ing, he is losing weight, he is sleepless, he has spat up blood, his skin is yellow, he has kidney' pains, his skin itches, he has attacks of fever, he suffers from headache, he feels tired, etc. This presenting symptom must be traced back to its underlying cause. This is done by means of a verbal and physical examination which enables the practitioner to group about the principal symptom-principal at least in the patient's estimation-the remaining necessary data, signs, and symptoms-in short, by a mental correlation of this data.'' In the following pages the author has arranged the symptoms which invariably present in this, that or the other condition and shows us of what they may be indicative. He teaches us, and very clearly, how to analyze and correlate these signs of abnormalities and this is done so plainly that even a tyro in medicine should be able to grasp and appropriate them to his use. The author wastes no words in his descriptions, but speaks with distinctness and a clearness which is pleasing, to say the least. He is scientific, but not ponderously so.

Not only will the practitioner, even though he be of years of experience, find much of interest in these volumes, but if the student will adopt them as his text, he will be led along the right road to proper and complete diagnosis. And every reader will find much which will improve his practice of therapeutics.

DISEASES OF THE THYROID GLAND, By Arthur E. Hertzler, M.D., F.A.C.S., Professor of Surgery in the University of Kansas School of Medicine, Etc. With a Chapter on Hospital Management of Goiter Patients, By Victor E. Chesky, A.B., M.D., Associate Surgeon to Halstead Hospital, Halstead, Kansas, 245 pages, with 106 original illustrations. Cloth, price $5.00 net. St. Louis: C. V. Mosby Company, 1922.

As was the case with the Reports of the St. Andrews Institute of Clinical Research, we are again getting away from the metropolitan centers, from which everything worth while is supposed to originate, to enjoy the work of two men whose work is all done in a small town hosptial. Although the authors approach us in a rather apologetic manner, we cannot see why they should offer even the slightest confession of lack of scientific knowledge, for from the reading of their pages we are led to believe that they have possibly given the subject considered closer attention than have some of their city brethren. They have at least studied their cases with care and have followed them from end to end and so have been enabled to give us detailed information relative to both normal and abnormal thyroids. As their has been an active practice and as they have founded their book almost wholly upon clinical experience, we find very little theorizing in any page, for they have been enabled to report actual cases and the findings therein. This makes the work much more scientific than were it filled to the brim with theory and that unproved. We are also pleased to

note the leaving out of copious statistics, for those are things which sometimes cloud our skies and give us wrong ideas, for we all know that statistics are, at times, far from established truth.

In reading this book we find that everything pertinent to the subject is well discussed and in such manner as give us a clear idea of what the writers desire to convey. Both the normal and abnormal thyroids are considered and the treatment of the abnormal is entered into detail. When surgical interference is indicated we find that detailed descriptions of technic are given and that in addition the text is elucidated by original drawings by the incomparable Tom Jones.

We are glad that at least two village Americans, like those of St. Andrews in Scotland, have had the nerve to present their findings to the world and we hope this will encourage others, so located, to go and to likewise, for we have always believed that much of value might be found in the smaller towns, where physicians have the time and inclination for close and serious clinical research.

THE SURGICAL CLINICS OF NORTH AMERICA (Issued serially, one number every other month). Volume 11 Number IV (Boston Number, August, 1922). 270 pages, with 107 Illustrations. Per clinic year (February, 1922 to December, 1922). Paper $12.00 net; Cloth, $16.00 net. Philadelphia and London: W. B. Saunders Company.

While this number of the Clinics does not cover as many subjects as have some others, it will be found of vast value to the reader, for it contains reports of more every day cases than has usually been the rule-the thing which all of us are encountering in our general rounds of practice. This, we feel, adds much value to the Clinics, fo rit gives us a something which we may apply, and with benefit to ourselves and patients alike. The reporters have not hunted out those cases which may occur but once in the lifetime of the practitioner, but have brought forward such things as hand, knee-joint and other abnormalties, which are of frequent occurrene and which the man in general practice is so frequently called upon to attend and correct. Not only has one particular condition been discussed, but in most instances it seems that everything which could be wrong with a joint or other part has been reported. Not only has diagnosis been given careful attention, but if operative interference has been deemed necessary the reporters have gone into detail relative to technic. This number is a real post-graduate course for the man in general practice and so much attention has been given to the details of all sorts that the reader should be able to handle the cases mentioned with better care, in every way, than htd he not read this book. Where necessary to further elucidate the text, original drawings have been introduced. Taken as a whole, it seems to us this is one of the best numbers of the Clinics which has been offered.

As stated in the previous paper, these chemical rays are of the shorter wave length. According to Pacini, if we compare the spectrum of the sunlight as it reaches the earth to that of the apparatus furnishing ultra-violet rays, we will find the former will be 7% and the latter 29% of these rays. This shows that for therapeutic purposes the apparatus will give far better results. Further he states that "owing to the laws of absorbtion influencing ultra-violet transmission through media, the wave lengths reaching us from the sun end in the region of 2,967 Angstrom units, whereas those from the mercury vapor lamp go as low as 1,850 Angstrom units. So that average sunlight gives neither the quantity nor the quality of ultra-violet energy furnished by the mercury arc in quartz."

For the purpose of furnishing artificially these rays for therapeutic applications, we have the electric arc, which was formerly used, and the more modern mercury quartz lamps of various makes. These of two varities, the air and water cooled, each having their distinct purposes. It must be remembered that these rays do not penetrate glass, for which reason glass goggles are used to protect the eyes. They do go through quartz, however, so that the lenses are made of this material as well as the applicators, these latter being of various shapes and varieties.

