PRESENT STATUS ANI) Tendency of Gynaecological Therapeutics, By ANDREW F. CURRIER. M. D., OF NEW YORK. Read before the Annual Meeting of the Woman’s Hospital Alumni Pmmnnr REPRINT FROM THE New England Medical Monthly? DANBURY, CONN.: The Danbury Medical Printing Co. 1890. PRESENT STATUS AND-: Tendency of Gynaecological Therapeutics, By ANDREW F. CURRIER, M. D., OF NEW YOHK. Head before the Annual Meeting of the Woman’s Hospital Alumni Association. REPRINT FROM THE New England Medical M/fom/iy DANBURY, CONN.: The Danbury Medical Printing Co. 1890. PRESENT STATUS AND TEN- DENCY OF GYNAECOLOGI- CAL THERAPEUTICS. ANDREW F. CURRIER, M.D., NEW YORK. Read before the annual meeting’ of the Woman’? Hospital Alumni Association. HOWEVER we may strive to dis- guise the fact, it remains a fact which continually recurs to the reflective mind that the masses of humanity move in lines which are marked out by the master-spirits, thus depriving us of much of our fancied independence of action. There is no occupation in life which is not thrilled by the magic of these superior influences, and, with the broadening of civilization we find them permeating the avenues which an in- crease of wants and desires and necessi- ties creates. From this increase of necessities have arisen the specialisms and specialists of modern life. There are no more universal geniuses, no more Aristotles who know everything, and Platos who think everything. Condi- tions exist because there is a necessity 4 for them. This necessity may not he permanent, in which case the conditions cease to exist, and something better takes their place. Gynaecology exists because of such a necessity, and its remarkable vitality suggests its perma- nence, at least for some time to come. It would be interesting to trace this stream from its simple beginnings in the remote past—for women have ever suffered with pelvic disease—through the ages to the majestic developments of the present century, but that would prolong to even a greater length than is desirable, or even bearable, the consid- eration of our theme, and we are often enough reminded that “art is long, life is brief.” Even in the short period which may be marked by the life of any of our number, there has been in gynaecological therapeutics an ebb and How in opinion and practice which teaches us that there are few constants in the work of any man, however gifted. We have seen radical changes in well-grounded O O 5 theories and convictions which were supposed to he fundamental and sub- stantial. And so it becomes not imper- tinent to ask: where do we stand? what of the future? < iymecologieal therapeutics naturally divides itself into medical and surgical, and, 1 must add, electrical, for that subtle force, electricity, which is daily assuming increasing importance as a therapeutic agent, is neither wholly medical nor wholly surgical, and yet has both medical and surgical bearings. It cannot be denied that the genius of such men • as McDowell, Recamier, Simon and Sims gave a direction to gynaecological therapeutics which was mainly surgical, because they were sur- geons themselves, and because the bril- liant results which attended the surgical treatment in their hands of the diseased ovary, the diseased uterine mucous m unbrane, and the accidents of par- turition quite overshadowed the results of the medical tendencies of the greater number of the French school of gyme- 6 cologists of the middle period of this century, and such British gynaecologists as Bennett, Simpson and Tilt. It is an illustration of the fact stated a few moments ago that men follow the more brilliant light. These surgeons alluded to would naturally be biased in favor of the surgical treatment of all pelvic disease, on the theory that it was the source of extra-pelvic disease and hence alone called for treatment. In other words, to follow anyone line of thought persistently, even though it be a broad and grand one, has more or less of a narrowing effect. May it not be that we, who have been brought up in the footsteps of these masters, have too rig- orously adopted their line of practice, and that this may account for the reaction which is occasionally seen in colleagues who break away from surgi- cal gynaecology altogether, and cease to consider themselves specialists in this field of work. Hence it happens, I believe, that the safest and most useful gynaecologist for female diseases, as a 7 whole, is one who is neither exclusively surgical nor exclusively medical in his tendencies, but who combines the skill and manual dexterity of the surgeon with the logical and reflective qualities of mind which especially characterize the intelligent physician. It would not be necessary to go outside the history of our hospital alma mater to illustrate