POINTS IN OFFICE PRACTICE 
IN THE 
TREATMENT OF THE DISEASES OF WOMEN. 
BY 
CHARLES P. NOBLE, M.D., 
SURGEON-IN-CHARGE, KENSINGTON HOSPITAL FOR WOMEN. 
REPRINTED FROM THE TRANSACTIONS 
OF THE PHILADELPHIA COUNTY MEDICAL SOCIETY, 
MAY 11, 1892. POINTS IN OFFICE PRACTICE IN THE TREATMENT 
OF THE DISEASES OF WOMEN. 
By CHARLES P. NOBLE, M.D., 
SURGEON-IN-CHARGE, KENSINGTON HOSPITAL FOR WOMEN. 
[Read May 11, 1892.] 
The limitations of office practice, in the treatment of the diseases 
of women, what should be attempted and what should be avoided, 
forms a subject of very practical importance to every one engaged in 
this department of therapeutics. 
I wish first to bring to your attention certain procedures which I 
believe should be avoided. 
Under the old regime, before the days of anaesthetics, and before 
the dawn of the antiseptic era, it was a somewhat necessary custom 
for the surgeon to minimize the gravity of operations, and to conceal 
the paraphernalia in order to avoid the mental effect on the patient 
which otherwise would be produced. This, however, is no longer 
the case. In those days, also, the nature of the causes of the inflam- 
matory processes which may follow operations were not understood, 
hence the necessity for careful preparation of the field of operation 
was not appreciated. As a result of these conditions disastrous con- 
sequences, due usually to sepsis, not infrequently followed apparently 
trifling operations. These facts cannot be borne in mind too strictly, 
nor can apparently trifling operations, done in the office without 
attention to every requirement of antiseptic surgery, be too carefully 
avoided. To twist off a polyp, to dilate the cervix, or to curette the 
uterus appears like a trifling operation, but if done without careful 
disinfection of the field of operation, and of the hands and instru- 
ments of the surgeon, serious inflammation of the pelvic tissues, and 
even death may result. It is not an uncommon practice for men to 
dilate the cervix “just a little” in the office, and to repeat the pro- 
cess from week to week, for the relief of dysmenorrhoea. This is 
called the gradual method of dilating the cervix. Some years ago I 2 
NOBLE, 
saw this done many times, and the consequences were what should 
have been foreseen—in a definite number of cases—infection with 
permanent crippling of the uterine appendages resulted. In the 
same way I have seen the dull curette used on the ground that its 
use is a trifling matter aud that it can do no harm. I feel certain 
that such practice is at least in part responsible for the present 
opposition to the use of the dilator and curette by a few men in the 
profession. Whatever is worth doing at all is worth doing well. 
Thorough work and clean work is possible only when a patient is 
passive from the influence of an anaesthetic. Hence I believe that 
all attempts at minor surgical operations on the pelvic organs in the 
office should be condemned. 
The routine employment of applications to the endometrium for 
the cure of endometritis is another method of treatment which should 
be avoided. The experience of Emmet, Thomas, and Goodell (not 
to mention others), has demonstrated that this method of treatment 
is unsatisfactory, aud that under certain conditions it is dangerous. 
When the uterine appendages are inflamed, and especially when the 
tubes contain pus, all manipulations of the uterus are liable to induce 
peritonitis, aud hence are contra-indicated. These facts have been 
demonstrated so conclusively by the experience of the past twenty 
years, that the same old blunders should not be made in the future. 
In my own hands application to the entire endometrium are made 
only after careful dilatation and curetting of the uterus, done under 
anaesthesia and with full antisepsis, and in the rare cases in which 
the uterine canal is very patulous. My own experience is similar to 
that of Goodell, Emmet, and others, that the less one uses intra- 
uterine applications the more he believes that they are harmful rather 
than useful. I would not go so far as Emmet and condemn intra- 
uterine applications absolutely, but I believe that their field of use- 
fulness is a very restricted one. 
The employment of pessaries does not cause as much evil as for- 
merly because the limitations of the use of the pessary are better 
understood. The teachings of the school of Hodge concerning the 
nature of the displacements of the uterus and their treatment by 
means of the pessary made a deep impression upon American medicine, 
and it is only now that much that was erroneous is being eliminated 
from current beliefs. Since Hodge’s day practically all that we know 
concerning injuries of the pelvic floor and pelvic inflammation has 
been discovered ; and theories concerning the sustaining forces of the 
uterus, the action of the intra-abdominal pressure, and the mode of OFFICE PRACTICE IN GYNECOLOGY. 
