WITH THE COMPLIMENTS OF THE AUTHOR. 
Origin and Development of 
Modern Gynecology. 
BY 
AUGUSTUS P. CLARKE, A.M., M.D., 
OF CAMBRIDGE, MASS., U. S. A., 
President of the Gynecological Society of Boston; Member of the Mas- 
sachusetts Medical Society; Member of the American Academy of Medi- 
cine: Member of the Cambridge Society for Medical Improvement; 
Member of the American Association of Obstetricians and Gynecologists; 
Member of the American Medical Association; Delegate to the British 
Medical Association; Member of the American Public Health Associa- 
tion; Member of the Ninth International Medical Congress; Member of 
the Tenth International Medical Congress at Berlin; Member of the 
Committee of the Inter-Continental American Medical Congress; Late 
Surgeon of the Sixth Regiment, New York Cavalry; Late Surgeon-in- 
Chief of the First Cavalry Division of the Army of the Potomac and of 
the Army of the Shenandoah; Brevet Lieutenant-Colonel New York State 
Volunteers; etc. 
The President's Address, Delivered at the Annufel Meeting of the Gyne- 
cological Society of Boston, January 14.1892. 
Reprinted from the "Journal of the American Medical Association," 
February 6,1892. 
CHICAGO: 
PUBLISHED AT THE OFFICE OF THE ASSOCIATION. 
1892. Origin and Development of 
Modern Gynecology. 
BY 
AUGUSTUS P. CLARKE, A.M., M.D., 
OF CAMBRIDGE, MASS., U. S. A., 
President of the Gynecological Society of Boston; Member of the Mas- 
sachusetts Medical Society; Member of the American Academy of Medi- 
cine; Member of the Cambridge Society for Medical Improvement; 
Member of the American Association of Obstetricians and Gynecologists; 
Member of the American Medical Association; Delegate to the British 
Medical Association; Member of the American Public Health Associa- 
tion ; Member of the Ninth International Medical Congress; Member of 
the Tenth International Medical Congress at Berlin; Member of the 
Committee of the Inter-Continental American Medical Congress; Late 
Surgeon of the Sixth Regiment, New York Cavalry; Late Surgeon-in- 
Chief of the First Cavalry Division of the Army of the Potomac and of 
the Army of the Shenandoah; Brevet Lieutenant-Colonel New York State 
Volunteers; etc. 
The President's Address, Delivered at the Annual Meeting of the Gyne- 
cological Society of Boston, January 14, 1892. 
Reprinted from the " Journal of the American Medical Association," 
February 6,1892. 
CHICAGO: 
PUBLISHED AT THE OFFICE OF THE ASSOCIATION. 
1892. ORIGIN AND DEVELOPMENT OF MODERN 
GYNECOLOGY. 
BY AUGUSTUS P. CLARKE, A.M., M.D., 
OF CAMBRIDGE, MASS. 
The ancients seem to have acquired much knowl- 
edge relative to the treatment of diseases peculiar to 
women. The early Greek physicians recognized the 
nature and importance of prolapsus uteri as well as 
many of the disturbing factors of menstruation. 
Mention in their writings is made of a fluor albus. 
The Greeks devoted much time to the consideration 
of what so long had been denominated "ulceration 
of the uterus." They speculated much on what 
should be the dimensions and position of the normal 
uterus; they understood, to a considerable extent, 
many of the more serious forms of dystocia. Their 
ideas of the various forms of uterine version were 
not unworthy of their genius. Many forms of ma- 
lignant disease were observed by them. Some of the 
causes of sterility appear in their writings. Promi- 
nent among these, was the preternatural contraction 
of the uterine canal. Some forms of periuterine and 
pelvic abscess were also known to them. These, for 
the most part, were believed to be limited to the os, 
and to the cervix uteri. The treatment employed for 
many of these lesions, morbid processes and peculiar 
conditions, was complex, and often fanciful, if not 
whimsical. It is useless, however, to attribute to the 
ancients advances in gynecology which they had not 4 
made. High tribute for many achievements, which 
people in early ages are supposed to have accom- 
plished is often paid by writers through over- 
strained appreciation. From a more critical exam- 
ination of the writings of the ancients, it becomes 
evident that no very important surgical measures in 
gynecology were undertaken. Indeed, we might say 
that nothing of consequence in this direction was 
achieved when comparison is made with recent suc- 
cesses. The long night of ignorance and supersti- 
tion, which prevailed in Europe, checked the growth 
and extension of the arts generally. Growth of sen- 
timent in favor of medicine and surgery, suffered in 
common with that pertaining to every other art dur- 
ing this period, though many of the rulers at that 
time were in some respects liberal and accomplished 
princes. The time at last came when imperial edicts 
could no longer hold in chains that spirit, which in 
humanity gives birth to progress. In 1514 Vesalius 
was born at Brussels. He proved to be the most em- 
inent anatomist of the sixteenth century. His great 
work on the structure of the human body has aptly 
been compared to the discovery of a new world. 
