Local vs. General Treatment 
in Gynaecology. 
BY 
ANDREW F. CURRIER, M. D. 
REPRINTED PROM 
Ebe ‘Neto York ffcetncal journal 
for March 6, 1886. Reprinted from the New York Medical Journal 
for March 6, 1886. 
LOCAL VS. GENERAL TREATMENT IN 
GYNAECOLOGY* 
ANDREW F. CURRIER, M D. 
There is something extremely significant to me in our 
assembling here, from near and from far, to compare notes 
as to the results which have accrued upon the foundation 
laid in our experience at the Woman’s Hospital, our hospital 
alma mater. I am sure that I but repeat the wish of every 
one present that our reunions may have for us the enjoyment 
which the periodical return of the Olympic games had for 
the youth of ancient Greece, and that they may be not only 
occasions of pleasant reminiscence and social refreshment, 
but fields of intellectual wrestling and mental contests in 
which there shall be honors for all. 
The question of local as opposed to general treatment in 
the practice of gynaecology is one which frequently pre- 
sented itself to my mind almost as soon as 1 passed out 
from the exclusively gynaecological atmosphere of the 
Woman’s Hospital, and I was not a little pleased to see 
that, at the last meeting of the British Medical Association, 
the question was discussed with great spirit and earnestness. 
As there was much in that discussion which was of great 
* Read before the Alumni Association of the Woman’s Hospital, 
January 20, 1886. 2 
LOCAL VS. GENERAL 
importance to all who practice gynaecology, I would heartily 
recommend it to your consideration. The opening address 
was made by Dr. W. S. Playfair, his subject being “On the 
Proper Sphere of Constitutional and Topical Treatment in 
Certain Forms of Uterine Disease.” Allusion was made by 
him to the attack upon gynaecologists by Dr. T. Clifford 
Allbutt in his Gulstonian lectures of the previous year 
(1884), from which the following extracts were cited: The 
patient, he says, becomes “entangled in the net of the 
gynaecologist, who finds that her uterus, like her nose, is a 
little on one side; or, again, like that organ, is running a 
little, or it is as flabby as her biceps, so that the unhappy 
viscus is impaled upon a stem, or perched upon a prop, or 
is painted with carbolic acid every week of the year, except 
during the long vacation, when the gynaecologist is grouse- 
shooting, or salmon-catching, or leading the fashion in the 
upper Engadine.” He (Allbutt) then proceeds to say to 
the College of Physicians that it is time that “ we complete 
our reaction from this gynaecological tyranny, and that we 
of this College no longer permit ourselves to be snubbed 
by these brethren of ours, who calmly tell us, with their 
superior airs, that our use of such expressions as uterine 
neuralgia, neurasthenia, and the like, comes from a narrow 
sciolism, and is grounded on the emptiness of our knowl- 
edge of uterine diagnosis.” These are sharp words, and 
must have been thoughtlessly used, for their author made 
the lame explanation, after being called to an account, that 
his remarks were not intended for the scientific and in- 
structed gynecologist, but for men who did not understand 
thoroughly the diseases which they professed to treat; in 
other words, we might say, he wished to be understood in 
a Pickwickian sense. There is no occasion to apologize 
for or defend gynecology as a practical science. As Daniel 
Webster once said of Massachusetts when one attempted TREATMENT IN GYNAECOLOGY. 
3 
to defame her, “ There she stands,” and the record of her 
discoveries and brilliant victories is ample excuse for her 
existence. As for Dr. T. Clifford Allbutt, his English con- 
freres belabored him sufficiently for his imprudence without 
any additional attention on our part. We are forced to 
confess, however, that the extreme picture of gynaecological 
sins of commission, which he has drawn in such vigorous 
and offensive lines, has within it a semblance of truth, and 
it will be profitable, I think, to find out, if possible, exactly 
what this is. 
