Correspondence.

New York, March 4, 1903.

To the Editor: At the last (fifty-third) meeting of the American Medical Association, held at Saratoga Springs, June 10-13, 1902, a joint resolution from the Sections of Cutaneous Medicine and Surgery and Hygiene and Sanitary Science was introduced in the House of Delegates as follows:

"Whereas, There is a burning necessity to check the spread of venereal diseases, and, assuming that the states cannot with impunity ignore the condition, it lies in the province of the medical profession to discuss and recommend to the respective state legislatures and municipalities means not regulamentative, but social, economic, educative and sanitary in their character, to diminish the danger from venereal diseases.

"Resolved, That the Section on Cutaneous Medicine and Surgery of the American Medical Association invite the section on Hygiene and Sanitary Science to co-operate with the Section on Cutaneous Medicine and Surgery in bringing about a propaganda in the different states, looking toward a proper recognition of the dangers from venereal diseases, and to arrange for a national meeting under the auspices of the American Medical Association for the prophylaxis of venereal diseases, similar to the 'International Conference for the Prophylaxis of Venereal Diseases, which meets again this year at Brussels, under the authority of the Belgian government."

This was later submitted to the House of Delegates, which endorsed the action of Section and adopted the following:

"Resolved, That a point committee of six from the Sections on Hygiene and Sanitary Science and Cutaneous Medicine and Surgery be appointed by the President to stimulate study in and uniform knowledge of the subject of the prophylaxis of venereal diseases, and to present to the American Medical Association a plan for a national meeting, similar to the International Conference for the Prophylaxis of Venereal Diseases, which meets again this year in Brussels, under the auspices of the Government of Belgium."

The Committee on Prophylaxis of Venereal Diseases consists of: Dr. Henry D. Holton, chairman, Brattleboro, Vt.; Dr. Ludwig Weiss, secretary, 77 East Ninetyfirst street, New York; Dr. George M. Kober, 1600 "T" street, Washington, D. C.; Dr. W. H. Sanders, Montgomery, Ala.; Dr. L. Duncan Bulkley, 531 Madison avenue, New York City; Dr. Frank H. Montgomery, 100 State street, Chicago, Ill.

The peculiar social, racial and political conditions of our country are so different from those on the Continent that they necessitate an expression of solely American ideas on this mooted question, both from a socio-economic and sanitary point of view.

The committee desires the support of the medical profession and the aid and powerful collaboration of the medical press of the country to help them in this work. It takes the liberty of soliciting expressions and views editorially and otherwise, and would be glad of personal

On April 14, 1903, the St. Louis Medical Society of Missouri will give a banquet in honor of Dr. Simon Pollak, Dr. William Johnston, Dr. William McPheeters and Dr. J. B. Johnson. All of these gentlemen are expresidents of the society and all are over 86 years of age. Dr. Simon Pollak is the oldest, the banquet being given on his eighty-ninth birthday. In honoring these men the society feels that it honors itself. The Committee on Arrangements has every reason to expect the full strength of the regular profession to be present on this occasion, and are making their preparations accordingly.

Tickets to the banquet will cost $5 each, and can be secured by addressing Dr. F. L. Henderson, Century Building.

Yours very sincerely,

F. L. HENDERSON,

Secretary of Committee on Arrangements.

Never prescribe for an inflamed eye without doing three things, viz.:

I. Without examining for a foreign body embedded in the cornea, or lodged beneath the lids.

2. Without seeing if cornea or iris is implicated. 3. Without determining the presence or absence of tension of globe.-Fenwick.

Never apply lead lotion (Goulard water) or silver nitrate lotion, should there be the slightest abrasion of the corneal epithelium. [Solid particles of oxide or carbonate of lead or silver become deposited and form permanent opacities.]-Fenwick.

Never omit to empty the bladder (if the patient canquent in operations for trivial troubles.-Fenwick. The most important part of the successful reduction of Colles' fracture is perfect reduction.-Senn.

The pain associated with every form of inflammation of the bone or of its periosteal covering is due to tension, and the severity of the pain is a fair measure of its intensity.-Bryant.

Remember the saying, "No internal opening to a fistula, or a blind fistula is usually a blind surgeon.”—Fenwick.

