The important question to be answered in the above case is as to what share, if any, the application of electricity had in causing the secondary hemorrhage. We believe that the electric current can hardly be held at all accountable, seeing that it had not been used for eighteen hours prior to the occurrence of the secondary hemorrhage, and this i3 the opinion expressed by Janvrin in regard to the ease. There is, however, a clear moral to be drawn from the report, and this is that stated by Janvrin: " In cases whore a moderate hemorrhage has been positively diagnosed (whether from a rupture of a superficial artery or a venous plexus, or from a partial rupture of the sac itself), and this rupture has occurred prior to the termination of the fourth month of gestation, it is undoubt edly better surgery to perform laparotomy at mice, and thus remove all possible danger of further hemoirhage, than to trust to electricity in any form." These instances, indeed, may be taken as per se contra-indica tions to resort to electricity, and we question if there are any other valid reasons why the agent. should not be used.
Abundant testimony in favor of electricity in the treatment of ectopic gestation might be here inserted, but it is unnecessary to do so since American obstetricians will nearly as a unit support the following proposi tion: Prior to the fourth month of gestation, in the absence of symptoms pointing to rupture, electricity is the agent par excellence in treatment, being safe, effective, and neither at the time of application nor afterwards subjecting the woman to special risk. When laparotomy has become so safe a procedure that all women subjected to it recover, then it will be time enough to follow the course advocated among others by Tait and Martin and remove the cyst as soon as it is discovered.
The use of electricity in ectopic gestation being considered as amply justified by its fruits, it remains to speak of the preferable current and of its manner of application. Either faradism or galvanism may be used to kill the fcetus. The former is decidedly more convenient seeing that the apparatus is more portable, but it has the disadvantage of not being so pleasant to the patient in that it shocks her. It has been used suc cessfully by Allen, Garrigues, Lusk, Reeve, Landis, and others. The interrupted galvanic current has been resorted to by Munde, B. Emmet, McBurney, and others, but in Mund6's case it is questionable if the rapid interruptions were not responsible for the deep shock into which the woman was thrown for a number of hours. Rockwell, however, favors this current, and in all his cases he has used it in the strength of from ten to twenty milliamperes. He believes that " there may be an advantage in its rapid increase by means of a rheostat. In this way the chemical and the physiological effects are greatly increased, without the disagree able effects and even the danger that might accompany an interruption of the same strength of current. The danger to be apprehended from an injudicious application of the faradic or the interrupted galvanic cur rent is the possibility of rupturing the over-distended tube."' This pos sibility, although such has never as yet resulted, should ever be oorne in mind, and therefore we question if it be not wiser to use the continuous current alone, aiming at the desired result rather through electrolysis than through actual shock or this combined with the electrolytic action. Rockwell further claims that galvanism is preferable to faradism since it is more certain in action and more penetrating, and also since it has greater influence on the process of absorption. No one, however, should be deterred from resorting to faradism in the absence of a galvanic battery, and it should be stated that in at least six cases a one-celled faradic machine was sufficient to destroy the foetus.' An important question to be still answered is as to whether electri city should be resorted to in octopi° gestation when this has advanced beyond the fourth month. Hitherto this has been about the limit of its application, and Thomas considers that at this period laparotomy, or, if the tumor be low in the pelvis, elytrotomy, is preferable to electricity, which after the fourth month leaves a fetus of considerable size to under go absorption. It may be fairly assumed that the foetus can be killed by electricity as well after as before the fourth month of gestation, and it will probably be uniformly granted that in cases of ectopic gestation we are fully justified in taking no account of the life of this foetus, seeing that it is growing'outside of its normal place to the imminent risk of the mother. The point to be settled then is as to the relative risk of lapar otomy and from leaving such a large body as the foetus is after the fourth mouth to be absorbed within the mother's abdomen. Garrigues answers
this question as follows: " In order to form an idea if it would be advis able to attempt the destruction by electricity in the middle and last part of extra-uterine pregnancy, we must consider the chances for mother and child if we let pregnancy go on unchecked. The cyst may burst at any time, and, although not absolutely fatal, this accident jeopardizes in the highest degree both lives concerned. Laparotomy may be undertaken at the end of thirty-two weeks, when the child is viable, as recommended in abdominal pregnancy by Gusserow, or in the tenth lunar month as preferred by Litzmann. But how miserable the prospects of success by these operations are appears from the excellent article of the latter, in which he has collected ten operations performed while the foetus was liv ing. Of these ten only a single mother (Jessop's case) recovered, and only four of the children survived, if, by a surviving child, we understand one who lives more than a few hours or days. To Litzmann's list may be added a case of Lawson Tait's and one of Neftel's of Stockholm, both ending in the loss of the mother and the recovery of the child. Thus it would seem that there is a small chance for the child and hardly any for the mother to be saved by the operation at or near term. On the other hand, Litzmann has collected thirty-three cases of laparotomy after the death of the child, of which seventeen, or more than one-half, recovered. Would it not, therefore, be not only justifiable, but wise and humane, if possible to kill the fcetus by electricity, whatever its degree of develop ment may be ? We know that there is a fair chance that it will be en tirely absorbed, except the bones, or become mummified. Among many other cases I shall only quote two recently observed by Matthews Duncan in which the festal heart was audible. The fcetus died before it had reached the term of viability, and both patients were well at last accounts. But even if the worst should come to the worst, and the fatal sac sup purate, causing septicemia, there would still be a fair chance of recovery by laparotomy, and at all events, an infinitely better chance than by laparotomy performed during the lifetime of the fcetus. The chances will even be better than in those cases in which suppuration sets in after end of gestation, for the smaller the fcetus and its envelopes the less trouble is to be anticipated." ' Although, so far, Garrigues stands practically alone in his advocacy of electricity at a later stage of gestation than the fourth month, it must be granted that the argument, as he puts it, is a very forcible one. The risk to the mother unquestionably increases as the foetus approaches term, and should the sac not rupture at this time when the attempt at labor is made, the likelihood of absorption of the fcetus with safety to the mother is probably less than when the fcetus had not attained its full stage of development. The answer to this question, however, must be left to the future. Expectation after the fourth month has certainly not yielded results at all to be proud of, and seeing that the ectopic foetus may strictly be looked upon as an ill-omened parasite, the conclusion may become general that it is proper to kill it at any stage of its development when by so doing the risk to the mother is at all lessened.
As for the manner of applying electricity to the sac, this should always be looked upon as an operation which may be followed by shock, and therefore it should be instituted only at the patient's house, or in a hos pital where rest in bed is practicable. It is customary to apply the negative pole against the cyst either per rectum or per vaginani, accord ing as it is better accessible by one or another of these channels. The ball or olivary electrode will answer very well for the internal pole, while the external, positive, electrode should be placed .on the abdomen as nearly as possible over the cyst. While the foetus may be killed at the first si.ance, it is advisable to pass the current daily until diminution in the size of the cyst and cessation of the signs of pregnancy vouch for the fact that the desired aim has been attained, and further when the gal vanic current is the one employed, absorption is unquestionably favored by repeated recourse to it.
A possible result from the use of electricity, to which reference should be made, is the conversion of an ectopic (interstitial) gestation into a uterine.' This is hardly likely to occur, however, in variety of ectopic gestation.