§ 3 s > *
RADIUM 227 ABSTRACTS
FROM LIMITED FIRST EDITION OF ONE THOUSAND COPIEs
To Miss Amanda J. Belser,
General Library,
ADDRESS University of Michigan,
Ann Arbor, Mich.
DATE MAILED 10/26/22
UNITED STATEs RADIUM Corporation, NEW YORK
R A D IU M
Abstracts of Selected Articles on
Radium and Radium Therapy
COMPILED BY
AMERICAN INSTITUTE OF MEDICINE
for
UNITED STATES RADIUM CORPORATION
T- NEW YORK
Copyright 1922
by -
UNITED STATEs RADIUM coRPORATION
NEW YORK
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PRINTED BY
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NEw York, N. Y.
R a d i u m
CONTENTS
SECTION I
Page
Radium—Its Physics, Biology and General Therapeutics. . . . . . . . 1
SECTION II
Radium in Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
SECTION III
Radium in
A. Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
B. Cancer of the Breast. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
SECTION IV
Radium in Malignant Disease,
Cancerous and Benign Growths. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
SECTION V
Radium in Dermatology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
SECTION VI
Radium in
A. Opthalmology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
B. Oto-rhino-laryngology . . . . . . . . . ** * * * * * * * * * * * * * * * * * * * * * 85
SECTION VII
Radium—Its Effect upon the Blood and Use in Blood Diseases. . . 99
SECTION VIII
Radium in Thyroid and Goiter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
- SECTION IX
Radium in Urology and Diseases of the Genito-Urinary Tract. . . . 115
SECTION X
Radium—Its Unusual Uses:
A. Rare Cases
B. Nerves
C. Gout and Rheumatism
D. Brain Conditions, Etc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
SECTION XI * *
Radium—Experimental Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
SECTION XII
Radium—Apparatus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
SECTION XIII
Radium -
A. Dangers of 3. -
B. Injurious Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
R a di u m
FOREVORD
In presenting to the medical profession this book of abstracts
from articles on the medical use of Radium, prepared for us by the
American Institute of Medicine, we feel that we are repaying in part
for the innumerable courtesies and kind assistance given us by so many
physicians all over the world. The work is a complete one and will,
we trust, be of service to users of radium who seek a ready reference
to the world’s writings on this very important phase of therapeutics.
|UNITED STATES RADIUM CORPORATION.
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THERAPEUTIC HISTORY AND PROGRESS
OF RADIUM
Like many another revolutionary discovery, the possibility of
employing radium as a therapeutic agent was first suggested by an
accident. Had Henri Becquerel been less scornful of his assistant,
Matout, when he remarked that his superior might find a safer reposi-
tory for a tube of pure radium than the pocket of his waistcoat, Bec-
querel would have been spared the discomfort of the burn upon the skin
directly beneath that same waistcoat pocket, which about two weeks
thereafter gave Matout a chance to employ the Gallic equivalent of “I
told you so.” But medical science might have waited much longer for
this invaluable adjunct to its armamentarium.
It was the “Becquerel burn” which gave Pierre Curie the idea
that radium might prove useful in medical work, but it was at Besnier's
suggestion that he offered some of the precious element to Dr. Danlos
of the St. Louis Hospital. This was in 1901. Since then, the thera-
peutic use of radium has advanced with the strides of a giant, so that
looking over the early number of Le Radium, the magazine which was
founded by the French workers in the first flush of their enthusiasm,
seems almost like reading ancient history."
Yet it was not until 1906 that radium therapy can actually be said
to have become a reality, for it was only then that Henri Dominici,
a profound student of the morbid reactions of connective tissue, set
forth the principle of ultra-penetrating radiation, resolutely turning
his face away from the then-prevailing opinion that filtration inevitably
removed the essential properties from radium. Dominici, “whose atten-
tion was awakened by the process of evolution without necrosis which
histology showed us to take place in the deeper tissues exposed to radia-
tion, noticed the homogeneity of the radiation after it had undergone
filtration by four millimeters of such a dense metal as lead. Elimina-
ting secondary radiation by another filter of very slightly dense matter
he noted that the rays thus selected presented remarkable properties,
characterized by a relatively marked innocuousness for healthy tissues,
whereas, on the other hand, they preserved all their special action on
neoplastic tissues.” ” `s a"
So it is to Dominici, next to the Curies themselves, that the world
owes its knowledge of the unequaled curative properties of radium.
Not only did he in the beginning make its employment practical and
effective, but he extended the scope of his experiments and researches
through six laborious years, so that practically all that was accomplished
in the field of radium therapy during that entire period was but a carry-
ing forward of what Dominici had initiated.
The abstracts here collected represent the contributions to medical
literature concerning the use of the radium element in the great struggle
References:
1 Béclère, A. : Sur l'emploi therapeutique des sels de radium. Le Radium;
2:49, 1905.
Abbe, Robt. : Action du radium sur quelques tumeurs particulières, ibid.,
p. 55.
2 Barcat, J.: Henri Dominici and his work. Arch. Radiol, and Electrother.
24: 343, 1919-1920.
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against disease. They have been culled from many sources, and having
broken through the barriers which unfamiliar language, geographical
remoteness, or even mere obscurity of publication heretofore imposed
upon them, are now arranged so as to be easily accessible to every medi-
cal man who cares to read in them a record of study, of labor and
of achievement, without parallel in the history of science.
No matter in what particular branch of the work he may be inter-
ested he will find here the reports of those who have actually labored
along this line. History alone can give perspective, but it is only by
traveling along a road that we can reach a point where we are able
to pause, look back, and note the landmarks in their true relations.
These articles—records inscribed sometimes in the bright sunshine of a
brilliant success, but very, very often in the dark shadow of a bitter
failure—are the landmarks along the pathway of the progress of radium
therapy. The records of successful achievement have much to tell us,
but there is also much to be learned from those who failed, and still
more from those who “darkness” was later “turned into day.” It is
well for those who enjoy all the benefits of a highly developed civili-
zation to give a thought now and then to the endurance of the pioneers
who made that civilization possible, and it is well for those in whose
hands radium is now performing such wonders to be fully familiar
with the work of those who preceded them, even in the youngest of all
the sciences.
The possibilities of radium therapy seem almost infinite, and there
is every reason to believe it is still in its infancy. But the record of
what has up to this time been accomplished, gathered together as it ap-
pears here, is already an impressive array of testimony to the possibility
of human progress into realms hitherto unknown.
R a di u m
SECTION I.
RADIUM-ITS PHYSICS, BIOLOGY AND GENERAL
THERAPEUTICS
United States Radium Corporation
New York
R a d i u m
SECTION I.
RADIUM-ITS PHYSICS, BIOLOGY AND GENERAL
THERAPEUTICS
Recent Developments in Radium Therapy.
R. Duncan, Calif. St. J. M., 19:102, 1921.
Radium is an element which owes its therapeutic properties to
certain rays emitted during the process of its disintegration. These
rays are termed alpha, beta and gamma rays. The first products of its
disintegration are helium, an inert gas, and radium emanation to which it
owes its radio-activity. It is to the changes produced by these rays in
the tissues that radium owes its therapeutic value. By means of an ap-
paratus perfected by Prof. Duane of Harvard University, it is possible
to collect from a sufficient quantity of radium in solution the emanation
which may be used for therapeutic purposes, and which has all the prop-
erties of the parent substance.
Radium emanation, a gas, is capable of great concentration. This
permits of having in a very small container several hundred times the
activity that might be obtained from a similar bulk of the radium salts.
This is of tremendous advantage where radium is to be applied within
cavities or where screened or unscreened tubes are to be buried with
the tumo, substance.
When a small amount of sodium chloride or a piece of lead foil is
encased in a glass tube properly connected with this apparatus, and the
emanation is brought and retained in contact with it for three hours, the
active deposits radium B and C, which emit beta and gamma rays, will
be deposited thereon, rendering the substance temporarily radio-active.
The salt may be dissolved in a proper quantity of water to pro-
duce a physiological salt solution, its radio-activity measured and
administered intravenously. Lead foil, when rendered radio-active in
this manner, may be cut into the desired shape for the treatment of
various superficial lesions.
To successfully employ radium emanation an adequate quantity
of radium is essential, one gram being approximately the minimum
amount that is practical. From each gram of radium in solution there
can be collected each twenty-four hours 166 millicuries, minus a small
loss. While the emanation collected undergoes rapid disintegration, los-
ing one-half every four days, and practically all in about twenty days,
more is being constantly given off, so that the number of millicuries
available at the end of thirty days is equivalent to the number of milli-
grams of radium element in solution. The author makes it a rule, unless
a special applicator is required, to collect the emanation in small glass
capillary tubes, approximately 34 centimeter in length and 1 millimeter
in diameter. These tubes are accurately measured to determine their
radio-activity. By encasing these tubes in various metal capsules, appli-
cators or screens, the character of the beta and gamma rays may be
modified as desired. *
Histologically it has been shown that, though all tissues are influ-
enced by a sufficient quantity of radium radiation, normal and patho-
logical tissues vary in their susceptibility, imperfectly formed cells and
tissues being less resistant than normal tissues. Janeway and Ewing
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have determined that carcinomatous cells are destroyed by one-fourth
the dose necessary to destroy a normal epithelial cell.
Beta rays with proper dosage, affect an area of about 1% centi-
meters; gamma rays, in sufficient quantity, and with proper screening
and technic may be effective for a distance of several inches. The beta
rays are used chiefly in superficial lesions of the skin and mucous mem-
brane. Where it is desirable to radiate deeper tissues, the beta rays
may, with one millimeter of platinum or other proper screening, be
absorbed, leaving available the more penetrating gamma rays.
The efficiency of radium therapy depends upon the proper radia-
tion of pathologic tissue. By means of a suitable instrument, the bare
or unscreened glass tubes containing the radium emanation may be
imbedded in a tumor, where they are allowed to remain. These tubes
gradually lose their activity, remaining active for about 20 days. In
certain cases where it is desirable to maintain a continuous radiation
for a considerable period of time, a number of these tubes with quanti-
ties varying from 5 to 10 millicuries may be imbedded at a distance of
about 1% centimeters. The dosage thus obtained may be computed
by multiplying the original amount buried by 132, which gives the total
number of millicurie hours dosage.
The author then mentions some of the conditions in which radium
raying has been of benefit, among them being : certain diseases of the
bladder, larynx, pharyngeal spaces, antrum, esophagus, superficial le-
sions, benign and malignant uterine bleeding, menopause, uterine
fibroids, uterine cancer, cervical carcinoma, Hodgkin's disease and
leukemia. He lauds the post-operative prophylactic use of radium,
especially after breast amputation.
On the Local and Generalized Action of Radium and X-Rays
upon Tumor Growth.
S. Russ, Helen Chambers and Gladys M. Scott, Arch. Radiol. &
Electrother., 26: 129, London, Sept., 1921.
In the treatment of tumors by radiation the action on the animal
body as well as on the tumor cells must be considered. The effect on the
latter varies with the amount of radiation; a large dose causes the death
of actively growing malignant cells; a somewhat smaller dose shows,
while a very small dose apparently stimulates the growth rate of the cells.
Differences are also observed in the effects on the animal body. Pro-
longed exposure of the animal to the rays causes wasting and death;
shorter exposures diminish the rate of increase of body weight without
apparently affecting the general health; and very small doses result in
the development of a state of increased resistance to an implanted tumor.
Experiments are here reported dealing with : (1) the effect of rays in
varying doses on inoculation; (2) the effect of rays in various doses on
the body growth of normal animals and the subsequent susceptibility to
inoculation of malignant cells; and (3) the effect of rays in various
doses on animals with tumors. Most of the work was done with a
Jensen rat sarcoma, although in addition another slow-growing rat
sarcoma and a rat carcinoma were employed. To test the effect of the
rays on the malignant cells, fragments of a tumor removed from the
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animal body were exposed for periods varying from forty minutes to
two seconds, and then implanted in normal rats; the rate of growth was
observed. The source of radiation was a capsule containing 20 mg.
radium bromid spread over an area of 4 sq. cm. and covered with a thin
layer of varnish to absorb the alpha rays and soft beta-rays. The lethal
dose was found to be about 35 for the Jensen tumor and the carcinoma,
and somewhat longer for the sarcoma. With diminished doses, first a
reduction was observed, and then a slight quickening of the rate of
growth as compared with that of an untreated tumor. The susceptibil-
ity of the animal receiving the implant is also a factor to be considered.
To test the effect of irradiation on the body weight, normal animals
were exposed to rays from a Coolidge tube, spark-gap 4.5 cm. between
5 cm. spheres, at a distance of 20 cm. with no screening except a thin
mica sheet below the tube, and a perforated cardboard over the box,
different batches of animals being exposed daily for one minute, twelve
seconds or two seconds, over periods of weeks. The longer exposures
cause a diminution in the rate of growth, but with a diminished dose
the increase was more rapid than in normal animals. In rats exposed
for twelve seconds daily over varying periods of time before implanta-
tion of tumor cells, the tumors grew at a slower average rate than in
the normal animal, although an absolute degree of immunity could not
be conferred. The longest exposures did not produce the highest de-
gree of immunity. Other authors have observed that, after very large
doses of x-rays, an immune animal becomes temporarily susceptible to
tumor inoculations, and the present authors have previously shown that a
single large dose of x-rays increases the susceptibility.
To test the effects of irradiation on animals with tumors, three
methods were used : (1) Four days after inoculation the radium cap-
sule was held against the graft; it was found that the exposure neces-
sary to prevent growth was practically the same as that required when the
tumor was irradiated outside the body. In another series double inocu-
lations were made, and four days later the tumors on the right sides
of the animals were irradiated for periods of from ten minutes to twelve
seconds, and the doses repeated at intervals of a week. Weekly expo-
sures of from ten to five minutes checked and those of one minute or
less increased tumor growths. Exposures amounting to one-fiftieth of
the lethal dose appeared to have an accelerating effect. (2) Twenty-
four animals were inoculated with tumor cells, and on the following day
one-half were exposed to the rays for twelve seconds, the graft itself
being screened with lead 2 mm. thick. Exposures were made daily for
a month, and the tumors of both irradiated and control animals were
measured twice a week. A decreased susceptibility to tumor growth
followed generalized irradiation. After having been shown that, while
repeated exposures to small doses increase the resistance of the animal,
the effect on the tumor cells is to accelerate the rate of growth, experi-
ments were made to determine which process outweighed the other. (3)
Two lots of animals were inoculated, and one lot was exposed for from
five minutes to two seconds daily for various periods of time. Longer
exposures retarded tumor growth, but in nearly every case the death
of the animal followed the five-minute exposures, while the one-minute
exposures diminished the rate of increase of body weight. With a
further reduction in exposure the body weight increased more than
3
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normally; but there appeared to be slight stimulation of the tumor cells.
The bearing of these investigations on radiologic treatment of tu-
mors in man is twofold: (1) With either radium or x-rays the uniform
irradiation of large tumors is hardly possible, and, while small variations
from the lethal dose are unimportant, if the radiation reaching the edge
of the tumor is so diminished as to form only a small dose the effect
on the cells may be stimulating rather than destructive. (2) While large
generalized doses lower the resistance to tumor growth, very small gen-
eralized doses have the reverse effect. It is, therefore, suggested that
the local intensive irradiation of a tumor should be supplemented by
feeble generalized irradiation of the patient, the tumor cells not being
exposed to the latter.
Radium and Research. A Protest.
C. Everett Field, Med. Rec., 100: 764, Oct. 29, 1921.
The writer openly criticizes the deliberate policy of belittling radium
therapy which has been the common custom of the Director of the
Crocker Cancer Research. He states that since 1913 he has made over
7,000 intravenous injections of radium element, in dosages ranging
from 10 to 100 micrograms, and has invariably, with one exception, wit-
nessed a remarkable increase in the red-cell count, in spite of the fact
that Dr. Wood of the Crocker Cancer Research is reported to have
affirmed that “radium does not increase red blood-corpuscles nor pre-
vent hardening of the arteries. It does not have a stimulating effect
on the appetite—if anything it kills the red blood-cells.” Furthermore,
radium markedly increases appetite and all digestive functions. In early
cardiovascular degenerations it has been favorably reported for twelve
years. Probably threescore careful radium therapists here and abroad
will bear witness to these facts. As for the statement that radium would
cure 1 case in 1,000 of cancer (made by Dr. F. C. Wood), one might
justly query why even the one cure occurred. The writer confesses
that he is entirely in the dark as to the purpose of any policy which
permits such statements to emanate from a research institution. The
writer then enumerates a large number of institutions devoted to radium
therapy and questions whether anyone would have the heart to hold out
to the cancer victim a hollow mockery to the effect that radium would
“perhaps cure 1 case in 1,000.” He repeats a favorite personal quo-
tation: “Radium is the most remarkable therapeutic agent emanating
from the laboratory of the Almighty.”
Dosage in Radium Therapy.
Gioacchino Failla, Am. J. Roentgenol., 8: 674, Nov., 1921.
Failla suggests that radiation doses be estimated according to the
amount of energy absorbed by the irradiated tissue; this includes not
only the pathologic tissue, but also the normal tissue surrounding it,
which must not be injured unduly. The success of the treatment de-
pends upon the relative amounts of radiant energy absorbed by healthy
and by diseased tissue, as well as upon the absolute amount of radiant
energy absorbed by the pathologic tissue. The intensity of a treatment,
4
R a d i u ºn
which may be measured by the duration of the exposure or by the
strength of the radio-active source, is not without influence on the final
result and must be taken into account. The physical constants which
enter into the complete specification of a dose are: (1) The strength
of the radio-active source; (2) its distribution; (3) the total filtration
used; (4) the duration of the irradiation; and (5) the relative positions
and distances of the source of radiation, the pathologic tissue, and the
normal tissue. On the basis of the above data the dose can be expressed
in any unit selected, but since the biological effect must be due to the
radiant energy absorbed by tissue, it is suggested that this be taken
as measure of the dose administered, and that it be expressed in calories.
At the present time it is not possible to express doses in calories for all
forms of radium treatment, inasmuch as some of the data necessary for
such calculations are unavailable. The same data are needed for proper
interpretation of clinical results, and, therefore, it is important that
experiments leading to the solution of this problem be carried on.
Examples are given to illustrate the advantages of the method of
dosage suggested. Doses of gamma radiation given with various appli-
cators at different distances from the skin, which produce the same
degree of erythema, are the same when expressed in calories but very
different when expressed in milligram-hours. The latter notation can
be used to represent only the amount of radium energy emitted by the
radio-active source, but not that part of the emitted energy utilized dur-
ing the treatment, which is really the dose. Once a system of dosage
based upon the effective radiation of tissue at any depth is established
the knowledge obtained from the treatment of patients can be used to
better advantage, and the difficult problem of determining the necessary
and sufficient doses for different pathologic conditions will be greatly
simplified. It should be noted, however, that even though the amount
of radiation necessary to destroy a certain tumor is known and admin-
istered, it does not follow that the patient will recover. If a mistake is
made in estimating the extent of a lesion, this will result in the giving
of an insufficient dose, and, therefore, a full knowledge of cancer is
essential for the successful application of radium. The method of
dosage for radium therapy suggested in this paper can be used for
roentgenotherapy as well.
Radium's Place in Therapy.
A. Strauss, Ohio State M. J., 17:315, May, 1921.
Radium therapy is coming into such general use that it is high
time the general practitioner became acquainted with these newer
methods of controlling and curing many malignant growths. Radium is
used in the form of insoluble sulphate except by those who possess more
than a gram, when emanations are employed. The various modes of
use are described, and the efficacy of the three types of rays. The
alpha have no therapeutic value, the beta are used for superficial lesions
and the gamma are the shortest and most penetrating. Cells differ in
their susceptibility to radium from most to least sensitive, in the follow-
ing order : lymphosarcoma, basal cell carcinoma, cubic cell carcinoma,
sarcoma of the uterus and skin. The more scirrhous a cancer, the more
resistant it is, The changes undergone by tissue exposed to radium are
5
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detailed, and the affections amenable to it discussed at length. These
are Group (1) those in which radium is the method of choice : lympho-
sarcoma, Hodgkin’s disease, sarcoma of the extremities, fibromyomata
of the uterus uncomplicated and not enlarged above the umbilicus, men-
orrhagias, carcinoma of the cervix uteri, carcinoma of the face, obstruct-
ing thymus in infants, keloids, epulis, nevus (hemangioma), and vernal
catarrh. Dr. Strauss emphasizes the fact that radium should not be
“properly reserved for inoperable cases” but should be used in prefer-
ence to operations wherever possible. Group (2) comprises diseases
in which radium is to be used in conjunction with surgery: carcinoma of
the fundus of the uterus and of the breast, of the prostate, of the bladder,
of the rectum, orbital tumors, glioma of the brain, carcinoma of the jaw,
of the tongue, of the lip, and of the antrum. Group (3) are affections
in which radium has given relief, but in which more experience is nec-
essary before its use can be advocated above other methods: leukemia,
corneal ulcers, toxic goiters, tumors of the tonsils, tuberculous adenitis,
carcinoma of the larynx, and of the esophagus, and leukoplakia. In
Group (4) radium is only palliative, as in advanced inoperable car-
cinoma. Group (5) consists of skin diseases which may be treated as
effectively by other means. Dr. Strauss describes the results which he
obtained in the groups mentioned, and makes conservative suggestions
regarding treatment. He cautions us to remember that “inoperable”
is no longer synonymous with “incurable.”
The Absorption of Radium Radiations by Tissues.
Gioacchino Failla, Am. J. Roentgenol., 8:215, May, 1921.
After a description of the apparatus used, consisting of a gold leaf
electroscope and conical ionization chamber, and after a detailed account
of the experimental procedure, including a list of limitations to which
it is subject, absorption curves are given for aluminum, brass and lead.
These show that (a) as the filter increases in density the transition from
soft to hard radiation is quite sharp; that (b) beyond a thickness of
filter of a few millimeters in the case of aluminum and brass the absorp-
tion is exponential, but not in the case of lead in the range of thickness
used; and this shows that (c) filtration by a small thickness of metal
is sufficient to give a radiation absorbable exponentially by metals of
medium or low atomic weight, the radiation, however, not being homo-
genous, as indicated by the lead absorption curve.
The exponential absorption serving as a criterion for the quality
of radiation in deep therapy, it is plain that a metal should be used as
the primary filter, and that a secondary filter, composed of light ele-
ments like tissue, should also be used to remove the soft secondary radi-
ation of the metal. Beyond a certain point, additional filtration, while
slightly increasing the penetrating power of the radiation, decreases its
intensity considerably. The limiting factor in deep therapy is the effect
on the skin. The fraction of skin radiation which reaches a given depth
can be varied to some extent by varying the filtration or the distance
of the applicator from the skin. Examples worked out by mathematical
formulae and tables based upon the projection of radiation curves in
combination with these formulae indicate how adjustments are to be
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R a d i u m
suited to individual cases. The coefficient of absorption depends upon
the quality of the radiation and the nature of the absorber. The same
radiation is absorbed to a different extent by different tissues. For soft
tissues the coefficient is proportional to the density of the tissue. The
absorption by tissue from different organs, excepting lung tissue, fat,
and solid bone, is nearly the same. One may take 0.075 as the coefficient
of absorption of gamma radiation filtered through 1.92 millimeters of
brass, and calculation from this gives 10 cm. as approximately half of
the thickness value of human muscle tissue for gamma rays. In prac-
tice solid bone forms only a small fraction of the total thickness tra-
versed by radiation and may be regarded as of no great consequence.
The results given in this paper may be used for the solution of
problems in radium therapy, noting that the radiation reaching any given
depth of tissue is always the minimum amount which will reach this
depth under the conditions of application, and that skin doses of beta
and gamma radiation are not to be compared according to the ionization
values given, but must be determined independently by physiological
experiments.
Radium and the General Practioner.
Julius J. Heimark, Journal-Lancet, 41 :284, May 15, 1921.
The progress which radium has made as a therapeutic agent is to
no one more important than to the general practitioner though a com-
prehensive knowledge of its usefulness is scarcely possible to anyone
who cannot give a great deal of time to its study. Much discrepancy
is found in the statistics. This the author attributes to the failure to
present comparisons on a similar basis, as well as to the fact that statis-
tics are compiled by inexperienced operators. -
From the radiologist's standpoint, he had to blaze his own trail.
Dosage, for example, was a matter of experimentation. Screening was
a problem, attended by errors resulting in severe inflammatory reaction,
producing fistulae or extensive sloughs. The value of cross-fire was not
appreciated early enough. Metastasis and adjacent glands were often
inadequately treated or neglected. But in spite of numerous difficulties,
radium has proven extremely successful and its zenith is not yet reached.
It is a valuable adjunct in the treatment of malignant conditions and is
too seldom used, the work done in cancer cases being the most important
phase of its application. In non-malignant pathology radium therapy
has but recently come into its own. Menorrhagia is mentioned as among
the most greatly benefited conditions, usually yielding to one treatment
by radium. If the proper dosage is applied it does not produce cessa-
tion of menstruation. Metrorrhagia is ideally treated by radium therapy.
Contraindications for its use in menorrhagia are histories of pelvic
infection and symptoms suggestive of malignancy in which cases abdom-
inal hysterectomy should precede radiation. In angiomas, radium is
recommended as the choice treatment. Unusual possibilities have been
demonstrated in the radium treatment of hyperthyroidism. In thymus
gland enlargement radium has certain advantages over x-ray treatment,
being more rapid and resulting usually in a cure after one treatment.
Tuberculous adenitis often responds to radium therapy, and when it does
not, other forms of treatment are not rendered less effective by being
7
R a di u m
preceded by radium. In a small series of incipient cataracts treated
with radium, 87.5 per cent. showed improvement in clarification. Small
doses of radium over the spleen in myelogenous leukemia usually result
in decrease of the number of these cells and decrease in size of spleen,
though there are no reports of recovery from this disease under any form
of treatment. Dermatologists find radium indispensable. Actinomy-
cosis has been successfully treated by radium. Chronic leukorrhea is
among the conditions too recently subjected to treatment for conclusions
to be available. If a death-rate exists at all in connection with radio-
therapy, it is extremely low.
A Report on the Clincal Use of Radium.
W. S. Newcomet, Therapeutic Gagette, 45 : 313, May 15, 1921.
During the last year the Radium Department of Jefferson College
Hospital, Philadelphia, Pa., has treated 193 new cases and continued
48 from previous years. Applications varied in length from one-half
hour to seventy-two hours. The cases were not selected, but were treated
just as they came to the department, many of them having advanced
to a moribund state. They were given the chance of whatever comfort
might be gained, even if only for a few hours before a fatal termination
of the disease.
In one case of sarcoma of the pelvis, the patient, who had been
under influence of narcotics for months, lapsed into coma for several
days after application of radium, but gradually recovered, becoming
rational, and since then has experienced little or no pain.
A case of carcinoma of the larynx, treated in February, 1915,
when the disease was well advanced, has been perfectly well up to this
time, with nothing of the trouble remaining except a little huskiness of
voice. The list shows recovery in several throat cases, although the
three-year period has not expired. Carcinoma of the esophagus has been
given special study, and, considering the inaccessibility and irritability
of the surrounding tissues, the results have been surprisingly good. It
is hoped that, by improved technic, at least the esophageal cases treated
early can be relieved. While in no instance was the disease eradicated,
there were two out of eight cases which so far improved as to be able
to eat solid food, and one case is still living. Results in the treatment of
keloid conditions of the esophagus have been exceptionally good, as a
rule. -
Carcinoma of the uterus, for which ridaum was used in previous
years only in hopelessly advanced stages, is showing improved results
as the cases are treated earlier. The effect on other pelvic structures
has not been so good, although several cases of malignancy of the bladder
and urethra have shown marked improvement. A case of epithelioma
of the urethra treated in December, 1915, still remains in perfect health.
Several rectal cases have been under observation, one for three years
and one for five. One case which had advanced to profuse bleeding,
shows a hard fibrous ring, and while there is still some disease, there
is freedom from bleeding and the patient is comfortable.
Mouth cases, though obviously difficult, especially when the disease
has attacked the tongue or alveolar portion of the jaw, have shown
8
*E*. R a di u m —i---->
good results when treated before the tissues had been severely injured.
Epitheliomas upon the face, when they occur on the lip, the ala of the
nose, and the mucocutaneous junction of the eyelid, show marked ten-
dency to recur after other treatment, and appear to react better to
radium. The recurrence in scar tissue is always more serious.
Several cases of sarcoma treated in previous years still remain
under observation. Sarcoma involving the sacrum, in a girl ten years
old, disappeared under radium treatment, and the bone structure which
had been destroyed was restored. Another case was sarcoma of the
antrum which had displaced the eye, upward and outward, the whole
side of the face being swollen and the roof of the mouth being displaced
downward. For two years patient has enjoyed good health, the only
permanent injury being a hole between the nose and mouth, covered by
a plate similar to that used for false teeth. -
Of the benign cases, the most interesting are reported to be those
of uterine fibroid and hemorrhage due to various causes sometimes
difficult to determine, and which, especially where there is profound
anemia, heart, kidney or lung complication, are inoperable. Radium has
controlled the hemorrhage and enabled patient to recover from debility,
so that further corrective measures were possible. These cases the
author finds, have enlarged the field of radium to such a degree that
it is almost supplanting older forms of treatment. Several of the in-
operable fibroid cases treated in 1915 have remained under observation
with no show of further trouble.
In this report is incorporated one submitted by Dr. P. Brooke
Bland, in which 22 uterine cases, classified nonmalignant, were treated
to control hemorrhage. In all a cure was accomplished, one application
being sufficient in all but one, who, suffering with large multiple fibroid
tumors of the uterus and being too profoundly anemic to withstand oper-
ation, required three treatments of 2400 mghrs. of radium. Forty-five
inoperable cases of malignant disease showed three cures; symptoms,
hemorrhage, discharge and pain were relieved; recession of the Super-
ficial portion of the tumor was observed in all; inhibition of the growth
was noted and in each occurred a marked improvement of the general
health.
Cases of angiomata, treated in 1915 and 1916 have shown ideal
results where proper care was taken. A few tuberculous lesions have
been treated. Where a nodule, supposed to be tuberculous or inflamma-
tory is treated and disappears rapidly, the results show that it should
be regarded as a sarcoma until proved otherwise. Tuberculous nodules
as a rule reduce slowly and leave a small, hard scar. A case of tuber-
culous sinus of the chest wall, of several years' standing, which had
failed to respond to other treatment was so far healed by radium that
the man (a physician) was able to serve through the late war in active
field duty. In cases of enlarged glands the results do not seem to differ
materially as between radium and x-ray treatment.
All cases covered by this report were treated by the crossfire
method, care being taken to guard against too severe reaction in the skin
and in the mucous membrane of the larynx, which appears to be espe-
cially susceptible to radiation. -
R a d i u m
Value and Limitations of Radium and Roentgen Rays in the
Treatment of Disease.
R. H. Boggs, M. Council, 25:377-82, May, 1920.
Both forms of radiation (radium and x-ray) have the so-called
selective and inflammatory action if given with sufficient intensity, but
with radium a reaction of greater degree can be produced without per-
manently injuring healthy tissues than with the Roentgen rays. There-
fore, radium can be used therapeutically with greater destructive power
locally than the Roentgen rays, but great care must be exercised, par-
ticularly if cosmetic results are desired. This explains why radium is
superior in treatment of cancer of the uterus and rectum, epitheliomata
of the lip, mouth, throat, eyelids or lesions situated on the mucous mem-
brane as well as its ease of application in cavities. It is universally
conceded that radium or the Roentgen rays is the method of choice in
treatment of epithelioma, but radium has certain advantages, one being
that it can be inserted in the diseased tissue. Cases of the above type,
especially epithelioma of the lower lip, are usually inoperable because
of the frequent recurrence in the scar, and because in cases involving
some of the adjacent lymphatic glands, operation on these glands can-
not be sufficiently complete, no matter how thorough the dissection.
Radium is indicated as a palliative measure in hopeless, inoperable
and recurrent cases. Lately radium is being used for primary cases in
carcinoma of the cervix when the disease extends into the cervical canal.
Radium is a specific palliative in inoperable cancer of the uterus. It
will clinically cure about one-third of the cases and subjective im-
provement is noticed in a certain percentage of the others. However,
recurrence takes place in many of these clinically cured cases within
two or three years.
Formerly it was thought that the therapeutic action of both radium
and the Roentgen rays was due solely to action on the ovaries, but it
has been demonstrated that radium applied locally destroys the endo-
metrium and endothelial cells of the capillaries, leading to their oblitera-
tion. Schmitz claims that the symptoms of change of life are milder
after radium than after Roentgen treatment. After radiation the meno-
pause ceases gradually and without the usual disturbances, such as vio-
lent flushing, sweats, palpitation, etc., which frequently accompany
normal change of life.
Radium and Radium Salts.
H. O. Sterns, physicist to the Mayo Clinic. Am. J. Elect. & Rad.,
38: 169, 1920.
Radium is a bivalent metallic element closely related to barium; it
is very active chemically and consequently difficult to isolate in its
metalic state and after isolation to keep pure as it reacts with air, form-
ing the oxide and nitride and finally the carbonate. On account of this
activity it is produced only in the form of its salts, principally the soluble
bromide, chloride, and the insoluble carbonate and sulphate.
Actions and uses: Solutions of radium or radium emanation are
said to increase the excretion of uric acid in the urine in some cases
and to decrease its concentration in the blood; to increase somewhat the
10
R a d i u an
number of red blood corpuscles; to cause temporary leukocytosis early in
the course of treatment, the mononuclear increase being relatively
greater:—no appreciable benefit is observed in leukemia. It is said that
radium increases general metabolism, and in vitro activities certain en-
zymes, pepsin, pancreatin, rennin, autolytic ferments, tyrosinase and
diastase.
It has been claimed that radium emanation is of value in all forms
of non-suppurative, acute, subacute and chronic arthritis (luetic and
tuberculous excepted), in chronic muscle and joint rheumatism (so
called) in arthritis deformans, in acute and chronic gout, in neuralgia,
sciatica, lumbago, and in tabes dorsalis for the relief of lancinating pains.
Its chief value is in the relief of pain.
The relief of pain is well established; in consequence, improvement
is sometimes observed but curative results appear to be lacking. Due
consideration should be exercised in judging the favorable reports pub-
lished.
Physicians should realize that the emanation following the giving
of an emanation solution (such as that from radio-active water genera-
tors) is very soon lost from the body (large proportion also escapes dur-
ing the process of drinking); whereas a radium solution leaves a large
part of its radium content in the system to be solvly excreted in the
course of several months. For this reason, radium solutions produce a
condition of radio-activity in the body for a longer period than emana-
tion preparations. It is not desirable therefore to consider the latter
equivalent therapeutically to a radium solution which is capable of pro-
ducing the same equilibrium amount of emanation.
Dosage: Radium may be administered as baths, by subcutaneous
injection in the neighborhood of an involved joint (0.25 to 0.5 micro-
gram in 1 or 2 c.c. distilled water), by local application as compresses
(from 5-10 micrograms), by mouth as a drink cure (in increasing doses
of from 1-10 micrograms three or more times a day), by drinking radio-
active water, containing only radium emanation (from 2–20 microcuries
of emanation, or more in 24 hours), by inhalation of the emanation,
the patient for two hours daily remaining in the emanatorium which con-
tains 0.0025 to 0.25 (average 0.1) microcurie of emanations per liter
of air. The Council will not accept any radium solution for internal
use, the dosage of which is less than two micrograms per day, nor any
radium emanation generator which yields less than two microcuries of
emanation per twenty-four hours.
A Lecture on the Technique of the After-Treatment of War
Injuries by Radium.
W. C. Stevenson, Med. Press & Circ., 1:27, 1919.
In 1914 the author treated with radium emanation needles a patient
having an extensive scar on the wrist due to an old deep burn which
caused a painful and rigid hand. In less than a week marked improve-
ment in the utility of the hand resulted, due to some freeing of the ten-
dons to the fingers, decreased tenderness, and general betterment of the
nutrition of the hand as a whole.
11
R a d i u m
Since 1917 the author has treated about 300 military patients by the
surface application of radium emanation, and it has been very exceptional
not to produce rapidly some improvement, in cases which often for long
periods have been unaffected by other methods, such as massage, ioniza-
tion, whirlpool baths, etc.
After giving some data on radium in general, the author comes
to the clinical consideration in dosage. Rays from radium come out
in every direction, and the intensity of radiation according to the distance
from their source is governed by laws similar to those of light. Hard
gamma rays will traverse the whole human body. Therefore when ra-
dium is applied to opposite sides of a limb this fact must be taken into
consideration and the dose per skin area reduced somewhat, especially in
the case of thin parts, such as the fingers and hand. For the same rea-
son, when adjacent skin areas are treated, the dose per area should be
less, especially in the central areas. As in the case of septic infection,
bulky parts like the thigh or arm, where there is more accommodation
for vascular changes, will stand a larger dose than the hand, the im-
mediate neighborhood of the knee, and over subcutaneous bone gener-
ally. Then parts affected by trophic changes should be given small
doses. - -
Dosage according to object of treatment: The largest doses are
required to free scar tissue due to the physiological organization of
granulation tissue following gunshot wounds and sepsis. About half
this dose is adequate to deal with adhesion in joints and round tendons.
For a purely analgesic effect on a tender scar where the nerve endings
are involved an eighth or less of the full dose is usually sufficient.
The standard applicator used by the author is a lead box consisting
of two shallow trays fitting into each other, made of 4 pounds to the
square foot commercial lead sheeting containing radium emanation in
glass capillaries.
Measurements: Lead, 1.57 mm. thick; area of bottom of box, 2 x 3
cm.; depth, 3 cm. - - -
The box is completely surrounded by six layers of paper, two to
three mm. thickness of cotton wool, and the whole made into a packet
about 4 x 5 cm. with sticking plaster. -
The lead cuts off all the soft rays from the radium, while the cover-
ing is absolutely essential to cut off secondary soft rays produced in the
lead by the rays from radium.
Dose of radium emanation for surface application : The author has
found by experience in cancer cases that by using the applicator just
described, over one area of skin, epilation, erythema, or ulceration of the
skin will occur in two or three weeks if the emanation is left on till its
activity has been reduced by 3.2 millicuries, for convenience called a
dose of 3.2 millicuries. . A dose of 3.2 millicuries is therefore a safe
dose for one area of skin in most circumstances. Skin with trophic
changes due to nerve involvement is very susceptible to radium burns,
and a third to a half of this dose should be the maximum.
Dose of radium emanation for surface application using standard
screen:-1.5 mm. lead, wool, etc., area 2 x 3, distance from skin 0.5
cm. (due to wool, etc.). Dose causing ulceration 3.2 millicuries,
12
R a di u m
For the treatment of gross scars. Arm, forearm, thigh, leg.
Over 1 area of skin ............................................................ 2.2 to 2.5 mc.
Over 2 adjacent areas of skin Total 2.8 to 3.2 m.c.
Over 3 adjacent areas of skin. Total 3.2 to 4.0 me.
Over 4 adjacent areas of skin. Total 4.0 to 5.0 mc.
Over 5 adjacent areas of skin. Total 5.0 to 5.5 m.c.
Over 6 adjacent areas of skin. Total 5.5 to 6.0 me.
Knee, elbow, ankle.
9* area …............................. 2.0 to 2.2 mc.
Over 2 adjacent areas ........................................................ 2.5 to 3.0 me.
Over 3 adjacent areas ........................................................ 3.0 to 3.5 mc.
Over 4 adjacent areas ........................................................ 3.5 to 4.0 me.
Over 5 adjacent areas ........................................................ 4.0 to 4.5 mc.
-: . On hands and feet.
* area “….................................. 1.5 to 1.7 mc.
Over 2 adjacent areas ........................................................ 2.2 to 2.5 mc,
Over 3 adjacent areas.......................................................... 2.5 to 3.0 me.
N ote:-In cases of hand and foot and thin forearms, skin surfaces
diametrically opposite one another should be considered as adjacent areas.
For the treatment of old teno-synovitis and adhesions due to injury
and disuse. -
Hand:—Between fingers:–0.3 to 0.7 mc. each interdigital space.
Total 1.0 to 2.1 mc. Two areas palm and two areas back of hand —
0.5 to 1.0 mc. each. Total 2.0 to 4.0 mc. Front and back of wrist:-
0.6 to 1.6 mc, each. Total 1.2 to 3.2 mc. Total for hand and wrist:-
4.0 to 9.5 mc.
Elbow —3.5 mc. for 3 areas; 4.0 me. for 4 areas.
Shoulder:-6 mc. for 5 areas. -
Knee —7 mc. for 7 areas. -
Ankle —4 mc. for 4 areas; 4.8 mc. for 5 areas.
Foot:-3 on dorsum, 3 on plantar surface. Total 4.5 to 5.0 mc.
For tender scars due to involvement of nerve endings, 0.5 to 0.7
mc. per area of skin. Similar doses should be given over nerves and
nerve plexuses and arteries with their sympathetic nerve supply in the
neighborhood of wound scars with the object of stimulating nerves to
perform normal functions, and to overcome “partial nerve block.”
Interval at which treatment may be repeated.
For scars:–After 4 to 6 weeks. Four treatments in six months.
For painful scars:–After 2 to 5 weeks.
For teno-synovitis hand;—With 4.0 mc. dose. Repeat in 14 days,
21, 28 days, and every month until 6 doses administered. With 9.5 mc.
dose, as for scars.
Note:–Except where there is extensive and deep scarring, as in
the thigh, where fairly large doses are required, apparently as good
results may be obtained by small doses more frequently repeated as with
large doses. On the whole, it is a mistake to think that the best results
will be obtained by maximum doses, and it is better, when in doubt, to
decrease the dose in military orthopedic cases, when one is not dealing
with malignant tumors or even benign growths like keloids but with cells
and tissues which are the normal consequence of inflammation directly
or indirectly due to trauma.
13
R a di u m
Internal Use of Radium.
D. C. Moriarta, Med. Rec., 94:586, Oct. 5, 1918.
The author states, “Whether the action of radium, when admin-
istered internally, is autolytic, catalytic, or by its electrical force exerted
on the individual cell, is beyond my determination. But I do know from
my laboratory findings that radium promptly and invariably increases
the number of red blood cells. From this single finding it is obvious
that the remedy is a potent one and must of necessity augment all of
Nature’s processes, no matter how complex they may be.”
The author commenced radium treatment with 15 milligrams of the
element in the form of a soluble chloride, 10 milligrams for an emana-
torium, and 5 milligrams with which to activate water. The author has
continued its use regularly in his practice since that time, as opportun-
ity presented, with many successes and few disappointments.
In the first cases treated by radium by the author he decided to
Omit all other measures, and to determine the merits attributed to radium.
The following points were determined in each instance: (1) Blood pres-
Sure; (2) blood count; (3) urine : (A) quantity; (B) specific gravity;
(C) casts; (D) kidney efficiency (as determined by phenolsulpho-
nephthalein test).
The author's method of administration and dosage was essentially
the same in all cases; clinical conditions did not govern dosage. Each
case was treated daily for a period of six weeks; in the emanatorium for
two hours, where there were 270 Maché units of radium emanation to a
liter of air, with varying quantities of activated water, internally, usually
a half liter which contained 113,000 Maché units to the liter, and some
of the cases also had intravenous injections of radium salts. Three of
the cases developed a marked reaction from the treatment (without in-
travenous injections) which was manifested by increased pulse rate,
temperature, nausea and vomiting, and great prostration, lasting in each
case about forty-eight hours. On resuming the treatment, a second
reaction occurred in two of them. The author finally succeeded in estab-
lishing a tolerance for radium in these cases by commencing with a very
Small dose and gradually increasing it. The number of cases observed
was 19, of which there were: 2 gout, 2 arthritis deformans, 3 diabetes,
2 intermittent claudication, 11 cardiovascular-renal disease. The 2 cases
of gout were old ones; both were enthusiastic over the remedy, stating
that the attacks were of shorter duration and less painful.
The cases of arthritis deformans were decidedly improved, particu-
larly as to the relief of pain, the diminished swelling in the joints, and
the increased action. In one of these cases the author was too anxious,
and used 40 micrograms intravenously, in addition to the usual proce-
dure. The patient became very ill and in a few hours practically col-
lapsed; blood pressure dropped from 230 to 110 Mm. Hg. Stimulants
and pituitary extract were administered, and after twenty-four hours
she was all right, except for malaise.
The cases of diabetes were negative, except for lowered blood pres-
sure and in increased red blood count.
The cases of intermittent claudication were relieved, that is, the
attacks of pain subsided and remained quiescent for about eight weeks.
The eleven cases of cardiovascular-renal degeneration were all
rather advanced; yet notwithstanding this fact, they all took on a feel-
14
R a di u m
ing of well-being and comfort, and the dyspnea, blood presure and kid-
ney elimination were unquestionably modified. Though the number of
cases treated was only 19, yet the following facts stand out so con-
stantly that the author accepts them: (1) general feeling of well-being
and betterment; (2) diminished blood pressure; (3) increased kidney
efficiency; (4) decided increase in number of red blood cells, varying
from 150,000 to 1,500,000.
The prognosis naturally depends upon how far the pathological pro-
cess has developed. Treatment must be prolonged, as radium is largely
indicated in chronic morbid conditions, in which the balance is not only
difficult to establish, but in which it is also easily upset.
Radium in Iternal Medicine. -
W. S. Newcomet, Radium and Radiotherapy, 1914, pp. 1-309.
Lea and Febiger, Chapt. XX. -
Dosage depends somewhat upon desired effect but may be divided
into two classes. First, those which call for slight exhilaration in the
physiological forces, and second, those which call for a profound effect.
In the former, baths, drinking water, and the breathing of relatively
small amounts of radioactive water or air are employed, and continued
for some time. A month or two before cessation, then after an inter-
mission of a few weeks or a month, another course begins, and this
regimen is continued until the desired result is obtained or the treatment
for some reason is abandoned. -
Changes are often observed in the blood, particularly in the begin-
ning, when there may be a decided leukocytosis. This may be influenced
by the action of these radiocative salts upon the bone marrow, where
it is supposed to be stored. The blood pressure often rises abruptly,
then gradually sinks until it goes below normal and remains there for an
indefinite period depending upon the dosage.
In diabetes mellitus the influence upon metabolism is reported to
have caused to some extent a lessening of the glycosuria. This was
accomplished by drinking water containing a high percentage of emana-
tion. The influence in lessening the pain that often accompanies the
neuritis in these cases was also quite marked.
Anemia: In the various forms of anemias, both primary and secon-
dary, radium may be found of value in conjunction with iron and other
forms of treatment, especially in these cases where there is a decided
splenic involvement; or where the lymph glands are enlarged as in
tuberculosis of these glands. :
Caution should always be taken in the administration of radium in-
ternally in all cases of low vitality; in severe grades of anemia; heart
disease of various forms; and care should be taken also in treating
women about the time of the menopause.
Thorium in internal medicine:–
Anemias: Both the primary and the secondary forms are most de-
cidedly benefited by these radioactive elements. &
15
R a di u m
In pernicious anemia these radioactive elements have in some in-
stances produced an increase in the blood supply for a temporary period.
The more severe grades of anemias are all treated by hypodermic or
intravenous injection, the strength of the solution varying with the judg-
ment of the observer, as no standard has been established.
Leukemia—both the lymphatic and myelogenic varieties—has been
treated by all forms of radiation and often temporarily benefited, and if
under some conditions one form of radiation fails, this is no indication
that the other will not prove beneficial.
The fact is frequently observed that in cases where the Roentgen
rays produce no improvement, they will be singularly influenced by these
radioactive elements; and in those cases of myelogenic leukemia where
the spleen is greatly enlarged, powerful applications of mesothorium will
reduce this organ considerably, with the same improvement in the gen-
eral symptoms. -
In certain forms of acute arthritis of the specific type, or a very
acute exacerbation of an old process, treatment should not be under-
taken until it has subsided into the more chronic form. With the exclu-
sion of these few contraindications, treatment, if well regulated and used
moderately, will, as a rule, be attended with success.
Cameron reports a list of 66 cases treated, and he divides the case
into acute, subacute, and chronic stages.
º º
. . ; ## # #
£ # 3 = ## ###
# 5 # # F# ###
2. – Z. }-4 C 37 t c 5 E
Acute primary infectious arthritis.......... .... tº tº e O
Subacute primary infectious arthritis.... 5 5 * @ º ºr
Chronic primary infectious arthritis...... 4 tº e º 'º º 2 . 2
Acute secondary infectious arthritis...... 3 .... 1 .... 2
Subacute secondary infectious arthritis. 14 1 1 7 2 3
Chronic secondary infectious arthritis... 17 1 2 2 5 7
Acute primary infectious arthritis.......... .... º e º e
Subacute primary infectious arthritis.... 3 .... .... 3 ....
Chronic primary infectious arthritis...... 6 1 1 2 1 1
Acute secondary infectious arthritis...... .... tº ſº e &
Subacute secondary infectious arthritis. 2 .... 1 .... .... 1
Chronic secondary infectious arthritis... 12 4 2 2 3 1
Total …...................... 66 7 8 23 11 17
Note: Cases are placed in the acute stage when motion in the af-
fected joint is not impaired other than by the acute inflammatory pro-
cess, and when there is a constant temperature curve. -
Subacute stage: When the joint can be moved by voluntary or pas-
sive motion without causing additional or recurring local inflammatory
symptoms or fluctuations in temperature.
Chronic stage: When degenerated or organized exudates cause
fixation and deformity.
16
R a d i u m
The method of treatment outlined in these cases was the inspiration
of 0.025 to 0.1 microcuries per liter of air, in an emanation room for at
least one and one-half hours each day; with this, 1 liter of emanation
drinking water containing 15–20 microcuries per liter, which may be
divided into four doses. This procedure is recommended in acute cases.