Never use violence in opening the eye if there be much swelling or spasm, because if a deep ulcer of the cornea be present, perforation may take place.-Fenwick.

Never forget that constipation alternating with diarrhea renders a rectal examination for stricture imperative. Fenwick.

Do not forget the probable need for a catheter after an operation on the rectum.-Fenwick.

Extracts and Abstracts.

THE X-RAY IN 1902.

The year 1902 will ever be remembered for the advances made in radiotherapy; in fact, within the year has it become popular and generally practicable. The facile pens of the X-ray operators have filled volumes; the journals teem with reported cures; no one can longer doubt its efficacy and marvelous action in the cases for which it is peculiarly applicable. The pioneer work of Schiff and Frend in Germany, and Pusey in this country, startled the world; to them is due the credit of the introduction of this valuable remedy.

In the spring of 1901 the writer had a case of rodent ulcer which absolutely refused to heal, in his care. About that time Pusey's first articles appeared and I went up to Chicago to investigate the X-ray treatment. Dr. Pusey kindly showed me his cases and apparatus. My patient was immediately sent him for treatment and returned cured. Since then I have tested the efficacy of the rays upon various skin affections with a machine of my own, with satisfactory results. I have never written anything upon the subject, yet I take this opportunity to place myself upon the list of its enthusiastic advocates. No method equals it in certain cases; in rodent ulcer and lupus vulgaris it is, in a way, a specific. Of course, there are many other remedies and methods, but none of them offer the results in these two conditions equal to the rays. The mass of literature and the number of reported cures force us to this conclusion. The Fensen method is painful, the exposures are longer, the results slower and the apparatus necessary more expensive and cumbersome than any of the X-ray outfits.

The simultaneous use of pyrogallic acid as advised by A. Gassman may be used with radiotherapy as well as in phototherapy. C. E. Skinner says a measure frequently extremely useful in connection with X-rays, where a broken-down ulcer responds to the rays, is the use of the static brush discharge. Other methods, as curettage (Taylor) or medication, can be often advantageously combined.

The use of the rays in diseases of the hair and its follicle has not been as encouraging as it at first seemed to offer, while its efficacy in patches of chronic eczema, psoriasis and some allied conditions has been marked in the hands of Zeisler, Pusey, Becleve and others. While the therapeutic effect of the X-rays may be extended to various inflammations of the skin, the chief interest here is centered in its action upon the malignant, chronic and disfiguring diseases, lupus, lupus erythematosus, rodent ulcer, epithelioma and sarcoma and allied conditions. There, of course, has been a great sameness and reiteration in the X-ray literature of the year-in the report of cases, their character, the technique of the operation, etc.-but here and there many important points have been mentioned and they may be enumerated as follows: (1) the apparatus; (2) tube; (3) quality and quantity of light; (4) dermatitis; (5) microscopical effects of the radiation.

Upon these five points, no doubt, rests the future scientific delineation, control and indications for the rays.

W. B. Snow has very clearly expressed his views upon the subject of the apparatus, and, as he has had a large experience, it is well worth considering. He believes it matters little what is the source of current which energizes the tube, whether from coil or static machine, so long as it excites the character of ray applicable to the case. He, however, prefers a static machine to excite a high-vacuum tube, applicable to deep-seated conditions, as when a coil is used for this purpose it is perilous to both coil and tube. E. C. Skinner claims that a tube excited by a coil will produce a dermatitis much quicker than the same tube lighted by a static machine, as a greater volume of rays are produced by the former, therefore it is preferable to use the latter source of energy in deep-seated conditions, as the skin does not so quickly become inflamed. It is very probable the life of a tube is longer when used in connection with a static machine.

The pioneer operators in Eurpoe used coils, therefore the probable source of their present prestige, but from the trend of the opinion of numerous experimental operators, especially in this country, it does not seem to make a great deal of difference as to the source of energy, the principal and vital question being the tube and the quality and vol-ume of the light. The pioneer operators used a coil and tubes of very low vacuum, and it has been thought that a greater volume of rays are thus emitted, and therefore a dermatitis more quickly produced by a coil and low tube; but a tube of high vacuum, excited by a static machine, will produce a dermatitis as quickly if brought closer to the skin and the time of exposure lengthened (Skinner.) The self-regulating tube possesses a longer life than the other forms, and probably is more capable of better adjustment. It is recommended by all operators to not "overwork" a tube; to allow it to "rest" a few weeks will often re-establish its power.

