The focus of infection may be located anywhere in the body. The usual site is in the head in the form of alveolar abscess, deep tonsillar or peritonsillar abscess and chronic sinusitis : A study of pathogenic bacteria that can usually be obtained from the tissues and exudates of the focus shows them to be of the streptococcus group. Occasionally the tubercle bacillus is found. Acute rheumatic fever, chorea, and rheumatic heart lesions are of undoubted focal origin. The tonsils are the most common source of chronic infection. Tonsillotomy is indicated in but one type of tonsil. Those tonsils which are obstructive and which are removed for other purpose than to increase the amount of breathing space. Complete enucleation of the tonsil with its hood and capsule is indicated and demanded in every case of chronically infected tonsils which are suspected of being the foci of systemic infection. One who has never probed a quinsy abscess would be surprised at the extent and depth to which pus may burrow. The mere lancing and the getting out of a large amount of pus does not always signify the end. Acute quinsy calls for a radical removal of the tonsils as an immedate curative agent. References. The writer has made free use of the following articles and he hereby acknowledges his indebtedness to the various authors: Burnmeister, W. H. The Protein Poison of the Tonsil. Babcock, R. H. The Various Types of Streptococcus En- Mouth Infection as a Source of Systemic Disease. (Jour. A. M. A., December 5, 1914.) Coolidge, A., and Garland, F. F. The Removal of Adenoids and Tonsils in Children. (Boston Med. and Surg. Jour., August 28, 1913.) Corwin, A. M. Tonsillectomy by the Sluder Method. (Jour. A. M. A., June, 1913.) Cabot, R. C. The Four Common Types of Heart Disease. (Jour. A. M. A., June, 1914.) Craig, C. B. Peridental Infection as a Causative Factor in Nervous Diseases (Jour. A. M. A., December 5, 1914.) Dupaquier, E. M. A Severe Case of Vincent's Angina. (New Orleans Med. Jour., May, 1914.) Dyas, F. G. Clinical and Experimental Results of Streptococcic Infections with Special References to thritis and Its Treatment. (Surgery, Gynecology and Obstetrics, June, 1914.) Ar Fischer, L. The Association of Follicular Tonsillitis with Acute Gastric Fever-A Clinical Study. (Med. Rec- Fedde, B. A. Retropharyngeal Abscess. (Med. Record, Ingals, E. F. What Relation, if any, Have the Faucial Ivy, R. H. The Mouth in the Etiology and Symptomatology of General Systemic Disturbances. (The Dental Review, August, 1913.) Langhorst, H. F. The Streptococcus Peril. (Med. Record, January 30, 1915.) Lubman, M. The Tonsil From a Surgical Point of View. (N. Y. Med. Jour., September 5, 1914.) Mayo, C. H. Constitutional Diseases Secondary to Local Infections. (The Dental Digest, February, 1913.) Nathan, D. Circumtonsillar Abscess. (N. Y. Med. Jour., July 4, 1914.) Ochsner, Á. J. (Jour. A. M. A., October 3, 1914, page 1189.) Rosenow, E. C. Bacteriology of Cholecystitis and Its Production by Injection of Streptococci. (Jour. A. M. A., November 21, 1914.) The Etiology of Articular and Muscular Rheumatism. (Jour. A. M. A., April 19, 1913.) Mouth Infection as a Source of Systemic Disease (Jour. A. M. A., December 5, 1914.) Richards, Geo. L. Relations of the Tonsils, Adenoids, and Other Throat Conditions to Tuberculosis and Cervical Adenitis. (Mass. Med. Society, June 10, 1914.) Stevens, B. S. Tuberculous Glands of the Neck; Their Relation to Diseases of the Nose and Throat. The Radical Operation for Their Removal. (Calif. State Jour. of Med., April, 1914.) Smith, C. M. Primary Syphilis of the Tonsil. (Boston Sandels, C. C. Gangrene of the Tonsils with Report of Theisen, C. F. Acute Thyroiditis as a Complication of Willis, B. C. Inflammatory Pathology of the Tonsil. A Geriatric Society. EDITOR MEDICAL COUNCIL: The New York Geriatric Society was organized on June 2, 1915, with the following officers: President, Robert Abrahams, M.D.; vice-president, Edward P. Swift, M.D.; secretary, I. L. Nascher, M.D., 103 W. 88th street, New York City. This is the first society ever organized for the scientific study of senile conditions, the causes of ageing, the diseases of advanced life and the home and institutional care of the aged. I thank you for your support of my efforts in behalf of the aged and ask your support of this society. I. L. NASCHER, M.D. Desiccation Surgery. A Factor in the Treatment of Malignant Disease. By WILLIAM L. CLARK, M.D., 1809 Chestnut Street, PHILADELPHIA, PA. Lecturer on Applied Electricity, Jefferson Medical College, Philadelphia. The systemic treatment of cancer has been disappointing, and all observers agree that local attack offers the best chance of cure or palliation. There is a diversity of opinion as to the method of choice for local