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dela des poumous, Arch. internat. de pharmacodyn. et de therapie, 39 :400-448, 1930. 7. Schmidt, C. F., Comroe, J. H., Jr., and Dripps, R. D., Jr.: Carotid Body Reflexes in Dog, Proc. Soc. Exper. Biol. and Med., 42:31-32 (Oct.), 1939. 8. Schmidt, C. F., Dumke, P. R., and Dripps, R. D., Jr.: Part Played by Carotid Body Reflexes in Respiratory Response of Dog to Small Changes in Carbon Dioxid Tension in Arterial Blood, Am. J. Physiol., 128:1-9 (Dec.), 1939. 9. Peabody, F. W.: Clinical Studies on the Respiration. I. The Effects of Carbon Dioxide in the Inspired Air on Patients with Cardiac Disease, Arch. Int. Med., 16:846864, 1915. 10. Eastman, N. J.: Asphyxia Neonatorum, Internat. Clin., 2:274-300 (June), 1936. 11. Selladurai. S., and Wright, S.: Mode of Action of Respiratory Stimulants: I. Mode of Action of Oxygen Lack, Quart. J. Exp. Physiol., 22:233-248, 1932-1933. 12. Shock, N. W., and Soley, M. H.: Effect of Oxygen Tension of Inspired Air on the Physiological Response of Normal Subjects to Carbon Dioxide, Am. J. Physiol. (Proc.), 126:628-629 (July), 1939. 13. Himwich, H. E., Bowman, K. M., Wortis, J., and Fazekas, J. F.: Metabolism of Brain During Insulin and Metrazol Treatments of Schizophrenia, J. A. M. A., 112: 1572-1573 (April 22), 1939. 14. Himwich, H. E., Alexander, F. A. D., and Lipetz, B.: Effect of Acute Anoxia Produced by Breathing Nitrogen on Course of Schizophrenia, Proc. Soc. Exper. Biol. and Med., 39:367-369 (Nov.), 1938. 15. Loevenhart, A. S., Lorenz, W. F., and Waters, R. M.: Cerebral Stimulation, J. A. M. A., 92:880-883 (March 16), 1929. 16. Stadie, W. C., and Martin, K. A.: Elimination of Carbon Monoxide from Blood: Theoretical and Experimental Study, J. Clin. Investigation, 2 :77-91 (Oct.), 1925. 17. Heller, E., Killiches, W., and Drinker, C. K.: Evaluation of Five and Seven Per Cent Carbon Dioxide Mixtures as Respiratory Stimulants, J. Indust. Hyg., 11 :293-300 (Nov.), 1929. 18. King, D. S.: Postoperative Pulmonary Complications: Carbon Dioxide as Preventive in Controlled Series, J. A. M. A., 100 :20-26 (Jan. 7), 1933. 19. Gellhorn, E.: Circulatory Studies on Anoxemia in Man, with Respect to Posture and Carbon Dioxide, Ann. Int. Med., 10:1267-1278 (March), 1937. 20. Kerr, W. J., Gliebe, P. A., Soley, M. H., and Shock, N. W.: Treatment of Anxiety States, with Special Attention to Certain Physiologic Manifestations, J. A. M. A., 113:637-641 (Aug. 19), 1939. 21. Henderson, Y.: Adventures in Respiration. Williams and Wilkins Company, Baltimore, 1938, pp. xi plus 316. 22. Farber, S., and Wilson, J. L.: Atelectasis of Newborn: Study and Critical Review, Am. J. Dis. Child., 46: 572-589 (Sept.), 1933. 23. Boothby, W. M.: Oxygen Therapy, J. A. M. A., 99:2026 (Dec. 10), 1932; 2106 (Dec. 17), 1932. 24. Council on Pharmacy and Therapy: Oxygen-Carbon Dioxide Mixtures, J. A. M. A., 114 :1077-1079 (March 23), 1940. 25. Davies, H. W., Brow, G. R., Binger, C. A. L.: The Respiratory Response to CO2, J. Exper. Med., 41:37-52 (Jan.), 1925.

