1436

Mastitis.But undoubtedly the most striking results have been

obtained in inflammation and abscesses of the breast bymeans of large cupping glasses applied over the whole organ,and used with the double purpose of inducing hyperæmiaand draining away discharge. Every case showed remarkableimprovement in a short time ; those in which abscesses hadformed were relieved with quite small incisions, and thosewhich had been lingering on for some time with continueddischarge in spite of constant drainage rapidly took on ahealing action with drying up of the discharge, while paren-chymatous thickening of the organ soon became diminished.Such results have been repeatedly confirmed in other

quarters, and many cases have been reported of commencingmastitis in which the disease has been aborted without the

necessity for any incision and without the occurrence of sup-puration with consequent crippling of the breast.

The treatment is quite simple, and the apparatus is notexpensive, though of course breakages occur from time totime. The cup is applied morning and evening, for short

periods of five minutes or so, with a few minutes’ interval,until an aggregate time of half an hour is taken to the sitting.After a little experience the patient can usually give greathelp in adjusting the glass and should be able to use it athome without difficulty.CASE 72.-A married woman, aged 28 years, was admitted in August,

1907, with mammary abscess. Small incisions had been made and tubesinserted. A large cupping glass was applied for half an hour to one hourdaily. The discharge dried up rapidly, the breast shrunk in size, andthe inflammation disappeared. The application was painless except atthe first time.CASE 73.-A woman, aged 22 years, was admitted in August, 1907,

with abscess of the left breast. This was incised and a tube was in-serted. A cup was applied daily. The right breast then suppuratedand a localised abscess formed. A small incision was made and a cupwas applied. Both breasts healed rapidly and inflammatory thicken-

ing soon subsided.CASE 74.-A woman, aged 26 years, was admitted in October, 1907,with mammary abscesses of three weeks’ duration. Both breasts werealmost entirely disintegrated by sloughing. Cups were appliedmorning and evening for 15 to 20 minutes with very satisfactoryresults.CASE 75.-A woman, aged 35 years, was admitted in October, 1907,

with mammary abscess of three months’ duration. The discharge con-tinued and several small abscesses had again formed. The breast wasincised, and cups were applied morning and evening for 15 minutes, withremarkably good results.

FIG. 8.

Large cup applied to breast (Case 78).

CASE 76.-A woman, aged 30 years, was admitted in December, 1907,- with mammary abscess of six weeks’ duration. There were tender andred fluctuant swellings and fever. Small incisions were made and cupswere applied for a quarter of an hour thrice daily. The result was very.good.

CASE 77.-A woman, aged 26 years, was admitted in December, 1907,with mammary abscess of a month’s duration, underlying the scar ofan old extensive burn of the chest wall. Sinuses were present andfluctuating swellings were felt. Incisions were made and cups applieddaily. The sinuses and abscesses healed well.CASE 78.-A woman, aged 30 years, was admitted in February last with

mammary abscesses and diffuse mastitis. The breast had been incised- and pints of pus had been evacuated about a fortnight before. The

breast was still too large for any cup to cover the whole organ and theinflammation was still continuing. Later the breast was coaxed intothe largest cup, which was applied daily for one hour in the aggregate.The inflammation subsided rapidly, the discharge soon ceased, and thebreast shrunk to reasonable size with disappearance of most of theparenchymatous thickening. The effect of the cups was very striking.The application of Bier’s passive hyperæmia for the treat-

ment of tuberculous disease, or for the resolution of chronicthickening and ankylosis of joints, is not here under con-sideration ; and all examples of tuberculous conditionsmentioned in this report refer therefore only to the septicinfections with which they were complicated.

Active Hyperæmia.Bier’s other means of treatment by active hypersemia, as

produced by hot-air baths is not applicable to acute inflam-matory diseases. The few cases treated during the period ofthe foregoing series were confined to varicose ulcers. In allof these there was a sharp reaction, but the results, exceptfor clearing up of the surfaces of sloughing material, werenot better than those obtained by the other methods usuallyadopted. -

Conclusions.In the German Surgical Congress of 1906,4 referred

to before, a general survey was taken of the results.

