"It is certain that the X-rays should only be used with great caution, and only by those who have had considerable experience both with the rays and with the disease. Often a few minutes' exposure sets up a violent reaction, which if improperly treated may result in an extension of the disease. On the other hand this reaction is sometimes followed at an interval by great improvement, and in other cases improvement sets in without any marked evidence of irritation."

Several of the cases mentioned were kindly transferred by Dr. McMurray from the skin department to the skiagraphic department of the Sydney Hospital, and the treatment was carried out under his supervision. I wish to thank Dr. Newmarch, of North Sydney, for

a

case in a man aged 74 of many years duration, which after treatment appeared to be perfectly cured.

Rodent Ulcer. Unfortunately I have only had the opportunity of trying the effects of the rays in one case, kindly sent to me by Dr. R. Steer Bowker. This was in a man aged 64, and, as seen by the illustration, involved the end of the nose. It was of several years standing, and had been scraped once. This case rapidly responded to treatment, and after 32 sittings appeared to be quite healed.

Hypertrichosis.-I have tried several cases. The hairs fell out after 15 to 30 sittings, but soon reappeared. In one case I continued treatment, on and off, for seven months, but eventually gave it up in despair, and removed the hairs effectively by electrolysis.

Keloid and Hypertrophied Scar Tissue.-In one case where hypertrophied scar tissue formed after an operation for tubercular glands of the neck I was successful in removing this after three months intermittent treatment with the rays. The Medical Annual of this year refers to the case, which was published in the Australasian Medical Gazette of April, 1901. Dr. W. H. Goode, who has since seen the case, expresses great satisfaction with the result.

Carcinoma. I have several cases at present under treatment, and shall report on them on some future occasion.

This embraces my limited experience in the matter, but the results obtained are so gratifying that I feel confident in predicting that the

therapeutic properties of the Röntgen Rays will be much availed of in the treatment of many indolent forms of skin disease.

[Since I wrote this paper-nearly two months ago I have had eight additional cases of rodent ulcer under treatment, each of which is rapidly responding to the radiations.]

TREATMENT OF CANCER BY RONTGEN RAYS.

By T. G. Beckett, L.R.C.P. & S., etc., Hon. Medical Electrician Alfred Hospital, Melbourne.

[Abstract.]

THE subject that I have the honour to address you on to-night is the treatment of cancer by Röntgen Rays, and before commencing I must ask for your kind indulgence towards me on account of two or three features in my lecture. In the first place, partly in order to make the most of the limited time at my disposal, I shall omit nearly all references to the published work of others, and confine myself almost entirely to my own personal experiences of this matter.

The second point I must apologise for is my presumption in giving this lecture at all, considering my limited experience in this work, and my only excuse is that this subject is so very new that I am not aware of anyone who can claim to have a very extensive experience of it yet. Owing to this fact it is quite possible that some of the opinions that I express to-night I may, after a more extended experience of a few years, be compelled to modify in the light of further evidence. The title of this lecture will naturally provoke the question: Can cancer be cured by X-rays? My answer is this, that by the aid of the X-rays, in easily accessible and superficial cases of malignant disease, we have an undoubted cure which has been proved by many successful cases and by many observers. In regard to more serious cases, where the disease has obtained a deeper hold, such promising results have been already obtained by some, that looking at the very early nature of our experience with this new line of treatment we have good grounds for hoping that, with improved methods and more extended experience, a wider range of possibilities is open to us. Even the present results are not to be despised, for how very many of what are serious and extensive cancers now were once only very small and superficial malignancies; that is, they could have been cured with our present means had they been treated early enough.

There are probably very many who will for many years only regard this new line of treatment as merely another cancer cure-another

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added to the long list of hopeless remedies ;and if I can only succeed in showing you tonight that it is something more than this, and convincing you that it is worthy of your serious attention and critical enquiry, then I shall be quite satisfied that I have not wasted my time this evening. At the same time I will endeavour to bring before you in as impartial a manner as I can the disadvantages and difficulties connected with this mode of treatment, as I do not wish to mislead you into supposing that we have an easy method of curing all cancer cases, because, although sometimes a cure is effected with a few applications, and very easily, yet this is not generally the case; on the contrary, as a rule, the treatment is tedious, difficult and somewhat expensive to carry out. These are the most serious drawbacks to it at present.

