around the kidney is taken in, and the redundancy is cut off 
with scissors. In doing this care must be exercised not to drag up and 
open the peritoneum near the lower pole of the kidney. The capsula 
propria of the kidney is thus exposed and is incised mesially, along the 
length of the convexity of the kidney, to the extent of seven or eight 
centimetres. This incision in the capsula propria should involve the 
lower half of the kidney rather more than the upper, as it is desirable 
to elevate the kidney as much as possible beneath the ribs while moor- 
ing it to the posterior abdominal wall. The incised capsula propria is 
peeled off from the kidney substance to the extent of 1.5 centimetres on 
either side of the incision along its entire length, and is reflected like 
the lapel of a coat, thus laying bare quite a large area of raw kidney 
surface. From four to six silkworm sutures are passed, embracing the 
muscles and fascia of the abdominal wall, the cut edges of the fatty 
capsule, the reflected as well as the still adherent capsula propria, the 
kidney substance itself, to the extent of including all the portion stripped EDEBOHLS, GYNECOLOGICAL OPERATIONS. 
11 
of capsule to a depth of six or eight millimetres from the surface. 
A drain composed of eight or tea strands of silkworm-gut is laid along 
the raw kidney tissue at the bottom of the wound, the ends of the drain 
emerging at either angle of the wound. The silkworm sutures are tied, 
cut short, and buried by closing the superficial fat and skin over them 
with running catgut. Usual antiseptic dressings. 
I have performed nine nephrorrhaphies for movable kidney after the 
above method, my first operation bearingdate of February 6, 1890, and 
do not know of a kidney so fixed becoming subsequently movable. 
Suture Material.—The materials used for suture play an important 
part in combined gynecological operations, and may, therefore, well 
claim a moment’s attention. I use for various purposes silk, silkworm- 
gut, catgut, tendons from the tail of the kangaroo, and chromicized 
catgut. 
Silk is used only for suture of intestine, and as a retractor in abdominal 
section, either lip of the wound being pierced and drawn outward by a 
piece of heavy silk. 
Silkworrn-gut is used in perineorrhaphy, and in operations upon the 
cervix invariably when perineorrhaphy is not performed at the same 
sitting, and sometimes even when it is. As a buried interrupted suture 
it is used for the following purposes : To close the canal, and anchor the 
ligament in the operation for shortening the round ligaments ; to unite 
fascia, muscle, and peritoneum in abdominal section; to attach the kid- 
ney to the muscular and fibrous structures of the abdominal wall in 
nephrorrhaphy; to secure the uterus to the deep structures of the 
abdominal wall in ventro-fixation. In bundles of from six to ten 
strands it forms an excellent material for drainage in Alexander’s opera- 
tion, nephrorrhaphy, and occasionally as a drain for the excessively 
thick fatty tissue of the abdominal wound in laparotomy. Its non- 
absorbability, strength, and insusceptibility to change constitute excel- 
lent qualities where secure and lasting closure of the firmer deep tissues 
and fixation of solid organs are required. It is as aseptic as silver wire, 
and as easily manipulated and tied as silk. 
Catgut in suitable sizes is used for all ligatures, and as a running 
suture loosely applied to hold together the superficial fat and skin in 
wounds of those tissues. Silkworm-gut in interrupted buried sutures 
to close the firmer deep tissues, and catgut loosely applied to unite the 
superficial fat and skin, form the most satisfactory method of closure 
of wounds such as the gynecologist is required to make. 
I have used kangaroo tendon quite extensively for some months past, 
but fail to see that it possesses any advantages over chromicized catgut. 
The latter, prepared as resorbable chromicized catgut, after the method 
of Doederlein, is superior in every way, cost included, to kangaroo 
tendon. 12 
EDEBOHLS, GYNECOLOGICAL OPERATIONS. 
