Short-Wave Diathermy 9780231890502

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SHORT-WAVE DIATHERMY

Short-Wave Diathermy BY TIBOR

deCHOLNOKY

Associate in Surgery, New York Post-Graduate Medical School, Columbia University

New York : Morningside Heights COLUMBIA UNIVERSITY 1937

PRESS

COPYRIGHT, 1937, BY COLUMBIA UNIVERSITY P R E S S Printed tn the United State* of America

FOREIGN

AGENTS

OXFORD UNIVERSITY PRESS, Humphrey Milford, Amen House, London, E.C.4, England, and B. I. Building, Nicol Rood, Bombay, India; KWANG HSUEH PUBLISHING HOUSE, 140 Peking Road, Shanghai, China; M ARUZEN COMPANY, LTD., 6 Nihonbaahi, Tori-Nichome, Tokyo, Japan

PREFACE the past eight years approximately 7 5 0 articles, books and other publications have appeared, dealing with short-wave diathermy, the majority of these being in foreign languages. It is only within very recent years that investigators in the United States, although the first in the field, have set themselves the task of studying short-wave currents in their experimental and therapeutic application, and of analyzing the reports coming from abroad, as well as of verifying the findings reported. It must be admitted that since the start was made, the results have been creditable. There is little question of the value of short waves as a therapeutic agent in some pathological conditions, although their efficacy in others is still a matter of controversy, and subject to further study and development. Many, perhaps exaggerated, claims have been made as to the therapeutic value of short-waves, some by the ubiquitous overenthusiastic practitioner, but most, unfortunately, by manufacturers and salesmen of short-wave apparatus, these only serving to throw what will eventually emerge as an invaluable aid in therapy, into temporary disrepute. Such undiscriminating enthusiasm is to be deplored in any field of endeavor, but particularly so where the fate of human health and well-being is at issue. Advances in science are not made by uncontrolled rush of emotion, but by balanced reason conjoined with experience. At the same time, what is radical today may be conservative tomorrow. What is needed now is a tolerant attitude toward those who are laboring to bring this most significant of contributions to physical therapy out of the mists of uncertainty, through which all new things pass, into the clarity of scientific exactitude. It is my hope that in offering to the medical profession this outline of the subject in its present state of development, with the survey of the laboratory and clinical work that have so far been carried out, a dual purpose will be served: that the book in itself will be of service to the profession, proving useful as a DURING

vi

PREFACE

guide to the application of short-wave diathermy; and that it will also serve as a stimulus to the further study which is so badly needed. There is no evading the fact that short waves are proving the most significant contribution of recent times to the application of electricity in medical treatment. I take pleasure in expressing my deep gratitude to Dr. Hermann Fischer for affording me liberal opportunity to pursue this study, on ample clinical material. My thanks go to Dr. Francis Carter Wood for the use of the Crocker Research Laboratory for experimental work, and to Drs. H. M. Marvin, Walter S. Galland, Erich Schwarzkopf, and H. W. Kohler for their criticism and helpful comment. I am especially happy to acknowledge my indebtedness to Dr. Ldszl6 Telkes, who was kind enough to help me with the collection of this material. Finally, I wish to express my appreciation of the editorial assistance rendered me by Miss Lucile Grebenc in the preparation of this work for the press. T I B O R DE C H O L N O K Y N E W YORK CITY

January 2, 1937

CONTENTS v

PREFACE

PART I.

INTRODUCTION

I . H I S T O R I C A L O U T L I N E OF S H O R T - W A V E D I A T H E R M Y

3

P A R T I I . T H E P H Y S I C A L A S P E C T S OF SHORT-WAVE DIATHERMY I I . T H E P H Y S I C A L A S P E C T S OF S H O R T - W A V E D I A T H E R M Y .

9

Principles of construction of short-wave machines; spark-gap and tube machines; measurements PART III. EXPERIMENTATION WITH SHORT-WAVE DIATHERMY I I I . E X P E R I M E N T S ON B A C T E R I A AND O T H E R ORGANISMS

27

Bacteria (staphylococci, streptococci, bacillus coli, tubercle bacillus, typhoid bacillus, gonococci, other microorganisms, general discussion); unicellular organisms; experiments on toxins; viruses; venom; plants I V . E X P E R I M E N T A T I O N ON A N I M A L S

40

Effect of short-wave treatment on growth and reproduction; action of different wave lengths on tissue; physiologic effects of short waves; biological effects of short waves; effect of short waves on blood and serum; action of short waves on electrolytes and colloids; local tissue changes; inflammation; temperature regulation after short-wave diathermy (temperature measurement) 67

V. WAVE LENGTHS

Wave lengths for short-wave diathermy; microwaves; specific effect, or specificity P A R T IV. T H E T E C H N I C OF DIATHERMY

SHORT-WAVE

V I . SHORT-WAVE TREATMENTS

Effect of short waves on prominent parts; inconvenient effects of exposure to short waves; contraindications to short-wave diathermy; surgical application of short waves (preoperative and postoperative); combination of short waves with other forms of treatment (drugB,

77

VU1

CONTENTS surgical, physiotherapeutic, mechanotherapeutic measures, irradiation therapy, diets, opotherapy as required, etc.); electropyrexia; short-wave diathermy as compared with diathermy (differences)

V I I . GENERAL AND MECHANICAL PRINCIPLES IN

SHORT-WAVE

97

TECHNIC

Burns and their prevention; electrodes for short-wave diathermy (rigid electrodes, flexible electrodes, size of the electrodes, shape of the electrodes, technic of application, principles of application) PART

V. T H E C L I N I C A L A P P L I C A T I O N S SHORT-WAVE D I A T H E R M Y

OF

V I I I . INFECTIOUS, ALLERGIC AND METABOLIC DISEASES

.

119

General considerations; infectious diseases (the common cold, pneumonia, pulmonary tuberculosis, erysipelas, erysipeloid, actinomycosis); allergic diseases (bronchial asthma); diseases of metabolism and of the ductless glands (gout, obesity, diabetes mellitus, disorders of the endocrine function) I X . DISEASES OF THE RESPIRATORY TRACT

130

Laryngitis; bronchitis; bronchiectasis; emphysema; pleurisy; empyema; abscess of the lung; pulmonary gangrene; technic of treatment X . DISEASES OF THE GASTRO-INTESTINAL TRACT

.

.

.

.

143

The oral cavity (the dental structures, tonsillitis); spasm of the esophagus; the stomach; (gastritis, peptic ulcer, gastric neuroses); the intestines; the biliary passages; technic of treatment X I . DISEASES OF THE GENITO-URINARY TRACT

155

The urinary tract (cystitis, pyelitis, nephritis, perirenal abscess; technic of treatment); the female genital tract (pelvic inflammation and infections, dysmenorrhea); the male genito-urinary tract (gonorrheal urethritis, diseases of the prostate, miscellaneous diseases, technic of treatment) X I I . DISEASES OF THE CIRCULATORY SYSTEM AND THE LYMPH GLANDS

171

The circulatory system (the heart); the vascular system; the lymph glands (tuberculous adenitis, Mikulicz' disease, noncontagious parotitis) X I I I . DISEASES OF THE LOCOMOTOR SYSTEM

184

The muscular system (tendovaginitis, bursitis); the bones (periostitis, osteomyelitis); the joints (arthritis, tuberculosis, technic of treatment, general comment); traumatic injuries X I V . DISEASES OF THE NERVOUS SYSTEM

Neurosyphilis; neuritides; migraine; miscellaneous nervous conditions

200

CONTENTS

ix

(impairment of motility, Parkinson's disease, syringomyelia, epilepsy, mental disease, brain abscess, hiccup, urinary incontinence of nervous origin, neuroma); comment X V . MISCELLANEOUS CONDITIONS

211

Diseases of the skin (furuncle, carbuncle, axillary sweat-gland infection and abscess, paronychia, cellulitis, and other infections of the extremities, phlegmon, miscellaneous diseases of the skin); diseases of the head (inflammatory disease of the sinuses, diseases of the eye, diseases of the ear, mastoiditis); mastitis X V I . MALIGNANT DISEASE PART

244 VI.

CONCLUSION

X V I I . CONCLUSION

251

BIBLIOGRAPHY

257

ABBREVIATIONS

295

INDEX

301

ILLUSTRATIONS 1. Molecular Dipoles between Condensor Plates; Electric Field Intensity Zero 12 2. Molecular Dipoles between Condensor Plates; Electric Field Applied 12 3. Schematic Representations of Electrolites and Dipoles; Alignment in the Electric Field 12 4. Parallel Connection of Resistance and Capacity . . . . 13 5. Series Connection of Resistance and Capacity 13 6. Schematic Spark-gap Oscillatory Circuit 14 7. Damped Electric Oscillations 15 8. Inductive Coupling between Two Electric Circuits . . . 16 9. Galvanic Coupling; Generator (primary) and Patient (secondary) Circuit 17 10. Undamped Oscillations 18 11. Vacuum Tube Oscilator; Tuned Plate Circuit Type . . . 19 12. A Typical One-Tube Electric Oscillator 21 13. Rotating Neon Tubes of Different Oscillations: a, A Rotating Neon Tube Indicating Uninterrupted Undamped Oscillations Delivered by a Machine with Vacuum Tube Delivering Uninterrupted Undamped Oscillations; b, A Rotating Neon Tube Indicating Interrupted Undamped Oscillations Obtained from a Machine with 2 Vacuum Tubes; ç, A Rotating Neon Tube Indicating Interrupted Undamped Oscillations of a Machine with One Vacuum Tube Disconnected 22 14. Vasodilatation in the Swimming Membrane of a Frog: a, Before Short-Wave Treatment; b, After Short-Wave Treatment (E. Pflomm, Archiv fur klinische Chirurgie, CLXVI [1931], 259) 60 15. Proper and Improper Application of Electrodes: Nose; a, Improper Application, Causing Current Concentration; b, Proper Application, Preventing Current Concentration 79 16. Proper and Improper Application of Electrodes: Knees: a, Improper Application, Causing Current Concentration; b, Proper Application, Preventing Current Concentration 100 17. Superficial Skin Burns, Caused by Faulty Application of Electrodes: a, Burns, Caused by Heat Coagulation on

xii

18. 19. 20. 21. 22. 23. 24.

25.

26.

27.

28. 29.

30.

ILLUSTRATIONS Prominent Points; b, The Same Lesions Healed, without Permanent Scar Formation Current Dispersion by the Unipolar Method Current Dispersion by the Bipolar Method Inductotherm Glass-Shoe Electrodes Special Electrodes: a, Vaginal; b, Breast; c and d, Sinus and Tonsil Flexible Electrodes Roentgenograms, Showing Tuberculous Exudate of Six Months' Duration, in a Grave Case of Pulmonary Tuberculosis: a, Before Short-Wave Diathermy; b, After 6 ShortWave Treatments within 4 Weeks (E. Raab, Kurzwellen Therapie, Berlin, 1934) Roentgenograms, Showing Gangrenous Interlobar Empyema: a, The Gross Size of the Lesion and Its Position, before Short-Wave Treatment; 6, Seven Weeks after Short-Wave Diathermy. The Lesion Is Barely Distinguishable and the Patient Has Been Discharged from the Hospital. (Courtesy of E. Schliephake) Roentgenograms, Showing Absorption of Lung Abscess: a, A Fluid Level Is Distinguishable below the Clavicle in the Right Upper, Indicating a Large Abscess in the Apex of the Upper Lobe; b, After 3 Weeks of Short-Wave Treatment, the Lesion Has Practically Cleared Up (Courtesy of E. Schliephake) Roentgenograms, Showing Gangrenous Abscess of the Lung: a, Wedgelike Area of Density Present at Base of Right Upper; b, On the Sagittal View, a Fluid Level Is Plainly Distinguishable, Indicating Drainage through a Bronchus; c, After 18 Days There is Almost Complete Disappearance of the Lesion, Following Short-Wave Diathermy (Courtesy of E. Schliephake) Roentgenograms, Showing Dental Granuloma: a, Before Short-Wave Treatment ; b, After 6 Short-Wave Treatments (E. Schliephake, KurzweUentherapie, 1932) Roentgenograms, Showing Recurrent Postoperative Marginal Ulcer: a, An Arrow Indicates a Sharply Defined Niche of Marginal Ulcer; b, Following a Course of Short-Wave Diathermy, the Niche Is No Longer Discernible . . . . Bartholin's Gland Abscess: a, Before Treatment by ShortWave Diathermy; 6, After Treatment by Short-Wave Diathermy . . .

101 104 104 105 107 108 110

123

135

137

139 145

149 163

ILLUSTRATIONS 31. Roentgenograms, Showing a Case of .Gonorrheal Arthritis: a, Before Treatment by Short-Wave Diathermy; b, After 2 Months' Treatment by Short-Wave Diathermy (E. Pflomm, from E. Schliephake, KurzweUentherapie, 1932) . 32. Furuncle of the Chest Wall: a, Before Treatment by ShortWave Diathermy; b, Four Days after Treatment by ShortWave Diathermy (6-Meter Waves) 33. Multiple Axillary Sweat-Gland Abscesses: a, Before Treatment by Short-Wave Diathermy; b, After 4 Treatments by Short-Wave Diathermy; c, After 12 Treatments by ShortWave Diathermy (Fourteen Days Later the Infection Cleared Up, Leaving Very Little Scar Formation) 34. Special Rigid Electrodes, for Treating Axillary Abscess 35. Palmar Abscess in a Diabetic: a, Before Treatment by ShortWave Diathermy; b, After Treatment by Short-Wave Diathermy 36. Roentgenograms, Showing Multiple Chronic Sinusitis: a, Before Treatment by Short-Wave Diathermy; b, Twenty-five Days after Treatment by Short-Wave Diathermy (In 27 Days There Was Great Improvement; in 6 Months the Patient Was Symptom-free) 37. Short-Wave Treatment with Breast Electrode 38. Action of Short Waves on Rat Tumors

xiii

191 214

224 225 229

236 243 246

PART I INTRODUCTION

I HISTORICAL O U T L I N E OF SHORT-WAVE DIATHERMY E L E C T R I C I T Y as a phenomenon has intrigued man since the time of Thales, about 600 B.C., but it has been put to practical use only within the past century. Its therapeutic application is of even more recent date, it having gained a place in the medical armamentarium about four decades ago. Within this short space of time, advances in physics have been notable and have had, as might be expected, direct or indirect effect upon this phase of the application of electricity. The latest development in this direction has been the new form of treatment known as shortwave diathermy, using high-frequency currents. The first studies in this field were made by James C. Maxwell in 1865 and in 1887 Hertz published his discovery, based on Maxwell's theoretical considerations. Hertz found that if a spark jumps between two conductors as the result of different potentials, the opposite potentials do not neutralize in a simple way, but oscillations can be detected. These oscillations were extremely rapid and produced electromagnetic waves which were invisible and which had the characteristics of light waves —that is, they could be sent through space. Fedderson was able to demonstrate the oscillatory character of neutralization by spark by means of a revolving mirror. This was the beginning of radio transmission in general, and of the development of the spark-gap transmitter in particular. With this device a high-frequency current was generated. The work of Nicolas Tesla in 1891 was the start of biological experimentation along these lines. He was the first to record the fact that heat production resulted from "bombardment of the high frequency alternating current," and to point out the possibility of its utilization for medical purposes. At the same time d'Arsonval, using the same current (approximately one

4

HISTORY OF SHORT-WAVE DIATHERMY

million oscillations per second), began to experiment on animals and human beings. Although he was successful in demonstrating a marked decrease in the toxicity of the diphtheria toxin after its exposure to the high-frequency current, and noted heat as an inconvenient by-product, the attention of the medical world was not immediately attracted. He may also be considered the first to have used condenser electrodes with higher frequencies than those later used in diathermy. Present-day diathermy machines were developed from his apparatus. In 1898 von Zeyneck used the high-frequency current to produce heat within the organism, and was followed in this by von Berndt and other workers. The method consists in placing two large flat metal electrodes, in the two designated areas, directly upon the body surface. To this form of treatment Nagelschmidt applied the term "diathermy" and demonstrated its value. A voluminous literature was the direct result of this remarkable accomplishment. The oscillation of this current was about one million. It was only recently, with advances in the domain of radio transmission, that it became possible by using sufficient power, to increase considerably the number of oscillations. This initiated new research, starting with Stiebock in 1925, who used currents of much higher frequencies (8 million) for therapeutic purposes. The electrodes were, however, still in direct contact with the patient and the procedure was therefore still a form of diathermy. Antedating this work by a year, Gosset and his co-workers in 1924 constructed an apparatus for experiments, which produced 150 million oscillations (2-meter waves); they reported the destructive effect of the high-frequency current upon plant tumors caused by Bacterium tumefaciens. Schereschewsky published his findings in 1926. He put the object to be treated in a condenser, through which a high frequency current was sent. The electrodes were insulated plates, thus introducing a dielectric between the object treated and the metal electrodes. He found that small animals, such as mice, died within a very short time when placed in the condenser field. Flies dropped dead at once under the influence of these

HISTORY OF SHORT-WAVE DIATHERMY

5

oscillations. In the fancy of the daily press, this was interpreted as a new form of "death ray." The result of further experimentation was published by Schereschewsky in 1928, and demonstrated, he believed, the positive curative action of these high-frequency currents on malignant rat and fowl tumors. In the course of research on radio transmitters, certain heat effects in the vicinity of the antennae were noted. Hosmer's physiological experiments revealed heat between the plates through which the high-frequency current flows, substantiating the effects noted by others. It is of interest that he warns against the general use of this heat so produced, as we cannot predict with certainty just where the extreme local heating might occur before the general body temperature gave sufficient warning. The serous cavities would seem to offer the optimum condition for such local heating, endangering the adjacent tissues.

One of the most prolific investigators in this field is Schliephake, who started his remarkable work in 1926, and with whom Esau and Patzold were associated. Esau succeeded in solving the problem of generating high-frequency wave lengths up to 100 million oscillations and more, of power sufficient to have appreciable biological effects in the condenser field. The first therapeutic application in human beings was made by Schliephake upon himself, using air-spaced electrodes such as are used today, by which he cured a furuncle on his nose. He can therefore be considered the creator of short-wave diathermy. At about the same time the short-wave broadcasting station of the Vatican started experimentation to ascertain the effects of these waves on growing plants. In 1930 Hinsie and Carpenter, in the United States, studied the effects produced by high-frequency oscillations, about 10 million (30 meters), on general paralysis. These studies were followed by further work by other investigators, among them Saidman, Pratt and Sheard, Mortimer and Bierman. The publication of early work in this field, briefly touched upon in these paragraphs, started an avalanche of research on the subject, with a voluminous aftermath of literature. It would be impossible, within the scope of a brief chapter, to follow the

6

HISTORY OF SHORT-WAVE DIATHERMY

different lines along which the many investigators worked, or to evaluate the results. Since these very recent beginnings, there have been, up to 1937, well over 750 articles in the current literature, and 18 books on the subject. The findings of workers in the various fields of medicine will be taken up in the chapters which follow.

PART II THE PHYSICAL ASPECTS OF SHORT-WAVE DIATHERMY

II T H E PHYSICAL ASPECTS OF SHORT-WAVE DIATHERMY* the medical point of view, a brief review of some wellknown principles of physics and a short summary of the characteristics of high-frequency currents, may be desirable at the outset of this work. Those who wish to learn more concerning the technicalities of the subject may find it expedient to consult the standard textbooks, especially treatises on physics and electricity in which the scientific and technical aspects are dealt with in a detailed manner, both from a practical and a theoretical point of view. According to our present conception of the curative value of short-wave high-frequency currents, the most important role is to be attributed to heat, for so far no other effects have been demonstrable with certainty. For this reason it seems necessary, before going into the details of production of highfrequency currents, to review certain fundamentals of electric heat production. It is a well-known fact that the electric current increases the temperature of the conductor through which it flows; that is to say, the electric energy is transformed into caloric energy. A conception of this transformation of energy may be obtained by the aid of the electronic theory of conduction. According to this theory, an electric current is established by the flow of free electrons through the conductor. Under the influence of the electric field, the free electrons within a conductor are accelerated and acquire a drift velocity which is superimposed upon their random thermal motions. Through collisions with the atoms of the conductor, the electrons lose their kinetic energy FROM

'Schwarzkopf, £., and I. Levin: "Physical Basis, Technical Development, Biological and Therapeutic Applicability of Electrothermic (Diathermic) Coagulation in Cancer" Arch. Clin. Cancer Res. II, 2, 3 (1926).

10

PHYSICAL ASPECTS

and thus generate heat. A similar theory holds good for electrolytes (solutions of salts, acids, bases), when instead of electrons the so-called ions are put into motion. This development of heat follows certain physical laws which were first expressed by Joule in the following formula. The amount of heat produced is: Q = Ki2rt

If the intensity of the current (i) is measured in amperes, the resistance in ohms (r) and the time (t) in seconds, and if the constant (K) has the value 0.24, the heat production is obtained in gram calories. The increase of temperature of the conductor through which the current is flowing, depends upon its mass and its atomic structure (which is responsible for the so-called "specific heat"), its shape, and additional factors, namely, loss of heat by radiation and convection. Animal tissues, which partly consist of electrolytes, are "semiconductors" of electricity, and therefore must conform to Joule's law. In medical practice, high-frequency currents are applied for internal heat production. The high-frequency current is an alternating current, that is, one which changes its direction at regular intervals, in contrast to a direct current, which always flows in the same direction. Its frequency is so high that stimulating effects do not develop in the tissues because the current impulse causing a minor chemical reaction in one direction, is immediately followed by an impulse in the opposite direction. Each impulse thus neutralizes very rapidly the effect of the preceding one, not allowing time for the production of the chemical changes necessary for stimulation. The high-frequency current of about one million cycles per second which is used in ordinary diathermy, produces heat mainly according to Joule's law. If the frequency greatly exceeds one million cycles per second, another mechanism of heat production comes increasingly into play. This is the development of heat by dielectric phenomena. It is well known that a direct current does not pass through a condenser, but that an alternating current is able to do so. If the potential of a direct-current source is connected to a condenser, which, in its simplest form, consists of two separated parallel plates, the current flows only while charge occurs. A suitable amperemeter in the circuit shows a sudden

PHYSICAL ASPECTS

11

deflection while charging, and also while discharging takes place. If a source of alternating current is connected to a condenser, the meter shows a constant deflection, since charging and discharging follow each other in rapid succession. The meter is too inert to show instantaneous values of current. By increasing the frequency of these alterations, keeping the amplitude of the potential constant, one observes increased deflection of the amperemeter. The current will also increase if the air is replaced by other insulators (dielectrics) such as oil, paraffin, mica, etc.; that is, the insulator increases the capacity of the condenser. The ratio of the amount of current flowing through the insulator-filled condenser to the amount of current flowing through the air condenser, is the dielectric constant. The dielectric constant of air is taken as 1 for the purpose of comparison with other materials. The dielectric constant of various materials is as follows: Air 1 Glass 4-10 Wood 3-10 Water 78.5 Fat 13.6 Serum 85.5 Proteins 85.0 The increased current flow in the different materials is due to the phenomenon of polarization. The theory has been advanced that the molecules of the dielectric are already charged negatively and positively at opposite ends, and hence are dipoles (fig. 1). These dipoles are aligned under the influence of the electric field, so that their positive poles are directed toward the negative condenser plate and their negative poles toward the positive plate (fig. 2). In a high-frequency alternating field which changes its direction several million times per second, the dipoles reverse their direction with the same frequency, the constant friction of neighboring particles producing heat by what is called dielectric hysteresis. This is similar to the heat production, by magnetic hysteresis, in the iron core of a transformer. In this case the molecular magnets are twisted back and forth. This heat is also roughly analagous to that produced by molecular friction in a metal wire, continuously bent back and forth.

12

PHYSICAL ASPECTS

The human body consists both of electrolytes and dielectrics (insulators), see Figure 3. The tissues may be conceived of as being composed of resistances to which condensers are connected in series and parallel. Figures 4 and 5 show resistances so connected to a capacity. We may therefore assume that heat is

1. Molecular Dipoles between Condensor Plates; Electric Field Intensity Zero

2. Molecular Dipoles between Condensor Plates; Electric Field Applied

produced by both mechanisms, providing the frequency is high enough (much higher than in diathermy current). The first process is heat production in electrolytes, according to Joule's law. Since the electrolytes contain both positive and negative ions, they are attracted and repelled respectively by

3. Schematic Representations of Electrolites and Dipoles; Alignment in the Electric Field

the positive and negative plates of the condenser, the anions moving toward the negative and the cations toward the positive pole. The ions in motion collide with adjacent particles, thus producing heat. The second process is heat production by dielectric hysteresis, that is, the twisting of the dipoles of the dielectrics in the condensers.

PHYSICAL ASPECTS

13

The different effects of diathermy and short-wave highfrequency currents may be roughly illustrated by the following fact: a block of wood can be heated in the condenser field by short waves, whereas with diathermy this is impossible. The amount of heat produced in an object or tissue depends mainly upon the intensity of the electric field, the frequency of the current, the dielectric constant, and the specific conductivity of the object or tissue to be exposed. Theoretically and experimentally, it has been shown that for a particular substance the heat generated will be a maximum

II

It 4. Parallel Connection of Resistance and Capacity

5. Series Connection of and Capacity

Resistance

at a specific frequency. In other words, for every tissue there is a frequency which produces an optimum heating effect. According to Pâtzold, the heating reaches its maximum if reaching its maximum at the end of about the ninth hour and regaining its normal level at the end of about the twentieth hour. The increase in cell count often starts within the first fifteen minutes. The total leucocyte count tends to be less pronounced as the treatments progress. The leucocytosis is characterized by an increase in the percentage of polymorphonuclear neutrophils,

SHORT-WAVE TREATMENTS

89

at the expense chiefly of the lymphocytes. In induced leucocytosis, there is an increase in the nonfilamentous (early) forms of the polymorphonuclear neutrophile leucocytes. Bierman used an ultra short-wave apparatus, capable of raising the body temperature about 6° to 7° F. in from 40 to 90 minutes. The treatments generally started in the morning, as they frequently lasted several hours. The patient was placed supine upon a glass-covered litter bed, between the surfaces of the two upright condenser plates—50 x 90 cm.—which were one meter apart. The patient was not in contact with the current, and was wrapped in towels, which were designed to absorb the perspiration and to help the rise of temperature. The patient's head was outside the cabinet. Before treatment, a cleansing enema was given and the patient was allowed a liquid breakfast. Oral and rectal temperature, pulse and respiration rate were recorded. Then the current was turned on. Perspiration started after fifteen minutes and the towels had to be changed to prevent arcing of the current. It was found that individuals respond differently to the treatment. Some have headache, nausea, shortness of breath, palpitation, thirst, or numbness of hands and feet. The face is flushed and the conjunctivae injected. The lips may become pale. The temperature is taken every ten or fifteen minutes by clinical thermometer, the current being turned off meanwhile. An electrocardiophone might be used for recording the work of the heart. When the desired temperature is obtained, the patient is placed under another hood, with a number of carbon filament lamps inside. In this way the temperature is maintained. The patient loses as much as five pounds through the violent sweating. At the end of the treatment, cooling takes place gradually. The treatments are given every other day, or according to the necessities of the disease. Auclair, Dausset, Bierman and others found that ultra short waves are helpful in neurologic conditions (paresis, tabes, multiple sclerosis); polyradiculitis, postencephalitic Parkinsonism and chorea; arthritis (infectious gonorrheal) particularly; thrombo-angiitis obliterans (not always successful); skin diseases (scleroderma, psoriasis; Kaposi skin sarcoma; mycosis fungoides, with transient results only). One case of Raynaud's disease was improved.

90

SHORT-WAVE TREATMENTS

Tenney conducted experiments with artificial fever induced with the 30-meter wave length. He also placed the patients in a boxlike cabinet and exposed their whole body to the irradiation. In 60 to 80 minutes of treatment, the temperature rose from 99.6° F. to 104° and 106°. On the basis of 1,000 treatments, he concludes that the fever created by short waves is less hazardous than that produced by intravenous injections. With short waves the fever can be kept entirely under the control of the operator, if kept below 107° F. Its application is simple and there is very little discomfort to the patient. He believes that this method of producing artificial fever is superior to other methods, and that the therapeutic results obtained are better. Tenney used generalized short-wave diathermy in several varieties of lues, arthritis, bursitis, myositis, and neuritis, generally with fair results. Bierman classifies the different possibilities of short-wave electropyrexia in combating various diseases. In some, high and sustained temperatures will be necessary to accomplish a thermolethal effect upon the invading organism, such, for example, as the gonococcus. In others, a mild degree of temperature elevation will be found more desirable, for example, when aiming at the dilatation of peripheral blood vessels in thrombo-angiitis obliterans. When an increase in leucocytes or increased tissue permeability is desired, a mild temperature elevation may be sufficient. In still other cases, we may find it best to create a mild degree of systemic temperature elevation with a high degree of localized heat. Such an arrangement may correspond to the condition existing when a localized area of infection occurs in the body. Contraindications to the use of "radiothermy," that is, short-wave diathermy of the body as a whole, will naturally vary with the degree of temperature elevation. Elevation of temperature of one or two degrees will not throw so much of a burden on the cardiovascular and other systems of the body as would greater temperature elevations. Severe organic lesions diminish the body's ability to respond to the additional load placed upon it by a rise in temperature. By means of systemic temperature elevation, the body increases its defense activities. Experience indicates that we may vary the character of the hyperthermia produced, as we desire to secure one effect or another. Bierman states that of the various methods available for

SHORT-WAVE

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producing hyperpyrexia, the most effective appears to be that of short-wave treatments. The source of the curative effect of electropyrexia is still an open question. Halphen and Auclair believe that it lies exclusively in the thermal effect of the waves. Belot is of a different opinion. He applied low-intensity waves with little energy output, which created only a slight systemic temperature elevation, believing that the exposure of the entire body to the electric effect of the short waves, rather than their heat effect, to be of curative value. Auclair supports his point of view by a report of a number of cases of tabes, Parkinsonism, poliomyelitis and asthma, in which the raising of the temperature above 104.5° F. proved beneficial. A temperature elevation up to 102.2° F. is thought to be satisfactory in rheumatism, polyarthritis and arthritis. That the source of cure lies elsewhere than in a rise of temperature is emphasized by Wagner- Jauregg, who points out that the belief that malaria therapy cures the paralysis exclusively through hyperthermia is erroneous, as there were some successful malaria treatments which were not accompanied by a rise in temperature. Neither does tuberculin nor staphylococcus vaccine therapy create any considerable fever in the patient. Consequently, the temperature rise is not necessarily the factor that brings about the cure of progressive paralysis. Further research will be needed to throw light on this problem, but aside from the outcome of these investigations, it is not premature to state that short waves hold, in the form of electropyrexia, an important place in the therapeutic field. The literature contains numerous reports on the use of short-wave electropyrexia (those of Babin-Chevaye, Humphris, Cotton, Wilson and Kellner, Binet, Laudat, Nagelschmidt, Bierman, and others). It is suggested that electropyrexia be combined with other therapeutic measures. In the case of syphilis, for example, its combination with specific drug therapy may accelerate the beneficial results. S H O R T - W A V E DIATHERMY AS COMPARED WITH D I A T H E R M Y

Since the advent of short-wave diathermy, its possible advantages over other physiotherapeutic methods, especially diathermy, has been a much-agitated question.

