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A M0MI1.Y JOURNAL DEVOTED TO THE CHEMIS­
TRY. PHYSICS AND THERAPEUTICS OF RADIUM
AND OTHER RADIO-ACTIVE SUBSTANCES
VOLUME SEVEN
APRIL 1916, TO SEPTEMBER, 1916
xa*
-v
PITTSBURGH, PA
1916

C O N T E N T S OF V O L U M E VII
NUMBER ONE. Page.
Arthur Burrows. A Report of the Manchester and District
Radium Institute from January 1st, 1915 to December
31st, 1915, 1
B. B. Boltwood. The Life of Radium 9
Reviews and Abstracts.
Evan O'Neill .Kane. Radium Therapy, 16
S. E." Sweitzer. Radium in Dermatology, 20
C. Everett #jejd. Radium. Its Physiochemica! Properties
Consider*!* with Relation to High Blood Pressure, 23
Guy

Walter C. Stevenson. A Method of Recording Radium Doses, 80
Richard Weil. The Treatment of Parotid Tumors by Radium, 86
James Ewing. Pathological Aspects of Some Problems of Experimental
Cancer Research 88
Howard A. Kelly. Some Radium Achievements, 88
Francis E. Park. The Treatment of Disease by Injections of
Deep-Sea Water and Radium, 91
F. J. Schoenberger and S. William Schapira. Application of
Radium in the Bladder for Carcinoma, with Report of Two
Cases, 94
NUMBER FOUR.
Henry Schmitz. Uterine Hemorrhages: with Special Reference
to Actinotherapy 97
Frederick Proescher. Conclusions Concerning the Value of
Radium-Therapy in Pernicious Anaemia, 102
Reviews and Abstracts.
Stephen Rushmore. Progress in Gynecology 110
NUMBER FIVE.
W. H. B. Aikins. Exophthalmic Goitre: with Special Reference
to the Etiology and Treatment with Radium, 113
Reviews and Abstracts.
H. K. Pancoast and William Alfred Sawyer. The Results of the
Use of Radium for Two Years at the University Hospital, 122
Henry Schmitz. The Action of Gamma Rays of Radium on
Deep-Seated Inoperable Cancers of the Pelvis, 124
Joseph B. Bissell. Bone Sarcoma Treated by Radium 126
NUMBER SIX.
Douglas C. Moriarta. Radium and Symptomatic Blood Pressure
129
Reviews and Abstracts.
Joseph B. Bissell. Special Radium Needles in Use at the
Radium Sanitarium of New York, 136
Frederick L. Hoffman. The Mortality from Cancer Through-
*^*=> out the World, 137
A_Howard C. Taylor. The Radical Operation for Carcinoma of
ISL> the Uterus, 140
.T^V. Martin. Radiotherapy in Cancer of the Uterus, 140
Clarence W. Lieb. The Nauheim Treatment as Given at the
Glen Springs, 143
383991

A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY, PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES.
Edited and Published by Charles H. Viol, Ph. D., and William H. Cameron, M. D.
with the assistance of collaborators working in the fields of
Radiochemlstry, Radioactivity and Radiumtherapy.
Subscription $2.50 per year, or 25 cents per copy in the United States and Canada
in all other countries $3.75 per year.
Address all communications to the Editors, Forbes and Meyran Avenues,
Pittsburgh, Pa.
VOL. VII. APRIL, 1916 No. 1
A REPORT OF THE WORK OF THE MANCHESTER
AND DISTRICT RADIUM INSTITUTE.*
THE ROYAL INFIRMARY. MANCHESTER.
From January 1st. 1915, to December 31st. 1915.
Arthur Burrows, M.D.. Radiologist of the Institute.
The greater part of the energies of a new department working
under complex conditions of inter-dependence with a number of different
hospitals must, in its first year, be spent in organization and getting tbe
machinery into running order. The scheme, however, seems now to
be fairly started, and the staffs of the constituent hospitals are doing
their best to make the Institute a success.
Owing chiefly to the war there have been difficulties in obtaining
certain parts of the necessary laboratory apparatus, but these difficulties
have been mostly overcome, and the physicist is now able to make all
the apparatus' essential for his own and for medical purposes.
The internal alterations effected in the building placed at the disposal
of the Committee by the Hoard of Management of the Manchester
Royal Infirmary have rendered the department convenient and compact.
Owing to the necessity of obtaining the best natural lighr possible for
the physical laboratory, it was necessary to make use of a somewhat
small room having a north aspect. While adapted for all ordinary
manipulations, it is felt that now that the routine has been fairly
established a research laboratory suitably equipped might with great
advantage be added to the Institute.
•In 1914. as a result of an appeal by the Dally Dispatch, a fund of ov*r
1150.000 was raised by public subscription for the purchase of radium ror use
In Ihe Manchester (England) and district hospitals. A gram of radium element
was secured and the committee appointed a radiologist. Dr. Burrows, and a
physicist. Mr. Lupton. to carry on the work. This work Is being carried on In
connection with the Cancer Research Laboratory, under Dr. Powell White and
his assistants.—Ed.

2 R A D I U M
The greater portion of the medical work of the department has
been the treatment of cancer in its various forms. This is qufte natural
when one considers the objects the founders of the Radium Fund had
in view; but it is hoped that in the near future the treatment of a number
of equally distressing, although not necessarily fatal, diseases will
be undertaken by the Institute.
A report on one, or even two, year's work must, owing to the
limited time which has elapsed, be an incomplete document, and all
results recorded and experiences gained regarded with extreme reserve.
The public are unfortunately prone to take an exaggerated view
of what radium treatment is able to accomplish and to raise up hopes
which cannot at present be realized, but steady work and improvement in
technique will undoubtedly tend to secure in the future a gradual improvement
in the results at present obtained.
In the treatment of cancer the difficulties remain many and grievous,
and until a sure method is devised of checking the formation of
secondary deposits, it will be possible in but few cases to claim cures.
The investigations of the Middlesex Hospital Cancer Research
Laboratories on carcinoma and sarcoma occurring in mice and rats have
suggested the possibility of producing immunity-to cancer by means of
radium, but no method of application or refinement of dosage has as
yet been devised which will produce this result with certainty in human
malignant disease. In a few cases the sudden and almost unexpected
disappearance of a tumour, or such signs of reaction as high temperature,
rapid pulse, &c, have suggested the formation of anti-bodies; but
this experience is uncommon, and for the present we must look more
for local than for general effects from radium treatment.
The practice of the London Radium Institute of treating only inoperable
cases of cancer has been followed. All cases of malignant
disease, except rodent ulcer, should, in the first instance, go to the
surgeon and his opinion concerning the advisability or non-advisability
of operation be accepted. Should he refuse to operate in a given case
treatment by means of radium or X-rays should be considered. In certain
border-line cases the use of radium may be advantageously combined
with operation. One of the cases of carcinoma of the tongue,
classified in Table I. under "prophylaxis," is an example of the value
of this method. When the tongue had been removed tubes of "emanation"
were inserted into suspicious situations. The patient is still well
six months after operation. One case of sarcoma of muscle was also
successfully dealt with by this method.
The department has carried on (he treatment of tumours by embedding
tubes of radium and radium emanation on a larger scale than
has, it is believed, been customary heretofore in tiiis country. In the
case of large and deep-seated tumours, the results obtained bv embedding
are as a whole better than those obtained by the application of
superficial flat plates. In a number of cases recorded in Table II. as
"improved," the primary growth has entirely disappeared. Thus much
pain and suffering have been saved, although secoudary deposits, many
of which have in their turn been diminished in sizfi' cur. have-disappeared,
have prevented the attainment of the result desired, ^he. case of carcinoma
of the colon.'which remains well at the end of this year, is a good
example of the value of this particular method. "'
Small tubes of emanation and occasionally of radium—the former
has many mechanical advantages—are employed for implantation. They

R a d i u m
r \< :' .'i •£ i> '
are contained in cylindrical metal-screens or filters to which silk threads
arc attached. The screens commonly employed are:—
(1) Tubes of silver, the walls of which are 1 mm. thick.
(2) Small tubes of platinum, the-walls of which are 3/10 mm.
thick. These are pointed and are of the type first devised and
used at the London Radium Institute.
(3) Stevenson and Joly's needles: these are of the bore of small
serum syringe needles. They are made of steel, and their
walls are three-tenths or four-tenths of a millimeter thick.
Originally they were left open at the ends and small emanation
tubes fixed in them by allowing heated paraffin wax to run
into their lumen by capillary action where it solidified as it
cooled.
A modification of the needle has been more generally used in the
department. Messrs. J. Woolley, Sons & Co., of Manchester, were able
to make, according to instructions, a needle, the pointed end of which
is solid and which can be screwed on or off. while the solid eyeleted
end can also be dealt with in the same manner. The emanation tube
can be introduced into the central cylindrical portion of the needle, while
the screwed-in ends obviate the use of wax. In the same easy manner
the emanation tube may be removed, and cleansing and boiling thoroughly
carried out. Emanation tubes are made in lengtihs to fit the cavities,
and there is no need to localize them once tlhey are in the needle. In
other respects the needle is identical with Stevenson's.
One or two other types of screen are occasionally used.
All doses of radium'are expressed in terms of radium element, and
the equivalent of emanation in "millicuries." This seems to be a more
rational method than employing the commercial standard of radium
bromide with its water of crystallization included, as the radium is the
source of the rays and these rays are Che agents employed in the usual
method of measurement, viz., by means of the electroscope. The
presence of other elements in combination thus becomes, except in a
limited sense, a matter of no importance.
The following observations were made during the year with regard
to the general facts to be borne in mind when burying tubes in growths
or when deciding if a case is or is not suitable for the same:—
(a) Thorough aseptic technique is as necessary as in general surgery,
because screened radium docs not have a markedly antiseptic
effect.
(&) Screens containing tubes of radium emanation may be boiled
since the internal pressure of the heated tubes is as a rule
well below that of the atmosphere. The boiling of tubes containing
radium salts is not worth while on account of the risk
of breakage.
(c) The object in radium treatment is to produce an adequate
and even distribution of the rays throughout a tumour. Thus
it is usually better to bury a number of weaker tubes in a
growth than to employ onestrong one for the same purpose.

R a d i u m
(rf) Accurate implacement of a tube in a growth is essential. It
usually happens, therefore; "that' it is better to make a large
incision and expose a tumour than to push tubes blindly through
a small cut in the skin. It is moreover safer.
(e) It may be ignorance, but it has rarely so far been found possible
to remove a cancer with one dose. This is a drawback which
time may cure. At present, however, too big a dose may produce
too violent a reaction with local necrosis of tissue.

R a d i u m
It usually seems, although conditions are so diverse that
it is difficult to judge, that if a dose be doubled less than half
,i. the previous exposure will be needed to produce the same
effect.
Speaking generally, tubes of 25 mcs. contained in screens
of silver 1 mm. thick, or platinum 3/10 mm. thick, placed in a
growth 2—3 cm. apart for twenty-four hours has been the most
usual treatment given at the department, but it is obvious that
every additional tube buried in a tumour must increase the total
radiation traversing any given point in the mass, so th,at the
aggregate dosage must always be considered. If we could find
out exactly the amount of radiation therapeutically needed per
cc. of a tumour, and an accurate method of estimating the
size of cancer growths, there would merely be left to the
physicist a mathematical calculation of the quantities to be
used to produce total absorption, and the use of a sufficient
number of tubes would remove the possibility of local overdose.
(i) In the treatment of malignant glands of the neck by means of
radium, careful attention should be give to the toilet of the
mouth. The presence of ulceration or of carious teeth may
lead to septic infection of neighboring glands which in combination
with enlargement of other glands, the result of the
existing malignancy, may produce on the introduction of a
radium tube definite abscess formation.
The majority of the cases treated during the year have been cases
of rodent ulcer, and of carcinoma of the breast, uterus, rectum, and
mouth.
The treatment of rodent ulcer continues to yield excellent results.
Short, unscreened exposures (1—3 hours) of strong plates of radium
arc still the best method of dealing with them. In fact, falling back
on the use of metal screens with longer applications is usually a sign
of failure; although such a treatment applied at the beginning may be
as successful as the unscreened method. Moreover it is unnecessary
and less economical. Stevenson's needles are of material assistance.
however, in clearing up certain ulcers with greatly thickened edges and
deep induration. In fact, many cases which would otherwise have been
regarded as hopeless have yielded perfect results following "needle"
treatment.
To carcinoma of the breast practically the whole of the general
remarks of this report apply. In a number of cases the primary
growth has been removed by radium, and individual secondary deposits
dealt with in the same way. Thus many of the painful and unpleasant
features of t£ie disease have been diminished, but usually a distant
metastasis has in the end placed the patient beyond hope. If the growth
be extremely large ^nd ^widespread the same state of inability to repair
is produced as in-the case of a nodule formed in an unfavorable position.
The treatment of carcinoma of the cervix of the uterus has. on the
whole, given good results. In dealing with such cases it has been
customary to give a general anaesthetic. In this way a tube of 50 mcs.

