The Polar Method of Electrotherapy in Gynecology

The Polar Method of Electrotherapy in Gynecology.$1$

Application, Dosage, and Medication.

By George J. Engelmann, M.D.,

Professor of Obstetrics and Diseases of Women at the St. Louis Post-Graduate School of Medicine; Fellow of the American Gynecological Society, British Gynecological Society, London Obstetrical Society, etc.

$1$Read before the St. Louis Medico-Chirurgical Society.

&emsp; In this paper I shall treat of those points which are of more general interest and of practical importance in gynecological practice.

&emsp; The use of electricity is rapidly gaining in favor among gynecologists, and this is due to the galvanometer, mainly, hardly less to the introduction of the polar method—i.e., the direct application to the tissues, and to the use of strong, effective currents—making it possible to apply the current without those long sittings of twenty and thirty minutes, which made it an impossibility for the busy practitioner heretofore. These are the essential features of the gynecological electrotherapy of to·day, in which the electricity which I advocate differs from the medical electricity which has so long remained in a very dubious light before the profession.

&emsp; This questionable medium has at once become a valuable agent; a very perceptible change is taking place in the profession; the very men who, not a year ago, denied the possibility of measurement and dosage, now appear as converts: the admirers of mild currents and half-hour sittings continued for months, are hushed by the undeniable logic of facts, by the astonishing results achieved by effective currents in a few short sittings; in short, medical electricity is now emerging from the primitive condition in which it has too long remained.

&emsp; Whilst commerce and industry have developed the most wonderful properties in this agent, and have utilized it to a marvelous degree, the medical profession has almost ignored it, though known for an entire century, since the time when Galvani, at sunset, on a September evening, one hundred years ago, while endeavoring to suspend the legs of a skinned frog, by a copper hook through the spinal column, to the iron railing of his garden terrace, observed the twitching of the muscles when the copper hook touched the iron railing. This event marks the first progressive step in the history of electricity since the discovery of the remarkable property of amber, 600 years B. C.

&emsp; Fertile brains soon developed the discovery of the Bolognese savant, which found favor especially among the French.

&emsp; The most important advance in the use of galvanism as a medicinal agent is, however, due to the labors of Remak, of Berlin, forty years ago, which we must accept as the basis of our work; upon this we build.

&emsp; Physiologists have developed the science, and neurologists have applied it, but the profession at large has gained but little; indeed, we may say that the teachings of Remak have not been utilized as they should have been. Gynecologists were not successful, because they merely followed the specialists, the neurologists, who had adapted the new remedy to their-own particular purposes, in a very different sphere; isolated, and even wonderful successes were reported, and created a temporary interest, which soon subsided. Even the success of Cutter, of New York, in the destruction of fibroid tumors, seventeen years ago, remarkable as it was, did not arouse emulation. The excellent results of Bruns, of Tubingen, in the treatment of goitre, and of nasal polypi, were noted by only a few and forgotten by them; the brilliant application of the electrolytic properties of galvanism for the destruction of supernumerary hair in the eyelid, made by our friend Dr. Michel, of St. Louis, would have met with a similar fate had it not been made so valuable to dermatologists by our colleague Dr. Hardaway, so that among a limited number of specialists this one property of galvanism was thoroughly appreciated; but to the profession at large the electric current still remained the same mysterious agent, regarded with indifference, with distrust, or with awe, until Apostoli, in 1883, gave us the key to the successful application of electricity for the destruction of fibroid tumors by urging, 1. Localization, the limitation of effect to one active pole, which must be placed within the tissues; and, 2. The use of currents stronger than any hitherto applied in medical practice. Upon these fundamental laws I have based the theory and practice of gynecological electrotherapy.

&emsp; Little can be said of electricity in gynecology; it has had no influence whatsoever upon the development of this rapidly progressing specialty; reference to even the latest and most thorough text-books affords the best proof of this fact.

&emsp; The gynecologist, unacquainted with the varying properties of the electric current, resorted to this remedy only when all other means had failed; in the most difficult and unyielding cases he tried an agent with which he was not familiar; he naturally failed, and as naturally ascribed his failure to the remedy he used.

&emsp; Need we wonder that no attempt was made to apply electricity in gynecological practice, when Sir James Y. Simpson stated that "Electrization of the uterus was all but useless, and that when uterine action had been apparently excited by galvanism it was a mere coincidence, or resulted from an impression made on the mind of the patient, or on the abdominal parietes by the electrode." Very little more advanced in his practice is Powell, a writer on medical electricity twenty years ago, who ridicules Simpson for this statement in his Practice of Medical Electricity, published in Dublin in 1869; though he tells us that the utmost care should be taken in recording cases, etc., he himself gives the following case histories: "Galvanism and faradism were applied for three weeks, and with marked benefit;" or, "he was put under a course of galvanism, and in five weeks the power of the arm began to return."

