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Crooks tube of what was the a very high vacuum, accidentally discovered that some crystals of barium-platino-cyanide, which happened to lie within the range of the tube, brilliantly fluoresced under the influence of the energy which came from the tube. He then discovered the same effect.

Experiments with photographic plates and with fluoroscopes made of pasteboard coated with various fluorescible salts, were matters of detail which speedily followed, and which, by the way, did not materially differ from the same experiments made by others before him.

Why, then, do we enshrine the name of Roentgen and place it in an immortal niche, which must ever be kept lustrous by this great discovery?

Because it was Roentgen, with the keenness of perception of the great hero, who assembled all that was known concerning this mysterious force, and at once coined the hitherto useless knowledge into a thing of real value to the world for all time. And as there was much that he could not account for scientifically about this new ray, with the modesty of the true scientist, and to indicate his ignorance of its true nature, he suggested that it be called the X-ray. An appreciating world, however, readily accorded him what he did not claim: the right to attach his own name to his epoch-making discovery.

Professor Roentgen made his first announcement to the Physio-Medical Society of Würzburg within the same year, 1895, in which he stated it as his belief that the cathode ray and the X-ray were not the same. He had concluded that while the cathode ray was essential to the production of the X-ray, they were not X-rays until some other change took place, and that this change probably occurred when the molecules of rarefied air in the tube, which were energized and set in motion in some peculiar manner by the cathode stream, struck against the wall of the tube, producing a greenish fluorescence in the substance of the glass, and through the medium of the latter exciting the X-ray. From this time progress in X-ray matters was rapid. Scientists in all parts of the world began to experiment with the Crooks tube and induction coil or static machine, and their observations were noted and exchanged.

While Roentgen's first experiments were made with the original pear-shaped tube, with no provision for focusing the cathode stream onto a target, and thus concentrating the source of light, it was not long before Herbert Jackson, of London, suggested to Prof. Roentgen the use of a device invented by Crooks some time previously, to accomplish this purpose. This was done by placing a piece of platinum in the track of the

cathode ray, attached to the anode terminal at an angle so as to receive the cathode rays at a focused point and deflect them onto the wall of the tube. At once the whole field of work was changed when this had been done. Instead of the greatly distorted and indistinct images which had been gotten from the older tubes, this modification yielded a result as surprising as it was gratifying. The image on the fluoroscope and dry plate was at once made sharp and proportional, and of as great importance as these improvements was the fact that the time of exposure necessary to make a photograph, more properly a radiograph, was reduced from as much as an hour to as little as half a minute.

As to the exact physical nature of the X-ray, several theories have been advanced. But that most generally accepted is the one proposed by Maason. He believed that the phenomenon was a sort of electric convection. The gaseous particles in the highly rarefied atmosphere of the tube obtain a negative charge from the cathode and are then at once repelled; the extremely diminished number of the ions of atmospheric gas in the nearly complete vacuum rendering them free to follow a rectilinear path unimpeded until they strike the wall of the tube, where they cause the green fluoroscence by mechanical action on the glass. It is this action on the wall of the tube, according to Maason, and most other authorities, which is the immediate source of the X-ray. Maason clearly demonstrated that the vacuum of a Crooks tube can be so highly rarefied as to render it entirely incapable of producing X-rays of any demonstrable quantity or quality. This is a fact well known to all workers with Crooks tubes. For when in course of time, and after long use, a tube gets, so to speak, very high, the coil or static machine upon which it has been used is no longer able to excite sufficient disturbance in the tube to generate the Xrays. But if such a tube be put on a generator of greater power or a coil of longer spark length, it may again work well for a considerable time, until the vacuum runs still higher. This observation might lead us to the conclusion that the highest possible vacuum obtainable results from electric decomposition of the remaining gases after. the mercurial pump has been used to the limit of its capacity.