radical therapeutic procedure, to be used "as something to try" when other measures, however ineffective and sometimes less rational, have failed. First employed for the treatment of pathologic lesions in 1896 4in a case of mammary carcinoma, it was rapidly adopted and widely used by professional and nonprofessional men alike. All types of diseases, both benign and malignant, were subjected to irradiation. There was no knowledge of its effect on living tissue, no means of controlling the quality of the beam, no accurate method of measurement, and no precedent to warn of the immediate or latent dangers of overdosage. As a consequence, many disastrous tissue reactions or "burns" occurred, giving rise to a fear and prejudice of its use which even now lingers in the minds of many. Today the roentgenologist can measure accurately, in an internationally accepted unit, the "roentgen" or commonly called "r" unit, the amount of x-ray produced by a given piece of apparatus in a given period of time. The quality can be governed by control of kilovoltage and filtration, thus removing all but the "human equation" hazard incident to irradiation. It is true that the roentgen ray can only be used safely by one who has a knowledge of its characteristics and of its clinical application. In the hands of the untrained it is, and will remain, a most dangerous method of treatment.
*

INCREASING USE OF ROENTGEN THERAPY

IN OPHTHALMOLOGY

ROENTGEN THERAPY IN THE TREATMENT OF ABSOLUTE GLAUCOMA*

By, LLOYD BRYAN, M1. D.
AND

A. JUSTIN WILLIA1'IS, MI. D. San Francisco

N spite of the large background of clinical and experimental information which has accumulated during the past four decades, roentgen therapy is still looked upon by many as an empirical and
* From the University of California School of Medicine, San Francisco. Read before the Section on Eye, Ear, Nose and Throat at the sixty-ninth annual session of the California Medical Association, Coronado, May 6-9, 1940.

That roentgen therapy is becoming more widely used in ophthalmology is attested by the fact that more and more cases are being referred to the radiologist for treatment, and a voluminous literature is accumulating on the subject. Aside from many types of intra- and extra-ocular neoplasms, roentgen therapy is of value in various ophthalmic disorders and infections. Many believe that some should be treated by radium, and others by the roentgen ray; but it is the writer's opinion that there is no evidence to support the claims of one over the other. Certain factors may determine which source it is most desirable to use in a given case, but the clinical' results should be the same with either. Some of the conditions in which radium or roentgen rays have been successfully used are listed: Absolute glaucoma10-'4; blepharitis9 ; blastomycoses ; cellulitis, orbital2; choroiditis3; corneal ulcers and opacities283; conjunctivitis, follicular,3 tuberculous,12 vernal 3; entropion 6; erysipelas 6; granuloma6; hemorrhage, traumatic3; iritis, simple and tuberculous2'3'8; keratitis, simple ulcerative, interstitial1 2 3 9; leukoma, combined with surgery'; maculae5; pannus, trachomatous31' 5; pterygium,2"3 postoperative recurrent5; opacities, vitreous 2 3,; sclerositis and episclerositis 3; staphyloma '; sympathetic ophthalmia2; trachoma,' 2 3 5 "x-ray almost a specific," acute and subacute; traumatic ulcers, infected3; and uveitis.1"3
FIRST USE OF IRRADIATION IN GLAUCOMA

Irradiation was first used in the treatment of glaucoma in 1906.10 Radium was so appl'ied that

February, 1941

ROENTGEN THERAPY-BRYAN-WILLIAMS
TECHNIQUE OF TREATMENT

77

TABLE 1.-Outlinie of Course in Relation to X-Ray Therapy

1937 30 July August 2 August 5 August 7 August 9

CASE 1.-MR. W. C. S. Dose 150 r Pain relieved in six hours. 150 r Pain recurred. No change in tension. 150 r Pain severe. No change in tension. 150 r Pain severe. No change in tension. Enucleation. CASE 2.-MR. C. S. 1939 Dose April 7 200 r Pain somewhat less in twenty-four hours. April 10 200 r No pain. April 12 200 r No pain. April 14 200 r Pain recurred very severe. April 17 200 r Pain recurred very severe. No change in tension. Enucleation. April 18 CASE 3.-MRS. M. D. 1937 Dose February 15 100 r Pain improved in twenty-four hours. February 17 200 r Pain improved. February 23 200 r Pain gone entirely. February 25 200 r Tension decreasing slowly. Followed for two years. No return of symptoms. CASE 4.-MRS. W. L. D. 1939 Dose April 14 200 r Pain improved in twenty-four hours. April 18 200 r Pain improved. April 21 200 r No pain. Gradual decrease in tension. Followed for eleven months. No return of symptoms.