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A score of writers have expressed their views on the differences between short-wave diathermy and diathermy, emphasizing the field of each. A complete misunderstanding of the nature of short-wave diathermy was shown by some authors. Stiebock, in an article published in 1925, in the early days of the development of this method, described his technic, which consisted of placing bare electrodes (not insulated) directly on the skin, concluding that in cases in which resorption of exudates must be accomplished and in all cases in which deep hyperemia must be created, there is no ground for the substitution of any other measure for the very satisfactory diathermic procedure. Considering the method he employed, his evaluation is not one of short-wave diathermy, but rather of the application of short waves in a manner characteristic of diathermy. Following these efforts came a radical change in technic and with it a better understanding of the differences between diathermy and short-wave diathermy, as it is used now. Noack emphasized the even, internal heating achieved by short waves and by no other form of physical therapy, which makes them superior to diathermy in properly selected cases. Nagelschmidt, in 1929, expressed the view that classical diathermy would not be superseded by short-wave diathermy or, as he calls it, "ultradiathermy," but that each would have its own sphere of usefulness. He thinks that the introduction of short-wave diathermy denotes a widening of the whole field of diathermy and opens to therapeutics a sphere in which classical diathermy has been of no value. Conversely, he believes, the new methods are not suitable for the treatment of many clinical conditions in which classical diathermy has been of the greatest possible use. With the continued development of short-wave diathermy, investigators come forward with more and more definite claims. Hinsie, studying the application of short waves to produce electropyrexia, believes that the great advantage in fever treatment by short waves lies in the fact that the temperature can be constantly kept under control. Rausch and others found in the course of numerous experiments that short-wave diathermy is simpler and less hazardous than diathermy and that burns are very rare, or almost impossible. The heat generated is homogeneous in quality, and does not increase pain, which diathermy

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sometimes does. Davis speaks favorably of the ease of application of short-wave diathermy, as compared with the difficulties in diathermy technic. Reiter states that the wave lengths of from 12 to 35 meters can be used in all cases in which diathermy has proved useful, and that the effects are greatly improved by the deep and uniformly penetrating quality of the waves. Furthermore, short waves can be used in acute inflammatory processes in which ordinary diathermy should not be applied. Cases of rheumatism, all forms of arthritis, neuritis, neuralgia, and sciatica are the main subjects for this powerful form of heat application. Schweitzer, comparing diathermy and short-wave diathermy, concludes that the latter requires a simpler technic, is more easily regulated with precision, and is more far-reaching in effect. This view is shared by K o b a k . I t was found by experimentation that the heating of tissue increased with the reduction of the wave length, that is, with the increase of the frequency, together with the electric capacity and conductivity. It was also found that a greater and more uniform penetration of heat within the body took place with short waves than by any other method. We believe, with Mortimer and Osborne, that with the help of phantom model experiments it is impossible with the present technic to measure the amount of heat generated in the living tissues. If we consider the reactions and the compensatory mechanism of the organism, which is under the influence of a complicated and incompletely understood nervous system, we must realize that laboratory experiments, however desirable, are sometimes futile. Mortimer pointed out that the blood flow and the rapid interchange in the living body may render the differences of temperature in the tissues negligible for all practical purposes. A much-emphasized quality of short waves, as McLennan, Burton, Schliephake, Patzold, Reiter and others have shown, is the selective thermal action on tissues. According to this theory there would be for each wave length a maximum heating effect in a given medium. If the selective heating effect were known as the characteristic electrical constant of the substances of the body, it would be possible to treat each separate part of the organism without directly affecting the others. This may

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appear feasible theoretically, but cannot as yet be applied in practice. Selective thermal action, which exists in experiments for different solutions and tissues, would necessitate further observation in the living human organism. Coulter and Carter have recently reported on such work. They were unable to find that such selective thermal action is present in the human body. Numerous model experiments have proved that in shortwave diathermy, when properly applied, heat is generated practically evenly in all layers of the experimental object. In diathermy, on the other hand, the temperature within the object rises much more slowly than that on the surface. The diathermy current, acting by conduction, follows the line of least resistance, and the energy will be transformed into heat, according to Ohm's law. The skin, for instance, which has a high resistance, absorbs a great part of the energy. Consequently only a lesser portion of the total energy is left to heat the tissues beneath the skin. The surface layers of fat again present a zone of high resistance and absorb much of the remaining energy. Bones offer the highest resistance of all, and the general statement may be made that the current which reaches the bones will flow around them without penetrating. It can be stated that in bones no heat of therapeutic value is generated by diathermy. Short waves, on the other hand, present a different picture. As pointed out above, in Chapters II-V inclusive, discussing physics and experimental work, short-wave current acts on the molecules of the substances under treatment, and consequently can affect tissues, such as the inner substance of bone, where diathermy would be less effective. Within the cranium, short waves can generate considerable heat, which cannot be said of diathermy. Gesenius made experimental observations with the laparoscope within the abdominal cavity of animals, noting vasodilatation. He found short waves superior for the purpose to other, classical methods of heat application. The main differences between diathermy and short waves in therapy may be tabulated as follows:

SHORT-WAVE TREATMENTS Diathermy

Frequency Wave length Electrodes Heat generation

500,000 one million/ sec. 600-300 meters Direct contact with body By ohmic losses (Joule's heat)

Heat generation in tissues with best conductivity

Uneven heat production; deep heating difficult :

Selectivity

None

Specificity

None

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Short Waves

10-100 million/sec. 30-3 meters Air-spaced and dielectric-spaced By ohmic losses, in addition to dielectric hysteresis More even heat production in all tissues; deep heating possible more simply and evenly Demonstrated experimentally Demonstrated experimentally

According to the focal-heat and the vibratory theories, short waves generate heat in each cell by dielectric hysteresis and by generation of Joule's heat, in this way attaining a thorough heating of each particle in the treated object. The diathermy current, on the other hand, flows around the cells and penetrates only to a limited extent, creating heat only according to Joule's law. That this is of importance where living tissues are being treated cannot be doubted. DIFFERENCES IN APPLICATION

In diathermy the electrodes are in direct contact with the body surface, whereas in short-wave diathermy the electrodes do not touch the surface to be treated; furthermore, the action of the waves can be regulated, as Schliephake has shown by changing the distance between electrodes and skin. Burns which may occur with short-wave diathermy are usually superficial and heal without marked deformity, as mentioned in the various clinical sections. But the burns consequent to diathermy are, on the other hand, more serious. Naturally, the results obtained by the hand of an expert with classical diathermy may be superior, in certain conditions in which this treatment may be definitely indicated, as com-

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pared with the results achieved with short waves in the hands of a beginner. There is no doubt of the necessity for properly constructed and manufactured apparatus, in the hands of especially skilled physicians, for use in properly selected cases. Only by observing these essential qualifications will short-wave diathermy achieve its greatest development and usefulness. According to Kovdcs, in some cases the clinical results are alike, regardless of the method employed, the choice being guided by convenience. Only further observations will determine the conditions in which short-wave diathermy may be preferable.

VII GENERAL AND MECHANICAL PRINCIPLES IN SHORT-WAVE TECHNIC are two habits which the operator of a short-wave machine should acquire until they become practically second nature. One is to instruct every patient before treatment begins, to inform the technician of any unusual sensation of heat, either in the field under treatment or elsewhere on the body. The second habit recommended is that of testing the skin sensitivity of every patient who is to be subjected to this form of treatment. If the skin sensitivity to heat shows evidence of being diminished or absent, this will serve as a warning to the technician to exercise particular care lest burns be produced on a patient in whom the sensitivity to higher degrees of heat is lessened. The simplest way to perform this test is by using test tubes of cold and warm water. While the technic of treatment of disease conditions is taken up specifically below, Chapters VIII-XVI, a few general principles may be noted here. In the matter of position, it is well to bear in mind that if the patient is comfortable there will be less tendency to shifting of position, either intentional or accidental, during the course of treatment. If rigid electrodes on a stand are used, such shifting of the patient may result in displacement of condensers and misdirection of current, although with wellinsulated electrodes this danger is slight. A table with adjustable ends, so as to raise the head or extremities and to facilitate placing the condensers beneath the patient, is an invaluable aid to good technic. Naturally, such a table should preferably be made of a material which would not act as a conductor of electrical energy, and for this reason also numerous metal parts and attachments are undesirable. A pad should be upon the table, made of an insulating material which is both easily cleaned and disinfected. In certain cases it may be more convenient or desirable to

THERE

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have the patient assume a sitting position, in which case the electrodes are fixed with bands (rubber) or fixed between the hands of a stand. No general rule can be laid down concerning the distance that condensers should be placed from the surface of the body, each case presenting a problem in itself; also, the differences in output of machines must be taken into account. Nevertheless, the general principle should be borne in mind that the depth of reach of the waves may depend upon the distance of the plates from the body. Hence, in practice, the operator should be thoroughly acquainted with the machine he is using, either through experiments on models, or from clinical observation, so as to be able to form an approximate idea as to individual variation of that intensity which will create the best therapeutic conditions without undesirable effects. In case of a deep-seated focus of disease, the distance of the condenser should be increased by means of intervening padding, or withdrawal of rigid electrodes fixed on stands, while for a surface lesion the active condenser will approach nearer the surface. Electrodes, their variations and types, are discussed below, while their physical aspects are dealt with in Chapter I I , " T h e Physical Aspects of Short-Wave Diathermy." The comments made here are purely elementary, and do not cover the many contingencies or problems presented by the individual case. A constant problem with which the technician is faced is, for example, the absorption or deflection of energies by tissues intervening between the focus of disease under treatment and the condensers. For generalized short-wave diathermy (electropyrexia), larger electrodes are used, with the patient within a specially constructed chamber, in order to prevent heat loss and to maintain the temperature at the desired high level. B U R N S AND T H E I R P R E V E N T I O N

The problem of preventing accidents or unpleasant sequelae of short-wave diathermy resolves itself into the prevention of burns, which are, so far, the only deleterious effect to be anticipated. Claims have been made, during the past eight years of

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its use, concerning the dangers of short-wave diathermy aside from superficial burns, but none have been observed. If burns or other accidents occur, the responsibility for them can definitely be placed where it justly falls, that is, upon the lack of experience of the operator or upon unsatisfactory machines or supplies. Burns from short-wave treatment are usually superficial and heal readily, leaving no residuals. Such superficial burns are observed in cases in which much perspiration takes place. Sweat promotes conduction and current concentration, which may, through carelessness, result in first and second-degree burns. As stated above, the responsibility rests squarely upon the technician. For this reason it was suggested at the beginning of this chapter that it should become a habit for the technician to instruct every patient to report any sensation of heat that is too great for comfort at any spot on the body, and to test the skin sensitivity of the patient. Current concentration is especially apt to occur if there is a prominent point in the field under treatment, such as the tip of the nose, the ear and so on. The illustrations below show how current concentration takes place on a prominent point when the electrode is improperly applied, and how current concentration is promoted when opposing skin surfaces are in contact, for example, the knees, the electrodes being on the outer sides. Burns in the former case are prevented by proper air-spacing and shaped electrodes, and in the latter by insuring sufficient space between the contiguous surfaces so that the current can pass evenly. The photograph pictures (fig. 17) such a second-degree burn taking place when the flexible electrode was applied directly to the swollen joints, the current concentration occurring at the illustrated points. These healed, however, within fourteen days, without sequelae. A point which should be noted and emphasized is that by using high wattage-output machines, heating may be of such a degree and so sudden as to cause heat coagulation, either superficial, or deep, as in the case of relatively less vascularized tissues (bone marrow), where the heat transported by the circulation may be less than in other parts of the involved tissue. If the operator is not cautious, taking into account the particularities of his machine, this accident may occur without the

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patient being conscious of more than a sensation of uncomfortable heat. Compression of the treated area, as well as perspiration, also predispose to burning. In order to prevent such regrettable accidents, it is highly important to use such high-output machines with extreme care, and with full knowledge of the possibilities. There seems to be a general tendency on the part of manufacturers to produce machines of very high output, but it has not yet been proved that

16. Proper and Improper Application of Electrodes: Knees a, Improper Application, Causing Current Concentration; 6, Proper Application, Preventing Current Concentration

for general use in short-wave diathermy such machines are to be preferred. They are required only in the case of deep-seated lesions, and most lesions met with in practice of medicine can be adequately treated with machines of lower output. Superficial burns may also occur if electrodes are improperly insulated or poorly manufactured. For example, if the insulation breaks or tears, there may be sparking which may cause burns. Burns have also been observed where cables touch the body apart from the area under treatment, resulting in higher concentration at the points contacted. Here again enters the importance of preliminary instruction of the patient, to report any uncomfortable sensation, no matter where located. Whenever this is done, the technician should at once turn off the current, reapply the electrodes to eliminate any possible error in technic, and

17. Superficial Skin Burns, Caused by Faulty Application of Electrodes a. B u r n s , C a u s e d b y H e a t C o a g u l a t i o n on P r o m i n e n t P o i n t « ; 6, T h e S a m e Lesion« Healed, w i t h o u t P e r m a n e n t S c a r F o r m a t i o n

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make a thorough investigation for the cause of the reported heat sensation. If cables touch the body, adequate padding placed between them and the body will prevent accidents of this sort. An unusual, one might say unique, accident was reported by Kling and Berg in the Journal of the American Medical Association (June 1, 1935). This, a case of third-degree burn, shows the disastrous results that may be brought about by an irresponsible salesman demonstrating a machine of this kind without clinical knowledge—bringing injury to the patient and discrediting in the practitioner's eyes a new therapeutic measure which is efficacious, providing the proper skill and knowledge are brought to its exercise. Heat coagulation of tissues to such a degree, in any normal individual with normal sensibility, must be accompanied by severe pain which would be a warning for immediate interruption of the current. The occurrence of such a severe accident may be interpreted as due either to abnormal sensitivity of the treated area, verging on the pathologic, or to faulty application (compression) of the electrodes and to the extremely strong intensity used. It should be borne in mind that short waves are heat itself and have analgesic properties, and the patient may not notice that small burns have been produced. Therefore, since to date there is no way of exactly measuring the necessary output for a given condition, the dosage rests solely upon the personal experience and judgment of the operator. It may be said, nevertheless, in spite of the difficulties inherent in a measure which is still in process of development, that short-wave diathermy may, on the whole, be considered entirely safe, fewer accidents occurring with this procedure than have occurred in the hands of experienced practitioners employing diathermy. We have only to recall the numerous accidents and disasters in the beginning of the era of diathermy, and especially of X-ray therapy. Summing up, it may be said that, aside from the proper intensity of current furnished by a reliable apparatus, the important factors in the prevention of burns (which so far as we know constitute practically the only danger) are proper airspacing and padding, and a dry skin.

SHORT-WAVE TECHNIC E L E C T R O D E S FOR S H O R T - W A V E

103 DIATHERMY

One of the greatest assets of short-wave diathermy is the fact that action of these wave lengths can be regulated by manipulation of the electrodes toward or away from the skin surface. The factor of control is important, and increased latitude in using the method is given by the use of one smaller and one larger electrode, by placing one nearer and the other farther from the body surface, and by the possibility of using the unipolar method. Experiments have shown that within certain limits the greater the air space between condenser plate and object, the more even will be the heat generated in the various layers of the object treated. If the plates are near, or very near the surface, then the effect on the skin will be greater and the depth effect less. In other words, the greater the distance of the plates from the surface up to a certain point, the more uniform will be the heating action. By proper adjustment of electrodes, it is possible to affect the deep structures as fully or more fully than the superficial layers. If the body lies close to the plates with only a thin dielectric between, and if the temperature of the body layers at different levels is taken, a decided increase will be found in the skin and subcutaneous fat, with diminishing temperature toward the interior. If the plate on one side is moved away from the surface about 2 or 5 cm., then much greater warmth is observed on the other side where the plate contacts. If the plate on the other side is then also moved away, homogenous warmth is observed in all layers. This fact has many practical aspects. If, for example, one wishes to treat one ear more intensively than the other, or if the seat of disease is nearer the skin on one side than on the other, then the condenser plates on that side should be placed nearer the skin than on the opposite side. More localized and concentrated heating may be obtained by a smallersized electrode, placed nearer to the pathological area, in opposition to a larger electrode with greater air space. In the case of a protruding anatomical part or a curved surface area within the condenser field, the concentration of energy lines in the field might become very strong at certain points. Small animals such as rats, when placed in the condenser field, showed burns on the ears, which later became necrotic and

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sloughed off. (See below, Chapter XVI, for a discussion of rats in cancer research.) In general, two electrodes are applied opposite each other. This is called the bipolar system. Groag and Tomberg devised a method requiring only one electrode, designated as the unipolar system. As Figures 18-19 show, the short wave field in this

18. Current Dispersion by the Unipolar Method

19. Current Dispersion by the Bipolar Method

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system is concentrated near the body surface and the energy lines are more dispersed, the farther away they are from the electrode. This system centers the effect of the short waves near the surface, and therefore it is particularly suited for the treatment of diseases in which the pathological area is near the skin. Thus success with the unipolar system has been reported by Groag and Tomberg in furuncles, gangrene, crural ulcer, arthritides, neuritis, neuralgia, thrombo-angiitis obliterans, lumbago, muscular rheumatism, and so on. Another method of treatment is that employing the solenoid, or inductotherm (fig. 20). In this country John R. Merriman, H. F. Holmquest, and S. L. Osborne, and in Vienna, F. Kowarschik, recommended the use of a coil around the part of the body to be treated. In the United States, 25-meter waves, and by Kowarschik the 4.8-meter wave, were used and it was evident that merely by placing a few turns of insulated cable around or about the parts to be treated, an electromagnetic field was created, similar to that obtained between the two electrodes of

20. Inductotherm

short-wave apparatus. This method would be especially useful in the case of the extremities, but general application could be achieved by special devices. According to Merriman et al., its heating characteristics are such that maximal heat is produced

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more readily in the more conductive (vascular) tissues than in the less conductive (adipose) tissue. These investigators believe that this method would meet the requirements of medical diathermy, including the production of hyperpyrexia. Kowarschik's conclusion is that solenoid application may prove to be satisfactory in conditions as yet undefined, especially those of the extremities. To date, however, the solenoid has not superseded the condenser plate in the application of short-wave diathermy, on account of the rapidly decreasing field strength in certain condition. Further experimentation and clinical observation will determine its exact use and its particular field. The bipolar system is used in practically all cases today because, by using electrodes of differing sizes, a smaller on one side and a larger on the other, placing one nearer and the other farther from the surface, one can satisfactorily concentrate the energy near the surface, and can consequently treat all affections for which the unipolar system is suited. In general, two types of electrodes are used: the rigid and the flexible. RIGID E L E C T R O D E S

The first application of short waves was based on experimental work which resulted in the conclusion that the metal electrodes should not touch the body surface directly, lest the undue concentration on the skin result in burns. All electrodes must be insulated. Schliephake used glass as insulating material, in the form of a glass disk, which at the same time fixes the electrode in the proper position and allows for the regulation of its distance from the skin surface. These disks are the so-called glass shoes, and the electrodes equipped with them are the glassshoe electrodes (fig. 21). The electrode is enclosed in the glass shoe, and by means of a screw it may be pushed forward toward the skin or withdrawn from it. This device allows for the required air space and can easily be kept clean. It also has the advantage that the electric field created by it is constant, and not altered by movement of the patient, for example in respiration. From a theoretical point of view, such movement on the part of the patient would allow more concentration, increasing the electric field during expiration and lessening it

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during inspiration. From a practical point of view, however, this seems to be of little importance. The glass shoes are usually so constructed as to be larger than the metal electrode which they enclose. This more easily eliminates the so-called " e d g e " effect. B y the use of electrodes properly constructed, it is possible to treat organs or diseased areas which ordinarily would not be reached by the electrodes used on the outside of the body. B y the use of such special electrodes, the body cavities—for ex-

a

b 21. Glass-Shoe Electrodes

ample, the mouth, vagina, rectum and so on—may be penetrated and treated by the waves. In adnexal affections an electrode, as shown in Figure 22a, can be inserted into the vagina, and one of the usual flat electrodes applied on the outside of the abdomen. The metal parts are naturally enclosed in some insulating material. Such electrodes should be employed chiefly if direct local heat effect is desired, but in practice they have rarely been used and are recommended only for the specialist. F L E X I B L E ELECTRODES

They consist of a metal plate, sheet or gauze, and are encased in some insulating material such as sponge rubber, felt or something similar. This type of electrode is made in different sizes, and can be properly and easily fitted or adjusted to the area to be treated. Flexible electrodes give a fairly even distribution of the electric field, with the least loss of electric energy, and facilitate the nearest approach to the surface when this is desired.

22. Special Electrodes a, Vaginal; 6, Breaat; c and d. Sinus and Tonsil

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Raab and others do not favor rubber-insulated electrodes, claiming that under certain circumstances they may be heated by the short-wave currents. Because of the high dielectric heat losses, they absorb a great part of the energy. This might easily cause burns, especially if the electrode were placed directly upon the skin. The ideal insulation for an electrode seems to be some nonconducting material which would be durable, withstanding the wear and tear of constant use; which would not absorb moisture; and which would have a dielectric constant of one, that is, it would not become heated and would not offer resistance to short waves. Raab recommended a glass pearl net as insulating material, claiming that it would give the proper flexibility, serve as a good insulator, and would not obstruct the evaporation of perspiration. The advantages inherent in flexible electrodes may be best observed in the treatment of various pathological conditions of the head and extremities. Such uses are illustrated below. As can be readily seen, flexible electrodes are satisfactory from the practical point of view (fig. 23). SIZE OF THE ELECTRODES

The size of the electrodes is of primary importance in achieving a cure. The electrodes should be interchangeable, and their size depends upon that of the object to be treated, or upon the surface of the area to be treated. It is self-evident that a smaller electrode should be used in the treatment of a furuncle than would be employed in the case of electropyrexia. One principle of the technic of application is the use of electrodes which are somewhat larger than the focus to be treated. Should the latter be more extensive than the available electrode, the diseased part may be divided into areas, to which treatment may be applied in consecutive order for the proper length of time. SHAPE OF THE ELECTRODES

A great variety of forms and shapes of electrodes are designed which, from a practical point of view, are not of the importance which is often attached to them. They are most frequently

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round, but they may be angular, or a combination of both shapes. With several pairs of different sizes, square, rectangular or other shape, most requirements will be satisfactorily met. It doubtless facilitates treatment if a larger number of electrodes of various shapes are at the disposition of the therapeutist. Such special shapes are recommended for sinuses, tonsils, axillary diseases, breast conditions and for the diseases of the genital tract. Some of these are shown in the accompany-

23. Flexible Electrodes

ing illustrations, and in other sections of this book. See Figure 22a, b, c, d. TECHNIC OF APPLICATION

The electrodes must be placed near to or in contact with the body. In order to assure the proper distance between the electrodes and the skin, a Turkish towel is first laid on the surface to be treated (if flexible electrodes are used). The flexible electrodes are put on top of the towel and, if necessary, fixed to the body by the proper means (rubber bands, adhesive tape, etc.). If the patient lies prone and the electrode will remain fixed by its weight, such aids to fixation may be omitted. In general, however, fixation by weight cannot be recommended, as skin burns may occur through the compression or because of accumulation of sweat. The number of Turkish towels varies ac-

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c o r d i n g t o t h e case, a n d b y m e a n s of t h e m it is possible t o v a r y t h e d i s t a n c e b e t w e e n skin and electrode f r o m 0.5 t o approxim a t e l y 5 c m . T h e a d v a n t a g e of t h e rigid glass e l e c t r o d e is t h a t it l e a v e s t h e area to be treated visible. A l t h o u g h it is possible t o g i v e s h o r t - w a v e t r e a t m e n t t h r o u g h c l o t h i n g , t h i s is not r e c o m m e n d e d for h y g i e n i c reasons (sweat), a n d s h o u l d be resorted t o o n l y if t h e p a t i e n t h a s difficulty in r e m o v i n g his clothes or in dressing himself. I n general, observation of the following rules will guard a g a i n s t m i s a d v e n t u r e : (1) B e sure t h a t y o u r p a t i e n t is n o t unders t a t i n g t h e f a c t w h e n he or she reports t o y o u t h a t t h e s e n s a t i o n of heat felt is l u k e w a r m or w a r m ; it s h o u l d n o t e x c e e d this. (2) T a k e i n t o account those b o n y protrusions w h i c h lie close t o t h e skin. (3) K e e p t h e treated b o d y s e c t i o n dry, a n d free of interfering obstacles. A v o i d s w e a t i n g , a n d r e m o v e adhesives. (4) W a t c h o u t for m e t a l parts, lest t h e y get i n t o t h e field of t r e a t m e n t . Rings, s a f e t y pins, and so on, s h o u l d be r e m o v e d . One c a n n o t d o better t h a n t o s t u d y the t w e n t y - f i v e rules q u o t e d b y K o b a k for t h e a d m i n i s t r a t i o n of s h o r t - w a v e d i a t h e r m y . T h e s e are cited in full as follows: Principles of application.—1. Considering that in radiathermy (shortwave diathermy), the sensitivity of the patient to warmth is the sole reliable guide to the regulation of dosage, it is essential to examine each patient for normal sensitivity to heat and cold, to exclude the presence of affections of the nervous system, which are characterized by loss of sensitivity and to avoid the danger of producing burns. 2. Each patient should be advised that the treatment must produce only moderate and pleasant warmth, and that the moment sensation of intense heat of a painful nature is experienced, he or she should report it to allow adjustments. 3. All metallic substances and objects within the field of treatment must be removed before treatment, to avoid intense localized heating and burns. Watches, keys, pocket knives, and the like must be removed from the clothing. It is not at all impossible that metallic foreign bodies imbedded in the tissues, as for example, old broken needles, bullets, and the like, may seriously interfere with the administration of radiathermy to that region. On the other hand metallic fillings of teeth do not appear to have given rise to any unpleasant effects. 4. Care must be taken when treating regions in which the bones lie close under the skin. Here the patients may complain of painful sensations instead of experiencing the pleasant warmth essential for success with radiathermy. This is known as periosteal pain. It is essential

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at once to switch off the apparatus and to await complete cessation of the unpleasant phenomena, after which treatment may be resumed with moderate dosage. 5. Chairs and tables on which patients are placed for treatment must be free of metal parts for the reasons given under Rule 3. 6. Oilcloth, art leather, old rubber mats, and any moist substance, all of which are so-called semiconductors, should not be employed as pads under any circumstances, not even with covering of nonconducting material. The principal reason is that semiconducting materials may become overheated and deviate energy, which in turn would nullify the effects of treatment. 7. All connecting wires and other metallic appliances to secure the electrodes should be thoroughly insulated and kept at a considerable distance from the patients for obvious reasons. Interposition of felts in incomplete insulation suffices. 8. To secure the proper depth effects the distance between the electrodes and the skin should be not less than one and not more than five centimeters, the variation depending on the size of the electrodes and the make of apparatus. As a rule the larger the electrode the greater should be its distance from the skin. 9. All felt pads used to produce separation of electrodes from the skin must be absolutely dry not only before but throughout the treatment. To prevent these pads from becoming moistened by the patient's perspiration, blotting paper, some cellular material, linen or similar stuff must be interposed between the skin and the felt pad. 10. When it is desired to obtain the maximum effect in treating the chest or the abdomen the following rules should be followed: (a) Set the short-wave apparatus for maximum dosage by the proper skin-electrode distance, subsequent adjustment of dosage being made with the regulating devices of the apparatus, (b) Maximum heat effect will be obtained with an apparatus having the greatest power, with the smallest intrinsic heating of electrodes and the intervening materials (e.g., feltpads) employed to secure skin-electrode distances. 11. Glass electrodes (Schliephake) have a superior depth and effect are therefore particularly indicated when one has to treat thick body parts such as the trunk, deeply located bones, and the like. For glass electrodes, too, cellular material, blotting paper or linen should be interposed to prevent the formation of sweat and resulting sparks, intense heating and burns. 12. Remove clothing in all cases where a maximum effect is aimed at and considerable perspiration may be anticipated, as when one makes use of large electrodes. 13. When short-wave treatment is given for superficial (skin) effects, medium depth effects are essential; for this reason skin-electrode distance must be maintained. It Bhould also be noted that with small

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electrodes the distribution of heat on the skin is not uniform, which becomes especially noticeable at uneven parts of the treated skin. 14. Unipolar treatment having a lesser depth effect is applicable when deep effects are not desired, e.g., when the head is to be treated and flooding of the brain is to be avoided; or in treating superficial lesions in close proximity to bones, in which case the skin-electrode distance should not exceed 20 mm. 15. Longitudinal treatments of extremities should always be given through the patient's clothing. 16. For the longitudinal treatment of extremities and when otherwise a maximum depth effect is either not desired or unattainable, one may make use of moldable electrodes for greater convenience. 17. All electrodes should be larger in area than the diseased part to be treated, in order to stimulate the lymph current of the adjacent structures. 18. During administration of treatments the physician should frequently ascertain by interrogating the patients whether the heat is felt at the proper place and pleasantly. As the resonance indicator of the apparatus, unlike the ammeter on a diathermy apparatus, is not a reliable guide to dosage and as patients frequently become dulled in sensitivity to intense heat after prolonged application, the physician must place his hand to the patient's skin from time to time to ascertain the degree of heating. Use of any regulating appliances must never be entrusted to the patient. 19. Whenever it is desirable to concentrate the short-wave treatment toward one (active) electrode for the purpose of affecting superficial wounds, infections or other lesions, the skin distance of the active electrode should be somewhat less than that of the inactive electrode. 20. As burns are more likely to appear where osseous structures lie close to the skin or where irregularities of contour occur, such as prominences and articulations, one should in all such places insure against such an accident by increasing the skin-electrode distance. Similarly one should not increase without control the dosage, simply because patients state they no longer feel warmth. As was pointed out in Rule 18, patients become dulled to the sense of heat and unnecessary increase of dosage may lead to burns. In all such cases the resonance indicator is of relative value as a guide. 21. With apparatus providing currents of different wave lengths, it is excellent practice to select shorter lengths for depth effect or when one has to treat suppurative processes. Longer wave lengths are best adapted to more superficial lesions, especially those without suppuration. 22. In the application of shorter wave lengths, the physician should exercise special control and watchfulness, as one cannot rely solely on the sensitivity of the skin to heat. Impairment of sensitivity even to a

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slight degree is always to be considered. Undesirable complications are avoidable by care. 23. In all cases affecting the head, especially when involving also the brain, individual reactions must be observed. Not infrequently patients complain of headache, dizziness, or other nervous phenomena, which dictate the usual precautions. 24. In application of radiathermy to patients suffering from heart disease the same precautions must be taken as with any form of heart therapy, including diathermy. Watching the pulse will guard against mishaps. 25. It is recommended that a Neon light in working order be always at hand when administering radiathermy. Occassionally it may become necessary to determine proper reasonance, to check the proper function of the apparatus, or to correct some mechanical defect. It is very unfortunate that some irresponsible manufacturers and salesmen insist that the application of short-wave diathermy is very simple, that it carries no dangers, and above all, that its technic may be acquired by anyone, regardless of the operator's general intelligence or knowledge of medicine. Such unethical propaganda in the interests of sales is only too apt to cast upon this relatively new and, in its proper place efficient, therapeutic agent the onus of quackery. Short-wave diathermy is not a cure-all and it most certainly should not be used without discrimination for every disease that crops up in medical practice. Short-wave diathermy should not be applied unless the pathological condition is clear beyond the possible limit of doubt. Due consideration should be given the question as to whether short-wave diathermy will give better results in a given condition than other forms of treatment, medical or surgical. After such consideration, if the choice falls upon short-wave diathermy, there should also be coupled with its application either the experience of the operator or of other creditable observers, the measure being employed with the utmost care. Ideally, of course, the specialist, familiar with the various therapeutic agents, would employ short-wave diathermy only where it is definitely indicated. It is recommended that the physiotherapeutist seek the advice or guidance of the speoialist. Such an arrangement would prevent the abuse of a good measure—for example, the employment of short-wave diathermy in a condition in which, for the patient's sake, surgery would be

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better. Similarly, there may be occasions when short-wave diathermy would lead to better results if it were supported by medication or specific therapy. It cannot be too often or too emphatically stated that shortwave diathermy is not magic. It is simply a new agent derived from a form of electric energy, which promises in the future to be enrolled with credit in the armamentarium of the physician.

PART V THE CLINICAL APPLICATIONS OF SHORT-WAVE DIATHERMY

VIII INFECTIOUS, ALLERGIC AND METABOLIC DISEASES

G E N E R A L CONSIDERATIONS

is a definite place for short-wave diathermy among modern therapeutic methods. Although, in the eyes of those unfamiliar with the procedure, it may appear open to question, there is no doubt from the clinical evidence presented that there is much in favor of its use, provided the operator is aware of its physiological, pathological and therapeutic action, and is skilled in its employment. From the practical point of view, its effect is chiefly adjuvant, increasing the resistance of the patient against the invading organism. That its action may be more specific and complex is probable, though as yet this is not specifically known. The statement can be made, however, that during the eight years since its first employment, experimental or clinical, upon the human organism, no permanently damaging effects have been observed. It is true that minor accidents have occurred which were attributable either to the variation in the machines on the market, there being no uniformity in those brought out by the different manufacturers, or to lack of knowledge and skill in the operator. It stands to reason that only those thoroughly cognizant of the physical properties of the measures employed, as well as possessing skill and general medical training, should apply short-wave diathermy in human disease. Unfortunately, there are always some who are not qualified to use newer therapeutic procedures, as yet on trial; and even in the case of skilled use, those uncertain effects, good or bad, which accompany a procedure which is still in course of development, are only to be expected. THERE

The results reported in the literature are not always comparable, owing to lack of technical uniformity and absence of full records. This unevenness will be eliminated with further

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development of the speciality. Both negative and positive reports increase our knowledge and furnish a basis for continued experimentation in those diseases which may reasonably be expected to be benefited by this form of treatment, but in which as yet the results are insufficiently checked or the work inadequately controlled. There is another sphere in which shortwave diathermy may be of great use, and that is as an adjunct to classical methods of treatment. It is my hope that the present contribution to the literature, though in many ways necessarily incomplete, may give a general view of the field, both experimental and therapeutic, in which results, good, bad or indifferent, have been obtained with this new medium of treatment, and that it will encourage further research and constructive, critical work. At the same time, it may not be amiss to voice again the reminder that, just as there are many roads to Rome, so there are also many therapeutic measures, and that short-wave diathermy, for the sake of its own future, should not be considered in the light of a cure-all. The patient should be given the benefit of good judgment in the choice of treatment to which he is subjected. Upon the conscience and experience of the physician rests the welfare of the patient. INFECTIOUS

DISEASES

T H E COMMON COLD

The usual forms of treatment of acute rhinitis—exercise, hot baths, fluids—which aim at relief of nasal congestion through peripheral dilatation, can be advantageously superseded by short-wave diathermy. Since this form of treatment comfortably and effectively increases vagotonic and decreases sympathicotonic effects, and results in an intense hyperemia, it fulfills the therapeutic requirements. Symptomatic relief in uncomplicated cases is obtained after from one to.three treatments. The stuffiness in the nose decreases after the first treatment, the air passages become free of obstruction, the headaches subside, and the nasal discharge quickly diminishes. Although the uncomplicated common cold usually runs a short course without treatment, it is so quickly and effectively banished by short-wave diathermy that recourse to this measure cannot be too highly recommended, if only for the sake of the patient's comfort.

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Technic of treatment.—Because of the anatomical position of the nose as a prominent surface organ, a special electrode may be used, not only in order to obtain the best results, but also to prevent undesirable after effects, such as burns. An electrode of this type is shown in Fig. 22c. Such a special electrode aids in the application of the current, as it can be adapted to individual anatomical requirements; and, in combination with the special tonsil electrode (Fig. 22d.) or rigid electrodes, it also greatly facilitates short-wave diathermy. Flat electrodes may result in current concentration, with the danger of overheating of prominent parts, as discussed in Chapter VII, "General and Mechanical Principles in Short-Wave Technic." Special electrodes require only the usual routine attention for use. Electrodes constructed with air spaces are used to advantage. The duration of treatment depends upon the severity of the infection, the usual time being from 10 to 25 minutes. The first treatment should not exceed 10 to 15 minutes, since the headaches which accompany the infection may be intensified by too long a treatment in the beginning. Subjectively, the patient should be conscious of agreeable warmth during the treatment. Treatments are daily at first, for from 10 to 20 minutes each, and are then continued every second or third day. It must be noted, however, that as yet no "specific" wave length has been determined for the clinical varieties of the common cold. PNEUMONIA

Tronside reported 27 cases of pneumonia, treated with short waves, without a fatality. It would be an important achievement were it possible to check the progress of pneumonic processes, and thereby the mortality, by this means. Schittelheim observed a more rapid resolution of the pneumonic infiltration after short-wave diathermy. Reiter favorably influenced suppurative pneumonia. Laqueur and Remzi successfully treated one case of bronchopneumonia after the acute stage had subsided. Hayer emphasized the especially beneficial effects of short waves in the chronic cases in which resolution is protracted. In milder cases of pneumonia in children, Votz used shortwave diathermy with good results. For details of technic in

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pulmonary disease, see Chapter I X , "Diseases of the Respiratory Tract." PULMONARY TUBERCULOSIS

The aim of treatment of this disease is arrest oí the tuberculous process and cicatrization of the disease area, thus achieving cure. To this end medical and surgical means have hitherto been employed. Since the advent of short waves as a new therapeutic agent, Schliephake and Liebesny have directed their attention to its use in tuberculosis. Although their results are as yet inconclusive, since the number of patients treated is too small to be conclusive, the results so far obtained, they believe, justify further investigation. Schliephake describes- variable nonconclusive results in 10 cases. He apparently succeeded in arresting the disease process in some of his other cases, with concurrent improvement in the general condition and with gain in weight. In the exudative form, Raab, and Hancken, noted absorption of the pleuritic effusion. The action is apparently the same as in cases of pleurisy with effusion; the short waves increase the resorptive power of the pleura (fig. 24a). After a few treatments the chest fluid is absorbed. Raab had a case of severe longstanding cavernous tuberculosis of the lung, complicated by serous effusion. This effusion was completely reabsorbed after six treatments with short waves within one month (fig. 24b). These authors failed to relieve cases of tuberculous empyema, especially when complicated by fistula. Schedtler also failed in tuberculous empyema (3 cases), but noted local and symptomatic improvement in 4 cases of tuberculous peritonitis. His results in pleuritis are noted below, in Chapter I X , "Diseases of the Respiratory Tract." In mixed infection, the reported results are both good and bad, Lob reporting failure. In surveying the results of investigators, it must be stated that in the field of tuberculous disease of the lung, short-wave diathermy to date has not proved so successful as in the case of lung abscess and gangrene. Nevertheless, it would seem to be worth while to continue investigations in this field. For principles of technic of application, see Chapter I X .