treatment, some preferring operative surgery to the exclusion of other methods, others depending upon chemical escharotics, the Roentgen rays, radium or electrical methods. Since there is no unanimity of opinion as to standardization of cancer therapy, it is apparent that no one method is completely satisfactory, but that each possesses merit, either alone or in combination, and this fact must be recognized if progress is to be made and the ultimate goal reached. It is generally agreed, however, that the complete destruction or ablation of cancerous tissue, by whatever means, offers the best chance of relief, and if practiced early this chance is better than when the disease is advanced. Unfortunately there is no accurate means of determining when this removal is complete, and failure in this accounts for recurrences. It is purely a matter of judgment, matured by wide experience, combined with boldness on the part of the operator to go well beyond the macroscopic pathology. Even then failures are common, and we are brought to the realization that cancer is one of the most troublesome problems with which the medical profession has to deal. Notwithstanding this, much can be done for cancer that is worth while, even in the most advanced stage, if not to cure, to relieve suffering and to prolong life. Seven years ago I devised, and have since advocated and practiced Desiccation Surgery for the treatment of selected cases of cancer and precancerous lesions. Operative surgery has the advantage in some cases, while Desiccation is better in others. The efficiency of both may be increased in some instances when used in combination. The value of Roentgen rays and Radium as a supplementary factor must not be underestimated. With increased experience the technic of Desiccation has been improved, its fields of usefulness enlarged, uses and limitations defined, and conclusions formed as to its value in malignant disease. A few words devoted to the rationale and differentiation between the various electrical methods may help to a better understanding of Desiccation. By Desiccation Surgery is meant the devitalization and ultimate removal by slough or curettage of abnormal tissues by utilizing heat of just sufficient tendency to dehydrate, but not to carbonize, produced by a mono-polar electric current of high tension, which is concentrated and applied to the lesion by means of a metallic conductor. Electrolysis, with modifications known as Ionic surgery or cataphoresis, destroys tissue by the electrolytic action of the galvanic current. Fulguration (non-destructive) does not directly destroy tissue, but it is asserted that when long high-tension sparks are applied to the field in malignant disease after radical operation, alteration of nutrition of the part ensues, preventing the proliferation of cancer-cells. It is also declared that the percentage of recurrences is less than with operation alone. Electro-thermic coagulation is produced by a bi-polar high-frequency current. No sparks are used by this method, but two electrodes are brought into direct contact with the tissue, the position of the indifferent electrode depending upon the direction in which the coagulation is desired. The current flows in both directions, and meeting with resistance in the body in completing the circuit, heat is generated in the tissues between the electrodes, producing the coagulating effect. Fulguration (destructive). In this country the term Fulguration has been employed to express any sparks of high frequency that have the property of destroying tissue, whereas, the original fulguration as described by deKeating Hart is non-destructive. On account of the general acceptance of the term "fulguration," the prefix "destructive" will be used to differentiate it from the Hart method, which is nondestructive. High frequency cauterization, however, is more descriptive, and would be a better term to use. Destructive fulguration is more closely allied with Des iccation than the other methods, because they are both destructive effects produced by a mono-polar high-frequency current, but are quite distinct in character. Destructive fulguration is produced from an induction coil or transformer with condensers and resonator, and Desiccation from a high-potential static apparatus, with added accessories for transforming it. Before proceeding, I again emphasize that Desiccation and Fulguration are not synonymous, as some seem to believe. They are produced by electric currents of different characteristics, and the effects upon tissues are dissimilar. The effect upon tissues of destructive fulguration may be compared to an operation with a saw-edged knife, while the effect of Desiccation may be likened to the more efficient, refined and comparatively painless action of a