cases, and not upon the scattered success or frequent failures which bespeak inexperience and want of judgment in technique.

This inhibition while not constant, yet occurs in direct proportion to the skill and experience of the operator, and the results, on the whole, are more favorable' each year, as time adds to the operator that judgment which contact with large numbers of cases alone can bring. Its value to the surgeon in operable cases is evident. In many personal experiences, a patient physically unfit for operation, has been built up by tonic treatment, while the disease was held in check by radiation till such time as a successful operation could be performed; then radiation was employed to promote granulation and prevent recurrence. The final results have been pleasing to both operator and patient. In frankly inoperable cases, the method of treatment has been used many times, with the happiest results, to prolong life and relieve pain. In some of these supposed hopeless cases a clinical cure has followed and persisted over periods of years.

This inhibitory action is to a degree in direct proportion to the dosage administered, which degree consists in the following factors, length of exposure, frequency of exposure, distance from the tube, penetration of the ray (vacuum in the tube) strength of excitment and quality of current. A general characteristic of malignant tissue is in its enormous rapidity of cell perliferation. This is checked and in some instances stopped by radiation.

The newly formed tissue low in vitality and physiological resistance to injury and endowed with poor reparative power, may, even and often does undergo tissue death, and is absorbed or thrown off en masse, and is replaced by connective tissue. If this process be complete throughout, a clinical cure results; if not, the growth is but temporarily inhibited and will, later, take on renewed activity. This effect is local. There is no antitoxin generated which circulates through the body to have effects at distant points upon foci, which have not been exposed to the radiation. No matter how thoroughly the original growth may have been destroyed, metastatie deposits will go on as usual, unless found and destroyed. The difficulty of an early recognition of metastatic foci is responsible for a very large part of the failures in other than primary cases.

The radiation from an excited crook's tube is capable, when properly ..pplied, of inhibiting malignant growth.

This inhibition is in direct proportion to the skill and experience of the operator and is not a constant result.

In certain cases this inhibition is so complete and permanent as to constitute a clinical cure.

In inoperable and apparently hopeless cases, the radiation may be employed with gratifying results to prolong life and relieve pain.

Its

It is of great value following operation to prevent recurrence. employment for therapeutic use must be confined to specially skilled physicians and surgeons, and its prostitution at the hands of nurses, orderlies, engineers, etc., should be opposed by all ethical men.

X-RAYS IN SKIN AND GLAND AFFECTIONS.

Dr. Russel H. Boggs, Secretary of the American Roentgen Ray Society, whose experience in the use of X-rays has been extensive, states in a paper in the treatment of skin and gliandular disease that X-rays has a stimulating effect when applied in small doses and a destructive action in large doses. The dosage of no other therapeutic agent, therefore, is more important. The rays should be used as carefully as strychnine or any other poisonous drug. In small doses the rays accelerate the processes of nutrition and in this way; aid in the healing of unhealthy ulcers. In many cases time is saved by using high frequency currents or Finsen light in connection with the X-rays. The irritation and trophic changes produced by the X-ray, are deeper than those produced by stimulating drugs. He has treated twenty-seven cases of lupus vulgaris and two of lupus erythematosus. Twenty of the cases of lupus were cured, four improved and one of the lupus erythematosus cured and the other improved. Four of the cases of lupus vulgaris had a relapse or a recurrence in which the X-rays were again effective. Each of the cases in which a relapse occured, stopped treatment as soon as the visible signs of the disease disappeared. Most of his cases were extensive and of long duration and could not be treated with Finsen light. He has been able to so improve his technique that one half of the treatments now are effective.

Of primary epithelioma he has treated thirteen cases, that had no operative interference. Nine of these are cured, two improved and two still under treatment. A permanent cure cannot be expected in the latter, as the disease is very extensive.

Nine cases of carcinoma of the neck involving the glands, which started as epithelioma of the lower lip, were treated. In each of these the epithelioma had been removed by the knife and there was a recurrence and the case referred for X-ray treatment. All these were hopeless from a surgical standpoint. At present, one case is apparently cured. Not one of these case would probably have recurred if X-ray had been employed after the removal of the epithelioma by the knife and a sufficient amount of radiation been given to destroy the remaining foci.

Excellent results have been obtained in tubercular glands by the X-rays. The same is true in tubercular sinuses. Seven cases of the former were treated with five cures, one is still under treatment and almost well, and one discontinued after a short time with but little improvement.

Obstinate cases of acne and chronic eczema respond to this treatment when all other forms of treatment have proved ineffective.

Out of twenty-four cases of carcinoma of the breast, all were favorably influenced by the rays, excepting one, sixteen of these have been operated upon and a recurrence taken place when they came under X-ray treatment. Six cases were considered hopeless and only inhibitory action expected by the physicians referring them. Two of the other cases which had never been operated upon were in such a condition that the surgeon had refused to operate. Out of the twenty-four cases treated therefore, there were only six in which much could be expected. Up to the present time, eight have died, of two trace has been lost, and the other fourteen are living. Seven are symptomatically cured, three are under treatment and are rapidly improvlng, and the other four are gradually becoming weaker. Several of these have been well for over three years, but this is too short a time to say that there will be no recurrence. His conclusions are, 1. Technique and judgment are largely accountable for both successful and unsuccessful results. 2. In the treatment of lupus, epithelioma, carcinoma, acne, eczema and tuberculous glands, X-ray ranks an excellent remedy. 3. In most cases of carcinoma, the combination of X-ray and surgery offers the best chance of recovery.

OPHTHALMOLOGY AND OTOLOGY.

Under the charge of G. STERLING RYERSON, M.D., C.M., Professor of Ophthalmology and Otology, Medical Faculty, University of Toronto.

THE TREATMENT OF EARACHE.