amply the class of men to which I allude. It does not follow, as has been asserted more than once during the past few months, that a gyna?cologist is either unsuccessful or unskillful or timid because he happens to believe that pelvic disease may be treated by other means than by those which are purely surgical. Neither should we go to the other ex- treme and criticize with harshness the published records of those whose surgi- cal performances seem more extensive than is warrantable from our stand- point of experience and opinion. It is hardly fair play to accuse a man of bad judgment, or worse, when our only data are the slender outlines of clinical 8 history, such as are usually given in the published reports of laparotomy series. Tubes and ovaries have doubtless been removed unnecessarily, for otherwise those who did this work would be un- erring in their judgment, and we know they are not. Women have been mu- tilated, if that term be preferred, but I see no more impropriety in removing a diseased and functionless ovary than a diseased eye, or leg, or finger. Many Avomen have been made sterile, and while I appreciate the importance and glory of maternity, I cannot admit that the highest function of women, under any and all circumstances, is to bear children. There may be honest differ- ence of opinion as to the utility of any operation, however beneficial, and any operation is liable to abuse, especially when its limitations are yet undefined. There is no one who does surgical work to any extent who does not make mis- takes—who does not regret that he has done some operations and left others undone. And for all such mistakes 9 there are always plenty of ungenerous criticisms as to his conduct and his motives. Let me quote, in this connec- tion, the golden words of the aged Tennyson: “I think it wisest in a man to do his work in the world as quietly and as well as he can, without much heeding the praise or dispraise.” (Van Dyke’s “Poetry of Tennyson.”) It seems to me there is a positive field for the medical treatment of some of the ailments which are peculiar to women, and I believe that a just recog- nition of this fact would go far to dis- arm the hostile criticism to which gynae- cology and gynaecologists are subjected. By medical treatment is meant the use of suitable drugs, diet, exercise, hydro- therapy, and hygienic measures in gen- eral. Take a class of cases which is by no means a small one, in which there are complaints of general relaxation and lassitude with constipation, loss of appe- tite, disturbed sleep and dysmenorrhcea. The pelvic organs are relaxed and flabby for they share the condition 10 which affects the muscles and mucous membranes in general. In such cases there is not infrequently displacement of the uterus, or ovaries, or vagina. This condition may be due to a moist and debilitating climate, or to certain occupations; and I have observed it in those who work in tobacco factories, laundries, hot kitchens and crowded manufacturing establishments, in all of which cases there was an insufficient supply of pure air. It may be due to improper or insufficient food, to severe labor such as driving a heavy sewing machine, or the care of a large family, to distress, disappointment or anxiety. In none of these cases is there any evi- dence of inflammatory or neoplastic disease. Such cases cannot be cured by surgical means, certainly not if surgical means alone are used. They may be cut or curetted, pessaires fitted, and drugs applied to the uterus and vagina, but this alone will not cure them, and it may make them worse. I could illus- trate by many such cases as the follow- ing: 11 1. Local applications of an astringent character were made several times in the case of a young married woman, with decided tendency to prolapse of the uterus and vagina, without much benefit. One day when the air was sharp and invigorating I was surprised to find the tissues firmly retracted, the vaginal portion of the cervix being contracted to about half its ordinary size. The patient was feeling very well. She had needed something to tone up her general condition. The local treat- ment had been practically valueless. 