R a d i u m
of emanation contained in a screerf^ifs Mum. of silver may be placed
accurately in Che cervical canat. Usually its action is reinforced by
inserting emanation needles in distant infected regions or in thick
masses of the growth. Three or four small platinum tubes pushed into
the substance of the cervix will produce an equally good result, but the
method is not so economical. Fungating growths of the cervix yield
most readily to treatment, while deep excavating ulcers with thick edges
are less satisfactory. Invasion of the vaginal canal is an adverse sign.
Four cases remain apparently quite well at the end of the year, and
many more have had remarkable, relief or complete absence of symptoms
far six montihs or more. " .
Carcinoma of the rectum, owing to its situation, can only be treated
by passing tubes of radium into the lumen of the growth. The presence
of sensitive mucous membrane makes the use of a dense or thick screen
(1.5 to 2 mm. of lead covered by rubber to cut off secondary rays)
essential. For the most part the relief of symptoms is all that can be
looked for. In one case in which the growth was unilateral a tube
was introduced into the rectum and placed against its inner aspect,
while another was pushed up through the perineum to the other side
of the mass. In this way a cross-fire effect wras produced. Unfortunately
the patient did not submit to further examination, and no observation
could be made.
Carcinoma of the mouth and tongue still gives unfavorable results.
but one or two cases have done remarkably well. The only method of
treatment which gives the slightest hope of success is implantation of
tubes; external applications are practically useless. At present it is
undecided if emanation needles with steel walls of 3/10 mm. thickness
introduced into the growth for about twelve hours give better results
than large doses of 30—40 mc. of emanation contained in pointed
cylinders of platinum the walls of which are five-tenths mm. thick. If
rubes of platinum three-tenths mm. thick are used, 15 mc. of emanation
is quite a large enough dose.
Mr. Lupton reports that 585 emanation tubes. 257 emanation tubes
for needles, 232 flat emanation applicators, and six special applicators
wore made during the year in the physical laboratory.
N.B.—This does not include the number of permanent radium tubes
and plates.
During the past twelve months Drs. Powell, White, and Harris
have prepared and reported upon 50 sections of various growths- and
morbid tissues submitted to them for microscopic examination. A number
of other growths have also been examined at the Clinical Laboratories
of the various hospitals participating in the scheme.
CLASSIFIED RESULTS.
Table I.
Free of disease at end of year 45
Improved 187
Not improved 123
Abandoned treatment 43
Died from their diesase 61
Too early to note result ,, ,. 51
Prophylaxis 9
Total 510

-V
R a d i u m
TABLE II.
Classification of Cases.
Disease.
Carcinomatas :
2 2
Anus ,. .
?
0
M
a
|
+>
«
•0 •
>
*H O : ^
2
0 •« a*
| ii
0
II
< —
Breast. . . .
Bladder. . .
Cervix uteri
Colon
Ear Glands. . . , .
Jaw (upper)
Jaw (lower)
Larynx. . . .
Lip. Mouth-pharynx
Tongue
Tonsil
Naso-pharynx
Oesophagus
Orbit
Ovary
Paget's disease
4
1
2
1
I •
1
22 34
9
21? 1
2
3
l
— 1 1
2
17 12
11 4
1
! ii=
1 1 -
2 1
1
4
1
80
2
6 46
2
1 6
1 8
5
1
3
4
38
24
7
8
6
Parotid and sub-maxillary glands .j — 8
2
Penis
Perineum
—
| —
I 7
l
4
6
2
Rectum [ 3 1 2
4
Scrotum — I 8 2-1 —
1
Skin (nose, ear, face, etc.) 3 4 1
2
Spine
Stomach Total
Thyroid gland
Sarcomata :
Vulva Glands and vagina
Jaw Prophylaxis (upper)
Long bones. ...
Muscle
Naso-pharynx.
Orbit (bony) ..
Palate
I —
21
I 36 — I 91 1109 I 15 30 323 2
I 1 I t '
20
—
8
I 6
1 \9r~ 3
10
•1 ! — I 2
l 1 I ~
- I —
1 r —
Periosteal. . . .
Popliteal
Pleura
Retro-peritoneal.
Supra-renal
Ribs.
Testis
. . .
Tonsil
• _
—"
I —
—
-
1 -
1 I -
1 1
1 1 —
Prophylaxis
Total,
• •! 2
8 9 I 2 4 I 31
Rodent Ulcer I 8 I 12 \ 26 | 24
'Combined with operation.
I
2 73

8' R a d i u m
Classified Table of Cases. Table II.— (continued).
P1MM4
Malignant Tumours:
Endothelioma
Malignant glands
Lymphosarcoma
Melanotic sarcoma ....
Mediastinal tumour . ..
Prophylaxis. '
2i >
z
a.
B
o
Z
>
O
b
e.
E
s
a *.
ii
*. 5
o -a u
* c
I z
Total. 8 | — I 10
Benign Tumours:
Fibroid uterus
Fibroma of hand
Fibro-adenoma of parotid gland
.
Certain tumours of doubtful nature ! 2
Papilloma of bladder I —
Glioma of orbit I —
Myeloid sarcoma I —
Papilloma, hard palate f —
Myxoma I —
Kraurosis vulvae et vaginae \ —
Capillary naevi I 1
Cavernous naevi
Circoid aneurysm Total I 3
General and Skin Diseases,
Chronic Inflammation:
Arthritis deformans ! —
Exophthalmic goitre I —
Eczema, Chronic I —
Granulomata of skin I —
Hodgkin's disease I 1
Keloid and vicious cicatrix I —
Lymphatic leukaemia ' —
Lymphangitis j —
Lupus vulgaris i —
Lupus erythematosus I —
Mastitis (chronic) I —
Metritis (chronic) I —
Macroglossia I —
Mucous colitis I —
Myositis (chronic) ' —
Myeloid leukiemia (acute) I —
Oto-sclerosis ' —
Pruritus I —
Pigmented mote 1 —
Spring catarrh I —
Sinus (chronic Total suppurating) ...| I 1 8
Tuberculous glands • 1
Uterine haemorrhage I —
11
If
7
12
6
2
1
4 I 27
I

R a d i u m
THE LIFE OF RADIUM*
Prof. B. B. Boltwood. Ph.D.,
VALE UNIVERSITY.
The life of radium, or the length of time required for a given
quantity of radium to be transformed and converted into other elements,
is a physical magnitude of conderable importance and interest. Its
chief significance lies perhaps within the special field of radioactivity
where radium occupies a unique position in being the only highly
radioactive radio-element which possesses physical and chemical properties,
and occurs in a sufficiently high state of concentration, to permit
its being obtained in reasonable quantities in an isolated and purified
condition. For this reason radium is considered and accepted as a
standard or typical radioactive substance, and its physical and chemical
properties, including the value of its atonric weight, are known with
a considerable degree of precision. For some time in the future, therefore,
radium will occupy this position of relative importance and will
serve as the basis for calculation and comparison wilh other radio-elements
possessing less striking chemical individuality.
An accurate knowledge of the life of radium is also important in
the field of geology, because of a method which is available for estimating
the geological antiquity of some of the older rocks and minerals
The method is dependent on the determination of the progress of the
radioactive disintegration which has taken place in those minerals containing
appreciable proportions of uranium. For the accurate calculation
of these important magnitudes an exact knowledge of the rate of
disintegration of radium is essential.
It is possible, moreover, to obtain an estimate of the probable life
of radium by a calculation involving as its basis a number of other
important physical constants. These constants will be referred to more
specifically later. If a knowledge of the life of radium can be arrived
at by experimental methods not directly involving these constants, then,
if the results given by the different methods are in good agreement, there
is good reason for assuming that the accepted values for these constants
are not very different from the true values.
The disintegration of radioactive substances is of such a character
that the transformation of the substance into other elements can be expressed
by a law in which the rate of transformation is an exponential
function of the time. The rate of transformation is independent of the
amount of material undergoing disintegration and is independent of the
temperature, the pressure or of any other external condition to which
we can subject the radioactive substance. It proceeds in such a manner
that if half of the material present is transformed in a given period
of time, half the remaining quantity will be transformed in a subsequent
time of equal duration, and half the amount still left will undergo change
in the third equal interval. This will continue indefinitely until the
amount remaining will be too small to merit consideration. Since under
these conditions some of the atoms of the radio-element will have an
inappreciably short life, while others will have an inconceivably long one,
it is impossible to attach any special significance to the term "life of"
a radio-element except under certain definite restrictions. The life of
'Reprinted from Science. N. S. XLII, pp. S51-859. Dec. 17. 1915.

10 R a d i u m
a radio-element may therefore be somewhat dogmatically expressed in
terms of the time required for exactly one half of it to be transformed
into other substances. This constant is known as its "half-value period,''
and it is the half-value period of radium which particularly concerns
us at the present moment.
The first estimate of the probable life of radium was published by
Sir Ernest Rutherford in the first edition of his text-book "Radioactivity"
(Cambridge, 1904). In the disintegration theory proposed by
Rutherford and Soddy the assumption was made that the expulsion of
a-particles by radium and other radio-active substances was coincident
with the changes taking place on the disruption of the atoms,
namely, that the appearance of the a-particles was indicative of the
simultaneous breaking up of the atoms of the radio-element. Rutherford
further postulated the theory that each a-particle had its origin in the
disintegration of a single atom, or in other words, that each changing
atom gave rise to a single a-particle. if this assumption were correct,
then an estimate of the total number of a-particles emitted by any radioactive
substance would afford a basis for judging as to the number of
atoms which underwent transformation in any given period. From the
results of experiments by W'ien on the number of beta particles projected
from one gram of radium bromide, and from considerations based on
the ionization produced in a gas by the a-particles emitted by a known
quantity of radium, Rutherford reached the conclusion that one gram of
pure radium element expelled 2.5X10'° a-particles per second. From
data based on experimental evidence it was assumed that the number of
molecules in one cubic centimeter of hydrogen at standard pressure and
temperature was 3.6X1019. Taking the atomic weight of radium as
225 it was then calculated that there were 1.8X1021 atoms in 1 gram of
radium.1
If the total number of atoms present was 1.8X1021 and the number
transformed per second was 2.5X1010, then the fraction of the whole
undergoing change per second would be 1.4X10*11, and per year 4.4x10**.
This indicated that the half-value period of radium was about 1,500
years.2
Another estimate of the life of radium was made by-Rutherford
in the Bakerian lecture delivered before the Royal Society in May.
1904. Assuming that the heating effect, which had been observed and
measured by P Curie in radium salts, was due to the bombardment
of the salt by the a-particles emitted from the radium which it contained
and concluding that heat energy which appeared was derived
from the kinetic energy of the moving n-particles. Rutherford calculated
the kinetic energy of a single a-particle on the basis of the data then
available. This he found to be 6X10*6 erg per second. The heatingeffect
of about 100 gram calories per hour observed for one gram of
radium corresponded to 1.2X106 erg per second. Considering the
radium salt as containing four a-ray products (Ra. Ra Em. Ra A and
RaC) and assuming an equal distribution of the heating effect between
these, it therefore appeared that the number of a-particles expelled per
second per gram of radium itself (and therefore the number of atoms
of radium breaking up per second) was 5x10'°. Applying the same
line of reasoning as had been used in the first instance for deriving
1—An error was made In this calculation, and the correct number based on the
data used should have been 3.6yl0"'. This would have given 3,000 years fop
Ihe half-value period
2—See preceding footnote.

R a d i u m u
the mmiber of atoms in one gram of radium, Rutherford obtained the
value of 800 years for the half-value period of radium.3
In the year 1905 Rutherford4 performed an experiment in which
the electrical charge carried by the a-particles from a known quantity
of radium was measured. This was found to be equivalent to 4.07X10"9
ampere per second for the particles emitted by one gram of radium.
Assuming the charge on each particle to be the same in value but
opposite in sign to the charge carried by a single electron; viz.,
1.13X10'19 coulomb, this gave the number of a-particles per second
from one gram of radium as 6.2X1010. Estimating, in this case without
the previous error, the number of atoms in one gram of radium as
3.6X1031, the value obtained for the rate of change of radium corresponds
to a half-value period of about 1,300 years.
A new and more accurate determination of the deflection of the
a-particles from radium in a magnetic and an electric field was made
in 1906 by Rutherford.5 This gave a value of 5.1 XlO3 for the ratio of
the charge to the mass (e/m) of an a-particle. Since the value of elm
for. the hydrogen ion in the electrolysis of water is nearly 104, Rutherford
decided that of a number of possible explanations of these two
differing values, the most probable one was that the a-particle consisted
of an atom of the element helium (atomic weight 4) with a charge twice
that of the electron. If this assumption is introduced into the last
previously considered calculation of the life of radium, the number
for the half-value period comes out 2,600 years instead of 1,300 years.
In 1908 Rutherford and Geiger* devised an experiment in which
the actual number of a-particles emitted by a known quantity of radium
could be accurately counted. They also accurately measured the charge
carried by a known number of these particles, and demonstrated the
correctness of Rutherford's earlier assumption that the charge on a
single particle was twice that carried by a single electron. From the
counting experiments it was evident that the number of a-particles
emitted per second from one gram of radium was 3.57X1010. Tlhe
results of these experiments also gave data from which a more accurate
estimate could be made of the number of atoms in one gram of hydrogen,
viz., 6.2X1023. Using the numbers thus derived the magnitude of
the half-value period of radium was again calculated and found to be
1,690 years.
A direct determination of the rate of disintegration of radium by
measurements of the decrease in radioactivity of a given radium salt is
not practicable from an experimental standpoint. The rate of disintegration
is so relatively slow and the experimental difficulties of accurately
measuring the very small yearly decrease in the amount of radium
present are so insurmountable that this method of attacking the problem
is practically excluded. There is. however, a way in which a knowledge
of the life of radium can be obtained which depends upon very different
principles from those involved in calculations employed by Rutherford.
This method was first suggested and applied by the writer, and its
general principles can be briefly described as follows:
a^The error mentioned previously was repeated here, and the correct value
i—-me
r !•
crix*r
• ".__«_ii
nit>nn

12 R a d i u m
The work of Bolt wood, McCoy and others has conclusively demonstrated
that radium is a transition product in the radioactive disintegration
of the element uranium. The sources of radium consist solely of
old minerals containing uranium. In these natural compounds the
uranium has been undergoing transformation for long periods of time
and the products of its disintegration have been accumulating and have
been retained in association with the unchanged uranium in the mineral.
Now the nature of the successive changes occurring in radioactive substances
is such that, in any system such as that represented by a uranium
mineral, after sufficient time has elapsed a comparatively simple relation
will exist between the quantities of the different genetically connected
elements present. The condition finally attained is known as a state
of radioactive equilibrium. In this state a simple expression will define
the relative amounts of the different, related radio-elements contained
in the mineral, and. what is more important to our immediate interests,
a very simple relation will exist between the amounts of the different
radio-elements undergoing transformation in equal periods of time.
The rate of change of a radio-element is, so far as our knowledge
extends, an unalterable and unvarying factor. It may De* defined in
terms of the fraction of the whole amount of the element- present which
undergoes transformation in any convenient unit- of thnt;- a. year' for
example. This factor is called the constant of disintegraffens of the
radio-element. Its character is such that if P represenfsrthe mnrtber of
atoms of a radio-element initially present, e is the- base- of the natural
system of logarithms, t is the time expressed in the- chosen units, and x
is the disintegration constant; then the number of atoms. Pt of the
element which will remain unchanged after the expiration of an interval
t units from the start will be expressed by
Xow. in any radioactive system comprising a parent substance like
uranium and a series of disintegration products, including radium, for
example, when a state of radioactive equilibrium has been established
the conditions will be such that the number of atoms of each of the
radio-elements in the series which undergo change in a given interval
will be the same and equal. Thus if U be the number of atoms of
uranium and .i, be its constant of change, and if Ra be the number of
atoms of radium with a constant of change .i», then a,U = *JRa, and
this will also equal the product of the number of atoms of any other
radio-element in the series multiplied by iff disintegration constant. It
should be evident from these considerations that the quantity (number
of atoms) of radium formed in any given interval, will be equal to the
quantity (number of atoms) of radium which is transformed in
the same interval, an essential requirement to the postulated
condition of equilibrium. If. then, we can determine by experiment
the quantity of radium which is formed in such a system.
we- obtain through this a direct measure of the quantity of
radium which has changed to other elements during the observed
period, and if we know the amount of radium present in the system we
can determine the ratio of the two amounts which will be the disintegration
constant of the radium. If radium were formed directly from
uranium it would be easily possible to separate the uranium from a
quantity of mineral containing a known amount of radium, purifv it

Raditjm
from all but traces of radium, allow it to remain until measurable
amounts of radium had been produced within it, and then compare the
radium formed from the uranium with the radium present initially in
the mineral. This was attempted, but it was found that the rate of
production of radium was too slow to be determined with any accuracy
and was far less than was to be expected from theoretical considerations.
This obstacle was overcome when in 1907 the writer was able to separate
from uranium minerals a previously unidentified radio-element which
was intermediate between uranium and radium in the series of atomic
transformations, and which by its own disintegration produced radium
in readily measurable quantities. To this element the name "ionium"
was given. It thus became possible to separate the ionium from a
mineral containing a known amount of radium, and to determine the
rate of growth of radium in this ionium. This is a measure of the
rate of production of radium in the mineral and therefore a measure
of the rate of disintegration of the radium.
*—
i
edge
Jranuim
T.i.l J .
U00 CUMl
r rmwuii
Fra tton of Ur allium /
hang year
1
i Hi. OJO.CC
Figure 1
It' vrnJ^ltHljIfU
%
§ 1
: : £ • _ - :
P tO
— 4
The two diagrams (Figs. 1 and 2) will perhaps be useful in making
the general conditions and method of procedure more easily understood
to those without a technical knowledge of the subject. In the first
(Fig. 1) the amount of uranium changing per year relative to the total
13