I. In the first place, gynaecology is a new science, still 
tar from complete, and scarcely two generations old, if we 
go back to the crude efforts of Henry Bennett with his 
cylindrical speculum and his caustic applications for every- 
thing which was contained in the very circumscribed field 
of his uterine pathology. The efforts of Simpson, Simon, 
Baker Brown, Sims, Graily Hewitt, Emmet, and others 
more or less well known in uterine pathology and practice, 
cover the period which extends to our own time, and have 
been to a greater or less extent a matter of personal obser- 
vation with all of us. All of these men have had their 
hobbies, which they have ridden with the persistence and 
determination of strong-minded men, and have produced 
decided effect upon those who came within the range of 
their teaching. A ith all of them the alpha and omega of 
their treatment can be summed up in the term mechanical 
therapeutics. 1 he result has been an unsettled mass of 
ideas in the minds of many of the followers of these great 
men, based upon experimentation and not upon fixed patho- 
logical truths, and this has led to a great deal of unneces- 
sary, or at any rate unsuccessful, surgical interference. Is 
there one of us who has not repeatedly seen, both in public 
and in private practice, women who narrate a well-worn 
story of pain in the back, bloating of the abdomen, head- 4 
LOCAL VS. GENERAL 
ache, and the whole train of familiar symptoms, and who 
begin or end it with the voluntary diagnosis of falling of 
the womb or inflammation of the ovaries? (As yet the 
idea of disease of the Fallopian tubes has not sufficiently 
permeated the public mind to yield ready-made diagnoses 
of that condition.) If we make a vaginal examination, as a 
gynaecologist is, of course, expected to do, how often it hap- 
pens that all the disturbance which is appreciable can be 
described in the terse if somewhat inelegant language of 
Allbutt—namely, that “their uterus, like their nose, is 
turned a little to one side, or, like that organ, runs a little ! ” 
It is not to be supposed that any intelligent gynaecologist 
would, to continue the line of thought of the vigorous 
writer just quoted, impale such an organ upon a stem or 
perch it upon a pessary, but, doubtless, we have all had an 
opportunity of knowing that such operations are performed, 
and for that not infrequently, and, tor the bad results which 
follow, gynaecology and gynaecologists are held responsible. 
It is proper to add, however, that the minor degrees of 
damage are usually received at the hands ot unpracticed 
men, since they wisely leave to others the operative pro- 
cedures in which the element of risk is prominent. How 
large a number of those operative procedures which were 
the results of the formative stage of gynaecology are now 
either obsolete or of questionable value ! 
II. Another fact which must be borne in mind, and which 
is accountable for much of the bad work which has been 
done in the name of gynaecology, is that it is, and long has 
been, a fashionable specialty. I here are two principal 
causes for this—first, the brilliant successes of the earlier 
gynaecologists which excited many imitators; second, the 
very large number of women who are, or think they are, 
sick with some form of disease of the urino-genital appara- 
tus. If we study the early history of gynajcology we shall TREATMENT IN GYNAECOLOGY. 
5 
find that those brilliant successes alluded to were mainly 
obtained from surgical procedures, especially those which 
had reference to new growths, and the consequences of par- 
turition. Nothing is so stimulating as success, and it is 
easy to understand how these pioneers, with quick and 
active intellects and with surgical tendencies sharpened by 
good results, might be led to the belief that all uterine dis- 
eases were amenable to relief, if at all, by surgical means, 
to the neglect of constitutional ones, their ideas of uterine 
pathology being thus narrowed to a surgical basis. Hence it 
follows that those who have attempted to carry out these doc- 
trines, often with imperfect comprehension of their scope 
and with imperfect skill, have sometimes been led into error 
and mischief. I need only refer, as an illustration of this 
tendency to resolve all problems in uterine pathology by 
resort to surgical procedures, to such operations as clitori- 
dectomy, which was advocated by Baker Brown for certain 
disorders of the nervous system, and discission of the vaginal 
portion of the cervix uteri, which was advocated and exten- 
sively practiced by Sims. Neither of these operations ever 
reached the importance which their advocates probably 
thought they deserved; they were tried and found wanting, 
and, except as matters of history, have passed into disuse 
and oblivion. The inference from the foregoing remarks 
would be that gynaecologists, with the experience and the 
mistakes of their predecessors before their eyes, should build 
upon broad principles, avoiding exclusive adherence to any 
one set of tendencies. They should recognize the harmony 
that ought to subsist between the genito-urinary apparatus 
and the other parts of the body, especially the nervous sys- 
tem, and, conversely, they should be willing to admit that a 
lesion of any part of the body, especially of the nervous 
system, may exist without necessary involvement of the 
genito-urinary apparatus, even though the patient should 6 
LOCAL VS. GENERAL 
express the conviction that disease of some portion of that 
apparatus is present. In order that this desirable end may 
he attained, there is need that ourknowledgj of uterine 
pathology be much more precise and much more extensive 
than it now is. We do not yet know the /ninutice pertain- 
ing to the function of menstruation, notwithstanding the 
excellent work that has been done in this field by Leopold, 
John Williams, Moricke, Wyder, and some others. We 
are in doubt as to the influence of the ovaries and tubes in 
certain important questions, and as to the relations of the 
bladder to the nervous system we can only give a series of 
shrewd guesses; in short, while there has been theorizing 
enough in regard to every morbid condition of the female 
genito-urinary apparatus, the yield of absolute facts and 
principles has not been abundant. 