2. An anaemic girl sixteen or seven- teen years of age had suffered with severe dysmenorrhcea since her first menstruation. The uterus was retro- flexed, but very movable. She received a course of mild cathartics for obstin- ate constipation, and Jflaud’s iron pills. Her next period was painless, her gen- eral appearance improved, and the uterus had resumed its proper position. In these and many similar cases the source of trouble is not in the genital 12 organs, and treatment should be regu- lated accordingly. For the young and unmarried, with whom this condition is the more frequently seen, there is a manifest advantage in avoiding local treatment. Should we not, therefore, make a broad distinction between med- ical and surgical cases, and treat the former solely by medical means, even though we may limit thereby the field of surgical gynaecology. Who will deny that the success of the honneopath- ists and all other irregular practitioners is due in great measure to the fact that they succeed in making the public think that mild measures are equally efficient with severe ones in the treatment of disease. Such measures are certainly more agreeable, for humanity in general is always willing to take the roundabout, rather than the direct, way in getting rid of its ills and ails, if the direct way involve unusual pain or annoyance. If medical means do not suffice to cure the ills in question, we still have the re- sources of surgery to fall back upon. 13 This leads to the consideration of the vast number of cases in which surgical means mainly or exclusively are indi- cated. As to the choice of surgical measures aud the pathological doctrines in various forms of pelvic disease, great changes have taken place within the past decade. Sims’ operations of pos- terior section and discision of the va- ginal portion of the cervix have been practically abandoned, stem pessaries are used with diminished frequency. The interior of the uterus is frequently and fearlessly entered with the curette, the dilator and the tampon, and abdomi- nal section are more common than were the minor operations at the beginning of the decade. The doctrine of the im- portance of flexions of the uterus, es- pecially antiflexions, is found to have been greatly exaggerated, and cellulitis no longer holds its position of great conspicuousness in pelvic pathology. If these changes have dealt severely with names and traditions which are cherished at the Woman’s Hospital, it implies no 14 lessening of our personal esteem for the living and the dead. Faith in men’s opinions must vary with circumstances and experience; faith in and gratitude to the men themselves should he un- changing. Dr. Emmet used to remark concerning certain of Sims’ instruments that they were perfect and insusceptible of improvement as they left his hands. Of what theory or line of practice can the same be said. It would be folly to attempt to discuss in extenso the great number of questions which bear upon the status and tendency of gynaecologi- cal therapeutics in its surgical aspects. Enough has already been said to war- rant the conclusion that both status and tendency are overwhelmingly sur- gical, and, aside from the massage sys- tem of treating pelvic disease of Thure Brandt and his followers, which is medi- cal, at least, in the negative sense, that it does not involve cutting, and the sys- tem of electro-therapeutics, Avith which the name of Apostoli is prominently identified, I know of no systematic 15 method of treatment in general use which is not mainly surgical. A rational system of therapeutics presupposes a rational pathology. Pelvic pathology has this disadvantage: that though it has been profoundly studied by the ablest investigators, their views as to the inflammatory diseases of the pelvis have never been brought into harmony. Without wishing to be con- troversial, I think we may profitably spend a few moments in the considera- tion of this subject. By pelvic inflam- mation is meant that most common affection in women, in which some or all the pelvic organs and tissues are evi- dently the seat of inflammatory changes, which changes may result in apparent resolution and restitutio ad integrum, in pain, in indurations, in suppuration, or in death. Questions which are perti- nent in this connection are: how does it originate, what does it involve, and how does it terminate; and the answers are almost as numerous as the investigators. We have within the pelvis: muscular 16 and connective tissue, serous and mu- cous membrane, nerves, blood and lymph vessels, and glands. Which are included in this disease? which are exempt? The theory of infectious origination— gonorrhoeal, puerperal, or traumatic-sep- tic is a fascinating and rational one for the great majority of cases. It involves the introduction from without of a virus upon the uterine mucous membrane, which spreads, possibly by epithelial infection, as Rindfleisch long ago thought cancer wras developed, through the uterus and tube, until the perito- nseeum of the ovary and its surround- ings is reached and infected. In very many cases the infectious and inflam- matory process is then arrested, yield- ing, for the time, at any rate, merely a local peritonitis, with exudation, which is susceptible, however, of changes of a degenerative character. This theory will account satisfactorily