13. Primary extirpation may have to be followed by iridectomy. 14. It is indicated in those cases of glaucoma which already have extremely poor vision, and where any interference with the eye proper might result unfavorably.

15. It is to be considered at all times when other operative measures are refused, irrespective of the form of glaucoma.

16. The excision of this ganglion has various effects upon the fundus oculi; none detrimental, however.

Compare Dr. Marple's summary (Medical Record) of the present status of the operation:

1. The operation of extirpation of the sympathetic ganglion is a safe procedure in the hands of a skillful surgeon.

2. That (as Ziehe says) while the material is not yet sufficient to reach a positive conclusion as to the permanence of its effect, it is nevertheless established that some of the glaucomatous cases have been improved for some months by resection; in others the condition apparently remains stationary. The results have varied, and one can not yet be sure in what cases it can be advantageously employed. It at least apparently does no harm. A considerable number of favorable results have been reported in chronic irritative and inflammatory glaucoma, as well as in simple glaucoma, in which oftentimes pain is abolished.

3. It does not replace iridectomy, but may possibly supplement the latter in case this is refused or has already resulted disastrously in the other eye, or is contraindicated, as in hemorrhagic glaucoma, dacryocystitis, etc.

4. Until our cases are observed more carefully and for a longer period of time it will be impossible to arrive at positive conclusions as to the indications for the operation or as to its permanent results.

I think Dr. Marple's summary explains the present status of sympathetectomy for glaucoma. Its application for the present must be in a comparatively few cases. In cases of hemorrhagic glaucoma, where for the present the operation seems the most applicable, it must not be forgotten that this tendency to hemorrhage is not purely a local affection; it is a local indication of a general circulatory affection, probably a sclerosis, so one should be careful of any or all surgery upon such subjects.

LOUISVILLE.

THE PRESENT STATUS OF RADIOTHERAPY AND

RADIOGRAPHY.

BY M. F. COOMES, A. M., M. D.

Professor of Physiology, Ophthalmology, Otology, and Laryngology in the Kentucky School of Medicine, a Member of the American Medical Association, the Kentucky State Medical Society, and the Louisville Clinical Society; Ophthalmic Surgeon to Louisville City Hospital and the Kentucky School of Medicine Hospital; Consulting Ophthalmic Surgeon to

Sts. Mary and Elizabeth Hospital; Ophthalmic

Surgeon to St. Anthony's Hospital, etc.

In this age of marvelous inventions and wonderful discoveries in every department of science, none has proven more prolific of good to mankind than the development of electrical science. The mechanics of electricity and the many wonderful things accomplished through the aid of electrical mechanism is enough to confound the most stoical philosopher.

The transmission of the human voice over thousands of miles of wire, and its exact reproduction at the distal termination, is one of the most astonishing results obtained through the development of electrical engineering.

The intensifying and amplifying of sound is another of the marvelous results of the development of the science of electricity, but the most startling of all of the discoveries in connection with this science was that of the discovery of the X-ray by Professor Röentgen. The announcement was received at first with much misgiving on the part of the most credulous; but little time, however, was required to prove the truth of Professor Röentgen's assertions, and now all the civilized world is familiar with the X-ray. Its value to surgery was evident from the beginning, but none of us, not even the lucky discoverer, ever dreamed that the Röentgen X-ray was to be the formidable foe of one of the most fatal enemies to the existence of man, viz., cancer.

The mere mention of the fact of having at our command a harmless and efficient method of curing cancer in some of its forms, and the certainty of mitigating the suffering of all persons so affected, at first sounds like a fairy tale-a thing that might be told "the marines"-but the stubborn clinical facts that are presented daily set aside all doubt, and has established beyond all question that in the Röentgen X-ray we have a most wonderful and active therapeutic agent. The most astonishing feature about the whole therapeutic process to the uninitiated is the possibility of destroying the morbid tissues and leaving the

healthy normal tissues intact. This, however, becomes easy of comprehension when it is understood that the tissues which enter into the construction of the normal body have a very much higher resisting power than those going to make up morbid structures, such as epithelial cancers, etc.; that the normal tissues of the body, as skin, mucous membrane, and muscles, offer a much greater resistence to the action of Röentgen X-ray than the cancerous tissues, and as a consequence the X-ray will penetrate the skin or mucous membrane and destroy an underlying cancerous mass and cause it to be dissipated and removed by the absorbents in one instance. In other cases, where the growth is extensive, it breaks down and sloughing results, removing the morbid structures, leaving the normal tissues intact and in position.

