structure, however, is the very last to be invaded; but once this actual invasion occurs, it becomes morally certain that the entire muscle will become the site of carcinomatous infiltration in a comparatively short

time.

Once the muscular structure becomes invaded, the prognosis in this class of cases becomes most unfavorable. A study of 65 cases of mammary amputation in cases in which the muscle was actually invaded by the disease, quoted by Heidenhain as being taken from the statistics of von Volkmann, Küster, and Helferich, shows that in all, except two, early recurrences took place.

The attention of surgeons, prior to the studies of Heidenhain, has been directed mainly to the question of the presence or absence of secondary lymphatic involvement in the axillary region. Yet it is doubtless true that a nearer and much more certain source of infection has been heretofore overlooked, namely, that through the medium of the retro-mammary lymph-channels passing to that reflection of the pectoral fascia which constitutes the posterior investment of the gland. Involvement of the fascia is always a serious matter, for the reason that the extreme tenuity and uncertain anatomical boundaries of this structure render it almost impossible for the surgeon to separate it from the underlying parts. Where attempts are made to detach it from the muscle, there are almost certain to be left behind remains of the connective tissue from the gland, particularly in thin individuals. These may, and generally do, contain lymph-channels already infected. 12 out of 18 mammæ examined with particular reference to this point, carcinomatous appearances were found, these consisting of either actual secondary growths or epithelial invasion of the retro mammary lvmph-channels. These appearances constituted the basis of a prediction that recurrence would take place, and in 8 out of the 12 cases, from which these specimens were taken, recurrence actually took place..

In

The importance of these facts to the practical surgeon is selfsuggestive. Instead of directing his attention to the condition of the axilla as of the first importance in a case of suspected carcinoma of the breast, his first care should be to determine, if possible, the amount and extent of involvement of the parts situated posteriorly to the gland. In any case, the attempt should never be made to avoid opening the muscular sheath during the operation, but rather it should be the aim of the operator to remove a slice of that portion of the muscle lying superficially and immediately adjacent to the diseased gland. Even in cases in which the latter is freely movable, this course is as rational as the very generally accepted one of dissecting out the lymphatic structures occupying the axilla, whether these are markedly diseased or not, in every individual case.

A still more radical course should be pursued in those cases in which the muscle is indubitably invaded. Here nothing short of an extirpation of a portion or all of the muscle will serve as any guarantee against the return of the disease. This should include the clavicular and sternal attachments, together with the periosteum at these points. As has been shown, the ease with which the muscular structure, once invaded, becomes extensively involved, is sufficient justification, in any given case, for the performance of this radical procedure. The operation is not rendered a very much more serious one because of this added feature, and the functional disturbance is scarcely noticeable.

No argument in favor of early and radical operations for the removal of the breast in carcinoma can be more striking and convincing than that which has for its basis the statement of the fact that the larger proportion of cases which pass a period of 3 years without recurrence are among those who have submitted to such operations; and the added fact that among those who have lived for a period of years (reaching, as in one of my cases, beyond 10 years), to the early discovery of the disease and its prompt removal may be attributed the immunity, in the majority of cases, from a return of the disease.

As to the expectancy of life, in those operated upon, and who have finally perished from the disease, either in loco or as secondary deposits, contrary to the opinion held by many, the argument is altogether in favor of the attempt to rid the patient of the disease. In my own observation, nearly a year of life was gained, on the average, among those operated upon, but who finally died of the disease, as compared to those who had allowed the disease to pursue an uninterrupted course.

GALVANISM IN THE TREATMENT OF CORNEAL

OPACITIES.

BY L. A. W. ALLEMAN, M. A., M. D.

Cases of corneal opacity are very frequently discouraging ones, alike to the patient and to the physician. It is almost an occasion of reproach to the physician that he should so frequently be unable to afford any relief to a patient who presents an eye, healthy in every particular, and capable of giving the best visual results save for some loss of transparency of corneal tissue, limited perhaps to a superficial layer. To the patient, likewise, a corneal opacity is particularly unfortunate, not only on account of the visual defect, but because it aggressively invites the attention of others to its existence.

Recent corneal opacities will sometimes respond quite readily to

treatment, and the reparative power of nature is undoubtedly greatly assisted by stimulating applications, massage, and the like, but we soon reach the limit of our usefulness; and for old opacities, little remains but surgical interference. This is frequently inadvisable, and

always unsatisfactory.

Corneal transplantation offers an inviting field, but thus far has accomplished but little. The clearing of the cornea surrounding the transplanted area will, it seems, be more frequently obtained than the permanent transparency of the engrafted tissue. Even were it a more generally successful operation, its utility is limited to those cases in which no benefit can be obtained from an iridectomy, and where the opacity does not extend through the entire thickness of the cornea.