keenedged bistoury. I wish also to correct a misunderstanding concerning Desiccation. In recent publications it has been referred to as being only effective for small growths, but not for growths of any size. This was my original opinion also, but the use of perfected technic and added experience has proven to me that there is no limit to the size of the growth, if accessible, that may be reduced by this method. Of course, it is not prudent to attempt growths in which large vessels are involved as in the neck or axilla. This work must not be attempted by the novice with the expectation of the best results, as they can only be obtained by one who has had sufficient experience to guide him to the ultimate perfection of technic. Since the rationale, rationale, instrumentation, technic, and indications for this method in surgical conditions was published before in THE MEDICAL COUNCIL, as well as in other journals, I shall not repeat details in the present paper, but shall confine the discussion to the advantages and disadvantages of Desiccation Surgery, and my routine management of cancer cases.* * point may be treated, as may a growth covering a large area, and to a depth within the limit of safety. The current has anesthetizing properties if properly applied, and is usually, but not always sufficient without other anesthesia. Nerve blocking or infiltration anesthesia may sometimes be employed to advantage, and in some extremely supersensitive persons a general anesthetic must be used. By reason of heat penetration there is a devitalizing action on cells of less vitality than normal cells, extending much deeper than the desiccated area; the normal cells recover. This has been shown by the frequent disappearance of malignant tissue at points removed from the area actually primarily desiccated. The current sterilizes the tissue and healing progresses rapidly. Channels are sealed, which lessens the likelihood of metastasis. Unlike the result after the use of the cautery, there is absence of much inflammatory reaction, and of contracted cicatricial tissue, insuring a good cosmetic result. There are no disadvantages to the Desiccation method, other than the expense and dimensions of necessary apparatus, which might be an objection in case of limited space. Desiccation surgery may be applied to growths in the following locations: Cutaneous surfaces, from the scalp to the plantar surfaces inclusive; accessible bone and cartilage; eye-lids and canthi, bulbar and palpebral conjunctiva; external auditory canal and tympanum; anterior and posterior nares; lips, buccal surfaces, tongue, alveolus, hard palate, uvula, faucial and lingual tonsils, pharynx, larynx and vocal cords; penis, urethra, bladder, rectum, vulva, labia, vagina and uterine cervix. In visceral cavities, as the bladder, etc., the endoscope is employed to expose the growth. Desiccation is a satisfactory method of treating the following, which may be considered as possibly precancerous lesions: Verruca, Roentgen ray and senile keratoses, moles, nævus pigmentosus and vascularis, artificial pigmentations, such as tattoo marks and coal marks, papillomas, urethral caruncles, leukoplakia, polypi, condylomas, chondromas, erosions, chronic ulcers, external and internal hemorrhoids, early Paget's disease, lupus, or any other accessible precancerous growths or lesions in which destruction of tissue, slight or extensive, is indicated. It is the aim to destroy these conditions with one treatment, and this is usually successfully accom The Advantages of Desiccation Surgery. Accessible abnormal tissue may be devitalized rapidly; there is no surgical urethral no surgical shock; the operation is bloodless, and may usually be done in an office without confinement in a hospital. This includes growths of the skin, mucous membranes, cartilage, periosteum and bone. It is a precise method; the smallest discernible *There is more technical information concerning the Desiccation method than could be incorporated into this paper, but those interested may obtain reprints covering further details by addressing the author. A result similar to this is usually obtained by one Desiccation operation, without employing other supplementary measures. Courtesy Adv. Ther. Result obtained by Desiccation employing Roentgen rays as a supplementary measure. Periosteum and bone involved in this case. Courtesy Adv. Ther. plished with the minimal amount of discomfort to the patient, and with superior cosmetic results. The following is the classification which I have formulated for personal guidance in the management of malignant disease in its various locations and stages. Malignant Disease. 1. Cutaneous Surfaces.-(a) Localized; (b) With Metastases. 2. Mucous Membranes.-(a) Localized; (b) With Metastases. 