*& iu£«-' ?->',?. ;.C8*XNf ■i-'.-V-': .'.;■• •»J>>vy : u'r.^tt&z-*''-- NATIONAL LIBRARY OF MEDICINE nlm oamosn t U.S. NATIONAL UBRARV OF MEDICINE NLM001405116 9NOia3w jo Aavian ivnoiivn 3NOIQ3W JO AMV 3NIDIQ3V.' jo Aav-jgn ivnoiivn ;' 35. Subperitoneal fibroid with sessile attachment to posterior wall of uterus. (From specimen in the Mutter Museum of the College of Physicians.) . 126 36. Pedunculated subperitoneal fibroid. (From specimen in the Mutter Museum of the College of Physicians.).......• l'-~ 37. Multinuclear interstitial fibroid with one nodule affected by calcareous degen- eration. (From specimen in the Mutter Museum of the College of Phy- sicians.) ............. 128 3S. Apostoli's vaginal puncture trocar, for use witli handle shown in Fig. 23. . 136 39. Author's vaginal puncture trocar (enlarged sectional view). .... 136 40. Author's abdominal puncture needle (shown in enlarged section). . . . 139 41. Diagram of original outline of tumor in Case 1.......144 42. Diagram of original outline of tumor in Case 5.......145 43. Diagram of original outline of Case 6.........140 44. Diagram of original outline of Case 7.........147 45. Diagram of original outline of Case 13.........14!) 46. Diagram of original outline of Case 17.........150 47. Original outline of tumor in Case 35.........152 4S. Outline of tumor in Case 35 after treatment........153 40. Original outline of tumor in Case 38.........154 50. Outline of uterus in Case 38 after treatment. ....... 155 51. Outlines of tumor in Case 46 at various dates........156 52. Original outline of tumor in Case 61, showing method of treatment. . . 158 53. Outline of Case 61 after treatment..........159 54. Outline of tumor in Case 1 of Dr. Haultain's before treatment. (Haultain.) 174 55. Case 1 after treatment. (Haultain.)........ 175 56. Outline of tumor in Case 2 of Dr. Haultain's before treatment. (Haultain.) 176 57. Case 2 after treatment. (Haultain.)........177 58. Sectional view of a case of hypertrophy and prolapse of the infravaginal cervix. 188 59, 60, and 61. Tripier's rectal, uterine, and vesical electrodes for displacements. 190 62. Tripier's faradic method for anteflexion.........191 63. Tripier's method of faradic treatment for retroflexion......192 64. Gaiffe pocket faradic battery...........228 65. The Massey transportable galvanic battery. ....... 238 66. The author's gold and zinc puncture electrodes. ...... 241 67. Hollow, bulbous electrode of gold for dissemination of mercury in cavities. . 242 68. Arrangement of apparatus and patient in the cataphoric treatment of cancer. 243 69. Outlines of circumference of sarcoma in Dr. McFadden Gaston's case. . . 252 70. Double, bipolar instrument for electrolytic destruction within a cavity. . . 254 71. Cystoscope of J. Howard Kelly........ _ 262 72. Urethral calibrator.............263 73. Kelly's urethral dilator.......... _ 264 74. Cystoscopic syringe.............265 75. Ureteral searcher. ••■•...... 266 76. Author's hemorrhoidal needle electrode....... 270 77. Diagrammatic representation of the cause of flow in hydraulic currents. . 278 78. Diagrammatic representation of the cause of flow in electric currents. . 279 79. Diagram of direction of current within a cell. 80. Diagram showing analogy of laws governing pressure in pump and dynamo circuits. ...... 280 281 LIST OF ILLUSTRATIONS. X1I1 PAGE 284 2S5 280 Three cells connected "in series."......... Three cells connected " for surface," or in parallel arc...... Graphic delineation of the pressure and volumes of currents from a single galvanic cell. ............ Graphic delineation of the pressure and volumes of currents from a battery of twenty cells arranged " for surface.".......287 Graphic delineation of the pressure and volumes of currents from a battery of twenty cells arranged "in series."........2SS Diagram of circuit arrangement for using incandescent current. . . .291 Author's switchboard for obtaining the galvanic current from the Edison in- candescent mains.............292 Geiger shunt-controller, or volt-selector.........293 Improved Massey current-controller..........294 Jewell graphite controller...........294 Arrangement of circuit for Jewell controller........295 Mcintosh switchboard for galvanic and faradic currents. .... 296 Carbon cylinder cell. ............ 297 Elements of carbon cylinder cell..........298 Flennning portable galvanic battery with meter and controller attached. . 299 Insertion of meter and controller in circuit of ordinary portable galvanic battery. ........ . . Mcintosh twenty-four-cell portable galvanic battery. The Kidder portable galvanic battery, showing top-plate and eleme Skeleton drawing of Waite iV Bartlett thirty-cell galvanic battel Massey current-controller. ........ Weston millianimeter, arranged specially for medical work. Jacketed pan for clay pads. ....... A uthor's wircd-cotton electrode pads. ..... Author's complete switchboard arrangement for both currents. Diagram of faradic battery. ....... Flemtning's No. 4 faradic battery. ...... Mcintosh faradic battery......... Knd-view of Rockwell's high-tension coil. .... Engelmann's faradic' battery........ I)e Watteville combiner......... The Massey improved Wimshuist-Holtz static machine. . Electrodes for use with static mchine. ..... Arrangement of circuit for Morton's static induced current. . Queen self-regulating x-ray tube. ...... Arrangement of static machine for the production of Roentgen ray The Kellogg sinusoidal apparatus....... Grapine representation of the sinusoidal current in Dr. Kellogg's (Kellogg.).......... Sinusoidal curve obtained by d'Arsonval...... Current from faradic apparatus. (Kellogg.) .... Current from faradic apparatus. (Kellogg.) .... Representation of magneto-electric current not sinusoidal in (Kellogg.).......... Current from du Hois-Reymond coil, (Kellogg.) . 500 iOl ;o2 !()4 ><)."> 107 luS 309 310 319 ...,., 323 324 325 334 337 341 343 345 346 apparatu.- character. 347 347 347 347 348 348 XIV LIST of illustrations. FIG. rA"r' 123. Characteristic marking of the rapidly-successive inductions of a poor faradic coil. (Kellogg.)..........• • ''"*' 124, Current from coil excited by Thompson-Houston arc light, alternating 16,800 times per minute. (Kellogg.)..........'^ 125. Mcintosh sinusoidal apparatus, with motor. ....••• 349 126. Kennelly sinusoidal apparatus and motor........350 127. Shaw's acid carbon cell, of large size, for running motors, lighting small lamps, etc..............351 12S. Sajous's lamp-holder and stand..........353 129. Isaac's search-light.............354 130. Phillips's electric head-light for four-or six-volt lamp......355 131. Author's pelvic transilluminator..........356 132. Apparatus of Chevalier Jackson as arranged for transillumination of the nasal passages and antrum. .......... 357 133. Alternating current-transformer of Williams, Brown irm mi' PLATE XVI. Gonorrheal Endometritis (Early Stage.) wrx a McFvnwGs co. uw mi* PLATE XVII. Corporeal Endometritis of septic origin. >w a Mcnmncc to lot ran.- PLATE XVIII. Purulent Leucorrhea in Metro-Salpingitis of gonorrheal origin. *5RT 8 MtFTUBBSF CO. W2 BULA CATARRHAL AFFECTIONS OF UTERO-TUBAL TRACT. 91 remained closed to important facts of upward extension of the condi- tions thus revealed by discharges, and applications were made to the uterus in the presence of salpingitis and ovaritis, which contra-indi- cated them. The other reason for the recent neglect of the naked-eye appear- ances of uterine discharges as a means of diagnosis and an indication for treatment is the therapeutic nihilism of recent leaders in gyne- cology, who have apparently despaired of curing any form of metritis, and busy themselves with methods for amputation of the organ. This is emphasized by the dearth of exact information in standard treatises as to the character of leucorrheal discharges, though it may be said that the work of Skene is a distinct exception in this respect. As stated before, all catarrhal conditions of the utero-tubal tract are essentially only portions of the same disease, yet the evidences of a predominant seat of the chronic form of the affection in one or the other location are most important from a practical point of view, for their proper understanding enables us to apply curative agencies with great precision. In Plates X to XVIII the author presents the first illustrations that have been published of the several varieties of cervical and cor- poreal discharges of persistent character, drawn and colored directly from nature. For this unique and novel series we are indebted to a rare combination of skill and patience in the artist, who spared no trouble and time in an effort to accurately portray on the spot the typical cases shown him.1 Cervical Endometritis.—In a state of health there are no appre- ciable discharges from either the uterus or vagina, save, of course, the menstrual Aoav and a slight mucous discharge which may precede or follow it. yet, Avhile there is no excretion, there is, in a normal con- dition, sufficient secretion from the mucous membranes of these parts for the maintenance of moist conditions, and, doubtless, for bacteri- cidal purposes, on the one hand, and the fostering of spermatic life, on 1 The coloring of these draAvings is Arouched for as a correct picture of the typical cases selected, and, as some of the cases Avere draAvn from patients at various hospitals, the artist Avas enabled to obtain a technical corrobora- tion of the coloring from the physician in attendance in every instance. For clearness of illustration it was, nevertheless, necessary to represent the A*agina as shorter than natural. 92 DISEASES OF AVOMEN. the other. The normal secretion within the vagina is Avhitish, acid in reaction, and tends to collect within the folds and about the cervix in unmarried women as a white, curdy deposit (Plate X). The nor- mal secretion Avithin the cervical canal is clear, slightly tenacious, and alkaline in reaction. In a condition of chronic inflammation this secretion of the Xabothian glands of the cervix becomes more tenacious, viscid, and opaque (Plates XIV and XV). It is, at times, so tenacious that it is impossible to wipe it away with a cotton swab. When the stage of the affection is still purulent this viscid, stringy mucus is stained by admixture with pus-corpuscles, and its reaction is at these times acid. This form of cervical catarrh is unquestionably more rare than the form to be described directly, and is thought, by the author, to be due to a profound microbic invasion of the Xabothian glands of the cervix from gonorrheal infection of long standing. In the other form of cervical endometritis the most prominent symptom is the --granular erosion," which is found spreading from the external os over a varying part of the vaginal portion of the cervix in an area concentric with the opening (Plates XII and XIII). This Avas described by Bennett and the older gynecologists as "ulceration of the cervix." The true nature of this morbid condition has been ascertained by Euge and Veit, in Germany, and de Sinety, in France, to be a morbid proliferation of the epithelium surrounding the ex- ternal os, in association with a similar condition Avithin the cervical canal. It is, therefore, usually not an ulceration at all, in the sense that a loss of substance exists, though this may be the case, but in- volves the singular fact that the cylindric epithelium of the cavity of the cervix is said to be reproduced outside of the os Avithin the eroded area Avhere pavement epithelium normally exists. Several ex- planations of this odd circumstance are given by recent Avriters, those of the surgical school holding that the condition is frequently pro- duced by an eversion of the lining of the canal by reason of laceration of the underlying tissues of the cervix in parous women, or by a simple ectropion of the membrane by reason of its morbid redundance in. nulliparas. As the condition is most frequently met with in women who have never been pregnant, the slight bearing of laceration on its production is, nevertheless, evident. It appears to the author that these studies do but little to clear up the practical questions at issue, and that Tyler Smith's claim that CATARRHAL AFFECTIONS OF UTERO-TUBAL TRACT. 93 the conditions obsen*ed are but secondary to a catarrhal endometritis Avithin the cavity are substantially correct. That an eroded, or, pos- sibly, hypertrophied and altered epithelium Avithout a catarrhal cavity may be produced by an acrid discharge from within it is well proved by the condition noted on the skin beneath the nostrils in neglected children with nasal catarrh, when a practically similar lesion may be seen. In some of these cases the erosion extends to the vaginal Avails even, making the resemblance more perfect. If the two conditions are analogous the absurdity of treating erosions external to the os by direct applications to this surface alone is evident. It is probable that this peculiar form of catarrhal invasion of the cervical cavity is due to a special form of pathogenic microbe, for ob- servers have noted that the affection may involve the cavity of the corpus as well as the cervix. That certain individuals are prone to contract it seems also established. When the Xabothian glands are also affected there is a tendency to a closure of their ducts, producing shot-like cysts projecting from the surface, which may lead, by pressure atrophy, to extensive cystic degeneration of the cervix. The constitutional symptoms of cervical endometritis are less marked than Avhen the affection is generally disseminated through the Avhole organ, yet backache, a sense of Aveight in the pelvis, and often menorrhalgia accompany the leucorrhea. In the treatment of these very obstinate affections mere applica- tions to the surface Avill be ineffective for the reason already given, that the disease is situated deeply in the cervical mucous membrane. The most effective electric method is the use of mercuric cataphore- sis, for here Ave have a penetrating microbicide and alterative that may be sent to any depth by interstitial diffusion. The zinc-mercuric method is probably as effective as the gold-mercuric, both being applied in moderate milliamperage of 30 to 50 to the cervical cavity. When associated Avith moderate degrees of corporeal endometritis, as it often is, it is generally more expedient to employ the mercury on either a silver or copper electrode, OAving to their smaller size and the possibility of properly shaping them to fit the cavity. Illustrative Cases.—A young lady of 22 AA'ho had been suffering from menorrhalgia Avith profuse leucorrhea for three years, Avas sent to me from a neighboring city. As there had been considerable instru- mental treatment, resulting in moderate dilatation of the introitus, 94 DISEASES OF AVOMEN. a small bivalve speculum Avas inserted (contrary to my custom in vir- gins, as erosion is easily detected by touch alone), revealing erosion of the os and a softened and dilated cervix as far as the internal os. On inserting the sound the internal os Avas found to be normally tight and the cavity of normal depth. It Avas clear, therefore, that the affection Avas confined to the cervix alone. As this case and the folloAving one Avere seen before the develop- ment of mercuric cataphoresis, the treatment employed Avas positive galvano-chemic cauterization from a bare platinum electrode inserted beyond the internal os and slightly withdraAvn before turning the cur- rent on. The strength employed Avas 25 milliamperes twice a week, folloAved by the faradic current. At the end of six weeks' treatment, followed by two weeks' rest, her condition was materially improved as to leucorrhea and the general symptoms, but the erosion remained little changed. The applications Avere now made once a Aveek for two months, Avith a final relief from all symptoms and a better appearance in the eroded area. Just Avhat the condition of the os is at present, four years since the termination of the treatment, is unknoAvn, but the patient remains in excellent health. Mrs. S., a married lady of 25, avIio had never conceived, presented symptoms similar to the last patient since her marriage, a period of three years. After much ineffectual treatment she applied to me in March, 1891. Her condition at this time Avas as follows:— Her principal symptom Avas menorrhalgia, associated with scant menstruation and intermenstrual backache. Examination revealed erosion extending a half-inch in all directions from the os, Avith copi- ous muco-purulent catarrh of a tenacious character. The inner os was small and the cavity, as a whole, measured but tAvo and one-half inches. In spite of the scanty menstruation it was thought best to employ the platinum electrode with the positive galvanic current, beginning with 20 milliamperes. The applications Avere made twice a Aveek. The following period was free from pain and there Avas a great lessening of the discharge Avithout any improvement in the appearance of the eroded area. After two months' desultory applications treatment was suspended for the summer, as she seemed practically well. In the fall the applications Avere renewed, oAving to one period having been pain- ful and for the purpose of curing the erosion, resulting finally in a complete restoration to health. Miss 11., a maiden lady of 40, had been in poor health for a long CATARRHAL AFFECTIONS OF UTERO-TUBAL TRACT. 95 time, but complained principally of a copious purulent leucorrhea and pain in the upper spinal region. There Avas no menorrhalgia. Examination revealed an enlarged, softened cervix, Avith an eroded surface, avUicIi I was able to shoAV to the artist (Plate XIII). Like the other cases mentioned, there Avere distinct evidences of non-in- volvement of the corpus. The treatment in this case Avas by cupro-mercuric cataphoresis, an ordinary nickel-plated sound being denuded of its plating by dipping it in acid, after Avhich it Avas amalgamated by redipping in acid and then in mercury and rubbing it on moistened cotton. The strength of the current Avas 35 to 40 milliamperes for ten minutes, repeated twice a Aveek. At the end of two months there Avas a com- plete resolution of the eroded area as Avell as arrest of leucorrhea. She received appropriate medication for her general health at the same time. Corporeal Endometritis.—Chronic inflammation of the cavity of the body of the uterus is characterized by an enlargement of this por- tion of the organ without participation of the cervix. This is readily detected by a comparison of the conditions found by simple touch with the enlargement detected by the bimanual touch, and particu- larly when Ave find the sound will go to a depth greater than the normal tAvo and a half inches without the cervix"s participating in the enlarge- ment. This condition is by no means rare, for it is liable to be found in all cases of chronic metritis due to subinvolution or to retention of septic materia],—in other Avords, Avhenever the condition has arisen independently of an upAvard extension from a previously inflamed cervix. The leucorrheal discnarge in these cases is serous, Avhether it be purulent or sanguineous, and is therefore readily distinguished from the eeiwical discharge, though not so readily observed in the act of issuing from the uterus. The therapeutic management of chronic corporeal endometritis differs so little from that of the larger number of cases of general chronic metritis that further consideration of the subject is incorporated in the folloAving paragraphs. Chronic Metritis.—The clinical experience of the author has led him to the conclusion that either uterine catarrh or its consequences are responsible for the sufferings of a large proportion of the patients, married Avomen in particular, avIio consult physicians for symptoms of obvious pelvic origin. Reference is made, of course, to cases of a chronic nature Avhich, on examination, exhibit an enlargement of the 96 DISEASES OF AVOMEN. unimpregnated uterus aboA*e the size natural to the state of life of the patient. Though such a condition may date from a puerperal sub- involution and the leucorrheal stage be long past, its dependence on an original bacterial invasion is none the less definite, for in an organ of this particular structure the active stage of inflammation repre- sented by the bacterio-phagocytic contest occupies but a small part chronologically of the so-called inflammatory process, the tissue re- action evidenced in a proliferation of the connective-tissue cells becoming a far more persistent feature. The stubbornness of an analogous inflammation of the nasal mucous membrane is quite familiar. The persistence of a catarrh of the uterine mucous mem- brane is even more likely, for the membrane in this case overlays a tissue more open to invasion, and subject to the periodic congestions of menstruation and pregnancy. Clear vieAvs of this nature are exceedingly important from a thera- peutic point of view, and will displace from serious consideration many minor mechanical faults of the uterus to Avhich too much atten- tion has been paid of late. Versions, flexions, and even moderate lacerations of the cervix become of secondary importance in a still movable uterus Avhich is the seat of this trophic disorder. The ver- sions and flexions are, in fact, often due to the interstitial changes within the uterine Avail, either from overweight or unequal distribu- tion of the morbid process to one aspect or the other of the muscular fibres, Avhile the healed laceration Avhich, Avhen it occurred, had opened the avenue of infection, will present no symptoms after the dissipa- tion of the inflammatory process. To cut out such healed scar-tissue at this stage is like locking the stable-door after the horses are stolen. Such a purely mechanical theory of uterine affections arose in the prebacterial age of medicine, and should be dispassionately re- viewed in the light of this important addition to human knoAAdedge. The direct cause of all cases of chronic metritis is, of course, a microbic invasion made possible by a lessened physiologic resistance or a traumatism. The special microbe involved may be either the gonococcus, in Avhich case an acute stage must precede the one under consideration, or more ordinary pathogenic varieties Avhich are ahvays present in the vagina and cervix, but never normally above the internal os. It Avould seem that the inner end of the cervical canal Avas, under ordinary circumstances, an inner line of defence against such inva- sions by virtue of its secretions, and that no pathogenic organisms CATARRHAL AFFECTIONS OF UTERO-TUBAL TRACT. 97 succeed in passing this point unless the defenses of the body are loAvered by neural conditions or by traumatism. A cumulative increase in a cervical endometritis, coupled Avith increased susceptibility, accounts for the upAvard invasion Avithout traumatism. Traumatism, as a cause of corporeal endometritis, Avhich is but the earlier stage of parenchymatous metritis, includes the cases due to Subinvolution, to the retention of septic remnants of fetal mem- branes after instrumental delivery or abortion, to laceration of the ceryix, and to the harsh use of instruments. .' The term chronic metritis includes, therefore, a variety of con- ditions with Avidely differing clinical characters, depending on the nature of the tissues mainly attacked, as well as the stage of the affec- tion and the character of the microbic cause. From certain clinical points of A'iew these cases of chronic metritis are divisible into two other classes that much resemble the divisions made by the late George M. Beard in cases of sexual disease in the male. In the one class the affection occurs as a purely local disease, the nervous organization of the individual being so robust that it fails to be affected by the local disturbance; in the other class a far less degree of local trouble may be found, associated Avith profound depres- sion and disorder of the nervous system,—a disorder that, at times, seems greatly disproportioned to the local disease. On these reflex symptoms some doubt has been thrown of late, but the best proof that pains in the anterior crural region and in the back, Avith or Avithout nervous prostration, are caused by this "irritable" uterus is given by the disappearance of such symptoms in a sufficiently large number of cases as a result of local treatment. The reason of the doubt may possibly have been a lack of neurologic training in certain gynecolo- gists, Avho have mistakenly treated such diseases as hysteria, neural- gia, locomotor ataxia, and even scoliosis, in the writer's experience, as mere nervous manifestations of pelvic disease. The prevalence and ultimate discredit of the recent fad in Avhich it Avas attempted to cure not only uterine inflammation, but many nervous diseases, by remov- ing scar-tissue from the cervix, may also be partly responsible for this attitude. In the first class of cases mentioned the treatment may be carried out in the office, but cases accompanied by nervous prostration are 98 DISEASES OF AVOMEN. suited only to the salutary care of an institution in Avhich both the local and nervous elements in the case will receive due recognition. Intra-uterine treatment is essential in these cases and is only sub- ject to the ordinary rules of gentleness and frequency, since it is assumed that no instances of extension of the disease to the appen- dages are noAV under consideration. The galvanic anode has generally seemed best in my practice whenever catarrhal symptoms are para- mount, and it is usually followed by either a primary or secondary monopolar faradic current before the instrument is withdraAvn. The character of the intra-uterine electrode is also important, the covered elastic instrument being usually preferable and easily inserted on account of the patulous condition of the os, unless, indeed, it be thought best to employ mercurialized electrodes on account of a pro- nounced abnormality of the mucosa still present. BetAveen the inter- vals of the intra-uterine treatment daily vaginal applications should be made. The effect of these relatively strong intra-uterine applications upon fertility deserves consideration. In a series of thirty-two cases reported in a paper before the American Electro-Therapeutic Associa- tion, in 1894,1 I Avas able to ascertain that six cases had become preg- nant since the termination of the treatment. At the same meeting x\postoli contributed a paper also, in which he reported eighty cases that had become pregnant after electric treatment. The proportions reported by me are, of course, not matters of definite ascertainment since a considerable number of the cases treated were not married, and may instances of pregnancy have, doubtless, occurred among the cases treated without the knowledge of either observer. Considering, hoAvever, that the greater number of all these were unquestionably sterile at the beginning of treatment, on account of the morbid con- dition of the mucous membrane and its discharges, it Avould seem that the effect is to increase the fertility. Post-puerperal Metritis; Neglected Subinvolution.—Arrested in- volution of the post-parturient uterus, whether due to inertia, non- traumatic infection, or traumatic infection, is more successfully and quickly treated by electricity than by any other means at our disposal. It is even a question whether normal involution Avould not be materi- 1 See Appendix B. CATARRHAL AFFECTIONS OF UTERO-TUBAL TRACT. 99 ally hastened by the systematic application of faradic currents to the highly contractile tissue still constituting the bulk of the uterus, as advised by Apostoli. Certain it is that Avhen the natural process is sluggish by reason of a diminished rate of shrinkage in the muscular fibres a few applications of the faradic current from the primary or a coarse Avire secondary coil Avill stimulate the flagging muscular tissue to develop its normal tone. Sanguineous discharges continuing be- yond the normal periods of their appearance, or recurring during the first month after parturition, may be controlled by one or two such applications; and if there is no sepsis or traumatism as a causative factor, no other treatment is necessary. Either the monopolar or the bipolar method may be employed, but the primary current is ahvays preferable. But it is rare for subinvolution to be of so simple a nature,— shreds of retained decidua, a morbid condition of the endometrium, a laceration or other trauma, being the determining causes of a septic endometritis to Avhich the subinvolution is due. In these cases the gahanic current is indicated with the simple positive pole or Avith zinc-mercuric cataphoresis if the hemorrhagic feature predominates, though in simple cases the covered elastic electrode is best on account of giving the least pain. The swelling method (gradually increased and diminished currents) should be employed, Avith a dosage varying from 25 to (>0, or more, milliamperes. To this the faradic current may also be added. For a septic condition of the uterus the posith'e mercuric pole is the most satisfactory, OAving to its distinct bactericidal poAvers, and, if the foul discharge comes from only small shreds of retained membrane or clots, it is quite unnecessary to resort to the risks and loss of blood attending the use of the curette. The drainage that folloAvs a galvanic application will usually be amply sufficient to carry off these shreds Avhen detached by the action set up by the current; but if the placental remnants be large and abundant the dull curette should be used before the alterative and contracting applications are made. In the authors opinion the sharp curette should be abandoned altogether, as its indi- cations are better met in every case by the galvanic current alone. Hemorrhagic Metritis.—-This condition is either due to the reten- tion of shreds in neglected subinvolution or to a vegetative hyper- trophy of the mucous membrane of the body (adenomatous endome- tritis), or finally to hemophilia. Its treatment, except when due to 100 DISEASES OF AVOMEN. the last-named condition, yields the most accurate and successful re- sults in the Avhole range of electro-therapeutics. The Avriter has never had a case fail to respond promptly to the proper use of the positive pole of the galvanic current, after the method popularized by Apostoli, in Avhich sectional electrodes are used for the purpose of cauterizing the entire mucous membrane of the cavity, step by step. Since the adoption of a mercury-coated zinc electrode, however, he is convinced that time may be gained by its use in place of the carbon instrument. The first applications Avith any kind of electrode are, nevertheless, likely to induce bleeding, which lessens in amount Avith each subse- quent application. The instrument should ahvays be bare, and the current-strength may vary from 50 to 100 milliamperes according to the obstinacy of the case. Hyperplasia of the Uterus, with or without Cervical Laceration. —It is by no means rare for the clinician to encounter cases, Avhich, presenting the nervous symptoms of chronic metritis related above, reveal, on examination, an enlarged uterus Avithout notable discharge from the cavity. The uterus, as a Avhole, may be enlarged, but the hypertrophy is generally limited to the corpus alone, Avhich is indu- rated, usually retroposed or retroflexed, and only moderately fixed if the appendages are healthy. Such cases are instances of the later stages of chronic metritis, and -will usually give a history of more or less discharge at an earlier period. The cervix, in many such cases, will shoAv a healed laceration, showing clearly the avenue by Avhich the infection originally entered. It is in this class of cases that Emmett's operation of trachelor- rhaphy has been most frequently performed, and some of my cases were instances in Avhich the operation had already been done, Avithout relief of the symptoms or material lessening of the abnormal bulk of the organ. It is, of course, conceivable that this operation may result in a lessened bulk of the uterus by its derivative and revulsive effects, though erroneously performed in a belief that the healed tear Avas a source of the symptoms; but this is rare excepting Avhen the cervix participates in the hypertrophy. The true lesion in these cases is unquestionably a degeneration of the muscular substance of the uterus and its replacement by embry- onic tissue of sluggish vitality. The ideal treatment is, therefore, one which will stimulate metabolic activities, promote absorption, and favor regeneration of the muscular fibrils. Nothing can equal the CATARRHAL AFFECTIONS OF UTERO-TUBAL TRACT. 101 negative pole of the galvanic current for these purposes, assisted by concurrent applications of the contracting faradic current (from either the primary or a coarse-Avire, secondary coil). The galvanic current is, by far, the most important portion of the electric treatment, and should be applied in appropriate dose either tAvice or thrice weekly. Illustrative Cases.—Mrs. M., aged 31, an excellent instance of the class mentioned in AA'hich the general nervous system had resisted the effects of pelvic disease, Avas admitted to the sanatorium from a neighboring city January 28, 1892. The uterine trouble from Avhich she suffered dated from her first confinement seven years before, and was aggravated by each of two subsequent confinements, the last hav- ing been eighteen months before. She complained of sacral aching and a dragging sensation in the pelvis Avhich Avas aggraArated by the erect posture and by Avalking, rendering her particularly miserable in the evening. Menstruation Avas regular, but scanty, and the alimen- tary functions Avere normal. There had been a history of considerable leucorrhea, but none Avas noAv complained of. Examination shoAved an enlarged, retroverted uterus Avith an eroded os and a cavity four inches in depth, exuding inspissated mucus. A spot in the rear of the uterus Avas extremely tender. She had been wearing a Smith-Hodge pessary, AAdiich Avas removed. Treatment Avas begun by vaginal alternatives of the galvanic current and the second- ary faradic, but it Avas quickly changed to covered negative intra- uterine applications of 30 milliamperes in vieAV of the absence of dis- ease of the appendages, alternating with the vaginal applications. In five days there Avas a decided relief of soreness; but it was necessary to continue treatment six Aveeks in the house, folloAved by several months' office treatment at intervals before complete symptomatic cure. At this time the uterus Avas normal in size and depth and but slightly retroposed. The completeness of the cure has been tested by five years' observation and one pregnancy Avithout relapse. Mrs. P., aged 33, Avas sent to me by Dr. Oaks, of Xorth Ridge- ville, Ohio. This case Avas a good example of the second class of cases mentioned, Avhere uterine disease reacted unfavorably on the nervous system in connection Avith other depressing agencies. She had been married but four years; but had been in bad health since four years before marriage, Avhich had been sterile. The beginning of the trouble was clearly in a virginal endometritis with menorrhalgia dating from puberty, and the gradually-increasing uterine involvement had been 102 DISEASES OF AVOMEN. assisted by a neuropathic heredity and the strain of nursing a sick mother. The pain continued very severe at the periods, with scanty Aoav, and there Avas vaginismus and dyspareunia. She complained of a neuralgic pain "all over the hody" that Avas most distressing at night. Examination showed the uterus enlarged, retroflexed, adherent, and very tender. The cavity was three and one-half inches deep and exuded considerable muco-pus. The patient was placed on a six weeks- course of intra-uterine negative galvanic applications of 20 to 30 milliamperes and the rest cure with general galvanic stimulation, and very shortly shoAved an improvement in both local and general symp- toms, followed by an ultimate restoration of health. Mrs. C, aged 26, applied for treatment at the Howard Hospital, complaining of weak back and pain in the pelvis. She had never been pregnant, and the leucorrhea, Avhich had lasted for four years, was clearly traceable to one or more attacks of gonorrhea. The uterus Avas but slightly above the normal size, yet tender and exuding abundant muco-pus. She Avas placed on positive intra-uterine applications of 20 milliamperes once a Aveek and negative vaginal applications twice a Aveek, December 12, 1890. Pain was shortly relieved, and by the folloAving month the leucorrhea had been controlled. For the table of the ultimate results in thirty-two cases see Ap- pendix B. Senile or Atrophic Metritis.—The importance of this form of metritis has been particularly shoAvn by Skene.1 It may be resultant either from a purulent endometritis of earlier years that has been neglected or it may be developed after the menopause. By reason of the lowered vitality of the senile sexual organs this affection is unusually intractable to ordinary methods of treatment, the ulcera- tion of the mucous membrane resulting in its ultimate destruction and of the tissues beneath it also at times. The resemblance to car- cinoma is very great in the later stages of erosion, from Avhich it can be clinically distinguished by the leucorrhea being muco-purulent or merely purulent instead of serous, as in cancer. Goelet has recommended the negative pole of the galvanic cur- rent, but my OAvn experience indicates that zinc-mercury cataphoresis is far superior owing to its non-cauterant action and the specially help- ful effects derivable from the nascent chemicals released. A less cur- 1 "Medical Gynecology," page 489. CATARRHAL AFFECTIONS OF UTERO-TUBAL TRACT. 103 rent-strength is, moreover, sufficient in the latter case, being propor- tional, hoAvever, to the extent and stage of the disease. Twenty to 50 milliamperes applied to the Avhole of the affected surface twice or thrice Aveekly quickly removes all odor and Avill result in a complete cure in several months. Metrosalpingitis.—-Though it is rare for the physician to encoun- ter an endometritis or metritis in an acutely active stage (unless due to gonorrhea or bad surgery), it is not unusual to be called in a case of acute or subacute salpingitis, either original or recurrent, and in such a case the judicious use of vaginal applications of the bipolar faradic current at the bedside Avill not only replace opium and other sedatives largely, but materially reduce the extent and duration of the inflam- mation. Care should be observed not to cause pain either by the in- sertion of the electrode or by the current, which should invariably be from a long, fine, secondary Avire and controlled carefully. The bipolar electrode should, of course, be warmed before insertion, as pointed out by Goelet, the patient lying at ease in bed and Avell covered, and the application should be prolonged for fifteen or twenty minutes. If distinct relief is experienced (and generally there is a pronounced relief of pain) the application may be repeated twice a day. Among the conditions closely allied to chronic catarrhal metro- salpingitis and salpingo-oophoritis are interstitial or parenchymatous salpingitis, purulent salpingitis, pyosalpinx, hydrosalpinx, hemato- salpinx, and simple ovaritis, Avith or Avithout prolapse of the organs. Each of these conditions is, of course, readily diagnosed during or after an abdominal section, but, as the desire of the conservative gynecolo- gist is the cure of the patient Avithout a cutting operation, he is re- stricted almost entirely to the very probable diagnoses made by an educated bimanual touch in connection Avith the subjective and other available objective symptoms; and Avhen Ave reflect upon the high training that may be attained by the skilled finger in detecting the grosser differences betAveen these several conditions, and the fact also that they are all merely different stages and differently situated evi- dences of the same disease,—inflammation,—it would seem that such diagnoses Avere amply sufficient for this class of Avork. If, for instance, the doubt lay between a simple salpingitis or an ovaritis, and the case could be cured by vaginal applications of electricity Avithout resolving the doubt, the patient would surely prefer us to leave the matter un- certain rather than have a dangerous exploratory laparotomy for the 104 DISEASES OF AVOMEN. satisfaction of curiosity, even though the curiosity be thoroughly scientific. In their pronounced stages these several conditions are quite amenable to reasonably correct diagnosis by touch, pointing to certain variations in the electric treatment. In subacute or chronic metrosalpingitis, evidenced by pain be- tAveen the periods, tenderness in one or both vaginal fornices, and by a more or less clearly defined enlargement of the tube or by mere bogginess in its region, the treatment must at first be altogether vaginal, both galvanic and faradic, though a moderate galvanic cur- rent may be quickly attained. The results in lessened pain and shrink- age of the hypertrophied tissue are soon attested, for the parts are membranous and easily reached by a sufficient density of current, even though indirectly applied. That drainage through the uterus may be promoted, particularly by the negative pole in the vagina, is unques- tionable. This treatment alone can be relied on to secure a practical cure in a considerable proportion of the cases, but the majority will demon- strate that vaginal applications of electricity alone will be insufficient, for the probable reason that much of the original mischief remains in the uterus. When, therefore, a considerable amelioration of the symp- toms has been gained by the vaginal treatment, but the progress thus far made does not continue, the uterus being reasonably movable, though Avith pain, and manifestly enlarged, we should resort to tenta- tive intra-uterine applications without further delay. The intra-uterine treatment should, nevertheless, be carefully watched, since acute salpingitis or ovaritis or an encysted purulent inflammation of either organ will be made worse by this form of treat- ment. Increased pain or a recrudescence of inflammation in a pyo- genic cavity will often, indeed, attend the mere passage of a sound; but, as recently pointed out by Apostoli, an intolerance of intra-uterine galvanic applications points so unerringly to encysted pus as to become a means of establishing an exact diagnosis. I am myself convinced that Ave may trench closely upon this debatable ground with every advantage to the patient if precautions be observed to eliminate all harshness of manipulation from the method. If, for instance, a covered spiral electrode only be used, inserted by touch only Avithout the speculum and Avithout draAving upon the uterus or otherwise dis- turbing its relations to the surrounding tender parts, Ave may test the CATARRHAL AFFECTIONS OF UTERO-TUBAL TRACT. 105 intolerance of the case to electricity itself, which is quite another matter from its tolerance to a more or less brutal handling plus the electricity. The spiral electrode will adapt itself readily and pain- lessly to any-shaped cavity, and, Avhen employed as a positive pole, which is preferable, will not only inaugurate a Avholesale change in the activity of tissue-metamorphosis within the affected structures of the uterus, but ultimately promote drainage from the uterine end of the tube, hess pain is produced also if the electrode be only partly inserted during the first applications. TAventy milliamperes is ample for a beginning in these tentative applications, repeated every fourth or fifth day, though the daily vagino-abdominal treatment should be continued as usual. The fol- loAving cases may be cited as examples in Avhich the uterine seat of the affection Avas still mainly predominant:— Illustrative Cases.—Mrs. W. F. D., aged 27, entered the sanato- rium from a toAvn in the interior of Pennsylvania Avith a history of continuous suffering since the birth of an only child, eight years before. Instruments had been used at her confinement and she Avas in bed three months aftenvard. There Avas a continuous sensation of Aveight in the pelvis, a band sensation about the Avaist, and constant pain in the bladder and ovarian region. Examination showed the uterus posterior-placed, enlarged, and braAvny, Avith a tender mass in the region of the left tube and ovary. She had painful periods and a constant, copious leucorrhea. For two Aveeks the patient Avas placed on A'agino-abdominal galvanic and faradic treatment and general electric stimulation, Avith but moderate results. I then determined to test the effect of intra-uterine galvanic treatment, 30 milliamperes, positive, being used Avith the elastic electrode. Considerable pain resulted from the first application, but before the next day the band sensation had disappeared, and never returned. The intra-uterine treatment Avas continued tAvice a Aveek for six Aveeks, Avhen she re- turned home practically well. Four years later the permanence of the cure Avas attested by^every evidence of blooming health. Miss P., aged 24j|Avas suffering from a catarrhal and congestive condition of the uterus and left tube and ovary, traceable to a fall from a hammock sixteen months previously, Avhich had been ineffect- ually treated by the ordinary methods. The most striking symptoms on admission Avere Aveakness in the back, inability to walk far, a sensa- tion described as a burning or itching in the ovarian regions, and a 106 DISEASES OF AVOMEN. considerable leucorrhea. Examination showed the uterus enlarged and giving exit to a muco-purulent discharge and the left tube very tender. She Avas placed on positive intra-uterine galvanic applications of 20 to 25 milliamperes to the cavity twice a Aveek, and both currents, vagino-abdominal, at frequent intervals for six Aveeks, folloAved by occasional intra-uterine applications for three months longer, result- ing in relief of all symptoms and a restoration to health which, at this writing, five years later, remains perfect. Mrs. W., aged 35, applied at the HoAvard Hospital October 22, 1895, complaining of pain in the back and loAver portion of the abdo- men and a peculiar sensation in the top of the head, Avhich dated from two miscarriages and a probable specific infection twelve years before. She had been sterile since the gonorrheal attack. Menstruation had been scanty of late. The condition of the cervix and its discharges are shoAvn in Plate XVIII, having been draAvn at the time by the artist. The bimanual examination revealed posterior fixation and moderate enlargement of the uterus Avith indefinable bogginess in the left tubal region. Just before seeing me a colleague in the hospital had given the opinion that a removal of the tubes and ovaries was essential to saving her life. She Avas placed on negative vagino- abdominal applications of 50 milliamperes for three months, during Avhich time there appeared great improvement in the symptoms. The treatment Avas now changed to cupro-mercuric applications within the uterus of 20 and 30 milliamperes once a week for three months. The symptomatic cure Avas perfect at the end of six months, the patient declaring herself Avell. Purulent Salpingitis.—A neglected catarrhal metrosalpingitis, particularly of gonorrheal origin, readily becomes muco-purulent, re- sulting in a more protracted electric treatment before a cure can be attained by the methods already described. If of long standing, and drainage through the uterine mouth of the tube has been unobstructed. Ave can readily detect the interstitial enlargement and exaggerated convolutions that have been looked upon as an after-excuse for many unnecessary amputations. Such a condition is as surely curable under positive vaginal applications, assisted by the faradic current and by subsequent intra-uterine treatment, as any similar catarrhal affection elsewhere in the body, the intra-uterine treatment being, of course, carefully employed Avith a view of increasing the drainage. If, on the contrary, a true pyosalpinx be suspected to exist on account of the CATARRHAL AFFECTIONS OF UTERO-TUBAL TRACT. 10? discovery of a cyst in this situation, the case is different. Such an accumulation of the muco-purulent discharge of the tube is usually due to an obstruction at the uterine orifice, and is not an ordinary abscess. In the presence of such a case Ave are at once confronted by the question of the advisability of attempting the cure of the chronic inflammation by electricity, or of referring the patient to a surgeon for an amputation of the all'ected part, noAV having become a Pyosalpinx.—The determination of the proper course to pursue with this affection is not easy, particularly Avhen Ave dismiss all mere prejudice in favor of one or the other method from the mind and are guided solely by an enlightened care for the ultimate good of the patient. The considerable number of instances in which apparently closed pus-tubes have been rendered patulous and capable of perform- ing their functions by a combination of vaginal and intra-uterine treat- ment, coupled with a statement recently made by Dr. J. M. Baldy, an uncompromising adA'ocate of the knife, that many tubes removed for pus accumulation are found to contain none at the time of opera- tion, should all tend to check a too hasty amputation of a yet curable organ. Should the tube, on the other hand, be firmly fixed by Avell- organized adhesions, and be the seat of an active accumulation of true pus rather than muco-pus, the chances for a cure by the ordinary electric treatment are very remote. As a rule, my OAA*n practice is to regard pus-tubes of distinctly gonorrheal origin as inadmissible of cure in this Avay, and yet the following cases Avould seem to set aside this conclusion to some extent:— Illustrative Cases.—Mrs. X., the mother of three children, the youngest of Avhich Avas three years old, came to me after she had been advised to submit to an operation for the removal of the appendages. Her ill health dated from the birth of the youngest child, but had been much Avorse for a year past. She had constant pain in the back and pelvis and Avas so lame in the left leg that walking was difficult and accompanied by an ungainly limp. The uterus Avas found to be large and exuding considerable foul-smelling muco-pus, and there Avas a partly-fluctuating lump on either side of the fundus, particularly the left, Avhich could be made out as enlarged and sacculated tubes. After admission to the sanatorium her physician Avas sent to me by the hus- band to state that her condition was mainly due to a gonorrhea which she had contracted about a year before. She Avas placed on the A'aginal and intra-uterine treatment described aboA*e. the intra-uterine 108 DISEASES OF AVOMEN. applications being given Avith an elastic, cotton-covered electrode, folloAved by rest in bed for tAventy-four hours. At first the cotton was saturated with a foul and bloody discharge after each treatment, but at the end of six Aveeks there Avas great improvement in every symp- tom, and she ultimately regained the poAver to Avalk indefinitely Avith- out limping and the local evidences of abnormality were greatly lessened. Mrs. S. J., aged 32, the mother of four children, the youngest of which Avas 4 years old, applied at the Howard Hospital for treatment August 12, 1889. She had not been well since the birth of the last baby, having had a vulvar abscess when it was three Aveeks old, and suffering from pain in the back and on micturition, and Avith a bear- ing-doAvn sensation since. Menstruation Avas regular, preceded and folloAved by an irregular leucorrhea. Examination showed the uterus to be of normal size, pushed fonvard, and partly fixed by a mass in the left tubal region, which Avas quite tender. She received eight negative vagino-abdominal applications of the galvanic current during the fol- lowing month, at the end of Avhich time the pain and lump had dis- appeared and the leucorrhea Avas greatly lessened. January 2, 1890, she reported herself three months' pregnant. Mrs. K. D., aged 28, applied at the HoAvard Hospital August 27, 1889, complaining of having been unwell since shortly after the birth * of her only child, five years before. There Avere sharp, lancinating pains in the regions of both ovaries, Avith a sensation of falling of the Avomb. Menstruation appeared only every other month, and there Avas no leucorrhea at this time. Examination shoAved fixation of the uterus and fullness in both broad ligaments. Tavo vagino-abdominal negative galvanic applications were made, Avhen she reported that there Avas considerable intermittent leucorrhea. An electrode was noAv passed Avithin the uterine cavity, finding it three inches deep, and 35 milliamperes, negative, applied. After this had been repeated once a menstruation occurred in the off-month, preceded by an offen- sive chocolate-colored discharge and f olloAved by symptomatic improve- ment. Tavo subsequent intra-uterine applications Avere made, and the patient reported a profuse, yelloAv discharge Avhich came on in a gush after the second application. No further treatment Avas given, as she reported herself as well; the bogginess in the tubal region had dis- appeared and the uterus was normal in size. December 12, 1889, she CATARRHAL AFFECTIONS OF UTERO-TUBAL TRACT. 109 reported at the clinic as still Avell and in the second month of preg- nancy. It should be repeated, however, that Apostoli, Gautier, Goelet, and other Avorkers are particular to Avarn against high currents or vio- lent procedures in inserting the electrode in these conditions as likely to precipitate an intolerance to electricity, particularly if the uterine end of the tube is incapable of being opened by a resolution of the inflammation, or if the inflammation is too acute. In cases incapable of resolution and drainage through the natural channels Goelet strongly urges vaginal electro-puncture and drainage through the opening thus made, provided the pus-tube is Ioav doAvn, adherent, and easily reached through the vagina for aspiration. The recent tendency among abdominal surgeons to avoid the abdominal route of major operation in favor of the vaginal for such cases seems extremely reasonable and in a line Avith this mode of employing elec- tricity as an adjunct to opening and drainage. He describes the method as folloAvs1:— Fig. 29rt.—Goelet's platinum cannula-electrode. "The cut (Fig. 29a) shoAvs the platinum cannula electrode (No. 4, French catheter scale) for the galvano-tapping of pyosalpinx through the vagina. The shaft is covered Avith an adjustable sheath (A) of hard rubber for insulation. This may be fixed at any point by the sereAV (B), and the degree of penetration limited. At C there is a three-way stop-cock, and at D a connection for an irrigator, as Avell as a socket for connecting Avith the battery. When the trocar (F) is Avith- draAvn, an aspirator may be attached to the rubber tubing (E), and, after the pus has been draAvn off by a quarter-turn of the stop-cock (C), the cavity may be flushed Avith an antiseptic solution passing in at D through the cannula. By turning the stop-cock straight again the fluid is alloAved to escape through the tubing (E) into the aspirator- bottle. ('are must be observed not to overdistend the Fallopian tube, 1 "International System of Electro-Therapeutics," page G-116. Philadel- phia: The F. A. Davis Co. 110 DISEASES OF AVOMEN. the Avails of Avhich have been much Aveakened in some cases. That I may not be misunderstood, I Avill say that I limit the degree of pene- tration usually to one centimetre, and deem the procedure appropriate only when the tube is close to the vaginal Avail, full, and tense, de- manding immediate interference. "The aspirating cannula is small, penetrates easily, and the in- sulating sheath can be adjusted, by means of a set-screw, so as to limit the extent of penetration to any degree desired. The method of appli- cation is as follows: Having fixed the degree of penetration, the point of the trocar is draAvn Avithin the cannula to avoid Avounding the vagina or the finger along Avhich the instrument is inserted as a guide. The vagina and vulva are rendered thoroughly aseptic by a douche of creolin or lysol solution, the index finger is inserted into the vagina against the most dependent or prominent portion of the sac, which is held firmly in position by pressure from aboAre on the abdo- men (this will not be necessary if the sac is already firmly fixed by adhesions), and the instrument is introduced along the finger and plunged into the sac; removing the trocar, the pus is AvithdraAvn and the cavity irrigated Avith an antiseptic solution.' The cannula is arranged with a two-way stop-cock, which alloAvs this to be accom- plished readily, but care is necessary, Avhen the tube-is not adherent, to prevent leakage into the peritoneal cavity. The solution should Aoav from a reservoir of moderate elevation, and much distension of the sac must be avoided. The stop-cock turned in one direction alloAvs an infloAv, and a quarter-turn in another direction an outfloAV, so that thorough irrigation is possible. The penetration of the cannula is limited by the insulating sheath and a set-screAv. It is arranged to alloAV a penetration of one centimetre, but half a centimetre is usually sufficient. "Before Avithdrawing the cannula it is connected Avith the posi- tive pole of the battery and a current-strength of 50 milliamperes is used for five minutes. This pole is preferred because of its well- knoAvn antiseptic properties, which are due to the liberation of oxygen and chlorine. Its peculiar reaction destroys the character of the pyo- genic membrane and promotes resolution in the sac-Avails and sur- rounding structures. The cauterization of the track of the cannula shuts it off from the tissues Avhich are penetrated, Avhereby extrava- sation and absorption of septic material are prevented. When the tube is not adherent the peritoneal cavity is penetrated, but the sub- CATARRHAL AFFECTIONS OF UTERO-TUBAL TRACT. Ill sequent cauterization induces an immediate adhesion of the perito- neal surfaces around the puncture, which effectually closes it from outside influences of an injurious nature. Sufficient drainage will ordinarily be afforded through the puncture-track, but, when neces- sary, it may be facilitated subsequently by passing a small probe or sound-electrode connected with the negative pole to enlarge the track (10 to 15 milliamperes will be sufficient). This operation should be performed only at the patient's house, and she should be put to bed immediately after. A loose dressing of iodoform or aristol gauze is placed in the vagina, and renewed every clay or two, when a hot douche of a 1-per-cent. solution of creolin is given. "The subsequent management of the case and the treatment nec- essary will be suggested by the condition remaining after evacuation of the abscess. Galvanization with the positive pole in the vagina will promote resolution of the surrounding structures, and the negative pole may be employed to hasten the absorption of deposits or soften and relax adhesions which interfere Avith the necessary mobility of the pelvic organs. Treatment of the co-existing endometritis must not be neglected. It is seldom possible to restore an absolutely normal condition; nor is it attained by the alternative,—laparotomy,—but a condition quite conducive to health, comfort, and usefulness may be brought about. Can as much be said of the radical operation, which deprives the patient of organs essential alike for her usefulness and happiness :"' Hematosalpinx.—This condition is not easily distinguished from pyosalpinx except by its recent appearance. In a thoroughly con- ducted transillumination of the pelvis a dark cloud will be found in the situation of the tubes in both affections. Hematosalpinx is noAV thought to be an arrested tubal pregnancy in some cases. Being but an effusion of blood or of blood and mucus, the proper treatment is a promotion of its absorption by negative vaginal galvanic applica- tions, the intravaginal electrode being pressed against the tumor as in the treatment of ectopic gestation. Several Aveeks' daily treatment with current-strengths of 50 milliamperes will usually be found suffi- cient to cause material shrinkage. In case this fails the method just detailed for pyosalpinx may be employed under antiseptic precautions, though I refrain from advising it. An abdominal section for an accumulation of material so easily absorbed as this is totally unjusti- fiable. 112 DISEASES OF AVOMEN. Hydrosalpinx.—This condition may be approximately distin- guished from pyo- and hemato- salpinx by the absence of tenderness and adhesions and by its long-standing character. Under transillumi- nation no cloudiness is observable in the situation of the tumor. Aspi- ration, followed by a galvanic application to the cavity, will usually insure a thorough cure. Pelvic Peritonitis.—This condition is usually consecutive to catarrhal disease of the uterus and tubes. The therapeutic manage- ment of an acute attack by the ordinary antiphlogistic measures, such as ice, iodine, etc., to the abdominal aspect of the swelling may be Fig. 30.—Line of rigidity in pelvic peritonitis. (Thomas and Munde.) greatly assisted by the use of Apostoli's suggestion of bipolar, fine- Avire, faradic applications within the vagina, as in the acute cases of salpingitis and ovaritis. No pain whatever should be produced either in inserting the Avarmed electrode or by the current, the latter being turned on very gradually and used for fifteen minutes daily, if relief\ of pain is gained. The cessation of pain by this means can only indi- cate more or less arrest of the congestive process attending the advance of the inflammation. In the treatment of the later stages of the acute process the bipolar faradic current is also most useful, to Avhich should be added positive galvanic vagino-abdominal applications in the more chronic CATARRHAL AFFECTIONS OF UTERO-TUBAL TRACT. 113 cases. The rapidity Avith Avhich the exudation forming the board-like vault of the \ragina, encountered by the finger in a plane represented by the dotted line in Fig. 30, may be made to disappear under this treatment is often astonishing, even Avhen the agglutination of the pelvic organs is of long standing. The following case is an excellent example:— Illustrative Case.—A married lady, 37 years old, was referred to me by Dr. J. A. Draper, of Wilmington, Del. She had had a miscar- riage seven years before and various attacks of probably specific vaginitis since, culminating in metrosalpingitis and pelvic peritonitis. Under the pain of the latter condition she Avas fast developing an opium habit. Examination revealed an enlarged uterus set in a hard- ened pelvic vault just as if plaster of Paris had been poured over it, as described by Thomas and Munde. She was admitted to the sana- torium on March 25, 1891, and placed on negative vagino-abdominal applications of 75 milliamperes, occasionally changing to galvanic alternatives in the same situation, together with the general rest-cure treatment. By May 5th she Avas symptomatically well, and my notes speak of great loosening of the uterus, though slight tenderness per- sisted to the left of the uterus. Several office applications were made during the following month, and on October 2d it is noted that the uterus is quite small and movable, and that no symptoms remain. This lady was seen five years later in the best of health, Avhich she attributed to the treatment received. CHAPTER IX. Chronic Inflammatory Affections of the Ovaries. Chronic Ovaritis.—The unexampled opportunities of studying inflammatory affections of the ovaries after their operative remoAral, recently enjoyed by the younger school of gynecic surgeons, might have yielded greater good to pathologic science than to some of the patients operated upon had the bucketfuls of specimens brought to the societies been thoroughly studied. As it is, the most important lesson taught by this misdirected energy, aside from its evidence of the cyclonic character of variations in professional opinion, is that ovarian and tubal affections are not easily differentiated from each other prior to operation, and that it is equally difficult to distinguish a curable from an incurable disease of these organs by a simple ex- amination. The great majority of ovaries and tubes thus hastily con- demned to extirpation are found after removal to be the seat of simple inflammation, and their unfortunate destruction is a heavy tax to pay for a relatfvely small number of cases incurably diseased thus dis- covered. A means of practically averting this causeless unsexing of Avomen has been recently indicated by Apostoli, the careful application of Avhich should do much to confine castrational operations Avithin their legitimate limits of the removal of useless organs. This consists in diagnostic test-treatments, Avhich, by aggravating the symptoms, make out a clear diagnosis of a condition demanding operation, or by amel- iorating the symptoms, indicate infallibly the presence of a curable lesion. This diagnostic test comprises two procedures: a bipolar faradic application and an intra-uterine galvanic application. If the former relieves the pain at once, or after several sittings, the probability is that the condition is neuralgic or congestive and scarcely inflamma- tory even. If an intra-uterine application of 35 to 50 milliamperes, (114) AFFECTIONS of THE OA'ARIES. 