No one has recommended any particular make of tube, each operator, probably, preferring certain makes. It is a well-known fact, cited by several operators, that of two tubes of the same make and equal resistance, one may possess great therapeutic value and the other little. In the treatment of a case a tube must be selected applicable to that case, and, as Becleve says, the capital factor in the method of application of the X-rays is the quality of the rays used. Of course, this quality depends upon the tube, and slightly upon the source of energy. Becleve remarks in his excellent thesis that there exists a whole. scale of X-rays which differ from each other by their power of penetration, on which depends their effects produced upon living tissues. Rays which penetrate very little, being quite entirely absorbed by successively encountered layers and have a deleterious action upon the skin, which may end even in its complete destruction. Rays which penetrate deeply are scarcely at all absorbed by the tissues they traverse and exercise no action, or only a slight one, upon them; they are indifferent. There exists between these two extremes a category of rays which have only mild penetrating power, which, being partly absorbed in certain pathological conditions, can provoke in the thickness of the skin a reaction leading to a curative effect. To produce at his will rays of which he knows the exact penetration is the most important point to the physician. Instruments described by Becleve are de

signed to determine this point. They are Villard's ampoule, the spintermeter, and the ridio-chrometer of Benoist. The rays absorbed are, therefore, the ones which produce the change in the absorbent tissue, and this effect is produced by the rays themselves and not electric waves (Scholtz). Scholtz experimented upon young pigs, and from these experiments confirms this fact. He says the effect is not only produced at the point of entrance, but also at the point of exit; therefore certain rays must be absorbed at both points, for those passing through do not affect the minor organs. The integumental changes produced by prolonged exposure to the X-rays is well outlined by Carl Beck, and pretty well conveys the general opinion upon this point. Beck divides them into three stages. Those of the first degree are characterized by hyperemia, the cutis being infiltrated and the temperature raised. Exfoliation takes place in small scales, and there is marked itching of the skin. There is concomitant falling of the hair and retrogressive changes in the glands and nails.

The second stage is marked by the formation of blisters. Inflammatory symptoms are pronounced; the pain and tension is considerable.

The third and gravest stage is characterized by the escharotic destruction of the irridated tissues. They show the signs of dry gangrene of brownish-black color. If the tissue exfoliates by a slow suppurative process, or if removed by surgical means, an ulcer remains which is very slow to cicatrize. These changes or the different degrees of this so-called "dermatitis" occurs in from ten to fourteen days after exposure. In some individuals this dermatatis may occur in a few exposures, whereas others may seem to possess an immunity which unfortunately often proves to be apparent only. There are certainly some who have a decided idiosyncrasy and are most readily burned. E. A. Codman has investigated the literature of X-ray burns very thoroughly, having reviewed all of the reported

cases.

He says that recorded cases show a minimum limit for safe exposure, but they also show a tremendous variation in the reaction of individuals to apparently the same conditions. Conditions which produce a severe lesion in one case, cause only a slight reaction in others. Kienboeck and others assert that the important factor is the degree of the vacuum of the tube-its softness or hardness, but Codman is strongly of the opinion that this element of variation lies in the susceptibility of the patient, the dryness or dampness of the skin; in his electrical resistance; in his anemia or plethora; in the acidity or alkalinity of the sweat; in his vaso-motor irritability, or in some other of the multiplicity of conditions which make a living organism different from a glass tube stimulated by a current of electricity. Codman places ten minutes at six inches distance a safe standard of exposure.

Pusey treats his patients with the greatest caution, using a low tube and short exposures, while others advocate the rapid production of a dermatitis to obtain quick therapeutic effect. As all parts are safely protected by a proper mask, the favorite material being lead foil or thin sheet lead, it probably makes little difference how rapidly the reaction is produced, unless it is for cosmetic purposes; a slower process obtains the best cosmetic result. It must

be remembered though that it is not always necessary to produce the objective clinical dermatitis to produce therapeutic reaction, as cited in cases reported by Duncan, Pusey and others. These cases improved after exposures had ceased, they having never during the treatment displayed any reaction whatever. But in the majority of observed cases improvement has more rapidly advanced after the production of a marked inflammatory reaction. This dermatitis is always significant of the desired specific action of the rays upon the irridated tissues and is histologically and clinically an inflammatory process.

