The human body is subject to only three conditions, or states, viz.: Normal, sub-normal or above normal. The normal body requires no therapeutics; the sub-normal conditions evidently require something of a stimulating nature. The X-ray is hardly indicated, although it does possess a small amount of stimulating properties. But as has been pointed out, the slightest amount of over-stimulation causes inhibition. That brings the X-ray down to practically one condition, and that is where some organ or tissue is above normal. In other words, the destructive action of the X-ray far exceeds all its other qualities. It apparently also possesses a predilection for glandular tissue, and the more highly organized the gland the greater is the destructive effect.

Only a few years after its discovery it was noticed that nearly all X-ray workers had become sterile. There was a complete absence of spermatozoa. This effect has since then been amply verified upon dogs, cats. guinea pigs, hen's eggs, frogs' eggs, seeds of various kinds.

I have under treatment two females, who for pathological reasons, should not again become pregnant. These patients have been under treatment three and four years, respectively. Every three months they receive X-ray exposures for fifteen minutes every other day for one week. So far the results are eminently satisfactory.

Pathological glandular overactivity is found in many skin lesions, such as epithelioma, lupus vulgaris, sycosis, favus, acne simplex, acne nodosum, eczema, hypertrichosis, hyperidrosis, etc. All these conditions are the result of some irritant in the system causing over-production which becomes pathologic. The X-ray is indicated in varying doses in each one of these conditions. While it must not be looked upon as a specific to the exclusion of other measures, such as eliminants and suitable diet, nevertheless, as far as the local effect is concerned, there is no agent that will so quickly and surely, and so perfectly remove an epithelioma as the X-ray. The cosmetic effect in nearly all these skin diseases far exceeds all other known methods.

It has been my good fortune, during the last few years, to treat, besides these skin lesions, a large number of constitutional diseases. One of the best results from the X-ray is seen in cases of Hutchinson's disease, tubercular glands, tubercular joints, splenic leucemia, etc.

Just a word about the much-dreaded so-called X-ray burn: We are well on the way of eliminating this troublesome part of the X-ray. One month ago I had the privilege of presenting to the dermatological section at the academy a technique that has, for the past three years, succeeded in over five thousand applications of preventing even as much as an undesirable reaction..

A specially constructed tube, "The Cornell Tube," designed by myself, is, contrary to all expectations, brought into direct contact with the lesion. No rays escape anywhere excepting directly upon the site where needed.

The operator, as well as the patient, are at one and the same time protected.

The successful use of the X-ray, therefore, depends upon the fact that the X-ray, primarily, is a destructive agent. When a destructive agent is applied to the tissues, there ensues a reaction; it is this reaction to the ray that is turned to therapeutic usefulness.

The application of the actual cautery, painting a joint with iodine, the production of a blister, touching a part with lunar caustic; all these, and many more, are destructive agents, yet, if properly applied in suitable cases, cause a certain reaction by the tissue; the virtue lies in the reaction, not the agent.

1239 Madison Avenue.

THE VITAL IMPORTANCE OF URINALYSIS IN CASES IN AN UNCONSCIOUS STATE AND OF UNCERTAIN HISTORY.

BY FREDERICK E. BEAL, M. D.,

Lecturer on Clinical Medicine in the New York Polyclinic Medical School and Hospital; Attending Physician to Northwestern Dispensary, New York City.

[Written for the MEDICAL BRIEF.]

Two cases, which during the month of October came into my service at the New York Polyclinic, impressed upon me with renewed force the importance of making prompt use of our best diagnostic methods in every case and not take for granted what is told us by those who have previously seen the patient. Not in the sense of belittling such previous opinion, but for the sake of the patient as well as the profession, we should give each case our very best efforts without prejudice. These two cases occurring at almost identically the same time, seem of sufficient importance to warrant my reporting them.

