Now, if it is possible to carry this procedure one step farther, and abort gonorrheal ophthalmia in its earlier stages, it would save many eyes. The abortion of gonorrhea of the urethra has been a subject of discussion for many years. Its attempt has been advocated and condemned, condemned and advocated. The pendulum has swung through all its phases. At present, from what I can learn, those in genito-urinary practice condemn attempts at aborting this disease in the urethra.

As to aborting gonorrheal ophthalmia, I have seen nothing of it in ophthalmic literature. On the contrary, teaching has been directly opposed to the use in the incipient stage of gonorrheal ophthalmia of any remedial agent in sufficient strength from which we might expect abortive action. Especially is this true of that most active of germicides, silver nitrate. But older views in medicine are sometimes changed in the light of modern etiology and the later advances in therapeusis. It is possible that such may be the case in regard to the present subject.

This idea was suggested to me by a little experience in my own practice, an experience so meager that it lends only to the suggestion of a possibility. I remember full well the old adage that it take more than one swallow to make a summer. I am fully aware of the broad foundation that facts must be reared upon, yet the results I refer to impress me so favorably that I dare to present them to you. I will report two

cases.

CASE I. J. S., colored, employe of I. C. R. R. There was profuse suppuration of the left eye, with great injection and chemosis. No corneal implication. Patient said the eye had been affected several days. The appearance of the eye was that of a typical case of gonorrheal ophthalmia. Patient also had at the time a urethral discharge. There was marked conjunctivitis, with slight mucoid discharge of the right eye, which had commenced, according to the statement of the patient, the day before. The treatment instituted was instillation of a twenty per cent solution of protargol every four hours, with almost continuous bathing of the eyes with cold (iced) water. The blennorrhea gonorrhoica (for such I took it to be in its incipient stage) affecting the right eye subsided promptly, and the eye was free from redness and secretion in four or five days. The inflammation and suppuration gradually subsided in the left eye (the one first affected, and in which there was a fully developed case of gonorrheal ophthalmia), and patient was discharged well in two weeks.

CASE 2. Mr. W. A. S., aged twenty-one, employe of I. C. R. R., referred to me December 20, 1901. Right eye very much inflamed with purulent secretion. The eye had been affected two or three days. The patient had urethral gonorrhea at the time. Diagnosis was gonorrheal ophthalmia of right eye. The left eye was not inflamed. I placed a Buller shield over the left eye and instituted the following treatment: Almost constant cleansing of the right eye with boric acid solution; iced cloths for twenty minutes each hour, and instillation of a twenty per cent solution of protargol every four hours.

On the following day when I saw the patient at the hospital-some twenty-four hours after I first saw him-the left eye, the one that had appeared well the day before, was injected and gummed up with a mucoid discharge. I believed it to be gonorrheal infection of the left eye-not the gumming up of the eye that we find when an eye is under a shield; so I removed the shield and had the same treatment applied to that eye as to the right eye, namely, cleansing, iced cloths, and a twenty per cent solution of protargol. In four days the left eye was well. The inflammation and suppuration rapidly decreased in the right eye, and on December 31st, eleven days after treatment was commenced, the patient was discharged well.

I know that to have made my diagnosis absolute I should have had a microscopical demonstration of the presence of gonococci in the secretions from these eyes. In the absence of microscopical verification I report the above two cases only, for I fully believe, as in each case there was present a disease of the urethra which had all the appearance and history of being gonorrheal, that the eye trouble was gonorrheal, and that the implication of the second eye in each case was gonorrheal, and by timely and efficient treatment the disease in these two eyes was cut short-aborted.

If, then, it be true that gonorrheal ophthalmia can be aborted by the use of an efficient remedial agent if seen in its incipiency, would it not be wise to begin treatment in all suspicious cases, in the absence of microscopical findings, with a germicide of such strength that should the suspicion of gonorrhea prove true there is a possibility of checking the disease?

As to remedial agents, I would not advocate this indiscriminate use of solutions of nitrate of silver. But since we have in protargol an innocuous and non-caustic agent of high germicidal power, and it is claimed the property of penetrating tissues deeper than agents like

silver nitrate or bichloride of mercury, that exert but superficial action on account of their coagulability-an agent that can be put into the hands of the patient with safety-I would advocate the use of this agent in efficient strength, from twenty to thirty per cent solution, to be used from five to six times a day, in every case of blennorrhea seen in its incipiency where there is the slightest suspicion of gonorrheal infection, and give the patient the benefit of the doubt.

PADUCAH, KY.

THE THERAPEUTIC USES OF THE X-RAY, WITH REPORT
OF CASES.*

BY JESSE T. DUNN, M. D.

Lecturer on Surgery and Rectal Diseases and Instructor in Laboratory of Surgery, Kentucky School of Medicine.