Where they tend to a more chronic character it is necessary to carry
large amounts of the emanation into the system by more and stronger
emanation waters, and also by the inspiration of charged air for a longer
period. If, however, the patient is not benefited in a period of sixty
days, usually the case can be regarded as one not suited to this form of
treatment.
Arthritis of gonorrheal origin is often benefited by the local appli-
cation of radium, and even in the later stages, where considerable exu-
dates have been thrown out about the joint, much relief is afforded by
the absorption of the products of inflammation.
Arthritis of specific origin is not benefited to a degree worth con-
sidering.
Chronic rheumatic arthritis of different types may be relieved and
to some extent the fibrous exudate may be absorbed. Where, however,
there has been absorption of the joint surfaces, with erosion, the out-
look is more or less hopeless; though it may be possible even under
the circumstances to soften the process to some extent and allow the
limbs to be placed in better position. Both the local and internal use
of radium is employed in these cases; the emanation taken internally
by breathing charged air, or the sipping of emanation water; locally
by baths, packs etc.
The emanation of radium is employed in doses of 100 to 1,200
Maché units per liter per day. In those cases where these applications
cause a rise of temperature, caution must be exercised. -
Arthritis deformans, one of the most rebellious forms of joint mani-
festation, has to some extent been strikingly benefited by the use of
radium. Pinch (London Radium Institute) has adopted the following
technique in the treatment of cases in that institution: The individual
receives 250 c.c. of radium emanation solution of a strength varying from
1-2 microcuries per liter each day and this form of treatment must be
continued for a long time. Out of a series of 21 cases, 1 was cured, 9
improved, 5 did not improve, 1 abandoned treatment, 1 was rejected,
while 4 still continue under active treatment. -
Radium and the Roentgen Rays in Radiotherapy; Their Uses
and Limitations.
W. S. Newcomet, J. A. M. A., 63: 743-47, Aug. 29, 1914.
Rays generated from a Crooke's tube may be considered as being
identical with those eliminated from radium, varying somewhat, however
in regard to force. The cathode and beta ray seem to be analogous; the
two have the same properties except in regard to speed. While the
cathode ray travels 5,000 miles a second, either from or impinging on
17
R a d i u ºn
the surface of the anode, causing the formation of Roentgen rays, the
beta ray is disrupted or exploded from the atom of one of these radio-
active salts and leaves it at a rate of from 45,000 to 100,000 miles —a
second, generating during this disturbance the gamma ray. It is Ob-
vious that when we have a force of 5,000 miles a second on one side,
with another of from 45,000 to 100,000 on the other, the results must
necessarily differ. A comparison of this with a large number of bullets
being projected from or impinging on a surface, in one instance the force
being from nine to twenty times greater than the other, gives us an
analogy. It follows that the gamma ray has far greater penetrating
powers than any Roentgen ray so far known, and, while it may be pos-
sible to build a Roentgen tube that will give the required speed of the
cathode particle, as yet (1914) it has not been produced and there is no
likelihood of its being accomplished.
Physiologically the difference between high and low radiation is of
greatest importance. While the low rays are always most active they
lack penetration, and it is well known that the so-called burn is likely
to follow their indiscriminate use. Therefore they are not so desirable
as the higher rays, which possess penetration and are by no means so
active in producing tissue change. This point may seem somewhat con-
tradictory, but on analysis it will be found that experience and theory
support each other. Let it be taken for granted that, as these active
low rays pass through tissue, a cell here and there feels the full force of
the radiation, while others are protected. This gives rise to a process
in which may be found conditions varying from stimulation on the one
hand to necrosis on the other, whereas, under the influence of the high
radiation, the effects are more uniform, each cell receiving an equal
amount of radiation. If this be true macroscopically, then why not apply
the same microscopically. For instance, the important part of the cell
is its nucleus; therefore, if the radiation is obstructed by the cell ele-
ments, the nucleus, being protected by them, naturally escapes; this
causes an inflammatory reaction, but it is doubtful if it results in the
death of the cell. On the other hand, if the radiation is high, all parts
of the cell receive about the same amount of radiation and this causes
an equal amount of degeneration in all parts and consequent death of
the nucleus. Therefore the high rays should prove most desirable as a
therapeutic agent. e
A second difference between the Roentgen radiation and that of
these radio-active elements is that there is not the least doubt that with
the gamma ray is carried a fairly large proportion of high beta rays,
which, although thought to be useless, have from an experimental point
of view a pronounced physiological significance, and it may be possible
that, as these gamma rays are projected through the tissues, the forma-
tion of secondary beta rays may cause the more active change in tissues
so commonly seen in reactions from radium. This may be due to
another condition, which is possibly secondary but plays a distinct rôle
in the issue between Roentgen and natural radiation: When the former
is employed, the point of origin of the rays is usually from ten to twenty
inches from the body, and in this bundle of rays is a wide variation of
one variety, a high tube containing a predominance of high rays, while
in a low tube the opposite condition prevails. This, however, suffers
modification between limits.
18
R a di u m
The mode of application of these radio-active elements differs from
that of the Roentgen rays; for instance, the radio-active Salt is usually
applied to the affected part in close proximity to the disease; therefore,
we have a given amount of high-penetrating rays springing from a point
near, and not at a distance, as is usual in Roentgen radiation. This
point is of more material interest if several sittings are given, for, should
there be an tissue between the diseased portion and the radio-active Salt,
it is not likely to receive the activity at more than one sitting.
Another point, brought out in Bayet’s work, is that the dosage of
these radio-active elements can be measured with an exactness absolutely
impossible in Roentgen radiation, and, while this is true to a great extent,
the variation in the amount of radiation from a Crooke's tube is not
of sufficient importance to cause it to be made an issue. Furthermore,
the idiosyncrasies that exist to both forms of radiation cause more
anxiety and are more important than the slight variation in dosage.
From the physical difference existing between these two forms of
radiation, it would be expected that the effect on tissue would also
be materially altered; and this view is substantiated by observation.
It might be said that the reaction produced by these radio-active salts
is decidedly more intense, is usually confined to a limited area, and is
in turn followed by a fairly rapid restoration of the part; the same degree
of reaction produced by the Roentgen ray would be more wide-spread,
the damage to the tissue in the affected part more uniform, and healing
extremely slow.
Even the reaction of a chronic character caused by these radio-active
elements will rapidly disappear if the process has not been allowed to
progress too far, while the same amount of damage done by the Roent-
gen ray would produce results that might last a lifetime.
Curiously, however, the varying susceptibility to these radio-active
elements seems to be in greater proportion than to the Roentgen radia-
tion. Many observers have called attention to the severe reaction that
is frequently seen; it is most alarming when it occurs, and is likely to
cause considerable anxiety. In a person of good physique it is not likely
to result seriously, but in the weak and debilitated it may lead to serious
consequences; the intense, rapid inflammation may lead to an extensive
cellulitis, with its train of concurring symptoms, and usually follows the
course natural to that condition, quite in contrast to the application of
the Roentgen ray. On the other hand, cases are often seen in which it
appears to be quite impossible to produce the expected reaction, and the
tolerance almost borders on immunity.
The fact that Roentgen burns have been treated and healed by
radium is sufficient to prove their wide variation. -
In cancer of the uterus, radium seems to possess a control not ob-
served with any other form of treatment, and while rarely permanent,
gives comfort to the patient and materially alters the course of the
disease.
These elements can be applied in cavities in which it is impossible
to bring the radiation from the Roentgen tube without penetrating the
intervening tissue, and it is in this field that the results seem to be some-
what better than those from the Roentgen ray. Such conditions as
polypi of the larynx can be treated without injury that leaves the imprint
of previous treatment on the overlying skin. In some instances, car-
19
R a di u m
cinoma of the palate and others of the buccal mucous membrane have
been healed. The cosmetic results are exceptionally good, and possibly
in those cases in which the Roentgen rays have failed radium often pro-
motes the desired results. In deep cancer the choice between massive
doses of deep radiation and the employment of these radio-active ele-
ments must be considered an open question.
The comparison of dosage between these two forms of radiation
is an impossibility. The existing difference in their physical nature,
their physiologic action and the mode of application does not permit it.
The wide difference of opinion existing between individuals using the
same form of radiation makes it difficult to analyze results, which in all
events depend largely upon the manner and skill of employment rather
than the quality and quantity of apparatus. Therefore at present dosage
in all fields of radiation is a variable quantity that must depend entirely
upon the opinion of the operator.
Radium in Internal Medicine.
L. G. Rowntree and W. A. Baetjer, J. A. M. A., 612: 1438–1442,
Oct. 18, 1913.
Radium as a drink cure : Radium emanation in solution is admin-
istered by mouth by varying and increasing doses (330, 1,000, 2,500,
5,000 10,000 Maché units), repeated three times a day. Lazarus has
introduced a sipping cure in which small amounts of radium emanation
are drunk many times during the day, thus keeping a certain amount of
the emanation constantly present in the body. This method is well
adapted for general use.
As inhalations: This is the best but also the most expensive method
of administration.
Indications: The value of radium is unquestionably established in
chronic and subacute arthritis of all kinds (luetic and tuberculous ex-
cepted), acute, subacute and chronic joint and muscular rheumatism
(SO-called), in gout, sciatica, neuralgia, polyneuritis, lumbago, and the
lancinating pain of tabes.
Table 9:—Summary of results of radium treatment in various
groups studied.
Diseases No. of Cases Improved
1. Chronic arthritis .............................................. 411 371
Arthritis deformans .......................................... 24 16
Muscular rheumatism ...................................... 59 49
2. Gout …..........…..…...... 166 86
3. Neuralgia .......................................................... 59 47
4. Sciatica ..................…................................... 115 91
Lumbago .......................................................... 5 4
Polyneuritis ...................................................... 8 8
Neuritis ............................................................ 5 2
5. Miscellaneous .................................................... 186 . 163
Total ...............................…................. 1,038 837
R a d i u m
On the Use of Radium for Local Application Within the Body.
A. C. Jordan, Lancet, 2: 1742, 1909.
In the interior of the body, as the mouth, throat, esophagus, rectum
or uterus, there seems to be a very real indication for the use of radium.
The author describes a method devised for this purpose. He uses
radium emanation in sealed glass tubes. The emanation is obtained from
a solution of 400 milligrams of radium bromide. The solution is
kept in a flask to which is attached a Töpler air-pump. The air in the
flask is kept partially exhausted, and whenever any radium is required
the pump is worked until the pressure is so low that the solution com-
mences to boil. Radium emanation is carried with the water-vapor and
residual traces of air into the tube leading out of the flask; this may
then be collected in a small length of glass tubing inverted over a cup
of mercury, and the tubing sealed in the flame. Thus the original stock
solution is never touched. The radio-activity of the emanation tube
begins to decay, so that in about four days it has lost half its radio-
activity. But while the emanation in the sealed tube is decaying, the
original radium (which had lost an equivalent amount of radioactivity)
is recovering. With a stock solution of 400 milligrams of radium
bromid, about 40 milligrams of emanation can be withdrawn daily with-
out diminishing the value of the solution.
Every glass tube of emanation is enclosed in a length of lead
“compo” tubing, the ends of the metal being closed down over the glass,
rounded off, and welded up. All the soft beta rays are absorbed in this
metal (the alpha rays cannot penetrate the glass) while some of the
hard beta rays and practically all the gamma rays are able to escape.
The metal tubing is put in a rubber tube the ends of which are closed
by a silk ligature, a considerable length of silk being left attached to
one end. The tube is then ready for insertion into the rectum or cervix
uteri in a case of recurrent or inoperable carcinoma. A 10 milligram
tube may be left in situ indefinitely (all night and through a greater part
of the day) without fear of producing any destructive action on the
normal tissues.
An advantage in using sealed tubes of emanation over glass tubes
containing crystals of radium bromide is that there is considerable risk
of losing a valuable tube of radium crystals if it be left in the rectum,
while the loss of a tube of emanation is not serious. Another advantage
is that the whole length of an emanation tube is uniformly radio-active,
while the crystals fall to one end of the tube. The author wishes to
impress the fact that this method is exactly the same in its nature as the
use of crystals of radium bromide in sealed tubes, while being more
convenient and not involving the risk of losing valuable tubes of radium
salts.
Considering the enormous energy given out by radium, and con-
sidering that the alpha rays possess about a hundred times as much
energy as the beta and gamma rays together it is obviously a matter of
great importance to decide whether it is not possible to use the alpha
radiation in treatment. This can be accomplished by exposing a nega-
tively charged conductor—for example, a wire—to the emanation in
order to concentrate the maximum possible quantity of active deposit
on its surface. Thus, surfaces are obtained whose activity per unit
area is enormously greater than could be obtained in any other way.
21
R a d i u m
Needles thus rendered active could be inserted in malignant growths
and exert all their energy. As the needles decay to half-value in about
twenty minutes they would have to be recharged and could be reinserted
into another part of the growth.
Influencing the Rapidity of Oxidation of Red Blood Corpuscles
by Potassium and Radioactivity. e
Philipp Ellinger, Hoppe-Seyler's Ztschr. f. physiol. Chem., 116:
266, Berlin, Oct. 22, 1921.
Potassium plays a part in maintaining the ion equilibrium in body
fluids, and possesses radioactive properties. It sends out beta and gamma
rays, of which the former rays show especially great penetrating power.
Bird blood-cells were used to determine the power of oxidation. Intact
erythrocytes do not permit cations to pass, so that the rapidity of
oxidation is practically uninfluenced by changes in the cation content of
the medium. The bird corpuscles are washed in the centrifuge, allowed
to freeze at —2°, thawed, mixed with the examining fluid, and oxidizing
power of the cell-suspension is determined by Barkoft's method. As
controls, the same kind of blood corpuscles were suspended in Ringer's
solution, both with and without potassium. The glassware used was
approximately the same size, so that the results read off in millimeters on
the manometer were comparable, after correcting for the thermoba-
rometer. Temperature of the thermostat was 37°-39°. The published
tables show that the presence of potassium in the medium is absolutely
essential for the oxygen respiration of the blood cells. When the amount
of potassium reaches a very low level, the oxidation power falls about
%, while an increase in potassium raises it. It is undecided whether the
influence of potassium depends upon the ion or upon the radiation.
Potassium can be replaced by rubidium but not by cesium. The rays
are not capable of replacing a lack of potassium. The emanation cannot
accelerate the oxidation process. Fluorescin, even in small amounts,
hinders respiration, while eosin in small doses furthers, and in large
doses hinders it. The furthering action seems to be independent of the
potassium action, and immediate. It has not yet been shown that other
radio-active elements can replace potassium.
The factor of Emanation in Radio-Active Baths.
W. Mittenzwey, Deutsch. med. Wehnschr., 47:961, Berlin, Aug.
18, 1921. e
Observations of the effects of radium baths on 636 patients at
Oberschlema are recorded; one spring of 640 daily liters contains 3,200
Maché units for drinking purposes, others contain 250 to 900 Maché
units per liter and an emanatorium for inhalation purposes contains 15
to 25 Maché units per liter of air. The indications for treatment are
the same as those for Wildbad and Gastein.
In chronic arthritis, pain was markedly diminished and function im-
proved in the inflammations remaining in the periarticular tissues after
acute joint rheumatism, also in primary chronic polyarthritis with cap-
sular hypertrophy and exudation, but less favorable results were seen in
22
R a d i u ºn
the more chronic cases with capsular shrinking and cartilaginous de-
struction; ankyloses and cicatricial changes were improved; the smaller
joints showed better results than the larger ones.
Unfavorable effects were seen on the heart, vascular and nervous
systems. Careful dosage is required in myocarditis associated with con-
gestion phenomena; slight disturbances of cardiac activity were favorably
influenced, especially from the improved diuresis. In arteriosclerosis the
blood-pressure sinks; if the pressure sinks 50 or more mm. it can be
used as a differential diagnostic measure in the presence of vasomotor
disturbances of the sympathetic or hyperfunctioning endocrine glands;
primary hypertension can be distinguished from the secondary form.
The effects in pure sclerosis and presclerosis can be determined early
and are available prognostically in cases of increased resistance in the
arteriocapillary system, but less definitely when neurasthenia is a com-
plication. The best results obtain in the field of nerve pains, as in true
postinfectious (grippe) neuritis and in acute rheumatic nerve pains, es-
pecially in sciatica, tabes, syphilitic diseases of the central nervous sys-
tem and muscular rheumatism. Visible results obtain in psoriasis.
Local emanation radiotherapy is governed by the theory that weak
dosage favors biochemical processes, strong ones inhibit and very strong
doses destroy. The processes favorably influenced are metabolism, the
general condition and all the basic processes of life. Only weak (250
Maché units) and strong (900 Maché units) were ordered. Poor results
were seen with insufficient dosage, the best dosage being 200 to 1,000
Maché units. All other kinds of therapy were omitted. All the patients
felt the need of rest after the treatment. Emanation therapy of 300
Maché units or more per liter of water is a stimulant and promotes the
processes of life. It is indicated in disturbances of cellular and body
metabolism such as the gouty-rheumatic diseases and senile phenomena.
Diseases with increased metabolism, asthenia and circulatory distur-
bances are not suited to emanation therapy.
Radium in Internal Medicine.
A. H. Werner, Med. Summary, 41: 271, Feb., 1920.
The author states, “The use of radium in the treatment of internal
disease is not quite old enough to give a full appreciation of its value as
a therapeutic agent. The indications and contraindications have not been
fully ascertained.”
In discussing the method of inhaling radium and that of taking it
in the form of a drink the author says, “I maintain that the inhalation
of 20,000 Maché units is not equal in action to 10,000 Maché units in
a drinking cure. On the other hand, we must assume that the cure in
an emanation is equal to the drinking cure, especially in diseases of the
joints. . We have observed that in drinking cures with high doses of
emanation (20,000 M.U.p.d.) no benefit was obtained by the patient, but
the cure in the emanatorium brought full relief.”
“The drinking cure, the inhalation cure and the radium baths all
have their place in the treatment of internal diseases and it is for the
physician to decide, which will be of the greatest benefit to his patient,
frequently a combination of all three is indicated. -
23
R a di u m
“The influence of the emanation on the blood picture: My experi-
ments in a very large material can be summarized as follows: In a
great number of patients we see a very great leukocytosis; even patho-
logical hyperleukocytosis can be increased. The increase can be higher
than 80 per cent; however, the differential count may remain unchanged.
In most cases we have a relative increase in the mononuclear cells and
in Some cases this may reach the extreme. Especially does this occur
in the emanatorium treatment but may also happen in the drinking cure.”
Cases. “A. H., forty years old; chronic progressive polyarthritis
and psoriasis, white cells count 10,500. After two hours’ treatment in
the emanatorium, 100 Maché units per 1,000 c.c. of air, leukocytosis
19,180.” -
The emanation acts as a diuretic.
Radioactivity in Therapeutics.
J. B. Bissell, Med. Rec., 93: 142, 1918.
To particularize as to the lesions most amenable to radium therapy,
there can be no question of its efficacy in certain benign and malignant
skin lesions.
In relieving the skin cancers about the face radium is practically a
certainty. This is fortunate, as in most neoplasms of this part of the
body, the necessary surgical procedure is mutilating and leaves ugly
deformities. Rodent ulcers are invariably cured if not too extensive, and
even the larger ones are favorably affected if properly and persistently
treated by radium applications. Neoplasms of the mucous surface of
the lips and cheek have a high degree of malignancy and are an excep-
tion to this rule. Prophylactic treatment of suspicious growths or abra-
sions of the lip during the cancer age is advisable. Leucoplasia of the
tongue responds favorably to scientifically applied doses of radium.
Recurring nodules in the skin following removal of cancerous
breast should always be treated by radium. If the treatment is persisted
in with proper dosage, it is usually successful. Often the nodules absorb
only under quite severe radium burns. Inoperable lymphosarcoma of
the neck and mediastinum fortunately disappears quite often under heavy
radium applications. The results in some of these patients treated by
radium are so astounding as to be almost incredible.
In inoperative uterine carcinoma of extensive recurrence radium
offers practically the only hope. Where radium can be applied to the
uterine canal in fairly large quantities, for a suitable period, where the
immunological forces of the human tissues can still be stimulated, where
the patient’s resistance is not exhausted, and the toxemia is not too great,
we may expect many favorable results. Radium is very useful many
times in cervical and uterine hemorrhages following recurring malignant
ulceration; where pressure, styptics, and packing fail, radium in large
quantity may produce thromboses of the vessels and thus check the flow
of blood.
Brilliant results are obtained in the treatment of fibroids of the
uterus by the use of radium. The symptoms improve, the tumors de-
crease rapidly, the menstruation becomes regular and the patient is
again a normal woman even to the extent of pregnancy if still in the
child-bearing age.
24
R a d i u m
Circumferential cancer of the rectum when inoperable is ideally
located for treatment with radium, and numbers of such patients have
been restored to health.
Striking cures of sarcoma of various types in the long bones are
frequent in the author's experience. Notably a case seen with Dr. Sayre
of spindle-cell origin in the head of the tibia in a young woman, 22 years
of age, and also one in a boy of 18 years of age with a spindle-celled
Sarcoma of the femur, superiostealin origin, treated with Dr. Coley, are
among the numerous ones seen in recent practice.
Physics and Chemistry for Medical Men.
A. Fernau, Wien. klin. Woch., 31 : 1160, 1918.
1. Transformation products of radium.
Radium (atomic weight 226) gives off two inert gases: inactive
helium (atomic weight 4) and radio-active radium emanation (atomic
weight 222). All three emanations, radium, thorium, and actinum, are
inert, monatomic gases. Radium emanation gives radium A which in
turn gives off radium B, and this radium C, radium C', C", radium D,
radium E, radium F, and finally, radium G, inactive lead. Radium A,
B, C, C, C", have an induced activity lasting about three hours; a
residual activity remains from which radium D, E, and F are produced.
Radium A and radium F are isotopic with tellurium, Radium B and
D with lead, radium C and E with bismuth. The lead obtained as the
end product of uranium disintegration is chemically identical with Or-
dinary lead, but also has a different atomic weight.
2. The rays of radioactive elements.
It is rather difficult to define a ray but the following is the least
objectionable definition: the most rectilinear orbit or direction of trans-
mission of any induced energy. The different kinds of rays are differ-
entiated by the degrees in which they are absorbed, and are classified
on this basis into soft and hard rays. Penetrability of the ray is depen-
dent not only upon their velocity but also upon their mass.
X-rays are helium atoms minus two negative electrons, thrown off
with a velocity equivalent to 1/10 that of light. Beta rays are negative
electrons and are much lighter than alpha rays, and are similar to the
cathode rays in Geissler tubes. Their mass is about 1800 times smaller
than a hydrogen atom, and about 7000 times smaller than a helium
atom. Therefore the beta rays have a much greater penetrability
(hardness) than the alpha rays. Beta rays are not homogenous. It
has been proven in magnetic fields that both alpha and beta rays have
II12.SS.
Gamma rays have no mass or charge, and possess therefore ex-
traordinarily large powers of penetration, greater than that of the hard-
est roentgen rays. They are not completely absorbed by lead plates
20 cm. thick, their mean path is about 250 m., their hardness so great
that they do not give sharp X-ray photographs.
The intensity of the rays varies inversely with the square of the
distance. This should be borne in mind by the physician, especially
in deep ray exposure.
25
R a d i u m
Reference Handbook of the Medical Sciences.
T. L. Stedman, 7:466, 1917, 3rd ed. (Pac-Sto).
“The indications for the internal use of radium are vague and also
the contraindications. Cases with severe endocarditis, pericarditis, de-
lirium cordis, severe neurasthenia and hysteria, especially in the meno-
pause, are given by Von Noorden as contraindications to the use of
radium internally. The value of the medical uses of radium has been
greatly exaggerated and reports are confusing. The great variations
in dosage add to this. There seems no question, however, that benefit
has been derived in certain forms of gout and chronic rheumatism and
neuritis. The effect upon the hematopoietic tissues either stimulative or
destructive must, however, be borne in mind. Improvement has also
been reported in cases of pernicious anemia, leukemia, erythrocythemia
and in hypertension; in the latter the blood pressure has been reduced to
normal and the subjective symptoms are said to disappear.
Internal therapy by radioactive substances is still too recent to ex-
press a very decisive opinion regarding its value. The duration of
favorable results reported is not known in most instances. There is
need of more control cases and particularly of a large number of cases
worked up in detail and followed to end results before certain conclu-
sions may be drawn.”
The Elimination of Soluble Radium Salts Taken Intravenously
and per os.
Harvey A. Seil; N. Y. M. J., 101: 896, May 1, 1915.
Radium taken into the body is continuously disintegrating with
the formation of the gaseous radioactive substance, radium emanation.
This gas is carried by the blood to the lungs, where the emanation passes
out of the blood by diffusion, and is lost from the body in breathing.
Conclusions: Taken by mouth, a much greater part of a soluble
radium salt is eliminated during the first three or four days, but after
that, the rate of elimination is sensibly the same as when the radium
is introduced by intravenous injection.
The main part of the radium is eliminated in the feces. When
the radium is taken by mouth, a smaller proportion of the excreted
radium is found in the urine than when the radium is injected intra-
venously. From 25 to 35 per cent of the radium taken by mouth re-
mains in the body four to five days after ingestion.
Radium solutions taken repeatedly by mouth have a cumulative
effect. However, the elimination of radium taken by mouth is about
twice as rapid as when the radium is injected intravenously. Therefore,
there will be required about twice as much radium to produce a given
result when the radium is taken by mouth.
Search for Thorium in Cancerous Growths.
J. Joly, Scient. Proc. Roy. Dubl. Soc., 14:345, 1915.
In an article in the Practitioner, March 1914, Dr. Lazarus-Barlow
records observations showing the presence in some cases of abnormally
large quantities of radium in morbid tissues. His experiments refer
to cancerous and malignant growths of various kinds. .
26
R a di u m
These results may be very significant, for, of course, the radiations
from the radio-active derivatives of radium are involved, and it has
been shown by observation that feeble gamma radiation may accelerate
the growth of such morbid tissues. Nor is it difficult to perceive a priori
reasons for the influence of the rays when their remarkable ionizing
powers are considered in connection with the chemical activities in-
volved in metabolism.
Dr. Lazarus-Barlow's results are, however, by no means uniformly
positive. The amount of radium present cannot in every case, be claimed
as abnormal. This fact suggested the desirability of seeking for the
presence of thorium in such growths.
Thorium is much more abundant in Nature than radium; in radio-
activity, however, the amounts present of the two series—i. e. Of the
radium series of element and of the thorium series—do not differ
seriously. Then if these elements are taken into the body, in amounts
proportional to their relative abundance in the surface materials of the
earth, their radio-active influence upon growth, etc., will be much alike
in importance, and if by any processes segregation of these elements
is equally promoted in any special organ, the effects will be similar in
kind and degree. As nothing is known about the causes at work in the
observed segregation of radium, it might well be that similar causes
operated to segregate thorium; such causes might even operate in the
latter case with greater efficiency than in the former. The author there-
fore proceeded to investigate and records some experiments.
The procedure adopted was to break up the tissues by maceration
in strong HCl over the water-bath. An almost perfect solution was
obtained in this way. The solution being dealt with is brought to such
a dilution as to boil freely. It is enclosed in a flask, and during brisk
ebullition a steady current of air is drawn through the flask above the
surface of the boiling liquid, and thence passes through a condenser,
and from this through drying tubes to a gold-leaf electroscope. The
condenser removes the steam, etc., returning condensible vapors to the
flask; the air is further dried in the short drying tubes and finally enters
the electroscope with much of the thorium emanation still present.
If the normal rate of loss of charge by the leaf is accelerated, the
significance of this acceleration is determined by adding to the boiling
liquid a small known amount of a solution of thorium. The accelera-
tion in the rate of collapse of the leaf produced by this enables the
readings to be calibrated.
In this method the effects due to any radium present may be neg-
lected if the precaution is taken of boiling off the radium emanation be-
fore connecting the flask to the condenser. This emanation only very
slowly regenerates in the solution, while the regeneration of the thorium
emanation is very fast.
The sensitiveness of the results to be recorded is determined by the
following experiment: -
Into one of the solutions, which had already been tested, and which
possessed a bulk of 900 c.c.'s, a quantity of standard solution of thorian-
ite was put, containing 16 x 10° gram of thorium element. The gain in
rate of collapse of the leaf was 8 scale divisions per hour. Hence one
scale division per hour indicates the presence of 2 x 10° gram of
thorium. If the total weight of tissue dissolved in this solution had con-
27
R a di u m
tained as much as 2 x 10" gram of thorium, this would have accelerated
the collapse of the leaf by one scale division per hour—an acceleration
quite determinable.
The following experiments were made:
I. Cancer involving stomach and lymphatic glands. Examination
of sections under microscope showed that about one-fifth part of
stomach was actually composed of cancer-cells.
145 grams were heated in 200 c.c. strong HCl. The solution was
made up to about 800 c.c. with distilled water. The whole solution
was treated in the manner described above.
The electroscope, which had been steady at a rate of loss of 3
scale divisions per hour before ebullition began, maintained this rate
unaltered. Hence thorium in amount greater than 2 x 10° gram, was
not present. This amount would be about 1.4 x 10' gram per gram of
tissue. The experiment does not bear on the presence of radium as the
solution was vigorously boiled before attaching to the electroscope.
II. Liver in part replaced by cancer. Conclusion of this experiment
is that more than 2x10° gram of thorium was certainly not present, i.e.,
about 8 x 10° gram per gram.
III. Sarcoma of ovary. Conclusion—No thorium was present in
amount exceeding about 9 x 10° gram per gram. -
IV. Myoma of uterus. Conclusion—No thorium exceeding 1.3 x
10' gram per gram.
V. Cancer of breast. Conclusion—No thorium exceeding 2.2 x
10' gram per gram.
VI. Sarcoma of knee. Conclusion—No thorium exceeding 2.5
x 10' gram per gram. -
It is desirable that the above results—which, as will be seen, are
consistently negative—should be extended. They possess a practical
bearing, for if it can be shown that thorium introduced into the system
is in every case, again eliminated while radium compounds remain
stored or become segregated within the body, the use of thorium for
internal administration would possess advantages over the use of
radium.
A Preliminary Report on Uranium, Radium and Vanadium.
Richard B. Moore and Karl L. Kithil; Department of the Interior;
Bureau of Mines; Bull. 70, Mineral Tech. 2, Wash. Gov. Print. Off.
pp. 1-101, 1913.
An abstract of part of the report of the Radium Institute of
London: -
“Statements from another source indicate that 80 per cent. of cases
of arthritis treated with comparatively strong doses of the radium emana-
tion dissolved in water are either cured or greatly benefited. The dosage
in such cases is as follows: The radium emanation obtained in one week
from one gram of radium bromide in solution is dissolved in 17 liters
of water. One hundred c.c. of this solution is taken twice a week by
the patient. This means that 1 gram of radium bromide can be used
for treating about 170 patients at one time. The exploitation of radium
in medicine has been carried even further. Inhalers, which usually
involve the inhaling of oxygen also, and “bath salts', containing small
28
R a d i u m
quantities of radium, are to increase; their value has by no means been
thoroughly demonstrated.”
Thorium X in Internal Disease.
O. Meseth. Münch. med. WChmschr. 602, no. 38:2105-2110, Sept.
23, 1913.
Thorium treatment in :
Sciatica—male, age 42; right atrophy; pronounced Laseque; thor-
ium X 50-150 e. S. u. given as a drink; drank total of 2300 e. S. u. ;
at first general improvement; then recurrence of pain; 3 eucaine injec-
tion; relief only temporary; 7 injections of 100-300 e. S. u. thorium X;
patient now feels pain only occasionally.
Sciatica—male, left sciatica since 3 months; salicylate and hot air
baths bring relief only when resting; eucaine injection brings 2 days
relief; thorium X ordered as a drink; 16 drinks at 50–100 e. S. u. com-
bined with 2 more eucaine injections; treatment brought complete relief.
Articular rheumatism—female; in 1910 articular rheumatism; fre-
quent pains in ankle joints since that time; recently also pains in wrists;
both ankles, left wrist and carpometacarpal joints swollen and tender to
touch; walking impossible; thorium X injections, twice 200, twice 300
and 100 e. S. u. ; pain rapidly decreased; result of treatment, no swell-
ing, no pain, joints freely movable, walking normal.
Secondary anemia—no sex, no age given, ulcerated stomach with
intense pain and periodic bleeding; thorium treatment, 17 injections of
50-200 e. S. u.; after the acute stomach symptoms subsided, the ery-
throcytes increased from 2,500,000 to 4,500,000; hemoglobin remained
at 55% ; general health good.
29
R a d i u m
SECTION II
RADIUM IN SURGERY
United States Radium Corporation
New York
R a d i u m
SECTION II
RADIUM IN SURGERY
Radium in Surgery.
W. S. Schley, New York M. J., 114: 573, Nov. 16, 1921.
Observation of several thousand cases during sixteen years' ex-
perience results in the conclusion that radium is applicable as an adju-
vant measure to surgical procedure or as an ameliorative of surgical
conditions. Radium has a good effect on the capillary nevus, and bril-
liant results have been secured in the larger hemangiomas, some of
which had been operated upon repeatedly without success. Keloid has
been removed leaving a flexible, soft skin and linear cicatrix; warts and
keratoses vanish after one treatment, as do intractable patches of ec-
zema and psoriasis. Inoperable carcinomas of the mouth, tongue, phar-
ynx and esophagus usually show an initial retrogression but are little
affected after this has passed, and progress unfavorably, although life
is often prolonged and pain relieved. Cases of apparent cure have been
reported at the end of two years. Internal malignancies have not yet
been conquered but merely retarded. These cases can be injured se-
verely by improper treatment. In one case of carcinoma of the urethra
and contiguous part of the bladder, the bleeding has stopped at the end
of a year’s treatment, the tumefaction is half its former size and the
health of patient is apparently unimpaired. Inoperable cancer of the
uterus is at times wonderfully benefited and occasionally cured. Carcin-
oma of the vagina does not improve. Fibroid uterus reacts astonishingly.
A case of enormous spleen of the Gaucher type has been most success-
fully treated with radium. The size has been greatly reduced, the hemo-
globin of the patient raised from 39 to 76% and her weight from 132
to 155 pounds. After 4 treatments she is still improving and working
hard daily. The enlarged thymus gland in infancy and childhood has
been successfully treated, and radium exposures have even been given as
an emergency measure in acute suffocation. Radiographs have shown
disappearance of the tumor in these cases and relief is often noticeable
in twenty-four hours. Lymphosarcoma of the glandular system and
mediastinum are showing two to four year cures. Inoperable conditions
of the breast are arrested and pain relieved.
Radium, therefore, affords a distinct adjunct to the surgery of both
malignancy and benignity, the technic of its employment having every-
thing to do with its success. Correct dosage is the one fundamental
principle of radium therapy and can be learned only by long experience.
Undertreatment may be as productive of harm as overtreatment. As
to its postoperative value in malignancies, there can be no doubt. Pre-
operative treatment over the many lines of lymphatic extension both
within and without the operative field will increase the number of sur-
gical cures. In the use of radium the chief factors to be considered
are: the different reactions established in different tissues, length of
exposure, quantity of radium salt or emanation, kind and quantity of
filtration or screening, character of growth and location, form of treat-
ment—surface or implantation and from what direction, frequency and
31
R a d i u m
size of doses. While radium is at present most useful in the epiblastic
surface tumors, its application is being constantly extended. The de-
velopment of radium treatment will rest with the clinician rather than
with the laboratory worker and radiologist, unless a closer relationship
can be established between the pathologist and the surgeon than has
formerly existed.
Radium: Its Therapeutic Uses in Surgery.
Arnold Schwyzer, Minnesota Med., 4: 533, Sept., 1921.
The uterus is a favorable area for the treatment of tumors. The
writer has observed the cessation of profuse menorrhagia in uterine
fibroid and an almost complete disappearance of the fibroid itself,
which was the size of a three months pregnancy, after a twenty-
four hours' vaginal application of 50 mg. of radium element. He
has not used radium in fibroids larger than a uterus 4 months preg-
nant. In all cases of simple uterine bleeding, menorrhagic or metror-
rhagic, a diagnostic curettage should be made. Intra-uterine application
of radium can be used at once, or it may be introduced vaginally. In
intra-uterine application, nausea may be severe, a watery discharge may
follow the treatment for months, and if even very slight and quite old
inflammatory residues exist in the adnexa, unpleasant results may appear.
Badly advanced cervix carcinomas with involvement of the vagina
forming foul ulcerated craters quite commonly improve amazingly. If
a return of the growth occurs, there comes a time when radium has no
further staying effect; the tumor then runs wild. Two cases of car-
cinoma of the upper jaw that had been operated on elsewhere came to
the writer three years ago. He first resected atypically extensively,
then applied the hot soldering iron to the limit of permissibility; 5,000
mg. hours of radium were given within a week starting a week or so
after the operation. Both patients are still well. In one case of car-
cinoma of the base of the tongue, the tumor was removed by a lateral
submandibular incision; radium was placed into the bottom of the re-
mainder of the tongue, and close watch kept for sudden edema of the
larynx. Later the wound gradually opened somewhat, and now, at the
end of a year, the writer has put a pedunculated flap over the opening.
In another case, in which a tumor of the size of a tangerine filled the
back part of the mouth and larynx, plugging the entrance to the larynx,
the large mass was removed from the posterior wall of the pharynx, and
50 mg. of radium inserted and packed tightly. The patient has had no
recurrence for two years. In 3 cases operated on six years ago, what
seemed clinically and microscopically to be a struma proliferans of
Langhans (a form of adenocarcinoma of moderate malignancy) was
extensively excised and strongly treated with radium, and has given no
further trouble. In carcinoma of the breast, the writer gives pre-opera-
tive x-ray treatment for two days in order to stun the cells enough to
make implantation less likely. The atrophic forms, which so often come
late upon the operating table, are definitely benefited by radium or x-ray.
32
R a d i u m
Radium Therapy as an Adjunct to Surgery in Inoperable
Malignancy.
William D. James and Albert W. James, South. M. and S., 83: 218,
May, 1921.
Whether or not inoperable carcinoma of the uterus, which has
been treated by radium, should be operated upon after all the gross
signs have cleared up, is the question discussed. In 15 such cases re-
ported by the authors, it was found that radium therapy had checked
the progress of the disease to such an extent that the clinical signs,
both local and general, abated until vaginal examinations failed to reveal
further manifestations of the malignant condition.
In these cases the radium was inserted within the birth canal in
direct contact with the diseased areas. Particular attention was paid
to thorough exposure of the cervix, and the radium was left in place
for a primary dosage of 400 to 600 mg. hours. The radium was care-
fully screened and the rays filtered through the containing glass cap-
sules, an aluminum or brass capsule, and one or more sheets of lead-
foil of 1 mm. thickness, the whole radium body with the screens and
filtering substances being rapped in rubber tissue and further filtered in
this way. The amount of radium used was from 35 to 60 mg. The
second irradiation was given within ten days or two weeks, and subse-
quent treatments at two-week intervals, then at three, then at four-week
intervals, over a period of several months, or as long as the condition
seemed to require. During the treatment, patient’s general health was
carefully looked after; tonics of iron and arsenic were prescribed, to-
gether with nutritious diet. In connection with the irradiation at the
site of disease, a thorough and systematic exposure of the patient’s body
to the x-rays was made. The results show that after four radium expo-
sures the hemorrhage was checked or had disappeared in practically
all cases. General upbuilding of body weight and vitality followed.
Several patients who were bed-ridden were able, after two months of
treatment, to attend to light household duties and to be up and about.
In all cases the vaginal discharge became somewhat lessened after the
second treatment and usually stopped entirely after the fourth applica-
tion. The blood-picture, which had been that of pronounced secondary
anemia, rapidly improved. Large, ulcerated areas along the vaginal
walls and extending up into the fornices healed with a minimum of cica-
tricial tissue formation. Nodular and cauliflower-like growths on the
cervix disappeared and the healing process took place so smoothly that
often it was difficult to discern where the growth had been. All patients
were instructed to report for reexamination every three months after
discharge from treatment, or earlier if symptoms developed.
In many of these cases, the clinical manifestations having so com-
pletely disappeared that the authors are “tempted to call the results
cures,” the question is raised whether operation should be performed
while the patients are apparently good operative risks. No opinion is
advanced by the authors except that they find in the literature that re-
currences in such cases prove refractory to further irradiation.
In the cases which proved hopeless, among the authors' patients,
radium treatment was continued for about a year, some of them having
received over 5,000 mg.-hours of irradiation, and the relief was such
that, even when in the throes of a rapidly developing fatal cachexia,
33
R a di u m
the patients were comfortable and were not compelled to resort to
opiates.
Uses of Radium in Surgery.
E. E. Bamford, J. Iowa State M. S., 11: 167, May, 1921.
It is not clearly understood what properties in radium rays cause
the changes in cancer cells. If this treatment is to surpass previous
methods it will be due to its effect on metastasis, since it is at this
point that surgery fails. It is at present believed that the hard beta and
gamma rays will penetrate tissues about 5 cm. with destructive effects
on the cancer cells, and that the normal tissue-cell will withstand a radia-
tion which destroys the malignant cells, the rays acting locally upon
them. If there is a constitutional factor in the causation of cancer, then
radium acting locally cannot be regarded as a cure.
An authority who has studied pelvic metastases states that in from
40 to 50% of operative cases of cervical and uterine cancer, metastases
are found in the pelvic nodes, which would seem to indicate that even
Wertheim's operation gives little assurance that all outlying cells are
reached. Here radium offers new hope. Radium is preferable to
surgery in that it does not require major or cutting operations and does
not disfigure. It should be used if possible in inoperable cases, for
treating early cancerous lesions of the cervix uteri, rectum, mouth,
tongue, throat and skin; many give radium first choice. Attention is
called to the existence of radium toxemia, noticeable in most cases.
When this reaction is considerable a temporary discontinuance of treat-
ment is required.
The Duty of Every Surgeon to Employ Radium.
E. O'N. Kane, Internat. J. Surg., 32: 193, 1919.
This author's belief is that, just as much as a surgeon finds it to
his advantage to employ a full line of surgical instruments, a capable
anesthetist and the x-rays, it would be equally to his advantage to use
radium. Surgery is not so narrow a profession as to confine the
operator to the limited services of a skillfully handled knife. The
patient entrusts himself to the surgeon expecting him to save or pro-
long life and alleviate suffering. If he does not include radium in his
outfit, he cannot, in many cases, fulfill this trust. While all operators
may not be in a position, personally, to own an adequate supply of radi-
um for their patient’s needs, it ought to be possible for them to rent
what they require. Every hospital should, as a matter of essential im-
portance, secure a sufficient amount, if it has not such already, and the
surgeons and physicians connected with the instititution should make it
their business to see that it continually increases its numbers of milli-
grams with the same assiduity as in the acquisition of charity beds, or
any other of its life-saving agencies.
Except in some pressing emergency no surgeon would be excused
for undertaking a major operation without providing himself with the
full surgical paraphernalia. Ignorance of what was necessary for the
undertaking would be no excuse for vital omissions; nor might the plea
of poverty relieve from censure, for radium, being no longer a mys-
34
R a d i u m
terious element of rarity, anyone can avail himself of its advantages,
either through a hospital in charity cases, or through some organization
which loans it out to its members.
Unquestionably, cancers can be, and undoubtedly are cured by the
knife alone, provided the operation is done early and includes a large
area of healthy tissue. Unfortunately most cases come too late, and
the work of the operator is largely palliative, often seeming to hasten
death by producing metastases due to the laying open of lymphatic
channels and vessels for rapid constitutional invasion. Every experi-
enced operator knows how fruitless late operation is, and longs for the
day when a specific cure will be discovered. Radium is not an infall-
ible specific; it is not an absolutely reliable “cancer cure.” It has its
disadvantages, and the failures after its employment are too many to
be ignored by those most sanguine in its praises.
It has, however, cured so large a proportion of cases as to give
it first place in the management of malignancies. It can and does do
what no other means as yet at our disposal (save x-rays to a much
lesser extent) render possible. Its emanations penetrate not only into
and through all visible, tangible portions of the diseased tissue, but
beyond into those where infection is not plainly demonstrable, though
actually present. But even if radium does not effect a permanent cure
(in many cases it does), if only a clinical cure of the cancer is obtained,
if only for a year or so in hopeless, advanced cases, this is enough to
demand its employment. These patients should be given the advantage
of what little life is left to them in comparative comfort with the
hope of a cure to cheer them. Should the case have passed beyond
even a clinical cure, the use of radium tends to arrest hemorrhage,
suppress offensive odors and relieve much of the pain.
The author does not mean to imply that he advocates abandonment
of the knife. But he insists that no malignancy should be treated with-
out radium either alone or associated with x-rays, whether operated
upon or not. Its use before the operation tends to limit those dangers
attendant upon surgical manipulation whereby lymphatic, circulatory
and metastatic extensions are produced. After operation a thorough
raying of all contiguous and suspicious areas has a wonderful prophy-
lactic influence against recurrence and should never be omitted. This
influence is, of course, relative and depends largely on the amount of
radium used. Skill and judgment in its application, among other things,
lend much to its success. The knife, thermal therapy, and any other
means at command are justifiably employed in this awful disease—
cancer. Yet, singly, or altogether, none of them yields as satisfactory
effects as radium.
Though radium therapy has received some hard knocks in its
early days, due to improper and inexperienced use; though it has been
discredited because quacks have used other means, pretending they were
radium; though personal jealousy on the part of those surgeons who
were not fortunate enough to possess radium has done much to injure
its reputation; despite all this, radium stands out as a most valuable
asset to the surgeon of to-day.
35
R a d i u m
Radium, Its Present Status as Surgery’s Adjunct.
C. E. Field, Med. Rec., 95: 1081, 1919.
The author confines this paper to a discussion on the treatment of
malignant tumors. From both a practical and clinical viewpoint the
action of radium as an aid to surgery may be classified into four divi-
sions:
(1) As a substitute for surgery.
(2) Before surgical proceedings as a preparatory method.
(3) Combined with surgical procedures.
(4) Postoperative or prophylactic.
In the first group are all lesions which are inoperable or ineradic-
able by any surgical means of enucleation. In all operable malignant
conditions or when the growth is ineradicable, radium is indicated.
Radium is indicated when surgery is impracticable or impossible, be-
cause of inaccessibility of the growth, its extent, its special nature, the
malcondition of the patient because of the prolonged duration of the
disease, or in cases where excessive mutilation or impairment of normal
functions would follow a proper removal.
Malignancy involving not only the uterus and adnexa, but the
adjoining lymphatics and neighboring structures, offers no hope of cure
by any ordinary surgical method of removal. Epitheliomaſa of the ear
or eyelid, of the entire lip or of the nose are presumably inoperable
for cosmetic as well as physiological reasons. Cancers of the tongue
are now regarded by most surgeons as inoperable, and radium becomes
the remedy of election. ; :
- There is a class of cases where surgery seems to hasten the death
of the victim, because operation seems to stimulate the growth recur-
rence of the neoplasm. Melanosarcoma is such an example. The only
hope of cure in these patients is the use of radium.
There are three specific diseases where the reports of relief by
the use of radium are so definite and certain and are confirmed by so
many cases, as well as by the experiences of such a number of observers
of unquestioned skill and veracity, that radium is, from the first, the
method of choice. The diseases referred to are lymphosarcoma, tuber-
culous glands, and fibroids of the uterus.
In the second class, radium is advised as a preparatory treatment;
here opinions are divided. Many operators advocate strongly the avoid-
ance of any interference with the affected tissue by radium application
before operation, contending that such treatment destroys much of the
recuperative quality of the neighboring structures and lessens the local
vitality, and also that it interferes with the absorbing power of the tis-
sues and affects adversely the general condition of the patient.
On the other hand, many observers assert that inoperable cancer
may become operable by proper radiumization. Nogier, of Lyons, ad-
vises repeated radiation of the lymphatics of the growth at the circum-
ference of the tumor. He proposes destroying the malignant cells and
blocking off the communicating and distributing vessels. This prevents
the carrying of those cells away to form metastases. Such radiation is
to be begun at the peripheral end of the lymphatics. The author heart-
ily sanctions this pre-operative treatment.
“In the third group are the cases in which radium application and
surgery are combined. This divides itself naturally into two classes.
36
R a d i u m
First, those cases in which it is impossible to remove all the cancer
tissue and it is desirous to employ radium in combination with surgery
to obtain the effect during operation and after the time of the operation.
To do this, immediately on finishing the excision an adequate amount
of radium is packed into the wound cavity before closing. This is
allowed to remain the required period of time, after which the sutures
are drawn in to bring the wound together. Second, where a large
cancer mass is to be removed in order to shorten the time of treatment
with radiumization, and cases where the operation is simply to avoid
the necessity of absorbing a large amount of broken down cancer cells
and toxins which otherwise must necessarily be carried off by the
physiological processes of the body. In this subdivision the operation
is performed in order to facilitate the use and effect of the radium.
Surgery is employed here to assist the action of radium. No operation
for a neoplasm is satisfactory which does not remove the most widely
spread cancer tissue. In sarcomata, especially, is a wide sweep of the
excision line indicated, and the operator is never quite sure that it is
wide enough. Radium, at the time of excision, would add to the
probability of a more thorough and extensive destruction of the sus-
pected tissue without dangerous mutilation. Theoretically this is an
argument for the use of radium in all operations, for in no case can it
be certain that the knife has extirpated the furthest cancer nests. In
the removal of the cervical carcinoma, for instance, infiltration into the
broad ligaments and vagina seems to call for radium at the time of the
operation and several hours thereafter.
“In the fourth group we have postoperative prophylaxis. Of the
necessity and the values of this method there can be no doubt and yet
many well known gynecologists, as well as skilful and experienced
general surgeons, still maintain a lukewarm attitude toward radium.