The Physical Properties of X-rays and their Mode of Action upon Tissues, etc. The exact nature of the X-ray is yet a matter of speculation, but the following throws some light on the subject, rather in a conjectural manner, and is worthy of careful consideration:

Radiotherapy and Phototherapy. Freund (British Journal of Dermatology, September, 1902, p. 339) states that all the radiant phenomena have the same physical basis. The physical properties of rays as applied to the skin possess chemical, fluorescent, and electrical properties, the effect varying with the dosage, from mere stimulation to destruction of tissues. In weak dosages the rays favor organic processes, such as growth of hair and production of pigment, but in stronger dosage they lower vitality, produce inflammation or actual necrosis.

Radiant heat, light, electricity, and X-rays similarly influence cell-life. As to the clinical effects of radiotherapy, the physiological effects are in direct proportion to the intensity of the "raying," but are in inverse proportion to the wave lengths. The reactions appear after a latent interval, the length of which is also inversely proportional to the wave-lengths and intensity of the "raying." Those rays which have the property of exciting fluorescence are also physiologically the most powerful. The action of the rays is long-persisting. Freund believes that in so-called "D'Arsonvalisation" the effects are solely due to the spark-discharges accompanying the use of the apparatus. All spark-discharges may cause physiological effects, which may result from (a) the mechanical bombardment of the tissues, (b) the production of heat, (c) chemical effects-formation of ozone, and (d) ultra-violet ray formation. The effects of sparking vary according to its intensity, being either stimulating or destructive. On the skin they affect the vasomotor system and tend to cause necrosis of the epidermis.

The action of D'Arsonval's apparatus is superficial and due only to the accompanying spark-discharge, and is useful in pruritus, lupus erythematosus, acne vulgaris, and pigmentary abnormalities. A simple spark

apparatus consists of a test-tube filled with water and connected with the negative pole of a coil, the positive pole being earthed. With this apparatus Brush-discharges can be obtained equal to those of Oudin's apparatus. The Brush-discharge is useful for widespread areas of disease and in the case of nervous people, the spark-discharge being applicable to more circumscribed areas. Treatment with the "electrified hand" is another spark-method, but a very mild one.

Dr. Milton Franklin, of New York (New York Medical Record, October 25, 1902), has this to say concerning the action of the X-ray:

The manner in which the rays affect the tissues is a matter of vague speculation at the present time. Some think that the effect is produced by the projection of molecules into the tissues; some that it is electrical energy that is projected; some that the vibrations cause the tissue elements to oscillate in a cycle out of harmony with their regular molecular motion, thus causing a disintegration of the molecular structure; some that the X-ray produces the ultra-violet ray within the tissue by a process of interference; and finally, though probably not correctly, the action has been considered due to the setting free of ozone within the tissues by the rays.

The modern, and at the present time generally accepted theory, is that the rays are composed of negatively charged corpuscles or electrons. A fact of some significance is that M. Goldstein has demonstrated that at the place where the rays impinge there is formed a thin layer of ultra-violet light.

Herr Schmidt holds that the cathode rays have a marked reducing power, and do not act by producing ultra-violet light, but more probably by saturating the electrolytic valency of the substance.

The action of the X-ray is beautifully demonstrated in the case of Thomas Martin, whose two photographs accompany this article. The first is a photograph of the man before the X-ray was applied. This shows the face and lips much swollen and distorted and the right eye almost closed. The second shows the same man sixteen weeks later, after all of the cancerous tissue had been melted away by the X-ray, and reparation commenced by the open spaces filling up with granulations and the edges of the sore cicatrizing. If this man is not fully restored, that is, if the cancerous tissues have not been entirely eradicated, the X-ray has done for him what other therapeutic agents could not accomplish and what the surgeons would not dare to undertake with the knife. He has no pain, and his life has been prolonged. Just how long, time will tell, as we can not say at present what the final result will be.

A further demonstration of the mode of action of the Röentgen X-ray is manifested in the destruction of the epiderm and the hair bulbs by exposure to its influence and the underlying structures remaining undisturbed, notwithstanding the fact that they were also penetrated by the same ray. These results all seem very wonderful, even to those of us who have observed the progress of the X-ray step by step in its action, from its advent into the arena of surgery and medicine up to the present time.

Each day makes it more evident that the X-ray is to play an active part in medicine and surgery. At this writing it is an established fact that it is probably the most efficient and reliable means of eradicating all superficial epitheliomatous growths.

In the treament of certain forms of epidermal cancers Dr. Williams states his conviction that the X-rays are of value. His experience indicates that we have either in the X-rays themselves, or in some form of radiation from the Crooks tube, a valuable therapeutic agent in epithelioma, the beneficial action of which may be brought about without causing a burn. The earlier the treatment is undertaken the better. It is not improbable that we may find its curative action