A wide variation in the technique is reported when using either radium or roentgen rays. That used in the cases in this series seems logical if the assumption of the mechanism of action is correct. The factors were 200 k. v. p., 0.5 mm., cu. 1.0, al. filters, and 5 cm. diameter portals, 50 cm. target skin distance. Filtration of 0.5 mm. of copper plus 1.0 mm. of aluminum was used on all the cases to allow a wider margin of safety in case a protracted or repeated series became necessary. The interval of treatment varied from one to four days, and the individual doses from 100 r to 200 r with equal results. It might be that more frequent applications of different-size doses will prove to be more effective in refractory cases. The largest total dose given to any of these patients was 1000 r, and in none did any undesirable reactions occur. None developed a roentgen conjunctivitis or skin erythema, and no late manifestations of damage have developed (Table 1).
INDICATIONS FOR TREATMENT

CASE 5.-MRS. K. O'B.

1940 Dose March 4 150 r Pain improved in twenty-four hours. March 6 150 r Pain improved considerably. March 8 150 r Pain entirely gone. Tension down somewhat. March 11 150 r Pain entirely gone. Tension down somewhat. March 13 150 r Pain entirely gone. Eye soft to pal-

pation.

the total dosage over a period of several weeks was only 12.46 milligram hours, given in individual treatments of 0.89 milligram hours filtered through lead. In spite of this infinitesimal dosage, the patient showed some temporary improvement, which was lost when the treatments were discontinued. Corbett reported three cases treated successfully in 1924.1" This method of treatment was not generally accepted, however, and it has only been in the past decade that irradiation has been looked upon as producing favorable results in the treatment of absolute glaucoma. The action of the rays is not fully understood, but is probably based upon mechanical changes produced in the orbital circulation, in addition to the analgesic properties which are well known and widely used in many other disorders. All of the cases of absolute glaucoma observed showed relief of pain before reduction in tension. The latter must be brought about by restoration of the uveal circulation through the destruction of the dammed-up white blood cells, thus clearing the way to allow the escape of the accumulated circulatory fluids. The popular idea that a primary circulatory congestion is produced by irradiation is erroneous. It is true that a lasting vasodilatation does occur, and this, followed by clearing of the capillary channels of circulatory debris, probably produces an acceleration of the transorbital circulation.

Roentgen therapy is indicated in every case of absolute glaucoma where the ophthalmologist is faced with the alternative of enucleation. Treatment should be given a trial for at least five days before enucleation is considered, and then only if there has been no subjective improvement. Failure of reduction of intra-ocular tension is not a good criterion of failure, since it may not occur until some time after the treatment is instituted. So far as is known there is no contraindication to treatment. In all the cases treated, pain relief was the first sign of improvement. This occurred to some degree in all cases within twenty-four hours after the first treatment. After relief of symptoms, the patient should be kept under careful observation and treatment resumed if any suggestion of recurrence is evident. The earliest decrease in intraocular tension occurred four days after starting treatment. In one case the fall was gradual, and two supplementary treatments were necessary six days after the first series to secure satisfactory results (case M. D.).
REPO1WS IN THE LITERATURE

Recently, reports of the beneficial effects of roentgen therapy of absolute glaucoma have appeared in the literature. Hess12 reported fifteen cases; of these, twelve were idiopathic, of which nine showed good results with relief of pain and lowered intra-ocular pressure. Three cases were unsatisfactory-one, because of dispersed dosage, became refractory; and two, because of subsequent ulceration, required enucleation. Three cases of secondary glaucoma failed to improve after treatment. He gave a total dosage of 800 r to each patient. Wachner"' reported fifty-seven cases; three acute, thirty chronic, and twenty-four of secondary glaucoma. Of all three grou.ps, 68.4 per cent were relieved of pain. A smaller percentage showed lowered intra-ocular tension. Kreibig14 reported two cases of chronic glaucoma in which the pain improved; five cases in the final stage in which

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TABLE 2.--Results Obtained by Radiation Therapy of Absolute Glaucoma

