This patient came down here from Massachusetts yesterday and submitted to examination last evening by Drs. Carmalt, Verdi, N. R. Hotchkiss, Eliot, and Bevan, of New Haven; Brown, of Danbury; and Overlock, of Pomfret. She was also examined yesterday on her way here by Dr. Maurice H. Richardson, of Boston. All of these gentlemen confirmed the findings noted above. I had hoped that she would be here today, but her courage was not quite equal to appearing before the Society.

These cases justify the bald statements that cancerous processes are amenable to roentgenotherapy, whether superficially or deeply located, and that it is capable of accomplishing beneficial results in cases of so severe a type as to present absolutely no hope of relief even, under any management.

This must not be understood as implying, however, that all cases of malignant disease will respond happily or with equal readiness, even when the highest degree of technical skill and the dictates of the ripest experience are invoked in the administration. Individual idiosyncrasy, as regards protoplasmic vitality and the strength of the tendency toward the normal development of cell types constitutionally inherent in different patients, enters the problem with great force. In some persons, cell vitality is at so low an ebb that but little disturbance is required to produce a widespread aberration from the normal cell types; in others, it is so pronounced that very large degrees of such irritation as usually induces malignant cell growth, are undergone with impunity. These same principles apply as regards the amount of corrective influence required to restore normal conditions in any individual case. But the cardinal fact that the beneficent power is inherent in the ray, remains demonstrated, and it is our future function to ascertain, and, if possible, gain control of these extraneous factors and conditions which introduce the element of uncertainty into the treatment of the individual case.

Roentgenization would appear, then, to be destined for a prominent rôle in the future therapy of cancer, and the next thing to be ascertained, viz., definition of that rôle, at once brings up for consideration the question, "Shall the ray be relied upon alone, to the exclusion of the knife, or shall it be applied in conjunction therewith, and if so, how?"

As regards the first part of the question, clinical experience has shown that it is justifiable, and usually preferable in judiciously selected cases, to rely upon roentgenization to the exclusion of the knife in cases of superficial epitheliomata, involving only the external skin. The proportion of successful results is just as large (some operators claim that it is larger) as that attainable with the knife or caustic pastes, the cure is just as radical, and the cosmetic results are much better. An additional advantage is that if recurrence takes place it is usually permanently amenable to a further course of radiation, whereby the extensive removal of tissue is avoided. I will say, in passing, that malignant processes involving mucous membranes do not respond as kindly to roentgenization as do those which are confined to the external skin.

In inoperable cases, wherever situated, roentgenization must of necessity be relied upon to the exclusion of the knife. That it merits consideration in even the most desperate of these, however, is demonstrated by the abdominal case already described.

As regards the second part of the question, clinical experience has shown that when the growth is deeply located or large in size, a much larger proportion of satisfactory results can be obtained by combining the knife and the ray, than by relying upon either alone. The logic of this proposition is as follows:

First, when a large mass of malignant tissue disappears under roentgenization, its disappearance is usually accompanied by a variable degree of general systematic toxæmia, which has been known to be severe enough to kill the patient of itself, and which is always liable to impair general or local metabolism sufficiently to greatly interfere with, and sometimes entirely defeat the restoration of normal conditions. Its removal by the knife, en masse, eliminates this danger.

Second, when the disease process is deeply located, the intensity of the influence which it is possible to exert upon the lesion is so lessened by the passage of the ray through the overlying tissues as seriously to impair its remedial effect. Removal of the lesion by the knife confines the work demanded of the ray to the destruction of microscopical, outlying foci of malignancy, whereby the probability of a favorable outcome is greatly enhanced.

Whether or not a cutting operation for cancer should be preceded by roentgenization, is still a mooted point. In its favor is the probability that limitation of the process can be effected through inhibition of the growth of malignant cells at its periphery, thereby increasing the probability that complete removal can be attained. On the other hand, grave impairment of the reparative functions of parts thus treated has been noted, and the loss of time involved in delaying the operation may at times be a serious matter. There is so little unimpeachable evidence that well-applied roentgenization has ever been instrumental in actively disseminating a malignant process, and so much in opposition to this theory, that this part of the subject is hardly considered to merit discussion among present-day roentgenotherapeutists, and we can dismiss the subject without further mention. As regards preoperative radiation, therefore, the conditions surrounding each individual case must determine its management.