There have been so many sensational claims made for radium in its
earlier day that we may excuse their skepticism. During the past two
years, however, many of the foremost surgeons have accepted post-
operative radiation without criticism. In fact, it is becoming a routine
measure with some gynecologists.
“Repeatedly, in the experience of the writer, under carefully car-
ried out radiations, malignant recurrences have disappeared. Nodules
have been destroyed and ulcerations checked. Hemorrhages have
ceased and, perhaps because of the mental benefits produced, the general
condition has greatly improved and the patient has been clinically re-
stored to health. If this is true, why not systematically make one or
more prophylactic applications of radium in every case to the involved
area at the location from which the cancer mass was totally removed
as well as to the surrounding tissues where recurrences might be as-
sumed to present?
“There is always something to be said about those cases where
operation is impossible or where recurrence is rapid and overwhelming
in its return. Such victims of malignant disease are not infrequent,
and for them there is no other chance, no other resource, except that
which may be granted by vigorous, massive and long-continued doses
of radium. It holds out for them at least some relief of pain, hemor-
rhage, odor, discharge, and other inconveniences or distress, and if
applied with confidence and belief in its efficiency, in adequate amounts,
37
R a di u m
by an expert of acknowledged skill, it may help them both physically
and mentally and restore, if only temporarily, the joy of life and hope.
We have not done all for such a patient unless this final means of heal-
ing is tried.”
Radium Versus Surgery—Some Comparisons.
C. W. Hanford, Interstate M. J., 24:930. 1917.
In the treatment of malignancy by surgery the preservation of
healthy tissue in the process of eliminating the lawless cancer cells has
not in the past been considered. The one aim has been to cut deep
enough to include all cancer cell nests.
As a result of this radicalism, when the lip, nose, cheek, or imme-
diate neighborhood of the eye is involved, the resulting scar is very
unsightly, and, while the patient is very glad to be rid of the malignant
growth, even if the mouth or eyelid should be drawn out of shape, yet
it would be much more gratifying to all concerned if the malignancy
could be obliterated without disturbing the cosmetic effect, except to a
very slight degree.
The author explains, from photographs and drawings, two cases
of epitheliomas of the lip, showing the amount of tissue the surgeon
would have to remove to totally destroy the growth, whereas the radium
treatment was just as effective, and the cosmetic result remained good.
Relations of Radium to Surgery.
D. T. Quigley, Med. Herald, 34: 5, 1915.
The author greatly praises the results obtained by the radium treat-
ment, when it is handled by a person properly trained and experienced
in its use. But a great deal of trouble and injury can be caused by
putting it into the hands of the unskilled.
The effect of radium is not the same as the x-ray. It has several
hundred times more penetration than the x-ray, the burns heal quickly
and with very little pain, and it has been found that the best treatment
for x-ray burns, x-ray eczema, and x-ray cancer is the application of
radium.
Mistakes have been made with radium by using too large a quan-
tity. If an unreasonably large quantity be used and the exposure be
too long, the patient will be overwhelmed with broken-down cells and
the resulting auto-intoxication may hasten the death of the patient.
Radium is a good thing, used in reasonable dosage.
Two of the leading clinics of Europe have substituted radium for
the knife in the treatment of cancer, but in most of the European
clinics and in the author's own work it has been reserved for inoperable
cases and post-operative treatment. In most inoperable cases the re-
sults of the treatment are very gratifying, and beyond any other treat-
ment. The first thing noticed is the disappearance of pain, then drying
up and disappearance of discharges and bleeding, then shriveling up of
the tumor mass.
Radium is indicated in every case of cancer: in the operable cases
as a post-operative treatment to prevent recurrence, and in the inoper-
38
R a di u m
able cases to relieve distressing symptoms, prolong life, and as a pos-
sible cure.
Schauta reports eleven clinical cures in twenty-two inoperable
cases of cancer of the uterus, Wertheim six out of eighteen, others in
proportion. Besides, a large number of inoperable cases have been
brought into the operable class by the retrogression brought about by
radium. No case of cancer or sarcoma should be considered hopeless
unless radium has been tried, and in no case of cancer should radium
treatment be neglected if it is possible for the patient to get the treat-
ment. Radium should not supplant surgery in any operable case, but
should be used in conjunction with surgery to get the best results. In
skin cancer about the face, radium is to be preferred to the knife, as
hardly any scar is left, and the results are at least equal to surgery.
In benign tumors the action of the radium is well brought out by Kelly's
statement that he does not operate any more for fibroma or myoma
except in the small per cent of cases where satisfactory retrogression
of the tumor cannot be brought about by the use of radium.
In keloid the action of radium is practically specific as it is also
in lupus and tubercular glands of the neck.
R a d i u m
SECTION III A
GYNECOLOGY
United States Radium Corporation
New York
R a di u m
SECTION III A
GYNECOLOGY
Radium Therapeutic Drainage of the True Pelvis.
Frans Daels, Gynec. et obst., 4:459, Paris, Nov., 1921.
One of the fundamental principles adopted by the author for the
radium treatment of tumors is to irradiate them at their base of inser-
tion and of lymphatic propagation. Three tubes of radium placed one
in the uterus, vagina, rectum or bladder, and the others on both sides
of the true pelvis, can sterilize tumors in a zone even greater than the
latter. In order to place radium tubes alongside of the lymphatic paths
and tumors of the pelvis, they are inserted in drains which can be easily
slipped under the peritoneum and vessels. There are various paths of
drainage, according to the location of the tumor and lymphatics which
are to be irradiated. After trying his method on a few patients the
author has applied it systematically to 3 cases of carcinomatous relapse
after hysterectomy, 11 cases which were deemed inoperable on account
of the extension of the tumor to the parametrium, vagina or bladder,
and in 2 cases of cancer of the cervix where vaginal hysterectomy was
also performed. No operative complications were noted. One patient
died of obstruction due to an adhesion of the intestine to the scar of a
vaginal hysterectomy. Another had a chill and fever on the fifth day
and died on the sixth from hemorrhage. In several patients the course
of the drains became infected. Three had transitory symptoms of neu-
ritis. In one a vesical fistula occurred which healed spontaneously.
Two patients had rectal ulcers, but in each a tube of radium had been
placed in the rectum for several hours. Finally, in a 60 year old woman
complete atony of the tissues was noted.
Definite clinical results are obtained by radium. Extensive ulcera-
tions have healed and cachectic patients have resumed an active life.
The first patients treated, who were given up as hopeless by surgeons,
still appear to be cured one year after the treatment. The author con-
siders the results encouraging but nothing more. He proceeds at the
present time as follows: Nonoperable cases; curettage and bilateral
drainage in one sitting. Operable cases: vaginal hysterectomy and
bilateral drainage in one sitting. Vaginal irradiation after a few days.
The Present Position of Radium in the Study and Treatment
of Uterine Cancer.
Wm. S. Stone, Surg., Gynec. & Obst., vol. 32, 509, June, 1921.
“Radium, in all recurrences, although less effective than in primary
lesions, produces immeasurably better results than operation, provided
they are not too far advanced and are not so closely related to the
bladder or rectum that to cause their regression will produce fistulae or
severe functional disorders.
“The discussion of the use of radium in primary uterine cancer
has largely centered about the term operability in defining its field of
41
R a di u m
applicability. From a practicable standpoint, the use of this term for
the classification of cases gives an erroneous idea of the importance of
the operation. In the hands of a few highly trained pelvic surgeons,
at the expense of a high primary mortality and numerous complications
and sequelae, a definite percentage of permanent cures has been ob-
tained, compared with which, because of the factor of time, our present
estimate of the value of radium must be largely measured by the pri-
mary results. Operation, therefore, for the treatment of uterine cancer
continues to be performed to an unjustifiable extent, producing un-
necessary suffering and mortality, and bringing discredit to both oper-
ation and all other sincere efforts to cure the disease. In other words,
the growth when it reaches the hands of a competent diagnostician has
extended, with few exceptions, to such an extent that palliation is the
only justifiable conception upon which to base the treatment. For
all cases, therefore, of primary uterine cancer, with few exceptions,
radium should be regarded as the method of choice. Of 34 cases, rep-
resenting about 25 per cent. of 139 patients who had applied to the
Memorial Hospital for treatment within 3 months after the beginning
of symptoms, a primary and complete regression was obtained in 16,
or 47 per cent., and a partial but substantial regression in all of the
remainder. Of the 16 cases in which the regression was complete, the
growth was limited apparently to the uterine tissues in three, and in the
other 13, the extrauterine involvement was not extensive. Of another
34 cases who had applied for treatment within 4 to 6 months after the
beginning of symptoms, the disease was considerably more advanced.
There were three, however, in which the growth was apparently limited
to the uterine tissues, and in all a complete regression was obtained. In
18, or over 50 per cent., although the involvement of the extrauterine
tissues was considerable and the regression could not be regarded as
complete in any, the disappearance of symptoms and restoration of
normal health was evidence of the value of the treatment. An improve-
ment followed the treatment in the majority of the others. There was
no improvement in a few, and in two instances the patients were, per-
haps, made worse. In forming an estimate of the permanency of the
primary results, the action of radium upon the tissues extends over such
long periods, 6 or more months, that it is idle for the purpose of sta-
tistical study to define the condition of the case until at least one year
after treatment. Without the knowledge also gained by operation
it is difficult to define results as measured by the extent of the original
lesion. There are numerous cases in these series of cases who are
apparently well 2 or more years after the treatment has been made.
“The question regarding the use of radium in the so-called border-
land cases has become a subject of frequent discussion, and it is in this
field, the writer believes, that radium has demonstrated its remarkable
value. With a properly adjusted dose and form of application, radium
may be expected regularly to destroy all intrauterine tissue, and it is
capable of destroying extrauterine tumor tissue to a depth fully within
the limits of what is generally regarded as operable with more certainty
than operation. We know that cases judged to be outside the limit of
operability are frequently made to appear to be well within such limits
after the use of radium and the limiting of the field of operability by
surgeons who are only using a comparatively small amount of the
42
R a d i u m
radium salt gives ample confirmation to this opinion. The question of
operating in this type of case after radium has produced an apparent
regression must await the reports of final results, but the histological
changes that radium produces in the extrauterine tissues show that such
a procedure is probably erroneous. If radium has caused a complete
destruction of tumor tissue, operation, of course, is unnecessary.
“Lastly, a strong plea is made to avoid treatment of primary cases
that are too far advanced. Unless this warning is generally and
promptly heeded, much unnecessary suffering will continue to result,
and radium will soon be as discredited as is the operation, in the eyes of
the public. There are numerous primary cases in which the general
health appears to be little, if at all, affected, but in which the local lesion
has advanced so far that all of the normal anatomical relations of the
pelvic structures are obliterated. To treat such cases will result only
in the premature production of the terminal stage of the disease.”
Radium in Gynecology.
Shields Abernathy, J. Tenn. State M. Assn., 14:91, July, 1921.
Unless the situation is changed by future studies in endocrinology,
radium will doubtless continue to be the main reliance in the treatment
of non-malignant uterine bleeding. Uniform success seems to be the
experience of all workers, in reports of these cases. As a rule one or
two small doses of radium not exceeding 600 mg. hours, restores the
normal menstrual life. A number of such patients are reported to
have borne children after the treatment. Care should be taken to
exclude malignancy. Pain lateral to the uterus usually indicates an
inflammatory process which radium lights up, with disastrous results.
Fibroid tumors of the uterus, where the growth is small, the con-
dition uncomplicated, and where surgery is contraindicated in the more
severe and complicated cases, are most safely and easily treated with
radium. -
A Conservative Estimate of Radium in Gynecologic Practice.
Chester Ford Duryea, Long Island M. J., 15: 243, July, 1921.
Too zealous radiation may cause so much destruction of tissue
that the patient is overwhelmed by the toxin thus produced and a fatal
termination is thus precipitated. To-day radium therapy can only be
properly instituted when it combines the support of the pathologist,
the biochemist, the physicist and the clinician.
In the light of our present understanding, every inoperable uterine
carcinoma case should be classed as a radium case and all carcinomas
of the cervix should be given radium as the method of election. A
conservative estimate of cervix cases shows clinical cures under radium
in about 30% of cases.
In idiopathic uterine hemorrhage radium under proper technic
gives results comparable with the best findings following any other
radical method of treatment. Practically all cases of this type respond
to proper radium treatment. Radium by no means displaces surgery in
the treatment of myomas, but in selected cases it must be the method
43
R a d i u m
of choice. We must always remember that the use of radium in fibroids
causes no primary mortality. In chronic endometritis radium usually
produces lasting relief. The dosage here calls for the use of a 50 mg.
tube, in a screen of 9/4 mm. gold, applied for a period of from four to
eight hours, and repeated in from four to eight weeks if required.
While Duryea hesitates to advocate radium for excessive hemorrhage
in young women under 30 years of age, he says that where hemorrhage
is of the dangerously excessive type, one has no choice. Radium is the
best agent at our command. In 192 essential uterine hemorrhage cases
treated at the Radium Institute during the past four years, over 90%
have responded with entire satisfaction. Radiation over the ovaries will
at times control uterine hemorrhage almost as effectively as the direct
intrauterine application.
Observations on the Technique and Indications of Radium-
Therapy in Uterine Carcinoma.
H. Schmitz, Surg., Gynec. & Obst., 31: 177, 1920.
A radium capsule within the cervical canal will disperse the rays
evenly through the pelvic cavity. The rays must penetrate 6 cm. of
tissue all around with such an intensity at the periphery that carcinoma
cells at this distance are destroyed. To keep the bladder and rectum
from too close proximity, they should always be emptied completely
just before beginning the treatment and kept empty during the treat-
ment.
Twenty-five mg. of the element in the form of an insoluble sul-
phate is packed into a glass cylinder, inserted in a silver capsule (wall
0.5 mm., length 1.75 cm.). Two such capsules are placed in a brass
filter which has a wall thickness of 0.7 mm. This absorbs the beta
radiation. A pure, black rubber tubing covers the metal and absorbs
the Sagnac rays.
The sensibility of carcinoma tissue is estimated to be one-half
greater than normal. Treatment is not repeated unless recurrence takes
place. Adequate drainage of the uterine cavity must always be pro-
vided. If pyometra develops, insert a soft rubber T drain into the
uterine cavity after each removal of the radium carrier and for several
weeks after discontinuance of the treatment, until the secretion is
negligible.
If local healing is obtained, the patient should not be subjected to
an operation.
Radium Treatment of Uterine Hemorrhage.
T. C. Kennedy and W. H. Kennedy, Med. Rec., Vol. 97: 141, 1920.
In the treatment of uterine hemorrhage, the gamma rays only are
used, the other rays being filtered by brass, silver, gold, platinum or
other metals.
The cases treated are: (1) those in whom no gross pathological
conditions can be found, and (2) those presenting a distinct pathological
condition, such as fibroma or carcinoma. In the latter case, the bleeding
should be considered only with the malignancy.
“Technique: The patient is given the routine hospital preparation
44
R a d i u m
for a vaginal operation. Gas is given and the cervix is dilated. The
radium is in an hermetically sealed glass tube and this is placed in a
silver tube .5 mm. in thickness; this, in turn, is put in a rubber tube
5 mm. thick. The radium prepared in this way is introduced into the
uterus and allowed to remain for from twelve to twenty-four hours.
“At the end of this period, the radium is removed, the patient is
permitted to remain home with instructions to keep off her feet for a
few days and to report her condition at the end of six weeks. As a
rule, we do not repeat the treatment under three months, but in our
experience only a very few cases have required a second treatment.
“Patients during the child-bearing period are given a smaller dose,
as it is desirable to preserve the menstrual function. Patients at or
beyond the menopause are given an application of from 600 to 900
radium hours, and this will usually be sufficient to produce a permanent
menopause. In the greater number of our cases there has been at
least one menstrual period after the administration of radium. It is
well known that the effect of radium is manifested slowly.”
Radium Treatment in 600 Cases of Menorrhagia.
L. J. Stacy, Am. J. Roentg., Vol. 7: 379, 1920.
While surgery is still the method of choice for young women who
have definite fibroids causing menorrhagia, and those with a suspected
carcinoma of the fundus, Roentgen rays and radium are successful
therapeutic agents in carefully selected cases and in women over
thirty-five.
“Of the series of 600 patients with menorrhagia with or without
uterine myomas treated with radium at the Clinic (Mayo) from July,
1915, to January, 1920, 438 have been head from. Sixty-nine of these
occurred in three patients; two were women of twenty-two who had
been given two tubes of 25 mg. radium for four hours each; the other,
aged twenty-six, had been given 25 mg. for nine hours. One patient,
aged thirty-one, with small multiple fibroids, was given two 25 mg.
tubes for six hours and the periods became regular and normal; three
years later she gave birth to a normally developed full-term dead child.
“Menstruation again became profuse two months after confine-
ment and four months later, 350 mg. hours were given. Two days after
treatment, the patient developed a rapid pulse and evidence of shock,
without rise in temperature or evidence of peritonitis, and died twelve
days later. This is the only death in our series and has not been satis-
factorily explained.
“One woman gave birth to a premature dead fetus after receiving
23 mg. radium for ten hours, and another gave birth to a premature
deformed fetus after receiving 50 mg. for six hours. One woman of
thirty-seven, who had 250 mg. hours, had two miscarriages at three and
six months. One woman of twenty-five, after 25 mg. for ten hours, is
now six months pregnant. One woman, aged thirty, who had had 25
mg. for ten hours, was questionably pregnant at the time she reported.
“In the treatment of menorrhagia in patients more than thirty-five
who have a fibrous uterus or a small myoma, and in younger patients
in whom myomectomy or hysterotomy is not indicated or in whom cur-
45
R a d i u m
rettement has not controlled the menorrhagia, radium is a very satis-
factory therapeutic agent.
“Radium should not be used, however, for patients who give a
clinical history or present physical signs of pelvic infection or of pyo-
metritis, nor for those who complain of chronic pelvic pain, since the
application of radium may light up a quiescent infection. We have had
three cases in which operation was done because of the infection after
the application of radium, in one in five weeks, in one in six weeks,
and in one in three months.
“In our series of 600 cases were 122 women under thirty-five;
nineteen were twenty-five or under. Eighty-nine were heard from.
The average dose of radium given to these patients was 293 mg. hours.
Menorrhagia was controlled by one treatment in 55.6 per cent.; a second
treatment was necessary to control the menstruation in seventeen cases.
In twenty-five, the periods were reported normal in amount; in eleven
irregular and scant, and in six, menstruation ceased; three of these
patients, aged twenty-eight, thirty and thirty-four, respectively, had
300 mg. hours. Hysterectomy was performed later in six patients: one
patient, aged thirty-two, was operated on eight months after receiving
400 mg. radium hours without improvement; one, aged thirty, was oper-
ated on one year after receiving 375 mg. hours treatment without im-
provement; one, aged twenty-eight, was operated on atter one year
because of pelvic pain, although the profuse flow had not returned ;
one, aged thirty-one, was operated on after receiving 200 mg. hours
treatment without improvement, and one, aged twenty-seven (a case
of hemophilia and myoma) was given 300 mg. hours treatment, then
transfused and given 400 mg. hours. Menstrual periods were regular
for eight months, followed by a continuous flowing for five weeks,
when the hysterectomy was performed.
“One girl of sixteen was given 100 mg. hours one year after a
currettement with only temporary improvement; the flowing was more
or less continuous, and two years and nine months after the radium
treatment, a hysterectomy was performed ; adenocarcinoma of the fun-
dus was found. Abdominal myomectomy was performed in seven
patients who received only temporary benefit following the radium
treatment; two of these had had radium treatment a second time.
“We attempt to give the women under thirty-five enough radium
to control the symptoms, but not enough to stop menstruation, and it is
difficult to judge the amount necessary in each case. It is better to give
a small dose, however, and if there is a recurrence of the profuse flow,
repeat the dose in three, four or six months, than to give enough at the
first treatment to stop menstruation. -
“. . . There were 478 patients more than thirty-five, and of
this number 349 have been heard from. In eighty-one (23.2 per cent.)
of these, the examination showed the uterus to be ‘fibrous’ or not
“large.” In 220 cases, the uterus was graded three on a scale of 1, 2, 3,
4 of the fibroids graded 1, and in twenty-nine the fibroids were graded
2 or 3. Thus in the large percentage of cases the treatment was con-
fined to the smaller tumors and the large doses given by many physicians
were not used.
“In the series of 349 patients it was necessary to repeat the treat-
ment in sixty-four, and an operation was done later in twenty. Only
46
R a d i u m
four of the twenty were given a second radium treatment, and two had
operations elsewhere too soon after treatment to obtain the effect of
the radium. Menstruation became regular and normal in thirty-nine
(11.17 per cent.).
“Of the patients more than forty, 263 were heard from ; in 185
(70.35 per cent.) of these menstruation had ceased. Only fourteen of
this group were given two treatments; four were given the two treat-
ments close together; the other ten received a second treatment after
from one month to one year.
“In the large percentage of those cases in which menstruation
ceased, there were two periods following the treatments before the ces-
sation. Improvement in general health was reported in 231 cases, and
gain in weight in 157 cases. No improvement was reported in sixty-
eight.”
The technique is the same as has been used for several years, dif-
fering only from that published earlier in that either emanation or
radium element is used, and in slightly larger doses for older persons,
but usually not more than 700 mg. hours. If that is insufficient, the
treatment is repeated in a few weeks or months.
The Therapeutic Use of Radium in Gynecology.
J. G. Clark, Surg., Gynec. & Obst., Vol. 26:619, 1918.
For the relief of symptoms and cure of cases of chronic metritis
and small myoma uteri radium may be a worthy competitor of myo-
mectomy, or hysterectomy, if certain conditions are fulfilled. Briefly, it
must effectively cure, must be attended by as small a risk or by even
fewer hazards than accompany a well executed operation, and must be
unattended by immediate or remote complications. The cure must be
permanent.
“We use radium only in very light dosage in the treatment of
young women in whom a tumor is not palpable, but who are suffering
from a depleting flow at the periods. In young women in whom a
myomectomy is possible, we advise operation, for in these cases the
uterus may be restored to normal, and the Ovaries are preserved.
Briefly summarized, we may say that we apply radium in the following
groups of cases:
“In large dosage, 50 milligrams for twenty-four hours, in women
suffering with myopathic hemorrhage or menorrhagia from myoma, in
women over forty years of age. In such cases, we expect to bring
on the menopause, and in practically all, we are successful.
“In smaller dosage, 25 to 50 milligrams for from three to eight
hours in young women with excessive menses incident to myopathic
changes, in very small myomata, in polypoid endometritis and in those
cases of irregular and profuse bleeding attributed to excessive func-
tional activity of the ovaries. ©
“Technique of Application: In every case a preliminary curettage
was performed and the curettings examined to eliminate the possibility
of carcinoma of the fundus. The radium, protected by platinum and
rubber, was inserted to the fundus of the uterus, where it remained for
from eight to thirty hours. 1n by far the larger number of cases the
47
R a di u m
time of application was twenty-four hours, and the amount of radium
employed was 50 milligrams. The patients were discharged from the
hospital in three to five days after operation.
“In the light of our review of cases, we are inclined to reduce the
dosage to 50 milligrams for twelve instead of twenty-four hours, be-
lieving that we will serve an equally satisfactory purpose with possibly
fewer menopausal manifestations in some cases.
“Results: Nitrous oxide anesthesia is usually employed, and the
discomfort to the patient is minimal. The shorter stay in the hospital,
with practically no lingering sequelae, is a large factor in hospital
economics and favors quick return to working efficiency on the part of
the patient. The post operative convalescence is so nearly negative as
to make it in no way comparable in danger or possible sequelae to that
of even the most ideal abdominal operation. . . . Only very occa-
sionally was the convalescence marked by disagreeable symptoms.
“We have obtained successful results in all but two cases. Five
patients were between seventeen and twenty-five years of age; in three
of these, the profuse menorrhagia has been reduced to a normal flow.
There were five cases between twenty-five and thirty years of age,
thirteen between thirty and thirty-five years, sixteen between thirty-five
and forty and sixty-one over forty years. In all except two cases, the
periods have entirely ceased for intervals varying from two to nineteen
months. Amenorrhea may immediately follow the application of rad-
ium; there may be one or at most two scanty periods, or slight, irregular
bleeding may occur for a few weeks before the permanent amenorrhea
is established. In several cases a scanty flow recurred after several
months, but this was again followed by amenorrhea.
“Only two unsuccesful results occurred: In the first, a case of
chronic pelvic inflammatory disease, the patient's chief complaint was
excessive and irregular menstruation. This case was diagnosed incor-
rectly as one of myopathic hemorrhage, and as a result of the operative
manipulation, there was a recurrence of the old process, and two days
after the application symptoms of acute pelvic peritonititis developed.
An abdominal operation a few weeks later revealed an old infection with
a superadded acute process. -
“In a second case, the radium failed completely after two 50 milli-
gram applications of twenty-four hours each in the presence of multiple
myomata. When the uterus was removed, no visible effects of the
radium upon the tumors or the ovaries could be detected.
“Pathologic conditions:
Myoma ............................................................…. 60
Chronic metritis ........................................................ 36
Polypoid endometritis ............................................. 3
Cervical stump .......................................................... 1
100
48
R a di u m
*—s.
“Influence on periods:
Immediate cessation ................................................. 40
One period ................................................................ 18
Two or more periods .............................................. 23
Return to normal and regular ................................ 15
No relief .................................................................... 2
Not stated ................................................................. 2
100
“Return of bleeding:
None ..............…...............…....…... 74
To normal after month of cessation ...................... 4
Once or twice only, then amenorrhea .................... 1
Profuse ...................................................................... 1
90
“Pain:
Absent ............................................................…. 64
Present ....................................................................... 30
Not stated .................................................................. 6
100
“Nausea and vomiting: f
None ...................................... • * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 58
Present ...................................................................... 25
Not stated .................................................................. 17
100
“Complications:
Present (pyometra) ................................................. 1
None .................................................….....….. 97
Subsequent operation necssary ............................... 2
100
“Menopausal symptoms (according to age):
17-20 "…~~~~ 1
20-25 ..........................................................…. 1
25-30 ..........................................................….... 1
30-35 .....................................…. 8
35-40 ..........................................................…... 8
40-45 .................…. 19
45-50 .............................................…. 10
50-55 ..........................................…. 5
53
None ..............................................................….. 37
Not stated .................................................................. 10
100
In a series of 100 cases of uterine cancer treated by radium, the
more or less massive vaginal hemorrhages were completely relieved in
49
R a di u m
60. There was a recurrence of hemorrhage in 10, and in only 4 was it
uninfluenced.
Radium should not be used preliminary to an operation. “In
border-line cases of cancer of the cervix, we invariably employ radium.
In advanced cases of cancer of the fundus we invariably perform a
hysterectomy.”
Of the 100 cancer cases, 4 devloped rectovaginal fistula and 4
vesicovaginal fistula. There was local healing in 52, no effect in 8,
hastened growth in 2.
The average stay in the hospital was three days, while in an
operation it is three weeks.
Radium in the Treatment of Cancer of the Uterus.
J. L. Ransohoff (Cincinnati), Lancet-Clinic, Vol. 74, n. S., 289,
1915. $
“No one who has seen radium used in the treatment of cancer
of the uterus can deny its beneficial action at every stage of the disease.
The question is how long does this beneficial action continue, and in
what stage of the disease should it be used. The results in inoperable
cancers are little short of miraculous. The bleeding and foul discharges
are arrested in a few days. Even if the cure is not permanent it is
worth while to check the terrible symptoms.
“Our dosage is 50 to 100 mgs. radium element, usually the latter.
Currettage is unnecessary. After a thorough cerolin douche, the radium
in 0.5 mm. silver capsules is introduced directly into the crater, where
it is held firmly in place by plain gauze packing. This packing must be
accurately done as it serves a two-fold purpose, to hold the radium in
place, and to protect the vaginal walls. At this stage a filter thicker
than 0.5 mm. is unnecessary, as it is sufficient to filter off the alpha and
soft beta rays, allowing the penetration of the hard beta rays which
have a rapid action on the superficial masses.
“The first treatment lasts twenty-four hours and is repeated in
about a week. The improvement is usually immediate. At the end of
the first week, the bleeding and discharge have, as a rule, completely
stopped and cauliflower masses have, in some cases, entirely disappeared
from the vagina. *
“At the subsequent treatments, which are given weekly at first,
then every three or four weeks, the radium tubes are enclosed in a
brass filter, one-half to one mm. thick, made in the form of a plaque,
which radiates the entire uterine area.”
This produces less burning secondary radiation. All containers are
enclosed in rubber tissue.
In eight months, eight cases have been freed from all signs of cancer.
“With one exception, these cases were inoperable and five had sub-
mitted to some previous palliative operation. One border-line case
. is clinically cured. One case had a small non-ulcerating recur-
rence in the vagina, which disappeared after one treatment.”
“Two cases died. Aside from these, there have been no ill effects.
We have had absolute freedom from all physical, local and constitu-
tional effects. We have seen no burns of the rectum or bladder and little
50
R a d i u m
rectal or vesical tenesmus. This may be attributed to the comparatively
moderate amount of radium used and the fractional treatment.”
Radium Treatment of Three Hundred and Forty-Seven Cases
of Cancer of the Uterus and Vagina.
H. A. Kelley and G. F. Burnam, J. A. M. A., 66: 2033, June 17,
1916.
The use of radium in sufficient quantities greatly enchances the
chance of permanent recovery of patients with uterine and vaginal
cancers. In early and good operable cases, the use of radium combined
with operation adds greatly to the chance of recovery without a recur-
rence. The most remarkable fact about the radium treatment of
uterine and vaginal cancers is that it often clears up those cases which
have extended too far locally and become firmly fixed to the pelvic
wall; in other words, cases which are utterly inoperable. The authors
have had 327 cases including borderline cases, of cancer fixed to the
pelvic wall, great massive cancers choking the pelvis, and many in which
there were general metastases and the radium was used to bring relief
alone. Over 20 per cent of this group have apparently been cured.
In a large number of those who were not cured, the discharges stopped,
pain ceased, and health was built up.
The Treatment of Cancer of the Uterus.
H. Schmitz, J. A. M. A., 77: 608, August 20, 1921.
The objects of this study are to discuss the prophylaxis of uterine
cancer, to review the diagnosis of carcinoma of the uterus, to group
correctly the various stages of the disease, and to base the indications
for a correct treatment on such a grouping.
Cases which are clearly localized after a physical examination
are operable cases and are treated by abdominal panhysterectomy.
Cases which appear to be doubtfully localized after a physical examina-
tion—borderline cases—and operable cases which are poor surgical
risks owing to complicating constitutional disease, form the ideal group
for radiational disease, form the ideal group for radiation therapy. Cases
in which a demonstrable invasion of the contiguous tissues and organs
and regional lymph-nodes is found on physical examination are clearly
inoperable and are subjected to intensive radiation. Hopeless and ter-
minal cases are treated symptomatically. -
The duration of an application of radium within the cervical canal
depends upon the intensity of the radiation striking the rectal mucosa.
This limits the extent of the action of radium in the pelvic cavity; the
parts lying near the bony periphery do not receive an adequate dosage.
This may be remedied by supplementing radium therapy by intense
doses of x-ray. Surgery in connection with such treatment is not
advisable, as these patients undergo a profound radiation toxemia,
and succumb easily to sepsis and shock. The technic for combining
x-rays and radium is outlined.
In the treatment of recurrences, the radiation must be as intense
51
R a di u ºn
as though the uterus had not been removed, regardless of the conse-
quences. The disease and not the patient must be treated. Pre-radia-
tion curretage and cauterization for post-radiation panhysterectomy
in the clearly inoperable cases render the patient's chances for even
temporary improvement decidedly worse. An active immunization is
produced by the action of radium on malignant cells, the cancer cells
being stimulated to produce a specific antibody for other similar cells
in the tissues of the patient being treated. Hence it is inadvisable to re-
move cells, the presence of which are necessary for the production of
an antibody.
From April, 1914, to December 31, 1919, 168 cases of uterine
cancer were treated with radiation. In some cases treatment was pre-
ceded by surgical procedures; as hysterectomy or cauterization, and in
others radiation was followed by hysterectomy. Since 1918 radiation
was used exclusively. The results show as apparent cure: 71.4 per
cent. operable cases; 54.5 per cent. borderline cases; 27.9 per cent. in-
operable cases; 2.5 per cent. terminal cases, and 2.2 per cent. of recur-
Te11CeS.
52
R a d i u m
SECTION III B
CANCER OF THE BREAST
United States Radium Corporation
New York
R a di u m
SECTION III B
CANCER OF THE BREAST
Radium Combined With X-Ray Treatment in Carcinoma of
the Breast.
George E. Pfahler, Am. J. Roentgenol., 8: 661, Nov., 1921.
Successful radiation treatment of the breast depends upon a clear
recognition of the extent and nature of the disease and upon the most
thorough and careful application of the radiation to every portion of
the malignant tissue for sufficient time and with sufficient intensity to
destroy every malignant cell. The roentgenologist should study the
whole question of carcinoma of the breast and its treatment as thor-
oughly as does the surgeon.
Pfahler recommends in operable cases an ante-operative course
of x-ray treatments over the breast, axilla, and supraclavicular region,
as much radiation as possible being given to the tissues within a period
of one or two weeks. Radical operation should be done within a few
days, and soon after (within three or four weeks after the first x-ray
treatment) a second course of radiation should be given, to the limit
of skin tolerance, the whole process being completed within two months
in an early or average case. If the disease has been extensive or if
metastasis in the supraclavicular region or mediastinum has occurred,
the treatments will have to extend over a longer time and be more
thorough. At least three areas should be treated: the mammary region,
the supraclavicular region, the scapular and posterior axillary region.
Pfahler uses the radiation from a Coolidge tube, excited by a
transformer, through 6 mm. of glass or aluminum, with a 9 in. spark-
gap and 5 milliamperes of current. With a focal skin distance of
30 cm. an exposure of twenty minutes is given; when the distance is
increased to 40 cm. the exposure is made for thirty-five minutes. Each
of the areas is covered twice within a period of two weeks. The
longer treatment is preferable, except for the radiation sickness which
usually follows.
In inoperable cases the best results are obtained by treatment similar
to the above, in combination with radium. The earlier it is begun, the
better are the chances of success. Two weeks after exposure to X-ray,
steel needles, containing 10 mg. of radium each, are placed throughout
the tumor mass, at distances of 1.5 cm., if the treatment is to last for
eight hours, or at distances of 2 cm. if the treatment is to be for sixteen
hours. The needles must be introduced under aseptic precautions
and into every part of the tumor, either at a single application or within
a period of one week. As a result the tumor usually disappears or
shrinks so that operation is possible. In recurrent carcinoma the same
method of treatment is followed. If the disease is localized to the
area treated, good results may be expected. Patients should be kept
under observation and should report for examination at increasing
intervals for an indefinite time.
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Radium in the Treatment of Carcinoma of the Breast as an
Adjunct to Surgery.
Ben R. Kirkendall, Am. J. Roentgenol., 8: 668, Nov., 1921.
Kirkendall believes that radium therapy, after a radical operation
for cancer of the breast, greatly lessens the chances of recurrence, and
in local recurrences often meets with success. In the non-operative
cases—those which were inoperable, and those which would not submit
to surgery—the results obtained by radium treatment alone encourage
its continued use. The preoperative and postoperative use of radium
in cancer of the breast is highly recommended particularly in virulent
cases. Kirkendall’s cases are grouped as follows: (1) postoperative,
in which radium was used directly after a radical operation, 43 cases;
(2) postoperative recurrences before radium was used, 44 cases; (3)
non-operative, 10 cases; (4) cautery, the disease being too far advanced
for any other surgical treatment, 4 cases; (5) preoperative and post-
operative, 8 cases. Of these 109 cases, 11 were unimproved, 29 were
improved for three months, 12 for six months, 6 for nine months, and
14 for one year or longer; 5 have been free from the disease for three
months, 7 for six months, 4 for nine months, 9 for one year, 4 for eigh-
teen months, 2 for two years, 2 for thirty months; 1 abandoned treat-
ment; 10 could not be traced. Fifty-three patients are still living.
The best results were obtained with 100 mg. surface pack, four
1 mm. brass tubes, containing 25 mg. each being placed side by side
between double thicknesses of black vulcanizing rubber, cured on one
side only. - -
Squares the size of the pack were marked off on the binder over
the dressing, which was made of 1 cm. thick, and the entire breast,
axillary and clavicular areas were treated with four hour applications.
When operation was performed the same pack was used, but over
1:5 or 2 cm. of gauze, and each area was treated twice, once before
operation and again immediately afterward, and for only three hours.
The skin reaction after this double exposure may be disregarded. In
recurrent cases a pack of 50 to 75 mg. was applied, with little or no
gauze interposed, or radium needles were embedded in the mass for
from three to eight hours.
Radiotherapy in Cancer.
R. H. Stevens, Grace Hospital Bull., 4:39, Apr., 1920.
In treatment of breast cancer the author believes the patient’s best
interests are conserved by careful and deep therapy of the growth and
the afferent and efferent lymphatic system over a period of several weeks,
several series being given two or three weeks apart before the operation
is done. Then the operation should be limited almost wholly to the
original growths, leaving the slightly affected axillary glandular sys-
tem to the x-ray treatment. The secondaries of cancer generally
respond much more readily to x-ray and radium than do the primaries.
Swelling of the arm from obstruction of the lymphatic circulation is
common on the operated side after amputation of the breast, because
of too radical an operation.
X-ray treatment and radium are perhaps the best agents we have
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R a d i u m
today for the treatment of cancer, but they are not specific for all types
of malignancy. The nearer the cell approaches the highest differential
type the less sensitive it is to the action of the rays, the squamous-
celled growth accordingly being the most resistant. Growths of this
type should be destroyed by electro-thermic (diathermic) coagulation,
according to the method of Wm. Clark of Philadelphia, using nearly
an ampere of d’Arsonval current (bi-polar) with the patient thoroughly
anesthetized. The growth is first blocked by inserting the needle con-
nected with one pole of the d’Arsonval current into the tissues all about
it, a few seconds in each place, till the tissues are cooked, and then
through the growth itself until the whole is cooked. It is then curretted
or cut away. The resulting wound heals kindly leaving a smooth scar.
Recurrences are not frequent in the neighborhood. Squamous-celled
growths, however, metastasize early and x-ray treatment should be
intelligently carried out for some time to the afferent and efferent lym-
phatic systems.
Operation should not be done after x-ray or radium therapy until the
local sound tissue and the blood have had a chance to recover from the
primary action of the rays, i. e. two to four weeks. Post-operative
treatment should be kept up for several weeks.
Radium Therapy in Cancer at the Memorial Hospital (N.Y.)
H. H. Janeway: pp. 184: 190. (P. B. Hoeber, 1917).
The best results in radium therapy are obtained in primary tumors,
because recurrent growths are unusually so wide-spread that temporary
improvement is all that can be gained. One case of primary operable
growth of the breast was treated by the author, using one excessive
treatment, causing the patient considerable suffering, but resulting in
apparent cure. The treatment used was 5 plaques; 250 m. c.; 1 mm.
silver covered with rubber; directly on surface of growth; 12 hours.
The treatment of one of a group of patients with advanced recurrent
cancer of the breast who were much improved by treatment was : 12
plaques; 600 m. c.; 3 mm. lead; 2 cm. wood; directly over nodules; 7
hours. Eight weeks later there was considerable retrogression of all
nodules. Three weeks later this patient received 4 plaques; 300 m. c.
3 mm. lead, 94 inch gauze; 12 hours. After an interval of eighteen
weeks received 4 plaques; 240 m. c.; 2 mm. lead, 2 cm. wood, 6 hours;
to supraclavicular glands, and 1 plaque; 100 m. c.; 2 mm. lead, few
layers gauze; directly to each cutaneous nodule, 6 hours.
In many cases of cancer of the breast the tumor is deeply situated
and the breast is fat and very mobile. These conditions render its treat-
ment by radium somewhat difficult. The site of the regional lymphatics
is some distance from the breast, and somewhat inaccessible to radium
therapy. Further, many cancers of the breast, those for instance having
a relation to a chronic mastitis may be diffuse and the suspected tissue
involved of considerable volume. Well-situated for radium treatment
are well localized tumors of the breast of small size, where there is no
excess of adispose tissue. As they form small nodules discrete and set
apart from the rest of the breast, they are satisfactorily covered with a
radium applicator. The success of treatment will depend on how far the
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disease has invaded the lymphatics. The use of radium can be offered
to those patients who dread and refuse operation, and it should also be
useful in cases where the wisdom of using the knife is doubtful.
The author does not recommend radium as a primary resort in mammary
Ca.11CCT.
Inoperable Carcioma of the Breast, Clinically Cured by Ra-
dium.
J. L. Ransohoff, Lancet-Clinic, 112: 618, 1914.
The author reports a case of cancer of the breast which was
inoperable because of a severe myocarditis and nephritis. The patient
had some months ago presented a scirrhus cancer in the upper outer
quadrant of the left breast. Radium treatment was begun in April 1914.
The tumor at that time was hard, nodular, infiltrating and about half as
large as a fist. There was no palpable involvement of the axilla. The
patient received three treatments, of twenty-four hours each, with 100
milligrams of radium, filtered through one-half millimeter brass, and
one centimeter cotton, using the cross-fire method. At present there is
absolutely no evidence of tumor in the breast.
R a di u m
SECTION IV
RADIUM IN MALIGNANT DISEASE,
CANCEROUS AND BENIGN GROWTHS
United States Radium Corporation
New York
R a d i u m
SECTION IV
RADIUM IN MALIGNANT DISEASE,
CAN CEROUS AND BENIGN GROWTHS.
Treament of Malignant Conditions with Radium.
William J. Young, Kentucky M. J., 19: 778, Dec. 1921.
Massive dosage, to the limit of the patient's endurance, with reac-
tions as a guide (except in conditions which have greately lowered re-
sistance) is the first rule to be drawn from Young's results. The excep-
tion, however, is as important as the rule. Coöperation with the surgeon
is always desirable; indeed, the line between operable and inoperable
malignancy cannot yet be so well defined but that the surgeon’s position
may depend upon his acceptance of radium as an adjunct. Nor is the
ground so solid under the radiotherapeutist that he should lead patients
to expect the miraculous. All radium treatment should be augmented
by x-ray treatments.
In breast cancer the x-ray will do better work in a shorter time
than will radium, except for direct insertion of the latter at special points
of invasion. Numerous surface lesions are here shown in photographs,
with the most marked absence of scar after healing following radium
application, always in the maximum dose, and seldom needing a second
treatment. In the mouth, tonsils, nares, nasopharynx, esophagus, and
trachea, with dosage just short of a burn, the percentage of cures has
greatly increased. A case of cancer of the ampulla of Vater, in which
radium was anchored through an incision, left for the prescribed time,
and withdrawn through the mouth, shows at least temporary improve-
ment. Cancer at the pyloric end of the stomach shows like improvement
after a dose of 50 mg. radium, lowered on a string through the
esophagus, allowed to find its way to the lesion under fluoroscopic obser-
vation, and withdrawn through the mouth. Patient becomes able to
eat anything he wanted. Treatment was repeated after eight weeks.
Uterine cancer, if in the fundus, is preferably for surgery; if in the cer-
vix, decidedly for radium. Youngs usual dosage is 150 mg. radium in 3
series, 50 mg. on each side of the external os and 50 mg. within the
cervix; a total of 6,000 milligram hours. Undertreatment means recur-
rence in from four to six months. Cancer of the bladder and prostate
gland are best treated by direct application of radium through a supra-
pubic opening. Malignancy of the rectum, when low, is for surgery,
reinforcement by radium; when high, the only successful technic is
direct application of radium through colostomy opening. A few in-
operable cases are thus rendered operable.
Radium Treatment of Hemangiomas.
A. Beck, Münch. med. Woch., 68: 1248, Sept. 30, 1921.
The author reports suprisingly favorable results following the
treatment of cavernomas by radium rays. The course and the action
of this treatment were such that a considerable increase in the angiomas
took place for the first eight or ten days, and the skin and mucous
membrane revealed an inflammatory reaction. After another two weeks
the tumors began to grow smaller and finally almost entirely disap-
peared. The radium treatments were long and intensive, but the author
thinks that if he had had better and stronger preparations, the dura-
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R a di u m
tion of the treatment could have been greatly shortened. The filtration
took place through 1-3 mm. lead, 1-2 mm. rubber, and several sheets
of paper or cellular tissue. Consequently, only gamma-rays and,
among these, only the hardest ones, were employed. The use of the
undoubtedly very active alpha-rays or beta-rays can be recommended
only for superficial angiomas. An exact filtration which can be ob-
tained in the way indicated is of importance. It is also absolutely
necessary to continue the radium treatment while the tumors are grow-
ing. This also furnishes a standard for the dosage.
The author's report refers to 3 cavernous hemangiomas, 2 of
which had already been treated once by radical operation and by alcohol
injections, but had relapsed after a few years, and presented a pro-
gressive growth. A further operation would not only have been very
dangerous, but it could not have been very radical, for technical and
cosmetic reasons. Other methods might have been used, such as chemi-
cal remedies, galvanocauterization, ignipuncture, or electrolysis. How-
ever, none of these treatments would have been without danger. They
might have caused thrombosis and embolism or infection. They would
also have been quite painful, and it would have been necessary to repeat
them several times, whereas the radium treatment—aside from slight
inconvenience—was not at 1 painful, and was much less dangerous
than the other methods.
The Response of Various Types of Tancer to Radium.
Douglas Quick, J. M. Soc. New Jer, ey, 18; 350, Nov., 1921.
Radium is not a “cure-all” but is the greatest single agent at our
disposal for combating malignant disease, sometimes producing a com-
plete regression of the disease and sometimes supplementing surgery
in producing the greatest good. In many cases palliative relief may be
afforded for some time with radium where no hope of a complete re-
gression could be entertained. However, there is a limit beyond which
it is useless and harmful to proceed. Radium reactions are painful in
certain types of cases, and this is one reason for withholding the treat-
ment in hopelessly advanced cases. This, however, does not include
all inoperable cases. Certain groups of conditions are now treated only
by radium. Generally, rapidly growing cellular tumors respond much
more rapidly to radiation, but the end-results are equally unstable,
because of the danger of early and widespread metastases. Osteogenic
sarcomas of bone are little improved by radium or radical surgery.
Neoplasms which tend to remain localized and to metastasize late in the
course of the disease are most amenable to treatment; those which
metastasize locally, only, are more suitable than those which extend
widely and early; and tumors extending through the lymphatics are
usually more amenable to treatment than those spreading through the
blood stream. Nerve and dense fibrous tissues are more resistant to
radiation than is epithelial tissue, and endothelial tissue is promptly
affected by radium. It is best to give one large dose to obtain complete
regression of an epithelial tumor, for later inflammatory reactions are
distinctly painful and lower the patient's vitality.
Radium may be applied as filtered radium placed on the surface
or at a distance from it, and as unfiltered emanation buried in the
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R a di u m
tumor tissue, the most important factors being accuracy and intimacy
of application. For many lesions, the use of filtered radium over the
surface is quite sufficient to produce a complete regression of the
disease, but this is extravagant because much radiant energy is being
wasted and the greatest intensity of the dose is being delivered to the
least vital part of the growth. Radium emanation decreases in value
at a definite rate, and thus can be measured, and may be collected in fine
glass capillary tubes which may be embedded in the tissues and left in
place. Thus the radiation can be distributed uniformly throughout a
neoplasm and placed where it is most needed; all of the radiation is
utilized and normal tissues are spared useless radiation. A very marked
lymphocytic infiltration is also induced, and this is the greatest single
defense of the body against malignant invasion.
In conjunction with surgery, emanation may be buried at any sus-
picious points within the wound, while it is still exposed; this does
not interfere with healing. This method is particularly valuable in
neck operations. Frequently a mass is surgically exposed and then
found to be inoperable. If there is doubt, emanation tubes should be
buried uniformly throughout the mass and the wound closed. Com-
plete regression over periods of from one to four years has followed
this treatment. In intra-abdominal new-growths, many cases show a
distinct advantage if emanation is introduced into the upper part of
the mass by the abdominal route, in addition to the usual treatment
below. Radium is particularly valuable in intra-oral carcinoma, and in
carcinoma of the larynx, but in the presence of cervical metastases a
combination of surgery and buried emanation is advised. Carcinoma
of the esophagus is extremely hopeless, and palliative relief is all that
can be accomplished. Little has been done with radium in carcinoma
of the stomach, but rectal cancer has shown good results. One of the
best fields for radium is carcinoma of the uterus, particularly of the
cervix uteri, for in the best bands, carcinoma of the cervix has passed
out of the operative field. With neoplasms of the bladder and prostate,
encouraging results have been obtained, although, in the former, surgical
exposure may very often facilitate treatment. Radiation has proven of
inestimable value in cancer of the breast, being a valuable adjunct to
surgery in operable cases and a blessing in inoperable and recurrent
CalSeS.
Surgery and radium both fail in the treatment of neurogenic
sarcoma. Giant-cell sarcoma gives good results, but true osteogenic
sarcomas are usually unsuitable to this treatment. Some regression
occurs, but dissemination through the blood stream is rapid and early,
and no means of successfully dealing with these metastases has been
found. Radium exerts spectacular effects on the lymphatic glandular
diseases, and regressions are very rapid but not permanent, although
palliative relief may be given for years.
The intravenous injection of an active deposit of radium has given
results of greater promise, but definite conclusions cannot yet be given.
Teratoid carcinoma of the testicle produces spectacular results, but
dissemination is so widespread that results are not usually permanent.
Brain tumors give a variable response, but experimental work indicates
that normal brain tissue withstands radiation very well. With parotid
tumors results have usually been successful.
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Radium Therapy in Cancer.
George Stuart Willis, Med. Rec., 100: 793, Nov. 5, 1921.