115 made with a covered,1 elastic electrode, aggravates the pain greatly and persistently, the possibilities are strongly in favor of a grave inflam- mation of the adnexa that indicates operative procedures. There is, of course, some discomfort under the second test even in curable cases, and this is more pronounced if the electrode be rigid and inserted with harshness, but the modification of Apostoli's method which I employ, consisting in the use of an elastic electrode, constitutes a most delicate test, as the pain reaction of such an application is at a mini- mum in cases amenable to electricity. In my OAvn practice such a test is rarely applied in this Avay, since I am convinced that many inflammations of the tubes and ovaries are capable of relief by electricity applied by the vagino-abdominal method that Avould be aggravated by intra-uterine applications. It is only, therefore, Avhen a vagino-abdominal or bipolar faradic applica- tion fails to give relief, and a simple vagino-abdominal positive gal- vanic application aggravates the pain, that a conclusion is arrived at that the condition is one that is impossible to cure in this Avay; for an intolerance of such treatment surely indicates too advanced a process, Avith suppurative consequences, tuberculosis of these organs, or other incurable local faults. As already remarked, the differential diagnosis between chronic catarrhal salpingitis and simple chronic ovaritis is difficult of estab- lishment with, absolute certainty, either from the subjective symptoms or by the bimanual examination, but the electric treatment of the minor stages of either condition is practically the same. The treat- ment, in other words, is directed to the inflammation itself, the cur- rent promoting absorption of the interstitial effusion as Avell as of edematous and serous collections Avhether situated in the tubes or ovaries. Such a method is necessarily interpolar and but sloAvly effect- ive in some cases, but the importance of the results that can generally be secured is very great and well worth the time and labor expended. The applications should be made daily or thrice weekly Avith both currents, the positive pole of a 30- to 60- milliampere current being employed for five minutes, followed by a medium or fine-wire, faradic current of the same duration, Avithout removing the electrode. The 1 The use of a covered elastic electrode makes this test more delicate than contemplated by Apostoli, eliminating the mechanical harshness of a stiff sound. 116 DISEASES OF AVOMEN. latter should be a carbon or zinc vaginal instrument covered with absorbent cotton, wet and soaped, and gently pressed against the ovary through the vagina. After turning the faradic current off the elec- trode may be gently shifted to the other side, if both ovaries be affected, and this current again turned on, though it is Avisest to re- serve the galvanic current in this situation till the next seance, alter- nating the sides for its application. Each application should be fol- lowed by repose in bed when this is practicable. Under this treatment the pain and tenderness lessen and adherent ovaries become looser through absorption of the bands of exudate, the symptomatic improvement proceeding Avith equal pace Avith the trophic and vascular restoration. From six Aveeks to six months Avill usually be required to attain such results. A more serious condition is present if the ovaries become pro- lapsed by reason of increased Aveight and the dragging effect of adhe- sions from attacks of circumscribed peritonitis. In this state the Avisdom of sacrificing the organs by removal becomes a question of importance, as their dislocated position renders them more subject to relapses and aggravations of the inflammation. It should be remem- bered, hoAvever, that the suffering is entirely due to the ovaritis and other inflammatory conditions preceding and accompanying it, often to a still existing endometritis or metritis, and that if Ave can restore the parts to a healthy condition in this respect a symptomatic cure may be attained, even though it be impossible to restore the organs to their proper position. The fact that the dislocated position of the organs renders pregnancy unlikely because of the lack of co-aptation of the fimbriated end of the tube to the ovary is no real argument in favor of the remoA*al, as one can never be sure that the tube is not equally displaced and thus capable of performing its functions if rendered free to move. An incurable tenderness or painfulness is the only practical or reasonable indication for castration. That a perma- nent symptomatic cure of ovaritis complicated by prolapse of the organ may be attained is attested by the folloAving cases, Avhich have been under observation for some time since the cessation of treat- ment:— Illustrative Cases.—A young lady, aged 21, Avas sent to me by Dr. John Chambers, of Kingston, X. Y., May 20, 1892, with the fol- lowing history: Her mother died of phthisis and her father and a brother of Bright's disease. She herself had ahvays been delicate, AFFECTIONS OF THE OAMRIES. 117 particularly since puberty, which appeared late and irregularly, quickly developing intense menorrhalgia. At 18 she Avas sent to Dr. T. Gaillard Thomas, Avho inserted a pessary, which relieved her for a time, but subsequently gave rise to much suffering. Returning to Dr. Thomas in 1891, she Avas placed under treatment at the Woman's Hos- pital, where oophorectomy Avas advised after a period of treatment. Her general condition on admission to the sanatorium was poor, eA'idencing malassimilation and some nervous prostration. The prin- cipal symptoms of discomfort Avere, hoAvever, directly traceable to the pelvic condition. The sitting posture, and particularly the use of a rocking-chair aggravated the discomfort and pain in the pelvis, Avhich was constant betAveen periods and extreme during the Aoav. heucor- rbea had been quite bad since the pessary Avas inserted. The menstrual periods Avere profuse, Avith Avorst pain on first and third days. Exami- nation shoAved tender and prolapsed ovaries, the left being enlarged and loAvest, Avith enlarged and prolapsed uterus, the latter being near the pelvic outlet and exuding a copious leucorrhea. The uterine cavity measured three and one-fourth inches. Much pain was devel- oped by the examination. She Avas placed on positive vagino-abdominal applications of 50 milliamperes, folloAved by the secondary faradic current in the same situation and general galvanic stimulation; the applications to be made daily, folloAved by rest. Great amelioration of the tenderness of the left ovary folloAved. At the end of the second Aveek a mild intra- uterine positive application with a covered elastic electrode Avas made, and repeated once in seven days during the remainder of the treat- ment, Avhich Avas continued for two months. On discharge her condi- tion Avas so satisfactory that a symptomatic cure was noted. In a letter dated February 3, 1896, more than three years after the end of the treatment, this lady reports herself in the best of health, Avhich she attributes entirely to the'methods employed. I have un- fortunately no notes of the size of the uterus or position of the ovaries subsequent to the treatment, but regard this defect in the record as of less importance than accurate statements of the ultimate result in the restoration of conscious health. A more difficult case was that of a married lady of 27, referred to me by Dr. Potter, of GermantoAvn, October 25, 1893. This lady was the picture of robust health in spite of an hypertrophied uterus and deeply prolapsed OA-aries, the latter being enlarged, tender, and 118 DISEASES OF AVOMEN. giving her much discomfort when Avalking or riding. The trouble dated back to a prolonged labor followed by laceration of the cervix, for Avhich a repair operation had been done by a distinguished sur- geon. There Avas a copious muco-purulent leucorrhea. In spite of the excellent union of the cervix obtained in the plastic operation the uterine body remained hyperplastic, the seat of an unpleasant dis- charge, and had a cavity measuring more than three inches in depth. The menstruation Avas irregular, appearing in periods of thirty-one and forty-one days. Vagino-abdominal treatment seemed to be of little service in this case, probably because the ovaries Avere not the principal seat of the trouble, though out of place, and it Avas necessary to attack the uterine trouble by intra-uterine galvanic applications. OAving to the great increase of tenderness evoked by these applications, Avhich Avere nega- tive and applied by the covered elastic electrode, not more than 35 milliamperes Avere used, and generally less, twice a Aveek, folloAved by the contracting, primary faradic current to the point of tolerance, then by a bipolar secondary. As a result, the leucorrheal discharge Avas cured, but when the patient ceased attendance the symptomatic cure and reduction of bulk Avere still imperfect. It is possible that, had this patient realized the importance of long-continued and regular treat- ment, as good results Avould have been attained as in the folloAving case:— Mrs. J. F., aged 31, applied for treatment at the HoAvard Hospital clinic May 7, 1896, with the folloAving history: Her only child Avas 11 years old. Eight years ago she had miscarried and had been an invalid ever since, having had vaginitis of probably gonorrheal origin about the time of the miscarriage. She had received the usual treat- ment, including pessaries, Avhich gave so much discomfort as to compel their discontinuance, and the advice that her ovaries should be re- moved was given at several hospitals. There was but slight leucorrhea at this time. Examination shoAved an enlarged and flabby uterus, someAvhat retroposecl, with tender tubal regions and distinctly prolapsed and enlarged ovaries. She Avas placed on vaginal positive galvanic applications of about 50 milliamperes three times a week. This was continued with great regularity for three months, during which time distinct improvement Avas noted in both the subjective and objective symptoms. On August AFFECTIONS OF THE OVARIES. 119 11th the tenderness had so far abated that it Avas considered Avise to begin intra-uterine applications of 40 milliamperes, posithe, folloAved by the fine-wire secondary. This Avas Avell borne, and was continued at Aveekly intervals for three months. In the latter part of January, l cases so treated. In the introduction to this Avork these justly eminent surgeons say: "For lon°- we had doubts as to the permanency of the treatment in the early cases. The later work has been much more satisfactory. But now more than two years have passed since all operations Avere given up for this treatment; and our first patient writes—and no one could have had more hemorrhage—that she has been perfectly well all summer, climbing hills and roAving in a boat. Another of the early and doubtful ones, Avho could never bear a large dose of electricity, tells us: T am noAv in excellent health, Avithout an ache or pain of any kind, and my periods are just a show, and nothing more, and give me no discomfort whatever. 1 hope you have been as successful with all your other patients as you have been with me. But it cannot be otherwise, for I am sure that no one could have been Avorse than I was with that awful hemorrhage.' This patient's importunity had almost driven me into doing hysterectomy for her. "At first Ave fell into the natural mistake of trying electricity on every case that presented any symptoms,—in some Avhen the tumors were almost certainly sarcomatous, and even in one who Avas in the last stages of old cardiac disease. We knoAV noAv that the cases best treated are those avIio are suffering much from hemorrhage,—the more, the better,—cases in Avhich something must be done; cases in which, two or three years ago, the question of operation of some kind Avould have been considered by us. "This treatment, it must be remembered, is a neAv thing. We began it in comparative ignorance. Electricity is knoAvn bv its results. and, Avorking on the living body, progress and improvement are slow. 1 "Electricity in the Treatment of Uterine Tumors, being Part II of Con- tributions to the Surgical Treatment of Tumors of the Abdomen," by Thomas and Skene Keith, pages 2f>.) rt seq. Edinburgh: Oliver & Boyd, 1889. 9 130 DISEASES OF AVOMEN. In the folloAving cases, therefore, are found some failures and some imperfect and incomplete cases; the marvel is rather that there are so feAV. Time and experience every day correct our Avant of knoAvledge and diminish these imperfections. No large uterine tumor has, with us, entirely disappeared under the electric treatment, but in four cases of small fibroids, three of which come into the present series, there is not noAv a trace to be found. "The carrying out of this treatment faithfully to the end is not an easy matter, and old tumors that are large, and that have bled for many years, take a long time to improve. The treatment runs away with time, and it requires care and thought. To the surgeon, by far the simpler plan is hysterectomy and the removal of the ovaries. But Dr. Apostoli's treatment saves our patient from risk of life by opera- tion, and saves them also from a horrid mutilation,—the one thing that they all dread. We believe it to be the right treatment, and our patients must get it, hoAvever great the inconvenience and monotony it may be to ourselves. Though our results after hysterectomy show the lowest mortality of any yet recorded, and though we have had but a single death after removal of the ovaries for fibroid in almost one hundred operations, Ave reject even the minor operation in favor of Dr. Apostoli's treatment, and'Ave reject hysterectomy altogether on account of the mortality that!has hitherto attended it all over the world. The method given us by Dr. Apostoli is good, and it will endure." In dedicating this Avork to Apostoli, the elder Dr. Keith, Avho has since passed to the great majority, leaving with us an ever-living memory of unsurpassed skill, exalted courage, and unflinching hon- esty, makes some additional statements Avhich might be taken as a final testament of a long and honored career concerning this matter:— "Since we began your treatment, noAv more than two years ago, Ave have ceased to perform any operation on the uterus by abdominal section. For myself, I have ahvays had grave doubts if I were justified in performing such operations at all, especially hysterectomy, for the mortality attending this operation is out of all proportion to the benefits received by the feAV. As time Avent on, and the number of operations became larger, my doubts as to Avhether I were doing right continued to increase, and that, too, in spite of the comparatively low mortality Avith AArhich I Avas favored, more especially in my private practice. I never had any such doubts as to the propriety of perform- FIBROID TUMORS. 131 ing ovariotomy, for, if ovarian cysts be left alone, death is almost certain, and even that is only reached after great suffering. With hysterectomy it is quite different. Hysterectomy is a hazardous oper- ation for the removal of a tumor that, of itself, rarely shortens life. The minor operation, on the other hand,—the removal of the ovaries, —requires no surgical skill for its performance. It is a great mutila- tion to a Avoman, being simply castration; and Avomen are beginning to find this out. It is not ahvays successful in attaining its purpose, for you Avill find in these pages some cases narrated that Avere cured by electricity Avhere operations on the ovaries had failed to give any relief. "Your method thus came to me at a very opportune time. You have taken aAvay from me those anxious doubts and fears that had so long vexed me. For long I had hoped much from electricity in the treatment of fibroids, but had only met Avith disappointment till your method Avas made knoAvn to me. It is in every way a neAV method, and it belongs to you and to no other. Y'ou have Avorked in the true scientific spirit. For five years you labored quietly at your clinic, kept up at your oavii expense, and open to all, before you made your work knoAvn. When it Avas made public, and ought to have had from all a warm Avelcome, or at least a patient hearing and honest investi- gation, considering the magnitude of your Avork, it Avas received Avith unbelief and ridicule. In common Avith many, I regret the unfair treatment you have received in this country. In spite, hoAvever, of the ignorance and prejudice displayed, your work is every day making its Avay, and it is impossible to resist the accumulating evidence there now is in its favor. That you will, in a feAV years, see your treatment adopted all over the world I have little doubt." The prophecy contained in the last sentence, quoted from Dr. Keith's work, has long since been fulfilled. Mode of Action of Electricity.—Much misconception has existed as to the mode in Avhich electricity is expected to act in these tumors, the original impression Avith many, uncorrected in the previous edi- tions of this Avork, being that the purpose of the applications Avas the physical, electro-chemic decomposition of the tumor-substance. This, of course, can be done Avith a sufficient current-volume, but it Avould be folloAved by the formation of a sloughing mass of dead tissue sur- rounding the electrodes that Avould be dangerous in tumors situated within the body, as these are. What does happen as a result of the use 132 DISEASES OF AVOMEN. of currents of far less volume and duration is a shrinkage of the tumor en masse, no greater shrinkage occurring in the parts nearest the spe- cial seat of application or puncture than in those situated most dis- tant. It appears, therefore, that the nature of the response is essen- tially trophic, the passage of currents of sufficient volume through the tumor causing an inhibition of the proliferating poAver of its abnormal cells, folloAved by a retrograde metamorphosis, quickened tissue-Avaste, and absorption through the lymphatics and veins, particularly the former, Avith Avhich these growths are abundantly supplied. Coin- cidently Avith this direct action upon the lowly organized embryonic tissue of the tumor, it is certain that an increased physiologic resist- ance of the healthy surrounding tissues (trophic stimulation) is pro- moted by the passage of the electric current, and, as the most plausible theory of the groAvth of these tumors involves a lessening of this re- sisting force as a primal cause, its stimulation must be essential to a cure. It will be seen that the essence of this discovery of Apostoli is that electricity may be used to arouse the natural forces of the body to remedy a faulty cellular groAvth by simply reversing the conditions that made the groAvth possible. The absorptive poAvers of the tissues are Avell known, even unstimulated by electricity,—bone, cartilage, and tumor tissues aseptically buried in the flesh being readily dis- integrated and removed; hence it is clearly seen that the most impor- tant element of the electric treatment is the reversal of the formative conditions of the neoplasm. The task of the physician is the selection of the cases in Avhich this can be done and the determination of the dosage and methods requisite for each case. The reduction in the size that folloAvs shortly after commencing a treatment adapted to the special case results, also, in a progressive relief of the pain, tenderness, and other pressure symptoms due to the groAvth. This early relief of pain and pressure symptoms must be partly due to the shrinkage alone, the nenres and organs that had been stretched and pressed upon being capable of adapting themselves to a still abnormal condition by reason of the partial relief afforded; but much of the symptomatic improvement must be due, also, to an elec- tric stimulation of the physiologic resistance opposing the groAvth, as evidenced by a lessening of any surrounding inflammation, restoration of pelvic and abdominal tone, and even increase in the thickness of the abdominal wall. FIBROID TUMORS. 133 In addition to the arrest and retrogression of the groAvth and the relief of pressure and inflammatory symptoms, an even more impor- tant and equally certain result is the cure of the hemorrhagic symp- toms that attend so many of these cases. This hemorrhagic tendency, which sometimes assumes alarming proportions, is due to one or both of tAvo characteristics: either a fungous endometritis (adenomatous degeneration of the endometrium) or to an hemorrhagic tendency of the tumor itself. That curettage is useful in correcting adenomatous degeneration is unquestionable, but it exerts no control over Avhat might be called the essential hemorrhagic tendency of a fibroid; hence is far inferior to electricity as an hemostatic in such cases. The sloAvly- produced effect of mercurial cataphoresis is, moreover, more certainly and permanently curathe of the fungous condition even than curet- tage, by reason of the more effectual eradication of the matrices of the growth. To effect this the electrode must be most thoroughly applied to all portions of the endometrium by the sectional method devised by Apostoli, in Avhich a bulbous anode as large as can be inserted is carried to the fundus, and, after a suitable application there, is Avith- drawn a distance equal to the length of the active surface and the current again turned on, the procedure being repeated until the instru- ment again reaches the internal os on the Avay out. The hemostatic effect Avill be heightened if the additionally alterative action of a zinc- mercury electrode is employed as active pole instead of platinum or carbon. In hemorrhagic tumors the action of electricity is, there- fore, dual, the local effect on the endometrium being hemostatic and the inhibition and shrinkage of the groAvth being antihemorrhagic. Selection of Suitable Cases.—All fibroid tumors in the early stages of their groAvth are suitable cases for this treatment, unless, indeed, Avhere electric treatment in the pelvis is contra-indicated by reason of a purulent collection Avithin this cavity. The presence of such a contra-indication is, hoAvever, infallibly announced by an aggravation of symptoms after the first feAV applications, and in the absence of this post-applicative reaction it may be confidently assumed that all tumors not yet emerged from the pelvis are amenable in a high degree to both symptomatic cure and anatomic arrest and lessen- ing. Of tumors so large as to have emerged from the pelvis and be- come abdominal in situation greater care in selection is requisite before promising the best results, for it should be remembered that neither Apostoli nor other authoritative writers have claimed that all 134 DISEASES OF AVOMEN. cases are equally amenable to electricity. After they have attained this size the intramural variety is most amenable to both amelioration and cure, though there are a certain number of smooth, monocentric fibromas of ball-like contour and firm texture that yield very slowly to anatomic change, even though they may be classed as interstitial or intramural because of a distinct situation within the uterine Avail. In most of these sloAvly-responding tumors of this character the uter- ine cavity is found stretched upon one side of the groAvth, the opposite wall being attenuated. When the cavity is more nearly central, and there are evidences of several foci of groAvth giving rise to a multi- nodular surface, the case is a most favorable one for marked diminu- tion as Avell as symptomatic cure. Distinctly submucous tumors are also suitable cases, the current arousing the contractile action of the encompassing muscular fibres as a re-enforcement of the special denutritive effect, and such tumors are thus brought further into the uterine cavity, becoming more pedunculated. Subperitoneal tumors, particularly Avhen pedunculated, are not easily reached by effective applications unless imprisoned in Doug- las's pouch, when they may be brought under the electric influence by vaginal puncture through the median line of the posterior wall of the vagina. When a subperitoneal tumor is very large and abdomi- nal in situation, and lying directly beneath the abdominal wall, ab- dominal puncture by the method described on page 138 may be used. Contra-indications.—Fibrocystic tumors, or unusually soft myo- mas, contra-indicate the intra-uterine and puncture methods, and the same is true of all fibroids complicated Avith acute 01 purulent lesions AA'ithin the pelvis or with abdominal ascites. Xon-purulent inflam- matory troubles in this region also contra-indicate both of these methods at first, but do not contra-indicate vaginal treatment, under Avhich they may so far improve as to make the more vigorous methods subsequently admissible. A successful case of destructive electrolysis of an intra-uterine fibrocyst is described on page 158, but the method employed Avas totally distinct from the Apostoli treatment, and the excellent result attained does not, therefore, controvert these conclu- sions. Unless Ave are in a position to dissolve and drain away the fibrocyst under full antiseptic precautions, as Avas possible in this case, the ordinary effect of electricity in promoting tissue-change is detrimental in the presence of the clogged lymph-spaces and deficient lymphatic circulation that is peculiar to this form of degeneration. FIBROID TUMORS. 135 Methods.—Bearing in mind, on the one hand, that the current should be concentrated as near as possible to the matrix of the tumor, and, on the other, that it is not always necessary to produce a lesion of the mucous membrane in an inaccessible locality, it folloAvs that the best methods in the majority of cases are: either intra-uterine applications with as large an active surface within the uterus as can be inserted, or vaginal puncture. It has not been my experience that vaginal puncture offers any quicker results than the intra-uterine treatment in interstitial or intramural tumors with accessible cavities, and I reserve it, therefore, for cases in which the intra-uterine treat- ment is impracticable or is clearly inefficient by reason of the growth being subperitoneal. Intra-uterine Applications.—The intra-uterine method is there- fore the method of choice in most cases, both for theoretic and em- pirical reasons, and is the method particularly associated with the name of Apostoli. Its employment for fibroids does not differ in technique from that described on page 59, to which the reader is referred, the special directions for the treatment of hemorrhagic cases being given on page 84. An important detail to be observed is to employ as large an instrument as can be inserted, in order that the local action shall be equally applied to the cavity. In many cases Ave are compelled to rely on the rigid sound-shaped electrode (Fig. 24), because nothing else can be inserted. This instrument, like all others used, should be properly curved, asepticized, and the insulation1 reneAved and carefully inspected before each insertion, the shellac or sealing-wax being carried doAvn to a point that will bring the bare surface entirely Avithin the internal os to avoid the formation of late atresias. Whenever it can be inserted I, hoAvever, prefer to employ the cotton-covered elastic platinum electrode (Fig. 25), or in hemor- rhagic or endometritic cases a suitable size of the zinc-amalgam elec- trode (Fig. 2C>), as positive pole, for recent experience has aroused a strong suspicion that the nascent oxychloride of mercury and zinc is of additional service in promoting arrest and absorption of the groAvth. When employed it should be freshly amalgamated previous to each application, to favor as great a dissemination of the mercury as possible. This necessitates the invariable employment of the posi- 1 Shellac or sealing-Avax fused on the shaft. 136 DISEASES OF AVOMEN. tive pole,1 even in non-hemorrhagic cases, it is true, but the denu- tritive effect is certainly greater than Avith the simple negative pole, besides the comfort to the physician of the knoAvledge that he is employing a most powerful antiseptic agency coincidently Avith the arresting treatment per se. Vaginal Puncture.—Keserved for subperitoneal tumors of pelvic situation, or interstitial growths Avith inaccessible cavities, this method ----- t..^ Fig. 38.—Apostoli's vaginal puncture trocar, for use with handle shown in Fig. 23. should only be employed through the posterior vault of the vagina OAving to the near situation of important structures in other portions of the pelvis. xVpostoli originally employed for this purpose a large trocar Avith a shoulder limiting its insertion to either a half or one centimetre, the vagina being protected by a movable sheath of hard rubber or glass; but since 1892, possibly owing to the author's advo- cacy of a completely-insulated puncture-track, or buried puncture, in Fig. 39.—Author's vaginal puncture trocar (enlarged sectional vieAv). the earlier editions of this Avork, he employs the trocar shoAvn in Fig. 38, with the sheath and handle shown in Fig. 23. The latest model of the author is shoAvn in Fig. 39, in Avhich the limiting shoulder of Apostoli is added, but the insulation is fused freshly for each applica- tion on the shank of the trocar itself, doing away with both the tube and the aAvkward edge of insulation, which hinders easy insertion, and 1 This instrument may, of course, be employed as a negative electrode if desired; but no diffusion by cataphoresis then occurs. FIBROID TUMORS. 13; securing absolute asepsis. As the author invariably employs the nega- tive pole, the instrument is preferably made of steel. The insulation is of hard rubber, a stick of Avhich is set on fire and applied to the heated instrument Avhile burning, the coating being then re-fusecl and made smooth in that Avay. When done carefully, the coating is continuous back of the bare surface at the point, the small shank in front of the shoulder being brought up to the diameter of the point by its thin coating, Avhich continues back over the shoulder on to the main shank without break. The instrument being thus freshly asepticized, as Avell as insu- lated, the vagina is douched Avith a bichloride or other antiseptic solution, and Avith the patient in the dorsal position, the hips resting on a firm table or operating-chair, the instrument is inserted Avith the point resting in the palmar surface of the index finger, thus shielding the Aragina. Beaching the projecting portion of the tumor at a spot previously determined on, the point is carried forward and pressed firmly into it through the vaginal wall, an assistant mean- Avhile steadying the tumor from above. When the full insertion is made and the abdominal pad placed the current is turned on until it registers betAveen 100 and 200 milliamperes, negative. The dura- tion of the application is the same as Avithin the uterus. The act of puncturing the vagina gives rise to considerable pain, but most Avomen are easily able to bear it, and the subsequent action of the current is no more painful than in the intra-uterine applica- tions, if the active surface of the electrode is carried Avell beyond the mucous membrane. Some of my punctures have been made under anesthesia, but I prefer to do Avithout general anesthetics, Avhen prac- ticable, on account of full anesthesia being necessary to obviate the troublesome movements of a partially anesthetized person. While withdraAving the instrument the finger should be pressed against the vaginal Avail alongside of it as a support, the insulated portion having a tendency to stick fast. Antiseptic douches will usually be the only after-treatment required, in addition to rest and hot applications for the relief of pain, should it appear. In case the puncture is made in the physician's office the patient should be sent home in a carriage. These punctures may be made as frequently as three times a month. I have myself made them tAvice a Aveek for a time, a slightly different spot being selected on each occasion; but Avhen employed so frequently the physician should be on the lookout for a local reaction, 138 DISEASES OF AVOMEN. Avhich should be the sign for a cessation of the treatment until it has subsided. Buried vaginal puncture will reduce fibroids and remove pain when the intra-uterine method is not tolerated. I have, moreover, never had a mishap or bad effect from its use, though this may be attributable to a careful selection of cases, as I can well conceive that the procedure might result in injury to important organs if employed in any case other than those in which the tumor is accessible by virtue of a practical protrusion into the posterior vaginal vault. Abdominal Puncture.—Where the tumor is so large as to be abdominal in situation and not readily reached through the cervical canal or by vaginal puncture I have found it expedient to puncture through the abdominal Avail by a method that I devised and described before the American Electro-Therapeutic Association before learning that the late Dr. Freeman, of Brooklyn, had employed a somewhat similar method in a cruder form. The fact that Dr. Free- man never published anything relating to his Avork had left the sub- ject of abdominal puncture of fibroids represented in literature only by the exceedingly crude and unscientific work of the early '70's, Avhen uninsulated electrodes resembling bayonets were used, Avith which the unfortunate patients Avere transfixed. To the bayonets Avas attached a battery consisting of a single cell. The infinitesimal current that Avas used in this harsh method, coupled Avith the fact that the work Avas done in the preantiseptic times, caused a mortality altogether out of proportion to any good results, and has given a bad name to abdominal puncture that is totally undeserved. These tumors are beneath our hands Avhen they have risen entirely into the abdo- men, Avith only the abdominal wall and hvo layers of peritoneum intervening. As contrasted Avith the pelvic route, scientific puncture from this direction is free from the embarrassing neighborhood of important organs if no intestines are in the Avay, is direct and exact, but possesses the one disadvantage of being intraperitoneal. By the expedient of employing only insulated electrodes to protect all tissues above the tumor the hvo pricks made by the needle in the peritoneum heal immediately, and in several hundred punctures made by me by the method described below there has not been a single instance of untoAvard results of any kind, and no evidence that any puncture resulted in adhesions. The details of the procedure as devised by the author are as fol- FIBROID TUMORS. 139 low: The punctures being invariably negative, small steel needles are used, three at each puncture, attached by branch wires to a single pliant copper wire as a conducting cord (Fig. 40). No. 22 or 24 in- sulated wire is much more convenient than an ordinary conducting cord. For the puncture needles there can be no better form devised than the straight Hagedorn surgical needle found in every instru- ment-shop. These needles possess the advantage of great ease of pene- tration, combined with lightness and strength, and the slit puncture made by them admits the increased bulk of the covering without hitch. This slit form of puncture also heals easily without a scar. The needle should be about three inches long, the first half-inch from the point being left bare and the remaining portion covered with hard rubber vulcanized on the shank as thinly as consistent with good insulation.1 It is easily attached to the copper Avire by the latter being passed through the eye and wound around the shank in contact Fig. 41).—Author's abdominal puncture needle (shown in enlarged section). with the metal. With the patient lying upon a large pad attached to the positive pole, these needles, properly insulated, sterilized, and attached to the negative pole of the battery by the branched Avire, are easily and painlessly thrust into the tumor through the skin, the surface having been previously rendered surgically clean. Just before the insertion of each needle the spot selected should be anesthetized by a chloride-of-ethyl or rhigolene spray. The current-strength has varied in my punctures betAveen 60 and 200 milliamperes, and the duration from six to eight minutes. After the removal of the needles the minute spots made are sealed by the application of collodion. As to frequency, it is probably best to alloAv at least one or tAvo Aveeks to elapse betAveen each application of electricity in this manner, 1 The insulation and reinitiation should be done before each puncture, by the physician himself, to insure asepsis from heat and soundness of the cov- ering. Melted hard rubber from an old thermometer-case set on fire Avill ad- here to the needle if the latter is heated. 140 DISEASES OF AVOMEN. although this depends on the size of the tumor and the field of tumor- surface accessible to the method. It need scarcely be said that no punctures should be made at any spot that might be covered by intes- tinal convolutions. The immediate inconveniences that folloAV these punctures, such as tenderness and pain, are generally less than those folloAving an intra-uterine application. As a measure of precaution, some patients under this treatment have been kept in bed in the sanatorium or hos- pital for tAventy-four hours after each puncture, but others have been punctured at the hospital or clinic and Avalked home shortly afterward. Vagino-Abdominal Applications.—Danion, a former pupil of Apostoli, has made the claim that mere vagino-abdominal alternatives are both sufficient and superior to the intra-uterine and puncture methods in the treatment of fibroids. This is unquestionably a mis- take as a broad claim, for the greater resistance of the tumor-tissue compels the bulk of the current to pass around it Avhen the active electrode is not Avithin its substance. That this method may act effect- ively upon some tumors is nevertheless certain, and the author had, in fact, used it long before the claims of Danion came to his attention. It is indicated as the proper treatment Avhenever the more active methods are for any reason inexpedient or contra-indicated, as AAdien there is more tenderness in the ovarian regions than Avould render intra-uterine treatment wise; Avhen periuterine congestion or an old pelvic peritonitis Avith adhesions overshadoAV the tumor in the pro- duction of symptoms; or Avhen the patient is so advanced in years or so feeble as to render more active treatment umvise. It may be also used Avith advantage in the intervals between the days of more active treatment. In employing the alternatives the ordinary vagino-abdominal method is varied by leaving the electrodes in situ after turning the current off, reversing the polarity at the commutator, and then turn- ing the current on again in the same gradual manner, repeating the procedure a number of times Avith a current-duration each time of about a minute. The advantages of this method are: greater con- traction of muscular fibre by reason of the variation of potential being exactly double what it Avould be with the same current-strength Avith- out reversal, and a protection of the vagina from erosion, since the electrolytic action is nullified in each reversal. Its disadvantage com- pared Avith simple vagino-abdominal applications, Avhich are, at times, FIBROID TUMORS. 141 preferable, is that the actions of electrolysis or cataphoresis are prac- tically Avanting. Results of Treatment by Electricity.—A method designed for the relief of human ailments must stand or fall on its ascertained results alone, no matter Iioav plausible may be the theory or hypothesis on which it is founded or explained. Tested by this rule, electricity in the treatment of fibroids has more than fulfilled the modest claims of Apostoli, for a much larger proportion of cases has been completely removed by absorption than was at one time thought possible, the extent of the original claims being merely a symtomatic cure and anatomic regression. Adhering to the rule of personal experience adopted in previous editions of this work, a tabulated list of eighty- six cases of fibromyomata of the uterus consecutively treated is given in Appendix A, the results in many of which are stated at periods varying from tAvo to ten years after the cessation of treatment. On analyzing this table the following results appear:— Cases resulting in anatomic and symptomatic cure: (a) Destroyed piecemeal by electrolysis through cervix. 1 (6) Extruded through cervix in whole or part........ 4 (c) Disappeared by absorption.....................12 Cases resulting in symptomatic cure: (a) With great reduction in size...................16 (b) With slight reduction in size...................21 (c) Without change in size........................10 Total cases resulting in practical success..............64 Symptomatic improvement only.................. 4 Failure to effect any change..................... 6 Made Avorse................................... 1 Total cases resulting in failure to relieve..............11 Ultimate results unknoAvn...........................11 Total cases........................................86 In computing the percentages of these results it is but just that the eleven cases in which the ultimate results are unknoAvn should be eliminated from consideration on account of the fact that these cases 142 DISEASES OF AVOMEN. were all dispensary patients who received but little treatment, it being, in the absence of definite information, as likely that this little re- lieved their pains and thus caused them to be careless about return- ing as that the results Avere only negative. Deducting these leaves seventy-five cases in which the results are sufficiently definite for statistical purposes. The sixty-four successful cases give, therefore, a percentage of 85.33 per cent, of successes, and the eleven cases of but slight improve- ment, or no improvement, give a percentage of 14.66 of failures. The one case that was made worse was a cystic intra-uterine growth that was improperly treated by electricity very early in the history of this method and before it was generally known that such cases should not be treated by the now classic intra-uterine method. Future statistics will naturally be clear of this source of error, as well as those arising in attempts to favorably affect subperitoneal tumors that are inaccessible to direct applications. And, even if no improve- ment be made in these figures in the near future, it is a distinct satis- faction to the conservative physician to reflect that in the 15 per cent, of cases in which electricity does no good it can be relied on to do no harm in proper hands, leaving the tumors unchanged for the trial of other methods. The slight responsibility in advising electric treatment is evident. On the other hand, the question is a far different one when the surgical removal of these groAvths is considered. With a mortality of one in four in the most skilled hands1 the physician assumes a serious responsibility who advises a resort to this method before the value of electricity has been tested in the case.2 There is no appeal from sur- gical failure. It should be the court of last resort. And, while lack of space forbids a complete discussion of the relative disadvantage of other methods, it may be said that a marked ^ozzi ("Clinical and Operative Gynecology," American translation, vol- ume i, page 310) gives a percentage of 25.80 of deaths in a list of 345 opera- tions in the most skilled hands. 2 A distinguished surgeon, noAv deceased, advised an operation in one of the author's cases. On being appealed to whether he Avould not have electricity tried if she, the patient, were Ms daughter, he at once assented and referred her to the writer, who has had other evidences that a higher conception of advisory responsibility preATails among physicians Avhen members of their own families are involved. FIBROID TUMORS. 143 contrast exists also betAveen the cases successfully treated by electricity and surgery. Successful removal of the tumor necessitates removal of the ovaries also, thus destroying the distinctively feminine character- istics of the individual; produces a weak spot in the abdominal Avail leading to hernia, which is practically far worse a tumor than the original fibroid; and in some cases produces painful neuroses due to cut nerves, and even at times insanity. Xo such sequences attend the electric treatment, Avhich invariably restores the patient to robust health and almost as invariably checks further groAvth of the tumor, even in cases Avhere more or less of the tumor remains after treatment as a harmless lump of flesh. Fifteen of the cases contained in the table deserve a report in full,—namely, the twelve cases that disappeared by absorption; one case that is tabulated as extruded in part but the bulk of Avhich dis- appeared by absorption; one case treated by abdominal puncture with notable results; and one case tabulated as destroyed piecemeal by elec- trolysis. Case Xo. I.1 An unmarried lady of 45, a patient of the late Prof. William Coodell, Avho had diagnosed a fibroid tumor four years pre- viously, was admitted to my private sanatorium February 11, 1888, suffering from general impairment of health due to a tumor (Fig. 41), about 5 x 3 inches in dimensions, developed from the right Avail of the uterus, apparently in the broad ligament. As there Avas a sharp turn in the upper portion of the uterine cavity it Avas thought at first that the tumor Avas broadly pedunculated, but subsequent exploration of the cavity proved that it extended a considerable distance to the right, and that the groAvth still formed the right Avail of the uterus, Avhich it had pressed very much to the left. As a doAvmvard prolongation of the growth could be easily felt close to the right vaginal Avail it Avas punctured in this situation and 150 milliamperes, negative, applied. This Avas repeated four times, Avith a resulting diminution in the pro- jecting portion of the tumor. Three years subsequently the patient came under observation again with a continuance of monorrhagia and no reduction in the upper limit of the groAvth. Under improved tech- nique an electrode Avas iioav passed four and one-fourth inches to the fundus and a series of positive intra-uterine applications made, vary- ing in strength from 30 to 100 milliamperes, the tumor becoming pro- 1 The numbers refer to the tabulated list contained in Appendix A. 144 DISEASES OF AVOMEN. gressively smaller. The patient reports, recently,—oxer ten years after the punctures,—that she is unable to find any sign of it and is in perfect health. Fig. 41.—Diagram of original outline of tumor in Case 1. Case Xo. 5. A married Avoman of 38 Avas kindly referred to me for electric treatment by Dr. T. HeAvson Bradford, of Philadelphia, early in 1888, at the Out-Patient Department of the Pennsylvania Hospital, at a time Avhen clinical material Avas verv valuable in testing; the then FIBROID TUMORS. 145 novel statements of Apostoli. The groAvth consisted of a hard, irregu- lar, multiple mass occupying the loAver half of the abdominal cavity, a central nodule extending two inches above the navel (Fig. 42). The main portions of the tumor lay to the left of the median line. The os Avas patulous, but lay so high in the vault of the vagina as to be reached by the finger Avith difficulty. Menstruation was regular, but profuse, and attended Avith severe pain at the beginning and end of Fig. 42.—Diagram of original outline of tumor in Case 5. each period. Chving to pressure, Avalking Avas difficult, and there Avas much SAvelling of the legs and feet. The treatment Avas at first by the negative pole, as this Avas early in the application of the method, Avith currents varying from 60 to 150 milliamperes, resulting in some uncomfortable sanguineous flows; but after five applications at appropriate intervals a distinct lessening of size Avas noted, enabling the patient to Avear dresses as much as four inches smaller at the A\raist. The improvement continuing, the patient 10 146 DISEASES OF AVOMEN. shortly after ceased treatment and took a position as cook in a large family. Eight months later there Avas a return of pain and tenderness Avithout increase in size, and, as it Avas desirable that rest should folloAv each application, she Avas admitted to the house department of the HoAvard Hospital and treated for six weeks Avith currents of 250 mil- liamperes. At the end of this time she could lie on the stomach for Fig. 43.—Diagram of original outline of Case 6. the first time in years, and the upper limit of the tumor Avas t\vo inches below the navel. She Avas seen five years later by one of the hospital nurses, to Avhom she declared that the tumor had entirely disappeared. Case Xo. 6. A single woman, aged 41, was referred by Dr. Frank Woodbury, with a history of hemorrhages twelve years before, at which FIBROID TUMORS. 147 time the tumor was first discovered. The menorrhagia had ceased for some time, but she Avas troubled with menorrhalgia and a most offen- sive leucorrhea. The pelvis and loAver third of the abdomen were filled Avith an irregular, hard mass, extending nearly to the navel, and separated by deep sulci into three lobes (Fig. 43). The os was found with difficulty, but was so stenotic as to foil all attempts at inserting a sound or electrode. An unsuccessful attempt Avas made to insert a steel needle into the tumor through the abdominal Avail, developing Fig. 44.—Diagram of original outline of Case 7. the fact that the tumor had undergone calcarous degeneration in its upper portion. A filiform sound Avas now passed two and a half inches into the cavity and 60 milliamperes applied successfully. Two days later a Xo. 18 Avire, tipped with solder, was inserted, and a week later an ordinary sound, by Avhich time the odor had disappeared from the discharge and never returned. The treatment was kept up for six months, as it Avas seen that a diminution Avas taking place, at which time her condition was as follows: General health much improved, 148 DISEASES OF AVOMEN. no leucorrhea, no menorrhalgia, cavity of uterus normal, and tumor shrunken one-third. Instead of being three-lobed it uoav consisted of three distinct tumors, movable upon one another, shoAving that the absorption had doubtless occurred in the base Avhere there Avas prob- ably no calcareous change. She reported to Dr. Woodbury recently that the tumor had disappeared. Case Xo. 7, referred by Dr. Bradford, presented an interstitial enlargement of the uterus to the size nearly filling the pelvis, in a patient 34 years old. There was a subperitoneal projection on the right the size of a large orange, extending up into the abdominal cavity to a level Avith the anterior superior process of the iliac bone (Fig. 44). She suffered from a copious purulent leucorrhea and constant pain in the left groin, rendering Avalking difficult. The treatment consisted of intra-uterine negative applications, beginning Avith 50 milliamperes and quickly increasing in subsequent applications to 150. Symptomatic improvement began very shortly and reduction in size Avas noted in the second month. The treatment was kept up about eight months. Examination subsequently showed a reduction of the uterus to normal and of the protuberant portion to a nodule no larger than a marble. Case Xo. 13 was the Avife of a physician in a Middle-Western State, aged 48,- and Avas sent to the sanatorium by the late Professor Goodell as not suitable for operation. She was having alarming hemorrhages almost constantly, which kept her in daily fear of a fatal issue. The tumor was very large, fully as large as an adult head, and of the smooth, hard, monocentric variety, the cavity being spread out on the right side Avith an extremely thin Avail on one side and a depth of five inches (Fig. 45). It had evidently developed in the left wall of the uterus and became submucous, but so large as to spread the organ out on its right. Treatment was commenced at once Avith a carbon electrode of large size, which Avas pressed into the tumor rather than applied to different portions of the cavity, as in sectional cauterization, on account of the very thin right wall. The hemor- rhages being alarming and the patient more than usually impatient, the treatment was pushed most heroically,—some twenty-two treat- ments in fifty-five days: about every other day, since a period inter- vened during the applications. Xearly all of these applications Avere of 250 milliamperes for the long durations of ten and fifteen minutes. As the hemorrhages were noAv arrested, she Avent home, but the natural FIBROID TUMORS. 149 result of a tedious separation of a portion of the tumor resulted, with slight rise of temperature. After this part came away the remainder of this large tumor sloAvly disappeared by absorption, and the patient, when heard from, ten years later, in March, 1898, was in perfect health, not a vestige of the tumor remaining. Case Xo. 17. This patient, a multipara, aged 34, was seen at the HoAvard Hospital, July 29, 1889, with an hemorrhagic fibroid Fig. 45.—Diagram of original outline of Case 13. filling the pelvis and extending above the level of the iliac bones. The upper portion Avas readily felt through the abdominal wall, being hard, somewhat flattened in shape, and with an irregular surface (Fig. 46). As the hemorrhage had lasted this time nearly two Aveeks, treatment Avas begun at once Avith a positive intra-uterine application of 110 milliamperes and continued twice a Aveek for two months. By September 27 th, on Avhich day the last application was given, 70 mil- liamperes strong, the tumor Avas almost gone, her color Avas improved, 150 DISEASES OF AVOMEN. and she Avas gaining flesh. As she did not return again to the clinic, she Avas specially sent for on December 12th, and the following note made after examination by several physicians present: "Examination shows no evidence of tumor. The only abnormal conditions present are a thickening of the cervix on one side, some fixation of the uterus, and slight leucorrhea. She states that her periods are regular, lasting but three days." Case Xo. 20. This case, a patient at the HoAvard Hospital, aged 30, presented a singular history, the exact stages of Avhich are left somewhat indefinite, OAving to her limited intelligence. On exami- nation, August 12, 1889, the uterus was found so large as to nearly fill the pelvis, with a nodular outline at the fundus. The os was virginal and the cavity measured three and one-half inches. She had been complaining of painful hemorrhages every three Aveeks for two years. An intra-uterine application of 60 milliamperes posi- tive was made, and nothing further seen of the patient for over four FIBROID TUMORS. 151 months, Avhen she returned, saying that it had caused pain twenty- four hours later, followed by a sanguineous discharge that continued three months, tAvo Aveeks of Avhich had been spent in a hospital. Still complaining of pain and leucorrhea, an examination showed that the tumor was much reduced (it is probable that a portion had been ex- truded). She was noAv placed on vaginal applications, which resulted in complete symptomatic cure by January 31, 1890, the leucorrhea being gone and the periods regular and painless. The hospital notes of this date say: "Xo sign of tumor except lumps in tubal region." Case Xo. 22 Avas also seen at the Howard Hospital, September 18, 1889, with a fibroid tumor situated in the right Avail of the uterus about the size of a goose-egg and giving a history of a year's dura- tion, Avith irritable bladder and other pressure symptoms. The treatment was intra-uterine negative applications of 60 milliamperes. Tavo months later there was considerable reduction in size. The notes say, under date of Xovember 1, 1889: "Examination shows uterus quite small and movable; no evidence of tumor." This condition was found to persist a year and a half aftenvard on the patient being visited at her home. Case Xo. 24. This lady, a AvidoAv aged 41, presented a typical instance of a small, bleeding fibroid situated in the posterior wall of the uterus so near the cavity as to give rise to alarming hemorrhages out of all proportion to the size of the tumor. At her periods she stated that she lost as much as some do in child-birth. Tavo years previously she had passed a polypus, and the hemorrhage, pain, and tenderness had persisted since then, becoming worse of late. The fibromatous uterus Avas much enlarged, with a projection on postero- lateral aspect and a cavity three and one-half inches in depth. The treatment of this case lasted exactly three months, being positive intra-uterine applications of a usual strength of 100 mil- liamperes Avith platinum electrode (the zinc-amalgam method not having then been devised), and resulted in the complete cure of the pain and hemorrhages, disappearance of the tumor by absorption, and reduction of the cavity to two and one-half inches. Her general health, which had been much impaired by loss of blood, was com- pletely restored. Case Xo. 35. This lady Avas sent to me by Dr. Davis, of Bridge- ton, X. J. She Avas 50 years old, and had been suffering from profuse and irregular menstruation for some time, but the tumor was not 152 DISEASES OF AVOMEN. discovered until Dr. Davis found it to be the cause of an attack of retention of the urine. When admitted to the sanatorium,—October 17, 1890,—the uterus was found to be pressed against the pubes by a hard growth attached by a broad pedicle to its posterior aspect, and extending from a level of the os to within two inches of the navel. Another nodule was the size of a walnut and freely movable (Fig. 47). The cavity was over three inches in depth. As the bulk of the tumor was subperitoneal and the lower end was easily accessible through the posterior vaginal vault, the treatment wras by buried vaginal Fig. 47.—Original outline of tumor in Case 35. puncture, negative, the needle being inserted from one to one and one-fourth inches beyond the vaginal surface. The punctures Avere all negative, and varied in strength from 100 to 150 milliamperes, no anesthetic being required. In all, ten punctures were made, a diminution in size showing after the second. At the final puncture,— March 2, 1891,—the highest point was four and a half inches below the navel,—a reduction of tAvo and a half inches in longitudinal diameter. On May 17th of the same year she returned by request, saying that it was impossible to feel any tumor through the abdominal FIBROID TUMORS. 153 wall. This Avas verified, no growrth Avhatever being ascertainable by external palpation. The bimanual showed only a slight roughness at the fundus (Fig. 48). At the present time, seven years after ad- mission, her health continues perfect, so far as the tumor is concerned. Case Xo. 38. This case is particularly noteworthy in presenting the history of complete disappearance of the largest tumor that, so far as the author is aAvare, has been caused to disappear by electrically- induced absorption without the assistance of the menopause. The lady in whose case this gratifying result has occurred wTas a widow Fig. 48.—Outline of tumor in Case 35 after treatment. 46 years of age, though since her restoration to health she has married a second time. She was first seen by the author on January 31, 1891, having been kindly referred by Dr. G. H. Whitcomb, of Greemvich, X. Y. The growth Avas at that time about the size of an adult head, the upper limit about one and a half inches below the navel, hard, knotty, and freely movable in the abdominal cavity, in which it mainly lay (Fig. 49). Examination showed it to be continuous with the uterus, the cavity being in the anterior portion, distorted, and difficult of penetration; large projections extended to the right and 154 DISEASES OF AVOMEN. left posteriorly. The patient said the groAvth had been discovered but three years before, though preceded by the intense menorrh- spasms from which she still suffered. One year before seeing me she had been placed under electric treatment by Dr. Whitcomb, whose intelligent application of the Apostoli method resulted in great relief of pain and a reduction of size from one and a half inches above the navel to the same distance below that point. The treatment had been discontinued for some time before the case first came under my obser- vation, but since her removal to Philadelphia there had been a recur- Fig. 49.—Original outline of tumor in Case 38. rence of menstrual pain and swelling of the tumor, and she was also suffering from an edematous swelling of the right leg. The exami- nation showed that the posterior projection, which was of more recent appearance, probably caused the edema by mechanically interfering Avith the venous circulation of the leg. She was placed on vaginal alternative applications of 150 mil- liamperes and subsequently on a weaker intra-uterine dosage. In three weeks' time she was able to lay aside the elastic stocking that she had been wearing. During the following month, however, a typi- cal attack of the prevailing influenza put her back someAvhat, and I FIBROID TUMORS. 155 Avas afforded an opportunity of witnessing an example of the intense menorrhspasms with Avhich she had been afflicted, accompanied by a swelling of the tumor to the level of the navel again. The treat- ment Avas, nevertheless, persisted in, and I had the satisfaction, some months later, of noting a great reduction. At the end of six months' treatment she was seen again by Dr. Whitcomb, who had some diffi- culty in finding the tumor. Six months later it had entirely dis- appeared (Fig. 50). The case was examined recently by the author, and but for an abnormal hardness of texture and a slight projection the size of a Fig. 50.—Outline of uterus in Case 3S after treatment. split almond from its posterior aspect, the uterus could not be distin- guished from a perfectly normal one. The enormous, irregularly lobulated groAvth had disappeared. The patient menstruates normally five days at a time, and Avithout pain; showing that the result was not assisted by the menopause, which has not yet appeared. Cases Xos. 42 and 70 complete the list of tumors that dissppeared by absorption, and are sufficiently described in the table. Case Xo. 46. Mrs. C. M. W., aged 45, Avas brought to the sana- torium by her husband on March 20, 1891. She was a nullipara under the average height, and the immense size of the tumor, in con- 156 DISEASES OF AVOMEN. junction Avith a lateral curvature of the spine, produced a most notice- able deformity. The tumor had been known to exist for fifteen years and had been accompanied by hemorrhages, the latter having ceased on appearance of the menopause six months ago. The menopause had not been of service in ameliorating the condition of the patient, except in the matter of stopping the hemorrhages, for her health was becom- ing worse and the tumor had made a distinct increase in size during the intervening six months. The groAvth was somewhat larger than the uterus at term, ex- lTlavcfi 20£ is^i TUavcPt 18> this day stop me in the street to thank me and it for their rosy cheeks; and the memory of those ten Avomen Avho are noAv no more, all tell me that I would be a traitor to the cause of truth if I remained silent, not only out of season, but in the very hour when it most needed to be spoken. "True, I can quiet my conscience when circumstances compel me to operate, by the reflection that one Avoman died Avhile under electric treatment, not through electricity, but through an error of diagnosis, for mistaking a tense, impacted, liquid tumor for a fibroid, which would not have been made if the abdomen had been opened, or, in other Avords, if the treatment had been surgical instead of elec- tric. This is the one and only case in Avhich, as far as my experience goes, I have ever had to seriously regret the use of electricity. M can still further soothe my conscience Avhen I am compelled to operate, by remembering that I have operated on ten Avomen, seven by abdominal hysterectomy, treating the stump by leaving it trans- fixed at the lower angle of the incision; and on three by remoA^al of the appendages, tying the ovarian arteries Ioav doAvn; and several others treated in the latter manner, at Avhich I Avas assistant, all of Avhom recovered and are noAv in good health. "When I visit the City of Brotherly Love, where the surgeons have declared Avar to the knife upon the electrode, I am often placed in an aAvkAvard predicament. When I tell my friend, Dr. Joseph Price, that I am going to spend a feAV hours at the electric clinic with Dr. Massey, he is surprised that a man of my intelligence can waste his time in such fiddle-faddling nonsense, and it is useless for me to assure him that I can shoAv him many Avomen in Canada, from Manitoba, in the west, to Xew Brunswick, in the east, Avho are pictures of health, and Avho have been cured by electricity. "On the other hand, Avhen I tell my friend, Dr. Massey, that I am going to spend the morning Avith Dr. Joseph Price, extirpating fibroids, he looks Avith pity on my blood-thirsty taste and misguided energy. "In vain I tell him life is too short to treat all my fibroid cases by such means. "In this someAvhat peculiar position Avhich I occupy, I have one consolation, and that is. or, at least, I hope that it will be so, that the 164 DISEASES OF AVOMEN. conclusions which I shall presently lay before you are those of one who is entirely unbiased and non-partisan, and are consequently to be accepted, as far as they go, in good faith. "My oavu opinion on the present status of electricity in the treat- ment of fibroids is fully made up, and I shall now endeavor to lay it plainly and honestly before you. "During the last year especially, although it has been growing gradually for several years, the conclusion has become evident that electricity is not suitable for every kind of case nor for every kind of doctor. "But it is as true to-day, as it ever was, that, for the cure of pain in, and bleeding from, the uterus, the application of the positive pole of the galvanic current, properly applied and of sufficient strength, to the uterine mucous membrane is, in the majority of cases, effective. The percentage of successes is greatest in those cases in which the fibroid growth is interstitial; not quite so great in the cases of sub- mucous groAvths, although in several of these cases a few applications have been followed by the expulsion of the tumor from th uterine cavity. The earlier the cases come under treatment, the more surely they are cured, many patients Avith small interstitial tumors in the an- terior Avail having been completely cured by me, and still more under the care of others; so that the plea for the early treatment of fibroid tumors by electricity is quite as just a one as is the early plea for operative treatment. Indeed, it is even more so, for, Avhile Ave can truthfully say that the electric treatment, Avhen undertaken early and with a correct diagnosis, is at the present day entirely devoid of danger, no one can truthfully say the same of the treatment by opera- tion. In fact, I am sorry to say that no one knows Avhat is the death- rate of the latter treatment. Three of the ten deaths which I have above mentioned have never been reported, and six of them Avere only reported at my urgent solicitation. "May there not be many other similar cases? When a woman comes to a doctor for menorrhagia and he discovers a small fibroid, is he to urge her to submit to an operation, Avhen he knows Avith the greatest skill and care she runs the risk of dying from the operation, and, if left alone, the death-rate is no more than 1 per cent., Avhile Avith electric treatment the risk is absolutely nothing? "When she tells me that she Avill not submit to an operation, FIBROID TUMORS. 