The unexpected serious results of a free and careless exposure to the X-rays in the early days of this new form of energy led up to the discovery of its therapeutic value in a certain class of diseases. X-ray burns were frequently reported from all quarters when we were not familiar with the dangers attending the application of this new light. These burns were of various degrees, varying from the slightest erythema to a severe slough involving the entire cuticle and underlying connective tissues. It was also noted that in hairy portions unduly exposed to the ray, a loss of hair resulted, which in a short time was reproduced.

A knowledge of the nature and effects of the X-rays is essential to the successful delivery of the treatment to all conditions in which this form of treatment is desired, because repeated exposures are necessary to obtain the curative results, and just herein lies the danger of this treatment. The kind of tube, whether hard or soft, the distance from the patient, the length of exposure, and the frequency of repetition, all require a nice adjustment to secure the end sought. That there is a limit of safety there can be no doubt.

As Pusey has said, the local effects of the X-ray may be stated to be, first, changes in the epidermis itself or its appendages: (a) pigmentation; (b) blanching of the hair; (c) outfall of the hair; (d) trophic

*Cases exhibited and paper read by invitation before the Practitioners' Club, October 14, 1902.

changes in the nails similar to those of the hair, sometimes resulting in the interference with the growth and in severer cases in the shedding of the nails. Second, changes in the corium and subcutaneous tissue. These are all inflammatory in character, varying from a slight erythema through all degrees of dermatitis up to necrosis.

This train of results being encountered by all who did X-ray work quickly led up to the present therapeutic use of the rays, which to-day chiefly consists in its application to the treatment of the following conditions:

1. Hypertrichosis, superfluous hair.

2. Diseased hair and hair follicles, as sycosis, tenia torsurans, and favus; in such cases the removal of all hair is essential to treatment.

3. Inflammatory skin diseases, as in chronic eczema, tubercular glands, and Hodgkin's disease, where stimulation and absorption is necessary.

4. Where the destruction of tissue of low vitality is necessary, as in lupus, epithelioma, etc.

5. Where the destruction of healthy, though unnatural tissue is desired, as in the various forms of birth-marks (moles, wine-marks, etc.).

6. Where destruction of the sweat follicles is desired, as in hyperhidrosis.

Removal of Hair. The removal of hair by this method in the hands of many operators has been entirely satisfactory. Freund, who was the first to use this method, met with success in his first as well as subsequent cases. The hair has never returned. Many cases have been reported in which many months have elapsed with no recurrence.

This method of removing hair is painless and much less tedious than by electrolysis. It also removes the "down" with almost as much ease as the large hairs. There is no evidence of application of any form of treatment for the removal of hair until a few days before the hairs are ready to drop, which is usually about the eighteenth or twentieth sitting, then there appears a mild erythema which I term a reaction, which may be kept within the bounds of safety by a careful adjustment of treatment. If too long or too frequent exposures are made a mild erythema may become a severe dermatitis which will result in a shedding of the superficial skin. The advent of the initial erythema is the signal that enough treatment at daily intervals have been given.

Subsequent treatments should be at such intervals as to continue a mild form of erythema. The hairs usually drop, or are easily removed in a few days after erythema begins. Treatment must not be stopped at this point, for the hair follicle is not yet destroyed; fifteen or twenty additional treatments will probably be necessary to insure their complete destruction.

CASE I. Miss L., referred to me in December, 1901, by Dr. Henderson. Patient aged thirty, with a heavy growth of hair over the lips, cheeks, and chin. These hairs varied in length from the finest "down" up to one and a half inches. This patient began treatment December 31, 1901, taking eleven treatments, a total of eighty-nine minutes. Reaction appeared on January 10th; treatment was discontinued. Hairs became loose and were easily removed, except under the chin. Short exposures were again given for seven days, beginning January 15th; discontinued treatment in five days, and when reaction subsided she received ten additional treatments of ten minutes each, resulting in reaction which continued until February 27th. At this time the hairs beneath the chin were still tight. After five sittings of ten minutes each, the treatments being directed to the hairy portions beneath the chin, gave a reaction which resulted in the removal of all the hair. On March 25th erysipelas began about the head and extended over the entire face and neck. The head and neck were not exposed to the rays during any portion of the treatment, having been covered by a lead mask. I could not account for this condition of cellulitis until a close inquiry revealed the fact that her father and sister were subject to erysipelas. This case ran a typical course and finally disappeared. In the meantime it was impossible to give her the treatment necessary to complete the destruction of the hair follicles, consequently a great many of the hairs thus removed returned.

That the X-ray did not cause this condition of erysipelas I am quite sure, because after the first attack of erysipelas had disappeared for ten days, without any subsequent exposure to the X-rays, the same condition of erysipelas developed and again subsided in due time, and a third time reappeared without having been exposed to the influence of the X-rays. I advised the patient to go to her home and wait until she recovered from this condition, when she should return and again take up the treatment.

CASE 2. Miss G. began treatment April 6th for the removal of a heavy growth of hair upon the lip. I gave her twenty-one sittings in