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ERYSIPELAS

While the usual form of treatment leads to quick resolution, in many cases of erysipelas short-wave diathermy has proved to be remarkably efficacious addition to the physician's weapons against it. If it is diagnosed in the early stages and if no ulcerations are present, cure may be obtained after one or two treatments (Schliephake, Raab, Pflomm, Schweitzer). The grave gangrenous form is also greatly benefited, and a quickly favor-

24. Roentgenograms, Showing Tuberculous Exudate of Six Months' Duration, in a Grave Case of Pulmonary Tuberculosis a, Before Short-Wave D i a t h e r m y ; 6, After 6 Short-Wave Treatment« within 4 Weeks

able outcome may result. The severity of the infection determines the number of treatments, and in severe cases two sessions may be instituted daily. Nevertheless, Lob emphasizes the fact that this form of treatment may not be entirely harmless, and that under improper dosage the local and general symptoms may be aggravated. Insufficient dosage may favor the process, or the results achieved may be no better than those following X-ray or ultraviolet-light therapy. In a septic case with temperature, Weissenberg effected a cure in three weeks. This was the case of a physician who had injured his finger in the course of his duties, followed two days

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later by diffuse edema of the entire arm, accompanied by intense pain. Daily treatments were administered for thirty minutes each at different areas on the diseased arm. The infection became localized and an abscess formed in the axilla, where it drained. According to Weissenberg, the impression was gained that the application of short-wave diathermy prevents the development of general sepsis, and favors a satisfactory outcome. In the general infections—septic conditions—Liebesny recommended short-wave diathermy directed to the liver and spleen, on the assumption that thereby the patient's general condition might be favorably influenced. He bases this idea on his clinical observations. ERYSIPELOID

Infective dermatitis, resembling erysipelas, appears usually on the hands and responds readily to various therapeutic agents. Lob observed the disappearance of symptoms within 3 or 4 days after a few treatments by short waves; this was followed by a cure. Failures were also noted. Technic of treatment.—The preferred wave lengths are those of the short range—4, 6, 8 meters—with a duration of from 15 to 35 minutes per treatment. On the whole, the employment of short-wave diathermy in the pyogenic infections of the skin is justified, and the results of this conservative form of treatment are promising. With improper technic, superficial burns are sometimes, though rarely, observed. These can easily be avoided by instructing the patient properly and by giving attention to appropriate air-spacing with electrodes. The principal cause of burns is perspiration. Hence the patient who perspires markedly should be treated with care. ACTINOMYCOSIS

This chronic infectious disease of cattle, transmissible to man, caused by the parasitic fungus Actinomyces bovis and commonly called "lumpy jaw," may develop in the soft tissues of the lower jaw, with involvement of the neighboring bone. This localization of actinomycosis may be amenable for shortwave treatment. There are no available records that actinomy-

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cosis elsewhere in the organism has been treated successfully. Liebesny succeeded in curing several cases of actinomycosis of the j a w with the 4-meter wave length, giving a t r e a t m e n t daily, 15 to 2 0 minutes being required to achieve results. H e observed t h a t the pain often stops after the first t r e a t m e n t , t h e infiltrated area becomes soft and breaks down, t h e abscesses formed being evacuated b y c o a g u l o t o m y * . Resolution is gradual, to complete healing and return t o normal conditions. I t is considered wise t o continue the short-wave t r e a t m e n t s at longer intervals, a f t e r healing has apparently taken place, in order t o prevent recurrence. Vaccines, preferably autovaccines, described b y Neuber, in conjunction with short-wave diathermy, are favored. Wessely considers short-wave diathermy the t r e a t m e n t t o be preferred in actinomycotic infections. Liebesny claims t h a t cures can be effected only with the shorter wave lengths, around 4 meters, and also states t h a t t r e a t m e n t with the 14-meter wave length aggravated the condition. Groag and T o m b e r g could not confirm Liebesny's beneficial results. According to L o b , after unsuccessful short-wave t r e a t m e n t even severe cases m a y be cured b y electrosurgery. Weissenberg cured 5 cases of actinomycosis in a period of from 3 to 10 weeks. Some of the cases were complicated b y large fistulas. As he obtained uniformly satisfactory results with different wave lengths, this would seem t o speak against the specificity of the 4-meter wave, as claimed b y Liebesny. Nevertheless, it would seem t h a t the lower range—4, 6 meters—is the most effective if equal intensity is used. T h e involved area should be placed well within the electric field. If larger areas are diseased, different sections may be treated daily. ALLERGIC

DISEASES

T h e r e are reports of symptomatic relief, observed in numerous cases of hay fever. BRONCHIAL ASTHMA

Beneficial results were obtained b y Schaffler and R6zsa, and the present author. T h e antispasmodic and the anti-inflamm a t o r y effect of short waves is the basis of their application in •High-frequency electric incision with coagulation.

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this affection. Laqueur compared the action of diathermy with that of short waves, and found that treatment with the latter resulted in a higher percentage of cures. The respiration became freer and easier from the beginning of the treatment, according to Raab and Rollin. It may be that the unduced hyperemia increases bronchial secretion, facilitating expectoration. Gruchella mentions a case in which improvement was obtained after 15 treatments. Osborne, using short waves in bronchial asthma, reported 14 cures, 10 cases improved, 4 failures, and 2 cases lost track of. Laqueur and Remzi had 2 failures and 10 successes. The number of cases reported is as yet very small and conclusions are not justified. We believe that in this complex field of medicine, short-wave diathermy should be used only in association with customary specific treatment, under the supervision of the specialist. D I S E A S E S OF M E T A B O L I S M AND OF THE D U C T L E S S G L A N D S GOUT

According to Raab, the gouty arthritides react well to shortwave diathermy, though Réchou and Babin-Chevaye believe that chronic form presents the best field. They used the treatment only very cautiously in the acute stage. Raab observed in many of his cases that the painful deposit softened after a few treatments, diminishing in size in direct proportion to the decrease in pain. Naturally, short-wave diathermy can be considered a means of achieving symptomatic relief only. Its action lies in the profound local hyperemia induced and the attendant extreme increase in blood and lymph locally. These bring about the dissolution of the tophi, with alleviation of pain. Frequently the blood cholesterin, also, is diminished. Since short-wave diathermy gives symptomatic relief, t should be administered in conjunction with other therapeutic measures, such as diet, drugs, and so on. The electrodes are so placed as to include the diseased area within the electric field. OBESITY

It has been argued that by inducing abundant sweating and increased metabolism, short-wave diathermy should be as effec-

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tive in weight reduction as other physiotherapeutic measures, such as hot air, paraffin, Turkish baths, light treatment, and so on. This is advocated chiefly by the French school. It may be best applied in the form of electropyrexia, especially in the obesity of endocrine imbalance, as for example, in adiposogenital dystrophy. Dausset claims to have obtained lasting results (six months) in a case of Frohlich's disease after fifteen treatments of generalized short-wave diathermy (electropyrexia). This observation may possibly rest upon an improvement in the balance of the internal secretions. DIABETES MELLITUS

There may be a possibility of stimulating the blood supply to the pancreas through short-wave diathermy, and thereby exercising a rejuvenating effect upon the damaged tissue. The idea that the damaged islands may be regenerated though shortwave treatments is purely theoretical, and in order to attempt experiments in this direction it is naturally of first importance that the cells should not be so far degenerated as to be beyond hope of regeneration. In the latter event, Raab states that shortwave diathermy could have no beneficial effects. Therefore, he believes that short-wave diathermy would be of use only in early cases in which the pathological changes have not advanced too far, and that even then, if no actual regeneration could be induced, would only hold the degenerative process in abeyance. Schliephake, working on dogs, found a temporary decrease in the blood sugar after short-wave treatments. Dausset treated a diabetic child of ten years, in whom the diabetes developed following influenza. He claimed to have obtained a normal condition of the urine after ten treatments. One year later the symptoms recurred and the short-wave treatment was repeated again with temporary success. No exact data as to blood chemistry, which might serve as a practical check on results, are given in the literature. DISORDERS OF T H E ENDOCRINE FUNCTION

The following observations are reported for the sole purpose of completing a survey of the work being done with short waves. I t must be stated, however, that the results in endocrinology to

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date need confirmation, and careful and intensive scientific study is necessary to give any estimate of the effect of such treatment in endocrine disorders. So far all is primarily theory, or cases unscientifically observed and reported. In thyrotoxicosis the results are contradictory, an occasional observer reporting improvement in symptoms and another stating that the measure is contraindicated. Weissenberg treated 12 cases of thyrotoxicosis with improvement in all, using weak doses, and marked gain in some. If the question arises as to whether or not short-wave diathermy might not be employed as a preoperative measure, its possible contraindication should not be lost sight of, in view of the increased hyperemia which it induces. Dausset and Babin-Chevaye state that they are able to influence thyroid diseases, changes in the pituitary, and ovarian disturbances. Dausset and Dognon think that at times smaller doses give better results, and may be effective in various endocrine disorders, adiposogenital dystrophy for one. It is of interest to speculate upon the possible effect of short-wave treatment on the hormones influencing growth, and the possible results to those unfortunate patients in whom developmental disturbances have established abnormal body proportions. French authors, led by Dausset, believe that one effect of short-wave treatment may be to accomplish descent of the ectopic testicles and to promote their growth on an endocrine secretory basis. Similarly, in treating the pituitary in amenorrhea, one may succeed in reestablishing normal menstruation. According to Dausset, it should also be possible, by such treatment of the pituitary, to control uterine hemorrhage, to relieve patients suffering from uterine congestion, and to arrest the growth of fibroid tumors. The effect of short waves on the thyroid is evidenced in diminution in size of the gland and especially in decrease in the metabolic rate, with gain in body weight. Tremor, tachycardia and exophthalmos are favorably influenced. On the other hand, hypothyroidism should respond to the invigorating effect of a stimulated blood circulation, through this treatment. Weissenberg states that parenchymatous goiter regressed after 25 treatments, using strong dosages. There was a decrease

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of 1} inches in the size of the neck. This manifestation of improvement was observed in other cases also. Dausset sums up his observations in the comment that shortwave treatment may affect the endocrines either directly, or by stimulating antagonistic hormone secretion. Obviously this is all, so far, pure theory. Jorns and Last experimented on rabbits, and found no injurious effects histologically after short-wave treatment (4 meters) of the thyroid gland, though its function was reduced. From the fact that generalized short-wave treatment of the scalp arrested falling hair and seborrheic conditions, Dausset and Auclair assume that the endocrine function had been improved. There are as yet insufficient observations on the effect of short waves in hyper or hypofunction of the pituitary. It is, however, Weissenberg's belief that the function of the gland may be influenced by such treatment. In 2 cases of amenorrhea, the reappearance of the function occurred, in one after 10 treatments and in the other after 3. He had also noted that in other patients treated for a variety of disorders, the menstrual period recurred earlier than customary. Such observations require confirmation. It would be equally futile to attempt an explanation of the claims that sexual powers at least temporarily are increased after treatment not only of the testes but also of other parts of the body. This is a matter that requires scientific observation and accurate and extensive investigation, and should be viewed with skepticism for the time being.

IX D I S E A S E S OF T H E R E S P I R A T O R Y T R A C T O W I N G to our limited experience in the field of pulmonary disease, we are not, as yet, in a position to pass final judgment upon the usefulness here of short-wave diathermy. Only by summing up the findings of practitioners, some of whom have devoted much of their attention to such cases, can some conception be gained of results in this field. To judge by these reports, it would seem that short-wave diathermy might be developed into a highly effective measure, provided continued study is applied. A good deal depends upon perfecting the technic and upon a clarification of the question of the dosage calculated to give the best results. Naturally, standardization of machines holds an important place here. Such continued study is highly desirable. It is very possible that this form of treatment will serve to reduce both the mortality and the period of convalescence, when used by physicians with adequate experience and knowledge of lung pathology. If no emergency impends, short-wave diathermy may always be tried before surgical intervention is resorted to. Schliephake believed from the beginning that pulmonary disease presented a field for short-wave diathermy. The air in the alveoli and bronci lowers the dielectric constant. Any marked increase of heat is prevented by the quick removal of heat, through vigorous circulation of the blood. Moreover, heat may also be given off in the expired air. This favorable situation is altered, however, when consolidation is present. In such a case the dielectric constant is high and the electrical field is correspondingly dense, or, so to speak, "drowned" within the lesion. Since abscesses and tuberculous tissue are devoid of vessels, the heat can be dissipated only in part, and these masses therefore become heated to a high degree. We see from experiments with bacteria that their activities are retarded by short waves at a higher temperature.

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This intensive local heat production in the pathological area, with its concomitant hyperemia—increased phagocytosis and so on—favors the destruction of bacteria and operates as an aid to the defensive mechanism of the organism against the spread of infection. B y some therapeutic action as yet unexplained, the infection becomes localized, its toxic effects are reduced, and the organism is able to overcome and resolve the pathological process. The indications for short-wave diathermy in thoracic conditions seem to embrace, aside from the specific infections, mainly the nonspecific inflammations and infections of the pleura and lungs. LARYNGITIS

Satisfactory results are reported in acute laryngitis, by specialists who claim that in the majority of cases one treatment is sufficient to cause improvement. In severe cases a number of treatments may be required for cure. It has also been reported, and this coincides with our own observation, that the hoarseness of singers after prolonged singing, which is due to a slight inflammation of the vocal cords, can be remedied with one or two treatments. In chronic conditions, it is questionable whether beneficial or permanent results can be obtained. BRONCHITIS

Short-wave diathermy seems to be of benefit in bronchitis (Ginsberg). Laqueur and Remzi were able to improve 2 out of 3 cases of chronic bronchitis. Berry treated a woman, 4 9 years of age, whose ailment was diagnosed as "chronic bronchial cat a r r h . " Her chief symptoms were a constant cough, worse in winter and upon lying down, which proved very disturbing to rest. For two months she received short-wave diathermy, beginning with daily doses of 15 minutes and gradually increasing to 20. As the treatment proceeded, the length of exposure increased, together with the intervals between treatments; in the last weeks, the treatments were 30 minutes in length, and twice a week. When last seen, 4 months after cessation of treatment, she had been free of cough, in spite of the inclement weather.

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Peters and Tegethoff found short-wave diathermy beneficial in chronic bronchitis, with results better than those following diathermy. We noted improvement after 3 treatments, in one of our patients who suffered from chronic bronchitis, but there was a recurrence after the patient contracted a new cold. In 2 cases the improvement was permanent. BRONCHIECTASIS

Surgical intervention in bronchiectasis all too often disappoints. It is well, therefore, to employ conservative measures first, and among these short-wave diathermy may be included. Schliephake, and Raab, state that in all cases of bronchiectasis treated by short waves, the expectoration is diminished. The former treated a case of bronchiectasis of the right lower lobe in a youth of 16. The patient had previously been treated by diathermy and other measures, and repeated pneumothorax did not improve his condition. He was given 25 treatments, at first daily with the 7-meter wave length; later with the 16-meter wave length, at first daily and later twice a week. In four weeks the patient improved to such an extent that he could be discharged from the hospital, and in four months he was entirely symptom-free, and following his occupation of gardening. Further cases are also reported by Schliephake, and Schedtler. I t is possible that short-wave diathermy decreases the secretion, thus favoring evacuation by the contraction of the vitalized bronchial muscles, providing the histologic changes are not too far advanced. Restitution of normal conditions may result, especially if the bronchiectasis is intrabronchial. Even if only the foul expectoration is reduced or rendered odorless by this form of treatment, this alone constitutes a great relief to the patients. I t seems to us that short-wave diathermy is worthy of trial in this field. EMPHYSEMA

The dyspnea of the patient with emphysema may be relieved by weak doses of short-wave treatment. This was the finding of Weissenberg, who studied a large number of cases.

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After such repeated treatment, with the patient aware of a sensation of mild warmth for about 10 minutes, he is relieved and expectoration is easier. This observer also succeeded in eliminating the irritative cough of infants, by a few weak treatments with short waves. PLEURISY

The observations of Schweitzer, Liebesny and Finaly, Laqueur, Wolfrum, Votz, Schittelheim, and others, would seem to show that short waves are indicated both in dry pleurisy and in pleurisy with effusion. Hayer states that of all pulmonary diseases, pleurisy reacts quickest and most favorably to shortwave diathermy. Absorption of the effusion takes place rapidly and the adhesions and their symptoms are favorably influenced. The regression of the fluid may be observed after the first treatment, and is usually cleared in from 3 to 16 treatments, depending upon the severity of the condition. In 14 cases of dry pleurisy with fever, pain and respiratory disturbance, the results were uniformly good. In 6 of 8 cases of pleurisy with exudate, resolution took place following short-wave diathermy (up to 40 treatments in some), and 2 remained unimproved. These cases were observed by Schedtler who noted that different wave lengths had a similar action. He recommended that puncture always be performed before the treatment. The action of short-wave diathermy is chiefly that of an active hyperemia, increasing the absorbing power of the pleura. In the case of long-standing pleurisy with adhesions, short waves act favorably from a symptomatic point of view, but naturally there are many failures. Laqueur and Lambrecht state that the short waves are less effective in the old adhesive pleurisy than in cases of more recent development. EMPYEMA

Schliephake, Liebesny, Raab, Reiter and others, using shortwave diathermy alone in empyema, report very satisfactory results in the majority of their cases, without surgical intervention, and attribute this favorable outcome to the increase in resorptive power of the pleura, which is stimulated by short-wave

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diathermy and which favors the absorption of the purulent exudate. In postpneumonic empyema, Schliephake repeatedly observed complete absorption within from 3 to 6 weeks. In 2 cases the condition of the patient was so critical that the surgeon hesitated to perform a rib resection. In both patients, the first 2 treatments were followed by marked symptomatic improvement and after further treatment the temperature gradually fell, in the course of from 5 to 6 days, to normal and remained so. The sedimentation time of the red blood cells was greatly decreased, and the subsidence of the effusion could be followed step by step. Within 3 weeks following pleural puncture which before treatment had brought up a thick purulent exudate, another puncture proved negative. Both patients were discharged as cured in 4 weeks. Pleural empyema is absorbed in a short time. Schliephake treated a woman with extensive postpneumonic empyema. I t was decided not to perform a rib resection, as the patient was not likely to withstand such an operation. After 5 daily shortwave treatments, the patient was free from fever and without pain. In the following 2 days the X - r a y shadow cleared up and after three weeks only a pleural thickening remained. The patient gained in weight and was discharged after 4 weeks. Similar improvement has also been shown in interlobar empyema, in which surgery is often difficult. In the case of a 14-year old girl, suffering from chronic right inter-lobar empyema following influenza of pneumococcic origin, short-wave diathermy was instituted by Schliephake as a last resort. The temperature had been continuously high, but fell to normal after 4 days of treatment. Gradual improvement and increase of weight followed, with complete recovery in 5 weeks. Schliephake reports further cases of extensive postpneumonic and interlobar empyema, in which complete resorption of the pus was effected in from 4 to 5 weeks without puncturing or opening the pleural cavity. Adhesions cannot always be avoided, but on the whole are considered fewer than is observed after rib resection. A striking feature is the rapid subsidence of the fever, patients usually being apyretic after from 3 to 5 treatments. The general condition frequently improves after the

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first treatment and insomnia in particular is greatly relieved. This admirable by-effect is evidenced in practically all patients. In 2 of his cases, the empyema was a sequel of Malta fever; the outcome was complete cure. Tuberculous exudates are also absorbed through short-wave diathermy, though a longer period of treatment—one to 2 months—is required. For reports of short-wave diathermy in

a

b 25. Roentgenograms, Showing Gangrenous Interlobar Empyema

a, The Grose Sire of the Lesion and Its Position, before Short-Wave Treatment; b. Seven Weeks after Short-Wave Diathermy. (The Lesion Is Barely Distinguishable and the Patient Has Been Discharged from the Hospital)

tuberculous empyema, see Chapter V I I I , section on "Pulmonary tuberculosis." With the exception of Lob, Schittelheim and Hayer, who claimed to have observed no benefit from short-wave diathermy, all investigators reporting their results in the literature are enthusiastic, advocating without reservation the use of this therapeutic agent in empyema (Neumann). The only contraindication is cardiac decompensation. Short-wave diathermy would appear to be of particular benefit in the encysted form of empyema.

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Abscess of the lung, either single or multiple, is of relatively infrequent incidence. It may be acute or chronic and, if the abscesses are multiple, the customary treatment is incision and drainage. The mortality is as high as from 60 to 85 percent under medical treatment, but this is reduced to about 40 percent by surgery. According to Schliephake, Liebesny, Raab and others, shortwave diathermy improved to an almost unbelievable degree the results in this serious infection. The duration of treatment, using Schliephake's method (larger air-spacing between electrodes and surface, in order to secure more homogeneous, deep action with high energies) was from 3 to 6 weeks. Operation is usually not undertaken at all until such preliminary course of treatments by short waves has been given that it may be possible to avoid surgical intervention. This is desirable, as postoperative convalescence is apt to be very long, and in addition postoperative mutilations and adhesions are frequent. Cure through short-wave diathermy is brought about not only through expectoration, but also by absorption, through the reduction of the infiltrative inflammation around the abscess. This can be clearly followed by serial roentgenograms, which will show a gradual clearing of the shadows. In the final stage only a faint shadow is visible around the abscess in the roentgenogram, but the level of the effusion remains to the last. When the abscess cavity finally begins to shrink, the effusion also disappears. Schliephake reported the largest number of cases of lung abscess (40), in which the progress made was checked simultaneously by roentgenograms and laboratory examinations. Liebesny, who was not successful in treating lung abscess in the beginning, owing to faulty technic, then adopted Schliephake's technic (noted above) and treated 6 cases without failure. Schliephake employed short-wave diathermy in 40 cases of lung abscess, many of them postpneumonic, postinfluenzal, one embolic, and one an aspiration abscess after tonsillectomy. Approximately one-half were accompanied by gangrene. The

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sputum contained a variety of bacteria, among them being the Streptococcus viridans, hemolytic streptococci, Staphylococcus albus and Staphylococcus pyogenes. All but 2 recovered without operation. In only one case was aspiration necessary. An embolic abscess in a man 31 years of age originated from a thrombosed varicose vein in the leg. He had high fever and foul purulent expectoration. The odor disappeared after two treatments with 12-meter waves. After 7 treatments, the patient no longer complained of pain. Roentgenograms demonstrated t h a t

a

b 26. Roentgenograms, Showing Absorption of Lung Abscess

a, A Fluid Level Is Distinguishable below the Clavicle in the Right Upper, Indicating a Large Abecess in the Apex of the Upper Lobe; b. After 3 Weeks of Short-Wave Treatment, the Lesion Has Practically Cleared Up

the abscess had disappeared and had left only a negligibly small shadow in its place. One abscess the size of a fist disappeared after a course of treatments extending over 8 days. In the second roentgenogram only a few faint shadows appeared where the abscess had been. The circumstance should not be overlooked t h a t such an abscess may break through into a bronchus and its contents be coughed up so that a spontaneous cure takes place. But on reexamination of the patient reported, this was seen to be impossible; the amount of the discharge diminished perceptibly immediately after the first treatment. Among 6 cases reported by Liebesny, one was t h a t of a man 29 years of age. The abscess was the size of a hand, situated beneath the right clavicle and characterized by foul expectoration of elastic tissue. The temperature and the amount of

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expectoration increased after 2 treatments, but after 4 the temperature fell and expectoration decreased. Roentgenograms showed decreased opacity, and the expectoration became odorless. After 16 treatments, the expectoration ceased, but further treatment was given as the roentgenograms still showed disease. After 29 treatments, the patient was entirely symptom-free. In cases of lung abscess reported by different authors and collected from the literature, Raab found 90 percent cured after short-wave diathermy. It is to be noted that the rapid discharge of the foul expectoration and the fall of temperature, among other symptoms, indicate that the correct technic is being used and point to continued improvement. Hemorrhage, as an untoward effect following short-wave diathermy, may be avoided by care in treatment (Bauer). Short-wave diathermy in abscess of the lung behaves as in other inflammatory processes, influencing favorably the defensive mechanism of the organism against the pathological process. In healing, the abscess cavity becomes filled with granulation tissue, followed by scar-tissue formation. It seems that in cases of multiple-abscess formation which are not suitable for surgery, short-wave diathermy would be especially indicated, even for those who are conservatively cautious. The astonishingly beneficial results reported in lung abscess are corroborated by X-ray reports, controlled, affirmed and followed up. Further observations may bear out the reports of clinical results of shortwave diathermy, which may be of special benefit for those patients suffering from this highly fatal disease. Judging by these successes, short-wave diathermy may become one of the most valuable of our conservative curative agents. PULMONARY GANGRENE

Gangrene may follow lobar pneumonia in debilitated subjects. The disease is not limited, as in the case of lung abscess, but spreads. The foul expectoration is characteristic. The prognosis is very poor. The treatment, if possible, is surgical. Nevertheless, a favorable outcome has been reported by Schliephake in the case of a boy 9 years of age, with bilateral suppura-

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tive pneumonia, in whom complete healing took place in 5 weeks. Liebesny treated gangrene of the left lower lobe in a man 39 years of age. Roentgenograms demonstrated a fist-sized abscess in the left lower area. Expectoration increased and the temperature rose after two treatments, but decreased after the third. After the seventh treatment, the expectoration amounted to 100 cc., as against 350 cc. before treatment started and 500 cc. after the first two treatments. In all, 40 treatments were given of from 20 to 60 minutes each, until improvement. In the other cases improvement was noted after the fourth treatment, as shown by physical examination and roentgenograms. When 15meter wave lengths were used, convalescence was longer than when the 8-meter wave was employed. In the latter case, cure eventuated after 17 treatments. T E C H N I C OF T R E A T M E N T

T h e position of the patient during treatment does not appear to be of special importance in the case of pulmonary disease. T h e recumbent position or the lateral may be selected, according to individual requirement and in the judgment of the operator, while if necessary the patient may be seated. T h e important thing is to bring the diseased area well within the condensor field. The electrodes should be large enough to create an adequate electric field and should be placed at a distance of several centimeters from the skin, in order to secure homogeneous, deep action at the desired level (Schliephake method). For this purpose it is recommended that the electrodes be placed anteroposteriorly and, in order to avoid improper concentration, the electrodes may be flexible, shaping easily and adequately to the chest wall. Larger rigid electrodes are used for concentration at greater depth. F r o m Schliephake's laboratory and clinical experiments, we know that a special technic is required to secure homogenous, deep action with short waves. T o this end it is necessary to employ an apparatus with a wattage sufficient to give such deep effect (above 300 watts). T h e recommended wave lengths are around 6 meters and the treatments daily from 10 to 20 or to 30 minutes in duration.

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According to Raab, greater energies are not necessary, as the short waves easily penetrate the chest wall and the air-containing lung tissue. It seems reasonable, however, to favor higherpowered apparatus in treating cases of more extensive pathological processes with more infiltration. The dosage is not yet exactly determined, and the treatment is guided by the patient's subjective sensations and by the experience of the physician. I t is individual in each case, depending upon the reaction on the part of the patient and on the pathological condition. No rule can be given at present, and perhaps not in the immediate future. The treatment depends upon the symptoms. The subjective feeling of the patient should be carefully noted. Any complaint not attributable to the pathological condition may require modification of the technic used, such, for example, as less intensity. The intensity should be so regulated that the patient will feel agreeable warmth in the depth of the chest. The duration of the first treatment should not exceed 10 or 15 minutes. Then, if the patient has shown no additional symptoms, the time may be increased to 15 or 20 minutes. After longer sessions patients sometimes complain of a sensation of light pressure and dyspnea, beginning two or three hours after the treatment and lasting a few hours. This is attributable (Schliephake) to the intense hyperemia of the tissue. Where these complaints occur, the intensity and the time of treatment should not be raised further. The dosage may be increased until a sensation of pressure in the chest follows the treatment, but this should not be uncomfortable for the patient. Another symptom complained of, especially in the case of pleurisy treated by short waves, is pricking—mild stabbing—pain in the chest, but this is transitory and of no significance. If the cough increases, the intensity should be decreased in the following treatment. An increase of temperature of 1° or 2° F . is frequently observed after treatment, but this usually falls within one or 2 hours. The rise in temperature is attributed not only to the internal heat generated by short waves, but also to the increased local metabolism. Schliephake observed a rise of about 1° F . in the evening temperature, after treating productive cirrhotic

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tuberculosis of the lungs. In this case the patient did not have an evening rise of temperature before short-wave treatment. Observations on blood pressure showed a fall, with a return to the earlier level after a few hours. Investigators concur in their observations that in no case treated did the patient exhibit symptoms, either during or after any treatment, which would necessitate termination of the therapy during the course of the illness. In every case of fatal outcome, death could not be attributed to short-wave diathermy. Proper dosage, as determined from experience and numerous observations, gives only beneficial results. It is to be hoped that in the future there will be standardized apparatus put out by the manufacturers, and that the measurement of short-wave energies will be brought to a degree of exactness which will facilitate accurate dosage.

