manipulated and introduced into the rectum or other cavities. It should be introduced before the tube is excited. Since the therapeutic effect of the rays decreases approximately as the square of the distance from their source, it would seem that this tube mounted with the above combination shield should, with a given excitation, have a much greater effect than an ordinary tube, hence it would not be necessary to use a strong exciting current or to make long exposures. If a strong exciting current be used, the target end very quickly becomes hot, and the heat may be radiated to such an extent as to produce discomfort or even burn the patient. In fact, Dr. Cleaves reports a burn occurring in this way from the overheating of Caldwell's shield. Bear in mind that this was not an X-ray burn, but

Fig. 2 illustrates (a) Crooke's tube; (b) hemispheres separated; (c) specula; (d) obturators; (e) tip of the handle; and (f) flange for attaching the specula.

a burn from overheated metal. Notwithstanding the apparent feasibility of this tube, because the source of energy is so close to the tissues treated, my results with it in treating cancer of the rectum have not been satisfactory. This I do not believe is because of the smallness of the tube, but because of its faulty construction, which makes it impossible to so manipulate the tube that its energy can be directed against the growth. Moreover, as the X-raidance from the normal X-ray tube is more powerful than that from Caldwell's and as the energy will have more therapeutic value when properly directed against the growth I had, for the purpose of using the

ordinary tube in localizing and directing X-radiance in the rectum. and other cavities, R. V. Wagner & Co. make for me the tube shield and specula herewith shown. (Figs. 2 and 3.)

This shield consists of two hemispheres so constructed as to be readily clamped together over the tube. They are made of brass of sufficient thickness to effectively screen the X-rays from acting upon the tissues which must be protected. The hemisphere opposite the target of the tube has a large opening through which the rays act. This opening is provided with a flange for grasping and retaining the speculum after it has been introduced into the rectum,

Fig. 3 shows the hemispheres clasped together over Crooke's tube (e); (a) the handle; (b) speculum; (c) flange; (d) clasps for holding the hemispheres together.

vagina or other cavities. Specula of various kinds, lengths and sizes may be attached to this flange according to the requirements. A handle for manipulating the shield and tube is attached to the opposite hemisphere. With the tube thus mounted the X-radiance may be easily directed toward the object treated. The maximum X-radiance is present at the end of the speculum regardless of the direction. in which it is pointing. The tube being enclosed and attached to one

end of the speculum brings the source of energy very near the tissues treated.

The energy from an ordinary tube is more powerful at a distance of six or eight inches from the tissues treated than from Caldwell's tube when it is in almost direct contact with them. To demonstrate one phase of this energy I submit herewith two radiographs,

Fig. 4. Radiographs. (a) made with the ordinary tube enclosed in the author's shield; time, 15 seconds; distance, 8 inches. (b) made with Caldwell's tube enclosed in the author's shield; time, 3 minutes; distance, 11⁄2 inches.

one taken with Caldwell's tube and the other with the ordinary tube enclosed in the author's shield. (Fig. 4.) In the former, the distance of the object from the target to the plate was 111⁄2 inches; time of exposure, three minutes. In the latter the distance from the target was eight inches; time of exposure, fifteen seconds. Both tubes were excited by the same energy and the same machine. The object was the metacarpophylangeal joint of the middle finger. It will be noticed that the picture taken at the end of the speculum

required much less time of exposure than that required by Caldwell's tube and that the definition is much plainer.

To use the apparatus the patient should be so placed that the handle will be between and parallel with the wires of the machine, then introduce the speculum, remove the obturator, cleanse the field with pledgets of cotton, insert a small pledget of cotton into the speculum to prevent the secretions from soiling the tube, connect the speculum with the shield containing Crooke's tube, grasp the handle with the full hand and then excite the tube. The operator now has complete control of the tube and speculum, which, under any and all circumstances, bear a distinct and definite relation to each other, and therefore he can at will direct the rays in any direction or into any cavity or artificial opening in the body.

COLUMBUS MEMORIAL BUILDING.

THE RELATION OF GONORRHEA TO TUBERCULOSIS OF THE GENITOURINARY TRACT.

BY DANIEL N. EISENDRATH, M. D., CHICAGO.

The question as to whether gonorrhea in either the acute or chronic stage, predisposes to a later tuberculosis or may even act as a direct exciting cause, is one which has not received the study it deserves. It is a possible sequel which one must think of in every case, especially in those patients who have a family history. of tuberculosis.

I shall endeavor in the present article to show that it may become a serious complication of gonorrhea, especially in the male sex.

In looking over the literature of gonorrhea and its sequele, one is surprised to find that there is a mere mention of the possibility of its being followed by tuberculosis. The only text book in which reference is made to it is Senn's Tuberculosis of the Genito-urinary Organs. In it he refers to a case reported by Birch-Hirschfeld, in which the gonorrhea imparted to the tuberculosis a very malignant character. A soldier, 24 years of age, in perfect health, contracted gonorrhea, which led to acute epididymitis. In the course of eight days he died of miliary tuberculosis. Miliary tubercles were found in the peritoneum, especially well marked at the internal abdominal ring on the side of the affected testicle; also in the pleura, meninges, Chicago Medical Society, November, 1902.

lungs, liver, spleen and kidneys. The epididymis was transformed into a cheesy mass. In the testicle itself numerous intercanalicular miliary tubercles were found, and a few cheesy nodules the size of a pea.

Watson (Boston Medical and Surgical Journal, Feb. 7, 1896) reports two cases of tubercular epididymitis and prostatitis preceded by gonorrhea.

Oppenheim (Virchow-Hirsch, Bd. 1, p. 238, 1890) reports a case in which gonorrhea was the predisposing cause.

Simmons (Deut. Archiv. f. Klin. Med., Bd. 38, p. 57, 1886) says that the majority of persons who suffer from tuberculosis of the genito-urinary tract come from tubercular families. Gonorrhea or trauma can act as an exciting cause in these individuals, and it should be treated very carefully in such.

Casper (Deut. Med. Woch., 1900, p. 662) endorses this position. He states that gonorrhea leads oftener to tuberculosis than one thinks. He found it as a preceding cause in 53 per cent of 35 cases of vesical tuberculosis. In 3 cases the tuberculosis immediately followed upon the attack of gonorrhea. In the remainder it was impossible to determine.

Synopsis of the first case: In a weak, twenty-seven-year-old male, right sided epididymitis following upon gonorrhea in fifth week. It did not run the usual course, but left a hard, nodular, caplike induration, which was followed by several indurations in the vas deferens in the next few months. Accompanying this there was an intense cystitis, which did not respond to the ordinary antigonorrheal treatment. This began to create suspicion of tuberculosis, and tubercle bacilli were found.

The second case was that of a man, healthy, thirty-five years of age, who had had a long standing gonorrhea, with cystitis. The latter was treated with internal and local remedies, and when the patient came to Casper, one and a quarter years after the beginning of the gonorrhea, the tenesmus and pain were very severe. A diagnosis of tubercular cystitis was made and confirmed.

Third case: Strong, hitherto healthy man of thirty-six years, in whose family there was no tubercular history. Here in this case six months after the beginning of gonorrhea, he began to have symptoms of cystitis without other complications of the gonorrhea. This continued for a year, when the diagnosis of tuberculosis was made.

Casper believes that a preceding attack of gonorrhea, especially in those who are predisposed to tuberculosis, acts like a trauma in aiding its development. It acts just as an injury in syphilis,