Combined Gynecological Operations.—Coming now to the sub- 
ject proper of the various combinations of gynecological operations, they 
may properly be divided into two general classes: 
1. Those combinations into which a laparotomy does not enter. 
2. Combinations of which a laparotomy forms part. 
The first class embraces, as far as the writer’s own practical experi- 
ence goes, curettement, amputation of the cervix, trachelorrhaphy, 
anterior and posterior colporrhaphy, lateral colporrhaphy, perineor- 
rhaphy, shortening of the round ligaments, and nephrorrhaphy. 
The combinations of this class perhaps most frequently called for are 
curettement and amputation of the cervix or trachelorrhaphy, and the 
combination of these with perineorrhaphy. These combinations should 
always be easily performed within the hour—l have done them 
repeatedly in half the time—and the writer holds that it would be gross 
injustice to a patient at the present day to submit her to two sittings 
for their performance. Indeed, an operator claiming to be an expert 
should, as a rule almost without exception, be able to perform any com- 
bination of operations in this first class that may be required in the 
individual case, excluding only those combinations into which shorten- 
ing of the round ligaments enters, within an hour and fifteen minutes. 
The operation for shortening the round ligaments—really a double opera- 
tion—properly performed, requires from twenty to forty-five minutes, 
and may even, in case of unusual difficulty in finding and isolating the 
ligaments, be protracted a little beyond the latter limit. 
The combination of operations of the first class next most frequently 
called for in the writer’s experience, is curettement, amputation of the 
cervix or trachelorrhaphy, and shortening of the round ligaments. This 
combination I have performed fourteen times and never required above 
seventy-five minutes. In one additional instance a perineorrhaphy was 
added to this combination without exceeding the time-limit just named. 
Next in frequency come the two following combinations: Ist. Ante- 
rior colporrhaphy and colpo-perineorrhaphy; 2d. Amputation of cer- 
vix, shortening of round ligaments, and perineorrhaphy. I find on my 
records memoranda of three of the first and four of the second combina- 
tions performed during the past two years. The time required for the 
first combination averaged thirty, that for the second combination 
seventy-five minutes. In one additional instance a trachelorrhaphy, in 
a second an amputation of the cervix, and in a third a curettement were 
added to the first combination, all performed within the hour. 
Nephrorrhaphy for movable kidney entered into combination with 
operations enumerated under the first class three times. Once it was 
combined with curettement for chronic endometritis and catarrhal sal- 
pingitis. A second time it was performed at the same sitting with 
curettement and trachelorrhaphy. In both instances I finished within EDEBOHLS, GYNECOLOGICAL OPERATIONS. 
13 
the hour. On a third occasion curettement, shortening of the round 
ligaments, and nephrorrhaphy were performed together in one hour and 
twenty minutes. 
There is no excuse for a mortality in any required combination of 
operations included in the first class. Perfect asepsis secures against 
infection, and the good judgment, alertness and skill of the operator 
should insure his patient against the risks of prolonged anaesthesia and 
accidental dangers. 
The indications for the various combinations of operations of the first 
class are given by the various combinations of pathological conditions 
existing in the particular case, and it is perhaps not too much for a 
woman who at the present day places herself under the care of a specialist 
in gynecology for operation to expect that all operative procedures 
required in her case, provided a difficult laparotomy be not among the 
number, be performed at one sitting. Indeed the modern woman 
worthy of the times may soon demand this as a matter of course. 
I am not quite prepared to make the same positive statement in 
regard to combinations into which a difficult laparotomy enters, although 
I believe we are rapidly approaching this point, and that farther im- 
provements in the technique, including that of laparotomies, will soon 
enable us, as a rule, to perform at the same sitting all operations, includ- 
ing abdominal section, that may be required in any given case. The 
Trendelenburg posture has helped us along a great way in this direction. 
Perhaps the most frequent, as well as the simplest, of the combina- 
tions into which an abdominal section enters is the combination of 
curettement with salpingo-oophorectomy for diseased tubes and ovaries. 
This combination, rationally so often called for by the coexistence 
and interdependence of endometritis and salpingitis in their various 
forms, has been quite freely discussed of late, more especially at the 
meetings of the New York Obstetrical Society. The consensus of opinion 
among prominent gynecologists is almost unanimous that the two opera- 
tions are, as a rule, required. The only difference of opinion seems to be 
as to whether they should be performed at the same sitting, and if so, 
whether the curettement should precede or follow the salpingo-oophor- 
ectomy. My own rule has been to do the curettement first, even when 
the presence of pus in the pelvis has been positively diagnosticated, 
being careful to do the curettement with the uterus in situ, i. e., without 
dragging down the organ. 
