lessened range of motion as compared with the sound side. Darkened areas in the lungs indicate disease of the lung substance, while cavities and emphysema are shown by clear, bright spots, or in the latter disease over all of both lungs. Pleuritic effusions are readily noted by the displacement of the lung and often also of the heart. In empyema the resistance to the light is much greater, and the area filled with pus is almost or quite black. Gangrene of the lung is similar in appearance to pneumonia, but the area is usually larger and darker. Displacement or enlargement of the heart may be readily noted and given its proper significance.

(d) Leonard has taught us how to make a positive diagnosis of renal or ureteral calculus by making a radiograph with a low tube—so low in fact that anything in the abdomen of greater density than the soft parts will be shown. He expresses perfect confidence in his negative as well as positive diagnosis, and his wide experience and perfect success make him our Nestor in this department. We can not yet as certainly find stones in the bladder or gall-bladder, but this is purely a question of technique and may be solved satisfactorily any day. It is important in all cases when ureteral or renal stones are located to operate as soon as possible afterward, not only for relief of the condition but also because the stone may move and not be readily found.

Thus briefly have I outlined the present status of the X-ray in surgical diagnosis. Truly we may say we are but in the infancy of this most wonderful art. Every day is bringing newer uses for the X-ray in all branches of medicine. No conservative expert will claim that everything in medicine is settled by its use, or that any agency we now have at our command should be discarded. It makes a most-may we not say the most-valuable addition to our diagnostic armamentarium, and its very value makes it more important that we should the more frequently examine the sputum and the blood, that we should all the better ground ourselves in the use of the stethoscope and microscope, that we should collect and keep more careful histories and case-notes, and above all that we be better, broader, more careful, and more painstaking doctors. BOWLING GREEN, KY.

THERAPEUTICS OF X-RAYS.*

BY JAMES B. KINNAIRD, M.D.

Mr. President and Gentlemen: Permit me to thank your Committee on Questions for selecting me to present a paper upon the "Therapeutics of X-rays," and pardon me if the subject is not thoroughly treated. The limited time at my disposal has prevented me giving an exhaustive paper upon the subject.

From the beginning of time men have been seeking for remedies that may alleviate pain and prolong life. The animal, vegetable, and mineral kingdoms have been brought into requisition with this end in view. We have advanced year by year, decade by decade, sometimes slowly and at other times with leaps and bounds, still we have not discovered the elixir of life. Prof. Loeb has startled the world by his recent experimentations, and has given electrotherapeutics a new impetus, that had already been set in motion by radiotherapy. It is not possible to prolong life indefinitely by any means at our command, but I think that years may be added to the lives of many disconsolate beings who have been waiting the inevitable, suffering with malignant disease. We have in X-rays an agent that has accomplished much in a class of inoperable diseases, and the future is pregnant with hope. Already many local and constitutional diseases have yielded to the X-light. While yet in its infancy, radiotherapy has removed from the minds of the public that ancient dread of cancer.

Many experimenters have reported marvelous results from the use of X-rays in the treatment of epithelioma, sarcoma, carcinoma, and lupus. The results obtained may only be temporary, but if relief can be given for only a short time much has been gained. If the results prove permanent we have an agent whose value can not be overestimated. Many experimenters have observed that pain ceases when a diseased condition is treated by X-rays. Those who have been addicted to the use of opiates for the relief of pain in malignant diseases have declared that the exposures give prompt and ofttimes permanent relief. This effect is produced probably by benumbing the nerve supply. A general tonic effect results from exposures, stimulating the nervous system, improving the appetite, and assisting assimilation.

My experience with X-rays in the treatment of diseases has been limited. The first case treated by me came under observation last

Read before the Kentucky State Medical Society, Paducah, Ky., May 7-9, 1902.

October, and although this case has been reported I shall give an outline of the treatment and the outcome of the case. This case, supposed to have been lupus, was referred to me by Dr. Mays, of Lowell, Kentucky, for advice as to the advisability of having it cauterized. At my suggestion she began the treatment, with meager hope of ultimate success. The treatment did not appeal to her as a rational measure, but she cheerfully pursued the treatment for seven weeks, when she was dismissed cured.

This patient, a married woman aged thirty-six, about eight years ago had a dry, itchy scale appear above the left eyebrow, which in time became elevated and bleb-like, peeled off, and began to ulcerate. In spite of treatment it spread until it had reached in size one inch in width and one and a half inches in length; had eaten its way over the eyebrow and was destroying the upper lid, with a decided tendency to dip into the post-orbital region, there being a small, deep fistula extending downward and backward. Local and constitutional treatment had failed to check its advance.

I began by giving exposures ten minutes in duration, with her face eight inches from the Crookes tube. The face and head were shielded with rubber cloth, a perforation being left to correspond with the diseased surface, through which the rays were applied. After the fourth exposure there was noticeable a tendency to granulation, which continued uninterruptedly until cicatrization was complete.