The air cooled lamps are used mostly for general or constitutional treatments, while the water cooled are more for local or internal cavity work. The two differ in their rays and therapy, which is well explained by Pacini. "When the electrical energy passes through the mercury vapor there is created a central stream of luminescence from which ultra-violet energy is emitted. This transformation of energy like many transformations, is accompanied with the evolution of much heat. The heat volatilizes the liquid mercury in the cathode reservoir and gives rise to a dense cloud of mercury vapor which envelopes the central luminescent beam. So that the rays must first be filtered through a mercury vapor mantle before passing the quartz in the air cooled lamp. Remembering that the short ultraviolet wave lengths are less penetrating than the longer ones (just the reverse to the conditions that obtain with X-ray energy), it is obvious that the air cooled lamp furnishes a dominantly long wave length spectrum. In the water cooled type the mercury mantle is condensed, leaving the ultra-violet energy free to issue from the quartz without previous filtration through mercury vapor; and sc the spectrum from this type of lamp is relatively richer in short wave lengths than the corresponding air cooled lamp." The same authority is given for the following table of comparisons

Air Cooled

"Near ultra-violet intensity. Biologic (dominantly). Chemically oxidizing. Relatively penetrating. Metabolic synergist.

Water Cooled

Far ultra-violet intensity.
Bactericidal (dominantly).
Chemically reducing.
Relatively superficial.
Metabolic depressor.

We are not yet sure of the exact nature of the phochemical reactions upon the organism by the application of these actinic rays, although much has been done along experimental lines. Experiments have shown that the effect upon protein solution is to make them less soluble, which is shown by their easier precipitation. These actinic rays are very harmful to the eyes, and snow blindness depends upon their reflection from large areas of snow, "these short rays being absorbed by the cornea and conjunctiva with resulting injury to their protein constituents.' (Editorial Journal A. M. A. 5-6-1922.)

The effect upon the blood is the stimulation of the lymphocytes, erythrocytes, and hemoglobin. In other words the blood picture changes very materially under the use of the actinic rays, which in the case of anemia, for instance, the change would be very material. "Light cannot act unless it is absorbed" is a recognized dictum and is called Grother's Law. Thus by stopping the rays within the body as by the blood stream, we improve the blood pathology either by destructive or constructive action. "Cell structures may be transparent to radiant light, yet opaque to actinic rays, and this explains the statement that opacity means absorbtion and absorbtion means chemical change, and this change may be beneficial or destructive according to the kind of tissue acted upon, the length of exposure, and the frequency of the vibratory wave. too short for absorbtion the action will be slight, while if all the waves are absorbed and the quantity is sufficient, destruction is enevitable." (Plank.)

While we recognize the effects of these

rays to be by their absorbtion, their action is determined by the length of the waves, the amount of time exposure, the contiguity of the lamp to the part exposed, and the character of the tissues being rayed.

The skin is very sensitive to the action of these rays, so when treatments are given, the exposures should be made in a graduated manner, starting with one minute as a rule so that there will be no skin reaction at first. The distance from the skin should be from 20 to 24 inches according to the case, the time can be increased by one minute with each succeeding treatment until there is a fair amount of skin tolerance, after which less care need to be used. Hyperemia being the object sought can be brought about quite easily and quickly.

A sunburn is the usual effect of too

long an application at first, but as this soon heals, it is not a very momentous affair except to certain sensitive people. When starting treatments it is well to explain to the patient just what may be expected, so he will be prepared for this If a burn is propossible accident. duced, a suitable time must elapse before another treatment is given. Tanning of the skin follows the proper technic, except when a severe reaction is desired, as for example in some skin diseases. For metabolic purposes, tanning is usually the object, and when this is accomplished, the exposures may be lengthened without danger of burns, as tolerance is increased.

As these rays are absorbed by the blood stream thereby acting upon metabolism, it is important that we secure a good blood supply where the rays can get to it. Naturally this means a good surface circulation, and in order to have that we ray the part well with radiant light and heat from an incandescent lamp. This will bring the blood to the surface capillaries where it offers the full activity of the actinic rays. This serves a two-fold purpose, active elimination by sweating and increased bactericidal action of the augmented blood stream. In various painful conditions there is the added effect of seda

tion.

The bactericidal action of these actinic

rays is demonstrated by their use in sterilizing water, such as in swimming pools and the drinking supplies of some cities. These rays appear to destroy bacteria wherever they come in contact with them. They are the irritating part of the sun's rays which cause sunburn, and are naturally stronger and in greater quantity where the atmosphere is clear of dust and smoke, as for instance at the sea shore and in the mountains, hence sunburn is more easily acquired in these places. The artificial rays or those produced by mercury vapor lamps possess greater powers of penetration and approach the characteristics of the X-rays, but unlike these latter rays, they are harmless as regards life. In fact their action is to counteract the disastrous effects of X-ray burns. This has been proven very conclusively of recent time, so that when this is generally known, there need be no more of this form of disaster, if proper technic is used.

These rays travel in straight lines, which makes internal cavity work possible, yet this same fact makes it more difficult to treat easily the sides of certain cavities, and for this purpose special applicators must be made. These are made of quartz, rock or fused, and are made in many and various shapes according to the needs. Cavity work Cavity work needs carefully worked out time tests which now can be done accurately by means of sensitized paper, which is somewhat like photographic paper. It is always best to accurately know the exact amount of time required for each treatment of this type particularly, as internal burns are not so easily cared for as are those upon the skin surfaces.

It

It is difficult to outline any one line of treatment in a paper such as this is, treating of the subject in a general way, but when the therapeutic care of individual cases come before us, this can be better done. It is hoped that this resume of the subject offers a glimpse of the possibilities of these rays, and that it will be at least helpful toward a better understanding of their usefulness.

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