There is no difference of opinion regarding the existence 
of a large number of diseased conditions peculiar to women 
for which no constitutional treatment is indicated, or at 
least only such constitutional treatment as shall place them 
in proper condition for obtaining the best results from the 
local treatment. 
(a) Such conditions as fistula, abscess, and new growths 
are purely surgical ones, and should be treated on surgical 
principles. 
(b) But there are other conditions for which local treat- 
ment is often solicited and employed, in which a point is 
strained when the cases are made purely gynaecological 
ones. 
(c) Still other conditions—in which the requirement for 
local treatment is apparent and undoubted, but in which the 
constitutional lesion, whether as cause or result, is sometimes 
overlooked—should be treated by a combination of local and 
general means. 
Concerning the first class of cases no argument is neces- TREATMENT IN GYNAECOLOGY. 
7 
sary. We all believe that pathological lacerations of the 
cervix uteri and perinseum, fistulae connected with the rec- 
tum, vagina, bladder, or uterus, fissures, strictures, and new 
growths of all sorts which are susceptible of operation, 
form the legitimate field for the use of the knife, scissors, 
or caustic, and we all agree that the greater the dexterity 
of the operator, and the greater the care and cleanliness 
with which he performs his work, the better—other things 
being equal—will be the result for the patient. 
The second class includes a great many women who are 
sure that they have disease of the womb or ovaries, but 
which, with our present knowledge of the pathology of 
those organs, and our present methods of examination, can 
not be made out. They are hysterical, but we now know 
that hysteria does not always imply womb disease, as its 
name falsely indicates. They are often anaemic; but anaemia 
requires constitutional treatment if that may be said of any 
disease. They are almost sure to be constipated, fretful, 
complaining, and a nuisance to themselves, their friends, 
and their physicians. There are three ways to treat such 
patients : One is the too frequently occurring routine method 
of applying iodine or some other astringent to the uterine 
canal or to the vaginal vault, following this with a vaginal 
tampon of cotton-wool soaked in glycerin, and then dis- 
missing the patient in the vague hope of hitting something, 
or effecting something, one scarcely knows what. This is 
the shallowest kind of gynaecological treatment—in fact, it 
is not rational treatment at all, but is merely a cloak for 
ignorance or indolence. And yet is it not a fact that this 
practice prevails in some of our crowded public clinics, in 
which the best results can not be expected, because of the 
superficial manner in which the cases must be investigated 
by a force of physicians which is too small for thorough 
work ? Another method of disposing of such patients is to 8 
LOCAL VS. GENERAL 
turn them over to the care of a neurologist if a lesion of 
the nervous system is suspected, or to a dermatologist if, as 
is frequently the case, there is a perceptible lesion of the 
skin, this being an easy way of getting rid of trouble and 
annoyance. If the consultant happens to have a very large 
practice, such a course would seem to be proper enough, for 
the theory of our work should be “the greatest good to 
the greatest number”; but, if, as is often the case, one is 
not so burdened with patients as to make such a course de- 
sirable, another method of treatment is available. In the 
first place, one should not be satisfied with an examination 
of the genito-urinary organs alone, such an examination in- 
cluding, of course, an analysis of the urine. One should 
interrogate, as far as possible, all the organs of the body, 
and, if no evidence of progressive disease is found, it 
would seem to be entirely rational to treat the individual 
symptoms. Thus the pain along the spine would call 
for cupping, the actual cautery, or electricity ; the dyspep- 
sia would call for suitable diet and drugs which would 
vary with the condition presented; and so with the other 
symptoms. First, middle, and always, one should endeavor 
to correct the pernicious habit of constipation, which 
we may almost look upon as the bane of womankind. 
How often does one find that the remedying of this evil 
causes a sudden clearing away of all the bad symptoms 
which have perplexed both patient and physician! One 
should give plenty of tonics, whether the choice be iron, 
quinine, strychnine, valerian, gentian, malt, cod-liver oil, or 
red wine. In addition to the foregoing, one should pre- 
scribe electricity, either locally or generally, or both ; counter- 
irritation, walking, riding, light gymnastics, rubbing, ex- 
posure to the sun, hot or moderately cold baths, and syste- 
matic eating, drinking, and sleeping, the requirements being 
varied to suit each individual case. Diversion is a matter TREATMENT IN GYNAECOLOGY. 