Now, why should X-rays cure cancer? I will endeavour to answer this question by first mentioning the more or less well-known facts regarding the properties of X-rays, and then the various theories or conclusions that can be drawn from them; and in regard to some of my theories I must caution you that, although I think my facts are all pretty well authenticated, yet I cannot say the same for my theories, which are mainly my own, and I cannot give you any authorities to support them.

The facts on which I am going to explain the action of X-rays are briefly these :-

1. These rays have the power of penetrating all substances in inverse proportion to their density and their atomic weights, and are capable of exerting chemical action after doing so, in this respect being different to any other rays that we are acquainted with.

2. X-rays exert a decided action on living cells, as shown by their action on the human skin, mucous membrane, and any portion of the body. It is quite possible that they also exert a bactericidal action on living micro-organisms, but the evidence on this latter point is at present very contradictory. This is a very difficult question to decide, as, unless the experiments could be conducted under similar conditions to what exist in the human body, merely negative results can have but little value. For instance, even a thin glass cover would be quite sufficient to considerably modify the effects of the rays, and unless the experimenter was experienced in working with X-ray tubes in a state of therapeutic activity-a point I shall come to presently-the X-rays he might use may have little effect.

3. The action on living tissue appears to be first of an exciting or inflammatory nature, and if the action is persisted in long enough the

reaction is of a necrotic character, and ultimately produces extensive and deep-seated sloughing action. In the early stages X-ray dermatitis, as it is called, is very similar in appearance to erysipelas. The action takes several days, a week or more, to develop, being slower in this respect than that produced by the Finsen light, and seems to be of a cumulative character, a point that often makes it very difficult to judge the correct amount of exposure to give.

4. When exposure to X-rays is extended over a length of time it produces an atrophying effect on the skin and appendages, nails and hair. This effect may occur without any preliminary inflammation, and is often seen on the hands of those working daily with the X-rays, especially if they are in the habit of testing their tubes by observing their hands in the screen, although only a few seconds' exposure occur in each case. It also tends to produce a contraction in the capillary circulation, and by means of this fact I have removed from the face those large superficial nævi commonly known as port wine marks. It is quite possible to do this without producing any inflammation, although great care is required to avoid it, and it takes some time and many exposures to do it.

5. I find these X-ray effects vary exceedingly in individuals and in different parts of the body. Briefly, the conditions I have found to influence them are dependent on the health and vigour of the parts, and also the blood supply; that is, any part that is freely supplied with blood, and in a healthy, vigorous condition, is very resistant to X-rays, and will stand a lot of exposure to a powerful tube before any reaction can be produced; and, on the contrary, if the part is in a diseased and weakened condition a reaction can often be produced after a single exposure. I think anything that tends to lower the vitality of any portion of the body renders it more susceptible to this X-ray reaction, and if care is not exercised most violent inflammation, and sloughing even, may result.

6. Now, in regard to the nature of cancer, I do not want to go too deeply into this. There are several here this evening that could probably tell you more about the latest theories than I can; but I think I can safely say that from a histological point of view it consists of a proliferation of cell growth of a very active nature which intrudes itself amongst the healthy and normal cells, and inducing wherever it spreads an extension of the same class of cells. Now, this tissue is characterised like all other diseased tissue with a lower vitality than normal healthy structure; consequently, upon any injury or the slightest cause, it breaks down, sloughs, and sets up suppurative action.

I now come to the particulars of the methods employed, and as most of this will only be of interest to those who have already had experience with X-ray work, I will be as concise as possible.