165 shall I assure her that I can do nothing for her, when I carry in my pocket the record of fifty similar or Avorse cases Avhich have been cured by electricity? Surely, that Avere dishonest. And yet the temptation to operate, in spite of the danger of surgical and the safety of electric treatment, is very great,—too great, in some cases, for us to resist. "Ours is a busy life, and there is not one of us here who has not often felt that life Avas far too short to accomplish all the good that Ave Avould Avish to do, and, for the Avant of a few more hours in the day, much Avork of value to our felloAv-beings must go undone. With this feeling strong AA'ithin us, a poor Avoman applies at the out-patient department of our hospital Avith a small interstitial fibroid Avhich has, hoAvever, doubled or trebled the bleeding surface of the uterine mucous membrane. We believe that Ave could cure her by a long and tedious course of treatment Avith electricity, from ten to fifty appli- cations; if there are no facilities at the hospital, then at o.ur office. If at the hospital, the time required for this case Avould seriously encroach upon the time allotted to our sendee there; if at an office there is the same, as well as other, objections. And when Ave have made the sacrifice and cured the Avoman, AA'hat is the reAvard? Per- haps, but not always, the Avoman's thanks. Our OAvn feeling of having done well, surely. But Avhen Ave turn to our brethren, Avhose esteem is and should be the greatest incentive that Ave can look for, to good Avork, Avell and conscientiously performed, Avhat do they say? We haAre no fresh and bleeding tumor to take to the medical society (as an Indian Avaves a white man's scalp), before our admiring brethren, as a trophy of our proAvess and our skill. I have shown the women over and over again; I have shown their clothing Avhich had to be taken in, as much as seven inches. oAving to the decrease in size; the women themselves have offered to state on oath that their bleeding had been arrested, their pain removed, and their general health im- proved. Hoav were these triumphs of therapeutic skill received? With loud applause, you will say. Xo, indeed! The praise bestowed 'upon the exhibitor of even an apparently healthy appendix, the re- moval of which Avas folloAved by the death of the patient, is Avild in its enthusiasm, Avhen compared Avith the manner in Avhich is received the report of a case of cure by electricity. Indeed, a sincere friend and admirer in our society Avarned me privately that my reputation was injured every time I showed a Avoman Avho had been cured by this means, and he urged me to shoAv no more. But I must continue 166 DISEASES OF AVOMEN. to cure them by that means as far as my time-limit and life-limit will alloAV. "How different Avhen Ave report an operation, Avhether the patient lives or dies. Everybody seems pleased and praises us in proportion to the danger to Avhich our patient has been exposed. But if she dies there are h-vo, at least, avIio must regret that it Avas performed,—the patient and the doctor; and sometimes there are the husband and the little children to be thought about. But how much easier to take the patient into the hospital and in a fe\v days perform hysterectomy, which we can do in a quarter of an hour sometimes. It is, as the French say, 'un mauvais quart d'heure,' but it is soon over and the patient's fate is sealed for Aveal or Avoe Avhen Ave have put in the stitch Avhich closes the peritoneal cavity. "After that the house-surgeon and nurses take care of her, and an average of three minutes a day for the next twenty days is the very most she requires of us. But with the electric treatment, Avhat Avith getting the patient ready, carrying out the asepsis of the vagina, and adjusting the apparatus, I have spent as much as one hundred precious hours on a single fibroid case. But the OAraries remained and many of the women are noAv the happy mothers of children and others are happy wives, capable of having children, though childless. "I have lately asked several Avell-knoAvn men, men of the highest surgical reputation (you Avould be astonished if I mentioned their names), Avhether they had employed the electric treatment with good results, and they have assured me that they had, although they have never reported them; and Avhen I asked them Avhat Avas the principal objection to it, they replied, in confidence, that it took too much of their time. And this I admit is a serious objection to it, but not an insurmountable one. There are hvo Avays in Avhich it may be sur- mounted; one is by having an assistant Avhose time is less precious than our oAvn, Avho has been trained to carry out the treatment Avith accuracy and care when Ave prescribe it for the disease Avhich our more experienced touch has diagnosed. And the other is by having several' rooms and a nurse to prepare the patient, including the antiseptic vaginal douche, and by devoting two afternoons a Aveek, and having these patients come only at that time, as many as six treatments an hour might be administered. "Xever before has it been so well demonstrated, as it is to-day, that by the division and subdivision of labor the Avorkmen become FIBROID TUMORS. 167 more and more expert. It does not surprise me, therefore, that the best results of the electric treatment of fibroids are obtained by such men as Apostoli and Massey, Avho employ this treatment alone. They both obtain results Avhich neither I nor any other operating gynecologist can hope for. In every large city Ave should encourage some one man to establish an electro-therapeutic clinic, where our poor patients, at least, might obtain the benefit of his skill in electric technique, after having obtained the benefit of our experienced diagnosis; in time, his reputation Avould reach the ears of the rich, and he Avould then have some substantial reward. "The present status of electricity is suffering as did the status of abdominal surgery a feAV years ago, because it has been tried by men Avithout sufficient experience, and has, as a consequence, been found Avanting. The electric treatment of fibroids requires knowl- edge of the pelvic contents as Avell as the electrician's knoAvledge of the power he is Avielding. "I must trespass on your time yet a little more Avhile I refer to tAvo points. One, a claim Avhich has recently been made by Apostoli for the electric treatment, AArhich I can heartily indorse; and the other an objection which has been made to it, which I can as heartily deny. "Apostoli has discovered that the very failures of electricity can be turned to advantage in the following manner: It has been found that in those cases Avhere the electric treatment has been badly borne and has been folloAved by febrile reaction, so that the patients have been turned over to the surgeon for operation, the presence of pus- tubes and pelvic peritonitis has been discovered. Apostoli has pointed out that electricity may be employed as a diagnostic agent for the purpose of detecting diseased appendages. "A remarkable instance of this came under my notice over a year ago. A young woman Avho had been employed in a restaurant in a Xew England toAvn gradually lost her health, and had pain and hemorrhage. She suffered agony with her periods, Avhich came too often and lasted long; so that her face Avas blanched and haggard. There Avas no difficulty about the diagnosis, as the tumor was large, round, symmetrical, in the median line extending up to the umbilicus, and could be easily seen and felt, bulging up the abdominal Avail. Several physicians in the United States, her family physician in Mon- treal, as Avell as myself, all agreed that it Avas a fibroid. One of them had tried electricity several times, but ahvays with bad results, and 168 DISEASES OF AVOMEN. so did I. As she Avas laid up in bed for several days each time, I con- cluded that the appendages Avere diseased, and after three applications I decided to stop and to perform celiotomy. On opening the abdo- men the tumor Avas at once seen surrounded by adherent intestines, but it still appeared a symmetrically pear-shaped fibroid. I could not, however, find the ovaries and tubes, and, Avhile digging around for them, I made a line of clearage Avhich, being followed up, I Avas able to dissect out a portion of the tumor; it proved to be a sausage- shaped pus-tube; this Avas delivered intact, tied, and cut off. Then folloAved a large cystic ovary; then the other tube, Avhich broke and inundated the field Avith pus; and then the other ovary, by Avhich time the supposed fibroid Avas gone and only a moderate-sized uterus re- mained. The pelvis Avas carefully Avashed out and drained; the patient made a rapid recovery and is noAv at Avork and enjoying perfect health. So that, in this case, Apostoli's dictum, that when the application of his method causes febrile reaction the tubes are badly diseased, Avas fully borne out. "Xoav, the objection to electricity which has so often been made to it, especially by one of my most esteemed friends in Philadelphia, that it causes adhesions, is not true. I maintain that one has no right to bring that charge (1) if fibroids which have never been treated by electricity do have adhesions, and (2) if fibroids which have been treated by electricity can be proved not to have become adherent. "Xoav, I am in a position to prove both of these facts. When in Baltimore I saAv the abdomen opened for fibroid, but it Avas so adherent to everything, intestine and abdominal Avails, that the operator, one of the ablest in the Avorld, did not consider it possible even to get the ovaries out, and the abdomen Avas seAved up. Xow, this case, the most covered Avith adhesions I have ever seen, you will say, had received many applications of electricity, and so I thought, judging from these statements, must have been the case. But careful inquiry elicited the fact that she had never received a single application of electricity. But that is only negative evidence. Let us see about some positive evidence. "Three or four years ago I treated a lady, head-mistress of a large public school a thousand miles aAvay, for hemorrhage and pain, by means of intra-uterine positive galvanism. She had received one year's leave of absence from her duties and the commissioners had advanced her one year's salary in order to regain her health, she FIBROID TUMORS. 169 being utterly incapacitated for Avork. l^ou may imagine that she Avas peculiarly anxious to get Avell, and therefore submitted to a very rigorous application of the treatment three times a Aveek with great fortitude, as high as 200 milliamperes being frequently given at a time. And this Avas not for one or a dozen applications, but for fifty times. By this time the bleeding and pain Avere nearly, if not entirely arrested, and I advised her to complete the cure by a feAV months' rest at her old home doAvn by the sea in XeAV Brunswick. This she did and came back to me in July Avith rosy cheeks and sparkling eyes. She and I would have been perfectly satisfied with the result, and I should have reported her among my cures, had it not been for one thing, and that Avas that she asked me the question: 'Can you promise me that the awful hemorrhages will not return after I have gone to my far-away home in the West?' This I could not ansAver her affir- matively. "Her next question Avas: 'Is there any other treatment by Avhich you can guarantee that result?' My reply Avas 'Yes, one only, and that is hysterectomy.' Although the operation Avas not required by her then present condition, yet, OAving to her financial situation, Avhich Avould preclude her ever coming to Montreal again, at her urgent request I removed her uterus. "Xoav, if the charges against electricity have a vestige of truth in them, I must have found the tumor covered Avith adhesions; in fact, the tumor and appendages must have been one agglutinated mass requiring some hours of patient toil to detach them, and for this I Avas prepared. But Avhat was my astonishment, on opening the abdomen and screAving a cork-screAV into the tumor to be able to lift it out smooth and shining as the top of a bald man's head; the trans- fixing of it Avith pins and circling it with the serre-neud was the work of a feAV moments and in a minute more the tumor Avas off. She ran her 5 or 10 per cent, of risk of death safely, and made a splendid recovery and Avas at the head of her school once more on Septem- ber 1st. "One such case carries more Aveight than a thousand assertions that electricity causes adhesions. "But I can duplicate it. A young lady Avho is now a trusted nurse in a Xe\v Y'ork hospital came to me, the first year I used this treatment, for hemorrhage and pressure symptoms caused by a large fibroid. She improA'ed so much that I decided that she ought to go 170 DISEASES OF AVOMEN. home by the time she had received fifty applications. But after the last application she began to flow before the time, and I asked her to wait until it stopped. It lasted seventeen days, a steady little stream of dark-red blood. I became momentarily discouraged and advised operation, Avhich was accepted, but I handed her over to a more experienced operator than I was, at that time. I assisted at the operation and the tumor came out Avithout the slightest difficulty, and was remo\red in the same way as the case mentioned above. I examined it most carefully and the only trace of an adhesion to be found was a spot about the size of a silver 5-cent piece, where the tumor had rubbed upon the brim of the pelvis on the right side and where she often complained of pain before coming to me. But there was not a sign of adhesion in the track of the electric current nor anyAvhere else except this one spot. The hemorrhage was due to a tiny opening in a sinus by the end of the electrode. "I dislike electricity, personally, because it takes up my precious time, but I Avant it to get fair play and not be blamed for sins that are not its OAvn. "There is one charge, however, which was frequently brought against the electric treatment of fibroids or rather against a method of applying it, in the past, and Avhich Avas Avell deserved, but no longer applicable, because no longer employed. I refer to the method of galvanic puncture. "The greatest claim for the electric treatment of fibroids that can be made is that it has no mortality and that it is absolutely safe. If it is not safer than any other treatment, or, in fact, unless it is absolutely free from danger, there remains only one advantage in its favor,—namely, the saving of the ovaries. But galvanic puncture, no matter hoAV performed, Avhether by the vagina or through the abdominal Avail, must ever be a procedure fraught Avith danger, and is to-day practically abandoned. If anyone still uses it, in the cause of electric treatment of fibroids, I beseech him to use it no more. The positive pole of the galvanic current gently introduced into the uterus will accomplish our object by unseen, but no less certain, means. It dries up the juicy, bleeding, mucous membrane, and by its tonic action upon the muscular tissue through Avhich must pass the vessels carrying nourishment to the tumor, its blood-supply is cut off just as surely as though we tied the ovarian arteries Avhich supply the body of the uterus. The action of the electric current as applied to fibroids FIBROID TUMORS. 171 is threefold. The first is not mysterious; it is but the arrest of circu- lation in dilated capillaries by an electro-chemic cautery. The second is no more difficult to understand than the action of ergot or strych- nine; it not only tones up the vasomotor system, making the calibre of the arteries less, but it calls into play the special and remarkable poAver Avhich the uterus possesses of controlling its OAvn circulation when it has the strength to contract. The third effect of the current, its electrolytic action, is, I admit, as mysterious as it has ever been, but not more so than the invariable absorption of syphilitic gum- matous deposits following the administration of iodide of potassium. Whether what Ave call electrolysis means the actual breaking up of an organic tissue into inorganic atoms, or Avhether it means, as seems more likely to me, that the groAvth deprived of its blood-supply under- goes fatty degeneration and is partly eaten up by phagocytosis, stimu- lated to greater activity by the trophic nerves, no one Avith a large experience Avith this subtle fluid can deny that a uterus infiltrated with and enlarged by the deposit of fibrous tissue, Avhether localized in the form of fibroids or diffused, as in areolar hyperplasia, so that the sound Avill enter four or five inches, will invariably diminish in depth by means of electric treatment. "Then again, Avhat is the enormously enlarged uterus after de- livery but a bleeding myoma? Does it not stop bleeding Avhen the arteries Avhich supply it Avith blood are squeezed by its contracting* walls? Does it not rapidly get smaller Avhen, for the Avant of blood and exercise, the immense mass of tissue silently undergoes fatty degeneration and returns to the blood, from Avhence it came? "Wonderful and almost incredible as the total disappearance of a fibroid or myoma may seem to some, it is no more mysterious than this Avonderful process of nature Avhich Ave call involution. Have those Avho doubt, and, even Avorse, deny the power of electricity to work a change in fibroids, never reduced the size and Aveight of a uterus Avhich nature had failed to involute? Has Emmett never re- duced its size by repairing a lacerated cervix? Have Churchill and Athill and ten thousand others with honored names never reduced the quantity of tissue in the uterus by the application of iodine? Have not a hundred thousand others ever reduced the Aveight of the blood and muscle and areolar tissue in the heavy uterus by means of glycerin and hot water and other therapeutic measures? "Then why, in the name of reason and justice, will you deny that 172 DISEASES OF AVOMEN. an agent which Ave can see blanching tissues before our eyes, and making muscles of every kind contract, why will you deny, I say, that it can diminish the blood-supply to, and favor the fatty degen- eration and absorption of, the fibrous or myomatous uterus? "The electric treatment of fibroids, reduced to the above simple equation and stripped of all the extravagant claims. Avhich Avere at first made for it, stands to-day upon a foundation so strong and true that it Avill find an honorable place in the treatment of fibroids as long as women shall dread to die by the surgeon's knife, which I believe will be as long as the Avorld shall last." These eloquently expressed convictions of Dr. Lapthorn Smith are so important that I deem it but proper that his paper should be quoted in its entirety, yet I must take exception to the adverse opinion expressed concerning electro-puncture. That this method should be retained in the hands of experts only I will fully grant, but there has been nothing in my personal experience to condemn the method. To shoAv that my position is borne out by the experience of others 1 will quote a recent paper from the Transactions of the Edinburgh Obstetrical Society for 1896-1897 by F. W. X. Haultain, M.D., F.R.C.P.Ed., Lecturer on Michvifery and Gynecology in the School of Medicine of Edinburgh. The paper Avas read on March 10, 1897. "More than hvo years ago I gave an account of my experience m the electrical treatment of uterine fibromyomata, Avith, perhaps, an enthusiasm as. to the benefits to be derived from its employment, which, from the someA\diat limited number of cases cited, might be questionable. Since that time to this I have continued to follow this method of treatment in similar cases, with results so encouraging that any enthusiasm then shoAAm. in its favor is, if possible, more pronounced. "It is not my intention to dilate further on the general hem- ostatic and curative properties of the treatment, beyond mentioning that in these respects it has since amply fulfilled the sanguine ex- pectations I then formed of its value; but it is my desire to place before you a record of three cases, treated by electro-negative punct- ure, Avhich are, perhaps, of more than usual interest. They represent, I may add, my entire experience in this method of electrical treat- ment. "Case 1. Mrs. H., aged 36, had suffered for many years from a large uterine fibroid, Avhich had, from the attendant hemorrhage, so FIBROID TUMORS. 173 reduced her health that Dr. Croom decided to remove her appen- dages. This he accordingly did on the 29th of October, 1893. "The operation, unfortunately, had no beneficial effect, either in arresting the hemorrhage or the groAvth of the tumor, and her con- dition Avent from bad to Avorse. From the extension doAvmvard of the tumor into the pelvis, pressure symptoms of a most exaggerated degree were developed. These consisted in complete urinary incon- tinence after previous retention, agonizing pains in the back, cramps of the loAver extremities, and albuminuria,—probably the result of pressure on the ureters. At the same time profuse uterine hemor- rhage rendered her exsanguine to a marked degree. Except under morphine she had, for months, neA'er been free from pain, and, quot- ing from her OAvn Avords, she 'frequently prayed for death to relieve her sufferings.' During this period injections of ergotine and other forms of medicinal treatment had been assiduously carried out. "By Dr. Croom's request I was consulted by her on the 7th of December, 1894, as, before undergoing hysterectomy, which had been recommended, she Avished to knoAv if electricity could be of any benefit. Though apparently hopeless, I determined to at least give her a trial of the electric treatment. In this determination I Avas supported by Dr. Milne Murray, avIio sa\v the patient, and of whose opinion I gladly aA-ailed myself. The local condition, on examina- tion, shoAved the true pelvis to be filled Avith a tumor, Avhich en- croached on the vagina to such an extent that it Avas impossible to reach the cervix, Avhich was high above the symphysis pubis. The upper border of the groAvth reached to three fingers' breadth above the umbilicus (Fig. 54). "On the 14th of December I commenced the electrical treat- ment, and adopted electro-negative puncture through the posterior vaginal Avail as the only method available. At this sitting I Avas enabled to pass a current of 150 milliamperes Avithout great discom- fort. The treatment Avas repeated on the 21st; and on the 23d the patient informed me that since the last application she had been entirely free from pain, an experience she had not had for months, and, further, that she could retain her urine Avhile in the recumbent position. The applications Avere continued at Aveekly intervals, and after the seventh application, on the 26th of January, she had abso- lute control over her bladder in any position. Applications Avere continued tAvice Aveekly until tAventy had been given, and as the 174 DISEASES OF AVOMEN. hemorrhage had uoav considerably abated, and the pain absolutely ceased, treatment Avas discontinued on the 19th of March. Unfort- unately, late in July, feeling particularly Avell, she resumed her cor- sets and Avent for a long Avalk, Avith the result that the old pressure pains and urinary symptoms returned, associated Avith severe vomit- ing and an increase in the albuminuria. The electrical treatment Avas again continued with the same satisfactory result as regards symp- toms, and after the tenth application I Avas astonished to find that the tumor had entirely passed into the abdominal cavity, and the Fig. 54.—Outline of tumor in Case 1 of Dr. Haultain's before treatment. (Haultain.) cervix could be reached with ease. Intra-uterine positive electricity Avas noAv commenced, and a further ten applications given, treatment being altogether suspended on the 10th of October, 1895. Since that time she has been in absolute health; menstruating regularly, for about five days; and, on examination, the tumor can now be felt freely movable in the abdomen, and springing from the fundus uteri, its upper border reaching about two fingers' breadth above the umbilicus (Fig. 55). It would thus appear that the tumor was essentially of the subperitoneal type, and had become accidentally FIBROID TUMORS. 175 incarcerated in the pelvis, Avhere it had continued to grow, but, after having become diminished in bulk, it had returned to the abdominal cavity. "Case 2. Miss S., aged 38, consulted me in February, 1893, on account of a large fibroid tumor which, for a Aveek previously, had caused complete retention of urine, and necessitated the regular use of the catheter. For some weeks before this time she had suii'ered from occasional transient attacks of urinary retention, Avhich occurred about her menstrual period. She had already consulted an eminent specialist, Avho stated that nothing short of complete removal of the Fig. 55.—Case 1 after treatment. (Haultain.) groAvth Avould benefit her; but, having heard from a friend about the electrical treatment of tumors, she decided to try if, by this means, anything could be done for her, before, as she graphically put it, she alloAved herself to be 'cut up.' "Beyond the urinary retention and its associated discomfort, she did not complain of any other Avell-marked pressure symptoms. She Avas stout and plethoric in appearance, and, further than suffering from a dull and almost constant headache, and a feeling of Aveight and fullness from the presence of the tumor, she felt strong and Avell. She menstruated regularly, but scantily, for about tAvo davs. On 176 DISEASES OF AVOMEN. examination, a large, solid swelling could be felt in the abdomen, reaching to two fingers' breadth above the umbilicus, continuous with a large solid mass Avithin the pelvis, which so obstructed the vaginal examination that the cervix could not be reached (see diagram, Fig. 56). Energetic attempts to push the pelvic portion of the tumor above the pelvic brim proved absolutely futile, though made Avith the patient anesthetized and placed in the prone and genu-pectoral positions. "Treatment by electro-negative puncture was commenced on the Fig. 5G.—Outline of tumor in Case 2 of Dr. Haultain's before treatment. (Haultain.) 24th of March, a strength of current of 180 milliamperes being used, with the astonishing result that spontaneous micturition could be accomplished the same afternoon, and from that day to this a catheter has never been again required. The first menstrual period Avas ex- tremely profuse, and lasted ten days. Subsequently, fifteen electro- punctures were made Avithin the next ten weeks, and by the middle of May the groAvth had so materially lessened in size that I could with difficulty reach the cervix, and Avas able to introduce the elec- trode Avithin the uterus. The cavity measured four and three-fourths inches. I then continued the treatment by giving a further fifteen FIBROID TUMORS. 177 applications with one electrode in this situation. I, however, main- tained the intra-uterine pole negative, as, from the increased men- strual periods her headaches had ceased, and I feared that the posi- tive pole might here cause a diminution in the amount, which Avould be injurious. "After the completion of the treatment the patient returned to her home in London, and I did not see her again till six weeks ago. On examination then I found the tumor still pelvic, situated on the posterior uterine wall, and about the size of a small cocoa-nut, the uterus and the tumor being freely movable together. The cervix Fig. 57.—Case 2 after treatment. (Haultain.) was easily reached, and the sound passed into the uterine cavity about three and a half inches: one and one-fourth inches less than Avhen first measured (Fig. 57). "The patient described herself as being in perfect health, and her menstruation perfectly regular, but much increased in amount. The tumor in this instance Avas evidently intraligamentary, as, though free from incarceration, it still retained its position Avithin the pelvis. "Case 3. Mrs. B., aged 46, Avas recommended to me by Dr. Mac- donald Robertson in May last. She suffered from complete urinarv retention, which had continued for three days. She had had pre- 12 17* DISEASES OF AVOMEN. vious transient attacks of similar nature. Menstruation regular and normal. "On examination, a large tumor Avas found impacted in the pelvic brim, tilting the uterus high above the symphysis pubis. Attempts at reposition into the abdomen Avere futile. Electro-negative puncture was adopted, Avith the effect that the same afternoon she was able, with difficulty, spontaneously to void urine. Retention, hoAvever, recurred the following day, and persisted till the next application of the battery, when again the urine could be temporarily voided vol- untarily. After the third application retention did not recur; after this, tAvo applications were made, but the patient, being extremely nervous, refused further treatment. Since that time I have not again seen her, but hear from Dr. Robertson that he has not again been troubled to pass the catheter, and she says she feels quite well. "On carefully revieAving the salient features of the result of the electrical treatment of the cases I have just described, the outstand- ing benefit derived in one and all is the rapid removal of the pressure symptoms. This, in the last hvo, Avas so immediate in its occurrence as to be difficult to credit; Avhile in the first case, though someAvhat slower in its development, it was equally striking. That this result is due to actual shrinkage in the size of the tumor there can be no reasonable doubt. Though inappreciable at first to the examining fingers, the subsequent course of Cases 1 and 2, as well as the Avant of other reasonable explanation, fully justifies this assumption. "In Cases 2 and 3 symptoms of pressure had only been experi- enced for a feAV days, and therefore any great diminution in the size of the tumor Avas probably unnecessary to relieve the urgent condi- tions present, and can be accounted for by contraction of the capsule. In Case 1, on the other hand, severe pressure symptoms had been present for months, and were becoming aggravated from the con- tinued growth of the tumor, and thus a considerable diminution in the size of the groAvth was necessary before they could be removed. That this shrinkage in the size of the tumor was permanent, and not merely a temporary benefit of the treatment (as is averred by many to be the only value of electrical treatment), there is no gain- saying. In Cases 1 and 2 no treatment has been adopted for more than eighteen months, yet. not only have the symptoms of pressure entirely subsided, but marked diminution in the size of the tumor is palpable. The sudden recurrence of pressure symptoms in Case FIBROID TUMORS. 179 1 is easily to be accounted for by the corsets pushing the tumor deeper into the pelvis. "Perhaps the outstanding feature in the effect of the electrical treatment in Case 1 is its success after the removal of the uterine appendages had failed. It Avould appear, from the writings of some eminent gynecie surgeons, that many cases previously treated by electricity subsequently find their way to them to be cured. Fortu- nately, such a necessity has in my experience been quite the excep- tion. In fact, I cannot recall a single instance in my knowledge. On the other hand, it is but rarely that the electrician seems to have had as yet the opportunity of stepping in Avhere they have failed. The case I have cited is, as far as I am aware, the only one published in which electricity had been adopted after surgery has failed, with the exception of a failure of Thornton's,1 in which he sarcastically attributes his want of success to the patient's falling into the hands of the electricians. IIoav the electricians fared he does not venture to state. "In Case 2 a someAvhat striking result was the increase of the menstrual Aoav, attended by an entire disappearance of the continuous headache from which the patient complained. This might be deemed probably of the nature of an accidental coincidence, Avere it not that I have observed the same results in other patients. It would appear that some exceptional cases of fibromata, even though associated Avith an enlarged uterine cavity, instead of increasing the menstrual Aoav, are actually associated with an abnormal diminution in its amount, which results in the attendant discomforts of plethora, as commonly met with at the menopause. Hoav the electrical treatment effects an increase in the Aoav it is difficult to conjecture; perhaps it may be by stimulating ovarian activity; but the fact remains that I have several times met with this curious phenomenon, Avhich has been attended by most beneficial constitutional results. Doubtless igno- rance of the mode of action is unsatisfactory; and it is perhaps this want of knoAvledge Avhich has influenced many in giving electricity so Avide a birth, and not a feAV to condemn it wholesale. But satis- factory results are all-important, and, so far as I personally am con- cerned, suffice to stimulate me to work contentedly in darkness, as probably by this means alone will any rays of light be attained. 1 Playfair and Allbutt, "System of Gynecology," page 629. 180 DISEASES OF AVOMEN. "A further point of very considerable practical bearing is that, in Case 1, after thirty puncture applications, the tumor rose out of the pelvis into the abdominal cavity. It thus shoAVS that if judicious puncture methods are employed there need be no fixing of the groAvth by dense adhesions to surrounding structures; and thus the argu- ment used by certain Avriters, that electrical treatment seriously in- creases the difficulties of future operation by causing dense adhe- sions, must, so far as this case proves, be absolutely groundless. Cer- tainly Avhere the old, crude methods of puncture Avere employed such a result Avas almost a necessity; but, Avith the insertion of the exposed portion of the electrode Avell Avithin the tumor, as noAv em- ployed, this complication is efficiently avoided.1 "The practical results obtained from the treatment of the above cases by electro-puncture, I think, thoroughly justify its adoption. Doubtless but three cases are too few from Avhich to form definite conclusions; but cases necessitating the employment of puncture methods are fortunately rare, and Avhere the intra-uterine method can be undertaken it should always be adopted, the results being equally satisfactory, less irksome to carry out, and associated Avith probably less risk to the patient. As I have already stated, the cases cited represent my entire personal experience in the electro-puncture methods, or, in other Avords, Avere all that I have seen (among 0Arer eighty cases in Avhich I have adopted electrical treatment) in A\diich I have been unable to insert the electrode into the uterine cavity. "If such beneficial effects are to be got from a conservative method in the treatment of fibromyomata, it is, indeed, surprising hoAv little its adoption is advocated, not to say Iioav heartily it is abused. "May be this is due to medical 'electricity' forming the trade- mark of so many advertising quacks, Avhich thus shock the modest conservatism of the high-toned, professional mind; may be, on the other hand, it is the prolonged irksome nature of the treatment Avhich prevents its adoption by the busy gynecologist; or, perhaps, its methods are too simple and commonplace to induce the laparotomist to leave the beaten track, of the linea alba, on Avhich he is ever trying 1 Dr. Haultain explains, in an unquoted portion of the paper, that he employs buried puncture, the details being similar to those given in the present work and probably first suggested by me in the first edition of "Electricity in the Diseases of Women," in 1889. FIBROID TUMORS. 181 to establish Avorld-records of statistical successes. But, Avhatever the cause may be, I think there can be little doubt, from a consen-ative point of view, that the electrical treatment of fibroids has not as yet had bestoAved upon it the consideration Avhich its results Avarrant. "It has its failures; but Avhat methods have none? It has, Iioav - ever, no mortality (this I state from personal experience and observa- tion), and here, undoubtedly, rests the main argument in favor of its adoption before other heroic measures are attempted. "Removal of the appendages has, in the hands of the average operator, a mortality of 8 per cent., and in a further 10 per cent. tails in any way to benefit the patient. According to Croom, 20 per cent, of Avomen continue to menstruate after this operation. Fur- ther, in a considerable proportion of cases in Avhich this operation has been begun it is unable to be completed. "Hysterectomy, in the hands of the most able and finished opera- tors, has a mortality of 10 per cent., and an average mortality of quite three times that amount. "Surely, then, if electricity as a conservative measure has any beneficial results Avhatever (and I can personally vouch for a perma- nent removal of symptoms for over two years of over 70 per cent. of cases), surely it cannot be altogether rejected and refused a legiti- mate trial. "The tAvo main conclusions Avhich may be arrived at from the cases quoted seem to me to be:— "1. That electricity has a decided curative action in some cases of fibromyomata, Avhen nothing else short of severe surgical measures can be recommended. "2. That from the absence of mortality in its employment, and also in that it in no Avay increases the clanger of subsequent opera- tion, electricity should, in a large proportion of cases of fibromyo- mata, be employed before recourse be had to radical surgical inter- ference. "I do not Avish to be sentimental, but I appeal to human inclina- tions. In a case of one aaIio is near and dear, avIio suffers from chronic invalidism as the result of a uterine fibromyoma, I ask Avhether many of us would subject her to an 8-per-cent. risk of life, with a further 15-per-cent. risk of failure by remoAral of the ovaries, or the terrible mutilation of hysterectomy, before at least trying all conservative means at our disposal. Personally, I unhesitatingly say 182 DISEASES OF AVOMEN. I Avould decline, and thus would give electricity, as the most effi- cient conservative treatment, an honest trial. Xo harm is done, no valuable time is lost, for in the majority of instances fibromyomata do not call for immediate interference. If it do fail—\vhich in my experience is the exception—Ave can then proceed Avith an easy con- science to other more radical and drastic measures. Why ovaries and uteri should be treated Avith less courtesy than other important organs (not to mention the teeth, Avhich have bestoAved on them in many instances infinitely more care and trouble to conserve them) is an enigma difficult to explain. Perhaps Avoman is herself to blame, the tendency of the age being to minimize the importance of these repro- ductive functions, of Avhich her matronly ancestors Avere so proud. "If such be so, it is little credit to the medical profession to foster the idea by condemning these organs, for but minor offenses. to capital punishment without any option." Dr. Lackie, in the discussion of Dr. Haultain's paper, said that he had had an opportunity of Avatching one of the cases Avhich Dr. Haultain had recorded. The patient at one time seemed to him to be dying from pressure symptoms and exhaustion, but the effect of the electrical treatment which Dr. Haultain carried out was such that now she seemed perfectly Avell. Hysterectomy Avas out of the ques- tion, as the patient almost certainly could not have borne the shock of the operation; and as it Avas impossible to reach the interior of the uterus on account of its displacement, he did not knoAV any other means that Avould have reduced the tumor and so saved the life of the patient. Dr. Lackie had recently observed in another case the effect of electricity in causing contraction of the uterus. Under this treatment a bleeding sessile fibroid had rapidly become polypoidal, and been easily removed, Avith great relief of symptoms. CHAPTER XL Displacements and Xon-traumatic Relaxations of the Pelvic Viscera. The subject of displacements of the uterus occupies a large share of the attention of practical gynecologists, partly on account of their inherent importance, and partly because the sufferings due to other conditions have been too frequently attributed to the dis- placement, under the ultramechanical development of the older gyne- cology, which regarded each elaborately classified bend or tilt as a pathologic entity, to be corrected by a specially shaped pessary. Fort- unately for our reputation for common sense, these several bends and tilts, with the exception of retroflexion and prolapse, may noAv be regarded as of no more practical importance, per se, than the shape of the patient's nose. Unless the bend or tilt is accompanied by a catarrhal or hyperplastic condition or by fixation of the uterus or other abnormality, it possesses absolutely no significance. The uterus being normally a most mobile organ, it is readily seen that the chief enemies of its static equilibrium are fixation, on the one hand, and either torn or atro]3hied supports or undue bulk on the other, and that our therapeutic efforts should be directed to a removal of these more important accompaniments. It is most important, also, to ascertain the chronologic sequence of the congestion or hyperplasia and the displacement in cases of mobile prolapse and retroversion not due to laceration, and here is where a singular lapsus occurs in the current vieAvs of many gyne- cologists, avIio, while fully convinced of the microbic and neural cau- sation of other inflammations, still adhere to the older theory of a mechanical cause for this one. My experience Avith hvo classes of young Avomen has convinced me that the congestion and enlargement of the uterus is the initial lesion in all cases except those due to lacer- ation of the pelvic floor at childbirth, the displacement being second- ary and sequential; the proof of this is the great rarity of prolapse and retroversion in nulliparous peasant Avomen Avho carry heavy (183) 184 DISEASES of avomen. weights, and the invariable association of endometritis Avith the very earliest stage of (and doubtless preceding) the prolapse or retroversion of young Avomen of the better classes. This sequence of events applies equally Avell to puerperal subinvolutions, which are a most fruitful source of displacements and relaxed ligaments. In these cases all admit that the causal condition is the failure of the physiologic changes that normally reduce bulk and replace effete muscular tissues. The hypertrophy necessarily antedates the displacement. It is not to be denied, of course, that the elevation of an enlarged and catarrhal or subinvoluted uterus by a pessary may, at times, relieve the intrinsic condition of the organ, though it usually fails to do so; but this occasional result is no reason to assume that the displacement or tilt Avas primary. Unless the advocates of the mechanical theory are prepared to affirm that the bend, tilt, or descent is to act the part of the microbe in this particular inflammation, they should admit that its etiology must be the usual one, and that the uterus has become tilted or prolapsed because it had become heavier as a result of the catarrhal attack. This reasoning does not exclude the mechanical contributing causes of retroversion and prolapse in non- lacerated cases due to the pressure of a tight corset, lifting weights, or a sudden jar or fall, but explains hoAV these mechanical causes, acting upon an already heavy uterus, are enabled to effect a disloca- tion of an organ naturally capable of most extensive movements Avith- out harm. The bearing of this question of the chronologic sequence of the congestion and displacement on the practical details of treatment is evident. An actual cure demands that particular attention be paid to the hyperplasia primarily, or to its cause in endometritis, metritis, or other inflammatory conditions that may still exist, and, if the remedy employed be the galvanic current, a concurrent treatment of the re- laxed supports is also gained. A therapeusis aimed merely at the effects of these trophic disturbances—the sagging—is unscientific and at times harmful. What can be Avorse in its effect upon already Aveakened muscular structures than placing them in splints by the employment of a pessary? Nature, surely, never designed that a skeleton should exist Avithin the vagina, and if the purpose of the physician in placing one there be not to improve upon nature's permanent arrangements, but merely to use this means to strengthen the muscles, it should be re- called that the Avhole teaching of the modern treatment of muscular displacements and relaxations. 185 insufficiencies tends to magnify the value of gymnastics and to dis- credit support and fixation. Many cases of moderate descent of a too-heavy uterus have been rendered permanently incurable by the persistent use of these contrhances, causing atrophy of the vaginal muscular layers and round ligaments. Their only proper indication is in the incurably dilated vaginas of middle-aged or elderly women, where a properly fitting support gives immense comfort, and should be worn, under frequent observation, until senile involution contracts the vagina and renders the uterus smaller. ELECTRIC TREATMENT. The Author's Method.—The pathologic basis for the use of elec- tricity in displacements and relaxation of the pelvic structures Avith- out fixation is of a hvofold nature, dependent, on the one hand, on its poAver to cure inflammatory conditions of the uterus Avhich have produced added bulk or congestion, and, on the other, due to its stimulation of the muscular structures of the uterus itself and its supports. VieAved in either light, its great adaptability as a curative agent is evident, for it associates the hvo essentials of diminishing the bulk and increasing the power of maintaining it. Clinical results fully bear out these theoretic conclusions, the only exceptions being cases Avhere the muscular structures have entirely disappeared by fatty degeneration. The details of treatment are largely dependent on Avhether the organ is freely moA-able or is fixed in its displaced position by the adhesions of an old pelvic peritonitis or by diseased appendages. In the latter case the applications must be restricted to the vaginal method until a considerable mobility has been gained, Avhen, if it is deemed wise to do so, the intra-uterine treatment may be begun. Here the principal source of suffering is usually clue to the inflammatory conditions external to the uterus, Avhich, in addition to being of prime importance of themselves, usually constitute a bar to intra- uterine treatment until greatly bettered. Both gahanic currents of 5<> milliamperes or more and secondary faradic currents should be used at each seance, Avith a cotton-covered vaginal electrode and ab- dominal pad. (For details of method see page 56.) If the uterus, on the other hand, is moATable and evidently larger than it should be in the particular physiologic condition of the patient, 18 (i DISEASES OF AVOMEN. and especially if there be a purulent leucorrhea, positive intra-uterine galvanic applications may be begun at once with an appropriate elec- trode, followed by the contracting primary faradic current. It is often best to intersperse several vaginal applications betAveen the intra-uterine, if the patient is in a position to receive daily or tri- weekly treatment. Xothing has been said, so far, of bipolar faradic applications in displacements. Where the faradic current alone is to be used, I usu- ally prefer the bipolar method, either Avithin the uterus or vagina, noAv that I have been able to thoroughly asepticize the instruments, but as I rarely employ the faradic current alone in these cases I find it best to use the same monopolar electrode and one insertion for both currents, turning on the faradic current after the galvanic has been turned off. The intra-uterine applications suitable to the curative treatment of the conditions underlying retroflexion or prolapse of non-adherent uteri are exactly similar to those advised in chronic metritis (page 95), and exactly similar contra-indications govern its employment. It is usually Avise to correct the displacement, hoAvever, immediately before each application. This is best done, in early and painful cases, by placing the patient in the knee-chest position and replacing the organ by manipulation Avith the fingers, assisted by gravity and by pressing on the fundus through the posterior vault Avith a pledget of cotton in a pair of dressing-forceps. In less tender cases of retro- flexion this is not necessary, the repositing being easily and pain- lessly accomplished by inserting the sound-shaped electrode into the retroflexed caAuty Avith the patient in the dorsal position. Pushing the handle to\Arard the pubis, the tip is noAv rotated gently forAvard before turning the current on, the action of the sound being assisted by pressure of the tip of the finger in the posterior vault, Avhen the fundus will usually glide easily into place if not pushed too far back against the promontory of the sacrum. The current is uoav turned on, as in the treatment of chronic metritis, the contracting faradic cur- rent usually folloAving immediately after the positive galvanic ap- plication from the same instrument. There is a distinct contraction, usually noticeable in these cases, immediately after the application, and it is extremely rare that it is necessary or Avise, in the author's opinion, to follow this application up Avith any kind of continued support, though some operators use DISPLACEMENTS AND RELAXATIONS. 187 a avooI tampon Avith glycerole of tannin or boroglyceride between treatments. As this distends the vagina, it is apt to measurably in- terfere with the strengthening of its muscular coats: a distinct object in the electric treatment of these conditions. Without its use the extent of reposition required at each succeeding application will grad- ually become lessened until that more or less permanent residuum of either retroflexion or prolapse is attained which persists after prac- tical, symptomatic cure, even Avhen all evidences of hyperplasia and inflammation have disappeared. Such are the most important details in the electric treatment of prolapse, retroversion, retroflexion, and the occasional cases of patho- logic anteversion, accompanied, as they usually are in all stages, by engorgement, hypertrophy, or periuterine inflammatory consequences, and this form of treatment is almost ahvays capable of removing pain, weight, discharge, constipation, or other evidence of a morbid condi- tion. It is by no means ahvays possible to entirely correct the back- Avard bend of the uterus or the doAviiAvard sagging in prolapse, the former being due to a local atrophy of the longitudinal muscular fibres of the uterus and the latter to profound changes in the mus- cular and fascial supports of the abdominal pressure, but enough im- provement may be gained from the cure of the intrinsic uterine in- flammatory conditions to take away all unpleasant symptoms and leave the patient unconscious of any departure from the normal posi- tion and shape of the organ. The following cases are excellent illus- trations of the possibilities of benefit from the measures recom- mended in prolapse, the cases illustrating other displacements being included among the cases of chronic metritis. A young lady of 26 years, sister of a physician, Avho had suffered from menorrhalgia and probably an endometritis since puberty, and had been dilated hvo years before seeing me Avith but slight relief from the intense pain at the periods, presented the typical symptoms of almost complete prolapse at time of consulting me, the uterus just presenting at the vulvar outlet. The body of the organ Avas slightly enlarged and all supports relaxed, the vagina being distended and thin-Availed, doubtless from the fact that she had Avorn a Smith-Hodge pessary for eighteen months. The pain in back, bearing-down sensa- tion, and weight were so great as to incapacitate her for the most ordinary activities. Of late, she had been sleepless and nervously exhausted. The pessary was at once removed and daily vaginal appli- 188 DISEASES OF AVO.AIEN. cations made Avith both currents for three Aveeks, Avith tAvo intra- uterine applications, the patient being told that she Avould feel Avorse for a time. Later, intra-uterine applications Avere employed once a Aveek, averaging 35 milliamperes. At the end of hvo months the uterus Avas sensibly smaller, remained higher, and gave only occasional symptoms of discomfort. The applications Avere noAv made once a month for three months, resulting in complete symptomatic cure. An examination at the end of a year shoAved the uterus in only mod- Fig. 58.—Sectional view of a case of hypertrophy and prolapse of the infravaginal cervix. erate prolapse, the vaginal supports firmer, and the patient uncon- scious of any remnant of the trouble. G. R., aged 20, applied at the clinic of the Howard Hospital on August 20, 1897, Avith complete prolapse of an hypertrophied uterus (Plate XX and Fig. 58). The cervix protruded about two inches be- yond the vulva. On passing the sound into the cavity of the uterus it entered seven inches. Bimanual examination shoAved that the fundus Avas well up in the superior strait. The condition had lasted hvo months. PLATE XIX .fee =*l A." Traumatic Relaxation of the Pelvic Outlet with Cystocele and Rectocele :'K i ■ .irnma: co irm ran/ PLATE XX. Hypertrophy and Prolapse of the Infravaginal Cervix in a young negress XRt a i&frrmics a> ua ma? DISPLACEMENTS AND RELAXATIONS. 189 The protruding cervix was pushed within the vulva and an intra- uterine application of mercuro-cupric cataphoresis made Avith 80 milliamperes, folloAved by primary faradic current. The vagina Avas then packed with absorbent avooI. On September 3d the uterus was still Avithin the vulva, and the treatment Avas repeated Avith a current of 40 milliamperes at this time and on four subsequent occasions, without packing the A^agina. Tavo months later the uterus Avas nor- mal in size and position. The results of intra-uterine treatment for retroversion and retro- flexion are about equal in effect to those gained in prolapse, it usually being easier to secure a symptomatic cure than an anatomic one, par- ticularly in retroflexion, though the anatomic improvement is very great. Tripier's Method.—The distinctive feature of Tripier's method of treating displacements1 is the local application of the faradic cur- rent to the atrophied fibrils of muscular tissue. This involves the direct, localized action of this current on the convex aspect of retro- flexion and anteflexion. In retroflexion the current is localized in the anterior Avail of the uterus, therefore, and in anteflexion it is localized in the posterior Avail. His directions for the treatment of anteflexion are as folloAv:— "The first thing to be done is to lubricate the rectal probe (Fig. 59), although it is the last one to be used, as later the operator Avould have no disengaged hand to do so. Then a toAvel should be placed within reach. "The uterine exciter (Fig. 60), having been dried by the left hand, is inserted into the uterus, using for this purpose the left forefinger as a conductor. After this the rectal probe is inserted; this is the most delicate part of the operation; if not Avell done it might be very painful. The olive must pass the internal sphincter, leaning a little on its upper edge, the concavity of the instrument pointing doAvn- Avard; after this it should be pushed forward, beloAV, and a little to the left. When the olhe has thus reached the bottom of the con- cavity of the sacrum a pause should ensue, then turn the probe Avhile eleA-ating its pavilion so that the concavity of the curvature is turned 1 "Engorgements and Displacements of the Uterus.'' by A. Tripier, "Inter- national System of Electro-Therapeutics." page G-135. Philadelphia: The F. A. Davis Co. 190 DISEASES OF AVOMEN. upward, and in this way cause the olive to face the rear Avail of the uterus. It would naturally seem that, on account of the development to the left of the rectal ampulla, the rotation would be easier on that Fig. 59. Fig. 60. Fig. 61. Figs. 59, 60, and 61.—Tripier's rectal, uterine, and vesical electrodes for displacements. side, but this is not the case; I have always found it infinitely easier to the right, and I have tried it both sides. After pushing the olive from right to left in the concavity of the sacrum, it must be brought DISPLACEMENTS AND RELAXATIONS. 191 back to the right, Avhile turning the concavity of the probe more and more toAvard the right. The pavilion, being held in the hand of the rectal probe, must be sloAvly elevated during this rotation movement until it has been completely effected. This precaution is neeessarv, first, in order not to use the uterus roughly; then, that the move- ment of rotation may be more freely effected. Fig. 62.—Tripier's faradic method for anteflexion. "When the curvature of the probe has been brought parallel to that of the sacrum, then only can the hand be gently loAvered, push- ing lightly so that the olive may come up, sliding against the Avail of the uterus. "This last motion, ho\vever, must only be accentuated when fara- dization has begun, in order to ghe it strength and assure a sufficient 192 DISEASES OF AVOMEN. contact. The rotation movement just described is not ahvays accom- plished Avithout meeting with some resistance; this is sometimes easily OATercome, but at other times it may be difficult. The operator should be able to judge according to the impression received by the hand controlling the probe. The most ordinary obstacle to this maneuver Fig. 63.—Tripier's method of faradic treatment for retroflexion. is the presence of a fecal mass, hard or soft, and it is something that cannot be foreseen. The best Avay to avoid it is to give the patient an injection of oil before the application. "The rectal exciter, once placed, should be held in position; then the conducting-cord must be attached with the right hand, AA-hich DISPLACEMENTS AND RELAXATIONS. 193 must, at the same time, hold the uterine exciter. It is necessary to get accustomed to manage these two exciters with the same hand, the other hand being free to control the faradic battery and to govern its action. This hand directing the apparatus must, hoAvever, be able noAv and then to assist the other one, if any cause should present itself to modify the connection of the hvo probes, in accentuating the motion of the rectal probe. The fact is that a definite position can- not ahvays be given at once to the rectal probe. I have already de- scribed one obstacle to its progress: the existence of a fecal mass in the intestine. If this should happen to be of any considerable size and a little soft it might cover the posterior wall of the uterus as with a plaster, which could only be penetrated little by little during the application. Muscular contractions form another obstacle to placing the probe. These alter the form of the cavity where the evolutions take place. They are of a flexible nature, and give Avay under the influence of faradization; hoAvever, the resistance they present cannot be overcome at once, and it is by interrupting the rotation during the application that this can be avoided. "In retroversion and retroflexion the anterior Avail of the uterus must be acted upon and vesico-uterine faradization employed (Fig. 63). The patient being in the dorsal position, the uterine exciter is first inserted, then the positive vesical, which is previously lubricated. After this the contacts are established and the apparatus put in action; the same hand then places the two probes in the required contact. The insertion of the vesical exciter is made like that of any ordinary probe; the pavilion (handle) must be raised at the time of operating, but only at that time, so as to lean the active tips on the anterior wall of the uterus. "The application should not last longer than three minutes, to avoid fatiguing the muscular structures." 13 CHAPTER XII. Relaxation and Functional Incapacity of the Abdominal Walls and Atiscera. In the remarks on the general examination and classification of cases, on page 10, emphasis Avas laid on the necessity for distinguish- ing betAveen pelvic affections and those that have their origin in re- laxations and displacements of the abdominal viscera. These latter affections are almost peculiar to Avomen, oAving to the frequency with Avhich their causation may be traced to the combined effects of corset- wearing, pregnancy, and sedentary habits. A few words on their clinical aspects is most necessary in a treatise on the conservative treatment of the diseases of women, and particularly in this work, OAving to the unique value of a certain combination of electric cur- rents in their alleviation. FeAV women pass through one or more pregnancies without a resid- ual weakening of the abdominal walls, Avhich, if uncorrected, remains a menace to their intra-abdominal tone in after-years. Xo one can believe for a moment that this abdominal laxity and protrusion is a necessary sequence of pregnancy, and there can be no doubt that it oAves its presence to the pestilential corset imposed upon occidental Avomen by a barbarous Avhim of our civilization. And do not let us be self-deceived on this point. I do not refer at all to tight-lacing and its horrible results on the abdominal viscera, but to the so-called loose-fitting corset of most comfortable shape, Avhose harmful effect is due to two factors: 1. It supplements the natural body-wall of the abdomen by an artificial, external skeletal support never intended by nature, resulting in atrophy and Aveakening of the abdominal mus- cles: the natural support of the body-Avail at this point. 2. During and after the first pregnancy this artificial skeleton, Avhich had here- tofore been a moderately equable support to all of the muscles of the abdomen, is efficient in the upper portion only, leaving about one- (194) RELAXATION OF ABDOMINAL ATALLS. 195 half unsupported in this Avay, and resulting in a remo\ral of pressure and consequent protrusion of the loAver half of the abdomen. This leads directly to either partial or general enteroptosis, or displace- ment of the holloAv viscera, and—if there is a tendency to fatty de- generation of the organs—to morbid dilatations also. The dragging sensations and backache thus produced are fre- quently mistaken for pelvic disease, though often not associated Avith any abnormality in that cavity. Constipation due to an enlarged and sacculated colon is invariably present; and, Avhen the organs exhibit also a Aveakened musculation OAving to fatty degeneration of their unstriated muscular coats, Ave may have profound effects on the general health from absorption of toxins and deficient secretion of the glandular organs. An arhythmic heart-action even may be traced to this condition. The most effective treatment knoAvn to the author consists in labile applications of electric currents to the Aveakened and dilated organs of a strength that will induce contraction, as Avell as pro- foundly stimulate glandular action. Such currents must be from 100 to 150 milliamperes, Avhich I believe is much more than has hereto- fore been given in this Avay, and should be simultaneously combined Avith the most poAverful primary faradic currents, applied from an active pad on the abdomen to the large indifferent pad on Avhich the patient lies, as shoAvn in Plate Y, the movements given to the anterior soaped pad resulting in a form of abdominal electro-massage of great service. In addition to folloAving the direction of the colon in these moArements, the active pad should be passed doAvn the flanks on each side, just above the pelvic bones, to further reach the motor points of the abdominal muscles. The poAverful currents advised are by no means limited in effect to the abdominal muscles, but constitute also a stimulus to the con- traction of the dilated intestines, gradually adding tone by the re- generation of muscular fibre. The galvanic current in this dose can also be relied on to stimulate the secretory and excretory organs of the abdomen, resulting in relief of constipation, general improvement in blood-conditions, and disappearance of irregularities in heart-action. In one case recently under treatment an improvement in the rhythm of the heart could be detected after each application, probably due to direct stimulation of the sympathetic nerves in the epigastric region. 