In the Brooklyn Medical Journal, December, 1904, Dr. Lafferts A. McClelland discusses this old and ever important subject as follows:

The objects of this paper have been to call attention to the importance of symptoms referable to diseases of the ear in childhood and especially that most common affection, earache, for it is a notorious fact that this very troublesome affection receives scant attention even from men in our profession who honor themselves with the opinion of duty well done. Under aetiology, it may be stated as a general principle that any disparity from the equal aerial pressure within and without the tympanum tends towards this affection. Therefore, what can be more noteworthy than that the common coryza, so difficult of treatment in children is a contributory cause. Frequently the nose and post nasal space is filled with a yeast-like supply of gurgling mucous, which is being churned backward and forward during respiration. This is often aspirated into the Eustachian tube and tympanum. Then, again, we must not forget the impinging of adenoid tissue and other enlargements about Rosenmüller's fossa which gradually choke off the sufficiency of air entrance into the tube of the ear.

The

pump-like action of an enlarged faucial tonsil will suck out, or aspirate, air at each piston-like motion during deglutition. Consequently the muscular structures concerned in the usual control of the air supply of the tympanum will lose tonicity. Again, at times the pharyngeal vault is filled with cobweb-like adhesions which often involve the openings of the Eustachian tubes. These hinder the action of the salpingopharyngeus muscle when, as they often are, found binding down the lips of the tube in all directions like little strands of dried catgut. Between the meshes made by such is ever present a catarrhal exudate viscid and persistent. Inspiration of water into the tubes during bathing is another cause common in the summer time. Nasal douches and the forcible sniffing of water into the nose are likewise fraught with similar danger. A violent blowing of the nose may be a factor. I believe that the inspiration of noxious stomachic and intestinal gases may also tend to produce this trouble.

Under pathology, let me be cursory, for here we have just that which would occur to an inflamed mucous membrane anywhere plus the results of emptying an aerated cavity of its air which occurs by deflation and absorption. We have a retraction of the membrane, due to its lack of aerial support. Soon it becomes congested. The mucous membrane swells and becomes oedematous and flabby, so that the walls of the affected area may become agglutinated. Then the transudation of serum follows. In acute catarrh of the middle ear the mucous membrane is alone involved, so that the fluid which accumulates is usually in the form of sero-mucus. I have not limited my observations too exclusively to the tympanum, for while the analogous, though not identical, affection which is known as catarrhal aural salpingitis might be considered distinctly, we will consider the combined affections which for our practical purposes are so closely correlated that their origin and tendencies are similar; for it is too common a fact that we may have an involvement from the orifice of the Eustachian tube all through the tube to its terminus and involving the tympanum too. The accumulation of fluid within the tympanum may be such as to distend the membrane so that its removal is urgently called for, if indeed the overdistention has not already been sufficient to produce a rupture of the drumhead.

In children the temperature usually is 102 degrees or 103 degrees and may run much higher. It may be ushered in by chills, vomiting or convulsions. Pain is excruciating and apt to be constant until the pressure is relieved. The piercing cries of the child with earache are to me peculiarly trying. Usually the infant places his hand to the affected ear. The membrane is diffusely hyperaemic and later may be seen to bulge so that the drumhead is forced low in the external auditory canal. After discharge takes place the canal is rapidly filled with a sero-mucus discharge

which can be seen to pulsate in rhythm with the arteries of the tympanum. The flow is often so great that the canal refills rapidly after cleansing. In adults, the pain is severe, but apparently less than in childhood. Prior to the exaggerated symptoms there is a feeling of stuffiness in the ears, muffled voice sounds, snapping and bubbling sounds due to air entering the fluid, pain, deafness, sometimes giddiness from labyrinthine pressure, mental hebetude is often marked prior to the distention.

Physical examination further shows besides the congestion, at the early stage, retraction of the membrana tympani, absence or displacement of the pearl or light spot, undue prominence of the hammer while later may be seen the fluid line and bulging of the tympanum.

Prognosis is usually good under appropriate treatment. This depends, however, largely on the character of the invasion, whether streptococcic, staphylococcic or pneumococcic.

Under treatment in the early stage there are two immediate considerations, viz., relieve the pain and abort further involvement. This may frequently be accomplished by thorough cleansing of the nose and post nasal space, preferably with cotton on probe, then the application of 110000 adrenal chloride solution on cotton when the cleanness and patency of the nasopharyngeal entrance will enhance the chance of re-establishing the intra-tubal and tympanic pressure by nature, or by the aid of Politzer bag. At times, when the membrane is retracted greatly, the Siegle's otoscope will withdraw the membrane's excessive impingement upon the ossicles and thus tend to replace the normal position. Liberal flushings of the canal with water of 110 degrees to 120 degrees delivered in a constant stream from the ordinary fountain syringe, using the smallest tip, which should be placed on the floor of the canal, but not pushed into it, will prove of much service in relieving the prevailing condition in mild cases. I believe that this simple procedure is not practiced at sufficiently regular and short intervals by many, who fail of the object in consequence. Half hourly intervals between the two quart irrigations is often indicated. Leeches to the tragus will often dissipate the agony of a suffering child so promptly that sleep will follow forthwith. A dressing to the ear may be found most comfortable and my preference is a large wad of warmed absorbent cotton packed loosely about it. A hot foot bath and a cathartic are often beneficial. Occasionally a hypodermic of morphia may be neces

sary.

Failing to abort the affection, sterilize the canal and incise the membrana tympani while the patient is under the influence of either nitrous oxide gas, ether, chloroform or a local anaesthetic, e.g. R. Alcohol, carbolic acid and cocaine (saturated solution), equal parts.

After operating, irrigate the canal with sterile warm saline solution or Thiersch's solution.