3. Inoperable Cancer. 4. Post-Operative Recurrences. 43 5. Sarcoma. 1. Cutaneous Surfaces-(a) Localized. Desiccation in my hands has been very successful in the treatment of epitheliomas and rodent ulcers of cutaneous surfaces, and I have the cosmetic results unexcelled. often seen features needlessly deformed by surgical operations for small epitheliomas, which would have been avoided had desiccation been employed. The success with this class of lesions has been due to thorough eradication of the malignant tissue with the additional inhibitory and destructive effect of intense heat penetration, also because blood and lymph channels are immediately sealed, because of which there is less likelihood of metastases. This is a class of cases in which operative surgery or chemical caustics should never play a part. When a large area is involved, a course of Roentgen ray treatments following Desiccation is advisable, taking advantage of their selective action on cancer-cells, lest there be some diseased tissue that possibly escaped Desiccation. This, of course, may not always be necessary, but it seems prudent to take advantage of this combination As much can be immediately treatment. accomplished by one Desiccation application as can be accomplished by the Roentgen rays alone in a comparatively long period of time, and Desiccation will heal cases that the Roentgen rays alone will not heal, but in combination the efficiency of both seems to be increased. The Coolidge tube supersedes the older types for therapeutic work of this kind. Cutaneous Surfaces.-(b) With Metastases. When metastases are present the results are usually unsatisfactory by any method, and no claims are made for desiccation, except in conjunction with radical operative measures, when the field may be desiccated after operation in suitable cases to seal blood and lymph channels, and to reach points that the scalpel perhaps did not reach. I consider it my duty, as a routine measure, to treat post-operatively with the Roentgen rays as a means of guarding against recurrence, promoting comfort to the patient, and prolonging life. In some cases Radium may be used to advantage in conjunction with Desiccation and the Roentgen rays, but unless a sufficient quantity is available it had better not be used, as I have seen many cases stimulated to rapid growth by using an insufficient quantity of Radium. 2. Mucous Membranes.-(a) Localized. In localized cancer of the mucous membranes, the results of Desiccation compare favorably with those obtained in localized skin cancers, although there is not the same assurance of success, on account of greater proneness to metastases, and because one cannot be sure that the adjacent glands are not involved, even though they may not be palpable. Mucous Membranes.-(b) With Metastases. When metastases are present, Desiccation is used only as a palliative. Unless too far advanced the chance of possible success afforded by radical operation or Desiccation followed by the Roentgen rays or Radium, should not be denied the patient. 3. Inoperable Cancer.-In absolutely inoperable cancer, whether of the skin or accesible mucous membranes, the initial lesion may be desiccated, and massive Roentgen ray dosage or radium applied to the glands and Dessicated site. Some unexpected good results have shown that this course is sometimes justified. In inoperable cancer of uterine cervix, Desiccation as a palliative measure has advantage over the curet and cautery, for the reason that a general anesthetic is unnecessary, there is less inflammatory reaction, it destroys the accessible diseased tissue quite as effectively, sterilizes, deodorizes and will stop bleeding. There appears to be, in addition to the primary destruction, an inhibitory influence upon cancer throughout the whole uterus and adjacent parts, probably on account of intense heat penetration. This is due to the great electro-motive force of the current. The cervix, when cancerous, is peculiarly insensitive to Desiccation, and can usually be treated as radically as desired without even a local anesthetic. 4. Post-Operative Recurrences. Desiccation has a field of usefulness in postoperative recurrences in any location that is accessible. For example, recurrences along the line of incision in cancer of the breast, may sometimes be treated to advantage by this method. 5. Sarcoma. In accessible sarcomas, if seen early, Dessication is a good treatment. In advanced sarcoma, the same general rules apply as in advanced carcinoma. Resume. Desiccation is a successful treatment for all benign neoplasms or other lesions of the skin and accessible mucous membranes in which devitalization of tissue is indicated, and one treatment is usually sufficient. All of such lesions must be regarded as possibly precancerous. |