accomplishments of others, to mention that my results have not been by any means so satisfactory as can be obtained, and I wish to supplement this very evident fact by the statement that my technique can and shall be very much improved in the near future.

As to technique, a few remarks will be made below.

Ranging from these undoubted authorities, and I have mentioned but a few among many, down to the mere dabbler in Roentgenotherapy may be found men of all sorts of opinions regarding the ray in both superficial and deep malignant diseases.

Let us question for a moment whence comes this lack of unanimity amongst honest and intelligent men in a matter that it would seem would require only clinical material and a certain equipment to settle.

In attempting to reconcile this division of the house with honesty on both sides, I am impressed with the following probable explanations.

First, the equipment is complicated, and not all workers know equally well how to handle their outfits to get a uniform or definite output from it. This much for conditions over which we may have control. Again, I am quite certain that factors enter, over which we have at present no control, and which we are not in any manner able to take into account. By this I mean changes in the delicate equipoise of the tube and energizing source which alter the product of the tube and give no sort of sign or signal to the operator, at least to the average operator.

And then the vast difference in the performance of tubes of various makes, and even of the same maker.

It is not the province of this paper to go into purely technical questions, but it can be readily seen that there are probably many pitfalls into which the less careful worker is liable to fall, to the detriment of any value that his work might have in placing this new science upon a solid footing?

Again, certain cases which appear to be similar in every respect from a clinical viewpoint differ materially in their reaction to radiation; some are benefited, others are not in any wise affected, while yet others seem to be irritated to increased activity. The cause of this difference in

susceptibility to treatment may reside in as yet unknown differences in the nature of the disease, or even in individual peculiarity of some sort. Certain it is, however, that this lack of uniformity obtains, even where the question of technique is beyond doubt.

As to other conditions that may be amenable to the beneficial influence of the X-ray, I wish to state with respect to the entire dermatologic field, that no Roentgenologist, as such, unless he be also a dermatologist, and has studied the pathology and therapeusis of the skin in the regular manner, has any right to set himself up as an expert who treats acne, eczema, psoriasis, tinea, and the legion of other dermopathies that have been attacked by over-enthusiastic Roentgenologists.

This sort of thing is the one pitfall into which the honestly intentioned though unwary advocate of the X-ray is liable to fall, and thereby to bring into disrepute the thing that he is trying to place on a scientific basis amongst the permanent therapeutic agencies of regular medicine.

We, as Roentgenologists, being masters of the technique of our specialty, must, in these dermatologic matters, take our instruction from the dermatologist, and instead of setting ourselves up as a rival institution, should become his ally and thereby enhance our value to the profession, to humanity, and to ourselves.

3. Method of Measurement.-The lack of a means of accurate measurement of the amount of radiant energy absorbed by the part treated during a given sitting and during an entire course of treatment, is another source of confusion that militates against comparison of results, both between different workers and in one's own work.

This haphazard dosage, hit or miss, is, I believe, more to blame for the lack of uniformity in the results of different workers than all other causes combined.

Until there shall have been adopted some unit of measure that is universally accepted and agreed upon at home and abroad, one that will prove out with all sorts of tubes and under all sorts of conditions, we shall be as badly off with respect to accuracy in our method as would be a pharmacist without a balance or a carpenter without a rule.

The pastilles of Sabouraud and Noire, the capsule and scale of Holzknecht, the

ionizing fluid of Freund, the sun and planet kaleidoscopic meter of Benoist, the socalled radio chronometer, the fluorometer of Williams, the scale of Walter and milliamperemeter, all have some particular advantage and all are of some definite value, but none of them is entirely satisfactory or it would have long since been universally adopted and standardized.

4. Technique,-As to the matter of technique, no dogmas can be indulged in at this stage of the science. We must work along general lines and suit the detail to our special conditions and more particularly to the individual case. Let each worker offer what has given best results in his work and out of the mass we will all pick the best.

5. Equipment.-My own general plan of action and equipment are as follows:

The source of energy is an eighteeninch coil of standard winding, run on a 220 volt direct lighting circuit. Mercury break.

My tubes are of several makes, including Gundlach, Friedlander and Muller types. The light I endeavor to produce I divide into hard and soft, according to the degree of vacuum in the tube.

By a hard light, I mean one that will back up a shunt spark of three inches or more, the soft light occupying the scale. on the other side of this point. There is plenty of opportunity for several intermediary shades of quality of light between these two extremes, according to the fancy of the operator, but this is all I have cared to try to keep track of.

