the beginning of treatment advanced cases of spinal disease, and four were advanced cases of hip joint disease.

At Hairmyres Colony the type of case admitted is not a hospital case, and opportunities of testing the effects of irradiation in bone and joint lesions is limited. But one striking case is perhaps deserving of notice. A boy aged thirteen, with tuberculosis of the spine and a discharging sinus, in the lumbar region, of eleven years' duration, was put on light treatment, and in eight and a half months "the sinus had completely healed with a healthy cicatrix and the patient's general condition was excellent."

Mr. Frank Jardine, F.R.C.S., surgeon in charge of the surgical tuberculosis wards at the City Hospital, Edinburgh, furnished statistics of the results of light treatment in cases of tuberculous disease of the knee, hip joint and spine, and comparative figures shewing the results in similar groups of cases treated without artificial irradiation. A detailed analysis of the interesting figures supplied would take too much space, but the broad general facts may be given.

Of 20 knee cases treated by artificial irradiation, 17 (85 per cent.) made satisfactory progress, and of 7 treated without artificial irradiation, 6 (85.7 per cent.) made satisfactory progress.

Of 25 hip cases irradiated, 11 (44 per cent.) made satisfactory progress, and of 26 treated without irradiation, 14 (53-8 per cent.) made satisfactory progress.

Of 37 spinal cases irradiated, 25 (69-5 per cent.) made satisfactory progress, and of 40 not irradiated, 22 (55 per cent.) made satisfactory progress.

These results do not appear to shew that artificial irradiation has any material effect on those deep lesions. Mr. Jardine is, however, satisfied that in the smaller joints and in superficial lesions irradiation is very helpful, but in the deeper lesions with a poor blood supply it is less useful.

Dr. Munro, Glenlomond Sanatorium, has had similar experience to Mr. Jardine in hip and spine cases.

15. Abdominal Tuberculosis.-As in the other deep-seated tuberculous lesions, results have varied. But in general, abdominal tuberculosis appears to respond better to irradiation than disease of the large joints. Dr. Smith, Robroyston, says that in his view "cases of visceral tuberculosis require careful selection and constant supervision when treated by light. Danger of over-dosage increasing toxæmia must be borne in mind. It is easy to produce a violent focal reaction with increase of pulse rate and elevation of temperature. Cases of tabes mesenterica are often greatly benefited, however, and sometimes large palpable gland masses diminish steadily in size until they can scarcely be detected. I have seen an abdominal sinus from which there came a profuse purulent discharge dry up in three months."

At Baird Street, Glasgow, Dr. Macfie reports that twelve non-resident cases were treated, and that seven of them healed

after four months' treatment. Three did not improve, and two died.

Dr. M'Gowan, Ruchill, reports good results, especially in cases with fluid in the abdomen.

Dr. Taylor, Aberdeen, says: "Admirable results were obtained with the ten cases of abdominal tuberculosis treated."

Dr. Cameron, East Fortune, writes: "Abdominal conditions on the whole do well. Children suffering from the tabes mesenterica type of infection improve remarkably, if attention is paid to the usual indications for exposure. Broken-down abdominal glandular conditions also do extraordinarily well under the same conditions. I have had experience of the treatment of two cases of fæcal fistula in young children. Both were cases of umbilical fistula, and in each case there was the usual mass of dense hard peri-umbilical induration. Both were sent to us as a last resort, and both were pictures of emaciation and misery. One child passed everything by the umbilicus, and all small intestinal contents at that, nothing but a little mucus coming by the bowel. I tried her on light treatment with much misgiving. The first effect noticeable was the soothing effect of the light, which literally gave her the only comfort she knew. The fistula has healed completely, the peri-umbilical mass is largely absorbed, her bowels move regularly per vias naturales, and she is a rosy happy child. The second child was not so acutely ill, and the fistula was only a partial one. She was also a later case, and has been on treatment for about three months only. The fistula is already healed, and she is entering upon a period of apparent recovery. A point of interest which was seen in these cases, and which is seen in many other conditions, is the tendency shewn to heal and then to break down again. These processes may alternate for a time before final healing takes place.