14
R a d i u m
amount present is shown by two cubes whose volumes are proportional
to the number of atoms involved in the transformation. In the second
diagram (Fig. 2) the first cube on the left is supposed to be of the
Figure 2
fcfcw.
I
I i
i. .... ».—
same size as the smaller cube in the first figure. Since the constant
of change of ionium is as yet undetermined, it has been assumed for
convenience to be approximately the same as that of radium, and the
amount of ionium in the mineral is therefore indicated as of the same
order as the amount of radium. With this limitation, and omitting the
slight complications involved by the existence of branch products, like
actinium, and products of a rapid rate of change, like the emanation
and radium-A, the diagrams represent the general conditions and
changes to be found in an old7 uranium mineral. The chief relation
of interest shown by the diagram is that since the radium changing to
radio-lead can not be determined experimentally with sufficient exactness,
it is equally satisfactory and very much simpler to determine the
ionium changing to radium and compare its quantity with the total
amount of radium in the mineral. As a matter of fact the actual amounts
of radium involved in these two quantities need not be known, it is only
their relative values which are required, since the value of the disintegration
constant is determined by the ratio of one of these to the
other. In this respect the method is independent of any standard of
purity of radium preparations, an advantage which is not possessed by
other methods which have been used for attaching the problem. Thus.
for example, the estimate of the half-value period of radium made by
Rutherford and Geiger as a result of their experiments in 1908, had
to be altered from 1,760 years to 1.690 years, when in 1912 the present
international radium standard was adopted.
The results of a number of experiments conducted by the writer
according to the method just outlined were published in 1908. In the
most satisfactory of these experiments the mineral taken was a quantity
of pure, primary North Carolina uraninite, almost free from secondary
alteration products. About 40 grams of this material were used and the
ionium was separated (with the thorium, which has identical chemical
properties) by the ordinary analytical methods for the separation of
7 There are well known examples of minerals too young for a state of
equilibrium to have yet been reached between their radioactive constituents.

RAPITJM 15
thorium. The growth of radium in this preparation of ionium was then
measured over a period of 147 days, and a rate of change for radium
corresponding to a half-value period of 1,990 years was obtained. The
results of the other experiments were in fair agreement with this value,
which was assumed to be the most probable one. It is interesting to
point out that this estimate was made between the time of .Rutherford's
estimate of 2,600 years and Rutherford and Geiger's estimate of 1,760
years.
In view of the disagreement of the value obtained by the "growing"
experiment with the value as calculated from Rutherford and Geiger's
work, it was reasonable to suspect that in the "growing'' experiments
all of the ionium was not separated from the mineral. Such a suggestion
was, in fact, made subsequently by Rutherford. A careful investigation
of some of the conditions associated with the usual methods, employed
for the chemical separation of smaller portions of thorium from
large amounts of uranium, indicated that a complete separation of the
thorium under such conditions was extremely uncertain if not altogether
impossible. The chemical behavior of uranium and thorium is
strikingly similar: in the case of the uranous (UO.) salts the chemical
analogy of the two elements is such a close one as to make any separation
at all almost impossible. Since an incomplete separation of the
ionium would lead to too small a production of radium in the growing
experiments, under the assumption that the separation was complete
the calculated half-value period of radium would receive too high a
value. It was therefore highly desirable that the experiments should
be repeated under conditions which would avoid any uncertainty, and
which would give an altogether trustworthy value for the life of radium
as determined by this method.
This work was undertaken in the university year 1913-14 in my
laboratory by Miss Ellen Gleditsch, who came to this country from
Norway for a year of study on a fellowship of the American Scandinavian
Foundation. The work has been carried out in a very satisfactory
manner and. after encountering a number of difficulties, she
has quite recently completed her experiments at the University of
Kristiania. A paper by her on the subject will appear in the January
number of the American Journal of Science.
Miss Gleditsch carried out four separate operations, which may
be briefly described as follows:
The first was with a specimen of very pure North Carolina
uraninite weighing 110 grams and containing 2.46X10"S gram of radium.
The growth of radium from the ionium separated from this material
gave a value for the constant of change of 3.7X10"1 (per year), which
corresponds to a half-value period of 1.836 years. ...
T?he second was with a specimen of Norwegian uraninite known
as Cleveite. weighing 180 grams and containing 3.2X10"5 gram of
radium. The ionium separated from this material grew radium at a
rate corresponding to a value for the constant of 3.9X10'4 and a ha.lfvalue
period of 1,780 years.
The third was with a specimen of Norwegian uraninite of the
variety known as Broggcrite. weighing 200 grams and containing
41X10'4 gram of radium. In this experiment the radium grew at a
rate corresponding to 4.2X1Q-4 for the value of the constant and indicated
a half-value period of 1.640 years.
In the fourth experiment a specimen of very pure Broggente was

16 R a d i u m
used, weighing 100 grams and containing 2.1 XlO"5 gram of radium.
The value obtained for the constant of change of radium was 4.1 XlO"4
and the half value period corresponds to approximately 1,670 years.
In this series of experiments the methods for effecting a complete
separation of the ionium were progressively developed and improved.
In the last two, the ones in which broggerite was used, there were
definite indications that a complete separation had been accomplished.
Moreover, Miss Gleditsch also measured the amount of radium in one
of my original ionium solutions in which the ladium had been growing
for a period of nearly seven years and found that the rate of growth
had been constant throughout the entire interval. This fact disposes
of the possible objection that the life of ionium is too short to give an
accurate value for the constant of radium as determined by this
method.
It is therefore apparent that the different methods which have been
used for esitmating the life of radium give results which are in excellent
agreement with one another. This agreement increases the assurance
with which the estimated values of certain important physical constants
involved in the calculation can be accepted as approximating closely to
the true values. As a matter of interest these constants will be mentioned.
Number of a-particles emitted per second by one gram of radium
(element) = 3.S7X 10w.
The charge carried by a hydrogen ion in electrolysis = 4.65X10"10
E.S. units.
The number of atoms in one gram of hydrogen = 6.2X1023.
The mass of the hydrogen atom = 1.61 XlO'24 gram.
The number of molecules in one cubic centinfeter of any gas at
standard pressure and temperature = 2.72X10'9.
The volume of the radium emanation in equilibrium with one gram
of radium = 0.62 cu. mm. calculated. =0.63 cu. mm. found.
The rate of production of helium per year per gram of radium
= 163 cu. mm. calculated. = 164 cu. mm. found.
Reviews and Abstracts.
Evan O'Neill Kane. M.D. (Kane, Pa.) Radium Therapy. Abstract
of a paper read at the Annual Meeting of the Elk County Medical
Society, January 13, 1916. "While the radium subject has been of
interest to me for some time, and while I had had it directly under
observation as it was employed by Doctors Burnam and Kelly, of Baltimore,
and Doctor Lee, of Rochester, I did not possess any myself until
about seven months ago."
"I have treated forty-three cases of cancer, with four deaths, and
employed radium for other conditions for about as many patients. We
all have our share of unfortunate incurable cancer cases to deal with.
I have certainly had mine, and last winter I was satisfied that more
than my share fell to my lot. It was one of these which drove me to
my purchase of radium. The case was one of cancer of the uterus with
involvement of both ligaments, bladder and rectum. I had been asked

R a d i u m i7
by a brother practitioner to remove the uterus despite the fact that the
termination of the case must be hopeless, trusting that thereby temporary
relief, at all events, would be afforded. As often happens in these cases,
an apparently complete recovery took place, pain being relieved, and the
patient regaining her former strength, cheerfulness and usefulness. It
was acutely distressing to realize that she must die, especially as she
put complete trust in me and showered me with grateful expressions
for saving her life. As the disease began to make itself apparent again,
with renewed activities in bladder and pelvic walls, I was so distressed
that I hated to visit her. The truth had to come, and I had to break it;
we all know how painful that is. I looked about in desperation for
some quasi-assurance of relief to take off from the poignancy of her
grief on learning her true condition. Having talked with her husband
and receiving his consent, I told her that I had observed that Dr. Lee,
of Rochester, was apparently making remarkable cures with radium in
such cases as hers, and suggested her going to him. Of course she
consented and went. She remained in his sanitarium but one week,
and two weeks later came to me for examination. To my astonishment
the entire cancer mass had vanished. There was not a vestige of it to
be discovered. Vaginal vault, bladder and rectum were soft, flexible,
and apparently sound, and no lymphatic enlargements or cellulitic cakings
could be detected anywhere. She was entirely free from pain, well and
happy. It seemed to me miraculous, and precipitated my purchase of
radium."
"To anticipate your question as to what next in this case, I will go
on and tell you the truth and the whole truth. Three months' of freedom
from pain elapsed, and then she came to me complaining of pain far
back in the sacral region—something like a dull backache. Vaginal
examination disclosed a suspicious hardening well up and back towards
the sacro-iliac junction, not as large as a hazel-nut. I again sent her
to Dr. Lee, who returned her to me after having melted this new formation
away with his radium as satisfactorily as before. A month later,
however, she began to have trouble with her bowels, vague pains, gas
trouble, and constipation alternating with diarrhea. She commenced
to lose flesh and show signs of stomach indigestion, eructation, vomiting
and the like. Complaining of constant pain at her appendix, I
thought this might be the* cause, operated, and found the lower abdomen,
and even as high as the umbilicus, studded everywhere with metastatic
beads, proving a general cancerous infection. A little later rectum.
vagina and bladder became the seat of renewed malignancy,—and so
the old story was told anew, of death from cancer."
"I cite this case in full not merely to show you why I purchased
radium so hastily, but because I wish to give you in fairness an example
of the cases in which radium docs not cure."
"One case, referred to me by Dr. Smith, of Johnsontown, of cancer
of the rectum, is, I think, still in a doubtful condition, but I have not heard
from him recently. In this instance, however, the cancer mass, which
filled the entire rectum, involving, also, the anus and extending out well
towards the ischial tuberosities, was so extensive as to make it appear
out of the question to do anything. Yet, within a month after treatment
was begun, no cancer masses were discoverable anywhere. The
radium burns, however, were extensive, and in order to institute the
treatment properly I had been forced to make an inguinal colotomy. The
discomfort from this, as well as from the burns, was considerable when

is R a d i u m
I last saw him, about six weeks ago, and made it impossible for me to
say positively whether cancer trouble further back might not still be
present. He was, however, far better off than before he came under
treatment."
"Now, as for my successful cases, time will not permit my going
into detail with all of them. I will mention, however, the most striking.
Five of these were inoperable cases of cancer of the uterus, with involvement
of broad ligaments, bladder and rectum; and four cases in which,
the cervix was involved, with suspicion of the body being also, but in
which there was no discoverable evidence of extension further. All
appear to have recovered entirely, and have regained flesh and strength,
—are looking and feeling well. Five are cases of face cancer, in three
of which there was involvement of the lymphatic glands of either temple,
neck or jaw. Two of these are still under treatment, but appear to be
rapidly recovering. The others seem entirely well. One of the face
cancers, sent me also, by Dr. Smith, was of the lower lip with some
glandular involvement just below the jaw. One case of cancer of the
tongue, tonsil, soft and hard palate, with extension to the glands of
the neck, referred to me recently through Dr. Glenn, of Bradford, has
only been under treatment about six weeks. In this case the glandular
mass in the neck, which was very large, has melted down to one-third its
size. While the burns in the mouth are painful, the tonsil involvement
and original tongue cancer, have •melted away so much that the man
can now swallow with reasonable comfort, and talks fairly intelligibly,
while at first both talking and swallowing seemed painfully difficult.
How far he will continue to improve I cannot say."
"A case of cancer of the tonsil, involving the palate, root of the
tongue and much of the upper pharynx, referred to me by Dr. Balmer,
of Brookville, had been declared inoperable by Crile, and was also a
severe diabetic. Under radium he made an apparently complete recovery,
being enabled to return to his business in Washington. I have
heard recently that he is ill, but I presume that is from his diabetes, for
which he had several times, before coming to me. had to resort to sanatarium
treatment."
"A very interesting case still under treatment, or rather observation
after treatment, and certainly a very rare one. is that of an old man
in his 103rd year. This patient has a large cancer of the orbit, with
extension to the lymphatics of the temple. The cavity was eaten out
so deeply as to suggest that the eye had totally disappeared. Examination,
however, proved that this organ had shrunken into a small lump
and been drawn by tissue contration in under the inner border of the
orbit. The cancer had existed between 18 and 20 years, and had, at the
time I took charge of the case, become so painful as to require the
nightly use of anodynes. Dr. Briggs. of Tidioute. who referred the
subject to me, did not expect that I could do much, if anything, for
him; but, knowing that I was interested in cancers, wrote me that he
thought the case worth my visiting in the light of a curiosity. I began
treatment promptly, subjecting not only the cavity to radium, but also
the nodular involvement on the temple. The first gratifying results were
the cessation of pain, no further opiates being needed, and the restoration
of sound and natural sleep. The side of the face swelled dreadfully,
becoming edematous and purple. I feared that, his age being
great, he would not have sufficient vitality to outlive the radium reaction,
which is violent. It took him a long time, but the reaction has

R a d i u m
entirely passed away. The nodular extension in the temple has disappeared,
the orbital cavity is filling with apparently healthy granulations,
and a healthy contraction of the whole area is taking place, with
adhesions of the marginal skin to the granulations wherever they reach
its border. Thus far, however, no distinct epithelial proliferation has
commenced. Whether this is possible at so advanced an age I am not
aware. I am preparing, if he continues to favor me by living, to place
skin grafts from a young subject in the filled up crater. In this instance
I am satisfied that I have cured the cancer, but whether it is possible
to bring about a healthy healing remains to be seen." Note Feb. 2nd,
1916. "This case has now so far improved as to now have the raw
tissue rapidly skinning over. This seems marvelous at any age to say
nothing of one-hundred and three!"
"More satisfactory to me than the treatment of my cancer cases
has been that of uterine fibroids. Several authorities, I observe, claim
that but 75% of uterine fibroids are amenable to treatment with radium.
Thus far all mine, njne in number, appear to be on the mend. All but
one of these were, in addition, ugly cases of flowing. Flowing in every
instance was entirely checked, and the fibroids have been steadily reducing
in size, so that I feel satisfied that operation will be unnecessary.
In several other instances, with flowing, but without demonstrable
fibroids, the hemorrhage has been satisfactorily checked."
"I had hoped to treat a large number of goitres with radium, supposing
that patients would prefer this mode of removal to operation,
and having seen some very gratifying work done by others. I have not
had, however, in all more than eight or ten subjects willing to allow me
to employ the radium treatment, nor have these been long enough under
observation to be worthy of report. I must say, however, that they
all seem to be improving,—that is, a reduction in size of the gland has
in every instance taken place. I have only one case of exophthalmic goitre
under treatment, and -this but six weeks. The pulse rate is markedly
reduced, the nervous tremor has disappeared, and the patient admits
herself to be feeling better."
"The lighter superficial work with radium placques on skin cases
appears to open a field of wide use for smaller amounts of radium. I
had admirable results in curing a large port-wine stain birthmark of the
arm by a 10 milligram radium placque; and have also cured a large
vascular naevus of the nose and lip in a baby with the same placque.
Warts, moles and keloids are entirely removed by it. The keloids, however,
require a number of treatments, and I question whether the moles
and Warts are not as well and more rapidly removed by trichloracetic
acid. The latter agent, however, has the objection of being painful."
"You may ask, "Does radium treatment occasion any pain?" No,
not during the treatment, nor often for weeks—sometimes four or five—
thereafter. Then there is frequently a sharp reaction, a burn resulting
even after screening. There is also a constitutional reaction in many
instances where a deep malignant growth has been subjected to prolonged
treatment."
"How do the burns get along?" Usually they heal rapidly and
occasion a surprisingly small amount of pain or discomfort, but in a
few instances (three in my brief experience) a deep scirrus-likc sloughing
ulcer results, which is slow and painful in healing. I am told these
are due to over-radiation, and could be avoided if one had not been unduly
hasty."
19