196 DISEASES OF AVOMEN. In pronounced cases of abdominal relaxation it will be wise to hasten relief by prescribing a suitable abdominal supporter at once, which may be discarded later as improvement progresses. CHAPTER XIII. The Border-line Between Gynecology and Xeurology. The restriction of the term "gynecology" to the pelvic diseases of Avoman is largely artificial and often harmful in leading to serious errors of practice. The science of the diseases of Avoman necessarily includes an account of all of the affections Avhich are either peculiar to her sex or which are so frequently manifested among Avomen as compared Avith men as to be more or less sequential to their general bodily, mental, and emotional natures. That there is no self-evident line betAveen the strictly pelvic and the extrapelvic affections peculiar to Avomen Avas manifest to the author many years ago Avhile enjoy- ing, at different times, the valuable privilege of professional asso- ciation Avith hvo of the most prominent practitioners of America in apparently different lines of investigation,—Drs. S. Weir Mitchell and William Goodell,—and it Avas a singular fact to note that the eminent neurologist Avas most solicitous that his cases should have the bene- fit of skilled surgical advice Avhenever any indications even pointed to this necessity, Avhile the eminent surgeon, at the height of his masterly Avork in the major surgery of gynecology, had the mental breadth to keep his private hospital filled Avith patients undergoing Avhat Avas strictly neurologic treatment, Avhile he might have easily folloAved the prevailing fashion and removed the ovaries of every one of them. But the average of professional Avork or breadth of character cannot be predicated from such men as these, and it is to be feared that like conditions of discernment and cool judgment are often wanting in both specialties, though it cannot be said of the neurolo- gists, at least, that a too-narroAv vieAv-point can lead so easily to dis- aster to the patient. And, indeed, no more difficult class of cases, from the point of vicnv of their diagnostic classification, can be found in the practice of medicine, and unless the physician has both a gynecic and neuro- logic facet to his crystallized experience he may make mistakes. (197) 198 DISEASES OF AVOMEN. The author particularly recalls a case under his care before the de- velopment of his gynecic training Avhere evidences of hysteria Avere associated Avith a vulvar discomfort, Avhich could have been none other than a minute caruncle. An imperfect examination was made, but the slight evidence of local disease did not seem to bear an etiologic relation of importance to the very manifest hysteric symp- toms existing, and the case Avas treated entirely from the neurologist's stand-point Avith but partially satisfactory results. A retrospective review of its management makes it evident that the local affection should have been carefully sought for and remedied simultaneously Avith the neurologic treatment, care being observed to so adapt and direct the latter that the patient's attention shall be attracted aAvay from an undue contemplation of the local symptoms. In the management of these cases of manifest hysteroid condi- tions associated Avith local disorder or lesion, whether pelvic or ex- trapelvic, it is clearly our duty to correct the local faults while pur- suing measures to eradicate the main affection; but I believe the profession will agree Avith me that too much stress has been laid upon the so-called "reflex" causes of nervous disease in recent years, though no one can deny the real importance of reflex nerve-strain from a degenerating or badly-functionating organ. Ovarian congestion and tenderness have been specially frequent in these border-line cases, and these organs have been removed time and again for conditions of exaggerated nervous disorder Avithout securing the expected relief, for the simple reason that the ovary was not the seat of the real dis- ease, but merely the spot at which appears the peripheral expression of a centric disease of the nervous system. Such a course of pro- cedure Avas, moreover, incorrect in the nature of the local remedy applied, for it should not be forgotten that centric disease may be favorably affected by peripheral applications to the end-organs through which it expresses itself, the remedy in these cases not hav- ing been a curative removal of the congestion or tenderness, but a violent amputation of a but-slightly-diseased organ, thus adding a distinct blow to an already-unpoised nervous system. In place of such heroic procedures Ave should substitute the locally alterative action of vaginal electricity, which is capable not only of removing the local congestion or hyperplasia, but, also, of producing a very valuable centripetal effect upon the disordered cerebral centres. An interesting demonstration of the latter truth is recalled in BORDER-LINE BETAVEEN GYNECOLOGY AND NEUROLOGY. 199 the case of a young lady referred to the author some years ago by Dr. Pepper, her home physician reporting that the pain and tender- ness in the region of the left ovary had become so great that she Avas rapidly drifting into the dangers of morphinomania. In addition to the marked hysteric condition present there was distinct bogginess in the region of the ovary complained of. This speedily diminished under positive vaginal treatment with both currents applied by a small cotton-covered electrode and abdominal pad, associated Avith remoA-al from home surroundings, general electricity, and massage, resulting in complete cure. The local conditions of this case Avere exactly similar to those of the following cases, both of Avhich were, hoAvever, more virulent in their hysteric condition, and ultimately illustrated the fallacy of the theory of a local pelvic origin of this protean disease of the brain. A young girl, of plain Pennsylvania-German parentage and the picture of Avholesome physical girlhood, was the patient of an able practitioner who had long been the family physician. During the serious and finally fatal illness of a younger sister a latent neuro- pathic diathesis became prominent in this patient, Avho Avent through an elaborate mimicry of the traumatic spinal meningitis of which her sister suffered in the same room, and seemed desirous of diverting to herself all the attention of a too-solicitous mother. After various changes in the manifestation of the neuropathy, and many thera- peutic efforts on the part of her physician, she Avas sent to the In- firmary for Xervous Diseases and placed under seclusion, rest, and massage without adequate electric treatment. About this time the patient's attention became fixed on a pain in the pelvis, aggravated at the periods, and her physician finally decided that the removal of the ovaries Avould be Avise, AAdiich Avas successfully done. The pain, hoAvever. became Avorse than ever after the operation, and nearly a year afterward her physician sent her to the author in despair. The uterus Avas noAv fixed and extremely tender at the stumps of the ovaries, with probably one or more irritating ligatures in these posi- tions, and the local electric treatment that she was Avilling to receive Avas of little avail. Obstinate boAvel obstruction gradually developed later, for Avhich a second operation was performed, this operation revealing a post-operative adhesion betAveen the appendix and the stump of the right ovary. The patient failed to rally from this operation, expiring some hours later. 200 DISEASES OF AVOMEN. A similar case in some respects Avas admitted to the sanatorium from Xorthern Ohio in 1895, the young lady's physician sending her for treatment for an adherent right ovary, Avhich Avas also enlarged and tender: a diagnosis Avhich had been made by himself and a distinguished surgeon of Cleveland. Fortunately for the possibilities of a fuller diagnosis, the patient's aunt accompanied her to Phila- delphia. An examination on admission led me to conclude that the pain complained of in the pelvis Avas mainly uterine in seat, no con- siderable periuterine or ovarian disease being manifest. I was, more- over, led to suspect an ovenvhelming neuropathic taint from a pecul- iar glitter of the eye Avhich will frequently be found in hysteric cases, and from the very apparent evidences that her famih Avere unsus- pectingly fostering her aches and pains: a view of the case that Avas not shared, at this time, by her physician. She Avas placed on combined neurologic and gynecic treatment, consisting of general galvanic treatment, massage, and regulated ex- ercise, and daily vaginal galvano-faradic applications interspersed Avith Aveekly intra-uterine applications of the same currents, and Avas sent home in a greatly improved condition Avith full directions for a con- tinuance of the methods at the hands of her home physician. This gentleman has kindly informed me since that the methods Avere not continued, but that laparotomy Avith remoyal of the ovaries was per- formed instead some months afterAvard, these organs being found normal and free from adhesions. The patient unfortunately suc- cumbed to the operation. The fact that these hvo patients died as a consequence of the operative procedures undertaken for their relief is, of course, not in itself a condemnation of the methods or the theories behind them, for in both cases the deaths Avere caused by accidental circumstances connected Avith operations that are usually more or less safely per- formed, though the fact that such possibilities attend a method of treatment of a non-fatal disease should never be lost sight of. But that clearer after-sight that is often more accurate than foresight sIioavs that the disease Avas disproportionate to the remedy, particu- larly when Ave consider Avhat Avould have been the natural history of the disease if all therapeutic efforts had been withheld, as in the cases of pneumonia studied by the elder Flint many years ago. Un- doubtedly both patients Avould have been still living, so far as the diseases under consideration Avere concerned. It is likely, also, that BORDER-LINE BETAVEEN GYNECOLOGY AND NEUROLOGY. 201 both Avould have been better by reason of changed internal and ex- ternal conditions through flux of time, or by reason of the too- indulgent relatives either mending their ways or being worried to death; at any rate they—the patients—would have been living. But entirely apart from the accidentally-fatal results noted in the two cases, each case indicated in another way that the local conditions were inadequate in themselves to cause the general con- dition complained of. In the one case the first operation, which was in every way an immediate success, left the patient in an unchanged neurotic condition, to which was added the sufferings from post- operative sequels. In the other case the early fatal result precluded any estimate of the effect of the operation in relieving pain, but by revealing the fact that there was no organic disease or morbid adhe- sion present the operation clearly indicated that a failure in this respect would have attended an immediately successful result. A thorough study of cases of this nature conveys several valu- able lessons to the thoughtful physician, chief of which is that they, with many other immediately successful cases, demonstrate ultimately the unwisdom of removal of normal ovaries for any form of hysteria. Of castration for curable diseases of these organs reference has been made elseAvhere in these pages (page 114). A second lesson admonishes us to include the patient's relatives in our scheme of treatment when it is impracticable to remove the patient from their influence for a sufficiently long period. In the case treated after the first operation the electric treatment was ren- dered ineffective by the fact that the patient remained at home dur- ing its continuance. In the last case the removal from home influ- ences was a valuable assistance to the treatment employed, and the patient Avas vastly improved Avhen circumstances rendered it neces- sary for her to return to surroundings that had been nervously hurtful since her birth. Had it been possible for this patient to have ob- tained congenial occupation elseAvhere, Avhich Avas suggested at the time, there is no doubt but Avhat a complete restoration to health would have occurred. The Rest Cure in the Treatment of Hysteria and Hysteroid Affections.—There is no question of the very great value of the "rest cure" in two distinct classes of affections: the hysteroid con- ditions and physical prostration, sometimes called nervous prostra- tion. Dr. Weir Mitchell, its distinguished originator, conferred a 202 DISEASES OF AVOMEN. lasting benefit upon humanity in making this method popular, and it should also be added that great credit in this connection is also due the late Dr. William Goodell, Avho proved that many so-called uterine affections were of really neurotic origin—"nerve-mimicries of uterine disease" and distinctly curable by this method. That many cases have been subjected to this treatment that were not proper subjects for it, and that it has been imperfectly applied, does not detract from its value when skillfully directed in properly selected cases. It is probable that the principal failures in the employment of this method have been due not only to . improperly selected cases, but to a misapprehension of the method itself. He Avho imagines that the "rest" is the main feature of the method in any case other than mere physical prostration is far Avide of the mark. This con- venient and pleasing term is only the name for a most rigid method of treatment, Avhich has as its chief elements the replacement of drug medication by valuable physical methods of affecting the body, asso- ciated with a rigid diet and a command of the will-power of the individual. In most cases the rest is a mere incident in the sub- jection of the patient to more important influences. I have already said that its chief field lies in the hysteroid con- ditions, and in these the most rigid application of its rules is most valuable. Without attempting the difficult task of defining these con- ditions I wish to point out that cases with hypochrondriac symptoms are not necessarily hysteroid, but often neurasthenic, as decribed in the next chapter, and that these cases are poor subjects for the Weir Mitchell method, mainly because the seclusion is harmful. Cases of physical prostration from absolute, not relative, overwork, are also good subjects for the method and respond readily to it. The chief features of this method, as employed by the author, are: complete removal from accustomed scenes and associates and rest in bed under the care of a specially trained nurse, Avho screens the patient from all communication with her friends for a definite period, usually at least four Aveeks. During the first hvo or three weeks the patient remains at absolute rest in bed, though she may rise to attend the calls of nature in all but the most rigidly treated cases. Massage is given daily in the morning. In the afternoon general galvanic stimulation is applied, preceded by the local electric treatment to the pelvis or to the stomach which may be indicated in the particular BORDER-LINE BETWEEN GYNECOLOGY AND NEUROLOGY. 203 case, and which is often so important Avhen there is evidence of a reflex origin of the nervous symptoms. The diet during this time is carefully specified, beginning Avith milk alone, 1 quart per diem, during the first seven days, to Avhich toasted bread is added at meal-times in some cases. During the second Aveek koumiss is taken betAveen meals and cocoa replaces the milk at breakfast and supper. In the third week full diet may be given, fol- loAved by 3 to 5 drops of freshly-prepared, chemically-pure nitrohydro- chloric acid in 3 ounces of AA7ater after meals, the koumiss being con- tinued betAveen meals. The getting-up, which begins at the end of the third or fourth week, should be very gradual,—at first, a half-hour, once a day, in- creasing a half-hour each day. After the patient completes her getting-up she continues the general electric treatment for a time longer, depending on the case, requiring an hour's rest after each daily application, and receives static insulation and breeze from a poAverful machine in the other half of the day in place of massage. CHAPTER XIV. Neurasthenia and Nervous Prostration. Neurasthenia, or the American disease, first described by the late George M. Beard, to Avhom American physicians owe the rescue of electro-therapeutics from the blighting effects of quackery, has since been the subject of much study and many treatises in several lan- guages, as physicians the Avorld over recognized that its occurrence Avas by no means limited by political boundaries, nor even by the existence of the environments of a new country. That it is peculiarly a disease of modern civilization, even though described to some extent by Burton in his "Anatomy of Melancholy," published in 1621, is but another Avay of saying that it is one of the penalties of that evolu- tionary development under Avhich society is continuously progressing. Of the exact nature of neurasthenia several vieAVS are current, the most reasonable being that it is a symptomatic manifestation of an imperfect performance of all, or nearly all, of the organic functions of the animal life, causing perversion of the nutrition and funetionation of the nervous system. Though it may be caused by- a sudden mental shock, such a causation is unusual, and the cases in AAdiich it occurs are more nearly related to hysteria. The assumption that excessive occupation clue to the claims of business or society is a frequent cause is but relatively true, for in a normal condition it is not Avork, but Avorry, that tells hardly upon the individual. In the abnormal con- ditions of alimentation and excretion, which are probably the primary cause of neurasthenia, a persistence in any occupation requiring a high grade of mental Avork or irregular hours becomes a persistence in rela- the overAvork, though the same exertions may be harmless under more normal conditions. The view that assigns the many functional derangements of the nervous system comprised in neurasthenia to an autointoxication due to an imperfect performance of the abdominal functions is gaining ground, and is evidenced by the recognition of lithemia, in many cases, in association Avith the nervous symptoms. (204) NEURASTHENIA. 205 An enumeration of the symptoms of neurasthenia Avould occupy more space than is aArailable in a work of this nature. Considered as a whole, the subjective symptoms usually display, in a most varied way, a more or less pronounced inability to perform Avith personal satisfac- tion the various tasks imposed upon the individual by the necessities of a social existence. Of objective symptoms the most pronounced are due to disordered action of the sympathetic system of nerves, dis- ordered circulation, and general metabolic sluggishness. In the treatment the main purpose should be to arouse the defective activities of the sympathetic and of the organs under its control. The effectiveness of peripheral applications, such as the cold bath of momentary duration or applications of static electricity, in restoring circulatory and nutritive control, is no argument against the abdominal origin of the malady, as these agencies exert poAverful afferent effects on the sympathetic ganglia as Avell as upon the cerebro- spinal centres of innervation. Of this nature are also massage and electro-motor stimulation of the limbs and body-surface, Avith the added advantage of a stimulation of the local circulation, nutrition, and tissue-metabolism; but, unless the abdominal sympathetic system is directly reached, the Avorst of these cases Avill fail of complete remedial alleviation, and dissatisfaction will result to both patient and physician. Rest and regulation of the diet added to these peripheral stim- ulations will do much for some of these cases, but will be lamentably ineffective in others. The importance of rest alone has been enor- mously overrated of late, so much so, indeed, that hundreds of patients Avho have done nothing but rest all their lives are put through a costly treatment by their physicians under an inordinate belief in this shib- boleth, only to find their neurasthenic symptoms made Avorse by the burdensome effect of temporary additions of fat, or their hypochon- driac symptoms intensified by a prison-like confinement. In Phila- delphia alone a number of such cases have leaped from their bed-room AvindoAvs. The fact that partial rest each day aAvay from home and under the surroundings of a Avell-regulated sanatorium is a most valu- able portion of the treatment will not make rest at the patient's home or in a boarding-house of equal effect. Shorn of its institutional set- ting, change of surroundings, and the expectancy that occurs when a number of such cases are treated together, this feature of the treat- ment is as often harmful as useful.' Rest and surface treatment in 206 DISEASES OF AVOMEN. lounge-ridden cases are much like certain farming observable in neglectful sections of the country where the surface-scratching of superficial farming fails to supplement the falloAv rest in producing good crops. In neurasthenia the causal conditions should be stirred from the foundation by appropriate medication and applications to the abdominal sympathetic. Electricity applied directly to the abdominal organs is a most valuable means of accomplishing this, and it should be supplemented by appropriate doses of exercise as Avell as rest,—the rest to folloAv each dose of electricity or mechanical exercise. Electricity has been used for years in this country in the treat- ment of neurasthenia, but it is to be regretted that its use has partaken so largely of the antiquated Duchenne methods as to be closely analo- gous to the soil-scratching style of farming referred to and equally imperfect in results. Even when retained in the hands of the physi- cian or an intelligent assistant these methods are merely a surface excitation, and fall far short of the possibilities that have been demon- strated by modern electrotherapy. Unfortunately, the battery is often relegated to the nurse under imperfect instructions, AArhich lessens still further any good results it might give. Aside from the assumption that an agent of this nature can be employed properly by unskilled persons, the fault of the Duchenne methods of motor stimulation in neurasthenia are: too great a reliance on the limited value of faradic currents; the use of electrodes of in- adequate size in the applications to the trunk, resulting in an insuf- ficient current-density at any point beneath the surface-muscles; and failure to apply currents of effective density to the abdominal ganglia and viscera. The excellent results derived from galvanic currents of 50 to 150 milliamperes in the utero- or vagino- abdominal applications of the Apostoli method first directed my attention to the value of large elec- trodes and considerable currents in these conditions. As a result of these gynecic applications, an improved general health is almost in- variable, Avhich, though in part due to the control exerted over the groAvth, must be often largely due to the necessary inclusion of the abdominal structures in the field of the current. Almost as good results in the stimulation of the sympathetic may be gained by placing the indifferent electrode beneath the back, in the shape of a very large wired-cotton pad, and the active one, Avhich should be six or seven inches in diameter, on the abdominal surface. A greater effect is neurasthenia. 207 obtained if the active electrode is given a circular motion, being lubri- cated by soaping, as all portions of the abdominal contents are thus successively brought under poAverful electric stimulation. The same pads are also useful in the administration of deeply- penetrating faradic currents, Avhich may follow the gahanic stimula- tion and should be primary; but time and effort may be economized by combining the primary faradic Avitn the galvanic after the galvanic alone has been employed, as this combination is peculiarly poAverful as a motor stimulant of relaxed muscular structures of all kinds, giving all the attainable efficiency of faradic currents, A\diile the more valuable galvanic current-action is continued. The applications to the peripheral motor-sensory apparatus are also best made by the galvanic current instead of the faradic, the patient continuing to lie on the large pad, Avhile the smaller one, which is to be kept negative and Avell soaped for lubrication, is carried over the motor points of each group of muscles of the limbs in a labile manner, all shock or unpleasant sensations being avoided by the free use of the controller and meter, the former permitting the current to be turned on after the pad is in position and off before it is re- moved from the limb. Only those muscles that are physiologically associated in action should be included in the same upAvard and doAvn- ward strokes of the pad. For full particulars of the mode of applying general galvanic stimulation the reader is referred to Chapter V. As complete motor stimulation of all the voluntary muscles is thus gained as is produced by the faradic current, Avith a greater stimulation of the peripheral nerves and tissue-metabolism. The sense of exhilaration is more marked than Avith the faradic current, and greater Avarmth of the extremities is produced. With scientifically applied currents as the principal feature of the treatment, other measures are conjoined as required, including mass- age if the bodily condition is much beloAv normal, rest for an hour after each treatment, nitrohydrochloric acid if the liver is sluggish,1 and possibly a gentle laxative for a time. In many cases thus treated the diet requires but little attention, for, above all things, Ave should not pamper the stomach, but rather Avhip it into obedience. The final result is apt to be a far more lasting acquisition of healthy blood and 11 helieve that the freshly-prepared C. P. XHC1 acid has a far-reaching effect in lithemic conditions, independently of a sluggish liver. 208 DISEASES OF AVOMEN. flesh than if the main features of the treatment Avere rest and over- feeding alone. In some cases, hoAvever, Avhere the nutrition is decidedly at fault, absolute rest may be used Avith great advantage for a time in connec- tion Avith the other remedies, but, if the electric treatment be of the kind described, the duration of absolute rest need not be greater than hvo Aveeks, to be folloAAred by hvo or four Aveeks of the electric treat- ment under the rest-and-exercise plan before the patient returns to the active affairs of life. The value of this modification of the "rest cure" has been attested by a number of years' successful employment Avithout a single failure, though previous experience Avith the rest-and-overfeeding method re- sulted in a number of partial failures to permanently cure the patient. Another most valuable systematic treatment of neurasthenia is that by static insulation, the static breeze, and light sparks draAvn from the most affected portions of the body. This method is specially recommended by Vigoroux, and probably acts by a general vasomotor and metabolic stimulation. Recovery is often indicated by an in- creased perspiration under treatment, particularly in cases that pre- sented a suppression of this excretion. On re-entering active life the former patient should remember that her indisposition Avas not one that had been acquired accidentally, but Avas the result of an imperfect response of the vegetative life to the particular environment; and AAdiile a continuance of the accustomed mental efforts may be conducive to a healthy will-poAver, nature ad- monishes her to seek a broader physical life, and to minimize the effects of artificial surroundings by spending a larger portion of each year in closer communion Avith itself. CHAPTER XV. Institutional Treatment. The importance of electricity as the chief therapeutic agent in the management of the neuroses and of many chronic disorders of an organic nature; its close association Avith massage, seclusion from accustomed environment, and other features of the rest-cure method; together Avith the necessity for costly equipment and special facilities for the application of strong currents in certain physical diseases, render some mention of institutional treatment specially appropriate to these pages. The practice of medicine is on the eve of evolutionary changes of vast magnitude. Closely associated Avith Avitchcraft, dhination, and the black art in past ages, it has not been Avholly emancipated from superstition even in the present century, in spite of a progress greater than the combined achievements of all preceding ages, for this progress has been largely confined to investigations as to the causation and ac- curate recognition of disease, and its cure by surgical methods, leaving the extension of knoA\dedge relating to the cure of disease by medical methods in a less advanced condition. The reason for this can only be the vast difference in the facilities offered for good Avork in these several departments, both in Europe and this country. In the leading European countries the governments directly foster and support inves- tigations relating specially to diagnosis, and in both Europe and America, particularly in the latter, numerous hospital establishments favor the development of surgical art. The absolute necessity of hospitals for good surgery, and the ease with Avhich charitable institutions may be made a\railable for this work, has resulted in a one-sided development of these establishments, Avhich has rendered them, at times, of but little service to purely medical art. And there are many reasons Avhy this should be so. A Avell- ordered charity hospital may do ideal work in surgery, for the master- hand itself may do the brief Avork that makes for success or failure, 14 (209) 210 DISEASES OF AVOMEN. leaving unessential details to less skilled hands; but the medical treat- ment of a charity case, in its best and most complete form, can rarely be administered by the chief physician Avithout a far greater sacrifice of time than he is able to make. This results in the Avhole machinery of the hospital being developed in a surgical direction, leaving it but imperfectly adapted for the treatment of any medical cases other than those acutely ill, or in Avhose cases the mere administration of drugs is sufficient. The charity hospitals have, therefore, been of but small value in the development of remedial arts as applied to the cure of non-surgical chronic ailments, for, in spite of a full appreciation of the value of drugs in this class of affections, it is not overstating the bare truth to say that they are of but little use. It is to natural forces and other physical agencies, carefully selected and applied by skilled specialists, that Ave must look for therapeutic advances that shall be commen- surate Avith similar advances in allied fields, and that this may be done it is absolutely necessary that special institutions be created for this particular purpose. It is but a remnant of superstition to rely upon advice and prescriptions Avhen the Avhole environment of the patient needs remedial adaptation; and this remedial adaptation can only be employed Avith adequate means and adequate appliances. Special institutions, thoroughly adapted to particular lines of Avork, are, therefore, a most necessary adjunct to modern medical progress, and the author looks fonvard to the time Avhen their value will be as Avell appreciated by the profession in all chronic affections as the modern hospital is appreciated as a means for good surgery. That the people for whose benefit they will be created already under- stand the value of institutional treatment is shown by the success of institutions noAv well patronized by them, some of which were estab- lished by uneducated persons. When this desirable improvement in the care of the non-surgical sick has been fully established, Ave will no longer be so inconsistent and untrue to our Avork as to present the spectacle daily Avitnessed of a physician prescribing mere drugs for well-to-do patients in a back parlor in the morning, which is bare of remedial appliances for the proper treatment of the persons who pay him for the highest expres- sion of his art, and in the afternoon catering to paupers in the splen- dors of a perfectly-appointed hospital. If the hospital facilities add to the welfare of the charity patient, surely institutional facilities are institutional treatment. 211 equally useful to the more deserving citizen. In reality there is a greater necessity for well-equipped work in battling with the ailments of intellectual beings, aside from the moral obliquity of a civilization that reserves its best services for its defective classes. The value of institutional facilities is particularly great in the practice of electro-therapeutics, owing to the magnitude of the instru- mental equipment required and the necessity for certain classes of ap- plications being performed under such circumstances that the patient may rest in bed immediately afterward. It also permits of a closer attention to details on the part of the chief physician, through an economy of his time, and makes it convenient to associate with the main element of treatment other remedial agencies of great service in this class of cases, such as scientific massage, radiant heat-baths, good nursing; regulation of dietary, rest, and exercise; and the mental medicines of discipline, expectancy, and environment. CHAPTER XVI. Maternal Sterility and Impotence. Aside from congenital deficiencies and anomalies of development of the essential organs of generation, Ave have been taught, since the days of Marion Sims, that the chief reason for sterility attributable to the Avoman is narroAvness or flexion of the uterine canal. When it is remembered that the narroAvest pin-hole os will admit a sound on careful manipulation Avhich is many times larger than the self-pro- pelling spermatozobid it Avould seem that this reasoning is incon- clusive. It is doubtless to the operative furor that the popularity of the stenosis-and-atresia theory of sterility is due, for, since the days of Sims and J. Y. Simpson, practically no form of treatment has been employed except some method of enlargement of the canal. This Avas at first accomplished by slitting the cervix, producing artificially, in other Avords, the same lesion for the seAving up of Avhich other costly operations Avere later devised. OAving to the combined ineffectiveness, morbidity, and mortality of this procedure, it has, of late, been super- seded by so-called "dilatation," Avhich is accomplished only by tearing apart the muscular and fibrous tissues that encircle the canal by poAverful steel instruments. Only exceptionally has this accomplished a cure of the sterility, Avhile it is, at times, folloAved by serious con- sequences in the shape of parametritis and diseased appendages. One case of ectopic pregnancy and a number of instances of uterine and OA^arian tenderness have been obseiwed by me after dilatation for this purpose in patients Avho Avere free from tenderness preAuously. Far more prominent causes of sterility may be found in imperfect participation of the uterus in the sexual orgasm, catarrhal changes in the mucus of the uterus and tubes, and inactive ovaries,—the last tAvo being the most important. A lessened aspiratory action of the uterus, Avhile rendering conception less certain, cannot be a serious impedi- ment, on account of the automobile poAvers of the spermatozooids. This defect may, hoAvever. be materially lessened by the general intra- pehic action of electricity, promoting the nerve-tone of the organs, (212) STERILITY and impotence. 213 particularly of the uterus and ovaries; increasing muscular contrac- tility; and quickening circulation. The method best adapted to accomplish this purpose is the vagino-abdominal galvanic application with covered vaginal electrode, Avhich should be negative, a current of 30 to 40 milliamperes being turned on and off, gradually and re- peatedly, by the swelling method. This may be supplemented Avith labile lumbar applications of the galvanic current to the sexual centre of the cord, the patient lying upon the face Avith a large pad under the abdomen. Of the toxic effect of altered uterine secretions on the fertilizing cells of the semen there can be no question, and it is in these cases that galvanic electricity applied Avithin the cavity of the uterus is of the greatest service by its alterative action on the secreting surface. Unless the intra-uterine treatment is indicated, also, by marked changes in the mucous membrane, the covered elastic electrode is best as promoting favorable changes in the mucous membrane Avith least traumatism. It has been my habit to employ the positive pole usually, though the choice of pole for this purpose is open to further investigation to determine whether the normal alkalinity of the uterine mucus should be increased by the negative pole or diminished by the positive pole. Possibly neither effect is important, the results depending rather on the simple excitation of a more normal secretion. Deficient activity of the ovaries can only be inferred as a cause of sterility in the absence of any demonstrable lesion or more patent defect of functionation on the part of the Avoman, and, of course, after the question of the possible sterility of the husband has been elim- inated. It may or may not be associated Avith lack of sexual appetence and responsiveness, for many Avomen conceive readily in whom the orgasm is deficient or absent. Any method of treatment that pro- motes increased activity of the pelvic circulation, such as negative A'agino-abdominal applications of either current, may increase ovula- tion, Avhile the musculo-tonic effect of the galvanic current turned on in the swelling manner repeatedly may do much to lessen a practical maternal impotence from Aveakened musculation, which is only less disastrous to the conjugal relation than similar conditions in the male. But feAV instances of this affection have been placed under my care for the purpose of curing the sterility,—but the in all, in four of which the treatment Avas successful at some time during a year follow- ing the cessation of the treatment, tAvo instances being almost imme- 214 DISEASES OF AVOMEN. diate. In one case that Avas a failure up to the date of her last report to me the ovaries Avere both prolapsed and the tubes also probably involved in the remnants of an old pelvic inflammation. Her sympto- matic condition Avas, nevertheless, improved. The slight attention paid to this subject is doubtless due, in part, to a lack of information as to the value of this method and, in part, to the prevalent disinclination of American Avomen for the burdens of maternity. That electricity may cure sterility Avhen the patient only asks that the pelvic pain of uterine inflammation be cured is shoAvn by the table on pages 384-87, Avhere, of thirty-tAvo cases of uterine disease that involved at least temporary or acquired sterility, eight had become pregnant after the treatment when my report Avas made (September, 1894). In a paper by Apostoli read at the same meeting of the American Electro-Therapeutic Association, as many as eighty cases Avere recorded as having become pregnant after intra-uterine electric treatment, some of them having conceived shortly after one application. Apostoli does not mention hoAV many of his cases Avere nulliparous after some years of marriage and, therefore, sterile, but of the tAventy-hvo cases reported in extenso in the paper,1 five Avere nulliparas. An interesting case of prolonged hemorrhagic metritis in a nullipara, the cure of Avhich Avas folloAved by pregnancy, is detailed on page 83. 1 Transactions of the American Electro-Therapeutic Association, page 371. 1894. CHAPTER XVII. Ectopic Gestation and Obstetrics. Ectopic Gestation.—This accident, Avhich has been proven of late to be of considerable frequency both by the records of carefully con- ducted post-mortem examinations and the experience of surgeons, is probably even more frequent in occurrence still, as many cases doubt- less recover after extraperitoneal rupture Avithout the diagnosis having been made. It is beyond the scope of this Avork to enter into a full discussion of the etiology and natural history of ectopic gestation, since the A-alue of electricity as a sole or principal remedy is confined to a certain stage of gestation only,—namely, from conception to the end of the fourth month, after Avhich time the consideration of the affection belongs exclusively to the surgeon. During these early months, never- theless, the electric treatment is clearly the method of choice, since it has been established by many competent observers that at this time the ovum may be devitalized and its complete absorption secured by this means, Avithout subjecting the patient to the dangers and uncer- tainties of abdominal section. Lawson Tail's classification of ectopic pregnancy, Avhich is gener- ally received, is as folloAvs:—- I. 0\arian, possible, but not proved. II. Tubal, in free part of tube, is (a) Contained in tube up to fourteenth Aveek, at or before Avhich time primary rupture occurs, and then progress of gestation is directed into (b) Abdominal or intraperitoneal gestation; uniformly fatal (unless removed by abdominal section), pri- marily by hemorrhage, secondarily by suppuration of the sac and peritonitis. (c) Broad ligament, or extraperitoneal, gestation, which (215) 216 DISEASES OF AVOMEN. (d) May develop in broad ligament to full term and be removed at viable period as living child. (e) May die and be absorbed as extraperitoneal hema- tocele. (/) May die and suppurating ovum be discharged at or near umbilicus, or through vagina, bladder, or in- testinal tract. (g) May remain quiescent as lithopedion. (/j) May become abdominal or intraperitoneal gestation by secondary rupture. III. Tubo-ovarian, or interstitial, is contained in part of tube embraced by uterine tissue, and, so far as is knoAvn, is uniformly fatal, by primary intraperi- toneal rupture (as b), before fifth month. From this it will be seen that the question of electric treatment is concerned only Avith Class II (a), unruptured tubal pregnancy before the fourteenth or sixteenth Aveek, and with the same condition after early rupture into the broad ligament, AAdiere it continues to develop, as in II (d). Tubal pregnancy is, by far, the most frequent form, and its early diagnosis becomes, therefore, a matter of great im- portance, though attended with much difficulty. Indeed, the possi- bility of diagnosis before primary rupture of the sac into the broad ligament, Avhich occurs at about the fourteenth Aveek, has been denied by some authorities, yet a reasonably certain diagnosis has been made by both surgeons and electro-therapeutists in many instances of late, some of them of sufficient certainty to Avarrant the surgical removal in the absence of proper electric treatment and all of them certain enough to Avarrant the electric treatment, Avhich Avould be equally applicable to most of the conditions for Avhich it could be mistaken. And herein lies one of the hvo chief advantages of electricity at this stage of ectopic gestation. Given a reasonable presumption that the case is one of tubal or intraligamentous pregnancy, the physician is not compelled to take the horrible responsibility of counseling a pos- sibly unnecessary unsexing operation in a young Avife, but, Avith a full recognition of the possible gravity of the case, may subject her only to the discomfort of absolute rest in bed for one or more months, and daily applications of a method that will kill the fetus if one be present, and subsequently promote absorption of the ovum and surrounding ECTOPIC GESTATION AND OBSTETRICS. 217 congestion, and, if the case is not one of ectopic gestation but a sud- denly enlarged tube from inflammatory congestion, an ovaritis, or a small fibroid, will be equally effective in arresting progress and con- tributing to a future cure. The laudable object of verifying the diag- nosis is secondary to the best interests of the patient, and in this case the patient's true interests point to the avoidance of the operation if the trouble can be cured Avithout it, Avhether its true nature is ever proved or not. The selection of electricity as the appropriate treatment is nar- roAved doAvn, as before stated, to tAvo stages in tubal pregnancy: (1) before rupture into broad ligament at or about the fourteenth Aveek; (2) after rupture into broad ligament. Diagnosis of Tubal Pregnancy Before Rupture.—Unfortunately, there are too often no symptoms to alarm the patient, or even to cause her to suspect pregnancy, until the onset of primary rupture of the sac into the tube, and this is not so surprising, when it is remembered that no small proportion of cases occur in those neAvly married, and therefore unfamiliar Avith the subjective symptoms of pregnancy, and in others Avho have been sterile so long as not to be looking for such a contingency. Such cases, moreover, are liable to have long felt some discomfort in the pelvis from latent catarrhal disease of the uterus or tubes, Avhich is possibly an important etiologic factor in the arrest of the OArum in the tube. The symptoms at this stage, if any be noted, are likely to be those of a normal pregnancy, usually accompanied by a continuance or even more frequent and abundant menstruation. More positive symptoms may, however, cause the patient to consult her physician, and these are the colicky paroxysms, attributed by Parry to contractions of the cyst. By others they have been attributed to minute hemorrhages. More likely they are merely the neuralgic ex- pression of an unaccustomed and groAving tension of the tube, the universal habit of sensory nerves being the explosive expression of a continuous tension or irritation. While the habit of examining all Avomen in the early months of even supposedly normal pregnancy should be aimed at as a routine measure, the physician should in- A'ariably make an examination by touch Avhen pain of this nature is complained of. On bimanual examination, Avhich, in a suspected case, should be as gently conducted as is consistent Avith a thorough mapping out of the pelvic contents, a soft, elastic, scmifluctuating tumor will be 218 DISEASES OF AVOMEN. found in the region of the tube, on one or other side of the fundus, corresponding, in size, to the development of the ovum.' This mass is quite evidently cystic to the educated touch and is usually more tender than any other cystic tumor with which it can be confounded. The cervix will present the softening peculiar to pregnancy, but the uterus will be found to be smaller than it should be at a correspond- ing period of normal pregnancy. Such are the presumptive signs of a tubal pregnancy prior to rupture. Though abdominal sections have been performed on the strength of diagnoses so arrhed at, and the condition at times veri- fied, there is grave reason to doubt that the diagnosis can be suffi- ciently certain before operation to Avarrant so extreme a measure. Indeed, cases have been recently reported Avhere the finding of slight traces of bloody serum near the tube Avas accepted by the operator as justifying- the operation, even Avhen no other evidence of the ovum could be found. Fortunately, these vieAvs Avere combated at a meet- ing of the XeAV York Obstetrical Society by Dr. A. Palmer Dudley,1 Avho explained that similar conditions had been found by him in operations during menstruation in the absence of any kind of preg- nancy. The gravity of the conclusions that lead a surgeon to per- form a dangerous operation resulting inevitably in castration on a young Avife of a feAV Aveeks or months is by no means slight, and Avhen this grave risk and abhorrent results are deliberately preferred to electric treatment, with the abundant testimony in its favor at this stage of the disease, the conduct of the surgeon savors of mal- practice, and should be condemned by all honest physicians. And this may e\ren be said of a case Avhere the presumpthe eA-idence of an unruptured tubal pregnancy is very strong, as there is, at this stage, no reason Avhatever why complete absorption should not follow electric feticide, permitting the tube even, and surely the ovary, to be subsequently brought into a healthy condition under vaginal applications. There is. on the contrary, no contra-indication to electricity Avhether the diagnosis be certain or uncertain. If it is a case of tubal pregnancy it may be cured in this way. If it be not, no harm is done by the treatment, Avhich may even be equally adapted to the actual diseases present, such as a salpingitis Avith exudation, lNew York Gynecological and Obstetrical Journal, page 109, July, 189G. ECTOPIC GESTATION AND OBSTETRICS. 219 or a non-purulent enlargement of the ovary. Both of these condi- tions are, in fact, relieved Avith such certainty by vagino-abdominal galvanic and faradic currents as to frequently leave the physician in doubt as to the true nature of the disease; but surely no sane woman Avould Avish an abdominal section to satisfy a scientific inquiry of no concern to her. Such ignorance can surely be borne in con- nection Avith the bliss of restored health, plus the retention of im- portant functions, Avhen Avisdom is purchased at such a cost. Diagnosis of Tubal Pregnancy At and After Rupture.—After rupture of the sac has occurred the diagnosis is far easier to make than before rupture. A sharp, agonizing pain in the pelvis, accom- panied by more or less collapse,—anxious expression, fainting, cold and pallid skin bedeAved Avith a cold perspiration, and a rapid and feeble pulse becoming imperceptible,—betokens a rupture into the peritoneal cavity if an antecedent history of presumptive pregnancy can be obtained and the pelvic examination coincides. The physical signs of intraperitoneal rupture obtainable by touch are not so Avell marked as A\dien the rupture is into the broad ligament. The mass at one side of the uterus is boggy and usually less in size than pre- vious to rupture. When the rupture is into the broad ligament a tense, exceedingly painful tumor is found on one side of the uterus, usually pressing the latter to the opposite side of the pelvis. To determine Avhether the case is suitable for electricity or must he at once consigned to surgery it is important to distinguish be- tAveen a rupture into the peritoneal cavity or into the broad liga- ment. The former produces the more profound shock and collapse, and on vaginal examination a less prominent tumor is found. The latter is accompanied by less shock and presents a more rounded, tense, and prominent tumor. In either case a Aoav from the uterus may exist, simulating abortion, from Avhich it is to be distinguished by the smaller size of the uterus, the possibility of, at times, making out a sulcus betAveen the tumor and the fundus, and finally by find- ing the uterus empty should it be thought necessary to sound it. Additional causes of error are confounding it Avith rupture of another Adscus, hematocele or hematoma from other causes, or a violent attack of hysteria. Should the condition of the patient indicate that the hemor- rhage is into the abdominal cavity instead of merely Avithin the layers of the broad ligament no time should be lost in haAdng the 220 DISEASES OF AVOMEN. abdomen opened and the bleeding-points tied by a competent ab- dominal surgeon. The whole question of the use of electricity hinges, therefore, on the presence of free bleeding into the abdomen. Electric Treatment.—As before remarked, the purposes of the electric treatment are hvofold: to kill the fetus and to cause its absorption. To accomplish the former poAverful currents are re- quired, which should ahvays be turned on gradually with the con- troller, and in the case of the galvanic current it is best to employ galvanic alternatives, the internal electrode being alternately posi- tive and negative. The current should be turned on gradually, held for tAvo minutes, turned off gradually, the polarity reversed Avithout removing the electrode, and the procedure repeated Avith the current in the opposite direction. The ordinary vagino-abdominal method (page 56) is employed, a cotton-covered vaginal electrode being pressed against the tumor in the vagina, Avith a large, moist, clay pad or other efficient dispersing-electrode on the abdomen. Faradic currents, Avhich should preferably be the primary of a poAverful coil, are thought to be best by some, and it is therefore Avisest to use both currents, one after the other, at least once daily until the sac shrinks and becomes less tender. The same treatment should then be continued at greater intervals and less dosage until absorption seems Avell under Avay. The gahanic dosage should be from 100 to 150 milliamperes and the faradic to point of endurance, all possibility of shocks being eliminated, particularly if rupture into the broad ligament has oc- curred. Dr. A. Brothers, of Xew York, has made a careful statistical study of the cases reported in medical literature, and his last paper1 on the subject deserves to be quoted in full as presented to the Amer- ican Electro-Therapeutic Association in September, 1893:— "First employed in Italy by Bachetti in 1853, and later by Braxton Hicks in England in 1866, the electric method of treating ectopic gestation was first resorted to on this side of the Atlantic by Allen, of Philadelphia, in 1869, and has since remained almost a purely American plan of treatment. In the paper which I Avrote, five years ago, for The American Journal of Obstetrics (May, 1888) 1 "Present Position of the Electric Treatment of Extra-uterine Pregnancy," Transactions of the American Electro-Therapeutic Association, page 170, 1893. ECTOPIC GESTATION AND OBSTETRICS. 221 I collected statistics of forty-three cases treated by electricity, with one death. In a paper published two years later, on the 'Subsequent Behavior of Cases Treated by Electricity,'1 I found that the twenty- five cases which I had been able to trace were doing well after a lapse of one to eight years, and that none of them had been com- pelled to undergo secondary operations. Many of these patients still carried traces of the old trouble, but without perceptible incon- venience. "Within the last few years the epidemic of laparotomy fever which originated in Europe has infected our shores and spread over our continent to such an extent as to temporarily displace this treat- ment from the position it properly deserves. As a result, the litera- ture of the past few years shows a smaller number of cases published than we should expect from the past success of this treatment, although a small band of able practitioners continue to adhere to their convictions and employ it, under judicious restrictions, Avher- ever it is properly indicated. "To bring this subject down to the present I have reviewed the literature at my command, and am thus enabled to present the table on pages 224 and 225. "I have therefore been able to find records of eighty-five cases of extra-uterine pregnancy in which electricity was employed to de- stroy the fetus. I do not regard this as a complete list, for some cases have been OArerlookecl and others have not been published. It is sufficient, hoAvever, to sIioav that the method has been pretty ex- tensively employed. "In two cases (60 and 61) the treatment apparently failed in the hands of very able men (Coe and Wenning), but subsequent lap- arotomy showed the diagnosis to have been faulty, for in both cases the gestation Avas intra-uterine. Coe saved his patient after she aborted, but Wenning, AA'ho had resorted also to aspiration, was un- fortunate in losing his. In Case 81. that of LeAvis, electricity was discarded and abdominal section performed, resulting in recovery.2 In one of Blaclct., 1877 N. Y. Med. Jour., March, 187S. . . . Trans. Am. (iyn. Soc., 187!)..... Trans. Am. (i'vn. Soe., 1SS2..... Am. Jour, otOhst., April, 1881 . . . Trans. Am. (ivn. Soe., 18s2..... Med. News, August S, 1882..... 'Trans. Am. (iyn. Soe., 1882..... Am. .lour, of Ohst., Feb., 1882 . . . Am. Jour, of Obsl.. Sept., 1882 . . . Trans. Am. (ivn. Soe., 1882..... Allg. mcd. Ceiitrztg., April, 1883 . . Beanl and Rockwell's '• Electricity " Beard and Rockwell's " Electricity " Beard and Rockwell's " Electricity " Trans. Am. (iyn. Soe., 1881 . . . * Trans. Am. (iyn. Soc., 1SNI . . 'Trans. Am. (i'vn. Soc, 188} . . . Am. Jour, of Ohst... (let., 1,881 . . Bost. Med. and Surg. Jour., Sept., 1884 Polyclinic, 1881. No! 15...... Med. News, July 11, 1885..... Med. News, July 11, 1885..... Am. .lour, of Ohst., Aug., 1885 . Med. News, Dec 12. 1885 .... Med. Rec, Jan. 23, 1880..... Med. Rec, June 20, 1880 .... Br. Med. Jour., Dee. 4, 1880 . . . Br. Med. Join., Dec 4, 1880 . . . Trans. Am. (iyn. Soc, ISSli . . . Br. Med. Jour., Dec 4, 1880 . . . Am. Jour, of Ohst., Dec, 1880 . Trans. Am. (iyn. Soc, 1887 . . . Annals of (iyn., Jan.. 1888 . . . . Trans. Am. (ivn. Soe., 1887 . . . Med. News, Jillv 11, 1885..... Am. Jour, of Ohst., April, 1887 . Am. Jour, of Ohst., April, 1887 . Am. Jour, of Ohst., May, 1888 . . Current. Electro-puncture Karadisni.... Karadism .... Karadism .... Karadisni .... (ialvanisin . . . Karadisni.... Karadisni. . . . Karadism .... Karadisni. . . . Karadisni. . . . Galvanism . . . (ialvanisin . . . Karadisni.... (ialvanisin . . . Static electricity (ialvanisin . . (ialvanisin . . . (Jalvanism . . . Karadisni. . . . Karadism, later g (ialvanisin . . . (ialvanisin, later (ialvanisin . . . (ialvanisin . . . Karadisni.... Karadisni. . . . Karadisni .... Karadism .... Karadisni.... alvanism . . . aradism .... aradism .... alvanism . . . alvano-punetui' aradism .... aradism .... alvanism . . . alvanism . . . )....... alvanism . . . alvanism . . . aradism. . . . Nationality. Result. Italy . . England U. S. . u. s. . IT. 8. . IT. 8. . IT. S. . IT. S. . IT. S. . IT. H. . U. S. . IT. S. . H. S. . D. S. . 0. S. . (iernian D. S. . K. S. . IT. S. . IT. S. . Sill D. S. . IT. S. . Sin K. S. . V. S. . U. S. . K. S. . ilk. . U. 8. . IT. S. . U. S. . IT. S. England Canada U.S. . England IT. S. IT. S. IT. 8. IT. S. H. S. V. K. IT. S. U.S. Recovery. Death. '. Recovery. Recovery. Recovery. Recovery Recovery. Recovery. Recovery. Recovery. Recovery Recovery. Recovery. Recovery. Recovery. Recovery. Recovery Recovery. Recovery. Recovery. Recovery. Recovery. Recovery Recovery. Recovery. Recovery. Recovery. Recovery. Recovery Recovery Recovery. Recovery. Recovery. Death . Recovery. Recovery. Recovery. Recovery. Recovery Recovery. Recovery. Recovery. Recovery. Puncture later caused death. Kctus discharged through vagina. Same case as No. 5. Normal pregnancy not disturbed. Collapse after first application. Kctus expelled into uterine cavity. Also puncture. Fetus removed through vaginal rent. Kat:d result after third application. Fetus extracted through vaginal [rent. i.e of Cases of Extra- cterine Prfcnancy Tueatf.d by Electricity (covchuh d). Case of Tavlor . . . AValker. . . (ialabin . . Ivletzseh . . Buck master Duncan and Steavenson Bolton and Steavenson Benton . . Uierwirth Edebohls . Coe .... Hanks . . McLean Coe . . AVenning Blackwood . Blackwood . Blackwood . Blackwood Blackwood . Blackwood . Blackwood . Sinouse . . Martin . . . Nedswetsky Nedswetsky AVarnek . . Kalahine . . Lewis .... St. John . . . (irandin & Coh (Tarriker . . . Ncdoroloff . . Reported in Med Rec. June 29. 1889 Med. Rec, Nov. 10, 1889 . Arch, de Tocol.. xvi, 1889 . Am. Jour of Ohst., 1888, xxi Med. News, 1888, liii . . . Br. Gyn. Jour., 1888 . . . Br. Gyn. Jour., 1888 . . . (Jaillard's Med. Jour., 1888 Ciaillard's Med. Jour.. 1888 Med. Rec, Dec. 7. 1889 . . Am. Jour, of Ohst., 1890 Am. Jour, of Ohst., 1890 . Am. Jour, of Ohst., 1890 . Am. Jour, of Ohst., 1890 . Am. Jour, of Obst., 1890 . Correspondence..... Correspondence ..... Correspondence ..... Correspondence ..... Correspondence ..... Correspondence ..... (Torrespondence..... Trans. Iowa Med. Soc, 1890 Austr. Med. Gaz., vol. ix Ann. de gvn. et d'oh., 1890. xxx Ann. de gyn. et d'oh., 1890, xx _ Ann. de gvn. et d'oh., 1890, xxx Ann. de gyn. et d'oh., 1890. xxx Trans. Col. Phys. Phila., 1891 •Tour. Am. Med. Assoc, 1892 N. Y. Jour. Civn. and obst., 1892 Edect. Med. .lour., 1892 Index Medicus, 1892 . . Current. Nationality. r/.v dischai g< d through rectum. Drbris discharged through vagina. Kctus expelled into uterus. Electricity discarded and laparot- j omy perfoi med. Kctus expelled into uterus. Kctus expelled through vagina. 226 DISEASES OF AVOMEN. every case in Avhich diagnosis is possible. On a middle ground, one lying betAveen these extremes, the truly conservative surgeon will find his appropriate position." "Although Pozzi in his 'Treatise on Gynecology' (American edition, 1892) condemns the use of electricity, the able editor of this Avork (B. H. Wells), quoting Byford, says: 'If Ave have a case of extra- uterine pregnancy in the early months it is safe to destroy the fetus by electricity and keep the patient in bed until absorption has no- ticeably commenced. If profuse, repeated hemorrhages occur, it is safer to operate at once.' "Parvin1 says: 'Throwing aside all doubtful cases, there remains a strong argument from actual experience in favor of the treatment of ectopic gestation, prior to the rupture of the fetal cyst, by elec- tricity.' "The Avorks on electricity in its relation to gynecology by A. H. Goelet,2 and Grandin and Gunning,3 are likeAvise strongly in favor of the employment of electricity in the treatment of early cases of ectopic gestation. Byford, Mann, Skene, Wilson, and many other eminent specialists in gynecology have also in recent times expressed themselves in favor of this plan of treatment. "The Boston Medical Society, at its meeting held on November 12th, 1892, received the report of the chairman of a committee ap- pointed to investigate the present condition of medical opinion Avith regard to the subject of extra-uterine pregnancy.4 The report reads: 'Immediate celiotomy, so soon as the diagnosis is established, is then, in the judgment of your committee, the only treatment Avhich should be considered before rupture of the tube.' If the gentlemen of this committee can spare the time to review the facts gathered in this paper, they may charitably allow a small place, at least, for the treat- ment of some of these cases by electricity. The fact is, in spite of the highly moral position taken by Lawson Tait, that feticide in extra-uterine pregnancy is considered justifiable in the interests of the mother by a great many practitioners. It is also a fact, which this paper proves, that, beyond one death in seventy-eight cases, no 1 "Science and Art of Obstetrics," Philadelphia, 1890. 2 "The Electro-therapeutics of Gynecology," Detroit, 1892. 3 "Practical Treatise on Electricity in Gynecology," Xew York, 1891. 4E. Reynolds, Boston Medical and Surgical Journal, January, 1893, vol- ume cxxviii, page 107. ECTOPIC GESTATION AND OBSTETRICS. 22T injury has ever been done by the use of electricity, and Avhere it has been directly abandoned for laparotomy no harm Avas done by the previous treatment. The treatment has maintained its reputa- tion for harmles.sness; and although, in the eyes of some, it has been dubbed 'ridiculous' and 'coAvardly' and the product of 'ignorant ob- stinacy," it continues to assert itself as a simple, innocent procedure which has its own proper sphere of usefulness." Dr. Brothers's list is, in itself, sufficient to establish both the possibility of electric feticide and the advisability of its employment in the class of cases recommended in this chapter; but, when con- sidering it as a record of the cases of this nature, Ave should remem- ber that many other patients have been cured under vaginal galvanic applications Avhich Avere possibly instances of extra-uterine pregnancy, but where diagnosis Avas too uncertain to permit them to be consci- entiously reported as instances of this affection. Abortion.—From Avhat has been said in the preceding paragraphs it is evident that in electricity Ave have a feticide of positive and definite value Avhich, Avhen applied Avithin the uterus, is certain to arrest the life of the embryo in those cases Avhere a consultation determines the necessity for so terminating the pregnancy. The negative pole of the galvanic current is preferable, as it attracts moisture by cataphoresis and excites noAv, the current-strength being from 30 to 75 milliamperes, applied on a carefully asepticized sound- shaped electrode insulated beyond the internal os. Five minutes is a sufficient duration every other day for a Aveek, Avhen it Avill be found that the ovum is so reduced in size and detached as to readily pass aAvay with but moderate uterine contraction. The first applica- tions are best made Avith the elastic instrument (Fig. 33), even cotton- covered, as by this instrument the chances of puncturing the ovum are diminished and the likelihood of its expulsion entirely increased. A feAV faradic applications subsequently will hasten involution. Hyperemesis Gravidarum.—Among the many useful remedies for the excessive nausea and vomiting of pregnancy none is more certain than the application of a fine-Avire faradic current to the solar plexus at the epigastric region. The anode should be placed at the back of the neck and the cathode, or negative pole, at the pit of the stomach, carefully avoiding the uterine region. The special value of this pro- cedure, Avhich is confined to fine-wire currents, is the direct sedation produced by it, though certain cases require instead that the sympa- 228 DISEASES OF AVOMEX. thetic nerves in this situation should be stimulated by galvanic cur- rents of 15 to 30 milliamperes applied from pads placed in the same position. Either of these procedures is likely to succeed in cases Avhere everything else fails, rendering the induction of artificial abortion unnecessary. Use of the Faradic Current in Labor.—This is a subject of vast importance to the practicing obstetrician, for by this much-neglected means a too-sloAv labor may be hastened, atony of the uterus cor- rected, post-partum hemorrhage instantly controlled, and involution so hastened by a few, or at times only one, applications, as to mate- rially lessen the lying-in period. Suggestions of this nature Avere made a number of years ago Fig. 64.—Gaiffe's pocket faradic battery. The exciting fluid is made in a few moments from bisulphate of mercury carried in a bottle (K) in a dry state, a spoonful of Avhich is to be added to each of the cells (L), Avater added, and the zincs replaced. by Tripier, and more recently by Dr. W. T. Baird, of Texas, and Dr. R. J. Xunn, of Savannah, Ga.; yet, doubtless owing to the fact that the busy accoucheur has no battery Avith him in the lying-in chamber and if he sends to his office for it finds it out of order, but little use seems to have been made of these suggestions. Bearing in mind that it is the faradic current only that is of service at this time, the remedy for this practical difficulty is the addition to the regular contents of the obstetric bag of a small Gaiffe battery (Fig. 64), Avhich is inexpensive and ahvays ready for use, for the solution employed is made instantly by the addition of a little Avater to a ECTOPIC GESTATIOX AXD OBSTETRICS. 229 spoonful of the bisulphate of mercury carried in the battery-case. A more powerful coil is, at times, of greater service, but, as the prin- cipal obstetric uses of the faradic current are due to its contractile power, the primary coil of the Gailt'e battery should be employed and the resistance of the circuit diminished by having the external pole or poles increased in size by a folded toAvel Avell wetted with a solu- tion of table salt. It should not be overlooked, also, that in all houses that are lighted by the Westinghouse alternating system (page 352), Ave have an excellent faradic current at hand by simply un- screwing a lamp and placing a Massey or Jewell controller in circuit with the patient, Avhen a current of any strength is obtainable by turning the crank to a point that gives perceptible results. Inertia Uteri.