&emsp; This was a time when, in the famous Guy's Hospital, patients were treated by shocks from Leyden jars passed through the pelvic regions from the sacrum to the pubis, giving the very acme of what we most cautiously avoid in its mildest form--i. e., shock.

&emsp; But we can go down to the very latest literature without an improvement in that vagueness which has killed electricity as a medicinal agent. What is the practice of those who in their writings urge precision in application and measurement? What is the practice of those who preach exactness, and tell us that the want of progress is due to want of precision? By their own case records we see that they themselves commit precisely the same error.

&emsp; We are in a stage of transformation, light is beginning to dawn, the importance of precision in application, dose, and record, is beginning to be appreciated, but not as yet fully understood or practised; so we see one writer telling us that Apostoli applied one and a half and two and a half amperes; another says that whilst he formerly used only twenty-five milliamperes, he now has applied as high as ten amperes$2$ (ten thousand milliampères!); another is recording the strength of faradic currents in milliampères.

&emsp; $2$ Ten amperes is the current used for the large electric lights on our streets; Inside lights in hotels and stores need a current of only six amperes.

&emsp; Ten amperes, through a resistance of sixty ohms, which is as low a resistance as we may expect in a fibroid, means a force of six horse power, this in electro-chemical force or heat would destroy the abdomen in a few momenls. Any unlucky fireman who for a moment touches non-insulaled parts of a wire carrying a ten ampere current is struck dead, and yet one enthusiastic electro-therapeutist claims to have applied a currenl of ten amperes to a living woman! Electric measurement is beginning to be appreciated, but is by no means understood.

&emsp; The state of gynecological electrotherapy is not yet clear; hence, I believe that a practical expose is in place, and conditions are now favorable to progress since gynecologists are beginning to develop the science. Hitherto nothing has been achieved for the reason that the gynecologist has followed the neurologist, and has endeavored to follow the practice of the latter in his specialty; this led to injurious or to negative results, and the agent was condemned either as dangerous or as useless. As electricity for illuminating purposes differs from electricity as a motor, so does the electrotherapy of the neurologist differ from that of the gynecologist, and I look upon the clear understanding of this distinction as absolutely essential to the development of electrotherapy; the want of it has been one of the most effective bars in the way of progress. Success was impossible with the indiscriminate application of electricity in the various branches of medicine; in gynecology we deal with resistances of 200 and 300 ohms, as low as 40, but never above 600 or 800, whilst we use currents up to 250 milliamperes, most commonly between 20 and 80 milliamperes; the neurologist, on the contrary, rarely goes as high as 20 milliamperes, and usually uses from 2 to 5 milliamperes, and the resistance of the tissues between his electrodes is from 5000 to 10,000 ohms and over.

&emsp; An essential to successful gynecological electrotherapy is a smooth current, the most complete avoidance of shock, which is, on the contrary, a valuable feature in the practice of the neurologist; we carefully avoid the effect of opening, closing, and reversing of the current, which is a highly important diagnostic and therapeutic resource in neurology.

&emsp; Successful electrotherapy was impossible as long as electricity was looked upon as an agent applicable here and there in the same way, and it has been my aim to establish and develop gynecological electrotherapy: as in all matters, if we wish to succeed we must ourselves work to our own especial purposes, I have, therefore, confined my work and my wriling to the subject of gynecological electrotherapy and I wish it to be clearly understood that I make no reference to other applications.

&emsp; The conditions are peculiarly favorable for the application of electricity to the female pelvic viscera:

1. The current can be confined to the part under treatment, as all the organs are gathered within the limits of the pelvis.

2. Diseased organs or morbid products can be reached directly by the electrode.

3. The low electrical sensibility of the parts makes the use of very strong currents possible. The skin, an electrically sensitive part, is not necessarily involved, and if so, only at the site of the indifferent or dispersing pole; as this is the abdomen, the current can be dispersed to any desired extent. The active electrode need never be in contact with the skin, and, however strong the current, the active intrapelvic pole need cause no pain.

4. The polar method can, by reason of the situation of the parts, be successfully applied and fully utilized, and by this method only are speedy results possible in gynecological practice.

