[Reprinted from the Transactions of the Philadelphia County Medical Society.] 
A YEAR’S WORK IN MINOR SURGICAL GYNECOLOGY 
AT THE KENSINGTON HOSPITAL FOR WOMEN. 
CHARLES P. NOBLE, M.D. 
[Read March 9, 1892.] 
Minor surgical gynecology, embracing the surgery of the pelvic 
floor, vagina, bladder, and uterus—excluding hysterectomy—has not 
received much attention at the hands of recent writers. This is 
partly because the attention of gynecologists has been devoted to 
the marvellous strides which have been made in abdominal surgery, 
and partly because this field of work is not so brilliant as that of 
abdominal surgery. It is true that minor gynecological surgery is 
not brilliant, but it is very important, and it seems to me that it is in 
some danger of being neglected by the surgeons of to-day. This 
fact has led me to report my last year’s work in minor surgical gyne- 
cology at the Kensington Hospital for Women, and to make certain 
observations on the various operations named. The following opera- 
tions have been done: 
Removal of vaginal cyst (post-cervical) 1 
Clitoridectomy (nymphomania) 1 
Excision of carcinomatous nodules (secondary after removal of breast) 3 
Uterine polyps (removed) .2 
Lipoma (removed) 1 
True pelvic abscess (drained after exploratory section had excluded 
disease of appendages) ......... 1 
Atresia of vagina (divided) 1 
“ “ vulva “ .... _ ,r ' '■» 1 
Cancer of cervix—curetting (death from ursemia) 1 
Amputation of cervix—cancer, 1; procidentia,v 
Anterior colporrhaphy (oval) . . . . Of / /. 1 
“ (Stoitz’s) . ( . 1 . 7 VtAt V. % 
Perineorrhaphy (Hegar’s) .... V . . „ .... ’ . . 1 
“ (Emmet’s) .... .. . ' . 17 
Trachelorrhaphy ........ 7 . .6 
Dilatation and curetting 18 
A a I IJi >K ii. 60 2 
NOBLE, 
One death occurred in a case of advanced carcinoma of the cervix, 
which was thoroughly curetted by Dr. Kelly. Death followed on the 
eighth day from “ cancerous uraemia.” This poor woman had been 
insane for some weeks—the insanity being due supposedly to absorp- 
tion of septic matter from the decomposing cancer. The operation 
was done with the hope of relieving this, and also to get rid of the 
necrotic mass. The other operations in the report were done by 
myself. The technique employed was quite similar for all cases. The 
patient’s bowels were well cleared out the day before, and were moved 
by enema the morning of the operation. In addition, the patient 
had a full bath and a sublimate vaginal douche. Operations were 
done under ether-anaesthesia in the dorsal position, with the Robb 
leg-holder and the Kelly perineal pad in use. The vulvar region 
and vagina were well scrubbed with soap and water, the vulvar hair 
was shaved, and the parts were well douched with sublimate solution. 
In this way an aseptic field was secured; all operations were done 
under irrigation with boiled water, sponges not being used. This 
technique is a little troublesome, but the results secured amply com- 
pensate for the outlay of time. 
I have made it an invariable rule to re-examine all patients before 
beginning the operation. This can be done most thoroughly when 
the patient is anaesthetized. If the uterine appendages are found 
inflamed and adherent, any proposed operation upon the uterus is 
abandoned. I believe this to be the only safe rule of practice. 