Total Cases 15 57 20 3 95 5 100
Good Results 10 39 17 3 69 3 T2
Failure 5 18 3

Hess Wachner Kreibig

slightly. He was not seen again until April 7, 1939, time his right eye was very painful and congested, there was no fundus reflex, and his intra-ocular tension for this right eye was twice the upper limit of normal. He was then started immediately on x-ray, which relieved his pain for the next six days; but from April 15 to April 18, 1939, the pain was so severe that enucleation finally had to be done. S. MAISLER, M. D.
at which
f
1

Corbett

This series Total

26 2 28

the pain disappeared completely; and ten cases of secondary glaucoma, of which seven improved and three required enucleation. Treatment given was 50 r units at intervals of two to three days to a total of 150 r followed by a second series in two to three weeks if indicated (Table 2).
REPORT OF CASES

Five cases are presented in this series, three of which obtained relief, two responded poorly, and enucleation was done in both, eleven days following institution of treatment. Each had an initial relief of pain, which later recurred. The intraocular pressure in these two cases was not affected by the treatment, while in the three cases treated successfully the increased tension gradually returned to normal.
CASE 1.-W. C. S. (Patient of Dr. Otto Barkan and Dr. S. F. Boyle.)

CASE 3.-Mrs. M. D. (Patient of Dr. Otto Barkan and Dr. S. F. Boyle.) Patient, age 64; first examined in 1935; complained of gradual reduction of vision, no halos or mists. Vision, right eye, hand movements and left eye, 3/10. Examination disclosed hemorrhagic glaucoma of the right eye and simple glaucoma of the left. Tension, right eye 70 (McLean) and left eye 80 (McLean). Several glaucoma operations were performed on the right eye in an attempt to normalize the tension, but they were ineffective. On October 14, 1937, developed severe pain in the right eye. With this increase of pain, vision was lost and enucleation was considered. X-ray treatment on several occasions. Pain disappeared and headaches have not returned. It is now two years since last treatment and the patient remains comfortable to date. S. F. BOYLE, M. D.
CASE 4.-W. L. D. (Patient of Dr. D. 0. Harrington.) Patient had a very severe diabetes since the age of fourteen. There was periodic neglect of her condition, and in August, 1935, there suddenly appeared a severe diabetic retinitis in both eyes, followed by vitreous hemorrhage and retinal detachment and, finally, by complete loss of vision. The tension on the first examination was normal. In 1936 there was a sudden rise in the tension of the right eye which subsided partially with better control of the diabetes. In April, 1939, there was a sudden onset of bilateral acute glaucoma, with steamy cornea and some degenerative changes in the cornea in the lower third. The eyes were very red and very painful, and the tension was 70 plus (Schiotz). The use of eserin drops and hot compresses and massage did not materially improve matters. On April 14, she was given her first x-ray treatment and, as you know, there was an immediate cessation of pain within twenty-four hours. The degenerative changes in the cornea continued to give some trouble, so that the eyes remained slightly injected locally in the area of the ulcers, but the pain was much reduced. The cornea gradually cleared under local therapy and with it the ciliary injection decreased, the pain disappeared, and the tension gradually came down. The patient was last seen on March 19, 1940, and has been very comfortable since September of 1939. DAVID 0. HARRINGTON, M. D.
f

Patient, age 73, was first seen on July 22, 1937. Past History.-Cataract extraction of the left eye elsewhere two years ago; following cataract extraction the patient struck shield with hand and ruptured eyeball. In 1936, cataract extraction of right eye was done elsewhere. Third day postoperative, he suffered renal colic and this was followed by intra-ocular hemorrhage. Discission of the right eye was done in 1937. History.-Vision, first examination at this office, right eye, fingers at three feet; left eye, amaurotic. The patient gave a history of glaucoma in both eyes of three years' duration. He stated that glaucoma was diagnosed in both eyes in 1934. Cyclodialysis was performed on July 22, 1937, on the right eye. There was severe pain the following day and hyphema. Secondary hemorrhage on the third day. The patient noticed positive scotoma. One week following, vision was reduced from previous counting fingers at three feet to bare light perception. Pain in the eye became intense, and retrobulbar inj ectioh with 4 per cent novocain was done. First x-ray treatment was given, and pain was relieved within six hours. Second x-ray on August 2 and on the 5th, tension remained high. The eye was painful and third x-ray treatment was given. On August 6, patient was nauseated; ocular pain continued. On August 7, final x-ray treatment. On August 9, as the patient suggested enucleation on account of continued ocular pain, the operation was done. Two years later the left blind eye was also enucleated due to recurrent attacks of pain.

