SURGERY versus ELECTRICITY IN THE MANAGEMENT OF SALPINGITIS AND AL- LIED CONDITIONS. BY ANNA M. FULLERTON, M.D., physician in charge, woman’s hospital, phila delphiA. FROM THE Medical and Surgical Reporter, August 16, 1890. [From the Medical and Surgical Reporter, August 16, 1890.] SURGERY VERSUS ELECTRICITY IN THE MANAGEMENT OF SALPIN- GITIS AND ALLIED CON- DITIONS. BY ANNA M. FULLERTON, M. D., PHYSICIAN IN CHARGE, WOMAN’S HOSPITAL, PHILA- DELPHIA. There is no better vantage-ground for the study of disease and the methods for its man- agement than that afforded by hospital prac- tice. Here, if anywhere, opportunities for careful diagnosis are obtained ; varied plans of treatment may be followed, and their sci- entific value may be established. The very large gynecological practice con- nected with the Woman’s Hospital in Phila- delphia affords especial facilities for the study and treatment of the class of cases referred to in this article. Hence, it is from a stand- point gained after several years of close ob- servation that I desire to show my reasons for considering the electrical treatment of salpingitis and allied conditions as unscien- tific and productive of results far more dan- gerous than those of the knife. The conservative tendencies of old-time workers connected with the hospital, and above all, perhaps, the difficulties formerly thrown in the way of the mastery of surgical 4 methods by women, led to the almost sole employment in the Woman’s Hospital for many years of what are known as conserva- tive methods of treatment—douches, poul- tices, fomentations, blisters, electricity, etc., in preference to the more radical procedures of surgery—excepting in cases requiring minor operations. The extravagant claims of Apostoli, acting as an ignis fatuus, drew several of our students to his clinics in Paris, whence they returned filled with his enthusi- asm, only to lapse, after a few months’ per- sonal trial of his methods, into an inexplic- able silence concerning them. The gener- ous excuses sometimes offered as to the prob- able reason for their failure in attaining his claimed results could not satisfy the inner consciousness of either speaker or hearer. In the light of the nineteenth century, the attempt to treat a diseased condition of doubtful nature, location and origin by un- certain means, which may or may not meet existing needs, savors too strongly of em- piricism. The Mohammedan woman, dy- ing in a harem, where the customs of her people have shut her away from all medical aid save such as her hand or tongue, thrust through a slit in the curtain of her bed, might indicate, is no more blindly treated than are many of the women in our own land with whom obscure conditions of dis- ease may be found buried beneath the tissues enclosed by the pelvic walls. It must be conceded by all, in this day, that scientific methods in the management of disease require, i, certainty of diagnosis; 2, a careful study and thorough understand- ing of the means best adapted for the cure 5 of existing conditions ; 3, the proper appli- cation of such means. By what occult power can the electrician determine the exact character of the condi- tion that exists in any given case, or the propriety of directing his current upon it ? Although he states that “if it is true that we cannot diagnosticate disease with accu- racy, we should, in justice to the patient, adopt a line of treatment suited to all the conditions that cannot be excluded ”—mak- ing, as it were, a universal remedy of elec- tricity. He tells us again, “ To accomplish this result requires some circumspection, as it is well known that intra-uterine applica- tions are apt to relight the slumbering fires of even sub-acute conditions.” Here he acknowledges the dangerous character of the remedy he uses, and, were he frankly to disclose the secrets of his clinical practice, would they not reveal what may be shown by the records of any elec- trical clinic; viz., that, even when used with circumspection — all known precautions against inflammatory complication being employed—the physician has frequently to be sent for to find the patient suffering from a traumatic peritonitis or allied affection induced by the electric current ? If such results occur in the hands of those long con- versant with the use of electricity, is it not criminal to place suggestions for its indis- criminate use before the minds of the pro- fession generally ? Recent surgery in the hands of a few bold and skillful operators has done much for methods of diagnosis in pelvic troubles by proving the harmless nature of the explor- 6 atory incision in hands properly trained to the work. The use of the knife for diag- nostic purposes should not be decried any more than that of the probe, if employed understandingly. Exploratory incision does not necessarily imply extirpation. The indiscrimate removal of unoffending organs is as