X D I S E A S E S OF T H E G A S T R O - I N T E S T I N A L T R A C T

THE ORAL CAVITY

SHORT-WAVE diathermy may be employed with benefit in the various pyogenic infections and inflammations of the mouth. Ulceration of the soft parts may be favorably influenced. Wagner believes that the more acute the infection, the more rapid is the response. It should be stated emphatically that any chronic ulcer or any lesion in the mouth that shows no tendency to heal should be considered cancerous until proved otherwise by biopsy. There is as yet inadequate data on tuberculosis and syphilitic lesions of the oral cavity. Weissenberg observed improvement of subjective symptoms in cases of aphthous infection. Fiandaca treated a young patient who developed noma during convalescence from typhoid fever. The process was arrested after 9 treatments, given daily for from 10 to 15 minutes. The report is illustrated with photographs. T H E D E N T A L STRUCTURES

Short-wave diathermy has proved to be of benefit in the numerous infectious processes of the dental structures. A number of investigators, among them Schliephake, Raab, v. Kohler, Liebesny, Schweitzer, Weinmann and Weissenberg, have reported cures in the treatment of gingivitis, periodontitis, purulent infection of the teeth, dental sinuses and granulomas. According to Schliephake, painful dental abscesses react quickly and favorably to short-wave diathermy. In one of his cases exhibiting a dental abscess of 14 days' duration, there was cessation of pain after the first treatment and complete healing after two subsequent applications. Fistulas react equally well. Employing short-wave diathermy, Schliephake succeeded in

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closing a long-standing dental fistula in three days. In our clinic we have observed, in the case of a patient treated for sinusitis, the diminution of the purulent secretion, coinciding with improvement of the subjective symptoms of the dental fistula but not such dramatic cures were obtained. Dental abscesses, according to Sparkenberg, can be cured by short-wave diathermy alone. Dental granulomas, which may act as foci of infection, frequently occur on teeth which support a crown or bridge and which, if extracted, would be greatly missed. According to Wagner, Reiter and Last, such granulomas can be cured by short-wave diathermy. In the course of treating several patients for chronic muscular rheumatism, Schliephake noted the complete amelioration of dental granulomas. Parodontitis may be cured, or in any case improved, by this form of therapy. In 4 cases reported by Schliephake, all the teeth were affected, the duration having been of 3 months and one, 2 and 10 years respectively. Cure took place in 3 of the cases after 4, 8 and 14 treatments respectively, over a period ranging from 4 to 14 days. The 14-meter wave length was used. In a severe case, discharging pus from numerous abscesses, cure was achieved only after 82 treatments in 80 days, with the 14meter wave length. R a a b claims that bone atrophy may be arrested by the action of short waves and, conversely, that bone production can be promoted by these wave lengths, through their stimulating action on the local metabolic processes and by the elimination of infection. Periodontitis has been reported cured in 2 or 3 treatments, granulomas in about 6 treatments, using the 16-meter wave length. Lux, however, could not obtain such results, which may possibly be accounted for by the differences in technic and apparatus. Technic of treatment.—The electrodes are placed on the cheeks, including the affected area and in such a way as to cover the upper and lower mandibles. The electrode on the affected side may be nearer to the lesion. The treatment should be from 10 to 30 minutes daily at first, and then on every second or third day. T h e wave lengths employed varied in the hands of

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different investigators, Reiter employing the 30-meter wave length and Schliephake favoring 4 to 14-meter wave lengths. TONSILLITIS

Short-wave diathermy opens a new field for the eradication of focal infection. In cases of subacute and acute tonsillitis, in which tonsillectomy is contraindicated because of the unfavorable condition of the patient, short-wave treatments can be given

28. Roentgenograms, Showing Dental Granuloma a. Before Short-Wave T r e a t m e n t ; b. After 6 Treatments

Short-Wave

before the proposed operation and may even render it unnecessary. Weissenberg believes that such preliminary treatment will prevent possible complications such as sepsis, metastatic abscesses, and so on. Stiebôck employed short-wave diathermy in diseased conditions of the tonsils in which surgery was contraindicated because of old age, hemophilia or cardiac or nervous disorders. He reported satisfactory results, and later used the same treatment with equal benefit in Vincent's angina. Weissenberg also reported a high percentage of favorable results, obtained in a short time through the use of this measure. Groag states that angina should be treated with short waves for the purpose of preventing the complication which may originate from tonsillitis. This condition may be cured at most within three days. In acute septic tonsillitis, short-wave diathermy is considered of value by Reiter, Schaffler and Rôzsa, and in several cases of acute tonsillitis we observed a spontaneous fall of temperature with improvement of the objective and subjective symptoms. In one case of proved streptococcus tonsillitis of two days' duration and showing a temperature of 102° F., the patient

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had immediate relief from pain and was able to swallow after one treatment each with 6 and 12-meter wave length for 10 minutes. Six hours later the temperature had fallen. Our impression coincides with that of other observers, that short-wave diathermy is indicated in tonsillitis. Nevertheless, further observations are necessary, in order to establish the basis of its specific curative value. It is a very difficult task to evaluate any one specific therapeutic agent in diseases of the mouth and throat, principally because of the great variety of disorders and because of the individual pathological history presented by each patient. It seems to us that in badly infected tonsils short-wave diathermy may be used as preoperative treatment, and that in cases in which surgical removal of the tonsils is contraindicated, short-wave diathermy would be an especially valuable method of treatment. Technic of treatment.—Rigid or special electrodes are recommended for the treatment of tonsillitis (fig. 22d). The diseased area is placed between the electrodes and a current is employed which will give the patient a sensation of agreeable warmth. The treatments should be given daily or every second day, for from 15 to 25 minutes. It is best to combine short-wave diathermy with other routine treatments. SPASM OF T H E E S O P H A G U S

Weissenberg reported the case of a man of 70 who gave a history of spasm of the esophagus of many years' duration. He improved after the first 2 treatments with short waves to the extent of being able to swallow fluids. He was symptom-free after 6 months of treatments, comprising 10 consecutive treatments with weak dosage. The recurrences were improved with further treatments with weak dosage. Weissenberg states that functional spastic conditions of the esophagus, as well as of the cardia and pylorus, respond favorably to the antispasmodic action of short waves. THE

STOMACH

GASTRITIS

A number of investigators, among them Hancken, Griibel, Noack, Schweitzer, and Wolfrum, according to Raab, found

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that short-wave diathermy in gastritis relieved the thirst, heartburn, and vomiting. These few observations, however, do not permit the drawing of definite conclusions. PEPTIC ULCER

Concerning the effect of heat on the secretory activity of the stomach, Miiller, and independently Bogendorfer, say that heat applications would result in decrease of the secretion and of the hydrochloric acid. Cold, on the other hand, would increase the secretion and thereby also the hydrochloric-acid content. Bogendorfer and Sell attributed this to reflex action through termic irritation. The pneumogastric stimulates, the sympathetic inhibits, the secretory activity of the stomach. The action of short waves, therefore, would seem to be stimulating to the pneumogastric and inhibiting to the sympathetic. On these grounds it was logical to introduce short-wave diathermy as a corrective of impaired secretory function of the digestive tract (Schliephake). Mahlo has done considerable research work in this field, principally by serial experiments on fasting men. Where insufficient secretion was present, he used for his research work 300 cc. of a 5-percent alcohol solution, making certain that no saliva was swallowed with it. This was removed after the treatment. According to him, short-wave treatment of the cardia would produce a different result from that which follows application to the pylorus. That the action of short waves cannot be explained as being solely the effect of heat is evidenced by the fact that a decrease in leucocytes occurs ten minutes after the start of the treatment, as noted by Schliephake, von Oettingen and SchultzeRhonhof. This temporary leucopenia changes to a leucocytosis, lasting from 9 to 24 hours. Mahlo believes that this may be secondary to short-wave treatment of the spleen. The action of short waves is not uniform. Mahlo examined 25 cases roentgenographically, and invariably found that increased peristalsis (confirmed by Bauer) was induced by short-wave diathermy, stopping at once with the interruption of the current. Secretion was also increased to such a degree that it was necessary to remove 25 cc. of clear fluid every 10 minutes. This effect

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lasted 40 or 50 minutes, descreasing thereafter, though treatment continued. The longest period of increased secretion was 70 minutes, but the degree of acidity diminished, which is in line with observations of the effect of other forms of heat therapy. Mahlo believes that in the majority of chronic ulcers, shortwave diathermy may create conditions favorable to healing. In most of the cases, acidity decreased, to anacidity in some. This diminution of hydrochloric acid is not constant, however. In a number of cases motility is increased, as observed roentgenographically, and this may be so pronounced that no secretion can be obtained. The analgesic effect of short-wave diathermy is no small factor in the symptomatic improvement. From his work, Mahlo draws the conclusion that short-wave diathermy can be a valuable adjuvant in the management of peptic ulcer. Schliephake agrees with Raab that no conclusions can as yet be drawn as to the ultimate effect of short-wave diathermy of peptic ulcer, since the cases treated are as yet too few. Hancken and Schütz found that even long-standing ulcers can be improved by short-wave diathermy, their opinion being based on roentgenographic control of those treated. Among our cases was one of marginal recurrent ulcer. T. McM., male, 29 years old, had had a gastric resection for peptic ulcer a year previous. He came now with symptoms of recurrence. Roentgenograms revealed the typical crater of a marginal ulcer at the stoma. Short-wave treatment was started with the 12meter wave length, and given in daily sessions for from 10 to 15 minutes. Definite symptomatic improvement was evident after the first 4, after which the treatments were given every second day, with further improvement. Following the twelfth treatment, the patient again complained of slight pain and vomited about one ounce of dark red blood. Treatment was suspended for 4 days, and then continued. Within a month, 15 treatments were given, at the end of which roentgenograms showed no signs of ulcer. The patient felt entirely relieved, except for occasional nocturnal pain which was relieved by alkalines or milk. The only dietary restriction was that he was kept to soft food. The patient returned to work 2 weeks after treatment was started, and roentgenograms 2 months later were negative. Five months

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after treatment he had gained 35 pounds and felt much improved. It was again necessary to operate upon him a year later. Although this is but a single case, it would seem that shortwave diathermy has possibilities as a therapeutic agent in peptic ulcer, especially of the marginal type. From Mahlo's research it is clear that acidity may diminish, and even change to the alkaline side. This effect, coupled with the analgesic action of short waves, may create conditions definitely favorable to heal-

29. Roentgenograms, Showing Recurrent Postoperative Marginal Ulcer a. Ail Arrow Indicates a Sharply Defined Niche of Marginal Ulcer; b. Following a Course of Short-Wave Diathermy, the Niche Is No Longer Discernible

ing. On the other hand, we observed that intensive dosage and too frequent application may occasion hemorrhage, which complicated the picture. The results obtained do not permit an accurate evaluation of the possible effect on organic lesions of the stomach and duodenum. We know that chronic ulcers, especially in persons of advanced age, become carcinomatous in from 2 to 10 percent, according to different authors, for which reason surgery should, if possible, be resorted to. There may, however, be cases of recurrent marginal ulcer following operation. It is in such cases that short-wave diathermy, combined with proper medical treatment, may give favorable results. To substantiate this impression, however, larger series of cases so managed and carefully observed, are necessary in the future. Weissenberg achieved

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symptomatic improvement after short-wave diathermy with weak doses, in several of his cases presenting hyperacidity with or without peptic ulcer. In ulcer with callus and in long-standing ulcers showing no tendency to heal and holding the threat of malignant degeneration, surgery is indicated. GASTRIC NEUROSES

A favorable effect of short-wave diathermy is shown in gastric neuroses. Peterson's observations are based on 130 such cases. He found that in cases with pyloric hypertrophy in which tenderness is present in the pyloric region, the symptoms subside after from 4 to 5 short-wave treatments. This beneficial effect lasts for several months, as verified by follow-up examinations. He believes, therefore, that regeneration of diseased ganglia and nerve substance of the sympathetic nervous system may be induced by short-wave diathermy. Weissenberg states that the irritable stomach may be cured by a single treatment with weak doses. He bases this assertion on his personal experience. T H E INTESTINES

Observations and case reports are scattered, a variety of diseases having been treated, but by and large no extensive series were studied and too often no details were given. This dearth of accurate analysis impairs the value of any conclusions that may have been arrived at. Rollin succeeded in improving a case of tuberculous colitis, with bleeding and discharge, in 12 treatments. Schedtler was successful in 3 cases. Kobak treated spastic colitis, and stated that short-wave diathermy proved beneficial. Without mentioning details, Babin-Chevaye, Hancken and others reported favorable results. In spastic conditions, for example spastic constipation, short-wave diathermy may be of benefit. R6chou, Laqueur, Remzi, Schliephake and Schweitzer reported improvement in chronic appendicitis and abdominal adhesions, especially those formed after operation. Schliephake obtained improvement in cases of perityphlitis and peritonitis and in inflammatory adhesions, and this was confirmed by Halphen and Auclair.

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In generalized peritonitis, Lob described treatment prolonged to 10 hours with favorable outcome. This observation is very interesting, as no damaging effects were observed after so long a period of treatment. This author also observed the beneficial effects of the measure in tuberculous peritonitis. In the case of gonorrheal infections of the rectum, shortwave diathermy may be beneficially applied, it is believed, but this remains to be substantiated. The inflammatory conditions and infections of the rectum and anal region should prove no exception to the benefit exercised in such pathological states by short-wave diathermy. Anal fistulas, perirectal abscesses and inflamed hemorrhoids may properly be treated with short waves. At least, its application may be tried preoperatively. We had a case, a young girl, who came in with a painful recurrent incomplete anal fistula of long standing, with periodic purulent discharge and infiltration. Three consecutive daily treatments resulted in absorption of the infiltration and reduction of the purulent to a slight serous discharge. This disappeared within 3 days without further treatment. A follow-up examination 6 months later showed the lesion to be completely healed. This one observation also needs confirmation by other studies. Weissenberg achieved beneficial results with short-wave diathermy in chronic nonspecific rectal disease and rectal tenesmus. T H E B I L I A R Y PASSAGES

Experience with short-wave diathermy in inflammations of the biliary tract is as yet insufficient to justify a conclusive discussion of the subject. More extensive observations, with careful checking by follow-up examinations, are necessary to substantiate the claims made for it in this field, as compared with other forms of therapy. It is possible, therefore, only to report the literature to date. It would seem that acute and chronic uncomplicated inflammations of the biliary passages are amenable to short-wave diathermy. As an adjunct to surgery in cases of cholecystitis with stones, this form of treatment is of possible value, since it reduces inflammation preparatory to surgical intervention, which may then be undertaken with less

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risk. Raab warns us, however, that in such cases the treatment should be milder in degree, in order to avoid the precipitation of attacks of colic resulting from the irritation of intensive treatment. Dietrich reported favorable results after a few sessions, in 14 cases of chronic cholecystitis; and Wolfrum, Leopolde, Drews, and others consider short-wave diathermy positively indicated in this condition. Kobak found that the gall-bladder symptoms were relieved after a few treatments, though this observation leaves the question of cure or continued progress unanswered. Raab sent a questionnaire to 20 physicians, and of these only 2 reported unfavorable results from this form of therapy. One case of chronic cholangitis following dysentery, reacted in attacks of colic. The other, a case of chronic cholecystitis, failed to show any improvement after short-wave diathermy. Weise subjected himself to this form of treatment in his third relapse, accompanied by violent pain, and obtained lasting beneficial results. Lambrecht reported 16 cases of cholecystitis with cure in 10, improvement in 5 and failure in one, after an average of from 8 to 10 sessions. Laqueur and Remzi obtained satisfactory results in their 4 cases of cholecystitis and one of cirrhosis of the liver. Schweitzer proved the subsidence of inflammation by using the duodenal tube as a control. Hancken reported a case of proved typhoid cholecystitis. He succeeded in reducing the patient's symptoms in 6 treatments, and after the cure typhoid bacilli could no longer be demonstrated. In a case of cholangitis with stubborn jaundice which proved resistant to other measures, Walter reported success after 3 sessions with short-wave diathermy. Peemoller, R6chou and Babin-Chevaye reported favorable results in hepatitis, cholecystitis, and cirrhosis. On the basis of a study of a large number of cases, Wolf advises the use of short-wave diathermy in cases of subacute and subchronic cholecystitis. These respond readily to this treatment, as a rule, and the period needed for cure is shortened. Those, however, who do not respond readily should then be treated by the classic methods. Acute cases, with definite peritoneal symptoms, are surgical problems to begin with.

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According to his experience, patients feel relieved after the first treatment, which is directed toward the upper abdomen. This amelioration may be due to increased blood circulation (hyperemia), and diminished edema, which reduces pain. After 2 or 3 treatments, with improvement of subjective symptoms, the temperature falls, the icterus diminishes and bile disappears from the urine. In cases of subacute, subfebrile cholecystitis, with moderate icterus, in which other therapy had failed, shortwave diathermy was surprisingly effective. In those with marked icterus, duodenal lavage with a 5 percent solution of magnesium sulphate is advised, in combination with short-wave diathermy. Patients with recurrent attacks of colic are not suitable subjects for short-wave diathermy and, if other conservative measures fail, operation must be resorted to. Haas and Lob made the interesting observation that pancreatitis may be successfully treated with short waves. T E C H N I C OF T R E A T M E N T

In treating intra-abdominal disease with short waves, the patient is, if possible, placed in the lateral position, either right or left. This avoids current concentration by compression or by accumulated perspiration, should the patient be lying upon the electrode, which might result in skin burns. In gall-bladder disease, it is preferable to have the patient lying upon the left side. The electrodes are selected according to the action desired. If a localized process is to be treated, a small electrode is placed on the abdominal site and a larger one upon the back. The distance between electrode and skin surface may also be altered, according to requirement of concentration at a given level. Weak doses are recommended, especially in ulcers and spastic conditions. Weissenberg observed that in one of his cases the condition became worse after strong doses (sensation of intense heat), and improved again when weaker doses were again resorted to (slight sensation of heat). Bearing in mind the observations of McLellan, Burton and Schliephake that liver heats more readily than other tissue, the intensity used in this region should be less than that employed in other intraabdominal inflammations. Wave lengths of from 6 to 15 meters were used. In the

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neuroses the duration of treatments may be from 10 to 20 minutes, but in ulcer a mild current for from 5 to 15 minutes should be employed as a precautionary technic, to avoid possible hemorrhage. The danger of bleeding in cases of ulcer treated by short waves cannot be emphasized too strongly. This may be the result of a marked hyperemia induced by this treatment, and may take place easily if the blood vessels in the diseased area are impaired, when overdistention of the vessels may result in rupture. Although hemorrhages were observed by Mahlo and by us, it must be said that they were not of serious import, although in the long run they may be so. In treating subacute and subchronic cholecystitis, Wolf suggested beginning with from 3 to 5 minutes' exposure daily, increasing the time gradually to from 10 to 20 minutes over a period ranging from 3 to 22 days, and using the 15-meter wave.

XI DISEASES OF T H E GENITO-URINARY TRACT

T H E URINARY T R A C T CYSTITIS

Heymann was able to cure a case of tuberculous cystitis with short waves, after the tuberculous kidney had been removed. PYELITIS

According to Raab, short-wave diathermy is especially indicated in this infection. In one of his patients pyelitis recurred at short intervals, with high temperature and much purulent discharge. Medical treatment with pelvic lavage was unsuccessful. After two short-wave treatments the patient's condition was improved, and the temperature was normal; and after several succeeding treatments, pus and bacteria were eliminated from the picture. The leucocytosis disappeared, and when seen several months later the patient was free of symptoms. Rollin, Walter and Dietrich confirmed this observation with their own results. Schweitzer, however, observed in one case increased pain without improvement after the treatment. Schliephake also failed in his cases. Votz believes that pyelitis in children can be favorably influenced by short-wave diathermy. The studies of Fabian and Graham showed that longer wave lengths, 20 to 40 meters, stimulate the growth of Bacillus coli. It would seem logical, therefore, to employ greater intensities and short-wave lengths—6 to 8 meters—in Bacillus coli pyelitis. Short-wave diathermy may be of benefit in stubborn chronic infections and in acute infections in which tumors, calculi and tuberculosis have been eliminated. Nevertheless, before crediting short-wave diathermy with the place claimed for it by Raab, further accurate observations are necessary.

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Whether pyelitis or pyelonephritis should preferably be treated with short waves, remains to be demonstrated by further experimentation. NEPHRITIS

Short-wave diathermy may be of benefit in uremia, by increasing the functional activity of the kidney and by lowering the blood pressure. The effect of short waves on blood pressure was shown by Rausch and others, who demonstrated that the blood pressure decreased 15 to 30 mm. Hg after short-wave diathermy. Followtreatment, the decrease in blood pressure persisted for a period (of days or weeks), as described also in the discussion of essential hypertension. The degree of permanent benefit in hypertension depends upon the anatomical changes that have taken place in the kidney and arteries. The best results are obtained in the early stages, when the blood pressure is characterized by a great lability. By repeated treatments, one may secure in such patients a condition that will be satisfactory for years. In the type in which advanced arteriosclerosis is present, the results are only transitory. Short-wave diathermy is, therefore, important only from the point of view of symptomatic therapy. Rausch also expressed the view that in the presence of parenchymatous changes, acute or chronic, short waves exert a more favorable influence than diathermy on the functional activity of the kidney. Votz believes that acute nephritis in children may be favorably influenced by short waves. Hellfors observed, in 2 of his cases of subacute nephritis, decided improvement after from 5 to 10 treatments. The albumin in the urine during the period of short-wave diathermy decreased from 2.5 to 1.5 percent. Rausch treated 14 cases of nephritis. The treatment lasted as a rule from 30 minutes to one hour. After the first treatment, the blood pressure dropped 15 to 30 mm. Hg, and this reduction was sustained, owing to the continued treatments. After from 4 to 5 sessions, the patients improved. Rausch suggests that further treatments of shorter duration, administered at longer intervals, would be effective in maintaining the improved condition of these patients.

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Dietrich saw improvement in 11 of his cases of nephritis, particularly marked in anuria, when the kidney region was exposed to treatment twice daily for one or 2 hours. After 3 or 4 days, secretion of urine was resumed. Schliephake claims to have obtained satisfactory results, manifested mainly in symptomatic improvement, in cases of nephritis. The observations reported are as yet inconclusive but there are indications that disordered kidney function may be benefited to some extent by short-wave diathermy. This applies in particular to the acute nephritides, for example, glomerulonephritis. Weissenberg observed cessation of headache following one short-wave treatment in chronic nephritis. It is recommended that the blood pressure be measured during and after treatment, as a control on the fall produced, as well as every half hour following treatment. The blood pressure falls rather quickly during treatment, arriving at its minimum usually toward the end, and remaining at that level for half an hour after treatment. By continued treatment the blood pressure falls slowly to lower figures. At these later sessions, the fall will not be more than 5 or 10 mm. Hg during treatment, the greatest fall occurring during the first treatment. PERIRENAL ABSCESS

Schliephake informs us that perinephritic abscesses may be treated successfully by short-wave diathermy, with or without surgery, and that when combined with surgery, convalescence is shortened. In a boy 8 years of age, perinephritic abscess followed rupture of the kidney after suture. A fistula formed, accompanied by high temperature. Short-wave diathermy cured the condition in 4 weeks. In a man 72 years old, Mahlo treated a metastatic perinephritic abscess which had originated from a furuncle of the nose. Before the short-wave diathermy was started, the patient had had, over a period of several weeks, high fever, malaise, loss of weight, pain in the left renal region radiating to the left thigh, with other symptoms. Improvement followed 3 treatments, and after 10 the patient was symptom-free. It is possible that short-wave diathermy may simplify the

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treatment of this infection, but no conclusions as to its value can be drawn as yet, in spite of the isolated reports of results obtained. Hutter and Liebesny treated sinuses after nephrectomy with short-wave diathermy, and were successful. One patient had undergone 4 operations in 6| months, with diathermic treatment at the same time. Continuous treatment with short waves was instituted, with fall in temperature and progressive improvement to practically normal, in 17 treatments; but no mention is made of definite cure. In our own case of sinus following nephrectomy, the patient received twelve short-wave treatments, but the discharge, though less purulent, persisted, and the sinus did not close for two months. Hutter and Liebesny found decided improvement after shortwave diathermy in 2 cases of tuberculous fistula following nephrectomy, which had proved refractory to ultraviolet and roentgenotherapy. Technic of treatment.—The condensor field is created in the region affected. The electrodes, large enough to cover the whole area, are applied, one on the corresponding lumbar region and the other to the hypochondrium. Greater intensities should be used for from 20 to 30 minutes daily, to achieve the desired therapeutic effect with lower-range wave lengths. In order to assure adequate penetration of the short waves, the distance of the electrode from the skin may be increased to from 1.5 to 5 cm. T H E FEMALE GENITAL TRACT PELVIC INFLAMMATION AND INFECTIONS

Judging from the literature and from our own limited experience, it would seem that short-wave diathermy has a definite place in the treatment of inflammatory affections within the female pelvis. Adnexal tumors, according to Dalchau, Laqueur and Remzi, in particular are quickly eliminated, with or without insignificant sequelae, within several weeks. Short-wave diathermy is beneficial in functional disorders, such as dysmenorrhea. As an aid in surgery, it is of definite use in controlling acute inflammation, as a preparation for operation. The heat effect and the supposed specific effect of short

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waves differ from that of other physiotherapeutic agents, for example, diathermy. With adequate intensity and proper technic, short waves penetrate more readily the thick muscular and bony walls of the pelvis and are thus able better to exert their effects. Nevertheless, some difficulties are presented by the anatomical position of the pelvic organs, they being placed between the intestines and the surrounding, relatively extensive, soft parts. The work of Raab, Schliephake, Bierman and Schwarzschild, Horowitz el al, and others, indicate that with the rise of local temperature, producing hyperemia, the organism is supported in its fight against the inflammatory and infectious processes encountered in gynecological diseases. Results are uniformly satisfactory. Hackemann treated 350 cases of pelvic inflammation and emphasized the fact that the best results are secured in the acute forms. In older, chronic cases, improvement is slow. In such cases he recommend ones or two courses of short-wave diathermy yearly. In his series he observed almost 90 percent improvement, with 80 percent cures. Dietrich reported the same percentage, after treating 120 patients, including cases in which hot air, diathermy and other measures had failed. Laqueur and Remzi treated 32 cases of adnexitis, pyosalpingitis and parametritis, with 28 beneficial results and 4 failures. Schliephake's results were doubtful in pyosalpingitis. Hackemann achieved permanent improvement in 2 cases of old adnexal tuberculosis. Acute infections Acute salpingitis.—The brief history of one of our cases of acute gonorrheal peritonitis and salpingitis is given herewith. A. N. had been treated for 2 months by local antiseptics for gonococcal vulvovaginitis. She developed sudden pain, muscular rigidity in the lower abdomen and a temperature of 103° F. When short-wave diathermy was started, her fever was 102° F. During the first treatment, the patient had a sensation of comfortable heat, but experienced increased pain after the second treatment, and the temperature rose to 105° F. During this high fever short-wave diathermy was again administered. The temperature fell the following day. After the fifth treatment pain

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decreased, and tenderness to pressure diminished. She slept well, usually after two treatments. There was gradual improvement, with less discharge. After the tenth treatment there was an intermission for 2 menstrual periods, and a few days later pain and fever recurred. Short-wave diathermy was again started and brought relief after 3 treatments, but the fever rose periodically to 100° F., with increased discharge. After 26 treatments in 6 weeks, the patient felt well but still had a discharge, negative for gonococci; but a mixed infection was present, which was also controlled in a short time. Lohrig and Wit tenbeck had similar cases in which the treatment was suspended during the patient's menstrual period, and in which apparently the infection flared up again. It would seem advisable to continue the treatment without interruption. Raab emphasizes the importance of not interrupting the course of treatment during menstruation; he observed that after the cessation of the menses, there may be a recurrence of symptoms. In 5 cases of pyosalpingitis, Dalchau was able to operate without danger after the acute inflammatory process had subsided and become localized under short-wave diathermy. Adnexitis.—Wittenbeck, Vogt, and Dalchau found that their patients usually were free from pain after 4 or 5 treatments, in the case of adnexal and pelvic inflamamtion. Diminution of adnexal tumors also occured during further treatments. This is what may be expected. After symptomatic relief is achieved, the inflammatory products are gradually eliminated. In 12 cases of peritonitis and adnexal infiltration, Vogt observed rapid lessening of the pain and a relatively short recovery. Dalchau, in his 16 cases, noted improvement in subjective symptoms, with fall in temperature after 2 or 3 treatments. Following 2 to 15 treatments, the inflammatory process localized, and this was followed by gradual improvement and recovery. In most of those cases in which adnexal tumor had formed, the symptoms subsided after a further 10 to 15 treatments. Sometimes symptomless plum-sized infiltrations remained. In gonococcal adnexitis with infiltration (8 cases), Dalchau combined specific treatment with short-wave diathermy, and observed improvement in subjective symptoms and temperature. The acute adnexal swelling, caused by mixed infection after

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miscarriage or pregnancy, was healed comparatively rapidly by Vogt with short-wave diathermy. Wittenbeck first reported a lack of success with the 15meter wave length, and concluded that short-wave diathermy was not as effective as diathermy. But after purchasing a machine which gave greater intensities and different wave lengths, he was able to confirm the results reported by other investigators. He found that in general the subjective symptoms improved first, and then disappeared with a gradual subsidence of .the physical signs. Usually the two proceed in a parallel course. Sedimentation tests may be used as a control on progress. In acute and subacute inflammation, in which diathermy has proved disastrous, favorable results may be obtained, he believes, and markedly so in acute conditions. There were cases however, in which short-wave diathermy had no effect. He concluded that the 12-meter wavelength is perhaps more active than the 15meter wave length, but wave lengths and intensities remain to be definitely determined in the future. Pordes, however, could not observe any advantage of short-wave diathermy in pelvic diseases. This negative report may have the origin similar to that of Wittenbeck's first lack of success. Proust, Moricard and Pulsford cured a variety of inflammatory processes of the adnexa with short waves, in cases which had not responded to diathermy. Chronic

infections

Chronic adnexitis.—The long-standing inflammation of chronic disease sometimes induces extensive adhesion formation, which may present quite a surgical problem. According to Raab, one must differentiate between the degree of inflammation and the extent of adhesion when considering the employment of short-wave diathermy. One may be masked by the other, but to be able to judge the effectiveness of short-wave diathermy, these components have to be considered. The inflammation is readily influenced by the treatment, but to resolve scarifying adhesions is possible but rarely by this means. If such adhesions are present, operation is indicated. Vogt observed that in chronic adnexal infiltrations which resist the usual forms of treatment, short-wave diathermy is without danger of complications and is beneficial. In obstinate

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gonorrheal adnexal tumors, he was able to relieve the patient of pain and of her subjective complaints. Such a case occurred in a woman 28 years of age, with a history of gonococcic infection of four years' duration. She had been treated with diathermy (18 sessions), with only temporary benefit and with no change in her condition. A right adnexal tumor, the size of a large plum, was present, painful, soft and fixed. There was a purulent cervical discharge. Short-wave diathermy with the 12-meter wave length and for 15 minutes was given daily. For the first 3 treatments, a vaginal electrode was used. The measured vaginal temperature before treatment was 100.2° F., and after treatment 104.5° F. as the average. The patient's condition remained unchanged. Pain was somewhat increased in the diseased area. For the fourth and fifth treatment external electrodes were used, with the 12-meter wave length, for from 15 to 20 minutes. After this, pain was less and there was decided improvement in the patient's condition. After the sixth treatment pain and discharge ceased, and she had no subjective symptoms. Control examination eight days later was negative. She was instructed to return if symptoms recurred, but in the six months since her discharge she has not been seen. Gesenius reported results in 180 cases of adnexal disease. In 65 the improvement was definite, and verified by gynecological examination. In 113 there was symptomatic improvement. Vogt states that about 80 percent of the chronic adnexal conglomerates can be cured conservatively by short-wave diathermy. Peemoller also reports favorable results in adnexal disease. Loiseleur reported a case of chronic salpingitis complicating pregnancy, which he treated with short-wave diathermy without deleterious effects on the pregnancy. Dalchau eliminated the symptoms of sciatica in 14 short-wave treatments of a pregnant woman in the seventh month. Paladini effectively employed short waves as a stimulating agent in uterine inertia following labor, in those cases that had failed to respond to medication. Metritis.—Ten cases of parametritis with abscess in Douglas' cul-de-sac, were treated by Dalchau with short-wave diathermy. Extensive infiltration was present. Abscess formation took place after a few treatments, and the abscess was incised

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and drained. The remaining infiltrations were resolved after continued short-wave treatment. In 4 cases of metroendometritis, Dalchau found that 4 treatments arrested the progress of the disease, as manifested by diminished discharge from the uterus, with cure accomplished after 12 treatments. In cases of endometritis Schumacher obtained variable results.

a

b 30. Bartholin's Gland Abscess

a, Before T r e a t m e n t by Short-Wave Diathermy; 6, After T r e a t m e n t by Short-Wave Diathermy

Bartholin's gland abscess.—Beneficial results of short-wave diathermy in cases of abscess of Bartholin's gland were reported by Dausset. We also treated 2 such cases, with prompt subsidence of the process. One was a young woman 26 years of age, who complained of severe pain of 6 days' duration, in the genital region. She could not walk nor sit. Her temperature was 102° F. Inspection revealed an elevated, firm, slightly fluctuating area, about 5 cm. in diameter, at the lower third of the right vulvar region, the inflammation covering an area 3 inches in diameter. The right vulva was red, edematous and swollen to 4 times

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normal size. Short-wave diathermy was started, with the 12meter wave length, 15 minutes daily, with some improvement after the second treatment. After the third, the process became localized and ruptured spontaneously during the following night, discharging about 10 cc. of sanguineous-purulent material. There was no further pain. After the fourth treatment, discharge ceased and infiltration disappeared. The lesion was slightly bluish-red, surrounded by limited edema. The next examination, 5 days after treatment was started, was wholly negative, and the patient was discharged as cured (fig. 30 a, b). DYSMENORRHEA

Weissenberg and Hackemann observed marked improvement, and in some instances cure, in cases of dysmenorrhea. The latter believes that a psychic factor may enter and support the effect of short-wave diathermy. Dalchau, in 3 cases, after dilatation and curettage had given a negative pathological report, observed that 6 treatments with short-wave diathermy were sufficient to eliminate pain, and that the succeeding menstrual period was normal and painless. Several investigators, including the author, express the view that dysmenorrhea can be beneficially influenced by short-wave diathermy. In one of our own cases in which dysmenorrhea was severe, the menstrual period became entirely painless after 2 treatments, given one day before the onset and on the first day. The relief was conspicuous. It is suggested that treatments in dysmenorrhea be giv^n as above, one on the day before the onset of the period and one on the first day, each for about 10 or 15 minutes, with a moderate intensity. Technic of treatment.—Two methods of application are available for the treatment of pelvic inflammation in the female, that is, the customary external mode and treatment by the vaginal route. The latter demands a great deal of attention during the treatment, and requires the constant presence of the operator. The accumulation of vaginal secretion or uterine discharge creates different dielectric constants, with the result that an electric energy which in the beginning created for the patient a sensation of comfortable warmth may quickly become too hot, owing to the greater concentration of the current.