During the first week I gave six exposures; second week, three; third week, two; fourth, two; fifth, two; sixth, two; seventh, three, making twenty in all, when the case was pronounced well. One month after the case was dismissed a small nodule appeared on the margin of the cicatrix, which yielded promptly to a few exposures.

The patient's general health was very greatly improved and the facial neuralgia has not returned. Immediate relief from pain was experienced from a single exposure. During the course of treatment a slight erythema, resembling a mild sunburn, appeared around the margin of the lupus, but there was no dermatitis.

The cicatrix resulting was unusually white, due probably to the destruction of the pigmentary layer of the skin. The color of the cicatrix is gradually resuming the normal appearance of the skin.

The second case that came under my care was a man aged eighty, who had an epithelioma at the outer canthus of the right eye. Eleven years previously a small nodule appeared at this location, which in time broke down and began to ulcerate. It had been stationary for several years.

At the time he first consulted me, December 11, 1901, it was one half an inch in diameter, circular, deeply excavated, with indurated edges. There was a small nodule about the center of the lower lid one fourth inch in diameter, and another on the nose near the inner canthus of the right eye one half inch by one fourth inch. Both were apparently in a condition for ulceration. There was a chronic conjunctivitis and slight ectropion. There was no indication of any specific lesion.

After a few exposures there was perceptible improvement. After eleven exposures, each of fifteen minutes' duration, extending over a period of thirty days, the epithelioma was entirely well, the nodules had disappeared, excessive lachrymation had ceased, and his conjunctiva was clear. In conjunction with exposures I gave him static treatment. When the case was dismissed he expressed himself as feeling better than he had for ten years. He returned home cheerful and hopeful, but unfortunately died three months afterward with heart failure. Up to the time of his death there was not the slightest indication of a recurrence.

I have under treatment a case of eczema which showed no tendency to heal from X-rays for a time, but a mild dermatitis followed, which has resulted in much benefit. This case, recently reported by me to the Central Kentucky Medical Association, I regarded as discouraging. Since that report was made a wonderful improvement has occurred. Even eczema should yield to this procedure. Some favorable reports have appeared in recent medical literature, and I believe that when the technique is better understood many forms of eczema will be treated successfully.

I have had under treatment four months a case of recurrent scirrhus in a woman fifty-one years of age, whose right mammary gland and axillary glands were thoroughly enucleated two years ago by a very skillful surgeon. One year after removal of glands a number of nodules appeared over the right sterno-cleido muscle and in the axilla. A second operation was done. Since that time numerous nodules have developed over the right pectoralis major muscle and epigastrium. Four months ago there was edema of right arm, with considerable pain. I began X-ray exposures at that time. Pain ceased, the edema disappeared, but the metastatic process continues. She has now an exasperating cough, for which I am using ozone, generated by static machine. Relief in this

case can be only temporary.

The first indication of scirrhus was a small nodule in the mammary gland eight years ago, when I insisted upon having an operation done.

Had an operation been done at that time the disease might have been eradicated.

At the present time I have a case under treatment referred to me by Dr. Mann, of Nicholasville, Kentucky, which was diagnosed lupus. No microscopial examination has been made. It has the appearance of sarcoma; the odor is very offensive, and the discharge of pus, large at first, has been lessened very materially, while the odor has been mitigated. The patient is a woman seventy-one years of age, mother of eleven children. Eleven years ago a black wart followed a hen-peck on her left hand, which became inflamed and in time began to suppurate. This spread over her wrist, thumb, and index finger. She consulted a physician in another locality, who applied caustics, in consequence of which she lost her thumb and index finger. This destruction of tissue may have been due to the disease. There was no return of the disease for a year, when an ulcer appeared on her left arm, then successively upon her face, lower lip, and left ear. Four years ago the right parotid gland became affected, broke down, and has continued to suppurate. When she came to me the parotid gland was enlarged to such an extent that it extended below the angle of the jaw, rendering mastication impossible. She had no appetite, was feeble and scarcely able to walk. Now her appetite and digestion are good and she can walk to my office without tiring.

She has had thirty-six exposures. The purulent discharge has decreased until now it is not one fourth in quantity and is less offensive than it was in March; the parotid gland has shrunken to its normal size; the nodules on face have disappeared, and one on left ear is undergoing atrophy. Her complexion, at first sallow, is now clear. Her general condition is improving, and instead of being despondent she is cheerful and contented. Her present condition is favorable, and treatment will be continued. With all the cases thus far treated I have used the medium and high vacuum tubes, more especially the latter, and the results have been satisfactory.

Workers in this line are at a variance as to which tube is to be preferred. Some contend that the best results are obtained from the high vacuum, others the low vacuum tube. If it is the light that cures, it makes very little difference which is used, for after all the light is only electricity. It is electrical energy that penetrates the tissues and brings about the results.

In making exposures I place the diseased surface at from two to eight inches distant, according to the case and frequency of exposures.