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MEDICAL SOCIETIES

MEDICAL SOCIETY OF LONDON.

AT a meeting of this Society held on Jan. 26th,Dr. R. A. YouNG presided, and a discussion on the

Medical4 and Surgical Uses of Diathermywas opened by Dr. E. P. CUMBERBATCH whose remarksare given in full in the front part of this issue.Mr. W. SAMPSON HANDLEY said that surgeons in

this country owed a debt of gratitude to Dr. Cumber-batch for his persistent advocacy of a method whichhad proved so useful, especially in cancer surgery.Diathermy sterilised the tissues from bacteria to aconsiderable depth, and this was of importance inoperations on cancer of the cervix and rectum wheresecondary infection around the growth prejudicedthe ultimate results. Over large fields of surgery thediathermy needle was, in his experience, superiorto the knife, and he believed that in a few years alarge proportion of surgical operations would be doneby diathermy. He had used both the cutting currentand the needle alone ; those who had not previously iseen the method would be astonished at the way inwhich the tissues faded away before the approach of theneedle without pressure from the hand of the operator.

It was, he said, about ten years ago that he beganto use diathermy in surgery, at first for inoperablecases of breast cancer with an ulcerated and septicsurface ; he had employed the needle with the viewof clearing up an unpleasant mess, and had beensurprised at the way in which wounds healed, whoseedges could not be brought together. In a few daysthe raw area was red with healthy-looking granula-tions ; healing was rapid and painless. Thus he cameto use the method for ordinary operable cases ofbreast cancer, handling the needle just as he hadhandled the knife, but not in the axilla for fear ofpuncturing large vessels. Since 1927 he had been

using diathermy practically exclusively for operatingon breast cancer. Provided the machine was

efficient-a very important consideration-primaryunion was obtained, and the wound could be suturedas completely as after a cutting operation. Themethod was slightly quicker than the knife. The isurface left should be uncharred, and for this reasonit was best to cut the skin with the ordinary knife.The diathermy knife killed all the carcinoma cells

lying in the plane traversed by the needle, and inthat way the risk of implanting cancer cells in freshareas was obviated. I

An important gain in breast surgery was in prevent-ing chill. In removing a breast by the knife one Idifficulty was to keep the flaps warm, constant

relays of hot swabs being necessary to prevent thechilling which would lead to ulceration and perhapssloughing. With diathermy the heat sufficed toeliminate any such anxiety. Bleeding, too, was muchlessened, and fewer vessels had to be tied. It was,however, better to tie a vessel than to apply a

terminal persistently to the bleeding point ; if

applied to vessels near the pleura, pleurisy mightresult. Following the diathermy method there wasa remarkable absence of shock, an observation whichhe commended to the attention of the physiologist.He was convinced that the stimulus of dividing anerve was less after diathermy than after the knife;this might account for the comparative freedom fromshock.

Surgical diathermy had certain drawbacks of its

own. Ether could not be used with the method,though that was immaterial, as other anaestheticswere available. At the end of seven days the skinedges might become red, as if they were passingthrough a phase of lowered resistance to the patient’sown staphylococci. This could be counteracted byspraying daily with antistaphylococcus virus. Themost serious danger was of over-heating a long thinflap which had been raised up by the needle, as thismight thrombose the nourishing vessels ; care mustbe exercised in the strength of current used. Duringthe past three years he had been endeavouring toextend the scope of diathermy to operations withinthe abdomen. For gastrectomy it possessed manytechnical advantages; shock was to a large extenteliminated, and there was an absence of the usualrapid pulse and collapse. He used diathermy fordividing the stomach, duodenum, and omentum,after applying clamps in the usual way. He showeda stomach removed in this way five days previously,free of any charring at the edges ; the chart indicateda return to the pre-operation pulse-rate within fivedays. No transfusion was necessary; the patient justhad free supplies of saline. The diathermy needlemust not, he said, be allowed to touch the bowel,as perforation would then ensue, either immediately orin a few days. He used a strand cut from the omentumto strengthen the line of suture in the stomach.

DISCUSSION.

Dr. F. D. HOWITT said there were three mainfields for diathermy. The first was the surgical, inwhich the current was concentrated at the activeelectrode in order to produce destruction at that

point. Secondly, medical diathermy, used when theproduction of heat was required internally, theelectrodes being placed accordingly. Thirdly, its

employment when sufficient heat was required to begenerated to sterilise tissues in cases of bacterialinvasion, without causing destruction of the tissuesthemselves. It had long been a matter of debateas to whether diathermy had any effect other thanthat of producing heat. Dr. Cumberbatch andothers considered that the raising of temperaturewas the only effect, while such authorities as Nagel-schmidt believed there was in addition a definiteelectrical effect. The speaker had tried to settlethe point by putting bacteria in capsules and applyingthe diathermy current, when it was found that thebacteria died at the same temperature as they did inan incubator. He had been pleased with the resultsof diathermy in cervical erosion and surgical sepsis.It was valuable for anal fistula and spasm, also forthe inflammation which sometimes ensued afterremoval of haemorrhoids. Anal spasm caused anaemiaof the tissues, and this prevented the mucous mem-brane from healing. After a special electrode hadbeen kept in the anus a few minutes the anus relaxed,and progressively larger electrodes could be inserted.Fissure of the anus could also be treated in the sameway. Another condition amenable to diathermy wascyclitis. Ophthalmologists told him that the mainindication in this condition was the application ofheat. When heat was applied by the ordinary meansof conduction and radiation to a vascular organ likethe eye it was quickly carried away by the superficialcirculation. The eye was of an awkward shape forthe placing of a pad, but by using an electrode witha metal base, shaped like an ordinary eye-cup andfilled with normal saline, diathermy could be applied