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When using the vaginal electrodes, it is vitally important to be certain that the electrodes are perfectly insulated. The electrode should be covered with one continuous piece of insulating material, to avoid direct conductivity of the electric current with resulting sparking and burns. It is therefore wise to use double insulation. We have observed small burns caused by faulty insulation of these electrodes, fortunately without serious consequences. This electrode is indicated in pathological processes in the cervical or paracervical region, unilateral parametrial inflammations, and wherever it seems to be more advantageous to have more extensive local heat. A vaginal electrode of appropriate size is lubricated and introduced into the vagina and fixed in a comfortable position. The other electrode is so placed that it will create the electromagnetic field in the diseased area. Owing to the possibility of frequent burns attributable to the physical conditions created in the vagina by the discharge, this method is not recommended for extended use. The most widely used method is the extravaginal, for transpelvic short-wave diathermy. Large electrodes are recommended for treatment of the pelvic contents. If a flexible electrode is employed, it is important that it be 8 by 12 inches in size, to cover the pelvis. By this means the "uneconomic" airspacing of the rigid electrode is avoided (Eckert). This applies also to treatment of diseases of the chest. If a small electrode is used, air spacing must be increased and a higher wattage employed. Application of the electrodes may be determined by the pathological area; for example, if the right adnexa is affected, a large electrode is placed in the lumbosacral region, a smaller one in the right inguinal region. The distance of the electrode from the skin surface should be greater at the back—about 2-3 cm.— than on the abdomen—1-2 cm.—if the inflammatory processes are localized rather more toward the abdominal surface. Preferably the patient lies on the healthy side, as this brings the diseased vagina between soft parts so far as possible, thereby creating anatomical relationships that are favorable to shortwave diathermy. By such precautions, symptoms of compression and heat stasis can be avoided, which would not be the case were the patient lying prone upon the electrode. Naturally

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where the patient's condition prohibits this position, she must lie on her back and on the electrode, but in such a case the interposition of a sufficient number of dry towels, preferably Turkish toweling, is required to assure an even heat effect. In case of intense perspiration, this nonconducting material must be changed during the treatment, as soon as the patient complains of greater heat concentration at a definite point. In our practice Turkish towels or pieces of thick felt seem to be most satisfactory for this purpose, when flexible electrodes are used. Rigid electrodes (with a special table if available) are more easily handled, the diseased part being placed between the condenser plates. The duration of each application should be from 20 to 30 minutes, beginning, however, with from 10 to 20 minutes, and increasing daily by 5 minutes. It is unanimously agreed among investigators that treatments should be daily in the beginning. Raab advises treatments daily of from 25 to 30 minutes' duration for the first 10 days, continued every second day thereafter until the desired effect has been achieved. Wittenbeck treated his patient every day in the beginning from 10 to 30 minutes, later every second day, employing the 12-meter wave length. Hackemann stopped for a period of observation after 5 or 6 treatments, and gave further treatment when definite improvement was observed. Staehler obtained better results with wave lengths of from 4 to 6 meters than with longer wave lengths. Schumacher warns against overdosage, which may eventuate in perforation of the pyosalpinx and may lead to peritonitis. Therefore, in adnexal infiltration he recommends a 3-minute period to begin with, increasing in a week to from 10 to 30 minutes. In gynecological practice, the heat produced may be measured and used as a basis for dosage. For this purpose the benzol thermometer recommended by Patzold and Korb, proves the most accurate. Mercury thermometers are not suitable for the purpose, as they concentrate the electric field. T H E M A L E GENITO-URINARY TRACT GONORRHEAL URETHRITIS

In bacteriological experiments it was found that the gonococcus is relatively easily destroyed by heat. Hence various phy-

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siotherapeutic methods producing heat have been used in the treatment of this common infection. But as is not uncommonly the case, the experimental results could not be duplicated in clinical practice. In chronic infections, the outlook seems to be more favorable from a therapeutic point of view, but in the acute infections nothing can as yet take the place of the classic treatment. An attempt has been made to use short-wave diathermy in acute gonorrhea in the male, but Schliephake, Nagell, and Berggreen could observe no noticeable curative influence. Liebesny believes that short-wave diathermy should not be used in acute uncomplicated gonorrheal disease, as it involves much time and expense without adequate compensating benefit. Gumpert used the 15-meter wave length for from 10 to 15 minutes in chronic gonorrhea in the male. Although he treated only 8 cases, he reports enthusiastically the quick results obtained after a few treatments. Gonococci could not be found after from 3 to 8 days, and the urine was clear. This bears out the observation of other investigators that in chronic gonorrhea of the so-called infiltrative type, short-wave diathermy may be of benefit. R a a b mentions a case of gonorrheal infiltration of the penis in which, after 3 treatments, the purulent discharge stopped, the infiltration disappearing entirely after 10 treatments. Last failed to cure acute and chronic gonorrheal urethritis. Schliephake, on the other hand, met with success in 2 out of 3 cases of long-standing paraurethral abscess, with fistula and positive bacteriological findings. Daily treatments of 30 minutes each cured one in 14 days; in the other gonococci persisted for 4 weeks, though the fistula had closed. Protargol injections were then started, in combination with short-wave diathermy, and within 2 days bacteriological findings were negative, from which the impression was gained that short-wave diathermy sensitized the action of protargol. The third case could be only partially improved, in spite of prolonged treatment. Most of the reports deal with negative results in treating gonorrheal infection in the male, with favorable results obtained in epididymitis.

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DISEASES OF THE PROSTATE

Acute and chronic inflammations of the prostate, and even those changes due to prostatic hypertrophy, seem to react favorably to short-wave diathermy. Last reported beneficial results in acute and subacute prostatitis. Hancken, however, states that chronic disease of the prostate would respond less favorably to short-wave diathermy. Liebesny states definitely that only genuine inflammations should be treated with short waves, believing that in prostatic hypertrophy short waves should not be used, as no shrinking of the hypertrophied tissue can be achieved by the treatment. On the other hand, the treatment has a permanent effect in dilating the vessels, with the result that in aged patients the prostatic plexus becomes varicose, and further treatment increases the possibility of hemorrhage. Neither should new growths of the prostate, whether benign or malignant, be treated with short waves. Weissenberg failed to induce improvement in 2 cases of chronic long-standing hypertrophy of the prostate. MISCELLANEOUS DISEASES

Raab claims to have been able to cure acute epididymitis in a few treatments. He mentions a case of 3 months' duration, characterized by severe pain, in which one treatment accomplished marked decrease of pain and swelling. Six treatments proved sufficient for cure. These observations were confirmed by Gleissner, Mahlo, Last, Dorst, Halle, and Liebesny. Halle and Hancken also report curative results in stubborn chronic epididymitis. It may be mentioned here that a temporary Steinach effect, as a secondary result of short-wave diathermy, was observed by some investigators. The present writer inclines to the view that in cases of phlegmonous inflammation of the scrotum, of streptococcic or staphylococcic origin, short-wave diathermy is definitely indicated, as it may lead to rapid cure without surgical intervention. It is, however, recommended that the pus be drained, after the infection has been localized by short-wave treatment. An illustrative case in the writer's practice was that of a man 67 years of age, who had been operated upon for rectal carcinoma 5 years before. An extensive local recurrence was removed by electro-

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coagulation by the writer. Following recovery, he underwent operation for a left hydrocele. Uneventful healing took place and the patient was discharged with slightly swollen but not tender scrotum. Four weeks after the operation, he returned with edema and enormous swelling of the scrotum and penis, to the size of a baby's head. Redness was mostly on the left side, and there was slight fluctuation and excessive tenderness to touch. The lesion was diagnosed as a diffuse infection, due probably to a secondarily infected postoperative hematoma. The patient was given short-wave treatment before he was taken to the hospital for incision and drainage. On January 23, 1935, the first treatment of 15 minutes' duration, with the 6meter wave length, was given. The following day, January 24, another treatment was given; pain and inflammation seemed to be localized at the left side, below the incision. Edema decreased. Two days later, following a third treatment, pain had subsided entirely, the lesion was half its original size, and about 5 cc. sanguineous-purulent material was discharged from a sinus formed spontaneously in the scar of the previous operation. Edema of the penis subsided and infiltration was present only at the left scrotum. Two days later (4 days after the treatment commenced) inflammation was greatly diminished and there was no further fluctuation or discharge. A last treatment was given 2 days after this, after which the patient felt well; infiltration covered an area about 1.5 inches in diameter, and there was a light reddish discoloration but no tenderness. The infiltration was gradually resolved, and 11 days after the beginning of short-wave diathermy, the patient was discharged as cured. He was well when last seen, 26 months later. Liebesny reported a case of erysipelas of the scrotum which, like erysipelas elsewhere, reacted well to short-wave diathermy Two treatments effected a cure. Kronfeld was able to effect a cure with short-wave diathermy in one of his cases of plastic induration of the penis. The gonorrheal affections of joints accompanying genital infection are taken up below in Chapter XIII, "Diseases of the Locomotor System." Tuberculous disease of the testicles, bladder and kidney should react well to short-wave diathermy, if the experiments of

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Liebesny can be duplicated in clinical practice. Weissenberg reported a case of tuberculous epididymitis accompanied by intense pain, in which the short-wave treatment repeatedly ameliorated the pain for a period of hours, but no mention is made as to the outcome of the pathological process. Heymann claims to have effected a cure in a case of tuberculous epididymitis with fistula. On the whole, no attempt can be made to evaluate shortwave diathermy in urology, as experience in this field is still too limited. In human beings, no damage to the germinal centers in the male or female has been observed. There are, apparently, no contraindications, then, from this aspect, and with proper care and consideration of all factors in an individual case, shortwave diathermy may always be tried. In the laboratory animal, the injuries observed in the testes were due to heat coagulation, caused by the relatively high intensities employed. TECHNIC OF TREATMENT

Liebesny warns us that in urological practice a special technic of treatment is necessary, as deep layers of tissue must be reached with the short waves. He believes that great intensities must be used and that the condensor plates must be 10 to 15 cm. distant from the body surface. In treating the scrotum, less intensity should be used. According to the usual technic employed, the male organs are placed between two electrodes so as to concentrate the electric field upon the pathologic site. The patient may also be placed in the "stonecutter" position, with the penis and scrotum reflected upon the symphysis, and one electrode placed above the genitalia and the other on the perineum. In treating the prostate, one electrode is placed in the anal region and the other over the bladder. Intensity is varied according to the depth of the lesion, greater intensity with greater depth. Length of treatment should be from 15 to 25 minutes daily, or every other day. Shorter wave lengths are recommended for the deeper lesions; usually the 6-meter wave lengths were used.

XII D I S E A S E S OF T H E C I R C U L A T O R Y S Y S T E M AND THE LYMPH GLANDS

T H E CIRCULATORY

SYSTEM

I T C A N N O T be too emphatically stated that so far all observations dealing with short-wave diathermy in the cardiovascular field are inconclusive. What has been done in the way of investigation is reported here for the sake of completeness, and no attempt is made to prove a point. The problem invites the serious student; there is ample opportunity for intensive study and scientific investigation. Short-wave diathermy in cardiovascular disease has still to prove itself. Kowarschik is of the opinion that the condenser field can be used for interesting diagnostic purposes in heart conditions. When placed between the two condenser plates, the human heart produces changes in the current by its varying size while in action. This variation of current flow can be registered graphically, and a curve, a so-called dielectrogram, can be obtained. This curve is typical in the normal heart, and shows characteristic differences in certain cardiac diseases (Atzler). THE HEART

Dognon and Piffault conducted animal experiments in a study of the effects of short waves on the heart. They observed that after prolonged treatment, there was a reduction in the cardiac rate, with a diminution of the amplitude of the systoles, until the heart stopped in diastole; but when the treatment ceased the heart resumed its action. This is of course, an extreme, and naturally not observed in human beings under treatment with physiological doses of short waves. The observation serves, nevertheless, as a warning that

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treatment should be discontinued should the heart action slow down. On the whole, observations in the field of cardiac pathology have been too few and too inconclusive, and either too carelessly made or too carelessly reported, to justify definite statements as to the place of short-wave diathermy in heart disease. It is, however, the general impression that caution should be exercised in its use, and that it is wise to abstain from prolonged treatment of the heart, particularly in the presence of marked organic disease of that organ. Some investigators believe that short-wave diathermy may be of benefit in functional disorders of the heart and in the cardiac neuroses. Rausch, reporting from the Kordnyi clinic in Budapest, made an extensive study of the effects of short waves in circulatory diseases, and came to the conclusion that the effects are mainly analgesic and antispasmodic. The effect of these wave lengths on blood pressure is mentioned above. In comparing diathermy and short-wave diathermy in heart disease, Rausch expresses the opinion that the latter has a distinct advantage over diathermy, this advantage being inherent in the homogenous warmth which it effects and which may favorably influence the cardiac pathology without increasing pain, such as is sometimes to be observed under diathermy. Angina pectoris.—Rausch states that short-wave diathermy is only of symptomatic effect in this disorder. In those cases in which the best results were obtained, the severe pain subsided immediately after the treatment. The subsequent attacks were milder and reduced in number. Meyer was probably the first to recommend this form of treatment in angina pectoris, and he spaced the sessions farther apart and at lower than the usual intensities. One of his cases improved after 6 treatments; a second after 3. One patient died within a short time in an attack, but his death could not be attributed to the treatment employed. Liebesny reported 5 cases so treated, in which the attacks stopped in a relatively short time. Among the improved cases was one in which a diagnosis of coronary thrombosis was established by electrocardiogram. Liebesny is of the opinion that the lowering of the blood pressure by short waves may be responsible for the good effect. Among those reporting favorable

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results from this therapy in angina pectoris are Hellfors, Hempe and Lambrecht. They replaced diathermy with short-wave diathermy. Improvement was also reported by Babin-Chevaye and Peemoller. Siegen and Hempe report results on 220 cases treated with short waves in conjunction with other measures. They found symptoms entirely alleviated in 43 percent, improved in 54 percent, and unimproved in 3 percent. They used the 8 to 15meter waves for from 8 to 20 minutes. They insist, however, that this form of treatment should be confined to the specialist. Short-wave treatments result mainly in vasodilatation, and even when small doses, with low intensity are employed, temporary palsy of the sympathetic system follows, as was shown by Pflomm's experiments. In angina pectoris, where insufficient blood supply, through narrowing of the nutritive blood vessels, causes pain, this form of therapy could be employed with great benefit. As we can obtain only temporary vasodilatation with the nitrites, the lasting vasodilatory effects of short waves—as was shown by Pflomm's experimentswould indicate their use, but only under the supervision of a cardiologist. Results of short-wave diathermy are especially favorable in those cases of angina pectoris in which the patients continue in their usual occupations, and in which there are relatively mild organic changes. These patients become symptom-free for a longer period. Weissenberg reports numerous cases benefited by short-wave diathermy, among which we find the case of an obese 50-year-old housewife, who had precordial pain with radiations to the left arm, accompanied by anxiety, especially when walking. Her symptoms could be promptly controlled by nitroglycerin. After the first short-wave treatment, the precordial pressure disappeared and after 10 applications of weak dosage, she was sufficiently improved to resume her normal occupation; after 20 treatments she was able to perform heavy work and to take longer walks—sometimes lasting 3 hours —without attacks, and dispensed entirely with the use of nitroglycerin. Functional disorders.—According to Rausch, the so-called irritable heart, characterized by fatigue, dyspnea, precordial pain and palpitation, may be improved by short-wave dia-

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thermy. The improvement is only symptomatic. "Heart-pains" (aortalgia) require more prolonged treatment before improvement takes place, and in the case of functional pain there m a y be as many failures as favorable results. Organic diseases.—In addition to the symptomatic effect, Rausch observed that the heart action increased also, with concomitant improvement in the circulation, even in the case of organic disease. In spite of the preceding observation of Rausch, Raab warns us against the use of short-wave diathermy in organic disease of the heart, and Rahnenfiihrer and Maier observed new symptoms and evident deleterious effects after this treatment. The treatment of the arteriosclerotic heart muscle distinguished by pain is unsuccessful, according to Mann. Schliephake claimed to have improved the symptoms of syphilitic mesaortitis. Inflammation of the heart muscle.—Judging from the results obtained by short-wave diathermy in inflammations of serous cavities, the assumption has been made that favorable results m a y also be obtained in the different forms of myocarditis. In myocarditis, Schliephake claims to have obtained satisfactory results, evidenced symptomatically and b y electrocardiogram. Rausch, however, voices the caution that in the case of heart disease one can never speak of final results, but only of periodic improvement. Schliephake described the case of a 19-year-old girl, critically ill with endocarditis. Her heart was decompensated, she was dyspneic and anemic, and examination revealed albuminuria and enlargement of the spleen. Blood culture was negative. After 5 sessions with short waves directed to the heart and spleen, the temperature fell and her general condition improved. In 20 days she was able to leave her bed. A few treatments over the kidney region stopped the albuminuria. The patient was discharged from the hospital in 5 weeks. Nevertheless, extreme care should be observed when venturing to treat such a serious condition as endocarditis with short waves. Technic of treatment.—Rausch and other investigators recommend treatments daily or every other day not to exceed ten minutes at one time. Only rarely is the period extended to fifteen

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or twenty minutes at subsequent treatments. A moderate intensity is used and controlled by the patient's subjective sensation of agreeable warmth. The 12- to 30-meter wave-lengths are recommended in preference to shorter lengths. There are no records concerning the use of shorter wave lengths. In inflammatory conditions shorter waves, from 4 to 6 meter may be preferred. T H E VASCULAR SYSTEM

Essential hypertension.—Short waves may have a sedative effect in essential hypertension, if we may judge by the observations of investigators (Chapter VI, "Short-Wave and Other Treatments," section on "Electropyrexia")- Every application of short waves, of any wave length, results in a diminution of the systolic and the diastolic blood pressures. This is more marked in hypertension. Rausch demonstrated that the hypertonic blood pressure decreases from 15 to 30 mm. Hg after the first exposure to the 30-meter wave length, and on subsequent exposures the fall was from 5 to 10 mm. Hg. With Dr. Watson's work we also observed this phenomenon, though to a lesser degree, with the wave length of 6-15 m. The subjective complaints subsided, or at least lessened, practically always after the first treatment, even with persisting high blood pressure. T h e blood pressure may be reduced gradually to a certain level. The fall is greatest in the beginning, and more marked, the higher the blood pressure, becoming less with each succeeding treatment until a certain level is reached. B y repeated treatments, however, one may maintain a condition that will be satisfactory for years (Rausch, Apel). In advanced arteriosclerosis, the effect on the blood pressure is only transitory, though short-wave diathermy may be an important aid in symptomatic therapy. In one case of essential hypertension observed by us with Dr. Watson, the blood pressure of 195 systolic and 115 diastolic dropped to 165 systolic and 86 diastolic after the first treatment, and resulted in improvement of the subjective symptoms after 8 treatments of the head, with the 15-meter wave length, of from 10 to 15 minutes daily. We obtained a reduction of 150

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systolic and 85 diastolic as the average, over a period of 3 months. End results, however, are open to question, as no follow-up observations for longer periods were made. The peripheral circulatory system.—Discussion in this section will be limited to those affections in which short-wave diathermy has been employed and in which positive or negative results have been reported in the literature, and will include our own limited experience. Short-wave diathermy is used in functional disturbances of the blood vessels mainly because it indirectly supports the action of the heart and attempts to reestablish the normal circulation. It is indicated mainly in angiospastic conditions. Halpert and Fedoroff found that in the trophoneurotic diseases of the vessels, there is a spastic condition of the capillaries of such a degree that the erythrocytes are not able to pass. They found that hot baths did not always result in dilatation. On the contrary, sometimes contraction of the capillaries followed. Heat therapy aims at dilatation of the vessels. The research of Pflomm showed that short waves inhibit the sympathetic nervous system and have a tonic effect on the pneumogastric nerve, the differences in the extent of action depending upon the wave lengths employed.* A marked dilatation of the blood vessels is the principal indication or evidence of the effect of short-wave treatment. This is especially true where angiospasm is present, though it is also noted in arteriosclerosis and endarteritis obliterans. The hyperemia induced by short waves differs from that resulting from ordinary heat. The vasodilatation following short-wave diathermy, which lasts for hours, cannot be influenced by adrenalin (Pflomm, Weissenberg). There follows a pronounced migration of leucocytes to the parts treated, thus raising to a considerable degree the phagocytic index. The vessel may dilate from 3 to 8 times its physiological size, and may remain so under the administration of small doses for 2 or 3 days if the small doses are repeated, and for 14 days if longer application and greater intensities are employed (Pflomm). These experiments appear to be supported by results in the *Weiasenberg made a similar observation, noting that the same wave lengths may differ in action in different cases, and even in the same case at different times. This may be due to a difference in the technic employed.

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clinical field. In the case of severe pain, the analgesic effect of the short waves helped to improve the subjective symptoms. Weissenberg observed immediate symptomatic improvement in acroparesthesia and Raynaud's disease under short-wave diathermy. On the other hand, in some of the cases of endarteritis obliterans and severe forms of gangrene, pain was intensified during exposure, but lessened after the treatment was finished. Hd observed only 2 cases out of his 900 patients, which showed motor nerve irritation. Most of the patients reported a sensation of warmth after the treatments, but a few stated that they felt cold. Decidedly satisfactory results were noted during the cold months. The patients seemed to bear cold weather for a longer period of time without angiospastic phenomena. Accompanying the improvement in the subjective symptoms was the healing of the ulcer. Weissenberg not only treated the diseased extremity, but also applied short-wave diathermy to the higher sympathetic centers along the cervical, dorsal or lumbar spine or midbrain. In one case of Raynaud's disease of the hand, the patient improved during the treatment, with immediate return of the symptoms after the treatment was over. Following 3 treatments of the mid-brain, definite improvement was noticed, and after 7 consecutive sessions the patient was entirely free of symptoms. A curious by-effect was the recurrence of the menstrual periods at earlier dates in all classes. This was attributed to treatments of the pituitary gland. In a series of 38 cases of peripheral vascular disease including arteriosclerosis, diabetic gangrene and Raynaud's disease, Liebesny was able to cure 9, improve 13, but failed to alter in any way the condition of 16. Last and RSchou reported satisfactory results in cases of Raynaud's disease. Liebesny was able to cure 2 out of 4 such cases, after 30 and 35 treatments. One improved and the fourth remained unchanged. Saidman reported favorable results in 3 cases. One case of acroparesthesia treated by Saidman, improved after 6 treatments, as evidenced by complete subsidence of pain. The patient could sleep again and also resumed her occupation. Marked improvement was obtained in cases of acrocyanosis by Dausset, but Laqueur and Remzi met with total lack of success in treating this condition.

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Last, Ruete and Weissenberg treated chilblains with benefit. Biirkmann treated 10 cases of chilblains, in sessions lasting from 15 to 20 minutes each, sometimes increased to 25 minutes, with beneficial results. One case with vesicles on the hands improved after 3 treatments, with decrease in pain and without development of necrosis. A frostbitten small toe was cured after 5 treatments and a nose improved after 7 treatments. In 22 cases of intermittent claudication without gangrene, short-wave diathermy cured 9, improved 5 and left 8 unchanged (Liebesny). Lob and Stiebock, and others treated this disorder with beneficial results, whereas Shaffler and R6zsa report a lack of definite success in this condition and in syphilitic endarteritis. In the case of intermittent claudication, an average of 30 treatments were given. It seems that short-wave diathermy does not influence advanced arteriosclerotic changes, though beneficial results are obtained in the earlier stages of angiospastic conditions. This holds for intermittent claudication, which, according to Liebesny and Last, does not react to short waves if the condition is far advanced. There may be regenerative changes in moderately affected cases, according to Schliephake, Dausset and Delherm. Babin-Chevaye was able to report a cure of senile gangrene after treatment lasting 3 months. In a case of moist gangrene, the gangrene was first changed to dry and then cured after 71 treatments (Liebesny). Results were by no means uniform in the treatment of endarteritis obliterans. Stiebock, Weissenberg, Hayer and Kobak, giving long series of treatments of varying lower and higher intensities, secured some satisfactory results and some failures. Hayer found that short-wave diathermy favorably influences endarteritis obliterans and gangrene, but that no permanent improvement resulted. It follows that this form of treatment could be most effectively administered according to the requirements of the pathological process, but the angiospastic condition from the therapeutic point of view becomes an individual problem. Of 29 cases of thrombo-angiitis obliterans with gangrene, Liebesny was able to cure 12 and to improve 5. One case con-

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sidered cured, recurred after 2 months, and 11 cases remained unchanged. Diabetes is not a contraindicant to short-wave diathermy, provided that the blood sugar is under control. In fact, 2 cases of diabetic gangrene were treated with favorable results. During short-wave diathermy the diabetic condition must also be treated.* It cannot be definitely stated whether the lesion itself or the regional sympathetic centers should be subjected to treatment, or whether one treatment should embrace both. The highest percentage of cures with short waves as shown by adequate follow-up examinations, should be diligently reported in the literature, so that more accurate statistics may be obtained, on which to base a comparison of results. At the present time shortwave diathermy in this field seems to cure approximately 30 percent, improve 30 percent, and fail in 40 percent. Aside from temporary aggravation of subjective symptoms (during treatment) described in a few cases, no aggravation of the pathological process has been observed. Consequently, as there is nothing to lose and everything to gain, this method of treatment should be widely employed. One may even suggest a combination of short-wave diathermy and the Pavax treatment as a possible solution in these difficult disorders. From our own clinical material, we wish to report a case of thrombo-angiitis obliterans in which a favorable lasting result was achieved in a comparatively short time. The patient, male, 60 years of age, had been suffering from intermittent claudication for 4 years. Recently the pain increased and redness, with a black spot, appeared on the left great toe. Examination showed the great toe and the second to be bluish-red, with areas of erythema extending toward the dorsum of the foot. Pulsation of the dorsalis pedis artery was hardly perceptible. The extremity was extremely painful to the touch and to pressure; the patient was unable to wear a shoe, and walked with the aid of crutch and cane. He had in the past been treated with infra red, ultraviolet radiation and diathermy, rest in bed, with occasional relief but no permanent benefit. He was advised to *See also an account of the control of a case of diabetic infection in Chapter XV below, "Miscellaneous Conditions," section on "Phlegmon."

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have his foot amputated. As a last resort, short-wave diathermy was tried. His condition remained unchanged for the first 4 treatments. H e received morphine every night and amytal during the day. After the sixth treatment, intensification of color was manifest in the great toe, but some symptomatic improvement was also noted. On the twentieth day acetylcholine injections were started,in conjunction with short-wave diathermy. Altogether, the patient received 15 injections. After the thirtysixth day definite improvement was noticed: pain was less, but the patient still had to take pantopon at night. The discoloration of the great toe was limited to the first phalanx. Continued treatments for 13 days resulted in further improvement, and drugs could be dispensed with. The great and second toes resumed a normal color and pain was entirely gone. The course of 26 short-wave treatments extended over 43 days and resulted in complete subsidence of subjective and objective symptoms. When last seen, 6 months later, he had no complaints, attended normally to his occupation, and enjoyed normal function in his foot. In this case short-wave diathermy, combined with acetylcholine injections, saved the limb. T w o other cases of thromboangiitis obliterans were treated with distinct symptomatic improvement, but the results were less favorable than in the case described above. Because of its antispasmodic (vasodilatory) and analgesic action, short-wave diathermy may become a valuable addition to the therapeutic measures employed by the cardiologist. Much more needs to be done, however, in the matter of research and scientific control, to establish it on a sound basis. Technic of treatment.—The affected part of the extremity is placed between two electrodes, which should be opposite each other. Strong doses may aggravate the complaint. Treatment, therefore, should be with weak doses, and given daily, provided the patient does not react in a manner to contraindicate this. In such an event, the treatment may be given every other day, with gradual increase of the intensity, in order to obtain the maximum effect. The intensity at first should be lower, increasing gradually. The treatment should not last longer than 10 minutes in the beginning, being raised to 20 and 30 minutes with increasing tolerance on the part of the patient. As there is as

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yet no accurate method of measurement, we must, for practical purposes, rely on the patient's subjective sensation of agreeable warmth as a guide in choosing the proper dosage. So far the wave lengths between 12 and 15 meters have been found most effective. In order to treat the regional sympathetic center, the electric field is created by placing two electrodes in such a position that they include the sympathetic ganglions—the cervical, dorsal or lumbar ganglions, depending upon the area involved. In the case of an ulcer, Schliephake advises covering not only the lesion but also the surrounding tissue with a large electrode. T H E L Y M P H GLANDS T U B E R C U L O U S ADENITIS

Among our cases was a man 25 years of age, with a history of having had an operation three years previous, which left a fistula at the manubrium sterni. He developed a slightly painful swelling in the right axilla, which gave the impression of being a tuberculous lymphadenitis. Ten treatments with the 16-meter wave length, for from 10 to 20 minutes each, were given in 12 days. The patient felt weaker after the course of treatment, had definitely less pain, but showed no clinical improvement. An operation was performed and aside from the usual picture of tuberculous changes, histologic examination showed nothing but vascular engorgement. Lob and E . A. Woods had no positive results in their cases of tuberculous adenitis. I t is our impression that in tuberculous adenitis no definite benefit accrues from the employment of short-wave treatment, except possibly when secondary infection is also present. In any event, the customary conservative or surgical treatment should be employed. MIKULICZ' DISEASE

The experiments by Von Oettingen and Schultze-Ronhof on guinea pigs showed that after short-wave treatment the number of leucocytes diminished. This was followed by an increase, within 3 hours, with a decrease in the number of lymphocytes. Pflomm met with the same result, and attributes this decrease to the destruction of leucocytes. I t might also be that

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they are fixed in the peripheral area which was the immediate focus of the treatment. Groag described a case of Mikulicz' disease presenting an atypical leucemic lymphomatosis, with aleucemic blood findings. Short-wave diathemy, directed to the diseased parotid gland, resulted in definite improvement in the blood picture, with persisting tumor which was cured by roentgenotherapy. As a means of checking his results with short-wave diathermy, Groag treated a normal girl and then examined the blood. The result was negative, from which he concludes that his findings in Mikulicz' disease are sustained and substantiated. NONCONTAGIOUS PAROTITIS

Short-wave diathermy may be used with success in noncontagious parotitis. We treated such a case, which developed metastatically in a patient with empyema. For 4 days there had been severe bilateral swelling and pain and purulent discharge into the mouth. Culture showed a streptococcus. The skin in the parotid region was reddened, and on the left side marked tender infiltration and slight fluctuation were noted. Using the 12-meter wave length for from 10 to 20 minutes, short-wave treatment was given, and after 3 treatments the jaw movements were freer and less painful. With 2 further treatments, the swelling was decidedly diminished and there was less purulent discharge from the ducts. In the course of the treatment, the patient was operated upon for the coincident empyema, with satisfactory result. No attempt was made to cure the empyema with shortwave diathermy. Altogether, 6 treatments in daily sessions accomplished a cure of the parotitis, and the patient gradually recovered from the surgically treated empyema. Raab states that chronic parotitis responds to short-wave diathermy, with rapid resolution of the inflammation. The treatment also prevents abscess formation, or promotes it if it has already begun. In the latter case, a lancet incision may be made if indicated. In the technical application, an electrode of a size sufficient to cover the parotid region is used, and in acute cases treatments are given daily, while in chronic cases they are spaced to every 2 or 3 days.

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Hoeffler claims that local infections such as parotitis, mastitis, and so on, can be as effectively treated with short waves in children as in adults, the duration of the treatment naturally being shorter—from 3 to 5 minutes daily. We obtained cures in 3 cases of cervical lymphadenitis of infectious origin in children after from 3 to 8 treatments.

XIII D I S E A S E S OF T H E LOCOMOTOR SYSTEM

T H E MUSCULAR

SYSTEM

S H O R T - W A V E diathermy has been employed in a variety of affections of the muscles—myalgia, lumbago, spastic contractures, rheumatism, and so on. Rahlwes, Bardenheuer and Peterson reported 76 cases in which short-wave diathermy resulted in quick improvement and cure. Lob and Schliephake found that lumbago reacts at once to short-wave diathermy. Our own observations confirm these findings. Sometimes the pain is relieved immediately, and the case can be cured in one or two treatments. In other cases of subacute muscle rheumatism, symptomatic cure was obtained in from 3 to 6 treatments. The eradication of foci of infection at the same time is advocated. The myalgias and spastic torticollis respond quickly and favorably. In contrast to other investigators, Schweitzer and Turrell believe that diseases of the muscles are less amenable to shortwave diathermy. As a rule, longer wave lengths—8 to 14 meters—were used for a duration of from 20 to 30 minutes, at an intensity that gives the patient an agreeable feeling of warmth. The electrodes should be placed so as to include the diseased area. TENDOVAGINITIS

This disorder, which is the source of an incalculable amount of pain to the sufferer, appears at any time of the year, is obstinate to the usual forms of treatment, and is the most commonly misdiagnosed of conditions. It is not at all unusual to find it miscalled neuritis or acute arthritis, particularly in the case of the shoulder or hip. The inflammation within the synovial structure produces friction, which explains the pain.

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I t is worth while to emphasize this condition and the discomfort and pain it causes, because it is so readily amenable to short-wave diathermy. Furthermore, as the treatment can do no harm it should always be tried when other measures fail, and in fact should be employed from the start if available. Lob reported beneficial results with short-wave diathermy in acute tendovaginitis and in cases in which exudation had taken place. Davis described a case of tendovaginitis in which decided improvement took place with the first treatment, and in which 6 treatments were sufficient to cure, clearing up the crepitation. Our own 4 cases were cured after from 2 to 4 treatments, in spite of the fact that other physiotherapeutic measures —ultra red light—had failed. Dr. W. G., of New York City, was kind enough to submit his personal case, in which his tendovaginitis of the dorsoflexor tendons of the wrist was cured with short-wave diathermy. Ten days before treatment was begun, pain was felt following a strain of the wrist while cutting a heavy plaster spica. T h e pain was felt along the dorsoflexor tendons of the right wrist. Four days after onset, the patient had acute pharyngitis and was confined to bed. There was slight elevation of temperature for one day. On the following day the wrist became acutely painful in all motions, and there was swelling over the dorsoflexor tendons. A plaster splint was applied to fix the wrist in dorsoflexion. Thirty grains of sodium salicylate were given intravenously, but there was no relief. Pain increased with increase in swelling, so that motion of the fingers was limited by pain. The thumb was not involved. On the following day the splint was molded, in an attempt to secure more support for the fingers. T h e salicylate administration was repeated, and aspirin was given every 4 hours in 4-grain doses. The salicylates were continued, but when after the third day there was still no relief from pain, shortwave diathermy was resorted to. During the first treatment there was a sensation of mild warmth throughout the wrist and hand and a slight increase of pain. The splint was reapplied but all medication was discontinued. Four hours after the treatment, the patient reported a sensation of pleasant warmth in the wrist and hand, accompanied by distinct diminution of pain, and definite increase of the surface temperature. This reaction lasted

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for 8 hours, at which time the surface elevation of temperature subsided. Pain was definitely diminished and finger motion more free and less painful. Following the second treatment, the phenomenon noted above recurred within several hours and lasted for about 5 or 6 hours. The following day the swelling over the dorsum of the wrist was 50 percent less. The wrist was painful only when the fingers were moved. After the third treatment the same manifestations recurred, but to a lesser degree and for a shorter time. The splint was discarded and normal use of the hand was possible. On the afternoon on which this treatment was given, the patient was able to reduce a fractured shoulder and to apply a plaster spica. No pain was present when the fourth and last treatment was given; a very slight temperature reaction followed this treatment. Within 5 days the wrist was entirely normal. In the subsequent examinations, there was no pain and no limitation of motion. Technic of treatment.—The wave lengths around 6 meters are recommended. In the main, the technic is as described in the general discussion of technic (Chapter VII, "General and Mechanical Principles in Short-Wave Technic") and consists in placing the affected area in the condensor field for from 10 to 25 minutes daily. BURSITIS

Subacromial bursitis, which is characterized by the deposition of lime salts, is benefited by short-wave diathermy much in the same way that it is improved by diathermy or roentgenotherapy. The increased blood circulation and the invigorating local effect induced by the treatment, cause the improvement. We had 7 cases in which symptomatic relief was obtained after from 4 to 8 treatments. In one, roentgenograms showed a diminution of the calcium deposit. Naturally, one cannot expect complete resorption of the calcium deposit if the process is far advanced. Davis, and Kobak also observed beneficial results in subdeltoid bursitis. Technic of treatment. The electrodes are applied opposite each other in such a way as to create an active electric field in the diseased area. We found the 6 to 12-meter waves satisfactory. The daily treatments should be from 15 to 20 minutes in duration.