&emsp; As I have discussed the subject at length in my first paper, on "The Use of Electricity in Gynecology," read before the American Gynecological Association, in September, 1886, I will here only recall the important points; these are:

&emsp; a. Localization of the current. The current must be localized and its effect confined as far as possible to the diseased organ or part.

&emsp; b. Use of one active pole. One pole exclusively, chosen for its peculiar properties, must serve as the active agent for the application of the current, and upon this its entire effect is concentrated; this is termed the active pole.

&emsp; c. Dispersing of the current. The current at the other pole must be neutralized as much as possible, and its effect rendered as little as possible perceptible; to accomplish this it is dispersed upon as large a surface as the configuration of the part will permit; hence, a dispersing electrode is used in connection with the indifferent or neutral pole, called the dispersing plate.

&emsp; d. The active pole should be directly in contact with the organ or part to be acted upon, or even within its tissue.

&emsp; e. The indifferent or dispersing pole should be opposite to the active pole so as to confine the tissue to be affected between their surfaces; it must be as near as possible to the diseased part and upon the largest and least sensitive surface which can be utilized.

&emsp; f. Use of effective currents. Currents of sufficient strength to accomplish the object desired in the shortest possible time, without detriment to the patient, should be used.

&emsp; The intensity of the current used in gynecological practice varies from 1 to 300 milliamperes; of most general use are currents of from 20 to 80 milliamperes.

&emsp; It must be remembered that I am not merely urging the use of currents as strong as possible, but of currents strong enough to be effective. Whilst a current of one or two milliamperes will relieve the pain of a contusion, a current of ten milliamperes will aggravate it. The intensity must be commensurate with the object in view.

&emsp; g. Precision in dose and measure. Knowledge of the force used and exactness in dosing it are a sine qua non to the effective application of electricity. It is as neccessary to know the electro-motor force of the elements and the milliampere intensity of the current used as it is to know the strength of a chemical solution, and the number of grains of the drug which are to be given.

&emsp; h. Use of proper instruments is as necessary to the electrotherapeutist as it is to the surgeon. The battery, by which the force is generated, is useless without proper means of dosing and of applying it, the milliamperemeter; suitable electrodes for the application of the current at the active pole, and for its dispersion at the indifferent pole, are fundamental requirements for a successful electrotherapy.

&emsp; Upon the acquisition of these aids the recent progress of gynecological electrotherapy is based.

&emsp; i. Recognition and proper use of the various qualities of the electric current. The electric current, both galvanic and faradic, is a most subtile agent, which may be made to serve many purposes, and which possesses numerous, greatly varying, and even antagonistic properties, which can be developed at will by the accessory apparatus and the method of application.

&emsp; The following are the most important factors by which the properties of the electrical current are changed, and upon which its varying medicinal effect depends.

&emsp; The therapeutic effects developed by the various properties of the current, so changed, are numerous, and electricity may be applied to serve as a:
 * Sedative.
 * Stimulant.
 * Counter-irritant and vesicant.
 * Muscle contractor.
 * Antispasmodic.
 * Tonic.
 * Promoter of development.
 * Absorbent.
 * Chemical cautery.
 * Coagulator.
 * Electrolytic.
 * Hemostatic.
 * Promoter of hemorrhage.
 * Decongestor.
 * And as a medicator.

&emsp; The greatest concern is generally felt in regard to the point of least possible importancer—that is, the battery itself; the question, What is the best battery? is so often asked that I will again repeat that this is immaterial as regards the effect. The current is the same, whether we use the sulphate of copper telegtaph cell, the zinc and carbon telephone cell, the Leclanche cell, or any of its modifications, or the ordinary medical dip battery. The physician must adapt his battery to his convenience and to his pocket. For stationary and cabinet batteries I deem the sealed Gonda Leclanche or the Diamond the most convenient; both with mUriate of ammonia, zinc, and carbon; the former with the oxide of manganese disk in place of the porous cup, which is liable to clog. This battery works steadily, and requires the addition of distilled water every six months, cleansing and refilling every year. The fluid is simple, non-corroding, and odorless. Portable batteries are now made with similar hermetically sealed cups of smaller size, and these, of course, are far more convenient than the dip batteries, which have so long ruled; of these, the Stohrer battery was the type. It seems, indeed, strange that in this progressive inventive country, from which all electric progress comes, these filthy, corrodable batteries should so long have remained the universal favorite. The hermetically sealed open circuit battery, with dry cups, or, at least, with harmless, odorless fluid, is the battery of the future for cabinet and portable purposes.

&emsp; The important instrument is the milliamperemeter, graded for general purposes from 1 to 100, for special work from I to 250 or 300. No work can be done without this, and it must always be in the circuit to be really useful.

