For purposes of study let us divide the action of the rays of Roentgen upon the operator, into four arbitrary stages:

(1) Preparatory stage or stage of first impression.

(2) Premonitory or threatening stage.

(3) Stage of inflammation and disintegration.

(4) Stage of chronic skin diseases, etc.

PREPARATORY STAGE, OR STAGE OF FIRST IMPRESSIONS. As you are all well aware, the operator receives no warning from the tube, experiences no sensations while being injured. After a time there is a little change of color of his hands and face. This he may erroneously attribute to the action of the solar rays.

"His face is like the tan."

(Longfellow, in the Village Blacksmith.) A few papules or postules with itching here and there or bran-like scales to a local skin trouble (prurigo, acne or pruritus), a little swelling of the hands and features to a circulatory disturbance, the falling out of his hair to senility, when in reality they are caused by the Roentgen rays which are rendering the integument more and more susceptible to their action. Such symptoms should be looked upon as harbingers of an impending storm.

During a long period of increasing susceptibihty, the oper

*Continued from December issue.

135823

ator may imagine himself an X-ray immune. As if by some special dispensation, he, like Shadrach, Meshach and Abednego, can walk in the fiery furnace (of the X-ray field) and not be burned.

PREMONITORY OR THREATENING STAGE.

The symptoms of this stage are itching, warmth, local diaphoresis, a mild seborrhea, partial anaesthesia, luxuriant or deciduous hair (in hirsute people, the shedding of the hair may be the first indication of the rays' effects), cutis ancerina (goose skin), very small shot-like bodies in the cuticle, a glossy appearance of the parts as if they had been varnished, oedematous swelling of the subcutaneous cellular tissue, causing the hands and face, to become puffy as they do in Bright's Disease, rendering the fingers and palm of the hand stiff and awkward, effacing anatomical markings and giving a general rotundity of contour. Punctate red spots, a few and scattered (discreet) or many and close together (confluent) in groups, patches or diffuse; some are raised, others on a level with the surface. They may cause the skin to become as rough as the surface of a nutmeg grater. Some of the minute elevations may be colorless. They can be seen by looking at the parts obliquely. They can also be discerned by careful palpation. There is a flushed look to the skin about them.

DISCOLORATION OF THE SKIN.

Red, reddish-blue, yellow, brown or black. The first two colors, due to vascular charges, may or may not disappear. The others always remain on pressure. Pigmented portions of the body are especially affected with pigmentation. The same is true of dark individuals. It is by keeping diseased parts of the patients who have malignant ailments in this stage of irritability, oedema, tanning or redness and partial anaesthesia, that the greatest number of cures can be effected. From this stage the operator may recover, with or without desquamation. Exclusion of all parts of actinic rays, a good sweating of the parts, and crowding all the other emunctories, will help to restore the parts. Otherwise, as the result of further exposure, an operation or an accident, such as a blow

or cut, to the irritated parts, the process will slowly, insiduously merge into the stage of chronic inflammation, with its "cardinal signs, calor, dolor, ruber, tumor and functio laessae" (quotation from lectures of Dr. Roswell Park, on Inflammation).

STAGE OF INFLAMMATION AND DISINTEGRATION.

The pathognomonic symptoms of X-ray inflammation as experienced by myself after seven years' exposure in the Xray field, were extreme itching with constant desire to rub scratch or dig into the affected parts. If the itching of the alleged seven years' itch could be crowded into a few months' time, it would not be more aggravating.

ERUPTIONS.

Scarlatina form rash, miliary papules, pustules and vesicles came in successive crops. They resulted from the more or less destructive inflammatory involvements of the follicles and their cellular elements, like thorns in the flesh or other foreign bodies. They were thrown off, leaving the skin honey-combed with small ulcers, oozing a hydro-serous discharge, alkaline in reaction. This discharge may be odorless or have a putrid smell according to the severity of the process. Some of the hairs could be drawn from their pockets as if they had been loosened by electrolysis.

EXFOLIATION OF THE SKIN.