—The contracting poAver of the faradic current is not entirely barred by the presence of the child in the uterus, for, if the usual head presentation exists and inertia of the uterus occurs in spite of a Avell-dilated cervix, Ave may apply the electrodes (either ordinary disk-electrodes or, preferably, pads about the size of the palm of the hand) on either side of the fundus near the navel, and turn the current on forcibly at the inception of each pain, or about the time the pain should appear, turning it off at each intermission and repeating the procedure regularly for a time. This -will not en- danger the heart or respiration of the child, being too far from these vital organs, and Avill usually soon produce such vigorous con- tractions that the forceps may be left untouched Avhile time is saved to the physician and much suffering saved to the patient. My oavii limited experience agrees Avith the statement of Dr. Baird, that the turning on of the current synchronously Avith the pains very mate- rially lessens the suffering of the patient, even in normal labor, Avhile at the same time the expulsive forces are re-enforced. Post-partum Hemorrhage.—When this alarming accident is due to inertia of the uterus, Avhich fails to contract properly and promptly after delivery of the placenta, there is nothing equal in immediate and thorough results to the primary or coarse-Avire faradic current applied with a bipolar electrode Avithin the uterus or a single active pole in that situation and the other on the abdomen. The bipolar electrode (page 66) should be of the kind capable of thorough asepsis, pref- erably in the flame of the alcohol-lamp, and the monopolar electrode should be blunt and properly insulated and asepticized. In an emer- gency Avhere such instruments are inaccessible an intra-uterine elec- 230 DISEASES OF AVOMEX. trode may be improvised for so large a cavity from a piece of wire about a yard long and a piece of rubber tubing a foot or eighteen inches long, in the folloAving manner:— Bare a considerable portion of the Avire, if covered, and bend this end in a long loop; twist and fold the end of the loop into a ball that will project beyond the end of the rubber tube Avhen it is passed through it, one end of the Avire remaining Avithin the tube and the other end being brought out at the opposite end of the tube and tAvisted around the tip of a conducting-cord, to make connection. The Avhole should now be immersed in boiling Avater for a feAV mo- ments to insure cleanliness, after Avhich the knobbed end may be inserted into the cavity and the instrument connected with one cord of the battery. The other electrode is placed on the abdomen and, if only an ordinary disk-electrode, may be increased in size by putting a folded napkin beneath it, Avell Avetted with salt Avater. The faradic current only is to be applied in this Avay. Recent Subinvolution.—This subject has been treated of else- Avhere (page 98), but it should be said, in this place, that subin- volution of the first or second month should be treated by the faradic or alternating current, preferably bipolar, though monopolar intra- uterine applications of either of these currents will check hemor- rhage, hasten involution, and not only permit a prompt getting-up, but avert later consequences in the shape of invitations to catarrhal invasions that so often supervene on this condition. CHAPTER XYIII. Maligxaxt Growths. Amidst the many uncertainties as to the true nature of the various forms of cancerous disease there are seAreral facts that all authorities are agreed upon, chief of which are the strictly-localized character of the affections in their primary stages, and that the seat of malignancy must reside in the special forms of cells found in the several growths. A most important question yet undecided is the true relation of these cancer-cells to their environment. That this relation is that of an inoculable germ to a culture-medium Avould seem to be indicated by the facility with Avhich autoinoculation may occur, either by grafts conveyed by the lymphatic or venous circula- tions or distributed to surrounding absorbent surfaces by the knife used to cut the tumor. Yet the persistent efforts of several observers have been but indifferently successful in the grafting of cancer from animal to animal. It is evident that the conditions of propagation are of a far more delicate nature than those attending the ordinary microbic affections, and that the discovery of these conditions will be associated with a greater advance in our knoAvledge of the nature of cancer than has occurred in modern times. The important question of the prevention of cancerous affec- tions, Avhich are said to haAre doubled in frequency in the past forty years, must aAvait this definite knowledge of their causation. ISTot so their treatment, for the twin facts of a primarily-local situation and delimitation of malignancy to the structure itself indicate that early and thorough remoAral or destruction of the malignant cells is the proper course. While this early destruction of a local malignant groAvth is uni- versally recognized as the only hope for its successful eradication, its accomplishment by the ordinary means noAv employed, the knife and caustics, is rendered difficult by the absence of a limiting mem- brane or capsule, there being no distinct line of demarkation between the morbid growth and surrounding tissues, the growth tending to (231) 232 DISEASES OF AVO.AIEX. invade the latter in every direction by irregular prolongations, \vhich are often extremely difficult to trace and remove at the operation. A means or agency Avhich would not only destroy all easily-accessible cancer-cells, but also traverse selectively these prolongations Avith the same result, is necessarily a most important step in the curative thera- peutics of this affection. Such a means the Avriter presented to the profession at the meeting of the American Medical Association at Philadelphia in 1897, in the massive dissemination of the nascent oxychlorides of mercury and zinc throughout the tumor and its rami- fications.1 The special merit of this method is that not only are the malig- nant cell-structures destroyed in all portions of the groAvth Avhere they are evident to the senses, but the hidden ramifications are also sought out by a diffusing current carrying nascent chemicals of a lethal character, Avhich traverse the cancer-ramifications as paths of least resistance, thus substituting a physical laAv for the unaided senses of the operator as a detecter and destroyer of the more distant ramifica- tions. In addition, it is the purpose of this method to arouse the defeated physiologic resistance of the surrounding tissues into re- neAved activity, that the errant cellular action may be again brought under the control of the trophic nervous system. The treatment of cancer by electricity alone is by no means a neAv thing, instances of successful results having been published by many physicians during the last forty years, and an important paper contributed to the subject by Dr. Robert NeAvman, of New York, at the meeting of the American Electro-Therapeutic Association in 1891. That these reported results attracted but little attention Avas doubtless due to the fact that they all, Avith the exception of those of Dr. Newman, occurred in the dark ages of electricity, AArhen it was practically impossible to duplicate the conditions under Avhich the agent was used, it being impossible to measure it, and doubtless often impossible to generate it in sufficient dose except by accident.2 1 See Medical Record, July 31, 1897. 2 For an excellent bibliographic review of the treatment of cancer by electricity in the past see an article by Mrs. Edith Faithfull in the Contem- porary Magazine (English) for March. 1892, the writer stating that, having been placed under this treatment after failure of the knife, she had searched out the literature of the subject. She has gathered a remarkable number of references to its successful use. MA.LIGXAXT GROAVTHS. 233 It is to Inglis-Parsons, of London, that Ave owe the revival of interest in this subject since the opening of the present age of electric poAver under control.1 Rejecting simple electrolysis as a chief mode of action, he prefers sudden current-alternatives of high poAArer (100 milliamperes), applied by means of needles Avhich include both poles Avithin the tumor, the "traumatic action produced by the sudden impact of a powerful alternating current through the tissues betAveen the tAvo points of insertion" being chiefly relied upon. As this method is extremely painful by reason of the shocks given as Avell as the bulk of current, the patient is fully anesthe- tized. The folloAving extract gives a full description of his method of treating malignant groAvths as adapted to the special variety men- tioned:— Inglis-Parsons's Method in Epithelioma of the Portio Vagi- nalis.-—"These cases, taken at an early stage, are very promising, because the disease, as a rule, has neither extended deeply nor in- vaded the lymphatic glands. If an operation is decided on, the pa- tient should be kept in bed for a feAV days, and an antiseptic douche should be used until the vagina is aseptic. The patient is then placed on the operating-table, in the lithotomy position; ether is adminis- tered. The next step to be taken will depend on the size, extent, and characters of the groAvth. If, for instance, there is a large ulcer Avith a great deal of soft, breaking-doAvn tissue, it is better, as a preliminary measure, to scrape this Avith a blunt curette, and apply strong perchloride of iron to check bleeding. In applying the curette no force should be used; only the friable material Avhich comes aAvay easily should be removed. One advantage of doing this is that the parts can be made thoroughly antiseptic: a consideration not to be lost sight of Avhen Ave may require to puncture the cellular tissue around the uterus through the vaginal Avail. "In other cases, Avhere the ulceration is slight and the tissues superficial, the curette is not required. Xoav, in the treatment of epi- thelioma by electricity it is necessary to rely upon the caustic action of the tAvo poles, for the reason stated before, that this form of 1 "The Healing of Rodent Cancer by Electricity," by J. Inglis-Parsons. London, 1S93: John Bale & Sons. 2 The author's method as applied to this affection will be found on page 2f>3. 231 DISEASES OF WOMEN. groAvth has a higher electrical resistance than the healthy tissues.1 Sims's speculum is passed into the vagina; the cervix is taken hold of by a strong pair of tenaculum forceps and pulled down as far as possible to the vaginal outlet by an assistant. A second assistant stands at the batteries, watches the galvanometer, increases the num- ber of the cells in the circuit, and alternates the current by means of a commutator, according to the directions of the operator. Tavo needles at a time only are used. One of these should be run into the growth; the other, held in the operator's hand and having a sharp point, makes a trench into the healthy tissue all around the growth. The depth of this will depend on the case. Through this edge the needle should be pushed under the growth; a current of 400 milliam- peres is left on for ten seconds, and then alternated by the assistant with the commutator for another ten seconds. The position of the needle should then be changed. In this manner the whole of the growth must be undermined, and when the operation is finished the whole of it should look bloodless and almost black. When the growth is extensive it may be necessary to do tAvo operations. As a rule, I never go on for more than an hour at a time. For carcinoma of the cervix the same precautions must be observed to keep the patient aseptic. As the ulceration is generally more extensive in these cases, the use of the curette, for scraping aAvay all of the dead tissues available, becomes more necessary. It must be done thoroughly, and, if there is a caulifloAver excrescence, this must be removed. Hemor- rhage can usually be checked by applying a pledget of cotton-wool 1 The electric resistance of cancer-tissue depends greatly upon its his- tologic arrangement. The greater the proportion of cells, the less the resistance, particularly if the cells be cylindric rather than the squamous variety; and, the greater the proportion of connectiAre tissue, the less the resistance. In cauliflower excrescence and soft medullary tumors the cells are in excess and the resistance less than in normal tissue. In the squamous-celled A-ariety, so- called "scirrhus," the resistance is likely to be much greater than normal, as stated by Dr. Parsons. It should be remembered, howeArer, that even in scirrhus the resistance is greatest in the centre of the growth and least at the periph- ery, Avhere Ave Avish the electricity to be the most deadly. In any case the cellular parenchyma of a cancer Avill convey more current than the fibrous stroma, since it contains more Avater; hence a moderate current traversing a scirrhous formation may be lethal to the scanty parenchyma by reason of con- centration.—G. B. M. MALIGXAXT GROAVTHS. 235 soaked in the strong solution of perchloride of iron. Bleeding vessels must be secured in the usual Avay. "When the patient is in a fit condition and the vagina is clean and free from odor, a second operation may be done Avith electricity. The patient is placed in the lithotomy position and the batteries and assist- ants arranged as before. It is advisable for the anesthetist to keep his finger on the pulse and indicate to the operator any serious variation. A blunt electrode is noAv passed up to the fundus and a needle is passed through the vaginal Avail into the cellular tissue surrounding the uterus. The current is then flashed through and alternated. It should be alloAved to pass for three seconds at a time. After ten interruptions the position of the electrodes can be changed. The blunt electrode should, during half of the operation, be brought into contact with the ulcerated surface Avhich has already been curetted. A second blunt electrode may lie passed into the bladder1 and the current sent through from uterus to bladder, and also to the rectum. The number of punctures required and the duration of the operation will depend entirely upon the extent of the disease, and must be left to the judgment of the operator. It is advisable to repeat the operation at the end of ten days or a fortnight. The patient can then be seen occasionally."2 While the method thus described by Dr. Parsons presents dis- tinct advantages over the knife in certain cases, as claimed by him (and it should be stated that he does not claim that it is best in every case), it is to be observed that it fills but one of the require- ments laid down at the beginning of this chapter, viz.: destruction of all apparent portions of the groAvth. The knife also does this prob- ably as fully as this method. The method does not subject the apparently healthy tissues beyond the groAvth to an influence capable of destroying latent centres of regroAvth, as may be done by a monop- olar application and radial diffusion. Its principal adA*antage o\Ter the knife is bloodlessness. It is a question, also, Avhether the mode by which it acts is not, after all, the electrolytic action of so large a current, even if the ' The author would hesitate to employ a current of this strength in these cavities unless they Avere themselves invaded by the groAvth. 2 "International System of Electro-Therapeutics." page G-233. Philadel- phia: The F. A. Davis Co. 236 DISEASES OF WOMEN. duration be slight and the polarity subsequently reversed. The de- scription of the condition of the growth after the operation is quite identical with the appearance of a similar growth after electrolytic destruction with the direct current. In ten seconds considerable electrolysis can be accomplished with 400 milliamperes, and if the electrolysis is then reversed the position of the ions will change place, but the electrolytically-killed tissue will, of course, not be revived. In an hour's work with a current of this strength so frequently re- versed in a small space the included tissues are largely reduced to simple, chemic elements. It is, however, possible that the shock of sudden reversals of a ten-second current may have a lethal action of its oavii on cell-life. Author's Method of Mercuric Cataphoresis as a Cure for Cancer. —It Avas Avith the encouraging precedents of Dr. Inglis-Parsons's un- doubted successes that the author began experimenting Avith carci- noma of the cervix uteri a number of years ago, and later Avith sarcoma of other portions of the body, and after several preliminary publica- tions1 he is noAv in a position to report results which, though feAV in number and not ahvays successful, yet point to the germ of a truth of vast importance to the human race; for the history of the cases will shoAv that the active principle of sarcoma and carcinoma can be killed by cataphorically impregnating the tumor witli nascent oxy- chloride of mercury in sufficiently massive dose, Avhile the cancer- holding tissues are not killed. The destructive effects of caustics on these groAArths is Avell knoAvn, 1 "Local Electrolysis and Zinc-Amalgam Cataphoresis in Malignant and Non-malignant Tumors," Medical XeAvs, March 9, 1895. "The Treatment of Hemorrhagic Conditions of the Uterus by Zinc-Amal- gam Cataphoresis," Journal of the American Medical Association, August 24, 1895. "Zinc-Amalgam Cataphoresis in Muco-purulent Inflammations and Malig- nant Growths," Philadelphia Polyclinic, October 19, 1895. "On a N~ew Treatment of Sarcoma," American Medico-Surgical Bulletin, June 27, 1896. "The Treatment of Cancer by a Xcw Method, viz.: the Electrical Dif- fusion of Nascent Oxychlorides of Mercury and Zinc," Medical Record, July 31, 1897. "On the Radical Cure of Malignant Disease by the Cataphoric Diffusion of Mercury from Gold Electrodes, with details of Late Improvements in the Author's Method," Philadelphia Medical Journal, March 19, 1898. MALIGNANT GROAVTHS. 23T but they act only Avhere placed, exactly as the knife does. By the cataphoric method a relatively-infinitesimal portion of the mercuric oxychloride acts lethally on the cancer-cells because of its nascent condition, and because it is carried by the current into the very cells themselves. But the most important point is that by the method we may cause the medicinally-laden current to seek out and follow the paths of proliferation of the growth by reason of its selection of paths of least resistance, and it is the failure to destroy these incipient proliferations that causes the frequent reappearances after attempts at extirpation with the knife. This selective tendency of the current is both absolute and relative, in the one sense being due to the phys- ical fact that cancerous ramifications usually invite the passage of a greater current in its transit from the active pole placed Avithin the groAvth to the distant indifferent pole by reason of a less electric resistance, due to its cellular structure; and, in the other sense, a selective action results from the lessened physiologic resistance of the cancer-tissue as compared Avith surrounding structures. Some of my cases have clearly proved that the cancer-cell has less physiologic re- sistance to this interstitial attack than normal tissue, for it-is found to lose its vitality at some distance from the electrode without being accompanied by necrosis of the healthy tissue. This diffusion of a metal from a corrodible electrode occurs only at the positive pole, as explained elsewhere (page 40); it is, therefore, necessary to connect the active electrode to this pole of the battery, and to furnish as large and perfect an indifferent electrode as can be placed elseAvhere on the body. It Avas the oxychloride yielded from a zinc electrode coated Avith mercury Avhich first attracted the author's attention to the possibilities of the cataphoric injection of lethal products into cancer-tissue. These experiments, Avhich began in 1803, were, hoAvever, but partially successful, OAving to the small dosage employed, and it has only been since May, 1897, and since the em- ployment of complete anesthesia, and massive doses, that the great value of the application has been demonstrated. Coincident with the use of anesthesia for the purpose of an immediate penetration of all portions of the cancer Avas the discovery that mercury could be employed as the actiA*e agent by amalgamating a gold electrode with it, and that when mercury was so used it quickly disappeared into the tissues: a phenomenon not before observed. All that remained to be done after this discovery Avas to devise means to 238 DISEASES OF AVOMEN. keep up the supply of mercury at the active surface of the gold in order that a proper amount of the nascent salt might be disseminated through the tumor, for the merely-amalgamated surface became quickly bare under any considerable current. This was accomplished by having the instruments (Fig. 66) made holloAV and perforated at the active extremities, in order that the mercury could be injected freely about the active surface before the current was turned on, a small glass syringe being used to inject the metal through a soft- rubber tube. Fig. 65.—The Massey transportable galvanic battery, as made by Williams, Brown & Earle, Philadelphia. The special features of this battery are the large size of the cells and their ability to permanently resist acids, being made of glass; the special mechanism for instant removal, amal- gamation, and replacement of the elements; and the mechanism AA'hich permits of loAvering and raising the elements with ease or of leaving them in any position desired. At .1 .-I are the binding-posts for attachment of the cords, the posts having their polarity marked on them. These posts rest on a sliding volt- or cell- selector (B). which permits any number of cells to be selected, as in the old-fashioned batteries, making a convenient controller for very high currents. To the element bar (C) the element MALIGNANT GROAVTHS. 239 Details of the Author's Major Method.—Source of Current.— The street-mains of an Fdison incandescent lighting current of 110 volts may be used, but the author's Avork has been done witli tAvo thirty-cell batteries of the acid-carbon variety coupled in series, giv- ing a combined pressure of about 120 volts. This battery force is usually essentia], as the available current required varies from 350 to 12U0 milliamperes or more. The batteries must be in the best condition, freshly cleaned, reamalgamated, and freshly charged. The ordinary portable galvanic batteries have too small a cell to main- tain this current-strength Avith certainty, and I have, therefore, de- signed a transportable battery Avith larger cells and better mechanism (Fig. 65) tAvo of Avhich can be relied upon to give sufficient current during the time required. They are made by Williams, BroAvn & Farle, of Philadelphia. The two batteries are placed in series by con- necting the negative pole of the first Avith the positive of the second, Avhen the positive pole of the first and the negative pole of the second will be the poles of the combination. Cords from these are carried to the binding-posts of the switch-board. Electrodes.—Considerable experimentation Avas required in de- vising the golden electrodes to be used in this electro-mercuric treat- ment of cancer. The earlier applications of mercuric cataphoresis Avere made Avith zinc electrodes heavily coated Avith mercury, but it was soon seen that the zinc surface became deeply eroded, and that a pure mercuric dissemination would require a more refractory surface for the electrode, and Avould probably produce quite different effects from that caused by the mixed chlorides. The only metal sufficiently resistant to the current that Avould combine Avith mercury Avas gold, connectors (E) are attached by a special deATice, which permits any pair of elements to be instantly removed or replaced. The elements when in position are simultaneously raised and lowered by the Avorm (D D), whicli is operated by beveled cog-Avheels actuated by a lever-handle. A few turns of the handle Avill immerse the elements to any extent desired, in Avhich position they Avill remain, thus forming an additional means of controlling the output of the battery. This form of battery, transport- able rather than portable, has been designed to furnish, Avithout detri- mental self-heating, the strong currents employed in the treatment of cancer, but is equally Avell adapted to ordinary medical work, the increased weight being offset by greater duration of the charge and of the zinc element. The cells should be emptied before being sent out, and refilled in the operating-room with electropoion fluid. 240 DISEASES OF AVOMEN. although it was soon observed that this metal would also be slightly eroded by a powerful current, resulting in the diffusion of a mer- curic chloride slightly mixed with auric chloride; this mixture, un- like that of zinc and mercury, Avas not essentially cauterant, and therefore fulfilled the conditions frequently demanded of cell-de- struction Avithout necrosis of the tumor. Eighteen-karat gold, in which the alloy should be silver, give the necessary rigidity, the alloy in the surface of the gold soon dis- appearing in the first use of the instrument. The shape given to the electrodes designed to pierce tumors is shoAvn in Fig 66, and the blunt, or bulbous, electrode for use in cavities in Fig. 67. After amalgamation the gold becomes brittle, so that it is necessary to construct the distal end, to which the conducting cord is attached, of some other metal not affected so easily. The larger electrode (1, Fig. 66) is finished with platinum for this reason and the small one with silver. (Platinum is totally unaffected by mercury, but silver will absorb it, though more slowly than gold.) These electrodes have been made for me Avith great care by Baerncopf & Co., 731 Sansom Street, Philadelphia. Both electrodes are so constructed as to be capable of being- heated to a red heat in the flame of a Bunsen burner or alcohol-lamp after use, and this should invariably be done, Avhen all the mercury will be driven off in a green vapor, leaving the gold clean and safe from further action of the mercury, as Avell as safe from danger of being broken. The same care should be bestoAved on the gold bulb and the metallic portion of the shank of the bulbous electrode. While thus getting rid of the remaining mercury that would othenvise ren- der them brittle, this heating of the electrodes results in complete asepsis of the instruments preparatory to their future use. When preparing for an application, the electrode or electrodes to be used should be amalgamated again, ample time being alloAved to do this thoroughly. To make the mercury adhere to the gold a bit of absorbent cotton should be moistened with dilute sulphuric acid and the electrode rubbed on it and dipped in mercury alternately, until an abundance of the fluid metal adheres to all parts of the active surface. Should it be desirable to insulate the shank of the electrodes, this may be done for each application by fusing shellac upon it to the extent desired, but this shellac should be removed in the subsequent heating process, in order that all portions of the in- Fig. G(>.—The author's gold and zinc puncture elec- trodes for the cataphoric treatment of cancer. (Reduced to Vs natural size.) No. 1 is constructed of 18-karat gold throughout, except at the point where the wire and rubber attachments are made, where it is constructed of platinum tubing, since the gold would crumble under the wire at- tachment when impregnated with mercury. Tlie special shape, somewhat similar to a pen and penholder, has been found to combine the qualities of greatest strength Avhen weakened by mercury, with least requirements of gold and easy penetrativeness. Holes through which the mercury may pass have been made near tlie point, back of which tlie stem is contracted to a smaller calibre in order that it may he coated with shellac at will, previous to the application. No transverse joints are admissible in the construction of the gold portion of the instrument, as these will be eroded under action and will break the How of mercury. The con- nection is best made by a piece of No. 22 bare copper wire, twisted as shown, as this permits the whole instrument, ex- cept the rubber tubing, to be asepticized in tlie flame at the time of driving tlie mercury off after use. By bavin" this copper wire about six inches long, that amount of conduct- ing material is also aseptic, keeping the less-easily-ascpti- cized cords farther from the wound. This instrument is intended for use in large external malignant growths, such as cancer of the breast, etc., but may be insulated for ap- plication within cavities. No. 2 is intended for smaller growths, and is constructed of silver or platinum, except near tlie active end, where a heavy jacket of gold is attached. It has a steel trocar to insure sufficient rigidity for penetration; this should be re- moved after placement of the electrode, and a rubber tube slipped over the outer end of the electrode for the injection of the mercury. No. 3 represents one of many forms of zinc electrodes for penetrative purposes. 242 DISEASES OF AVOMEN. strument be freed from the mercury before being put away. The steel trocar in the smaller electrodes should be removed for both heating and reamalgamation, and asepticized in some other way. The Indifferent Pad.—On the operating-table a lead plate is laid, about 12 x 20 inches in size, to which is affixed a binding-post for attachment of the negative cord. Over this is laid a thick pad of some absorbent material well soaked with hot Avater. This pad should be thick enough to prevent local action, and should extend Avell over the edges of the lead plate. Preliminary Details.—Before etherization is begun the batteries and switch-board, or, in the absence of the latter, a separate con- troller and meter, should be properly disposed and connected and the Fig. 67.—HoIIoav, bulbous electrode of gold, for dissemination of mercury in cavities. perfection of circuit tested. Arranged on an aseptic tray on a con- venient table there should be a bistoury for making incisions for the electrodes; the electrodes themselves, thoroughly and freshly amal- gamated and with rubber tubes attached for injection of the mer- cury; and a small glass syringe filled with metallic mercury. An additional supply of mercury should be placed in a dish on the table. Assistants.—Besides the etherizer, the operator will need an assistant to inject the mercury after the electrodes are inserted and another assistant to turn on the controller, the operator himself being sufficiently employed in the management of the electrodes and in noting the current-strength and effects. The Application.—The patient having been etherized and placed MALIGNANT GROAVTHS. 243 on the table, or etherized on the table itself (Fig. 68), the indifferent pad should be examined and pressed close to the body, the greater portion of it being behind the hips and against the thighs. Xo por- tion of the metal plate should touch the body. With a narroAV bis- toury a slit should be made in the tumor in an appropriate spot and an electrode thrust deeply into place, near, but not too close, to its base, for the principal action is doAvmvard. In hemorrhagic tumors the slight hemorrhage that this occasions may be aA^oided by insert- Fig. C8.—Arrangement of apparatus and patient in the cataphoric treatment of cancer. ing the electrodes as the negative pole by temporarily reversing the connections and turning on sufficient current for this purpose. Having inserted the electrode or electrodes required and veri- fied the polarity of the active electrodes as surely positive, the glass syringe should be inserted in the tubes of each electrode in turn and an abundance of mercury forced into them and into the tissues about them. The necessity for an excess lies in the rapid dissipation of the portion adhering to the gold under a strong current, and, unless an 244 DISEASES OF AVOMEN. abundance of the metal remains in electric contact previously to turn- ing the current on, the gold will lose contact Avith the mercury near it, and a mere positive cauterization will result. The mercury is held Avithin the electrode by the spring clip. Should the duration of the application be considerable, additional quantities of the mercury may be injected without interference Avith the current. The Current-strength and Current-duration.—The strength of the current and its duration depend entirely on the extent of the groAvth. The author's applications under ether have thus far A^aried between 350 and 1200 milliamperes, and in duration between four- teen minutes and half an hour. It is quite likely that both of these extremes can be wisely increased in large groAvths where immediate results are necessary, for it is evident that a sufficient quantity of mercury should be acted on and disseminated to produce a lethal density of the agent in all parts of the groAvth, no group of cells being permitted to escape. That this Avill require a time proportional to the distance of the remotest groups of cells from the nearest electrode is evident from the statements concerning the cataphoric speed of substances on page 46. No increase of current will make up for a lack of penetration due to insufficient duration. It should be the aim of the operator to accomplish complete results at the first application, though a second application can be made a month later, if it is seen, during the healing process, that this aim has not been accomplished. Immediate Results.—Within a feAV moments after an adequate current has been turned on the tumor will become someAvhat blanched and shrunken, these appearances increasing during the application. About each electrode a grayish-white necrotic area will form, of lim- ited extent, Avhich Avill serve to maintain subsequent drainage. If there has been any odor due to previous necrosis or ulceration of the cancer, this will disappear during the application, and will not be likely to return if the application has been thorough. The amount of pain suffered by the patient after emerging from the ether varies. If the tumor is large and previously painful, the latter will be lessened permanently by the application, though severe pain, Avhich is readily controlled by morphine, is often felt for several days subsequently Avhen the cataphoric action has been carried deeply into healthy tissue and the secondary reaction has been Avell estab- lished. This secondary reaction is a marked feature after applica- MALIGNANT GROAVTHS. 245 tions to organs that are only partially infected by the cancer. It is doubtless due to an irritative reaction of the surrounding normal tissue, and thus assists in delimiting further cancerous growth at the periphery of the tumor. The reaction and accompanying pain cease about the third day, Avhen the patient is free from pain and Avill re- main so. After-treatment.—The tumor is dressed Avith dry acetanilid poAv- der and absorbent cotton daily, after being cleansed from the gray discharges and the excess of mercury Avhich pour out, and the Avounds become clean and ready to heal by granulation in from tAvelve days to three weeks. During this process there is but little tenderness and no unpleasant odor. Details of the Author's Minor Method.—Most of the earlier cases mentioned beloAv Avere treated by the milder method, in Avhich anes- thesia Avas not used and amalgamated-zinc electrodes were employed. The action of the combined zinc-mercuric oxychlorides formed from such electrodes is totally different from that of pure mercuric cata- phoresis, a whitish eschar being quickly formed about each electrode, which becomes an extensive slough if a strong current is used. This slough is not entirely inodorous, but has a special value Avhen quick destruction of an hemorrhagic sarcoma of large size is desired, when the zinc may be used in the major method Avithout causing the loss of a drop of blood. The currents usually tolerated Avithout ether rarely exceed 50 to 80 milliamperes, according to the location of the growth, though I have used 300, the details of the application being othenvise the same as in the major method. It should be repeated daily or as often as possible until a cure is effected. The minor method, Avith either zinc or gold electrodes, is suit- able for small local gro\vths and in cavities in Avhich the assistance of direct vision is lacking, but it is ahvays inferior to a thorough application, and should never be employe!! Avithout a reasonable pros- pect of a speedy mastering of the groAvth. Such is a brief outline of the methods and their technical -details, but it should be understood that these details are subject to change, in accordance Avith the individual characters of the growth and the part of the body in \vhich it is situated. The underlying principle that constitutes the novelty of the method is that there is a virtue in the electric diffusion of nascent chemicals throughout a malignant groAvth Avhich, Avhen of sufficient density per area, will cause an in- 246 DISEASES OF WOMEN. terstitial death and ultimate absorption of the malignant cells at a distance from the electrode, without destroying the connective tissue surrounding them, and that this intracellular lethal action is inde- pendent of and additional to the ordinary destructive action of a strong current in the immediate neighborhood of the electrodes. Illustrative Cases.—The discovery of this peculiar action of nas- cent oxychloride of mercury Avas made Avhile the author was con- ducting the treatment of a case of inoperable carcinoma of the groin in August, 1893, by means of a carbon electrode used as the positive pole, Avhich had been the method employed in a number of cases of carcinoma of the cervix uteri Avith but indifferent results. The rapid disintegration of the surface of the carbon-ball instrument employed in this particular case under the heavy currents used suggested the value of zinc cataphoresis, then already in use in endometritis and other benign conditions, and the mercury was first applied to the sur- face of the zinc to keep the latter from adhering to the surface of the wound as it Avould otherAvise do. But there Avas an improvement noted in the outer edge of the groAvth at some distance from the electrode by the next day, and this, coupled Avith the facts that the wound became rapidly aseptic and that the use of 100 milliamperes for some minutes lessened the amount of mercury adhering to the electrode, showed that the mercury itself Avas diffused in greatest amount, and suggested the immense advantage that might accrue from the use of such an agent. This case, in Avhich the carcinoma was about three inches in diameter and adherent to the great vessels of the thigh, became much better under prolonged employment of the milder method, nearly the Avhole of the diseased area filling in with healthy granulations and the gentleman regaining the power to Avalk; but it Avas unfortunately impossible to eradicate the cancerous infiltration of the femoral artery and vein, and the termination Avas ultimately fatal. This case, together Avith the folloAving seven cases, taken from the paper read before the Section of Practice of Medicine of the American Medical Association in June, 189T, represent the author's experience in the first series of cases to that date, though only a portion of them occurred in the practice of gynecology. Case 2. The second case, and the first apparently complete suc- cess, Avas a recurrent sarcoma of the palate, Avhich had been partially destroyed by the A\rriter by ordinary electrolysis in 1893. This man, MALIGNANT GROAVTHS. 247 W. H. L., aged 39, had been sent to me by Drs. Hemminger and Bixler, of Carlisle, Pa., with a sarcoma of the left palatal arch fully the size of a goose-egg, which he had declined to have removed at the University Hospital. Nearly complete destruction with platinum needles gave him comfort for a year, when it was noticed that lumps were redeveloping in the scar. He was at this time (in 1894) placed on the mild zinc-mercury method, which was kept up daily for six weeks, resulting, after some subsequent treatment, in a disappearance of the growth. Case 3. The third case treated by the method Avas a farmer from Salem County, X. J., aged 55, with an immense epithelial cancer of the face, extending from the external angle of the right eye to the under border of the loAver jaw, the functions of the corresponding eye and ear being abolished and the right ramus of the lower jaw destroyed. He was admitted to the Howard Hospital and an effort was made to change the character of this immense surface by the milder method described, the current not exceeding 100 milliamperes, and the treatment AA-as kept up for some months. As no permanent change of sufficient magnitude Avas produced, he Avas finally sent home in a slightly improved condition. I have learned since that he died about a year later. Case 4. Mrs.----, aged 50, Avas sent to the author by Dr. Saylor- BroAvn. of Williamsport, Pa., October 8. 1895, in a condition of pro- found anemia and cachexia from an upper-rectal ulceration of tAvelve years' standing. She suffered from considerable pain in the left groin and had from twenty to tAventy-five black, foul-smelling stools per day. Local treatment Avas undertaken Avith a neAv, IioIIoav, rectal elec- trode similar to the gold electrode shown in Fig. 66, with an olive- shaped active surface consisting of mercurialized zinc, and so con- nected Avith a syringe that its insertion Avas facilitated by a cushion of albolene dilating the rectum ahead of the electrode bulb. A con- striction Avas encountered about six inches from the anus which was extremely sensitive. From 40 to 100 milliamperes Avere employed with mercuric cataphoresis. After several applications a piece of tumor-tissue came away about the size of the last joint of the little finger and Avas sent to Dr. Alfred Stengel for microscopic examina- tion, Avho pronounced it carcinoma. A large number of such pieces came aAvay subsequently, and after a prolonged treatment she was sent home considerably improved in Aveight and general health, Avith 248 DISEASES OF AVOMEN. the greater portion of the ulceration healed over, and haAdng not more than tAvo or three stools per day. Case 5. The fifth case, Mrs.----, aged 36, of Muncie, Ind., came under my care March 3, 1896, with a recurrent sarcoma of the left pectoral muscles about 3x4 inches in superficial extent and appar- ently pressing upon the brachial plexus and the blood-vessels of the arm, for the left arm was SAvelled and the seat of constant pain. Less than two years before, in July, 1894, the left breast had been re- moved by a distinguished surgeon in the West. This case Avould have been an excellent one for the stronger method described, which had not yet been developed. An opening Avas made in the skin and a zinc-mercury electrode inserted daily with about 100 milliamperes, under cocaine, cataphorically applied. After a number of applications the SAvelling and pain in the arm disappeared, and later a piece of the sarcomatous tissue came away about 2|xl inches in size and resembling a piece of sponge filled Avith cheesy material, and the Avound Avas in a fair way to heal. Unfortunately, acute mania devel- oped at this time, the patient's mental condition having been sus- piciously exalted for some time before admission, compelling her hus- band to take her home, where the acute mental affection terminated fatally. Case 6. Mrs. A., aged 51, of Salem, N. J., came under my care in June, 1896, suffering apparently from general prostration. In searching for the cause I found a suspicious ulceration of the os uteri, the cervix being enlarged, hard, and very irregular in outline and badly ulcerated, exuding considerable discharge characteristic of carcinoma. Suspecting malignancy, I at once conferred Avith her hus- band and suggested the neAv treatment. He, however, decided to take her elseAvhere for additional counsel. A Aveek later he brought his Avife back to me, saying that he had taken her to Professor Parvin, Avho concurred in the diagnosis of carcinoma and advised curettement, to be followed later, possibly, by removal of the uterus. Being still dissatisfied, the patient Avas taken to a homeopathic physician, who also pronounced the affection carcinoma, but proposed that the pa- tient come under his care for electric treatment. This latter sug- gestion caused the gentleman to bring his wife back to me, and she Avas placed on mild daily applications of the mercurial cataphoresis with currents varying irom 50 to 100 milliamperes applied by the smaller-size zinc electrode of the set shown in Fig. 26, Avith the shank MALIGNANT GROAVTHS. 249 curved someAvhat. The duration of each application was under ten minutes. This active treatment Avas continued for about six Aveeks, the local conditions improving rapidly, Avhen she Avas sent home to return for an application three times a month. This was changed later to once a month. The uterus is uoav normal (February, 1898), the diseased area being completely healed and general health restored. By appoint- ment she was taken to Professor Parvin to verify her restoration to health on the 28th of May, 1897. Case 7. Mrs. P., aged 70, is iioav under treatment at the dis- pensary of the HoAA^ard Hospital for carcinoma of the cervix of the scirrhous variety. The cervix had practically disappeared by erosion when the treatment Avas begun in the fall of 1896 and the patient suffered from frequent hemorrhages, continuous Avatery discharge, and hypogastric pain. The uterus Avas fixed and the vagina atrophied, shortened, and surrounded by unyielding walls. Under mild intra- cervical applications Avith a small zinc-mercury electrode the hemor- rhages ceased, pain became infrequent, the discharge lost its offensive odor and nearly ceased, and a cachectic condition has been replaced by relative health. The rigidity of the shortened and narroAved va- gina continues, but the Avhole mass can now be slightly moved. The patient is still under treatment. Case 8. Mrs. E. M., aged 47, came under by care at the HoAArard Hospital in the autumn of 1896, and was the first case operated upon by the stronger method. A tumor existed in the scar-tissue and skin at the site of the right breast, the breast having been removed by a surgeon at the Hospital of the University of Pennsylvania about three years previously for carcinoma. The tumor was about the size of a half of an orange. The glands of the axilla were normal and had not been removed at the operation. An attempt was at first made to arrest the growth by the milder method, but, this appearing too sIoav, the tumor Avas operated upon by zinc-mercuric cataphoresis Avith 1000 milliamperes at the hospital on May 3. 1897, in the presence of Drs. A. E. Eoussel, E. P. Bernardy, and the hospital residents. The tumor at this time had increased considerably since first seen, measuring 3£ x 3f inches. In this ap- plication, the negative electrode, a moistened disk, was also placed"on the tumor, making the application bipolar. An immediate blanching and shrinkage of the groAvth Avas noted, 25U DISEASES OF AVOMEN. Avith the production of small necroses at the site of each electrode and in the centre. At the end of thirteen minutes the current was turned off, the electrodes withdrawn, a dry dressing applied with iodoform dusted over the surface, and the patient put to bed. The sloughs separated painlessly in ten days, leaving an apparently healthy granu- lating surface, but before this time the interesting fact Avas noted that the tissues betAveen the electrodes that had been elevated, hard, vascular, and purplish witli malignancy, but had not become ne- crosed, Avere noAv level Avith the surrounding surface, soft, and pos- sessed of a healthy pink color; shoAving that an influence or substance passed between the electrodes capable of destroying the cancer-cells that was unable to devitalize the normal tissues containing them. All evi- dence of malignancy had disappeared except at one spot, about the size of a marble, that Avas unquestionably abnormal, and another spot that appeared doubtful. At the end of a month these two remaining spots Avere subjected to a second application under ether, this time strictly monopolar, with the negative pads on the abdomen and back. Five hundred milliam- peres were applied, divided between five zinc-mercury lancet elec- trodes, in the presence of a number of physicians in attendance on the meeting of the Americal Medical Association then in session in Phila- delphia. The cup-shaped depressions that resulted when these ne- croses separated seemed to include all that had been malignant, the surrounding flesh being soft and normal; but, Avhile they were filling Avith healthy granulations, internal metastasis, of probably earlier formation, carried the patient off. The methods here described have since been applied success- fully to the following cases:— W. 0., aged 39, an employee of a sugar-refinery in Philadelphia, applied for treatment late in October, 1897, suffering from a sarcoma of the superior maxilla, Avhich caused protrusion of that side of the face and projected into the mouth, having caused four teeth to pain- lessly fall out. The case had been seen by Dr. Hearn and by a sur- geon at the Medico-Chirurgical Hospital, both of Avhom diagnosed sar- coma, and advised removal of the whole upper jaAv. On October 27, 1897, he was placed under ether, and 300 milliamperes applied for fifteen minutes, with mercury abundantly supplied from a gold elec- trode. I was kindly assisted by Dr. Bernardy in this case, whose in- terest in the subject has been most unselfish. The result of this MALIGNANT GROAVTHS. 251 application Avas less perfect than it Avould have been Avith a longer duration, and it was found that but one-half of the tumor Avas favor- ably affected. Office applications were begun four days later Avith an amalgamated-zinc electrode, which could be painlessly thrust into the tumor Avithout any form of anesthesia, though currents of more than 40 milliamperes were unbearable. As these latter applications seemed to have an adequate effect on the remaining portion of the tumor, they Avere continued thrice Aveekly for tAvo months, during which time the sarcomatous tissue showed a decrease that Avas per- ceptible daily, both in loss of substance and encroachment of the sur- rounding normal tissue. At the end of tAvo months all malignant tissue had disappeared, leaving a cavity that was quite narroAV, con- sidering the size of the groAvth, and Avhich has since grown progress- iATely smaller. A cachectic color that the patient presented Avhen first seen has been replaced by the ruddy hue of health. A lady of 66, Avho had had the right breast removed in January, 1897, presented evidence of recurrence in the line of a lymphatic vessel in October of the same year. On the 11th of December she Avas placed under ether, and three small amalgamated-gold electrodes inserted, through Avhich mercury Avas injected and catapliorically dif- fused by 500 milliamperes for fifteen minutes, Avith the kind assist- ance of her physician, Dr. Ida E. Kichardson and Dr. W. C. Thomp- son. At the end of this time all the malignant nodules were softened, and a grayish-white spot appeared at the entrance of each electrode. The after-pain Avas considerable and lasted about tAvo days, but there was no further pain during the period of healing, and there is uoav a normal cicatrix Avithout evidence of remaining infection. The most recent case Avas that of a Avoman of 56 avIio presented herself Avith an ulcerated carcinoma of the sublingual saliA'ary gland. The tumor Avas groAving rapidly and gave rise to excruciating pain, the progressing involvement of the tongue preventing the sAvallowing of solids. She Avas placed under ether on December 28, 1897, with the kind assistance of Dr. S. J. (iittelson, and 400 milliamperes Avere employed Avith a gold electrode and mercury for half an hour. A horrible odor that had been emitted from the groAvth disappeared during the operation and never returned, in spite of the fact that the whitish slough produced did not separate entirely until the expiration of three weeks. The edges of the excavation cicatrized shortly after- ward, and she is iioav Avell in every respect. The intense radiating 252 DISEASES OF AVOMEN. pain from which she suffered disappeared about four hours after the application and never returned. Corroboration of these results has been afforded by the inde- pendently conducted observations of Dr. J. McFadden Gaston, of Atlanta, Ga., who reported a successful case of sarcoma someAvhat similarly treated at the meeting of the American Surgical Association at Washington in May, 1897. Os Pubis Fig. 69.—Outlines of circumference of sarcoma in Dr. McFadden Gaston's case. / With Dr. Gaston's kind permission I give the details of this case from his paper1 in an abbreviated form. A boy of 12 presented a sarcoma in the hypogastric region of the size represented in the outer line of Fig. 69. Dr. J. B. S. Holmes, of Atlanta, made an exploratory incision, but found that the adhesions to the surround- 1 Annals of Surgery, August, 1897. PLATE XXI. ^v€^ ^ Carcinoma of the Cervix Uteri. MALIGNANT GROAVTHS. 253 ing tissues Avere too great to permit of its removal. He Avas after- ward seen by Dr. Hunter Mcliuire, of Richmond, Avho had a specimen removed and examined microscopically by Dr. M. D. Hoge, Jr., the latter pronouncing it a small, round-celled sarcoma. A radical opera- tion Avas again declined. He Avas turned over to Dr. Gaston on No- vember 16, 1895, Avho had not seen my publications on the subject at this time. Dr. Gaston at first used simple electro-puncture A\'ith positive needles around the base of the growth with a negative sponge electrode on the opposite margin. This Avas repeated on alternate days, but Avas later changed to the cataphoric administration of Don- ovan's solution,—the double chloride of arsenic and mercury,—the solution being placed on the positive sponge electrode and the needles being noAv negative. The absence of a milliamperemeter rendered the exact dosage uncertain, but dependence Avas placed on the local effect at the negative needles in increasing or decreasing the number of cells used as the cells varied in freshness of charge. Minute vesica- tions alternating Avith pits Avere noted Avhere the solution Avas applied and the usual eArolution of hydrogen at the negative needles. The progressive shrinkage is best realized by a reference to the figure, Avhich is copied from Dr. Gaston's paper. He reports the pa- tient entirely cured and Avell on May 31, 1897. It should be added that Donovan's solution Avas given Avith other alteratives by mouth during the cataphoric treatment. Technique of the Author's Method for Carcinoma of the Portio Vaginalis.—In my own method for the treatment of carcinoma of the cervix uteri a bulbous electrode of zinc, freshly amalgamated with mercury, of a size nearly filling the ulcerated cavity if small, is em- ployed as a monopolar positive pole, the negative pole being tAvo pads of suitable material covering the abdomen and back and both connected with the negative binding-post. The pads being in place, the patient lying in the dorsal position on the dorsal pad, the active pole is passed into position Avithout other preparation of the patient than a simple daily antiseptic douche, for the method is itself poAver- fully antiseptic in effects. Preparatory curettement is very rarely performed except to remove manifestly necrotic shreds or masses, as it is unnecessary with the method and wasteful of blood and strength. The zinc bulb may be about two centimetres long and of a size to fit the caArity. all portions not touching the diseased area being freshly coArered Avith fused hard rubber or shellac. If no cavitv exists, as 254 DISEASES OF AVOMEN. in cauliflower excrescence, the most prominent portion of the tumor is to be destroyed by needles and simple bipolar electrolysis, for which tAvo needles, the positive of platinum (or of zinc), are inserted into it. For a case of this nature the author devised the double bipolar instrument (Fig. 70), the two prongs per pole increasing the current by lessening the local resistance and insuring more rapid progress. In all cases the monopolar zinc-amalgam applications are finally relied upon to complete the destruction of the cancerous margins and prolongations by repeated applications, extending over months if necessary, until the physiologic activity of the surrounding tissues is regained, and healthy granulation tissue replaces the morbid growth. The current-strength required varies from 50 to 200 mil- liamperes, the insensitive nature of the uterus frequently permitting the latter strength to be attained without anesthesia. The duration Fig. 70.-—Double, bipolar instrument for electrolytic destruction within a cavity. of the applications, which should be daily or triweekly, may vary from ten minutes to a half-hour, every consideration uniting in urging a rapid prosecution of the work.1 When observed in a superficial carcinoma the immediate result of the application indicates a lessened hyperemia of the growth; a light-gray pellicle forms about the spot touched by the electrode, Avhich comes aAvay at the end of a feAV days, leaving the superficies of the growth someAvhat shrunken. Under daily repetition of the process the cavity formed by the destruction of tissue becomes larger, but the reduction in the size of the groAvth is greater than Avould merely correspond with this destruction of tumor-substance, for the periphery will be found to be shrinking, the soft, normal tissue en- croaching on the indurated edges. The applications must be con- 11 am noAv testing the advisability of employing ferric cataphoresis from iron electrodes, Avith the strong currents mentioned, in prolonged treatment. MALIGNANT GROATTHS. 255 tinued until the cavity is surrounded only by normal edges of but- slightly-indurated tissue, the determination of the point Avhen the margins are found to be healthy being a matter of delicate judgment. The cavity and the sanious discharges issuing from it during active treatment are nearly aseptic and odorless by reason of the antiseptic character of the nascent oxychlorides of zinc and mercury which have united with the superficial necrosed tissue; but antiseptic douches should be directed as an assistant in maintaining an odor- less condition. Healing is to be prevented by frequent treatments until the physician is assured that the last vestige of loAvly-organized cells has been destroyed and the normal trophic condition of the part restored. This method is, of course, only applicable in strictly local car- cinoma or sarcoma, extension to other portions of the body by means of lymphatics or veins rendering it a palliative only. Since Avhen em- ployed in any case it quickly lessens pain and promptly checks hemor- rhage, its value as a palliative in incurable cases is nevertheless evi- dent. Where the strictly local tumor is of large size and capable of being removed by the knife, it may be better to do so, and reserve this method for subsequent employment on the first reappearance of the growth in the cicatrix of the operation. CHAPTER XIX. Benign Tumors of the Breast. The mammary organs of Avomen are subject to inflammatory indurations and adenomatous groAvths that simulate malignant tumors and often cause grave anxiety. A presumptive diagnosis of benignity is, hoAvever, often possible by a careful consideration of the symp- toms, among those favorable to benignity being the youth of the patient, distinct evidences of inflammatory reaction, tenderness, sIoav growth, and non-adherence to the overlying skin. What might be termed a chronic lobular mastitis is probably the most painful form of tumor of the breast, presenting a nodule from the size of a hazel- nut to that of a considerable portion of the gland, Avhich is tender to the touch and the seat of a constant ache. Such tumors are most frequently found in young Avomen, both married and single, and are often in close sympathetic relation AA'ith disordered menstrua- tion or even ovarian congestion. These painful inflammatory indurations are particularly amenable to external galvanic and faradic applications, particularly the former, the tenderness and unpleasant sensations yielding to a few applica- tions and complete resolution ultimately occurring. The necessity for prompt treatment is accentuated by the possibility of the inflam- matory condition proving a favorable seat and stimulus for the devel- opment of a previously existing malignant matrix. The application is made with the patient reclining upon a dorsal pad of large size, the actiAre pad, Avhich is preferably negative and of a size equal to the induration, being pressed over the latter. This pad should be very moist and well soaped, and may be slowly rotated to lessen the action on the skin, the latter being kept in good condi- tion for painless transmission of effective currents by being bathed daily Avith alcohol. Gentle massage in the direction of the lacteal ducts Avill assist the treatment. Skene, in a Avork Avhich deserves to be regarded as a pioneer treatise on the science of medical gynecology as contrasted AA'ith the (256) benign tumors of breast. 257 merely surgical treatises that have preceded it, describes a probably similar condition under the name of "areolar hyperplasia of the mam- mary glands."1 With the exception of the first case, in which the breast Avas removed, some t\venty-three instances had been observed by him, and all recovered under medical treatment Avithout resort to surgery. How many of these cases would have preserved their breasts in less conservative hands? In all such cases the suspicion of malignancy, either present or prospective, Avould have been suffi- cient to warrant ablation at the hands of surgical enthusiasts, and an inflation of the statistics of non-recurrent malignancy Avould have surely resulted. These cases are, of course, not tumors in the path- ologic sense. The most common benign tumor of the breast is the adenoma, Avhich is usually found as a small, hard lump from the size of a pea to that of a walnut. They may be multiple, and differ from both chronic lobular mastitis and malignant tumors by having a limiting membrane and being movable. They are apt to be more tender than a malignant tumor. Such a tumor is easily removed by a surgical operation for enucleation, leaving the breast largely intact and Avithout risk of recurrence; yet if the patient is averse to this there are two electric procedures available: either simple percutaneous gahanic applica- tions or percutaneous iodine cataphoresis (by Avhich the groAvth is arrested by stimulating the physiologic resistance of the surrounding tissues, removing pain, and lessening the growth) or by puncture and simple negative electrolysis. 1 "Medical Gynecology: a Treatise on the Diseases of Women from the Stand-point of the Phvsician." bv A. J. C. Skene, M.D.. page 355. D. Appleton & Co. 17 CHAPTER XX. Diseases of the Urethra, Bladder, Rectum, and Sigmoid Flexure. diseases of the urethra and bladder. Caruncle.—This little tumor of the urethral orifice, which often gives pain and discomfort out of all proportion to its size, may be eradicated by several electric methods, after it has been temporarily anesthetized by the cataphoric application of a cocaine solution. The cocaine should be applied on a cotton pledget saturated with the solution and held on the part by a carbon or platinum electrode, positive, with 5 to 15 milliamperes for some minutes, the negative indifferent pad being on the abdomen. If the growth is pedunculated the galvano-cautery loop may then be passed over it and the heat turned on as it is tightened. A sessile growth is best destroyed by negative puncture, folloAved, at the same sitting, by a small positive zinc-amalgam electrode pressed into the opening thus made; 10 to 15 milliamperes will be sufficient. Stricture or Ulcerations of the Urethra.—The treatment of strictures or ulcerations of the female urethra is as successfully ac- complished as in the male and much more readily managed. The negative pole is, of course, necessarily the active one, as we wish a relaxing and softening effect, the electrode being the same as em- ployed in the anterior urethra in males, having straight shanks Avith bulbs of different sizes. When not provided with these the physician may use the long-shanked zinc-amalgam electrodes designed for intra- uterine applications (Fig. 26) the smallest size being usually appro- priate. When the latter are used they are best lubricated by mercury, but not for cataphoresis, since the negative pole is imperatively neces- sary for dilatation, and, like all other electrodes to be inserted within the urethra, should be scrupulously cleaned, preferably fire-cleansed, before insertion. Five to 8 milliamperes is a sufficient current- strength, the current being turned on when the stricture is reached, (258) diseases of the bladder and rectum. 259 the operator gently pressing the instrument fonvard until it passes the contracted portion, then re-engaging it from behind. The pro- cedure should be repeated every three or four clays until a cure is accomplished. Ulcerations of the urethra are best treated (as ulcerations else- Avhere) by positive zinc-amalgam cataphoresis, very small currents of 3 or 4 milliamperes being sufficient. Neuroses of the Urethra and Vulva.—Incontinence of urine in the adult may be corrected by a urethro-abdominal or urethro-sacral application of the primary faradic current, turned on in the SAvelling method for t\vo- to five minutes daily or every other day. In young girls or children the same results can be attained usually by external pubo-sacral applications of the same current with ordinary disk elec- trodes. The treatment of painful or pruriginous affections of the vulva, urethra, or bladder—such as pruritus vulvce, vaginismus, etc.