LOUISVILLE, KY., Nov. 12, 1902. Dear Dr. Butler:

In the case of Birdie suffering from laryngeal lupus, I find there has been a marked improvement since my previous examination. The nodule that was located above the true cords in the receding angle of the thyroid has entirely disappeared. The tumefactions over the posterior surface of the cricoid have diminished in size. The outlines of the vocal cords can now be easily made out, and there is considerable improvement in the voice. Thanking you for the courtesy, I am very respectfully, T. C. EVANS.

CASE III. M. C. Carpenter; referred by Dr. C. W. Kelly. Male, age 39, white, single, no history of syphilis. Patient shown; also photographs. Trouble began with enlargement of glands in neck, September, 1901. Had glandular mass extending from behind right ear along course of sterno-cleidomastoid muscle for five inches, hard and somewhat fixed; another bunch of glands under submaxillary bone, not so hard and more movable; also nest of glands along anterior border of trapezius and in space between the sternocleido and trapezius muscles just above the cavicle. Some enlarged glands on left side, but not nearly so marked. Patient complaining of shortness of breath, and some pain in neighborhood of spleen, but no apparent enlargement. Unable to do a full day's work without much fatigue. According to the patient's statement, he would work one week and lay off two. Temperature June 3, when first seen by writer, 101 3-5, pulse 110. Blood examination shows hemoglobin 63% of normal, red cells 4,954,000, showing low blood unit; white cells 5,000, somewhat below normal in number. The patient had previously consulted Dr. Dugan, who refused operation, and whose diagnosis was Hodgkin's disease, in which the writer concurred. Measurement around neck at this time on level with thyroid cartilage was 41 cm. (16 inches.)

Treatment begun on June 4; on June 15 patient's condition was somewhat improved, and measurement of neck 39 cm., on June 22 some dermatitis and measurement 38 cm. Treatment has been vigorously pushed in this case, only stopping when dermatitis and blistering made it necessary. After a month of treatment patient was able to work regularly, only stopping for a few days at a time on account of the discomfort from dermatitis. On August 10th blood examined and hemoglobin found 85% of normal, an increase of 22 %. Patient has recently had some involvement of glands of right side, a small bunch over clavicle, with return of slight fever, but since pushing treatment is now on the mend again. The glandular enlargement seems to be under control, no extension being noticeable in last two weeks. It is only fair to state in this case that the patient in the beginning of treatment was given a tonic of iron, arsenic and strychnia, and before coming under X-ray therapy had been given active treatment along this line by Dr. Kelly.

I think we can safely give the X-ray credit for the benefit in this case. The neck now measures 37 cm. (143 inches). The skin is somewhat thickened from the long continued treatment, and if not for this factor in the case the measurement would be considerably less. The glands, although still somewhat enlarged and hard, are much less so than before treatment, and the large tumefaction under right ear is considerably less and more moveable.

CASE IV. J. S., white, aged 50. First seen June 4, 1902. The picture shows condition as far as external appearances are concerned. Patient has hard mass growing from deep structures of upper jaw on right side, extending down and involving lower jaw. Growth fixed and with no definite outline, apparently growing from periosteum. He is unable to open his mouth more than half an inch. First noticed trouble in March,

when "neuralgia and swelling" began in upper jaw. Four teeth were removed, pain was relieved, but swelling continued and increased. He now has an ulcerated cavity in upper jaw with foul-smelling discharge. Patient shown to Falls City Medical Society, and the general opinion expressed was that it was sarcomatous. Patient put under X-ray treatment on June 4. His consent was gained to carry out active treatment, he assuming all risk as to burning, as this was considered a desperate case. After one month the tumor of upper jaw softened and became considerably less in size, but general condition was bad, marked anemia and rapid loss of flesh. July 10 deep structures of neck became involved, and by the 22d patient's condition was such as to warrant discontinuance of treatment. Patient died in August.

On

ČASE V. June 3, Mrs. D., referred by Dr. Frazier, photograph shown, white, female, age 86. First noticed "wart" on lower lip, near right corner of mouth, about Christmas. This broke down and ulcerated, and patient now (June 3) has an ulcer involving about half of lower lip, which has destroyed a portion of lip the size of a dime. It may be of interest to note that patient smokes a pipe. Condition typical epithelioma with hard rolled edges. Enlarged gland, somewhat fixed, on right side forward of angle of jaw.