Among other speakers Lexer was inclined to restrict theapplication of hyperaemia without incision to the slighterforms of inflammation only, otherwise it was too risky.He thought also that the duration of the disease wasnot shortened and that, therefore, it was necessary tobe on the watch for complications arising in the courseof the ailment. Most of the other surgeons agreedthat erysipelas and other streptococcic infections were

not suitable for the treatment on account of their tendencyto spread beyond the band, and that diabetes and varicoseand thrombotic conditions of the veins were contra-indica-tions, although cases of all these were reported as beingsuccessfully treated. On the other hand, there was almostunanimity with regard to the beneficial effects on teno-

synovitis, cellulitis, and joint infections, while milder cases ofosteomyelitis were greatly improved and aborted.

Bier himself reported further excellent results with osteo-myelitis but admitted that his best ones were obtained in theslighter forms which had recovered in many instances with.out necrosis of bone. He had decided of late that pain duringthe constriction by a band was not always a contra.

indication, as he had successful results in spite of it. It willbe seen that our results have in the main borne out theseconclusions, with the exception of the cases of arthritis.Moreover, it has struck us time after time how some cases,which have apparently been gaining no improvement fromhypersemia and where the band has been given up in

consequence, have after a while shown a sudden healingtendency, difficult to define but quite appreciable, as if somealteration in the character of the disease had been producedby the former treatment.

In conclusion it may be admitted, without makingextravagant claims for this method, that we have a

valuable adjunct to other surgical treatment both for the

prevention and the cure of inflammatory diseases. And itis specially with the former object that this report is pre-sented with the hope that a wider use may be made of it bythe general practitioners in dealing with such conditions inthe earliest stagesGlasgow.

___________________

NOVEL METHODS OF OPERATION IN THEREMOVAL OF MALIGNANT TUMOURS.

BY HORACE MANDERS, M.D. BRUX., F.R.C.S. ENG.

THE combined surgical and electrical treatment forcancer, recently called "fulguration" " (or treatment bylightning), a term proposed by Professor Poggie in pre-ference to that of I I sideration " (or treatment by flashes),the name given to the method by its introducer, Dr.de Keating-Hart of Marseilles, has created lately a con-siderable and increasing interest on the continent. In the

English medical press there have been but few communica-tions, of which some are so electrically vague or incorrectthat it would be impossible for anyone not well versed in

4 Zentralblatt für Chirurgie, 1906.

1437

the practice of oscillatory electricity to gather what the

technique really is. The best communication is naturallyfrom the pen of Dr. de Keating-Hart himself in the currentnumber of the Archives oithe Roextgen Rays, but even thisarticle leaves much unsaid. As the journal in question isdevoted to the higher technicalities of therapeusis by elec-tricity the article by Dr. de Keating-Hart is very likelyto escape the notice of surgeons who might wish to essay intheir own practice this novel method of operating uponcancer. A correct and fairly detailed account in a journalperused by the profession generally may be of wider service-may fill up any hiatus left in earlier communications-andenable a comparison to be’drawn between this system andthat of "electroscision," which I now make public for thefirst time.The novelty in " fulguration " consists in the application of

oscillatory electricity in combination with actual surgery;there is neither novelty in the technique nor in the apparatusused. So long ago as the Moscow Congress of 1897 Dr.Oudin drew attention to the destruction of condylomata,&c., by means of what is now known as fulguration, but theapparatus available in those days did not give a sufficientlylarge output to deal thoroughly with the more serious andrefractory epitheliomata. In 1904 the Gaiffe-d’Arsonvalapparatus had been designed, which fully answers the pur-pose by giving a short, thick, hot spark instead of the

longer, thinner, and less effective spark of the earlier formof apparatus. With the’ new form epitheliomata wereeasily and rapidly destroyed. Dr. Oudin read a paper beforethe Societe Française d’Electrotherapie et de RadiologieMedicale on June 15th, 1906, in which he drew attention tothe radical cure of epitheliomata by this means, and M.Bergoni6 and M. Bordier have been able to report similarcures by the same technique which I have quoted in a pre-vious article.2 It is not necessary to have recourse only tothe apparatus mentioned; equally good results can beobtained with an ordinary high-frequency apparatus pro-vided that an electrolytic interrupter is used, but the

following points must be borne in mind : the retardation ofoscillation should depend upon the impedence of the induct-ance and not upon the capacity of the condensers ; hencethe condensers should not have a capacity of much morethan 1-300th of a microfarad and the number of loops in theinductance coil should be considerable.