Vesalius did not rest altogether on beds of roses, for 
in controverting some of the errors in the doctrines 
of Galen, he incurred reproaches and brought upon 
himself violent hostilities from several anato- 
mists of his time. All this led to healthful exercise, 
and stimulated others to more careful dissection and 
study of the human organism. 
The wars in which the different nations of Europe 
were often engaged, did much toward opening the 
way for greater knowledge in surgical measures. 
Baron Larrey, who accompanied Bonaparte to Egypt, 
and who also served at Waterloo and at other battles, 
was among the early contributors to surgical advance- 
ment. The "Treatise on Gun-shot Wounds," by G. J. 
Guthrie, at the termination of the wars in Spain, Por- 
tugal, France, and the Netherlands, in 1814 and 1815, 5 
did much toward opening the way for a more rational 
practice. Prominent among the results of military 
engagements were those furnished by the Kaffre wars, 
and by the battle of Salamanca, and by the engage- 
ments at Cawnpore in Hindoostan. The results of 
the battle of Solferino were still more important. At 
this battle, according to some accounts, in one day 
11,500 French, 21,000 Austrians, and 5,300 Sardin- 
ians were wounded and taken from the field. Those 
of us who participated in the Civil War of our own 
country, know that the results far surpass all others 
for help in surgical knowledge. The Franco-Prussian 
and other wars of still more recent date, have yielded 
much for consideration on the part of the surgeon. 
The discovery of the use of anaesthetics in 1846, in 
Boston, has universally become a priceless boon for 
suffering humanity. The encouragement which the 
arts have received has led to countless improvements 
in the construction of surgical instruments, appa- 
ratus and in the preparation of dressings. Notwith- 
standing all these helps, with the light afforded by 
the extended opportunities for surgical advancement, 
development and progress in gynecological proced- 
ures were for a long time slow and uncertain. The 
successful results as first obtained in the ovariotomy 
cases undertaken by McDowell, of Kentucky, and by 
others at a somewhat later date, even though some 
apparent recoveries followed, were not sufficiently 
great to impress tire more conservative surgeons that 
such operations at that stage of our knowledge were 
justifiable measures. The occasional or the few 
recoveries occurring after such operations were looked 
upon perhaps, more in the light of what the human 
organism, under certain circumstances, could endure, 
than as indications of what should-have been under- 
taken for an attempt at radical cure or for relief. 