&emsp; The current selector I need not mention, as no battery is without one, and it is all-important that we have this means of gradual increase of the current, element by element, which I deem of more general utility, more simple, and almost as gentle as the water rheostat.

&emsp; The wire rheostat to measure resistance, the interruptor, the metronome to break the current, the rheotome to change the current, the water rheostat to interpose resistance, or increase or decrease the current without even the slight jar occasioned by the insertion of single elements, are not necessary for ordinary work; but these, like the coulombmeter to measure the quantity of electricity, the voltmeter to measure the electromotive force of the elements, and the amperemeter to measure their ampere capacity, are all demanded for progressive scientific investigation.

&emsp; The electrode, the most simple of all the accessories, and on account of its very simplicity the most neglected, is as important as the battery itself. I blame that despicable sponge electrode in part for the neglect into which electrotherapeutics have fallen in this country; every battery was supplied with two of these abominations, and as the practitioner soon found that he could not accomplish much with them; he thought electricity useless and put aside his battery.

&emsp; The sponge electrode is a filthy, current-absorbing instrument, which must be cast aside. If a small electrode is wanted, the metal plate can be used, covered with absorbent cotton soaked in warm water; this offers no appreciable resistance and is renewed without any trouble for each patient; in fact, time and trouble are saved, as it takes more time to soak thoroughly the sponge electrode than it does to cover the disk with absorbent cotton and apply this instrument, which is saturated by momentary immersion.

&emsp; I propose to speak more fully of the dispersing electrode, as it is this which is so important, partially so from the fact that on account of its very simplicity it has been neglected. Electrodes for various purposes, for use in connection with what I call the active pole, have been devised in numerous forms to suit the locality in which they were to be used, throat, ear, uterus, or bladder, but where any but the mildest currents are to be applied these are ineffective unless the current at the indifferent pole is sufficiently dispersed; only by rendering the neutral pole painless, by dispersing the current at this pole sufficiently to render it indifferent, can the other active pole be effectively used.

&emsp; For this purpose then we must have an electrode of large surfade and of good conducting material, so that the resistance it offers is reduced to a minimum. The stronger the current, the more intense the effect derived from the active pole, the larger must be the surface for its dispersion at the indifferent pole, and the larger must be this surface that I he peculiar effects of this pole may be neutralized and that cauterization may be avoided.

&emsp; The effect of the active pole is in no way reduced thereby, as the density of the current is not appreciably diminished in applications by the polar method, whether the dispersing electrode is large or small.

&emsp; The larger this is, the better; its size is limited by the surface to which it is applied, and for gynecological purposes three sizes are desirable.

&emsp; No. 3 is used with mild currents, and preferable when possible, as it is easily placed without disturbing the clothing, even under the corset; this should, as a rule, not be used with currents of over 15 or 20 milliampères.

&emsp; Attached to a long, insulated handle, it makes a good spinal electrode, better for this purpose is one 3 inches by 5 inches, with the same surface (15 square inches).

&emsp; No.2 is still readily manipulated, though not so easily shifted from side to side and must be used with currents from 20 to 60 milliampères.

&emsp; No. 1 is necessary for intensities above 60 milliampères, if the current is to be applied without giving pain; to place this the clothing must be loosened.

&emsp; These three sizes will generally suffice, although I have used No. 0,8 inches by 10 inches with a surface of 80 square inches, for the application of very high intensities in electrolysis, and No. 5 for cutaneous faradization, round, 2 inches in diameter, like the old sponge electrode.

&emsp; I would urge these dimensions for general adoption, in order that that uniformity which is so desirable to an understanding may be attained.

&emsp; The electrode consists of a pliable sheet of lead perforated with holes one line in diameter, one inch apart, and is covered with a layer of punk or absorbent cotton, which is held in place by a thin buckskin or kid. These electrodes conduct as well, and are in every way as serviceable as the clay electrodes of Apostoli. The cover is immaterial, if a good conductor and absorbent, but it is important that the plate be of very pliable metal, so as to adapt itself to the undulations of the surface upon which it may be placed.