reprehensible as the indiscriminate use of electricity. The existence of abscesses in the connec- tive tissue of the pelvis which Dr. Massey regards as primary and which he concedes “necessitate surgical intervention,” have come to be regarded by surgeons of experi- ence as largely secondary to intra-tubal or ovarian disease. It is the knife used for ex- ploratory purposes which has proved this. As a matter of clinical experience varia- tions of temperature are of little value in the differential diagnosis of these conditions. When the surgeon finds an inflamed dis- tended Fallopian tube, the fimbriated ex- tremity of which is firmly glued to the ovary, af trace of fimbriae gone, the two organs so firmly bound together that any effort to separate them must destroy the integrity of one or both; when, further, he finds the tube constricted at interspaces throughout its extent, the dilated portions constituting separate pockets for pus, the attached ampulla pouring pus into a cavity or cavities in the ovary, he sees the utter futility of any power other than the knife for remedying the deplorable condition which exists. Is it wise, therefore, to subject patients to loss of time and money while one uses ex- perimental means for overcoming a condi- tion which is an unknown quantity ? Is it 7 not because such methods have been largely employed, and surgery left as a last resort, that abdominal section has in the past been regarded as attended with “ dangers and uncertainties ”? May not the same objection be brought against any procedure ; as, for instance, Caesarian section—when left until the vital forces are unequal to the strain or when other procedures have produced complications which make surgery more dangerous ? Witness the change in the attitude of the professional mind towards the graver obstetrical operations since the early recognition of existing needs and prompt and early action have attained their recent brilliant results ! Will not even Dr. Morris Longstreth con- cede that many women, reported to have died of typhoid fever, peritonitis, inflamma- tion of the bowels, septicemia—puerperal or other—may have been the victims of some obscure, suppurative pelvic disease ? The fact that pelvic diseases among women are terribly prevalent well warrants the French saying: “La femme est une malade /” as also Tait’s recent utterance: “ For the greater part of my life I have been engaged in the study of, and practice amongst, the special diseases of women, and no conclusion is more firmly rooted in my mind than a devout thankfulness that I be- long to the other sex !” This suffering ex- istence which seems to be the lot of the great majority of women, should be a mat- ter of serious thought and profound study on the part of the medical profession. Pre- ventive measures should be as carefully in- vestigated as curative. It does not do for 8 us, however, to pretend, in the meantime, that we do not see that many of the lesions which exist are hopeless as to cure and re- quire radical measures for relief. The sen- timental theories concerning “ the limbo of a neutral sex” can only have any weight with those not called upon to suffer. Even these objections are reduced to a minimum in view of the experience of the most noted gynecologists who find that no mental or moral changes result from the ablation of the uterine appendages. Although it is de- sirable to possess the sum total of our or- gans in their perfection, I hold that it may be wisely said to any human being regarding the physical as the spiritual frame, “ If thy right eye offend thee, pluck it out and cast it from thee; for it is profitable for thee that one of thy members should perish, and not that thy whole body should be cast into hell!” Who can conceive an existence more awful than that of a hopeless, painful, linger- ing invalidism, even when supported by the consciousness of sex ? Perhaps in the devel- opment of our higher natures even the medi- cal profession may come to look upon inter- ests which affect the physical nature alone as of minor importance. To illustrate the points I desire to estab- lish, I will give a brief resume of nine con- secutive cases of abdominal section per- formed within the past week in which, dur- ing the absence of my colleagues, I was kindly aided by Dr. Joseph Price. These were not picked cases, but simply such as happened to be in the hospital at the time. Case i. Ovarian cystoma. An English 9 woman : 60 years old; single; brought to the Hospital suffering from peritonitis. She had a resistant tumor, apparently uterine, extending two fingers’ breadth above the umbilicus and entirely filling the pelvis. Her suffering from pressure symptoms was extreme; the left leg being swelled to twice its normal size. The patient was un- able to pass urine except when standing. The tumor had been diagnosticated as fibroid and electricity had been advised. The urgency of