Much may be expected from the medical treatment of malignancies
in conjunction with radium therapy. The two main factors necessary
for success in the treatment are: (1) that the growth is accessible to
the action of the rays of radium, and (2) that the physical condition of
the patient is such that he can withstand the treament. Our experience
at the New York Post-Graduate Hospital has been that it is necessary
to treat the patient rather than the growth. For example, in treating
a patient who has a hemoglobin content of 55% and only 3,000,000
red blood cells per cubic millimeter, it is impossible to use as large a
dose of radium at one time as in the treatment of a patient who has a
comparatively normal blood-count. From a urinary standpoint, a
phenolsulphonephthalein excretion of less than 50 in two hours is con-
sidered a contra-indication for radium therapy.
The use of radium is discussed in (1) superficial cancer; (2) oral,
laryngeal, and esophageal growths; (3) uterine, cervical and vaginal
growths; (4) rectal growths; (5) carcinoma of the breast. In general
12.5 mg. needles are imbedded into the growth, one needle to each centi-
meter of space. The treatment of cancer of the mouth, nose and
esophagus consists in the application of 10 mg. needles. In many of
these cases there was marked diminution in the size of the tumor mass,
but few cases escaped infection which proved more disastrous than the
original growth. In cancer of the esophagus, the insertion of radium
through the esophagoscope, resulted in no cures, but the condition of
4 patients was greatly improved, from the palliative standpoint.
In carcinoma of the cervix, the uterine body and in rectal growths,
preoperative and postoperative irradiation should be employed. Great
progress has been made in the treatment of cancer of the rectum. A
preliminary colostomy is advised in all cases of carcinoma of the rectum.
Needles containing 12.5 mg. of radium are inserted under either local
or gas and oxygen anesthesia. These needles are applied 1 cm. apart,
once a week for four weeks, and then it is usually possible to have some
1dea as to the amount of further treatment. Willis also uses a tube
screened by 1 mm. of gold and 1 mm. of hard rubber, especially made,
containing from 60 to 100 mg. of radium, applied daily for one hour
This method has been adopted to prevent sloughing and toxemia, which
occurred when massive doses were used at one time. In the treatment
of cancer of the breast, it is suggested that the breast be removed by
an elliptical incision and that the axillary space be left undisturbed,
leaving all postoperative treatment in the hands of the radium therapist.
In the treatment of bladder and prostatic cases, the technic of H. G.
Bugbee of New York is followed. While this improved technic has
been in force too short a time for permanent cures to be reported, the
fact that the initial growth has been removed in each instance seems
encouraging as to the future outlook.
Closer coöperation is necessary so that the early use of radium
may be proven; further experimentation is needed in order to determine
the action of radium on abnormal tissues. Radium should be used in
the case of all malignancies before and after operation. The relative
value of radium emanation and salts of radium can be determined only
after further experimentation.
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The Progress in Radium and Roentgen Therapy in the Treat-
ment of Malignancy.
Russell H. Boggs, Internat. J. Surg., 34:308, Sept., 1921.
Unfortunately, the radiologists trained in therapy are not numerous
nor can other men be taught in a few weeks. In treatment one must
take into consideration the facts that the virulence of a growth increases
with an increase in lymph supply, that it is absolutely certain that
radiation will decrease the permeability of the cancer cells by producing
a fibrosis of the lymph spaces, that unless all malignant cells are killed
the disease will be only arrested and not cured, and that an incomplete
operation never cures. Postoperative radiation decreases the number
of recurrences, but when more than one chain of lymph nodes are in-
volved the operative cure is rarely possible.
There are four methods of obtaining intensive radiation: (1) by
imbedding many needles in the organ involved; (2) by using heavy
filtered x-rays through a number of points of entry; (3) by using
heavy filtered rays having high voltage over large skin areas; (4) by
using a pack of radium tubes properly spaced in order to give off a
large amount of scattered rays. By imbedding radium a lethal dose
can be given without burning the skin, but in determining the lethal
dose one should consider the depths and extension of the lesion as well
as the chains of lymphatics most prone to metastases. When a lethal
dose is given, radium is the most efficient means of treating malignant
growths of the mouth and throat. Some very advanced ulcerated
growths have been cured by radiation and coagulation. In breast cases
surgery is contra-indicated if the ulceration is large, if the growth is
deeply fixed, and if the lymph nodes are palpable and fixed. Imbedded
radium and surface radiation make this form of treatment as thorough
as amputation. Surface application of radium and x-rays followed by
imbedding radium leads to clinical cures without opening the lymph
channels; and operation, if later indicated, is performed when nearly
all cancer cells are destroyed. The results in carcinoma of the rectum,
bladder, esophagus and stomach have been good, but the treatment is
more difficult because the growths are obstinate and the affected organs
functionating.
Is Radium Therapy a Dangerous Method?
H. Rubens-Duval, Paris chir., 13: 180, April–May, 1921.
Many so-called inoperable cancers which were treated with radium
as a last resort have been completely cured, as determined both clinically
and histologically. That metastases occur more frequently after radium
treatment is due to the type of case which the radium therapeutist is
offered to treat. Most of them have already had the primary growth
removed by surgical means. It has been suggested that the radium may
liberate only partially devitalized cells which travel to distant parts in
the blood stream, but this statement has never been confirmed in any
way. On the contrary, surgical procedures can without difficulty cause,
by mechanical means, the dislodgment of cancer cells. Clinically this
fact is well known and many growths are therefore considered as “noli
me tangere.” Some have thought that the destruction of cancer cells
by radium might cause the formation of an autovaccine, thus protecting
the organism from metastasis. This is not true. It is possible, however,
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R a di u m
that the destruction of healthy tissues about the cancer may affect the
line of defense which has been formed against the growth. Incomplete
removal of the original growths has been followed by cure. It would
seem that in these cases the body was able to overcome the remaining
cells. Partial radiation may cause stimulation of cancer cell growth.
Radium does not cause metastasis but it may activate that which is
already in existence, and in this respect is not unlike the surgical means
of treatment. Severe burns, sloughs and neuritis have done much to
give radium a bad name, but are not as numerous as appear at first
glance. The more careful infiltration methods have reduced these
complications materially. The use of radium should be confined to
specialists.
That radium has caused the spread of infection has not been proven,
since the surgical procedures (such as curettage and dilatation of the
cervix in uterine cancer) are just as responsible for this result as is
radium. Vomiting, insomnia, febrile reactions, and radiotherapeutic
shock are uncommon and last for variable periods, but generally termin-
ate after the radium is removed. Whether these reactions are due to
destruction of red blood cells or to absorption of toxic products from
cancer cell destruction is a question. In nephritic, diabetic and cachetic
individuals radium must be used with caution for this reason.
The Treatment of Sarcomas with Radium, and Report of Cases.
S. W. Mowcrs, Northwest Med., 20: 206, Aug., 1921.
Experience convinces the author that operable malignant growths
should be treated with radium, in combination with X-ray therapy,
before and after surgery. and that inoperable cases should always receive
thorough radium and X-ray treatment.
Of 10 difficult cases here reported, only 1 resulted fatally. This
was of sarcoma of the left parotid gland, recurring three months after
surgical removal; it was ulcerated, with a foul gangrenous discharge,
and was entirely inoperable. After five months of treatment with
radium, only a slight amount of induration remained, the tissues were
soft and movable, and the patient resumed his work without discomfort.
Observations were continued until the ninth month, when serious ill-
ness led to decompression operation for secondary tumor of the brain;
no tumor was found, but autopsy a few days later showed metastasis
involving the cerebellum.
Of these 10 cases treated with radium the 9 which showed clinical
recoveries were: (1) a recurrent sarcoma of the neck; (2) a recurrent
sarcoma of the shoulder, treated for five months; (3) a large mixed-
cell sarcoma springing from the left ligament two years after partial
hysterectomy for uterine fibroids — there were adhesions so dense that
the mass could not be completely removed; it was tied off, a radium
tube inserted, and the abdomen closed; healing seemed complete at the
end of two and a half months of radium applications; (4) another
inoperable sarcoma involving both tubes and ovaries, with intestinal and
retroperitoneal masses filling the pelvis, was treated for periods of a
month's duration with an equal interval of rest; during the second treat-
ment period the uterus was found to be movable, and only slight indura-
tion remained in the ligament; (5) a child 2% years of age had a
palpable, painful mass in the appendiceal region, which upon explora-
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tion proved to be inoperable sarcoma. Radium, applied after healing
of incision, removed all induration and symptoms before the third
month; an examination six months later was negative; (6) a sinus,
with recurrent hemorrhages, remaining two years after a thyroid oper-
ation, with marked symptoms of involvement of the esophagus, con-
firmed by X-ray, was closed and the thyroid gland reduced to normal
size; (7) lymphosarcoma of the throat at the site of removal of a
former mass near the left tonsil cleared after five months of radium
applications; (8) angioma in a baby, involving the outer aspect of
the thigh, with a broken-down and ulcerating center, which appeared
to be sarcomatous, healed after five weeks; (9) a large tumor involving
the angle and the ascending ramus of the inferior right maxilla, with
extensive bone involvement, as disclosed by the roentgenograph, showed
clinical recovery after five months. Observations are continued in all
cases in which the physician’s advice is followed.
Radium Treatment of Cancer: A Plea for Co-operation betweez
tween Surgeons and Radiotherapeutists.
Wm. J. Young, Kentucky M. J., 19:450, Aug., 1921.
The chief action of radium is to resolve hypertrophic tissue,
whether its situation is normal or foreign. As malignancy is the
reproduction of a foreign substance in normal body tissues or organs,
it should be amenable to radium therapy. Insufficient dosage with
either radium or roentgen ray has the effect of stimulating the process.
Massive dosage is not as easy with the unstable factors in roentgen ray
application as in radium treatment. However, burns are of slight
consequence in the prospect of a cure as compared with the alternative.
In treating skin cancer, the aim is to produce a clinical cure by one
dose of radium. If failure should follow a third dose, surgery is
recommended in the author’s cases: No agent is as effective as radium
in the treatment of precancerous lesions of the skin. Basal cell epith-
eliomas are always amenable to massive dosage. Squamous and prickle-
cell types are more resistant, and where deformity will not be great,
excision is advised, extending 94 in. beyond the diseased area. Radium
should then be applied, extending 94 in. beyond the line of resulting
scar. If there is infiltration beneath the skin, it is always well to excise
and follow with radium. For all malignancy which is inoperable, inac-
cessible by surgery, or in which metastasis has occurred, radium is the
one agent. The roentgen ray should be employed to assist in blocking
points of metastasis. Where the avenues of metastasis are extensive,
with a large area to be treated, as in breast cancers, the roentgen ray
is preferable. In cancer of the uterus, if the disease has involved the
abdomen, radiation below may give rise to stimulation above. Car-
cinoma of the prostate should always have radium, preferably applied
through a suprapubic opening, whether or not surgery is employed.
The Treatment of Tumors by X-Rays and Radium.
Robert B. Greenough, Boston M. and S. J., 184: 622, June 16,
1921.
The process of development of the latent effects of radiation on
the living cells is unknown. Unabsorbed rays have little effect on
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the tissues through which they pass, the penetration of the different
rays following a definite physical law. The tissues show differences
in susceptibility to radiation; cells undergoing nuclear division being
especially vulnerable and certain types of cancer cells being affected
4 to 7 times more readily than healthy cells. By radiation living tissue
may be destroyed en masse, growth may be temporarily inhibited, or
its rapidity stimulated and the manner of growth may be modified. The
massive destruction of complex tissue demands a dose of radiation
sufficient to kill all the different cells; but in treating non-malignant
disease and in the palliative treatment of cancer, all of the cells exposed
to radiation need not be destroyed. To cure cancer all cells must be
destroyed. Direct radiation is particularly effective with non-meta-
stasizing carcinomas of the skin in both squamous and basal-cell varieties
and may be used when operative removal is impracticable. The insertion
method — using bare tubes of emanation or the needles holding radium
salts—or emanations at their tips produce death en masse of the tumor
tissue but can be used only on the surface of the body. Inside they
cause deep, dangerous infection. Beta-rays are best for massive destruc-
tion. X-ray cancer may result from long-continued and slowly healing
X-ray burns. New growths in blood vessels and connective tissues are
the first histological change after radiation and appear before changes
in the epithelial cells. With papillomas and keratoses, a mild treatment
is given, the cells grow normally, abnormal cells are cast off, and the
lesion is cured without a scar. Lymph-adenoid, ovary and testicle tissues
are especially sensitive to radiation and so are tumors in those tissues.
Surface cancers are curable, cancers of the mouth are more resistant.
Advanced cases of squamous-cells or glandular cancers may be helped
by stimulation of the connective tissue growth. Cancer tissue contains
many cells engaged in mitotic cell division and cells in this condition
are particularly sensitive to radiation. If only the cells in mitosis are
affected by the treatment, other cells may grow later. Repeated ex-
posures to radiation produce a gradual loss of sensitiveness. Massive
destruction effect of radiation by direct application is necessary to cure
malignant disease.
Treatment of Angiomatous Tumors with Radium.
M. Degrais, Bull. et Mém. de Soc. de Chir. de Paris, 46:572, 1920.
The gratifying results obtained from the treatment by radium of
angiomas have been communicated to the Academy of Medicine more
than twelve years ago and it is interesting to note the persistence of
the good effects. Mons. Degrais insists on the superiority of this mode
of treatment over that of divers therapeutic processes. Radium does
not require anesthesia, is painless, does not scar. It causes diffuse
vascular spots as well as large, limited tumors to disappear; it is
efficacious against mucous angiomas (lip, cheek, tongue, soft palate),
and presents no danger to the neighboring organs, when the tumor is
localized, for instance on the eyelid or on the parotid gland.
Experience has shown the author that angiomas are the better
eradicated the sooner they are treated, therefore this may be undertaken
during the first months of life and babies can tolerate perfectly the
dressing which holds the apparatus; on the contrary other mediums of
treatment can hardly be undertaken with safety until a later age, which
allows the tumor to develop.
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SECTION V
RADIUM IN DERMATOLOGY
United States Radium Corporation
New York
R a di u m
SECTION V.
RADIUM IN DERMATOLOGY
Radium in Dermatology.
C. J. Brocman, Ohio State M. J., 17: 841, Dec., 1921.
During the past year, Broeman has had under treatment about
50 cases of the basal-celled variety of epithelioma, located on the face,
neck, ears, scalp, arm and thigh. Radium has been employed in all the
cases, and the results have been uniformly favorable. In epithelioma
of the eyelid, radium therapy was especially successful. With the
prickle-celled type, located on the face, forehead, mouth and tongue,
the writer has not been so successful. He believes this to be because
in such a malignant growth, prone to metastasis, nothing can be accom-
plished unless treatment is undertaken very early. All his unfavorable
results were in cases of long standing. If radium is applied early
enough, it will seldom fail to cure any form of cutaneous cancer. The
prompt treatment of any suspicious nodule, whether it is possible to
differentiate between the basal or the prickle-celled type or not, would
greatly increase the percentage of success. In applying radium to
the superficial basal-celled epithelioma, the half-strength, 10 mg. plaque
is the most desirable apparatus to use. In treating epithelioma of the
eyelids, or even of the eyes themselves, sometimes the plaques will
suffice, but more often tubes are necessary, especially when the inner
canthus is involved. It is important to administer all treatments within
ten days, so that the last treatment will be finished before the reaction
occurs. For the treatment of prickle-celled carcinoma of the face, from
50 to 100 mg. of radium should be applied, with heavy screening, such
as brass or lead, at a distance varying from 3% to 1 in., the exact dose
and technic depending upon the conditions at hand. Secondary gland-
ular involvement should receive deep massive treatment, but if the
glands do not respond promptly to the rays, surgery should be employed
A case of endothelioma, of twenty-four years' standing, involving the
right parotid gland, showed no sign of recurrence after a year and a
half, disappearing after three treatments of 600 mg. hours each. In
cancer of the lip, when no glandular involvement has occurred, radium
is preferable to any other means of treatment. At least 50 mg. must
be used, preferably in the form of one or two 25-milligram tubes. The
first application should be for at least six hours, and the tube should
be well screened with at least 9% in. distance between the tubes and the
surface of the lip. As a prophylactic measure, deep radium exposure
should also be given to the cervical region, but where the glands are
enlarged the use of radium should be confined to the lip and the glands
extirpated by surgery. Good results have been obtained with the large
tuberous vascular angiomata, and the so-called “port-wine stain” may
be greatly improved if treatment is begun early in life. The spider
nevus is best treated by the electric needle. In handling either the
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pigmented or vascular nevi, care must be observed not to overtreat
the patient. In applying radium to keloids the size and location of the
growth must be taken into consideration. The plaque will give good
results if the keloid is small and of not too long standing.
Radium Treatment of Leukoplakia.
E. Lekisch, Wien. klin. Wehnschr., 34: 462, Sept. 22, 1921.
Leukoplakia, even when not syphilitic in origin, often requires
treatment on account of subjective symptoms or on account of the
danger of carcinoma. The usual treatment with the silver nitrate stick
is dangerous because the repeated irritation may stimulate the develop-
ment of carcinoma. The author believes radium to be the best of the
various methods of radiotherapy. Riehl says that the subjective symp-
toms are favorably influenced by irrigation of the mouth with water
containing radium emanation (50,000 to 200,000 Maché units to the
liter). For treatment, a flat container is used in which a thin layer of
radium barium sulphate is placed and filtered through a metal plate,
0.2-0.3 mm. thick, which excludes all of the gamma rays and most of
the beta rays. If desirable to filter out all the beta rays, a thicker metal
plate should be used. To exclude the secondary rays the container is
surrounded with a layer of wadding and gutta percha, 0.5-1 cm. thick,
and 12-23 mg. of radium is placed in the container. The treatment
lasts from one-half to one hour, often longer, and is repeated every two
weeks. If there is a marked inflammatory reaction, the intervals may
be lengthened. In all cases complete clinical recoverv and freedom
from symptoms were obtained. A severe kraurosis vulvae was cured
by 8 treatments with 23 mg. of radium.
Radium Technic in the Treatment of Malignant Diseases of
the Skin.
Douglas Quick, Arch. Dermat. & Syphilol., 4:322, Sept., 1921.
Special applicators for radium as now used at the Memorial Hos-
pital, New York, were evolved from the work of the late H. H. Jane-
way. FXclusive use of radium emanation affords a wider range of
usefulness; it can be used in tubes of a variety of strengths; silver,
platinum and glass are the filters preferred. There are three special
applicators, made respectively of wood, lead-foil and dental wav. A
fourth is a steel cone devised by Duane of Huntington Memorial Hos-
pital, Boston. On a wooden block radium tubes are held in place by
paraffin poured over them. The block, 5 mm. thick, is held to the
lesion by adhesive strips. Where brief applications are desired, two
ordinary wooden tongue depressors, strapped together, hold radium
tubes at one end and furnish a long handle by which the operator can
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hold them to the lesion. On the lead-foil, 0.1 mm. in thickness, an
active deposit of radium is used and the foil is folded as a filter, cut
(with long scissors held away from the operator) and placed to cover
the exact area of lesion. This is especially used for lesions about the
eyes. Concentration is regulated for applications of a few minutes
by the use of long forceps held well away from the operator. Accurate
approximation and comfort to the patient are the advantages of this
method. Ordinary dental modeling compound, placed in hot water
until it becomes pliable, is placed over the lesion and radium tubes are
pressed into it. Approximation is perfectly maintained. An illustra-
tion of an applicator made for a lesion on the side of the face shows a
concave mold with radium tubes embedded in the inner surface; a
photograph shows it applied, firmly adhering to the face, en contour.
The steel cone has a flat base, an opening in the center, and one or
more grooves in its top. The tubes are placed in the grooves; contact
with the lesion is through the opening; the steel container eliminates
all appreciable radiation extending laterally; it is used for such lesions
as those behind the ear, where surrounding parts must be protected.
Adhesive strips hold it. For interstitial insertion into lesions requiring
it, small glass capillary tubes of radium are loaded (by a special type of
forceps) into a trocar needle.
Radium Therapy in Lupus Vulgaris.
Josef Kopp, Strahlem therapic, 12:469, Berlin, April 20, 1921.
Radium therapy is still the principal method for all cases of lupus
which still show foci in the mucous membrane of the nose or of the
outer throat, either isolated or with diseases of the outer skin. Flat
foci lying in or a little below the level of the skin are especially adapted
to this therapy. The radium preparations are put in new silver capsules
of 0.2 mm. wall thickness which absorb nearly 67% of the beta-rays.
Copper filters 0.2 to 0.3 mm. in thickness should be used. The Dominici
tube of platinum, the walls of which are 0.3 mm. in diameter, are used for
the nasal mucous membrane and for single hollow cavities. The healthy
skin is protected with several layers of lead sheets with covers of rubber
or thick paper. The dosage of the radium treatment was generally
arranged so that from 75 to 112% of the skin dose was applied at
intervals of four to five weeks. Too violent reactions in the form of
superficial ulcerations were always an indication for increased caution
either in the lengthening of the intervals between the single applica-
tions or in the diminution of the single doses. Foci which were exposed
to more than 5 or 6 single doses (from 80 to 100% of the erythema
dose) without being healed, no longer belong to the group of lupus
cases that can be cured by radium. The writer now believes in pre-
liminary treatment of cases with from 2 to 4 x-ray seances of from
5 to 6 H each with 2 mm. aluminum filter corresponding to a hardness
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of 1.8 cm. half value stratum. Then from two to three radium seances
were given of from 0.9 to 1% of the erythema dose. The cosmetic
results are highly satisfactory and the skin remains soft and smooth.
In lupus affections of the conjunctiva several cases were cured in from
four to five seances of from 50 to 60% of the skin dose, with from
0.1 to 0.2 mm. of copper filter. Contraindications are congenital hyper-
sensitiveness to radium, active hyperemia and general cachexia. Radium
therapy succeeds, however, only in a minority of cases in causing the
complete disappearance of lupus without influencing the surrounding
tissue. The results are better when the surrounding tissue becomes
slightly inflamed, that is, when the erythema dose is somewhat exceeded
and therewith the histogenous antibody formation is furthered.
Radium Treatment of Vascular Naevi.
Laborde, La Médicine, 2: 696, 1921.
In treating naevi which invade the face it is important to consider
cosmetic results. It is therefore very important not to produce inflam-
matory reactions. The treatment of vascular naevi often demands the
use of radiation that is not very penetrant, which requires great pru-
dence, for if the sluggish beta rays have an incontestable curative value
on certain lesions, they require extremely delicate handling. In fact,
the doses susceptible of an elective action are very close to those of
inflammatory or necrosing doses. Between the elective, therapeutic and
the caustic dose, the limit is narrow, and the utilization of slightly pene-
trating radiation requires an exact knowledge of its action. Its use
has the advantage of permitting considerable reduction in the duration
of the irradiations, and thus an appreciable amount of time is gained.
This consideration is of much importance when dealing with babies,
in whom the angioma is situated in the neighborhood of the nervous
centres. Applications of long duration, in the neighborhood of the
nervous centres, are dangerous in the case of infants, because they
may produce grave vascular lesions.
(Apparatus is described.)
Treatment of small angiomas: A cure may be obtained in 4 or 5
applications of 30 minutes each with intervals of 5 to 6 days, by using
a flat apparatus containing 4 milligrams of radium element per square
centimeter, and filtered by 1/10 millimetre of aluminum and 2-3 milli-
metres of gauze. An interruption of two months should follow before
resuming the treatment, if a cure has not been reached during the first
series of applications.
Treatment of deep angiomas: In this case it is necessary to use
more important doses of radiation. To treat, for instance, a vascular,
subcutaneous tumor of the cheek, one may place the apparatus on the
side of the mucous membrane and on the side of the skin. Apparati.
containing an average of four milligrammes of radium element per
square centimeter, filtered by 5/10 millimetres of lead, 3 millimetres
of rubber are allowed to remain in place 6-8 hours. It is impossible
to limit here the number of sessions necessary, this depending upon the
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tumor, conditions, etc. Angiomas of the lip are treated in the same
way. -
Treatment of portzvine spots: Extreme care should be taken to
avoid any inflammation of the skin. In most cases it is better not to
try to obtain a complete decoloration, but to stop treatment when the
skin has reached a rose tint. This treatment requires patient persistence.
One may proceed in the following manner: The first series of
irradiations are given in sessions of 40 minutes with an enamelled
apparatus containing 2 milligrams of radium element per square centi-
metre, filtered by 1/10 millimetre of aluminum and a few layers of
gauze. There are consequently two sessions in 15 days for each zone
treated. After an interval of two months, a second series of irradiations
is undertaken with the same apparatus, the rays being filtered by 3/10
millimetre of aluminum, the sessions lasting 2 hours. After an addi-
tional interval of two months, an irradiation of 12 hours duration is
given with the same apparatus, the rays being filtered by 5/10 milli-
metre of lead and 5 millimetres of gauze. These applications are thus
renewed every three months until a partial decoloration is secured.
Some Complications Observed in the Treatment of Angiomata
with Radium.
William S. Newcomet, Urol. and Cutan. Rev., vol. 24, pp. 602-606,
October, 1920.
It has been generally recognized that moles and other forms of
angiomata are often the focal spot for some malignant degeneration.
For this reason it is advised that all angiomata be treated in early life,
or as soon after discovery as possible. Many of these malignant cases
result from what is often diagnosed as “birth-mark.” In the average
case radium will give by far the best results in the treatment of angio-
mata. Their removal by the surgical procedure does not always
accomplish the desired result, due to the fact that these vessels are
not normal, and, when their circulation is impeded, are apt to undergo
further dilatation. The writer cites two such cases.
The first case, a woman, developed a hemangioma upon the fore-
arm, extending down over the wrist and upper part of the hand. Most
of it was removed by operation. A careful dissection was undertaken,
although it was found impossible to follow all the ramifications through
the cellular tissue. A few days after operation it had again developed,
and was about one-fourth the original size. The forearm and wrist
were “cross-fired” with radium and this absolutely controlled the en-
largement and caused it to subside.
The second case was treated some years after operation. In the
interval the mass had reached its original size. The patient, a male,
a professional dancer, had a large hemangioma under the right axilla
which extended backward over the shoulder and downward over the
area of the scapula. This was removed, but recurred in a few months.
This occurred seven years before patient came under Newcomet’s ob-
servation, The rubbing of the garments frequently caused the lesion
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to bleed and caused much discomfort. In addition several small keloids
had also formed in the scar of the operation. Radium was employed
in three sittings about six weeks apart, and applied over twelve different
areas, totalling 5,400 milligram hours. One millimeter of lead and about
a half-inch gauze was used as a filter. There was very little reaction,
and the patient was able to continue his work during the whole period
of treatment. The angioma has disappeared, although a few small
keloids remain. In cases where time does not permit a thorough radia-
tion a mild radiation is advised which should precede surgical inter-
vention or one of the electrical methods.
Although Newcomet considers radium as the ideal means of treat-
ment in most cases, destroying all the undesirable tissue and leaving a
Perfectly healthy skin over the site of the former lesion, there are
some cases in which its use has not proved entirely satisfactory. Among
these are mentioned cases formerly treated with some cautérant, heat,
chemical or electrical methods. Several cases have come under the
writer's observation where CO., ice or hot water had been employed,
and in each instance resulted in only a partial destruction of the nevus,
beside often leaving a sloughing ulcer. In these cases, although the
application of radium need not be modified, it must be remembered that
more scar formation is to be expected. However, when there is apparent
atrophy in the skin structures, radiation should be withheld, for if the
application of radium is pushed beyond the limit of tolerance, ulceration
of long standing is likely to result, followed perhaps by the development
of telangiectasis or keloids. The same results are seen where radium
fails to produce the desired result, and the application is pushed. This
causes a severe reaction of the tissues, which is usually followed by
ulceration and scarring. This applies to the type of large, thick, pig-
mented angiomas or hemangiomas with large vessels, and covered with
a thick, leathery tissue. sº
Again, if some inflammatory condition of the skin develops during
the course of radium treatment, when the reaction is at its height,
disastrous results may follow, as was observed by the writer in two
cases, one of measles and one of erysipelas. }
While the reaction is at its height, care must be taken to guard the
part from trauma. This would apply especially in the case of young
children, where rubbing of the affected part results in ulceration. In
these cases, the ulceration is liable to cause scarring.
Further, the writer says: “Barring these cases where the area of
the defect is about one centimeter in diameter, the hemangiomata are
the most common. The difference in structure in relation to their
treatment by radiation is mainly in the character and size of the vessel
and of the amount of healthy skin covering the mass. A few of these
will be mixed in structure and pass gradually into the true pigmented
mole. With this wide variety of tissue, one can readily appreciate the
difficulties encountered in their treatment by radiation. However, it
might be said that the greatest difficulty is presented when these lesions
take on the character of a ‘port-wine stain' or a very flat pigmented
mole over an extensive surface. These are the cases that usually result
in failure and will develop ulcerations, telangiectasis and keloids upon
the slightest degree of over-radiation.” With these exceptions, New-
comet believes radium to be one of the greatest agents for the treatment
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*-
of angiomata. Judgment must be employed, however, as to when and
how to apply radium, also whether some other agent should be used
as an auxiliary. It is advised that all applications of radium be made
lightly, also that plenty of time should be allowed between treatments.
The entire area should be radiated equally. This will give uniformity
to the surface and prevent bad edges. Should an operation be neces-
sary, it is urged that it be preceded by radiation; if this is impossible
radiation should follow immediately after the operation.
Treatment of Vascular Naevi with Radium.
Montgomery and Culver, Boston Med. & Surg. Journ., 183:412.
1920.
On March 21, 1918, a baby girl of ten months was referred to
the authors for a large, cavernous naevus 1.50 cm. in diameter and .50
cm. high, situated on the inner surface of the left upper arm. At birth
it was a small red spot and had grown steadily ever since, and with
especial acceleration within the past two months, so that either opera-
tion or control was felt to be imperative. Its surface was covered with
vascular stellate red patches, and its substance felt like a loose bag.
Seventy-five mgms. of radium were applied on the tumor for 3%
hours, which not alone stopped the growth of the tumor, but secured
a decided retraction. Two mistakes, however, were committed. Only
the radium tubes employed with the silver and brass capsules were
screened. The capsules had become radio-active and therefore caustic,
and a burn resulted. Where the skin was not burned telangiectasis
from the radium was not obtained. The authors now usually employ
new coverings of lead, or keep the capsules, when not in use, apart from
the radium. They also employed in this case, one plaque which was
screened with lead, but too lightly, and no cellulose screen of wood, felt,
paper or gauze was interposed. After the first burn, this accident was
avoided. After five treatments, scattered through a period of eighteen
months, the mother reports that the arm is almost like the other, except
for a few superficial dilated capillaries, due, as already mentioned, to
imperfect technique.
A female infant, ten months of age, was referred to the authors
with a very large naevus of the left cheek. It was a raised, deep red,
cushion-like naevus with a rolled border and a sunken center. A strong
plaque of radium, 24.23 mgm. over the centre, screened with lead 1.50
mm., wood 2.00 mm. and one thickness of adhesive plaster, and on
each side a 25 mgm. tube enclosed in its silver and brass tubes and
screened besides with 1 mm. of lead, 2 mm. of wood, and one thickness
of adhesive plaster was used and retained in place for five hours. On
March 27, a similar treatment was given, but with less thickness of
lead (0.40). On May 27, 1919, the tumor was so reduced that only
one radium tube could be used over it. This tube contained 25 mgms.
of radium element and was enclosed in its silver capsule. Besides, it
was screened with lead 1.00 mm., wood 2 mm., and was retained in
position for five hours. On November 5, 1919, a similar radiation was
given and the tumor was so reduced in size that it is thought no
further radiation will be given for a very long time, if at all,
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Screening is of the greatest importance and must necessarily vary
with the type of lesion treated, with the concentration of the radium
preparation employed, and with the time this preparation is retained
in place. :
“One fundamental principle to bear in mind is that it is far better
to err on the side of the screening too much. This precaution is
especially necessary when a cosmetic result is wished for, as is so
frequently the case in naevus. In the first place there is a difference
between screening and shielding. The shield is employed to protect
the surrounding tissue. If the lesion is small, a hole for it is punched
in a piece of thick lead, say 1 mm. thick. The hole should be a little
larger than the lesion. This lead has to have either cellulose (paper,
wood or gauze), or rubber between it and the skin to prevent the
action of the secondary rays. The surrounding tissues having been
shielded, the screen is placed on the face of the radium applicator and
then applied and firmly plastered down with adhesive plaster.”
The Removal of a Birth-Mark with Radium.
Dr. W. R. Bathhurst, Urol. & Cutan. Rev., 22:55, 1918.
The author believes radium to be the best available treatment for
the removal of a vascular nevus. In most cases, however, months are
required to effect a cure. A case is cited of a baby, having a growth
which covered the upper eyelid to a point a little above the eyebrow,
and the disfigurement was accentuated by the growth being of a deep
purplish color. The birthmark was eliminated, and but a very small
scar left, such as any body or girl might have from a slight burn or fall.
Treatment: 18 hours in fractional doses with 10 mg. radium
element. Full strength applicator. Treatment began September 4,
1916, and was continued at varying intervals until a total of 18 hours
exposure was given using a 10 mg. full strength applicator with number
one brass screen 14 hours, and 4 hours screened with .10 aluminum
screen. No exposure lasted over 30 minutes on any one spot.
Radium in Rodent Ulcer — According to Sequeira small rodent
ulcers do well with radium. The radium of strength 500,000 units is
applied for four hours on a suitable plate, covered with a varnish, and
again covered with a single sheet of gutta percha tissue. The applicator
is fastened in situ with strapping or a bandage. One such application
is often sufficient to cure a superficial lesion of moderate size. The
reaction begins in about ten days, and at the end of three weeks a
blackish slough falls off, leaving a smooth cicatrix. In some cases the
application has to be repeated several times. Where there is a deep
infiltration, the radium covered with a thin sheet of lead is left in
position for ten, twelve or twenty-four hours. The lead prevents any
severe dermatitis, and sometimes the results are remarkably good.
Combination of Specific and Destructive Properties of Radium –
Wickham, and Degrais point out that sometimes it is well to combine
the destructive and specific properties of radium. The possibility of
producing rather strong inflammation of keloids, without the risk of
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relapse, is due, not only to the special process according to which the
repair of diseased tissues takes place, but also the filtration effected by
the first layers of keloidal tissue. Indeed, whilst the latter receive
intense and massive total doses, the deeper layers are only affected by
the more penetrating rays, which, having passed through in small
numbers, excite a gentle effect; a double action is therefore simul-
taneously produced; destruction in the superficial portion of the keloid
and specific beneath that region.
Radium in X-ray Burns — A number of x-ray operators are
employing radium in selected cases and as an auxiliary. These men
are in a way more competent to handle it efficiently, having made a
study of radiotherapy in general. Several of them who have suffered
from x-ray dermatitis have had resulting lesions cured by radium.
Angioma and Radium.
Gordon B. New, Jour. Lancet, vol. 37, pp. 445-48, Minneapolis,
July 1, 1917.
New believes that surgical treatment of angioma is of little value,
and advises the use of radium. In his experience, angiomas have not
recurred following this form of treatment, as they usually do follow-
ing any operative measures, while the scarring that results is disfiguring
Small quantities of radium used in the treatment of superficial angiomas
or purplish birthmarks bleach out the condition, leaving the skin almost
normal in appearance. Extreme care must be exercised, or a whitish
disfiguring scar will result. These superficial lesions are best treated
by a small plaque of radium kept moving constantly over the involved
area. Larger quantities of radium are required for large, cavernous
angiomas often seen about the scalp and face of children. It may be
used in the form of a plaque or tube properly screened and elevated
from the tumor. Emanations may be employed, when available. The
best method, however, is to place a tube of radium in a rubber finger-cot,
inserting it directly into the tumor. When using this method about the
lips and cheeks of children, ether anesthesia should be given. A small
incision should then be made inside the mouth a short distance from
the angiomas, and the radium inserted directly into the tumor through a
channel burrowed with a small, straight forceps. The incision should
then be closed with catgut. When done entirely in the inside of the
mouth there is no visible scarring and no deformity of the skin. The
tumor disappears, leaving a normal condition. It is best to wait two
or three months between treatments. Although angiomas in children
respond most readily, many remarkable results are seen as a result of
treatment of adults. Many cases of extensive cavernous angiomas about
the tongue or floor of the mouth, involving the submental and sub-
maxillary regions, which seem hopeless from a surgical point of view,
are cleared up when treated by the cross-firing method from the inside
of the mouth, and outside of the neck.
Case: Child, 4 months old, brought because of angioma of upper
lip. Tumor, noticed at birth, had been increasing in size. No improve-
ment had followed treatment, which consisted of a weekly injection
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of alcohol, for six weeks. Examination showed a large cavernous
angioma involving entire length of upper lip, and bulging the lower
part of nose. The lip was one inch thick in the center. There was a
marked eczema on face and scalp. On October 26th, a 25 mg. tube of
radium in a rubber finger-cot was inserted into the inside of the upper
lip, and left in place for eight hours. On February 1st the lip showed
an improvement of about 75 per cent. A 22-mg. tube was inserted into
the inside of the lip and left in place for eight hours. The child was
next seen on April 10th, when the lip was found normal.
Relative Value of Radium in Dermatology.
A. F. Holding, J. A. M. A., 63: 741-43, Aug. 29, 1914.
In malignant lesions of cavities, in which the neoplasm is inac-
cessible or difficult to expose to direct application of Roentgen rays,
such as the esophagus, rectum, vagina, urinary bladder, fauces, etc.,
radium has greater possibilities than any other similar agent in use at
present. One fact that would seem to justify hopes of superior results
from radium is that the most penetrating Roentgen rays in use repre-
sent the output of a 60,000 to 100,000 volt current, while it is estimated
that an electric current of from 600,000 to 1,000,000 volts would be
necessary in order to produce Roentgen rays of as great penetration as
the most penetrating rays of radium; that is, currents ten times greater
than the strongest currents now employed for the Roentgen rays.
Previous to the advent of improved Roentgen ray tubes of the Coolidge
type, this argument was more convincing than at present. With the
penetration of the Roentgen rays completely under one's control, it
is reasonable to hope that Roentgen rays can soon be generated having
nearly as high a penetration as the gamma rays of radium, and it is
certain that Roentgen rays can soon be produced from electrical sources
in greater quantity and at less expense than the gamma rays of radium
can be obtained. Radium is easier to apply than the other agents.
Discussion — Dr. J. F. Schamberg : “Radium has one distinct
advantage over the Roentgen ray — the constancy of the dosage. With
radium one knows the exact amount of energy given forth; we secure
a constant effect from a certain quantity in a certain time from a certain
distance. Despite the various energy-measuring devices that have been
used to secure precision of dosage of the Roentgen ray, there is still
latitude for error. Radium also has the advantage of simplicity of
application and of applicability to certain cavities of the body which
are inaccessible to the Roentgen rays. Another advantage is the kindli-
ness with which radium burns heal.” !
Dr. W. A. Pusey: “I think there are certain things that can be
done with radium that cannot be or at least have not been duplicated
with the Roentgen ray. I have seen many cases of angioma successfully
treated with radium that could not be duplicated with the Roentgen ray.
As to lesions about the nose and eyes, I do not think such patients can
be well treated with the Roentgen rays, lest we set up a severe reaction,
while with radium I do not hesitate.” -
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SECTION VI A
OPHTHALMOLOGY
United States Radium Corporation
New York
R a d i u m
SECTION VI A
OPHTHALMOLOGY
Radium for Cataract.
W. S. Franklin and F. C. Cordes, Am. J. Ophth., Ser. 3, 3: 643-
647, Sept., 1920.
The authors quote Cohen and Levin's technic: “The purpose of
this paper is to describe the technic and give our results in 31 cases
Our method of application differs from the published description and
has been the result of gradual development and dosage somewhat
arbitrary. In the use of screens and distance we have been guided by
the experience of the Department of Dermatology of the University
of California.”
They are using 9.95 mg. of radium element in the form of radium
barium sulphate in a circular gold plated plaque over an area of 50.26
sq. mm. The apparatus consists of a specially designed silver cup to
facilitate handling the radium. The bottom of this cup is made of a
piece of silver 0.5 mm. thick and screens out practically all but the
gamma rays. The cup is embedded in a block of vulcanite, the bottom
of which is 0.6 cm. from the silver cup. The vulcanite is used as an
easy method of obtaining a certain fixed distance and thus has the
advantage over gauze pads. The container is now applied on a lead
plate 1 mm. in thickness. This plate is shaped to cover the eyebrows
and lashes and extends over the cheek a short distance. Directly under
the radium is a hole 8 mm. in diameter (the diameter of the radium
plaque). The lead plate acts as an additional safeguard against alopecia
of the eyebrows and lashes and gives a convenient method of applying the
radium. There is some doubt as to the harm done by secondary rays,
which in this apparatus are given off by the lead plate, and to prevent
the possibility of injury from these rays, a piece of rubber dam is placed,
as an additional safeguard, below the lead plate.
“The patient is placed in the prone position and the lids of the
eye under treatment held closed by applying a small strip of surgeons'
isinglass plaster. A small gauze sponge is placed on the eye to prevent
the apparatus from coming in direct contact with the patient. Over
this gauze sponge the radium apparatus is placed and held in position
by two tapes and two small pieces of adhesive plaster. The patient is
told to fix the ceiling with the uncovered eye, thus bringing the lens
of the eye under treatment more directly under the radium. In this
method, the radium is about 1.2 cm. from the eye.
“The matter of dosage is rather an uncertain one, varying with
each type of radium applicator. A milligram hour is the exposure to
1 mg. of radium for one hour. The term gives a method of dosage
for a given plaque of radium if the conditions of screening and distance
are included. In most of our cases, we have been giving 10 milligram
hours twice a week for 4 weeks and then once weekly until the process
is stationary. Following this, one exposure a month is given. Experi-
mentally it has been shown that the normal tissues of the eye are more
resistant to the radium than the tissues of the skin, consequently the
eyelid gives a valuable indication against an overdosage, as a reaction
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R a d i u m
would take place in the lid before any injury could be done to the
structure of the globe.
“A radium emanation plant has been installed at the University
Hospital and we are now using radium emanation in the treatment of
a series of cases. The tubes are screened with silver so that the silver
cup is omitted in the application; with this exception the method remains
the same. The length of exposure varies according to the strength of
the tube. The dosage given is equivalent to 10 milligram hours. For
example if a tube checks up as equivalent to 20 mg. gamma radiation,
the time of exposure would be for half an hour. It is too early as yet
to give the results with this method.”
Before starting the radium-therapy, the vision and ophthalmoscopic
findings were carefully noted. An examination was made monthly and
the result recorded. When the vision remained stationary one month an
application of 10 milligram hours every four weeks was found to hold
the improvement.
The authors’ conclusions are:
“The application of radium does no injury to the normal struc-
tures of the eye. .
“It apparently has a selective action upon the lens.
“Radium improved the vision in 84.3% of our cases.
“A consistent and known dosage seems advisable.
“Frequent treatments are necessary in the beginning.”
1
º
:
The Therapeutic Use of Radium in Diseases of the Eye.
H. H. Janezway, Arch. Ophth., 49: 156, 1920.
Although the Memorial Hospital has been using radium for five
years, the eye cases, which have been referred to it for treatment, have
been few until the last year or so. The following cases have been
treated :
7 cases of sarcoma.
1 case of old keratitis.
cases of glioma.
cases of nevi of the eyelids.
cases of vernal catarrh.
case of epibulbar melanosarcoma.
2 cases of epithelioma of the scleral conjunctiva.
60 cases of epithelioma of the eyelids.
i
Sarcoma – Of the seven cases of sarcoma, four tumors were intra-
orbital sarcomas. The radium treatment was not signally successful.
The other three cases were sarcoma in the choroid. From the treatment
of these seven cases it may be concluded that radium will produce a
temporary improvement, though not a complete retrogression in ad-
vanced lesions. This marked susceptibility, which the large recurrent
growths have shown, indicates that cures may be expected in some
cases, if the recurrences can be treated early. Moreover, an early
recurrent growth can be treated more effectively because of its accessi-
bility to the use of buried emanation, a more powerful method of han-
dling it than the surface application alone. Certainly every case oper-
ated upon should be given the benefit of one posttherapeutic prophylactic
76
R a d i u ºn
treatment. As regards the treatment of early sarcoma of the uveal
tract the evidence at hand does not support the view that radium should
replace enucleation.
In sarcoma of the orbital cavity external to the eyeball radium
plays a very much more important rôle. Experience does not support
the views that in these growths it will save the eye, yet it encourages
the belief that it will save the life of the patient. After a preliminary
radium treatment, exenteration should be performed and afterwards a
post-operative treatment by unfiltered radium placed by cotton support
in the center of the orbital cavity. One thousand mc. hours is not too
heavy a dose. A severe reaction may follow but if the growth has not
already metastasized the patient’s life may be saved.
Keratitis — Radium treatment was not successful.
Glioma—Some authors have reported favorably on the use of
radium in glioma, but the author's cases, although improved in some
instances, have not been altogether successful.
Nevi of the lids — Excellent results have been obtained in the
treatment of nevi of the lids. The red birth-mark has been replaced by
a cutaneous surface only slightly paler than the normal skin. The
majority of these lesions occur in children and the treatments are best
made short. Moreover, the majority of these lesions are superficial and
little filtration is needed. The very superficial lesions are treated with
filtration of only 0.2 mm. aluminum at a distance of 0.5 cm., giving
a dosage of 12 to 15 me. hrs. per sq. cm. The author recommends for
irregularly shaped. larger, superficial nevi the use of applications very
carefuly shaped to the contour of the lesion, upon which the radium
must be uniformly distributed. Deeper nevi may be treated with 0.5
mm. of silver filtration at the same distance from the skin and a dosage
of 40 to 60 mc. hrs. per sq. cm. according to the extent of the lesion.
Vernal Catarrh — The treatment of vernal catarrh by radium has
been most successful. A single radium application is capable of pro-
ducing an improvement approaching a cure. Sometimes a second
treatment is necessary. Due to inexperience in a few of the earlier
cases, a little scarring has been done, but never to a degree which
seriously diminished the return of the conjunctiva to its normal func-
tion. The method now adopted is the application to the tarsal surface
of the conjunctiva of a very thin 0.1 mm. piece of lead cut to accurately
fit the tarsus and evenly covered with the active deposit from emanation.
Epithelioma of the Orbital Conjunctiva — In this disease and in
epithelioma of the lids radium has also performed an indispensable
service. Epitheliomas of the eyelids in which practically no destruction
of the lids has been caused, and also in some cases where there has
been lid destruction, are best treated by surface application. Such is
made more accurately by making first a mold of the diseased area and
surrounding tissue of dental modeling compound. The compound is
warmed and thus softened. It is then placed over the area mentioned
and left to cool and harden. When hard it is removed and the diseased
area is outlined upon it. The radium enclosed in 94 mm. silver tubes,
one to every sq. cm., is inserted in the mold, which is replaced and left
over the growth long enough to administer 60 mc. hours per Sq. cm.
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R a d i u ºn
A Case of Bilateral Glioma of the Retina Apparently Arrested
in the Non-Enucleated Eye by Radium Treatment.
M. J. Schoenberg, Arch. of Ophth., vol. 48, p. 485, 1919.
Axenfeld reported a case of glioma of the retina of both eyes in
an 8 months’ old baby. The right eye was enucleated; the left eye
containing several foci was treated with mesothorium and x-rays with
encouraging results.
The author's case was that of a girl of 5; was under observation
over 3 years. Since the age of one month mother noticed that “the
shine of the pupil of the left eye was different than it ought to be.”
Examination showed a typical appearance of a glioma of the retina of
the left eye which was later enucleated. While on the table the right
eye was examined and there was found a sharply circumscribed, grayish
white tumor, limited above and below by branches of the retinal artery.
It occupied an area a little larger than a quadrant of the eyeground,
extending from the margin of the disk nasally and below, towards the
periphery, but not reaching it. The area was surrounded on all sides
by patches of choroidal atrophy with pigmented borders. There were
two small spots of gliomatous degeneration in the central portion of
the area. Above, was another small grayish mass occupying an area of
about four to six disk diameters.
On April 10, 1916, first radium treatment given by Dr. H. H.
Janeway — “Radium emanation 36 me. with lead filter, applied to the
right temple for 4 hours. Sept. 22, 1916, second treatment: 58 me.,
filtered through a 4 square cm. lead plaque, held over the eve at a
distance of 1 cm. for 8 hours. On June 7, 1918, a third treatment
of 209 me. over the right side of the orbit, kept for 14% hours, filtered
through plaques of lead 2 mm. and silver ¥4 mm. thick.” In June,
1919, the child was in good condition. The opacity in the lens appears
slightly more dense. The impression is gained that all that was left of
the glioma is a degenerated necrosed mass.
The Action of Radium on Cataracts.
M. Cohen and I. Levin, J. A. M. A., 732, p. 1193, Oct. 18, 1919.
A great many eye conditions such as trachoma, vernal catarrh,
and various tumors of the eve-ball and adnexa have been treated with
radium without impairing the normal structure of the eyeball or its
function. The methods used are very similar to the technic of the
deep radium therapy employed in the treatment of malignant tumors
and various other conditions.
Radium emits alpha rays, beta rays, and gamma rays. The first
two act only as a general caustic on all the tissues found on the surface
to which the radium is applied. The hardest beta, and especially the
gamma rays, have a selective action which causes their efficacy in the
treatment of deep conditions. The selectivity of the rays consists in
the fact that they may influence pathologic structures while leaving
the neighboring normal tissues practically intact. These gamma rays
represent only about one per cent. of the total amount of radiations.
Koster employed in his glass tube 2 mg. in gamma radiations; there
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R a d i u m
were possibly not enough soft radiations to injure the normal tissue;
but, he had only an extremely small amount of gamma radiations to
do the actual work. In modern technic, 10–20 and more times the
amount of radium used by Koster is used. All the irritating soft rays
are filtered off and only the selectively acting gamma rays are utilized.