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Dr. Crocket, Bridge of Weir Sanatorium, states: This type of disease gives most brilliant results, particularly the exudative form. The treatment is, however, also good in the dry adhesive type, combining X-ray treatment with light treatment in this condition, as in the case of glands."

Mr. Jardine, Edinburgh, gives comparative figures, shewing the results of treatment in these cases with and without artificial irradiation. Of forty-two cases irradiated at the lamps four were cured, five very much improved, eighteen improved and fifteen. remained unchanged, got worse or died. The satisfactory results formed 64-2 per cent. of the total.

Of forty-four cases treated without exposure to the lamp, seven were cured, six very much improved, eleven improved, and twenty remained unchanged or got worse or died. Satisfactory cases formed 53-4 per cent. of the total. It was noted that of the irradiated cases 14 per cent. died, and of the non-irradiated cases 26 per cent. died.

16. Pulmonary Tuberculosis.-The untoward results that frequently followed the irradiation of patients suffering from

pulmonary tuberculosis by natural sunshine led to the belief that ultra-violet irradiation was unsuitable for this class of case. In recent years, however, by the adoption of a careful technique, encouraging results have been obtained and opinion now appears to be undergoing a change. There has so far been only a limited amount of work done in this connection in Scotland, and it is too early to express an opinion as to the precise value of irradiation, natural or artificial, in pulmonary tuberculosis.

Perhaps of all the centres in Scotland, Aberdeen shews the greatest number of pulmonary cases treated by irradiation. Dr. Taylor states that 156 adults suffering from pulmonary tuberculosis were irradiated. No fewer than 92 per cent. of the cases were classified Turban-Gerhart Stage 3. Of the total number 78, or 50 per cent., shewed improvement; 52, or 33-3 per cent., remained stationary; 18, or 11-6 per cent., retrogressed, and 8, or 5.1 per cent., died. Of 120 children suffering from hilus tuberculosis all made the most favourable progress as was to be expected."

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Dr. Taylor takes the view that the disappointing results previously experienced when lung cases were irradiated were due to the adoption of a hard and fast technique. In his experience good can only be got from irradiation if close attention be given to the response of the individual. He observed the effects upon temperature, pulse-rate, cough, amount of sputum; bacilli per field, general response, pigmentation and weight. His cases were X-rayed at intervals, and a careful clinical record observed.

Dr. Crocket, Bridge of Weir, says that the "results in cases with pulmonary tuberculosis have not been discouraging, Of 72 patients who have had light treatment and who were suffering from pulmonary tuberculosis, 85 per cent. have improved. Apart from light treatment, 67 per cent. of our pulmonary patients generally improve. The treatment therefore apparently was an aid rather than a hindrance. The features. we have noted regarding the cases thus treated are:--

(1) The general condition and the mental outlook were improved in practically every case. (2) The lung lesions shewed fewer adventitious sounds or other indications of activity. (3) The cough was relieved in 92 per cent. of the cases. It was much improved in 70 per cent. In 8 per cent. it became worse or was not benefited. The sputum was practically unaffected in 20 per cent. In 54 per cent. it was very much reduced or ceased. (4) Wheezing, often indicative of congestion, is frequently removed by light treatment. I have had several intractable cases which seemed to be due to an irritative spasm of the bronchi who did excellently with general exposures. (5) The appetite is usually improved, particularly if there has been abdominal mischief. Of the cases with anorexia or dyspepsia 76 per cent. received definite benefit from this treatment. It is not advisable to give the treatment for one hour before meals, as patients usually complain that it interferes with their

ability to enjoy their food. (6) Weight is not benefited as often as one would expect. In spite of an increased appetite, 30 per cent. of our cases did not increase in weight while under treatment. (7) Sleep is often greatly improved. In 9 per cent. it was apparently affected unfavourably. Insomnia was recorded.

"In regard to hæmorrhage, we have not found it to occur more frequently with this treatment than in ordinary practice. Out of the 75 patients, in only four cases has hæmorrhage occurred. One was very severe; the patient died within a few minutes of its occurrence. Two were moderate. The fourth had merely a trace of coloured sputum. I am of the opinion that these hæmoptyses would have occurred apart from such treatment.