For sutures, silk, catgut, and silkworm-gut have been used. For 
general purposes I like silk ; but it should not be used where the 
sutures cannot be removed in one or two weeks. Catgut I have 
found very useful for sutures having but little strain to bear, as, for 
instance, the upper sutures in perineal operations. Silkworm-gut has 
the advantage that it is non-absorbent; hence it is to be preferred 
where sutures must be left in a long time, as, for instance, in the 
cervix, when the cervix and perineum are repaired at the same sit- 
ting. It has the disadvantage of being stiff, which property makes 
it somewhat hard to remove, and gives the patient some pain. After 
operations the vagina is carefully dried, a pencil of iodoform (25 
grains), together with a strip of iodoform gauze, is introduced, the 
vulva is sprinkled with a powder of iodoform (1 part) and boric acid 
(7 parts), and then a cotton pad is placed over the vulva—held in 
place by a T-bandage. After perineal operations the urine is drawn 
for two days; after which the patient is allowed to urinate. The 
gauze is removed after forty-eight hours; after which a sublimate MINOR SURGICAL GYNECOLOGY. 
3 
douche (1 : 2000) is given once daily. The bowels are moved on the 
second day and regularly thereafter. An abundant soft diet is per- 
mitted. The external sutures in perineal operations are removed 
about the eighth day; the internal sutures at the end of the second 
week. When the cervix has been repaired at the same time, the 
cervical sutures are removed at the end of the third week or even 
later. One should err on the side of leaving the sutures in long 
rather than that of removing them early. 
Patients having perineal operations are permitted to sit up in two 
weeks; those having a curetting, in three or four days; those having 
a trachelorrhaphy, in a week, etc. 
The secret of success in plastic surgery is good asepsis, and careful, 
painstaking, and accurate denudation and suturing. I have never 
failed to secure good union, which has always been primary through- 
out, with two exceptions—one stitch-hole abscess and one small 
hemorrhage (hgematoma). 
Dilatation and Curetting.—Within the past ten years pro- 
fessional opinion concerning these operations has fluctuated widely. 
Before the antiseptic era curetting was considered a dangerous opera 
tion. Its danger at that time I feel satisfied was due partly to lack 
of antiseptic measures, and partly to bad diagnoses. At that time 
our knowledge of the diagnosis of chronic salpingitis was very im- 
perfect, and many accidents (peritonitis) resulted from operating on 
the uterus when the tubes contained pus or other septic fluid. Since 
the antiseptic era, in the hands of men capable of making a diagnosis 
of uncomplicated disease of the uterus, and of excluding chronic 
pelvic inflammation, these operations have been done with impunity. 
Of late, the legitimacy of the operations has been questioned by Dr. 
Joseph Price, on the ground that many cases of salpingitis and pus 
tubes have come under his care in which dilatation or curetting has 
been done. This fact is no argument against the legitimacy of the 
operations, nor against the fact that, when properly done in un- 
complicated cases, the operations are perfectly safe and free from 
danger. 
Did the women seen by Dr. Price (and by others, including myself) 
have the tubal disease before the uterus was dilated or curetted ? 
Were the operations done under rigid asepsis? I believe that blun- 
ders in diagnosis and blunders in asepsis should bear the blame in 
these most unfortunate cases, and not legitimate surgery. In my own 
hands no such untoward results have occurred. On the contrary, 4 
NOBLE 
under the strict limitations laid down, my confidence in the value and 
safety of the operations increases as my experience grows. 
Dysmenorrhcea.—Three cases of dysmenorrhoea, due to partial 
development of the cervix, with anteflexion, and characterized by 
“cramps” during the flow, were*treated by dilatation. Dilatation in 
this class of cases has always given good results. The cause of the 
“cramps” is a poorly developed cervix with a narrow canal, whose 
caliber is further lessened by the anteflexion. 
A broader experience has induced me to use the dilator for dys- 
menorrhoea much less frequently than formerly. I consider it abso- 
lutely contra-indicated if there is tubal inflammation, and believe that 
it is of little use in relieving pain, unless the latter is distinctly inter- 
mittent and cramp-like in character. 
The pains accompanying menstruation due to inflammation of the 
uterine appendages, or of the uterus, or due to a depressed state of 
the blood, with pelvic neuralgias, are not benefited by dilatation, and 
in such cases it should not be done. 