3 
action of the pessary have been profoundly altered, especially through 
the labors of Schultz. 
The mistake should be avoided of regarding a retro- or other 
“displacement of the uterus.with adhesions” (according to the old 
nomenclature) as a disease of the uterus, and especially the greater 
mistake of treating such a case with a pessary. The disease in such 
cases is to be sought in the appendages. 
With the rarest exceptions the use of pessaries should be limited 
to cases of retro-displacement or descent of the uterus, in which there 
has been no peritonitis and no laceration of the pelvic floor. If in 
such cases the displacement is first corrected and then a properly 
fitting Smith-Hodge, Emmet, or Thomas pessary is inserted no harm 
will result, and a cure will often be effected if the patient is carefully 
watched and the pessary kept clean. 
Evil results, which should be avoided, follow the use of the pes- 
sary, in proper cases, when it is introduced without the previous 
reduction of the displacement; and especially when the pessary is 
inserted against inflamed and tender ovaries and Fallopian tubes. 
When the theory is abandoned, that the pessary is a lever which 
holds up and tilts forward the uterus, and instead the theory is 
adopted that the pessary acts by pushing the vault of the vagina 
toward the sacrum, and hence pulling the cervix backward, and that 
the fundus is kept forward by intra-abdominal pressure, this useful 
instrument practically will cease to do harm because it will no longer 
be used in cases of “ fixed uteri” and in cases of unreduced displace- 
ments. 
The routine use of the sound as an instrument of diagnosis is 
another practice which should be avoided because of the danger 
of carrying infection into the uterine cavity, and the risk of un- 
wittingly inducing abortion, and because a diagnosis can be made 
more accurately by the bimanual method without the slightest risk 
to the patient. 
I shall now briefly present certain views concerning the positive 
side of office practice. 
Unquestionably in gynecology, as in the whole field of medicine, 
successful treatment rests on accurate diagnosis, hence the necessity 
of carefully studying each case, not only as to the condition of the 
pelvic organs, but as to the state of the general health. The 
observing gynecologist early realizes the interdependency of diseases 
of the sexual and of the other systems of the body. Especially is 
this true of functional conditions, including the vascular supply of 4 
NOBLE, 
the pelvis. Many women complain of symptoms referable to the 
sexual organs which are clue to pelvic congestion, in turn due to a 
feebly acting heart, or to a sluggish portal circulation, or to lack of 
use of the muscles of the body. Just as these conditions predispose 
to hemorrhoids, or increase the size of hemorrhoids already present, 
so do they predispose to pelvic hyperesthesia, and greatly increase 
the symptoms of any morbid condition present in the pelvis. 
Likewise the influence of morbid states of the nervous system, 
especially the conditions known as hysteria and neurasthenia, upon 
the symptom-complex of pelvic disease is most marked. And the 
same is true of malnutrition and anaemia. 
Whether a given pain is due to gross disease in the pelvis, or is 
due to hypersesthesia of the pelvic nerves induced by pelvic conges- 
tion, or whether it is a manifestation of hysteria or of neurasthenia, 
or is a neuralgia due to anaemia and malnutrition is a problem 
always intricate, and at times difficult of solution. 
These considerations should never be lost sight of in studying the 
problems of pelvic disease; and I feel certain that a full appreciation 
of them is of the greatest importance in pointing the way to success- 
ful treatment. 
Successful management of pelvic disease means very much more 
than the use of local treatment. Broadly speaking, I believe that 
fully as much, if not more, can be accomplished for women suffering 
with pelvic disease by hygienic management and general medication 
as by local treatment. Of course, this statement does not include 
cases requiring operation. Frequently what is most required is to 
regulate the bowels, to correct digestive disturbances, to give iron 
and arsenic for ansemia, to advise rest and recreation for the over- 
worked, and to infuse hope into the despondent and hypochondriacal. 
In my own work I feel that I have no more important ends to 
accomplish than to combat malnutrition, ansemia, and constipation, 
and to induce overburdened women to live more in the open air, and 
to secure more hours for relaxation and amusements. 
In the actual diagnosis of pelvic disease, by physical examination 
of the parts, touch and the bimanual examination are the safest 
guides. No instrument will reveal so much as the educated sentient 
fingers. Indeed, the bimanual examination is of more value than 
all other methods of diagnosis combined. In no other way can the 
entire pelvis be explored, and the condition of the uterus and its 
appendages be known. Vision and instrumental aids to diagnosis OFFICE PRACTICE IN GYNECOLOGY. 