Carl Beck assumes, in discussing the pathology of X-ray dermatitis, that if in chronic inflammatory processes constriction of the vessels takes place, the papillæ starve. A hair extracted after prolonged irridation is found to have lost its structure. The skin shows thickening of the tunica intima of the small blood vessels; fibrous tissue in reticular arrangement is deposited and the tunica muscularis and tunica adventisia are affected in the same

manner.

The most elaborate work of the year upon the histopathologic changes produced in healthy and diseased skin by the X-rays is that of W. Scholtz. He found that distinct alterations did not appear until about the sixth day after exposure, when he noticed a swelling and edema. of the epithelial cells, accompanied by a clumping and shrinkage of the muscle, while vacuoles appeared here and there in the protoplasm of the cells. Many of the cells seemed to be in the process of amitatic demission. Mitoses were rarely seen. The corium was markedly edematous, the fibers swollen and stained badly. The connective tissue cells seemed to be affected in much the same way as the epithelial; also the cells of the appendages to the skin and those of the intima of the larger blood vessels. An inflammatory collection of leucocytes were observed about the vessels beneath the epidermis, and here and there betwen the degenerated cells. Mast cells were painful. Toward the center of the lesions were superficial vesicles in the stratum corneum, upon rupture of which ulceration seemed to quickly follow.

In other words, the X-rays cause upon healthy skin a cellular degeneration which is followed, after it reaches. a certain stage, by an inflammatory reaction, the blood vessels became dilated, and an extravasation of serum and leucocytes supervenes, resulting by phagocytosis in the complete destruction of the degenerated cells. In irridated lupus tissue Scholtz found about the same degeneration and inflammation.

Carl Beck thinks that the changes which take place in a malignant neoplasm under the rays is of the nature of a chronic inflammation. The nutrition of the superficial strata is disturbed, the cells starve, and, if over irridation is continued, necrosis may result. Some sections of carcinoma show colloidal changes.-(Interstate Med. Jour.)

Remember in extravasations of blood beneath the gluteal fascia there is rarely any bruise or sign of injury to the skin. Do not mistake such for an abscess.-Fenwick.

BY WM. ALLEN PUSEY, A. M., M. D., OF CHICAGO.

with

The question of protecting surrounding surfaces against the effect of X-rays, comes up in all methods of using the agent for therapeutic purposes. This can be done in two ways: first, by surrounding the tube with an opaque covering so that the rays have exit only at one point; second, by covering the surrounding parts with some material opaque to X-rays. The first method is usually carried out by placing the tube in a box with a window in it through which the desired area of X-rays has exit. An example of these boxes is the one recommended by Williams, which is essentially a wooden box, painted on the inside with white lead. The objection to this method is the cumbersomeness of such a device and the inconvenience of using it. The second method, that of interposing shields between the rays and the surface, is more convenient under most circumstances. The first material suggested for these shields was lead, and lead in some form is the material generally used. Schiff and Freund suggested sheet lead one-twenty-fifth of an inch thick, to be covered with a blotting paper. Kienboeck uses lead plates, which he covers flannel. Williams uses for the the face "a mask made of gauze, and pressed into the shape of the face, such as may be purchased at theatrical supply houses," and he covers this with tin foil. Others have suggested the use of several layers of lead foil such as is used for lining tea boxes. Grube has suggested a foil made of 95 per cent lead and 5 per cent tin, plated with tin. This makes a foil of the brightness of tin that does not rub off like lead. Two to four thicknesses are required in order to furnish sufficient protection. I have invariably used sheet lead from one-fiftieth to one-twenty-fifth of an inch thick. Röentgen states that sheet lead one-sixteenth of an inch thick practically excludes all X-rays. I have found on trial that a rapid photographic plate, covered with lead one-twenty-fifth of an inch thick, shows almost no trace of X-rays from a strongly lighted hard tube after fifteen minutes' exposure. Fifteen minutes' exposure to a similar light of a photographic plate under one-fiftieth inch lead shows appreciable but very slight effect. The onefiftieth inch lead, therefore, probably furnishes perfectly safe protection. I have found, however, lead one-thirtysecond of an inch thick not too thick to be conveniently handled, and it is, I believe, the best thickness for these masks. Lead of this thickness of any width can be obtained from any plumber's supply house. My practice from the start has been to cover the masks on both sides with ordinary wrapping paper. This makes them clean to handle, furnishes satisfactory insulation for the lead, and has the advantage of being easily washed off and replaced. It is simpler than the other coverings suggested and can be more readily renewed. These lead sheets can be made of any size, with apertures in them of any desired shape, and very little ingenuity is required to adapt them to any of the surfaces of the body. For most work about the face these masks can be very readily adapted without any especial shaping, but where it is desired to make a mask of the shape of the face, I have found it exceed