Maason's idea, condensed, is that it is the presence in the tube of free ions liberated by dissociation of the atmospheric gases under the influence of high exhaustion, which ions move in straight lines at a tremendous velocity until they strike the wall of the tube, which accounts for the X-ray phenomenon. But whether the rays themselves

are matter in motion, rays of light which may be polarized, or some other kind of molecular vibration, remains an unsettled question.

It has now been a decade since the world became enriched by this latest of great scientific achievements; but in that short time, so widely known has it become, and so necessary to the conscientious physician and the surgeon, that we may well say of it, qui non proficit deficit; he who does not profit by it, shall be the loser thereby.

The trialphan diadem of anesthesia, antiseptics and antitoxines, sets with lustrous honor on the brow of medical science of the nineteenth and twentieth centuries. And now, to glorify the day in which we live, there comes the announcement of a new ray of light and hope to lead us farther on, where the darkness shall be illumined and where suffering and affliction shall be found and relieved, all toward the working out of human salvation through the forces of Nature, dominated, as we may or may not believe, by something more than the mind of man.

A CASE OF TERTIARY SYPHILIS WHICH RESEMBLED IN ITS COURSE AND AND SYMPTOMS PHTHISIS PULMONIS.

WALTER FISCHEL, M. D.

ST. LOUIS.

Clinical History. Fred R., age 46, married. A native of Germany. Occupation, teamster, also has worked as a fireman. Entered the City Hospital November 11, 1905. Chief complaints were loss of appetite and weakness.

Family History.-Mother and father living and healthy, ages 80 and 78. One sister died of consumption.

Habits. Has never been a heavy drinker. Smokes some. Has always been a hearty eater. Patient is married and the father of three healthy children.

No

Past History.-Up to last February had been a very healthy man. Had grippe fifteen years ago, and again last February. other sickness except several attacks of gonorrhea. Denied syphilis.

Present Trouble. Ever since the last attack of grippe in February had not been well. His apetite had gradually failed; first for meats and then for everything; and he said that he had lost 75 or 80 pounds since April. Since July he had been too weak to work. During the early part of July he had severe pains low down on the right side of his chest anteriorly. These pains he said felt as if he were being crushed in a vise.

He

had never had any pains directly referable to the stomach, but he had vomited a great deal at times. Vomitus never contained blood or material resembling coffee grounds. Bowels usually constipated, but sometimes loose. Never any blood in the stool. Had had a slight cough for some time, and occasionally had night sweats. During the summer he said he had malaria.

During October patient was in the hospital for about ten days, and his case was then diagnosed as probably incipient phthisis, although no tubercle bacilli could be found in sputum and there were no positive physical signs of phthisis in the lungs.

Present Condition.-On November 11, when patient entered hospital he had temperature of 100 deg., pulse 96, respiration 20. Had a slight cough and a scanty muco-purulent sputum. Complained of feeling chilly. No appetite. Bowels constipated.

Physical Examination (at time of entry).Patient is a man about 5 feet 7 inches tall, weighing 100 pounds or less. Very much emaciated. Skin of a sallow color. Mucous membranes pale. Pupils equal and react to light and accommodation. Abdomen retracted No tenderness on pressure. No palpable masses. Liver and spleen were not palpable, although latter seems enlarged to percussion. On skin over abdomen and thorax are a number of small red papules which do not fade on pressure.

Chest is thin. Supraclavicular fossae are very deep. Respiratory movements equal on the two sides. Can find no suspicious area in the lungs except for a small space just by the angle of the left scapula where there is slightly diminished resonance and can hear a very few small crepitant rales. Tactile fremitus also slightly diminished and no inorease of vocal resonance.

Laryngoscopic examination shows the mucous membrane of the pharynx and larynx to be congested and covered with a thin layer of grayish mucous. No ulceration visible. Heart is not enlarged. First sound is weak. Second pulmonic sound slightly accentuated. Pulse is small, soft and regular. Urine normal.

Blood.-Leucocyte count November 13, 6600 per cu.mm. Differential leucocyte count showed a slight relative decrease in the polymorphonuclear and an increase in the large lymphocytes. No malaria plasmodia found after repeated and frequent examinations of the blood, both in stained and fresh specimens. No tubercle bacilli could be found in sputum. The following notations made in the history will give an idea of the course of the disease while the patient was in the hospital.