Now that laparotomy, when undertaken with all 
modern equipments and under the strictest precau- 
tions, has become a recognized measure of treatment 6 
for various lesions and diseases affords no justifica- 
tion for those, who, at first, persistently continued in 
the work without the necessary preparation for the 
trying emergencies which so often arose, even though 
some apparent recoveries followed. It is not those 
who first enter the ranks, but those who go into bat- 
tle all prepared for the best service, we should most 
delight to honor. The most important advance in the 
progress of gynecology has been the more general rec- 
ognition of the Influence of bacteria in the production 
of certain morbid processes. The recognition of the 
agency of microorganisms in causing septicaemia, and 
diseases of kindred nature, has effected an entire 
change in the various methods of treatment, and has 
been productive of results in surgical operations more 
brilliant than have been found before recorded in the 
history of our art. The importance of this fact was 
slow in gaining acknowledgement; most surgeons were 
inclined to regard the presence of bacteria connected 
with the pathological changes rather as the result, 
than as the original cause of morbid processes. The 
old systems of operative surgery were too strongly 
entrenched to be dislodged by the bare thought of 
the presence of an unseen foe. There had been de- 
veloped along with the surgical art, a tendency toward 
mannerisms. The brilliant display in the large 
amphitheatre of a hospital had its fascinations which 
were felt no less by the masters of surgery than by the 
crowding spectators. These feats of surgical process 
could not be relinquished at the first onset made by 
what was termed "the new fledged theorists." The 
new system, however, had come to stay, though 
minor details in method are subject to change. The 
patient workers in quiet retreat, and in an atmos- 
phere uncontaminated, and made aseptic, were able 
to show results that could not be gainsaid. It mat- 
ters but little whether the carbolized spray with 
complicated dressings, or the irrigator with prepara- 
tions of bichloride is employed so long as special 7 
precautions are carried out to prevent contamination 
of the incised tissues. Different antiseptic agents 
and the manner of the application of each may pre- 
sent results which are not altogether alike, but the 
general effect will always favor the adoption of some 
precautionary methods against the occurrence of 
sepsis. It is an undoubted fact that with surgeons 
in lesser matters of detail, there has never been an 
entire unity of proceeding. This apparent difference 
in what may be termed the exemplification of the 
technique, is owing, no doubt, to the various degrees 
in appreciation on the part of the individual surgeon 
of the importance attaching to each of the several 
steps to be taken in any special method proposed. 
Some operators work largely under the influence of 
mechanical intuition, while others, acting from a 
general comprehension of what should be done, will 
not limit their sphere of action by observing formu- 
lated methods; they are inclined more to rely upon 
their original resources to meet casual emergencies. 
It is claimed by some operators that in their prac- 
tice, results in laparotomy without the employ- 
ment of antiseptics have been as favorable as in 
those cases in which their use has been adopted. In 
answer to this it may be said that much, no doubt, 
depends on the manner of operating. Those who 
enjoin the strictest measures for general cleanliness, 
and are exceedingly expert in operating, and who 
maintain the strength of the patient against the in- 
fluence of shock, may succeed because the exposure 
of the patient is reduced to a minimum. It cannot 
be denied that the tissues in the living organism are, 
to a great degree, antagonistic to the action of bac- 
teria. It is only after the vital fluids have become 
overwhelmed by the presence of such germs, or when 
they have become peculiarly sensitive to their action 
that the chief danger is to be apprehended. But this 
is no argument against the use of antiseptics, or why 
the potency of the virus of the invading bacteria 8 
should not be attenuated. It is always wiser to take 
every precaution when convenient, than to assume 
that the subtle fluids of nature are in her direst ex- 
tremity alone sufficient for preserving her integrity. 
This leads to the consideration of another point 
which is of much practical importance. 
While it is desirable, in all important gynecologi- 
cal operations, to keep the wound aseptic, it is also 
absolutely necessary to be on the watch, lest the 
strength of the agent employed be so great as to 
weaken the resisting power of the tissues against the 
action of the microorganisms. Sir Joseph Lister, in 
his contribution on the present position of antiseptic 
surgery, before the Tenth International Medical Con- 
gress, at Berlin, makes mention of what he had stated 
at the London Congress, that normal blood and se- 
rum, and even pus, were by no means favorable soils 
for the growth of microbes in the form in which they 
are present in the air. As regards the spray, Sir Jo- 
seph remarked that he felt ashamed that he should 