—is by no means so simple, though often yielding the best results. We must here search for an organic or constitutional basis for the symptoms, such as erosions, lithemia, toxemia, or kidney disease, to be corrected simultaneously Avith the appropriate local application. It needs scarcely to be said that Ave employ the high-tension faradic current for a mere neurosis, having in view its anesthetic effect. If this be ineffective a Aveak solution of cocaine may be cataphorically driven in from a covered carbon electrode by a feAV milliamperes, the active electrode being positive. For neuralgia of any portion of the pelvis a vaginal bipolar fara- dic current is usually effective Avith the high-tension coil. Atony of the Bladder.—Contractile and tonic effects may be readily produced in the functionally Aveakened bladder by including the organ between the poles of a vagino-abdominal application of either current. A quickened micturition is, in fact, frequently noticed by patients undergoing this method for other purposes. In the pa- ralysis from long distension, as in cases of chronic cystitis, particu- larly Avhen fatty degeneration of the muscular coats of the organ is suspected, intravesical applications of the primary faradic current should be made, and, if vesical irrigation of antiseptic fluids be prac- ticed, the current should be applied simultaneously by the swelling method Avhile the bladder is ejecting the liquid. This may be done by attaching a twisted-wire socket for connection with the battery 260 DISEASES of avomen. to an ordinary silver catheter, insulating all but the tip with fused shellac, and employing it as an electrode. While the liquid is re- gurgitating the current will increase its force perceptibly, thus caus- ing contraction of the bladder under the most favorable conditions. The irrigation is the only element of this application requiring spe- cial discrimination as to frequency, or producing possible reactions from overuse. Cystoscopy.—In order that this subject may receive the most thorough and practical discussion, the author has requested Dr. Harris A. Slocum, Professor of Gynecology at the Philadelphia Poly- clinic, to prepare a statement which will include the fruits of his Avide experience in the examination of the bladder in Avomen:— Gynecologists have, for some time, recognized the close sympto- matic relation of diseases of the uterus and its appendages Avith those of the bladder and such parts of the ureter and urethra as are in close proximity to it. This is probably due to the fact that the viscera of the pelvic cavity are supplied by the hypogastric plexus of the sym- pathetic, situated in front of the promontory of the sacrum, betAveen the tAvo common iliac arteries. It may be noticed that the three principal pelvic organs in the female have a similar nerve-supply. The upper portions of the blad- der, uterus, and rectum receive a nearly pure sympathetic distribution from the ovarian and inferior hypogastric plexuses of the sympathetic. Their movements are unconsciously performed and entirely re- moved from the domination of the Avill, permitting, in the bladder and rectum, automatic adaptation to varying amount of contents, their retention during sleep, etc.; in a measure, this vieAV also applies to the uterus A\'hen that organ is engaged in gestation, the sole object of its existence. The outlets of these organs have a large proportion of insulated, spinal nerve-fibres. The sphincter ani receives filaments from the hemorrhoidal branch of the fourth sacral, the bladder and urethra being supplied from the third and fourth sacral, and the cervix the same. These introduce the elements of control or inhibition to the exit of each excretory organ (parturition is a modified excretion), more marked in the bladder and rectum, while evidently not at all volitional in the cervix. The inhibitory function of the spinal element in the uterus is exerted, as before indicated, in the resistance offered by the cervix to DISEASES OF THE BLADDER AND RECTUM. 261 the rhythmic contractions of the uterine muscle during gestation, and is probably the chief reason for their presence in that part of the organ. It is the intimate relation of the nervous and vascular supply of the pelvic tissues that contributes mainly to their close symptomatic relationship; the rectum, as Avell as the bladder, frequently requiring investigation in seeking the cause for symptoms apparently uterine. The purpose of this contribution is to give a brief description of the ordinary methods of examining the bladder as applied to office practice, and Avill not deal Avith diagnosis or treatment. Tavo methods of investigation are available: the indirect and the direct. In the former the view of the bladder is obtained through Xitze and Leiter's cystoscope, Avhich consists of an angled tube resem- bling a urethral sound, about twenty-one millimetres in circum- ference. The tip of the instrument contains a tiny electric light behind a AvindoAv of quartz. At the recedent angle Avithin the tube is a prism so placed that the rays received from the bladder-Avail are reflected through a telescope to the eye of the examiner. After con- necting the rheophores, contact is made and broken by means of a milled screw placed conveniently to the forefinger. Several modifications of this instrument have been devised, among Avhich may be mentioned that of Skeene's, in Avhich a ureteral catheter may be used and the ureters catheterized Avhile under in- spection. In examining the bladder by this method, Avith the patient in the dorsal position, its interior is cleansed of mucus, pus, or blood if present, and filled Avith a Avarm, Aveak boric-acid solution, using a four-ounce glass or hard-rubber funnel, tAvo feet of rubber tubing connected by a glass tube tAvo inches in length Avith the catheter to be used. From four to eight ounces are necessary, according to the capacity of the bladder. It requires a certain amount of experience with this instrument to obtain a correct impression of Avhat is seen. The appearance of the area inspected varies Avith the distance of the prism from the bladder-Avail. At 5 millimetres it is magnified to nearly tAvice the normal size; at 20 millimetres it is less than normal, AA'hile at 15 mil- limetres the view obtained about represents the true size of lesions as they exist. This distance is approximately secured by allowing the tip to touch the bladder-wall, and then withdrawing just suf- 262 DISEASES OF AVOMEN. ficiently to clear it. Contact between instrument and bladder should otherwise be avoided, as the heat generated after three to five minutes' use is sufficient to burn painfully, and might give rise to a cystitis that had not previously existed. Rather than continue a long, uninterrupted examination, it is far safer to shut oft the current for half a minute after three to five minutes' use, and allow the instrument to cool. The second, or direct, method—described by Pawlik and Kelly— is far more satisfactory in examining the bladder in the female. The speculum is a straight, metallic tube nearly 10 centimetres in length, made in sizes of from 5 millimetres to 21 millimetres in diameter, Fig. 71.—Cystoscope of J. HoAvard Kelly. Avith a flaring proximal extremity, a handle placed at an obtuse angle, and an obturator, snugly fitted, to facilitate introduction. When necessary, the urethra is dilated with Kelly's steel urethral dilators or his calibrator: a spherically-handled metallic cone 7.7 centimetres in length, 4 millimetres in diameter near the apex and 16 millimetres at the base, and graduated at each 2-millimetre increase in diameter. For office use or ordinary examination the 9-millimetre and 10-millimetre sizes are sufficient. The bladder-wall is easily ex- amined through them, and they rarely require a preliminary dilatation. Other instruments required are: one or tAvo urethral catheters, an aluminium applicator, and an appliance for removing accumulating urine. One of three positions may be chosen in which to place the DISEASES OF THE BLADDER AND RECTUM. 263 patient: Sims's position; the dorsal, with extreme elevation of the hips, and flexion of thighs and legs; and the knee-chest position. The latter is generally to be preferred; it is quickly attained and permits the maximum of ballooning. Corsets, bands, and all sources of constriction must be loosened, and the patient instructed to breathe freely and gently, not forcing the air from the lungs. The bladder should be thoroughly emptied before introducing the speculum, and voluntary voiding generally clears it of all fluid. After having observed the preliminary instructions regarding the clothing, the light from the head-mirror is throAvn upon the urethral opening, and the speculum, warmed and oiled, is gently inserted in the meatus. Bear in mind the slight curve to the urethra, and begin the operation by having the handle slightly depressed and the beak pointing a degree upAvard. When it has penetrated for about an inch Fig. 72.—Urethral calibrator. or an inch and a half, raise the handle half an inch to bring the instru- ment in the line of the canal and continue the introduction. If care and great gentleness are obsen7ed, the operation, in the majority of cases, Avith Xo. 6 speculum, is almost painless. The average time con- sumed is one and a half minutes. It must be done sloAvly, especially in office-work, Avhere the patient at once goes from the house to the street. The greatest amount of resistance will be met just before the beak enters the bladder, and it is just here that the patient may first complain of pain. The amount of pressure used is hard to estimate, but is probably tAvo ounces, and this, Avith an occasional rotary move- ment, is sufficient to allow of the insertion of the speculum into a bladder that is tender and irritable from chronic inflammation, Avith a minimum amount of pain at the time, and safety for the patient after she has left the office. The examination may now be begun, bearing in mind that, in 264 DISEASES OF AVOMEN. the majority of inflammatory cases, the lesions will be found on or near the floor of the bladder (the uppermost portion when in the genu-pectoral position). Tavo favorite spots Avhere inflammatory areas are apt to be found are directly in the neck of the bladder (ex- amined last, as the tube is being removed), and to either side of the neck. The latter can only be seen by carrying the outer part of the speculum far over to the side, at least forty-five degrees from the median line. This, too, should be done sloAvly and gently. Much more can be elicited from the tissues by gentle and persistent handling than by a sudden force that is apt to surprise them into resistance. When there is a tendency for the vagina to distend and encroach upon the space needed for the bladder, as is often the case Avhere a lacerated or dilated perineum exists, the patient should gently strain and expel the air from the vagina, after the speculum has entered the bladder and before the obturator is removed, then, by pressing the * Fig. 73.—Kelly's urethral dilator. perineum against the anterior vaginal Avail and removing the obtura- tor, air enters the bladder, and its distension is accomplished. If the ballooning is not satisfactory, the bladder being held in contact with the end of the speculum, it may be due to holding the breath, strain- ing, an oblique position of the thighs, or a rigidity of the dorsal or abdominal muscles. See that the thighs are perpendicular and the back well curved toward the table; then, instructing the patient to breathe gently and to avoid straining, the wall will generally fall away from the speculum and permit a full examination to be made. During the examination the accumulating drip from the ureters becomes annoying, surging up to and filling the inner end of the speculum with each expiration. This may be removed by Kelly's ap- pliance, consisting of a rubber tube 50 centimetres in length, with a rubber ball at one extremity, and a holloAV, perforated, metallic sphere 6 millimetres in diameter at the other, for introduction into the blad- der. If the metal ball is replaced by the long nozzle of a hard-rubber DISEASES OF THE BLADDER AND RECTUM. 265 uterine syringe, this little contrivance Avill be found to ansAver the purpose perfectly, being more easily and quickly introduced and removed. Dr. George E. Shoemaker devised and reported an apparatus for keeping the bladder dry. He used a quart bottle the cork of AA'hich was fitted Avith tAvo rubber tubes. Through one of these the bottle is exhausted of air, and to the other is attached a ureteral catheter, Avhich is inserted along the Avail of the speculum, is too small to inter- fere Avith the field, and readily removes the urine. He has also had a small tube soldered in the lumen of the speculum, to the outer end of Avhich the exhaust tube is attached. Fig. 74.—C'ystoscopic syringe. If these appliances are not at hand and the urine accumulates rapidly, a quick and ready method of emptying the bladder is to Avith- draAv the speculum until the inner end just reaches the neck of the bladder (shoAvn by the appearance of a narroAV ring of mucous mem- brane at the end of the instrument), and request the patient to rise from the knee-chest position to kneeling. This brings the inner end of the speculum to a plane beloAV the rest of the bladder and empties it at once. A short explanation to the patient satisfies her and ghes her a moment's respite by changing her position. Another method —the simplest of all—is to partly AvithdraAv the tube and ask the patient to strain gently. This brings the acting floor of the bladder 266 DISEASES OF AVOMEN. up to the opening, when by gently depressing the mouth of the instrument the desired object is accomplished. To lessen the amount of urine excreted, see that the patient drinks no fluid for an hour before the examination is made. It is essential that the bladder should be thoroughly distended, not only to open up all hiding-places for erosions, ulcers, or other lesions, but that the mucous membrane may be presented in its true colorings. A partially-contracted bladder is a shade darker or redder than Avhen fully distended and might easily mislead in esti- mating the degree of inflammation. Several healthy bladders (with all possible aseptic precautions) should be previously examined, to learn the appearance of the normal organ. It is not desirable to have the inner end of the speculum too near the wall. Withdraw from half to two inches, according to the degree Fig. 75.—Ureteral searcher. of illumination. More of the field is seen at one glance and a better idea of relations secured. The choice of light depends upon circumstances. In the office the electric head-light, Avith a reliable Edison-Lalande or other battery is satisfactory, providing one is fortunate in the selection of a lamp. These may last six months or a year, or they may be destroyed in a few minutes Avithout redress from the dealers. When connection Avith the battery is made the highest resistance should be interposed at first, to prevent a possible destruction of the carbon filament. Without care, one may burn out a lamp in an instant. If, for any reason, the electric head-light and battery are not to be obtained, the light from a good lamp or gas-jet reflected from a head-mirror will give satisfactory results, and, finally, in the absence of these, similarly reflected daylight gives all the illumination neces- sary, and has the advantage of presenting the parts in their true and easily recognized colors. In office-work, therefore, the only essential DISEASES OF THE BLADDER AND RECTUM. 267 instruments are a head-mirror, one six-millimetre speculum, and an aluminium applicator. A clear recollection of the nervous and vas- cular supply to the various organs of this region Avill go far toAvard a correct interpretation of symptoms, and the intelligent applica- tion of the proper treatment. One Avill lose no time in becoming thoroughly acquainted Avith the essential and relative anatomy of the parts. Applications through the cystoscope are best made Avith a slender aluminium applicator, carrying a thin layer of cotton on the end. Care should be taken not to wrap too thickly, to avoid pinching a fold of mucous membrane against the sharp edge of the tube Avhen Avithdrawing the applicator. The latter may be so thinly, yet service- ably, Avrapped with cotton that the eye may folloAv it doAvn the Xo. 9 tube to the spot to be touched, thus confining the medicine to the area needing it. An important feature in connection Avith cystoscopy is the exam- ination of the ureters. These pass diagonally through the wall of the bladder and enter it about 1 inch in front of the uterine neck,.and \ to \ inch from the median line. In order to bring them into vieAv, the speculum should be turned about thirty degrees from the median axis, and, Avith the patient in the genu-pectoral position, the handle is depressed until the mouth of the ureter is brought into vieAv. The appearance of this opening is not ahvays the same, and is, at first, rather difficult to find. It may appear as a small dimple Avith pouting edges, a small slit, or an area of deeper color than its surroundings. A fairly accurate guide is found in the jet of urine issuing from it. If the kidney and ureter of the side under observation are intact, a small, shining line of urine may be traced upward to its emergence. In rare conditions, probably of unusual stimulation of the ureteral muscular fibres, the mouth of the ureter is unexpectedly indicated by the appearance of a tiny stream of urine, such as Avould be projected from an hypodermic syringe, forcibly ejected across the inner opening of the speculum, sometimes striking its loAver Avail with a faintly audible tinkle. Further discussion of the examination of the ureters will not be entered upon here, but attention is called to the fact that inflam- mation of the loAver end of these tubes may, at times, be the cause of hitherto obscure and persistent backache, evidenced by the testimony of the patient, AA'hen the sound enters the canal, that there is Avhere 268 DISEASES OF WOMEN. the trouble lies, and, afterward, by the disappearance of the symptom after proper treatment. The color of the mucous membrane lining the bladder varies very much in different people, and at different times in the same sub- ject. It is several shades darker for a week before the menstrual period, increasing as that time approaches, rendering it desirable not to examine at that time, except Avhen the lesion is a very light one. It is then better to select that period, as an area of hyperemia that was not visible before, becomes plainly so during the period of pelvic turgescence. It would be well, in such a case, to make two exami- nations: one a Aveek after the menses have ceased and one the day before it is again expected. The contrast would indicate the relative integrity of the different capillary areas. The average color of the healthy bladder is pale-flesh color, Avith occasional reddish or bluish streaks, very fine, generally short—not over half an inch, and sometimes dichotomous. These are the small veins, and are rarely altogether absent. The shade deepens as the neck of the bladder is approached, and at the sphincter is apt to be a deep red, Avhich continues Avith gradual paling along the urethra to AA'ithin a quarter or half an inch of the ostium, Avhen it reaches the shade as seen Avithout the speculum's aid. Let each case be carefully and gently handled, both to avoid in- juring the tissues and to reassure the patient's mind. Frequently the first attempt to examine an extremely nervous patient induces marked mental distress, and requires judgment as to Avhether to con- tinue the efforts or wait until another time. The air contained in the bladder is \rariously disposed of. If the treatment does not extend to the urethra, use the same procedure mentioned AA'hen speaking of the disposal of the accumulating urine: Avithdraw the speculum to the inner extremity of the urethra, place a small receptacle under the mouth of the instrument, and request the patient to rise to the kneeling posture. Urine and air escape, the bladder collapses, and the speculum is entirely removed. If, as is often the case, the urethra likeAvise needs to be treated, the application is made during the sIoav Avithdrawal of the speculum, leaving the bladder distended Avith air. A soft-rubber catheter may easily be inserted and the viseus Avill be emptied when the patient either stands up or lies doAvn. Occasionally, AA'hen making applications at the patient's house, DISEASES OF THE BLADDER AND RECTUM. 269 the rubber catheter is permitted to remain in situ for a A'ariable length of time: from half an hour to four hours. This prevents a diluting of the medicament, and alloAvs a longer period for its action upon the mucous membrane, but must be done tentativeLy, to avoid irritating it. While it is not desirable to have a patient leave the office Avith air in the bladder, yet, should this occur, it rarely need cause anxiety. It is usually voided upon reaching home, Avith the first attempt to pass the urine, and is seldom folloAved by untoAvard results. DISEASES OF THE RECTUM AND SIGMOID FLEXURE. The frequency Avith Avhich the physician in the practice of gyne- cology encounters diseases of the rectum makes it wise to add a feAV paragraphs on these conditions in Avhich electricity is of signal service. This is an electro-therapeutic field that has been much neglected in spite of good Avork that has been occasionally recorded. Anal Fissure.—In cocaine cataphoresis Ave have an excellent and almost painless method of healing these troublous conditions of the anal outlet, AA'hich -will frequently make divulsion of the sphincter unnecessary. The patient is placed in position for examination, pref- erably leaning fonvard, face doAArnAA'ard, over the head-end of a couch, and the anus carefully examined in the light of a head-mirror or electric head-light. When the painful erosion or fissure has been found the small pad is slipped under the abdomen and made nega- tive, Avhile the positive electrode, of platinum or carbon covered Avith absorbent cotton dipped in a 10-per-cent. solution of cocaine hydro- chlorate is applied to the erosion and from 1 to 5 milliamperes turned on for some minutes. Usually one application is sufficient to pro- mote healing; at any rate it should not be repeated until a sufficient time has elapsed to test the possibility of healing having occurred. Hemorrhoids.—Both external and internal hemorrhoids are readily and radically cured by making use of the coagulative and styptic action of electricity AArithin the pile by means of puncture. Thanks to the anesthetic A-alue of cocaine cataphoresis this procedure may be made almost painless, and the subsequent discomfort during the healing process is less than by any other method. The electric method, Avhile radical in results and free from danger, possesses, there- fore, the adArantages of being possible Avithout general anesthesia. 270 DISEASES OF AVOMEN. The patient being in the position described in preceding para- graphs, the pile is exposed to a good light, those within the sphincter by means of a rectal speculum, and a carbon or platinum electrode with cocaine solution on cotton applied as already described. The cocaine electrode is made to cover the most prominent portion of the pile which is intended to be punctured and the material diffused by anodic cataphoresis for about seven minutes with a current of 15 to 25 milliamperes according to the discomfort produced. At the end of this time a small platinum needle on a staff some six inches long (Fig. 76), insulated to a half-inch from the point, is inserted Avith but little sensation and a current of 5 to 20 milliamperes turned on for ten minutes; a blanching effect is soon seen to occur in the pile, and the instrument may be withdrawn without bleeding from the point of insertion if sufficient current has been used. This puncture will probably be sufficient for the one hemor- rhoid; at any rate, healing should occur before repetition in that Fig. 76.—Author's hemorrhoidal needle electrode (sectional view, shoAving appearance when coated Avith shellac). tumor, but other tumors should be sought for and a similar cataphoric application and puncture made at the same sitting if the patient's endurance of the posture continues long enough. If the needle has been insulated in such a manner that an eighth of an inch of the shellac insulation Avill folloAv the point into the pile, further insertion being guarded against by a shoulder or bulbous portion of the insula- tion at the proper spot, the after-treatment is very slight, consisting of cleansing injections of hamamelic extract or a Aveak solution of acetanilid after defecation Avith occasional applications of an ointment of either of these agents by means of a rectal ointment-applicator. Prolapse of the Rectum.—Moderate degrees of this mechanical displacement of redundant rectal Avails may be successfully treated by a combination of tAvo methods: labile intrarectal applications of the positive pole of a combined galvanic current of 20 milliamperes and the primary faradic (the author's rectal electrode [Fig. 67] being used) and submucous puncture. DISEASES OF THE BLADDER AND RECTUM. 271 The purpose of the labile rectal application of both currents is the stimulation of the muscular Avails of the rectum and the various muscular structures adjacent, in order that the normal tone may be restored. This is usually followed by an immediate retraction of the protrusion, Avhich frequently remains in proper position for increasing periods of time after this simple application. If made daily it may cure moderate conditions of prolapse without further elaboration of method. In the absence of the amalgamated-zinc electrode, AA'ith Avhich it is proper to employ the positive pole (the mercury prevent- ing cauterization under the moderate current and constant movement advised), the negative pole may be used Avith a rectal olive of any metal. The Sims position is usually the most convenient for this maneuver. The purpose of the submucous puncture is the production of a cicatricial adhesion betAveen the redundant Avails and the underlying areolar tissue. Either pole may be used, the position of patient and anesthetic cataphoresis being the same as described in the puncture of hemorrhoids. The needle is inserted at but a slight angle Avith the longitudinal axis of the rectum, and about 20 milliamperes used for ten minutes. But little can be accomplished by puncture, how- ever, as the adhesions produced in such a manner are evanescent. Stricture of the Rectum.—The unsurpassed value of electricity in strictures of the rectum is Avell shoAvn in Xewman's article in the "International System of Electro-Therapeutics." Its special action here, as in other strictures, is the dilating and softening effect of the negative pole and the possibility of causing absorption of the cica- tricial fibrous structure causing the stricture. The size of the bulbs required makes it possible, as Avell as necessary, to use much more current than in the urethra, with added boldness of technique. The instrumental equipment, in addition to the usual abdominal pad for a dispersing- pole, consists of a rectal electrode Avith shank about nine inches long to Avhich three or four sizes of bulbs may be screAved, varying in diameter from one-third to one inch. Semi- elastic shanks have been advised by some writers and repeatedly used by the author, but are rarely satisfactory in the firmer or narrower strictures, OAving to one's inability to direct the bulb properly. An important improvement applied to these electrodes by the author is shoAA'n in Fig. 66, AA'hich is tunneled for attachment to a syringe in order that a cushion of Avater or oil may be made to precede the 272 DISEASES OF AVOMEN. instrument, dilating the natural channel up to the point of the stricture.1 Essential elements of success in this Avork are a knowledge of the anatomy of the rectum and of its several sphincters, and extreme gentleness in passing the electrode to the contracted spot, Avhere but slight pressure is demanded, the dilating effect of the current of 20 milliamperes or more being relied upon. Should the stricture bear evidence of being due to a malignant groAA'th, the fact that the author's electrode bulbs are of zinc comes in play, since Avhen Avell amalgamated the polarity of the instrument may be changed to positive after the diseased spot has been reached and a stronger application of mercuric cataphoresis made before it is Avithdrawn, as in the ulcerative conditions described beloAv. Ulcerations and Adenoids of the Rectum.—For these conditions the mild zinc-mercuric cataphoresis is indicated, -with current- strengths of 30 to 50 milliamperes applied from olive-shaped zinc instruments. The results are most excellent, and could probably be attained in no other way. 1 The author does not claim the tunneled rectal electrode as a novelty, except as applied to a dilating instrument for the upper rectum, holloAV rectal electrodes having been devised by Boudet, King, Cleaves, and others. CHAPTER XXI. The Cosmetic Applications of Electricity. The chief cosmetic uses of electricity, in addition to the restora- tion of a normal clearness of complexion by a galvanic stimulation of the liver and other abdominal organs, is the destruction of super- fluous hairs on the face or elseAvhere, the remoAral of small surface- tumors of the skin, moles, and A\-arts; of nevi, or port-Avine marks; and of pigmented nevi. Electricity, or, more particularly, the solvent action of the negative pole of the gahanic current, is, in every Avay, the best method of removing these blemishes, Avhich, Avhen situated on the face or other conspicuous portion of the skin, not only mar the appearance of the person, but are often responsible for an un- happy disposition in the persons thus afflicted. The skillful applica- tion of the proper remedy for these deformities is not the highest work of the educated physician, it is true, yet it is by no means beneath him, and, AAdien it is remembered that the proper performance of the AA'ork demands a considerable knoAvledge of the anatomy and pathology of the skin, it is his duty to rescue it from the hands of ignorant charlatans. Superfluous Hair.—The destruction of superfluous hair is accom- plished by the electrolytic destruction of the germinal papilla at the bottom of the hair-follicle, and it may be said that there is no other knoAvn \vay in Avhich this may be done Avithout destruction of the adjacent skin. The Avorld is indebted to Dr. W. A. HardaAvay, of St. Louis, Mo., for the discovery of this fact, Avhich has been further elaborated by Dr. George H. Fox, of XeAV York, and the late Dr. Plvm. S. Hayes, of Chicago. The pole employed is inA^ariably nega- tive and a current-strength of from ^ to 2^ milliamperes is sufficient, according to the size of the hair and the duration of the application, AA'hen it is concentrated at the point of a fine needle inserted into the follicle. This amount of current may be obtained from a variable 18 (273) 274 DISEASES of avomen. number of cells when a controller is used, though it is thought to be more painful if the voltage is greater than that obtained from about twenty cells. As the physician will be most apt to use the same apparatus for this Avork as that employed in ordinary therapeutic applications, it is only necessary to cut out some cells by a switch- selector or otherAvise attach that number of cells to his switch-board. The special instruments required are a needle and a pair of epilating forceps, the latter to be broad-pointed, non-serrated, and with a Aveak spring. A proper needle is a matter of extreme importance, since it is necessarily very fine to traverse the smaller hair-follicles which are already nearly filled Avith the hair themselves, yet the point should be so blunt as not to pierce the sheath of the follicle, but merely follow the hair to its base. Specially-ground jeAvelers' broaches have been generally recommended, of steel, since the negative pole is invariably used, but I have preferred one less easily broken, which has been made from hard, gold spectacle-Avire. This is ground fine and with a very small bulbous point. The handle should be light and without any current-breaking mechanism, as is sometimes mistakenly added, the cord to be attached being unusually light. I have in some instances succeeded in insulating the needle a few lines above the point by fusing a light coating of hard rubber on it. This Avill permit the electrolysis to be restricted to the point, beneath the actual sur- face of the skin, and will lessen pain and scarring. The patient is placed in a large chair by many, but the writer prefers in this and all other face applications that she lie on a couch in a good light with her head Avell up on the head-piece, the opera- tor sitting behind and leaning over with his elbows resting on the side of the pillow. The poles of the battery are thoroughly identified and the positive binding-post connected Avith a moist pad laid on a toAvel in her lap, on which the patient presses her hand to close the circuit and raises it therefrom to break it at command, the pad becom- ing thus a delicate controller to make and break the circuit Avithout suddenness. Everything being in readiness, the needle, connected Avith the negative pole with an appropriate cord or very fine insulated wire, is inserted into the follicle Avithout piercing its Avails, the patient is directed to press the pad, the proper amount of current is turned on through the Massey controller, which is not thereafter disturbed, and COSMETIC APPLICATIONS. 275 the action of the current noted. AVhen the hair is loosened, as it will be in a fe\v seconds, if the needle has been properly placed, it is removed by the forceps in the other hand of operator; the patient is directed to raise the hand, when the needle is removed, reinserted into another follicle, and the process repeated. The patient's hand is ahvays up, therefore, Avhen the needle is either inserted or removed, greatly lessening the pain, Avhich is often considerable. After the skin has been broken by an application a strong solution of cocaine should be spread over the surface, and though the polarity of the electrode -will not carry much of it in by cataphoresis a distinct dull- ing of sensation will be soon manifest from it, doubtless by absorp- tion through the little punctures made. If four hairs are removed at the angles of a surface a little over a half-inch in area the inclosed space quickly becomes anesthetized, permitting the hairs within it to be removed at this sitting Avithout sensation. But it is not wise to remove hairs closely contiguous, OAving to the tendency of the little cauterizations to coalesce, producing too palpable a scar. The seance should not be prolonged beyond a half-hour at a time, in the interest of both patient and operator. A fcnv hair-papillas will escape destruction at the hands of even skilled operators; but they are readily removed Avhen they reappear. To guard against an undue number of these, care should be observed not to remove the hair until it is thoroughly loosened. Moles and Warts.—The special advantage of negative electrol- ysis in the removal of both moles and Avarts is that it enables us, by a nice adjustment of the destructive action to the actual tissue to be destroyed to devitalize the little tumor at one sitting Avithout the destruction of the underlying skin as Avith acids or the knife, the slight scar left for a fe\v Aveeks disappearing entirely after a time. The details are practically the same as for the removal of a hair, except that a sharp needle is used, passed into the growth a little distance above its base, and that about 5 milliamperes is usually re- quired, turned on A'ery gradually. The current should be continued until the groAvth is quite disintegrated in the case of moles, but Avarts often disappear after only a partial destruction of their bases, appar- ently by an influence on their nutrition. In either case the crusts should be left undisturbed until they fall off, to avoid scarring. Nevus Vasculosus (Port-wine Mark).—This congenital dilatation of the capillaries of the skin is at times of large extent, constituting 276 DISEASES OF WOMEN. a serious disfigurement. Its treatment, Avhich necessitates an occlu- sive inflammation of the capillaries, is both tedious and painful, yet the results attainable are fully worth the effort. The active pole, negative, to avoid undue scarring, consists of a number of needle- points projecting from a disk, enabling as many punctures to be made simultaneously. The current is empirically regulated and maintained (at about 3 milliamperes per needle) until a white wheal appears at each puncture, Avhen it is turned off and the instrument reapplied at another place. The result of each healed puncture is a minute Avhite scar at its site, and it is therefore necessary to repeat the ap- plication a number of times at intervals of a month in order that the AA'hole surface may be turned into a slightly roughened cicatrix, Avhich is far more sightly than the nevus. The application is quite painful and for a thorough treatment it is wise to employ anesthesia, particularly since the applications are necessarily at long intervals. It is possible that if the needles Avere of irido-platinum and the positive pole used the greater scarring from short applications would be of advantage, but the author is not aware that this has been tried. Nevus Pigmentosus.—This form of nevus, characterized by the deposit of pigment AA'ithin the skin and frequently by the associated groAvth of superfluous hairs, is treated in the same Avay as the vascular nevus, the hairs being first removed in the usual Avay. The pigment is, at times, apparently decomposed by the electrolysis, the metallic constituents being deposited on the negathe needle. PART II. RUDIMENTS OF MEDICAL ELECTRICITY. CHAPTER XXII. Physics of the Galvanic, or Direct, Current. While our knoAvledge of the true nature of electricity itself is yet indefinite, it is fortunate that its manifestations in motion—the only condition in which it is of service to physicians—are as real, comprehensible, and measurable as a simple current of Avater. If there is mystery attending its use in medicine it is the mystery of all remedies applied to yet imperfectly understood physiologic and pathologic processes. Certain facts relating to their non-compressibility have led recent investigators to regard electric currents as currents of a real fluid. Be this as it may, the fact that their laAvs in motion are exactly analogous to those of hydraulic currents has enabled us to frame a definite mental picture of them, and assists us greatly in a compre- hension of their qualities. If Ave examine a stream of Avater issuing from a reservoir (Fig. 77) Ave Avill find tAvo qualities which will not be difficult to separate in the mind: pressure and volume. The former is the force by Avhich Avater transports itself, due to gravity, and depends on the height of the Avater in the reservoir. It is the same in all pipes issuing from it, Avhether large or small. The volume of Avater carried by a pipe, on the other hand, depends on the size and length as well as on the pressure. Electromotive Force (Pressure).—In electric currents the force (277) 278 DISEASES of avomen. governing the transportation of the energy is called electromotive force, due to a kind of electric gravity, or heaping up of energy at the positive pole. This force is likeAvise independent of the size of the conductors attached to its reservoir, but the bulk, or volume, of the current will depend on the size and length of the conductor as well as on the electromotive pressure. Just Avhy a contrivance such as a gahanic cell should give rise to the pressure leading to current-floAv is not so clear as is the anal- ogous pressure-origin in water-currents. It is easy to conceive that Fig. 77.—Diagrammatic representation of the cause of flow in hydraulic currents. The pressure, measured by a vertical scale of feet, is due to the elevation of the source, or reservoir. The amount of Avater delivered Avill depend on the calibre of the pipe as Avell as on the height of this pressure. a water-current will Aoav doAvmvard through pipes by virtue of the actual Aveight of the Avater, the available weight being proportional to the vertical height of the water-column. All that Ave knoAV of the cell-origin of electric pressure is that it is an inherent quality of any two metals that one is positive to another Avhen both are plunged into an acid or saline bath, and that a current starts from the sub- merged surface of the positive element toward the submerged por- physics of the galvanic current. 279 tion of the negative element and emerges at the unsubmerged por- tion of the negative element. The upper portion of the negative ele- ment (Fig. 79) is, therefore, the positive pole, as it is at this point that an accumulation of electric energy occurs in a cell, Avhile a corre- sponding deficiency is found at the upper portion of the positive ele- ment, constituting the negative pole. When the two poles are united by a conductor, such as a wire, the body, etc., a current Aoavs from the positive pole to the negative pole in response to nature's effort to re-establish an equilibrium. It is, however, the peculiar virtue of a good cell that the difference of level is maintained by chemic action Fig. 78.—Diagrammatic representation of the cause of flow in electric currents. The pressure (or electromotive force), measured t>y a scale of volts, is due to the elevation of the electric level of the positive end of the conductor by the particular generator in use. The amount of cur- rent delivered Avill depend on the size and conductivity of the Avire as well as on the height of this pressure. between the liquid and the elements, resulting in a constant main- tenance of the pressure at the positive pole and a continuous current- effort at equilibrium until either the chemic activity of the liquid is exhausted or the positive element is consumed. We can ascertain the direction of the current always by knoAving that it is invariably the positive element that is consumed, on the surface of which the cur- rent begins. By knoAving this, Ave knoAV that the outer portion of the 280 diseases of avomen. opposite plate is always the positive pole of the cell. It so happens that zinc is almost invariably used as the perishable element in a cell, and usually carbon the unattacked element; hence the positive pole of such a cell is the outer portion of the carbon, or a wire at- tached to it. A galvanic cell with its circuit "open"—i.e., without conducting material connecting its poles—may be said to resemble a small reser- voir full of water with the outlet closed and ready to supply a cur- rent to a pipe. When the poles of the cells are connected and a current flows it is like the same reservoir with valves open, supplying a current of water to its pipes, the water-level in the reservoir being Fig. 79.—Diagram of direction of current within a cell. maintained by pumps that are analogous to the chemic action within the cell. But the galvanic cell is by no means the only method by AA'hich electromotive force may be created. Fig. 80 indicates how a dynamo, electric machine, or induction apparatus may cause a pressure by heaping up energy at the positive pole, showing its analogy to a pump. The Volt.—The unit of electromotive force, or pressure, is the volt; so named after Volta. It has been derived from mathematic calculation, based on fundamental units of length, mass, and time,— the centimetre, gramme, and second, or C. G. S., system of units. physics of the galvanic current. 281 The physician, hoAvever, needs but to remember that the practical volt is almost exactly the amount of electromotive force produced by a good zinc and copper cell, knoAvn as the Daniell cell. Tavo such cells, arranged in "series" as in Fig. 78,—that is, Avith the zinc of the first connected Avith the copper of the second,—will raise the poten- tial in the circuit to tAvo volts. Five such cells Avill give five volts and ten cells ten volts, the unconnected copper of the first cell being the positive pole of such a battery and the unconnected zinc of the .....^—^...........m JPci77-t./o or JBtfnctmo Fig. 80.—Diagram showing analogy of laAvs governing pressure in pump and dynamo circuits. last cell the negative pole. Of the cells in medical batteries it may be said that all zinc and copper cells possess an electromotive force of about one volt, zinc and silver cells about the same, and zinc and carbon cells about one volt and a half. An ordinary portable battery of thirty zinc-carbon elements, such as is largely employed Avith acid solutions, gives, therefore, a current Avith a pressure of about forty- fhe volts Avhen in good condition. Resistance.—It Avas said above that the pressure of an hydraulic 282 DISEASES OF AVOMEN. current from a reservoir of a certain height was independent of the size of the pipes through which it issued, being the same Avhether the pipe was large or small. The amount of water passing through the pipes will, however, depend on their calibre and the frictional resistance of the Avater against the sides of the pipe. The calibre of an electric conductor is equally important in regulating the volume of the current that will pass through it from a given pressure, while a certain frictional resistance to electric conduction exists in the metallic conductor itself not unlike the internal friction of the pipe. The Ohm.—-The adopted unit of resistance is the ohm, named for Professor Ohm, of Germany, and is equal to the amount of resistance presented by a column of mercury one metre high and one millimetre thick. A more convenient idea of this amount of resistance is con- veyed by the statement that it is equal to that presented by a Avire of pure copper two hundred and fifty feet long and one-twentieth of an inch in diameter. Five hundred feet of such wire will give two ohms resistance, and one thousand feet four ohms. On the other hand, if the two hundred and fifty feet of copper Avire be twice the area in cross-section it will give but a half-ohm resistance, and so on. The resistance of a conductor is therefore directly as to its length and inversely as to its cross-section. Specific Resistance.—Homogeneous conductors, such as metals or solutions of definite proportions, present differing resistances, hoAv- ever, even in conductors of the same size and length. A one- tAventieth-inch iron Avire, two hundred and fifty feet long, for in- stance, will present a resistance of 5.36 ohms, because an iron wire of the same size and length has a resistance 5.36 times greater than copper. This differing facility of conduction is an inherent quality of different substances, and is called their specific resistance. It is probably due to a frictional resistance to Aoav presented by the con- stituent molecules of the conductor. The resistance of copper is taken as the unit of comparison, or 1. Table of Specific Resistances. Metal. Specific Resistance. Silver ............................... 0.77 Gold ................................ 1.38 Aluminum........................... 2.29 Zinc ................................ 2.82 physics of the galvanic current. 283 Metal. Specific Resistance. Iron ................................ 5.36 Tin................................. 6.76 Platinum ............................ 7.35 Lead ............................... 9.96 German silver......................... 10.09 Antimony ........................... 18.07 Mercury ............................. 47.48 Bismuth............................. 64.52 Graphite ............................1106.00 Gas-carbon ..........................2037.00 The Law of Ohm.—In hydraulic currents it has been said that the volume of the Avater circulating in a pipe Avill depend on the pressure, on the one hand, and the calibre and length of the pipe on the other. The corresponding relation of pressure and resistance to current in electricity is knoAvn as Ohm's law, having been formu- lated by Professor Ohm in 1827. It is mathematically expressed by the formula E (electromotive force) C (current) = — .--------- R (resistance) or that the current is equal to the electromotive force divided by the resistance. Units of Current.—The Ampere.—The amount, or volume, of current circulating in a conductor is measured in amperes. This unit of current-volume is fixed as the amount circulating through a re- sistance of one ohm from a pressure of one volt. A Daniell cell would, therefore, maintain an ampere through tAvo hundred and fifty feet of one-tAventieth-inch copper Avire if its own internal resistance could be excluded. The Milliampere.—For medical purposes the ampere is too large a unit; hence the milliampere, or one-thousandth of an ampere, is used for this purpose. The Coulomb.—The current delivered eA'ery second by a circuit having a pressure of one volt and a volume of one ampere is equal to a coulomb, the unit of measure for current-quantity. This unit, or its corresponding diminutive, the millicoulomb, is rarely used in medi- cine, unless electrolvsis alone and not the additional effects of more or less suddenly applied volume are required. A record of the milliam- 284 DISEASES of avomen. peres used and the duration of the application conveys more informa- tion than a mere record of the millicoulombs would. Internal Resistance of Cells and Batteries.—In a circuit made up of a battery and external conductors there are tAvo kinds of re- sistance to be reckoned with in estimating the AA'hole amount to be encountered,—viz., the internal resistance, or that given by the solu- tions and elements Avithin the cells, and the external resistance, or that given by the Avires, cords, electrodes, and body. Incandescent currents Fig. 81.—Three cells connected "in series." may be said to have external resistance only, as the internal resistance of the vast reservoir made up of street-mains, dynamos, etc., is too small to require the physician's attention from this point of vievv. Application of Ohm's Law to the Arrangement of Cells.—The A'arious needs of electricity in medicine require that currents of varied pressure and volume be used, the pressure being employed, as a rule, merely for the purpose of carrying sufficient volume through the tissues. If but a milliampere or so is required the pressure need not be great, but if a large volume is desired to be passed through the PHYSICS OF THE GALVANIC CURRENT. 285 poorly conducting skin the pressure must be from fifty to a hundred volts. A single Leclanche cell gives a pressure of about one and a half volts. To get a current of seventy-five volts from a battery of such cells Ave must arrange fifty of them "in series," as in Fig. 81,— that is, Avith the zinc of the first attached to the carbon of the second, and so on. Such a current will have sufficient pressure to carry the usual amounts of milliamperes required in medical applications, but it will not heat a cautery-knife, because it will be impossible to get Fig. 82.—Three cells connected "for surface," or in parallel arc. more current-volume from the Avhole battery thus arranged than can be obtained from a single cell on short circuit (or Avorking with its poles connected directly Avithout appreciable external resistance), be- cause its output will be limited by its OAvn internal resistance. To increase the output in the latter case avc must decrease the internal resistance, Avhich is done by either increasing the size rather than the number of the cells, or by arranging the cells "for surface" or in multiple arc,—that is, Avith all the carbons connected together as the one positive pole and all the zincs connected together as the negative 286 DISEASES OF AVOMEN. pole, thus making them one cell many times larger than the original one (Fig. 82). The internal resistance in this latter arrangement is decreased by broadening the path of the current through the battery itself. By a computation of the internal resistances of cells and a calculation of the pressure required to overcome the external resist- ance Ave can easily tell Avhether Ave need a few large cells or many cells that do not need to be large. To the mathematic mind but little effort is required to com- prehend such facts. To those rusty in figures I commend the fol- lowing graphic delineation of the laAV of Ohm as applied to currents from cell-batteries, an ideal cell Avith an electromotive pressure of one volt and an internal resistance of one ohm being depicted for conven- ience of illustration:— 'EXTERNAL" RESISTANCES. o ,\ I 10 100 iooo Ohms. I .9 .476 .082 .OOEO .000892 AMPERE. Fig. 83.—Graphic delineation of the pressure and volumes of currents from a single galvanic cell "when Aarious resistances are inserted into the external circuit. The cell shoAvn at the left of the cut has an electro- motive pressure of one volt and an internal resistance of one ohm. The divisions of the drawing to the right of the cell represent imaginary longi- tudinal sections of the currents obtained on short-circuiting the cell and after successively inserting into the circuit the several resistance coils indicated in the upper portion of the figure. The heavy shading in the first three divisions shoAvs the exact proportions of volume to the eye as compared Avith a full ampere, indicated by a broken line. The light shad- ing shows the proportion of pressure, Avhich is uniformly maintained throughout. The volume in the last three spaces is indicated by the fig- ures beneath, but is much too small to be shown to the eye on the scale adopted. Fig. 83 shoAvs to the eye the effect made on the current-volume from a single cell by inserting \rarious amounts of resistance into the external circuit. The cell has a typical pressure of one volt and a PHYSICS OF THE GALVANIC CURRENT. 287 typical internal resistance of one ohm. When its terminals are joined by a short band of copper, so thick as to present no appreciable re- sistance, the current-volume produced is one ampere. If, uoav, the short band of copper be replaced by a coil presenting a resistance of one-tenth ohm, making, together Avith the internal resistance of the cell, a total of one and one-tenth ohms, the resultant volume will be diminished to nine-tenths of an ampere. When another coil, giving a resistance of a full ohm, is added, Fig. 84.—Graphic delineation of the pressure and A'olumes of currents from a battery of twenty cells arranged "for surface." The battery, acting as an enlarged cell, has an electromotive pressure of one volt and an in- ternal resistance of one-twentieth of an ohm. The first three imaginary current-sections shoAv the proportions of volume to the eye. the total noAv being tAvo and one-tenth ohms, the volume maintained is less than half an ampere. A corresponding reduction of the vol- ume occurs, AA'ith the inclusion of each additional amount of resist- ance in the external circuit; and Avhen the whole series of coils is placed in circuit, aggregating, together Avith the internal resistance, 288 DISEASES OF AVOMEN. a total of one thousand one hundred and twelve and one-tenth ohms, the current-volume is brought doAvn to less than nine-tenths of a milliampere. The resistance of the body with approved electrodes may be said to be represented by the last two coils of the figure (from one hun- a EXTERNAL RESISTANCES E J_ its 1 10 100 1000. Ohms Fig. 85.—Graphic delineation of the pressure and volumes of currents from a battery of twenty cells arranged "in series." The battery has an electromotive pressure of twenty volts and an internal resistance of twenty ohms. The heavy shading in the first five imaginary current-sections shows the exact proportion of volume on the scale of the preceding cuts. The space allotted to represent pressure is reduced, for convenience, to one-half the scale adopted in Figs. 83 and 84. dred to one thousand ohms), Avhile that of the platinum loop of the galvano-cautery knife is nearest that of the first coil. The effect of increasing the cell to twenty times its size (or coupling tAventy similar PHYSICS OF THE GALVANIC CURRENT. 289 cells for surface, i.e., all the zincs to one pole and all the carbons to th2 other), is shown for both uses in Fig. 84, demonstrating the value of the method Avith the slight external resistance and its inefficacy for the greater. The effect of an increase in the voltage in passing more current through the higher resistances is sIioavii in Fig. 85, AA'hich also displays the disadvantage of this method in the low resistances, as the additional cells bring Avith them additional internal resistance. 19 CHAPTER XXIII. The Production and Control of Galvanic Currents. The galvanic currents used in medicine are procured from bat- teries of cells arranged to give sufficient voltage (from 10 to 150 volts, according to the nature of the medical work) or from reliable direct-current incandescent lighting-mains, the latter usually having a pressure of 110 volts. In either case the currents are modified by an applying apparatus consisting essentially of a controller and meter, with the necessary switches and binding-posts. Where reliable Edison incandescent circuits are available that are either under the absolute control of the operator or placed underground and kept free from danger of contact with arc-light and trolley-car wires and kept con- stantly supplied with current, there is no reason for the physician to use a battery as a source of current. All batteries require intelligent care and are likely to give more or less trouble in replenishing and repairs, all of Avhich is relegated to the dynamo-house in the case of incandescent circuits. Yet no one should begin the use of an in- candescent circuit until he has assured himself by investigation that his circuit is free from the defects and dangers referred to. sources of current. The Incandescent Circuit.—Being assured that there will be no possible interruption of the current to be delivered from the 110- volt Edison direct-current mains,1 its use in medical applications is very simple, the tAvo supply-wires being attached to the apparatus, AAdiether it be a cabinet or table switch-board, just as the wires lead- ing from the carbon and zinc elements of the battery are attached. The polarity of each wire should first be tested as described on page 1 The Westinghouse system of incandescent house-lighting, so largely used in smaller toAvns, employs an alternating current totally unlike those consid- ered here, and, of course, lacking in the properties of a direct current. Its employment in medicine is referred to elsewhere. (290) PRODUCTION AND CONTROL OF GALVANIC CURRENTS. 291 312 and labeled, the positive \vire being permanently attached in the place arranged for the Avire from the carbon pole of the battery and the negative in that for the zinc. Tavo precautions are, however, essential, one being that the electrician should insert a fuse betAveen the mains and apparatus to permit not more than one ampere of cur- rent to circulate through it; and the other that no switch that will short-circuit the current be permitted in the cabinet or other ap- paratus. These precautions are to be observed to preserve the meter and other apparatus from burning out, and they are both important on that account, particularly the rearrangement of SAvitches, since all Fig. 8G.—Diagram of circuit arrangement for using incandescent current. A, lamp-socket Avith plug inserted; B, double conductor; C, controller; D, meter; K, electrode binding-posts. the older apparatus and batteries have switches that short-circuit the cells every time they are turned. If a separate meter and controller are used instead of the per- manent sAvitch-board they should be connected up Avhen used, as shoAvn in Fig. 86, after testing and marking the polarity of the in- candescent terminals. One Avire is connected directly with one of the binding-posts for the electrodes1; the other conductor is carried to one binding-post of the controller; from the other binding-post of the controller a wire is led to one binding-post of the meter, and from 1 It would be Avise to have a one-ampere fuse inserted on this wire. 292 DISEASES OF AVOMEN. the other binding-post of the meter a wire is led to the remaining electrode binding-post. The electrode binding-posts should noAv be marked Avith their respective polarity signs. In handling the electrodes and cords of an incandescent circuit thus arranged one must be careful not to bring the metallic parts of opposite poles together unless the controller is turned off. This precaution is merely to preserve the fuse or instruments from being burnt. There is absolutely no other danger from the use of a proper Fig. 87.—Author's switchboard for obtaining the galvanic current from the Edison incandescent mains. circuit of the Edison current, as the full strength of this circuit can force no more current through the body than can the full strength of any good battery of seventy or eighty cells. To avoid such acci- dents to the apparatus the controller should ahvays be kept Avith the crank at the starting-point Avhen not in actual use, and the metallic parts of the electrodes and cords should never otherwise be brought together. When currents of moderate strength are to be used it is some- PRODUCTION AND CONTROL OF GALVANIC CURRENTS. 293 times an advantage to reduce the pressure of the Edison current by inserting a lamp in the circuit Avith the controller, meter, and patient, or the patient may be placed in a shunt circuit at will as in Fig. 88. Fig. -Geiorer shunt-controller, or volt-selector. To place the patient in a shunt circuit means that the cur- rent is split into two routes, the one in which the patient is placed being capable of such variation of resistance, in relation to the other circuit, as to take more or less of the total voltage. 294 DISEASES OF AVOMEN. An improved Massey controller, made on the shunt principle, specially adapting it to the Edison current, is shoAvn in Fig. 89. This may Fig. 89.—Improved Massey current-controller. The patient is placed in a shunt circuit. Fig. 90.—Jewell graphite controller: an adaptation of the author's con- roller, so arranged that the patient is placed in "shunt circuit." also be used Avith a battery of cells. In both cases the current should be turned off Avith a SAvitch AA'hen not in use. as a little current -will otherwise Aoav through the shunt. The Mcintosh Co. also manu- PRODUCTION AND CONTROL OF GALVANIC CURRENTS. 295 facture an excellent shunt current-controller for these purposes (Fig. 90) Avhich may also be used with a battery of cells. Stationary Battery of Cells.—Where a battery of cells is required as a source of current, and it is to be used in the office or hospital building only, a stationary battery of permanent primary cells is es- sential. Such a battery consists of from 40 to 75 cells arranged in a series on shelves in a cabinet or convenient closet. By arrangement "in series" is meant that the zinc of the first cell should be connected by a Avire or other connector Avith the carbon of the second cell, the zinc of the second Avith the carbon of the third, and so on. When Fig. 91.—Arrangement of circuit for Jewell controller. It will be noticed that a current-breaking switch is placed in the main circuit. This should be off the button when not in use, to save slight cell-action. The meter should be inserted in the patient's circuit. all the cells are thus connected it will be found that the carbon of the first cell and the zinc of the last one are free. A wire attached to this carbon will be the positive pole of the battery and another attached to the zinc will be the negative pole. The current from such a battery must be used through a controller and meter placed per- manently and directly in series, as described for the incandescent cur- 296 DISEASES OF AVOMEN. rent. These Avires, or "mains,"' may be carried throughout an insti- tution, terminating in a pair of binding-costs on a Avail-board, each binding-post being permanently marked with the proper polar sign, after due ascertainment of the identity of the pole.1 The only cells worth considering for this purpose are the open- circuit bell-ringing cells easily procured from first-class hardAvare- stores in any part of the country noAv that electric bells are so com- mon. These are all one or another variety of the Leclanche cell, consisting of carbon and zinc elements in a saturated solution of chloride of ammonium. These cells are said to be of the "open Fig. 92.—Mcintosh switchboard for galvanic and faradic currents derived from Edison incandescent mains. circuit" variety because they remain in good condition for long periods Avhile unused, or with the circuit open. If used on a circuit of Ioav resistance for many minutes at a time they tend, hoAvever, to run down by polarization, but will recover if allowed to rest. The variety noAv universally used is a simple carbon cylinder cell, the cylinder made in one piece with the cap, the zinc passing through an 1 An additional pair of binding-posts is attached to another circuit in the author's sanatorium Avail-boards for a current to operate the faradic coil. PRODUCTION AND CONTROL OF GALVANIC CURRENTS. 297 insulated opening in the latter. In setting up these cells care should be observed not to permit the solution to wet the upper edge of the jars, as this would favor capillary "creeping" of the salts. The zincs should be cleaned at least once in six months, and if renewed at the end of a year or eighteen months will postpone a thorough overhaul- ing for a much longer time when the battery receives but moderate use. Portable Batteries.—Portable galvanic batteries are, at best, troublesome, yet indispensable when the patient must be treated in Fig. 93.—Carbon cylinder cell. This form of cell has practically superseded all other forms of Leclanche cells. her own home. An efficient source of electricity for use in gyne- cology is, hoAvever, only relatively portable, for they are much too heaA'y to be carried from house to house in a carriage, the most that can be done being to leave one with each patient,1 for ease of porta- bility is apt to be secured at a sacrifice of efficiency. Much attention has been directed, of late, to portable batteries consisting of chloricle- 1 In large cities a thirty-cell acid battery may be hired and recharged monthly at a moderate cost. 298 DISEASES OF AVOMEN. of-siher cells. Such batteries are a distinct luxury, as they may be carried in the carriage or hand Avith the utmost ease and are ex- tremely convenient for a journey or visit in consultation, but one must not feel certain that they will do more than furnish a testing current for neurologic examinations or slight treatment. They are unfit for the heavy Avork of gynecology or general galvanic applica- tions, and if found to be accidentally out of order are incapable of Fig. 94.