The actual technic consisted in covering the radium with brass, photo-
graphic paper and gauze, and placing it over the lid. The distance
between the radium substance and the eyelid was about 2 cm.; 2 to 3
mm. of brass screening and 2 cm. gauze were used. The exposures
lasted from one to two hours and were repeated twice a week during
the first five weeks and then once a week. Of twenty-four cases studied,
87.5 per cent. improvement occurred in the first few weeks of treat-
ment; this improvement remained stationary, and there was no retro-
grade to the original condition in anv of these patients. The authors
feel that it has been thoroughly established that radium does “no injury
to the eye and does produce some, if ever so slight, biologic alteration
in the lens.”
Dr. Cohen, in the discussion, says: “We know that radium does
not injure the capsular epithelium in normal frogs' eyes. As regards
affecting the cornea, we believe that, if properly applied to the cornea,
radium will produce no ill effects to the structure of the eye.”
Leukosarcoma of Iris, Treated by Radium.
S. Gifford, Arch. Ophth., 47: 241, 1918.
A case is reported of a man who had a leukosarcoma of the iris.
Rather than have the tumor removed or the eye enucleated, he decided
to try radium treatment. For ten days he received daily treatment
with from 32 to 48 milligrams of radium bromide, each treatment
lasting from twenty to thirty-five minutes, the tube being applied to the
outer surface of the closed lids in all of the treatments except two. At
these two treatments, the tube was held directly across the cornea by
conjunctival sutures. The immediate result of this treatment was facial
paralysis. This persisted for nearly a year, then gradually disappeared.
The tumor diminished somewhat in size, but after the lapse of a month
began to grow again. Eventually the eye was enucleated.
The author says, however, that the iris offers very favorable condi-
tions for treatment by radium. The rays reach the growth through the
clear cornea almost as if it were on a skin surface, and the results of
the treatment are as open to observation. If it is unsuccessful and the
growth continues to increase, operation may be resorted to with about
as good a chance of success as if it had been done at first. It may be
with even a better chance, as even partial sterilization of the tumor cells
would lessen the danger of their multiplying if some of them should
be forced into the circulation by the operation.
Though the results of such treatment in intraocular tumors have
been so far rather meager, some of them seem very positive. It would
seem, then, especially in tumors of the iris, that treatment by radium
should be seriously considered. Where the growth is not especially
rapid, even if it has reached the iris root, such treatment should be
79
R a di u m.
offered to the patient as an alternative to operation, he being observed
carefully during each treatment. Where operation is refused, it would
seem only just to the patient to advise radium very urgently.
Treatment of Vernal Conjunctivitis with Radium.
W. A. Pusey, J. A. M. A., 71:806, 1918.
In the course of the last fifteen years, the author has treated with
Roentgen rays or radium several cases of vernal conjunctivitis. The
results with either agent seem to be the same, and the application of the
radium to the inner surface of the eyelids is so much less difficult than
that of Roentgen rays that in the last few years he has used only radium.
Following is the technic to be used :
The lid to be treated is everted and held in the everted position
by clamping lightly with lid forceps. The blade next to the eye is of
Solid heavy metal, so that it prevents the eye itself being reached by
an appreciable amount of rays. The outer blade consists of a rim with
a large opening which leaves exposed the area of conjunctiva for the
application of the radium. In these cases the author has used a flat
radium applicator containing in varnish 5 mg. of radium element. This
application is of sufficient strength to produce a bright erythema on
normal skin by an application of ten minutes through thin rubber cloth.
In order to avoid discomfort, the author does not make anv pressure
in applying the radium to the lid, but passes it back and forth over the
lid just short of the point of contact with the surface. He has estimated
that in an application applied to the whole palpebral conjunctiva with
the applicator moving about, each part of the surface of the conjunctiva
gets an exposure of one-third the total application; that is, with an
application of thirty minutes, the applicator being moved back and
forth, each part of the lid gets an exposure of ten minutes. The author
has preferred to make the application in broken doses. He makes an
application of five minutes’ duration over the whole lid for six successive
days, so that in the course of a week the conjunctiva gets thirty minutes
of a moving exposure, each part of the lid thus getting ten minutes.
This exposure with the author's applicator has not proved sufficient
to give any evidence of Roentgen-ray reaction. After such treatment,
the patient is usually allowed an interval of several months, depending
on the condition of the conjunctivitis. Usually the first series of treat-
ments is followed by distinct improvement. In one successful case,
the author gave four series of such exposures in the course of a year
without at any time producing an apparent radium reaction in the
case, but obtaining a completely successful symptomatic result. The
number of cases treated is not sufficient to warrant any dogmatic state-
ments, but all have been cases of severe vernal conjunctivitis, with
papillomatous thickening of the conjunctiva, with characteristic grayish
pellicle, and with extreme photophobia. They have been of many years'
duration, have resisted skilful treatment before, and in the cases in which
the author has been able to carry the treatment along as far as he
thought necessary, the results have been successful to a noteworthy
degree. Some cases have shown symptomatic curves that have now
persisted for several years. The results, indeed, have been so gratifying
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R a d i u m
in these otherwise entirely intractable cases, and the treatment so easy,
that the method is worthy of wider application than it has received.
Mesothorium Treatment of Eye Diseases.
N. J. Cuperus, Arch. Ophth., 46: 126, 1917.
In many cases of eye disease where the usual remedies are without
avail, treatment with radium and mesothorium is favorable, particularly
in chronic blepharitis, chronic inflammations of the conjunctiva, cornea,
iris or vitreous. Vision is not improved in old opacities of the cornea,
although the opaque areas become less dense. The proper moment
at which to begin treatment is the one when nothing further can be
accomplished by the usual methods of treatment. One or two treat-
ments with these remedies are sometimes followed by a surprisingly
good result. If the keratitis or iritis is acute or painful, treatment
with these remedies should be cautiously applied. The author was not
able to confirm their analgesic action. Even if the eyes are kept quiet
during the treatment, the application of these remedies is sometimes
followed by an unpleasant irritation which may last for months, though
permanent damage has never been observed.
In the first years, the remedy was exclusively applied in trachoma.
Cohn saw results from the application of 1 mg. radium for from ten
to fifteen minutes. The granules atrophied and the conjunctiva became
smooth. Selenkowsky, Darier, Thielemann, Dinger, Kardo-Ssissojew,
and later Fortunati observed similar results. At the same time other
names appear as opponents to radium treatment. These were Birch-
Hirschfeld, Jacoby, Braunstein and Samkowsky. They were not satis-
fied with the results they obtained, and observed relapses. In 1910
Lawson and Mackenzie Davidson reported on radium treatment in eye
diseases, particularly in cases of corneal ulcer, intersitial keratitis, epi-
scleritis, pterygium, conjunctivitis, and macula corneae. The quantity
of radium used varied from 5 to 59 mg. and the length of application
was five minutes. These authors were satisfied with their results except
in the case of macula corneae.
Among the articles. which have appeared in recent years, that of
Prof. Koster and Dr. Cathis is particularly worthy of attention. The
treatment was extended to other cases: iridocyclitis, choroiditis, de-
tachment of the retina, blepharo-conjunctivitis, and favorable results
were obtained; 5 mg. of radium were applied. The length of applica-
tion varied from one-half to one hour, and the remedy was applied as
near to the affected eye as possible without directly touching it. The
eyelids were held apart by the fingers of the other hand.
Report of a Case of Melanosarcoma of the Orbit, Treated with
Radium.
E. B. Heckel, Arch. Ophth., 45: 465, 1916.
A case is reported of a man who had a blind eye which he wanted
enucleated because it was becoming painful. Upon enucleation a mela-
nosarcoma of the orbit was found. After the man had worn a pros-
81
R a di u m
thesis for six months, it had to be removed because the tumor was
growing and pushing the prosthesis forward and downward. After
radium treatment, the patient did nicely for six months. In short, at
intervals of about six months, for over two years, radium treatment was
applied to check the growth. The patient’s general health, however, is
now on a rapid decline.
The value of radium, if used in sufficient amount, in malignant
disease of the orbit is, in the opinion of the author, clearly demonstrated
by this case. The radium kept this neoplasm of the orbit in absolute
abeyance, and the patient in a condition to follow his vocation during
a period of two and one-third years.
The author presents the following technique: Make an incision
through the skin of the lids about 5 mm. from the free border of the
lids, completely encircling the palpebral fissure; then dissect the skin
only of the lids to the bony orbital wall; then with an electric-cautery
knife, at a cherry-red heat, by repeated punctures directed toward
the apex of the orbit and as close to the bony wall as possible, completely
sever the cone-shaped orbital content, and then introduce one hundred
milligrams of radium element and allow it to remain in place twelve
hours, the radium to be introduced again at some future time if neces-
sary or advisable. The author is strongly convinced that one application
of one hundred milligrams of radium element is of more value than
several applications of a less amount. -
Radium-Therapy.
Louis Wickham and Dr. Degrais; Cassell and Co., Ltd., London,
N. Y., Toronto and Melbourne, p. 277, 1910.
The authors quote a case of glaucoma in a man treated with radium.
The patient reported for treatment in December, 1906. He was com-
pletely blind in the left eye and partially so in the right. This eye could
distinguish some shadows. The diagnosis was “inoperable glaucoma.”
of several years’ standing.
The treatment commenced Jan. 23, 1907, repeated daily until and
including February 5. It consisted in the application of apparatus
No. 1, for 20 minutes on each place, with the interposition of a rubber-
covered lead sheet, 1% mm. in thickness. The instrument was applied
on the right and left fronto-superciliary region, exactly above the eye-
ball, and on the temporal region. This rubber-covered lead sheet had
been used before only as a protective “caché”. The object of directing
the rays through the thickness of the sheet was to lessen the total
intensity, to avoid surface action, and to act very deeply. In this technic
the mistake was made of allowing the secondary rays of Sagnac to act,
and there was a slight, very superficial erythema.
The patient seemed improved, but there was a return to his original
condition on March 26th. This technic is reported as the first attempt
at filtering radium rays through a lead sheet. Before this, since 1905,
pads of cotton-wool and aluminum sheets had been used as screens.
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R a di u m
Radium Rays and Their Effect on the Normal and Blind Eye.
Greef. Deut. med. Woch., 30: 452, March 24, 1904.
In the experiments undertaken, 1 gram of a mixture of barium
chloride and radium chloride was used. This contained about 0.02 g.
pure radium, and was wrapped in a paper case, and then enclosed in
iron for safe transportation.
1. Earperiments upon healthy eyes – In the dark radium confers
upon paper, or upon a barium-platinum-cyanide screen a peculiar phos-
phorescence which flows brilliantly in absolute darkness. When the
radium rays were applied directly to the eye it acquired a peculiar
diffused, sea-green appearance which was very intensive. The peculiar
color became weaker as the preparation of radium was moved further
away from the eye, stronger as it came nearer. The phosphorescence
was not caused by the container of the radium salts, since this was
leather. Nor was it possible to say that the rays were projected from
the eyes, for they did not appear to come from any one definite part
of the eye. The placing of non-transparent objects between the rays
and the eye, or closing the eyes, did not affect the peculiar light effect.
Thus radium rays differ in their effect upon the eye from x-rays in that
firstly, the former are perceived by the eye without artificial aid, while
it is only possible to perceive x-rays after great precautions have been
taken; and secondly, the radium rays must be far stronger inasmuch
as they penetrate opaque objects, and are not diminished in strength in
the process, whereas x-rays would be absorbed. Parts of freshly excised
eyes of cows, such as the cornea, lens, vitreous humor, retina, were
exposed to radium rays. Very, very slight signs of phosphorescence
were shown.
Experiments on blind eyes — In total blindness in which any of
the nerves controlling sight, etc., is destroyed, it is impossible to restore
vision. If there is the least perception of light, radium rays will pene-
trate where light rays would not. The radium rays do not present
a sharp image, however; only a diffuse light. Occasionally letters, or
other objects constructed out of a barium-platinum-cyanide screen, or
of opaque material, and subjected to radium illumination, are per-
ceived. As yet there is no practical use of radium in restoring vision.
Radium
SECTION VI B
OTO-RHINO-LARYINGOLOGY
United States Radium Corporation
New York
R a d i u m
SECTION VI B
oto-RHINo-LARYNGology
Radium Technic in Treating Cancer of the Esophagus. Pre-
liminary Report.
C. W. Hanford, J. A. M. A., 78: 10, Jan. 7, 1922.
The task set for radium in malignancy of the esophagus is difficult
because one is working in the dark, except for the aid of the fluorºscope
which will show the location of the stricture if one exists, but can tell
nothing of the thickness of the walls of the canal nor the extent of
the lesion. The five requisites mentioned by Mills and Kimbrough for
the proper emplacement of radium in the esophagus are considered by
the writer in his series of 18 cases. (1) Three methods are commonly
employed to determine the location; (a) the fluoroscope after the
ingestion of bismuth or barium; (b) sounding with olivary bodies, and
(c) esophagoscopy, which is not favored except for the purpose of
securing a section for microscopic examination. (2) As a means of
effective and nontraumatizing canalization of the stricture. fair sized
olivary bodies are passed and in cases of extreme stenosis dilatation is
done by means of a device, popularized by Sippy, made of piano wire.
(3) For maintaining the radium in contact with the tumor the applicator
is left in position the required number of hours and then easily removed
by means of the attached strings. (4) The roentgenogram will show
clearly the position of the carrier. Six hours after placing carrier,
patient should be placed behind the fluoroscope and given a small amount
of fluid bismuth, and observations taken to determine if the carrier is
still in the right position. (5) The dose selected is 50 mg. and the
time of exposure from eight to ten hours. Starting at the lower position,
at the end of eight hours the string should be pulled up 1 in., at the
end of another eight hours another inch, and so on. The treatment is
usually repeated in from three to four weeks.
Conclusions show that advance has been made, for in a disease that
was always fatal, a percentage of patients is now saved. Dysphagia is
relieved. The majority of patients are benefited, and life is prolonged.
Gastrostomy is avoided. A more perfect system of dosage, however,
is required.
Atrophy of Lymphatic and Tonsillar Tissue by Radium and
X-Ray.
C. Augustus Simpson, Virginia M. Month., 48: 473, Nov., 1921.
One of the drawbacks to x-ray treatment of the tonsils is the
irritating effect upon the parotid gland. It is only enough to produce
a dryness of the mouth and this lasts only two or three days, but it is
disagreeable to the patient. It may be avoided by a special technic
which the author devised. A flat dermatological 30 mg. double strength
radium applicator may be used, covered only with a laver of sterile
rubber tissue; by applying this unscreened applicator on the surface of
the tonsil and using three points, Hampson x-ray through aluminum
externally, a cross-fire of radium and x-rays is so concentrated on the
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tonsil itself that other structures of the neck are not affected and the
effect upon the tonsil is sure. An applicator specially made (Radium
Company of Colorado) is 34 in. long, 1% in. wide, oval shaped, with
all corners and angles smoothly polished; it contains 26 mg. of radium,
covers a surface of the dimensions mentioned, and is stronger than the
double-strength square skin applicator. The radium is on the surface
of the metal capsule, having no aluminum to cover it and filter out the
valuable beta ray. All of the more valuable beta rays are available.
This applicator is the strongest made and the effects of the rays are
immediate and marked. From cases in which the technic has been
tested, and from six years’ experience in atrophying the thymus gland
with x-ray, the author is positive that he can cause complete atrophy
and disappearance of any tonsil in from one to three treatments. Elim-
inating any suffering, hemorrhage and anesthetic, it should be a valuable
method, especially in cases in which surgery is contra-indicated.
Case of Intranasal Epithelioma Cured by Excision and Radium.
Literature.
lººm” Roy, Ann. Otol., Rhinol, and Laryngol., 30: 748, Sept.,
The patient came on account of soreness and closure of the left
nasal cavity which had been present for several months. This was
accompanied by a scabby condition and occasional bloody discharge.
Just within the left nasal cavity could be seen a small growth at the
anterior end of the inferior turbinate, close to the mucocutaneous mar-
gin, dry and about the size of a bean, slightly scabby, sessile in form,
with tendency to bleed if touched. It looked like a fibrous papilloma
and was easily removed with cold wire snare and but very little hemor-
rhage. Pathological report described it as a basal cell epithelioma. Four
weeks later there was considerable irritation inside the nose, accom-
panied by scabbing and bleeding and the patient was referred for radium
treatment. Nineteen months later there has been no return of the
trouble. Contrary to the opinion of several observers, the writer's
experience leads him to conclude that radium is much more effective in
epithelioma than in other forms-of malignant growths. He believes
that in massive tumors of the sinuses radium without operation is
useless. However, thorough operation combined with immediate radia-
tion through a wide opening in the face, which for purposes of observa-
tion is allowed to remain permanently, will give better results than we
have been accustomed to consider possible.
Radium in the Treatment of Epithelioma of the Lip.
Douglas Quick, J. Radiol., 2:1, Dec., 1921.
Quick, speaking for the Memorial Hospital, states that the primary
lesion in epithelioma of the lip should be treated entirely by radium.
In the more deeply infiltrating lesions this should be supplemented by
the use of radium emanation imbedded interstitially. For the treatment
of primary tumors a mould of dental modeling compound is made to
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fit the lesion and silver tubes, the walls 0.5 mm. thick, containing
radium emanation are sunk into this mould to a depth of 4 mm. The
tubes are so arranged that one is available for each square centimeter
of Surface to be covered. For lesions of ordinary size, the dose given
is 60 to 65 millicurie hours per square centimeter of surface. The
tubes must extend well beyond the limits of the growth in all directions.
In the average case this surface radiation is sufficient; but, for the treat-
ment of deeply infiltrating growths, it is supplemented by burying small
glass capillary tubes of radium emanation in the substance, by means
of fine trocar needles, and leaving them in situ. The total radiation
from 1 millicurie of emanation is equal to about 132 millicurie hours.
In all cases the cervical nodes, whether palpable or not, are treated with
either radium or x-ray externally. Following this, cases without pal-
pable nodes are kept under observation. If nodes are involved, or
become involved, a complete unilateral neck dissection under local anes-
thesia is done and radium emanation in very weak tubes is buried
throughout the wound. Dissection of the opposite side may be done
subsequently if indicated by the presence of nodes. External radiation
following operation is advisable in the majority of cases.
While too little time has elapsed to permit of comparison with
surgical statistics, experience at the Memorial in unselected cases in-
dicates that radium deserves the foremost place in the treatment of
lip cancer, and, if properly applied, will produce results surpassing the
present surgical statistics with a minimum of sacrifice on the part of
the patient. The resultant scar is in most instances scarcely discern-
able. Of 115 cases treated during the last four and one-half years,
which could be traced, 80, or 69.5%, are free from disease; and of
these 16 are over three years’ duration, and 4 over four years. Twenty-
seven of the patients have died, and 8 are becoming steadily worse.
Of 92 primary cases without palpable nodes at the time of admission,
67, or 72.8%, are known to be clinically free from the disease. Two
of the patients died of intercurrent disease and another of apoplexy,
although clinically free from carcinoma. The remainder could not be
traced.
Malignant Neoplasms of the Upper Respiratory Tract and
Radium Therapy. &
Paul Delobel, J. d. sc. mićd. de Lille, 39:265, Oct. 23, 1921.
The author treated the following cases with radium : (1) Vegetat-
ing epithelioma of the left nasal fossa, in a woman of 46, the nature
of which was confirmed by histological examination; 200 mgm. of
radium applied during thirty-six hours. Three months later the nasal
obstruction and pains had disappeared but the opacity of the maxillary
sinus persisted. (2) Epithelioma of the larynx in a man of 40. The
appearance of this was very similar to a tuberculous ulcerative and
infiltrating lesion. The patient had been previously tracheotomized, so
radium was introduced through the wound and left thirty-six hours in
the larynx. The condition of the patient remained stationary after
three months and a marked regression of an indurated glandular mass,
which had at first increased, was obtained following x-ray treatment.
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(3) A vegetating epithelioma of the larynx in a man 68 years old.
Histological examination showed the tumor to be an epithelioma with
epidermic pearls. Tracheotomy was rendered necessary by the asphyx-
iated condition of the patient and several days later, the author intro-
duced the radium through an opening made in the thyroid cartilage, as
retrograde catheterization of the trachea had proved impossible. Three
months later the larynx was still congested but no traces of vegetations
could be seen on the vocal cords. -
Without entering upon a consideration of ultimate results, the
author calls attention to the simplicity of radium therapy, whereby grave,
painful and mutilating operations are avoided. Rubber sounds con-
taining radium are used by Delobel for the applications. For the
nose, the sound is introduced carefully into the diseased nasal fossa and
kept in position by adhesive plaster. For the larynx, radium tubes are
placed on top of each other in the sound, so as to reach a height corre-
sponding to the length of the larynx (3.5 cm.). The sound is pushed
through the tracheotomy opening and caught in the mouth with clamps.
Another sound, which is passed through one of the nasal fossae, is
used to draw the first through the anterior naris, care being taken to
have the radium-bearing portion of the sound at the level of the larvnx.
This technic may be applied to ulcerative cancerous lesions. Two
failures in vegetating cancers are recorded. Delobel hopes to avoid
thyrotomy through the use of a semi-flexible, blunt, metallic catheter.
Squamous Cell Carcinoma of the Antrum. Report of a Case
Treated with Radium Alone That Is Free from Recurrence Twenty-
Two Months After the Last Application.
J. Harper Blaisdell, Boston M. and S. J., 185: 570, Nov. 10, 1921.
A statistical comparison in methods of treatment by operation, by
combined cautery and radium, and by radium alone. For the results by
operation, Blaisdell quotes Davis’s “Malignant Growths of the Upper
Jaw and Antrum,” a report of 39 cases in the Charing Cross Hospital,
London. Of these 39 cases, 19 were cases of squamous cell carcinoma,
5 of which were considered inoperable because of extent of the can-
cerous process; of the remaining cases operated upon, that could be
traced, the cancer returned in 6 within the following year; only 3 of
the 19 cases were free from recurrence for periods of twelve month
to two and a half years. o
For the results from treatment combining cauterv and radium,
Blaisdell refers to New’s “Treatment of Malignant Tumors of the
Antrum.” According to New, the Mayo Clinic has abandoned removal
in favor of combining cautery and radium. A series of 33 cases cover-
ing a period of three years is reported. Of these, nearly 50% were
considered untreatable because of extent of the process; 19 cases of
this group were squamous cell carcinoma, and 11 of the inoperable were
among this group. In this series there was no operative mortality and
no postoperative chest complications; in 2 cases where the floor of the
antrum was involved, the eve on the affected side was lost from reaction
to cautery and radium. Final results of this series, from a period of
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R a d i u m
twelve to twenty-seven months after treatment, show 2 deaths, 2 recur-
rences, 1 without data, and 3 non-recurrences. -
For the results of treatment by radium alone, Blaisdell details th
case of 1 of his patients, a man 63 years old, with squamous cell carcin-
oma due to a gauze dressing left in a tooth socket by a dentist. This
patient came for treatment two years after the original tooth trouble,
and six months after symptoms referable to the antrum had appeared.
There was an immediate excellent effect after the first treatment, but
second treatment was followed by a period of three months of extreme
suffering, due to necrotic processes. During this period the constitu-
tional effect upon the patient was most striking; it is described as a
mental dulling and complete physical failing; appetite failed, weight fell
from 180 to 130 pounds; memory failed, the mind became childish;
pain was so extreme as to require morphin for several weeks, and the
patient was confined to bed for the last month of this period. The
eye on the involved side was not affected, however, at any time. Fatal
termination seemed the only possible outcome. But a large mass of
sequestrum came away one morning, the patient got out of bed the
same day, and his appetite came back immediately. The final result
was complete removal of the antrum and its surrounding structures
from the mouth to the orbit. Normal tissue healed readily; no further
treatment or procedure has been necessary. Within a comparatively
few weeks the patient returned to his work, as vigorous as he had been
all his life; his weight returned to 185 pounds. His speech is thick
and difficult to understand, and he has some trouble in eating, but he
declines any prosthetic device to help this condition, at present. No
recurrence has appeared in the twenty-two months that have elapsed
since the second treatment.
A Device for Radium Treatment of Malignant Tumors of the
Jaws. * >
J. Bercher, Paris méd., 11: 205, Sept. 3, 1921.
In the treatment of tumors with radium, the radium element can
be brought into contact with the malignant tissues either by means of
platinum needles embedded in the tumor, or by means of radium tubes.
The radium tubes must be kept in contact with the tumor for a con-
siderable period, often as long as eight days. A support for them must
be constructed that may be easily borne by the patient and will not
interfere with the action of the radium. Metal must not be used.
Vulcanized rubber is the best material. An impression or plate is made
of the maxillary region where the tumor is situated, the teeth in this
region having been extracted; on this model, a rubber plate is con-
structed at least 2 cm. thick in the region of the tumor, and small
openings are made in which the radium tubes can be placed, of sufficient
depth so that the radiation will be homogenous, the tubes not being in
direct contact with the tumor, but at a definite distance from it, while
the surrounding tissues are protected from the action of the radium by
the rubber. When the tubes are in place, it is fixed in the mouth and
covered with paraffin or wax. If it cannot be held in place without
metal clasps, these must be placed as far as possible from the radium.
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;
:
;
It should be worn night and day, but may be removed at meal times as it
interferes with mastrication. The construction of this rubber plate
varies in each case with the site of the tumor, the shape of the jaw, and
the condition of the surrounding tissues. This may often tax the in-
genuity of the stomatologist: In some cases where, owing to previous
operation or radium treatment, there is considerable scarring and sclero-
sis in the region of the tumor, surgical débridement may be necessary
to make free access to the tumor possible.
Treatment of Hypertrophied Tonsils and Adenoids by Radium,
a Preliminary Statement.
F. H. Williams, Boston M. and S. J., 184: 256, March 10, 1921.
The author criticizes Witherbee's method of using Roentgen rays
to treat the tonsils from “under the angle of the jaw” and the adenoids
“through the back of the neck” because of the danger of exposing other
parts to the action of the rays, as the lymphoid tissue. When radium
is used the maximum radiation reaches the tonsils and adenoids; also
the output is constant and the dosage can be exact.
Use 50 mg. bromide of radium in a flat container, with the rays
filtered by 0.83 mm. of aluminum, held directly against or near the tonsil.
Withdraw the radium every few minutes, or as often as it is comfort-
able for the patient, until the total exposure of fifteen minutes, more
or less as required, has been reached. Improvement is immediate but
the ultimate results may be expected only after some weeks. Two or
three treatments at intervals seem to be more satisfactory than one.
The author has devised a container to be held midway between
the tonsils. It consists “of a disk of lead (not more than 2 cm. in
diameter and about 1 cm. thick, more so in the middle) with a hole
bored through its center, somewhat flared at each end, for the exit of
the ray, and another bored from the outer edge radially to a little be-
yond the center. The tube containing the radium may be slipped
into this and the opening afterwards closed by screwing a metal handle
part way into it. The uvula, the back of the throat and the parts be-
hind it are thus protected by about 1 cm. of lead. When treating one
tonsil only, the opening towards the other may be closed by a plug of
lead. Appropriate filters should be used.”
Another instrument, shown in a sketch, consists of a small bulb
at the end of the bent portion of a glass tube, for the radium. The
straight end is inserted into a metal handle about 30 cm. long. The
radium is kept in position in the bulb by stuffing the tube with spun
glass, and more spun glass is pushed in until the tube is nearly filled,
the end being closed with a cork. An aluminum filter cap is slipped
over the bulb and then the bulb and bent portion of the tube are enclosed
in sheet lead, except the lower end of the bulb. The lead should ex-
tend more or less beyond the bulb according to the area to be treated.
“Before applying the radium, the throat should be moistened with
a suitable solution of cocaine to prevent gagging. . . . All instru-
ments should be covered with two thicknesses of rubber, and for this
purpose two rubber finger cots are stretched over them and far down
on the handle, where they may be secured by a strip of plaster.”
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Radium in the Treatment of Malignant Tumors of the Nose
and Throat. Its Use and Possible Abuse.
R. Sommenschein, J. A. M. A., 75: 860, Sept. 25, 1920.
Radium : Indications for use: (1) When surgery is impossible
or impracticable; (2) combined with surgery when complete removal
is impossible; (3) in inoperable cases to relieve pain, hemorrhage,
odor, discharge, sepsis.
Action on various types of tumors: (1) Favorable influence on
round cell sarcomas or lympho-sarcomas; (2) less effective on squam-
ous cell carcinomas; (3) practically ineffective on epitheliomas con-
taining epithelial pearls, and on carcinomatous glands.
Comparison with Roentgen Rays: (1) Beta and gamma rays of
radium have greater penetrative power than any of the Roentgen rays;
(2) radium destroys cancer cells at a distance of only 2.5 to 4 cm.
from tube, but this action can be increased by cross-firing; (3) radium,
produces a greater degree of reaction without permanently injuring
the healthy tissue.
Advantages: (1) Small, portable, easily handled applicators;
no appreciable depreciation; (2) no danger of high tension electric
shocks; (3) easy application to inside of tumors without destruction
of intervening tissues; to inside of cavities like larynx, pharynx, etc.;
(4) produces painless coagulation and necrosis; (5) effect easily con-
fined to small areas.
Disadvantages: (1) Requires longer exposure, on the average
four hours per area; (2) burns are usually unimportant, but if occur-
ring in the larynx they may cause gangrene; (3) large doses of radium
may cause toxemia, due to escaped radiation and affecting bone marrow,
liver, or other organs.
Therapeutic effect: Depends on (1) amóunts of radium used;
80-100 mg. kill cancer cells in seven hours; (2) length of exposure;
short for superficial effects; longer for deep effects; (3) distance of
application; (4) filtration; silver and lead have equal powers of ob-
structing rays; platinum has twice their absorptive action; air space
prevents radiations of certain length from passing; rubber tubing
0.25–4 mm. thick cuts off the secondary rays from the filters; filters must
be of definite thickness depending on quantity of radium and type of
tissue treated.
The Use of Radium in Carcinoma of the Face, Jaws and Oral
Cavity. e
E. Fischel, J. Missouri M. Assoc., 17, No. 7:267–269, Chicago,
July, 1920.
Introduction :
1. Material for this article has been collected from Barnard Free
Skin and Cancer Hospital; cases were selected to demonstrate useful
application of radium.
2. Cases are submitted to conference of entire staff; method of
treatment is decided by confreres; extent and nature of operation is left
to surgeon’s judgment.
91 .
R a di u m
3. Hospital has acquired 100 mg. of radium in tubes; a 10 mg.
placque; a 10 mg. needle; radium tubes have been the routine treatment;
use of radium placque has been restricted to superficial basal cell growths.
Types of carcinoma :
1. Majority of basal cell epithelioma yield to any method of treat-
ment; x-ray will cure nearly 100 per cent; basal cell can usually be
clinically differentiated from other types.
2. Some squamous cell carcinomata have low malignancy and are
readily destroyed; comparative malignancy may be determined by
rapidity of tumor growth.
3. Most prickle cell carcinomata are very resistant; readily extend be-
yond visible or palpable limits of the disease; comparative malignancy
may be determined by rapidity of tumor growth; this type is commonly
found about face, jaw, oral cavity. *
Methods of treatment:
1. Recognized treatments of carcinoma are surgical removal; actual
cautery; destruction by x-ray, radium or high frequency current.
2. Surgical removal gives quickest results with least disability to pa-
tient; danger factors are nervous shock, traumatic shock, hemorrhage,
anesthesia; ideal surgical primary operation removes tumor together
with lymph glands, lymph channels, normal tissue surrounding the
tumor; this type of operation now physiologically possible in carcinoma
of lower lips, tongue, floor of mouth, breast, uterus, penis, upper and
lower extremities.
3. High frequency current and actual cautery positively acton tumor
without opening fresh blood and lymph channels; healing is a slow pro-
cess because the devitalized tissue must slough before repair can
begin.
4. X-ray treatment cures nearly 100 per cent of all cases of basal cell
facial epitheliomata; so far it cannot be relied upon to destroy even
superficially the more malignant types of tumors.
5. Radium treatment least upsets routine life of patient; maximum
dose can be directed over an absolutely exact area; will destroy growths
of considerable depth and extent with a minimum of scar formation;
radium can be buried in the tumor mass itself and is therefore of great
value as an adjunct to surgery in otherwise inaccessible tumors; initial
dose should be the maximum one needed for complete destruction of
carcinoma; persistent use of radiation after growth has failed to re-
spond favorably should be condemned.
Results of radium treatment in:
1. Carcinomatous facial ulcers—radium can be relied upon to
heal these.
2. Carcinoma of eyelids—radium is most efficient, method of
treatment; does not damage globe, vision or distort eyelid.
3. Carcinoma of lower lip—radium has replaced surgical treat-
ment; in primary lesion radium should be used in large unscreened
dosage; technique at clinic is that: if glands are palpable wait three
months after first radiation before removing submental and submaxil-
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lary lymphatic system; if submental glands are palpable wait six weeks
after first radiation before resecting glands; if submaxillary glands are
involved radiate lip and perform Stewart type of operation within one
week and later remove all superficial and deep lymphatic tissue of both
sides of neck.
4. Carcinoma of jaw, oral and buccal cavities—radium has a
limited use only; reason for lack of success is probably a purely techni-
cal one; difficult to maintain surface applicators in one position within
the mouth; difficult to have soft parts remain steadily opposed to ap-
plicator; carcinoma involving bones of upper or lower jaws should be
surgically removed and remnants of the growth destroyed by supple-
mental use of radium; 1 case of inoperable carcinoma of lip, tongue
and floor of mouth became operable from the use of radium; 1 case of
extensive carcinoma of the antrum remained well fifteen months after
operation supplemented by radium treatment of apex of antrum.
5. Leukoplakia—radium is the only efficient treatment of leuko-
plakia just changing into malignancy. §
6. Verucca-like epithelioma of buccal mucous membrane and
alveolar process—radium acts like magic.
Malignancies of the Mouth and Neck.
E. H. Skinner, Nebr. State M. J., 5, No. 7: 194-197, Norfolk,
Neb., July, 1920.
Radio technique:
1. In the orifices, sinuses and upon all mucous membranes radium
is more reliable than x-rays; its radius of activity rarely exceeds 2 cm.
2. Radium without sufficient filtration gives immediate super-
ficial effect with sufficient filtration and distance it gives the deeper
effects.
3. Radio-toleration of skin may be increased by alkaline washes
and sun baths.
4. Radio-toleration of patient may be increased by alkalization
with soda bicarbonate, potassium citrate, potassium bitartrate, milk of
magnesia, Kalax water, magnesium sulphate by mouth or enema, com-
bined urotropine and salol medication.
5. General strength of patient may be saved and period of irradi-
ation shortened by electro-coagulation and surgery.
6. Radio-therapy requires six times the filtered x-ray dosage that
the skin will tolerate in order to produce an erythema dose 7.5 to 10 cm.
deep; cross-firing through six skin fields is essential for proper irradi-
ation of every deep area.
7. In glandular metastasis and prophylactic irradiation it is neces-
sary to give huge x-ray dosage of high spark gap, with ample protection
filtration and cross-fire through multiple fields of entry.
8. Radio-therapy is successfully completed only when coarse hair
disappears and skin tans under exposures with total tolerance of time.
Radio-therapy in:
1. Leukoplakia—Abbe, the pioneer radiotherapist, stated (1913)
that radium is the only curative treatment; it is the specific treatment
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R a d i u m
and quickly controls leukoplakia; can be applied upon dental-rubber-
impression-compound to any part of mouth; dosage varies with depth
of lesion; violent reaction necessary to hasten results.
2. Lymphosarcoma—radium is almost a specific in these cases;
both radium and x-ray treatment given every three weeks; growth
usually reduces 60 per cent, within three weeks, vanishes within two
months; permanent results obtained only with prolonged treatment;
prolonged post operative radiotherapy is essential to prevent recurrence.
3. Epulis—near-sarcomas of alveolar portions of superior and in-
ferior maxillae; may be removed by surgery or actual cautery; post-
operative radio-therapy guards against recurrence; may be limited to
original site of tumor since there is no glandular metastasis in this
condition.
4. Osteo-sarcomas—radiotherapy may be used as primary treat-
ment with good results; may be combined with surgery and actual
cautery in removing sarcomas of the maxilla and antrum; reports 1 case
of sarcoma of right eye and right maxillary sinus with recurrence after
two operations, treated with 50 mg. radium tube inserted in antrum,
remarkable recession after two weeks, reduction to normal after six
weeks, case remained well for six months, prophylactic raying of glands
and antrum continued; reports 1 case of malignant antral Sarcoma with
glandular metastasis in neck, treated postoperatively with x-ray, meta-
stasis checked and gradually reduced, treatment continued for eight
months, condition favorable.
5. Osteo-chondroma—reports three cases, all completely relieved
by radiotherapy, oldest case cured five years ago after four successive
series of exposures, 2 cases operated twice for recurrences; Osteo-
chondroma apt to recur unless vigilant raying is maintained for at least
six months, all signs of recurrence have disappeared; immediate pro-
longed postoperative radiotherapy insures best results.
6. Tonsillar cancer—radium relieves odor, discomfort and major
portion of pain; radium may be directly inserted into cancerous growth
and enlarged neck glands; no cures have been achieved in 3 cases of
inoperable tonsillar cancer; treatment reduced tissues and checked
growth in 1 case still alive two years after treatment.
7. Cancer of the tongue—radium relieves pain and odor in inoper-
able cases; danger lies in overtreating with radium and obtaining dis-
agreeable reactions; radium treatment should be supplemented by
prophylactic medication, such as a mouth wash of potassium chlorate,
morphine, atropin, papine to relieve pain, tannic acid as astringent, soda
bicarbonate as a packing; early lesions can be managed with radium
treatment of lesion and deep x-ray blocking to lymphatics of the neck
down to the trachea to complete operation of mouth carcinoma.
8. Cancer of the lip—block dissection including the lowest glands
essential to successful operation; deep intensive radiation destroys ac-
tivity of lymph glands, shrivels and fibroses them; radium should be
applied to actual lesion; x-ray deep therapy to tributory neck glands
for several months after operation; denser lesion responds more
promptly to radium; softer lesions like epuli, papillomata, sarcomatous
detritus, dirty ulcer bases, should be eradicated by surgery or diathermy
before applying radiotherapy.
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Some Considerations upon the Present Status of the Etiology
and Treatment of Cancer, with a Report of Four Cases of Cancer
of the Larynx Successfully Treated with Radium.
D. B. Delavan, Tr. Am. Laryngol. Ass., 41 : 131-137, 1919.
The permanent effects of surgical treatment of laryngeal cancer
are little known as accurate statistics have never been compiled. Use
of radium and x-ray deserves most attention among methods of local
treatment. Four cases are outlined.
No. 1: U. S. carcinoma of larynx; distinct swelling over left
arytenoid and some over right. Appearance simulated tubercular
laryngitis, mucus being gray and subjacent tissue edematous. No
evidence of tuberculosis was found in the lungs, sputum or secretion
from the larynx. Later a superficial growth developed in the larynx
which was removed under suspension laryngoscopy. The growth rede-
veloped and on March 24, 1917, radium was applied as follows: 4 x 25
mc. platinum filter, 1 mm. rubber tube inserted in larynx for 2 hours.
On June 7 complete laryngectomy was performed. Recovery was ex-
cellent and the voice is clear. Patient still wears a tracheotomy tube.
No. 2: Extensive carcinoma of interior of larynx. Radium was
applied in August, 1918, as in No. 1. Radical extirpation of larynx
followed in Jan., 1919. By the following June a small enlargement in
the external scar. This is subsiding under radium treatment. Develop-
ment of speech is slow but satisfactory.
No. 3: U. S. laryngeal carcinoma. Two-thirds of the interior of
the larynx, the left side of the base of the tongue, and left lateral wall
of the pharynx were involved. The lumen of the larynx was practically
obliterated and dyspnoea urgent. Tracheotomy was performed in Jan.,
1918. Because of extent of growth and advanced age of patient,
radical operation was not advised. After a temporary arrest, the dis-
ease reasserted itself and was treated as follows: May 23, three tubes,
9.8 mc., were embedded in the growth for 132 hours: June 26, one tube,
4.9 mc., was embedded for same length of time. Ten days later there
was still edema in the treated area. On July 12, pack treatment was
applied and on July 21, radium treatment was resumed, a pack being
placed over the left side of the neck, 1222 me. for 40 hours. July 27,
pack over right side, 1456 me. for 5% hours. Marked improvement.
March 1, 1919, under chloroform, tracheotomy tube, a foreign body
and several small masses of redundant tissue were removed, after which
tube was reinserted. Patient still under observation although all activity
seems to have ceased.
No. 4: Epithelioma left vocal band. Voice hoarse, excessive to-
bacco smoker. Surface of vocal cord destroyed by ulcerated tumor but
infiltration was slight. Sept., 1918, 880 mc. filtered through 2 mm.
lead was applied externally on each side over larynx at a distance of
5 cm. from the skin for 534 hours. Complete retrogression followed
and the only evidence seems to be some cicatricial tissue which causes
hoarseness.
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Treatment of Laryngeal Neoplasms with Radium.
L. Barajas, Med. Ibera., 1919, Numero extraor. 1, Cong. mac. de
med. y cirug., page 101.
As they are still uncertain the results of the use of radium in
laryngology are at present being carefully watched.
The radium should be placed in the larynx in situ, using the gamma
rays and avoiding the stimulation of the secondary rays. Cases of
spreading epithelial tumors evidently undergo a process of amelioration,
even to an apparent cure, after the first applications of radium if the
dosage is adapted to the case and the subject. In all cases observed by
the author, however, the tumors reappeared in a very short time, and
in 58 cases not one complete cure was obtained.
Radium exerts a positive retarding action in the growth of neo-
plasms, in some instances causing an encysted lardaceous degeneration.
Its analgesic action in moderate doses is evident and constitutes one of
its most important benefits. The use of radium does not change the
indications for operation which is the best treatment, but is valuable
for patients who refuse operation. It is not known to what extent
postoperative applications influenced recurrences because those in whom
recurrence has begun go on in the same way in spite of the radiation,
and when there is no recurrence we cannot be sure whether this condi-
tion is due to successful surgery, or to the radiation.
The author found that the dosage should not be less than 45 or 50
milligrams, not more than 75 or 80 milligrams, with a maximum dura-
tion of 2 hours each application, which should be made as frequently
as the reaction of the organism after treatment will permit. The greater
the amount of radium used and the longer the time of application, the
more rapid and intense the reaction.
The use of radium in hemorrhagic forms of neoplasms is not recom-
mended, as it increases the hemorrhage both from the neoplasms and the
Surrounding tissues.
The pavement-celled epithelioma is the most refractory to radio-
therapy and its exacerbations most evident, but the beneficial effects of
radium are very evident in papillomata, absolute cure having occurred
in cases of multiple recurrent tumors of this type. In ulcerative tuber-
culosis radium is completely contraindicated, while in lupus its benefit
is positive.
The author is satisfied that radium merely retards the development
of some varieties of epitheliomata, hastens it in others, and completely
cures none, but that it greatly decreases the pain.
Radium Treatment of Cancer of the Tonsils.
M. Lannois and Moutet, Lyon Méd. 126: 495, 1917.
The authors report the present condition of patients given radium
treatment a year or more ago. One young man has nothing left of his
tonsils, and the enlarged glands in the neck and axillae have subsided
to normal size and shape. He has been an active wage earner during
the year since, but recently some enlarged glands were palpated in the
inguinal region. They do not seem to be metastases but a new mani-
festation of the lymphadenia to which he is subject.
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Two other patients are at work with no indication of recurrence.
In a fourth case, a woman of 74 was treated for a lymphosarcoma
in the left tonsil. A needle with stout thread was passed through the
anterior pillar and the platinum tube containing 48 mg. of radium was
drawn by the thread into the depth of the tonsil, a hole being burrowed
for each end of the tube in the abnormal tonsil tissue. A small tampon
of gauze was placed over it and the tube was left in place for nineteen
hours. The dose applied was 912 milligram hours. Improvement was
rapid, the tumor promptly subsiding, and in a month or two both tonsils
had completely retrogressed.
In another case the cancer in the tonsil was far advanced but the
symptoms were notably improved by implanting the radium tube in a
slit made with the bistoury in the tumefied tonsil. It was left in place
for twenty-four hours, and the condition was much relieved. The ap-
plication was repeated later, and swallowing became less difficult but the
enlarged glands in the neck were not modified. The man is now taking
a course of Roentgen treatment for them, but his condition is pre-
Cºl.1"1011S.
Angioma of the Larynx.
G. Sterling Ryerson, Canad. Med. Assn. Jour., 2:111-113, 1912.
Angioma of the larynx, up to the time of writing this article,
seems to have been a rare affection, but few cases having been reported
in the literature.
Histologically, the cavernated tissue in angioma is lined with a
single layer of epitheloid cells. The vascular spaces may be empty or
filled with laminated clots. The surface partakes of the epithelium of
the part. The stroma may undergo mucoid degeneration, giving the
growth a mixed character.
Angioma cavernosa presents the appearance of a raspberry-like
mass and may be either sessile or pedunculated. It may appear in any
part of the larynx, but is most common on the vocal cords.
As a review of the literature revealed the disastrous results of
treatment often occurring from galvanocautery or crushing with for-
ceps, Ryerson decided to use radium. This was done with success in
the writer’s case.
Case. Woman, single, age 55 years. Patient complained of dif-
ficulty and oppression of breathing at times, but no pain, hoarseness or
cough. No family history or growth of tumors. Patient’s mother had
“thick neck” and died of heart failure at an advanced age. Present
difficulty began about a year previous to present examination (May,
1909), with stiffness and pain in the tongue and occasional difficulty in
breathing. Patient said that some enlarged veins at back of tongue had
been burnt off. No difficulty in swallowing. Examination of the larynx
showed on the left side of the anterior surface of the arytenoid, on the
ventricular band and along the external margin of the vocal cord, a
bluish-purple mass lobulated, and presenting the appearance of a small
raspberry. On the anterior surface of the right arytenoid was another
similar body, but smaller, which extended beyond the arytenoid. Patient
had a small goiter,
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Regarding the treatment by radium the writer says: “In view of
the disastrous effects of operative interference, I determined to try
radium, and obtained from Dr. E. E. King a tube of German radium
of unknown activity.
“With Dr. King's assistance an applicator was devised and treat-
ment begun. Meanwhile, I communicated with Dr. Wickham in Paris,
who advised a special applicator furnished with three mg. radium,
activity 1,000,000. This was obtained in due course and treatments
continued at intervals of three months, for a year. At the end of that
time there was a considerable improvement, but much of the mass still
remained. I then obtained a small disc containing 10 mg. of radium,
activity 500,000, and had an applicator made so that it could be intro-
duced into the larynx. I continued the treatment with the former
intervals, when a marked improvement was soon noticeable. By April,
1911, it had disappeared, except a small point which I though I could
venture to cauterize with electro-cautery without danger. I did so,
and today where formerly there were two vascular growths there are
two small cicatricial nodules.”
This was Ryerson's first experience with radium treatment. He
believes that had he had the requisite appliances when starting the
treatment, combined with experience since gained with this form of
treatment, the cure would have been accomplished in half the time.
One of the difficulties encountered was the impossibility of retaining
the applicator in place longer than from one to three minutes at a time,
in spite of liberal cocainization.
The writer does not believe that the goiter bore any direct relation
to the throat lesion. The difficulty in breathing may be due to a possible
edema of the larynx, which has been said to accompany the condition
of angioma of the larynx.
Angioma and nevi, in the writer's opinion, resist radium in direct
ratio with the age of the patient—the older the subject, the greater the
resistance. This applies to the mucous membrane as well as the skin.
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SECTION VII
RADIUM-ITS EFFECT UPON THE BLOOD AND
USE IN BLOOD DISEASES
United States Radium Corporation
New York
R a di u m
SECTION VII
RADIUM.–ITS EFFECT UPON THE BLOOD AND USE
IN BLOOD DISEASES
The Influence of Radioactivity in the Treatment of Hyper-
tension.
C. E. Field, Med. Rec., 98: 1051, Dec. 25, 1920.
The author states, “Observing carefully our clinical results, to-
gether with conservative deductions made from our laboratory findings,
we do not hesitate in placing radium in the very forefront of thera-
peutic measures for the relief of hypertension.”
Administration: Radium may be administered by means of ema-
nation inhalation, radioactive waters for drinking, solutions of radium
salts for drinking, by means of emanation baths, or by intravenous or
subcutaneous administration of radium bromide or radium chloride.
Wherever dosage in micrograms of radium salts is quoted, it refers to
radium element. Radium has absolutely no toxic effects, it being ac-
cepted as harmoniously by the human system as is sunlight by the plant.
Most interesting research is now being made in measuring the
radioactive content of the blood for weeks following treatment. The
activity of radioactive waters is of short duration and consequently they
are limited in their application. It is probable that no emanation can
be traced two hours after taking, whereas radium solution by mouth
can be traced and measured up to the sixth day. Following an intra-
venous injection of radium chloride, it can be traced in the blood at
least twelve weeks thereafter.
“So far as dosage is concerned in high blood pressure, we are largely
governed by the chronicity of the case and the involvement. Personally,
I feel my best results have been shown in what we would term low
dosage.”
It is the author’s usual plan to give an injection of one 25 micro-
grams (radium chloride) ampule (2 c.c. normal saline solution), and
following with solution of distilled water, two ounces, containing 2
micrograms of radium chloride given by mouth as one dose three times
a week. After four weeks this drinking solution is cut to two doses
per week. While the results are prompt, the author never accepts a
case for less than twelve to sixteen weeks treatment and observation,
Careful record of the laboratory findings are always to be made.