I have recently had the opportunity of inspecting a deKeating-Hart apparatus and noticed that the resonator,which is of the Oudin type, is a quarter as long againas is usual. This is fixed upon a table with thecondensers, in the form of two Leyden jars underneath-avery usual form of high-frequency apparatus. The con-densers at first sight appear to be of very large capacity,but a closer inspection shows that the glass of which theyare composed is exceedingly thick, so that the distancebetween the armatures (usually denominated by the symbolb) is relatively very great ; hence the true capacity of thejars is much less than it appears. Thus the relation of con-denser to inductance is, as it should be, according to whatI have already said. The tuning, by which the maximumvalue of the spark at the free end of the resonator is

obtained, is effected by throwing more or less loops of wireinto the oscillating circuit by means of a flap contact.Dr. de Keating-Hart’s special electrode consists of an

internal moveable conductor, inclosed within a short glasssheath set in a vulcanite handle. This conductor, whichconsists of a wire terminating in a small sphere of about thesize of a pea, can be slipped up and down the glasssheath by manipulating a button of insulating material onthe stem after the fashion of a pocket propelling penciland after the idea of a Bisserié electrode. The glasspart of the sheath is in the form of a beak like an

ordinary water-tap; it is of considerable thickness withan internal diameter of about a quarter of an .inch. Theend is open and the whole of the sheath is made hollow toallow of carbonic acid or sterilised air being pumped through,the idea being to cool the electrode and possibly the spark.Personally, I do not think that this would have the slightesteffect and in any case would be quite needless.There are two methods of applying the "fulgur

" men-

tioned by Dr. de Keating-Hart which have been termedbipolar and unipolar respectively, both vile terms, insomuch

1Oudin: Archives of the Roentgen Rays, July, 1906.2 Oudin: Ibid.

as in oscillatory electricity there are no poles. The properterms are bi-phase and uni-phase, but by whatever name wecall them the difference between them is this-that in the

bi-phase the patient is attached directly to one extremity ofthe oscillating circuit, and is fulgurated from the end of theresonator, in which case the fulgur is very severe anddestructive, a seeming advantage, but as it causes suchviolent contractions’as to be dangerous in the neighbourhoodof vital organs it has to be used with caution. In the uni-

phase method the patient is not attached to the oscillatorycircuit at all but to earth. The fulgur in this method being’much less violent is more manageable and is preferred by Dr.de Keating-Hart certainly in the late stage of the operation.There is a third method which I do not find mentioned byeither Dr. de Keating-Hart or by any of his disciples. It is anintermediate method, in which the patient is treated by onephase and the other is supplied from the floor, walls, &c., ofthe room by connecting the proximal end of the inductancecoil to earth. I generally use this method at the East LondonHospital for Children to destroy warts, growths, &c.

’

For the actual operation metal tables must be avoidedbecause of the violence of the sparks. Dr. de Keating-Hart divides the operation into four stages : (1) surgical ;(2) electrical ; (3) surgical ; and (4) electrical. 1. The sur-

geon divides the tissues and lays bare the neoplastic masseswithout separating them. 2. The tumour is fulgurated by’the strongest sparks so as to produce the greatest possibleeffect in the shortest time. The duration of this is from,’a few minutes up to ten."3 3. The surgeon excises the

growth. 4. Fulguration again. In his article Dr. de’

Keating-Hart says little about this fourth stage, which isreally the most interesting and important, and gives neitherdirections nor the length of time of application. Benckiserand Krumm of Karlsruhe, who witnessed such operations 4.

give the duration of the fulguration as " about 45 minutes."The tissues become ischasmic and the cut capillaries cease tobleed. No actual scab is’ termed but a fine layer of clot,which eventually becomes detached, as happens in burns.The wound is then closed, provided with thorough drainage,and covered with gauze plentifully sprinkled with sodiumbiborate, over which is placed a large pad of cotton wool..This dressing, which is changed after 24 hours, is often verypainful. Cicatrisation is rapid after the slough separates,’but complete healing is slower than after an ordinary surgicaloperation. ’

Several views have been taken by different observers of theaction of the fulgur upon the tissues. Dr. Oudin 5 is of

opinion that the heat of the spark acting as a thermic causticis not the sole cure, for he has seen (and this is my ownexperience also) warts disappear in a mass through whichthe fulgur had cut but a single track. He thinks that a-

spasmodic state of the capillaries, with perhaps a certaindegree of cellular necrobiosis, must play a part, also thatthese sparks, like x rays, seem to have a selective propertyupon neoplasms. Rene Desplats 6 says that a reaction occurs-in the healthy tissues-a reaction which is lymphatic andeliminating, a kind of lymphorrhoea which drives all histo-logical traces of cancer out of the lymphatic vessels. Dr.de Keating-Hart assumes that the fulgur exercises a specialvitalisirig action in the cells of the organism, inciting themto become physiologically more active and indirectly to gaina vital mastery over the cancer cells. Nagelschmidt 7 isexceedingly trenchant in his criticisms and fails to appreciatethe claims put forward by the exponents of the new method.He’ says that both from the point of theory and frompractical experience he is forced to believe that fulguration’is a clumsy method of applying heat and at the same time avery costly one.