ever have recommended it for the purpose of destroy- 
ing the microbes in the air. He further says, that if 
we watch the formation of the spray, and observe 
how its narrow initial cone expands as it advances, 
with fresh portions of air continually drawn into its 
vortex, we shall see that many of the microbes in it, 
having only just come under its influence, cannot 
possibly have been deprived of their vitality. Yet 
there was a time, he says, when he assumed that such 
was the case; and, trusting to the spray implicitly, 
as an atmosphere free from living organisms, omitted 
various precautions which he had before supposed to 
be essential. Such a confession of being misled seems 
hardly necessary to have been made; for, on reflec- 
tion, it must be admitted that the employment of the 
spray could never have been otherwise than benefi- 
cial. For the foreign substances in the air, which 
bear the disease germs, coming in contact with the 
elements of the spray, are in large degree pre- 9 
vented from gaining admission into the wound. The 
constant wetting down of the foreign material con- 
taining the germs, I had, for some time before the use 
of the spray was discontinued, come to believe was 
the true secret of success. By this means the germs, 
if not destroyed altogether, were in large measure 
rendered hors de combat. Another interesting feature 
brought out in Sir Joseph's paper, is the reference to 
the results of Metchnikoff's experiments in regard to 
intercellular digestion in the amoeboid cells. By 
these experiments it has been found that these mi- 
gratory cells, with whose amoeboid movements we 
have long been familiar, feed also like amoebae, and, 
while almost omnivorous in their appetite, have a 
special fondness for bacteria, taking the bacteria into 
their protoplasmic substance and digesting them, 
thus preventing their indefinite propagation among 
the tissues. The cells which exercise this devouring 
function, Metchnikoff, according to Lister, termed 
phagocytes. In the experiments referred to, spores 
of anthrax were introduced under the skin of the 
green frog; these were destroyed by the phagocytic 
action of the leucocytes. When, however, the leuco- 
cytes wese excluded from penetrating the animal's 
lymph, the spores sprouted and grew into luxuriant 
threads of anthrax in the lymph. The results of 
other experiments are mentioned, favorable to the 
adoption of the phagocytic theory. Respecting the 
use of sutures,, the author says we can understand 
that the leucocytes may creep into the intervals be- 
tween the fibres of a silk thread, and destroy any 
microbes that may have lodged there before they 
have had time to develop serious septic mischief. 
But there must surely be a limit to the thickness of 
the threads. No one, he imagined, would feel justi- 
fied in leaving in the peritoneal cavity an unsteril- 
ized cord as thick as a finger. The author says it 
would be wise to sterilize even so slender a cord as 
g-'o- of an inch, which Mr. Bantock, of London, uses 10 
for tying the pedicle of the tumor. Who can say, 
continues the author, that septic mischief may not 
occasionally lurk in the ligature in a form which may 
baffle the phagocytes? The extended investigations 
made regarding microorganisms have been produc- 
tive of important achievements. 
I have been asked why it did not occur at the time 
to some of us who had extended experience in the 
late war, 1861-65, that the remarkable and speedy 
recoveries after operations for severe injuries of the 
abdominal organs, and of other parts of the body, 
were due to the direct influence of the agents em- 
ployed, as now embraced under the term antiseptics. 
In answer to this I am able to state, from personal 
experience and observation while in the service, with 
the rank of assistant surgeon and surgeon-in-chief 
of the First Division of Cavalry in the Army of the 
Potomac, and of the Army of the Shenandoah, that 
many of the medical officers did recognize the con- 
nection between such speedy recoveries and the agents 
employed. Hydrargyri chlor, mitis, and also solu- 
tions of hydrarg. bichlor, corrosivi, were known to be 
efficient in destroying maggots appearing in wounds. 
These agents were employed in modifying and in pre- 
venting altogether the occurrence of suppuration. So 
also was the liquor sodae chlorinate, and the liquor 
zinci chloridi. All these, as well as other agents is- 
sued among the medical supplies, were often employ- 
ed for preserving bodies for dissection, for embalm- 
ing, for lessening suppuration and for overcoming it 
altogether. The solution of zinc was also used for 
washing and cleansing sponges and surgical instru- 
ments. I should further state that the medical offi- 
cers of the army always recognized the fact that 
unhealthful surroundings were favorable to the pro- 
duction of a pus-generating atmosphere. Hence the 
frequent employment of the various disinfectants for 
correcting and preventing such conditions. When one, 
therefore, comes to consider the subject more careful- 11 
ly, it will appear that our knowledge of the agency of 
microorganisms in the production of suppurative pro- 
cesses comprised about all that Mr. Lister demonstra- 
ted when he began the work of his remarkable career. 