the symptoms and the pa- tient’s expressed wish led to operative pro- cedure after two weeks’ antiphlogistic treat- ment. Extensive omental and intestinal adhesions were found. The tumor proved to be a multilocular papillomatous cyst of the right ovary. Its lower portion had bur- . rowed downwards into the pelvic fascia from which it had to be pulled out. The removal was difficult. How much would have been achieved if electricity had been used in this case ? Case 2. Ovarian cystoma. A colored girl 17 years old, entered the Hospital with a history of irregular chills and fever accom- panied by diarrhoea which had lasted some weeks. A fluctuating tumor was found reaching to the umbilicus. The pelvic or- gans were so drawn up that the relation of the tumor to them could not be determined. Cyst of the kidney could not be excluded. On operation, extensive and dense adhesions were found. A cyst of the right ovary was first removed, which evacuated nearly a quart of chocolate-colored fluid. The cyst of the left ovary, about the size of a large orange, was filled with fetid pus. It was 10 adherent posteriorly to the descending colon, which was almost gangrenous at that point. This patient had been under the care of two different electricians at different times. The particulars as to their treatment could not be obtained. Case 3. Chronic salpingitis with adhesions ; one very large cystic ovary; the other scler- osed. Patient, 40 years old, married for eight years; had had one child, seven years old ; had a history of constant ovarian pain with scanty menstruation. A course of elec- tricity, negative galvanism, applied per vaginam had been tried for two months, three times weekly, without benefit. Case 4. One pus tube. In this case there was chronic salpingitis, and the fimbriated extremities of both tubes were occluded and adherent to the ovaries. Numerous perito- neal cysts studded the tubes. Adhesions were numerous, and removal was difficult. The patient was 28 years old ; married ; had had three children, and had been a constant sufferer with pelvic pain for eight years, fol- lowing an attack of puerperal fever. Case 5. Double pyosalpinx and abscess of ovaries. The patient was 18 years old; married two years. She had had one child ten months before admission to the Hospital, since which time she had been ailing. Five weeks before admission she was seized sud- denly one night with intense abdominal pain, followed by an attack of inflammation of the bowels, with chills and fever. Thus she was brought to us. On removal both tubes were found immensely distended with pus; 11 the ampulla firmly adherent to the ovaries, which were riddled with abscesses. Case 6. Double ovarian cysts. They were the size of a hen’s egg ; the tubes were enlarged and occluded, and the fimbriated extremities were closed. The patient was 24 years old; married two years; has had one miscarriage. She has a history of profuse and painful menstruation, and was admitted into the Hospital with peritoni- tis. Case 7. Hematosalpinx of right side, hy- drosalpinx of left. This patient’s ovaries were much enlarged. She was 29 years old; married eight years; had had two children and one miscarriage. She entered the Hospital for severe paroxysmal pains with flooding. She gave a history of one missed period. Electricity had been advised, also a dilatation with curetting of the uterine cavity. Case 8. Tubercular salpingitis and ovari- tis. This patient had pus in her tubes, com- plete occlusion of the fimbriated extremities, and a general tubercular condition of the peritoneum. There was accumulation of a large quantity of peritoneal fluid in her abdomen. She was 14 years old, and had a history of suppressed menses with ab- dominal enlargement. She had extensive adhesions. Case 9. General pelvic exudation, bur- rowing pus-sinuses opening into vagina, and through right iliac fossa. Vesico-vaginal fistula. The patient was 2 7 years old; married two years. Two months before admission to the Hospital, she had had a difficult labor, terminated by forceps. At 12 the time of her admission her temperature was 104°, and she had irregular chills. Shortly after she had discharge of pus from the vagina, and pointing of pus in the right iliac region. Abdominal incision showed the pelvic organs to be immovably fixed to the pelvis. The anterior face of the uterus was adherent to the abdominal wall. The exploring finger, carried to the right side of the uterus 1 found a sloughing mass the size of a walnut, which was removed. • The pel- vis was filled with pus, and the adhesions were too dense for further procedure. The abdominal and pelvic cavities were thor- oughly washed out and drained. The above cases illustrate the varied na ture of pelvic inflammation. In how many of them would electricity have been of any benefit ? 1 Our microscopist has not yet reported the charac- ter of the tissue composing this mass.