5 
are of value, but their usefulness is restricted to cases of vulvar, 
vaginal, and cervical disease. 
On making the bimanual examination I have found it most useful 
to employ two fingers in the vagina instead of one. At least half 
an inch is gained in this way. A distinct advantage is gained also 
by using the fingers of the left hand for exploring the left side of the 
pelvis, and of the right hand for the right side of the pelvis. 
If the confidence of the patient is gained, and her fear of being 
hurt is removed, and if she is instructed to breathe regularly during 
the examination, in almost every case the entire pelvis can be ex- 
plored. At times, when the vagino-abdominal method of examina- 
tion is unsatisfactory, the recto-abdominal examination clears up the 
diagnosis. 
The speculum is of value as an aid to diagnosis only in cases of 
vaginal and cervical disease. Its chief importance is as a canula to 
facilitate the making of applications to the cervix and vagina. Hence 
one should be selected which can be used without causing pain. This 
indication is met by the Sims’s speculum, but its use involves the 
necessity of an assistant, and in addition the expenditure of unneces- 
sary time, hence it should be used only in special cases when it is 
desirable to study vaginal or cervical lesions, or when there is great 
pelvic tenderness, or when there is a cancer of the cervix, which 
might be abraded by the bivalve speculum with the induction of 
hemorrhage. I have found the virgin size of the Nott trivalve 
speculum the most satisfactory for general use. 
In making applications to the cervix and to the vault of the 
vagina, I have found a whalebone applicator, made for me by Lentz 
& Sons, to be of such convenience that I show it here. It is a 
tapering rod of whalebone ten inches in length, flattened at the 
smaller end. A layer of cotton wrapped upon the applicator is suf- 
ficiently secure for use in making applications to the vagina and 
cervix, and yet can be removed easily and quickly by grasping it 
with forceps. In this way it is possible to avoid staining the fingers, 
and the loss of time necessary in removing the medicated cotton from 
the ordinary aluminium applicator. Another advantage is that its 
size prevents its introduction into the undilated uterine cavity. 
In conclusion, I will urge again that it is wise in office practice to 
avoid all operative procedures and all methods of treatment which 6 
DISCUSSION. 
are painful, because of the dangers of inducing inflammation and 
septiciemia. The office treatment of the diseases of women should 
be limited to prescribing the hygienic, dietetic, and medicinal reme- 
dies appropriate to each case, and to the employment of vaginal and 
cervical applications, the reposition of displaced organs, the careful 
use of massage, and the fitting of pessaries. 
DISCUSSION. 
Dr. Barton Cooke Hirst : I have very little to add to this comprehensive 
paper. I quite agree with the writer that the treatment of gynecological cases 
in the office should be restricted as much as possible. I early learned this by 
an experience with one or two distressing cases in which I was obliged to 
remain in the office long after office hours to watch them. 
There are one or two little points which might be enlarged upon. One is 
the rectal examination. At the first examination of a patient I resort to it 
in every case. I have found in quite a number of instances that I have been 
able to detect an abnormal condition of the ovary which was wholly inappre- 
ciable through the vagina. The rectal examination, if sometimes of no use, 
does no harm and entails no risk. 
There is another point that I think might have been touched upon. There 
is a danger in this kind of practice which should not be lost sight of, and 
the true nature of which should be exploited'wherever possible. I refer to 
the disagreeable consequences arising from the examination of erotic females 
and of designing women. This is not a pleasant subject to dwell upon, but it is 
a constant danger, and harm of a serious kind may come to the practitioner if 
it is ignored. I think, therefore, that the possibility of erotic excitement, and 
the possibility of blackmail in office gynecology, should be referred to, in order 
to warn the younger men, and so far as we can to give the laity an idea of the 
true nature of the majority of these cases. There is a well-known case in this 
city of an unfortunate dentist who was sentenced to jail on this account, and 
yet I have been told that he undoubtedly was innocent. The same experi- 
ence may occur to anyone. 