When Mr. Lister, however, came to recognize the in- 
fluence such extraneous factors had over the condi- 
tion of the parts after surgical operations, he seemed 
determined to crystallize that knowledge, and to for- 
mulate rules for attempting its broader application. 
It appears that Prof. Lister founded his theory on 
what was termed the researches of M. Pasteur. This 
theory embraced the idea that the septic properties 
of the atmosphere were owing not to the oxygen, or 
to other gaseous elements, but to minute organisms 
everywhere suspended in the air; that the power of 
the microorganisms was due to their vitality, that 
the decomposition occurring in the injured parts 
might be prevented by applying as a dressing some 
material capable of overcoming the energy of the 
floating particles. The agent which Prof. Lister used 
was carbolic acid. The publication of his papers on 
this subject first appeared in 1867. In 1863, a work 
on this subject was published by Dr. Lemaire, of 
Paris. This author had entered very thoroughly and 
scientifically into the consideration of the septic ac- 
tion of infusorial germs suspended in thd'air; he had 
discussed the theories of Schultze, Schwann, Pouchet, 
Helmholtz, Bernard, and of other investigators. Dr. 
Lemaire had used carbolic acid in many conditions 
requiring surgical and other measures for relief. De- 
clat, Kiichenmeister and others, had paid much at- 
tention to the subject, before the publication of Mr. 
Lister's views. (See London Lancet, 1867 ; also 
Braithwaite's Retrospect, Vol. Ivi.) 
Another subject which has been coming more and 
more important is the treatment of uterine myomata. 
The exhausting haemorrhage which so often attends 
the presence of large fibroids renders, a resort to sur- 
gical interference necessary. Removal of the uterine 12 
appendages, and especially the Fallopian tubes, if it 
does not fully control haemorrhage, lessens the ten- 
dency to it. The operation for the removal of the 
tubes not only gives relief, but effectually overcomes 
all suffering and effects a permanent cure. We can- 
not always tell whether this occurs as the result of 
cutting off the blood supply through the removal of 
the appendages, or as an interruption of the men- 
strual phenomena, or through excision and loss of 
the nerve tissue. Pyosalpinx and salpingo-ovaritis 
are affections for resort to laparotomy. In all such 
cases the diseased tubes and ovaries should be re- 
moved. Sometimes the pus does not escape through 
the distal extremity of the tube, but dilates its canal; 
it may open into the uterine tissue and give rise to 
pelvic complications. This will often be evidenced 
by abscesses recurring at irregular intervals and dis- 
charging through Douglas's cul-de-sac and through 
the vaginal fornix. 
The presence of such a condition is always to be 
deplored; it can safely and permanently be cured 
only by a resort to laparoto'my. Another condition 
connected with the Fallopian tubes worthy of the 
highest consideration is that occurring in cases in 
which the septic material escapes through the ab- 
dominal extremity of a patulous canal. The occur- 
rence of this condition almost invariably gives rise 
to more or less general peritonitis; this will endanger 
the life of the patient unless speedily relieved by 
operative interference. All are glad to realize that 
the.progress in gynecology has advanced beyond the 
mere routine practice of attempting to correct uterine 
version or laceration of the cervix and perineum; 
that happier days can be anticipated by those women 
who, having contracted matrimony and having be- 
come pregnant, find that they are subjects of deform- 
ity of the pelvis. The brilliant achievements in 
abdominal surgery give assurance that Caesarian sec- 
tion is not only a legitimate operation, but one almost 13 
entirely free from danger; also, that the tragic scenes 
heretofore witnessed in certain cases in which em- 
bryotomy was resorted to maybe relegated to history. 
The progress made in gynecology has reduced to a 
minimum the horrors attendant on extra-uterine 
foetation. 
The recent achievements in gynecology have made 
full returns for what it received from other branches 
of the surgical art. By the advances made in ab- 
dominal section the surgeon of to-day is enabled to 
operate and even to cure a large class of cases com- 
prising every variety of hernia. Diseases of the 
appendix vermiformis are no longer the approbium 
of medicine. Cases of intestinal obstruction can 
often be treated successfully by surgical interference. 