made in wood. On this mold it is easy with a little practice to hammer the lead sheets into perfect masks of the face. Holes of any shape can be cut in them and the masks then covered with paper. For exposing special parts masks of special design are required, but with a little patience I have never found it difficult to adapt a mask to any part of the body. For making exposures in the mouth and pharynx I have used lead masks of sufficient size to cover the face; to this is soldered at right angles a short piece of block tin tubing such as plumbers use, and a hole is cut through the mask to correspond with the hole in the pipe. The pipe can be molded or cut to the shape desired. In this way a speculum can be improvised which I have found quite useful. The patients have not objected to it. For making vaginal exposures I have used the ordinary Ferguson glass specula. The patient is placed on an ordinary gynecological table on the back, with the knees drawn up as for vaginal examination. The thighs are protected by lead masks, which reach from below the knees to the inguinal folds. Another mask is made wide enough to entirely protect the perineum, with a slit in it corresponding in width to the speculum. This is placed around the speculum in such a way as to protect the perineum. The speculum must be retained in position by an assistant's hands, and the additional protection needed in order to cover all exposed parts is furnished by a lead mask which the assistant places around her hand. This plan of protecting the perineum, while apparently cumbersome, has proved not difficult to carry out and satisfactory.

For making exposures in the mouth or vagina, or even in the rectum, Caldwell's tube furnishes far and away the best method. Indeed his tube for treating these cavities is in my opinion the greatest single addition that has been made to the techic of the therapeutic application of X-rays.

A good deal of ingenuity has been wasted in trying to devise masks to supersede lead or other metals opaque to X-rays. Among these hard rubber masks have been suggested. Hard rubber furnishes almost no obstruction to the passage of X-rays, and furnishes no adequate protection against the X-ray effects on tissues. If for any reason it is impossible to use lead, some slight protection may be obtained from the use of the oxid of zinc adhesive plaster. It is also possible to make a paste of an indifferent ointment and some powder opaque to the X-rays that will give protection. If bismuth subnitrate, which is opaque to X-rays, is rubbed in sufficient quantities with vaselin, or any other indifferent ointment, a paste may be made which furnishes strong obstruction to the X-rays. A layer one-sixteenth of an inch thick of a paste made of equal parts by weight of vaselin and bismuth furnishes fairly good protection to the skin upon which it may be spread.

At one time it was said that the coating with vaselin of a surface to be exposed to X-rays would protect it against X-ray burns. I have seen X-ray burns occur in many instances under vaselin and other ointments transparent to X-rays. Lately the interposition of a layer of paraffin has been suggested for the same purpose. This suggestion is doubtless a lineal descendant of the vaselin

idea and is absolutely useless. I have experimentally produced X-ray burns under a coating of paraffin one-sixteenth of an inch thick, and I have no doubt that with equal ease I can produce a burn under a layer of paraffin one-half an inch or an inch in thickness. Indeed, I think it may be stated dogmatically that nothing will prevent X-ray effect upon the tissues except substances which are opaque to the rays. The only thing necessary to produce X-ray effects upon the tissues is for the rays themselves to reach the exposed surface.-Interstate Med. Jour.

THE PATHOLOGY OF THE TISSUE CHANGES CAUSED BY THE ROENTGEN RAYS, WITH SPECIAL REFERENCE TO THE TREATMENT OF MALIGNANT GROWTHS.

BY CARL BECK, M. D., NEW YORK.

While the treatment of malignant growths by the Roentgen rays has not yet gone beyond the experimental stage, it has established a series of new and most important facts which are well worth attracting the attention of the medical profession. It was obvious that the integumental changes which manifested themselves after prolonged exposures to the Röntgen rays generally called "X-ray burns"-suggested their therapeutic utilization. In considering the pathology of these changes, conclusions can be drawn for the therapeutic modus operandi.