In superficial lesions, whether sarcoma or epithehoma, I use the soft light with tube from two to three inches from the surface to be treated and produce a reaction as soon as possible.

By reaction I mean a zone of active leucoplasia and erythema about the lesion, with possibly superficial necrosis of the ulcerated area. This can be done quickly in a few treatments or slowly after weeks of tentative applications, according to the aggressiveness of the operator.

Though it has not been in the past, in the future it shall be my practice to have all excrescences and protruding masses ablated by the knife or curette, for it is a waste of time and of the endurance of the patient to wait for the ray to do what can be done better and more quickly by the surgeon, or even by a paste.

6. Filters.-Filters are never used in this class of cases. Filters being understood as various substances, such as rub. ber, leather, aluminum, wood, tinfoil, and various fabrics, designed to absorb such of the rays as it is desirable to prevent reaching the parts under treatment.

The hard light is reserved for treatment of the deeper seated lesions and it is here that the filter comes into play.

It is necessary to use the filter to protect the overlying skin through which we must pass in reaching the seat of disease, and thus avoid having our work interrupted by an untimely reaction in the skin, which, if the treatment were persisted in, would become a hasty burn.

As a filtering medium I use pure rubber discs about two millimetres thick, held in position by means of a thick rubber tube shield, fitted with metal hoods of various sized apertures through which the light is made to pass. In these apertures the rub. ber is placed in one or more thicknesses according to my fancy.

7. Protection of Operator and Patient. -A few words anent the most important question of protection of operator and patient from the dangerous effects of accumulated dosage in places where its effects are not desired.

From the Roosveltian race suicide point of view, it were better had more of the members of the active Roentgenologic guild begun to wear the leaden apron sooner than they did. I believe there has been one birth recorded in a certain X ray association in the last five years.

The question is a vexed one as to whether it is better to cover the tube, or shield the patient by covering all exposed parts that are not intended to be irradiated, with sheet lead or with rubber painted with white lead.

Personally, I content myself with covering the tube by means of the above mentioned shield. It strikes me as being more practical, and is certainly more convenient to eclipse the light at its centre of origin than to endeavor to cover its field of dissemination.

8. Reporting Results of Work.-As to the reporting of results of work in this field, I would enter a plea that we do not lose our heads and fly out into print because of a few apparent cures. For we might in the passionate moment of excitement born of a temporary success, make

statements that we might not take the pains to correct later when time has had an opportunity to test our results. We should thus become the unwilling source of false statistics and erroneous teaching, all of which merely places that day farther away when Roentgenotherapy will stand upon a solid footing, and when to be called a Roentgenologist will mean something more than that the one so styled knows how to throw the switch and hold the watch, and wait with composure to see what will happen.

9. Destructive or Radiolytic vs. Resolv. ent Effect.-There is yet one point in this subject of such importance that it must not be passed without at least passing notice.

Upon what action, chemical, electrical, or actinic, do we depend for the effect which we hope to derive from the X ray? Is it a tearing down or a building up, or is it a combination of both? ls the socalled resolvent action by which the ray is supposed to single out the adventitious cell and annihilate it at the side of the normal cell undisturbed, a theory made to suit the thing hoped for, or will it be a proved fact?

I shall not pretend to answer these questions. No man can, as yet. That there is an action, however, apart from the purely destructive, is fast becoming more and more confirmed. And as to the widely differing susceptibility of various cells to the destructive, if not the stimulating, action of the ray, there is at present no doubt.

In conclusion, permit me to call your attention to the fact that, whereas most great and epoch-making discoveries have found their field of usefulness in only one direction, that of Roentgen has shed its beneficent light with the liberality of the warming sun, and to day finds us indebted to the X ray not alone for what it has unquestionably done in alleviating human suffering, but as well for invaluable service in the field of diagnosis.

Shine on, oh, mystic light, and blaze the way to yet greater fame and glory, to honor the name of William Conrad Roentgen.

DISCUSSION.

DR. V. P. BLAIR, St. Louis, Mo.: I want to say two things. I had a case treated by another gentleman in St. Louis, in which I had removed a superficial epithelioma with recurrence in the

scar. It was treated by the X-ray, and two years afterward it had not returned, and, as far as I know, it has not returned since. Dr. Wells' treatment is good. He is the only man I have seen who could give a satisfactory picture of the limitations we work under.