It is impossible to obtain satisfactory statistics as to the frequency of lesions of transparency of the cornea. Having once applied for relief and receiving little encouragement, patients do not drift from one eye clinic to another, consequently the records of these institutions would lead us to infer that such cases are more rare than is actually the case; but when we remember the vast number of cases of keratitis that we daily see, many of them so severe that they must leave permanent traces of their existence, we are convinced that corneal opacity must be a very common affection.

It is with great pleasure that I present a contribution to the therapeutics of these unfortunate cases, which I believe to be of some real value, and that offers at least some hope of improvement in nearly every case.

The method of treatment to which I refer, is the application of galvanic electricity directly to the surface of the cornea. So extravagant have been the claims of some of the advocates of electrotherapeutics that the profession in general, having been disappointed in their endeavors to justify these statements by their own experience, are inclined to look with great distrust upon any plea for the further extension of this method of treatment.

I have, therefore, endeavored in making the experiments with which I have been for some time engaged, to avoid as far as possible all errors which may arise from careless observation or too vivid imagination on the part of patient or physician.

In testing the vision from time to time I have used artificial illumiation of unvarying brilliancy, and, by frequently changing the testletters, have endeavored to prevent the patient from committing them to memory.

I have measured the vision exactly in each instance, using a steel tape as a measure of distance, to obtain greater accuracy.

When in any case I have used a mydriatic, either to ascertain what

vision could be obtained through the clear cornea surrounding the scar when the pupil was dilated, or to better observe the condition of the lens, iris, etc., I have either taken no records of the vision till the effects of the mydriatic have passed away, or have indicated in my records that the pupil was dilated at the time the record was made.

During treatment the visual record was always taken before the instillation of cocaine or the application of the current.

The idea of using galvanism for the removal of corneal scars first suggested itself to me from noticing the good results obtained by gynæcologists in some cases of old inflammatory deposits in the pelvis. It seemed to me reasonable that a similar absorption of repair-tissue could be brought about in the cornea, and that electricity would prove a most valuable therapeutic agent, could it be so applied as to produce sufficient molecular disturbance in the cloudy area to bring about its absorption, while at the same time it should have no ill effects upon the healthy tissue of the eye.

B

FIG. I.

I concluded that a small electrode applied to the surface of the cornea was indicated, since by this means a current of great density would be applied directly to the diseased point and since the greatest molecular activity is induced at a point directly in contact with the electrode, the indication of strictly limiting the current's action would be best fulfiled. I apply the other electrode to the cheek, making the path of least resistance through the soft tissues of the face, in order

not to bring the intra-cranial organs nor more of the globe than necessary within the circuit. By reference to Fig. I., the advantage of the small electrode in immediate contact with the cornea may be readily The current is represented as consisting of a certain number of strands, in both instances the same. It is apparent that the current is brought to bear much more directly upon the cloudy area in A than it is in B. (Fig. I.)

seen.

It was my original intention to make use of some of the preparations of mercury commonly employed in the treatment of corneal opacities, hoping by the combined action of mercury and electricity to obtain better results than from the use of either agent alone. I made several experiments, usually with the yellow oxide, but found it well nigh impossible to find any vehicle for the mercury which would at the same time act as a good conductor and prove unirritating to the eye. I finally hit upon an expedient which has proved very satisfactory: it was to make the tip of my electrode of silver, which plunged into a bath of metallic mercury, would form with it an amalgam and hold a globule of mercury on the end of my electrode. This makes a smooth and adjustable cushion to apply to the cornea; it fits itself perfectly to the corneal curve, and precludes the possibility of any unevenness on the surface of the electrode damaging the cornea. Whether or not the mercury in any way assists the action of the current it is quite impossible to say, but be this as it may, it furnishes in practice a most satisfactory tip for the corneal electrode.

After trying various forms of electrodes, I find the most desirable model to be the one shown in Fig. II. It consists of a small silver bar, a, 12 mm. in length, insulated, except at the ends, by a hard rubber shell; the exposed surface at the lower extremity is slightly concave, the better to hold the globule of mercury, and is 7 mm. in diameter. The upper extremity carries a thread which screws into a metal collar at 6, allowing the tips to be changed when corroded by the action of the mercury. The collar is attached to a copper spring, c which still further protects the cornea from injury when the electrode is moved in the fingers, and at the same time being perfectly flexible, allows the tip to be adjusted to any desired angle, which greatly assists the convenience of application. The spring is fastened to a hard rubber handle, d, 10 cm. in length and 1 cm. in diameter, through which a conducting wire is carried to the binding post, e, at the upper extremity. (Fig. II.)

I have found this electrode most convenient in practice, and fulfiling all the desired indications.

In the immediate application of electricity to the cornea some form of galvanometer is essential. My first few experiments were conducted