Some time ago I suggested that there might be distinguished three different degrees, just as in ordinary burns, the first degree being characterized by the symptoms of hyperemia, the cutis being infiltrated and the temperature somewhat higher. Exfoliation takes place in small scales. The most pronounced subjective symptom is a tormenting itch in the skin. Effluvium capillorum, which manifests itself, as a rule, without showing any visible signs in the integument, belongs to the same category. It seems that there is a regressive metamorphosis (atrophy) of the differentiated elements of the skin, viz., the glands, hairs and nails.

The main feature of the second degree consists in the formation of blisters, the clear or yellowish contents of which lift the corneous from the mucus stratum of the rete Malpighii. The inflammatory signs are well pronounced, the tension is considerable, and the pain is intense accordingly. After the removal of the blisters the corium is exposed as a red and sore surface (bullous form of Röntgen-ray dermatitis).

The third and gravest degree is characterized by the escharotic destruction of the irradiated tissues. They show the signs of dry gangrene, and their appearance is brownish-black. If they exfoliate by a slow suppurating process, or if they are removed, as they should be, by surgical interference, a granulating ulcer remains the cicatrization of which may take months (necrotic form of Röntgen-ray dermatitis).

The most characteristic difference between ordinary burns and the integumental changes produced by the Röntgen light is the fact that the latter do not manifest themselves before the lapse of a period of incubation, as a rule, after about two weeks.

This stage, which we may properly call the latent, lasts

about ten days in the simple type of Röntgen-ray dermatosis. Then the integument becomes hyperæmic. At first there is a light, later dark, redness, and finally the skin becomes brown and scaled. After a few weeks there is complete recovery. Sometimes slight pigmentation of the integument remains.

In the bullous type of the Röntgen-ray dermatitis, after an incubation of about two weeks, intense reaction takes place. This is of a subjective as well as an objective character, and lasts about as long as the period of incubation. Then cicatrization takes place. If the area of irradiation was covered with hairs, depilation occurs. process of regeneration of the hair is slow. Pigmentation and teleangeiectasis nearly always remain. The necrotic type of the Röntgen-ray dermatitis, as a rule, develops a few days later than the bullous form, and requires months for its cure.

The terra-cotta-like hands of skiagraphists demonstrate the chronic type of Röntgen-ray dermatosis. Their integument is wrinkled, shriveled, vulnerable, and partially cracked, the nails are horny and also cracked, and the phalanges are so much thickened that there is tension while motion is exercised. The elasticity is lessened and the sensibility increased. Effluvium capillorum is an invariable companion. Undoubtedly there is a cumulative influence.

Examination of the integumental changes in men as well as in lower animals shows a disturbance of nutrition in the walls of the blood vessels, just as in ordinary burns, the main difference consisting in the slower development of the process. The peculiar chemical influence of the Röntgen light on the tisues is so exerted that the nutrition of the cells is impaired.

It is only when this impairment has reached a greater degree that the signs described above manifest themselves. And these signs are again influenced by the power and amount of the Röntgen light. It must also be considered whether the tissue is normal or diseased (compare reaction of cancerous areas). A greater or lesser susceptibility must also be admitted.

The fact that in some individuals dermatitis has supervened after a few exposures, while others have remained free for years, suggests the existence of such an idiosyncrasy as, for instance, I was, in spite of the freest manipulation of my armamentarium, never affected by the rays, so that I was inclined to imagine at last that I was blessed with a certain immunity. But when one day I was handling powerful tubes in connection with high tension, I noticed an intense burning sensation at the dorsum of the right hand, the surface of which I used to turn toward the Röntgen tube while the strength of the light was tested through my own wrist. The burning sensation was accompanied by a most distressing tension, which was intensified by every motion. At first the hand appeared erythematous. Later on it became terra-cotta-like, and then the epidermis exfoliated in small scales, so that it resembled leather. Perspiration ceased entirely. During the sultry days which came in such an unwelcome number last summer, the distress was especially great; this 'I would explain from the stimulation which rendered the hardened follicles functionless. I then substituted the left hand for the fluoroscopic control, and protected the right