DR. QUITMAN KOHNKE, New Orleans, La.: I was not present during the whole of Dr. Wells' discussion. If he has not done so in his paper, I hope he will, in closing the discussion, touch upon the essential nature of X-ray action. We know that some hold that it is a specific action of the ray upon the diseased tissue; others that it merely excites a latent natural resisting power and that nature cures. I do not know that that point has been definitely settled, but it is important if it has been that we all should know it, and I trust the doctor in closing the discussion will touch upon that and give us the latest view of that phase of the question-the essential nature of the X-ray in its curative action.

DR. WELLS (closing): I said in my paper about all I felt it was safe to say on that subject of the actual reason for the changes, and just suggested that they might be entirely destructive, in which sense we have a cauterizing agent, or that it is resolvent in its effect.

Now, speaking of the latter view, we have the cases of leukemia that respond so wonderfully and so immediately in most cases to the treatment. This is evidence of the singling out of certain lines upon which the X-ray is made manifest, and certainly not the detrimental effect of others. Now we know that mere fact. I do not care to go into a discussion of the various theories. There are enough of them, goodness knows, but they can be read, and really I would like to consider it out of the province of this paper to go into that purely physiologic-pathologic view of the question. This was rather an attempt to give an honest exposé of a littla clinical work and its results, with just enough of the technical thrown in to show you that in my own work I probably knew what I was talking about, so as to make the report of some value to you.

Chloroform for Rigid Perineum. Chloroform may be used as suggested by Souuthworth in the following combination to overcome a rigid perineum in labor: Chloroformi, 60 oo or oz. ii; ætheris, 30 or oz. i; spiriti odorati, 500 or O i. M. S-Apply locally. This mixture acts quickly and well, large heads safely passing the perineum, which had previously threatened an extensive rupture.

Camphor Carbolic Liniment. Camphor gum, oz. xii or 360 00; phenolis, dr. iiiss or 14 00; alcoholis, dr. v or 20 00, M. S.-Dissolve the camphor in the carbolic acid and then add the alcohol. A very efficient remedy in burns, sprains, bruises, etc.-E. C. CULBERTSON, Caldwell, Ohio.

I have to present to your attention this evening an interesting case of aneurism of the thoracic aorta, an aneurism more or less latent, one of symptoms rather than physical signs, in which diagnosis would have been in doubt without the valuable aid of the X ray.

The patient is, as you see, a well-developed, rather muscular male. He is fortysix years of age, thirty-two years of which have been spent in his trade, that of molder. He entered the Cincinnati Hospital on March 12, 1907, complaining principally of difficulty in breathing and a distressing cough. His family history presents nothing of interest. As to his personal history, he states that he has always been well up until three years ago. During the last three winters he has been annoyed with rheumatic pains and frequent colds. These would leave him in summer. He denies syphilis; admits over a period of many years a rather excessive alcoholism, averaging five or six glasses of whisky and as much beer per day. He smokes very little, but chews to excess. His occupation necessitates the frequent lifting of heavy objects, some of them weighing over two hundred pounds.

His present attack began about the first of last November, when his cough became very annoying. This was not at first accompanied by expectoration, but gradually this latter symptom has begun to manifest itself, and expectoration has become steadily more profuse. The greatest amounts are brought up after he has remained quietly in one position for a considerable period-hence, in the early morning. At about this time, too, he noticed some difficulty in breathing, particularly when stooping or upon slight physical exertion. This dyspnea would at times become most distressing, giving him a sense of impending suffocation and often amounting to orthopnea. A curious fact in connection with these dyspneic attacks is that they are usually relieved by hyper-extension or hyperflexion of the head. A severe attack of this character

is what influenced him to come to the hospital for relief. A late symptom has been some difficulty in swallowing. His appetite has been excellent, he sleeps fairly well when not dyspneic, he has had no vomiting and his bowels have been fairly regular. However, he felt himself growing weaker and has lost from his normal weight about thirty pounds (he has gained seven pounds since his entrance into the house). On admission to the hospital his temperature was 99° F., pulse 124, respiration 40.

PHYSICAL EXAMINATION.

Eyes: No difference in pupils ;' they react normally to light and accommodation.

Respiratory system: No paralysis of either abductor, no tracheal tugging.