November 17.-Since entering hospital patient has not been without fever until this morning Temperature has ranged from 99.4 deg. to 102.2 deg. F., and is always higher in the evening. Pulse usually about 100, and respirations between 20 and 26. Patient has had a hacking cough, and complains some of throat feeling sore. Has had several night sweats. Has not vomited since entering hospital.

November 27.-Patient has not improved any. He has been having drenching night sweats every night and cough is severe.

November 29.-Patient told me today that fourteen years ago he had a sore on his penis, and shortly after that much of his hair dropped out. Also had a swelling in his groin which did not suppurate. Following this suggestion I prescribed hydrarg.chlor.corros. gr. 1-30 and potass. iodide sat. sol. mx, increasing one drop each day.

December 7.-Patient seems to be improving. Does not have night sweats now, but complains of itching of skin at night. Appetite is fine. Weight today 120 pounds. December 12.-Yesterday and today patient had severe chills followed by high fever and sweating. This morning noticed a small area of redness under right eye which area has increased in size rapidly during the day. Skin is edematous and slightly indurated. Margins of redness sharply defined.

Diagnosed erysipelas and patient transferred to the Emergency Hospital.

December 21.-Returned from Emergency. During the time he was away he received no antisyphilitic treatment and feels worse.

December 25.-Weight 128⚫ pounds. again improving.

Is

December 29.-Physical examination recorded. Still looks emaciated, but not nearly so much so as he did a month ago. Tongue is clear. Abdomen not retracted. No abnormalities found in abdomen. Patient has a small rectal fistula. Chest expands well. Lungs give good resonance all over and no rales heard. Heart not enlarged-first sound muffled. No murmur. Pulse is strong.

Nervous System.-Pupils are small but react slightly to both light and accommodation. Right knee jerk is slightly exaggerated. Left one is diminished. Achilles reflex is present on left side and absent on right. No ataxia of either hands or feet. Very slight Rhombergism. When patient walks he seems to have difficulty in raising his right toe from the ground.

December 30.-Patient has recovered sufficiently to go home and continue treatment there. He was therefore discharged.

When he left I gave him prescriptions for the bichloride and potassium iodide, and

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I asked the patient to present himself tonight before you so that you might see for yourselves his present condition, and if any cared they might examine hito.

The diagnosis made in this case was based almost entirely on the results of treatment, taken with the history of an initial lesion which from the patient's description could not be definitely called specific.

Up to the time the patient confessed to having had a sore no definite diagnosis had been made, but the course of the disease with its progressive emaciation and weakness, and its beginning after an attack of grippe, together with the symptoms of anorexia, hacking cough, slight mucopurulent sputum, remittent type of fever and profuse night sweats all pointed to tuberculosis.

Syphilis of the lungs is said to be such a rare disease that I hesitate to claim such a diagnosis for this case. The physical signs pointing to a lesion in the lungs were at no time pronounced, and yet this very point, I gather from the descriptions of the disease I have read, is rather in favor of the diagnosis.

Dr. E. Aufrecht, in Nothnagel's Encyclopedia, describes a case of his own which in many respects resembled mine both in the history and the physical findings. In brief the case was as follows: Mrs. F., age 42, admitted to his hospital in March. At age of 23 had contracted syphilis. For a year before she entered hospital had been short of breath when mounting stairs. For six months had had a feeling of constriction about the chest, had suffered much from cough. During past six months had lost 24 pounds in weight. When entered face had slightly livid appearance; respiration difficult. Nothing abnormal could be found in heart or lungs; nothing abnormal seen in larynx or trachea.

Potassium iodide was administered, and in four weeks patient was so much improved that she was discharged.