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so that the concentrated heat reached the interiorof the orbit. Mr. 0. G. Morgan had treated thus atGuy’s Hospital 14 cases of cyclitis, three of whichwere acute, and some of them followed cataractextraction ; nearly all did well in spite of age.The treatment resulted in a diminution of ciliarycongestion and of pain in and around the eye, and indisappearance of keratitis punctata. Usually 10 to12 sittings were necessary.Mr. C. HAMBLEN THOMAS spoke of the application

of diathermy to ear diseases; in older conditionsthe relief was only temporary, as judged by thehearing. For tonsils he thought it would be difficultto sterilise a deep-seated infection at the base nearthe capsule. When removed a tonsil was oftenfound to have a small abscess at its base.

Mr. W. IBBOTSON spoke of a case in which heremoved, by diathermy, a carcinoma of the pharynx ;the rapid healing afterwards surprised him.

Mr. MORTIMER WOOLF said that for two years hehad used diathermy in all operations for carcinomaof the breast ; shock was less, operation was quicker;it was miraculous how the tissues disappeared on theapproach of the needle. Recently he had been

dividing the skin with a very fine diathermy needle,using a rather stronger current. If done at the rightspeed it was easy to obviate charring on the one hand, Ior scratching on the other. He now used the knife

only in the region of the axillary vein, for fear ofproducing a clot which might extend into the main Ivein. I

Mr. PHILip TURNER referred to two cases whichhe had treated by diathermy 17 and 18 years previouslyand were now well and showing no signs of disease.One was that of a woman who had malignant ulcera-tion of the lip and nose, whom he showed to the

Clinical Section of the Royal Society of Medicine atthe time. The other was a patient with advancedtuberculous glands and broken-down sinuses, thecondition persisting year after year, and there wereseveral calcareous masses in the neck. These end-results were interesting in the light of the much

greater use of diathermy at the present day for variousconditions.

REPLY.

Dr. CumsERS zcvi, after saying he thought Mr.Handley must have been the first in this country touse the cutting current in abdominal surgery, raisedthe question of nomenclature. The term diathermyknife had been used, but it was, he thought, con-fusing because one could use a scalpel as an activeelectrode, first coagulating the tissue around it, and

then cutting through it; that was the diathermyknife, but the reference was to a needle and thecutting current. The term " cutting current" wassuitably applied to the current itself. For the elec-trode which divides the tissue the term " acusector "

had been suggested by Howard Kelly, while Wyeth,the protagonist of cutting current surgery in theUnited States, preferred the term " endothermyknife." A special machine had been constructed inAmerica under the direction of Harvey Cushing andBovie for producing various kinds of cutting current.Whereas the same current would cut all kinds oftissue, such as skin, fat, muscle, &c., it must bemodified for each tissue if healing by primary unionwas to occur. The English machines did not, hethought, give precisely the same kind of current asthe American ; they gave a current which could

coagulate en masse as well as cut. It was uncertainwhether a coagulating current was equally suitablefor cutting. The current from a machine in Howard

Kelly’s clinic, which he had tried, cut beautifully butdid not coagulate ; for the latter purpose the currentfrom an adjoining part of the machine was used.Dr. Howitt had spoken of the method of action ofoscillatory currents. For himself, he felt sure thatit was the heat that was responsible for the thera-peutic effects, though possibly the currents mighthave in addition some other action on chemical pro-cesses. Prof. d’Arsonval had found that the appli-cation of high-frequency currents to diphtheritictoxin caused a reduction of the toxicity, even whenprecautions were taken to prevent rise of tempera-ture. In reference to Mr. Thomas’s remarks on theapplication of diathermy in otology, he had so treateda few cases of catarrhal deafness but without strikingresults. The action of the current in diseases of theeye and ear was simply to raise the temperature ofthe interior; where there was inflammation theeffect of the heat was to aid the resolution ofthe inflammation. Another effect was to increase the

blood-supply. Vaso-dilatation had been talked of,but it was, he thought, more correct to attributethe increased blood-supply to acceleration of thecirculation. At a temperature even as high as 114° F.there was surprisingly little erythema, but diathermyincreased the rate of flow of the blood, perhaps bydiminishing its viscosity.As to the use of diathermy in the throat it had

been claimed possible to destroy the entire tonsil atone sitting ; on the other hand, Dr. Dan McKenzierecommended piecemeal destruction, the operationbeing repeated at intervals of a week or more untilno lymphoid tissue remained. In the pharynxmassive malignant growths could be coagulated bydiathermy, leaving the patients in so little discomfortthat they would be able on the next day to sit up inbed or even walk about. Mr. Woolf had spoken ofthe Anderson method of stopping the haemorrhagefrom the larger vessels which took place when theywere cut. Their divided ends were picked up withforceps and the current directed along the metal;it heated the ends of the vessels until they coagulated.The sealed ends, coagulated in this way, remainedin the wound which healed by first intention. Butwere these vessels permanently sealed ? Mr. Dunhill ’had told him of a case in which haemorrhage hadoccurred from one of these supposedly sealed vessels.The long duration of freedom from return in Mr.Turner’s cases constituted, he thought, a record. Acase of ulcer of the lip, clinically malignant, treatedby diathermy was free from recurrence, he said, fiveyears afterwards ; but he had no microscopic evidenceas to its true nature.