Fifty, a hundred times, or more, the epidermis was thrown off in scales of various size, shape and consistency. In places slightly affected, the desquamation was scarlatinaform, the disease painless. Where quite severe, the scales were at first thick and macerated, pseudo-membranous. Late in the disease the scales became desiccated and appeared as they do, in many forms of skin disease. If the scales were torn away, the surface bled freely from the points of their attachment.

INFLAMMATORY MOUNDS.

Where the process is quite severe but attacks circumscribed areas more severely than intervening spaces, inflammatory mounds appear capped with a white membranous patch. In time the patch breaks down leaving a ragged-edged crater

like opening. A common position for these mounds is over the articular surfaces, but they may form upon the dorsum of the hand, the fingers and in other localities.

EXTENSIVE ULCERATIONS.

If the inflammatory process is severe, the eruptions, small ulcers and mounds all become confluent, the surface breaks down, forming large ulcerated excavations with a raised border. Their central position may be either naked or covered with a thick, whitish pseudo-membrane. Under these conditions the suffering is intense, the discharge sanious and offensive.

PAIN AND SUFFERING.

For a description of the pain and suffering, hyperaesthesia paresthesia, no language sacred or profane is adequate. The sting of the honey-bees or the passage of a renal calculus is painful enough, but are comparative pleasures, because being paroxysmal they have a time limitation.

Extreme tenderness to the slightest touch. Hot and cold waves and flashes, warmth, tingling, pricking, throbbing, stinging, crawling, boring and burning sensations, as if the parts were on fire and contained bugs, and other living things. Feelings as if the anatomical structures were being moved from one position to another. All of these sensations are proportionate to the depth of the inflammatory process. All forms of radiant energy, light, heat, magnetism, ultra-violet rays, etc., increase the suffering. The parts are irritated by soap solutions or attempts to use them for any purpose. The suffering is also augmented if the affected members are allowed to become dependent, hence the afflicted operator holds his hands high above his head, even sleeping with them in that posture. If the inflammation in his hands is severe, muscular action will be temporarily lost, the fingers immobile. He must be dressed, undressed and fed by attendants.

HEALING OF THE PARTS.

There are abortive efforts of the parts to heal. They heal over only to break down again, or healing in some places they break down in others. No healthy scabs form over the

ulcers, no laudable pus, so called, appears. The formation, of granulations and scar flesh is defective, consequently the processes of repair are indolent, ineffectual, requiring months to restore the parts. Eventually the epithelial cells will spread from the margin and islets, over the ulcerations, and the injured parts are thus supplied with a thin investment. Muscular power returns. Wherever the hair is restored, as it frequently is, it will return more vigorous.

Physiological rest, an elevated position, exclusion from all forms of actinic rays, the burning away of deciduous material with dioxygen, the employment of formaldehyde, ten per cent solution as an antiseptic wash, and a thick dressing of equal parts of vaseline and powdered starch, evacuation of pustules and the wearing of kid gloves for several months after the acuteness of the attack has passed, will aftora considerable relief to the sufferer. Dr. Robinson of Philadelphia uses picric acid, Dr. Jering of the same city employes the lead plaster.

I quote the following, illustrating an extreme degree of chronicity of X-ray inflammation, also showing how the operators who work with the most powerful apparatus and the greatest number of hours per day, are usually the greatest sufferers.

London, Aug. 6, 1903, via Associated Press: "Two doctors belonging to the London Hospital have been affected by Xrays in a manner similar to that of the assistant of Thomas A. Edison, and have been compelled to abandon their work. They were engaged for a long time in making examinations of and manipulating diseased parts, while the X-rays were directed on their patients. When they began to suffer, they tried gloves on the backs of which lead foil was sewn, but these impeded the movements of their hands and were discarded. One of the operators ceased opertaing under the rays, eighteen months ago, yet his hands have improved little despite constant treatment."

To return to my own case, large red blotches and some pustules appeared upon my face and neck, with a burning sensation followed in time by desquamation and restitution. The