The abdomen is then opened, the diseased parts removed, and the 
operation completed by a final irrigation of the uterine cavity with 
1 : 2000 sublimate solution, to remove any infectious matter that may 
have come down from the tubes into the uterus during the manipulations 
within the abdomen, I have proceeded thus in quite a number of 
instances and have never had cause to regret doing so. I prefer this 14 
EDEBOHLS, GYNECOLOGICAL OPERATIONS. 
order to doing the laparotomy first, closing the abdomen, and taking the 
chances of internal hemorrhage by slipping of an intra-abdominal liga- 
ture during the subsequent curettement. 
In addition to the combination of curettement with removal of dis- 
eased appendages, I find on my records two cases of fibromata uteri in 
which I combined curettement with removal of the normal adnexa. 
Among the combinations of abdominal sections with other operations, 
hysterorrhaphy or ventro-fixation of the uterus figures very prominently. 
I leave out of account here those cases in a which a laparotomy is 
the only operation performed, and in which, after extirpation of dis- 
eased appendages, or removal of a tumor, etc., the uterus is fastened to 
the anterior abdominal wall in closing the latter. 
The most frequent combination of hysterorrhaphy is with curettement. 
Indeed, I would lay it down as a law that curettement should always 
precede laparotomy for ventro-fixation of an adherent or non-adherent 
retro verted uterus, just as it should invariably precede shortening of the 
round ligaments. The condition of the endometrium in retroversion as 
well as retroflexion always calls for a curettement. 
I have on my records two cases in which a badly la cerated cervix 
coexisted with retroflexion of an adherent uterus, the appendages being 
apparently normal. In one of them a trachelorrhaphy, in the other an 
amputation of the cervix, was performed at the same sitting with 
curettement, severing of adhesions, and hysterorrhaphy. 
Prolapse operations. We next come to the important class of plastic 
operations for prolapsus uteri, partial and complete, into any and every 
combination of which operations ventro-fixation of the uterus should, as 
a rule to which there can hardly be an exception, always enter. 
I find upon my records notes of nine combined operations for pro- 
lapsus uteri, upon eight patients, one of the patients being operated upon 
twice. In all but one of these cases the prolapsus was complete, form- 
ing the so-called procidentia uteri, the uterus and vagina being com- 
pletely outside of the body between the thighs. 
The conditions existing in the case of incomplete prolapsus called for 
the following combination of operations: Curettement, anterior col- 
porrhaphy, ventro fixation of uterus and colpo-perineorrhaphy, which 
were performed at one sitting within the hour, and resulted in a lasting 
cure of the descensus uteri. 
The case of complete prolapsus operated upon twice occurred in a 
virgin, and was associated with, and due to, tubercular peritonitis with 
ascites. I have already reported the case in full, in a paper on “ Tubal 
and Peritoneal Tuberculosis,” published in the Transactions of the 
American Gynecological Society, 1891, and shall therefore not enter into 
further details here. 
In three cases the complete prolapsus and its associated conditions EDEBOHLS, GYNECOLOGICAL OPERATIONS. 
15 
called for the performance at one sitting of the following operations: 
Curettement, amputation of the cervix, anterior colporrhaphy, ventro- 
fixation of the uterus, and perineorrhaphy. In each of the three cases 
the five operations were performed within seventy-five minutes, and the 
women all remain cured; the first of the three cases, however, having 
been operated on only a little over a year ago. 
In another case, also of complete prolapsus in a nullipara, I started 
out to do the same series of five operations just reported upon, but 
changed my mind during the course of the operation, and performed 
double lateral colporrhaphy instead of anterior colporrhaphy and colpo- 
perineorrhaphy, the other operations being the same as in the other three 
cases. This was my first experience with lateral colporrhaphy, and, 
owing to this fact probably, the combination demanded one hour and 
fifty minutes. The result, however, has been equally as gratifying as in 
the other cases. 