First, the foundation of the whole treatment is the coil, the source of your electrical energy, and I strongly recommend for this class of work the most powerful class of coil you can command. An induction coil should be regarded as an electrical transformer, the means by which you transform a low voltage with an enormously high one; and the bigger the coil the larger the current you can safely put through it, and the greater the volume or amperage of the discharge in your secondary. Now most unfortunately for this, I think all X-ray work coils are made and sold by the length of spark, and it is quite possible by using very thin wire and other methods known to the trade to produce a coil giving a long spark, and yet the output in the secondary may really be only a poor one. The best class of coil for this work is one with a large primary of low resistance, and a certain proportion of larger wire than is usually used in the secondary, and you will be able to obtain a splendid discharge. I attach some importance to this point,

and several observers have come to the conclusion that all coils are not suitable for this work. I usually work with a 20-inch coil, and seldom go beyond 10 or 12 inch spark, though occasionally up to 15 inches. A 10 or 12 inch spark from this coil is quite a different thing from the spark of a 10 or 12 inch coil, and gives off from a powerful X-ray tube a much larger volume of X-ray, which is what is wanted in these cases. I used a mercury break of the McKenzie-Davidson pattern, which is very adjustable in many ways and gives a great variety of speed. The electrolytic break has been used with much success by some workers, but I should anticipate considerable trouble in maintaining the most suitable vacuum in the tubes, which is always a great difficulty and is a most essential point. I work with a voltage of from 8 up to 20, according to the effect I am trying to get, but the point that requires watching most carefully is the actual amperage passing through the coil. I usually use from 5 or 6 up to as much as 12 and even 15 amperes, which is a much larger current than usually used. I always run the current through an ammenter in series with the coil, and by watching that can tell pretty well what effect to expect. The current I obtain from accumulators, by far the steadiest and most reliable current to work with. I cannot recommend primary batteries for this work; they are not constant, and run

down considerably after two or three minutes' consecutive work. The greatest difficulty is with the tubes, and if there is any secret in the success it lies with this. Most of the work has up to the present been done with X-ray tubes constructed for radiographic purposes, and most of these are unsuitable. In the first place more than half of those in common use have very little therapeutic activity; they have been constructed for a very different purpose, could and some of these tubes I believe you give any amount of exposure and get absolutely no result. As a broad, general rule the tube that is most active is generally a new one, a soft tube, or one that has been quite recently exhausted. The reaction is obtained with these most readily, but must be used with greatest caution, as they sometimes produce most alarming X-ray burns. A safe tube to use is one with an equivalent spark resistance of 6 to 7 inches, and deeper penetration can be obtained, especially with a much harder tube. A plan I have adopted is to take a very hard tube and make it very hot over a large Bunsen flame. The tube should be able to stand this and yet not go below 6-inch resistIf this is run for three minutes, then heat it up once again as hot as the tube will stand. A good reaction can thus be got with much deeper penetration than given by a soft tube. Unfortunately, one of the greatest difficulties is that there is no easy method of judging the therapeutic activity of any tube, and these vary very much, and unfortunately never remain constant for any long period. The great difficulty is that a tube may be too active, and as you may not find it out, and you are giving daily exposures the full effect of which do not show for a week, at the end of this time you are suddenly surprised at the very serious reaction you get. The reverse may be the case, and you may work a week or two and get absolutely no result. You can only judge by your daily experiences, and working with a good variety of tubes, that you have some idea of their relative peculiarities. There are special tubes now being made for this work, and I am trying some. Of course you must use some method of screening. Sheet-lead is the only absolutely reliable material that I have worked with. Lead-foil may often be used if care is exercised, but remember in a long case the rays will ultimately get through it, although this sometimes may be an advantage.

ance.