There is a great deal to be said in favour of the views’expressed by Ren6 Desplats, for in the treatment of warts weoften see this lymphorrhoea at the time of the application, the’appearance of which, as pointed out to me by Branth of Now’York, is an indication at once to stop the application, andthere can be little doubt in the minds of those who are in thehabit of using this technique in local conditions that these-sparks have a selective and ’elective property over growths.That the fulgur will destroy any low-class cell with which it

3 Benchiser and Krumm : Brit. bred. Jour., August 15th, 1908.4 Benckiser and Krumm: Ibid.

5 Oudin : Loc. cit.6 Le Nord Médical, Jan. 15th, 1908.

7 Deutsche Medicinische Wochenschrift, March 5th, 1908.

1438 ’

comes into contact seems certain. Nagelschmidt chieflybases his views on the fact that if a bacterial or amoebicculture is sparked by the fulgur it is practically impossible toobtain sterility. As it has never yet been proved that thecancer germ is either a bacterium or an amceba I fail to seethe cogency of his argument.

If fulguration has in any way reduced to a minimum therecurrence of cancer after operation the combined operationis fully justifiable and must be regarded as a distinct gain intreatment. The demerits of the new operation are : (1) thatthe length of time during which the patient must be keptunder anaesthesia is much prolonged; (2) that the anaestheticmust be chloroform, because the more volatile ether is aptto catch alight from the sparks ; (3) that anæsthesia, besidesbeing prolonged, must be deep, because the fulguration,especially in the second stage of operation, when the bi-

phase method is used, is very painful; (4) the disadvantageduring the operation of having to change from one instru-mentation to another; (5) the difficulty of managing andcontrolling a rush of violent sparks ; and to these must beadded (6) the uncertainty of being able to reach everypart of the incised area with a series of sparks which arenot continuous but intermittent, as will be explainedimmediately.

Electroscision.-The whole of the disadvantages enume-rated above may be obviated and greater security attained byan entirely novel method of operating, to which I have giventhe name of electroscision. The essence of the technique isthe utilisation of the continuous and undamped oscillationsof electricity instead of the intermittent and rapidly dampedtrains of oscillations employed in the production of ful-

guration. The principal differences between the two are thatin fulguration the spark really resembles forked lightning inits discharge, for a violent stream of sparks springs from theelectrode to the most salient points opposed to it, so that itis quite possible for a germ lying in a sulcus, or even well inthe open, to escape its destructive influence. Like lightning,too, the spark is intermittent. Just as the condenser cloudhas to be charged up again to the breaking point beforeanother flash can occur, so must time elapse until the Leydenjars are again recharged by the coil or by the transformer, I

whichever is used. True it is that the fulguration sparkappears to be continuous, but that is a visual error due to theretention of impression upon the retina ; there is actually arelatively very wide interval indeed between each train ofsparks. The disruptive discharge of a condenser is all overin the 100,000th part of a second and cannot take placeagain until the condensers are recharged. Let us take themost rapid means we have of effecting this-that is to say,by means of the electrolytic interrupter, which will break thecurrent from 600 to 1000 times per second. With the mostfavourable of these figures we find that, although we get 1000trains of sparks per second, yet each train lasts no longerthan 1-100,000th of that period; consequently to one periodof effectivity there are 99,000 equal periods of total inactivity.Reckoned in time, this means that for the sum of only onesecond of actual fulguration there are 999 seconds, or about16½ minutes, of absolute ineffectivity. Expressed in linealmeasure, to three centimetres of action there would be nearlythree metres of inaction. On the other hand, in electro-scision there are no trains of oscillations violent at first

though rapidly extinguished but oscillations which are

continuous and steady, of an even alternation of phase, andgiving quite a small spark, less bright even than the scintilla-tion of a little medical battery, yet possessing all the

destructive, selective, and physiological attributes of thefulminating spark in an enhanced degree.The instrumentation for the production of the continuous

’oscillations used in electroscision differs considerably fromthat used in the ordinary high-frequency of intermittentoscillations. It is much less cumbersome, as we do not needeither the heavy coil with its condenser or the equallyweighty transformer. The apparatus is extremely simple.It consists of : (1) a resistance to control the current ; (2) agap in the main circuit, in which an arc occurs when thecurrent flows ; (3) a chamber for the arc gap so constructedthat it can answer the purpose of containing air or any gasunder pressure or a vacuum at will; and (4) a shunt circuit.across the arc gap, consisting essentially of a condenser andof an inductance coil in series with it.