Endometritis.—Fifteen cases of uncomplicated endometritis have 
been treated by dilatation and curetting. Nine of these were cases 
of fungoid endometritis with resulting uterine hemorrhages. I believe 
that this procedure best meets the indications in all cases of uncompli- 
cated chronic endometritis. By removing the thickened portion of the 
diseased endometrium and providing a freer vent for the uterine secre- 
tions, most cases of endometritis can be cured promptly, and the remain- 
der are much improved. The number of cases in which it is necessary 
to make intra-uterine applications is thus much reduced, and these 
women are saved the necessity of undergoing a prolonged course of 
painful intra-uterine treatment. By promptly curing women with 
chronic endometritis another important point is gained—the disease is 
cured before it spreads to the tubes. 
The results in my hands have been most satisfactory in cases of 
fungoid endometritis, especially those of short duration, resulting 
from abortions. Cases of chronic endometritis with purulent leucor- 
rhoea have been most intractable, and in these cases it has been 
necessary to make weekly applications to the endometrium (by means 
of the applicator) of pure carbolic acid, Churchill’s tincture of iodine, 
or a saturated solution of chloride of zinc, for some weeks after the 
curetting. I wish to call attention to the small number of cases of 
uncomplicated endometritis in this series. Omitting the fungoid cases, 
there were 6 out of 128 women admitted to the hospital. This is 
about the average in my practice. MINOR SURGICAL GYNECOLOGY. 
5 
In fungoid endometritis I have found the curette so valuable, and 
other methods of treatment (in marked cases) so futile, that I am 
unable to understand how those gentlemen who oppose the use of the 
curette treat these cases. The only other resort is electricity; but 
the curette will accomplish in a few minutes what it requires weeks or 
even months to accomplish by electricity. 
The results obtained by the curette in uncomplicated endometritis 
are so good that of late, forgetting the teachings of past- experience, 
certain operators have proposed to treat cases of endometritis com- 
plicated by chronic tubo-ovarian inflammation in the same way. It 
seems to me that careful men cannot protest too strongly against such 
treatment. In the first place, the danger of setting up fresh sal- 
pingitis and peritonitis is acknowledged (except by the few) to be 
great: and in the second place, should the endometritis be cured 
(which is doubtful because of pelvic congestion kept up by the tubo- 
ovarian inflammation), the graver disease of the appendages remains. 
The wiser plan, if the appendages are diseased, is first to remove 
them, and then actively treat the endometritis; or if the appendages 
are but slightly diseased and do not require ablation, to treat the 
patient by applications of iodine to the vaginal vault, and the use of 
glycerin tampons, at the same time using every measure to improve 
the local conditions by general medication.. 
It happens not infrequently that when the inflamed uterine append- 
ages are removed, an endometritis is left which causes the patient 
some annoyance. These cases are often reported by those hostile to 
modern surgery as showing that the abdominal section has failed to 
cure the patient. These gentlemen have a mental strabismus, and do 
not see that the section has accomplished the end aimed at, the abla- 
tion of the diseased uterine appendages Whether this alone will 
cure the patient depends upon whether the particular patient has any 
other disease. If she has an endometritis, this must be cured; if 
anmmia, or indigestion, or malnutrition, these must be treated. 
I wish to protest against the vieAV that endometritis as a rule causes 
much distress, except the annoyance of a leucorrhoea, unless it in- 
duces hemorrhage. Where women having endometritis suffer much 
pelvic pain, and are semi-invalids, the cause of the pain or invalidism 
is to be sought elsewhere—in the uterine appendages, or in the vital 
organs, or blood state. It is a narrow man who attributes all the 
symptoms complained of by women to disease of the pelvic organs, 
and who forgets that women have an unstable nervous system, easily 
influenced by morbid conditions of the general economy. 6 
NOBLE, 
In discussing endometritis it should not be forgotten that other con- 
ditions besides endometritis can cause a discharge from the uterus. 