But after four days she returned complaining of grave attacks of apnoea. These attacks reappeared frequently and could only be controlled by morphin injections. After the prolonged use of iodide potassium improvement took place and she was discharged in

June, although not quite free from dyspnea. Four weeks later she was again brought to the hospital suffering from intense dyspnea, stertorous breathing and cyanosis of the face. While so far the lungs had appeared to be normal and the symptoms had been ascribed solely to a syphilitic sclerosis of the large air passages, there were now discovered dullness and fine rales on the right side of the thorax from the middle of the scapula down. Fever had never been present before, but now the temperature ranged from 102.7 deg. F. to 97.6 deg., and was higher in the mornings than the evenings. After five days she died. After five days she died. At the autopsy the middle lobe of the right lung was found to be almost airless, cloudy, of tough consistency and a cut surface, pale gray, not granular.

There was also found a sacculated aneurism of the aorta which pressed upon the trachea just over the bifurcation, leaving only a narrow slit-like opening in the lumen. The microscopic examination of the affected lung showed the alveoli mainly filled with small round cells interspersed with red blood corpuscles. In addition to this there was a considerable increase in the thickness of the walls of the smaller vessels, the adventitia being chiefly affected.

Dr. Aufrecht cites this case with the mi

croscopic findings as definite proof that there may exist a diffuse pneumonic disease secondary to syphilis. An occurrence which has been doubted by many.

Fortunately for the patient my case did not come to the same end as Dr. Aufrecht's, but it struck me that there was much simil arity in the histories of the two cases, and I have therefor taken the liberty of this lengthy quotation.

SYPHILIS OF THE LUNG.*

ELSWORTH SMITH, JR., M. D.

ST. LOUIS, MO.

Professor of Clinical Medicine, Medical Department of Washington University: Physician St Lou s Mullanphy and St. Louis Skin and Cancer Hospitals.

THE case so cleverly presented by Dr. Fischel is certainly of the greatest interest for through the diagnosis, which appears to be as clearly established as is possible without post mortem verification it is placed among a very unusual class of diseases.

Syphilis of the lung is certainly one of the rarest of affections, as shown, for instance, by

*Opening of discussion of a case of tertiary syphilis simulating phthisis pulmonaris, reported by Dr Walter Fischel at a meeting of the City Hospital Medical Society, at the City Hospital, March 1st, 1906.

the following summary of cases in the work of Samuel West, M. A., M.D., of St. Bartholomew's Hospital, on Diseases of the Organs of Respiration, volume 2, page 838, where "Haslund (1) records, that of 6000 syphilitic patient admitted into the hospital at Copenhagen during a period of seven years, two cases only were diagnosed as suffering from pulmonary syphilis during life.

"The post-mortem record of the same period show, that out of 105 autopies of children with congenital syphilis, lung syphilis was found in four cases only; and that out of eighteen autopsies of adults acquired syphilis (eight males and ten females), lung syphilis was found in three (une male and two females). In only one of all these seven cases was the condition diagnosed during life.

"Heller (2) though states that of syphilitic children, 50 per cent show interstitial pneumonia, and more than half of these have pneumonia alba, while of non-syphilitic children only 20 per cent show lung affection of any kind. It is only in still-born children that the most marked forms of pneumonia alba are found.

"After a careful analysis of 87 cases Hiller (3) concludes that with a more persistent and careful examination for the tubercle bacillus, lung will ultimately disappear from literait is quite likely that syphilitic disease of the

ture.

"K. Fowlers states that there are only twelve instances of syphilitic disease of the lung in adults in the museums of all the London hospitals together. In most of these, though the question of tuberculosis was carefully considered, the absence of bacilli does not appear to have been proved."

Lues of the lung is among the tertiary manifestations of the disease, and may appear any time between the fifth and fifteenth year after infection, and even later.

As to the pathological lesions present West enumerates three, which he considers may be referred to this disease, namely:

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All authorities, I believe, agree, that the so-called syphilitic phthisis is now an obsolete term, as there is no progressively destructive lesion of the lung in syphilis, though thera may, at times, be a cavity formation from the breaking down of a gummatous deposit, but the destructive process does not spread beyond the focus.