for the great frequency of disease of the tubes and ovaries in connection with attacks of 17 pelvic inflammation. Again the peri' tonitis may become diffuse, the exuda- tion abundant, while the roof of the vagina presents the characteristic in- duration, and more or less extensive suppuration may follow. Or the peri- tonitis may become general and the issue fatal. In cases of puerperal infection it is sufficiently demonstrated that the virus often traverses the veins and lymphatics with great resulting constitutional disturbance, in addition to that which is located within the pel- vis, and which yields symptoms similar to those resulting from inflammation of other origin. But there are also many cases of pelvic inflammation which are apparently not of infectious origin: for example, those which occur in unmarried women from the sudden checking of the menstrual flow, and the physical condition and symptoms in such cases may quite resemble those in which there is, in all probability, an infectious origin. Such cases are ex- tremely common, are seldom fatal, and 18 there hangs a veil of mystery about their etiology and their consequences which is yet to be drawn. Post-mortem investigations of pelvic inflammation must be taken with a grain of reserve, on account of the changed conditions of the tissues and fluids which death presupposes. Such investigations are, notwithstanding, of the highest import- ance, and have taught us many valuable lessons. As long ago as 1848, Mercire observed (post-mortem) the frequency of inflammatory changes in the tubes and ovaries of prostitutes. Ten years later Bernutz demonstrated that it was the peritomeum which was mainly in- volved in pelvic inflammation, and not the cellular tissue, as his French con- freres had maintained, and that this inflammation was especially located in around the tubes and ovaries. A few years later Konig and Schlesinger elucidated sub-peritonseal pelvic abscess, by showing the course which must be taken by fluids accumulating within the pelvis. In puerperal cases the existence 19 of inflammation of the cellular tissue of the pelvis has been frequently demon- strated. Thomas quotes Aran, West, Nonat and McClintock as recording such cases, in which it complicated peri- tonitis, and adds, in his forcible manner: “As a result of parturition or abortion, it is so well known as to make the exhi- bition of proof here almost unneces- sary.” (“Diseases of Women,” fifth edition, p. 491). Martin holds that there are many cases of pelvic abscess of non-puerperal origin in which the cellular tissue is extensively idvolved. lie has also seen frequent illustrations of adenitis in connection with pelvic inflammation, and in non-puerperal cases. (Pathology and therapeutics of the diseases of women.) Hence there is no tissue in the pelvis which may not be involved in an attack of pelvic in- flammation, but it would seem from present information that the peritonaeum is the most frequently involved, and is the source of the greater number of serious lesions. 20 Much of the abdominal surgery of to-day is based upon pelvic inflammation. It is ovariotomy matured, foreshadowed by Battey and Hegar, and developed largely by Tait. It has proved too seductive for the resisting powers of the general surgeons, and they have amplified it, thereby adding to their own glory and the welfare of humanity. Who would have thought that the removal of an ovarian tumor would lead to exsections and resections of uteri, spleens, kidneys, gall-bladders, livers and intestines. With this en- largement of the field has grown up a vigorous literature of abdominal sur- gery, and it is not improbable that in a very few years the small number who devote their time exclusively to this department of surgery will have in- creased to a large class, and we may see colleges and hospitals conferring special degrees upon abdominal surgeons, as some of them now do upon obstetricians and physicians. Such progress will be in the interest both of humanity and scientific medicine. 21 . A great contribution to abdominal surgery was made by Senn in bis recom- mendation of bone-plates for use in wounds of the intestines. The catgut rings of Abbe, and the catgut-rubber rings of Brokaw and Davis are effect- ive modifications of Senn’s idea. It seems to me that the value of these to gynaecologists has not been thoroughly appreciated, for it is not a rare accident that the intestine should be torn in the removal of diseased tubes and ovaries, or other diseased structures of the pelvic or abdominal cavity. In the question of the treatment of the thick and fleshy pedicle of solid abdominal tumors, how gratifying it would be if a perfect method could be devised. It would seem as if it were almost within our grasp, for, with