20 R a d i u m
"What is the probable proportion of permanent cures as compared
with relapses? I am not in a position personally to answer this, but
as a large proportion of the subjects treated have been already allowed
to pass into the cancer cachexia stage, I should presume that the number
of relapses will be found to largely outnumber the permanent cures.
At the same time, no one who has experienced the satisfaction of
employing radium will, I am sure, ever be satisfied to do without it."
"Shall radium be employed in conjunction with the knife before or
after it when dealing with malignant neoplasms? Surgeons, as a rule, if
they admit the efficacy of radium at all, claim that it should only be
employed as an adjunct to the knife. I thought so at first, but begin
to question seriously the correctness of this opinion. If one can be
sure that his knife has gone well beyond the area of contamination he
may with propriety operate, thus removing center and circumference.
the whole source of mischief. Thereafter, indeed, radium may be
employed to ray the outlying tissues and purge them of any possible
undetected secondary centers. It might, on occasion, be justifiable to
use radium in these same areas before resorting to the knife in order
to build up a barrier of cancer resistance. These may be reasonable
assumptions, but. as a rule. I believe it will be ultimately admitted that
if radium has, as we radium workers believe, a selective action directed
against cancer cells and their development it should be given a first place
in the treatment of malignant disease, and thereafter the knife employed
only as a dernier resort."
"The obvious objection to the knife in dealing with cancers has been
clearly demonstrated by Dr. Percy of Galesburg. in his heat treatment
of malignant diseases. He has shown beyond question that the knife
stirs up and drives into the lymphatic and blood stream the cancer cells.
against which nature has been previously able to oppose at least a partial
barrier of resistance. As a result extensions and metastases take place
with alarming rapidity in the majority of cases. Percy, therefore, condemns
the cold knife in toto. saying that if operation must be resorted
to it should be only by a knife heated to redness, that it may cook the
tissues through which it passes before dividing them, thus continuously
setting before it a defense against cancerous progress. His theory has been
borne out by practice, and he has obtained remarkable results. On the
same principle radium, and, to a certain extent, the X-rays can do for
cancer what Percy's heat treatment does, only. I believe, with less danger
from destruction of tissues, as well as with less pain."
S. E. Sweitzer. M.D. (Minneapolis). Radium in Dermatology.
The Journal-Lancet, Vol. XXXV, N'o. 24. pp. 679-83. "Radium was
first used in dermatological work. The use of the ravs was brought
about by Becquerel. who put a tube of radium in his pocket, and a
burn resulted. This drew attention to its action upon the skin, and
Professor Curie gave a quantity to M. Danlos. of the Hospital St.
Louis, and experiments were begun upon cutaneous therapy."
"Radium occurs in nature associated with barium. The radium
element itself is very difficult to obtain alone; and therefore it is used
in the form of a radium barium salt."

R a d i u m 21
"For cutaneous work radium is used in flat varnish-applicators,
which have a metallic back, and arc usually square. The radium is
evenly distributed over the surface, and covered with a varnish. These
applicators are prepared in full strength, half strength, and quarter
strength. A full-strength applicator contains 5.4 mgm. of radium
element per square centimeter of surface; a half-strength applicator
contains 2.7 milligrams of radium element per square centimeter of
surface, and a quarter-strength contains 1.35 milligrams per square
centimeter. I have found a half-strength applicator containing 10 milligrams
of radium element most serviceable for general cutaneous use."
"It is important to know how much radium is used, how screened,
the length of time used, and the total time used. Merely to say that
'I cured: a Roentgen-ray carcinoma with radium,' as has recently been
done, not stating the amount used or the time applied, is of little help
to others. Generally speaking, when a large quantity of radium is used
a shorter time is necessary to produce a given effect than if a small
quantity, is used."
"Radiunr gives off alpha, beta and gamma rays. The alpha rays
are cut off by the varnish in the applicator. We use the beta and gamma
rays. The gamma rays are many times more penetrating than the
ordinary Roentgen ray, but the new Coolidge tube gives off rays that
approximate thcgamma rays of radium."
"It has been* found that using the radium without any screen or
filter is irritating to the skin, and may produce telangiectasis; and therefore
we interpose filters of different metals in varying degrees of
thickness, according to what extent of rays1 we wish to cut out. As the
radium in contact with these various metals causes them to give off
secondary rays, which are irritating to the skin, we cover these screens,
or filters, with several layers of black photographic paper, and outside
of this a piece of rubber dental dam."
"In order to protect the healthy skin, if the lesion is smaller than
the applicator, I use about five or six thicknesses of ordinary lead foil,
and cut it out to fit the lesion to be treated. A piece of dental dam is
placed under the lead next to the skin to avoid the secondary rays.
I hold the protector on by means of adhesive strips, and then place the
radium over the lesion and fasten it with adhesive."
"When radium is used on the skin, we get reactions of varying
degrees of intensity, such as (1) simple erythema; (2) erythema fol-
•ved by desquamation; (3) vesiculation with superficial ulceration
(4) deep ulceration with the formation of a scar. These reactions
depend upon the amount of radium used, and the filter and the length
of time used. Pusey says that the manifestations of a radium reaction
are first seen in the endothelium of the superficial vessels, almost a«
soon as in the epithelium of the glands of the skin; then in the deeper
epithelial layer; and, finally, in the connective-tissue structure of the
skin. It exerts a selective action upon diseased cells; and in this manner
they are destroyed, and the healthy cells left."
"Radium has been used in a large number of skin diseases. I will
touch upon its use in pigmentated and capillary nevi. lupus erythematosus,
and epithelioma, as I have found it especially valuable in these
conditions."
"In raised pigmented nevi a do.-e sufficient to produce a slight
crusting is used. I use a ten-milligram applicator screened with 0.1 mm.
silver for thirty minutes. This can be done two or three times with
two-day intervals."

22 R a d i u m
"In capillary nevi I Use a screen of .01 mm. of aluminium, giving
applications of fifteen to twenty minutes. After the reaction is over, this
can be repeated until the desired result is obtained. In a few cavernous
angiomata of children I have proceeded with a screen of 01 mm. silver,
using about the same dosage as for the elevated pigmented nevi. In
general, I have found the cosmetic results excellent. It must be remembered,
however, that we must make haste slowly; and many months
must elapse before a cure is completed. Too large or insufficiently
screened doses will produce a white scar, instead of normal-looking
skin."
"CA6E-REPORTS OF TWO CURED CASES."
"Case 1.—Baby L., aged 3 months,, Angioma the size of a marble
on the right cheek. November 9, 1914, radium screened with black paper
(I was unable to obtain the .01 mm. aluminum filter at that time) used
for 20 miruites. A slight reaction resulted, and some flattening occurred.
November '30, 1914, the same screening, radium used for 30 minutes,
with slight reaction and shrinking. January 11 and January 1,5, 1915.
I used'a O.T'mm. silver filter for 30 minutes. February 26, 1915, the
same dose was given. Seen on April 6, 1915, the result was fine."
"Case 2.—Baby Lundquist, aged 3 months. Large elevated pigmented
nevus behind the right ear. November 4, 1914. radium 10
minutes; November 21, 30 minutes; December 29, 30 minutes; February
24, 1915, 35 minutes."
"These were all screened with black paper. April 12, 14. 16. 1915.
radium was used for 30 minutes with a screen of 0.1 mm. siver. On
May 21, 1915, the baby was seen and the result was excellent."
"Lupus erythematosus is a most intractable disease; and numberless
remedies have been recommended in its treatment."
"Simpson reports a number of cases treated with radium with
excellent results. I have treated only a few cases. One is nearly
cured atthe present time, and the others are too recent to report results.
It does not prevent recurrences; but in favorable cases good results
may be expected."
''It is necessary to use destructive doses; and filtering is indicated
to prevent excessive reactions. I use a 0.1 mm. silver filter, and ray one
hour a day for five or six days. It is often necessary to repeat this
dose; and sometimes I have found it better to use radium unscreened
in cases that are very intractable. My results have been promising, but
the treatment is of necessity very tedious."
"Epithelioma, as is well known, responds beautifully to radium,
often curing where the Roentgen rays have failed. I first treated these
cases with radium unscreened; but I have found a deeper penetration
and less reaction by using a 0.1 mm. silver screen, and ray for one or
two hours a day for a total of eight or ten hours. My results have
been most excellent."
"A CASE OF KPtTHEMOMA."
"One of my early and most interesting cases was Mr. M„ aged 77.
He had an extensive rapidly growing epithelioma on the left side of
the nose, the left cheek, and the upper lip. It was not an operable
case."
"In October, 1914, I gave him an unscreened exposure of an hour
a day for four days. It required three applications of the radium at
each sitting to go over the lesion. In five weeks this was repeated; and

R a d i u m 23
in January, 1915, one small spot was still active, and therefore I used
a 0.1 mm. silver screen, and gave an exposure of seven hours. To date
he has remained well and the cosmetic result is all that we could ask
for. I would treat such a case now entirely with a screen, in order to
limit the reaction."
"CONCLUSIONS."
"I. Radium has a definite value in the treatment of certain skin
conditions."
"2. It is easily controlled, and is of accurate dosage."
"3. Its application is unattended by pain, and is very pleasing
to the patients, especially the young and very old."
"4. The cosmetic results are excellent."
C. Everett Field, M.D. (New York). Radium, Its Physiochemical
Properties Considered with Relation to High Blood Pressure. Medical
Record, Vol. 89, pp. 135-139, January 22, 1916. Presented before the
Washington Heights Medical Society, at New York, November 23,
1915.
"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 a,nd' new
an element. The theories relating to the causative features of high blood
pressure are many; but for our immediate need we care nptrto 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 fn the flow of the blood stream, for we may content.ourselves
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 arc exact and the physiological and biological
manifestations that follow must to a similar degree, be definite. Therefore
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 resistance
is reduced. A factor that by some has been discounted is the viscosity
of the blood; yet a change in type exerts an enormous influence of 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 arc the outcome of the influence of radium on
the various ferments that may be disordered."
"I am frequently asked the question. 'Just what can we hope for
clinically?' 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
development of a nephritis. Indeed, I feel that there is a reason to
believe that Bright's disease as a symptom may be wiped out. When
nephritis and cardiac lesions are advanced, the pathological processes

24 R a d i u m
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."
"Administration.—Radium may be administered by means of emanation
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. Whereever
dosage in micrograms of radium salts is quoted it refers to radium
element. Radium has absolutely no toxic effects, it being accepted as
harmoniously by the human system as is sunlight by the plant. The
classification of clinical and dosage data reported by Rowntree and
Baetjer is of considerable worth. Dosage in radioactive or emanation
water is being used in variation of from 1000 to 1,000,000 mache units,
and the pure radium element in the form of radium chloride has been
administered intravenously in dosage as high as 1000 micrograms or
the equivalent of 2.700.000 mache units in one dose without any untoward
effects. With radioactive waters, von Noorden found but little
results until his dosage of water approximated 20,000 mache units daily.
The usual dose of radioactive or emanation waler used by the London
Radium Institute gives a minimum of 250.000 mache units daily and a
maniixum of 1,000.000 mache units. Procscher and Cameron have made
over 2000 intravenous injections of radium chloride in doses averaging
50 micrograms, and my personal observations cover the administration
of over §00 similar treatments, and I find no report of any unpleasant
effects. That radium is not permanently deposited, and that it is finally
eliminated from the system is well covered in a research by Seil. Viol.
and Gordon, who showed the character of complete elimination and its
duration in the human. Most interesting researchis-now being done 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 intravenous injection of radium chloride it can be traced in
the blood at least twelve weeks thereafter. Some of the earliest of
injections of radium element were made by Brill. Falta. Freund. Zehner.
and von Xoorden. The latter reported no disturbing effects and urged
larger doses and deeper study."
"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. 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 my usual plan to give an injection
of one 25-microgram (radium chloride) ampulle (2 cc. normal saline
solution), and following with a solution of distilled water. 2 oz.. containing
2 micrograms of radium, 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 arc prompt. I never accept a case
for less than twelve to sixteen weeks' treatment and observation. Careful
histories of the laboratory findings are always to be made. The

R a d i u m J3
patient may or may not be placed on diet and other rules of hygiene
as may seem indicted. In private cases I would of course observe the
above, in others I have 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 distress, vertigo, and headache
disappear in many cases within a few days."
"Where radium solutions per os alone are given, my 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
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
tlesired. 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 I can reply that fully threefourths
of the cases have held without further treatment for from six
to twelve months. There are many of the early case? treated nearly two
years ago that have suffered no material rise. Others where pressure
has gone up sufficient 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 a large number of my 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 unfavorable
action following the administration of the soluble salts of radium, I
would naturally urge caution in attempting sudden reductions in compensatory
high pressures. Here must come a full understanding as to
the type of compensation. For the purpose of this paper I have intentionally
refrained from dealing with compensatory cases and my selection
has been in 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.
"The following case histories, selected from the group, although
reported with limited detail. I trust will serve to illustrate everyday
types with results that should be indicative.- Almost all of these cases
had received general treatment for a greater or lesser period and
were classed as well advanced. In the entire series there were but
eight cases that failed to respond and three of these were single-treatment
patients. Several of the cases herein reported are one-treat"