CONCLUsIoN.-Four x-ray treatments did not relieve pain in absolute glaucoma in this case. S. F. BOYLE, M. D.
CAsr! 2.-Mr. C. S. (Patient of Dr. S. Maisler.) Patient, 52 years of age, was first seen on February 24, 1939. He gave a history of having blurred vision of the right eye for the previous one month. He had a central venous thrombosis, and his intra-ocular tension was normal. He was placed on a saturated solution of potassium iodid. When seen two weeks later, his vision had improved

CASE 5.-K. O'B. (Patient of Dr. D. 0. Harrington.) Patient was first seen by me on February 29, 1940. She had an extremely red, very painful right eye of four days' duration. This right eye, she says, had been completely blind for six months or more and the vision had been gradually decreasing for two years before that. The exact history of visual loss is rather indefinite, but she had not had any previous irritation or pain. The onset of the present complaint was sudden and the pain was so severe as to cause nausea and vomiting, and seemed to extend well into the head and occipital region. Examination showed a typical acute congestive glaucoma. The tension was 75 (Schiotz). The cornea was steamy, there was a generalized congestion of the whole eye, the pupil was maximally dilated and fixed, the lens was completely opaque from an old cataract, and fundus was not seen. There was absolutely no vision. On March 4, the condition of the eyes was essentially the same, in spite of local therapy, with the addition of a fairly good-sized anterior chamber hemorrhage. Patient was sent for x-ray therapy, and the following day there was considerably less pain. By March 8 the patient complained of no more pain, either in the eye or in the head. The hemorrhage was absorbing, the pupil was definitely smaller and the tension

February, 1941

THE LITERARY PHYSICIAN-WHITE

79

had gone down somewhat, although it was still elevated. By March 13 the eye was soft to palpation. The pupil was back to normal size, injection had considerably diminished, and the pain had completely subsided. D. 0. HARRINGTON, M. D.
SUM MARY

13. Wachner, G.: Roentgen Therapy of Absolute Glaucoma, Strahlentherapie, 62:198-203, 1938; Die R6ntgentherapie der absoluten Glaukome, Strahlentherapie. 62:198203, 1938. 14. Krubig, W.: Roentgen Irradiation of Eyes Blinded by Absolute Glaucoma, Wien Klin. Wchnschr. (July), 1936.

Roentgen therapy can be of value as a supplementary form of treatment in absolute glaucoma, and in some cases by its use enucleation may be avoided. In the event of failure, removal can be done without fear of undesirable complications arising as a result of the irradiation. A review of other ophthalmic disorders in which roentgen therapy can be of aid is included.
CONCLUSIONS