Patient was given almost daily treatments for a week, and after that every other day. Treatment limited to growth at first. In six weeks decided improvement had taken place in condition of lip, cicatrization had begun, and at least half of ulcerated surface had healed. The patient at first volunteered the information that pain was much less and she was able to sleep better, but in a short time pain returned, and has continued steadily ever since. Gland under jaw now began to increase in size and attention was directed to this, but with apparently no effect. About August 1 reparative process ceased in

lip and a rapidly destructive process began which was not controlled by active treatment. At present lower lip is almost entirely destroyed, and a large mass fills space under tongue between lower maxillas. Treatment discontinued. The writer feels that a mistake was made in not attacking enlarged gland first, and in too free use of lead plate to protect surrounding structures. It is our practice now to treat a much larger area around growths of this character, giving enlarged glands, whether fixed or not, as much or more attention than the original growth.

CASE VI. M. G., male, age 56, white. Referred by Drs. Ray and Lederman with diagnosis of epithelioma of outer canthus of left eye. This patient I present to you this evening.

First noticed small wart on upper lid four years ago; the growth gradually spread to outer canthus. He now (June 2) has slightly ulcerated and indurated condition of outer third of upper lid, involving outer canthus, with some involvement of outer portion of lower lid. He is unable to raise the lid well.

First treatment (June 2) repeated every other day until the 10th; at this time could raise the lid with less pain. On June 12 dermatitis appeared, and some conjunctivitis, by June 22, without any further treatment, when an active dermatitis had developed. Treatment resumed July 6, when all evidence of dermatitis had disappeared; by July 15 the ulceration had disappeared, and patient states that eye is well as far as pain is concerned. can see by examination of the patient an apparent cure. Only time can tell whether there will be a return. You will also note that the lashes in neighborhood of epithelioma are gone. The patient tells me he had been troubled with "wild lashes" before treatment. This condition is relieved, but at the cost of appearances.

You

CASE VII. T. A., June 16, colored, age about 30; referred by Dr. Hollo

way. History of syphilis. Has growth three inches long, one inch wide in left groin, ulcerated, with hard and rolled everted edges, area being painful. Section examined by Dr. Hays and pronounced undoubted epithelioma. Only seven treatments, extending over ten days; ulcer began to take on healthy appearance, some evidence of healing. This patient stopped coming for treatment and I am unable to report his present condition.

Present

CASE VIII. June 18, male, white, aged 50; referred by Drs. Ray and Lederman. One sister died of cancer; wife died of cancer of uterus. Has had truble in mouth one year. condition, June 18, ulcerated growth on hard palate, left side posteriorly, very painful. Enlarged glands, hard and somewhate fixed, extending from angle of jaw forward to near mental foramen. Patient an alcoholic.

Treatment begun June 18, and has been carried on as steadily as patient would permit. Has been somewhat careless and occasionally absents himself for days at a time. Have endeav

ored to treat inside of mouth with special appliance, but patient objected to discomfort. Condition now somewhat worse than when treatment began. Pain greatly relieved, but growth somewhat larger, and glands increased in size, but softer; no evidence of breaking down. Have recently had teeth pulled, and hope to accomplish more by treating inside of mouth.

CASE IX. June 23, Mrs. D., female, age 70, white, referred by Dr. Bodine. Tumor size of hen's egg in lower right quadrant of right breast. Slight glandular involvement in axilla. Tumor very painful at times. Patient would not submit to operation; X-ray treatment advised. Treatment begun June 23. After eight treatments, on July 1, pain relieved; some return of pain on July 4; by July 10 pain much less, and from this time until July 30, when treatment was stopped on count of dermatitis, pain about relieved. August 6, treatment stopped be

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cause of dermatitis and blistering present, which caused considerable discomfort. Patient seen September 6, with Dr. Bodine, at her home. Tumor in breast slightly softer and probably smaller, and giving little or no pain. A large growth, apparently growth, apparently connected with liver, very apparent, and causing pain and discomfort. Of course, no further X-ray treatment was administered, as patient was feeble and nothing could be promised from it. Patient died in October.

CASE X. June 24, G. R. J., white, age 75, referred by Dr. Wm. Cheatham. First noticed small sore on right ear three years ago, this continued to appear and disappear until last Christmas, when distinct ulcer appeared. Present condition, ulcer, which has destroyed a great portion of auricle from upper portion of helix to lobule. leaving a ragged portion of upper part of helix remaining. The contiguous tissue to auricle, posteriorly, hard and infiltrated with cancer. Microscopical examination shows epithelioma.