Dr. William H. Parish : The paper which has been presented is a very 
safe and sound one. The main point submitted in it is that we do harm to 
our patients in our office work. I am confident that too much is attempted 
in the office, and can recall a number of instances in which patients were 
made worse by the treatment there instituted. It is a wise procedure on the 
part of Dr. Noble to bring this subject before us, in order that the experi- 
ences here related may be of service to others. The dangers of sepsis, now 
fully appreciated, were at one time not recognized by the surgeon and gyne- 
cologist. At that time it was quite the universal practice to introduce a 
sound into the uterus of every woman who presented herself for examination, 
unless there was strong reason to believe that pregnancy existed. I do not 
doubt that much trouble is still caused by the sound or other instrument 
being carried into the uterus—measures to avoid sepsis not being observed. DISCUSSION. 
7 
I practically agr.ee with Dr. Noble in all the detailed statements made in 
his paper. I have long given up the practice of gradual dilatation in the 
office. In some cases it is injurious, and in many it is of no service. If the 
operation is needed, it should be done at the patient’s home, or in a hospital, 
with proper precautions. The same remarks are true as to the use of the 
curette. 
With reference to the use of intra-uterine applications in the treatment of 
endometritis, although early brought up to the belief that these were essen- 
tial in almost every case of endometrial inflammation, I now think that they 
should be reserved for cases that are exceedingly obstinate, or where there is 
septic material in the uterus. These applications should always be made at 
the house of the patient or in the hospital. 
The use of pessaries has largely diminished, but one who sees these cases 
will be surprised to find how many pessaries are used in cases where there is 
no indication for them, and where they do no good, and even do great harm. 
They are used where there are contra-indications—such as adherent uterus 
or adherent ovary. I have not much faith in pessaries, limiting their use to 
cases of simple falling of the uterus, with or without retro-displacement. 
So far as erotic cases are concerned, I think that they are exceptional; but 
it is well that their presence should be recognized. In a number of years of 
practice, I have not come across a case that gave me any concern. I know 
of two or three physicians who would not examine a woman except in the 
presence of a third person, and in one case except when another member of 
the family is present. 
Dr. William E. Ashton: I agree with Dr. Noble that a great deal of 
harm has been done and will be done through office practice. If we are to 
do anything in the office in the way of gynecological work, we should approach 
it with the same aseptic precautions as though we were opening the abdominal 
cavity. The experience of the past and the present certainly shows that 
tinkering in a septic way with the uterine cavity is responsible for many cases 
of tubal and ovarian disease. 
I believe that pessaries have a very limited use. It matters not whether 
the pessary acts by pressure upon the posterior wall of the uterus or by 
elongating the posterior wall of the vagina and bringing the cervix back- 
ward, as in either case damage is done to the utero-sacral ligaments, which 
are the chief supports of the uterus. These ligaments are elongated, and as 
a result we have an increase of the trouble when the pessary is removed. The 
use of the pessary should be limited to those cases where, for a short period 
of time, we wish to shore up the uterus, and to cases where the uterus is but 
slightly prolapsed and retroflexed. The pessary is especially useful in preg- 
nancy when there is retro-displacement and prolapse. Its use in these 
cases for the first four months prevents the possibility of incarceration. 
Dr. Noble has brought out in a forcible way the importance of constitu- 
tional treatment .in the diseases of women. The time has passed when we 
expect much from local treatment. Unless we recognize the necessity for 
constitutional treatment we shall get bad results. 
Dr. Joseph Hoffman : The remarks of Dr. Noble in regard to uterine 
massage and those of Dr. Hirst can well be put alongside of one another in 
a critical way. Dr. Noble speaks of uterine massage being allowable in the 8 
DISCUSSION. 
office. Dr. Hirst says that in certain erotic females there is danger in office 
treatment. If there is anything that is apt to bring on these dangers, it is 
the abominable practice of uterine massage. I think that it would be no 
more reprehensible to have a male attendant in the women’s division of the 
Turkish bath, than for a man to practise uterine massage. I think that it is 
disreputable, foul, and wrong. I say that from the moral side of the ques- 
tion. Any trouble in the uterus that needs to be broken up by massage is a 
trouble that is so far gone that it is not safe to break it up. It is not safe to 
break up adhesions in the pelvis by this means. When we have our fingers 
on these adhesions we know how difficult it is to break them, and they may 
even require the use of the scissors. Uterine massage is out of place both 
morally and physically. 
A word in reference to pessaries. In this reaction against the use of pes- 
saries we are perhaps going too far, and may forget that they are sometimes of 
use. I can put my fingers on three cases of acute retroversion occurring in 
the past few weeks, where great benefit has followed the use of the pessary. 