In another case of complete prolapsus, previously operated upon with- 
out success by a very distinguished confrere, the following combination, 
requiring one hour and fifty minutes, succeeded in effecting a cure: 
Curettement, anterior colporrhaphy, posterior colporrhaphy, perineor- 
rhaphy, and ventro-fixation of the uterus. The changes produced in the 
various tissues by the unsuccessful previous operations were responsible 
for the undue length of time required for the successful combination of 
operations. 
Finally, I have to report a failure in combined operations for com- 
plete prolapsus uteri. It was my first case, a lady of fifty, and after 
performing curettement, amputation of the cervix, anterior colporrhaphy, 
and perineorrhaphy, I proceeded to shorten the round ligaments for 
the purpose of sustaining the uterus from above. Just here a double 
mistake was made, which I wish to record for the benefit of those who 
may not have had a similar experience. The first mistake was to do 
Alexander’s operation for prolapsus. Shortening of the round ligaments 
is emphatically not a proper operation, singly or in combination with 
other operations, for prolapsus uteri, partial or complete. The indica- 
tions for shortening the round ligaments are given in prolapse of the 
non-adherent tubes and ovaries, and par excellence in retroversion of 
the non-adherent uterus, the appendages being normal, although per- 
haps displaced. The second, mistake was in expecting to find the round 
ligaments in a woman who had passed the menopause, after which period 
in a woman’s life the round ligaments atrophy and undergo fatty 
change with the uterus, only in a more pronounced degree. Of the 
fifty-one cases in which I have operated for shortening the round liga- 
ments, this is the only one in which I failed to find the ligament, as 
well as the first and last case in which I attempted to perform the oper- 
ation in a woman past the menopause. To return, however, to the case— 16 
EDEBOHLS, GYNECOLOGICAL OPERATIONS. 
it proved a complete failure. Had I supplemented the plastic operations 
below by a ventro-fixation of the uterus, I feel confident, from the 
balance of my experience in this direction, that I would have scored a 
success. 
It is just this—with this one exception—satisfactory and successful 
experience with plastic operations for the cure of complete prolapsus 
uteri which compels me to regard total extirpation of the uterus for the 
cure of prolapsus as uncalled for and unjustifiable under ordinary con- 
ditions. By ordinary conditions I mean those in which the prolapsed 
uterus is neither the seat of a neoplasm, nor, without containing a 
neoplasm, itself so increased in size that it may not be reduced to about 
the normal size of the organ by means of an amputation of the cervix. 
This fact, moreover, must be borne in mind, that in aggravated cases of 
complete prolapsus, such as I have reported above, even total hysterec- 
tomy is insufficient in itself to cure, but to be efficient must, as a rule, 
be supplemented by various plastic operations upon the vagina and 
vulva. 
It may be proper to add that the wounds of the various operations 
entering into combination in the above cases of complete prolapsus all 
healed by primary union in each instance. 
A rather complicated combination of operations I have reported in a 
case presented to the ’New York Obstetrical Society. As the case is 
described in full in the New York Journal of Gynecology and Obstetrics, 
April, 1892, p. 379, I will here only outline it: Suppurating intra- 
ligamentary cystoma; unilateral chronic pelvi-peritonitis; secondary sal- 
pingitis and appendicitis; extensive laceration of cervix, and of perineum 
through sphincter. Curettement; trachelorrhaphy; removal of cyst, tube, 
and appendix vermiformis at one sitting; recovery. I will merely add 
that three months later the patient returned for perineorrhaphy for 
complete tear through sphincter, which operation has been successfully 
performed. I might cite additional instances of laparotomies for various 
conditions combined with plastic operations, all successful, were there 
any special object in doing so. 