The military surgeon is now profiting by the experi- 
ence gained in our department. Penetrating wounds 
of the abdomen implicating the colon, small intes- 
tine, stomach, bladder, or other viscus or organ, can 
now be successfully treated by abdominal section. 
In regard to the treatment of cancerous disease of 
the uterus it seems scarcely necessary for me to say 
that some improvement has been made. The method 
of total extirpation of that organ, carried out as I 
witnessed it performed by Prof. A. Martin, of Ber- 
lin, is undoubtedly the best that has heretofore been 
devised. Published statistics on this subject I am 
persuaded would fully justify the general adoption of 
this method of proceeding. It must be conceded, 
however, that our knowledge of cancer in its various 
manifestations is as yet in its elementary stage. 
Another subject which has taken on much interest 
in gynecological circles is the treatment by electricity. 
Much has been accomplished by the judicious use of 
Faradism. Excellent results have been reported when 
this form of electricity has been used singly, and also 
in connection with galvanism. That form of elec- 
tricity which has been of the most absorbing interest 
is that of electrolysis. The splendid results reported 14 
by Apostoli, of Paris, and by his followers, as ob- 
tained by this method of treatment in chronic 
metritis, intra-uterine polypi, hsematocele, certain 
uterine fibroids, and other affections connected with 
the genetalia and pelvic organs should not be over- 
looked. 
Without entering into any extended consideration 
as to the value of such method when placed in com- 
parison with more radical measures, I cannot refrain 
from remarking that the credit of originating this 
method of treatment by electrolysis rightfully be- 
longs to a member of this society. Our associate, 
Dr. Ephraim Cutter, was evidently the first in the 
field. By his ingenuity, skill, and rare courage he 
succeeded in perfecting a method and in carrying it 
out successfully in the treatment of uterine fibroids. 
His success in this direction should be a lasting 
honor to his name. 
In conclusion, I would say that the Gynecological 
Society of Boston should feel that it has good reason 
for congratulation, for it is now twenty-three years 
since it was founded and took up the work with noble 
purpose. At the time of its organization gynecology 
was in all the schools an unrecognized department of 
medical science. Its presence here in Boston, the 
metropolis of New England, was regarded as an in- 
novation. It would, indeed, have been surprising 
had not some opposition been directed toward its 
work and its methods. Its membership originally 
was limited to a few, and no one was able to gain en- 
trance who did not give promise of becoming an 
active worker and a fit representative of the art. Its 
Secretary,1 fresh from extended opportunities abroad, 
and from the discipleship of the renowned Simpson, 
of Edinburgh, became a power for directing and ac- 
complishing work. He was an exponent in the prin- 
ciples and methods of practice that was scarcely 
i Dr. Horatio Robinson Storer. 15 
equalled by any gynecologist found in this or other 
lands. That the society was able to carry on its work 
and to cause its influence far and wide to be felt, the 
several volumes of its transactions in its first series 
are its abiding witnesses. The subjects brought for- 
ward for consideration have been numerous and im- 
portant. Eminent gynecologists in this and in other 
countries have made frequent reference to these 
interesting pages. Our society has kept abreast with 
the times and with the progress everywhere made in 
medical science. Our doors are now open to every 
one who has made a record and has given evidence 
of a desire to advance along the lines we have estab- 
lished for our work. Prominent medical gentlemen 
in this and other places, after seeing the importance 
of the work this society has had before it, have 
profited by our undertaking. They have established 
new societies, whose objects have been to promote 
interest in work like that in which we have been en- 
gaged. Foremost among such societies organized is 
the American Gynecological Society; also one of re- 
cent date is the American Association of Obstetri- 
cians and Gynecologists; others also have been 
founded. Not the least among such distinguished 
bodies is the Gynecological Society of Chicago, and 
also that of Detroit. The Section of Obstetrics and 
Diseases of Women connected with the American 
Medical Association is now fortunate in having so 
far succeeded in accomplishing much good work. An 
awakened interest for this kind of work is felt in 
Great Britain, Germany, and in other countries. If, 
however, some of these younger societies are rivalling 
us in advances into the darkness beyond, it will not 
work to our detriment; it will only show that the 
work of our society was wisely undertaken, and that 
the founders built far better than they knew.