rare exceptions, it is included in the notion of asepsis. It was the dream of Sell render, death rob- bing him of the glory of accomplishing it. It may lie in the free use of the cau- tery, for no one has surpassed Keith’s results. It is doubtful whether it will 22 ever be evolved from Bantock’s or any other extra-peritoneal method. The Caesarean section and extra uter- ine pregnancy are obstetrical subjects but I venture to refer to them because there are few gynaecologists who are not obstetricians also, at least in so far as obstetric surgery goes. The Caesar- ean section furnishes yet another dem- onstration that the resources of anti- septic surgery are almost unlimited. Though its field must be a narrow one, it is improbable that it will ever again fall into disuse. The statistics of the surgical treatment of extra uterine pregnancy have accumulated with sur- prising rapidity. Take the wonderful series of cases of Tait alone, and we see the possibilities of relief from one of the direst calamities that can befall a woman. There are probably hundreds of well-authenticated cases now on rec- ord in which surgical treatment has brought relief and happiness. This fact should have great weight in comparison with any other methods of treatment 23 which have been tried, for, however successful such measures may have been, the number of cases is yet too small to prove anything on the ground of supe- rior efficacy. In the plastic surgery of the female genital organs it would seem as if the limit of accomplishment had almost been reached. The genius of Sims and Emmet and Bozeman, all familiar names to us, has quite abolished the terrors of fistula in its various forms, and the followers and imitators of Sims and Emmet have built upon their foundations in the countless modi- fications which have been made of the other plastic operations. The simplest operation upon the perineum with which I am acquainted, and one which, so far as I can judge, is as effective as any, is that which is commonly known as the Tait operation, though it was performed and described by the late Dr. Alfred C. Post a year or two before his death. This seems to me only a more expedi- tious method of the operation which was for so many years performed by 24 Dr. Emmet. The operations upon the anterior vaginal wall are based upon the principles laid down by Sims, and whether you amputate the vaginal por- tion of the cervix or excise its mucous membrane according to Schroeder’s directions, the principles have been enunciated by Emmet in the operation of trachelorrhaphy. There yet remains much to be said of the other surgical procedures in gynaecology, including the entire held of intra-uterine therapeutics, operations upon the round ligaments, the use of pessaries, and the treatment of malignant disease. One is staggered in attempting to include so vast a sub- ject in the brief limits of a paper. Concerning the radical operations for maligant disease of the genital organs, especially the uterus, it cannot be said that the ultimate results have been brilliant. Take the most favorable statistics of the most successful Ger- man operators, and how small is the percentage of permanent cures in cases which were undoubtedly malignant. 25 But who has the wisdom to suggest anything better than the free use of the knife or cautery? The reports of gyne- cological societies in all parts of the world, and the eagerness with which gynaecological instruction is sought at all schools and hospitals where it can be obtained, show that the number of those who are interested in this subject is in- creasing with wonderful rapidity. There are few first-class general hospitals of any size in which gynaecological work is not done. The boldness and fre- quency with which the abdomen is opened, and for causes which a short time since would have been considered utterly inadequate and unjustifiable, is absolutely startling. Tubal and ovarian disease, pelvic abscess, uterine displace- ments, peritonitis or even a suspicion of them, are now a sufficient excuse for abdominal section, if only for diagnos- tic purgoses. There are certain facts in connection with this subject which we cannot afford to ignore, however conservative we may 26 desire to be. The mortality from these multitudinous operations is surprisingly small and is steadily diminishing. The fear of evil results from laparotomy seldotn deters men from doing it, thanks to antisepsis, or cleanliness, for they mean the same thing. These facts must he well considered before we in- veigh against indiscriminate laparot- omies. Is it not possible that if we try to play the role of obstructionists the stream of tendency will rush by regard- less of us, and leave us on the shore mere drift wood ? Far better is