26 R A D I U M
rrtent types. Such a method, without follow-up dosage, is not advised,
but the final results are none the less interesting."
"There is an opportunity of vast'importance here waiting for the
real research worker to pick up the thread and trace the terminal
activities and results as they may relate to the physiochemical properties
of radium in catalysis and autolysis. Beyond giving treatment to the
active case, we are now called upon to give attention to those measures
of prevention which will enable those advancing to the fifth and sixth
decade to grow old gracefully."
"Case I.—Mrs. R. H., aet. 67. Previous history one of health.
Called for treatment following prolonged spell of vertigo—thought by
family to be a slight stroke—pressure 220 mm. Had complained of
distress around heart. No compensatory influences. Brisk cathartic
followed by 50 megm. radium intravenously. Twenty-four hours later
pressure 180 mm. Four days later back to 200 mm. A second injection
of 50 megm. given on tenth day reduced pressure to 175 mm. Under
the influence of 6 megm. per week in divided doses for eight weeks pressure
fluctuated between 160 mm. and 170 mm. It is interesting to note
that the patient's waist measurement after ten weeks had reduced seven
inches."
"Case II.—Mr.-P. R.. broker, aet.* 58. Suffered from trifacial
neuralgia for eighteen months. Had received all treatments including
injections of alcohol in the nerve sheath. Pressure 175 mm. Limited
arteriosclerosis, nervous. loss of memory, exceedingly poor digestion,
excessive intestinal fermentation. Two injections five days apart of 50
megm. each'were given. Final-pressure taken four weeks after first
injection showed 140 mm. Pain subsided to the point of almost entire
freedom. However, during the eighteen months that have passed at
times there is a slight tinge of pain that reminds him that- there is still
some small influence at work."
"Case III.—Mrs. L. M., aet. 50. History of chronic nephritis of
ten years' standing. Cardiac hypertrophy. Blood pressure 200 mm.
Marked edema of lower extremities, shortness of breath. Had been on
rigid diet fo.r five years. Headaches constant. Rheumatoid pains and
some arteriosclerosis. This patient was treated with radium solutions,
for drinking only, on a dosage of 2 megm. t.i.d. for ten days, then 2
megm. per day for two weeks. But little influence was shown on the
pressure for nearly three weeks, although the patient's breathing was
much improved and the edema was less. Increased her exercise. Treat*
me nt was carried on for ten weeks longer, on a dosage of 6 megm.
weekly and. then discontinued. Gradual decrease in pressure to 170
mm. Six months have elapsed and patient.has had no .disturbing
symptoms."
"Case IV.—Mrs. M.. aet. 60. Pressure 180 mm. Consulted for
arteriosclerosis in early stage. Characteristic symptoms. Had had
operation for gall-bladder trouble. Years of gastrointestinal fermentation.
Radium solution only advised. In five weeks took 102 megm.
of radium. Discontinued on account of marked general improvement
in vitality. Digestive processes improved."
"Case V.—Mr. T. S., literary man, aet. 67. Pressure 165 mm.
Evidence' of early arteriosclerosis, insomnia; precordial distress, with
evidences of cardiac load; exhaustion on slight effort. On request was
placed on radioactive waters in dosage of about 15.000 mache units
daily. After three weeks reported with great improvement. Com-

R a d i u m 27
plexion clear, eyes bright, ready* for^e&ercisc and remarked that he did
not know he had a heart. I^essure reduction about 15 mm."
"Case VI.—Mrs. E. B., aet:'-6L—-Had suffered from neurasthenia
more or less for eight years. Haa. been treated for "nervous 4ieart."
Commonly complained of much gas formation after eating. Pressure
170 mm. Pulse 90. Heart 'slight ' hypertropied. Complained of
smothering sensation over heart. Rheumatic tendency with a" borderline
on gout. Intravenous treatment could not be given. Under administration
of 28 megm. per week in form of drinking solution most
of the troublesome symptoms disappeared, but up to the fifth week,
when all treatment was discontinued, there was practically no change in
the blood pressure."
"Case VII.—Mrs. E., aet. 67. Rheumatoid arthritis. Case of advanced
stage. Pressure of 175 mm. Arteriosclerosis advanced with
all active symptoms, most trouble asthmatic tendency, on rigid diet.
Had received treatment at all the noted spas with only temporary, relief.
Compensation poorly officiating. Radium solutions in low dosage by
mouth relieved respiratory symptoms and improved precordial distress
to some degree. On advancing the dose to 6 megm. daily, after ten
days' reaction in the rheumatoid processes presented. This pain seemed
to activate her other troubles. All treatment discontinued for ten days.
Treatment renewed on small dosage of 2 megm. daily and again relief
was obtained. No action whatever on the blood pressure could be
observed."
Case VIII.—Mr. J. M., broker, aet. 62. Systolic pressure 180 mm.
under observation and treatment fifteen months previously. Case presents
symptoms of vertigo, precordial distress, insomnia, etc. Gastrointestinal
fermentation prominent. Recently developed nephritis. Administered
by intravenous method 50 megm. radium July 12. Pressure
July 14. 150 mm. Improved respiration noted. July 18, 25 megm.
radium intravenously, followed three times weekly with 2 megm. radium
in distilled water per os. September 2, systolic 140 mm. All physical
symptoms relieved. Urine showed no albumin or casts."
"October 10 patient discharged pressure 150 mm."
"Case IX.—Mrs. D., aet. 57. Pressure 210 mm. General arteriosclerosis
with all symptoms. Had been a very active woman; had to
cease all occupation for the last eight months. General treatment influenced
the hypertension only temporarily and gave little improvement
in symptoms. One injection of 50 megm. given intravenously; pressure
came down 30 mm. during the next twenty-four hours. At the end of
three weeks, pressure had settled at 188 mm. and all symptoms had
disappeared. General health very good and could do all work she used
to do ten years ago. Reports a year after the injection that she is in
fine shape. Pressure 185 mm."
Case X.—Professor, aet. 50. Violent headaches for the last six
years. Had to stop his lectures frequently. All functions disturbed,
specially digestion.' Wassermann negative. Arteriosclerosis with blood
pVessure of 230 mm. General intestinal fermentation. No other known
cause. One injection of 50 megm. radium element given at 12 noon.
Pressure down to 200 mm. at 6 P. M. Four weeks after injection
patient has pressure of 176 mm. and says that he never felt better; has
the sensation of having much smaller weight of body. Attends to daily
work regularly arid a year after the injection is in very good health."

28 R A P t U M
"Case XL—R.. butcher. Consulted -for general -malaise, headache,
vertigo, etc. - Blood pressure 200 xnm. , One' injection of 50 megm.
reduced the pressure to 180 mm. in 9$v£fl hours, -^Had 4 65 mm. "at the
end of ihree-weeks. Varies-from .160-mm. to 465 "mm. at the end of
.eighteen months.: Patient jn ..very good health."
"Case XIL—Mr. W.. act. 72. Suffering from trifacial neuralgia
for. the Jast -eleven years. General health fairly good. Blood pressure
220 mm. One 50 megm. ampulle injected at 3 P. M. Next morning
pressure was 180;mro.; .three -weeks .after the injection shows 175 mm.
to 180 mm.-andstayed atthis mark since that time (a year and a half).
Most surprisingly, the neuralgia disappeared almost completely soon
after the injection and has not reappeared since."
"Case XIII.—Butcher, aet. 60. General rheumatic condition for
the last twenty years. Blood pressure 190 mm. One 50 megm. radium
injection reduced the pressure to 160 mm. in four days and it settled
at 150 mm. at the end of a month. Patient in absolutely good health at
the end of a year."
"Case XIV.—Mrs. C, aet. 50. Subacute rheumatism. History of
either neuritis or rheumatism for the last two months. Pressure 200
mm., following the administration of 50 megms. radium-element intravenously,
reduced in five days to 160 mm. and 150 mm. after ihree
weeks. All rheumatic symptoms disappeared completely in about ten
days. Reports in very fine health after a year; pressure 160 mm."
"Case XV.—Mrs. R. P., aet. 50. Suffering from neuritis for the
last six years. Could not sleep more than an hour in the night. Pain
in the left arm. and from base of skull down to the lumbar region
almost constantly. Blood pressure 205 mm. No form of treatment
produced any noticeable change either of the neuritis or blood pressure.
Injected 50 megm. radium element intravenously. Pressure 180 mm.
the next day—170 mm. at the end of three weeks. Pain almost gone
except in a small spot at the base of the skull. Second injection caused
the pain to disappear completely in twelve days. Patient reports every
month. At the end of a year no pain had recurred—patient can sleep
from ten to twelve hours every night and take a nap in the afternoon
; has gained thirty pounds and says she feels twenty vears younger."
"Case XVI.—Mr. W., coal dealer, aet. 65. Blood pressure 230 mm.
Violent headaches, dizziness, advanced arteriosclerosis. No improvement
under any form of treatment for the last ten years. One 50 megm.
injection of radium element lowered the pressure 50 mm. in a period
of four weeks. A year from the injection patient has pressure of 175
mm. and has had no recurrence of his former symptoms."
"Case XVII.—Mr. S.. aet 72. General arteriosclerosis. Complained
of feeling heavy together with a general sensation of malaise and
anxiety. Rheumatic pains for the last twenty years, subacute attacks
more frequent and compel him to stay in bed about once every two
months for a period of one to two weeks. Blood pressure 240 mm.
One injection (50) megm. radium element) brought the pressure down
to 190 in five days. All rheumatic symptoms had disappeared in four
weeks. Patient reports every month and is very grateful to radium
treatment. After the period of a year no symptoms have reappeared
and the general condition is very good—blood pressure 190 mm."
"Case XVIII.—B., aet. 45. General condition bad; no "other symptoms
except increasing.weakness, loss of weight and anxiety; almost
constant headache. Blood pressure 260 mm. reduced to 210 mm. in

R a d i u m 29
four days with an injection of 50 megm. radium element; 200 mm.
in seven days. Patient reports often and at :jhe .end of six months has
gained thirty pounds, feels fine and pressure is 18

30 R a d i u m
"Most of the cases of canter, in - which radium treatment has been
used, have been inoperable cases, many almost moribund, and in this type
of cares radium treatment has achieved what no other treatment could
do. As a palliative it has relieved the pain, stopped the discharges, and
done away with the foul odor, conditions, which make the last days'of a
cancer sufferer; as well as those who may be near, almost unendurable.
Radium has brought relief in hopeless cases and a peaceful end. More
than this it has removed the local growths in many cases and has
brought about clinical cures. As in surgery, only the test of time can
tell whether a real case cure has been effected."
"Surgery offers no hope in advanced cancer cases, particularly
Where metastases have formed. In such conditions we are forced to
turn to other methods of treatment and in many cases radium with the
hard X-rays, or radium with surgical procedures have done much to
relieve and, in some instances, to remove the malignant growths."
"The value of radium is not established by one success, nor does
one failure prove its lack of value. Yet there are many who condemn
radium for its failure to effect a cure in all cases (most of them hopeless
before they turn to radiumV On the other hand there has been the
over enthusiasm of those who have worked carefully with adequate
amounts of radium and have noted its wonderful results. The remarkable
results which radium has been able to produce in apparently
hopeless cases, have been the pardonable cause of this enthusiasm.
That radium is of definite value in the treatment of certain types of
malignant growths is well established. Like all other agents it has its
limitations, and it is far from being a panacea."
"For the present cancer can be considered as curable only when
it can be removed from the body. Just now, there is a great wave of
publicity sweeping this country, with the object, if the cancer is to be
checked and destroyed, of bringing to people's attention the necessity
for early operative measures. This work will be of great vatue. but in
spite of it we will continue to have malignant growths to treat, and when
one considers the enormous number of people dying each year as a
result of cancer, it is easy to realize that surgery alone will pot suffice
for the treatment of cancer."
"We must bring to bear all the forces at our command, if we are
to be successful in the conquest of cancer, and for this reason I would
like to call your attention to the greater value of surgery plus radium
as treatment for many forms of malignancy."
"Successful surgical treatment has as its basis the complete removal
of all the malignant growth. This is only possible where the growth
is local, and conditions permit of its complete removal. Who has not
seen cases that have been hastened to a fatal end by faulty operative
measures or an epithelioma on the lip or tongue which after operation
has .extended rapidly through the glands of the neck? Yet one does
not condemn all surgical proceedures on this account."
"The basis of the action of the radium rays is a selective destructive
effect of the rays upon malignant tissues, the same dosage of rays
not producing the destructive effect on the adjacent normal tissues.
Histological studies have shown conclusively that there is this selective
effect of the rays. Therefore, radium rays are not to be classed with
the caustics and the cautery which destroy all tissues with which they
come into contact. Histological studies have also,.shown the protean

R a d i u m 31
character of malignant neoplasms. This branch of pathology is like
a fourth dimension of medicine and surgery. We are grappling in the
dark with problems beyond our comprehension, and in such cases we
are forced to be empirical, and conservative. Yet our advance is hindered
by our empiricism and conservatism."
"When the value of any method is generally recognized, then it
is hard to convince people that anything is even better. The value of
surgery in cancer is unquestioned, and yet on the whole, is there not
room for much improvement?"
"Radium therapy for more than superficial conditions dates back
to less than a decade, and even now the technic of radium therapy is
still far from being finally determined. It has been only within the
past three or four years that radium has been used in larger quantities
with the heavy screening to cut off beta rays. The international radium
standard has been established for several years, so that it is possible
for workers to know exactly what they are working with. When you
consider that there is probably less than 60,000 milligrams (about two
ounces) of radium element in all the radium preparations in the world,
and that a large proportion of this radium has been in use for only
a brief time, and that the bulk of this radium is in the possession of a
few institutions or individuals, you can begin to realize that we are
just at the threshold of the knowledge of radium therapy. Now radium
preparations may be secured, having definite radium content, and this
marks a great step in the fixing of a technic of radium therapy. The
next advance can come when statistics are made available, showing the
results of radium treatment .and the duration of improvement. At
present there are only a comparatively few workers in the field of
radium therapy, and many of us have not as large amounts of radium
as would be desirable, so that the number of cases that can be treated
at one time is necessarily limited. However, it is out of the total of
such work that the final judgment as regards radium therapy is to come.
and I take this occasion to present some reports that have come out
of my personal experience in the use of radium in combination with
surgical treatment, in cases of malignant growths."
"Case I. Mrs. J. C, aged forty-seven years, married. Diagnosis:
medullary carcinoma of cervix. Father and mother were alive and
well; also four brothers and three sisters. Patient had diphtheria fifteen
years previously and measles ten years previously. She had hdd two children.
Urinalysis: Urine cloudy, amber, acid, specific gracity 1.009.
negative for glucose, trace of albumin, many epithelial cells and few
leukocytes. Blood: May 11, 1915. hemoglobin. 39 per cent.; red blood
corpuscles, 3.840,000; leukocytes 12.000, June 20, 1915. hemoglobin, 52
per cent.; red blood* corpuscles 3,860.000."
"November, 1914, patient ' began to have uterine hemorrhages;
this condition continued for nine weeks and discharge began to have
offensive odor. On Jauary 4, 1915, patient had a large polypus removed
and in February a supravaginal hysterectomy was performed for
fibroid uterus. May 10, a large sloughing mass was removed from
cervix which was cauterized. Radium treatment began May 12. 1915,
and patient had 7395 milligram hours of treatment. She was discharged
as clinically cured, August 14, 1915."
"Case 2. Mrs. J. E., aged sixtyfive years, married. Diagnosis:
Carcinoma of vagina. Father died of old age; mother died at the age

32 R a d i u m
of fifty-eight years with liver trouble; one sister was at Warren asylum
and three sisters and two brothers were alive and well. Patient
had had the diseases of childhood."
"At the beginning of November, 1914, patient noticed, off and on,
a slight flowing with no pain. At the end of November, her physician,
upon examination, advised immediate operation. December 3, 1914, the
patient was operated upon by Dr. George Reed who performed a complete
hysterectomy. Radium treatment was begun March 3, and the
patient had 5590 milligram hours of treatment. Discharged as clinically
cured May 28, 1915."
"Case 3. Mrs. P. E„ aged forty-one years, married. Diagnosis:
Carcinoma of breast. Father was alive and well; mother died of pneumonia
at the age of sixty; one sister and one brother were alive and
well. Patient had had the diseases of childhood.
"About November 1, 1914, patient noticed a soreness of left breast.
Complete removal of breast was performed December 1, 1914. Urinalysis
was negative. Radium treatment was begun March 22, 1915, and
patient had 4520 milligram hours of treatment. She was discharged
as clinically cured August 15, 1915."
"Case 4. Mrs. A. W. W., aged sixty-two. widow. Diagnosis:
Carcinoma of breast. Father died of heart trouble, aged sixty-two;
mother died, aged seventy-eight, cause of death unknown. Patient had
had the diseases of childhood."
"About December, 1914. patient noticed a lump in left breast; she
suffered severe pain in breast and down left arm up to time of operation.
Complete removal of breast was performed February 4, 1915.
Radium treatment was begun March 15, 1915, and up to August 6 patient
had 4288 milligram hours of treatment."
"In conclusion, I wish to emphasize that what is necessary now i*
co-operation rather than destructive criticism, if we are to be able to
establish the value of radium therapy in the treatment of malignant
growths. Those who pioneer in any field have and expect to have hard
work before them. The days of pioneering in work with radium are
far from being past, yet this agent has been demonstrated and is being
accepted more and more widely as a most valuable adjunct to the older
methods of treatment. We would not replace surgery by radium therapy.
but rather, by combination with radium therapy, make surgery more
effective. The surgeon can remove the greater partof the malignant
tissue, but the radium rays in suitable cases can go in and destroy all
of the remaining malignant cells, and in tiie treatment of even inoperable
superficial cancers, carcinoma of the uterus, the prostate, flhe rectum,
and the breast, and in spindle-celled, round-celled sarcoma, lymphosarcoma,
in rodent ulcers, radium has been shown to be of definite value.
and the future will rather add than subtract from our present estimate,
as the work goes on. and the amount of radium available increases."
"Note: After the report of Case 2 was given before the state society,
the patient had a sudden recurrence of the disease in the large
bowel and subsequently died."