&emsp; The electrode must be soaked in hot water, the superabundance of which is expressed before it is placed. The water is to be as hot as it is comfortably borne by the patient; cold water must be avoided, as it lessens the conducting power of the electrode, offers greater resistance than hot water because it does not saturate the epidermis so rapidly, and because it is not only uncomfortable, but might even endanger a patient suffering from a chronic inflammatory trouble, for which we so often make these applications. Salt must be avoided; it is not necessary, as it was for the poorly conducting sponge electrode, the instrument which I suggest being a much better conductor, and salt is injurious to instrument and patient. When used upon electrodes by which currents of high intensity are applied, the electrolytic action of the galvanic current decomposes the salt, and chlorine is developed at the positive pole, by which the amount of pain may be increased and the electrode is corroded. Upon a mucous surface the effect of the chlorine generated at the positive pole from a salt water electrode is very perceptible.

&emsp; The shape of the electrodes used with the active pole varies greatly with the object for which it is applied, and any number have been devised; important for the gynecologist and serviceable in the majority of cases are the following four:

&emsp; 1. A fine, pliable uterine probe, insulated up to within three inches of its end by a glass tube which can be removed (glass or hard rubber being preferable as they can be washed in acids and rendered thoroughly aseptic).

&emsp; 2. A heavy, but pliable uterine sound, equally insulated.

&emsp; 3. A needle or stylet for puncture, to be used within the tissues, with movable insulator.

&emsp; 4. A metal ball or oval-shaped electrode with six-inch insulated stem, for vaginal applications.

&emsp; These electrodes must be so arranged that firm connection, best by a screw, can be made with the rheophore; and one of the intrauterine electrodes must be of non-corrodable metal, best of platinum, for use in connection with the positive pole; as oxygen and acids are set free at this pole, an electrode of corrodable metal is soon affected and is not only rendered useless, but is imbedded in the tissues and hard to withdraw.

&emsp; It will be found convenient to have a stylet and sound in one and the same instrument, of platinum, one end straight and pointed, the other curved and blunt, which. can be inserted with either end in the handle, to be used as a sound or stylet.

&emsp; For proper dosage the following elements are required in

Other measures by which all details of the application are recorded with precision for scientific research, though not necessary for simple treatment, are the following:

&emsp; The galvanic current, thanks to its commercial value, can now be measured and dosed with the utmost precision, and all its practically important characteristics can be more accurately recorded than those of any other medicinal agent. For all practical purposes—I am speaking only of the application of galvanism by the polar method, in gynecological practice—we need only know the intensity of the current in milliampères, the time of application, and the site, nature, and size of the electrodes.

&emsp; The resistance of the tissues in ohms is not practically necessary, as in gynecological practice we know that the resistance varies between 60 and 800, usually between 200 and 300 ohms, and this is more closely indicated by the location of the poles, as the physician who applies electricity judiciously and scientifically should know about what the resistance of certain parts generally is.

&emsp; The density of the current, however important in other methods or in other localities, varies but little in gynecological treatment by the polar method, as it is practically the same in all but the intrapolar applications, as, for instance, to the ovaries. The active pole being always small, either stylet or ball, the effect sought in its immediate vicinity differs but little whether the current is dispersed upon a large or small plate. Still. I have named the location and size of the dispersing electrode among the elements necessary for dosage and record; by means of this the density can be calculated, though I have included it, not for this purpose as much as for the convenience of the physician to facilitate repetition.

&emsp; The practically important elements for record and dosage of faradic currents are the electro-motive force of the generating element, With the distance between the coils, the character of the secondary coil, and the number of interruptions per minute; but this will only be possible with perfect standard instruments, which are not yet made in this country, so that this is as yet impossible, and the utility of this form of electricity is very limited, on account of the imperfect apparatus in the hands of the profession.

&emsp; The determination of the milliampère intensity of a faradic battery is more than useless, it is deceptive, as the ampère intensity carries no conception of the true force of this kind of electricity, which is produced by induction, and by frequent making and breaking of the current.

&emsp; If passed through a coil of long wire the milliampère intensity is greatly reduced, and yet the effect of the current is increased. I mention this only to prevent entanglement by the erroneous ideas advanced by some.

&emsp; The milliampèremeter. &emsp; Upon the use of this instrument, absolutely essential to successful practice, the present advance in gynecological electrotherapy is based. The instrument may be either horizontal (tangent) or perpendicular, and for gynecological purposes should indicate from 1 to 250 milliampères. Whilst the neurologist may need one with more exact reading from 1 to 10, enabling him even to distinguish one-half or one-quarter of a milliampère, the gynecologist must have wider scope, and, as a rule exactness to a single milliampère is not essential; the intensity usually employed is from 10 or 20 to 60 or 80 milliampères; in rectal, urethral, and vesical applications, the want of an instrument plainly showing fractions of a milliampère is sometimes felt, as two or three milliamperes only are used, but in genteral use this is unnecessary.