it to seek to guide and direct influences which we cannot check, and moderate the current rather than vainly try to stop it. Finally, what is the position of electro- therapeutics with reference to gyntecol- ogy. In my opinion it is one of those conditions for which the necessity ex- isted, and which will stay as long as the necessity lasts. Keith in the introduction to his re- recently published book on “ The treat- 27 ment of uterine tumors by electricity” with that admirable candor and frank- ness which are characteristic of the man, gives to Apostoli supreme credit for all the advances which have been made in this field. This is hardly just. As well forget McDowell in the far more extensive and perfect work of Wells, Keith and Tait. Far be it from me to detract from the praise due to Apostoli for his brilliant inventions, his patient work amid indifference and ridicule, and his magnificent results. But Apos- toli has only developed the work of his precedessors. He owes a great debt to his master Tripier, and he should not belittle the pioneer work of Cutter and Kimball, Freeman and Semeleder. Many men are venturing upon an extensive use of electricity without understanding the physical principles upon which it is based. This is not only irrational but dangerous. As well use deadly poisons without know- ing their effect or their antidote, nay, far better to use poisons for most of 28 them give fair warning before their work is accomplished, but a High ten- sion electric current gives no warning that profound effects will result and absolute steadiness of current is an end yet unattained in most batteries. High tension currents are offered as a substi- tute for purely surgical measures in the treatment of uterine tumors and one must not forget that there is an element of danger in their use. Most of the text-books which attempt to teach the elements of medical electricity are con- fuxive and abstruse, and those which say that such knowledge is unnecessary are not safe guides. To me it seems more satisfactory to go over the entire subject of electricity in a standard text- book on physics, <»,mot’s for example, than to eke out the necessary inform- ation from the average work on electro therapeutics. Primers upon this sub- ject, like that recently published bv Skene Keith are most useful for acquir- ing the fundamental facts of the sub- ject; the books of Massey and Bigelow 29 are also plain and practical for the most part. A valid objection to the claims of certain electro-therapeutists is that they are too extravagant. Polar effects are sufficiently well demonstrated, and inter-polar effects are doubtless fre- quently attainable, but I have as yet seen little to convince me of the im- portance which Apostoli ascribes to secondary currents, that is currents generated within the tissues. Baraduc’s method of capsulotomy which is des- igned for the electro-cauterization of the capsule of interstitial fibroid tumors of the uterus and the circumcapsular zone has no advantage that I can dis- cover over the thermo-cautery, and such operations are not free from the danger of sepsis and sloughing (See Jour, cle Jded. de 7W/.sSept. 8, 29, Oct. 6, 1889). The value of the electro-cautery as used by Apostoli for the arrest of luemor- rhage and the relief of fibroid tumors of the uterus has been amply demonstra- ted. It is not unlikely that the useful results are due to the tissue destroying 30 action of the cautery and the denu- trition which attends the subsequent cicatrization. If that is the case it is heat rather than electrolysis which is the efficient agent, and the results could or would be obtained with instruments far less expensive and complicated than are necessary for a complete electrical outfit. In the treatment of bleeding malignant tumors of the pelvis by the galvanic current I have had an experi- ence which was very unfavorable. The bleeding was indeed arrested and for a few days the patient made good im- provement, but peritonitis of a severe character soon developed, and I could attribute it to nothing but the direct or indirect effect of the electricity. At the least, such experiences should teach us the need of extreme caution in the use of this agent. The faradic current will be found to have an excellent local tonic effect upon relaxed tis- sues of the vagina or the uterus and for catarrhal endometritis a galvanic current of low tension answers very well, 31 though it is no better than a suitable curetting. If the foregoing remarks may have seemed somewhat fragmentary the excuse offered is that there was no intention of contributing any new facts to the liter- ature of gynaecology, but simply to suggest old ones, which might be dis- cussed to our mutual edification. 159 E. 37th St., New York.