Where radium solutions by mouth alone are given, the author’s
dosage starts at 6 micrograms per day in three doses; this to continue
for four weeks as a rule, then to follow at 6 micrograms per week for
the balance of the course. This plan of treatment does not give as
uniformly good resutls as a course inaugurated with an intravenous
injection. The plan of insisting on the long time treatment was arrived
at, owing to the fact that after the initial drop in pressure, or within
five days, the patients generally felt so much improved that there was
a tendency to discontinue treatment. It was necessary to make it clear
that the early relief had nothing to do with the permanency of the effect
most to be desired.
As to the permanency of this treatment the author states “that
fully three-quarters of the cases have held without further treatment
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for from six to twelve months. There are many of the early cases
treated nearly four years ago that have suffered no material rise.
Others where pressure has gone up sufficiently to produce symptoms
have been quickly touched up with a two or three weeks' treatment.
Some of these returned with their trouble on account of growing bold
with their diet.” An interesting feature in the author's cases has been
an activation of sexual powers. Insomnia and nervous symptoms are
improved and the patients invariably take on a feeling of well being.
“Compensatory functions can be sustained and greatly improved
at times with extremely low dosage of radium. In such cases we may
observe both systolic and diastolic pressures slowly coming down in a
fairly even proportion. Although I can find no record of any unfavor-
able action following the administration of the soluble salts of radium,
I would urge caution in attempting sudden reductions in compensatory
high pressures. Here must come a full understanding as to the type
of compensation.”
The Blood Cholesterol in Malignant Disease and the Effect of
Radium on the Blood Cholesterol.
G. Luden, J. Lab. & Clin. Med., 4:849, 1918.
“Aside from the effect of radium on metabolic processes and
thereby indirectly on the composition of the blood, the following consid-
erations may help account for the reduction of the blood cholesterol
(Bloor I) following radium treatment. Schulze and Winterstein have
shown that cholesterol is oxidized and disintegrated by the action of
light. It is known that radium is photoactive. It is possible, therefore,
that the photochemical activity of radium may cause the changes ob-
served in the cholestrol content of the blood after radium treatment.
The increase of the cholestrol split products in the blood, namely, the
increased difference between Bloor I and II, supports this interpretation.
“If we compare the disintegration of cholesterol in the body to the
combustion of fuel by fire, changed or oxidized cholesterol may be com-
pared to fuel that has been consumed and thus rendered harmless,
whereas pure, unchanged cholesterol Inay be compared to fuel that has
not yet been consumed. An accumulation of unconsumed fuel con-
tains in itself the latent possibility of starting a conflagration. It is
possible that, although we know pure cholesterol promotes cell division,
changed cholesterol may fail to do so. A high percentage of unchanged
cholesterol, such as is found in carcinoma, would therefore represent
an opportunity for undue cell proliferation that is an element of danger.
This danger appears to be reduced or eliminated by the action of radium
since it is found that the amount of changed (possibly harmless) choles-
terol increases in the blood as the condition of the patient is improved
by radium therapy.
“The reduction of the blood cholesterol values by the administra-
tion of the thyroxin in myxedema, however, cannot be looked upon as
the result of photochemical activity. The thyroid hormone is not photo-
active. Nevertheless the blood cholesterol values are lowered by the
use of thyroxin as well as by radium treatment. We know that the thy-
roid hormone is capable of increasing the rate of basal metabolism—
and that increased metabolism is accompanied by a reduction of the
:
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Radium
cholesterol content (Bloor I) of the blood, similar to that produced by
radium treatment. This fact, whatever the chemical or physiologic
process to which it is due may prove to be, shows that the effect of
thyroxin on the chemical composition of the blood is similar to that
of radium.”
Some Phases of Radium Action with Special Reference to the
Hematopoietic System.
Millet and Mueller. J. Cancer Research, 3: 127, 1918.
1. The blood of ten cases of squamous-cell carcinoma of the cer-
vix uteri and vagina has been studied in order to ascertain the immediate
and remote effects of radium and x-ray treatments upon the formed
elements of the blood.
2. The immediate effects of radium on the blood are not altered
qualitatively by previous x-ray or radium treatments, although the quan-
titative action may be somewhat diminished during a second treatment.
3. The remote effects of radium on the blood are essentially
similar to the effects of combined x-ray and radium treatment.
4. Individual slight differences in response to radium applications
are often noted to occur again on a second application in the same
individual.
5. The immediate effects of radium on the blood are the fol-
lowing:
a. An immediate drop in total white count reaching its maximum
from one-half to six hours after the application.
b. A return of the total white count to its former level within
twenty-four hours after the application, usually within the first twelve
hours.
c. An occasional secondary rise of the total white count to a
point well above its original level from twelve hours to three days after
the application.
d. A close adherence of the total polymorphonuclear count to the
curve of the total white count.
e. An absence of characteristic changes in the total lymphocyte
and total large mononuclear counts.
f. A tendency of the total lymphocyte count to follow in some
degree the fluctuations of the total white count, especially when these
are marked. This effect is not constant.
g. A tendency of the relative lymphocyte count to drop, and of
the polymorphonuclears to rise during the course of treatment. This
tendency is reversed during the period immediately following the re-
moval of the radium.
6. Remote effects of radium treatment on the blood are as
follows:
a. Early.
(1) Fall in lymphocyte count from two to four weeks after treat-
ment, sometimes lasting till the end of the second month.
(2) Fall in polymorphonuclears after treatment, sometimes simul-
taneous with the fall in lymphocytes but usually coming later and being
less striking.
(3) An attempt of the lymphocytes to recuperate, as shown by
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a rise in most cases at some later date varying from three to nineteen
weeks after treatment, to the approximate level seen before treatment.
b. Late.
(1) Changes in the relative counts as the patient’s resistance
weakens, with increase in polymorphonuclears and decrease of lympho-
cytes, but without leucocytosis.
(2) Terminal leucocytosis, due in the main to increase of the
absolute polymorphonuclear count, although usually accompanied by an
absolute decrease in lymphocytes.
A Metabolism Study of a Case of Leukemia During Radium
Treatment.
Knudson and Erdos, Boston M. & S. J., 176: 503, 1917.
The case was a woman, thirty years old, suffering from myelogen-
ous leukemia. The spleen was greatly enlarged, and white count was
495,000 at the beginning of radium treatment.
The treatment consisted, briefly, in applying 50–60 millicuries of
radium emanation (50-60 mg. of radium element) to small areas on
the abdomen, which was marked off, indicating the outlines of the en-
larged spleen. Each area was rayed for four hours during the first
series and six hours during the second and third series of treatments.
Each series of treatments required three to four days to cover the sur-
face over the area of the enlarged spleen. Between the series of
treatments about four to six weeks were allowed to intervene, the time
being determined by the examination of the blood.
No attempt was made carefuly to regulate the diet, although a
record of food taken was kept and found to vary within narrow limits.
The diet was practically purin free during and following the series of
treatments. It consisted chiefly of bread, cereal, potatoes, milk, butter,
eggs, fruit, and occasionally beef, chicken, and a few vegetables.
The urine was collected for 24-hour periods in thymolized bottles
and brought to the laboratory for analysis immediately after the 24-hour
period was up. At the beginning of the first series of treatments the
urine was collected daily from Nov. 6 to 13 inclusive, and after that
date it was collected on an average of three times a week except during
two periods of a week each when it was discarded because of men-
struation.
Total nitrogen was estimated by the modified Kjeldahl method,
urea by the urease method, ammonia by Folin's method, uric acid by
Benedict's modification of Folin's colorimetric method, creatinin by
Follin's method, phosphoric acid by titration with uranim acetate, and
the acidity by Folin's method. The urine was at all times during the
treatment free from albumin and sugar.
From the experiments it was noted that the volume of urine in-
creased 50% in the first seven days from the beginning of treatment.
The total nitrogen, urea nitrogen, and ammonia nitrogen excretions like-
wise showed remarkable increases in the first seven days. The total
nitrogen increased about 115%, urea nitrogen 140% and ammonia nitro-
gen 150%. The uric acid nitrogen increased less than any of the other
nitrogen excretions, only about 28%. The uric acid would be expected
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to increase considerably more since the tissue which is disintegrated is
rich in nuclein material and should be among the products of disinte-
gration. It may be that the uric acid is broken down further, due to
radium having a disintegrating action on uric acid as it does in vitro.
According to Sarvonat, radium emanation decomposes uric acid, oxalic
acid is found among the products of decomposition. Another theory
why uric acid may not be increased so much is that of Gudzent and
Lowenthal. They found that radium emanation has a pronounced in-
fluence on purin metabolism, the action being due to activation of those
ferments which are responsible for building up or for cleavage of uric
acid according to which ferment action predominates. In this case in
which the uric acid would be expected to increase considerably, it may be
possible that the cleavage ferment is activated, in which case it would
break up the uric acid.
Coincident with the increase of the nitrogen constituents, the total
acidity and phosphates show a very decided increase; the former is in-
creased by about 235% and the latter 174%. The total acidity was
parallel, to a certain extent, with the excretion of the total phosphates.
After the seventh day of the first series of treatments all of the
excretory products show a slight drop. However, these excretory prod-
ucts, in spite of this drop, are at a higher level at the time of the next
series of treatments than at the beginning of the first series.
In the second series of treatments it seems that the same effect
occurs as in the first series—an increased excretion, the total phosphates
reaching in this series on the tenth day an increase of 445% over the
excretion for the first day of the experiment. The high level of ex-
cretion seems to occur about the tenth day compared to the seventh day
in the first series. There is in this series a slight drop in the excretions
after the tenth day and then later a rise, so that at the beginning of
the third series of treatments the excretions are again at a higher level.
It may be that the radium action is still effective at this date or that
there is very little or no retention of products at this stage of the
disease.
The third series of treatments began January 27. Since excretions
were high just before the treatment began, there does not appear a
decided increase in any of the constituents except the phosphates on
the eighth day after the beginning of the third series.
Conclusions.
1. The excretion of total nitrogen, urea, ammonia and phosphates
are enormously increased immediately after the action of radium.
2. The uric acid output is only slightly increased compared to the
other nitrogenous constituents.
3. Surface applications of radium over the spleen accelerates the
disintegration of nuclein tissue, resulting in the above increases.
4. The phosphates show the most remarkable results, increasing
as high as 400% at times over the excretions at the beginning of treat-
ment.
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X-Ray and Radium Treatment of Leukemia and Hodgkin’s
Disease.
I. Levin, Med. & Surg., 1, No. 4:411-416, St. Louis, Chicago,
June, 1917.
Definition.
1. Leukemia—bone marrow, spleen, lymph gland are the blood-
forming organs which probably take part in forming this disease.
2. Hodgkin's disease—also called pseudo-leukemia; pathologic
changes noted in blood, spleen, lymph glands; cervical and axillary
lymph glands most frequently involved; lymposarcomatosis is a type
of Hodgkin’s disease involving the hyperplastic lymph glands; medias-
tinal tumor is another type involving the intrathoracic lymph glands;
they probably all present one group of diseases of the hematopoietic
system; no definite evidence that Hodgkin’s disease is caused by an in-
fectious agent; its relation to malignant neoplasms is more probable and
borne out by the results of x-ray and radium therapy.
Mechanism of action of ar-ray and radium on Hodgkin’s disease.
1. Blood, spleen, bone marrow, lymph nodes are most sensitive
body organs to action of radium and x-rays; a certain time after cessa-
tion of raying the blood-forming organs recover their normal state.
2. Red blood cells are quite resistant to raying action; neutro-
phile polymorphonuclear cells remain intact longest; lymphocytes and
unripe leukocytes or myelocytes are most easily affected especially in
the leukemia blood.
Technique of treatment:
1. Coolidge tube used exclusively; focal skin distance eight inches;
length of spark 8% inches.
2. Bauer penetrometer measuring hardness of the rays and mil-
liamperemeter are placed so as to be observed constantly through a lead
glass window; hardness of rays is kept at 10 Bauer and 5 milliamperes
sent through the tube.
3. Skin field represents a circle one to two inches in diameter;
location depends upon region treated ; numbers of fields are mapped out,
four are treated at every sitting.
4. Regions treated are spleen, shafts of long bones, sternum,
chest wall, liver, affected lymph glands.
5. Treatments given three times per week for about six weeks;
initial doses 10 x to each field until tolerance is ascertained; dose later
increased to 20 x per field; treatment controlled by blood examination;
at first blood-smear before and after treatment, later one weekly blood
examination; blood picture usually improves in about six weeks when
treatment is interrupted; next series of treatments depends on patient's
condition.
Results of treatment in:
1. Hodgkin’s disease—affected lymph glands rapidly diminish
to a certain extent under x-ray, more readily under radium treatment;
marked improvement in general health of patient; treatment should
continue for months; if interrupted for a time the first evidence of new
glandular enlargement indicates repetition of treatment; unsatisfactory
and merely palliative results are probably because radiation was begun
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only late in course of disease and not pursued with sufficient energy;
in a few early cases radiation has succeeded in arresting the disease for
a number of years.
2. Splenic pseudo-leukemia—radium acts more promptly on en-
larged lymph glands; combined x-ray and radium treatment therefore
advisable; in majority of cases condition subsides under this treatment
and life is prolonged.
3. Mediastinal tumors—one form of Hodgkin’s disease; fluoro-
scopic chest examination necessary in early cases; immediate energetic
raying of chest whenever enlargement of mediastinal glands is observed;
clinical symptoms usually expressed in advanced stage of disease; re-
sults of treatment therefore temporary; yet many cases are reported
where x-ray plates before and after treatment show marked decrease in
size of tumor and improvement in general clinical symptoms. t
4. Lymphosarcoma—a malignant degeneration of hyperplastic
ſymph glands; a late stage of Hodgkin's disease; a priori results of
x-ray and radium treatment can therefore be only palliative; yet cases
are on record where far advanced disease was kept in check for as
much as a year and a half, or some of the affected glands completely
disappeared under radium treatment.
Conclusions:
1. Leukemia and Hodgkin's disease are the most hopeless condi-
, tions in medicine.
2. X-ray and radium treatment should be given as soon as diag-
nosis is made; results of these treatments are most encouraging; treat-
ment must be conducted with great energy.
Hemolysis by Means of Radium Rays.
W. Hausmann, Wien. klin Woch., 29: 1289, Oct. 12, 1916.
Red corpuscles suspended on an agar plate were completely de-
stroyed at the end of a thirty-six hour exposure to radium rays (the
destruction was seen to start in less than twenty-four hours). Further
experimentation proved that this effect should be ascribed to the beta
rays.
Radium. Its Physio-Chemical Properties Considered with Re-
lation to High Blood Pressure. -
C. E. Field, Med. Rec., 89: 135, 1916.
According to von Noorden, radioactive elements exert forces which,
in accord with the definite laws of physics, markedly influence biologic
processes. Furthermore, the chemicophysical properties of radium may
be traced in the human body even in the minutest doses. Metabolism,
while classed as a body chemistry, is in itself dependent to no small
extent on physics. In the laboratory radium readily activates and in-
tensifies fermentative and digestive processes; within the body, it
stimulates even more actively the numerous ferments. The efficiency
of radium in catalysis and autolysis will be better understood if for a
moment we review a few of the commonly well-known facts as regards
this element.
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Radioactive substances present three distinct products of disinte-
gration which we term rays. Alpha rays are positively charged helium
atoms and constitute 90 per cent. of the energy of radium. Beta rays,
also electrons, in turn are negatively charged particles. Gamma rays
are not material in nature, being classified as exceedingly short-length
waves of ultra violet light. In the process of decay or transmutation,
something happens within the tiny atom of radium, and much as the
meteor flies from the planet, the alpha ray is spontaneously thrown
off into space with a speed of over 12,000 miles per second. From
this another and still another particle is born until the entire series in
evolution is complete. In common with the liberation of the alpha
particle, we have the formation of a gaseous substance known as ema-
nation, which contains in itself all of the power and energy of radium.
The radiations of emanation acting as carriers of enormous energy
within the body develop heat and electricity and foster chemical trans-
formation. By its use we permeate the body with a stream of electrons
through the channel of the blood stream. It carries a normalizing ac-
tivity to the tissues, fluids, protoplasma, cells, and nuclei. Therapy with
radioactive substances may be designated as the administration of fluid
electricity. This is probably the most clear description we could give
of its physical force and purpose.
To have the radium situation clearly before our minds, we must
acknowledge that much of the early experimental research with radium
had many of the hindrances common to the study of so rare and new
an element. The theories relating to the causative features of high
blood pressure are many; but for our immediate need we care not to
debate now whether it is due to a hyperplasia of the suprarenal capsule
or, according to the old theories of Cohnheim and Traube, to mechanical
interference in the flow of the blood stream, for we may content our-
selves in the belief as clinicians that faulty ferments of toxic origin are
the basic factors.
From the earliest experiments to the present, lowering of high
blood pressure during radium treatments has been the common report.
Physiochemical processes are exact and the physiological and biological
manifestations that follow must to a similar degree, be definite. There-
fore it is that, in almost 95 per cent. of the high blood pressure cases
treated, certain improvements are promptly noted, precordial distress,
headache, vertigo, disappear at times even with small dosage. The
general energy of the heart is markedly improved, and peripheral re-
sistance is reduced. A factor that by some has been discounted is the
viscosity of the blood; yet a change in type exerts an enormous influ-
ence on the arterial system—under emanation it is rendered less viscid.
The elasticity of the muscular wall of the artery relieves the heart of
much unnecessary load. When the tonicity is low, increased tension
results. Radium emanation improves the general muscle tone of the
entire system. All these processes naturally are the outcome of the
influence of radium on the various ferments that may be disordered.
Recognized early, metabolic processes may be promptly improved
with the hope of a permanent cure. We have a right to assume that
the process of hypertension can be checked so as to prevent the develop-
ment of a nephritis. Indeed, there is a reason to believe that Bright's
disease as a symptom may be wiped out. When nephritis and cardiac
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R a d i u m
lesions are advanced, the pathological processes can surely be held in
check and life in a measure conserved ; while at the last stake with a
broken compensation we may sustain the patient by lowering tension,
building up resistance, increasing somewhat the elasticity of the blood
vessels, thereby lessening the danger of their rupture and materially
adding to the comfort of the patient.
So far as dosage is concerned in high blood pressure we are largely
governed by the chronicity of the case and the involvement. Personally,
the author feels his best results have been shown in what we would
term low dosage. Delano of Boston has checked up some exceedingly
important findings derived with low dosage. He has found his average
dose to be 4 micrograms daily. It is the author's usual plan to give an
injection of one 25-microgram (radium chloride) ampule (2 c.c. nor-
mal saline solution), and following with a solution of distilled water,
2 oz., containing 2 micrograms of radium chloride given by mouth as
one dose three times a week. After four weeks this drinking solution
is cut to two doses per week. While the results are prompt, he never
accepts a case for less than twelve to sixteen weeks’ treatment and
observation. Careful histories of the laboratory findings are always
to be made. The patient may or may not be placed on diet and other
rules of hygiene as may seem indicated. In private cases he would, of
course, observe the above, in others he has preferred to watch the
results without special or rigid diet. Under such a treatment we have
a right to expect by far the large majority of cases of systolic pressures
(running from 160 mm. to 200 mm.) to be influenced to drop from
15 mm. to 40 mm. As a rule, active symptoms such as precordial dis-
tress, vertigo and headache disappear in many cases within a few days.
Where radium solutions per Os alone are given, the dosage starts at
6 micrograms per day in three doses; this to continue for four weeks
as a rule, then to follow at 6 micrograms per week for the balance of
the course. This plan of treatment does not give as uniformly good
results as a course inaugurated with an intravenous injection. The plan
of insisting on the long time treatment was arrived at, owing to the
fact that after the initial drop in pressure, or within five days, the pa-
tients generally felt so much improved that there was a tendency to
discontinue treatment. It was necessary to make it clear that the early
relief had nothing to do with the permanency of the effect most to be
desired. In dealing with a disordered metabolism of long standing it
would be unwise even to assume that radium would accomplish the
impossible. Patience and real radium with or without a portion of
psychology are necessary factors to the successful administration of
those cases. In your mind will naturally arise the question, what of
the permanency of such treatment. To this the author replies that fully
three-fourths of the cases have held without further treatment for from
six to twelve months. There are many of the early cases treated nearly
two years ago that have suffered no material rise. Others where pres-
sure has gone up sufficiently to produce symptoms have been quickly
touched up with a two or three weeks' treatment. Some of these re-
turned with their trouble on account of growing bold with their diet.
An interesting feature in a large number of cases has been an activation
of sexual powers. Insomnia and nervous symptoms are improved and
the patients invariably take on a feeling of well being.
107
R a di u m
frn-
Compensatory functions can be sustained and greatly improved at
times with extremely low dosage of radium. In such cases we may
observe both systolic and diastolic pressures slowly coming down in a
fairly even proportion. Although the author can find no record of any
unfavorable action following the administration of the soluble salts of
radium, he would naturally urge caution in attempting sudden reduction
in compensatory high pressures. Here must come a full understanding
as to the type of compensation. For the purpose of this paper he has
intentionally refrained from dealing with compensatory cases and his
selection has been a measure confined to those types showing relatively
a high systolic and a low diastolic pressure. In a series of 135 cases
classified, the average systolic pressure was 190 and the average reduc-
tion showed at 40 mm.
Radium, X-Rays and the Living Cell.
Colwell & Russ, London, 1915, Chap. 7, p. 176, G. Bell & Sons.
V. Noorden and Falta showed that an increase in the number of
white cells occurred in the blood of certain patients submitted for some
hours to an atmosphere containing emanation and that this increase
was sometimes followed by a decrease.
As a result of observation on blood counts at various intervals
before and after the injection of radium in dogs and rabbits by Brill
and Zehner, they state that after the first rapid rise in the number of
red cells there is a further important increase and this may reach as
high as 13,000,000 per c. mm.
The increase is a function of the amount of radium per Kilogram
weight of the animal. Pathological forms of blood cells were not met
with.
In a summary of their work they state that on the leukocyte system
there was in all cases a strong stimulation, but with strong doses there
is also a harmful effect upon the red cell system; they only observed a
stimulating effect, which in many cases lasted a long time.
Chambers and Russ showed that the red cells of the human blood
are hemolysed much more easily by the alpha rays than by the beta and
gamma rays; in fact, no hemolysis was observed with quantities very
much larger than the ionising effects of these rays would have indi-
cated as being sufficiently large to produce hemolysis.
The leukocytes are also affected by exposure to the emanation.
Prolonged exposure leads to the complete disintegration of the leuko-
CVteS.
y Benjamin, Reuss, Slenka and Schwartz showed the susceptibility
to the x-rays of the lymphocytes: there is a decrease, and the increase
in the polymorphonuclear leukocytes that often results from an ex-
OSUIT e.
p Tartarsky considers three ways in which the lymphocytes in the
blood may be destroyed—(1) the lymph glands and follicles may be
specially sensitive to the action of the rays, their function being so
interfered with that the production of new cells is hindered or com-
mletely stopped; (2) they may be destroyed in the circulating blood; or
(3) the normal evolution of the lymphocytes to the polynuclear leuko-
cyte may be accelerated under the action of the rays with the result that
108
R a d i u ºn
there is a reduced number of lymphocytes found in the circulating blood.
Tartarsky considers the first to be the most probable way in which the
x-rays act.
Aubertin and Beaujord call particular attention to the oscillatory
nature of the graph before a normal condition of the blood is reached.
From the detailed blood counts it is possible to trace the variations of
each class of white cell and in this way determine the relative part they
play in the process by which the blood returns to normal.
During the leukopenia, the polynuclear forms generally decrease
in number but not so greatly as other varieties. A notable increase in
the eosinophile and mast cells is a further evidence of a state of hyper-
activity in the bone marrow together with a reduced activity of the
spleen.
As a general conclusion they state that: “A medium dose of x-rays
causes a condition of hyper-activity of the bone marrow which, though
apparently paradoxical, is the more accentuated the more marked the
decrease in the leukocyte content of the blood; this condition disappears
only when the blood content is normal.”
Changes occur in the human blood as a result of chronic exposure
to x-rays. Aubertin states that the blood of seven radiologists in good
health was not quite normal, the most marked feature being a diminu-
tion of red cells.
Senn discovered that x-rays have a beneficial effect upon the blood
in leukemia. Bruce and Ledingham in cases of spleno-medullary leu-
kemia found that the bone marrow was in a markedly hypoplastic con-
dition; the neutrophile elements were found to be almost entirely re-
placed by undifferentiated basophile myelocytes in a proliferating con-
dition. Ledingham cautions against the continuation of x-ray treat-
ment once the total leukocytes are normal.
It is not definitely known how far the Beta rays penetrate the
tissues of the body, while the penetrating power of the gamma rays is
much greater than that of the beta rays.
They correspond on the average to a very hard type of x-rays,
more penetrating than any x-rays yet produced by mechanical means.
The clinical importance of secondary radiations, whether induced
by beta, gamma or x-rays, is difficult to estimate.
Ionisation due to beta rays is less intense and less localized, while
the gamma rays have a small ionising action, which may, however, be
distributed over a very large space.
Generally speaking, the penetrating power of x-rays lies between
that of beta and gamma rays. It is, however, possible to produce x-rays
which are more easily absorbed than swift beta rays are; and on the
other hand “very hard” x-rays are more penetrating than the softer
types of gamma rays.
The Value of Radium and X-Ray Therapy in Hodgkin's Dis-
ea SC.
Harry H. Bowling, J. Radiol., 2:20, Dec., 1921.
The etiology, pathology, symptoms, differential diagnosis, prog-
nosis, and treatment of Hodgkin’s disease are discussed. In all early
cases of glandular enlargement, an isolated gland should be removed
109
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for examination by a pathologist. For radium treatment the author
employs 50 or 100 mg. doses of Salt of emanation, contained in either
silver or brass capsules of 0.5 mm. thickness, and filtered in addition
through 2 mm. of lead, the radium being held at a distance of 2.5 cm.
from the skin by means of a gauze pad or a wood block. Twenty hours
of treatment are given with the silver tube, and ten with the brass. Two
to four areas are usually radiated at one time with intervals of two to
three days from 5,000 to 6,000 mg. hours being applied to each right and
left cervical and supraclavicular area and inguinal areas, and from 1,000
to 3,000 to the auxiliary areas.
In giving x-ray treatment, a 23.7 parallel spark-gap is used with
5 milliamperes of current, the distance being 30.5 cm., the time twelve
minutes, and the filtration 6 mm. of aluminum and a piece of sole leather.
The chest is divided for treatment into four areas and the back into
eight. Exposures are repeated every three weeks until 6 or 8 treat-
ments have been given; then an interval of three months is allowed to
elapse. The x-ray treatments are usually given at the beginning or at
the end of the radium exposures.
Bowling believes that the life expectancy of the patient should be
increased by intensive radium treatment of the superficial glandular en-
largements and deep x-ray therapy of the thoracic and abdominal
cavities, whether the roentgenograms are positive or not. Huge glandu-
lar enlargement and mediastinal involvement are markedly diminished.
The generalized pruritus may diminish and in some cases may entirely
disappear.
Radiation in the Treatment of Leukemia.
A. Soiland, J. Radiol., 2:25, Dec. 1921.
The effects of radiation from the x-rays and radium are apparently
alike. If radium is used, a sufficient amount must be employed to insure
deep effects. The author frequently employs radium over the spleen
and x-radiation over the Osseous structures and glandular fields.
Technique for radium over the spleen that the author ordinarily
employs is the following: The area is divided off into squares, eight
centimeters in diameter. One hundred milligrams radium element, with
one-half millimeter of silver, one millimeter brass, and two millimeters
hard rubber filter, are placed in a wooden block, the whole wrapped in
gauze, making a skin distance of three centimeters when applied. A
total of fifteen hundred milligram hours is applied to each of the eight
centimeter squares. At the end of this series, a blood count is made,
and upon the findings thus obtained, additional treatment is regulated
to suit the individual patient. It has not been found necessary to use
radium over the bones.
110.
R a di u m
SECTION VIII
RADIUM IN THY ROID AND GOITER
United States Radium Corporation
New York
R a d i u in
SECTION VIII.
RADIUM IN THY ROID AND GOITER
Pathologic Classification of Thyroid Gland Diseases with Ra-
dium Treatment in Toxic Goiter.
R. E. Loucks, Am. J. Roentgenol., 8: 755, Dec., 1921.
Loucks believes that radium is the treatment of choice. He recom-
mends the use of at least 100 mg. in four tubes, screened in 1 mm. of
brass and 1 mm. of gum rubber, and placed on a gauze pad 2 cm. thick.
Two or three areas are treated, depending on the size of the gland, the
size of the pad, and the amount of radium. The exposures vary from
eight to ten hours over each area. From careful observations on a
number of cases, Loucks finds that the systolic blood pressure is lowered
in those cases in which there is a high blood pressure, although the
degeneration of the heart and kidneys has not become permanent, and
that the blood pressure is raised in those cases in which compensation has
been reëstablished.
In patients with a metabolic rate around 80, it was lowered for the
first two weeks, raised for the third and fourth weeks, and then gradually
decreased for the next few months. In those with a metabolic rate above
100 with broken compensation it gradually decreased after the third
week. The metabolic rate was found to be normal in many very active
cases three months after treatment.
Metabolism being the standard of toxic activity, the rate measure-
ment will verify clinical findings, prove results of treatment, and show
a physiological indication for future measures.
Radium Emanations in the Treatment of Goiter.
W. I. Terry, J. A. M. A. 76: 1821, 1921.
In the treatment of bad risk cases of exophthalmic goiter, it occur-
red to the author that radium emanations could be introduced into the
substance of the thyroid under local anesthesia, and with a minimum of
traumatism. He inserted eight tubes of radium emanations, represen-
ting ten millicuries, in the case of a patient with an extreme degree of
hyperthyroidism with exophthalmos. Since then he has employed a simi-
lar procedure with ten other cases. With the advice of Dr. L. R.
Taussig, the dosage of emanation has been reduced to six or seven
millicuries and is contained in about six minute capillary tubes.
The technic is simple. Under local anesthesia, a spinal puncture
needle of small calibre, is introduced into the thyroid. The tube is
pushed out of the needle by an obturator slightly longer than the hollow
needle. This procedure is repeated until all the tubes containing radium!
are deposited in various parts of the thyroid gland. The emanations
thus act from within the goiter and tend to inactivate it and prepare
the patient for operative treatment should it be deemed advisable.
It is not expected that this form of radium treatment will supplant
ligations, but it offers lessened risk, according to the author’s opinion.
Of the eleven patients four were considered sufficiently improved, after
a lapse of from four to ten weeks, for partial lobectomies. One patient
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died of acute hyperthyroidism following a partial bilateral lobectomy.
The other seven patients are still under observation and have shown
improvement.
Radium Treatment of Enlarged Thymus Glands in Infants.
A. C. Heublein, Am. J. Roentgenol., 7: 191, 1920.
The author was called into consultation to see an infant practically
moribund from the effects of an enlarged thymus gland. Although
roentgen therapy was recommended as up to this time it had proved to
be the only effective method of treatment, yet partly from an experi-
mental standpoint, and also in view of the fact that with radium the
author had observed a rapid diminution in the size of other pathological
overgrowths, he departed from the accepted method of treatment and
used radium.
The result was so eminently satisfactory that he has treated all
other cases in a similar manner. The technic which was followed was
cross-firing with 100 milligrams of radium element, filtered through
0.3 mm. silver, at a half-inch skin tube distance through four portals
of entry, the tube being placed over the anterior aspect of the chest
directly over the thymus gland. The tube is left two hours in each
position, which makes a total dosage of 800 milligram hours. As time
is such an important factor in these serious cases, the author has now
substituted 200 milligrams with half the time of exposure.
In a series of 41 cases the dosage administered seemed to be suffi-
cient to cure large as well as small thymic overgrowths in one applica-
tion, and as now it is conclusively proven that the thymus has no function
after birth, there is no need to fear over-treatment. Possibly these
results could have been obtained by a single intensive X-ray treatment,
but in a review of the literature, no such results seem to have been
reported.
- The author, in concluding, emphasizes the following points: Thy-
mic enlargement is a common disease in infants. Radium as well as the
roentgen ray is specific in its effects, but radium has the following
advantages: It is portable; it gives the desired result in one treatment;
it is simple, thus eliminating the dangerous element of fright, as infants
resist the fixation necessary in roentgen ray treatment, and this very
fixation may be the exciting cause of thymic crisis and death; radium
is a safe procedure, as the skin tube distance never varies in the most
refractory child.
In the four cases reported, all treated by radium, the babies became
normal within a week at the outside, and have remained so ever since.
Radium in Exophthalmic Goiter.
W. H. B. Aikins, N. Y. M. J., 104: 49, 1916.
The author has been very favorably impressed by the use of
radium in exophthalmic goiter, especially since it has proved to be
efficacious in cases where medicaments, organotherapy, x-rays and
hydrotherapy have given only mediocre results, or none at all. Abbe,
of New York, first used radium successfully in exophthalmic goiter,
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R a di u m
and his favorable experience of its results has been repeatedly confirmed
by other writers. The experiments of Victor Horsley and Finzi show
that the most constant changes after the application of radium affect the
blood and lymph vessels. The author's own clinical experience shows
that, when applied over the thyroid, the more penetrating radium rays
diminish the vascularity and reduce the secretion of the gland.
Dawson Turner, who has had very favorable results, thinks that
radium has two definite advantages when compared with the x-rays,
i.e., (1) the possibility of giving definite doses; (2) the fact that it can
be applied without noise or excitement, while the patient remains in bed.
The author then gives detailed reports of seven cases of exoph-
thalmic goiter successfully treated with radium.
Case 1.-Three thyroidectin tablets, each containing five grains,
were give daily, and in addition a radiation of 100 mg. hours was given
with a large radium plaque. A week later the circumference of the
neck had diminished from fifteen inches to fourteen, the pressure symp-
toms were better, and the patient felt better. Five weeks after begin-
ning the treatment, the neck measured thirteen inches, the tumor had
almost disappeared, and the patient has been well ever since.
Case 2.—The treatment adopted was rest in bed, ice bag over the
heart, and administration thrice daily of a quinine hydrobromide capsule.
The thyroid gland was subjected to a heavy exposure of radium rays.
Three months later the neck had gone from fourteen inches down to
twelve and one half; tachycardia and nervous symptoms disappeared.
Furthur radium treatment has since been given; patient has now con-
tinued well for over two years, and has resumed her normal life.
Case 3.−Neck measurement sixteen and three quarters inches.
Radium applied to the thyroid brought the circumference to twelve and
one half inches.
Enormous Goiter with Grave’s Disease; Permanent Health
Six Years after Cure Following Radium Treatment.
R. W. Abbe, Ann. Surg., 54: 235, 1911.
Dr. Abbe presented a woman who had suffered from exhausting
symptoms of Grave's disease for a year and a half; to wit, palpitation,
suffocation when lying down, tachycardia (pulse 120), trembling, pro-
gressive feebleness, anorexia and perspiration, enormous increase in the
thyroid, with dyspnea, inability to ascend stairs, and with moderate
exophthalmus.
As the goiter was hopelessly inoperable, and as some claims had been
put forth for the Roentgen ray treatment of goiter, as well as for
operative work, on the cervical sympathetic ganglia, Dr. Abbe conceived
the idea of radiating the neck and goiter by inserting a strong radium
tube into the goiter for twenty-four hours. No other treatment was
adopted excepting occasional enemata and the use of Carlsbad salts.
The goiter began to subside in two weeks, and in eight weeks was
so far reduced as to be nearly normal. The patient was soon restored
to health, and during the following six months was able to walk many
miles daily, to play tennis and to resume her usual occupations. She
has remained in perfect condition for six years, with no return of the
goiter. •
113
R a d i u ºn
Dr. Abbe, in reply to a question as to whether he had employed the
radium treatment in other cases of exophthalmic goiter, said he had
treated many cases with this remedy; most of them had shown distinct
improvement, and some were cured, as was this one. He had selected
this case for presentation on account of the enormous size of the goiter.
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SECTION IX
RADIUM IN UROLOGY AND DISEASES OF THE
GENITO-URINARY TRACT
United States Radium Corporation
New York * f.
R a di u m
SECTION IX
RADIUM IN UROLOGY AND DISEASES OF
THE GENITO-URINARY TRACT
Experience with Radium in Cancer of the Prostate.
H. G. Bugbee, J. Urol., 6:459, Dec., 1921.
The author used the strong cystoscope holder of Young to grasp
a rectal and urethral applicator, thereby maintaining the radium in
accurate and close apposition with the area treated ; he also applied the
radium needles through the perineum in the center of the lateral lobes,
according to Barringer's method, using the screened element instead
of the bare emanations. In addition he employed superapubic drainage
in every case of retention of more than a few ounces; in the future he
intends to establish a suprapubic opening in all cases of external involve-
ment because the part of the prostate about the urethra and vesical
Orifice is the part that is most effective in causing obstruction and
retention. The gland protruding into the bladder and underneath the
bladder mucosa is most difficult to reach by perineal needles, while
intravesical surface applications have a limited action, are poorly borne
and cause irritation. The needles plunged into the midst of a growth
tend to honeycomb it and when this is followed by surface applications,
the mass rapidly recedes. Before beginning treatment, the patient
should be carefully examined for the presence of bone or visceral
metastases, the condition of the blood and the urinary and intestinal
functions. Seventeen case histories are given in detail. The general
condition of the patient requires careful consideration and a certain
amount of body resistance must be present; elimination must be active
and the blood index good if cancerous tissue is to be destroyed and
eliminated without causing profound toxemia. Elimination is favored
by giving digestible, nourishing food, by maintaining intestinal function,
by diet, by mild cathartics and by colonic irrigations. Large doses of
bicarbonate of Soda are given and iron is beneficial. In fifteen months,
changes were noted in cancerous prostates, observable with no other
form of treatment.
Of the 17 cases, 5 were treated by radium needles through the
perineum and direct applications to the rectal surfaces of the prostatic
lobes, using a specially constructed applicator, the radium screened with
gold and guttapercha and held in position by a strong clamp; the pro-
static surface is carefully mapped out and the applications are accurately
made and distributed. Four cases also had intra-urethral applications.
Of 4 patients given suprapubic drainage only, all showed symptoms of
systemic cancer, the drainage only relieving the intense bladder symp-
toms; in these cases, an attempt at destruction of the cancer by radium
would have only added a toxemia. Two cases died of systemic disease
and the other two are alive but failing from general carcinomatosis.
The four cases opened suprapubically and given needle applications from
above and also perineally showed retention and extensive involvement,
1 of which empties his bladder with a healed drainage wound, a second
is draining although no growth is palpable, and the other two have
suprapubic tubes with the growth diminishing rapidly in size. By
suturing a Pezzer catheter into the bladder wall when the needles are
115
R a di u m
introduced suprapubically, the needles can be withdrawn and the wound
closes tightly at once, allowing the patient to go about his business
immediately. One patient, in whom a resection of the bladder wall
and prostate was done with external application of radium, was free
of recurrence one year after operation. The last case treated by per-
ineal needles only was improved. In slowly growing cancers, better
results obtain from suprapubic destruction of the gland followed by
surface applications. As cancer cells have been demonstrated patho-
logically after radium treatment, it becomes questionable whether or not
it is possible to destroy the entire growth. The term “cure” should
not be used in these cases.
The author has seen the best results from exposure of the prostate
suprapubically, destruction of the cancer by radium needles introduced
through the prostate from above, close to and parallel with the urethra;
from needles introduced into the prostate through the perineum and late
surface radium applications accurately made, while drainage is main-
tained. The return of bladder function may be tested by clamping
the suprapubic tube. When voiding is free and no growth is palpable
through the suprapubic sinus, the fistula is allowed to close and treatment
is continued through the perineum by needles and the rectum by surface
applications, as long as any growth is palpable.
The Treatment of Cancer of the Rectum by Radium.
Douglas Quick, Am. J. Roentgenol. 8:746, Dec., 1921.
Quick thinks the term “cure” should be abandoned and that the
results should be described as apparent freedom from the disease or
“clinical cure” for a fixed period.
Every case of rectal cancer should be classified in 1 of 3 groups,
depending on the extent of primary growth, metastases or probability
of metastases, age and general physical condition. In Group 1 should
be placed all cases in which a reasonable hope for complete regression
can be entertained; in Group II, advanced cases in which a reasonable
hope for palliative relief can be entertained; and in Group III, hope-
lessly advanced cases in which the physical agents hold out no chance
for relief. Such a classification is necessary for the formulation of a
plan of treatment for each individual case, With better medical edu-
cation, lessening of fear and distrust on the part of the patient, and
improvement in technic with the physical agent, Group III should be
steadily reduced.
In Group II, the first consideration must be the comfort of the
patient. If surface applications of radium internally will relieve dis-
charge, bleeding, pain, and obstruction and prolong life then it should
be so employed, but not to the point of serious discomfort. In these
cases, buried emanation should be used sparingly if at all, as the reaction
from large doses is too severe to warrant its use for purely palliative
relief. In some cases a colostomy may be an urgent necessity.
In Group 1, radium should be used in as large doses as possible
and through all available channels, to effect a complete regression of
the growth. In the majority of the cases an exploratory laparotomy
is advisable and can usually be done under local anesthesia with very
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R a di u m
little risk to the patient; it frequently offers a much more accurate
means of introducing radium emanation into the upper portion of the
growth. If it is found that a temporary colostomy will facilitate treat-
ment it can be done at the same time. In many of the smaller growths
a laparotomy is not essential for localization of the disease, as they
can be treated very accurately through the proctoscope. Treatment of
these smaller lesions is not attended by an appreciable amount of dis-
comfort, but there is justification in subjecting a patient to this where
there is a reasonable hope for complete regression of the disease
Emanation in sufficient amount should be distributed accurately and
uniformly throughout the growth, preferably under gas and oxygen
anesthesia. Filtered radium should be applied internally in every
way that the anatomical relations of the individual case permit. In
certain cases, especially bulky growths involving the small sphincter,
surgery may be employed to advantage after intense radiation.
The statistics of surgery alone even in the strictly operable cases
leave much to be desired, and unfortunately sufficient time has not
elapsed to permit of the determination of radium treatment with the
improved methods of application. Quick thinks, however, that past
experience warrants the treatment with radium of operable as well as
of some of the more advanced cases.
Radium Therapy of Teratoid Tumors of the Testicle.
B. S. Barringer and Archie L. Dean, Jr., J. A. M. A., 77: 1237,
Oct. 15, 1921.
Treatment by radiation and then operation for teratoid tumors of
the testicle, as advised by the late Dr. Janeway, has given some brilliant
results. These tumors may be divided into adult embryomas or tera-
tomas, which are comparatively rare, grow slowly and respond less
readily to radium; embryoid, teratoid or mixed tumors, which are more
frequent than the foregoing; and, embryonal malignant tumors, which
are most often seen, grow quickly and respond well to radium therapy.
The tumors arise, with rare exception, from sex cells situated in the
rete testis and the teratoma may develop either toward the testicle and
epididymis, involving both in a large tumor mass, or much more rarely
toward the epididymis, forming a typical tumor of the epididymis.
Diagnosis of these tumors is often difficult although when the tumor is
typical, the whole testicle is an irregular, hard mass in which no dis-
tinction between the testicle and epididymis can be made and the main
diagnosis is between teratoma and gumma. However, a positive Was-
sermann test usually indicates gumma, although one patient with a posi-
tive Wassermann test had teratoma testis. In two cases the teratoma
grew atypically and involved the epididymis alone, giving a picture not
unlike tuberculosis of the epididymis. Preoperative diagnosis is very
important because the author knows of no patient in whom the tumor
was incised who did not succumb to local recurrence. When the tera-
toma occurs in an undescended testicle the diagnosis is most difficult.
Present operative methods, like orchidectomy and the radical operation
show poor results.
The operative technic approved by the author is carefully explained.
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R a di u m
Following a careful physical examination, with roentgenograms of the
chest, and when distant metastases are not found, the testicular tumor,
spermatic cord and abdomen along the tract of the spermatic vessels
are treated with the radium pack and the patient goes home, returning
for weekly examination. With rapid reduction in the tumor, delay
operation for weeks or months to get the maximum effect of radiation;
but in tumors which do not decrease in size, operate in three to six
weeks. In operating, the testicle is not handled before its vessels and
lymphatics are cut lest tumor cells be squeezed into the general circu-
lation. Any glandular metastases are dissected out and tubes of screened
radium introduced for a time. Finally the vessels are cut high up and
the testicle is dissected out and removed and the wound sewed up.
This operation has been performed 8 times-with no postoperative deaths
and does not seem to be serious. From three to six weeks after the
wound is healed, radium packs are again applied over the length of the
scar. Both early and late cases show recurrences after operation and
even in one of the primary operable cases of the adult type, irradiated
before and after operation, the patient died of recurrences some months
after operation. Although teratoma testis is extremely malignant, the
author believes that radium is a very valuable adjunct to operation in
dealing with the disease.
The Use of Buried Emanation in the Treatment of Malignant
Tumors. -
H. H. Janeway; Am. J. Roentg., 7: 325, 1920.
The conclusions upon the advantages of this method have been
confirmed.
Jndications for the use of buried emanation:
Prostate and bladder—The emanation tubes are buried in the
prostate through the perineum, or when accuracy requires, may be
introduced safely through the anterior wall of the rectum.
The chief advantages of embedded emanation for the growths of
the mucous membranes above mentioned are the accuracy of the primary
application, the economy in the use of radium, and the ease with which
residual incompletely treated remnant of the tumor, left after the initial
treatment, may be destroyed by embedding emanations in these rem-
nants as soon as they are identified. Often one such supplementary
treatment of the tumor process is sufficient to dispose of a growth from
which otherwise a fatal recurrence would take place.
The most important detail in the successful treatment of these
growths is the correct interpretation of the changes in the post-thera-
peutic period.
Dosage: It is difficult to formulate rules for dosage, and such rules
are always subject to modifications imposed by the special conditions
present in any case.
The volume of the tumor is the most important factor in determin-
ing the dose, but the shape of the growth is of almost equal importance,
and influences the dosage hand in hand with the volume. An elongated
superficial growth will, for instance, require almost the same dose as
a circular superficial growth with a diameter equalling little less than
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R a di u m
the long axis of the elongated tumor. A flattened tumor with little deep
infiltration requires approximately the same dose as a spherical tumor
with a diameter equalling the long diameter of the flattened growth.
Between these variously shaped tumors there is a great difference in
cubical volume, but the difference in the number of the millicuries
required by them is not proportional to this difference but rather to
the difference in the number of square centimeters in the plane of the
tumor's largest diameter. For these reasons the diameters of tumors
are the most practical guides to the doses required by them. (The
author gives a table with the approximate dosage used at the Memorial
Hospital for epidermoid carcinoma, etc.)
Radium Therapy of Cancer of Bladder and Prostate.
G. Kolischer, Am. J. of Surg., vol. 34, p. 323, 1920.
Gold seems to be the best material for radium filters in bladder
work, first, because the filtering capsule does not have to be very thick,
on account of the high atomic weight of the metal, thus permitting easy
introduction through the natural channels; and second because in eight
years' experience the author has never noticed any damaging of pelvic
or abdominal organs.
The time of primary introduction of radium into the bladder de-
pends on the condition of the viscus. If there is no appreciable cystitis
the radium may be inserted without any preparatory steps.
Tumor cases that are accompanied by infiltrating cystitis of such
a degree that the bladder is unable to retain even very small quantities
of urine are not proper objects for primary radium application. Such
bladders are opened by the suprapubic route. Thus the annoying stran-
gury is relieved and at the same time the tumor is made easily accessible
for the treatment preparatory to the application of radium. The pre-
paratory treatment is electro-coagulation of the accessible parts of the
growth. The surgical diathermy immediately does away with hemor-
rhage and pain and furnishes another advantage: The stimulation of a
malignant tumor occasionally observed under raying never occurs in
instances of previous electro-coagulation. -
The radium treatment may follow immediately the coagulation of
the growth; in fact the radium rays seem to enhance and accelerate
the detachment of the eschar produced by the diathermy.
The application of radium to prostatic cancers is conducted on the
same principles. Prostatic cancers causing pronounced pains due to
the capsular tension, that are not promptly relieved by radium, call
for suprapubic opening of the bladder and electro-coagulation of the
prostatic tumor.
For the placing of radium or similar substances, into the unopened
bladder, the author uses a silver sound, the tip of which consists of a
detachable hollow gold tip of 3 mm. thickness into which the glass con-
tainer carrying the radio-active substance is placed. This sound has a
calibre of 21 Charrière. Frequent urination is encouraged to keep the
bladder contracted. This, together with the fact that the irradiation of
radium through a gold container will always extend to at least 4 cm.
distance, will always insure that at least one part of the tumor is under
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R a di u m
the influence of the therapeutic rays. If the bladder was opened pre-
viously to the radium application, the container and filtering capsule
are dropped into the bladder through the suprapubic opening.
The author leaves the radium container in the bladder for 24 hours
and repeats the treatment once every week, utilizing the intervals for
antiseptic treatments of the viscus.
If it is deemed advisable to apply the radium per rectum to a pro-
static tumor, a heavy lead cap is slipped over the filtering capsule to
protect the rectal mucosa, which is susceptible to the destructive in-
fluence of radium rays. In this cap a little fenestra is cut; the container
is then placed in the rectum in such a way that this opening lies against
the prostate, while the balance of the rectal ampulla is entirely screened
off. In order to maintain the capsule in this position it is connected with
a stiff rod that carries an adjustable curved cross bar which is made to
fit into the anal rim, in which position it is fastened by tape or adhesive.
The author injects proteus enzyme into the prostatic tissue which
seems to enhance the radium action.
If a few radium treatments do not produce decided improvement,
continuance is hopeless and the author resorts to electro-coagulation.