—Elements of carbon cylinder cell. repair by the user. The most reliable portable battery must still be the inconveniently-portable sulphochromate-acid batteries that are so liable to splash acid over carpet and carriage unless carefully handled, and that are sure to get out of order if not constantly used, for these batteries can be readily put in order by any electrician at slight ex- pense, and no one should practice electro-therapeutics who cannot keep them in order himself if necessary. A thirty-cell battery of this kind can be depended on to furnish from fifty to seventy-five milliam- peres for a daily application for two weeks with one charge of solu- PRODUCTION AND CONTROL OF GALVANIC CURRENTS. 299 tion, at the expiration of which time a change of solution will make it as good as neAv again. The chloride-of-silver dry-cell battery Avould be quite unequal to such a proper requirement. Some of the portable dry-cell batteries of other makes Avhich at first sight Avould seem to be useful, OAving to the relatively large size of the elements, claim an efficiency limit of but 15 milliamperes. The original cell of the type used in the acid batteries is knoAvn Fig. 95.—Flemming portable galvanic battery Avith meter and controller attached. as the Crenet cell, and consists of carbon and zinc elements immersed in a solution of bichromate of sodium and dilute sulphuric acid,—the electropoion solution. The internal resistance of this cell is very small and the chemic action intense; hence a large current-output results in the short periods of time in Avhich it is proper to use it continuously. The essential feature of the cell is the provision for raising the zinc, or, in the complete batteries, both elements, out of the acid AA'hen not in use: a precaution that is necessary if Ave Avould 300 DISEASES OF AVOMEN. save the zincs from being consumed by "local action," or irregular electric action betAveen the particles of pure zinc and the metallic impurities found in the commercial article. This local action is greatly minimized Avhen the battery is in use and waste of material saved by coating the zinc Avith mercury, or "amalgamating" it. The mercury unites with the zinc Avith greater ease than Avith its impuri- ties; hence a surface of pure zinc in mercurial solution coats this element, the mercurial coating remaining until the zinc is consumed. For gynecic purposes the acid battery should possess either Fig. 96.—Insertion of meter and controller in circuit of ordinary port- able galvanic battery. The cord from the first carbon is carried to meter and controller; that from the last zinc directly to patient. twenty-four or thirty cells, ghing a pressure of forty to fifty-five volts in accordance AA'ith the condition of the liquid, excellent exam- ples being procurable from a number of manufacturers in this coun- try, notably Flemming, of Philadelphia; Waite & Bartlett, Jerome Kidder, and Van Houten & Ten Broeck, of Xew York; and the Mcintosh Co., of Chicago. There is but little choice betAveen these PRODUCTION AND CONTROL OF GALVANIC CURRENTS. 301 instruments, for none are usually supplied Avith controllers. In such case a meter and. controller should be inserted into circuit AA'hen in use (Fig. !)(>), the terminals of the battery being treated exactly as the incandescent terminals described above. This omission has recently been supplied by Otto Flemming in the battery shrown in Fig. 95, which represents a portable acid battery of tAventy-four cells with controller and meter attached, thus embodying an instrument of great utility and convenience and but moderate weight, OAving to the cells being constructed of hard rubber. Fig. 97.—Mcintosh twenty-four-cell portable galvanic battery. This battery is one of the simplest and most convenient of its kind. The elements, in sets of six, are immersed by simply lifting the section from the drip-cup and lowering it into the cells at its side, the connector being then lowered until it engages in a cleft in the next contiguous set. All danger of accidental interruption of the current, as when the cells them- selves are moA'able, is thus obviated. The box is set into the lid in such a manner as to preA-ent the latter being closed unless the elements are put back into their drip-cups, thus conserving the zincs. The special value and convenience of the recently-devised trans- portable battery of the author (Fig. 65) is by no means limited to the treatment of cancer. The large size of its cells and the other 302 DISEASES OF WOMEN. mechanical improvements render it of unusual value in all gynecic Avork. Care and Maintenance of Portable Galvanic Batteries.—When Fig. 98.—The Kidder portable galvanic battery, showing top plate and elements. The cells are raised in place Avhen in use. laid aside for any considerable time the cells of these batteries are best emptied and kept outside the case, or the case itself kept open. When about to be used the zincs should all be carefully amalgamated PRODUCTION AND CONTROL OF GALVANIC CURRENTS. 303 with mercury, which is best done by dipping them into an amalgamat- ing solution, or, in its absence, in battery-fluid, after which the mer- cury should be rubbed into their surfaces until they are thickly coated AAdth this metal. Previous soaking of the elements in hot water will help to clean the zincs and Avill be useful in cleansing the pores of the carbons. Unless the carbons are clean and the zincs brightly amalgamated the battery-action will be very unsatisfactory and the zincs irregularly and uselessly consumed. The fluid, or electropoion solution, used in these batteries should be made of bichromate of sodium and not of the potassic salt, as the latter is liable to split both the carbons and the cells by a heavy deposit of chrome-alum crystals. An excellent formula is: 1 pound of bichromate of sodium, 1 ounce of bisulphate of mercury, to 1 gallon of Avater; mix in earthenAvare vessel and set aside to cool before using. The bisulphate of mercury will tend to maintain the amalgamation of the zincs. The cells should be lowered away from the elements immediately after the termination of the application. APPLYING-MECHANISM. The essentials for applying a galvanic current, AAdiether derived from a portable or stationary battery of cells or from an incandes- cent circuit, are a controller and meter and the necessary conducting- cords and electrodes, together Avith certain switches and binding-posts for greater convenience. These are usually assembled on a switch- board or cabinet, but may be used by simply connecting the separate parts together, as shown in Fig. 86. The Current-controller.—The purpose of this instrument is the regulation of a current to suit the case under treatment, permitting the desired number of milliamperes to be turned on without shock after the electrodes have been placed in position, and similarly turned off at the termination of the application. The author's graphite con- troller was first designed and termed a "current-controller" in 1887, since Avhich time the aptness of the designation has caused it to be applied to the governors of trolley-cars and other industrial users of current of various kinds, hntil it Avas improved by the adoption of the shunt principle it Avas the most convenient and only practical in- strument for the direct control of currents from a fraction of a mil- 304 DISEASES OF AVOMEN. liampere to three hundred milliamperes without waste of current, and should be used for the regulation of all ordinary medical galvanic currents, no matter what their source. It also controls the faradic and sinusoidal currents with equal facility, and where combination batteries or cabinets are used all currents should be made to traverse it before reaching the patient in order that all risk of shock may be eliminated. In principle of action this controller (Fig. 100) depends on the Fig. 99.—Skeleton drawing of Waite & Bartlett thirty-cell galvanic battery. interpolation into the circuit of the variable resistance of a tapering area of graphite rubbed on a ground porcelain surface from an ordi- nary lead-pencil, the base of the area being nickel-plated and con- nected permanently Avith the metallic circuit. Over this area a radially-pivoted contact moves, the pivoted end being also perma- nently connected with the metallic circuit. When this spring touches the point of the area a slight current Aoays from metal to metal PRODUCTION AND CONTROL OF GALVANIC CURRENTS. 305 through the poorly-conducting graphite layer, the current increasing gradually as the area included betAveen the two metals becomes less, until finally, when the spring passes on to the nickel-plated base, all the current the battery is capable of is turned on, or, at any rate, all resistance of the controller is cut out. The instrument is not designed to measure the current, but merely to govern it, the milliampere- meter, which should be invariably in the same circuit, indicating the number of milliamperes actually passing through the apparatus and patient at any moment. The point of the area is often too thickly Fig. 100.—Massey current-controller. In this original form the patient is in direct series with the main-line of current. coated Avith pencil-mark Avhen the instrument is new, and should be slightly rubbed off, and the material should be kept particularly heavy at its junction with the nickel to avoid a slight jump in the current Avhen it is desirable to turn the full force of the battery on. After a time the graphite becomes Avorn in places, requiring reneAval by merely rubbing a soft pencil over it, preferably the BBB Faber pencil. There are two conditions in AA'hich the improved Massey con- troller (Fig. 89) is superior to the older form, and that is when we 20 306 DISEASES OF AVOMEN. wish to give a weak current from a large number of cells, or a very strong current from either cells or incandescent mains; in both of these instances the shunt principle gives a gradation with least dis- comfort. The current-controller has entirely superseded various clumsy and shock-producing devices knoAvn as current-selectors, which, except when employed as a two- or three- point SAvitch in conjunction with the controller for occasional use of a less number of cells than the whole, or in controlling the very heavy currents of cancer, are now obsolete and deserving of special description only in works devoted to the history of electro-therapeutics. Water-rheostats are almost equally objectionable, being clumsy, unstable, incapable of sufficiently quick movement for many applications, and ahvays leaving a small amount of resistance in the circuit. The use of the controller with the in- candescent current has already been referred to (page 291). The Meter.—This instrument is also indispensable to the phy- sician, who has no more right to subject a patient to the influence of an unmeasured current of electricity than has a pharmacist to fill a prescription with unweighed or unmeasured drugs. The number of cells employed is incapable of giving definite knowledge, owing to the varied resistance of the skin in different individuals. Without entering into details as to the construction of these in- struments, for Avhich the reader is referred to rudimentary treatises, it is sufficient to say that until the construction of the Weston ammeter in 1889 the industrial users of electricity as well as phy- sicians Avere dependent on meters constructed on the principle of the deflection of a compass needle by a current. These are all liable to alteration and deterioration, seriously affecting their value after vari- ous periods of use, and are, moreover, affected by neighboring masses of iron or steel. The Weston meter is constructed on a different principle, the mutual induction of coils, and is now accepted both at home and abroad as a standard of correct measurement. Through the suggestion of Dr. Wellington Adams, AA'ho has produced a most valuable treatise on the physics of electrotherapy, the Weston com- pany has placed a medical milliammeter on the market (Fig. 101) which leaves nothing to be desired. It has two scales, the upper reading from 0 to 500 milliamperes and the loAver from 0 to 10 in tenths, the scales being unusually large and readable. It is also so constructed that the lower, or red, scale may be used as a volt- PRODUCTION AND CONTROL OF GALVANIC CURRENTS. 307 meter for the measurement of an electromotive force below one hundred volts when it is in circuit Avith the resistances contained in a small box accompanying it. To measure the voltage of a battery or cell beloAv ten volts the zero-marked binding-post of the resistance- box is connected Avith one binding-screAv on the instrument and another Avire is carried from the cells to be measured to the resistance- box post, marked 1000; the reading of the loAver scale will then indi- cate the volts and tenths of volts Avhen the circuit has been properly closed from the opposite pole of the tested cells to the meter. To measure the voltage of a Avhole battery (of one hundred volts or less) the same connections are made, except that the Avire is changed to the binding-screAv of resistance-box marked 10,000 ohms, these Fig. 101.—Weston milliammeter, arranged specially for medical work. There are two scales, the upper measuring to 500 milliamperes in divisions of 5 milliamperes, for which the negative wire should be attached to the binding-post marked 500; and the lower scale, measuring to 10 milliam- peres in divisions of Vio > f°r which the negatiA7e wire should be placed in binding-post marked 10. The positive Avire is ahvays placed in post with plus-mark. readings being also on the lower, or red, scale and each division normally representing the tenth of a milliampere noAv reading a volt. The binding-post on the meter marked Avith a + sign should be con- nected AA'ith the carbon AA'ire of the tested battery as in the ordinary use of the instrument as a milliammeter. The convenience of having an instrument capable of testing the voltage of cells and batteries that may be imperfect or needing repair, Avithout extra cost. Avill be greatly appreciated by physicians. 308 DISEASES OF AVOMEN. The value of this type of meter has been so uniformly demon- strated by the exhaustive tests annually conducted by the Committee on Meters of the American Electro-Therapeutic Association that a number of manufacturers, notably the Edison Manufacturing Co., Otto Flemming, and the Mcintosh Co., have constructed meters on a similar principle. All meters of this type have one binding-screAv marked for the positive pole and are, therefore, not adapted for a reversal of the cur- rent through their mechanism. The commutator, or pole-changer, of a switch-board should, therefore, be intercalated in the circuit be- tAveen the meter and the patient, rendering reversal easy, without dis- turbing the course of the current through the meter. Fig. 102.—Jacketed pan for clay pads. Hot Avater is poured into the interior through the pipe shoAvn. Electrodes.—Electrodes for percutaneous and permucous appli- cations of galvanic currents consist of an active and a dispersing electrode or pole, under the modern practice of considering the polarity rather than the direction of the current. The active elec- trodes vary in nature and form for each special application and are, therefore, fully described in the portion of this Avork relating to special affections and particular procedures. The purpose of an application being usually the concentration of the current in or through a certain organ or set of organs with as little unpleasant sensations or actions elsewhere as possible, the role of the indifferent electrode is not only the mere completion of PRODUCTION AND CONTROL OF GALVANIC CURRENTS. 309 the circuit, but it should render the current-effect at this point as inactive as possible. This is done by increasing the surface of con- tact and by making the moist conducting-joint (page 31) between the metal and the subdermic tissues as perfect as possible. It was the application of this principle in the construction of the abdominal clay pad by Apostoli that gave the present impetus to the use of strong currents in gynecology, as already noted. The Apostoli Clay Pad.—The clay for this purpose should be Fig. 103.—Author's wired cotton electrode pads. 1, abdominal pad, for general use. 2, spinal pad. 3, large dispersing pad. of the variety used by potters, and should be kept in the consistence of soft mud by admixture -with" Avater in a covered crock. The pad should be made freshly for each application, or each morning when used daily, and is most comfortable to the patient Avhen heated in a jacketed pan (Fig. 102) in the space betAveen the double bottom and sides of which boiling Avater has been poured. Before putting the clay into the pan t\vo layers of mosquito netting or a single layer of tarlatan should be spread out OArer the bottom, the material being 310 DISEASES OF AVOMEN. large enough to reach beyond the edge of the pan to enable the clay to be lifted out after the pad is made by grasping its ends. The pad should be about an inch thick and of a sufficient size to cover the abdomen of the patient. After loAvering it on the abdominal surface a block-tin or lead plate supplied Avith a binding-post or socket for attachment of the cord is pressed doAvn upon it. This plate is best shaped like a four-leaved clover and should be nearly as large as the pad. Ready-made clay pads are poor affairs compared Avith a pad sn Fig. 104.—Author's complete switchboard arrangement for both currents. made and less useful than the cotton pads next to be described, which have displaced all forms of clay pads in the great majority of the author's applications. The Author's Wired-Cotton Pads.—The most convenient pads for a dispersing electrode to be used on any part of the body are the author's wired-cotton pads (Fig. 103), Avhich are made in two or more sizes as follows: In the centre of a piece of muslin somewhat larger than the intended pad the end of a spool of No. 20 soft, brass wire is seAvn. The Avire is then coiled in an increasing spiral and securely PRODUCTION AND CONTROL OF GALVANIC CURRENTS. 311 sewn in place on the muslin, each spiral being about half an inch from the preceding one, until the desired size is obtained, the shape being oval for the large pad and round for the smaller. When it has attained dimensions of about 7 x 11 inches for the larger and 6 inches for the smaller, a small turn is made in the Avire and scavii doAvn to prevent pulling out, and a considerable length of Avire is left for con- nection Avith the battery. This free end should be at one end of the spiral for the large pad and in the centre of the small one. Six or eight layers of absorbent cotton should noAv be cut to shape and piled on the Avired side, and on top of the cotton a piece of muslin is placed to be folded over and seAvn to the edge of the back of the pad. The pad should noAv be quilted lightly through and through to keep the cotton from packing, and when the end of the Avire left free is made into a spiral friction-socket for connection Avith a battery-tip by Avinding it about the end of the tip, the electrode is complete. Such pads are easily made by an intelligent nurse. They are wet with hot Avater and freely soaped Avith ivory soap on the contact- surface farthest from the AA'ire AAdien used. Before each subsequent use with a new patient they should be boiled for a feAV minutes. The smaller one of these pads is most conveniently used as an active electrode in general applications (page 53) or as an indif- ferent pad for small currents. Office Switch-boards.—Fig. 104 illustrates an exceedingly con- venient and complete SAvitch-board for office use or an institution that is Avired from a permanent battery of cells. It may be attached to a portable table Avith a cable-conductor of four Avires for connection with Avail-boards in each room. Current for galvanic treatment and for operating the faradic coil is thus conveniently obtained in any part of the house from poAverful and reliable stationary batteries of cells in a cell-closet. The current from the galvanic battery is thus easily controlled at the bedside. To operate the faradic coil at such a distance requires about six chloride-of-ammonium cells arranged two abreast in a series of three, and the Avire should be of moderately large size. CHAPTER XXIV. Experimental Handling of Galvanic Currents. Xo one should apply an electric current to a patient without having previously familiarized himself someAvhat with its practical management; and it is best for the beginner to emphasize the lessons thus gained by a moderate demonstration of the sensory effects on his person. With the battery set up or put in operation, the meter and controller being in circuit, the small electrode discs and cords may be attached to the binding-posts for the folloAving experiments: To Test for Current. (Experiment 2).—Set the controller for least current (in the graphite controller with the crank on the be- gining of the pencil-mark to the right of the rubber bridge), and bring the brass parts of the electrodes together. The meter will show a deflection of more or less milliamperes. If there is no deflection a break exists in some part of the circuit. To Test the Power of the Battery and the Range of the Con- troller. (Experiment 3).—Unite the poles directly by means of a conducting-cord or wire, and note the gradual increase in the cur- rent as the crank is moved toward the broader graphite. This pro- cedure is Avasteful of battery poAver, but will show the total capacity of the battery through these resistances, if the meter registers high enough. With the incandescent current the increase should not be above the capacity of the meter. To Test the Polarity of the Electrodes. (Experiment 4).—If in doubt as to which is the negative pole and which the positive pole of a galvanic battery or pair of incandescent terminals, place the tips of the cords in a solution of potassium iodide. The compound will be electrolyzed, iodine appearing at the positive pole as a broAvnish cloud, and potassium at the negative pole. If the potassium iodide be dissolved in starch-water, the discoloration at the positive pole is blue instead of brown, the nascent iodine immediately uniting with the starch. A more quickly performed test than this is to ascertain which tip gives off the greatest amount of gas Avhen immersed in (312) experimental handling of galvanic currents. 313 simple or saline Avater, the negative possessing this distinction on account of the hydrogen-gas given off at its surface being double the volume of oxygen at the positive. The negative pole also ghes the most sensation Avhen suddenly brought in contact with a sensitive part of the hand. Comparison of Metallic Contact with Moist Cotton to Cotton Conduction. (Experiment 5).—Having set the controller for a weak current, note the number of milliamperes in circuit Avhen the brass surfaces of the tAvo electrodes are brought together, and the number when the two Avet surfaces of cotton or sponge are pressed together. This Avill shoAv the immensely greater conductivity of brass. As the current is not intended to go right back to the battery in this manner during ordinary work, it is called "short circuiting," and is wasteful of the battery poAver and dangerous to the delicacy of the meter. Application of Dry Metallic Electrodes to Skin Compared with that of Wet Electrodes. (Experiment 6).—Experiment now with the dry metallic surfaces of the little electrodes pressed down upon dry skin surfaces. Little or no current will be shown by the meter if the skin is free from moisture, even Avith the controller set for full strength. Substitute Avet cotton-covered electrodes for the dry ones, and a current Avill be shown both by the sensations and the meter. The current passes Avith exceeding ease from metal to metal Avhen in contact, either dry or wet; but passes from dry metal to the body Avith difficulty. This is because the cuticle is practically a non-con- ductor; not until the air-spaces of its horny layers are filled with Avater, Avhich is a reasonably good conductor, will it permit the current to penetrate to the moister tissues below, and even then the bulk of the current passes through the SAveat-ducts and any congested or abraded spots. Electrode coverings are therefore designed merely to hold a layer of Avater betAveen the metallic surface and the skin, act- ing as a conducting-joint. In making the experiment just detailed AA'ith dry metallic points instead of a flat surface, an intense burning sensation will soon de- velop if the full number of cells are used and the points well pressed down. This burning coincides Avith the appearance of some current in the circuit, as shown by the meter; but the number of milliam- peres by no means corresponds with the intensity of the burning; very little current passes, in fact, when the pain is greatest. This 314 diseases of avomen. pain of the "galvanic brush" is usually described as due to the con- centrated action of the minute current-quantities upon the most su- perficial and sensitive nerve-filaments; but doubtless the real reason is the microscopic spark leaps through the cuticle incident to this mode of current-transmission. Effect Produced on the Current-volume by Salt Water on the Electrodes. (Experiment 7).—Set the controller at a given place and leave it there (or use the full strength of a certain number of cells), and note the number of milliamperes passing through the hand Avhen both Avet electrodes are pressed upon opposite sides; leaving the battery-strength undisturbed, remove the electrodes and saturate them with salt Avater. When they are replaced, a considerable increase in the number of milliamperes passing through the hand will be found. The sensations will be still more acutely increased. Saturated salt Avater is about three thousand times a better con- ductor than distilled Avater; hence the use of salted Avater on electrodes increases the current by lessening the resistance offered by the con- ducting-joint at the points of entrance into and egress from the body. It is of great service when the battery-power is deficient or accident- ally low; but its constant use is inadvisable, owing to the dispropor- tionate increase of pain produced by it and the bad effect upon the electrodes, Avhich are quickly oxidized. The excess of pain is doubt- less due to the irritant effects of the products of the decomposed chloride of sodium. Effect upon the Current of Different-Sized Electrodes. (Experi- ment 8).—Xote the number of milliamperes passing through a part of the body from the full strength of fifteen cells,—(1) when two small electrodes are used; (2) when two medium ones are used; (3) when tAvo large ones are used,—care being observed to place them in the same spots and press their whole surface in contact. If it is more convenient to use all the cells in the way advised gen- erally in this work, instead of using the full strength of only fifteen, it may be done by simply setting the controller for a comfortable cur- rent Avith the small electrodes, and leaving it untouched in the subse- quent steps of the experiment. The increase of current when the larger electrodes are used is exceedingly striking. The cuticle, as has been explained, is the chief obstacle to the current; and from a given number of cells but a cer- tain quantity can be forced through each square inch of its surface. experimental handling of galvanic currents. 315 The more square inches are included in the conducting surface, there- fore, the more current will go through from the given number of cells; but there will be no increase in (and possibly a slight diminu- tion of) the number of milliamperes passing through the original square inch of skin, unless the number of cells is increased or the resistance of the controller lessened. The use of broad electrodes is indicated, therefore, Avhenever we wish to introduce a large current into the body Avith a minimum of pain and without a special con- centration at the points of entry. It is the only Avay to affect deep structures by percutaneous transmission Avithout excessive pain, and for such purposes both electrodes are large. In gynecic Avork, Avhere the effect of a single "active" pole is alone desired, the other "in- different" pole is made sufficiently large to secure easy penetration Avithout such local action. Comparison of the Effect of the Same Current-strength when Concentrated and Diffused. (Experiment 9).—Connect the body with the positive pole of the battery by means of a large moistened electrode on its surface. This will form the indifferent pole. Select (1) an equally large moistened electrode for the active pole; place it on another part of the body; connect it Avith the negative terminal of the battery, and bring the current up to, say, eight milliamperes, as shown in the meter. Xote the slight pain produced. (2) Exchange the large active pole for a medium-sized one, moistened of course, and bring the current up to the eight milliamperes. The pain will be increased, OAving to the concentrated action of the same number of milliamperes. (3) Use next a fine point as active pole, Avell covered with moist cotton, and again bring up the current to eight milliam- peres. The pain is quite decided. As the size of the active pole is diminished, the current being kept the same by adjusting the controller, there is an increase in the intensity of the pain corresponding to the increased density at this spot. The indifferent pole is left large in this experiment, as in so many gynecic applications, because it combines a slight resistance to the current Avith the least local pain. The experiment illustrates admirably the axiom that more force is required to get the same- sized current through a small place than through a large one,—a principle that applies self-evidently to most things. Increase of pain accompanies with great certainty an increasing concentration of a given number of milliamperes on the skin surface; 316 DISEASES OF AVOMEN. but it should not be forgotten that this is because of the peculiar sensibility with which the body-sheath is endowed. Beneath it and in the interior of less sensitive cavities there is no such admonition to guide us; hence the use of a meter becomes more imperative in the latter situations, for the current is just as active Avhether pain is felt or not. It is only at and near the junction of mucous membrane Avith the skin surface, such as the lips, vulva, etc., that great sensi- tiveness to currents exists; and here it is even more sensitive than on the skin surface, in accordance with a fuller endoAvment of sensitive nerve-filaments. Differing Resistances of Skin Surfaces. (Experiment 10).— The differences in the resistance offered by the skin of various parts of the body, and of different persons, is readily shown by the effect on the meter at each position, the battery and controller being left undisturbed. The face, inner surface of the limbs, etc., will show more current (presenting less resistance); Avhile the back and outer surfaces of the limbs will show less current (presenting more resist- ance), etc. That these differences depend almost entirely on varying thick- nesses of cuticle is proven by the showing of more current Avith the poles on distant but thin spots than when alongside of each other on thicker cuticle. The difference betAveen corresponding parts of the skin of different individuals is also at times considerable, especially when a clear-skinned blonde and pallid brunette are compared. Comparison of the Resistance of Skin and Mucous Membrane. (Experiment 11).—Connect but a small number of cells, say fifteen, with the meter and controller, in order that the full strength of that number of cells may be used. Having put the indifferent pole on the abdomen or back, cover an insulated-stemmed vaginal electrode with absorbent cotton, wet it, and direct the subject of the experiment to hold it between the bare arm and chest in such a manner that the whole conducting surface is in 'contact, as it would be in the vagina. Turn the current on gradually noAv to its full extent by means of the controller, and note the number of milliamperes. Reverse the con- troller until there is no current, and introduce the electrode into the vagina. The current may then be again increased by the controller to its full capacity, and the number of milliamperes noted in this situation. A marked increase in the milliamperes will be noted in the EXPERIMENTAL HANDLING OF GALVANIC CURRENTS. 317 vagino-abdominal circuit over the merely percutaneous one, on ac- count of the lessened resistance encountered at the active pole when placed in contact Avith mucous membrane. Alteration of Nerve-irritability Within each Polar Region. (Experiment 12).—Attach two medium-sized electrodes of the same dimensions to the binding-posts, place them (well wetted) on the skin over each peroneal nerve just back of the head of the fibula, and in- crease the current to five or ten milliamperes. The burning pain under the negative electrode is in distinct contrast to the numb sensation under the positive. The Effect on Nerves of a Slowly Varied or Continuous Current Compared with that of a Sudden Current-variation. (Experiment 13).—Proceed as in Experiment 12, noting that no pain or motion is produced in the distant parts of the nerve if the five or ten milliam- peres have been attained by a gradual increase from zero. With the current at this height remove noAv one of the electrodes and reapply it (or break and make the circuit by an interrupter),—a contraction will be produced in the muscles supplied by the motor fibres, and a sudden sensation in the areas supplied by the sensory fibres of the nerAres. The actual performance of these and similar experiments is un- equaled in its teaching poAver. Besides familiarizing one Avith many details essential to successful work Avith the continuous current,—such as the necessity of ahvays using a meter; the possibility of avoiding shock, even with poAverful currents; the adA'antage of ample battery- force held in easy check by a controller; and the Avisdom of using large and small electrodes as Ave Avish non-local or local effects,—it will sIioav that the practice of electro-therapeutics, while relieved of many unnecessary and obsolete theories, may still remain free from the formidable task still imposed by some recent A\'riters, who recom- mend that the resistance of the tissues be calculated and recorded in each case. As Avell might they say that Ave should measure the dark- ness in a room rather than the light produced in the effort to dispel it; in the one case the photometer and in the other the milliampere- meter are all-sufficient to convey full information for practical pur- poses. CHAPTER XXY. The Faradic Current. Mode in which Faradic Currents are Produced.—Faradic cur- rents are isolated rises of pressure in a wire, produced at the moment of breaking or making the galvanic current of a cell Avhich circulates in its immediate neighborhood. This current is named after Michael Faraday, who first discovered that a current would be so produced in a closed-wire circuit placed over or close to another in which a galvanic current was varied. The strength of the current so pro- duced is proportional to the strength of the producing current, plus the length of the wire subjected to the influence of the inducing cur- rent-circuit; so that convenience necessitates the coiling of one in- sulated wire about the other, producing a solenoid, or induction coil, in Avhich many feet of Avire occupy but a small space. It is necessary that the two Avires, carrying the inducing and induced currents, should be close to each other and properly insulated throughout. The action of the inducing current from the cell in the first coil is increased if a soft iron core be inserted Avithin it, making Avhat is called an electro-magnet. In a simple coil of but few turns, or in tAvo straight wires placed close to each other, a current arises in one direction in the second Avire on closing the cell-circuit in the first, and another current arises in the other direction on opening the cell-circuit. The current that appears in the secondary coil at opening the cell-circuit in the pri- mary is direct, or in the same direction as the cell-current, Avhile the current that appears in the secondary at the moment of closing the cell-circuit is inverse. The primitive faradic current is, in other Avords, a to-and-fro, or alternating, current. In the batteries Ave use this is also true of the currents from the secondary coil, though, for reasons to be shoAvn, only the direct currents are therapeutically im- portant. An equal electromotive force and an equal volume arise in each direction, causing an equal amount of electrolysis (which is thus continuously neutralized), yet the therapeutic effects are very dif- (318) THE FARADIC CURRENT. 319 ferent on account of the greater abruptness of potential rise in the direct current; and as the only purpose for which faradic currents are used in medicine is the muscle- and nerve- stimulation or seda- tion that a minute current can produce Avhen very suddenly devel- oped, the secondary current of opening is practically the only one used.1 A faradic battery (Fig. 105) consists essentially of one or more galvanic cells placed in circuit with a primary insulated AA'ire sur- rounding the core, and Avith an automatic device to alternately break and make the cell-curent. Over the primary coil is slipped a bobbin Fig. 105.—Diagram of faradic battery. haA'ing another coil of insulated wire wound about it. This second, or secondary, coil has no metallic connection Avith the cell or the cell- current, deriving its current by induction because of being placed over and close to the primary coil and core. The operation of the apparatus is as follows:— The cell-current, proceeding from the carbon pole of the cell, traverses the primary coil and returns to the cell through the in- terrupter, the platinum points of the latter being in contact. In the 1 The direct current of opening is formed and completed in 0.000275 sec- ond, Avhile the inverse current of closure took 0.000485 second. 320 DISEASES OF AVOMEN. act of traversing the coil this current makes the core magnetic, which in turn attracts the small armature on the interrupter, breaking the cell-current; the magnetism of the core having now disappeared, the spring returns to contact, when the whole process is repeated. The rapidity of this automatic action depends on many factors that will be referred to later. At the instant of closure of the cell-current a reverse induction arises in the secondary coil, but this rises sIoavIv on account of what is called self-induction between contiguous wind- ings of the primary coil. At the instant of opening the cell-current a direct current arises in the secondary coil of much sharper curve of ascent (because there is but little self-induction to interfere with it). But no currents arise in the secondary coil unless its ends are closed by a patient or other conductor at S S. Recurring to the primary coil, it will be noticed, by reference to the figure, that the patient, Avhen connected by electrodes with the primary binding-posts P P, is placed in what is known as a "shunt," or parallel circuit with the primary coil. This permits an infinitesimal amount of the cell-current to traverse the tissues Avhen the spring is in contact; but since the resistance of the coil is less than an ohm and that of the patient some hundreds of ohms it will be seen that practically all of the cell-current will take the short road through the cell instead of going through the patient. At the moment of closure of the cell-current a reverse current does arise in the primary coil by self-induction, but this never reaches the patient, being expended, as already stated, in blunting the sharpness of rise of pressure in the cell-current at closure. When the cell-current is opened at the in- terrupter, however, the primary direct induction arising in the pri- mary coil has no recourse but to traverse the patient placed in con- nection Avith the binding-posts at P P. This induced current of opening, known among electricians as an "extra current," is the med- ical primary current, and gets much of its force from the demag- netization of the core; and, since it is produced in a coil nearer the core than any secondary Avire can be, the volume of the current may be greater, other factors remaining the same. The direct inductions only can reach the patient, the inverse inductions being neutralized by the cell-current. The primary current is, therefore, not in any sense an alternating current. Means of Controlling Faradic Currents.—In the sledge or du Bois-Reymond apparatus, Avhich is the one found in the best gynecic THE FARADIC CURRENT. 321 apparatus and in the large cabinets, and is decidedly the best form, the secondary coil is made to slide over the primary, the inductions in the secondary gradually strengthening as the secondary Avindings are more and more subjected to the influence of the cell-current in the primary coil and of the core. To slide the secondary slowly over the primary is, therefore, a method of turning the secondary current on, and to slide it off a method of turning it off. The reverse is true of the primary current, Avhich is Aveakest Avhen the secondary completely covers the primary, and is increased by uncovering it. The secondary coil thus acts as a damper on the primary,1 abstracting the inductions to itself. xVn old form of Duchenne's apparatus provided for con- trolling the current by covering both coils Avith a tube, which, Avhen a complete cylinder, dampened the inductions in both coils and core by permitting circular inductions around its oavu circumference. The cheaper portable apparatus of the present day accomplish the same regulation by a sliding cylinder covering the core only, but both methods of regulating Avith cylinders have the disadvantage of not reducing the currents to zero, leaving a slight shock AA'hen the circuit is closed Avith Aveakest current. The most convenient method of regulating or controlling faradic currents is by setting the coils at the position for the greatest cur- rent of the kind required and then passing the current through the same controller employed Avith the galvanic current, Avhich will be found to ansAver perfectly. This method is invariably folloAved by the author. Though so-called faradometers have been both promised and con- structed, there has been no Avay devised to measure faradic currents actually traversing the patient, OAving to their slight volume and short duration. Arbitrary records of position of coils are employed for comparison, Avhile therapeutic dosage is governed mainly by the effects obtained. The Cell and Cell-current.—One red-acid or tAvo chloride-of- ammonium cells are usually sufficient to operate the coils, a greater number being required at times Avith the long Avire coils. The zincs should be kept in order and brightly amalgamated and the solution 1 The secondary coil Avould not have this damping effect on the primary were it not that an automatic arrangement closes its end for this purpose, making it practically a tube. 322 DISEASES OF WOMEN. fresh, as the Avork of these cells is heavy, uniformity of interrupter action and full induction requiring that about half an ampere should circulate through the primary coil. Since the circuit is all metallic outside the cell, with an external resistance less than an ohm, one or tAvo good cells will suffice. The Primary Coil and Core.—The proper construction of faradic coils is just now the subject of much discussion in electro-therapeutic circles, a standing committee having been appointed by the American Electro-Therapeutic Association to conduct investigations, and while Fig. 106.—Flemming's No. 4 faradic battery, possessing a high-tension coil and excellent primary, controlled by the du Bois-Reymond slide. it is beyond the scope of this Avork to enter into technical discussions that would be too voluminous for its pages, the growing importance of these currents in gynecology necessitates a succinct statement of the features that are at present thought to be essential in a properly- constructed gynecic apparatus. It is too true, as stated by Goelet and Engelmann, that the great majority of physicians have purchased, and are still purchasing, apparatus that is practically worthless for gynecic purposes. Even much of the best apparatus recommended by these authors has too small a primary coil and core to give a really powerful contracting primary current. The most useful size of pri- THE FARADIC CURRENT. 323 mary coil, in the author's experience, is that usually found in the Flemming Xo. 4 faradic battery and his cabinet apparatus. The dimensions are: length of core, 5^ inches; thickness of core, f inch; the coil contains 120 feet of Xo. 18 copper Avire, wound in four Avindings. The resistance of the coil is eight-tenths of an ohm. It is likely that these proportions are nearly correct, as no additional contracting poAver Avas gained in several experimental coils, either Fig. 107.—Mcintosh faradic battery. by doubling the length of core and coil or by changes in the size or length of the Avire. Primary Current.—Since the primary coil is made of a compara- tively short thick wire, permitting of but few turns about the core, the electromotive force developed in it is not nearly so high as in the secondary coil. Its nearness to the core results in heavy amperage in comparison to the latter coil, however, which is rendered greater by the slight resistance of the short thick wire. In regulating it with the Massev controller the secondary coil is removed all the way, or 324 DISEASES OF AVOMEN. to the greatest extent desired, and the controller turned on until a sufficient contraction is obtained. 0\ving to the Ioav pressure, it will be noted, no current is felt until the controller is half-turned on, but the current increases with augmented rapidity as the point of no re- sistance is reached. The converse is true with the high-pressure currents of the secondary coil, most care being required to make the increase gradual at the beginning of the graphite area. Uses.—The primary current is indicated Avhenever Ave Avish to produce fullest contractions of muscular tissue, whether striated or Fig. 108.—End-vieAV of RockAvell's high-tension coil, as made by the Jerome Kidder Manufacturing Company. unstriated, provided the total resistance of the circuit is not great. When applied through externally placed electrodes, therefore, Ave must use large Avell-moistened pads, and, if it be monopolar, the in- different pad must be large. It is particularly adapted to bipolar work, oAving to the small resistance between the electrode surfaces, and is indicated in recent subinvolution and in atonic conditions of the boAvels and bladder. The Secondary Coil and Current.—As already stated, the sec- ondary coil must be made of a long fine Avire if a considerable electro- THE FARADIC CURRENT. 325 motive force (as yet not accurately measured) is to be developed for use in producing sensory and vascular sedation. Currents from very long Avires are best for use in conditions of semi-acute irritation, when rapidly successive inductions of high pressure and extremely small volume only are bearable. As a condition of greater tolerance is established a more distinctly contractile current will give increased curative effects; hence an instrument for gynecic use should have several interchangeable secondary coils to choose from, the coil adapted to the case being slipped over the primary as required. The earliest effort in this direction in this country Avas the portable faradic Fig. 109.—Engelmann's faradic battery. apparatus of Dr. George J. Engelmann, formerly of St. Louis, in which three secondary coils Avere used. The Engelmann Coils.—Xo. 1, coarse Avire coil, is made of Xo. 16 Avire, about 225 feet long. This is used for motor stimulation, though a good primary coil will do better Avork of a similar kind. Xo. 2; intermediate coil. This is made of Xo. 21 Avire, about G75 feet long, and produces less painful contractions. Xo. 3; fine-Avire coil. This is made of Xo. 31 wire, 1980 feet long, and the effect is moderately sedative. The Goelet Coils.—OAving to the possibility of obtaining greater C�/A 326 DISEASES OF AVOMEN. sedation by a still longer wire in the fine coil, Dr. A. H. Goelet, of Xew York, has introduced a set of three coils of still greater elabora- tion, the two fine spools having SAvitches on the end, permitting of the tapping and using of different lengths of wire from the same coil. They are constructed as follows:— Coarse coil, Xo. 22 Avire, 750 feet long. Intermediate coil, Xo. 32 wire, 2400 feet long, tapped at 1600 feet and 900 feet. Fine coil, Xo. 36 wire, 4500 feet long, taped at 3000 feet and 1500 feet. The Goelet coils, Avhen supplied Avith a properly-made primary coil and core, leave nothing to be desired in their adaptation to the most varied therapeutic indications. The Interrupter, or Rheotome.—This is a most important part of a good gynecic apparatus and is unfortunately seldom Avhat it should be. I am convinced that the simple vibrating spring-hammer of Xeef, which is the kind usually found on even the best batteries, should be abandoned entirely in favor of Avhat I have called the boAAr- string interrupter of Flemming, or else of the "singing rheotome" of the Galvano-Faradic Co. The boAV-string interrupter is simply an extension of the spring to double its length, both ends being attached to posts, to one of Avhich a tension-screAv is attached to increase or lessen the tension of the spring and thus regulate the time of the vibrations. The armature*is attached to the middle of the brass spring and the platinum plate for contact near the fixed post. Besides regu- lating the frequency and amplitude of the vibrations by the tension- screw, Ave regulate them also Avith the set-screAv carrying the platinum contact-point. This device gives easily the rate of vibration suitable for muscular contraction, which is from 1 to about 3000 per minute, and this rate serves Avell for sensory sedation if the fine coils are used. According to d'Arsonval, the highest stimulation may be obtained from a suitable coil between 3000 and 4000 interruptions per minute, the stimulation decreasing with a further increase of the rate until with 7000 to 9000 interruptions of a medium current it is no longer felt. Vibrations above 3000 per minute are therefore sedative ratheT than stimulating, the separate excitations of muscle and nerve blend- ing together, muscular excitation finally ceasing, and the sensory ex- citation changing into a numbness. There is no really practical means of measuring the rate of THE FARADIC CURRENT. 327 vibration of springs, however, the Ioav or high note emitted by them being the most convenient method of approximate estimation. Regu- larity of rate, with consequent regularity of current-rise and fall, is particularly essential, not only in sedation with high-frequency cur- rents but for painless contraction; hence a spring that gives a con- fused or jarring note should be discarded for one that can be adjusted and maintained to a clear note, Avhether Ioav or high. With all springs, Fig. 110.—De Watteville combiner, to Avhich is added a pole-changer, or commutator, Avith index pointing to the negative pole. hoAvever, there seems to be an unfortunate liability to sudden changes when the relative position of the coils is changed during a seance. To p^et rid of these disadvantages Engelmann has revived the wheel-interrupter, worked by an electric motor and easily capable of regulation and record of frequency. This apparatus gives promise of being highly useful, though I haAre, as yet, had no experience with it. Such a method of current-interruption enables us also to get a wider range of currents from the ordinary coils, since a one-way primary current may be obtained from any secondary coil by sending a suf- ficiently strong cell-current through it.1 1 See Medical News, February 3, 1894. 328 DISEASES OF WOMEN. Polarity of the Faradic Current.—The primary current of a faradic coil has as distinct a polarity as the galvanic, being ahvays in one direction, as explained above. The secondary currents have also a distinct polarity in their physiologic'action, though not so marked as is the primary, the direct inductions being stronger and more abruptly produced than the inverse inductions. The electrode attached to the negative pole of either current will, therefore, be found to be the most stimulating when applied to nerves and muscles, and the positive most sedative. Indications for the Use of Covered and Bare Electrodes with Faradic Currents.—The use of a moist conductor to convey the faradic current through the skin to nerves and muscles beneath it is fully as important as in the case of the galvanic current; for, although the former current leaps from a dry metallic disk to the skin with great facility, and is therefore best adapted to the dry-brush method of stimulation, it expends its action at such times almost entirely on the dermic surface and nerve-ends, the polar region being extremely superficial. The moist co\rering permits a greater penetration and ex- tension of this region; hence, a deeper action Avith less surface pain. Within moist cavities, hoAvever, the use of a moistened covering on the exposed conducting surface of the electrode is totally unnecessary, as the moisture of the cavity itself readily favors this distribution of the current. The bare electrode is, moreover, introduced into such cavities AA'ith greater ease. The handles of such electrodes should, of course, be properly insulated, to protect the vulva and other parts not designed to be affected. Experimental Comparison of the Electromotive Force, or "Press- ure," of the Faradic Current with that of the Galvanic Current. (Experiment 14).—This may be roughly done by touching simul- taneously, Avith dry fingers, the bare terminal Avires of a full-strength galvanic battery. Xo current is felt, since the sixty to ninety volts of pressure in such a galvanic current are not sufficient to make the current jump through the minute layer of air betAveen the finger and the wire; moist fingers permit a little to get through. If, noAv, the dry fingers be simultaneously brought in contact with the bare ter- minals of a faradic current of merely medium strength considerable tingling will result; its pressure is amply sufficient to cause it to leap through this air-space. There are two practical applications of this fact besides its dem- THE FARADIC CURRENT. 329 onstration of the main quality of electromotive pressure: one indicates the need of a more careful insulation of the faradic current to pre- vent accidental shocks; and the other, the greater adaptability of this current for the electric-brush application to the body-surface. Action of the Faradic Current on Sensory Nerves and Muscles. —XotAvithstanding the exceeding Aveakness of this current in "bulk" or "volume," the great requisite for usefulness in the mechanic arts and in the chemic destruction and metamorphosis of tissue, a slight acquaintance Avith its action on any part of the body is apt to impart an exaggerated idea of its physiologic poAvers. Being essentially a series of exceedingly abrupt current-creations, its power to excite the functions of nerves and muscles is unique, and the manifest phe- nomena of pain and muscular contraction conceal its total inability to produce profounder impressions on the body. A nerve or muscle, brought Avithin either polar region, is throAvn into action as each induction arises, just as an abrupt variation of the galvanic current, Avhether a rise or fall, produces a similar phenomenon. Each induc- tion produces a separate stimulus, therefore, and it is only when they MIoav each other very rapidly, as Avhen a rapid interrupter is used, that the separate stimulations seem to blend together, producing a continuous contraction or sensation. Even then the impressions on the nerve are those of distinctly-separated, though rapidly-successive, currents. The sedative effect produced by high-frequency currents from the fine coil is probably of the nature of a temporary anesthesia of the terminal sensory apparatus. The faradic susceptibility of the sensory nerves of the limbs and trunk is fully shared by those of the pelvis, although the lessened sensibility of the normal uterine and ovarian nerves permits the em- ployment of current-strengths not bearable on the skin surface. The vulva, on the contrary, like other muco-epidermic junctions, is ex- quisitely sensitive to this stimulus, and should be protected from it in all ordinary applications by Avell-insulated electrode stems. The sensibility of the vagina is about midAvay between the two. Therapeutic Uses.—This current acts only on nerves and muscles, stimulating each into action or developing anesthetic effects, and its use is, therefore, limited strictly to such conditions as exhibit nervous or muscular laxity or pain. But is this limitation a very narrow one? How many of the commoner cases met in daily prac- tice present just these shortcomings, especially those encountered in 330 DISEASES OF AVOMEN. a public clinic? The case after case of displaced and prolapsed uteri that present themselves, with or Avithout rectocele or vesicocele, and with intact perinei, teach the paramount importance of muscular tone of the vaginal Avails and uterine ligaments in the maintenance of a normal condition. When this tone has been lost, it is evidently the part of rational medicine to endeavor to restore it, if possible,—not to prolong and intensify it by erecting a false skeleton Avith a pessary or tampon Avithin the vagina. Properly constructed bipolar electrodes are peculiarly efficient in attaining this contractile action on relaxed pelvic muscles, inclusive of the uterus itself. Bipolar vaginal applications may be Avith the coarse-Avire coil or primary current if there is no inflammatory con- ditions present, but in the latter case the pain and violent contrac- tions produced by these currents are capable of increasing the mis- chief. The combination of mild contractile and anesthetic effects obtained from a similar use of fine-wire currents is, on the contrary, most beneficial, even in subacute inflammation; hence bipolar fine- Avire currents are useful in a large number of cases, the simple anes- thetic effects rendering them invaluable in either inflammatory or non- inflammatory neuralgias. Electrodes and Dosage.—As a rule, the active electrodes required for galvanic applications may be used for this current, and a similar dispersion of current at the indifferent pole is advisable when used after the monopolar method. The absorbent-cotton pad will, of course, be more convenient than the clay if a faradic current only is to be used. The only electrodes peculiar to the faradic current, and Avhich should not be used with other currents, are the bipolar electrodes, of Avhich the one for use Avithin the vagina is the most commonly employed. Apostoli's bipolar vaginal electrode as modified by Goelet (Fig. 22) is decidedly the best. In this instrument the designer has adopted the bulbous projections suggested by me to make better con- tact with the mucous membrane, and has also altered the relative pro- portions in such a way that the instrument is practically self-sustain- ing within the vagina. Apostoli's intra-uterine bipolar electrode (Fig. 27) remains the best in design, but all intra-uterine bipolar electrodes are clumsy and difficult to thoroughly asepticize. The selection of the dose is purely empirical, as Ave have, at THE FARADIC CURRENT. 331 present, no means to measure this current beyond the individual scale of each instrument. The best guide to the strength required in a given case is gained from the sensations of the patient, the cur- rent having been brought up from zero to the point of easy tolerance, after placing the electrodes in position, in the same gradual manner as advised for galvanic applications. If Ave do not shock by a sudden turning on or off, there is no possible way in Avhich the patient can be harmed; so that our main point in muscular applications is to use as much current as the patient will bear, and it is astonishing hoAV much can be given in this Avay with one pole in the vagina or uterus and a large dispersion on the abdomen. Weaker currents are better for neuralgic conditions, as a rule. The milliamperemeter is, of course, useless Avith this current. CHAPTER XXVI. Franklinic, or Static, Electricity. Physics.—The electricity produced by static machines is of ex- ceedingly high pressure (53,000 volts per centimetre of spark-length, according to Lord Kelvin) and very slight volume (five-thousandths of a milliampere to a quarter-inch spark, according to Sprague), though the volume per spark-length really varies with the number of plates in the machine. With a current possessing such an in- finitesimal volume it will be seen that the principal therapeutic effects are due to an inconceivably high polarization of nerve and muscle. When the spark is applied to the dry body it undoubtedly disrupts the cuticle on its way to the moist tissues that act as the surface of the conductor, the surface nerves of sensation receiving the brunt of the excitation; but if moist electrodes be employed, as first suggested by Morton, the spark is conveyed through the skin by conduction rather than disruption and deeper nerves and muscles are then readily reached, as Avith other currents. Since the volume of these currents is so slight, it is, of course, essential that an interruption of the cur- rent, or sparking space, must exist someAvhere in the circuit Avith the patient for any action to be manifest, the completely closed external circuit giving us a galvanic, or continuous, current of only five-thou- sandths of a milliampere,1 which is practically nothing. There is, however, another important physical effect produced by this form of electricity besides the polarization of nerve and muscle by transmitted currents. This is the static effect of the charge on the body-surface Avhen sparks are not used. The equally-diffused charge as in static electrization, and particularly the concentrated charge on the portion of the body opposite the electrode administering 1 This calculation of the milliamperage of franklinic currents Avas made from old machines, and is doubtless much greater with the many-plate ma- chines noAv used. (332) franklinic, or static, electricity. 333 a spray, have peculiar and yet but imperfectly explained actions on surface-nerves and tissues. For a full explanation of the principles involved in the operation of a static, or influence, machine the reader is referred to more com- prehensive Avorks on electro-physics. The machine may be described in brief as similar in operation to a dynamo, a minute charge given to a paper-element inducing a reciprocal charge on the nearest por- tion of a revolving plate, Avhich, by rapid revolution and reaction effects, multiplies the charge to a full load. The paper elements on the stationary plates of the main machine are analogous to the field-magnets of the dynamo and the revolving plates to the armature. The medical influence machines now made on a large scale in America are merely an improvement of the Holtz pattern, in which the principle of induction Avas substituted for fric- tion about 1865, the improvements consisting in multiplying the plates, protection from atmospheric influences, and perfecting the mechanical features. The revolving plates are plain discs of glass, coated Avith shellac, Avhich permit of the greatest development of an initial charge, though it has been found that the Wimshurst improve- ment is superior in the development of this initial charge, though inferior in its multiplication. The most perfect apparatus ncAv con- sists of tAvo separate machines, placed in the same cabinet, but preferably in separate compartments, the Wimshurst machine being merely used as a charger Avhen the main battery has lost its charge. Analogous combinations are frequently found in dynamo-houses. Selection and Care of the Static Machine.—The author has fre- quently been asked if a static machine is a necessary adjunct to an office outfit in the practice of neuro-gynecology. Though skeptical originally on this point himself, a long experience has convinced him that it is of far more relative importance than a faradic outfit, though still far beneath the galvanic apparatus in relative value. Compari- sons are of but little moment in such matters, hoAvever, the indica- tions for the use of each current being usually distinct and separable. Xo office is thoroughly equipped for good Avork Avithout all three of these currents. In the selection of a machine it should be understood that the electromotive force of the current is determined by the diameter of the revolving plates and its volume by the number of these plates. Xoaa', a most important form of treatment in neurasthenia and allied 334 diseases of avomen. conditions is the static spray and static charge, and, Avhile adequate sparks may be applied from machines of but moderate size, these two procedures demand that the machines shall possess at least six revolv- ing plates, which shall be at least thirty inches in diameter. These Fig. 111.—The Massey improved Wimshurst-Holtz static machine. details are really as important as the number and efficiency of the cells of a galvanic battery. Secondly, it should be remembered that these generators of elec- tricity consume nothing but the poAver required to turn them, the current being developed by the motion of parts composed of specially franklinic, or static, electricity. 