Whatever will cause congestion of the uterus will cause uterine dis- 
charge. For example, subinvolution, constipation, feeble heart, lazy 
habits, malnutrition—as from phthisis, erotism, etc. Treatment 
addressed to the causative disorder will stop such uterine discharge. 
This class of cases calls for no treatment of the endometrium. 
Stoltz’s -Anterior Colporrhaphy.—This operation has been 
done twice during the time covered by this report. It is specially 
adapted for cases of procidentia in which cystocele is a marked feat- 
ure. The cases have been treated with most gratifying success by 
amputating the cervix above the vaginal junction, doing Stolz’s oper- 
ation on the anterior vaginal wall and Emmet’s operation on the 
perineum, the combination of operations being done at one sitting. I 
have had but one failure in my experience. This was in the person 
of a woman having complete procidentia, whose tissues had undergone 
marked fatty degeneration. 
Perineorrhaphy.—One Ilegar’s operation was done on a woman 
having a patulous introitus. Seventeen operations were done after 
the manner of Emmet for injuries to the pelvic floor, involving lacer- 
ation of the levator ani muscle and loss of pelvic support. 
It seems strange to me that men who are familiar with the an- 
atomy of the pelvic floor, and with the nature of the injuries it 
sustains during labor, can differ so widely concerning the nature of 
the operation required to repair the injuries sustained. Not to con- 
sider the lacerations extending into the bowel, there are two general 
classes of lacerations of the pelvic floor: 
1. Lacerations involving the vulvar commissure, and extending 
scarcely to the vagina, scarcely beyond the plane of the hymen. 
These are the insignificant lacerations, which at most give rise to a 
gaping introitus vaginae, but which involve no appreciable loss of 
pelvic support. Such lacerations are median, and involve no very 
important muscular structures. The bulbo-cavernosus and the trans- 
versus perinei muscles may be divided, but the laceration does not 
extend far enough up the vagina to reach the levator ani. Usually 
it is indifferent whether such lacerations are closed or not. The 
result to be gained is scarcely sufficient to compensate a woman for 
submitting to a secondary operation. In my opinion, however, even 
such lacerations should have a primary perineorrhaphy. If a second- 
ary operation is done, the Ilegar operation best meets the indications. MINOR SURGICAL GYNECOLOGY. 
7 
The flap-splitting method will answer, but it leaves an ugly fold of 
tissue at the orifice of the vagina. 
2. Lacerations extending along the vagina, and involving more or 
less of the levator ani muscle or muscles and the deep fascia, accord- 
ing to the extent and depth of the lesion. Such tears, as a rule, not only 
involve the commissure of the vulva, as in class 1, but also extend up 
the vagina, and without exception extend up one or both sulci. They 
are never median. The tough pelvic fascia seems to deflect the lacer- 
ation to one or other side. But whatever the explanation, it is a fact 
that deep, extensive lacerations do not extend up the middle line of 
the vagina, but up one or both sulci. Sometimes the injury is wholly 
in the vagina, and the commissure of the vulva remains intact. 
Hence these tears are Y-shaped when the commissure of the vulva is 
involved and the tear extends up both sulci. They are 1 -shaped 
when the commissure is involved and the tear extends up one sulcus 
(one arm of the Y is not represented). And they are Y-shaped when 
both sulci are involved and the commissure escapes (the leg of the 
Y is not represented). The principal tissues involved in the injury 
are the levator ani muscle or muscles and the deep fascia. The in- 
jury extends two or three inches from the plane of the skin perineum. 
As is ■well known, pelvic support depends upon the integrity of the 
levator ani muscles and the pelvic fasciae; hence the loss of support 
resulting from the injury is in direct ratio to its extent. When the 
lesion is extensive, the bladder, bowel, and uterus prolapse. 
A very careful and somewhat extensive study of this subject from 
the clinical side has convinced me that the foregoing propositions rep- 
resent the facts in the case, and are not theoretical. I believe that 
the reason certain gynecologists of prominence do not accept this 
pathology is because they do not see much of obstetrics, and they 
have not studied the nature of lacerations immediately after labor. 