Roentgen operators are unanimous, however, in the belief that every ablation for cancer should be immediately followed, as a routine measure, by roentgenization, which belief is based upon the following:

First, a large proportion of recurrent malignant growths do not respond kindly to roentgenization, perhaps because of the increased malignancy with which operative interference seems to imbue some cancers, notably sarcomas.

Second, if roentgenization is delayed until recurrence is manifest, the process may then have become so widely disseminated as to preclude the possibility of benefit from radiation.

Third, if the affected area is radiated immediately after radical extirpation of the lesion, the degree of remedial (destructive?) influence demanded of the ray will be limited to such as will be necessary for the elimination of microscopical foci of malignancy, whereas, if recurrence is awaited, the remedial influence required will be much greater because the lesions will be much larger and better developed, and the degree of increase demanded may be so great, especially when deeply-located structures are involved, as to be impossible of attainment. Under such circumstances we would be confronted with a condition which might have been prevented

had we acted promptly, but which our remissness had allowed insidiously to develop and compass the destruction of the patient.

Fourth, we know that in a certain proportion of cases treated by a cutting operation alone, recurrence will not take place and the cure will be radical. On the other hand, we also know that we never can assure any one patient that recurrence will not take place in his case, and we are perfectly certain that recurrence will declare itself in a large proportion of all cases. If immediate postoperative roentgenization is omitted in any one case, that may be the very one in which we shall encounter recurrence, and it is highly probable that had we applied the ray immediately after the operation, the accident would have been prevented. By roentgenizing every operative case therefore, we are assured of having exerted every effort for the relief of the patient, and that we have saved all of our cases that it was possible to save.

Fifth, it is imperatively incumbent upon us to apply any measure which has the power to destroy or inhibit malignancy, to the task of lessening the proportion of post-operative recurrences; that the Roentgen ray manifests such a power, is proven beyond a doubt, and the clinical experience of those who have thus employed it, with a correct technique, has amply confirmed the validity of this contention.

The consensus of expert opinion today, then, may be broadly summarized as follows:

First, in superficial malignant lesions involving only the integument, roentgenization is the procedure of election.

Second, in operable lesions more deeply located or involving mucous membranes, the advisability of combining ablative surgery and roentgenization should always be earnestly considered, and such combination will give the best results in the majority of

cases.

Third, a course of Roentgen ray applications should follow every cutting operation for malignant disease, as a routine measure, and sometimes, perhaps, should also precede the operation.

Fourth, roentgenization should be persistently applied to all inoperable cases as long as the patient shows any signs of response, however slight.

By far the most important factor which is active today in determining whether the results of roentgenization shall be satisfactory or the reverse, is the degree of knowledge possessed by the operator concerning Roentgen ray phenomena, both physical and clinical, and his ability to utilize this knowledge practically; in other words, the technique. The difference between the results of intelligent, scientific, efficient roentgenotherapeutic technique and the reverse, resembles very closely that which would obtain between appendectomies performed in a tenement house kitchen without antiseptic precautions by a second-year medical student, and the same operation performed in a well-equipped hospital by a master of surgery. The subject of technique, however, is too specialized in character to admit of discussion in detail at this time, and I shall not enter upon it further than to call your attention to the following facts which have more or less vital bearing there

upon:

First, there are electrical conditions generated in the neighborhood of an excited Crooke's tube, and perhaps other radiations than those of Roentgen emanating therefrom, which probably play a considerable part in the physiological influence exerted.

Second, the Roentgen radiation from any Crooke's tube, whether of high or low vacuum, is composed of rays of varying degrees of penetrative power present in varying proportions as regards quantity.

Third, only those rays which are absorbed by the tissues, i. e., reach, but do not penetrate through them, effect physiological modification thereof; hence an operator must know which rays are best adapted to the particular pathological condition under treatment and be able to so manipulate the generating apparatus as to obtain them.

Fourth, the penetration of the Roentgen radiance generated by a given Crooke's tube, is directly modifiable by the amount of current used to excite it and by the introduction of resistance (sparkgap) into the tube circuit. This latter factor is especially effective when a static machine is employed as the tube excitant, so much so, indeed, that a tube so low in vacuum as to give off no appreciable Roentgen radiance at all without spark-gaps, can be made to deliver rays of high penetrating power by their use.