It

"It is also said that rise of temperature frequently follows on light treatment when pulmonary lesions are present. That may be the case with over-exposure. certainly is not the case in our experience with moderate doses. In ten cases which had been running an intermittent temperature for several months, this subsided satisfactorily, although they were having the exercise of walking to and from the light baths.

"I think it is most important for all cases with active pulmonary mischief to lie during treatment. The strain of sitting in one position, often on a seat without a back, is too much for such cases. This in itself is sufficient to produce hæmoptysis and rise of temperature.

"General radiation with the quartz mercury lamp is certainly in many cases of catarrh of the bronchial mucosa very beneficial. Chronic bronchitis is one of the most troublesome features of many old-standing cases of lung tuberculosis.

"In all cases it should be given tentatively, particularly for the first few weeks."

In Glasgow from 30 to 40 cases have been treated, some at Robroyston and some at Baird Street. With regard to the Robroyston cases, Dr. Smith says that when the pulse-rate is accelerated by treatment and does not return to normal within an hour, he reduces the exposure. Practically all his patients gained in weight, and in four the sputum became negative and expectoration almost ceased. He thinks his experience sufficient to shew that ultra-violet irradiation can be attempted even when the lesions are extensive, without any grave risk to the patient. His experience with intermediate and advanced cases lends encouragement to the view that early cases might receive great benefit from the tonic effects of irradiation.

A few cases have been treated in other centres, but the experience gained in Aberdeen, Bridge of Weir and Glasgow forms the main body of evidence as to the value of irradiation in pulmonary tuberculosis in Scotland. The technique of irradiation in pulmonary cases is of primary importance, and great

care is necessary in very gradually raising the patient's tolerance. The technique adopted should be subject to modification from day to day according to the response of the patient, and all treatment should be carried out under strict medical supervision. This is true of irradiation for any condition, but in pulmonary tuberculosis it is imperative.

Reviewing the question of ultra-violet irradiation as a therapeutic agent in the treatment of tuberculosis, it appears to be impossible at this stage to define its precise value as a curative agent. There would seem, however, to be almost universal agreement among light clinicians that the light bath has a markedly tonic effect upon patients, making them brighter, improving their appetites, their sleep, and their general feeling of well-being. This in itself is a matter of great importance, apart from whether irradiation has or has not any directly curative effect.

The

We are handicapped in estimating the value of irradiation as a curative agent by the absence of comparative figures shewing the percentage of cures or of cases markedly improved without irradiation. Such figures are available for Edinburgh, but they are restricted to spine, hip, knee and abdominal cases. evidence they furnish is not very encouraging. On the other hand the general experience in Scottish centres in cases of glandular, abdominal and bone disease, and disease of the small joints, is such that there is hardly room for doubt that artificial irradiation is of value. In most institutions, open-air treatment, which necessarily implies a certain amount of irradiation by natural sunshine, especially in summer, also adds to the difficulty of assessing the value of artificial irradiation. Reports from institutions in the south of England, notably Carshalton, seem to indicate that results on the whole were as good without artificial irradiation as with it. Scottish experience hardly agrees with this view. It is possible that the difference may be accounted for by the greater amount of natural ultra-violet radiation available in the south throughout the year. It has already been said that there is practically no ultra-violet radiation in the midlands of Scotland from late October till April, whereas the south of England gives very fair readings during the winter months. Whether the beneficial effects of irradiation are due mainly to exposure of the skin to the stimulating effects of cool air or to the direct action of the ultra-violet rays has not been finally determined, but it seems clear that radiation per se has specific biological effects which are beneficial to the living organism. Its analgesic effect has been commented upon by many observers. Dr. Cameron, East Fortune, writes: "I have seen a young adult suffering from genito-urinary tuberculosis, who suffered days and nights of pain, pass into peaceful sleep under the light. His hour was the one of the twenty-four and he lived for it. I have known cases of young children with fæcal fistulæ, resulting from mesenteric tabes, who literally knew their only hour of peace under the lights, and who screamed when they were taken away. This effect must be seen to be believed, and