Mrs. M., aged thirty-eight years, married, was admitted to my service October 12, 1907, at 6:45 P. M., with a definite history, loquaciously reported by an excited husband, of typhoid fever with perforation of the bowel, demanding an immediate operation. I rather hastily examined the patient for signs and symptoms of perforation and found none. There were no points of tenderness, no distention of the abdomen, no symptoms of typhoid either in abdomen, breath or involuntary stools. Temperature 102° F., pulse one hundred and ten, with the patient lying in deep coma, from which she could be aroused only after great effort. Because of the extreme edema I found in her limbs, extending even above the knees (notwithstanding the fact that the husband confidently asserted that this condition had existed for a long time and had nothing to do with her present illness), and also because of the marked accentuation of the second aortic sound heard over the aortic region, I ordered the house surgeon to catheterize and make a quick examination of the urine.

About this time I was called hurriedly to see a case on another floor of the hospital, that was brought in as an emergency case of obstruction of the bowels, demanding immediate laparotomy.

Taking advantage of the time required to make the urinalysis in the first case, I found the condition of the second case as follows: Miss K., aged forty years, unmarried, formerly an actress of considerable fame. Because there had been gradually increasing unconsciousness, and no movement of the bowels for three days, her attending physician believed it to be a cause of obstruction of the bowels and ordered the patient into the service of one of the professors as an emergency case. Examination revealed a temperature of 99° F., pulse one hundred and thirty, sharp and distinct. Pupils not markedly dilated. No rigidity nor distention of the abdomen. Only by careful palpation could the presence of any mass be discovered therein.

Respirations, which I would call especial attention to, were laborious and stertorous on inspiration; soft, sighing and inaudible on expiration. Coma was so profound that it was impossible to cause the slightest indication of consciousness. The characteristic acetone odor of the breath was noticeable.

Again I ordered immediate catheterization and hurried examination of the urine, in which was found nine per cent of sugar, the presence of acetone, with an excess of ammonium. I immediately counseled that the patient was dying from diabetic coma and that there was no evidence of any obstruction of the bowel, and even if it had existed, operation was wholly contraindicated. This patient lived some nine hours, gradually sinking and dying in typical diabetic coma.

Reverting to the first case, an examination showed almost solid. albuminous urine (the pathologist reported that he had never seen urine more dense), with casts, hyaline, granular and bloody. A diagnosis was unqualifiedly made of parenchymatous nephritis.

This patient's subsequent history is of interest. Her temperature steadily rose for four days and despite all efforts in the way of diuresis, diaphoresis and hydragogues, it reached 107° F. At this time we were able to induce some movements of the bowels-markedly watery stools, when her temperature dropped to 103° F. Her pulse even when temperature reached 107° F., remained between one hundred and one hundred and ten. She continued in this comatose condition until her death four days later.

I simply offer these cases in evidence of the importance of the examiner making a careful study of each case, and not accepting the diagnosis of the attending physician, whose responsibility ends where his begins.

76 W. Eighty-fifth Street.

REPORT OF A CASE OF ANEURISM OF THE SUBCLAVIAN; LIGATURE IN THE FIRST POSITION; RECOVERY.*

BY HERMAN E. PEARSE, M. D., Kansas City, Mo.

The cure of aneurism is a matter for operative procedure only; the so-called "medical" treatment by aconite, iodide of potassium, and other cardiac depressants, gives a record of scant success. The only generally successful method has been the ligation of the vessel with or without excision of the sac and in later years the intrasacular suture after the method of Matas of New Orleans. Where the aneurism can be isolated and all branching vessels easily secured and ligated and the entire sac reached and removed, the double ligation, proximal and distal, with excision of the sac, offers the greatest certainty of cure. The establishment of collateral circulation must be considered, and the question of the life of the part supplied by the vessel must be weighed and risked.