9 
of prime importance, and it should be innocent, healthful, 
and stimulating. It might be supplied by cheerful society, 
suitable reading, and other useful employment, and such 
amusements as would really amuse and leave no stain be- 
hind. As to vaginal examinations and local treatment per 
vaginam, I think that we, as professional gynaecologists, 
should make ourselves heard in no uncertain tones. If no 
disease of the genito-urinary organs is discoverable, what is 
the use of such treatment ? 
Is placeboic treatment of this character entirely warrant- 
able, especially in young and unmarried women, even though 
we are met by the assertion that women who are in this 
condition feel that they require treatment per vaginam, and 
will get it from our neighbor if not from us? If we are to 
appreciate the responsibility which is laid upon us by those 
who intrust their wives, sisters, mothers, or daughters to 
our care in this most confidential relation, we shall never 
allow that gynaecology, in so far as our influence is con- 
cerned, should become a mere makeshift to satisfy the 
whims of nervous women. 
In the third class I should include the great multitude 
of cases concerning which we have sufficient evidence that 
local treatment is very often beneficial, but in which, also, 
there are morbid conditions which require general treatment, 
and these conditions are sometimes the result of disease of 
the genital organs, and sometimes are entirely independent 
of them. Therefore it follows that we do not always cure 
the patient when we have cured the apparent disease of her 
genital organs, and that such cases deserve careful study, 
that we may appreciate them in all their bearings. In this 
class I would include mainly the displacements of the 
uterus, and to a lesser degree the major and minor inflam- 
mations of the pelvic organs and tissues. Concerning the 
first of these divisions there have been more argument, dis- 10 
LOCAL VS. GENERAL 
putation, and difference of opinion than upon any subject 
in the domain of gynaecology, and, like many another unfor- 
tunate subject in gynaecological pathology, the differences 
of opinion continue. We all know the tenacity with which 
Graily Ilewitt and his followers cling to the so-called me- 
chanical theory which bases uterine disease upon displace- 
ments, from which theory there have been many desertions 
in recent times (and I confess that I am one of them). 
We also know the influence which the writings of 
Schultze, Fritsch, Vedeler, and others have had in breaking 
down the mechanical theory, especially as regards the sig- 
nificance of anterior positions and malpositions of the uterus. 
It does not seem to me at all questionable that very many cases 
of so-called anteversion or anteflexion are not pathological. 
The same is true, but to a lesser degree, concerning retro- 
flexions and versions and latero-flexions. Each case must 
be judged upon its particular merits. Given a case in which 
there is displacement of the uterus, with symptoms which 
are referable thereto, be they the symptoms which traction 
or undue pressure upon the bladder would produce, which 
traction upon the utero-sacral or broad ligaments or press- 
ure upon the rectum would produce, or which would be 
produced by a confined volume of fluid trying to pass an 
abnormally small os internum, or in another case trying to 
traverse a narrow passage made by an acute flexure, and 
made additionally narrow, in this as well as in the other case 
of assumed stenosis, by a congested mucous membrane— 
given any of these conditions, I say, and the mechanical 
theory becomes a rational basis for treatment. I am quite 
well aware that the assertion has been made that dysmenor- 
rhcea may exist without flexion or stenosis of the uterus or 
its canal; also that flexion or stenosis may be present and 
menstruation be painless. This assertion, however, proves 
nothing to the detriment of the well-established principles TREATMENT IN GYNAECOLOGY. 
11 
of mechanics which are illustrated by the conditions which 
were assumed. 
Having, then, a uterus which can be restored to the axis 
of the pelvic strait without too great a display of violence, 
with an absence of pelvic inflammation, T believe that the 
unfortunate viscus, to quote again from Allbutt, may with 
safety be perched upon a suitable pessary, though I am 
skeptical as to the propriety of impaling it upon a stem, at 
least in any cases which I have ever seen. Neither have 
1 any especial predilection for the greater number of the 
ingenious anteversion pessaries which are in use, nor for 
many of the other varieties upon which their inventors have 
expended much time and patience, and by means of which 
they have accomplished some harm, and, it is to be feared, 
very little good. I must, furthermore, confess my skepti- 
cism as to the value of the frequent forcible rapid dilatations 
of the uterine canal which have become so fashionable with- 
in the last few years. Certainly, dilatation is a valuable 
means of local treatment, but the slower method with gradu- 
ated sounds seems to me far more rational and far prefera- 
ble, because less dangerous. I have seen the rapid method 
practiced many times, and never discovered that the results 
were any better than by the old-fashioned method. 