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BONES

Bone is a poor conductor of electricity. For this reason, before short-wave diathermy was developed, electrotherapy proved less effective in treating diseases of the osseous structures than in treating those of the soft parts. We know now, from work reviewed elsewhere in this book, that shorter waves generate heat evenly when introduced into the bones. This fact, in addition to other physiological attributes, has opened a rich field for their therapeutic use. Bone, from a clinical point of view, consists of calcified tissue, of periosteum and of medullary tissue. These are intimately connected. Hence inflammatory states usually affect the entire structure. The diseases of the osseous structure in which short-wave diathermy has proved to be most efficacious will be discussed below. PERIOSTITIS

Turrell found that periostitis of the dorsal aspect of the tarsus, ineffectually treated with diathermy, was completely relieved after the first treatment with short-wave diathermy, and when seen after six months the patient showed no evidence of relapse. In the traumatic form of periostitis, improvement of the subjective symptoms took place quickly after institution of short-wave diathermy, with regression of local pathology (Hancken, Hellfors, Lux, Rollin and others). OSTEOMYELITIS

Our knowledge of the real value of short-wave diathermy in acute osteomyelitis is still so limited that much further study will be necessary to afford a proper evaluation. If employed in acute osteomyelitis, it should be used with care, and where no immediate danger presents itself. In extreme cases, with severe toxemia, surgical measures should be used conservatively. If no definite involvement of the periosteum is found, an incision should be made and short-wave diathermy started. If this does not improve the condition within a few days, a further operation should be performed.

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In subacute and chronic cases in which no sequestration can be shown, results are remarkably satisfactory, although the number of reported cases is limited. Where sequestration is taking place, short-wave diathermy may promote demarcation before surgical removal of the sequestrum. Schliephake states that where no roentgenographic changes are demonstrable, the condition can be cured by short-wave diathermy. He believes that the patients are best treated in the early stage, when no grave changes are evident roentgenologically. It is also favorable to cases of long standing, especially those in which sequestration can be hastened. The bone substance around the sedt of the disease becomes more strongly calcified and sharp demarcation takes place. The sequestra are sometimes ejected spontaneously through the fistulas, or they can easily be removed. This sharp demarcation is a characteristic evidence of short-wave effect. In one of Schliephake's cases sequestration commenced under short-wave diathermy and in from 4 to 8 weeks the sequestra were spontaneously discharged through the fistula and others were removed by sequestrotomy. This patient had been in the hospital for 4 years. According to Weissenberg, one may expect the spontaneous discharge of larger sequestra, but in the cases of smaller sequestra the fistulas persist until they are removed by surgery. In Liebesny's series of 15 cases, 4 were acute and 11 chronic. He cured all his acute cases in from 12 to 20 treatments. One case of osteomyelitis of the femoral head was symptom-free after 9 treatments. Of the 11 chronic cases, 3 were cured in from 17 to 23 treatments, 7 were greatly improved after from 7 to 48 treatments, and one was unaffected. Laqueur and Remzi obtained favorable results in 3 cases. Ammon and Raab failed in one case of acute osteomyelitis. We report the following 2 cases from our clinical material, as being of interest. T. P., a girl 12 years of age, gave a history of osteomyelitis of the left leg, under treatment for 7 months. When seen, there was a painful swelling of 8 days' duration, discharging pus. It was tender, red, and infiltrated for an area about 2.5 inches in diameter. Seropurulent discharge issued from an opening about 2 cm. in diameter. Roentgenograms showed no sequestration,

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but atrophy of the lower end of the femur. Before operation was undertaken, a request was made for short-wave diathermy. After the third treatment, the patient had no more pain, the local condition was decidedly improved, the discharge was only slightly bloody, and serous, and there was no induration or tenderness. The wound was granulating. One more treatment was given, after which the wound was clean and covered with a scab. There was no discharge. The patient was discharged cured from the hospital 5 days after the first treatment. The second case was that of a lad 6 years of age, who had had osteomyelitis in different parts of the body at different times and had been operated upon 4 times. When seen, there was swelling, with redness and pain, on the arm just above the left wrist. Roentgenograms showed a periosteal abscess of the radius, without bone sequestration. Pain was increased on pressure. The temperature was 101° F. Short-wave diathermy for 15 minutes, with the 10-meter wave length, was given twice, after which pain was much less and pus and serum were discharging. T w o further treatments were given with the 6-meter wave length for 15 minutes, after which the lesion was much improved and the patient was discharged very much improved as to his condition. A follow-up examination 5 months later showed the child to be cured and attending school regularly. Short-wave diathermy is especially indicated, frequently in combination with surgery, in those cases in which it is desired to hasten elimination of the inflammatory processes and sequestra. Technic of treatment.—The diseased area is brought into the electric field by placing the electrodes opposite each other, one on either side of the lesion. The electrodes should be larger than the lesion, to ensure the proper effect. It must be repeated here emphatically that the electrodes should not be placed side by side, as it is done in diathermy, but that they must be placed opposite each other, with the lesion between them, in order to create the strongest electric field, thus ensuring penetration of bone. The lower range of wave lengths (4 to 6 meters) is recommended if the lesion is deep-seated. If large bones are involved, stronger power must be used. The treatment is daily, for from

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15 to 25 minutes. Every second day, in chronic cases, is the recommended procedure after the first 5 or 10 treatments. T H E JOINTS

Inflammation, traumatic lesions, infections and the changes caused by these, fall within the range of short-wave diathermy. From a pathological point of view, the structure of the joints differs from that of other tissues. One deals, here, with the capsule, the inner synovial lining, and the bones, which give varying manifestations of the different processes. For example, in inflammation an excess of fluid is formed, which fills the joints and results in fluctuation and effusion. This effusion may be bloody, as a result of trauma; serous, as in chronic or neuropathic conditions; or purulent, through infection with pyogenic organisms either directly or through the circulation. It is a well-known fact that in the different forms of arthritis, acute or chronic, physiotherapy had always been of primary importance. To create heat and hyperemia is the guiding principle in treatment. Short-wave diathermy enables us to promote both heat and hyperemia in a relatively simple way. The heat that is generated is homogeneous, that is to say, it penetrates evenly through all the tissues of the joint and even the bone. As Pflomm's experiments have shown, it creates a lasting hyperemia with the proper analgesic effect. From the experiments of Jorns, Miiller and Lauber, we know that fluid absorption is markedly accelerated and cannot be brought about by other physiotherapeutic methods, as for example, diathermy, to the same degree. By its analgesic action, also, shortwave diathermy facilites physiotherapy of traumatic conditions. Investigators agree that short-wave diathermy gives the best results in the acute and subacute inflammations of the joints, in which diathermy can be used only with extreme caution and even then with the danger of undesirable reactions. ARTHRITIS

Schliephake treated the different types of inflammatory arthritis with satisfactory results. Davis reports a case of infectious arthritis of both hands, treated 3 times a week for 6

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weeks. At the end of the course of treatment, pain and stiffness were entirely gone and the patient was beginning to use her hands in her household duties. Weigel treated a case of postpneumonic arthritis of the wrist, thereby not only preventing the necessity of surgical intervention but achieving cure after a relatively short time, with excellent ultimate functional result. Gonorrheal arthritis.—Schliephake, Schittelheim, Davis,

a

b 31. Roentgenograms, Showing a Case of Gonorrheal Arthritis a. Before Treatment by Short-Wave Diathermy; b. After 2 Months' Treatment by Short-Wave Diathermy

Nagell and Berggreen, Kobak and others, report favorably on short-wave diathermy in gonorrheal arthritis. Pain subsided quickly, sometimes after the first treatment. This we also noted. Considering the severity of the pain in this condition, the alleviation of its severity alone is of great value. The swelling and inflammation also subside in a relatively short time. Pflomm treated a gonorrheal arthritis of the wrist in which the roentgenogram showed distinct changes of the articular surfaces, and these became entirely normal, with free motion of the hand, after the course of short-wave diathermy. Especially conspicuous was the healing of a very serious case of gonorrheal arthritis of the knee, reported by Vogt, in which function of the joint was completely restored. Weissenberg reported 2 cases of gonorrheal arthritis cured by short-wave diathermy: one, with only a slight swelling of one of the joints of the foot, was cured in 5 treatments; the other, with arthritis of the right shoulder,

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required 40 treatments over a period of 2 months. Motion in the latter was reacquired only very slowly, but to the full extent. Weissenberg used the 12 to 15-meter wave lengths. Graf published an account of 9 cases of gonorrheal arthritis treated with 14 to 19-meter wave lengths. The ankle joints were cured after 29 treatments of from 20 to 30 minutes' duration. He noticed that the foot was swollen after large doses. He succeeded in curing an elbow-joint infection in 13 treatments and that of the knee joint in 43 applications. We also noted swelling of the leg and ankle after prolonged treatment, of from 25 to 30 minutes, with the 15-meter wave length, of a gonorrheal arthritis of the knee. This subsided, however, after further treatments in which the period of exposure was reduced to 15 minutes. Laqueur and Remzi obtained improvement in symptoms, or cure, in 23 cases after a relatively short period of treatment. In only one case did short-wave diathermy fail to give the usual favorable result. A case of gonorrheal infection of the shoulder joint is reported by Du Bois-Reymond. The arm was fixed in abduction without active motion and with painful passive motion. Pain on pressure was very marked. After the first treatment the pain diminished, and in 20 treatments, in the course of 6 weeks, it resolved completely. Massage and exercise were soon started, which are also recommended by Laqueur. This careful and gradual therapeutic procedure resulted in complete cure, with free motion. It is obvious from this résumé of reported cases that in gonorrheal arthritis short-wave diathermy may well be the therapeutic method of choice. The results are uniformly satisfactory. Traumatic arthritis.—According to Lob, quick resorption of the exudate takes place under short-wave diathermy. Paschetta believes that short-wave diathermy gives remarkable results in traumatic arthritis, and that these are the better, the sooner after the injury the treatment is instituted. He reported 8 cases, among them contusions, treated at once, which were cured in from 2 to 3 treatments; his chronic cases were discharged after from 6 to 12 treatments. Among our 47 cases of arthritis of varying etiology, we had

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3 of traumatic origin with negative roentgenograph^ findings. All responded promptly to short-wave diathermy, one in 5 treatments and 2 after 4 treatments. R a a b reports on the impressive results obtained by Noack, Mannes, Wolf and Schors. Dausset and Delherm were successful with patients in whom other measures had failed. Among these were 5 cases of post-traumatic arthritis, with one cured and 4 showing improvement. Atrophic arthritis.—The author believes that in atrophic arthritis success is not so general. Nevertheless, improvement can be achieved, providing the morbid changes are not of too long standing. Exudative forms are more amenable from the symptomatic point of view. In cases of atrophic arthritis with effusion into the joints, Schliephake found that short-wave diathermy completely relieved the pain after 3 or 4 treatments, and that motion was greatly facilitated by resolution of the swelling. Removal of foci of infection was combined with the short-wave treatment. Last improved a case of atrophic (rheumatic) polyarthritis, after 29 treatments of the tonsils. Equally satisfactory results were reported by Turrell, Schaffler, Herzum, Dausset, R6chou, Halphen and Auclair. One of the cases of atrophic arthritis treated by us was as follows: M . M ., female, 66 years of age, was admitted to the hospital with impaired function of both knees, accompanied by pain. She had received a variety of treatments, including typhoid toxin injections, and diathermy. Her condition, growing worse, required extension casts, and when no improvement resulted, but rather the contrary, the question arose as to whether she should be sent to a hospital or home for incurables. After a 5-months' stay in the hospital, short-wave diathermy was given. The first treatment for 10 minutes, with the 15-meter wave length, was followed by immediate subjective improvement. This improvement continued during the course of 6 daily treatments for 25 minutes, with moderate energy. She was then able to walk with help, remaining on her feet for 20 minutes at a time. Further improvement with continued treatment, with stronger doses, took place, and she was able to leave the hospital after 15 treatments in 17 days, walking without assistance and with practically no complaints. This remarkable improvement

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had been maintained, at the time of writing, for one year. She has not been taking medication of any kind. Raab believes that the improvement in subjective symptoms and in motion is made possible by the resorption of the effusion, which in turn decreases pressure within the joint, bringing about greater freedom of motion. Peemoller made a similar observation. Hypertrophic arthritis.—Although marked improvement takes place in these cases, it is logically too much to expect that short-wave diathermy will bring about anatomical changes. The pain frequently disappears after a few treatments, though occasionally it may be increased after the first treatments, subsiding in the course of succeeding sessions. Davis mentions among his cases one of chronic arthritis in which the patient was first treated, without definite improvement, by diathermy and massage. Short-wave treatments, in the course of 2 months, decreased the swelling, and roentgenograms showed great improvement in the joint. Similar favorable reports are made by Peemoller, Sennewald, Schaffler, and R6zsa. Last met with success in treating hypertrophic arthritis of the shoulder, coxitis deformans and spondylo-arthritis. On the other hand, Rehn states that short-wave diathermy has been overestimated as to its effects in arthritis. Laqueur and Remzi, who treated 35 cases of hypertrophic arthritis, using mostly the 15-meter wave length, reported 5 failures in the group. Dausset, among his 9 cases of chronic arthritis, cured 2, improved 5, but failed in 2. Horsch published a statistical survey covering 160 cases of chronic arthritis; besides the failures, 38.5 percent showed favorable results, with 2 genuine cures; and 22.6 percent improved in hypertrophic arthritis. Berry reported the case of a 69-year-old woman with hypertrophic arthritis of the shoulder, hips, knees and lower spine, further incapacitated in the right shoulder through a fall. After a course of short-wave treatment, she recovered the use of her arm. We have treated 35 cases of hypertrophic arthritis, and on an average have secured subjective improvement after the second to the fifth treatment. The pain was decidedly diminished, swelling decreased and function improved. With continued treatment, a great deal of relief was given these patients, al-

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though there were a few failures. Those cases in which pathological changes have taken place in the articular surfaces, for example exostosis formation, could not be favorably influenced. Among the cases reported by Weissenberg was that of a man, 28 years of age, in whom short-wave treatments, consisting of 155 sessions in the course of 2 years, were given with periodic improvement. No damaging effects resulted from the large number of treatments, but neither were any changes in the deformed osseous structure observed. Experience so far is too limited to permit the drawing of definite conclusions as to the value of short-wave diathermy in this crippling form of arthritis; but judging by what has been accomplished, it is fair to say that with further study and continued development, short-wave diathermy will prove a boon to such sufferers, especially as an adjunctive measure together with general medication and the usual methods of treatment. It has been demonstrated by experience that a number of those unsuccessfully treated by diathermy were symptomatically improved by short-wave diathermy. TUBERCULOSIS

Reports of the use of short waves in tuberculous disease of the osseous tissues are as yet too scanty and scattered for proper evaluation, and further data are necessary. Furthermore, in a condition of such serious import, so refractory to treatment, and so related to other factors, careful observation as well as careful application of a therapeutic measure is vital for the sake of the patient, as well as in the interests of science. Some of the reports are so vague that their import is uncertain. Others are mentioned here primarily for the purpose of indicating the direction in which this work has so far been carried. In 4 treatments with short-wave diathermy, Heymann reported that he was able to close 5 long-standing fistulas in a case of rib tuberculosis. Lohrig observed the closing of the fistulas in a tuberculous joint after 14 treatments of from 6 to 8 minutes' duration. Liebesny reported a case of tuberculous tendovaginitis, with tubercles on the thumb, unsuccessfully treated for 2 years with roentgenotherapy and other measures. The infection had been

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contracted in the course of a post-mortem dissection. Using short-wave diathermy, Liebesny claims a cure in 2 months, with complete function of the hand. Two years later the patient was still free of recurrence. At the International Congress of Radiology, Zurich, 1934, Liebesny demonstrated cases of tuberculous arthritis in which improvement had been obtained; and Pflomm and Liebesny believe that certain forms of tuberculous arthritis can be cured by short-wave diathermy. Nevertheless, in spite of reports of an indefinite degree of improvement in a few cases, short-wave diathermy cannot be used generally in this condition. Lob reported negative results. Last believes that favorable results can be looked for only in old fungous tuberculosis of the joints, pain in the healing stage being favorably influenced. In the other types of tuberculous arthritis, pain and inflammatory process were increased by this treatment. On the whole, it is clear that so far as short-wave diathermy in tuberculous bone disease is concerned, the question is as yet unsettled. Short-wave diathermy in this disease should be given with extreme care, if at all! In chronic cases and even in the presence of fistulas, the treatment may be of benefit, at least to clear up secondary infections. It would also be interesting to learn what results could be achieved in treating tuberculosis of the joints, if radiotherapy were combined with short-wave diathermy. In the case of proliferative arthritis, this combination may give better results. A great deal of experimental data is required before short-wave diathermy could be used with a clear conscience in tuberculous lesions. T E C H N I C OF T R E A T M E N T

The main principle of the technic lies in placing the affected joint between two electrodes, in order to obtain an active effect of the electromagnetic field. The size of the electrodes should be governed by the extent of the area to be covered, the electrodes reaching well beyond the joints. Flexible electrodes can be adapted to the curvature of the joint, but rigid electrodes may be used, although they must be placed at a sufficient distance from the skin surface to avert undue concentration of the current at one point. In the case of the larger joints, the electrodes should

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be placed at a distance of several cm. from the skin, to assure homogeneous and deep action. Schliephake suggests 3 cm. as the distance for the elbow and knee, 4 cm. for the shoulder joint, using a 10-cm. electrode. It is well to place Turkish toweling as insulating material between the flexible electrodes and the skin, to secure the required distance. This serves not only to maintain an adequate distance, but also absorbs perspiration, thus avoiding blistering. I t is wise to start with a low dosage and to raise this gradually. Ten minutes' exposure with moderate energy, giving the patient a sensation of agreeable warmth, is a good beginning. The dosage is increased little by little, to daily exposures of from 20 to 30 minutes each, according to the size of the joint. In chronic cases, a series of 10 daily treatments are given, followed by treatments every other day or every third day. Nagell and Berggreen used the 4-meter wave length, and as a rule gave no more than 10 minutes of treatment at one time. Some of their patients with gonorrheal arthritis received treatments 3 times a day. Others were treated every second day. Pflomm, observing lasting effects, on the basis of his experience, gave treatments every second day in gonorrheal arthritis. The majority of those reporting their findings used principally the 15-meter wave length (Laqueur and Remzi); Graf used the wave lengths from 14 to 19 meters, with beneficial effect. The question of wave length is still unsettled, and it is very urgent. It's answer must be based on experimental work, bearing in mind that the short wave lengths penetrate better than the longer. Summarizing what is recorded in the literature, it may be said that in the treatment of joint disease the wave lengths from 4 to 15 meters appear to be those most used. I t is interesting to note, however, that in one of our cases of atrophic arthritis of the hand, no improvement took place after 8 treatments with the 12-meter wave length, but remarkable improvement occurred after a change had been made to the 6-meter wave, using the same intensity. This may, of course, be purely coincidental, although other authors also have found the 6 to 7meter waves more effective.

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G E N E R A L COMMENT

The fact should be emphasized that local short-wave diathermy will be of benefit only in cases of mono-arthritis—since only the treated joint responds to the measure—unless the entire field of disturbed function can be covered by the electrodes, as in the case of hands or feet. This would apply especially in atrophic and hepertrophic arthritis, which are considered to be systemic, rather than local disorders. The disturbances of endocrine function at the age of involution have a bearing on this. Thus electropyrexia may have a stimulating effect upon the endocrine system. Judging by reported results, it would seem that favorable effects are achieved in traumatic arthritides, apparently satisfactory results in the gonorrheal arthritides, and immediately beneficial symptomatic results in atrophic arthritides. As to the final results, nothing can be definitely stated, as too short a time has elapsed since short-wave diathermy was adopted and applied, and as the follow-up work is necessarily insufficient. It is not at all improbable that several courses of treatment at intervals will be found necessary in individual cases, a procedure which, according to observations, is harmless. In the hypertrophic arthritides, satisfactory symptomatic relief has been obtained, without, however, influencing the changes in the joint which had been already established. Arrest of the disease process is questionable. A longer follow-up period may throw light upon this point. In the mono-arthritides, from 6 to 30 or more treatments for from 20 to 30 minutes each are necessary to achieve curative or palliative results. In polyarthritis, electropyrexia may be more successful. It is advisable also to supplement short-wave diathermy by the customary adjuvant measures. The warning should be reiterated to use short-wave diathermy in tuberculous arthritis with extreme care and under strict supervision, as its curative function here is as yet open to question. TRAUMATIC I N J U R I E S

Injuries resulting in hematoma, sprain, and in lesions of the

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soft parts may be affected favorably, both symptomatically and functionally, by short-wave diathermy. Laqueur and Remzi, and Lob, reported quick organization and absorption of hematoma. I have also made this observation. Effusion into the joints and extravasation of lymph are readily removed by this treatment. Turrell found short-wave diathermy beneficial in sprains of the wrist or ankle. Early traumatic arthritides and peri-arthritides may be cured by a few treatments. This is also true of infected wounds and lacerations, which are cleared up in a short time. In all cases of trauma, examination is necessary before shortwave treatment is begun, in order to exclude those lesions to bones and tendons which may require surgical or orthopedic repair. Berry reported a case with somewhat dramatic features. A 58-year-old woman received an injury to the anterior wall of the thorax, with extensive bruising and extravasation on the median aspect of both breasts and with tenderness and swelling over the sternum. Daily treatments of 15 minutes' duration resulted in a "dramatic disappearance" of the extravasation, suggesting the possibility of achieving a similar result in the case of injuries of the joints. Peculiarly enough, the author continues, the patient's symptoms of chronic cholecystitis, with which she had suffered for years, disappeared entirely during the course of treatment.

XIV D I S E A S E S OF T H E NERVOUS S Y S T E M IN THE therapeutics of diseases of the nervous system, any agent or procedure which holds the possibility of causing organic injury must be used with caution. This holds true of short-wave diathermy, which should not be used indiscriminately and without cautious approach. It should be employed only after thorough study of the individual case and the indications for this treatment, and with care as to technic. Results are as yet by no means conclusive. The material is scattered; in some instances only isolated reports have been published, although Krojl presented a study of 260 classified cases. A good deal of study will be required before the place for short-wave diathermy in diseases of the nervous system will be adequately appraised. NEUROSYPHILIS

In the field of fever therapy, it is clear that the greatest praise goes to investigators in the United States. Fever therapy of syphilis has been under investigation for some years. Recently, electropyrexia has come to take the place of other forms of artificial fever, with interesting and promising results. Experimentally, Carpenter and Boak cured by short-wave diathermy, rabbits inoculated with syphilis. Hinsie and Carpenter were then the first to use the measure in clinical cases of general paralysis. The valuable work of Bierman, Hinsie and Schwarzschild is well known to the medical profession. Local application of short waves to the nerve centers in general paralysis was tried for the first time by Schliephake. He directed the treatment to the center of the lesion, by placing the electrodes on the head for an hour daily. He used an apparatus of high output and employed the 12-meter wave length. The patients experienced a sensation of pleasant warmth. This direct application made it possible to giv& a treatment that was more agreeable and less

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strenuous than electropyrexia. The oral temperature did not rise above 100° or 101° F. He found that his patients did extraordinarily well and that their weight increased during treatment. In the case of tabetic patients, examination showed the pupils rigid, and the patellar and ankle reflexes absent. After treatment over a period of 3 weeks, the eyes and reflexes were normal. This method could be combined with specific medication. In the crises of tabes, Krusen found short-wave diathermy to fail completely, while Kronfeld observed temporary amelioration of the pain. Pieper, after applying weak currents for 6 minutes, found that he could dispense with analgesic medication. The crises of tabes, according to Schliephake and Weissenberg, can be spaced further apart in some cases through short-wave diathermy. Halphen, Auclair and R6chou treated 500 cases with partially beneficial results, as reported by Schliephake. In general paralysis, Kauders, Liebesny and Finaly experimented with short-wave diathermy. Kauders worked with 5 patients. He used the 15-meter wave length with round electrodes 18 cm. in diameter, and gave up to 30 treatments varying in duration from 20 to 30 minutes. The patients were in the advanced stage of the disease, with memory and intelligence already suffering from the malady. Owing to the limited number of cases treated, no definite conclusions can be drawn, but the impression is gained that in certain cases remission can be brought about. The temperature during treatment rose by 0.3° to 0.8° F. Kauders and others believe that a not inconsiderable effect of short-wave treatment in the paralytic process is the effect it exerts on the cerebrospinal fluid, both during and after treatment. A definite increase in total albumin is noted. There is also a marked rise in the number of cells. This lasted for several months after the conclusion of the treatment. The globulin reaction and the Pandy and Nonne-Apelt reaction were much more pronounced after the treatment than in the case of patients treated with short waves for other disorders. Notwithstanding these pronounced changes in the cerebrospinal fluid, suggesting a meningitic process, the patients showed no symptoms pointing to meningitis or meningeal irritation, and were in no way disturbed in their general well-being. The

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improvement, however, lasted only a few months. Within a year 2 of the patients died, and necropsy revealed evidence of old extravasation in the dura. This should serve as a warning against the careless use of short-wave diathermy. In his book, Liebesny described a case in which the first treatment was for 20 minutes and the succeeding treatments (29) for 30 minutes. In 5 other cases the treatments did not extend beyond 20 minutes each. The average increase of temperature was 0.5° to 1° F. Short-wave diathermy, with the dosages and method used today, shows a tendency to clear and absorb the infiltration, but the paralytic process in the cortex is not influenced. The serious disturbances in the meninges and vessels, which result from short-wave diathermy at great intensities, are apparently irreparable. Wagner-Jauregg believes that it is erroneous to ascribe the effect of malaria therapy exclusively to the hyperthermia which is induced thereby. There are successes with malaria therapy in which no rise in temperature has taken place. Consequently, he thinks, it is not the fever that brings about cure. This view seems to be supported by the results of tuberculin and staphylococcus vaccines, the administration of which does not cause fever. It is still an open question, both as to diathermy and shortwave diathermy, whether they cure through hyperthermia only. Wagner-Jauregg suggests combining these two forms of treatment with specific antiluetic therapy, in order to promote beneficial results. He believes that it is still too early to give a final opinion as to the possibilities of short-wave diathermy in general paralysis. Further studies should, however, be pursued, with larger numbers of patients and adequate controls. Wagner-Jauregg refers to Schleiphake's experiments in attacking the disease in its location in the brain by treating the head. Beneficial results might come from such a procedure. Netjritides

Schliephake, Lob, and Laqueur report favorable results obtained with short-wave diathermy. Among the cases treated were some which did not respond to diathermy and other physio-

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therapeutic methods. It is known that in acute cases, as well as occasionally in chronic cases, diathermy may result in aggravation of the condition. According to Laqueur, painful reactions are rarely observed after short-wave diathermy, and when they do occur they are transitory. The homogeneous even heat generated by short waves acts more effectively upon the diseased nerve, whereas in the case of diathermy, the current circulates in those tissues which have the best conductivity. Ravault and Ceccaldi and Weissenberg, had best results with weak doses. On the other hand, Raab states that good results can be obtained only with apparatus of high output, which secure deep penetration and even, deep heating of tissue. He further maintains that failures can t e attributed to weak dosages. In acute cases, it is well to follow the recommendation of Weissenberg, that is, weak doses in the beginning, which may be increased according to the patient's reaction. Authors agree that acute sciatica responds better and quicker to short-wave diathermy than the chronic form. In obstinate cases the usual physiotherapeutic measures are recommended in combination with short-wave diathermy. Weisz treated several cases, and Peterson 90 cases, with beneficial results. Of 20 cases, Kroll reports 16 improved after an average of 15 treatments lasting 15 minutes each. In stubborn cases of sciatica, which had been resistant to other forms of treatment, Lob achieved success with short waves. In cases of recent onset, he advises careful treatment to begin with, with weak dosage, in order to avoid undesirable reactions. The dosage is gradually increased. Even in some cases showing changes roentgenographically in the fourth and fifth lumbar vertebra or in the lumbosacral joint, short-wave diathermy gave satisfactory results. Last observed favorable results in sciatica and trigeminal neuralgia under local application of short waves, and stated that no unfavorable after-effect was observed over a long follow-up period. Schliephake is of the opinion that local treatment of sciatica is not enough to achieve adequate results, and suggests electropyrexia for the lower part of the body, including the legs. This procedure should secure results also in chronic and refractory cases.

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Laqueur and Remzi, using the 15-meter wave length for 15 minutes daily, found short-wave diathermy effective in 22 cases of neuritis. They failed in only 3 cases. In our own clinical experience, it was difficult to decide as to the advantage of local short-wave diathermy over other therapeutic methods. We treated 18 cases of neuralgia, with improvement in 50 percent and cure in 25 percent. It should be noted, however, that most of the cases were referred for short-wave diathermy after other customary medical and physiotherapeutic methods had failed. The technic for sciatica is the same as for other conditions, that is, the electrodes should be placed opposite each other with the tissue between, and not both on the same side of the body, as in diathermy. Ravault, Kroll and Ceccaldi place the electrodes upon the point of emergence of the sciatic nerve from the spine, the electrodes thus being in an oblique position in the sacrogluteal region. Raab recommended treating the thigh and leg separately. Wertheimer, following this procedure, obtained satisfactory results. Pitzen used the 15-meter wave length with success in sciatica, by treating across the leg. He remarks that treating the length of the leg might be even more successful. This is questionable, as the effect of this procedure would be analogous to that achieved by diathermy. Kroll claims cures in 7 cases of neuralgia of the lumbosacral plexus, which had been treated on an average 18 times. Miiller and Stiebock treated 32 cases of neuritis with their special method, and suggest further experimentation along this line. In chronic neuritides they used the 10-meter and even shorter wave lengths. The treatments lasted from 3 to 5 minutes. One of the electrodes was a head plate, applied to the specified part of the body. The other was a brush electrode, which they passed along the diseased nerve route, alternately pressing down and lifting the brush. Although the patients complained of disagreeable internal heat, the authors maintain that this method generates no noticeable heat within the body. The brush electrode caused a little scorching and burning of the skin, in fine points. These disappeared after a few days. In acute neuritis, these authors used a wave length of from

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50 to 60 meters. They firmly maintain that no heat effect is generated, but suspect that a special electric effect is responsible for the curative action. Plate or ring electrodes were used. Pitzen was entirely unsuccessful in his attempts to cure or ameliorate intercostal neuralgia, which was a consequence to scoliosis, and finally concluded that his failure lay in the anatomical compression of the nerve by the bony structure. Kroll achieved satisfactory results in 2 out of 3 cases of intercostal neuralgia, with an average of 18 treatments of 10 minutes' duration. Hoffman treated brachial neuralgia by placing the electrodes on both elbows with the arms in abduction, this promoting conduction. Of 22 cases of this type treated by Kroll, only 4 were unsuccessful. The treatments averaged 10 in number, and were 10 minutes in duration. The group included some which were complicated by palsies of rheumatic origin. In trigeminal neuralgia, short-wave diathermy may result in irritation occasionally, and in such cases it is well to interrupt treatment by a lapse of a few days. Kroll reports 12 cases, of which 7 were genuine trifacial neuralgia, receiving from 6 to 25 treatments of an average of 10 minutes each (preauricular application). These reacted as follows: definite improvement in 6, in 2 of which short-wave diathermy had to be resumed within 3 months. Of 3 cases of trifacial neuralgia, with arteriosclerotic basis, 2 were improved. Of 13 cases of palsy of the facial nerve of rheumatic origin, all recovered after short-wave treatments (average 26 in number), the largest number of treatments given in any one case being 46, and the smallest 10. Dietrich found that cure can be achieved in from 60 to 70 percent of cases of trigeminal neuralgia, while in intercostal neuralgia this figure can be raised to 90 percent. Liebesny had a case of trigeminal neuralgia, which, after being reported cured by 6 treatments, recurred in 6 weeks, and could not be influenced by the same dosage as before. Schweitzer found that in the acute neuralgias some cases will respond to very small doses, others will react with increased pain; and he concludes that the treatment with short waves must be individualized.

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Weissenberg states that polyneuritis, and trigeminal, brachial, occipital, and intercostal neuralgias, respond well to weak doses. Kroll recommends electropyrexia in polyneuritis, as giving better results than local treatment to different parts of the body. It is his opinion that the traumatic neuritides respond best of all to this form of treatment. Raab collected data on cases reported, from which he finds that in neuritis the cures amount to about 60 percent of the cases, with improvement in 10 percent and failure in 30 percent. Kroll's technic is to use the 4-meter wave length, with from 1.5 to 2.5-cm. air-spacing. Each treatment is of 10 minutes' duration, except in very sensitive patients, for whom the treatments are limited to 5 minutes. MIGRAINE

A number of investigators, among them Babin-Chevaye, Drouet, Liebesny, Schliephake and Weissenberg, are of the opinion that in true migraine short-wave diathermy gives the best results of any form of treatment, especially if the migraine is of angiospastic origin. The headaches frequently stop after one treatment for 10 minutes, and in a few cases it is necessary to give another treatment the following day. Drouet reports 7 cases in which definite and complete cure was achieved in a majority with from 4 to 15 treatments. The action of short waves is essentially one of vasodilatation, which explains the rapid and sometimes immediately palliative effect during treatment. Though definite cures are reported, permanent cure depends upon the extent of the pathological changes in the diseased area. No damaging effects on the brain were observed after this treatment. It is reported that the patient may be dizzy for a few minutes, but this subsides completely. This is attributed to the hyperemia induced in the brain and its covering. The technic is simple. The head is placed in the frontooccipital position, between two electrodes. Moderate intensity is recommended and the duration of the treatment may be from 10 to 15 minutes. The patient will experience an agreeable sensation of warmth. The treatments are given twice weekly.