The case presented here was one in which these chances and all others had to be taken, on account of the desperate nature of the growth and the certainty of disaster if it were left to take its course. The patient, Mr. G., a Swede, age forty-one, is a well-built, muscular man, in robust health. He consulted me early in May, 1906. He is a locomotive engineer by occupation, running on the Frisco railroad. He was never ailing except that about November, 1905, he noticed a "big pulse," as he described it, on the right side of the neck at the level of the collar bone.

He was

About February he began to suffer pain in the arm and to feel tingling sensations in the ring finger and little finger of the right hand. treated for rheumatism at first until the doctor found out about the "big pulse in the neck," when a diagnosis of aneurism of the subclavian artery was made. He went to his company surgeon, but received no encouragement of possible cure. He then went to the company surgeon at Thayer, Mo., Dr. Edwards, who called Dr. Harvey Maloney in consultation. Dr. Maloney advised him to come to St. Luke's Hospital and place himself under my care. The docetor wrote: "I have a patient here who has an aneurism of the right subclavian artery external to where the cerebral artery is given off. He is a Swede, about forty-one, single, good habits, physical condition good, except some trouble with right arm. Now from a medical standpoint there is nothing to offer this man. What can you do surgically? He is fairly well fixed and is anxious to have something done if there is any chance. He will come up to Kansas City any time to see you. Let me know just what you think about it." I reproduce the letter as an example of clear-cut definite English and frank, terse, statement of fact.

I found upon examination a pulsating tumor in neck on the right side. It lay behind and also on each side of sternocleido-mastoid muscle, but

Read at the meeting of the Missouri State Medical Association, May, 1907.

mostly external to it. It rose above the clavicle for about two inches. It gave only a faint bruit over its body, but over the base of the heart and the right subclavian region it gave a pronounced one. Radial pulse of right side pronounced; left side absent on account of old injury to the left arm. I advised him that the case was possible of operation, but one that carried about it a ninety per cent death rate. I gave him the facts and figures as follows:

The American Text Book of Surgery, 1892, page 243, says: "If the aneurism is small and limited to the third portion, digital pressure upon the proximal side of the subclavian, although difficult for anatomical reasons, may be attempted in conjunction with constitutional treatment. Pressure directly upon the sac has been successful in a few cases. If compression fails, the artery should be ligated upon the distal side, since proximal ligation has proven ineffectual. It may be necessary, where other means have failed, to ligate the artery on the proximal side as a preparatory step, and then immediately to amputate the arm at the shoulder joint."

Deaver reports sixteen cases of ligation at the first portion, with thirteen deaths (1889).

Bryant reports twenty-one cases with nineteen deaths (1899).

Dennis quotes Ashurst in the Int. Encyclo. Surg., Vol. III, reporting fifteen cases with thirteen deaths (1902).

Twentieth Century Practice, page 589, quoting from Ballance and Edwards' "Treatise on Ligation of Great Arteries with Observations on the Nature and Progress of Aneurism" (McMillan, London, 1891), reports fourteen cases, all of which died-mortality of one hundred per

cent.

I am unable to present figures and statistics of a later date than the above, which shows sixty-six cases with fifty-nine deaths-a death rate of ninety per cent. I submitted these facts and figures to my patient and he requested me at once to operate. Before doing so, I asked him to consult Dr. George M. Gray, the surgeon of St. Margaret's Hospital. This he did, Dr. Gray confirming the diagnosis. Desiring to secure for my patient the advantage of Dr. Gray's well-known skill, I requested Dr. Gray to be with me at the time of operation, which he kindly consented to do. I set the day of operation for May 25, 1906, and directed that the patient lie quietly in bed for the intervening two weeks. I also gave him a dose of ten grains of iodide of potash after meals three times a day. I believe the two weeks' rest and iodide had not a little to do with the successful outcome of the case.

May 25th the patient was etherized by Dr. H. C. Andersson, and an incision was carried along the surface of the clavicle and upward along the posterior border of the sterno-cleido-mastoid muscle. We had confirmed Dr. Maloney's diagnosis of the growth, i. e., external to the verte