Anyone can convince himself of the truth of the foregoing statements 
by studying recent lacerations. 
(For the sake of completeness, submucous laceration or over- 
stretching of the levator ani muscle may be called class 3.) 
For the cases embraced under class 2, no operation will yield such 
results as the Emmet operation. The important lesions are in the 
sulci of the vagina, and can only be reached by denuding and suturing 
the sundered tissues in the sulci. As a means of narrowing the 
vagina it has the further advantage of making use of the natural 
folds of that canal. The walls of the vagina fold upon themselves 
in such a way that the lines of contact in transverse sections make 8 
NOBLE, 
the letter H. The sulci of the posterior wall represent the lower half 
of the legs of the H. It will be noticed that the walls of the sulci 
lie naturally together, so that, if they are denuded and sutured, the 
parts come together surface to surface. This is a very positive ad- 
vantage in securing strong union, in addition to the advantages of 
raising the posterior wall of the vagina against the anterior, and of 
making a new mediate attachment of the vagina to the levator ani 
muscles. 
I need not dwell upon the advantages possessed by the operation 
in cases of well-marked rectocele, in which the sulci are very deep. 
In no other way can the rectocele be so well rolled into the vagina. 
My experience with the operation embraces some fifty cases. The 
results have been uniformly good, with one exception—the case of 
procidentia already referred to. 
The other operations which are recommended for the cure of this 
class of lacerations are the median operation of Ilegar (or some slight 
modification of it) and the flap-splitting operation of Tait. 
Median operations are based upon the theory that the injury sus- 
tained is rupture of the perineal body, and that the operation is to 
restore this body. Time will not permit me to discuss this question 
in extenso. The nature of the injuries have already been considered, 
and they are lateral, not median. The old theory of the nature and 
function of the perineal body has been disproved by Emmet, whose 
views I accept; hence it appears to me that the indifferent results 
secured by median operations is due to the fact that they are based 
on a false conception of the anatomy and of the injuries of the pelvic 
floor. 
The advantages of the flap-splitting method are even less than 
those of the method of Hegar. In the rules laid down for perform- 
ing the flap-splitting operation, we are told not to make the incisions 
deeper than a half-inch (from the surface of the skin perineum); that 
is to say, lesions situated further up the vagina than one-half an inch 
from the skin surface of the perineum are not affected by this oper- 
ation. Inasmuch as the entire levator ani muscle lies above this 
plane, it is evident that the Tait operation is worthless in the class of 
lacerations under consideration. The Tait operation accomplishes 
just about what the old Baker Brown episiorrhaphy did—it narrows 
the orifice of the vulva. 
What I have said about this operation is based upon the anatomical 
considerations involved and upon the results obtained by a prominent 
professor in this city. At least twelve patients who have been oper- MINOR SURGICAL GYNECOLOGY. 
9 
ated upon by him have been seen by me at the clinic for diseases of 
women at the Northern Dispensary. All had a narrow vulvar orifice, 
and all had more or less rectocele, with deficient pelvic support, and 
the symptoms complained of before operation. My personal expe- 
rience embraces one case, which was sufficient to demonstrate to me 
the lack of anatomical basis in this operation. 
Trachelorrhaphy.—Trachelorrhaphy was done six times. Ex- 
perience adds to my appreciation of the value of this operation in 
appropriate cases. I am satisfied that the dangers and failures to 
achieve good attributed to it by some operators depend upon poor 
judgment in the selection of cases. 
Either insignificant lacerations are repaired, or lacerations compli- 
cated by inflammation of the uterine appendages are operated upon. 
In the first case the laceration caused no symptoms, and its repair 
relieved none; in the second case, if the patient escaped a peritonitis 
as the direct result of the operation, she continued to suffer from the 
morbid condition of the appendages.