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Schliephake recommends the 15-meter wave length as giving the best results. Liebesny advises avoidance of the short wave lengths, on the ground that they may be too irritating to the brain. We cannot agree with this view, as we treated numerous affections of the nose and eyes with 6, 8, and 10-meter wave lengths, the brain here being necessarily treated also, because of the position of the electrodes; yet we noticed no signs nor symptoms of deleterious effects. Some of our patients fell asleep during treatment, but no disagreeable effects were observed. It is important, however, not to prolong the treatment beyond 25 minutes, and not to use too great intensity. MISCELLANEOUS N E R V O U S CONDITIONS

A few isolated reports of the use of short-wave diathermy in a variety of diseases of the nervous system are available. Saidman noted improvement in the paralysis following poliomyelitis, and this without a rise in the temperature. In encephalitis, Schliephake observed improvement in the chronic phase of the languor, apathy, drowsiness and muscular rigor, but the tremor remained unaffected. Schaffler-R6zsa improved 3 cases of chronic encephalitis. Groag-Tomberg observed the symptoms subside after 35 treatments with the 3-meter wave length, for 15 minutes daily. Becker and Kronfeld, and Hayer, met with encouraging results in multiple sclerosis. Weissenberg also note improvement, especially where spasm was present. The condition of one patient, who had great difficulty in walking, so improved that he could ride a bicycle. Spontaneous remission, however, cannot be excluded as a possibility. At the Fourth International Congress of Radiology in Zurich, 1934, Delherm and Devois discussed the use of short waves in hemiphlegia. They achieved favorable functional results, using large electrodes for 20 minutes at a time, with a very weak current. Cases were described in which the function of the hands was restored sufficiently to permit writing and sewing. Among the experiments reported are those of Hoff and Weissenberg, who used the 15-meter wave length with electrodes of different sizes, to treat the brains of patients. They observed

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a vagotonic and a sympathicotonic effect, which may, at a subsequent treatment, either be absent or be the reverse of what it was, according to the varying sensitivity of the individuals. Thus the more pronounced effect appeared on the side on which the smaller condensor had been placed, owing to the denser field, even though patients were conscious of greater heat increase on the side with the larger plate. With glass condensor electrodes, the air space between plate and head was at least 0.75 inches, and one to 4 amperes was used. These authors treated the cerebellum and the frontal lobes of normal patients, and found that the arms which had been held forward, swung during the treatment to the side opposite the smaller electrode. These and similar experiments point to an influence exerted by short waves on the function of the brain. IMPAIRMENT OF MOTILITY

In contrast to the action of the faradic and galvanic current, the high-frequency current does not irritate the motor or sensory nerve endings. Nevertheless, Weissenberg on occasion observed muscular cramps during treatment, after intensive doses of short waves. In cases of facial palsy, Kellner observed muscular contractions on the palsied side. Dausset saw regression of the symptoms of palsy in hemiplegia. Weissenberg treated such cases with weak doses of short waves and noted improvement. Cures in facial palsies, after 5 or 6 treatments, have been reported. Stefanesco and Georgesco treated 6 cases with success. They gave daily treatments with short waves for from 20 to 25 minutes, and after from 15 to 18 days short-wave diathermy was combined with galvanization. Short-wave diathermy should be started on the day of the onset of the disease. The palsied muscle groups of the extremities do not recover in any wise differently after short-wave diathermy than they do after other methods of treatment (Weissenberg). PARKINSON'S DISEASE

There are reports in the literature, including Weissenberg's 18 cases, in which short-wave diathermy improved the symptoms of Parkinson's disease. Akinesis especially yielded to treatment well, and tremor and drooling could be controlled with 10 or more treatments of the head.

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SYRINGOMYELIA

Less favorable results than in Parkinson's disease were observed by Weissenberg in syringomyelia. EPILEPSY

Longer intervals of freedom from attack were achieved in some cases, and in a few the attacks were completely eliminated, according to Weissenberg, through treatment of the cervical sympathetic or treatment of the head (8 to 15 treatments). Others report similar results. MENTAL D I S E A S E

Among 8 cases of melancholia treated with short waves, Weissenberg observed 2 successes. The head was treated, in one case 25 times in 10 weeks. Dementia praecox.—Horn treated 10 cases of dementia praecox with 15-meter waves, by exposing the brain for 20 minutes for a course of 30 treatments. Results were essentially negative, but necropsy was performed on 2, who died 8 and 10 months' after the termination of treatment. The findings showed that, although there was a clearing up of the infiltration, this was only in the most superficial cortical layers. Under the cortex, the pathological process continued unchecked. Horn believes that the effect of short waves on the cerebral vessels is mostly a specific effect on the sympathetic. Nevertheless, in his patients the oral temperature rose as much as 1° F . , though he hopes to be able to avoid this with changes in technic. Of course, the rise in oral temperature is not indicative of a rise in brain temperature. BRAIN ABSCESS

Schliephake successfully treated a case of brain abscess, the improvement being evidenced in a decrease in the number of leucocytes; the duration of treatment was 4 weeks. It may be that short-wave diathermy will prove beneficial, especially in cases of multiple abscesses. HICCUP

Weissenberg was able to arrest singultus in 6 cases, with one short-wave treatment, after the hiccups had lasted from a

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number of hours to 14 days. The treatment, 10 minutes in duration, was directed to the occipital region and to the upper abdomen. This author failed in one case of postoperative singultus. This beneficial effect is on the vegetative nervous system. URINARY INCONTINENCE OF NERVOUS ORIGIN

In 5 of 6 cases of urinary incontinence due to multiple sclerosis, syphilis, traumatic hematomyelia, enuresis nocturna (spina bifida) and a neuropathic state in general, patients were free from recurrence after short-wave diathermy directed to the bladder-sacral area. An average of 18 treatments were given and with a few exceptions, all the patients were relieved. NEUROMA

Kroll believes that the inflammatory type of neuroma, for example amputation neuroma, is amenable to short-wave diathermy. COMMENT

For a true evaluation of the place of short waves in the treatment of diseases of the nervous system, much more study and experience is required. Short waves may be used in weak dosages of longer wave lengths, combined with other therapeutic agents. The treatment may aid in promoting cure by its hyperemic or analgesic effects. In general, it seems that in some cases weaker energies give better results than stronger energies. This applies especially to those cases presenting acute conditions.

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D I S E A S E S OF T H E S K I N

THE success of short-wave diathermy in infections of the skin has been ascribed to several factors, chief among which is the marked vasodilatation which is the immediate result of the application of short waves. The increased circulation increases phagocytosis. Incidentally, there is the antitoxic and bactericidal effect which assists the organism in combating infection. FURUNCLE*

Although as a rule most furuncles are cured by conservative treatment, there are cases with marked inflammation and eventual abscess formation which require surgical intervention. It is in this type of case that short-wave diathermy has proved to be of particular benefit, as a simple and mild form of treatment. In the past 6 years, Schliephake has treated more than 500 cases of furuncle and furunculosis, of greater and lesser severity. He reports only 2 failures, attributable to the patients themselves. The cases were unselected, just as met with in general practice. The average number of treatments required were from 2 to 6, and the average time until cure was effected was 4.6 days. Pflomm stated that short-wave diathermy induced cure on an average in 6 days, whereas the normal healing period for the lesion under ordinary conditions is 13 days. In the follow-up examinations no recurrence was observed. Hoeffler and Weissenberg reported rapid cures, with smaller doses, in children. Schliephake, Raab and others noted that by treating only a few furuncles, the remainder were apt to subside spontaneously. *Arch. Physiother., XVI (1935), 587-94.

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I t was also found that chronic recurrent furunculosis was cured, after treating periodically-recurring furuncles, and a follow-up record, in some cases of some months and in others of years, showed no recurrence. This may lend support to the hypothesis that absorption from furuncles treated by short waves, induces some sort of autovaccination which prevents recurrence. A number of investigators, including the present author, favor this view. Schliephake thinks that the dead and dying bacteria give rise to a form of autoinoculation. For example, in the case of furunculosis, one can observe a definite shrinking and regression of a whole group of smaller boils, after treatment of a single large furuncle or carbuncle. For this reason, it would seem advisable to subject furuncles with abscess formation to short-wave diathermy, if there is no emergency, even if surgical intervention is contemplated. This holds good also for axillary abscesses. In the case of facial localization of furuncles, especially on the lip and nose, short-wave diathermy without doubt gives the best results, since it lowers the mortality and the danger of serious complications. The danger inherent in labial and nasal boils is well known. The infection may invade the cavernous sinus, by way of the vena angularis or vena ophthalmica superior, with fatal outcome. Because of the possibility of such a serious complication, the tendency has been toward a conservative treatment, since the operative mortality has been given as between 5.5 and 30 percent, according to different authors. For this reason, short-wave diathermy proves to be a peculiarly efficacious measure. Liebesny, out of a series of 81 cases of facial furuncles, reported one death of meningitis, or 1.2 percent. His cases were localized as follows: lower lip, 7; upper lip, 30; nose, 24; chin, 14; forehead, 2; cheek, 4. In some cases the temperature, already high, rose to higher levels after the first shortwave treatment and fell after the second and third. As a rule, the inflammatory process was arrested and pain usually decreased after the first treatment. The redness subsided and became demarcated after from 2 to 4 treatments. This was also the case in furuncles of the auditory canal. Although the lesion may not proceed to suppurate, a relatively quick abscess formation was frequently observed. This evacuated spontaneously,

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or was drained through an incision best performed by electrocautery or electrosurgery. Where no distinct fluctuation was present, short-wave diathermy alone was sufficient. In the infiltrative stage, the infiltration may soften and resorption may take place without discharge. The pain and tumor usually subside after the first or second treatment. After a few treatments, the skin becomes loose and wrinkled and quick regression is observed. For a few days the skin may be a bluish or brownish-red, gradually fading to normal, without tenderness or sensation of tension. In those cases in which a core has developed, surrounded by inflammation and with edema or abscess, and in which surgery is usually resorted to, the throbbing pain and tension will subside after the first or second treatments with short-wave diathermy. After from 12 to 24 hours, demarcation of the inflammatory area is observed. The lesion may acquire a dull bluishbrown color, gradual resolution of the edema follows, with softening of the entire infiltrated area; abscess formation around the core is moderate, and there is spontaneous elimination of the core, accompanied by a small amount of purulent, seropurulent or serosanguineous discharge. With subsidence of the inflammatory process, healing takes place in an average of from 2 to 5 treatments, in from 4 to 6 days and, after the pathological process is terminated nothing remains but a small scab over what was the necrotic focus. In the case of furuncles of a more advanced stage of development, which are already softened and where an abscess has formed, the pus is spontaneously evacuated after or during, the first treatment, and healing takes place with unusual rapidity in 2 or 3 days. In severe cases, healing is quicker if the affected parts of the body are immobilized until the inflammation distinctly subsides. As a rule, patients are not prevented from pursuing their usual occupations or the routine of their daily lives. A few illustrative case reports from our material follow: 1. Furuncle of the buttock.—The patient, female, 50 years of age, came for treatment on October 8, 1934, stating that she had suffered from boils since June 15 of that year. Surgery had been resorted to several times, and an anesthetic had been required for the opening of one boil in the gluteal region.

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Clinical Findings.—A large furuncle of a week's duration was situated on the left border of the anal and gluteal region, and was so painful that it interfered with walking, sitting and sleeping. The skin was red and edematous over an area 2 inches in diameter. In the center of the lesion was a small scab. On palpation, the entire area was tender and infiltrated, and sligKtly fluctuant in its midportion. One treatment was given with the 6-meter wave length for 10 minutes, followed the next day by a second treatment. There was decided subjective improvement,

32. Furuncle of the Chest Wall a. Before Treatment by Short-Wave Diathermy; 6, Four Days after Treatment by Shortwave Diathermy (6-Meter Waves)

and only slight pain. The area of infiltration was diminished and of a dark bluish-red. Three more treatments were given, with gradually diminishing inflammation and infiltration. A moderate amount of serous discharge necessitated a small dressing. Six days after the first treatment, all that remained was a painless area of infiltration under a small scab. The patient was discharged as cured. No further furuncles developed during the following 6 months. No recurrence was observed and a fine pin point of scar indicated the site of the original lesion. 2. Furuncle of the neck.—Dr. F., 63 years of age, presented a large furuncle on the left posterior side of the neck, which had developed 4 days before. He complained of throbbing pain and tenderness, radiating to the shoulder and the occipital region. Clinical findings.—The inflamed and infiltrated area was

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about 1.5 inches in diameter. After the second treatment with short-wave diathermy, using the 6-meter wave length for 15 minutes, the subjective symptoms subsided. There was no pain, although tenderness to palpation and on motion continued. The inflammation became localized, with central fluctuation and pointing. After the fourth treatment, the core was extruded with a slight amount of pus. The lesion was slightly tender to the touch, and an area of infiltration about 0.75 inch in diameter remained. After two further treatments, the infiltration and tenderness disappeared; and after a sixth, only a bluish-red area about one inch in diameter, circling a small scab, gave evidence of the former site of infection. The lesion healed completely in three weeks, without surgical intervention and with a practically invisible scar. The healing in this case was unduly prolonged as the patient came for treatment spasmodically, neglecting it whenever subjective relief had been obtained. 3. Furuncle of the face.—A.B. female, 23 years of age, developed a painful furuncle 3 days after a pimple had been manipulated. When first seen, the left side of the cheek had been swollen for a day and the patient was unable to speak or to eat in a normal manner. The left chin area and cheek were swollen and red. Near the left angle of the mouth was an infiltrated area about one inch in diameter, surrounded by an edematous area of about 1.5 inches. From the center of the lesion, pus exuded from a small sinus. Short-wave diathermy was given for 15 minutes, and the patient reported relief from pain 6 hours later. The next day the swelling had decidedly diminished, with a slight seropurulent discharge. After the second treatment, on the third day, the swelling had subsided completely. The inflammatory area was about 0.75 inch in diameter, and there were no subjective symptoms. Altogether, 3 treatments were given, using the 6-meter wave length for 15 minutes, and the patient was discharged. The pathological process subsided in 5 days, leaving first a reddened area which cleared up in a few days, and finally only a scar about one mm. in size. 4. Furuncle of the right lower arm.—T.W., boy, 11 years of age, had undergone splenectomy 3 years before for thrombocytopenic purpura, and gave a history of having had 15 transfusions on different occasions, to control bleeding.

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Clinical findings.—There was a painful tumefaction on the right lower arm, of 2 days' duration. The proximal radial third of the lower arm was red and edematous, over an area about 21 inches in diameter. The area of infiltration, about l j inches in diameter, had a bluish hue, with the core showing in the center as a small yellow point. There was tenderness on palpation, but no fluctuation could be detected. Because of the history of purpura, operation was considered inadvisable. A first treatment with the 6-meter wave length, for 15 minutes, was given, and on the following day edema and inflammation were considerably diminished and, although tenderness to touch was still present, the pain had subsided. The lesion was discharging and about 1 cc. of sanguineous pus, followed by moderate bleeding, could be obtained by gentle pressure. A second treatment was given, and on the third day there was no further pain, with only slight edema and localized inflammation around the discharging sinuses. An ecchymotic ring, about 1.5 inches in diameter, was noted around the lesion. A third treatment was given, and 2 days later there was no sign of inflammation, and only a slight area of painless infiltration topped by a small scab. The ecchymosis gradually faded. Cure was accomplished within 5 days, with 3 treatments. 5. Furuncle of the sacral region.—G.M., female, 61 years of age, a diabetic, suffered from a furuncle on the lower back. The lesion was of 5 weeks' duration. It had discharged periodically and had grown more extensive. The patient was unable to lie in bed because of the pain. Inspection revealed a red infiltrated area about the size of an apple, not discharging, but tender to the touch. Following the first 2 treatments with short waves, the lesion was smaller and softer and less tender to the touch. Fluctuation was absent, but there was very slight serous discharge. Two more treatments were given with the 6-meter wave length, for 15 minutes each, and these effected a complete cure. The only lesion remaining was a small area of painless infiltration with a small scab in the center. There was no recurrence while the patient was under observation, a period of 3 months. 6. Furuncle of the left eyelid.—E.S., female, gave a history of swelling and pain of the left eyelid and eye, of 3 days' duration. On the left upper eyelid was an area, one inch in diameter, that

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was red, swollen and edematous. The patient was unable to open her eye. The eye showed conjunctivitis and an area of infiltration 0.5 inch in diameter, with a yellow spot in t"he center. The glands in the pre-auricular region were swollen and tender. Following 2 treatments with short waves, the pain decreased and the edema subsided, but the original lesion increased in size, inflammation was more distinct and fluctuation was present. A small incision was made under local anesthesia, and about 4 cc. of pus removed. Two days later the swelling and inflammation had subsided completely, and the 2 incised wounds showed healthy granulations. In this case operation was indicated, to relieve the patient and to promote prompt healing. These selected cases give a clear picture of the effectiveness of short-wave diathermy in promoting healing of furuncles. We gain the impression that the conservative treatment of furuncles, with the aid of short waves is a decided advance over methods hitherto employed. Short-wave diathermy is a simple method, with no attendant dangers, and in most cases it renders surgery unnecessary. Nevertheless, as we have stated, in certain cases it may be necessary to make a small incision in order to quicken the healing process, and to facilitate evacuation. In our 51 cases of furuncle, it was necessary to incise (by lancet) only twice. These were instances in which abscess formation was present, inconveniencing the patient by its size or location. When surgery is employed, its conjunction with short-wave diathermy shortens the time of recovery. Furuncles in the auditory canal are rapidly relieved by shortwave diathermy. We observed relief from pain after one or 2 treatments, and complete regression of the infection in from 2 to 6 treatments, over an average period of 4 days. The 6-meter wave length was used for from 10 to 15 minutes, and surgical intervention was unnecessary in 8 cases. According to Ruete, electropuncture, in addition to short-wave diathermy, may be necessary in some cases. Technic of treatment.—The method of applying the current for furuncles is relatively simple. The electrode should cover the lesion and the surrounding inflamed area. In order to obtain the best electric field for curative purposes, electrodes of differing sizes may be used, a smaller one on the lesion and a larger for

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the opposite pole. This will result in greater concentration of the electric field in the affected area. In the treatment of furuncles, the Tomberg unipolar application may also be usefully employed. Should the lesion to situated on anatomically prominent parts, for example the tip of the nose, then rigidly fixed electrodes with proper air-spacing may be used to advantage. All the wave lengths within the range of short waves may be successfully used. Schliephake, Raab, Last and the present author prefer the 6-meter wave length, or the 12 to 16meter wave lengths. Schliephake and other investigators believe that the 8 to 12-meter wave lengths are not so effective. If there has been faulty technic, for example if too strong a current has been employed in order to obtain a marked heat effect, a mild degree of heat coagulation of the superficial cutaneous layers may occur. This is characterized by a bluishred discoloration of the area surrounding the furuncle. In such an event, healing is prolonged to 8 or 10 days, without, however, any deleterious effects resulting. If there is a concomitant lymphangitis, this will regress simultaneously with the healing process in the main focus of infection. Should there be an accompanying regional lymphadenitis, it will also yield to the short-wave diathermy directed toward the involved area. If the affected glands are near the principal lesion, the cure of both may be accomplished by a single series of short-wave treatments. There appear to be no contraindications. The patient treated with short waves does not exhibit marked secondary effects. On the contrary, the method is definitely indicated in cases in which surgery is not without its dangers, that is, in diabetics and in hemophilia. CARBUNCLE

The von Seemen treatment of extensive and severe carbuncles destroys the infection through electrocoagulation. This leaves a clean granulating surface, after from 7 to 12 days, which is ready for the plastic procedures of skin transplantation. Very often the treatment of carbuncles with short waves is a simpler and milder method, shortening the duration of the affection and causing fewer complications, if instituted in time, as evidenced by a statistical survey of the literature.

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In the early stages, when only infiltration with tenderness is present, resolution may take place, as in the case of a furuncle, after irom 3 to 5 treatments. But where extensive necrosis is evident, the wound clears after an average of from 6 to 8 applications, and is then covered with fresh healthy granulations. It goes without saying that where fascia and muscle are involved, the healing period is longer, even though distinctly shortened by short-wave diathermy, as compared with the course of healing under other forms of treatment. Scar formation takes place quickly, owing to the stimulating biological processes by this form of therapy. This therapeutic agent is especially recommended for use in diabetic patients. Raab describes a man, 72 years of age, with a carbuncle on the neck, measuring from 4 to 6 inches in diameter. This case was treated unsuccessfully with light therapy, protein injections, and other measures. The temperature was 102° F., and the patient was in an unsatisfactory condition generally. After the second treatment with short waves, the lesion began to regress, became softer and, after 1'4 treatments, clear healthy granulations, with subsequent cure, ensued. Raab believes that in this case shortwave diathermy was a life-saving measure. Certainly there are cases in which it is wiser to combine surgery with short waves, in order to hasten healing. Two cases from our own material illustrate this point. A young man, 28 years of age, gave a history of suffering for 6 days from a carbuncle 2.5 inches in diameter and situated on the neck. The patient's average temperature was 99.9°F. On November 10,1934, the first short-wave treatment was given, after which the patient's temperature returned to normal and he felt comfortable. Two days later, an abscess had formed, with distinct fluctuation, but not markedly tender. As resorption could not be expected, an incision 1 cm. long was made with the electric knife with coagulating current. About 10 cc. of pus was discharged. Culture showed staphylococci. Two days later, the patient had no pain nor discomfort. At the point of incision was a small granulating wound, with slight serous discharge. The patient was discharged next day, after having had four short-wave treatments, with the lesion showing a small area of infiltration, covered with a dry scab over the site of incision. Follow-up ex-

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amination 12 days after the beginning of the treatment showed that a complete cure had been effected. T h e other case was that of a man 45 years of age, with a furuncle and a carbuncle of the neck, and who gave a history of having been suffering for 3 months from the lesions in this locality. He had been operated upon several times for these periodically recurring infections. The present carbuncle had caused him much suffering for about two weeks. It presented an infiltrated red area with edema, about two inches in diameter, with several yellow cores in the central portion. The urine was negative for sugar. Two short-wave treatments in two days were given, with improvement in the subjective symptoms. Daily treatments were continued, with further local and general improvement. After the fifth treatment, the lesion was no longer discharging and the reddened area of infiltration was reduced to 0.5 inch and was no longer tender. The lesion was entirely healed in 7 days. T h e treatments were from 10 to 20 minutes in duration, using the 12-meter wave length. Five days after discharge, the patient returned with an inflamed area on the chest, two and a half inches in size, slight elevation of temperature, the general picture suggesting a new streptococcus infection about the right breast. This lesion was cleared and healed in 4 days under shortwave diathermy. While this lesion was under treatment, a fresh lesion appeared on the neck, on the site of a scar from a former surgical intervention. I t became swollen and very tender. After 2 treatments, it opened spontaneously, evacuating about one cc. of purulent matter. T h e next day there was an abscess, with distinct fluctuation in this area, and lymphadenitis on the corresponding side of the neck. This patient developed a subfacial abscess, which gave him a great deal of discomfort. I t was incised 1 cm. by electrosurgical incision with the coagulating current. Without further drainage, this resulted in the evacuation of 5 cc. of sanguineous-purulent material. Treatment for 6 days with short waves resulted in a cure. The lymphadenitis subsided after 2 treatments. Three other cases healed readily in from 10 to 15 days, with short-wave diathermy and without surgical intervention. Had no recurrence during the 6-month follow up. Pain is quickly relieved after 2 or 3 treatments, as a rule. In Liebesny's 15 cases of carbuncle of the neck, cure took place in

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between 8 and 14 days. Schliephake, on the basis of an extensive series, found that large carbuncles heal in from 10 to 20 days, after from 8 to 15 treatments, without surgical intervention. Lob observed increased inflammation of the carbuncles treated, with aggravation of the condition, which was attributed by Schliephake and Weissenberg to overtreatment. Lob also believes that short-wave diathermy should not be employed in acute surgical infections, in fact, that the measure may be dangerous to the patient and the surgeon. He compares the action of short waves to hyperemic treatment of pyogenic infections, and states that, as such, the treatment may result in increased exudation. Through the increased tissue tension within the bacteria and the toxins may penetrate to the adjacent deeper tissues. He believes, therefore, that it is important to open widely and to drain the diseased area. Cases may be observed in which overdosage occurs easily when the protective powers of the surrounding tissues are destroyed. Hence, instead of supporting the organism, short waves, in such instances, may become destructive. After a survey of reported cases, however, we find that such aggravation clearly could not be attributed to the short-wave diathermy. Also, there are unquestionably cases in which proper surgical drainage is indicated, in conjunction with short-wave diathermy. I t is therefore desirable to employ short waves only under the supervision of thé surgeon, who should decide the proper time for intervention. It should be noted that the treated area will often show an increased redness after the first or second treatment, giving a picture of "increased inflammation" which is apparent, not actual. The patient's subjective symptoms are improved, even when a rise in temperature for a day is observed. Judging by reported results in the literature and by our own cases, the treatment of carbuncles by short waves impresses us as being eminently satisfactory. It is a mild, conservative form of treatment, giving quick comfortable resolution of the lesion, even in cases of diabetes, in which it is particularly indicated, simultaneously with the control of the sugar content of the urine and the blood. Nevertheless, in certain cases, after a deep abscess has

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formed, drainage quickens the healing process, and to this end a small incision should be made, preferably by electrosurgery or cautery, while continuing short-wave diathermy. The healing of the lesion after short-wave diathermy is very satisfactory from the cosmetic point of view, as only small scar points remain where the cores were situated. The decision that surgical intervention is indicated is a matter of judgment and experience. Technic of treatment.—This is the same as for furuncles. It is a good plan to cover the entire inflamed area with one of the electrodes, and to prolong the time of exposure from 15 to 25 or 30 minutes daily. Two different electrodes should be used, the smaller one covering the diseased area, the larger one placed on the opposite side of the body. The electrodes can be placed on the head without harmful effect. Greater concentration in the electric field in the diseased area may also be obtained by placing the electrode closer to the surface of the diseased area than on the opposite side. The Tomberg method of unipolar application can also be used in such treatments. It is important to obtain an even exposure, with stronger doses than in the case of furuncles. The more severe the condition, the longer the treatment should last, but by no means should it exceed 20 or 30 minutes. Usually from 5 to 8 treatments, of from 15 to 20 minutes daily, will suffice to bring about healing. The recommended wave lengths, as suggested by different investigators, are 4, 6, 8 and 12 meters. In the cases of large carbuncles, progress is less rapid, but resolution invariably takes place and the temperature subsides to normal after a few treatments. AXILLARY SWEAT-GLAND INFECTION AND ABSCESS

As every practitioner knows, pyogenic infection of the axillary sweat glands is sometimes obstinate to treatment. Many measures are employed, cure eventually following. Roentgenotherapy and vaccines have also been used with success. In complicated cases, recurrences are common. Since the advent of short-wave diathermy, this form of treatment has been acknowledged, by those who have used it, to be superior to any other form of treatment. Early infiltration is resorbed after from 3 to 5 treatments. If abscesses have

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formed spontaneous evacuation with quick healing may follow from one to 3 treatments. Tenderness usually subsides after the first or second treatment, and the inflamed areas decrease in extent and become limited. Sometimes there is distinct shrinkage of skin over the lesion. In other cases swelling may be increased, and tenderness may become more acute until spontaneous rupture occurs. Some patients, more sensitive than others, cannot bear pain well. In such cases, opening the abscess may be advisable, using high-frequency cutting (coagulotomy) or cautery for drainage, in combination with short waves. Electrosurgical or electrocautery incision of abscesses is advised, for one thing, to prevent dissemination of the infection in the surrounding tissues. A second reason is that the wound edges are thus covered with a film of coagulated tissue. Granulation being delayed in this manner, the wound remains open until the abscess is discharged. The slower healing of the wound edges prevents untimely closure and clogging, therefore drainage can be omitted. Short-wave diathermy should be continued until complete healing takes place, in order to preclude recurrence. This is assured, when no infiltration or pathological changes are present. Scar formation is avoided by this form of treatment. Estimates by various authors give a healing time 50 percent shorter by short-wave diathermy than by other methods. Healing depends to some extent upon the stage and severity of the lesion, but usually it takes place between 3 and 14 days, after from 2 to 10 treatments. Rarely, from 14 to 21 days are necessary for cure. Immobilization of the arm shortens convalescence. Liebesny reported a series of 26 cases, in which from 14 to 21 days were required for cure. In the follow-up examinations, recurrences are rarely observed. Technic of treatment.—Special electrodes, on the same principles as those employed for furuncles and carbuncles, are used for axillary abscesses. When both axillae are affected, the electrodes may be placed in both, but they are usually treated separately. Capaldi found that only the 8-meter wave gave him results. It proved effective in one case in which the 4 and the 15-meter waves had been without result. He stresses the fact that the 4 and the 15-meter waves generated more heat than the 8rmeter

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wave, and draws the conclusion that the benefit in the latter does not rest in its heating effect. We cannot agree with this observation, since we obtained our best results with 6, 12 and 14-meter wave lengths. We are under the impression that in superficial infections, such as axillary abscesses, the wave length is not of primary importance. The time of application varies from 10 to 30 minutes, depending upon the character of the lesion.

PARONYCHIA, CELLULITIS, AND OTHER OF THE

INFECTIONS

EXTREMITIES

Short-wave diathermy has been found very useful in pyogenic infections of the extremities. In early cases of paronychia and allied infections, quick resolution follows after 2 to 3 treatments. The infection regresses and, if pus is present, slight spontaneous discharge may be observed before healing takes place. In some of the more advanced cases, it may be possible not only to arrest and cure the infection, but also to save the nail. If the nail has already separated, it should, with the surgeon's advice, be removed, after some treatment with short waves has been given. If there is deep involvement of the soft parts, short-wave diathermy may not bring about retrogression of the infection, but only a localization of the process. In the event that pus has collected and no further improve-

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ment is evident from short-wave treatment, drainage (by electrosurgical incision) and evacuation of pus will be necessary, similar to the procedure carried out in axillary abscesses. On the whole, cure is achieved in a shorter time with shortwave diathermy than with other measures and, if bone is involved, sequestration occurs earlier than it does otherwise. Schliephake found that he had to intervene surgically in only 3 cases, in a series of several hundred pyogenic infections of the fingers. It seems to us, however, that surgical intervention is indicated definitely in cases showing tendon necrosis or bone sequestration, and that the simultaneous administration of short-wave diathermy has a tendency to arrest the progress of infection. The demarcation of the sequestration is also accelerated by short-wave diathermy. A few illustrative cases follow: (1) Dr. H., surgeon. His injury was sustained in the course of operating. Pain and inflammation had been present for two days. The skin around the thumb-nail was red, swollen and tender to touch, in an area about 2 cm. in diameter. After the first short-wave treatment, the pain diminished, and after the second, definite demarcation of the infection took place, followed in 12 hours by the discharge of a small amount of seropurulent material. Three days after treatment, there was a small bluish-red area without symptoms of infection, which cleared up quickly. This was a case of cure after 2 treatments, with the 6-meter wave length, of 15 minutes' duration. (2) Mrs. R. P. There was a history of pain and inflammation around the nail of the right fourth finger, of 6 weeks' duration. A small amount of seropurulent material was discharging from around the nail bed. Iodoform gauze packing was inserted, but after a few days the lesion showed no improvement. Two treatments, 10 minutes in duration, were given, with the 6-meter wave length, after which the pain and discharge subsided. Cure was effected with the third treatment, 4 days after the commencement of short-wave diathermy. (3) Mrs. A. S. Paronychia and cellulitis. The history was of a splinter, penetrating beneath the thumb nail. This the patient removed in part. She complained of intense, throbbing pain. The whole thumb was swollen, red, edematous and very tender to the touch. Around the nail a large phlegmonous bulla

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was exuding pus. The temperature was 101.6° F. The patient was admitted to the hospital for operation, but this she refused. Short-wave diathermy was begun on December 14, 1934, using the 6-meter wave length for 20 minutes. The throbbing pain stopped at once. The patient slept well that night, and the pain decreased markedly. The next morning there was only slight pain without discomfort, decreased swelling, and no elevation of temperature. Examination of the hand revealed distinct fluctuation on the palmar surface, suggesting deep involvement and tenovaginitis. Tenderness was localized around the first phalanx. A second treatment was given the next day, with the same wave length and for the same time as the first. Improvement continued and the temperature remained normal. The patient left the hospital and did not return for further treatment. She was visited at home two weeks later, and stated that she had not returned because the finger "did not hurt." The finger was normal in appearance, but still tender to pressure around the first phalanx. Gradual resolution followed, with ultimate normal function. Kowarschik, Last, Stieböck, von Köhler, Nagelschmidt and others confirmed Schliephake's favorable results. On the other hand, Haas and Lob consider it dangerous not to intervene surgically. We incline to the view that short-wave diathermy in these infections should be under the supervision of the surgeon, who will know best when surgical intervention is indicated. In the case of a specific infection, such as syphilis or tuberculosis, a favorable influence can be exerted by short-wave diathermy, in combination with the proper specific treatment (Liebesny). Technic of treatment.—With wave lengths around 6 meters, treatments daily or even twice daily, for 15 or 20 minutes, are recommended, according to the extent and severity of the lesion. The average case may be cured in from 2 to 15 treatments, depending upon the gravity of the individual case. The average time of cure is from 3 to 16 days. PHLEGMON

Short-wave diathermy of this diffuse inflammation of the connective tissue leads almost without exception to resolution

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or to localization in abscess, after from 2 to 5 treatments. If the abscess is considered by the surgeon to be too large for spontaneous resorption under short-wave treatment, a small electrosurgical incisions to promote drainage is justified. Surgical intervention, in conjunction with short-wave diathermy, should be instituted in progressing phlegmonous infection of the subcutaneous and soft tissues and intermuscular spaces. Case report: Mr. C. C., 68 years of age, with phlegmonous cellulitis (streptococcus), gave a history of having been operated upon a month before for extensive cellulitis of the right thigh. The wound showed no tendency to heal. Among other forms of treatment, the patient had received treatment with ultraviolet light. When first seen, the entire lateral side of the right thigh was red, infiltrated, and tender to the touch. There were 2 sinuses, from the previous incisions, about one-half inch in diameter, discharging seropurulent material. The first treatment, lasting 15 minutes with the 12-meter wave length, was given January 23, 1935, and the patient professed to feel comfortable following the treatment. After the second treatment, on the next day, the discharge became more serous in character. Following the third treatment, 2 days later, the wound was granulating, the infiltration was softer, and there was less discharge. A fourth treatment was given on the next day, and a fifth 2 days later. Erythema localized around the site of the previous incision. There was no more discharge. The wound was covered with a dry scab. The patjent was discharged as cured in 7 days, and follow-up examination verified and substantiated the cure. Another case illustrating the control of diabetic infections by short-wave diathermy, without surgical intervention, is the following. The patient, female, aged 62 years, cut her hand with a knife. A week after the injury, the wound area showed pus and was swollen and painful. In one of the New York hospitals, a small incision was made and a wet dressing applied. The urine was not examined. Within the next 2 days, the infection became more widespread and several pustules appeared on the wrist and the back of the hand. When the patient came under my care, three weeks after the injury, there was on the palm a large phlegmonous lesion and 16 pustules on the wrist and

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back of the hand, measuring from one-half to one cm. in diameter. The urine gave a 4-plus reaction for sugar (fig. 35). The first short-wave treatment lasted 15 minutes, with the 6-meter wave. The number of pustules increased every day up to the sixth short-wave treatment, until there were in all 29. Two weeks later, after the tenth treatment, there was decided improvement. Complete cure took place in 3 weeks.