THE LITERARY PHYSICIAN: A NOTE ON OSLER'S ESSAYS* By WILLIAM WHITE

Los Angeles

FALCONER MADAN'S remarkofthat Osler, Medicine, in his Principles and Practice

"succeeded in making a scientific treatise literature," has been partly substantiated with the recent publication of This Generation, an anthology of selections from recent American and English literature.' For along with Robert Frost, the eminent New England poet, Edna St. Vincent Millay, Robinson Jeffers, and other contemporary poets, Theodore Dreiser, Eugene O'Neill, and James Joyce, appears Sir William Osler's "Neurasthenia" from the 1930 edition of the Practice. Preceded by a brief note which calls Osler's writings "invariably gentle, kind, suave, but hard and clear in their scientific authenticity," the selection from Sir William is included in the section entitled "Scientific Observers"; and two other observers are William Beebe and Julian Huxley. But this is not the first time Osler's writings have been in anthologies, although it is the initial instance of the Practice being used for its literary value. "The Student Life" has been the most popular of his many essays; and just this summer a new anthology, Reading and Thinking,2 included it (in part) side by side with Oliver Wendell Holmes's "Autocrat of the Breakfast Table." Incidentally, a few pages from Dr. Hans Zinsser's Rats, Lice, and History, and Dr. Logan Clendening's The Humilan Body, are also in this unusual compilation. Christopher Morley was the first critic to use "The Student Life" in a collection of essays, and, in doing so, he remarked that Osler's "honorable place as a man of letters" should be "more generally understood."3 Professor Franz Montgomery4 and Professor Warner Taylor5 later chose this brilliant essay for their anthologies. Osler's "Science and Immortality" has also found its way into a volume of literary essays, The Farther Shore, which is limited, however, to the topic of immortality.6 I have elsewhere pointed out certain literary7 and historical8 aspects of the essays by Sir William. No one can avoid, on reading his many essays-or even the magnum opus, the Practice-coming to the conclusion that innumerable classical allusions and the wealth of literary flavor must have been born of a tremendously wide reading and research. Doctor Cushing's Life of Sir William Osler and the enormous Bibliotheca Osleriana's keen critical annotations give sufficient proof of this. One could certainly get a liberal education in literature merely
*

1. It is to be strongly emphasized that roentgen therapy should only be given after ophthalmologic consultation, and that close observation and co6peration between the ophthalmologist and roentgenologist are essential to produce satisfactory results. 2. Five original cases of absolute glaucoma are presented, of which three cases were completely relieved of symptoms and the intra-ocular tension reduced. 3. The results obtained in ninety-five cases of absolute glaucoma reported in the literature are reviewed. Sixty-nine of these were benefited, while twenty-six failed to respond to the treatment. 4. There are no contraindications to the treatment, and since there is no known means of selecting cases everv case of absolute glaucoma should have a trial of irradiation when enucleation is the only other alternative.
450 Sutter Street. REFEREN CES

1. Di Marzio, Q., and Salvatori, G. B.: Results of Roentgen Therapy in Certain Eye Diseases, Strahlentherapie (Jan.), 1932; Resultate der R6ntgentherapie bei einigen Augenaffektionen, Strahlentherapie, 43 :68-81, 1932. 2. Lane, Laura: Radiation Therapy: Its Scope in Ophthalmology, Arch. Phys. Therapy (Dec.), 1931. 3. Desjardins, A. U.: Action of Roentgen Rays and Radium on Eye and Ear-Experimental Data and Clinical Radiotherapy, Am. J. Roentgenol., 26:639 (Oct.) ; 787 (Nov.), 1931. 4. Grubbe, E. H.: Priority in Therapeutic Use of X-rays, Radiology, 21:156-162 (Aug.), 1933. 5. Hilgartner, H. L., and Hilgartner, H. L.. Jr.: Radium in Lesions of Cornea, Arch. Phys. Therapy, 15:103-107 (Feb.), 1934. 6. Laurence, W. S.: Results in X-ray Treatment of Lesions of the Eye, Journal of the Tennessee State Medical Association, 29 :2831 (Jan.), 1935. 7. Pendergrass, E. P., and Andrews, J. R.: Radium Emanation Treatment of Vernal Catarrh, Am. J. Roentgenol., 34:637-640 (Nov.), 1935. 8. Negru, D., and Michail, D.: X-ray Treatment of Tuberculous Iritis, Fortschritte a. d. Geb. d. Roentgenstrahlen, 53 :544-548 (March), 1936; Die Rontgenbehandlung der Iristuberkulose, Fortschr. a. d. Geb. d. Rontgenstrahlen, 53:544-549 (March), 1936. 9. Richards, G. E.: Radiotherapy in Lesions About Eye, Am. J. Roentgenol., 36:588-602 (Nov.), 1936. 10. Radium Therapy, by Wickham and De Grois. Funk and Wagnalls, Part II, Chapter IX, pp. 227:278. 11. Corbett, J. J.: Effect of Radium on Glaucoma, Boston M. and S. J., 190:1082-1084 (June 19), 1924. 12. Hess, P.: Roentgen Treatment in Absolute Glaucoma, Strahlentherapie, 49 :422 (March 7), 1934; Die R6ntgenbehandlung des Glaukoma absolutum, Strahlentherapie, 49 :422-426, 1934.

versity.

From the Department of English,

Pacific States Uni-