Fifty mg. of radium or mesothorium is sufficient for the application to
vesical or prostatic tumors.
Carcinoma of the Bladder.
B. Lewis, Urol. & Cutaneous Rev., vol. 24, p. 6, 1920.
It is generally agreed now that benign tumors are curable by means
of fulguration; that malignant papillomata are amenable to treatment
with fulguration and radium; but a division of sentiment comes with
regard to infiltrating carcinoma. Geraghty holds that this is made worse
by fulguration, but may or may not prove amenable to radium therapy.
Everyone recognizes the greater resistance and rebelliousness of the
latter form of tumor; but that it is without the pale of curability or is
inappropriate for fulguration is yet to be proved. Certain of our cases
seemed favorably influenced both by radium and fulguration; and no
little credit has been given to the intensive employment of x-ray with
the Coolidge tube as recommended by Pfahler.
We are under, the impression that the use of radium and x-ray
prepares the growths for greater amenability to fulguration, and are in
the habit, in the infiltrating cases, of using them first and fulguration
(d’Arsonval current) later, if there is pronounced tumefaction.
The author gives five cases of carcinoma of the bladder, which were
treated with radium or x-ray or both, followed by fulgurations, with
the following results:
Case 1. April 14 to 18, 1917, patient received 18 hours application
of radium.
During the next three months, 14 fulgurations were done, when
the tumor, and all bladder symptoms entirely disappeared. The patient
is well now three years since treatment was begun.
Case 2. After a series of intravesical radium treatments (begun
July, 1917), 13 series of x-ray exposures and numerous fulgurations,
patient has improved to a state where she weighs more than ever before,
does housework, etc. Tumor mass has decreased until in Sept., 1919,
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R a di u m
there was no tumor visible, but only an indurated, ulcerated mass the
size of a silver quarter. There is still slight incontinence and the
patient is not well, but the improvement has been great.
Case 3. July, 1918: 34 hours of radium, x-ray treatments and
fulguration every 3 or 4 weeks. Tumor has been reduced to the size
of a small pea. Patient feels improved.
Case 4. March, 1917: 50 mg. radium for 2 hours. Repeated 6
days later. Fulguration at intervals of a week to a month. Ulcer
gradually disappeared. Dec., 1918; mucosa smooth and healthy. Good
report recently received from the patient.
Case 5. October 21, 23 and Nov. 2, 1918: radium ; following this
four series of X-rays and nine fulgurations were given. April 1919:
tumor had entirely disappeared. October, 1919: all bladder symptoms
gone and patient well.
Experience with Radium in the Treatment of Diseases of the
Urologic and Cutaneous Systems. -
J. M. Lee, Urol. & Cutan. Rev., 24 : 575, 1920.
“Although some German observers and others dissent, most sur-
geons accredit radium with a selective action for diseased tissues. This is
especially marked in most forms of malignancies, in which it changes
the cells back to more nearly the embryonic type from which they
developed. This selective action is not so pronounced in growth of
epithelial tissue as it is in those of connective structures; neoplasms,
here particularly, are about six times more readily acted upon by the
radium than the normal tissues which surround them. In many cases the
growths soften, shrink and disappear without destruction of the normal
tissues, in such a short period, sometimes two weeks, that the whole
process seems incredible, even to the initiated. In other cases, the pain,
hemorrhages, and foul discharged cease, and the part cicatrizes and
leaves a soft, yielding scar, without contraction, deformity or unsight-
liness. Sometimes regression to a marked degree is secured, and the
case progresses no further. This fibrosis of the neoplasms may be
allowed to remain inactive or be excised and the wound rayed or not
as conditions indicate. Again inoperable tumors may undergo suf-
ficient regression to permit ready removal, and thus bring the patient into
good condition. -
“In diseases of the urologic system the remedy is of service, espe-
cially in the milder forms of cancer, as the papillary variety of the
bladder; and acts well frequently in those extensively attached growths
for which no operation is indicated, except extirpation of the bladder
and transplantation of the ureters in the loins, the abdomen, the vagina,
or hollow viscera for drainage. In such cases large dosage must be
employed. The squamous cell variety of the disease is very obstinate
here as everywhere; and a guarded prognosis must be given if this
pathologic variety is known to be present. Large dosage must be em-
ployed in this condition if any hope of benefit of the patient is enter-
tained; this must be accomplished by abundant screenage. A supra-
pubic cystotomy may be necessary or the brass tubes enclosed in a
catheter or rubber tube may be used in women. In men the catheter
alone may be employed. A number of cystoscopic instruments have
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R a di u m
been devised, but they do not carry dosage enough to reach these wide-
spread carcinomata. A word of caution here should be given, for if too
much dosage at too frequent intervals is used, the case may be aggra-
vated by undue radiation or a condition developed which resembles con-
centric hypertrophy of the bladder. Where the growth can be palpated
needles may be employed from any convenient surface by the use of
either local or gas anesthesia. Various forms of ulcers and hemorrhages
of the bladder are favorable conditions to treat.
“The management of hyperrophy and cancer of the prostate is fast
coming into the field of radium-therapy; and a number of cases of
cancer of this organ have been clinically cured and remain well after
several years. Hypertrophy of the prostate by urethral, rectal and
needle applications is yielding to the newer methods and many cures are
reported. The patients are not obliged to give up their business pur-
suits for more than a few days at a time and the treatment is gaining
in popularity.
“Prophylaxis by radium has a large and increasing field of use-
fulness, in diseases both of the skin and mucous membranes.
“Many diseases of the cutaneous and urologic systems like rhino-
phyma, keratosis and many other diseases are fast coming into the field
of radiosurgical therapy. I am convinced that the former malady, par-
ticularly, is better treated by radium than the knife.
“Up to the present we have rarely refused treatment to any unless
they were actually moribund and in rare instances we have secured
clinical cures in some of these, and foul discharges, hemorrhages and
excruciating pain have been relieved in most of the others. Neverthe-
less the treatment of such cases is an injury to radium therapy as the
vast majority of such patients must eventually succumb; then their
cases are heralded as examples of the inefficiency of radium. Surgery
rightfully does not accept such risks, and now, as we better understand
the limitations of radium, we should be more careful in the selection of
our cases. Perhaps we should not treat hopeless cases at all, for no
matter how carefully we warn them that our efforts are expected to
be palliative only, they, and their friends are likely to gain the impres-
sion somehow that cures are intended. Could we conscientiously adopt
even approximated the methods employed in surgery and refuse hope-
less cases, many other thousands of pitiable sufferers would be rescued
from the grave annually.”
Cancer of the Prostate. A Combined Surgical and Radium
Method of Treatment.
R. H. Herbst, J. A. M. A., 72: 1610, 1919.
In 1915 Barringer described a method of treating cancer of the
prostate by introducing a single needle containing radium through the
tissues of the perineum into the tumor mass. The author presents a
modification of this principle.
While many excellent results have been obtained with radium in
the treatment of superficial cancers, the results in the deeper seated
neoplasms have not been very encouraging, owing largely to the diffi-
culty of bringing the radium directly into contact with the involved
areas. It is the author's belief that this is accomplished in cancer of
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the prostate by exposing the tumor both above and below and by in-
serting multiple needles, containing radium, in different directions, thus
bringing the radium into contact with the most remote parts of the
growth. -
Method of treatment.—A suprapubic cystotomy is made (usually
under local anesthesia), with a liberal opening in the bladder wall So
as to give easy access to the involved bladder neck, because in practically
all these cases the tumor is fixed and cannot be pushed up into the
bladder. A bimanual examination is then made to determine the limits
of the tumor. By means of a needle carrier, gold needles 1 inch in
length, each containing 12 mg. of radium, are inserted into the tumor
mass 1 cm. apart in different directions. The tumor is virtually con-
verted into a pin cushion. A silk guide, which is attached to each
needle, is brought out of the suprapubic wound, and by means of it the
needle is withdrawn. These needles are left in place for from tweive
to fifteen hours, depending on how much of an exposure is desired.
They are readily removed by traction on the silk guides. One such
exposure will usually cause the removal of most of the upper part of
the tumor, although this can be repeated after a few weeks if found
necessary. As most of the tumors begin in the lower part of the gland,
a second introduction of needles is made into this part of the tumor by
making a dissection through the perineum and obtaining a complete
exposure of the lower part of the prostatic mass. It is well to allow
from four to six weeks to elapse between the two steps of the operation.
It may be readily seen that by this open method we are able to insert
the unscreened radium directly into all parts of the tumor, and the action
of the radium takes place in the center of the carcinomatous nodules.
There is little reaction or pain following even long exposure. It is
well to make the upper exposure first, because following the introduction
of the radium a temporary swelling occurs, which is likely to cause com
plete retention, should the lower application be made first. -
|
Recent Progress in Treatment of Cancer of the Prostate, Sem-
inal Glands and Bladder. -
H. H. Young; So. M. J., 11: 120, 1918.
Radium, applied through the rectum, urethra and bladder, offers
great benefit in extensive cases of cancer of the prostate and seminal
vesicles. Hope of radical cure is not impossible.
Early cancer of the bladder at the base is effectively treated by
radium with the aid of three new cystoscopic instruments designed by
the author and described in this article. The radium capsule may,
under direct cystoscopic vision, be placed accurately, on the bladder
turnOr.
For treatments per rectum the cystoscope is not necessary and a
smaller instrument has been constructed, which carries the radium in
its beak. By means of a finger in the rectum, the capsule of radium,
with this instrument, may be placed at any desired spot against the
posterior surface of prostate, seminal vesicles or bladder. The mechan-
ical holder (which clamps upon the ball near the end of the instrument)
holds the instrument where desired. Using 103 mg. of radium in a
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platinum capsule, the author found that from 20 to 30 treatments of
an hour each, may be given to the prostate and seminal vesicles, per
rectum, without producing more than slight irritation in most cases, if
the location of application is different each time. Positions about 5
to 10 mm. apart are selected. In some cases they overlap, but as a
rule from 2 to 4 weeks elapse between the two overlapping treatments,
The treatments are given, usually every other day.
Vesicle papillomata have a great tendency to malignancy and should
have radium applied to their bases after destruction with fulguration.
Chronic Interstitial Nephritis: An Apparently Hopeless Case,
Benefited by Treatment with the Emanations of Radium and Thor-
1ll III.
F. E. Park; N. Y. M. J., 104: 66, July 8, 1916.
Case: Patient was first seen by the author Oct., 1914. “On exam-
ination, I found a woman of 62 years, fairly well nourished; color poor;
tongue coated; slight degree of anascarca present. She was very weak
and unable to assist herself.” There was a mitral murmur of the heart.
Pulse 120 and blood pressure, systolic, was 240 mm. Hg. The urine
was pale, specific gravity 1.010, with slight trace of albumin. Digestion
was impaired, there being much fermentation, and she had a great deal
of gas. She complained very much of pressure in the head and singing
sound in the ears.
The treatment consisted of radium emanations in the form of
drinking water and injections intravenously. She also wore a pad
over her heart. She was also given 30 c.c. of the radioactive plasma
(Quinton) daily. After the first week she began to show signs of
improvement. Up to that time she had been too weak to feed herself.
The appetitie began to come and there was a steady change in the urine.
At the end of eight weeks she was eating a variety of things and walk-
ing about the room. By January the urine was practically normal, also
the heart, except when under some excitement, and she began walking
outdoors a little. By February she was walking every morning half a
mile on the sidewalk in front of the sanatorium, and her pulse was
constant at 72, while the murmur was not to be heard. She discon-
tinued treatment and returned to her home. A year later there was
still improvement.
The author states, “Judging from a two years' large experience in
this field, I venture to predict that the day will come when it will be
a customary thing as middle age is reached, regularly to take a course
of radium treatment in order to revive and stimulate the functions of
the whole body and put back by appreciable years the inevitable decline
which we call old age.”
The Technic of Radium Treatment per Urethram in Prostatic
Carcinoma.
J. Cauhapé, Intermat. Clin., 1:200, 1916.
Before commencing radium therapy, a methodical examination
should be made of the urethra and bladder, which will give all neces-
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R a d i u in
sary indications for whatever preliminary treatment may be required so
that the radium therapy may be carried out successfully. The patient,
being relieved of his functional disturbances, voids his urine freely, and
vesical tenesmus is overcome; in other words, all vesical irritability dis-
appears, so that he will have a greater tolerance for the radium catheter
and can support applications of long duration.
The ordinary aseptic measures are to be resorted to in the applica-
tion of the treatment: cleansing of the glans penis, asepsis of the an-
terior urethra by irrigation with a solution of boracic acid or oxycyanide
of mercury 1 in 4000.
If spontaneous micturition does not previously exist, if there is
a marked amount of residual urine, if the bladder has not been kept
empty by suprapubic drainage, the viscus should be emptied by the
catheter, this being followed by an antiseptic irrigation given through
the catheter, the latter being progressively withdrawn.
When the patient experiences difficulty from the contact of the
instrument, a few drops of a solution of stovaine should be injected,
so as to produce at least a partial anaesthesia of the urethral mucosa,
before passing the instrument. This practice should be resorted to only
in very timid patients or those who really suffer, because it deprives
the operator of the important indications furnished by the special sensi-
bility of the urethra. With a complete local anaesthesia the radioferous
tube may be improperly placed or the physiological limits of the toler-
ance of the tissues in respect to the radiations may be exceeded. Such
accidents, however, can only occur in inexperienced hands.
As to the apparatus, a silver tube with walls half a millimetre thick
should be selected, directly containing from 5 to 50 milligrams of radium
sulphate. The tubes devised by Wickham and Degrais in the treatment
of prostatic cancer have walls three-tenths of a millimetre thick and
contain, according to the case, 1, 2 or 5 centigrammes of radium sulphate.
The patient being in the recumbent position, the pelvis slightly ele-
vated and the legs flexed on the thighs and the thighs on the pelvis,
a tube usually containing 5 centigrammes of the radium salt is carried
to the prostatic urethra. To accomplish this, the radioferous tube, pro-
vided with a metallic thread attached to the eye on the plug which closes
the tube, is introduced into an elbow caheter down as far as the first
eye, but without going beyond it. It is fixed in this position by rolling
the remainder of the metallic thread which passes out of the pavilion of
the catheter around the end of the instrument.
Thus arranged, the instrument is passed into the urethra accord-
ing to the ordinary rules of catheterization. In order to place the tube
exactly in the prostatic urethra it is absolutely necessary that the tube
shall not exactly fill the lumen of the catheter, and that the lumen of
the latter should remain sufficiently patent so as to allow the free flow of
the vesical fluid.
The proper placing of the tube is accomplished in exactly the
same way as that of a catheter a demeure. With a little practice and
careful manipulation one will always be able to place the instrument
at the “drop by drop” point, as the urologic expression goes, and at this
point the eye, near which is the tube, exactly attains the neck of the
bladder.
No matter what displacements one may then give to the catheter,
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R a di u ºn
whether in the desire to act in the prostatic urethra, the neck or in the
cavity of the bladder, by following the method of placing the instrument
here described a sure landmark for localizing the exact situation of
the radioferous tube will be had. Dr. Minet has utilized, for intra-
urethral applications of radium, an elbow gum catheter, the beak of
which is hollowed out so as to receive the radium tube, this being screwed
on to the instrument and having a lateral eye to assure the emptying
of the bladder in case endovesical applications are to be made along
with those of the prostatic urethra in cases in which it is indicated to
act on the prostatic growth of the bladder walls or simply to treat a
malignant neoplasm arising in the latter organ.
Although this catheter is ingenious in construction, it does not
appear to be more useful than the ordinary elbow catheter containing
the silver tube as above described, and which, at least in applications
in the prostatic urethra, should be the instrument of choice. Instead of
the ordinary elbow catheter, one might perhaps advantageously sub-
stitute an elbow catheter having a single eye placed at the bend, but
this would not make any change in the technic to be followed.
And in respect to this, Dr. Pasteau very properly points out that
it is absolutely necessary to introduce and fix the tube in the catheter
before any attempt at catheterization is made, because once the catheter
is introduced it would be quite impossible to push the radium tube down
into place, as it would be caught at the bend of the instrument and there-
fore could not pass beyond the membranous urethra.
It occasionally happens that the catheter, with the tube within, is
passed with some difficulty, producing rather sharp pain in the deep
urethra. This is due to a too great rigidity given to the instrument by
the tube, and in order to avoid this Wickham and Degrais have used,
instead of a single tube, two tubes half the length of the single one,
placed one above the other in the other in the catheter, so that they make
a sort of joint which allows the easy passage of the instrument over
any obstacle in the urethra. In other words, it is a great advantage to
employ two silver tubes 15 millimeters long, each containing 25 milli-
grams of the radium salt, instead of the 35-millimeter tube with 5
centigrams of radium.
When the instrument has been placed in proper position, it is neces-
sary to retain it in this situation and avoid any displacement. For this
purpose one may use Escat's instrument, which is an elastic band placed
around the base of the glans, to which are attached some small wire
arcs connected with a ring attached to the catheter, a few millimeters
from the meatus. The other ordinary devices may also be employed,
but the simplest is to fix the catheter to the pubic hair by double cotton
threads, tied to the catheter very near the meatus. The two ends,
on each side, are united by a knot at the base of the glans. They then
are passed respectively above and below the penis, to be again knotted
on the lateral aspect of the organ, after which they are tied to a tuft
of pubic hair.
In the technic the totality of the gamma rays and a variable pro-
portion of the beta radiations are utilized. The latter, being animated
with a greater rapidity, are, consequently, endowed with a greater
power of penetration, but the walls of the catheter prevent the unfor-
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R a di u m
tunate secondary accidents, so that it is possible to prolong the duration
of the applications so long as desired.
It follows, from the well-known value and efficiency of these in-
complete radiations in deep-seated regions of the body, such as the
esophagus and prostatic urethra, that one should allow the instrument
to remain in contact with the tissues as long as possible, and always
in inverse proportion to the radio-active intensity. It should here be
recalled that, in order to eliminate all danger in long applications, it
is necessary that the walls of the catheter shall form a complete screen
around the surface of radiation of the tube, which must never be seen
at the eye of the catheter. : .
The author then summarizes the rules for radium therapy of pros-
tatic carcinoma. Every third day the catheter, with its radium tube
or tubes as described, is introduced into the prostatic urethra and fixed
in place for two hours. The total number of applications being six,
represents twelve hours of radium application for each case. The treat-
ment may be renewed according to the therapeutic results obtained.
Following each seance, after the catheter has been withdrawn, a
urethral irrigation may be given if considered indicated. ,
A urethroscopic and cystoscopic examination should be made from
time to time in order to study the changes which have taken place. In-
stillations of silver nitrate and irrigations with the same substance in
1 : 1000 solution may sometimes be employed with advantage in the
interval of the applications. !
The unsatisfactory results obtained by very radical operations., such
as Young's, in prostatic carcinoma, have convinced the author that
radium therapy is indicated in many cases, as the results so far have
been very encouraging and satisfactory. The six cases in which this
treatment has been employed and which the author has followed, show
encouraging results; in fact, much better than those obtained by a radical
operation. - t
Radium Therapy in Urology.
H. Schüller, Wien klin. Woch., 27: 122, 1914.
Stenosis of the urethra through keloid proliferations, tumors of
the prostate, vesicopapilloma or sarcinoma, are all indications for radium
therapy. Although some tumors do not respond to ray exposure, it is
indicated whenever an operation is impossible, especially since the
healthy vesico and rectal mucous membrane is not easily injured by
the rays.
As to the technique, a gradual increase to the maximum dose was
obtained as follows: 60 mg. radium bromide in a small tube 1 cm. by
4 mm., filtered through 1% mm. platinum-silver for 36 hours was
applied endovesically without any signs of irritation; 100 mg. radium
bromide filtered through 2 mm. gold and 2 mm. gum then applied
rectally for 24 hours. Bladder and rectal tissue is relatively very
resistant towards radium; in only one case did marked proctitis set in.
In three cases of callous cicatricial stenosis of the urethra the
effect of exposure to the rays was very satisfactory; similiarly in two
out of nine cases of gonorrheal stenosis. Those cases are refractory
in which no cicatricial proliferations are present. Mild hypertrophy
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of the prostate may be treated by radium rays as long as it is not a
fibrous, adenomatous proliferation. From eleven cases, three cases were
decidedly successful, and one surprisingly successful.
Out of five cases of non-operable cases of incipient carcinoma of
the prostate, two were not affected; one was seen to be healed; in
another the pain was relieved in two or three weeks and the progress of
the disease stopped; in the last the ulceration increased. Out of seven
inoperable cases, one was entirely healed; in two the size of the tumor
was diminished; three remained unimproved and one case became worse
with the appearance of a severe vesical hemorrhage. -
One case of frequently relapsing multiple vesico-papillonna was
cured completely to date. In carcinoma of the bladder, those in women
are more accessible to treatment than those in men.
Radium Therapy in Cancer of the Prostate.
H. C. Bumpus, M. Clim. N. Am., 3: 707, Nov., 1919.
After a short, concise history of the various methods that were
used for the application of radium in carcinoma of the prostate since
this kind of treatment was first instituted, the author comes down to his
own method of application.
He uses four needles, the combined strength of which is about 50
mg. These are inserted through the perineum, two on each side of the
mid-line, and allowed to remain in the gland about twelve hours. Be-
fore the needles are applied, the field of operation is anesthetized.
After the skin has been infiltrated, the hypodermic needle is thrust deep
in, close to the inner margin of the spin of the ischium, and the pudic
nerve is infiltrated.
This nerve supplies the greater portion of the perineum, and on the
ability to anesthetize it successfully depends not alone the ease of pro-
cedure in accurately applying the needles, but also the patient's com-
plete freedom from pain. After allowing time for complete anesthesia,
the left forefinger is inserted in the rectum and the general contour of
the growth ascertained. With the right hand the needles are then
plunged through the perineum in a downward direction until their tips
are felt hrough the rectal mucosa, when, by a slight upward thrust they
are made to enter the gland substance at the desired points. Safety-
pins are placed through the eyes of the inserted needles to insure against
their loss under the skin. An opium and belladonna suppository is
inserted to allay any subsequent discomfort as the cocain wears off, and
the patient is placed in bed in the usual position. The needles are left
in position for approximately twelve hours, giving a dosage of about
600 mg. hours.
After the localized reaction due to the insertion of the needles
has subsided the patient is given rectal treatment. This consists in
applying a 50 mg. tube of radium directly over the prostate. As an
applicator, the author uses a piece of sheet lead cut in the shape of a
spoon. The small metal container holding the radium is placed in the
bowl and the lead is bent over three sides of it. Over this a brass
tube is slipped to filter the beta rays on the exposed side; the rectal
mucosa is, therefore, screened by lead on all sides except directly over
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R a di u m
the prostatic area, and there the irritating rays are filtered out by the
brass tube. After the applicator is inserted and placed in the desired
position, with the open side of the bowl next to the prostate, the handle
is bent at right angles and atached to the thighs or buttocks by surgeon's
plaster. This method allows the patient to move about freely while
recumbent and while the applicator is still in position, thus doing away
with the discomfort necessitated by remaining on an examining table
to which a rigid mechanical arm is attached. The radium is left in
position for a time sufficient to assure a total dosage of 200 mg. hours.
When it is possible to do so without causing trauma in cases in which the
growth has not obstructed the urethra the patient is also given 200 mg.
hours in the prostatic urethra, the radium being inserted by means of
a soft-rubber catheter; the gland receives in all 1000 mg. hours.
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SECTION X
RADIUM-ITS UNUSUAL USES
A. Rare Cases
Nerves *
Gout and Rheumatism
:
Brain Conditions, Etc.
United States Radium Corporation
New York
R a di u m
SECTION X
RADIUM.–ITS UNUSUAL, USES
A. Rare Cases
B. Nerves
C. Gout and Rheumatism
D. Brain Conditions, Etc.
The Action of Radium on Tumors of the Bone.
I. Levin, Med. Rec., 100: 673, 1921.
The writer has shown in a previous publication that in skeletal
metastasis of carcinoma the two reactive processes within the bone, the
Osteoporosis and the Osteosclerosis, are frequently present alongside,
near the same tumor. Usually the osteosclerosis is very imperfect,
the metastatic nodule increases in size, suppresses the power of the
organism to create new bone, and progressively destroys the old bone.
The spontaneous healing power of the organism is thus quite imperfect.
The writer has demonstrated on a series of cases that radium and
roentgen therapy may enhance the healing power of the organism,
destroy at least a major part of the malignant tumor, and surround it
with newly formed bone. The following two cases, which have not
been previously published, may further illustrate the mechanism of the
action of radium on malignant tumors of the skeleton.
Case 1.-Mrs. F., 54 years of age, consulted Dr. Willy Meyer for
carcinoma of the left breast. In the course of the examination there
developed a pathological fracture in the middle of the shaft of the
right humerus. Roentgenogram showed complete destruction of bone
of the diaphysis of the humerus in an area over one inch long. There
was no clear evidence of skeletal metastases elsewhere. In view of the
fact that Dr. Meyer was acquainted with the writer's results in radio-
therapy of skeletal metastases and the condition in the breast was oper-
able, he decided to do a radical removal of the breast and refer the
patient to the writer for the treatment of the fracture. The method
of treatment consisted in covering the fractured area with three packs
of tubes of radium emanation. One pack was placed over the anterior
surface, the other over the external and the third over the internal sur-
face of the humerus. In all 208.9 millicuries of radium emanation
were applied for sixteen hours. The emanations were filtered with
% mm. of silver, 2 mm. of brass, 1 mm. of leather and about 2 inches
of gauze. The splints were applied over the radium packs to retain
the correct position of the bone. One week later a similar application
was made for sixteen hours of 249.1 millicuries. The following week,
or two weeks, after the first radium application, a roentgenogram
showed a callus formation and the ends of the bone in good position.
The patient could support her arm without splints. Such a prompt
formation of a functionally perfect callus in a pathological fracture
which on the first roentgenogram did not show the least tendency to
osteosclerosis indicates that radium therapy must be an efficient agent
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in many diseases of the skeleton in which osteosclerosis could neutralize
the pathological process.
Case 2.—Mrs. G., age 24, consulted the writer in 1920 for a tumor
in the region of the upper third of the right tibia. The roentgenogram
shows a defect in the upper third of the tibia of an area about two
inches long and one inch wide. The patient refused an amputation.
The writer then excised the tumor, which invaded the muscles, and
excochleated the bone to such an extent that only a thin shell of the
outer wall of the compact bone of the tibia remained. A cavity was
thus formed in the bone about two and one-half inches long into
which was placed a specially constructed brass box containing a series
of radium emanation tubes, 213.0 millicuries in all, and left for sixteen
hours. This was followed by several applications of radium packs over
the operative field. A roentgenogram taken twelve months later showed
the cavity filled with compact bone. Palpation also failed to detect the
cavity which was formerly present in the bone.
The analysis of these two cases, as well as of all the previous cases
reported by the writer, indicates that radium causes a very rapid forma-
tion of new bone. The callus in Case 1 formed more rapidly than it
would have formed in a traumatic fracture without the aid of the
radium. It seems feasible to suppose a priori that radium therapy may
also hasten callus formation in fracture and increase the success of bone
implantations. In fact, Knox claims to have used x-rays in cases in
which bone grafts have been used in the restorative operations.
The analysis of Case 2, as well as of the sarcoma cases previously
reported, clearly indicates that similar results may be obtained in other
pathological processes of the skeleton. Multiple myeloma of the bone
is more akin to lymphosarcoma than to true sarcoma, or carcinoma, and
must therefore be more radiosensitive than the latter conditions. Chronic
inflammatory diseases of the skeleton, osteitis or osteomyelitis, present
frequently pathological pictures very similar to those of sarcomata of
the bone. It is very difficult, for instance, to distinguish between a
giant cell sarcoma and a so-called hemorrhagic osteomyelitis. More-
over, the writer has previously shown that the action of the radium
and roentgen rays on tumors and on infectious granulomata is quite
analogous. It is plausible to expect then that if a focus of chronic
osteomyelitis were prepared surgically in the same manner as it was
done by the writer in Case 2, and then treated with radium, a satis-
factory clinical result may be obtained.
Radium Treatment of Vulval Vegetations in the Course of
Pregnancy.
P. Degrais, Gynác. et obst., 4:493, Nov., 1921.
Although vulval vegetations are relatively unimportant in them-
selves, the asepsis of the genital zone at the time of labor is made
difficult by them. As radium applications are painless, do not produce
any reaction, and cause a rapid disappearance of the vegetations, their
use can be strongly recommended. For vulval vegetations Degrais
recommends the use of varnish apparatus in spite of the fact that these
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have fallen into disfavor because their beta rays are not partly absorbed
as is the case with tubes and needles, and these rays are wrongly con-
sidered as useless or dangerous. As a matter of fact, vegetating lesions
of the skin are more sensitive to the total radiation of radium. An
apparatus 4 cm. Square and containing 10 mg. radium bromid is applied
for forty-five or sixty minutes. When the vegetation has a wide base
of implantation, or when there is cicatricial tissue as the result of
previous caustic treatment, it is better to filter slightly. In this way
the application may be prolonged without fear of a reaction (lead filter
0.1 mm. thick, length of application, three to five hours). Healthy skin
between vegetations should be protected with lead 0.5 mm. thick. For
vaginal vegetations the author uses tubes of platinum having walls 0.3
mm. thick and containing 25 mg. radium bromid. One or two applica-
tions lasting eight hours in all are made. Three or four weeks after
this treatment, the vegetations completely disappear and the genital
region becomes normal again.
Effects of Radium Emanations upon Brain Tumors.
C. H. Fragier, Surg. Gynec. Obst., 31: 236, 1920.
Because the rate of growth is surprisingly slow, because brain
tumors are often inaccessible or unlocalizable, because they do not
metastasize but continue until the end confined to the original focus,
because they are often not directly but only indirectly responsible for
the subject’s death, because technical difficulties interfere with their
radical removal, there is a field for some physical agency, which will
not only arrest the growth of the malignant lesion, but even lead to a
process of retrogression. It was with this thought in mind that in
1914 the author secured by gift for the University Hospital 125 milli-
grams of radium and deposited it in the care and at the disposal of
Dr. Henry K. Pancoast. Since that time, radium has been applied in
his clinic under the direction of Dr. Pancoast in the treatment of brain
tumors in 24 cases, and from these he has selected 3 cases as illustra-
tions of what radium may accomplish. In these there seems to be
indisputable evidence that by radium emanations the growth of the tumor
has been arrested and in all probability the tumor destroyed.
Case 1–In 1914, an inoperable tumor of the pontile angle was
found at operation. At the time the patient was stuporous and totally
incapacitated. Eighty-five milligrams of radium were implanted in
tumor for fifteen hours. Six weeks later improvement was first noted;
4 months later the patient was ambulant. Six years after the first treat-
ment the patient is living and while symptoms of cerebellar disturbance
have not disappeared, the condition is now stationary.
It is perhaps too soon to make a final report on this case. There
is no doubt that the effect of the first treatment was very extraordinary.
The patient was in eatremis and it was not thought he would survive
more than a few days, or weeks at the most. The tumor was of large
dimensions, with ample exposure on the operating table, but quite in-
operable. That the patient should have been transformed from a bed-
ridden and stuporous condition to an ambulant state would seem to
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R a di u m
admit of but one interpretation. That there is evidence still of disturb-
ance of cerebellar function may be accounted for on the grounds of
permanent damage to the cerebellar tissue by the growth before the
treatment was begun. This view is further substantiated by the fact
that since the Second application the condition appears to be stationary.
Case 2.—Child with evidences of serious disturbances of cerebellar
function, chiefly left. Unable to stand or sit, difficulty in talking and
swallowing, marked adiadokokinesis, hypermetry, vertigo, headache,
nausea and vomiting, and postpapillitic atrophy. Following suboccipital
decompression and serial application of radium, there was an extra-
ordinary improvement in every particular so that 8 years after first
observation the child has been restored to almost perfect health.
The outcome in this case has been more striking than in Case 1,
in that vision has been conserved at least in one eye and the residual
signs of cerebellar disturbance are but trifling as compared with the
original state. There is, however, in this case a link of evidence missing
in that the tumor was not exposed on the operating table. However,
the clinical picture would seem to admit of but one interpretation. View-
ing the case in the light of a therapeutic achievement, the results 7
years after the first treatment have been, to say the least, extraordinarily
gratifying.
Case 3.−Recurrence of headaches and visual disturbances 19
months after a sella decompression. Following a course of glandular
feeding, x-ray and radium therapy there was a disappearance of Scoto-
mata, restoration of normal vision, and reëstablishment of menstruation.
There was no recurrence 3 years after treatment was instituted.
The return of normal vision and the abatement of one of the
evidences of pituitary disturbance — amenorrhea — were the two strik-
ing results of treatment in this case. Either of them would have been
sufficient to convince one that the structure of the pituitary had been
decisively influenced; otherwise (after the relapse which followed a year
after the operation), vision would not have been restored nor menstrua-
tion reëstablished. There is to be considered in this case, however, the
fact that both radium and x-rays were used and to each must be accred-
ited a share in the results. So far as the author knows this is the first
case in which the radium was applied to the pituitary body, as Dr.
Pfahler directed, through the posterior nares.
The author concludes as follows: “My purpose in this brief note
is to call attention to the possible achievements of radium emanations
in a field that offers many opportunities. I must speak very guardedly
in order not to be misleading. I offer in evidence three cases of brain
tumor where the growth of the tumor, in the light of the clinical
evidence, has been arrested at least, the tumor possibly destroyed, in
periods of observation covering a maximum of eight years.”
Radium Emanation in Hay Fever.
F. E. Park, Mod. Rec., 93: 284, 1918.
The author has successfully treated two cases of hay-fever with
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radium emanation. One case he cured accidentally. A patient, of very
nervous temperament and in a generally run-down condition due to
business strain, came for treatment. This man had always been well
except for an annual attack of hay fever. He was given a six weeks'
treatment with radium emanation and discharged in good condition. He
had no attacks of hay fever for three years after that, when he came
back for treatment of his old trouble, the hay-fever. He received the
same course of treatment as previously, and inside a week there was
complete relief of all symptoms. The treatment was continued for two
weeks longer, when he was discharged and had no further trouble
during the rest of the season.
Having had such success with his first case, he tried it purposely
the second time. This patient was a middle-aged, overworked woman
who had had hay fever attacks of maximum severity for thirty years
back with no intermission. She came to the author's notice two weeks
before the usual date of the beginning of her attacks. He proposed
trying to get a prophylactic result with a course of radium emanation.
This was done and the treatment was extended over a period of four
weeks. As a result she passed through her first summer and autumn
with no hay fever, becoming so bold finally as to weed in her garden
and deliberately expose herself to the same influences that had formerly
affected her.
The Use of Plastic and Elastic Fxation—Prothesis in Radium
Therapy.
L. Edling, Münch. med. Woch., 64; 417, March 27, 1917.
By means of a plastic material, hardened however at body heat, it
is possible to fix radium in the correct spot and thus eliminate the
difficulties in the treatment of oral cavity, nasopharynx, etc., with
radium. So-called “casting material” (Abgüssmasse) which dentists
use for making casts of teeth, gums, etc., was used since at 40°-50° C.;
it is very plastic. This may be used for casting tumors, ulcerations,
mucous membranes, etc. The slightest unevenness would be modelled
and hence each part of the tumor could be recognized, and the radium
apparatus adapted to it. The subtsance itself may be used as a filter,
or a metallic filter added. In treating the surface of the skin glycero-
gelatine oxide of zinc was used as the fixing material.
Radium in Gastric Carcinoma.
C. E. Field, N. Y. M. J., 102: 1171, 1916.
“The increasing frequency of gastric carcinoma and its tremendous
mortality make it a subject of great importance. Surgical treatment,
following early diagnosis, presents most encouraging results, but early
cases are few and far between. In advanced cases, surgical interference
is not evolving treatments which promise radical advantage, and we
must search for relief along other channels. I am frank in saying
that we are not able to present satisfactory results in gastric carcinoma
from the use of radium, although many have attempted to give treatment
in various ways. Special applicators of silver and rubber with handles
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suitable for introduction have been used, but the inability definitely to
locate the mass and give proper application is sufficient reason for the
fact that there is but little literature.
“When we review the subject and note the surprising lack of evi-
dence, we are constrained to ask, Has radium any place in the treatment
of gastric carcinoma other than purely experimental? Judging, first
by the results that are evidenced from application of radium in the
urinary bladder; secondly, by the opportunity for application in cases
where exploratory incision for diagnosis is to be made; and, thirdly,
in using it for the relief of pain in inoperable cases, I should not only
say that radium has reason for active consideration, but I feel confident
that it will not be long before encouraging findings follow an improved
technic.
“Undoubtedly, the fear of producing radium burns and the conse-
quent danger of perforation have deterred many from attempting
treatment. Furthermore, the lack of suitable means of introducing
under the field of vision an applicator containing radium of sufficient
potency and maintaining it in proper position for an hour or more,
have been deterrent features. The gastroscope may come into play, but
even in the hands of so talented an operator as Chevalier Jackson, it
has been hardly possible to secure application by such means. Many
esophageal cases are treated with success, but not so growths at various
portions of the gastric wall.
“In the urinary bladder, Dr. Winfield Ayres, of New York, has
been giving treatments with radium that are promising. By means of
a gold screen applicator attached to a flexible silver wire, constructed
in such a manner as to permit it to gain access through the cystoscope,
he is able to make application directly to a cancer mass which is in direct
vision, and give a dose of 200 milligram hours at a time. Careful regu-
lation of the dose, combined with experienced technic, gives assurance
of no bad effects and much to be expected. Dr. Hugh Young, of Balti-
more, has devised many new types of radium applicators for bladder
work and commonly uses very high doses.
“With the stomach, we hope that some device will be presented in
the immediate future to give us the same possibility of application that
is afforded in the bladder. Einhorn, of New York, some time ago,
employed a radium gastric applicator, called the radiodiaphane, which
was simply a radium tipped applicator, which carried a rubber tube and
permitted gastric distention by means of a hand bulb. This instrument
was used in numerous instances, but for the most part was reported
as unsuccessful.
“Dr. Robert Coleman Kemp, of Fordham University, has given us
a new instrument known as an inflating gastroscope, which will have
advantages where operation for diagnosis or treatment is decided upon.
It certainly would serve as a most practical means of making a direct
initial application of radium. In some cases it might be advisable to
create an abdominal fistula for continuing treatments. In such an in-
stance it is possible to use a smaller calibre instrument. The Kemp
apparatus is certainly a step in the right direction, although I am of
the opinion that its author had little thought of advancing it as a means
of administering radium therapy. -
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“That the world is not standing still as far as effort is concerned,
is shown by the fact that von Czerny, of Heidelberg, has reported
observations in several thousand gastric carcinoma cases. His exper-
iences detail the direct application of rādium, the use externally of
radium compresses for relief of pain, and the injection of the soluble
salts of radium. With the latter treatment, he avers that he has checked,
for a time, active congestion, relieved pain, and reduced stenosis to the
point of allowing the passage of food.
“Bissell, of New York, has reported palliative results from the
intravenous injection of solutions of the soluble radium salts containing
100 micrograms of the element. Such means of treatment are plausible
for the purpose attempted, and are rich in possibilities. Paul Ehrlich
states that the application of antitoxins and serums had reached its
zenith, and the next great step in therapy will be the employment of
radium solutions combined with other curative agents (possibly colloids)
yet to be announced. There are several research workers doing most
interesting work along this line. Possibly, the complete destruction of
cancer will not come until we can present treatment that can be admin-
istered directly through the body fluids.
“I regret exceedingly that it has been impossible for me to present
more encouraging data, but in the light that is now mine I feel that
progress is being made and that not many years are to elapse before our
hopes will in liberal measure be realized.”
Action of Radium Rays on Heart Action.
H. Zwaardemaker, C. E. Benjamins and T. P. Feenstra, Nederl.
Tijdschr. v. Geneesk., 2: 1923, 1916.
The isolated frog heart beats on for a longer period after the heart
cavity has been flushed with salt solution or Ringer's solution. The
author observed that this solution contained a radio-active element,
i. e. potassium; this is the only radio-active substance present in the
animal organism. It seemed, therefore, of importance to ascertain
if this potassium might be replaced by other non-organic radio-active
substances, which contained the same degree of radio-activity. This
proved to be possible with rubidium, uranium, florium and radium; it
seemed as if the radio-active elements in ionic form circulated free in
the fluid and in this way entered the cellular tissues; when they are
expelled the heart action ceases.
The cause of this effect must be oligodynamic as the gamma rays
play no part. It was then attempted to obtain the same result with
radium treatment through external raying (beta and gamma rays).
Hamburger used for this purpose a decerebrized frog, whose heart was
flushed with Ringer's solution. Exchanging this for a potassium-free
solution resulted in cessation of the heart beat within thirty minutes.
The radium preparation was now placed within several cm. of the
heart; the heart soon beat regularly once again. If the radium prepara-
tion was removed the pulsation ceased. -
There are two kinds of perisystole: (1) resulting from lack of
radioactivity; (2) resulting from superfluous radioactivity. They may
137
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easily be differentiated in the following manner. The potassium free
fluid from the rayed pulsating heart is exchanged for Ringer's solution.
If the organ contained superfluous or merely sufficient radioactivity,
the heart action ceases; if, however, the organ suffered a lack of radio-
activity, the pulsations become more marked instantly. Thus a suffi-
ciently rayed heart may be made to cease beating with Ringer's solution
containing calcium or made to resume beating with Ringer's solution
free from calcium. This sounds paradoxical. Calcium-free Ringer's
Solution produces very rapidly a cessation of the heart beat which
raying does not affect.
There is, of course, a process in the internal heart quite inde-
pendent of calcium deficit and simultaneous potassium compensation.
This process, the secondary radioactivity, remains in the heart and
governs its action. It is remarkable, however, that a potassium-free
frog-heart is mechanically quite non-irritable, before resuming its action
after raying.
A Study in the Internal Therapeutics of Radium.
Samuel Delano, N. Y. Med. Rec., 88: 137, July 24, 1915.
Radium emanation may be introduced in several ways, viz.: by
injection, by inhalation, by bath, and in solution by drinking.
The author gives numerous case reports.
Case 5: Rheumatoid arthritis: M., aet. 72. All joints, especially
hands and knees; distortion and increase in size; unable to sit down in
a chair, dress himself, or go downstairs. First week sharp reaction;
seventh day, “first good day”; in three weeks, after 36 micrograms
radium and twelve radium baths, dressing himself every morning,
coming downstairs alone, getting down in a chair and up, and going
out. Marked diuretic effect, interfering with sleep; also excitant.
Patient lost sight of.
Case 10: F., aet. 50. Wife of a physician; mild arthritis defor-
mans (chronic progressive) of fingers; took 24 micrograms of radium
without admitting benefit.
Case 27: Elderly woman with rheumatic arthritis, especially
affecting neck, which was painful and offered difficulty in moving.
Twenty-four micrograms radium over three weeks and radio-active
earth effected much improvement according to both patient and doctor.
Case 40: Interstitial nephritis, marked arteriosclerosis: F., aet.
70. Chronic invalid for some years; confined to room; increasing
edema of ankles; decreased amount of urine; very marked anemia.
Under radium continuously for three months, about 190 micrograms
being taken. There was the most remarkable improvement; edema dis-
appeared ; urine increased from fifteen to forty-five ounces, and main-
tained itself; great improvement in appetite, color and spirits. Urea
also was measured and showed increase. The patient improved enough
to go out riding. The radium was omitted for a couple of months.
Patient had suddenly uremic convulsions with pulse of 150 of great
irregularity, and complete suppression; she seemed about to die. Radium
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R a di u m
was resumed cautiously and her condition rapidly improved. The
doctor and the family paid the greatest tribute to the treatment.
Case 42: M., aet. 12. Fssential diabetes with accompanying
parenchymatous inflammation of the kidneys. The patient was lethargic,
moped, and it was for this that the radium was prescribed in the hope
of getting a stimulant effect; it was an unqualified success, so that it
was kept up for a couple of months. The effect on the sugar excretion
was also appreciable; a quantitative analysis was not made, but the
somewhat increased amount of urine was reduced to normal and the
qualitative test was less marked. The patient was lost sight of.
“Radium can reduce blood pressure, but there was no opportunity
for, such specific applications of it. So likewise radium has marked
effects on the blood picture, but no cases of pernicious anemia or leuk-
emia offered themselves.” . - -
What can radium emanation do as revealed in this series?
1. It is diuretic. This is perhaps the most consistent single effect
of radium. The ratio is perhaps in 7 out of 10 cases. This feature
may be rather rapidly produced or show in any pronounced way only
after three or four weeks. -
2. It is a laxative — not so often as it is a diuretic, but in a large
percentage of cases. This does not mean that it produces loose motions
but only what seems ascribable to quickened peristalsis.
3. It is a tonic and stimulant . . . This tonic and stimulant effect,
while not to be regarded as reflecting the most essential physiological
activity of radium, is, nevertheless, a very important and satisfying
exhibition. - -
4. Metabolism and nutrition. . . . There is much dispute as to
radium in regard to increasing the nitrogenous metabolism . . . What
radium does no the laboratory table it would seem likely to repeat inside
the body (which so often is not the case), because it is present in the
system in the same unchanged form. . . . The effects of radium on
nutrition of the skin seems very good. “Old skin brightens up and
looks younger. . . . .” -
5. External and topical. Even a weak solution (2 micrograms
to 2 ounces) is anodyne. It gives instant relief to toothache; this a
dentist has confirmed in several instances.
Dosage: In making a radium salt from the basis of dosage, it
must be borne in mind that the amount of emanation present is subject
to a definite law — it cannot be more than the equilibrium quantity,
which is a fixed constant. Quite otherwise is it with emanation per se
— the amount of which present can be increased ad infinitum. The
basis of comparison between a solution of a radium salt and a merely
radio-active water (emanation) is quite unequal. . . .
In the preparations used in this series the maximum of emanation
had already collected, and thus in association with 1 microgram of
radium we have 1 microcurie of emanation, or 2,700 Maché units by
measurement. . . . . . - - -
The object being to introduce the emanation into the blood lodging
it there by the immediate route of the vein, is, of course, the method
par excellence; hypodermic or deep injections would come next, and
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giving by the mouth last. Here, owing to the extreme diffusibility of
the emanation, there is a considerable portion of it lost without passing
into the systemic capillaries. . . .
Administering radium per os has perhaps one advantage, viz., its
local action on stomach and digestive tract. The influence here is
undoubtedly considerable and favorable.
Preliminary Report of Large Angiomatous Tumor on Baby,
Treated by Radium.
D. T. Quigley, West. M. Rev., 20:235, 1915.
A case is cited of a baby two weeks old, having an enormous tumor
under the arm, which had doubled in size during the two weeks of the
child’s extra-uterine life, thereby threatening to become fatal.
Owing to the tender age of the baby, operation was considered
out of the question. The danger of hemorrhage also made it impossible
to bury radium in the mass. It was therefore decided to treat the tumor
by cross-fire from the outside. In giving the treatment great care
was exercised to avoid a dose in any place that might cause enough
destruction of tissue to break into one of the blood vessels and thereby
cause hemorrhage. The radium was used with a combination of dis-
tance and metal filtration and by the cross-fire method, nearly every
night for three weeks. The dose was gauged somewhat according to
the constitutional reaction and the amount used was from 15 milligrams
to 125 milligrams of the radium salt.
The tumor began to shrink in size so rapidly that at the end of
the first week it had gone down one inch in size. At the end of the
third week it was about half the size it had been when treatment was
begun. Baby still under treatment and condition satisfactory. The
blood vessels that held the threat of hemorrhage have been destroved,
and if operation becomes necessarv to remove the remains of the mass
the author feels that it can be done safely.
The Use of Atrophan and Radium Emanation in the Treatment
of Gout and the Arthritides.
4. F. Chace and M. A. Fine, J. A. M. A., 63:945, Sept. 12, 1914.
In contraindication to gout, arthritis is not characterized by an
excessive concentration of uric acid in the blood; and this difference,
in the author's experience, has been of aid in distinguishing between
these conditions. . .
With regard to the influence of radium emanation on uric acid
metabolism, various European workers have emphasized essentially two
points: the increased elimination in the urine and the reduction or
disappearance of uric acid of the blood. The increased elimination of
uric acid in the urine under the influence of radium emanation is
perhaps due to the induced leukocytosis with subsequent leukolysis.
“We have thus far treated thirteen cases of gout and arthritis in
an emanatorium with radium emanation of 0.5 to 150 Maché units per
liter of air in one to two hour sittings for one to two months; two
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cases of arthritis with radium drinking-water; and five cases of arthritis
with injections of radium bromid equivalent to 50-100 micrograms of
the element. In no instance was there any change whatever in the uric
acid concentration of the blood. -
“With regard to clinical effects, we may say that in only two
instances — those in which radium solutions were injected — did there
appear to be any improvement. Here again, however, we feel that the
treatment should be extended over a greater interval, before conclusions
can be properly drawn with regard to clinical results.”
Treatment of Brain Tumors by Radiation.
Henry K. Pancoast, Am. J. Roentgenol., 9:42, Jan., 1922.