:

Lungs On quiet breathing there is a marked suppression of breath sounds all over the left chest, anteriorly and posteriorly, particularly marked in the subaxillary area. On deep breathing this is not quite so marked, and over both lungs there may be detected a rumbling character to inspiration, amounting in the upper chest anteriorly to stridor. No râles present. No evidence of consolidation.

Apex

Circulatory system: Heart: beat displaced a little to the left. There is faint pulsation at the upper part of the right chest immediately to the right of the sternum; also at times in the second left interspace to the left of the sternum; also occasionally at the supra sternal notch. Pulsation has never been expansile in character and there has been no thrill. On percussion, the area of heart dullness seems to be increased, particularly in an upward direction, diminution of resonance being detected almost to the upper border of the sternum, and extending in an arched direction several centimeters on either side. On auscultation we have found at times a faint systolic bruit at the aortic ring and

a muffling of the first sound over the pulmonary area, though these conditions have not been constant. There has been no diastolic murmur nor diastolic shock. The pulse has ranged in rate from 100 to 140, is of fair tone and to the finger does not in the radials vary in strength or time. With the Cook modification of the RivaRocci sphygmomanometer the blood pressure has ranged from 150 to 160 m.m., right and left, a slight increase over normal. There is no edema of either arm.

Chest: There is a prominence to the chest at the junction of the manubrium and gladiolus and the second costal cartilages. The prominence is equal upon both sides, has existed as long as the patient can remember, and is probably due to rickets; it bears no relation to underlying conditions.

Urine

The specific gravity of the urine has varied from 1014 to 1020, is usually of a light amber color, no albumin or sugar, no casts, occasional pus cells.

Temperature: The highest temperature the patient has had was the evening of the day of his admission to the house, when it reached 101°; since then it has rarely been over 99°.

So much for the physical signs. Now a few words as to his symptoms, particularly after having had him under observation for a few weeks. His principal complaints were, as has been said, dyspnea and cough. The former while he has been in the house have differed in no way from the description already given. The cough is of a ringing, brazen character, exceed-. ingly characteristic, and was what led us to an examination of the chest by means of the X-ray. The patient expectorates from six to eight ounces of a muco-purulent material every twenty-four hours; as has been said, large amounts are liable to be expectorated after a prolonged quiescent stage. Examination of the sputum shows no crystals, no tubercle bacilli, but a large number of streptococci.

Pain: None anteriorly even with the severe spells of coughing; at times deepseated boring pain in the dorsal region of the spine, and radiating to the sides. There has been no hemorrhage from respiratory or digestive tracts.

Dysphagia: A significant symptom since his entrance into the house has been development of a dysphagia. This symptom is not constant, but when it does occur is

very distressing; at times he has even had difficulty in swallowing liquids. (In this connection I will state that Dr. Lange, at the time of the X-ray examination, had him swallow several capsules of bismuth, one of which lodged in the esophagus for fifteen minutes).

As can readily be seen from a review of these symptoms and physical signs here presented, we could not be justified in making a positive diagnosis of aneurism, though some condition in the mediastinum producing pressure upon adjacent organs could be readily suspected. Accordingly, an X-ray examination was ordered, the result of which was all that could be desired. In studying the plate, which is here presented, it is to be remembered that it represents the organs about onefifth larger than they really are; also that the heart and aorta are being viewed, as as it were, from the rear. Bearing in mind these details it is to be observed that there is is a pronounced swelling of the aorta almost immediately after it is given off from the heart. This tumor extends from the upper margin of the right third rib at its juncture with the sternum to the middle of the second interspace, and with its greatest convexity some four centimeters to the right of the sternum. No pulsation was noted with the fluoroscope. To the left, extending from the lower margin of the articulation of the clavicle with the sternum to midway between the second and third ribs, and projecting at the point of its greatest convexity some five or six centimeters to the left of the sternum, is another tumor, which, with the fluoroscope, was distinctly pulsatile. This pulsation has been outlined in the plate presented very prettily by a secondary fainter shadow exactly the width of the clavicle; that is to say, that at the moment of pulsation the tumor extends from the upper margin of the sterno clavicular joint to midway between the second and third ribs at the para sternal line, while at the upper left portion of the tumor there is a more pronounced excursion.

It will be noted in comparing this plate with that of a normal heart, which Dr. Lange has kindly placed at my disposal, that the heart in the aneurismal patient is considerably enlarged. It is also of interest to observe that the axis of the heart is greatly displaced, inclining some fifteen to twenty degrees farther than usual toward