The favorite seat of the syphilitic lesion is, first, the middle lobe of the right lung, and then the lower lobe of either the right or left lung.

The above points in morbid anatomy are of interest, especially from the standpoint of diagnosis in that they tell us that syphilis, in attacking the lung, tends in the vast majority of cases, to produce an infiltration going on often to consolidation and fibrosis, which lesion is situated, in the vast majority of cases, in the middle lobe of the right lung.

The diagnosis, though of pulmonary syphilis is, as a rule, not altogther satisfactory, as it rests, largely, on negative evidence. Absolute verification of the diagnosis can only be made in the autopsy room, though, of course, several cases have been correctly appreciated during life. Practically the disease, in the vast majority of cases, must be differentiated from pulmonary tuberculosis. The clinical diagnosis of the affection very largely depends on

1st. The establishment of the undoubted presence of a syphilitic infection, and especially of lesions in other parts of the body.

2d. The absence of the tuberculin reaction or, on repeated examinations, of tubercle bacilli in the sputum.

3d. Evidence of an infiltration or consolidation of lung tissue, especially situated in the sites of predilection, heretofore alluded to. 4th. Effect of anti-syphilitic treatment. All the other symptoms and signs may be

identical in the two affections, except the evidence of a progressive destruction of lung

tissue.

We should also always remember that the two diseases may co-exist.

From the standpoint of treatment the great importance of making a correct differential diagnosis between syphilis and tuberculosis of the lung is made especially apparent by

the following cases from Schnitzler (4):

"His first case was that of a woman, thirty

two years of age, who six years after infection was attacked by gummata and ucleration of the larynx, and at the same time suffered from a pneumonia of the middle pulmonary lobe, which was completely cured by the administration of large doses of potassium iodid. Two years later the patient was again treated

(4) Nothnagel's Encyclopedia, volume on Diseases of the Lung, page 654.

for ozoena and infiltration of both lower lobes and of the middle lobe. The pulmonary affection was again cured by the use of iodid of iron."

"The second case was that of a man, twentyfive years of age, who five years after infection, was treated for ulcers in the soft palate, gummata on the epiglottis, ulcers over the right arytenoid cartilage as well as on the vocal cords, and in whom at the right base posteriorly bronchial respiration was present, furthermore over the entire lung rough indistinct breathing with coarse and fine crepitant rales. After the use of potassium iodid -at first 2 gm. (30 grains), later 5 gm. (75 grains) a day-all symptoms of disease disappeared; after several weeks' treatment not a trace of syphilitic infiltration could be detected by means of the most minute physical examination.

"The third case was that of a female laborer, who complained of hoarseness, cough, and severe dyspnea. The percussion notes teriorly as well as anteriorly, the respiratory were slightly shortened over both apices possounds were rough and indistinct, covered by a loud laryngo-tracheal stenotic sound; extensive dulness could be demonstrated over bronchial respiration and sometimes crepitant the inferior angle of the left scapula, where rales could be heard. The diagnosis "tuberculosis of the lungs," made on the strength of these findings, was not discarded until laryngoscopic examination showed ulceration of the epiglottis and of the vocal cords as well as a deep ulcer with ragged edges and floor covered with purulent exudate over the left arytenoid cartilage, and it was accordingly ascertained that syphilitic infection had taken place six years before. Seven chok

ing spells led to the suspicion of the presence

of laryngeal stenosis. After five weeks' treatnormal. The ulcers on the vocal cords, on ment (inunction cure) the larynx was almost the arytenoid cartilage, and on the epiglottis were cured and left only scarcely perceptible traces. The voice was loud and strong, although still a little hoarse. The infiltration of the lungs had disappeared except a

slight dulness in the apices; the cough was gone, and the dyspnea, the removal of which

by tracheotomy had already been decided

upon, existed only in the memory of the patient."

And to these I should like to add the following:

F. S., aged 42 years; American; living apart from wife; waiter by occupation; entered our service at the St. Louis Mullanphy Hospital, June 25, 1903, giving the following history:

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