As regards the mortality of combined operations into which a lapar- 
otomy enters, the death-rate will depend to a very great extent upon that 
of the special intra-abdominal operative interference called for. Thus, 
when ventro-fixation of the uterus forms the only intra-abdominal pro- 
cedure, no matter how many simultaneous jdastic operations are per- 
formed in combination with it, the mortality should be nil. It becomes 
quite a different matter, however, when, for instance, curettement and 
laparotomy for puerperal pyosalpinx or intra-peritoneal puerperal abscess 
are called for in the same case. The mortality of the laparotomy then 
becomes the determining factor, and is, of course, not lessened—nor, in 
my estimation, increased—by the accompanying curettement. Of the EDEBOHLS, GYNECOLOGICAL OPERATIONS. 
17 
entire number of cases in which the author has performed combined 
operations he has lost but one, a case of retained secundines, septic 
endometritis, puerperal pyosalpinx, and intra-per'itoneal abscess, i. e., an 
extreme, almost necessarily fatal case of puerperal sepsis, in which but a 
week ago I curetted the uterus, removed the pus tubes, and emptied the 
intra-peritoneal abscess at the same sitting. Had I performed the 
laparotomy without the curettement, the result would have been the 
same to the patient; the author’s mortality in combined operations, 
however, would have remained where it was a week ago, i. e., at nil. 
Lest I may be suspected of never having had a failure in combined 
operations, I will conclude this paper by reporting all the failures, com- 
plete and partial, that I have had: 
Failure No. 1. A case of retroversion of the adherent uterus, with 
laceration of the hypertrophied cervix, called for curettement, amputa- 
tion of the cervix, and ventro-fixation of the uterus. After finishing the 
curettement, in doing the amputation of the cervix, repeated hemorrhage 
required the removal and reinsertion of all the cervical sutures three 
different times in succession. So much time (nearly an hour) was lost 
in this, and in securing the bleeding vessels, that I considered it impru- 
dent to prolong the anaesthesia sufficiently long to add the laparotomy. 
The latter was successfully performed two weeks later. 
Failure No. 2. Curettement, amputation of the cervix, and shorten- 
ing of the round ligaments were called for in this case. After per- 
forming the two former operations, and isolating and drawing out both 
round ligaments, the right round ligament in the final pull was torn out 
of the uterus. Both Alexander wounds were closed, and ventro-fixation 
of the uterus immediately added. The patient made a good recovery. 
Failure No. 3. The same combination, plus a perineorrhaphy, was 
called for as in the case just related. In performing the Alexander the 
left round ligament was pulled out of the uterus, and, as in the previous 
instance, ventro-fixation was immediately substituted for shortening of 
the round ligaments. Uneventful recovery. 
These two cases, and the one already reported in this paper, where I 
failed to find the ligaments in a woman past the menopause, embrace 
all the disagreeable experience which I have had with the operation for 
shortening the round ligaments. 
As in combined gynecological operations the time element is of such 
great importance, it. may be proper to state that wherever the time of an 
operation has been mentioned in this paper it has always been reckoned 
i from the first incision to the tying of the l&st suture. 
In conclusion, the author would refer to the dearth of literature 
’dealing comprehensively with the subject of combined gynecological 
operations. The only publication, the title of which indicates an attempt 
at a systematic treatment of the subject, which he has met with, is a 
paper by Munde (“ Combined Operations in Gynecology,” New York 18 
EDEBOHLS, GYNECOLOGICAL OPERATIONS. 
Medical Journal, May 18, 1889), the scope of which is, however, 
more limited than that of the present paper. 
Summary.—The tendency of modern gynecology is to progress in a 
surgical direction. 
The uncertainties and unreliability of other methods of treatment as 
compared with the results obtained by surgical measures are proverbial. 
With the rapid strides forward of surgical gynecology, this contrast is 
daily becoming more accentuated. 
Increased confidence in results growing from increased experience and 
progressive skill will incline the individual operator more and more to 
trust to surgical resources. 
Many cases require more than one gynecological operation to effect 
a cure. 
All gynecological operations required in a given case should at the 
present day, as a rule almost without exception, be performed at the 
same sitting. The patient has a right to expect this from the expert 
claiming to possess the highest degree of operative skill. That this will 
be the standard of the near future the author does not doubt. 