Brain tumors are adapted to radiotherapy for several reasons: (1)
In a large proportion of cases they are made up of malignant cells,
and are, therefore, susceptible to radiation. (2) They are slow-growing
and rarely metastasize. (3) It is permissible to remove part of the
growth surgically and leave the rest for radiation. Pancoast's work
has been based upon experimental observations of the effect of radium
on the normal brain tissue of dogs, from which it has been concluded
that on the human brain the surface dose of fairly well filtered radium
concentrated over a small area should not exceed 1400 mg. hours, and
had better be well below this amount. The safe dose from implantation
is much smaller than the safe surface dose. In the case of tumors
presumably completely removed by the surgeon, implantation is contra-
indicated unless a large cavity persists and the radium can be packed
in its center; otherwise the treatment should be by crossfire radiation,
for which radiation radium is to be preferred. The scalp is marked
off into squares of 1% inches, and each square exposed to 110 mg.
radium in a lead box of the same inside dimensions, with the
open end covered by 2 mm. aluminum and 5 ply thick rubber-dam
filter, for one hour. In this wav 30-50 squares are treated, as may be
necessary, and the exposures, slightly reduced, can be repeated as soon
as the skin reaction subsides. If the tumor has been only partly
removed, or not at all, the radium can be implanted, as nearlv as possible
in the center of the tumor. Implantation should be supplemented by
external cross-fire radiation. When the tumor is not localized or not
found at operation dependence must be placed on general external cross-
fire radiation. Implantation into pituitary growths exposed by the
transsphenoidal route is not advised but the radium can be applied to
the nasopharynx, and external cross-fire radiation used to supplement
the application.
Pancoast reports 32 patients treated, of whom 18 are still living,
from one to seven vears after the first treatment. He believes that
radiation has a decidedly beneficial effect and recommends the method.
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SECTION XI
RADIUM.–EXPERIMENTAL STUDIES
United States Radium Corporation
New York
R a d i u m
SECTION XI
RADIUM-EXPERIMENTAL STUDIES
The Action of Radium on Transplanted Animal Tumors.
Francis Carter Wood and Frederick Prime, Jr., Strahlentherapie,
12: 1071, Berlin, Nov. 16, 1921.
In radiotherapy of tumors it is important to know the length of
irradiation, the amount of radium element, and the distance between
radium tube and tumor. When the majority of beta-rays has been
eliminated by suitable filters, the action of radium is somewhat decreased,
but the activity of gamma-rays is subject to the same general laws which
govern the beta-rays. Sublethal irradiation retards the growth of tumor
cells for some time; still shorter treatment appears to stimulate cell
activity. At a distance of 1.1 mm. and using a filter of 0.4 mm. thick-
ness, 100 mg. radium can destroy tumor cells in fifteen minutes, 83 mg.
after one hour, 30 mg. after one and a half hours. No difference was
noticed with any of the tumors treated. But when beta-rays had been
filtered out, there was a great difference in the time required to destroy
tumor cells. A 5 mm. filter paper was used in addition to 1.2 mm.
brass; that is, the distance of the radium element from the tumor was
about 6.9 mm. Extended experiments showed that 100 mg. and 83 mg.
radium destroyed tumor cells only after seven hours.
These findings apply with fair accuracy to malignant tumors in
human subjects. Beta-rays are extensively absorbed by 1 cm. depth of
surrounding tissue; hence for deep irradiation only gamma-rays can be
used, and the time of exposure is about 8 times as long as when beta-
rays and gamma-rays are used. The action of radium rays on tumor
cells in vivo is less distinct than that on isolated cell elements. This
explains why an irradiation which will destroy a small metastatic bone
in man may be inactive in the case of a primary vascular carcinoma.
The Effect of Radium Emanation on the Adult Mammalian
Brain.
Halsey J. Bagg, Am. J. Roentgenol., 8: 536, Sept., 1921. - -
Bagg's experiments were primarily concerned with the histological
changes following exposure of the adult brain to radiation from radium
emanation and the extent to which the normal brain can be radiated
without destroying normal functional activity, the unsatisfactory results
obtained in surgical removal of brain tumors justifying the study of
the treatment of such tumors by physical means. Experiments were
carried out on rats, guinea-pigs, rabbits and dogs. Four methods were
tested: (1) Radium emanation in minute glass tubes, without other
filter, was placed permanently beneath the scalp in some instances and
directly in the tumor in others. Each tube contained from 0.2 to 1.5
millicuries. (2) Larger doses of unfiltered radium emanation, 63 to
255 mc., were placed in the brain and left for various periods. (3) A
comparatively large amount of radium emanation filtered through 1 mm.
of platinum and contained in a capsule applicator was inserted in the
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brain for thirty-five minutes. (4) Two large doses of heavily filtered
radium emanation, 4,000 and 9,000 millicurie hours respectively, were
given externally over the head. A still larger dose, 12,030 millicurie
hours, was applied in a similar manner over the left temporal region of
a monkey. 3 -
. The author concludes that of the 4 methods the application of
heavily filtered radium emanation over the scalp may be considered a
relatively safe procedure for the treatment of brain tumors. The bury-
ing of small doses of unfiltered radium emanation (mainly beta-ray
radiation) is also suggested as a favorable method of treating such
growths. The relatively sudden destruction produced by comparatively
large doses of unfiltered radium emanation makes this method unsafe.
While the applicability of embedding filtered radium emanation is still
uncertain, it is possible that by using still larger doses than were em:
ployed in these experiments, and decreasing the filtration, this method
may also prove to be valuable.
. It was noted that nerve tissue was markedly resistant to gamma-ray
radiation; this reaction is probably associated with the relatively adult
condition of the nerve cells. The changes in the brain following radia-
tion were largely due to the destructive action of radium emanation
on the blood vessels. There was a marked localized reaction, associated
with a pronounced leukocytic infiltration, following the insertion of
small doses of unfiltered radium emanation in the normal brain These
lesions were especially interesting, because of the absence of neurological
symptoms. f -
In the case of the monkey that received a strong dose of heavily
filtered radium emanation over the brain, there was no subsequent loss
of previously established motor habits.
Experimental Research in the Aciton of Beta- and Gamma-
Rays of Radium on the Tissues in Radiopuncture.
A. Lacassagne, J. de radiol. et d'électrol., 5: 160, Paris, April 1921.
The advantages of intrastitial radium therapy are: (a) utilization
of the total sphere of irradiation; (b) direct contact of the rays with
the matter to be treated; (c) relative assurance against radio dermatitis.
This technic has the one disadvantage of traumatic puncture of the
tissue. f
The replacing of radium by its product of disintegration, its emana-
tion, by reducing the volume of the radio-active focus, permits of
puncturing the neoplasm with only insignificant traumatism." The
author reports a series of experiments as to the comparative value of
elective radiation and of caustic diffuse radiation in the treatment of
cancer. Taken individually each series of experiments confirms the
theory that the lesion of necrosis increases with the initial strength of
tube employed and the thickness of the screen. **
The lesions provoked by intramuscular irradiation of the ovaries
have the following characteristics: (1) They are elective. They affect
certain follicles of the organ to the exclusion of others, such as the
interstitial glands and yellow bodies. (2) Their extent is in proportion
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to the strength of the dose administered. (3) They are independent of
the degree of screening.
Elective action may be attributed to the tempered beta- and gamma-
rays, caustic action to soft beta- and gamma-rays, although this subject
is most complex.
In applying Curie therapy to cancer: (1) The radium puncture
by means of screened needles is always to be preferred to naked tubes.
(2) The power of the initial dose should never exceed a degree which
would produce reactionary necrosis of the surrounding tissue. (3) It
is important to obtain sufficient raving to sterilize a malignant tumor
without causing tissue necrosis. (4) In applying radium through tubes
of great intensity, the secondarv screen should be at least as thick as
the ray of the cylinder of necrosis.
The Response of the Animal Organism to Repeated Injections
of an Active Deposit of Radium Emanation. Intravenous Injections
in Dogs.
Halsey J. Bagg, J. Cancer Res., 5: 301, Oct., 1920.
The experiments reported were undertaken to determine the sever-
ity of the physiological reaction to intravenous or subcutaneous injec-
tions of an “active deposit” of radium emanation in dogs. It was
ſound that large intravenous doses of an active deposit of radium
emanation produced a considerable reduction in the number of white
blood cells, as much as 80% of their total number, but that the simul-
taneous reduction in the number of red blood cells was less, amounting
to only about 25%.
Repeated doses, amounting to a total of 338.4 millicuries distributed
in four intravenous injections, apparently produced a very marked de-
crease in the number of circulating lymphocytes of the blood. Digestive
disturbances, such as severe vomiting and diarrhea, occurred, as well
as a considerable reduction in the body weight. In several cases, the
body temperature rose following the treatments, possible because of an
adaptive reaction on the part of the animal organism to the toxic
condition produced by the sudden destruction of a considerable amount
of cellular material. Daily urine analyses showed very decided in-
creases in the total nitrogen content: the amount of urea, creatinin,
uric acid. and total phosphates; while relatively small or moderate doses,
if administered after the organism had already been injured by a prev-
ious injection, produced definite changes in the chemical content of the
urine, indicative of destructive changes.
Microscopically, there was considerable congestion in the principal
viscera. The liver showed general fatty and granular degeneration; the
kidneys showed granular degeneration of the tubule cells; and the
spleen presented considerable congestion, while the splenic pulp was
largely drained of cells. The lymphoid tissue of the bone marrow
was largely replaced by fat. There was extreme congestion in the
pulp of the lymph-nodes in one animal, associated with a reduction in
size of the lymph-follicles. The lungs in one animal were normal;
while in the other, which received the larger total of the radio-active
solution, they were congested and showed slight signs of emphysema,
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The colon in one of the animals was markedly congested, and showed
signs of active mucus production. The other organs showed no
definite changes.
The author concludes that when the active deposit of radium eman-
ation is used intravenously, as a therapeutic agent, great care should
be taken to grade the dose in accordance with the general physical
condition of the patient, which should be determined by frequent urine
and blood analysis, and that if more than one dose is given during the
treatment, the second dose should be made smaller in accordance with
the strength of the original dose.
The Effect of Intravenous Injections of Active Deposit of Radi-
um on Metabolism in the Dog.
Theis and Bagg, J. Biol. Chemistry, 41 : 525, 1920.
The present work was carried on to study the effect of the active
rays of radium upon the general metabolism of the dog. Solutions of
sodium chloride which contained active deposit from radium emanation
were used. To prepare the solutions, sodium chlorid is first dried and
packed into a bulb and left in contact with radium emanation for three
or four hours. The emanation is then pumped off and the salt dissolved
in water in such concentration as to give a solution isotonic with the
blood. The solution is drawn into a syringe and the amount of activity
determined by a gamma-ray instrument. After the injection, the radio-
activity remaining in the syringe is again determined and the amount
injected computed by difference. The radio-activity is expressed in
millicuries. It should be noted that the number of millicuries injected
cannot be controlled exactly, as an irregular quantity (25 to 50%) will
remain in the syringe The rapid decay of the active deposit introduces
a second source of error in estimating the quantity injected. Radium A
decays completely within fifteen minutes after the preparation of the
solutions. Since the injections were made after fifteen minutes, onlv
Radium C need be taken into account. Radium C falls to 3% of its
initial value within three hours, so that the physiological activity of the
injected solution can last only a relatively short time. The physiological
effects are presumably due to the alpha-radiation.
The first experiment was done on a Dalmatian dog. The first six
days (Feb. 28 - March 5) serve as the control period before the first
injection. On March 5 the dog received an intravenous injection of
95 millicuries of the active deposit. On the day of the injection there
seemed to be no effects on the general condition of the animal, but on
the two following days the dog had to be coaxed to eat the food and
the feces were softer than usual. After this no further general effects
were present. An examination of the nitrogen partition shows a sharp
rise in the total nitrogen output, which reaches its maximum on the
second day after the injection. This increased nitrogen is distributed
among all the nitrogen constituents except creatinin. Ammonia in-
creases proportionally more than does urea. Indeed the increase in
the ammonia suggests a definite acidosis. The uric acid increases bv.
about 50% over that of the preliminary period. It is possible that this
is associated with the destruction of white blood corpuscles which fol-
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lows the injection. Phosphates and urinary volume both tend to show
definite increases over the preliminary period.
The total nitrogen remains high for five days after the injection,
and then drops suddenly. The ammonia and particularly the uric acid
drop more slowly. The latter does not reach the level of the preliminary
period until twelve days after the injection.
On April 4th the dog received a second intravenous injection of
30 millicuries of the active deposit. This dose is scarcely a third of
the quantity given in the preceding experiment. The total nitrogen
again increases, and again the maximal figure is reached on the second
day after the injection. The small dose employed in this experiment
is followed by only a slight and transitory rise in uric acid. On the
third and fourth days after the injection creatinin shows an increase
well above the preliminary period.
On April 15 the dog received its third injection of the active
deposit. On this day 42 milicuries were given. This injection is
followed by a marked and prolonged effect. Total nitrogen, urea and
ammonia increase and remain high for almost two weeks. Creatinin
and uric acid both show a marked increase. The high figures for those
constituents continue for about eight days after the injection. Through-
out the series of treatments on this dog, there is a steady increase in
the volume of urine eliminated. At first the amount was 200 c.c. and
after the treatments it gradually rose to 1 liter.
On May 8 the animal received a fourth injection of 64 millicuries.
This was followed by vomiting and refusal of most of the food for
several days. The fact that the third and fourth injections were smaller
in quantity than the first, and were followed by marked general effects,
shows that the animal failed to recover completely from previous treat-
ments with the emanation. Shortly after the fourth injection the animal
was killed. Autopsy findings are not reported in this article.
In general, the results of the experiments on the second dog, a
bull terrier, were about the same as the results on the Dalmatian. The
effect of the injection seems to be cumulative, because the third treat-
ment (first dog) only a little larger than the second injection, produced
a very marked effect, while the fourth treatment, although smaller than
the first, produced nausea.
Effect of Radium Rays upon Cane Sugar and Agar.
A. Fernau, Biochem. Ztschr. 102: 246, 1920.
Experiments conducted by Fernau upon a 2% aqueous solution of
cane sugar prove that cane sugar is inverted by the action of the radium
ravs, either with or without the presence of platinum black as catalyzer.
This inversion is a primarv effect of the radium rays, and does not
follow secondarily from the formation of hydrogen peroxide and the
resulting aciditv.
When a 1% aqueous solution of agar was subjected to radium rav
bombardment the viscositv altered so that it almost equalled that of
water, and the agar reduced Fehlino’s solution, indicating hvdrolytic
dissociation into, most probably, galactose and arabinose. Although
hydrogen peroxide affects agar similarly the experiments with cane
sugar suggest that this too may be a primary effect of the radium rays.
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Results of the Exposure of Animal Ovaries to the Rays of
Radium.
J. M. Maury, J. A. M. A., 74: 1711, 1920.
The experiments here recorded were made for the purpose of
determining the changes brought about in the ovaries of rabbits by
exposing them to 50 mg. of the element radium for twelve hours. This
dosage was selected because it is that generally used in cases of so-called
idiopathic uterine bleedings but which are now regarded as being due
to an abnormal condition of ovarian secretion.
As some of these cases, particularly in young subjects, can be
cured by the internal administration of pituitary extract, it is possible
that not all of them are due entirely to ovarian conditions, some being
due rather to a disturbance of the balance normally existing between
the output of the pituitary gland and the ovaries.
It is well known that the intra-uterine application of radium has
an effect on menstruation proportionate to the dose, 50 mg. of the element
applied for twelve hours being sufficient to stop menstruation for several
months, and in some instances to establish the menopause permanently.
The generally accepted theory is that this result is brought about by a
destructive action of radium on the follicles most advanced in develop-
ment, menstruation returning after the voung follicles, on which radium
is supposed to have had no effect, have had time to mature. Little
account seems to have been taken of the effect which must be produced
on the endometrium, on which its greatest power must be exerted.
Considering the small amount of radium used in these cases and
the distance from the uterine cavity to the ovaries, to one who is
accustomed to the use of radium there must be some doubt arising as
to the results being brought about in the manner claimed. It is also
difficult to imagine a satisfactory reason why the mature follicles should
be killed and the less mature ones remain uninfluenced, especially as
everywhere else in biology, the less mature a thing is the greater its
susceptibility to disintegrating influences.
In determining changes which may have resulted from treatment,
great difficulty is encountered because the normal ovarv presents no
fixed standard for comparison. In normal ovaries, degeneration is
present to a greater or less degree in follicles in all stages of develop-
ment, comparativelv few completing the cycle of growth to maturity
and rupture with the discharge of a living ovum. This is particularly
true in the rabbit, because ovulation does not take place without copilla-
tion. Follicles maturing except at this time do not continue to live.
but die and degenerate, and, as pointed out by Graves, all those folſicles
arriving at maturity during pregnancy must become atretic. It was
therefore necessary to examine a large number of normal ovaries to
familiarize oneself with the great variations that mav exist.
Ovaries of rabbits differ from the human ovaries in the amount
of epithelial tissue present. While the human ovary may be described
as a connective tissue organ containing graafian follicles and having
a fibrous capsule outside of which is the germinal epithelium, the rabbit
ovary is a mass of epithelial cells having a thin connective tissue cortex
surrounded by the capsule and germinal epithelium. Most of the folli-
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cles are found embedded in the connective tissue cortex. The epithelium
of the body of the ovary can easily be distinguished from the epithelium
of the corpus luteum by the latter cells being of larger size and sur-
rounded by the theca.
The ovaries of rabbits occupy a rather fixed position in either
flank, close to the abdominal wall and just above the crest of the ileum.
In this position they are much closer to radium placed on the skin
surface than are the ovaries of the human being to radium placed in the
uterine cavity. Having less tissue intervening, they are therefore more
susceptible to the action of the rays.
Fifteen female rabbits were treated, each being given a dosage of
600 milligram hours, the radium applied to the skin surface overlying
the ovaries. One was killed in three weeks, two in four weeks, two in
five weeks, four in six weeks, three in eight weeks, and four in nine
weeks. The ovaries removed were not touched with fingers or forceps.
They were placed in 70% alcohol at once and run up for paraffin sec-
tions as soon as possible. The first few were sectioned serially and
examined throughout. This consumed much more time than was avail-
able, and was found to be unnecessary. Therefore in the others, from
fifty to seventy-five sections were removed from each side and from
the middle portion of the ovary and examined, making about 150 to
200 sections from each ovary. In the examination of sections, special
attention was given to the germinal epithelium, the connective tissue
cortex, the blood vessels and the follicles.
Macroscopically, the ovaries varied greatly in size. One, a sclerotic
ovary, was a mere strip of tissue composed, as seen under the micro-
Scope, of only connective tissue with almost no follicles. The author
does not think this was the result of the treatment because the ovary
was removed only three weeks after treatment, and there were no signs
of follicles in a state of degeneration and almost no small follicles of
any size, a change so great that it could hardly have taken place in
three weeks. The variation in size seemed to depend on the number
and size of the atre:ic follicles and corpora lutea present. Both in
number and size these structures varied greatly in different ovaries.
In all ovaries examined, the germinal epithelium was present, and in
normal condition. The connective tissue cortex varied much in thick-
ness in different ovaries, even the two ovaries from the same animal
presenting considerable variation. The blood vessels showed no signs
of endarteritis, and as they normally have unusually thick walls, this
change could easily have been observed had it been present.
As would naturally be expected, the greatest variation was shown
in the condition of the follicles. In seven of the ovaries examined
there were no follicles approaching maturity either alive or in a state
of degeneration. In twelve there were living follicles at or close to
maturity which showed no evidence of having been affected by the
treatment. In the remaining eleven all the large follicles were in a
state of degeneration. Deducting, therefore, the seven ovaries not
containing follicles of sufficient size to be supposedly affected by radium,
there remain twenty-three, twelve of which contained large follicles
showing no effect from treatment. e
In addition to this evidence, two rabbits were put with a male
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and became impregnated five weeks after treatment, in one four and
in the other five embryos being removed from the uterus several weeks
later — rather convincing evidence of the viability of the ovum when
it was discharged from the ovary.
Two other animals which had become pregnant were later treated
and did not miscarry, indicating that the membrana granulosa of the
mature follicles, from which the corpus luteum cells are probably
formed, was not degenerated; for it is well known that if the corpus
luteum of pregnancy is destroyed in its early stages, the fetus will
be cast off.
From these results the author thinks it a fair deduction that a 600
mg. hour dosage of radium does not produce degeneration of the folli-
cles of the ovaries. 5
Radium in Experimental Cancer.
F. C. Wood, Proc. Pan. Am. Scient. Cong., 10: 500, 1917.
It is extremely difficult to apply the necessary scientific criteria to
the investigation of human tumors, as far as radium therapeutics is
concerned. It is not always possible to obtain satisfactory specimens for
microscopic examination, especially if the tumor is in the internal organs,
the danger of over-treatment with resulting severe burns is always
imminent, and in this country, at least, we are unable to obtain any
Satisfactory proportion of autopsies on persons dying from any cause
after treatment. The result of this is that the medical literature is filled
with a lot of practically worthless reports of the effect of radium on
tumors.
The author is of the opinion that the percentage of cures of cancer
is extremely small and confined mostly to certain groups of tumors,
among them the basal-cell tumors of the face, the epulides of the jaw,
the giant-cell sarcomata of the long bones, the adeno-carcinomata of the
uterine body, and certain lymphosarcomata. All of these tumors may
undergo a spontaneous disappearance, at least for such periods as would
warrant the diagnosis of a clinical cure, or are curable in some instances
by the mere removal of the main mass; although later there may be a
fatal recurrence. For these and other reasons it is necessary to turn
to spontaneous or implanted tumors in animals as a means of scientific-
ally testing the therapeutic value of radium.
First, it is important to know what the minimal lethal dose of
radium is for cancer cells outside of the animal; the viability of the
treated cells being tested by inoculation after treatment. Such experi-
ments have shown that when the alpha rays are removed by suitable
filters, 100 milligrams of radium element at a distance of approximately
5 millimeters require one hour to kill carcinoma or sarcoma cells of the
mouse or rat in vitro. If the filter used is of sufficient thickness to
remove all of the beta rays also, the time required is increased seven or
eight fold. The experiments have shown that in order to produce these
effects no other factors are in play except the amount of radium. the
length of the exposure, and the distance between the radium and the
tumor cells. This furnishes a lethal coefficient which can be plotted
as a simple rectangular curve and by means of this anyone can deter-
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R a d i u m
mine the exact length of time required to kill a cancer cell at a given
distance with a given amount of radium.
Second, it is necessary to find the lethal dose of radium for cancer
cells when these are left in the tissues with their full blood supply, and
experiments carried out to determine this have shown that the amount
of exposure required to produce the same results is considerably greater,
in fact nearly double the amount required in vitro. Evidently there is
some interference with the destructive action of the rays caused by the
renewal of the cell substance through the circulation.
Third, it is important to find the lethal coefficient for human cancer.
So far as clinical experience goes, the lethal death point of human and
animal tumor cells is very nearly the same. As it is impossible to
inoculate human cancer cells after treatment, it has been necessary to
grow them in culture, a complicated and difficult procedure. Another
factor in the treatment of human material is that it is probably not
necessary, in order to produce a cure, to kill all of the cells; but that
if a certain amount of radiation is given, the closure of the blood
vessels by the endarteritis which the radium produces and the new
growth of connective tissue induced as a repair process following the
arterial thrombosis and as a direct effect of the irritating action of the
radium on normal tissues, may effect a choking of a certain amount of
the carcinoma, and produce a temporary or symptomatic improvement
of considerable extent. This may explain the fact that in some cases
less exposure is needed to cure a small human cancer of low virulence
than to kill a mouse cancer in vitro.
Experiments in treating primarv tumors of animals and the results
of treatment of human cancers of high malignancy have, however,
shown that in those portions of the growth where the cells of the tumor
are in contact with normal structures it is extremely difficult to destroy
the healthy blood vessels, and, therefore, to influence the shell of car-
cinoma tissue, which still remains, even though the main mass may have
disappeared under the influence of the radium. It is from this shell
of actively growing neoplasm, thin as it may be, that recurrence takes
place and this is the difficult phase for any permanent cure.
To a certain extent we are able to judge the type of tumor which
may be influenced with radium; that is, any tumor rich in giant cells,
especially of the myeloplax type. But, until we know just exactly what
radium will do, it is improper to apply it to operable tumors, and we
ought, therefore, in our experiments on human beings, still to use only
such tumors as are decided to be absolutely inoperable.
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SECTION XII
RADIUM-APPARATUS
United States Radium Corporation
New York
R a di u m
SECTION XII
RADIUM-APPARATUS
Instrumental Difficulties and the Error of the Square of the
Distance in Curietherapy.
D'Halluin, J. de radiol. et d'électrol., 5: 502, Paris, Nov., 1921.
It has been customary to express values in terms of radium bromid,
instead of metallic radium. Until recently tubes containing the bromid
were deficient, in that they were not always exactly filled, and the salt
was therefore freely movable and unevenly distributed. To test this
a silhouette of the tube can be taken on a plate. The law of the square
of the distance holds true only for punctiform sources of emanations.
but not when a series of tubes are used together, for in that case the
point irradiated receives both direct and oblique rays. Oblique rays are
less active according to their length. As curietherapy is commonly used,
therefore, the intensity appears to be inversely proportional to the dis-
tance (not to the square of the distance), although the formula is com-
plex and depends upon numerous factors.
Lead Block for Holding Radium Needles.
C. F. Bowen, J. A. M. A., 76: 1397, 1921.
Physicians using radium needles appreciate the difficulties in
threading them. The trouble has been to hold the needles properly while
they are being threaded. It is not a question of the mechanical difficulty
of holding them so much as it is of protecting one's fingers while the
needles are being threaded.
The author presents a device which has been of the greatest
mechanical help and at the same time offers protection from the rays
given off by the radium. It consists of a block of lead about two inches
wide and four inches long into which have been made ten holes for
holding 100 mg. of radium, distributed in ten needles.
The holes are of sufficient depth so that when the needles are placed
in them just the eyes project above the surface of the lead block. The
row of holes is placed along the one side so as to give greater thickness
of lead between the needles and the operator. If the end of the thread
is properly prepared, it can be held in a pair of long forceps and the
needles threaded without difficulty. The surface of the block of lead
can be used to steady the forceps holding the thread. #
After the needles are properly threaded they can be removed from
the lead block and sterilized before being inserted. It is even possible
to place the entire block of lead, containing the threaded needles, in a
receptacle containing the sterilizing fluid; but in this case the holes in
the lead ought to be of sufficient size so that the antiseptic can readily
enter and surround the needles. Such an apparatus completely protects
the operator and makes the threading of the needles much easier.
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R a d i u m'
An Inexpensive Radium Capsule Holder.
G. E. Pfahler, Am. J. Roentgenol., 8:30, 1921.
There is much risk in handling the capsules containing radium
element, and in the process of screwing these capsules together or
separating them there is unnecessary exposure of the fingers to danger.
Any device that will help to keep the fingers at a distance will be useful
and will lessen damaging effects. Several capsule holders have already
been designed, but each one will fit only the capsule for which it has
been made. The author therefore searched in instrument stores and
elsewhere, but finally went to a hardware store, where he found a chuck
which is 10% cm. in length and which can be adjusted to take any of
the capsules varying from 4 to 6.3 millimeters. The cost of this chuck
is 85 cents, plus the labor of drilling the soft jaws. It is necessary
to drill out the chuck in its central portion so that when it is wide open
it will just grasp the largest sized capsule. i i
In the author’s experience this chuck is superior to the instruments
made costing $12 to $15. It can be lengthened as much as desired
by setting the handle into a wooden handle. (Fig. 1 shows a Goodell
Pratt Co. Second Size Drill Chuck). The remainder of the metal,
if desired, may be covered with rubber.
There are three plates, Fig. 1, as mentioned above, Fig. 2 showing
a Starret Pin Vise grasping one of the radium capsules, and Fig. 3
showing the same pin vise with cap removed, showing the jaws which
have been drilled out sufficiently to take varying sized capsules.
The Effect of Different Filters on Radium Radiations.
E. H. Quimby, Am. J. Roentgenol., 7:492, 1920. r"
In deep radium therapy, filters of various metals are used to remove
the beta and soft gamma radiation. There is considerable difference of
opinion as to what metal is most suitable for this purpose. For instance,
some use lead almost exclusively, while others strongly condemn it. In
any case, what is of importance is the quality of the radiation reaching
the tissue After carrying on a group of experiments, the author comes.
to the following conclusions: *
Equivalent filters of different metals have been determined which
give the same intensity of ionization in the apparatus described in
the article.
When the radiation filtered through these “equivalent” thicknesses
is transmitted through tissue, the ionization produced is not the same.’
For thin filters, up to half a millimeter of brass or its equivalent,
the radiation transmitted by lead is more penetrating than that trans-
mitted by brass, which in turn is more penetrating than that from
aluminum. When the absorption by the tissue becomes great in com-
parison to that by the filter, this effect is obscured.
For thick filters, equivalent to one millimeter of brass or more, this
effect is reversed, the radiation transmitted by lead having a larger
percentage of soft radiation than that transmitted by brass or aluminum.
To obtain, the necessary penetrating radiation for deep therapy, in
general a combination of filters is necessary. When substances of high
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atomic weight are used as filters, a considerable part of the emergent
radiation is easily absorbed in tissue. Hence the necessity of a second-
ary filter of low atomic weight to remove this soft radiation. The
analysis by tissue of the transmitted radiation enables us to determine
what additional filtration is necessary when any metal is used as the
primary filter.
For practical reasons brass is a good substance to use as a primary
filter. Its secondary radiation is not very intense and can be removed
to a sufficient extent by a few millimeters of rubber, which have the
same effect as an equal thickness of tissue. A thickness of 2 millimeters
of brass is sufficient for deep therapy.
The results obtained in the author’s experiments are directly ap-
plicable to the treatment of patients, since the results by the tissue used
is the same, within the limits of experimental error, as that by living
t1SSue.
Apparatus for Implantation of Radium Emanation Points.
R. M. Lewis, Surg. Gynec. and Obst., 30: 528, 1920.
In treating certain types of malignant tumors with radium, the
implantation of minute capillary glass containers filled with emanation
is more efficient than in any form of surface emanation. The emana-
tion or active gas is given off from the radium, and transferred by a
mercury pump into a fine capillary glass tube about 3 to 4 mm. long,
which is then sealed.
For growths of the bladder the author devised an instrument which
would work through a cystoscope. A stylet is attached to the trigger
to push the end of the stylet out flush with the end of the needle, thus
forcing out and embedding the emanation in the tissue. Before using
the instrument alcohol sterilization is sufficient. The tiny emanation
containers are laid in the hollow needle in front of the plunger. A little
sterile vaseline on the needle point prevents the contained point from
slipping out accidentally.
An Instrument for the Application of Radium to the Bladder.
William H. Woolston, Surg, Gynec. Obst., Dec., 1920.
For the application of radium to tumors of the bladder wall Wool-
ston uses a capsule of platinum, silver, or gold, preferably the first, on
one end of which there is a clip attachment. This clip is made of a
watch spring, and the points are sharp so that they grasp the tissues
firmly. The arms form a figure eight, and are firmly embedded in the
end of the capsule. At the other end there is an eyelet for the attach-
ment of a strong silk cord or fine wire. The forceps used has a hollow
cylindrical shaft about fourteen inches long with a hollow obturator or
plunger. When the capsule is drawn into the forceps the closed end
of the figure eight is compressed, opening the jaws of the clip. By
means of the obturator or plunger the capsule is expressed, and the
spring clip is released, the points grasping the tissues as it closes.
When the clip is firmly attached and the instrument removed, the
guide of silk or wire running from the capsule through the urethra to
the outside is fastened to the thigh with adhesive plaster until the
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R a d i u m
radium is taken out. To remove the capsule the guide is threaded
through the obturator and the capsule engaged into the end of the
instrument. When the obturator is withdrawn and traction put on the
guide the capsule is drawn into the forceps, the clip is compressed so
that the jaws open, and the tissues are released. The bladder should
be kept distended with five or six ounces of sterile water during the
application in order to prevent the walls from falling together, in which
case a burn might result on the normal mucosa. The instrument can
be used only through a direct operating cystoscope.
Glazed Flat Radium Applicators.
Ch. H. Viol. Radium, 9:13, 1917-18.
As the flat varnish applicators are not very durable, the author
has devised a glazed flat applicator which lasts longer. These applica-
tors are prepared using a lead-free glass, such as has been used for
years in the preparation of tubes of radium salt. Being lead-free, the
density of the glaze is low, and the absorption of the softer rays is not
much greater than in the varnish applicators. This absorption of beta
rays is reduced to a minimum by the use of as little glaze as possible,
since it was found that some of the first glazed applicators prepared
were not altogether satisfactory because of the absorption of too great
a proportion of beta rays. Owing to the high melting point of this
glass silver has been selected as the best metal for the backs, and the
applicators are supplied without the usual handle, in the form of flat,
square or circular discs, containing the radium salt uniformly spread
over the glazed area, the glaze being fused in a slight depression in
the metal disc. Slight cracking in the glaze sometimes results but
experience has shown that this is not serious, placques in this condition
having been suspended in boiling water, and then dropped into ice water,
repeatedly, without loss of radium; and even rough mechanical treat-
ment such as repeated dropping the placque from a height of three or
four feet to a hard floor has not caused the glaze to chip out.
The limitations as regards amount of radium salt per unit area
is not as great for the glazed apparatus as for the varnish. Thus far
there have been prepared a number of placques containing 25 mgm.
of radium element in an area of two square centimeters, which on the
London Radium Institute basis is two and one-third times full strength.
These applicators have been found quite satisfactory in service, and
are of a “strength” that would be very difficult to prepare using varnish;
and if prepared with varnish would have a brief life of usefulness before
requiring remaking. The life of the glazed applicators should be much
longer than that of the varnish applicators of corresponding strength,
as the glass does not deteriorate the way the varnish does, and the greater
mechanical strength of the glazed applicators should make them with-
stand rough handling much better than the varnish applicators.
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Descriptions of Two Radium Applicators for Malignant Dis-
ease of the Mouth and Pharynx.
C. H. Bubb, Arch. Radiol. and Elec., 21 : 293, 1917.
The first applicator was for a case of endothelioma of the soft
palate. It consists of a vulcanite plate with an extension carried back-
wards 'corresponding to the area of the growth, but not in contact with
its surface, a space of 3/16 inch intervening. On the palatal or
upper surface of this vulcanite extension are fashioned a series of
antero-posterior and lateral grooves. The grooves are lined with lead
and serve to accommodate one or more tubes of radium. The tubes
are prevented from slipping by two metal flanges, working on a swivel
at one end and notched at the other end to allow the flange, in the closed
position, to embrace a screw inserted into the vulcanite. This screw
can be tightened when necessary. By this means the radium tubes
are securely retained in a known position. The lead lining of the
grooves effectually screens surrounding tissues and allows the action
of the emanations to be localized to any desired area of the growth.
The second applicator was for a recurrent epithelioma of the
pharynx. In this case a skeletal appliance was adopted as the patient
had a solitary canine tooth standing in the upper jaw. The apparatus
consists of a shell crown, divided on its buccal surface, to which is
attached a screw and threaded bolt so that a firm grip can always be
maintained on the tooth. From this gold crown an oval wire extends
backwards to give attachment to a vulcanite block, corresponding roughly
in size to the area of the growth. This block is lined with lead on
its palatal and pharyngeal surfaces and permits the insertion of a
lozenge-shaped radium tube as well as a circular one. The method of
fixation is similar to that described in the preceding case.
Treatment of Sclerotic Middle Ear Diseases with Radium. The
First Successful Application of the Method: New Apparatus.
Z. von Dworgak, N. Y. M. J., 106: 598, 1917.
In the treatment of otosclerosis and other middle ear disease, the
author uses radium rays as well as the radium emanation. He believes
that the use of the radium-ennanation is original with him. He applies
it directly in the tympanic cavity, as the tympanum, like all other fibrous
membranes, offers much resistance to the rays.
The amount of radium varies from one to ten mgm. radium ele-
ment. The radium tubes are applied by means of the radium applicator
and are centered in the ear by means of a head-band to which is attached
a small ear speculum, by means of which it is possible to introduce and
remove the applicator and watch the reaction. A brass filter eliminates
the alpha and beta rays and the therapeutically active gamma rays
penetrate the tympanum and middle ear. A larger amount of radium
is also used to ray the entire ear region.
The author manufactures the radium emanation in an emanator
of special construction. Oxygen bubbles out of a tank through the
liquid in a bottle which contains the radium in solution. The quantity
of this oxygen is regulated to a nicety by means of two manometers and
a gas meter. The oxygen in passing takes up the radium emanation
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R a di u ºn
and can be used for inhalation, by means of a mask or in a room, for
the activation of water for drinking purposes or for the treatment of
the ear directly in blowing it through the Eustachian tube in the middle
ear. In the latter case he uses either the pressure of the oxygen alone,
or combines the emanator with the Meyer-Rowan instrument which the
author has adapted for that purpose, so that sound waves or air under
pressure will force the emanation into the tympanic cavity, depending
on the character of the disease being treated. At times he has had the
patient inhale radium emanation and let him inflate the Eustachian
tube by Valsalva’s test.
In all cases it is necessary to remove the excess radium emana-
tion after the treatment by means of suction from the external auditory
meatus or by pressure through the Eustachian tube or both combined;
for radium emanation remaining in the middle ear could ultimately
cause damaging after-effects. Radium D, one of its products of decom-
position, lasts sixteen years and might remain active too long in the
middle ear.
A Direct Reading Emanation Meter (Ionometer).
H. Greinacher, Ztschr, f. Balneol. Klimat., etc., 8:56, 1915-16.
A machine is constructed which measures directly the amount of
radium rays present in the air, indicating this by means of the ionization
effect of radium rays. The apparatus consists of three parts. (1) A
small box containing two metal plates; (2) an electroscope with two
leaves; (3) an upright rod. All except the rod are enclosed in a wooden
CaSe.
The way in which the meter works is as follows: The lower
plate is charged by means of a current. Since both plates are covered
with a radio-active substance, the air between them is a conductor.
The upper plate is thus charged, and simultaneously, the electroscope
and the projecting rod (Z). The leaves of the electroscope spring
apart, and rest at the zero point on the scale. If the air around Z is
ionized, electricity flows out from Z into the surrounding air. A corre-
sponding current, however, is flowing in from the air between the two
plates. The electroscope is discharged, the leaves draw nearer to each
other. The distance through which the leaves move while approach-
1ng each other is governed by the amount of electricity, i. e. emanation
in the air. Each movement of the leaves corresponds to a definite
amount of emanation present in the air. Hence the scale measuring
fhe distance through which the leaves move is so divided that each
scale division represents a certain amount of emanation per liter of air.
For the initial charging of the instrument contact can be made
with the electric lighting system. A voltage of 220 is essential, however,
so that if the existing voltage is only 110, an auxiliary battery of 110
volts must be employed. If desired, instead of connecting with the
lighting system, a battery of 220 volts may be used. For other voltages
the author has constructed another instrument.
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New Conceptions Relative to the Treatment of Malignant Dis-
ease with Special Reference to Radium in Needles.
W. L. Clark, Penn. M. J., 24; 214, Jan., 1921.
The lethal action of radium, and in a lesser degree of the x-rays,
upon malignant cells of all types – some types resisting more than
others — has been proved both in the laboratory and in practice.
It is recommended, after observing the good results in practice,
that at least one maximum radium treatment with proper technic be
given preparatory to any surgical procedure for the purpose of first
inhibiting and finally rendering benign the migratory cells in the ducts,
and producing glandular fibrosis. It has been the author's custom
to allow a week or more to elapse between the radium treatment and
whatever operative work is undertaken; but if the lesion is growing
too fast, this may be modified. At least three cross-fire radium treat-
ments, averaging six weeks apart, should also follow operation.
If the invaded glands have not broken down, they will usually
disappear under judicious cross-fire radium treatment. If the glands
are small, treatment may be given externally; if large, radium needles
should be inserted directly into the glands.
The adaptation of hollow, metallic needles, each containing some
radium salt — preferably the sulphate — representing a known quan-
tity of radium element, has revolutionized radium technic. The author
uses needles containing 5 to 10 milligrams. These needles are used for
insertion into malignant growths and glands, or into an organ contained
in the peritoneal cavity after exposure of the lesion by laparotomy.
The method of application by needles is more accurate and produces
more favorable results than application from the outside or insertion
of a capsule through an incision. Put there are times when only the
two latter can be used.
As many needles as necessary may be inserted 20 to 25 mm. apart,
to any depth into the tissues, thus taking advantage of concentric cross-
fire radiation from needle to needle. If a sufficient number of needles
are available, they may be grouped together and put into a capsule
of brass or other metallic filter and covered with rubber. These may
be used in the same manner as the ordinary radium capsule, or the
needles may be placed side by side in a suitable flat metallic container
covered with rubber and used whenever a flat plaque of standard
construction is indicated for the treatment of malignant disease. After
various experimentations an alloy of steel and nickel known as “non-
corrosive steel” was adopted for the needle. These needles have been
made to order in lengths varying from 20 to 30 mm. Some are round
with tapering point, others having cutting, trocar points, some are flat
but maintain their hollow center. The eye of the needle is tapering
so that it may be withdrawn easily by means of a braided silk thread
after insertion below the surface. The shorter needles are used in the
more delicate structures, the long ones in those less delicate and more
extensively diseased. The wall thickness is invariably 0.5 mm. The
diameter at the widest point is 2 mm. The hollow needles are divided
about 1 mm. below the eye.
It is still the opinion of some physicists and radiologists that
radium needles are of little practical utility, since it is thought that
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the secondary radiations from the metal in contact with the tissues cause
great irritation and objectionable sloughs even with short exposures.
Clinical experience has shown the fallacy of this idea, if exposure is not
too long. Besides, the radium needles are inserted into moist tissues,
and the film of moisture surrounding the needles may be sufficient to
absorb the secondary rays and destructive beta rays. These needles
may sometimes remain in the growth for 24 hours, causing its retro-
gression and even disappearance, but no destruciton by sloughing.
Radium needle treatment should be administered in a hospital under
strictly sterile conditions with a trained nurse in attendance. No rule
can be given as to individual treatment, as each case is different, but
as a general rule, the needles placed in sarcomatous tissue 20 mm. apart
should be withdrawn in 12 hours. In carcinoma needles placed 25 mm.
apart should be withdrawn in 18 to 24 hours.
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SECTION XIII
RADIUM
A. Dangers of
B. Injurious Effects
United States Radium Corporation
New York
R a di u m
SECTION XIII
RADIUM
A. Dangers of
B. Injurious Effects
The Dangers of Penetrating Radiations and Means of Avoid-
ing Them.
André Broca, J. de radiol. et d'electrol., 5:414, Paris, Sept., 1921.
Radium emanation consists of positively charged particles, which
after they have lost their charge, form helium. As this gas is inert,
its so called toxicity can be due only to the penetrating rays which are
bound up with it, and which can reach considerable importance only in
an atmosphere charged with the emanation, which, being gaseous,
rapidly diffuses. It is probable that almost always, especially near min-
eral deposits, there is a certain harmless amount of emanation in the
air that we breathe. When the cause of the danger is thus known,
precautions can be taken : proper screening and ventilation are suffi-
cient protection to the personnel of institutions, whose health should
be further guarded by frequent blood counts and vacations. Persons
living in the neighborhood have nothing to fear.
Attendants should be careful never to touch the emanation tubes
except with forceps, and to keep at a safe distance. The current gen-
erated can be measured in milliamperes by a gold-leaf electroscopc
screened with metal. Attendants of persons who have just been
treated should not remain constantly nearer than 3 meters to the bed.
The danger is of the same degree of probability as that daily run by
physicians and nurses in the care of contagious diseases, and is really
inconsiderable if it is clearly understood and proper precautions are
taken.
Precautions for Radium Workers Against the Rays.
A. Félix, J. radiol. et d'électrol., 5 : 61, Paris, Feb. 1921.
There are two means generally employed for protection against
radium rays, first distance, which is very efficacious, and second, the
interposition of absorbing screens. Régaud and Ferroux have devised
a number of simple sorts of apparatus which give a maximum of con-
venience and security to the worker. There are continous pressure
pincers for holding the tubes, as well as pincers of another form for
the manipulation of the filter cases. There are also pincers for the
manipulation of the platinum needles. Cylindrical nickled copper cases
for carrying the bare tubes should be used, and these cases may be
carried by the dozen in nickled copper boxes lined with lead 3 mm. thick.
These boxes in their turn are placed in a leather sack or in a wooden
box fitted with a long strap which will keep the active tubes at least
25 cm. away from the hand in carrying them. To guard against the
danger of removing the tubes and arranging them for use, a table has
been devised for a single operator composed of two thicknesses of wood,
2 cm. each, with two sheets of lead, 1 cm. each, between the two pieces
of wood. In the middle of one side of the table, where the operator
is to sit, is a rectangular shield, also composed of 2 cm. of lead between
two thicknesses of wood. This shield is 40 cm. wide and 25 cm. high
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R a d i u m
:=e
The shield is placed vertically to the edge of the table and the operator
sits So that the shield protects his breast, hisarms passing in frontof itoneither
side so that he may manipulate the active apparatus on the table.
Thanks to this arrangement, the torso and lower limbs of the worker
are protected by the 2 cm. of lead from all the beta radiation and from
90% to 100% of the gamma radiation. Only the forearms and the head
are left unprotected. The table is very solidly constructed of oak. The
lead is covered first for reasons of cleanliness and second, the intense
secondary radiation produced by the lead might finally seriously injure
the skin of the arms. The worker should always keep in mind the im-
portance of the factor of distance, which is equally necessary, whether
the rays are well or slightly filtered.
Danger of Radium. Use of Protective Methods.
Bordier, Bull. de l'Academie de Méd. Paris, Mar. 1921.
It seems that radium submits those who handle it to graver dangers
than the x-ray. The knowledge of this danger is the more urgent,
inasmuch as no warning is given as is the case with the x-ray, by skin
lesions, particularly those of the hands. It is on the hematopoietic
organs that the radium rays act, and this in a surreptitious manner, to
the ignorance of the subject who does not feel any pain and finally ends
in grave trouble, even fatal pernicious anemia, as in the three cases of a
nurse, an attendant, and a laboratory boy. In these three cases the
number of red corpuscles had fallen respectively to 1,100,000, 800,000
and 527,000 per cubic millimeter. Anemia in the three cases was typi-
cally alike, existence of polynuclear leukopenia and complete absence of
regeneration signs. This anemia had all the characteristics produced
by toxic gases, like nitrotoluol.
The conclusions of the dangers of those who are exposed to radium
rays are based on laboratory experiments and the blood examination of
several attendants of both sexes in the Radium Institute.
Several rats were exposed to radium rays for different periods,
the femur marrow was then treated with eosin and methylene blue. It
was observed that the number of mitoses diminished neatly and fell
from 80 normal to 40, according to the duration of the irradiation. In
regard to the attendants, the examination of the blood furnished the
following: the majority present a notable diminishing in number of
red blood corpuscles comparative with blood of subjects living in same
building but not exposed to radium. These experiments show that the
very penetrative radium can have destructive action on the marrow of
the bones and the other hematopoietic organs. It is well to call the
attention of the radiologists to the danger of new x-ray bulbs; the
penetrative strength of these rays is daily becoming stronger and more
akin to that of radium rays, thereby submitting radiologists to dangers
of the same order as observed in the foregoing cases.
Radium Burn of the Vagina Resulting in an Ileo-Vaginal Fis-
tula.
T. W. Harvey, J. M. Soc. New Jersey, 17:418, 1920.
Mrs. D. aged 68. Twenty years ago had had a vaginal hysterec-
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tomy, and has had no local symptoms since then. In 1920 she began
to have a bloody vaginal discharge. Examination showed a small ulcer
on the hysterectomy scar in the vagina. As this did not yield to treat-
ment, Mrs. D. was sent to the Memorial Hospital. A section of the
ulcer showed that it was epithelioma and the application of radium was
advised. The reaction of the radium treatment was quite severe, but
the local symptoms disappeared with the exception of a slight vaginal
discharge.
About six weeks after the radium treatment, a fecal discharge
began to come from the vagina. This was very irritating and very pain-
ful. Exanmination showed that there was a normal middle scar with
a small perforation from which there exuded a discharge of the contents
of the small intestine. Operation set the patient right once more, and
she now has no local evidence of the disease, only the radium scar.
The accident of a fortuitous adhesion of the intestine to one side
of a scar, which became the seat of an epithelioma on the other side;
the burning by radium which penetraed the intestine and caused the
fistula; the disappearance of all signs of malignancy after the applica-
tion of the radium, these are the unusual features of this case.
Injuries. Due to Radium. Reports of Typical Cases and Rec-
onmendations for Prevention.
T. Ordway, Scient. Am. Suppl. , 81: 254, 1916.
The author reports in detail nine cases of injury to the fingers due
to the handling of radium and radio-active substances. The local
objective changes consist chiefly of flattening of the characteristic ridges,
thickening and scaling of the superficial layers of the skin and even
atrophy and intractable ulceration. These lesions are usually slight
compared with the marked subjective symptoms, such as paresthesia,
anesthesia of varying degree, tenderness, throbbing and even pain.
Various methods have been devised for avoiding these injurious
local effects, by the least possible contact of the fingers with the radium.
Forceps or special vises are used for holding tubes and Screwing in or
out the tips and eyes; special applicators in the form of metal boxes
have been constructed so that the active tubes may be added after the
filtration and protection have been arranged, and the surface applicator
is then slipped by forceps into a special rubber envelope and fastened
with adhesive. This is particularly to avoid wrapping them up by hand
in sheet rubber. Leaded gloves, fingers, etc. are clumsy and are not
readily worn.
In placing active tubes in special applicators, it will probably not
be possible to avoid all contact with radium, and as the effects are not
apparent at once, as when handling very hot objects, it will be difficult
to train a worker to avoid contact with the active apparatus.
In the work of making routine application of radium there should
be a routine in the staff, and persons affected should be freed, at least
temporarily, from such work.
Various general systemic symptoms and also blood changes mav
be produced by exposure to radio-active substances. In order to avoid
possible general disturbance, the body should be protected as far as
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possible by metal screens in form of boxes or plates about the radium;
there should be frequent ventilation of work-rooms, particularly if
radium emanation is present, and a change of duty, shorter hours and
periodic physical examination of those working with radio-active sub-
Stall CeS.
Lilliſill
OF MICHIGA
721 5838
164