One patient was bleeding twice a month, another was incapacitated from 
work, and the third was almost unable to work. There is as much care 
needed in the fitting of a pessary as in the fitting of a stocking or a shoe, and 
the pessary should be adjusted for each particular case. 
I disagree with Dr. Ashton in regard to the use of the pessary in pregnancy. 
If I wanted the woman to miscarry, I should use a pessary, for I believe that 
the irritation of the pessary would induce miscarriage. Where the uterus is 
retroflexed, the best plan is to restore it mechanically, and then allow the 
patient to remain in bed as long as necessary. 
Dr. G. Betton Massey : From a philosophical point of view, the sense 
of the paper is that gynecologists are unnecessary. If these diseases ot 
women are to be cured by hygienic ajid constitutional measures, why cannot 
the general practitioner do all that is necessary ? In my experience, the cases 
that come to me outside of dispensary practice have had that tried. We are 
to be congratulated that the time has at last come, in minor surgical gyne- 
cology, when the gynecologists themselves are willing to acknowledge bad 
results. If they would but sit down quietly and apply the same serious judg- 
ment to their major gynecology, they would reach somewhat similar results. 
For the life of me I cannot understand why it is unsafe to pass an aseptic 
instrument into the cavity of the uterus, and yet it is safe to perform abdominal 
section in order to make a diagnosis. It is the abdominal sectionists who are 
willing to acknowledge the noxiousness of local treatment. I think that 
one of the explanations of this anomaly is attributable to the position taken 
by Philadelphia gynecic surgeons, wherein they differ from gynecic surgeons 
in other cities in failing to appreciate the value of electrical treatment in the 
office. If they used electricity in these cases they would find that the patients 
are better able to go home than to come to the office, and their exceedingly 
agnostic position would be modified materially. • 
Dr. Noble: I consider the rectal examination as a most valuable expedi- 
ent. In the paper, which is a running commentary on many points, it was 
not possible to go much into detail. I stated, however, that if the bimanual 
examination by the vagina was not satisfactory, the rectal examination should 
be resorted to. DISCUSSION. 
9 
As to the reason that it is not wise to put a sound into the uterus, patholo- 
gists have taught us that the vagina constantly contains germs, and that the 
cervix as high as the internal os also contains germs, but that for some reason 
the internal os offers a barrier to the further ingress of germs, so that the 
endometrium is protected against invasion. If we pass an aseptic instrument 
through the cervical canal, it may carry germs into the uterus and set up 
inflammatory trouble. In my own hands the sound is used principally to 
reposit the uterus in a definite class of cases. Occasionally the uterus is so 
flexible that the ordinary bimanual method of Schultz will not answer. If 
the patient is put in Sims’s position, the uterus usually can be replaced, but 
occasionally the sound will be required. I always clean the cervix as well as 
possible, and see that there is no disease of the appendages. 
My reference to uterine massage in the paper consisted of this phrase— 
“the careful use of massage.” I think that the field of usefulness of mas- 
sage is extremely limited. So-called cases of displacement of the uterus with 
adhesions are cases of adherent appendages which require removal, particu- 
larly if the tubes form retention cysts. Occasionally we find cases in which 
there has been peritonitis and the appendages are adherent, but from the 
symptoms and the physical examination there is no reason to believe that 
the tubes are occluded and distended. The adhesions may be light, and 
there may be retro-displacement of the uterus. In a few such cases I have, 
by careful packing of the vagina for a long time, been able to overcome the 
retro-displacement and give the patient much relief. I am very suspicious of 
active massage, and certainly would not put myself in the position of recom- 
mending it in inflammatory conditions of the uterine appendages. It is only 
to be used in these rare cases. I have nothing to say on the immorality of 
the measure. 
I agree with Dr. Ashton that if we have a retroflexed pregnant uterus, 
and if by manipulation it is possible to reduce it, it is a good practice to 
introduce a well-fitting pessary. At the same time I think that is well to keep 
the patient quiet for a reasonable length of time. I have not infrequently 
used a pessary in these cases, and have not had abortion follow. 
My paper was not a plea for the existence of gynecologists, but it was upon 
some points in office practice ; therefore I do not feel called upon to reply to 
Dr. Massey’s criticism. Dr. Massey remarked that if gynecologists would 
use electricity, more patients would go home in a better condition than when 
they came to the office. But even he has detailed a case to-night in which 
the patient was so sick after leaving the office that she required the services 
of a physician, and was unable to return to the office, but had to go to bed to 
have the treatment applied.