[Reprinted from the American Gynecological and Obstetrical Journal 
for May, 1896.] 
A NEW OPERATION FOR CERTAIN CASES OF 
PROCIDENTIA UTERI * 
By Charles P. Noble, M. D., 
Surgeon in Chief, Kensington Hospital for Women, Philadelphia. 
The operations usually done for procidentia uteri, in my hands, 
have yielded very satisfactory results. For some years I treated 
these cases by amputation of the cervix, anterior colporrhaphy, and 
perineorrhaphy. Of the cases operated upon in this way, in only 
one did the uterus again markedly prolapse. In some of them, how- 
ever, especially when the uterus was retroverted, it would sink enough 
in the pelvis to cause dragging sensations, and also to favor the for- 
mation of a small cystocele. The percentage of cases, however, in 
which even this partial failure was observed, was quite small. I have 
myself operated a second time but once in all cases operated upon 
by the method described. In one other case the operation was a 
complete failure. 
During the past few years, in addition to the operations formerly 
done, when the uterus was markedly retroverted, and in all cases in 
which procidentia was marked, I have done a hysterorrhaphy. Of 
these cases, so far as I know, a cure has been obtained in all but one. 
Not only have the cases not returned to me for further treatment, but 
also I have failed to hear of them as being in the hands of the 
various other gynaecologists in the city. 
These general remarks are made to show that I feel that the aver- 
age case of procidentia can be satisfactorily dealt with by the opera- 
tions heretofore in use for the treatment of this condition. Failure 
to obtain good results, as a general statement, in my judgment, is due 
to the application of the operations rather than to the operations 
* Read before the Philadelphia Obstetrical Society, March 5, 1896. 
Copyright, 1896, by J. I). Emmet, M. D. 2 
Charles T. Noble, M. I). 
themselves. There is a class of cases, however, to which these re- 
marks do not apply. I refer to those cases of complete or partial 
procidentia, in which the vagina is stripped off from the rectum and 
Douglas’ pouch is deepened down to or near the anus. 
dominal pressure in these cases can act very much more disadvan- 
tageously than in those cases in which Douglas’ pouch occupies its 
normal plane, and therefore the probabilities of recurrence after 
operation are much greater than in the more usual cases of prociden- 
tia. As illustrating this point, I will report the case of Mrs. B., 
who consulted me first in November, 1894. Her age is forty-seven 
and she is the mother of seven children. For twenty-three years she 
has had falling of the womb, and for twenty years complete proci- 
dentia. On examination, the uterus was found.,.completeTy prolapsed, 
protruding from the vulva. The vagina also was turned completely 
inside out, and a large cystocele was present. The posterior vaginal 
wall was stripped away from the rectum down to the anus, and the 
lateral vaginal walls likewise were stripped away from their normal at- 
tachments. On February 9, 1895, I operated upon her by amputating 
the cervix and performing anterior colporrhaphy, perineorrhaphy, and 
hysterorrhaphy. She made a good recovery from her operation. The 
result from the perineorrhaphy, it should be said, was not as good-as 
is usually obtained. Mrs. B. was much improved for a time, 
uterus remained in the pelvis. It was not long, however, after she 
resumed her usual occupation before the posterior waif p{ the vagina 
bulged forward, dragging upon the cervix, which in time elongated 
sufficiently to protrude from the vulva, although the fundus remained 
attached to the abdominal wall. It was evident that a more radical 
procedure was necessary to cure this patient. On January 25, 1896, I 
reopened the abdomen and did a hysterectomy after the method used 
in dealing with fibroids. The cervical stump was sewed up, and it, 
together with the stumps of the broad ligaments, was covered over 
with the bladder peritonaeum. The remaining portion of the cervix 
was then anteverted, and the posterior wall of the cervix was sewed 
to the abdominal wall. As the attachments of the vagina to this part 
of the cervix are very intimate, it practically amounted to sewing the 
vagina to the abdominal wall, without having the disadvantage of 
opening into this canal. A careful examination of Douglas’ pouch 
showed that it was deepened almost to the anus. On February 20th 
lateral colporrhaphy and perineorrhaphy were done. Mrs. B. has 
made a good recovery from these operations and has a very firm 
perinoeum. A New Operation for Certain Cases of Procidentia Uteri. 
3 
I report this method of dealing with this class of cases as a dis- 
tinct advance on the methods heretofore in use, recognizing, how- 
ever, that the abnormal deepening of the pouch of Douglas has not 
been remedied, and that therefore intra-abdominal pressure may 
again cause the posterior wall of the vagina to bulge forward. In 
that case the only thing additional which can be done is to cut 
through the vault of the vagina behind the cervix and pack the pelvis 
wi‘h gauze, with the object of obliterating Douglas’ pouch by the 
formation of adhesions. I wish to offer the operation reported here- 
with, and the suggestion of the packing of the pelvis with gauze, as a 
contribution to the treatment of this particular class of cases of pro- 
cidentia.