A MONTHLY IOURNAL DEVOTED TO THE CHEMISTRY, PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIO-ACTTVE SUBSTANCES.
Edited and Published by Charles H. Viol. Ph. I).. and William H. Cameron
with the assistance of collaborators working in the fields of
Radiochemistry, Radioactivity and Radiumtherapy.
Subscription $2.50 per year, or 25 cents per copy in the United States and Canada
in all other countries S3.75 per year.
Address all communications to the Editors, Forbes and Meyran Avenues,
Pittsburgh, Pa.
VOL. VII. MAY, 1916 No. 2
THE LOCAL APPLICATION OF RADIUM SUPPLE­
MENTED BY ROENTGEN THERAPY*
By Russell H. Boccs, M.D.,
PITTSBURGH, PA.
The therapeutic action of a local application of radium is due to
rays emitted, which penetrate the tissues and therein produce certain
changes. The character and extent of changes depend upon the quality
and quantity of the radiation. Weak radiation may stimulate the cells,
while larger doses inhibit cellular functions and finally cause death.
Every cell is susceptible to this stimulation or inhibition, but the effect
varies in degree with the cells of different tissues as well as with the
dosage. Thus the glandular epithelium of the testicle, ovary, breast.
liver, spleen, thymus, thyroid and lymphatic glands is more susceptible
than the stroma of the same organs.
Investigations have shown that both the rays given off radium
and the X-ray tube act primarily on the nuclei of the cells and inhibit
their power of proliferation before the function of the cell is impaired.
Embryonic cells and those which arc undergoing active proliferation
are the most susceptible. It has been shown that malignant growths are
retarded «by radiation and become less malignant, although they may not
have diminished in size or disappeared. By further increasing the
quantity of radiation, the injury becomes more pronounced and the
cells are completely destroyed, the rays acting differently on the various
types of cells, i.e., destroying one kind of tissue and leaving the other
adjacent tissues intact or so slightly injured that they will completely
recover.
•Surnrr. Gynecology and Obstetrics. Vol. XXII. pp. 358-65, 19!6. American
Journal S'Roentgenology. Vol. Ill pp. 92-101 191« Read at the Annual meetlng
of tho American Roentgen Ray Society. Atlantic City. 1915.

34 R a d i u m
The therapeutic action of radium on a new growth not only consists
in the destruction of the tumor cells but also in its action on the bloodvessels.
The endothelial cells of the intima degenerate, the lumina of
the vessels retract and finally arc obliterated and consequently the tumor
cells cannot obtain the nourishment needed for their maintenance of
life and for their proliferation.
When a tube of radium is brought in contact with a growth or is
inserted into it, a certain dosage will inhibit the proliferation and finally
cause necrosis of the cells nearest it, while further away from the tube
the same kind of cells will be stimulated. This observation has been
made by many and is a settled fact. The statements made as to the
depths in which the cells are affected vary between two and five centimeters,
two and one-half being that which is generally accepted. So
radium has its limitations in the treatment of malignancy and must be
supplemented by something which will destroy the metastasis in the
deep lymphatic glands which cannot be reached effectively by radium
rays.
The quantity of rays reaching tissues adjacent to the radium tube
diminishes inversely as the square of the distance. The more susceptible
a cell the smaller the dose necessary for its destruction, and consequently
the greater the distance at which it may be influenced;
since the rays decrease as the square of the distance from
thel radium, it necessarily follows that tissues acted upon must be
as close as possible, and whenever it can 'be arranged, the abnormal
tissue should be brought in contact wfth the radium container, while
the normal tissue should be as far as possible flrom it. When large
growths have been treated, it has been determined by biopsy that the
periphery of the growth is stimulated by the attenuated rays that are
able to reach through, while the malignant cells in the tissues in contact
with the radium are destroyed. Many have long realized, since light
decreases inversely with the square of the distance and if the source of
radiation is placed in contact with the skin of the patient, that the dose is
many times stronger on the surface than at a depth where the ch'sease
must be destroyed. The greater the distance the source of radiation
is placed from the surface of the body the more nearly the tissue at a
depth will be rayed homogeneously. With an X-ray placed twenty
inches from the surface, a growth situated four inche* below the surface
will receive almost the same amount of radiation as the skin less
the amount cut off by absorption of the four inches of tissue. Some
radium workers who have large quantities of radium, have placed it at
a distance, thereby reaching a more nearly homogeneous radiation than
by bringing it in contact with the surface of the body, but until they
can obtain many grams of radium this is not any more practical than
attempting to treat cancer of the uterus with five milligrams of radium
locally and expect results.
As it greatly increases the time of exposure to increase the distance
of the source of energy, a roentgen tube should be placed as close as
possible without impairing results at the desired depth. The shortest
distance can be determined only by the amount of radium radiation given
locally as well as by the amount of cross-firing. Of course the loss by
absorption must be supplemented by cross-firing.
1 he general opinion at present is that all malignant tumors are in
their early stages merely local, so that a complete cure may be obtained
by early and complete removal. Unfortunately no clinician is able at

R a d i u m 35
least to st^atc when such is the case; the facts are quite otherwise.
Generalization and recurrence in the cicatrix and the glands frequently
follow even when the tumor has been completely excised in its early
stage. So frequently is this the case that we are bound to conclude that
the disease is regional and not entirely local from the beginning, even
before the neoplasm is recognizable by the naked eye, because the whole
of the lymphatic circulation as well as the glands are already infected.
This is shown by the fact that recurrence is frequently seen in the
cicatrix of an incision at a considerable distance from the original lesion.
Leduc states: "For some considerable lime after this regional infection
by malignant disease, the lymphatic glands are able to defend the
organism against the general invasion of the disease. The glands here
play a double role: they are both fortress and garrison, arresting the
invasion, and defending Dhe organism against the entrance of the
pathological germs."
If his deductions are correct the surgical removal of the lymphatic
glands even in a very early operation for cancer is to be deprecated,
unless every part of the garrison, i.e., the lymphatic glands, which are
holding metastatic cancer cells, is removed at the time of operation.
Otherwise it removes the only barrier to the invasion and the only defense
of the organism, thus hastening the end. We are sure that the
surgeons would not operate on a great many cases that they do if the
visceral generalization had been as easily recognizable as the local recurrence
in the glands or scar, or if they would have had these cases treated
most thoroughly and radically by modern radiation. An incomplete
surgical removal neither prolongs life, retards the progress nor affords
palliation, but rather hastens the progress. This is not true of radium
applied locally because the lymphatics are never opened, but it has the
disadvantage of not giving off rays which will act at sufficient distance
from the radium tube to destroy the cancerous cells in all the adjacent
lymphatics.
Experience of the past two years has shown that we cannot treat
successfully with radium at a greater distance than two, or a maximum
of three centimeters. It has been universally accepted that cancerous
growths can be promptly, and also apparently permanently, cured at this
depth from the radium tube. If. however, the disease is advanced and
there is infiltration of the growth into adjacent lymphatics, the cure is
only apparent. The local growth may disappear but if metastasis had
taken place before the treatment was given, it will progress, no difference
how much or how long the radium is applied if it is only effective from
two to three centimeters from the tube.
Larger quantities of radium have been tried and by increasing the
time of exposure to influence -cancerous cells at a greater depth, but the
universal reports show that not much success has been accomplished in
this direction. The overlying tissues were damaged beyond recovery
regardless of the kind of filters employed. The rays of the radium in
contact with the growth were too intense where they entered and too
weak at a greater distance from the tubes than from two to three
centimeters. To place the radium at a distance from the surface in
order that the rays will be nearly uniform at the point of entrance and
at the distance required renders the radiation too weak even if several
grams were employed. The same is not held true of the present X-ray
tube which, when powerfully excited, gives off many thousand times
more rays than anv one has ever used. It has been estimated that

36 R A D I U M
ninety-two grams of radium would be necessary to place the radium at
the same distance in order to obtain at a depth of ten centimeters the
same intensity of radiation as with the X-ray tube.
Warnekros, in order to compare the relative quantics of the rays
from an Xsray tube and. radioactive substances, introduced Kicnbock
strips into the vagina of patients suffering from carcinoma and rayed
the abdomen by roentgen tubes at a distance of twenty-two centimeters
from the skin. A partial account of these tests is given in the Archives
of the Roentgen Ray Journal, May, 1915, which is very instructive,
Bumm and Warnekros concluded as follows in regard to the hard
roentgen rays on deep tissues: "We estimate that, in the treatment
by roentgen rays of visible malignant growths one needs a quantity of
about 300-500 X, in order to destroy and heal growths of two centimeters
thickness. The same quantity of 300-500 X must reach the
depth of tissues if deeply situated cancerous tissues are to be destroyed.
The depths which come into consideration reach to about ten centimeters.
Our experiments and observations on dead and living persons
show that at a depth of ten centimeters, when Kienbock strips had been
introduced into the cavity of the vagina and had been subject to radiation
from the outside of the abdomen, the intensity diminishes from
100 to 15, that is to about 1/7 of that at the surface. To obtain, at a
depth of ten centimeters, 500 X, we must give to the surface 3,500 X,
and in order to apply this great quantity without serious damage to
the upper tissues, only hard rays must be used, with a sufficiently large
distance from the skin, according to the principle of homogeneous radiation
by E. Dessauer, and the rays should enter the body through different
parts. Our experience shows that all this is possible, and that it produces
the same results in deep-seated cancers as are obtained in superficial
growths."
In the treatment of any form of malignancy, the proper quantity
of radiation must reach the diseased tissue, otherwise good effects cannot
be obtained. Clinical experience has proved again and again that
permanent results mean more than superficial treating and removing the
visible part of the disease. Cures by such treatment are only apparent,
with relapse in a short time. Attempts to cure malignant tumors with
inefficient radiation have only led to incomplete success. The roentgen
ray has been found to be the only agent which is capable of checking
and permanently curing well-established malignant growths in which extensive
involvement has taken place, although radium is far superior
in its local action on any mass situated in cavities where it is necessary
to concentrate the rays. Therefore, radium applied locally, supplemented
by roentgen rays to the adjacent tissue, gives the ideal form of radiation
because all the malignant cells can be stronger rayed with less injury to
the healthy tissues. This is a fact beyond dispute. It has been proven
without doubt that many cases of inoperable cancer of the uterus have
been apparently cured by radium alone applied in the vagina; and also
by our present roentgen methods alone, but a combination of both
carried out scientifically seems the practical method and should cure
more advanced cases than either alone.
Both surgery and radium are local methods of treatment and
metastases in distant parts are beyond their reach in a large majority
of cases. The disadvantage of surgery is that it removes a large amount
of healthy tissue as well as the abnormal. There is always a limit

R a d i u m
to the removal of normal tissue by the fact that the vitality of the
patient is interfered with and consequently hastens metastases of the
malignant cells left in adjacent tissue. The advantage of radium is
that it will destroy the malignant cells without injuring the normal. It
does more than cautery or removal. It destroys the cancer cells, leaving
the healthy tissue. The disadvantage is that, with any known technic,
the rays do not reach beyond a certain depth and, while the disease in
the superficial layers is destroyed, it is only inhibited or unaffected in
deeper parts. This shows the necessity of using radium in cavities,
cross-firing as much as possible or inserting the tube in the growth
and raying the adjacent lymphatic supply as thoroughly as possible.
We are still looking for the homogeneous ray. I believe that radium
is the ideal form of radiation for a depth of two and one-half centimeters.
We are expecting Professor Coolidge in the near future to
have a tube which will give us this form of radiation. It is in this
direction we are looking because surgery has about reached its limit.
While the radium workers' results have been wonderful since filtration
and cross-firing have been used, they realize that until large quantities
of radium have been obtained, this form of radiation, like surgery, has
about reached its limit.
Before this society it is unnecessary to go into detail of describing
the value of homogeneous radiation and how to obtain it. But I wish
to call attention to the fact that most of the radium institutes are not
treating the metastases with roentgen rays and for this reason their
results are inferior to many of the Germans', who never use radium alone
in advanced cases. Do they neither know the limitations of radium nor
the value of roentgen therapy? This, I believe, is one of the reasons
why many of the radium reports read thus: "This caused the disappearance
of the growth. One year later the patient died of metastasis without
recurrence." It appears that these radium workers are in the same
place that the noted surgeon Gross was when he made the statement
that he had not cured a case of cancer of the breast in twenty-five years
by the removal of the breast. During the last three years I have frequently
seen cases which have been treated by radium in different places
whfch would bear out this statement.
In epithelioma or carcinoma of tongue, mouth, throat, lower lip.
uterus or rectum, the disease is seldom seen and diagnosed before the
adjacent glands are involved. In many cases the glands are not palpable
but metastasis takes place long before the glands can be detected
by palpation. This is something every physician should know by this
time with the amount of emphasis most authorities have placed upon
this fact, but I do not believe that some of the medical profession will
ever learn it. Even some well-informed surgeons will tell you that
they have removed all carcinomatous tissue and that post radiation
would be superfluous. It is absurd for any one to he guided by tactile
sense in determining whether there are cancer cells in the adjacent
lymphatics. Sad experience in the past has proven this to be a fact.
Do they not know the nature, of cancer?
It is becoming a universal fact that the removal of a cancerous
growth locally and as much of the adjacent lymphatic tissue as is
possible, or the disappearance of the local mass by radiation, is a contradistinction
to a cure. Tfhis might be considered a clinical cure, but a
cure means the permanent removal of a malignant growth and its nonrecurrence
in any other part of the body. The rationale of the complete
37