I think that it would be rather beyond the scope of thisarticle to enter too fully into technical details ; I have

mentioned them elsewhere. a Suffice to say that by a specialform of arc, which for the sake of brevity I call the " zenal," I have been able to dispense with the nuisance of hydrogengas as used in Poulsen’s system of continuous oscillations,which has been much mentioned in the press during the lasttwo years. I have also done away with the cumbersomemagnetic field and by certain dispositions I arrange for theperfect safety of both operator and patient. Lastly, I

provide a simple and perfect tuning by varying the capacityof the condensers both in the oscillating circuit andin the derived circuit which I use to obtain the requisitepotential. In this system we do not require the potentialnecessary in the spark system, which runs into from

250,000 to 300,000 volts. The operation itself presents noremarkable features. The whole is carried out by thesurgeon himself. The knife is fitted with an ivory handle,through which runs the conducting wire to the blade, whichthus becomes both the instrument of section and that which

conveys the thermic, physiological, and electric phenomenato the tissues at the same moment as they are divided. Thetissues are seared as they are cut and the capillaries aresealed as they are divided ; hence there is little or no

bleeding and no need for sponging and disturbance of cancercells, a point greatly insisted ’upon recently. 9 The surgeonhas a good view of his parts, for the wound made is not theleast like an ordinary burn; I have already described itsappearance. 10 At the closing of the wound the needles maybe placed in a holder provided with insulating handles. Theonly objections I know of are two and are of quite minorimportance. One is that the surgeon may get a burn if heshould touch his hand with any part of the blade of the knife,and the other is the hampering caused by the conductingwire being attached to the knife.

Harley-street, W.

RECENT INVESTIGATIONS INTO THEPATHOLOGY AND TREATMENT OF

GENERAL PARALYSIS ANDTABES DORSALIS.1

BY W. FORD ROBERTSON, M.D. EDIN.,PATHOLOGIST TO THE SCOTTISH ASYLUMS, EDINBURGH.

I PROPOSE to state very briefly some of the main resultsof the observations that have been made during the pastyear in the course of the special investigation into the

pathology and treatment of general paralysis and tabesdorsalis commenced by my colleagues and myself in 1902.For the sake of those who are not familiar with the contentsof the published papers I shall preface what I have to sayby a short summary of the observations and conclusions

already recorded. We have found that bacilli of the

diphtheroid group, possessing prominent meta-chromatic

granules, can be shown to be invading the tissuesin all cases of advancing general paralysis and tabesdorsalis. The chief seats of invasion or of the in-fective foci are the naso-pharyngeal and oral mucosæ incases of general paralysis and the genito-urinary tract incases of tabes. Evidence of such invasion has been obtainedby the direct examination of scrapings from the surface ofthese mucous membranes. Confirmatory results have beenyielded by bacteriological examination. Further evidence in

support of the occurrence of such invasion has been obtainedfrom the examination of the cerebro-spinal fluid removed bylumbar puncture. In the centrifuge deposit from this fluidbacilli have been demonstrated in several instances and intwo cases the deposit has yielded a pure culture of a similarbacillus. Growths of diphtheroid bacilli have now beenobtained from the brain post mortem in numerous cases ofgeneral paralysis and these micro-organisms have also beendemonstrated in microscopical sections of the brain. It hasbeen ascertained that two species of the diphtheroidbacilli isolated from cases of general paralysis or of tabesdorsalis are often virulent to mice and rats, whilst being

8 Journal of the Roentgen Society, No. 17, vol. iv.9 Technique of Cancer Operations, by Ryall, July, 1908.

10 THE LANCET, April 18th, 1908, p. 1176.1 A paper read before the Interstate Medical Congress, Melbourne,

held on Oct. 19th to 24th, 1908, in the Section of Neurology andPsychiatry.