Almost

Treatment begun June 24. daily treatment until July 28, when dermatitis with some blistering appeared. This patient required more active treatment to bring reaction than any yet seen. By July 10 some improvement seen in lower portion of ulceration, but destructive process still active in upper portion. Treatment stopped on July 25 until August 6, when destructive process seems about stopped and some effort at repair takes its place. Active treatment from August 6 to 13, when considerable dermatitis, with some blistering, appeared. Treatment stopped for four weeks and patient allowed to go home. On September 5 he returned with decided improvement-the ulcer healed across in center, margins of destroyed ear healed or healing, the ragged remains of helix. having united to remaining auricle by third intention, showing active repair. Some remains of carcinoma in upper and lower angle of wound. Treatment continued more or less regularly until

October 31, with no further improvement. Patient anxious to get home, so used sulphuric acid paste on remaining carcinomatous tissue, when he was sent to his home in the country.

CASE XI. Skiagraph showing destruction which had occurred as result of epiphysitis.

CASE XI. W. W., male, white, age 10. Little patient had history of an abrasion of the skin near the ankle joint, eight weeks before. Very slight evidence of injury at present, small scar remaining. Ankle swollen, red, and very painful, patient taking morphine four or five times a day for relief. Any movement of joint caused great pain. Mother in last stages of phthisis. Evidently an inflammation of the synovial membrane of joint, probably tuberculosis in character. Dr. Gilbert and Dr. Vance, who also saw the case, concurred in the diagnosis.

Treatment begun June 25, patient being carried to office with limb on pillow. After first first treatment pain much less, and by July 3 morphine stopped. Treatment has been continued steadily with exception of one month rest during August. To-night you see him walking, and any amount of movement of joint causes no pain. No mechanical dressing or appliance was used

except light gauze bandage. The slight limp which you notice seems due more to habit than pain, as he says he has none. He still uses one crutch, as I am somewhat afraid to allow him the full use of limb as yet. I show you skiagraphs taken Saturday which throw some light on the condition. These show destructive process which has been going on in lower end of tibia, an epiphysitis.

CASE XII. Mrs. R., white, age 45, married; referred by Dr. Gilbert. Patient and photograph shown. Trouble dates back to April, 1896, when she injured her left breast; had pain for year following, and then noticed some hardness and retraction of nipple. You will note that the trouble has been chronic in character dating over six years. Her condition on July 16, when first seen by the writer, is well shown in photograph. Patient extremely anemic and thin, a large nodular and ulcerating mass extending from inner border of right mammary gland to behind axilla on left side. This mass measured eleven by five inches. In addition to this you will notice in photograph a number of individual nodules ranging in size from a walnut to small pea. glandular mass was present in left axilla and enlarged glands the size of a walnut in right axilla. Left arm much swollen and useless. Apparently a hopeless condition. The patient has been seen from time to time by a few of the members present, all of whom gave a very grave prognosis. The condition is unquestionably cancerous. Several severe hemorrhages have occurred from mass.

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CASE XII. Before treatment. Nodular, ulcerating mass 11x5 inches. A number of individual nodules present.

healthy scar in place of it. There still remains an ulcerated surface, irregular in outline, 4 by 21 inches in widest part, but healing rapidly. Some individual nodules still remain, especially

CASE XII. Present condition. Healthy ulcer 44x24 inches remaining.

in back behind axilla, but these are flattened out and disappearing. Some in front are still present but all much smaller than when first seen. The glandular mass in left axilla is gone

and that in right considerably decreased in size. The left arm is now fairly useful, although still somewhat enlarged, ably on account of the hyperplasia due to long-continued passive congestion. This is certainly the greatest triumph for the X-ray that has come under the writer's observation. A great deal is due to this woman's pluck; she has never expressed any doubt as to her ultimate recovery, and even when she was at her worst and I could give he no hope she was certain she would get well.

CASE XIII. July 28, case referred by Dr. H. M. Pusey. J. G. F., white, age 39, married second time, first wife died of carcinoma of uterus. No family history of cancer. Has had irritation of glans penis for some years; had foreskin split when a boy. When seen on July 25 had two distinct neoplasms on foreskin, with portion of glans penis destroyed; enlarged glands in left groin. groin. Removal of foreskin was advised, and X-ray treatment. Patient demurred. Dr. Frank was consulted, who removed neoplasms and referred case for X-ray treatment. Section examined and pronounced epithelioma. Treatment continued until September 9, when some improvement was noted over small area, but extension of trouble along penis. Advised amputation, which Dr. Frank did and sent case back for treatment. At this time patient had large fixed gland in left groin, with line of induration extending to anteriorsuperior spine. Has been under treatment now since September 27. No marked improvement, slight diminution in size of gland in groin, but no softening, and some return of pain in stump of penis.

CASE XIV. Only treated one day.

CASE XV. Referred by Dr. Dabney. F. P., white, age 51, minister, mother died at 87, said to have had cancer. Patient referred for treatment on account of ulceration of larynx, believed by Dr. Dabney to be carcinomatous. Patient also seen by Dr. Ray in absence of Dr. Dabney.