Goodell, who is one of the foremost advocates of rapid 
dilatation, and certainly as intelligent and competent an 
operator as practices this method, recently announced that, of 
seventy-six single women in whom this operation had been 
performed by him, forty-live were cured ; of sixty-nine mar- 
ried women, forty-seven were cured.* It is fair to presume 
that, when all things are taken into consideration, these fig- 
ures represent the maximum of success by this method, and 
it is far from perfect success. With any or all of these means 
* “Med. News,” Dec. 12, 1885, p. 645. 12 
LOCAL VS. GENERAL 
of local treatment—pessaries, dilatation, or vaginal medica- 
tion—there are some patients who refuse to be cured, even 
though the local diseased conditions may, to all appearances, 
be removed. They remain anaemic or hysterical, or, at any 
rate, do not get well, and it becomes evident that the trouble 
is too deeply seated to be removed, if it may be removed 
at all, by any method of treatment which does not take 
into consideration the nutrition of the entire body in gen- 
eral and that of the nervous system in particular. In many 
of the chronic cases of pelvic inflammation we are equally 
powerless to produce a cure by the ordinary means of local 
treatment. All honor to Dr. Emmet for suggesting the 
continued application of moist heat to relieve such con- 
ditions, and no man can spend eighteen months in the 
Woman’s Hospital without being convinced of its great 
value. Similarly, no man can pass through that experience 
without seeing patients in whom this, as well as all other 
means of local treatment, is ineffectual. Such patients 
frequently become bedridden, being in pain almost con- 
stantly, the pain being greatly exaggerated during the men- 
strual epoch, and the chances preponderate that they will 
become confirmed in the opium habit if circumstances will 
permit. The results in these cases are that many remain 
uncured and incurable; others submit to laparotomy as a 
final resort, with hysterectomy, oophorectomy, or salpingec- 
tomy, according to the extent to which the different organs 
are found to be diseased, or the degree of faith with which 
the operator adheres to this, that, or the other theory con- 
cerning the effect of their removal. Of the remainder there 
are doubtless some for whom a systematic course of general 
treatment, in addition to the local, would prove beneficial 
or curative. I know that the management of such a course 
requires an amount of patience and devotion which the 
majority of busy men, whether in general or special prac- TREATMENT IN GYNAECOLOGY. 
13 
tice, are not willing to give, or perhaps could not give with- 
out detriment to other important interests. In almost all 
cases of this character it seems to me that the patients 
would be more successfully treated away from their homes 
and home sympathy. The course of treatment might be 
similar to that which was outlined in connection with the 
previous (6) class of cases, being varied, as was stated in 
that connection, in accordance with the requirements of 
each case. The establishment of small hospitals for the 
reception of such patients, wdtli a sufficient number of medi- 
cal attendants to admit of the careful study and record of 
each case, would seem to me to be desirable. Finally, there 
are two points with which I have endeavored as a gynae- 
cologist to charge my own mind. One is that the practice 
of gynaecology means the practice of medicine in a broad 
and liberal sense; the other is that it is the application of 
common-sense principles to the practice of medicine. There- 
fore It would seem that a gynaecologist should be armed at 
as many points as possible. Living, as most of us do, in 
cities, there may not be the need of special acquirements 
for the treatment of the eye, ear, throat, etc,, which can be 
treated successfully only by those who have such acquire- 
ments. There are, however, morbid conditions of various 
parts of the body wrhich are otten associated, and intimately 
associated, with disease of the genito-urinary apparatus. 
Mention has been made of diseases of the skin, of the nerv- 
ous system, and of various constitutional and visceral dis- 
orders which often seem to radiate directly from a disease 
of the uterus or its surroundings. Concerning the other 
point, we are obliged to take the dictum of no man as to 
methods of treatment; that is to say, if the proposed meth- 
ods, past or present, do not impress us as reasonable, we 
should have independence enough to strike out in a line 
which does seem reasonable. This is peculiarly a time in 14 
LOCAL VS. GENERAL TREATMENT IN GYNAECOLOGY. 
which methods and men are tested by their merits, and 
fortunate is that man upon whose methods the seal of ap- 
proval is placed by his fellow-workers; fortunate and happy 
should we esteem ourselves, as representatives of a great 
institution, if it falls within our power to develop the noble 
purpose for which that institution was founded—the relief 
of the sufferings of women. 
38 Wkst Thirty-sixth Stiikkt. REASONS WHY 
Physicians staid SnMe 
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