35. Palmar Abscess in a Diabetic

a, Before Treatment by Short-Wave Diathermy; b, After Treatment by Short-Wave Diathermy

Though there may not be anything unusual in this case, I considered it of interest because the patient refused all further surgical intervention as well as blood examinations. We were able to control the infection without treatment of the diabetic condition. Animal experiments show that short waves directed to the central nervous system may increase the blood sugar for a time. They are without such effect when applied to other parts of the body, except the pancreatic region. In the latter case, the effect is a definite decrease of the blood sugar, after an initial slight increase.

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In presenting this case, which is of relatively slight scientific value, the thought suggests itself that it might stimulate interest for further investigation and research in the problem of diabetic infections, as influenced by short-wave diathermy. Laqueur and Remzi also reported that they were successful in all cases of phlegmon treated with short waves. Technic of treatment.—In treating phlegmonous infections, the recommended wave lengths are 6 and 14 meters, for from 15 to 25 minutes' duration, depending upon the depth and the extent of the infection, short-wave lengths being more effective in deeply seated infections. The entire affected area should be covered with the electrode, beyond the pathological process. The other electrode is placed opposite, and from 0.5 to one inch distant from the skin surface, in order to secure greater concentration in the electric field in the area treated. Dosages are regulated by the patient's subjective sensation of comfortable warmth. It is wise, in the case of discharging wounds, to place a sheet of cotton or gauze or, better still, a piece of Turkish toweling between the electrodes and the skin, if flexible electrodes are used. This makes no difference in the therapuetic results, and has the advantage of keeping the electrodes clean and avoiding skin burns, which may occur if the electrode gets wet. If the secretion from the wound is sufficient to soak through the insulation, the treatment should be interrupted long enough to change the insulating material. Rigid electrodes may be used with greater advantage, where sufficient airspacing prevents the above inconveniences. In no event should adherence to surgical principles be slackened. COMMENT

In none of our acute, subacute or chronic cases could we attribute aggravation of the infection to short-wave diathermy. We treated some cases with short waves alone, and others with short waves in combination with surgery. With our experience, limited though it is, we could substantiate the observations of investigators reporting in the literature. We also gained the impression that in the case of infection, short-wave treatment should be considered before other treatment is instituted. This is

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especially true in the infections such as furuncles, carbuncles, erysipelas, paronychia, cellulitis of the body or extremities, etc., in which surgical intervention may thereby be rendered unnecessary. Our experience in the case of suppurative tenosynovitis is as yet too limited to justify an estimation of final results, but it would appear that a combination of short-wave diathermy and surgery would be most effective. Short-wave diathermy, in addition to rendering surgery unnecessary at times, also shortens the period of convalescence, the patients suffer less, and the cosmetic and functional results are more satisfactory. Finally, short-wave diathermy is an excellent agent in the hands of the surgeon, but may prove a dangerous tool in the hands of one without surgical experience. MISCELLANEOUS DISEASES OF THE SKIN

Aside from the successes reported with short-wave diathermy in furuncles and carbuncles, the favorable results obtained in other skin disorders, although reports are not extensive, would indicate that with further study short-wave diathermy should become a valuable addition to treatment in this field. While treating a patient with furunculosis with short waves, Schliephake observed that the concomitant eczema healed in a short time. Further employment of this measure in eczema substantiated the observation. He succeeded either in curing or in improving eczemas of varying etiology, in a relatively short time. Many cases of long standing, which showed no improvement under local and dietetic treatment, were improved after 2 or 3 short-wave treatments, and cured after from 2 to 10. In a series of 12 cases, 9 were cured and 3 improved. In one case it required 25 treatments to produce results. The lesions, with few exceptions, cleared up in from 2 to 10 treatments. Weissenberg also cured exudative eczemas, in the course of treating other affections with short waves. Auclair and Réchou recommended electropyrexia in generalized eczema. Auclair reported one case cured and 2 improved in eczemas of unspecified origin. We treated a case of generalized allergic eczema, of 4 months' standing, with short-wave diathermy. The lesions covered the body, particularly the abdomen

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and legs. The patient was unable to sleep because of the intense itching. For 15 treatments, however, only the lesions on the chest and one area on the leg were exposed to the short waves. The patient professed himself improved, the skin was dryer and there was less itching. It is possible that in this case generalized electropyrexia would have resulted in cure. Saidman and Cahen observed improvement in different types of eczema, in chronic ulcers and in lupus. Meyer and Saidman recommended short-wave diathermy in the different forms of pruritus. In one case of pruritus vulvae, they obtained a beneficial result after 3 treatments, but they also state that the treatment did not modify the course of the disorder in chronic cases. Dausset and Auclair mention having improved seborrheic conditions of the scalp. They observed the regrowth of hair in 6 cases, and also arrested the falling out of the hair. These results may be attributed to an improvement in endocrine function, as in these cases generalized short-wave diathermy was administered. These observations may be considered exceptional, and the author doubts whether such experiences will be repeated. Pflomm, in the course of treating various pathological conditions of the skin, observed in 2 cases that patches of psoriasis disappeared after from 3 to 4 treatments, extending over a period of 10 days. Remier reported improvement of scleroderma, following short-wave diathermy. In acne vulgaris, Schliephake obtained lasting beneficial results with this form of treatment. In acne vulgaris refractory to the unusual forms of treatment, we had one success and 2 failures. Rahlwes observed some favorable results, as well as some failures, in cases of acne of the face. Last recommends shortwave diathermy in acute acne vulgaris, and Last and Stein advocate this treatment in pubertal acne and acne of endocrine origin. From 15 to 40 treatments were necessary, using the 6meter wave for from 25 to 30 minutes, before improvement was obtained. The acne of bromism disappeared without incision, within one week after short-wave diathermy was commenced. No lasting improvement was observed in acne rosacea. Rapid resolution of herpes zoster after short-wave diathermy

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was observed by Saidman, Bretschneider and Compère. This was also noted by us, in 2 cases. Ruete obtained satisfactory results in erythema nodosum and in pernios. There are favorable reports for syccosis vulgaris. Mahn was able to achieve complete cure in a case of X-ray burn, after prolonged short-wave diathermy at weekly intervals, in treatments of 30 minutes. Technic of treatment.—In localized conditions, the diseased area is placed between suitable electrodes, which should cover the affected parts. Longer wave lengths are recommended—12, 14, 16, 25 meters—except where treatment of lymph nodes is desired, in which case wave lengths of from 6 to 8 meters are used. In a case with a generalized disease condition, electropyrexia may be better than local short-wave diathermy. D I S E A S E S OF THE H E A D INFLAMMATORY DISEASE OF THE SINUSES

Sinusitis, as every medical practitioner knows, may be one of the most obstinate conditions he is called upon to treat. With the advent of short-wave diathermy, an effective measure with which to combat this affection and to bring comfort to the harassed patient, has been added to the physiotherapeutic armamentarium. Short-wave diathermy alone, or its combination with irrigation, has proved to give most beneficial results, and to curtail to a marked extent the duration of the disease (Raab, Hiinermann, Haiman). It has frequently rendered radical intervention unnecessary, and has proved effective in cases which had failed to respond to other forms of treatment. While it is, of course, left to the judgment of the specialist whether or not to use short-wave diathermy in conjunction with the customary therapy, it is not unusual to effect a cure without the latter. We are under the impression that short-wave diathermy should always be tried first in acute, subacute or chronic cases, before surgical drainage is undertaken. As compared with diathermy, the main advantage of shortwave diathermy is the equal, uniform field—local heat action, penetrating the bony walls of the cavities, whereas diathermy merely hurdles them. That the resorptive power of the mucous membrane of the

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sinuses is stimulated, becomes evident after a few treatments. The nasal discharge, even if present in large amount, begins to diminish after a few treatments. Control examination, with transillumination and roentgenograms, demonstrates a gradual diminution of the clouding until normal conditions are restored. Empyema of the antra and adjacent sinuses is a source of misery to the victim and taxes the skill and ingenuity of the physician. It is exceedingly difficult to treat effectively and, even after radical operation, it often recurs or spreads to neighboring cavities. Schliephake believes that in this field shortwave diathermy proves a boon. Unquestionable benefit was achieved in a case of empyema of the ethmoid sinus, which had proved resistant to every other form of treatment. He reported a case of antral empyema of more than 20 years' duration, in which complete comfort for the patient was achieved after a series of treatments with short waves. A 6-meter wave was used for a half hour daily at first, with the plates applied to the right and left cheeks. In this type of case, the obnoxious odor generally disappeared in from 6 to 10 days, and the incessant use of handkerchiefs was rendered unnecessary, since the secretion of pus was so markedly reduced. In from 4 to 6 weeks, these patients were nearly symptom-free. Schliephake states, "At any rate, the patient can be spared an operation but it cannot be expected that a mucous membrane which has undergone severe pathological changes in the course of suppuration can be completely restored to its normal functional capacity." After a few short-wave treatments, the diminishing purulent secretion changes to a mucous discharge, signifying the improvement in the pathologic condition. The sensation of dryness also improves readily. Swift amelioration is especially conspicuous in the acute forms. In chronic cases with mixed infection and in which degenerative and proliferative changes have taken place in the mucous membrane, the most troublesome symptom, in addition to headaches, dryness, localized pain, and changes in resonance of the voice, is the foul purulent discharge, which may become continuous. Some of the patients are disabled physically and become unwelcome socially. In cases of this type, short-wave diathermy proves a boon, relieving subjective and objective

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symptoms. Improvement, to the extent of 50 to 75 percent, occurs after from 6 to 15 treatments, depending upon the severity of the individual case. The nasal secretion is diminished, the purulent discharge is converted into a mucous discharge, and the foul odor practically disappears. Pain usually disappears gradually, and only exceptionally at the very start. Severe pain may persist for a longer period, but with eventual relief. It must be admitted that complete cure cannot be obtained in all cases, even after prolonged treatment, but at least palliative results can always be achieved, with proper applications of short waves. Schmidt and Leichner,* reporting results of short-wave treatment of sinus disease in 55 cases, noted marked improvement in 39, moderate improvement in 11, slight in 2, and total failure, even as to relief of pain, in 3. According to Liebesny, chronic inflammation of the sinuses reacts better to the 8-meter than to the 15-meter wave length. Although exact comparison of results by short-wave diathermy and other radical and conservative measures is as yet out of the question, the balance seems to favor short-wave diathermy. A not insignificant factor is the painlessness and comfort of the method to the patient. Peemoller's results with short-wave diathermy were better than with diathermy. Investigators are practically unanimous in their view that this therapeutic measure is the most effective agent, and one that frequently renders surgical intervention unnecessary. Failures occur, just as with any other therapeutic measure. It should be borne in mind that patients exhibiting symptomatic relief or cure are not necessarily cured of the pathological condition, and treatment should be continued until the roentgenograms show clear sinuses and until irrigation results in a clear fluid. As an illustrative case report, the following may be presented. This was one of our patients, an 18-year-old girl, suffering from chronic pansinusitis. She had undergone several operations and had been under regular treatment in Europe and the United States for 10 years. When short-wave diathermy was started, she was using 15 handkerchiefs a day for the excessive sanguineous-purulent discharge. Her voice was nasal in pitch and she had continuous headaches. After 6 treatments with the 6•Personal communication to the author.

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CONDITIONS

meter wave length for 15 minutes at a time, the discharge was reduced to mucopus only in the morning. After 12 treatments in a period of 3 weeks, there were no more subjective complaints, her voice was clear, and there was a slight, clear mucous discharge. The treatments were continued twice weekly, then once weekly, for 4 weeks. Three months after discharge, the patient appeared to be well, but was instructed to return at once for further treatment in the event that she contracted a cold. An occasional symptomatic treatment was given, until all symptoms

36. Roentgenograms, Showing Multiple Chronic Sinusitis a. Before T r e a t m e n t by Short-Wave Diathermy; b. Twenty-five days after Treatment b y Short-Wave Diathermy (In 27 D a y s There Waa Great Improvement; in 6 Months the Patient Waa Symptom-free)

subsided. She had altogether 3 courses of treatment during the year, with prompt relief, and has been well for the past 10 months. We obtained a cure in our 15 cases of acute sinusitis in from 4 to 8 treatments. Of 39 cases of chronic sinusitis, temporary cures were obtained in 30 percent after from 8 to 24 treatments, definite symptomatic improvement in 60 percent, and failure in 10 percent. It should be noted that our cases were, in the majority, those referred from other clinics, after other treatments had proved unsuccessful.

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Aggravation of subjective symptoms.—Schliephake, Haiman and Raab succeeded in curing a large number of cases with short-wave diathermy alone. His observations bear out our own, that is, that after the first or second treatments the patient's subjective complaints may be somewhat aggravated, but that this is followed by gradual improvement under continued treatment. In our own cases, where the patient presents symptoms of slight aggravation, the short-wave diathermy is continued as before, except at a lessened intensity. Raab also describes a case in which, toward the end of the treatment, the patient experienced neuralgic pain around the sinuses—"healing pain"— which subsided with further treatment. This may be ascribed to the reaction of the mucous membrane of the sinus. Experience, however, makes it possible to vary the length and intensity of the applications so as to avoid the inconvenience and unpleasantness of these secondary symptoms. Technic of treatment.—The electrodes should be molded to the nasal surface, in order to avoid undesirable current concentrations. Special sinus electrodes, which cover all the sinuses, thus assuring adequate and even field action without covering the eyes or interfering with respiration (fig. 22c), were recommended. The sinus electrode is applied with a proper lining, to insure absorption of perspiration. Another large electrode is placed in the occipital and shoulder region, or the electrodes are placed on the cheeks. The treatment at first is for from 10 to 15 minutes in duration, and is then increased to from 15 to 25 minutes. In acute cases the patient is treated every day until definite improvement sets in (50 percent), usually after from 3 to 10 treatments, after which the treatments are given every second day until the patient is practically free of symptoms. In cases in which the maxillary sinuses are involved, the electrodes are placed at both cheeks, in which case air-spaced rigid electrodes may be used to advantage. If air-spaced electrodes are used, the frontal or ethmoidal sinuses are treated in the anteroposterior position, using a smaller electrode to cover the disease area, this having an air-space smaller than that of the opposite electrode. This assures current concentration at the desired level. The airspacing may vary slightly, in accordance with the output of the machine and with the location of the diseased sinus.

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In maxillary sinusitis, the rigid electrodes are applied in opposition, cheek to cheek, on the principle outlined above. Should there be a concurrent tonsillitis or pharyngitis, the neck electrodes may be used (fig. 22); or these infections might be treated separately. But rigid electrodes are more convenient to use. In chronic cases the same procedure is followed as for the acute type, at first daily, and after improvement has begun, every second day. As a general rule, the acute form is cleared up in from 4 to 8 treatments. Chronic cases, however, will require longer treatment, usually from 8 to 30 sessions. In such obstinate cases, Raab recommends that after the fifteenth treatment, treatments should be given only every second or third day. Schliephake considers the 4 to 6-meter wave lengths as the most effective in acute and chronic sinusitis. The wave lengths used in our cases were 6, 8, and 12 meters. An effort was made to use each of these 3 wave lengths in cases as similar in character as possible, the purpose being to determine thereby the most effective wave length in the acute and chronic cases. With the exception of 2 cases of chronic sinusitis, the patients thus treated did not in general complain of symptoms which could be attributed to short-wave action. These 2 patients complained of more intense headaches and refused to return for further treatment, in spite of urging. The results are very promising, although adequate follow-up records over a long period are still lacking. Recurrence.—Recurrence may take place after fresh exposure to infection, which, however, will respond favorably to shortwave diathermy; and it is possible to bring the patient's condition to the pre-infection level by a short course of treatment. DISEASES OF THE EYE

On the basis of experimental work, short-waves are reported as being indicated in atrophy of the optic nerve and in corneal ulcer (Babin-Chevaye), on the assumption that there is a deep, lasting hyperemia and revitalization of the tissues. Indeed Jacquet was able to observe marked vasodilatation after shortwave diathermy on ophthalmoscopic examination, and in one case noted hemorrhage which cleared without grave results.

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Although Kiewe's experiments on enucleated animal eyes and on living guinea pig eyes showed that heating of the posterior pole is stronger and that coagulation temperature may be obtained with resulting damage to the eye, such effects have not been noted clinically where short waves have been used in treatment. Nevertheless, the danger of possible damage should be kept in mind. Kiewe could not improve tuberculous processes in the eye, but found short-wave diathermy beneficial in scleritis. E. von Kohler and Hertenstein experimented on animal eyes, studying the deep effect of short waves. Griiter inoculated guinea pigs' eyes with standardized herpes virus, and observed delayed evolution of the keratitis on the first to second day, but failed to secure lasting favorable result. He treated 22 cases of superficial serpigenous ulcer with short waves, with healing within 6 days in 17 cases, leaving soft scar tissue. Among the more advanced cases, 2 healed and 3 remained uninfluenced. He concluded that the superficial lesions reacted more favorably than the deep. Orbital phlegmons generally receded quickly after shortwave diathermy. Krause found this treatment uniformly successful in phlegmon of the lacrimal sac and in inflammatory processes of the eyelids. Gutsch recommends short-wave diathermy in all types of iridocyclitis, tuberculous lesion, inflammatory disorders and palsies of the ocular muscles, but reports failure in corneal disease, scleritis and glaucoma. Short waves seem to increase the fluid exchange of the eye, and after more intense treatment this takes the form of a fibrous exudate. The treatments were given daily for 20 minutes, for from 4 to 7 days. If a more powerful apparatus is used, the doses should be of shorter duration. The electrodes must be kept dry, and protected against the moisture of lacrimation; otherwise, accidents may occur. Air-spaced electrodes are preferable. DISEASES OF THE EAR

Reiter successfully treated cases of otitis media. It seems to us that in the presence of distinct pressure, paracentesis, in conjunction with short-wave diathermy, is indicated to prevent

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complications; this should naturally be decided by the specialist. With a few treatments, A. Laszlo* cured a case of catarrhal otitis, and 6 cases of furuncle of the auditory canal, in 4 days on an average, and without a failure. In otosclerosis, and all catarrhal conditions short-wave diathermy may be of benefit. MASTOIDITIS

A number of authors have reported favorable results with short-wave diathermy of mastoiditis, among them being Last. There may be cases of moderate severity, in which this measure alone will induce cure, and it should reduce the inflammatory process in all cases. But our experience to date does not permit conclusions to be drawn, although favorable results have been obtained. Further observations are necessary by the specialist, to establish the exact point at which short-wave diathermy can be used with benefit. MASTITIS

Inflammatory conditions of the breast are readily amenable to short-wave diathermy. According to Hoeffler, mastitis neonatorum can practically always be cured by short-wave diathermy, if subjected to daily treatments from of 3 to 5 minutes' duration. Mastitis may be acute, subacute or chronic, and shortwave diathermy may prove of benefit in each type. In the acute and subacute forms the inflammatory process and the infiltration may be checked in a relatively shorter time than by other methods. Consequently, either resolution or abscess formation will take place. When a small abscess has formed and the general condition of the patient, as judged by the surgeon, will not necessitate immediate surgical intervention, short-wave diathermy will reduce the inflammation, decrease the edema, and localize the pathological process, with a gradual absorption of pus. If the purulent accumulation is such as to necessitate immediate drainage, this may be achieved by a small electrosurgical incision. In superficial abscess insertion of tampons is not required during the continuation of the short-wave treatments. There may be cases, however, especially with deep-seated abscesses, in which a rub* Personal communications.

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ber drain may be required to assure uncomplicated recovery. Incision by electrocautery or electrosurgery is recommended, as by these methods the blood and lymph capillaries will be closed. Also, through the coagulation of a small layer of tissue, the clogging and untimely granulation of the skin incision will be prevented. Laqueur and Remzi report beneficial results in acute mastitis. Dalchau treated 15 cases of mastitis. When he began with short-wave diathermy in the early stage of acute mastitis, the inflammation regressed entirely after from 3 to 5 treatments. In general, he confirms the healing process noted above. In most of his cases, the subjective symptoms subsided after the first treatment. In the cases in which abscess had formed, a small lancet incision was made. Egan states that incision may be avoided by the use of short-wave diathermy, and, in 6 cases of pueperal breast abscess, found the results very gratifying. One of our cases of subacute mastitis illustrates a possibility of burns while under short-wave diathermy, resulting in a small superficial area of coagulation at the site of novocain injection. This small area of coagulation healed readily, leaving a scar the size of a pea. The lesion developed after puncture for bacteriological material. The novocain injection into the skin formed a point of protrusion in which coagulation took place. The case report follows: The patient, female, 43 years old, stated that 4 days before she had experienced sudden pain in her right breast. Redness appeared after 2 days. Physical examination showed that the right breast was increased to half again its natural size. It was red, slightly edematous, and under the skin there was a firm area of infiltration about 2 inches in diameter, slightly adherent to the overlying skin. It was tender on palpation. A few swollen, slightly tender lymph glands were noticeable in the right axilla. The temperature was 99.6°F. Aspiration was performed, but no pus could be obtained. The first short-wave treatment was then given with 6-meter wave length, for 15 minutes. The next day the patient expressed herself as being much relieved; she had slept well and had no pain. The infiltration had subsided and the redness diminished in area. On the site of the novocain injection, a small vesicle

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with serous exudate was present, and there was desquamation of the superficial layer of epithelium, presenting the picture of a second-degree burn. This was attributable to the fact that the novocain infiltration created a higher concentration of the electric current, resulting in local coagulation. The second treatment was given with the 6-meter wave for 15 minutes. Two days later the patient was much improved. The area of infiltration was soft and diminished in size. A third treatment was given with the same wave length and of the same duration. In 3 days the patient felt entirely well. A spot of infiltration about one inch in diameter, slightly painful on palpation, was present in the center of the breast. There was no redness of the overlying tissue, but at the point of novocain injection there was yellow necrotic tissue of about one cm. in diameter. Treatment was discontinued. Gradual resolution of the infiltration and healing of the burned area followed. The patient was seen 2 weeks later, at which time the breast was healed and the site of the coagulation necrosis remained as a red spot, 0.5 cm. in diameter; ultimately resulting in a small scar formation. Aside from the quick beneficial effects of short-wave diathermy, this case demonstrates the necessity for care in treating areas which have been the site of injections of anesthetics. There are as yet no available records giving results of shortwave diathermy in chronic mastitis. It seems to us, after treating 20 cases with variable results, that this condition may be influenced favorably. In our cases, symptomatic relief was obtained on local treatment of the affected breast, especially if no marked glandular changes were present. At this time, however, no definite conclusions can be drawn, even though relief was obtained where gland therapy and other medication had failed. The time of observation and follow up record have been too short. Tuberculosis of the breast, especially with fistula, may also respond to prolonged short-wave treatments, and this may be effectively resorted to if operation is contraindicated or refused. In treating breast conditions, especially adjusted breast electrode may be used (figs. 22b and 37).When the electrode is applied on the breast, a larger electrode is placed on the opposite side of the chest. If no specially designed electrodes are available, a pair of rigid air-spaced electrodes of the proper size should be

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so applied as to include within the electric field the whole pathological area. The length of time of application may be from 10 to 20 minutes, daily. In the case of chronic mastitis, the treatments may be spaced at longer intervals. Owing to a lack of sufficient material, no comment can be made at this time as to the proper wave length to be used.

37. Short-Wave Treatment with Breast Electrode

Application of the general principles of short-wave technic are recommended here as described above in Chapter VII, "General and Mechanical Principles in Short-Wave Technic." If the left breast is involved, it is wise to apply the electrodes in such a manner as to exclude the heart from the electric field. Since we do not as yet know the exact action of short waves on the different organs, the brain and the heart should, if possible and on general principles, be excluded from the electric field when neighboring tissues are being treated.

XVI MALIGNANT DISEASE the appearance of a new measure upon the therapeutic horizon, new hopes rise for possible victory over cancer. Since the high-frequency current was already being so effectively employed in different cancer operations, it was hoped that in short waves an even more effective agent had been found. From the surgical point of view, temporarily this hope soon vanished, in view of the results of the laboratory experiments of Katsura and Ito, and Ravault. Much experimentation has been carried out with short waves in the treatment of malignancy. A cause for hope of therapeutic effectiveness was seen in the success achieved by Schereschewsky in large-scale experiments on inoculated animal tumors. Schereschewsky used the most malignant experimental tumor and constructed an apparatus which furnished 68,000,000 cycles per second (4.4-meter waves), according to the suggestions of Professor G. W. Pierce, of Harvard University, in order "that tissue cells placed in a electrostatic field and subjected to the displacement currents caused by the rapid alternations in polarity of the field may undergo some mode of electromechanical vibration which might well have definite effects upon the cell." The tumors were implanted on the right anterior surface of the belly. When they reached the size of from 5 to 10 mm. diameter (in about 3 days), they were treated with a specially constructed electrode from one to 4 times, with from 4 to 18 minutes of treatment. Almost without exception recrudescence was achieved, as a rule in 10 days. Final recovery was secured in practically 25 percent of the cases. In all, however, there seemed to be some shedding of the hair, so that the involved area could be detected for from 2 to 3 months after absorption of the tumor. The remaining 75 percent succumbed to intercurrent disease after the tumor had receded. A histological examination by Dr. S. B. Wollbach, of Harvard, was as follows: WITH

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In general, the immediate effects of the agency you have supplied to the tumor is necrosis of the tumor cells and the accompanying vascular and connective tissue structures. The general picture produced is that of so-called coagulation necrosis and the most familiar corresponding picture that I know of is in completely infarcted tissue. A very striking phenomenon, however, as brought out in the slides, is the extraordinarily rapid disappearance of the necrotic tumor. I am quite unfamiliar with anything corresponding to it. In the few microscopic preparations submitted, one gets the impression that there has been very rapid solution, possible solution by autolysis (?) of the cells including the nuclei. Using the same technic, Schereschewsky also obtained curative results on Rous chicken sarcoma. A histological study of tumors, removed immediately after exposure to high-frequency current of the given dosage, showed that normal tissue cells surrounding the tumor seemed to be influenced by the current to a lesser degree than the tumor cells. Later, Schereschewsky found that the heating of mouse sarcoma to 48° or 49° C. for three minutes, prevented its growth when transplanted into mice. He could also bring about regression of tumors by circulating hot water through hollow copper applicators until the tissue temperature rose to 48° or 49° C., though it required a longer time than by electric current. At the same time he noted that although the skin was but little heated by the high-frequency field, the temperature in the interior of the tumor rose rapidly, reaching 48° or 49° C. in from 1.5 to 2 minutes, depending upon the size of the tumor. Our own experiments with wave lengths of from 6 to 14 meters, were not conclusive. Results were obtained only with wave lengths of from 3 to 5 meters, when the electrodes were applied at a distance of from 5 to 10 cm. from the body surface. Two types of tumor—highly malignant rat sarcoma and Flexner carcinoma—were inoculated into the belly of rats, and practically all the animals perished. Only 5 out of the last 25 survived, in 2 of which regression of the tumor was observed after several applications of short waves. In 2 others recurrences took place after partial regression. The accompanying photograph illustrates the results achieved with wave lengths of from 3 to 6 meters. In Rat 1 (left) strong dosage resulted in complete necrosis of the hindlegs, tail and tip of the ear, without influencing the tumor in its growth with the exception of a small spot of coagulation necrosis in the tumor on the right side of the belly. In

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Rat 2 (ceDter), using less intensity of current and concentrating on the inoculated tumor masses, we obtained coagulation necrosis similar to that obtained with a high-frequency coagulating current (by inserting a needle into the tumor and destroying it with electrocoagulation). It is curious to note that the tumor was destroyed only on the right side, where the electrode approached nearer than on the other side, and supposedly resulted in heat coagulation of prominent tumor tissue. The other side

38. Action of Short Waves on Rat Tumors

continued to grow, uninfluenced. Rat 3, (upper right in illustration) shows that if a greater intensity is used, it may destroy the growth and the animal may recover. In this instance the animal lost one of its hind legs by dry necrosis, but survived and recovered, no tumor being found on subsequent pathological examination. In the right lower corner is a rat which was treated daily for from 2 to 4 minutes, with moderate intensity, for 5 succeeding days. Coagulation necrosis resulted in the 4 inoculated tumor masses, but after 2 weeks, while healing was progressing, recurrence took place which eventually killed the animal. Hopes for a selectivity of short waves for tumor tissue have faded, and the effects produced experimentally have been obtained only beyond the limits of physiological safety. While it may be possible eventually to develop a technic which will

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destroy animal malignancies in a high percentage of cases, it is our impression that the results obtained by ourselves and by other investigators (Pflomm, Reiter, Haase and Lob, and others) are essentially due to a heat effect, resulting in coagulation of tumor tissue and of the vessels furnishing the blood supply. Histological examination shows a similarity to the picture of electrocoagulation. The effects produced by Schereschewsky may be induced by electrocoagulation of tumor tissue, as the pathological findings indicate, and are similar to what we achieve with electrosurgery. According to Groag and Tomberg, there are no methods at present available by which the biological effects of short waves, the localized heat effect, and the specific electric influence may be separated or isolated. Feeble short-wave application may stimulate growth, as may be done with diathermy. This may explain the failures reported, following short-wave diathermy in human tumors, as compared with the successes reported in animal experiments. It is interesting to note that the 3.5-meter wave is the critical point of differences in tissue-heating characteristics. Overgaard recently stated that it is possible to exert a healing influence on implanted tumors by subjecting them to shortwave diathermy. The effect, however, does not differ from that following treatment with diathermy, and may be interpreted as simply a heat effect on the tumor tissue, an effect toward which normal tissue is less tolerant. Taylor found short-wave diathermy ineffective in inoculated animal tumors, in combination with radium therapy. There is some evidence that short waves may "sensitize" the tumor cells, making them more susceptible to succeeding roentgen and radium therapy, though further research is necessary to establish this point. Apparently the principal result as yet achieved with shortwave diathermy in human malignancies, on the basis of our own experience, is some reduction of concomitant secondary infection in the open tumor masses. From this point of view, it is possible that short waves may become an adjuvant measure, after the development of proper technic, facilitating surgical intervention or radiation therapy, although at the present time the measure does not surpass electrosurgery in this respect.

PART VI CONCLUSION

XVII CONCLUSION short-wave diathermy was first introduced, its undeniable advantages, as shown in the results obtained by competent clinicians, were constantly denied and its use deprecated by many outstanding physicians. This is by no means unusual. There has never been a therapeutic measure, which in its initial stages has not had to suffer the skepticism of a conservative profession. To a certain extent, such an attitude is right, and proves in the end to be an asset rather than a liability, for it acts as a check on unbridled use, and compels intensive and scientific study until the new measure has proved itself. Short-wave diathermy is emerging from the hinterland of intolerance into which it was thrust for these past years. Continued intensive study by competent investigators, who are both clinicians and physiotherapeutists; continued research, experimental and clinical; continued improvement of machines and the accessories for their use, have gradually modified the physician's skepticism, until he is willing to concede the usefulness of short-wave diathermy, provided it is administered by competent men who know both their medicine and their physics. He is now more willing to give it a trial. Much, however, remains to be done. An actual evaluation of the results of short-wave diathermy will be possible only when the apparatus becomes standardized, and when the dosages for the many pathological conditions, in all their individual variation, become determined. This will, in turn, depend upon the wave length (frequency) of the applied current, on wattage, size and type of electrodes, distance of the area to be treated, duration of treatment, and so on. It will be many years before these uncertainties will become certainties, before exact indications for short-wave diathermy will be sharply defined, and the benefit to be derived clearly known. WHEN

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CONCLUSION

These problems rest in the hands of the physician, experienced in other forms of treatment, who will be in a position to judge the superiority of short waves over other medication in each specified diseased condition. At present, short-wave diathermy may be considered purely a form of heat therapy. It is superior to other forms of heat therapy, however, because of its deep action, and is definitely to be favored in certain conditions. Another advantage over other forms of heat therapy is the fact that short-wave diathermy is less cumbersome to manage, is simpler and more hygenic in use. It belongs to the field of physiotherapy, and its use, in combination with other standard treatment, should be encouraged by the specialist. The dosage is as yet uncertain, for no one knows just how much heat the individual patient or the particular pathological condition requires. From the practical point of view, however, when applied by one trained in the method, the degree of heat desired is usually achieved, even though it is not measurable. The principal field of application of short-wave diathermy is that of the inflammatory processes. While it may be used with benefit in acute infections, subacute and chronic cases show the most favorable results, although surgical intervention, combined with short-wave diathermy, may still be required. While the effect of short waves is analgesic and antispasmodic, the chief beneficial action seems to be the induction of an intense and lasting hyperemia. By such action, short waves vitalize, directly or indirectly, the pathological focus, and support the weakened tissues. They combat the invading disease organisms within the pathological focus, either by creating a less favorable medium for the growth of bacterial life, or by promoting the accumulation at the disease area of the defensive reserves of the body. In rheumatoid and arthritic conditions, short waves may eliminate the focus of infection, or, by increasing local metabolism, arrest the disease, eventually reestablishing function. Very satisfactory results are obtained in injuries of the bones and joints, nerves and soft tissues, in circulatory disturbances and allied conditions, the effect of short waves here being analgesic and antispasmodic. In the field of neurology, the vibratory

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effect of short-wave diathermy, in addition to the heat action, may produce the desired results. Short waves have proved to be a valuable addition to the treatment of sinus infections and to that of lung pathology, with the exception of tuberculosis. The uses of short-wave diathermy are varied and multiform. It should always be tried where benefit may be derived from it, it having proved itself during the past 8 years of clinical experience one of the least harmful of the physiotherapeutic agents.

BIBLIOGRAPHY AND ABBREVIATIONS

BIBLIOGRAPHY For abbreviations used in this list see page 295.

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