335 adapted materials under narroAvly defined conditions of dryness and cleanliness. It folloAvs that too much skill cannot be expended in the purely mechanical parts of the machine to insure proper Avear under the necessary motion, and that the user should exercise reasonable care in maintaining the proper adjustment of the stationary plates to pre\rent harmful friction betAveen the several parts, proper adjustment of the belt, and the dryest attainable air-space within the case. This latter is best maintained by several dishes of the anhydrous chloride of calcium, which should be heated to dryness Avhen deliquescent. A most important reason for the selection of the largest and best static machine for therapeutic Avork is that this othenvise useful ap- paratus forms also a most valuable means of developing the x-rays of Roentgen Avith but slight additional expense for the tube and fltioroscope, thus rendering a special coil unnecessary for this purpose. The large machines now produced in America are far superior to any of foreign make that the author has used, but some of them are still in the transition stages of mechanical development. Messrs. Detwiller, Biddle & Co., of Xew York City, have recently placed on the market a Holtz machine combining all the most desirable features of these machines Avith such additional improvements as my OAvn experience has suggested (Fig. 111). It Avorks Avithout disappoint- ment in all conditions of Aveather and gives at least double the out- put of current of any other machine of equal size. The x-ray effect produced by it Avhen a tube of sufficient size and highness of vacuum is attached is magnificent, defining the deeper portions of the trunk in a hitherto-unsurpassed manner. To prevent leakage all edges and corners of the case have been rounded and the usual brass screAV heads that project from the case have been eliminated. The charger is a modified Wimshurst, simpler than formerly made, and more reliable and rapid in charging. It is placed in the base of the cabinet, Avhich separates it from the corroding effect of the ozone generated by the machine proper, and economizes the space occupied in the office. The shaft of the large revolving plates is composed of one piece of rolled steel, insulated entirely by a polished hard-rubber sleeve, enhancing the appearance and preventing sparking inside the case. Tin's shaft runs in specially-made ball-bearings, AA'hich are noiseless, and Avhich reduce the friction to a minimum. Case-hardened steel cones, which are adjustable, take up all the Avear and all end-motion, and prevent shifting or rubbing of the plates. A speed of four hundred revolu- 336 DISEASES OF AVOMEN. tions per minute—necessary for the best x-ray work—can be safely maintained. Besides a number of other improvements of an electro- technical character, a feature of great importance is the simple and ready means of replacing any part broken by accident. All parts are supplied by the manufacturers in duplicate and may be put in place by the physician without difficulty. To one living at a distance this point is of importance. The accessories furnished with this handsome machine are shown in Fig. 112, the electrodes being made of aluminum, securing light- ness and non-corrodibility. The machine can be easily driven by hand or by an electric or Avater-motor of one-sixth horse-power. Methods of Application.—In all applications the patient sits or stands on an insulated platform (which should be elevated from the floor by solid glass legs), and the platform or projecting portions of clothing should not be closer than tAvo feet from the machine-case or other furniture, to prevent leakage. Much confusion has resulted from various directions given by Avriters as to the proper method of connecting the patient Avith the machine, a recent author of a very ambitious Avork devoted to this current alone specifying that one pole should ahvays be grounded by connection Avith a Avater-pipe or gas-fixture, and pictures elaborate Aviring of his office for this purpose. He even goes further than this, and specifies at least tAvo simultaneous "groundings" of opposite poles at times; but Avhere he gets the other earth for a connection does not appear, though a different set of pipes communicating Avith the same cellar-floor seems to be meant. The Avay out of this sorry confusion is to remember that the current from this machine obeys laws exactly similar to those of all other electric currents; and, Awhile it may take the circuitous route through the cellar, a better one is the direct metal route via the chains and rods back to the other pole. It is impossible to increase the efficiency of a machine during any direct method of treatment (e.g., the spray or sparks) by including pipes, the earth, etc., in the circuit, the Avhole current being produced by the machine tearing apart the ether within itself. What has been mistakenly regarded as a ground is the direct electrization of the Avails of the room surrounding the static machine by connecting the opposite pole to it during the first procedure to be described,—the static charge,— Avhich is Aveak unless the Avails of the room are made a condenser by FRANKLINIC, or static, electricity. 337 direct connection Avith the opposite pole; and this is best done by attaching the chain to a good metallic reservoir, such as a pipe, im- bedded Avithin it. With this exception, all methods of application Fig. 112.—Electrodes for use Avith static machine, with platform for patient, the latter being insulated twelve inches by solid glass legs. 1, aluminized telescoping standard, with aluminum ball and point electrodes for stationary treatment with spark and spray and for support of umbrella for head-breeze. 2, aluminum hand-massage roller electrode. 3, aluminum hand ball electrode for applying sparks. 4, aluminum hand point electrode for applying spray. 5, aluminum hand brush electrode for applying mov- able breeze. 6, aluminum and glass director electrode for internal applica- tion of sparks or spray. 7, hand sponge electrodes for Morton's induced current. S, shepherd's crook, and chains for connecting platform or patient with prime conductor of machine and electrode. 338 DISEASES of avomen. are exactly analogous to the method of a "dispersing" and an "active" electrode, though I frequently moderate the spark treatment by in- terposing a longer or shorter floor-space in the circuit. This is done by dropping an end of the chain from the active prime conductor to the floor; near it rests the end of another chain connected Avith the active electrode, thus forming a rude, though effective, controller. It should ahvays be remembered, hoAvever, that when even the carpet is thus put into one of the circuits from prime conductor to patient that we get a condenser effect, due to charging the room, and this is accentuated Avhen Ave charge metal masses in its walls. The best method of reducing the strength of a spark application to suit a timid or Aveak patient is to have the machine turned very sloAvly and press the ball-electrode close to the skin, the sparks being then-only of a length equal to the thickness of the clothing. It should be stated here that the Leyden jars, or condensers, are very rarely to be used in the spark applications, and never any other than the smaller one when employing machines of many plates, as the effect on any part of the body not profoundly anesthetic is terrific. They are not to be used at any time during a spray application. When not used in the shunt-controller application of the Morton static induced currents they are best out of the Avay on top of the machine-case. Before taking any spray treatment about the head ladies should invariably remove any metallic articles, such as hair-pins, etc., as otherwise the spray effect is spoiled by slight sparking betAveen these objects and the scalp. They should also remove the corsets and re- place the outer garments, or else don a woolen sac, before taking a spark or spray application to the body. Clothing formed of good dielectric material, such as wool and silk, intensify the effects. (a.) The Static Charge.—The patient is seated in a cane-bot- tomed chair placed on the insulated platform and holds in the bare hand a chain or rod connected with the pole selected, the rods having been widely separated. From the other pole a chain is carried to a neighboring gas-fixture or water-pipe, in order that the whole room may receive the charge from this pole. When the machine is put in operation the patient will be highly charged with the polarity with Avhich she is connected by the chain in her hand, the effects being greater if she be connected Avith the positive pole. A good speed FRANKLINIC, OR STATIC, ELECTRICITY. 339 of the machine is required. The current escapes from the patient at all points and angles, the charge being maintained by rapid revolu- tion of the plates. A peculiar sensation is produced, and in many persons free perspiration results. Considerable emphasis is laid upon the physiologic and therapeutic effects of this application by some writers. It is distinctly sedative. (b) The Electric Spray.—With the patient in the position just described and holding the chain attached to the positive pole, an electrode having one or more sharp points is connected Avith the negative rod and held at a distance of from six inches to a foot from various parts of the body-surface, Avhether covered Avith clothing or not. The point is electrified negatively and communicates its charge to the adjacent air-particles; the latter are attracted to the nearest portion of the body-surface, giving rise to a discharge by convection, in the shape of a continuous, slightly-luminous spray of electrified air. if the current is Aveak, there is a distinctly cooling sensation, the ell'ects of the actual Avind predominating; but a really-effective spray soon produces a pricking and feebly-burning sensation, particularly at the roots of the hair and other points of special discharge. The application may be carried over all parts of the body, or may be localized at a painful spot for some minutes by attaching the point of a Cleaves combination stand resting on a glass or rubber plate placed on the floor. The spray is Aveaker Avhen the active electrode is connected Avith the positive pole. The head-spray (Plate XXII), Avhich is extremely useful in all conditions of cerebrasthenia, is given in the same Avay, a head-piece bearing many points being connected Avith the negative pole and sus- pended about six inches above the head. This method is a general tonic and cerebro-spinal derivative, and is useful in conditions of nervous prostration, insomnia, hysteria, and neuralgias of mild degree. It should precede the more vigorous treatment by sparks in very nervous persons. An intermediate method between the spray and sparks is obtained by using a AA'ooden electrode, Avhich permits a more Adgorous spray to be directed against a part. (c) Sparks.—With the insulated patient holding a chain in the bare hand attached to one pole, a roller electrode is attached to the other pole by means of a chain and is passed swiftly over the surface of the Avoolen or silk clothing (Plate XXIII). The sparks that pass are 340 DISEASES OF AVOMEN. but the thickness of the clothing in length and are very numerous. With an efficient machine this form of sparks is usually too strong for most persons, and it may be further tempered for sensitive cases by interposing the resistance of the floor, a third chain or rod passing from the operator's pole to the floor on Avhich the end of the chain attached to the electrode also rests at some distance (Plate XXIV). To increase the effect of the sparks the electrode is held at the distance of an inch or more from the clothing. The nature of the outer cloth- ing exerts an influence over all forms of these applications, a moist surface, or a cotton or linen one, taking the current to itself rather than permitting a proper penetration to the body. A good insulat- ing outer garb is essential, preferably of rough woolen material. The mild sparks are a general stimulating tonic, and specially useful in the backache of nervous persons, the severe sparks being useful also in anesthetic conditions. The Leyden-jar condensers are not used except in profound anesthesia. (d) The Franklinic Induced Current.—Dr. Morton, of Xew York, has introduced a method of making percutaneous or permucous ap- plications of what is knoAvn as the franklinic induced current in which both electrodes are applied to the body Avith moist coverings, as in faradic or galvanic currents. It should, of course, be under- stood that a sparking space must exist someAvhere in the circuit, and in this case it is in the metallic circuit rather than at the surface of the body. Very short sparks only are bearable, in the neighborhood of a line in length. Better results are obtained if the condensers are used, giving additional amperage. Fig. 113 shoAvs the connections, the smallest-sized Leyden jar being usually employed and the electrodes are put in position with the rods touching before the machine is started, the right-hand rod being then screwed apart slightly from its fellow. The pressure of the current is determined by the distance betAveen the balls. This cur- rent is an alternating one, reciprocal sparks passing through the pa- tient betAveen the external coatings of the condensers contempo- raneously Avith the sparks betAveen the balls. It is said to be more effective at times than the faradic current, but is more troublesome to manage, the cords and electrode handles requiring to be specially constructed Avith high insulation. A better control may be exercised over this current by placing the patient in shunt Avith a Cleaves static controller. T • PLATE XXIV.—Indirect Sparks (condensers should be removed). FRANKLINIC, OR STATIC, ELECTRICITY. $11 (e) Ozone Administration.—The passage of these high-pressure currents through the air results in the production of considerable quantities of ozone from the aerial oxygen, easily detected by the peculiar odor or by its turning paper a blue color that has been moistened Avith a solution of potassium iodide. It can be adminis- tered from a small electrode with a number of points which is held a feAV inches from the mouth and nostrils of the patient, who is seated on the insulating platform connected with the opposite pole. After Using the Machine.—To maintain the charge all chains should be removed from the prime conductors immediately after use and the rods left separated. Therapeutic TJses in Gynecology.—In adaptability to the needs 1111111111111 Fig. 113.—Arrangement of circuit for Morton's static induced current. of the gynecologist the static current depends for usefulness on his recognition of the neural relationships of many affections apparently arising in the sexual organs, as Avell as on the purely neural character of much of his work, for its value in chronic sciatica, insomnia, chronic rheumatism, and various neuroses is very great. An im- portant fact first noted clearly by Apostoli is that the strong spark treatment enables us to discriminate betAveen hysteria and neuras- thenia. In hysteria the patient is capable of receiving a truly enor- mous voltage in the shape of sparks, with but little sign of feeling them. This is because hysterical analgesia is so common in these cases, and it may be noted that under the stronger sparks the hys- 342 DISEASES OF AVOMEN. terical cases improve until finally the sparks give as much pain as normally produced. In neurasthenia no such tolerance of the spark treatment is ever found, this form of application being usually so stimulating as to be wisely replaced by the spray. Among the cases favorably affected by this current those of neurotic backache stand pre-eminent, and, in fact, some form of static treatment may well be conjoined with pelvic applications of other currents if this symptom be prominent in connection with organic pelvic disease. For mere sedation the positive charge may be used. For neurasthenic condi- tions the positive spray, or the stronger negative spray, either station- ary or mobile, followed later by the lightest, shortest sparks. When a patient is under other forms of treatment for hysteria or neurasthenia it is usually necessary to suspend applications during the menstrual periods. At these times the static spray or static charge may be substituted Avith advantage, maintaining the treatment without the harmful break that often interferes Avith quick results. That no disrobing is required for this application is a distinct advan- tage at this time. Menstrual discomfort is lessened, and no risk of causing an undue Aoav is encountered as might be the case with the galvanic current. The treatment of menorrhalgia of the neural type may be con- ducted, at times, entirely Avith the static currents, the negative spray being directed to the lumbar region, Avith the patient sitting sidewise on a chair placed on the platform and grasping a chain connected Avith the positive pole. The spray should be strong enough to pro- duce distinct stinging sensations, and may be followed by light sparks to the same spot and to the hypogastric region. These applications are always helpful at and before the menstrual periods in nervous Avomen, particularly if the nervous symptoms present at these times are attended by scanty Aoav. For the treatment of the nervous disorders of the menopause, either natural or when artificially produced by ovariotomy, the static methods are often extremely useful, rendering the employment of neurotic and sedative medicines unnecessary. Both the head-spray and general sparks may be used. Production of Roentgen Rays by the Static Machine.—Eoentgen, or x-, rays have heretofore been most largely serviceable in the surgery of the bones and of missiles imbedded in the body, the fleshy organs and such morbid conditions as come under the notice of the gyne- FRANKLINIC, OR STATIC, ELECTRICITY. 343 cologist casting but slight shadows on the fluoroscope and photo- graphic plate. Eecent reports of the action of these rays on the skin Fig. 114.—Queen self-regulating x-ray tube. have added an element of possible therapeutic usefulness to their con- sideration, hoAvever; and, in view of the fact that a static machine, such as is'indispensable in the larger work of the neuro-gynecologist, 314 DISEASES OF AVOMEN. forms also an excellent means of exciting a Crookes tube for this work, a feAV remarks are added on this method of producing the rays. The only instruments needed in addition to the static machine are the tube, a stand for holding it, and a fluoroscope, rendering the outlay quite small for this special use of the machine. Even the smaller static machines will excite tubes made Avith an appropriate exhaustion, but the best results are obtained from the large instruments, preferably one Avith from six to ten revolving plates of large diameter. The tube, which should be of the "focus" type, should be specially suited to the machine, the dimensions and char- acter of the machine being given to the tube manufacturer before it is purchased. The long, doubly-insulated terminals of the focus-tube are specially useful Avhen the static machine is employed as exciter. In use the short tube attached to the middle of the bulb is gently, but firmly, clamped in the stand in such a position that the opposite side of the bulb is toward the object to be radiographed. The concave electrode must be attached to the cathode, or negative pole, of the machine by a light AA'ire and the platinum plate to the anode. In action the cathode rays proceed from the concave electrode and focus on the anode, from which spot they issue in a powerful stream and impinge on the glass. It is at the glass surface that the Eoentgen rays become separated from the cathode rays, the latter not penetrat- ing the glass. The method of making connections is shown in Fig. 115. It is necessary to have the condensers in circuit (and a size of condenser must be selected to suit the tube), Avith the rods well separated and a spark-gap somewhere in the circuit; this is easily accomplished by slipping a ring on one rod-handle to give a short spark; or a neater arrangement is the author's spark-regulators, which are attached to the hard-rubber handles near the brass portion of the rods. One wire is attached to the binding-post on the regulator and the other to the brass parts of the opposite pole, which should have its rod well drawn back. The wires for this purpose should be very light, to avoid too much traction on the tube. The best way to ascertain which pole of the machine is the cathode and which the anode (and in some machines they are liable to change from time to time) is to bring the discharging-rods close together and start the machine; the resulting spark will be bright FRANKLINIC, OR STATIC, ELECTRICITY. 315 and solid next to the anode and bluish next the cathode. If a mis- take is made and the tube is connected Avrong a ring of light appears at its equator and no lighting up of the fluoroscope will occur. Fig. 115.—Arrangement of static machine for the production of Roentgen rays. The machine should be run at full speed for the production of Roentgen rays. It is Avell settled that the dermatitis that folloAvs x-ray exposure at times is extremely unlikely to be encountered Avhen the rays are produced by the static machine instead of the usual coil. CHAPTER XXVII. The Sinusoidal and Incandescent Alternating Currents. The Sinusoidal Current.—For a number of years the author has been aAvare that the successful production of muscular stimulation Fig. 116.—The Kellogg sinusoidal apparatus. Avith a minimum of pain Avas largely dependent on the smoothness and clearness of the note produced by a good interrupter of a faradic apparatus; that "raggedness" or irregularity of these very imperfect (346) sinusoidal and incandescent currents. 34? Fig. 117.—Graphic representation of the sinusoidal current 01 Dr. Kellogg's apparatus. (Kellogg.) Fig. 118.—Sinusoidal curve obtained by d'Arsonval. Fig. 119.—Current from faradic apparatus (Mcintosh). A, make; B, break. (Kellogg.) Fig. 120.—A, current from faradic apparatus (Mcintosh), same as Fig. 114. but with different adjustment of the rheotome; B, current reversed. (Kellogg.) 348 DISEASES OF WOMEN. Fig. 121.—Representation of magneto-electric current not sinusoidal in character. (Keilogg.) Fig. 122.—Current from du Bois-Reymond coil. B, break. (Kellogg.) A, make; Fig. 123.—Lnaracteristic marking of the rapidly-successive inductions of a poor faradic coil. The time-markings indicate 1/280 second each. (Kellogg.) Fig. 124.—.1, current from coil excited by Thompson-Houston arc light, alternating 16,800 times per minute; B, current from secondary coil of ordinary faradic apparatus excited by alternating current. Time-markings represent intervals of 1/280 second. (Kellogg.) SINUSOIDAL AND INCANDESCENT CURRENTS. 349 means of interrupting the inducing current produced induced cur- rents that Avere of limited contraction-usefulness on account of the pain produced. While on a visit to Dr. J. R. Kellogg in the summer of 1887 he Avas surprised to find a magneto-electric machine in use in his operating-room Avhich produced vigorous contractions Avith but slight sensation (Fig. 116). The exact reason for this Avas not knoAvn until the researches of Professor d'Arsonval, of Paris, several years later, on the graphic delineation of the curves of induced currents, shoAved that a curve of smooth and uniform rise of potential pro- duced painless contraction, Avhile irregular rises and falls of potential Fig. 125.—Mcintosh sinusoidal apparatus, with motor. Avere painful. By means of an electrograph the curves of current- variation may be readily recorded on a revolving cylinder, the accom- panying figures (117 and 118) representing the curves thus obtained by d'Arsonval and from Dr. Kellogg's apparatus. The curves shown in Figs. 119 to 124 are in marked contrast to these, showing the ragged character of the irregular rises and falls of potential and ex- plaining the pain-producing character of all faradic currents of any considerable volume. The sinusoidal current has a smooth and gradual variation, con- sisting of both an equal rise of potential above and fall below the 350 DISEASES OF AVOMEN. zero-line. This latter curve of variation represents the highest and most painless efficiency in muscle-stimulation with slight amperage, the contraction being proportional, of course, to the three elements of volts of rise, suddenness of rise, and milliamperage of current. It is thus seen that the sinusoidal current is typically adapted Fig. 126.—Kennelly sinusoidal apparatus and motor. for muscular stimulation, for by properly constructed apparatus we may apply a far greater milliamperage for this purpose than the pain- producing qualities of the primary faradic current will permit. The exact milliamperage of these currents is yet undetermined, depending on the current circulating around the field-magnets of the alternator, but that it is usually intermediate betAveen the galvanic and faradic SINUSOIDAL AND INCANDESCENT CURRENTS. 351 is shown by the fact that they will readily stimulate the special senses of sight and taste. The ease with which a large number of complete alternations per second of this smooth character can be obtained adapt the sinu- soidal current also as a nerve-sedative. Sinusoidal currents are produced by little alternating-current Fig. 127.—Shaw's acid carbon cell, of large size, for running motors, lighting small lamps, etc. dynamos, with either permanent magnets or electro-magnets, Avhich are operated by any convenient source of poAver, an electric motor being the best. The patient is placed in a shunt circuit with a Massey controller, Avhich is operated in a reverse manner,—that is, the lever is placed all the way around on the nickel-plated base of the graphite area at the start, \vhen all the current goes through the instrument instead of the patient; by turning the current off the controller gradually it wi 11 increase through the patient's circuit with equal step. 952128 352 DISEASES OF AVOMEN. The only drawback to this instrument as compared with faradic apparatus is its bulkiness and the fact that from two to four large acid-carbon motor cells must be used to operate it and the motor, or four times as many Edison-Laland cells, in the absence of the more convenient street-current. The Incandescent Alternating Current.—This current, which is very largely used at present as an illuminant of houses and offices, is obtained from step-doAvn transformers placed on the exterior of the house, by means of which the high voltage of the street-mains is reduced to either 50 or 104 volts, according to the transformer used and the lamps supplied. It may be employed in medical applica- tions in place of the faradic, but, not being truly sinusoidal in char- acter, is generally painful even when greatly reduced. The author's current-controller forms an efficient means for its control, Avhen protected by a small fuse, the instrument being simply intercalated betAveen one wire from a lamp-socket and the patient, the other wire from the lamp-socket going direct to the patient. As already said, this current is distinctly faradic in character and incapable of lasting electrolysis or cataphoresis. It can, in no sense, be employed as a galvanic current, therefore, in spite of the similar heat- and light- producing effects in the large amperage traversing the filament of the lamp. There is, at least, one emergency in Avhich its modern ubiquity may make it of service in saving life,—namely, in post-partum hemor- rhage in a house supplied with this current and where a battery is not to be had. The cord of a drop-light could be unwound and one AAlre applied by coiling it in a wet pad to be placed on the back, while the other is dipped in a dish of Avater; a third Avire from the opposite side of the dish of Avater going to a pad on the abdomen. When the AAlres in the Avater are brought closer or when a little table-salt is dropped into it, a means of gradually increasing the current to the point of tolerance is thus readily produced, with powerful contracting effects on the relaxed uterus. CHAPTER XXVI11. Electric Light as an Illuminant and as a Therapeutic Agent. Direct Illumination of the Vagina.—Various methods have been devised for illuminating the vagina through the speculum by both reflected light and direct light produced by incandescent lamps. As Fig. 128.—Sajous's lamp-holder and stand. a source of light to be reflected from a mirror, there is no special advantage in the incandescent light Avhere a Welsbach burner or ace- tylene-light is obtainable; in fact, it is inferior to either of these, though at times more convenient on account of its readier movability. Either a 16-, 32-, or 50-candle lamp is essential if the light is to be 354 DISEASES of avomen. reflected by a head-mirror, and the use of these lamps, of course, necessitates the taking of current from street-mains, as any kind of primary or secondary batteries of the voltage required would be both too troublesome and too expensive in maintenance. The light may be fixed on a holder or held by a second person. Of portable electric lights Sajous's lamp-holder and stand is shown in Fig. 128, but there is a mistake evident in the attachment of so small a portable battery, or any portable battery, to a lamp described as having a resistance of sixty ohms, which is intended for a current of at least fifty volts. Sajous also describes1 the search-light of C. W. Isaac, of London (Fig. 129), consisting of a lamp mounted on a movable base of hard rubber Avithin a tube in which it slides, in the front portion of which is set a parabolic mirror so adjusted that the arch of the filament is as near as possible coincident with its focal point. The mouth of the Fig. 129.—Isaac's search-light. reflector is closed by a small glass cover, which protects the lamp and prevents the silver from being quickly tarnished. A mirror arranged in this way would doubtless be an improvement on Phillips's head- lamp or if placed behind the filament of a 50-candle lamp on the Sajous stand would be better than the Tobold condenser shown. As imported, this lamp is intended for a smaller lamp supplied by a battery. Owing to the interference of the knees and the general position of the patient during a gynecic examination, the use of the head- mirror and reflected light is more inconvenient than is the case in other medical Avork, and better illumination is accomplished by the 1 "International System of Electro-Therapeutics," page 1-6. Philadelphia: The F. A. Davis Co. ELECTRIC LIGHT AS ILLUMINANT AND IN THERAPEUTICS. 355 use of miniature lamps carried on a head-piece in such a way that the light projects betAveen the eyes in a line Avith the line of vision. These small lamps have the added advantage that they may be sup- plied with current from a feAV large acid motor cells in the office or portable storage cells of a few volts elsewhere. The best of this kind of apparatus is that devised by Dr. W. C. Phillips, of Xew York (Fig. 130). This is light of weight, easy of adjustment, and has a good lens. The instrument consists of a narrow, but strong, steel band, similar to Fox's, lined throughout with fibre. Attached by a rotary- motion joint is a small condenser Avhich carries a 4-candle-power lamp of four or six volts. By means of a thumb-screAv at the side of the Fig. 130.—Phillips's electric head-light for four- or six- volt lamp. condenser the focus may be easily and quickly regulated without re- moving the lamp from the head. To furnish the current for this lamp in office-AVork the best generator is the Shaw acid-carbon cell (Fig. 127), two of Avhich should be coupled up in series for 4-volt lamps and three for 6-volt lamps. In case a German-silver-wire con- troller or rheostat is used Avith these cells, an additional cell will add to the length of time that the fluid can be used. The fluid requires to be renewed quite often. The storage battery is more expensive, but more convenient, if an Edison circuit is convenient for charging, but in the absence of this facility the storage battery is a nuisance, except as an expensive means to obtain a portable light. Small lamps mounted on slender holders may be held in the 356 DISEASES OF AVOMEN. speculum for examination, but are in the Avay in case manipulations are necessary. Transillumination of the Pelvis.—The fact that limited thick- nesses of the body, such as the finger and part of the palm, may readily become translucent to the rays of even a moderately strong light seems to have been lost sight of as a means of diagnosis until the laryngologists took it up in 1888, Avhen Cozzolino, of Xaples, fol- loAved by Voltolini, of Breslau, illuminated the A\-alls of the nose and accessory cavities and the larynx; the former by miniature lamps Avithin the closed nostril or mouth, and the latter by a lamp on the outside of the neck, covered by an obturator, the light being per- ceived by the use of a laryngoscopic mirror within the dark pharynx. The application of the principles thus disclosed to gynecology has been retarded by the greater thickness of the body in this situa- Fig. 131.—Author's pelvic transilluminator. tion, rendering the miniature lamps that are capable of being intro- duced ineffective as a source of light. I have, hoAvever, myself suc- ceeded in illuminating the abdomens of moderately thin women by the lamp devised by me (Fig. 131), which consists of a 6- or 8-volt lamp mounted on a holder in front of a plane reflector, and the Avhole inclosed Avithin two test-tubes separated by rubber bands. The special advantage of this arrangement is the two air-spaces separated by the test-tubes, reducing the radiation of heat and permitting ready cleans- ing. The abdomen is illuminated by a reddish glow half-Avay to the navel. This light is, hoAvever, insufficient to illuminate the tissues in case of fat, or corpulent, patients, and, as the value of the procedure hinges on the absence of transmission as an evidence of pus accumula- tions and possibly tumors of dense consistence, it is evident that a more poAverful light is necessary. This may be obtainable in the ELECTRIC LIGHT AS ILLUMINANT AND IN THERAPEUTICS. 357 Jackson apparatus (Fig. 132), though I have not tried it, which em- ploys the principle discovered by Belin in 1889, that a glass rod will transmit rays of light to its extremity Avithout heat if the rod is silvered, the rod even being capable of being bent into various shapes. The apparatus is of two parts,—an electric lamp of 50-candle poAver and a silvered glass rod. The lamp is inclosed in a case silvered within and blackened Avithout. Projecting from the side of the case is a metal neck into Avhich fits a perforated asbestos cork; through the cork passes the glass rod, Avhich is also silvered over except at the ends, the silvering being protected by varnish. The brilliant light Fig. 132.—Apparatus of Chevalier Jackson as arranged for trans- illumination of the nasal passages and antrum. Avithin the lamp-case is transmitted axially through this rod and issues from the distal end Avith undiminished brilliancy. The rod does not get hot, and should be slightly Avarmed before insertion. Another mode of obtaining transillumination of the pelvis is to place a 32- or 50-candle-poAver lamp over the abdomen in a conical receiver made to exclude all light except that Avhich traverses the skin and abdominal Avails; if a speculum be then placed in the vagina the tissues will be seen to shine Avith a red gloAV. All Avork in transillumination should be done in a thoroughly darkened room. 358 DISEASES OF AVOMEN. The value of transillumination is limited by the fact that all living tissues appear nearly the same in color and shade. It is im- Fig. 133.—Alternating current-transformer of Williams, Brown & Earle. possible to make out the anatomical parts except the large veins and the bones, and these only by a darker shading. Accumulations of Fig. 134.—Controller for lighting small lamps and heating cautery- loops from Edison current. pus will appear as a dark shadow, while cystic tumors are lighter than their surroundings. Xo light is transmitted if there be extensive exudations, and dense fibroids and possibly cancerous tumors cast a ELECTRIC LIGHT AS ILLUMINANT AND IN THERAPEUTICS. 359 shadow or interfere Avith transmission. Hematomas should also be opaque, if the general rule holds good that dead tissue is opaque to the rays. With a satisfactory source of light, the value of this procedure in diagnosis is evident. • Electric Light as a Therapeutic Agent.1—The therapeutic use of Fig. 135.—The Kellogg electric-light-bath cabinet. electric light is mainly due to the facility Avith which an application of radiant heat may be made to the whole or a part of the body. A 16-candle light inclosed in a bell-shaped shield placed over a painful *For Report of Standing Committee on "Electric Light as a Diagnostic and Therapeutic Agent," see the Transactions of the American Electro-Thera- peutic Association, page 295, 1S94. 360 DISEASES OF AVOMEN. spot will quickly and pleasantly do all that a hot application can do to relieve pain and possibly more, for it may be that the effect is due as much to the penetration of light to the nerve as it is to the heat. Such an application will be folloAved by a circumscribed redness, and repeated applications will tan the skin like sunlight. Moist heat—a radiant poultice—may be applied locally by wrapping the lamp in wet cloths (leaving the base of the lamp unmoistened, of course). Dr. J. H. Kellogg has detailed a series of experiments on the physiologic effect of the electric-light, or radiant-heat, bath in a paper before the Americal Electro-Therapeutic Association.1 He employed a cabinet lined Avith mirrors and containing sixty incandescent lamps, so arranged that the patient lies in an horizontal position, the lights being placed on three sides (Fig. 135). The patient lies on a suitable Fig. 136.—The electrotherm: an electric heating pad for replacing hot-Avater bags and bottles. couch with rollers, which is pushed entirely within the cabinet, or only so far as to expose such portions of the body as it is desirable to bring under the influence of radiant heat and light. It is only necessary to protect, by a sheet and piece of mackintosh, any portion of the body Avhich it is desired to exclude from the action of the bath. The results of his investigation shoAved that the electric-light bath Avas superior to either the Turkish or Russian baths in stimu- lating vicarious elimination by the skin, the amount of perspiration induced being fully double that induced by the Turkish bath in the same time. 1 Transactions of the American Electro-Therapeutic Association, page 153 1894. ELECTRIC LIGHT AS ILLUMINANT AND IN THERAPEUTICS. 361 The electrotherm, or electric hot pad (Fig. 136), is an excellent substitute for a hot-Avater bag for local applications of heat to the body, the special adA'antage of the instrument being the maintenance of the desired heat for any length of time required, in AA'hich it is incomparably superior to hot-water bags. APPENDIX A. TABLE OF EIGHTY-SIX CONSECUTIVE CASES OF FIBROMATA, WITH DETAILS OF TREATMENT AND ULTIMATE RESULTS. (368) Table of Ekjhty-six Consecutive Cases of Fibromata Uteri Under Electric Treatment. H CO ■< O d Referred By or Treated At Z u H h O U a < Known Dura-tion of Groavth. Description of Growth. Clinical Symptoms. Method of Treat-ment. 1 45 4 years. Interstitial growth, size of cocoa-nut, projecting into right broad ligament. Pressure on bladder and menorrhagia. Buried puncture, —, (>0 to 200 ma. at intervals of a week, folloAved by intra-uterine. 2 47 20 years. Interstitial and sub-peritoneal multi-nodular growth fill-ing abdomen to 4 inches above umbil-icus. General pressure symptoms and im-pairment of health. Intra-uterine, 100 to 200 ma., eight times, daily. 3 Dr. H. A. Kelly, Balti-more. 49 38 5 years. Submucous, sessile fibrocyst, enlarging uterus symmetric-ally to size of seventh month of pregnancy. Bloody and watery discharge, pain, and general impairment of health. Intra-uterine, — and 4-, 25 to 300 ma. every other day un-til os dilated and tumor presented. 4 Dr. T. Hew-son Bradford, Philadelphia. 2 years. Submucous sessile polyp of small size ; u t e r u s hypertro-phied ; cavity four inches. Pain and purulent leucorrhea. Intra-uterine, — and +, 40 to 150 ma.; ten applications. Results. Time After Cessa-tion of Treatment When Results Were Verified. Sympt. cure and early reduction of size one-third. Re-cent report of pa-tient says growth has disappeared. 10 years. Temporary aggrava-tion of pain due to frequency of treat-ment ; subsequent improvement. 1 year. Septicemia occurred during expulsion of tumor, followed by death on the twelfth day. Relief of symptoms; reduction of tumor to a nodule and of uterus to normal size. Dr. T. Hew- son Bradford, Philadelphia. 3H 2 years en- Dr. F. Wood- bury, Phila- delphia. 41 Dr. Bradford, Philadelphia. 34 12 years. 9 in os. Dr. William 40 ' l\ years. Pepper, Phil- adelphia. Dr. Bradford, Philadelphia. 42 1 year. Intramural, multi- nodular growth, till- ing abdomen and extending two inches above navel. Subperitoneal and intramural multi- nodular growth, ex- tremely hard, tilling pelvis and lower third of abdomen. Prof use and hastened Intra-uterine, -f- and Sympt. cure; patient periods, severe pain, and difficult loco- motion. Constant pain, ag- gravated at periods. which were of 12- week type, and pro- fuse, offensive, pu- rulent leucorrhea. Intramural growth Constant pain in left tilling pelvis, Avith groin and on walk- subperitoneal pro-: ing, with profuse, jection reaching purulent leucor- crest of the ilium. rhea. Intramural symmet- ric fibroid of large size, wedged in pelvis and extend- ing to the navel. Severe pain, inflam- matory attacks, pressure symptoms, and impairment of health. —, (55 to 150 ma. at intervals of week or more. reports ance. disappear- Intra-uterine, 60 to 200 ma. — tAvice Aveekly. Later once weekly. Patient reports dis- appearance. The discharge quickly cured. Intra-uterine, —, 50 to 150 ma. tAvice a Aveek. Disappearance of tu- mor and of all symp- toms, and reduction of uterus to normal size. Bands of ad- hesion left. Intramural nodule, 2 Pain and other press- inches in diameter, ure symptoms, with in posterior wall of menorrhagia and retrollexed uterus. profuse purulent leucorrhea. Intra-uterine, 80 to Quick release up- 250 ma. — every ward into abdomen, other day. Later, with improvement every fourth day. of health ; subse- quent reduction to two inches below navel (one-third). Intra-uterine, 50 to Sympt. relief and 125 ma. — twice weekly, with inter- vals of non-attend- ance. considerable shrink- age. 8 years. 4 years. 8 years. years. 3 mos. Table of Eighty-six Consecutive Cases of Fibromata Uteri Under Electric Treatment (continued). CO o d Referred By or Treated At Dr. Bradford, Philadelphia. z Ph o a o ma. electrode. flexible Exhausting hemor- rhages and impair- ment of health. Intra-uterine. 4-, 50 to 75 ma. Sectional carbon electrode. Intra-uterine, 4-, 100 to 250 ma. Carbon electrode. and slight reduction in size, after limited treatment. Patient lost sight of. 3 years. 4 years. Cure of hemorrhages, reduction to 1 inch above navel, and restoration of health. Intra-uterine, 4-, 45 Cure of hemorrhages, to 75. Rigid elec-J reduction of size, trode. and restoration of health. Profuse periods, hem- Intra-uterine, 4-, ' Symptomatic cure orrhagic at times ; and alternatives, 50 and some reduction pain and tenderness. to 100 ma. 2 years. 3 years. Recent. Table of Eighty-six Consecutive Cases of Fibromata Uteri Under Electric Treatment (continued). w < O U o d Referred By or Treated At w H Ph fa o a Known Dura-tion of Growth. Description of Growth. Clinical Symptoms. Method of Treat-ment. Results. Time After Cessation of Treatment When Results Were Verified. 58 Dr. Lawrence Wolff, Phil-adelphia. 40 3 years. Interstitial and sub-peritoneal abdomi-nal tumor extend-ing 3 inches above navel. Cavity, 4 inches. Tortuous. Menorrhalgia and tenderness with leu-corrhea, but little pain. Hemorrhagic and tender, and has sup-pression of urine from pressure. Menorrhagia and pain, with feeling of weight. Constant Avatery, at times bloody, dis-charge, and impair-ment of health. Intra-uterine alt., 60 to 150 ma., followed by faradic. Symptomatic cure and reduction to 1£ inches above navel. Recent. 59 Howard Hos-pital. 40 2 years. Interstitial abdom-inal tumor, extend-ing to navel. Intra-uterine, +, 60 to 75, and vag. appl. for short period. Symptomatic cure; no note of reduc-tion in size. Lost sight of. 60 Dr. S. M. Ross, Al-toona, Pa. 29 2 years. Interstitial pelvic tumor size of lemon posterior to fundus. Intra-uterine, 4-, 50 to 100 ma. Bipolar intra-uterine punctures, 400 to 700 ma. Symptomatic cure; no reliable infor-mation as to reduc-tion. Complete destruc-tion of intra-uterine tumor and reduc-tion of nodular uterus to size of a lemon. 61 Drs. Hem-minger and Bixler, Car-lisle, Pa. 39 7 years. Intra-uterine sessile fibroid, thoroughly cystic and vascular, size of seventh month of preg-nancy. Os dilated. 3 years. 62 40 3 years. Interstitial abdom-inal tumor size adult head, extend-ing 3 inches above navel, with ascitic fluid in peritoneum. Constant bleeding and shortness of breath on walking. Intra-uterine, 4-, 50 to 60 for short time. Reduction in flow to normal. No change in size. Subse-quently removed by Dr. Kelly. Dr. S. S. Maynard, Frederick, Md. 50 13 years. Interstitial pelvic tumor of fundus, the whole about the size of a fist. Some pain and ten- Intra-uterine, —, 30 derness ; had been to 50 ma., and vag. greatly relieved by galv. previous attendant i under electricity. Symptomatic cure, arrest of growth, and some reduction in size. 4 years. Dr. William Goodell, Phil-adelphia. 32 8 years. Interstitial pelvic tumor of fundus about size of goose-egg- Menorrhalgia and severe attacks of pain. Had been opened by a surgeon who desisted from removal. Intra-uterine, —, 30 to 40 ; mainly vagi-nal on account of pain. Improvement of symptoms. Recent. Dr. A. W. Knox, Raleigh, N. C. 34 46 1 year. Multiple interstitial and subperitoneal tumor size of an orange. Interstitial pelvic tumor size of hen's egg, with peri-uterine tenderness. Cavity, 3£ inches. Pain and pressure on bladder. Intra-uterine, 4-, 40 to 80 ma. Symptomatic cure and slight reduction in size. Dr. J. Cham-bers, Kings-ton, N. Y. 6 mos. Hemorrhagic peri-ods ; severe pain in ovarian regions. Just recovered from peritonitis. 4- vagino-abd. fol-lowed by intra-uterine, —, 30. Symptomatic cure and distinct reduc-tion in size. 3 years. Dr. J. Rey-nolds, Pots-dam, N. Y. 43 45 2 years. Interstitial abdomi-nal tumor of large size to \ inch below navel. Cavity, 4 inches. Growing rapidly and had become very uncomfortable. Intra-uterine, —, 40 to 50. Arrest of growth for 8 months after short treatment, and symptomatic cure to date of report. 1 year. Dr. T. C. Rich, Will-iamsport, Pa. 8 years. Very large abdomi-nal tumor, size of uterus at term. Exsanguinated and cachectic from con-stant hemorrhages and recent attack of peritonitis. Temp. 101°. Intra-uterine, 4-, 100 to 200 ma., ; carbon electrode, al-ternating with vagi-nal galv. Surprising restora-tion of health, fol-lowing gradual ces-sation of hemor-rhages ; later dim-inution of size. 6 mos. Table of Eighty-six Consecutia^e Cases of Fibromata Uteri Under Electric Treatment (continued). 69 70 Referred By or Treated At Howard Hos- pital. 71 72 73 Dr. H. W. Elmer, Bridgeton, N. J. 48 34 47 54 46 Known Dura- tion of Growth. Un- known. 4 years. 9 mos. 4 years. 5 years. Description of Growth. Abdominal tumor, interstitial, extend- ing to 1 inch below navel. Cavity en- tered 3 inches. Multinodular inter- stitial and subperi- toneal tumor about size of fist. Interstitial pelvic tumor, size of fist. Multinodular pelvic tumor size of fist (suspicion of malig- nancy ). Interstitial abdom- inal tumor size of egg-plant, extend- ing to 2\ inches of navel. Cavity, 4 inches. Clinical Symptoms. Method of Treat- ment. No symptoms par-; Intra-uterine, +, 20 Reduction in size to ticularly pointing! to 60 ma. 2 J- inches below Results. to tumor. Patient has lupus of skin. Tenderness extreme, menstruation scanty. Hemorrhages every 3 weeks for 3 years. Very profuse ; now almost constant. Constant hemor- rhages for several years, with impair- ment of health. Hemorrhages at periods and some i m p a i r m e n t of health. Intra-uterine, —, 60 to 80 ma. Later, — vaginal puncture, 200 ma. navel. No continuous relief of tenderness, and tumor still grow- Intra-uterine, 4-, 50 Symptomatic cure to 100 ma. and great reduction in size. Intra-uterine, 4-, 50 Arrest of hemor- to 150 ma. Carbon electrodes ; later zinc-amalgam cata- phoresis 50 to 100 ma. rhages and improve- ment of symptoms. Tumor probably smaller. Intra-uterine, +, 40 Symptomatic cure to 100 ma. and some reduction in size. ?, ° J" r1 " H x § ■" fa | S a 5 *- < t> Hr"^ 6 mos. Recent. 2£ years. 2 years. 2 years. CO 00 74 75 76 78 79 Dr. F. H. 30 Martin, Chi- cago, 111. Howard Hos- pital. 77 Dr. W. S. Janney, Phil- adelphia. Dr. Thomas Drysdale, Philadelphia. 6 years. 38 3 years. Un- known. 43 ' 6 mos. I 26 45 Recent. Interstitial pelvic tumor size of laige fist. Interstitial tumor of size of pullet's egg. Cavity, 3 4-, retro- flexed. Profuse periods. Tumor again grow- ing after operation for tying broad liga- ments. Adherent vag. sinus. Intra-uterine, to 60 ma. pelvic, Hemorrhagic peri- fundus, | ods. Lame in left leg from pressure. Health depressed. Interstitial tumor of about 2 inches in diameter, project- ing into Douglas's pouch. Intra-uterine, +, 50 to 75, flexible cot- ton-covered elec- trode interspersed with vag. galv. pelvic Occasional hemor- Intra-uterine, 4-, 50, fundus ; rhagcs, some tender- and vag. galv. ness, and impair- ment of health. Interstitial abdomi- nal tumor filling lower abdomen to 2 inches above navel. Hemorrhagic peri- ods, tenderness, and general impairment of health. Interstitial pelvic Pain and menor tumor, size of cocoa- nut. Cavity, 4 inches. rhagia. 4 years. Interstitial abdomi- Frequent nal tumor size of | rhages and adult head, fillip lower half of abdo- men to navel. Cav- ity, 6v inches. hemor- menor- rhagia, with pain, leucorrhea, and im- paired health. Intra-uterine, zinc- amalgam catapho- resis, 40 to 80 4-. Symptomatic im- No ad- provement in pain vice since and hemorrhage. treat- Tumor smaller. ment. Intra-uterine, +, 35, flexible electrode, on six occasions. Intra-uterine, 4-, 200, sectional elect.; later zinc-amalgam cataphoresis. Disappearance of hemorrhages, limp, and other symp- toms, and sonic re- duction in size. Disappearance of tumor and symp- tomatic cure. Symptomatic cure and considerable reduction in size. Symptomatic cure. Symptomatic cure and reduction to 2 inches below navel. 6 mos. 1 year. Recent. Lost sight of. Recent. Eighty-six Consecutive Cases of Fibromata Uteri Under Electric Treatment (concluded). Referred By ok Treated AT H z u H ■< fa O U) 40 Known Dura-tion of Growth. Description of GROAVTH. Clinical Symptoms. Method of Treat-ment. Results. Time After Cessation of Treatment When Results Were Verified. Dr. R. H. Hamill, Phil-adelphia. 5 years. Multinodular ab-dominal tumor of large size, 2} inches above navel. Mens, twice a month with constant pain. Intra-uterine, +, 100 on eight occa-sions. Unknown. Tumor subsequently re-moved by Dr. Ha-mill. Howard Hos-pital. 27 1 year. Symmetric abdom-inal tumor J inch above navel. Cav-ity very narrow. Hemorrhagic periods and very profuse muco-purulent leu-corrhea. Intra-uterine, +, 30 to 150. Symptomatic cure. No record of change in size. Howard Hos-pital. 35 Un-certain. Large mass of firm texture and irreg-ular shape posterior to uterus, appar-ently connected. Several attacks of peritonitis and con-stant pain. Vag., 4-, 50 to 150. Symptomatic cure and much reduction in size. 1 year. Howard Hos-pital. 37 10 years. Very large abdominal tumor—waist, 36.1 inches circumfer-ence—e x t e n d i n g 13! inches above pubes. Hemorrhages and pressure symptoms. Intra-uterine, +, 75 on several occasions. Results unknown. 1 year. 2 years. 2 years. ! i Large abdominal Hemorrhage and Intra-uterine, 4-, 30 Results unknown. tumor extending 3] pressure symptoms, to 150. inches above navel. Interstitial pelvic Profuse hemorrhages, Intra-uterine, tumor, size of cocoa- nut, firmly fixed. Multinodular ab- dominal tumor ex- tending 1 inch above navel. and attacks of peri- tonitis. Health im- paired. Cramp-like pain in abdomen. 100 ; later zinc- amalgam catapho- resis, 75. Symptomatic im- provement. No change in size. Intra-uterine, 4-, 125 Symptomatic cure ma. ; flexible trode. elec- and reduction of tumor to 1 inch be- low navel. For an analysis of this table see page 111. APPENDIX B. TABLE OF THIRTY-FOUR CONSECUTIVE CASES OF CATARRHAL DISEASE OF UTERUS UNDER ELECTRIC TREATMENT. (383) 384 DISEASES OF WOMEN. Table of Thirty-four Consecutive Cases of Catarrhal No. OF Case. Age. Duration OF Disease. Depth of Cavity, Inches. Mobility. Discharges. 1 34 15 years W* Fixed Slight muco-pus 2 27 1 year W± Movable Hemorrhagic leucor. 3 26 2 years 3 Movable Hemorrhage, leucor. 4 34 8 years 3% later 2^ Fixed Profuse, purulent 5 •21 2 years 3 to 2^ Movable Profuse, purulent 6 22 1 year 2J4 Movable Inconstant mucoid 7 38 3 years 3 Movable Inconstant mucoid 8 23 3 years V/2 later 2l/2 Movable Constant muco-pus 9 36 9 years 3 Movable None at present 10 27 8 years 3 Adherent Copious purulent 11 28 8 years 3 Movable Copious mucoid 12 32 8 years 3+ later V/2 Movable Slight inconstant 13 27 4 years 3 Adherent to left Inconstant 14 25 2 years 1% Movable Profuse muco-pus 15 25 3 years 2% Movable Profuse 16 37 7 years not sounded Fixed Copious purulent 17 22 16 mos. 3K to iy2 Movable Copious mucoid 18 31 6 years 4 to 2% Movable Moderate mucoid 19 30 9 years 3 Movable Copious muco-pus 20 21 3 years 3% to 2% Movable Mucoid 21 25 18 mos. 3 Movable Slight mucoid appendix b. Disease of Uterus Under Electric Treatment. 385 Condition of I'TEKUS. Moderately hyper- trophied Corporeal hyper- trophy Slight enlarge- ment Corporeal hyper- trophy Normal size Some enlargement Hypertrophied Hypertrophied Moderate hyper. Hypertrophied with large cavity Corpus 2 inches in diameter, cavity huge Capacious cavity Moderate hyper. Slight hyper. Slight hyper. Hyperplasia Engorged Hyperplasia Slight hyper. Prolapsed uterus, with hyper. Hyperplasia Complications. Left salpingitis; deep laceration of cervix Deep stellate lacer- ation of cervix Retroversion and stenosis Monolateral lacer- ation Severe menorrhalgia Severe menorrhalgia First degree of pro- lapse Tenderness in left ovarian region Menorrhalgia A lacerated cervix had been repaired without relief A lacerated cervix had been repaired without relief Tender and enlarged ovary Menorrhalgia Menorrhalgia Dense masses in region of both broad ligaments Nervous prostration Evidences of old pel- vic inrlam. Left ovary prolapsed Nervous prost. Mode of Treat- ment. — vag. followed by — intra-uterine, 15 + intra-uterine flex. elect. 30 and vaginal galv. + intra-uterine, 25 (twice only) -f intra-uterine, 25 to 65, with flexible elect. + and — intra-uterine, 8 to 25, and vag. galv. + intra-uterine, 50 to 40 + intra-uterine, 70, and prim, farad. — intra-uterine, 10 to 25, and + vag., 70 + intra-uterine, 15 to 25, and vag. galv. + intra-uterine, 35, and gen. galv. — intra-uterine, 20 to 35, and — vag. + intra-uterine, 20 to 35, and — vag. galv. — vag., 60. and farad. and + intra-uterine, 20 -j- intra-uterine, once only + intra-uterine, 20 + vag., 100 to 150 + intra-uterine. 20 to 25, and vag. galv. intra-uterine alterna- tives, 70, and vag. galv. + intra-uterine, 20, and vag. galv. + intra-uterine. flex. elect.. 25 to 40, and vag. gal. — intra-uterine, 20, and vag. galv. Results. Cure, followed by preg- nancy Improved Cure, followed by pregnancy Improved, followed by pregnancy Cured Cure d, followed by two pregnancies Cure, with improve- ment of prolapse Cured Cured Cured Improved Cured Symptomatic cure, ad- hesions remain Cured, followed by pregnancy Cured Symptomatic cure, ad- hesions loosened Cured Cured, followed by pregnancy Improved Cured, ovary still low Improved 386 DISEASES OF AVOMEN. Table of Thirty-four Consecutive Cases of Catarrhal No. OF Case. AGE. Duration of Disease. Depth of Cavity, Inches. Mobility. Discharges. 22 29 7 years 3 Movable Profuse muco-pur. hemorrhagic 23 24 7 years 3 Movable Copious mucoid 24 24 3 years 2M Movable Copious purulent 25 22 4 years 3 Movable Constant mucoid 26 26 6 years 3+ Adherent Profuse offensive muco-pus 27 26 4 years 3 Movable Profuse muco-pus 28 31 3 years 3 Movable Profuse muco-pus 29 26 4 years 2% Adherent Profuse purulent 30 40 2 years 3, later 2% Movable Hemorrhage, leucor. 31 30 3 years 3H Movable Mucoid 32 30 1 year 3 Fixed Muco-pus 33 34 1 year 3, later 2% Movable Muco-pus 34 38 5 years &A Slightly adherent Muco-pus APPENDIX B. Disease of Uterus Under Electric Treatment (concluded). oS7 Condition of Uterus. Complications. Mode of Treat-ment. Results. Stenosis, cervix Menorrhalgia + intra-uterine, 20 to 50 Cured Nervous prost. + intra-uterine, 25, and vag. galv. +Intra-uterine, flex. elect., 20 to 80, and vag. gal. Improved Cured, followed by pregnancy Moderate hyper. + intra-uterine, 20 to 35 Cured Hyperplasia Prolapse of ovaries and largement of ovary both en-left + and — intra-uterine, 20 to 30, and secondary faradic Discharge cured and enlargement lessened Tenderness in ova- + intra-uterine, 50 Cured rian regions Hyperplasia — intra-uterine, 50 Improved Tubes involved — intra-uterine, 50, and vag. galv. Cured Hyperplasia .+ intra-uterine, 50 Cured, followed by pregnancy Tenderness thickening at broad lig. and left — intra-uterine, 15 to 40 and neg. vag. Cured Tenderness thickening at broad lig. and both — intra-uterine, 35, pre-ceded by — vag., 50 Symptomatic cure Hyperplasia and prolapsed — and + intra-uterine, 50 to 75 Improved Hyperplasia and prolapsed +■ intra-uterine, 25 to 50 (for two months) Greatly improved. Two years later hys-terectomy for sup-posed cancer, with fatal results IXDEX. Abdominal puncture, 13-* relaxation, 15 Abdoinino-dorsal applications, 55 Abortion, 227 Absorbent cotton, 31 pads, 309 Acid carbon cell, 351 Adams, Prof. W. G., 33 Adams, Wellington, 306 Adenoids of rectum, 272 Alterative action of electricity, 50 Alternating incandescent current, 352 Amalgamation of zincs, 300 Amenorrhea, 72 Ampere, the, 283 Anal fissure, 269 Analgesic action, 59 Anelectrotonus, 48 Anions, 39 Anodal diffusion, 42 Anteversion, 187, 191 Antisepsis, 22 Apostoli, G., 17, 18, 24, 25, 32, 40, 48, 5^, 60, 63, 84, 88, 98, 114, 127, 341 Apostoli bipolar electrode, 56 clay pad, 309 intra-uterine electrode, 60 puncture trocar, 136 Areolar hyperplasia of mamma, 257 Arrangement of cells, 284 Aseptic precautions, 22 Aspiration, 20 Atony of bladder, 259 Atresia of cervical canal, 212 Bactericidal action of electricity, 48 Baird, W. T., 228 Battery fluid, 303 Beard, George M., 204 Benign tumors of breast, 256 Bimanual abdominal examinations, touch, 16 Bipolar applications, 58 Bladder, atony of, 259 Border-line between gynecology neurology, 197 Brothers, A., 220 Buckniaster, A. H., 62 Campbell, H. F., 67 Cancer, 231 author's method, 236, 239 Parsons's method, 233 Carbon cylinder cell, 297 Care of portable batteries, 301 Caruncle, 25>* Cataphoresis, 42 Cataphoric speed of atoms, 46 Catarrhal affections, 86 Catelectrotonus, 48 Cations, 39 (380) 390 Cautery controller, 358 Cells, portable, 297 stationary, 295 Cervical endometritis, 91 Chemic effects of electricity, 40 Choice of pole, 50 Chronic metritis, 95 Clay pad, Apostoli, 309 Cleaves, M. J., 44 Cohnheim's hypothesis, 121 Combiner, 327 Commutator (pole-changer), 327 Contra-indications to intra-uterine ap- plications, 65 Controllers, current-, 303 Corporeal endometritis, 95 Cosmetic applications of electricity, 273 Coulomb, the, 283 Cozzolino, 356 Current- concentration, 35 controllers, 303 diffusion, 32 Cystoscopic syringe, 265 Cystoscopy, 260 D'Arsonval, Professor, 326, 349 De AVatteville combiner, 327 Differences between currents, 51 Direct current, 277 Direct organic stimulation, 48 Direction of current in cell, 280 Diseases of rectum, 269 Displacements, 183 Dolbear, Prof. A. E., 25 Dorsal position, 15 Duration of application, 64 Dysmenorrhea (menorrhalgia), 74 Ectopic gestation, 215 Edison current, 290 DEX. Electric-light bath, 359 Electricity as a remedy, 24 Electrode asepsis, 22 coverings, 31 Electrodes, 308 Electrolysis, 38 Electromotive force, 277 Electro-puncture, abdominal, 138 vaginal, 136 Electrotherm, the, 360 Endometritis, 91 cervical, 91 corporeal, 95 Engelmann coils, 325 faradic battery, 325 Environment, influence of, 1 Epithelioma, 233, 253 Erb, Professor, 25, 33 Examination of cases, 9 Excitation of function, 46 Experiments with currents, 312 Extra current, 320 Extra-uterine pregnancy, 215 Faithfull, Mrs. Edith, 232 Faradic currents, 318 Fibroid tumors, 121 clinical varieties, 123 contra-indications, 134 methods of application, 135 mode of action of electricity, 131 natural prognosis, 127 origin, 121 results of treatment, 141 selection of cases, 133 Fissure of anus, 269 Flemming No. 4 faradic battery, 322 portable battery, 299 Fluid for battery, 303 Fox, George H., 273 INDEX. 391 Franklinic electricity, 332 induced currents, 340 Functional incapacity of the abdominal walls, 194 Gaiffe battery, 22* Galvanic current, 277 Galvano-chemic cauterization, 59 Gautier, G., 44 Geiger shunt controller, 293 General faradic stimulation, 55 General gahranic stimulation, 53 General practitioner and electricity, 28 Goelet, A. H., 44, 57, 59, 102, 103, 109 Goelet's bipolar A'aginal electrode, 59 faradic coils, 325 Goodell, William, 53, 202 Grand and Famarque, 161 Granular erosion, 92 Hardaway, W A., 273. Haultain, F. W. X., 172 Hayes, Plym. S., 273 Head-spray, 339 Hematosalpinx, 111 Hemorrhagic metritis, 99 Hemorrhoids, 269 Heredity, 2 Hollow, bulbous electrode, 242 Holtz machine, 335 Hydrosalpinx, 111 Hydrothermal applications, 68 Hyperemesis gravidarum, 227 Hyperplasia of uterus, 100 Hypertrophy of cervix, 188 Illumination of vagina, 20, 353 Impotence, 212 Improved Massey controller, 292 Incandescent current, 290 Indirect stimulation, 46 Inertia uteri, 229 Institutional treatment, 209 Internal resistance, 284 Interpolar region, 37 Interrupted galvanic currents, 51 Interrupter (rheotome), 329 Intra-uterine applications, 59 faradic applications, 66 Isaac's search-light, 354 Jacketed pan for clay pads, 308 Jackson, Chevalier, 357 Jackson's transiUuminating apparatus, 357 Jewell current-controller, 294 Keith, Skene, 129 Keith, Thomas, 129, 161 Kellogg, J. H., 161, 349, 360 Kellogg's electric-light bath, 359 sinusoidal apparatus, 346 Kelly's cystoscope, 262 ureteral searcher, 266 urethral calibrator, 263 urethral dilator, 264 Kelvin, Lord 332 Kennelly sinusoidal apparatus, 350 Knee-chest position, 67 Labor, faradic current in, 228 Laceration of cervix, 100 Law of Ohm, 283 Leclanche cell, 296 Limitations of electricity, 29 Local action, 300 Malignant growths, 231 Mammary tumors, benign, 256 Martin, F. H., 62 392 INDEX. Massage, 70 Massey abdominal puncture needle, 139 cancer electrodes, 241 current-controller, 294, 305 double, bipolar electrode, 254 hemorrhoidal electrode, 270 improved static machine, 334 intra-uterine electrode, 61 method of treating cancer, 239 pelvic transilluminator, 356 spiral intra-uterine electrode, 62 switchboard, 292 for both currents, 310 transportable galvanic battery, 238 vaginal puncture trocar, 136 wired-cotton pads, 309 Maternal impotence, 212 sterility, 212 Mcintosh faradic battery, 323 galvanic battery, 301 sinusoidal apparatus, 349 switchboard, 296 Measurement of tumors, 14 of voltage, 307 Medicamental cataphoresis, 45 Menorrhagia, 83 Menorrhalgia, 74 nervous, 77 ovarian, 82 uterine, 78 Menorrhspasm, 76 Menstrual derangements, 72 Mercuric cataphoresis, 44 Metallic cataphoresis, 43 Meters, milliampere-, 306 Metritis, chronic, 95 hemorrhagic, 99 post-puerperal, 98 senile, 102 Metrorrhagia, 83 Metrosalpingitis, 103 Milliampere, the, 283 Milliamperemeters, 306 Millicoulomb, the, 283 Mitchell, S. Weir, 71, 201 Moles, 275 Morton, William James, 44, 332, 340 Morton's induced current, 340 Nabothian glands, 92 Nervous menorrhalgia, 77 prostration, 204 Neurasthenia, 204 Neuroses of the urethra, 259 of the vuh-a, 259 Nevus pigmentosus, 276 vasculosus, 275 Newman, Robert, 232 Normal formula of motor responses, -16 Nunn, R. J., 228 Obstetrics, 215 Ohm, law of, 283 Ovarian congestion, 119 menorrhalgia, 82 Ovaritis, chronic, 114 Ozone administration, 341 Parsons, J. Inglis-, 233 Pelvic peritonitis, 112 Persistent uterine discharges, 90 Pessaries, 70 Peterson, Frederick, 42 Phillips, W. C, 354, 355 Phillips's head-light, 355 Polar regions, 36 Polarity of faradic current, 328 Polarity test, 312 Pole-changer (commutator) 327 Portable batteries, 2!)7 Port-wine mark, 275 Post-partum hemorrhage, 229 I'ost-puerpeial metritis, 9* Posture in treatment, 67 Predisposing causes, 1 Pressure (electromotive force), 277 Primary coils, 322 faradic current, 323 Prolapse of rectum, 270 of uterus, 1*7 Purulent salpingitis, 106 Pyosalpinx, 107 ijneen self-regulating x-ray tube, 343 Rectal touch, 19 Pectum, adenoids of, 272 fissure of, 269 prolapse of, 270 stricture of, 271 ulcerations of, 272 Relaxation of abdominal walls, 194 of pelvic viscera, 1*3 Resistance, 281 Rest cure, the, 201 Retroflexion, 183, 192 Retroversion, 1*3, 193 Rheotome (current-interrupter), 326 Roentgen rays, 342 Sajous's lamp-holder, 353 Salpingitis, 106 Salt Avater on electrodes, 314 Sarcoma, cataphoric treatment of, 252 Scanty menstruation, 73 Secondary coils, 324 faradic currents, 324 Series arrangement of sells, 295 INDEX. Shaw acid carbon cell, 351 carbon cylinder cell, 297 Shunt circuit, 285 Sims's position, 19 speculum, 20 Sinusoidal current. 346 Skene, A. J. C, 6*, 91, 102, 119 Skin resistance, 316 Slocuin, H. A., 260 Smith, A. Lapthorn, 28, 161 Specific resistance, 282 Spinal applications, ~>r> Stabile (stationary) applications, 5 Static charge, 338 electricity, 332 electrodes, 337 in menstrual affections, 342 ' machine, 333 sparks, 339 spray, 339 Stationary battery, 295 Stenosis, 212 Sterility, 212 Storage battery, 355 Strength of application, 64 Stricture of rectum, 271 of urethra, 258 Subiirvolution, 98, 230 Superfluous hair, 273 Switchboards, 311 Tait, Lawson, 215 Tampons, 69 Test for current, 312 for polaritj', 312 Transformer for alternating currents. Transillumination of pelvis, 356 Transportable battery, 23* Tripier, A., 24, 40, 5*, 1*9, 228 394 IXDEX. Ulceration of rectum, 272 Units of current, 2*3 Unity of uterine and tubal catarrh, 86 Urethra, neuroses of, 259 strictures of, 258 Uterine menorrhalgia, 78 sound, 17 Vaginal applications, 56, 5* douche, 68 puncture, 136 Volt, the, 280 Voltolini, 356 Volume of current, 2*3 Vulva, neuroses of, 259 Waite & Bartlett battery, 304 Warts, 275 Westinghouse current, 229, 290, 352 Weston milliameter, 307 Wheel interrupter, 327 Wimshurst-Holtz machine, 335 Wired-cottou electrode pads, 309 Wylie, W. 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