38 R a d i u m
removal must include modern radiation, because even in the very early
cases complete removal by surgery, no difference how early and how radically
performed, only removes the disease in a certain percentage of cases.
A continued study of the lymphatics in their relation to carcinoma for
over twenty-five years hlas led to more radical operations for their
removal and has increased the numbers of cures by surgery, but still
the most radical methods will only cure a fair percentage of the early
cases. Bloodgood states that when deep-seated cancer is clinically
malignant it is usually hopelessly inoperable. The many long and
tedious operations for cancer of the breast, the most radical operations
for cancer of the uterus, bladder, rectum and throat, must at least be
supplemented by modern radiation which makes it more radical in
order to cure the highest percentage of cases. The members of this
society who have been advocating the addition of radiation to surgery,
should at least be gratified that they have succeeded in convincing the
best surgical authorities of this fact. Many of the surgeons realize
this more fully tl(an some of the members of our society, who are
making roentgen examinations of the highest degree and doing very
little radiotherapy. Our society has done much in the past and has much
to do in the future to standardize methods and educate the medical profession.
The latest surgical authorities recognize the value of modern radiation
as a necessary adjunct to operation and as a palliative procedure in
the hopeless cases. In this connection let me cite several paragraphs
from "Johnson's Surgery." just issued: "Extensive indurated cutaneous
epitheliomata involving the subcutaneous and underlying tissue, even
with bony involvement, are as successfully treated by massive doses of
light, moderately filtered radium as by surgical intervention and, when
successful, with far better cosmetic results Inoperable lesions can
be regularly reduced and the pain and discharge diminished, and latterly,
with the larger amounts of radium at our disposal, a total dissipation has
occasionally resulted with a fair prospect of permanent relief Inoperable
tumors can sometimes be made operable and a cachectic general
condition can often be greatly improved by radium applications to the
offending mass or masses. The increasing success as shown by results
reported in the more recent years, undoubtedly has been due to a concentrated
effort to project greater masses of rays more equally distributed
throughout the tumor and the immediately surrounding tissues.
Epithelial cancers of the uterus, rectum and breast have seemed
to be more influenced by radium treatment than the other inoperable
or recurring epitheliomata Carcinoma of the cervix and uterus
is anatomically well situated for radium applications, owing to its tendency
to spread around the walls of the organ, leaving the cavity of the
vagina, cervix and uterus patent for the insertion of radium tubes on
various applicators or in catheters. A 50-mg. tube of the element filtered
with 2 to 4 mni of foil and left in place for 24 hours will relieve pain,
hemorrhage and discharge and, in a few rare cases, the lesion has
entirely disappeared over a period of months after radium treatment,
the cervix and uterus tending to resume somewhat their original contour
and appearance Such applications to inoperable carcinoma
of the rectum have occasionally prolonged life for months and even
years and saved the patient the discomfort of an artificial anus."
The symposium on "Cancer of Certain Pelvic Organs." read before
the Massachusetts Medical Society. June Oth. from a clinical standpoint

R a d i u m
should be studied by every one interested in the treatment of malignancy.
This symposium emphasizes the importance of still more radical operations
than have been heretofore performed for carcinoma of the pelvic
organs, or else the addition of radium and the X-ray or some unknown
treatment before we are able to cure a majority of cases which can be
diagnosed clinically. The surgeons who took part in this symposium
were not only surgeons of the highest rank, but each had specialized
and directed his attention to only one of the pelvic organs. For the past
two and a half to three years in the Massachusetts General Hospital all
the cases of cancer of the uterus have been assigned to Dr. Farrar Cobb
for operation and all the cases of cancer of the rectum have been
assigned to Dr. Daniel Fiske. This has undoubtedly allowed each to
perfect his technic to a high degree and their statements are worthy
of very careful consideration. Cobb's description of the Wertheim
operation in the following words certainly should prove to us that applying
radium locally in the vagina would not eradicate the metastases in
the adjacent glands when the removal of the tissue at such great distance
from the local growth is found to be necessary: "The radical abdominal
or Wertheim operation is concisely the removal of the uterus and a
liberal portion of the vagina through a median abdominal incision, with
thorough dissection of the ureters and bladder with removal of as much
of the parametrium on both sides as possible, the regional lymph glands
being removed only if palpably enlarged. The operation is a difficult
and tedious one, and the medical profession and public should be made
to understand that it is an operation only to be attempted by surgeons
especially interested and trained in this work."
Since according to Cobb, 50 per cent, of all cancer of the uterus
cases come too late for curative operation and of the operable cases
only 50 per cent, are cured, and there is an operable mortality of from
9 per cent, to 30 per cent, and so much can be accomplished in the hopelessly
inoperable cases, it does not seem presumption to suggest that
each cancer patient should at least be given the benefit of modern radiation.
This certainly shows that Cobb considers the ordinary operation
incomplete when he advocates such a radical operation as can be done
only by the most skillful and especially trained surgeons. Even then
the immediate mortality in a series of cases reached as much as 25 per
cent, to 30 per cent. Such a radical operation in selected cases only
cures 50 per cent, of the cases operated upon. Mis address to any one
who is at all familiar with the results of modern radiation, strongly
advocates radium applied locally and the raying of the entire lymphatic
supply of the pelvis by the most efficient roentgen methods. Until a
better cure is found nothing less should be accepted as a standard or
routine. A failure on the part of any one should be considered as
much a criminal neglect on his part as a failure to use the ordinary
necessary aseptic precautions.
In this symposium Dr. Daniel Fiske gave the statistics of Harrison*
Cripps cases to show how absurd it was to talk about carcinoma of the
rectum as a benign condition, which are as follows: "He saw four
hundred and forty-five patients and operated upon 107. Of those 107
cases 17 per cent, died from the effects of the operation, and 40 were
alive five years after the operation, that is. 9 per cent, of the total
number seen. It would be fair. I am sure, to say that not more than
5 per cent, would be alive at the end of ten years."
In this symposium Dr. Arthur L. Chute states in the following
;v

40 R a d i u m
words: "The story of carcinoma of the bladder is most discouraging
when we consider the small number of cures that we effect by means
of operation." He further states: "There are just enough cases remaining
well after operation to allow us to say that cancer of the bladder
is not absolutely hopeless and to spur us to renewed effort in hope that
when we have a clearer understanding of the condition that our results
will be better." Dr. Chute adds this: "It has been held that metastasis
takes place late in cancer of the bladder. I doubt if this is necessarily
so; and I believe that operations cannot in most instances be considered
radical, unless we take into account this lymphatic involvement. I believe
the condition is probably this: that so long as a growth is confined
to the mucous layer of the bladder there is probably no lymphatic involvement
; that the moment it invades the deeper layers we have
lymphatic involvement."
If it were possible to make an early diagnosis when only the mucous
layer of the bladder was involved, it would seem possible that such
conditions could be promptly healed by radium and a few results have been
reported, but unfortunately these cases are usually diagnosed late and
it is more difficult to apply radium to the bladder than to almost any
other organ in the body. The danger of setting up an obstinate cystitis
is always to be remembered. From studying the lymphatic supply of
the pelvic organs it is readily seen how difficult, if not impossible, it
is to remove the adjacent glands involved at the time of operation, no
difference how radically it is performed It is usually impossible to
remove all the glands affected. The question when operating is, if
the glands are affected, where arc you going to stop? There is a limit
to everything.
A thorough study of this symposium on cancer and metastasis in
general shows us why such free thinkers as Bumm, Doederlein, Kelly
and other noted gynecologists have adopted the use of modern radiation
as a routine method in all their cancer cases at least post-operatively.
It is only a question of time until the entire medical profession will
come to the same conclusion. The following is Kelly's report in the
Maryland Medical Journal. July, 1915: "In nearly 30 per cent, of the
inoperable cases even the disease has disappeared under efficient radiation
with large amounts of radium element. This was true in a group
of over two hundred cases treated by Dr. C. F. Burnam and myself.
It is a common sight to witness, too, the disappearance of growth
recurring in the vaginal vault after operation. It is a question for the
next three years to settle, whether we will continue to operate on any
of the group of cases which melt down under our radium therapy
Up to the present radium has been used repeatedly to shrink an inoperable
growth down and then to operate radically."
It is not necessary to quote the results of the work which has
been done and reported to members of this society. It would be well
if our members would refer physicians interested to one of the many
articles which have thoroughly reviewed the literature. There is an
excellent article by Henry Schmitz in Surgery. Gynecology and Obstetrics,
January. 1915. which has undoubtedly been read but not considered
sufficiently by all the gynecologists. There can be no doubt
in regard to the benefits derived from modern radiation if properly
given in conjunction with surgery. The probability of explaining one
of the causes which are leading to neglect by many in using post radiation
is that they usually asked too much of radiation. Too often in

R a d i u m «
the treatment of cancer all we see is the surgical removal of the line
ol deiense, leaving the lymphatic glands of the adjacent tissue which
cannot be removed untreated until a marked or clinical recurrence has
taken place, but even then the disease is retarded, the pain relieved
and the fetid odor diminished in a large percentage of cases and a
clinical cure obtained in some cases.
During the last nineteen months, I have had a limited experience
with radium m cancer of the uterus. Treating fourteen cases, ten were
recurrent and the other four were so far advanced that they were
beyond the operable stage. All improved except two, in that the disease
was checked, the growth diminished in size, the pain relieved and the
offensive odor lessened or entirely checked. Three have been clinically
cured, and one, which is still apparently cured, I reported before this
society a year ago. In two other cases the disease has nearly all disappeared.
These results are remarkable when you consider all were
hopeless as far as any other treatment was concerned, and that four
cases were taking heavy doses of morphine when they were referred.
In this connection I will report the following: Mrs. D., age 33, was
referred to me by Dr. Werder for a recurrent carcinoma, following a
radical operation for carcinoma of the cervix. The recurrence was
marked in the vaginal cicatrix and the hemorrhage and discharge were
excessive. On account of her age and the rapidity with which the
recurrence was growing, she was considered a very unfavorable case.
At the first treatment she was given 2,000 milligram hours of radium,
and this was repeated four 'weeks later. Following the first radium
treatment she was given radiotherapy over the anterior abdominal wall,
backhand perineum, the same as the Kroenig, Gauss method of treating
fibroids of the uterus. The same amount of roentgen radiation was
given again after the second radium treatment. Four weeks later Dr.
Werder examined the patient and stated that he was unable to detect
any disease and considered the case clinically cured. She was again
given another radium treatment, supplemented by roentgen therapy, as
a prophylactic measure.
Mrs. F. was referred by Dr. Gardner, who stated that he saw the
case for the first time three weeks prior and that she gave a history of
having had hemorrhages for at least two years and at that time she
had consulted a physician who told her that the ulceration might be the
beginning of cancer. Following this, she had not seen a physician until
the pain had become so severe and the discharge so offensive that she
consulted Dr. Gardner ,who referred her to me for radium treatment.
Some of the necrotic tissue was destroyed by cautery, after which she
was given 3,000 milligram hours of radium with heavy roentgen treatment
as described before. At the end of two months all the cancerous
tissue had disappeared except a small area, which entirely disappeared
six weeks later. She was given additional prophylactic treatment and
is apparently cured, but the time is entirely too short to give any
prognosis.
I have not had as good results in the treatment of carcinoma of
the rectum or bladder. However, sufficient results were obtained to
offer this method of treatment as a palliative measure in the hopelessly
inoperable cases and with the possibility of a cure, or at least further
increasing the number of cures in conjunction with surgery. Three
of the rectal cases were greatly improved and great palliation was

-12 R a d i u m
obtained. In one advanced case the palliation was remarkable, in that
the mass was reduced in size and the patient had normal bowel movements
for six months after the radium treatment.
My results in the treatment of malignant growths of the throat
with radium, as a whole, have been very gratifying when you consider
the hopeless condition of these patients when they were referred. All
were far advanced and operation had been refused except, of course,
in some of the cases which were treated post-operatively. One case of
carcinoma of the tonsil was reported in the Arei«' York Medical Journal,
July, 1915. Another case which was greatly improved and in which
all the disease disappeared was given additional treatment, until finally
the surrounding tissues broke down, producing an infection of the throat;
and while the patient did not recover, I do not believe she died of
carcinoma. This case I believe would have done much better by treatment
in small divided doses rather than by the heavy massive dose. A
case of epithelioma of the inside of the cheek has been apparently cured
for nine months. This case responded in a remarkable manner and
the ulceration healed, leaving very little deformity. An epithelioma of
the palate showed marked improvement at first, but later broke down
and did not respond to further treatment. I might cite a number of
cases treated, but the few mentioned briefly will suffice to illustrate my
points in this paper.
The cases of epithelioma of the tongue which I have treated were
all advanced cases with the usual involvement of the sublingual glands
as well as with deeper metastases. While encouraging results were
obtained, i.e., the local lesion decreased in size and the metastases checked
in nearly all, in only one case did the local lesion entirely disappear. So
far I have not treated a favorable case and can speak only of the cases
far advanced which were hopelessly inoperable. Cancer of the tongue
and buccal membrane are less influenced by radium than cancer in almost
any other situation. This is not entirely due to the greater lymphatic
supply, with a consequently greater tendency to metastases and
the difficulty often in making prolonged applications, but it appears that
there is not the same difference between the relation of abnormal and
normal tissues. In order to give sufficient radiation to destroy all the
cancer cells, greater care must be exercised to avoid injuring the healthy
tissue beyond repair. The same caution is not necessary in the treatment
of cancer in most other situations. Also the muscles are early
infiltrated in epithelioma of the tongue and infiltration of the muscle
makes the disease more resistant to radiation. From the experience I
have gained in the treatment with radium in such cases the results are
better when the treatment is given in divided rather than massive doses.
This allows the normal tissue to recover. However, in all cases except
epitheliomas situated on the tongue, throat or in the rectum. I would
advocate massive doses given as quickly as possible. Then it naturally
follows if this is true that you are unable to give as much radiation and
the same comparative curative results cannot be obtained in epithelioma
of the tongue.
In epithelioma of the lower lip. radium supplemented by roentgen
therapy is a perfectly legitimate method of treatment, provided the
cases are selected by an expert and the operator is qualified. I believe
this will give equally as good if not better results than the removal
of a section of the lower lip with the sublingual glandular tissues. With