For beginners, the safest rule is to keep the tube at a safe distance. I have never seen any injurious effects follow when you fix the tube at a distance of 12 inches and upwards. The time of exposure I vary, the same as the current, according to the degree of reaction. I wish to obtain, from as little as one

minute up to 15 minutes. Cases at first should be treated daily, nothing less is any use even twice a day would be an advantage; but once the reaction is obtained, and patient on road to recovery, then two or three times a week is sufficient. Finally, I recommend a long period of once a week, which I think does much to ensure against a recurrence. Another feature in my treatment has been this, as you will notice in some of the cases I am going to show you: I have not in serious cases trusted entirely to the X-rays alone, but have been very glad to avail myself of the surgeon's skill. In this way I am convinced I have shortened the case, made the result to be attained easier, and in no small degree contributed to the ultimate success. It might be objected by a superficial critic that on this account I cannot fairly claim these cases as being due to the X-rays. So far as that goes I feel the greatest indifference whether the surgeon or myself takes the credit of the cure. I am quite willing to admit "honours are easy," but at the same time I will ask any experienced surgeon to carefully observe the exact nature of what has been done in the cases I will show you, and he will see that it is of such a nature that no surgeon would dare to perform such a little excision of tissue; the amount cut away is so small that the patient is left in as good a condition as before. As most of you know, if such a kind of operation were done in a similar case without the X-ray treatment, recurrence would be so prompt and rapid that the operation would be worse than useless. I will ask you to take particular note of this when I bring these cases before you.

My

In regard to the question of recurrence, of course this treatment is far too new to tell yet what our experience is going to be. I will only say that up to the present I have not yet read of any case recurring that has been completely cured; neither have I yet seen it myself. own opinion is that this will not occur provided that the treatment has been thoroughly efficient and kept up at increasing intervals for some time after recovery. I have not time to go fully into this, but I will just point out this is not such a serious question as it looks, because the position will be totally different to recurrence after an operation when the disease recurs in a worse position than before, and the next operation must be a more serious one; whereas under this treatment the position will be not only no worse, but probably less difficult to treat than before. If you cured it once, probably you could do so again. No one thinks any the less of the successful treatment of acute rheumatism because of its tendency to

recur; it simply indicates further treatment required. It is probable, I think, that the patient will most likely be cured, and in as good a condition as before the attack, but he can hardly expect to be better than that, and as cancer did come on once it proves the existence of a cancer diathesis, and therefore he must stand a certain risk of getting it again. I quite expect to hear of cases recurring, because it must happen sometimes that the treatment is not efficiently applied nor continued for sufficient length of time. So I should not take too much notice of solitary cases recurring. Time and experience can only prove what will happen in the majority of them. I will now conclude my lecture by bringing under your notice a few selected cases in which this treatment has been successful, and also a few still under treatment; and in regard to some of these cases I must in justice observe that whatever success I have attained is in no small degree due to the valuable advice and surgical assistance that I have received from Mr. O'Hara and Dr. Cooke, who have all through shown the keenest interest and readiness to help me in the treatment of these cases, and I must admit that but for this help I could not have undertaken cases of so serious a character by means of this treatment alone. I have also to thank Dr. Kelvington for the trouble he took in preparing the microscopic specimens, and his careful reports on the same, which perfectly accorded with the histories of these cases. In regard to the diagnosis of all these cases, they are all, in my opinion, undoubtedly cases of cancer; in most of them the diagnosis is beyond all possible dispute, and where any room for question of diagnosis exists, I have endeavoured by the aid of microscopical examination of experts to obtain all the possible evidence on this point. will commence with rodent ulcer, which, as you all know, is now generally recognised as of a malignant nature, and I would remind you that this was the first kind of these classes of diseases to be treated by X-rays, and so far with uniform success.

I

A.B.-This case was sent me by Dr. Cooke. The patient, aged 75, in very feeble health, with a typical rodent ulcer of five years' duration over the left temple, about the size of a sixpence, and exactly over the anterior branch of the temporal artery. The patient was not in at all a favourable condition for getting any ulcer to heal, and his case proved a very obstinate one; over 70 or 80 applications were required, and at last I got it completely healed up. The treatment lasted from January 11th till the end of March. It has remained perfectly healed ever since, and, as you see now, the ulcer has quite disappeared.