Success in combined gynecological operations presupposes first of all 
perfect asepsis and a not too prolonged anaesthesia. The duration of the 
latter need but very rarely exceed one and a half hours even in the 
most difficult cases. 
Other things necessary are the requisite degree of operative skill and 
dexterity, sufficient and efficient assistance, a perfected technique of the 
various operations attempted, and an instrumentarium suitable for rapid 
work. 
Combined gynecological operations may be divided into two general 
classes: 
1. Combinations into which a laparotomy does not enter. 
The expert operator should be able to perform any required com- 
bination of operations of the first class within the time-limits of safe 
anaesthesia. 
2. Combinations of which a laparotomy forms part. 
The same statement holds good of the combinations of operations of 
the second class into which a simple laparotomy enters. When a difficult 
laparotomy forms part of the combination the patient’s interests may 
occasionally be better served by operating at two sittings. 
There is no excuse for a mortality in combined operations of the first 
class. The mortality of combinations into which a laparotomy enters 
will depend upon that of the special intra-abdominal operative inter- 
ference required. •plje Jodrrjal 
of the MEDICAL SCIENCES. 
MONTHLY, $4.00 PER ANNUM. 
WITH 1892 The American Journal of the Medical Sciences enters upon its seventy- 
third year, still the leader of American medical magazines. In its long career it has 
developed to perfection the features of usefulness in its department of literature, and 
presents them in unrivalled attractiveness. It is the medium chosen by the leading minds 
of the profession on both sides of the Atlantic for the presentation of elaborate Original Articles; 
its Reviews are noted for discernment and absolute candor, and its Classified Summaries of 
Progress each month present an epitome of medical advances gleaned by specialists in the 
various departments. According to unquestionable authority, “It contains many original papers 
of the highest value; nearly all the real criticisms and reviews which we possess, and such 
carefully prepared summaries of the progress of medical science and notices of foreign works that 
from this file alone, were all*other publications of the press for the last fifty years destroyed, it 
would be possible to reproduce the great majority of the real contributions of the world to medical 
science during that period.” 
Medical NeWs 
WEEKLY, $4.00 PER ANNUAL. 
THE practical value of The News is proved by its continually increasing subscription list. 
Every method of conveying serviceable information is utilized. Leading writers, teachers, 
and practitioners furnish original articles, clinical lectures, and brief practical notes; 
hospital physicians and surgeons detail the latest approved methods developed under their 
enormous opportunities; progress is gleaned from the best journals of all civilized nations; a 
special department is assigned to important abstracts requiring ample space for adequate presenta- 
tion ; able editorial writers deal with important questions of the day; medical literature is 
impartially reviewed; society proceedings are represented by the pith alone; correspondence is 
received from medical men in position to know all occurrences of medical importance in the 
districts surrounding important medical centres, and matters of interest are grouped under news 
items. The News, in short, is a crisp medical newspaper, a necessity to every practitioner. 
Its sphere is different from and complementary to that of the ideal medical magazine, The 
American Journal. To lead every reader of either to prove for himself the value of the two 
combined, the commutation rate has been fixed at the rate of #7.50 per annum. 
The Year-Book of Treatment for 1892 
Gives a classified summary and review of the real advances in treatment made during 1891, in all 
departments of the science of medicine. Price $1.50; or in combination with either or both the 
above journals, 75 cents. Ready early in iBgi. 
The Medical News Visiting- List for 1892 
Published in four styles: Weekly, dated, for 30 patients; Monthly, undated, for 120 patients per 
month; Perpetual, undated, for 30 patients weekly per year; Perpetual, for 60 patients weekly 
per year. The first three styles contain 32 pages of important data and 176 pages of assorted 
blanks; the 60-patient perpetual consists of 256 pages of blanks. Price, each, $1.25. In com- 
bination with either or both above periodicals, 75 cents. Or, Journal, News, Visiting List 
and Year-Book, $8.50. Thumb-letter index for Visiting List, 25 cents extra. 
LEA BROTHERS & CO., PUBLISHERS, PHILADELPHIA, 706 & 708 SANSOM STREET.