R a d i u m 43
our present methods of roentgen therapy it is reasonable that the disease
in these lymphatics can be eradicated in more cases than can be done by
surgery.
At the meeting of this society three years ago at Niagara Falls,
I quoted a paragraph from Murphy in regard to epithelioma of the
lower lip which 1 believe will bear repetition. "In a series of cases
published. 52 per cent, of the patients who had carcinoma or epithelioma
of the lip, without any demonstrable metastasis at the time of operation,
died of cancer, and 76 per cent, of the patients who had any
demonstrable enlargement of the glands at the time of operation died
a cancer death."
In the inoperable epitheliomas of the lower Tip the growth can be
regularly reduced in size and the pain and discharge diminished and in
some cases the disease has entirely disappeared with a fair prospect of a
permanent cure. If the lesion is removed by surgery, on account of the
great lymphatic supply, all the glands cannot be removed down to the
mediastinum, so radiotherapy should be used as a prophylactic measure
at least.
It is necessary for the operator to know the relative value of radium
and the roentgen rays when combining these two agents. In carcinoma
of the uterus, for instance, nothing could be expected from a local application
of radium with less than from twenty-five hundred to five
thousand milligram hours, using nothing less than 50 milligrams of
radium element. Then after a rest of three to five weeks another course
of treatment is usually necessary. When roentgen therapy is added it
should be given in the same manner and quantity as it is used for the
treatment of fibroids. How often both forms of radiation is to be repeated
must be determined by the judgment of the radiotherapeutist who
must be a clinician, because lie cannot be entirely guided by the surgeon
who is not familiar with any form of radiation. To secure permanent
cures the effect of the radiation must extend from the primary growth
out to the metastasis and the deleterious effect on normal tissues
avoided.
Discussion.
Chevalier Jackson, (Pittsburgh). A number of years ago I did many
operations for malignant disease about the nose, mouth and fauces. Since
narrowing my field of work to endoscopy and laryngeal surgery, I no
longer do any operation in the regions just mentioned; but long before
narrowing my field of work I had refused to operate upon malignancy
because my results had been so bad. The cases were so uniformly
subject to fatal recurrence that I did not deem operation justifiable.
Therefore, I am in a position most heartily to endorse and welcome
the advent of the beautiful work that is being done by Dr. Boggs and
other members of this society with the roentgen ray and with radium
in the treatment of malignant disease of _ the nose, mouth and fauces.
Now let us consider for a moment malignant disease of the larynx.
Nowhere else in the human body has the surgery of malignant disease
yielded such brilliant results as in thyrotomy (or laryngofissure) _ for
malignant disease of the larynx, provided the operation is limited strictly
to operable cases. In using the word operable no reference is had to
the question of the patient surviving the operation. The important
question is as to recurrence and any case in which recurrence is likely
should be considered an inoperable case. As demonstrated many years

44 R a d i u m
ago by Sir Felix Semon, operable cases are those in which the growth
is strictly intrinsic and of very limited extent. Semon obtained 85 per
cent, of cures by thus limiting his operations. His results have been
equaled by Sr. St. Clair Thomson, Mr. Tilley, myself and others who
have followed in Semon's footsteps in the selection of the case for
operation. Unfortunately, however, cancer of the larynx is relatively
very rarely discovered early enough to permit of cure by operation, either
because there has been no symptom that the patient noticed early or
because for some other reason the patient's larynx has not been examined
laryngoscopically. The last time that I added up statistics of
cases seen by myself in 27 years, I had done only 27 thyrotomies out of
211 cases of laryngeal malignancy. Unfortunately it requires a great
deal of courage to say "hands off" and, also unfortunately, the surgeon
yields to his natural impulse to give the patient a chance, even though
remote, of cure by operation, when dealing with a case like cancer of
the larynx which, if left alone, yields 100 per cent, mortality. But
these cases that are inoperable should be dealt with by radium and the
roentgen ray as advocated by Dr. Boggs.
Henry Pancoast (Philadelphia). Anyone using radium for
therapeutic purposes must thoroughly understand and constantly bear
in mind the therapeutic action of the radiation emitted—that cells are
susceptible to stimulation, inhibition of function or reproduction, or
destruction, and that the administration or the dose must be of such
quantity and quality as to induce the effect that will bring about the
desired result.
Both roentgen rays and radium rays are employed in certain conditions
for their stimulative effect, because a stimulation of the tissues
is the effect that is necessary to bring about a cure. Dr. Boggs' paper
deals particularly with malignant disease and one might on first thought
imagine that stimulation could be disregarded in this connection because
it was an effect that was not desired in treating malignancy. This
effect of radiation is, however, a most important one to consider for
the reason that it is a very difficult one to avoid when we do not require
it. I am a firm believer in the possibility of stimulating malignant
growths, although I realize that there are many who are opposed to
such a view. I believe that in inexperienced hand the stimulative effect
of radium radiations may be readily produced, especially at the periphery
of a growth where cell proliferation and the spread of the neoplasm
are the most active and dangerous, and in metastases. Unfortunately,
this effect is too often unwittingly produced by those of the widest experience.
It is just as important that these portions of a growth receive
destructive dosage as any other part.
One of the most important points brought out in Dr. Bogg's
paper, is his statement of the generally accepted knowledge that where
complete necrosis of tissue may be caused by radium just at the point
of its application, the destructive effect does not appear to be exerted
further than 2.5 cm. on an average from that point. Beyond that distance,
therefore, either stimulation may be induced, or the effect is so
slight as not to seriously interfere with malignant cell proliferation.
As a concrete example for the application of these facts, let us take
a case of inoperable carcinoma of the uterus, with extension into the
broad ligaments and possibly with lymphatic metastases. How foolish
it is to expect a permanent cure from the application of radium to
the cervix, even though we may obtain a most gratifying temporary

R a d i u m 45
local result, if the malignant cells proliferating at a distance beyond 2.5
cm. in the primary growth or in metastatic deposits cannot be destroyed.
We have accomplished no more than a localized destruction in a widespread
growth. Such treatment is frequently followed by a more rapid
invasion of the surrounding structures.
Further discussion would be unnecessary if wc were obliged to stop
here because we reached the limit of our possibilities, but such is not
the case. There is still one very effectual agent to be used and one that
is too frequently disregarded by those who employ radium alone. If
additional and completely effectual radium applications cannot be made
at other points, an additional effect may be produced by cross-fire
roentgen radiation, the object of which is to intensify the action of the
radium radiation beyond the point where its destructive effect ceases.
In the case of uterine carcinoma when there is the least suspicion of
extension beyond the limit of control by radium it would certainly seem
as though our patient had not received adequate treatment unless the
radium applications were supplemented by such cross fire roentgen
radiation as is employed in the treatment of a uterine fibroid. Each
agent alone has accomplished some good results, but both together
should accomplish far more.
Cancer of the rectum has not responded nearly so favorably to
radium treatment as has carcinoma of the uterus. I do not believe
that a growth in the rectum can be properly and adequately treated
imless a preliminary colostomy is performed. At least this is so in
the large majority of cases, and this fact is not nearly so fully realized
as it should be. Without the operation, we are prevented from pushing
the treatment as energetically as we should because of the discomfort
of the patient due to the effect of the radium on the mucous membrane
of the bowel and the continuance of the function of the part. Discomfort
is often greatest in the sphincter region, and when this area is
invaded, the treatment must be most vigorous because of the greater
likelihood of metastasis.
Our experience has been entirely in accord with that of Dr. Boggs
in connection with cancer of the tongue, throat, and rectum. Too
vigorous radiation is to be avoided because of the danger from extensive
devitalization of healthy tissues. The dosage should be much
less at one time, as a rule, than in uterine carcinoma, and should be
divided and repeated.
RADIUM IN MILITARY SURGERY-
By William H. Cameron, M.D.,
PITTSBURGH.
The suggestion that the stimulating effect of radium might prove
of value in the treatment of such conditions as infected wounds, deep
sinuses, nongranulating surfaces, etc., came after observing the effect
of the rays when inadequate amounts were employed in attempted tissue
destruction. In so far as I am aware, the utilization of the idea was
first carried out by Dr. Joseph B. Bissell of New \ork, who secured
splendid results in a small series of cases that had previously resisted
all other surgical measures.
^nna. Medical Journal. March. 1916, pp. "9-53. Vol. XIX. No. «-

46 R a d i u m
Being ambitious to develop a method that gave such promise, I
was fortunate in securing the cooperation of several military surgeons
attached to the R. A. M. C. who, like many of their fellows, were greatly
concerned regarding the treatment of just such cases as I have mentioned.
As a result of this interest, my associate, Dr. Benjamin R. Almquest,
and myself were permitted to direct the clinical application of radium
in several military hospitals in England. This work extended over a
period of some ten months, and included observations on over one hundred
cases.
Although the more important physical and chemical properties of
radium have become a matter of general knowledge, it may be well at
this point, to recall a few pertinent facts which have a direct bearing
on the particular subject under discussion.
It will be remembered that radioactivity is a property of some
forms of matter, and is due to a process of spontaneous atomic disintegration.
Most forms of radioactive matter are characterized by the
sending out of rays. In radium, these rays arc of three types, the
easily absorbed or alpha rays (which are positively charged helium atoms
shot out with terrific velocity from the disintegrating atoms) ; the more
penetrating beta rays, which consist of negative electrons (particles
1700 times smaller in mass than the hydrogen atoms) moving with
velocities approaching that of light; and the very penetrating gamma
rays (a form of radiation analogous to the Roentgen rays, but having
much greater penetrating power).
The measurement of radioactivity may be made in various ways as.
for example, the observation of the effect of the rays on a covered
photographic plate. Electrical methods of measurement arc the simplest.
and most readily give quantitative results. By means of the electroscope
accurate measurements can be made of quantities of radium as small
as one ten-thousand-millionth of a gram.
In radium we have, then, an agent that can be accurately measured,
an important fact in scientific investigation. Moreover, it practically
produces its effect without any appreciable disintegration (one half of
any amount of radium element disintegrates in about 1700 years) and
this property makes for therapeutic and financial economy.
In a communication of this character, it is impossible to give other
Chan a general outline of the results obtained. It is also impossible
to discuss in detail the relative value of this method over that of other
methods universally employed by military surgeons. We desire to say.
however, that we consider the bactericidal power of screened radium almost
nil, and that its beneficial action resides in the power of the rays
to penetrate tissue and, when used in proper amounts, to stimulate local
circulation and cell activity. In other words, it is a convenient and
more effective way of assisting nature than any other method devised.
While in England. I noticed accounts of a remarkable antiseptic
solution developed by Dr. Alexis Carrel. It is not intended that radium
will replace such an agent. As a matter of fact, radium is not employed
for the same purpose since, as I have stated, not being an antiseptic.
it can not prevent infection, but when infection is present it will
assist nature to resist invasion, a far better thing than introducing a
chemical substance which destroys only the germs vvith which it comes
in direct contact. Destroying bacteria in a test tube, or in a surface
wound, is an entirely different matter from doing this in living, inaccessible
tissue and, unfortunately, most wounds produced in battle are

R a d i u m
inaccessible. "By all means prevent infection by the best aseptic or
antiseptic means at hand; after infection, build up general and local
resistance." According to Sir Almroth Wright, this is the present day
tendency in military hospitals.'1
We want it clearly understood that the "dose of radium" for this
work must be carefully regulated. It is obvious that a wound acutely
and virulently infected will not require as vigorous radiation as one in
the subacute of chronic stage. In acute wounds, the natural defensive
forces are active, and as long as nature has the upper hand, the wise
surgeon will not interfere unless, perhaps, it be to establish drainage.
Consequently, in acute cases we do not use radium unless we feel that
stimulation is required and then, following out the method we consider
best (the method employed by one of England's foremost investigators
—Sir Almroth Wright), we simply add a soluble radium salt, two to
fifty micrograms, to a normal saline solution, and use it as a continuous
douche. By this method we feel that we are furnishing just enough
stimulation to bring a constant new supply of white blood cells into
action. We admit that a normal saline solution will of itself do this
for a certain length of time, but again quoting Sir Almroth Wright,
"lbs action is not constant;" whereas radium, being practically indestructible,
is always active.
We reserve radiation by means of radium tubes for cases in the
subacute or chronic stage and with a little experience any physician
may become expert in the proper application. The necessary appliances
arc such that for simplicity, compactness and convenience, the outfit
can not be surpassed.
In many cases of extreme shock, loss of blood, etc.. we administer
an intravenous injection of from fifty to one hundred micrograms (element)
as radium chlorid, in two cubic centimeters of normal saline
solution. This is because we feel that no other agent will build up
general resistance so rapidly.
From our laboratory findings in America and from our clinical experience
in England, we now feel justified in calling attention to this
work. Wc desire also to express our thanks to the English surgeons
and officers who have so generously assisted us in our work and to
the American gentlemen whose generosity made it possible for us to
carry out our investigations.
Following I submit a few brief case histories giving an account of
the equipment used and the technic employed.
EQUIPMENT.
Two tubes—25 milligrams of radium element each.
One tube—18 milligrams of radium element.
Four tubes—10 milligrams of radium element each.
Ampules—50 micrograms of radium clement in 2 cc. normal saline.
Ampules—100 micrograms of radium clement in 2 cc. normal saline.
Solution—2 micrograms of radium element in 60 cc aq. destil.
Solution—100 micrograms of radium element in 200 cc. normal
saline.
1—In recent reports from Germany. It Is noted that hackward wounds are
belns exposed to sunlight. While in Paris. I was Informed that the violet rays
were employed for that purpose. How much more efficacious and convenient to
employ radium rays.
47

48 R a d i u m
TECHNIC, LOCAL APPLICATION OF RADIUM TUBES.
Screening: The screening employed for this work was one millimeter
of silver, the secondary rays being regulated by thin rubber or
celluloid tubing.
Amount of radium employed in given case: This factor is regulated
by the amount of induration present, the appearance of granulating
surface, and the character of discharge.
Time of application: Regulated by effect wanted (stimulating or
destructive) plus a consideration of the points mentioned above.
General remarks on technic: The most serviceable tube for general
military surgery is one containing ten milligrams of radium element.
This material is contained in a sealed glass tube about one half an inoh
long. This glass tube is enclosed in a silver tube about one inch long.
The thickness of the silver is one millimeter. This silver tube is, therefore,
a universal applicator. The rubber of celluloid tubing used as
additional screening can be easily sterilized. In acute cases the tenmilligram
tubes is placed for about ten minutes; in cases of long standing,
from fifteen to thirty minutes. In acute cases, one application is
made every third or fourth day until discharge is less; in cases of long
standing, application is made every second day. When the longer period
of time is employed, screening of tube is slightly increased.
EMPLOYMENT OF A SOLUBLE RADIUM SALT IN SOLUTION.
Intravenous injection: In order to secure a permanent solution and
one that will give exact dosage, radium element in the form of a soluble
salt must be employed. The salt must be dissolved in absolutely sterile
saline solution or sterile water, sealed in glass ampules, again sterilized
and permitted to stand for thirty days before using. To inject into a
vein, an all-glass syringe with steel needle is used, the skin is
sterilized in the usual manner and the most convenient vein selected.
Local use of radium solutions: What has been said regarding
radium solution for intravenous injection also applies to radium solutions
for local use. A solution containing two micrograms of radium
element to sixty cubic centimeters distilled water is the most serviceable
for general use. This solution is injected into the wound with a glass
syringe after the wound has been douched with sterile water or saline.
If gauze drainage is used, the gauze Should be saturated with the
solution.
The solution is employed, with normal saline, as a continuous
douche (drop method) in severe cases of infection; also as a rectal injection
(continuous drop method) in cases of severe shock. An intravenous
injection of one hundred micrograms will, however, give better
results in this latter condition.
CASES.
1. G. G. Malaria, two months' standing. Fifty micrograms radium
element into the median basilic vein. Improvement in general condition
noted in three days. Return of chills in sixty days. Patient should have
received a second injection but failed to return.
2. T. P. Lacerated wound of right arm; compound comminuted
fracture; infected; symptoms of general infection. Condition standing
from April 4 to July 15. Improvement noted after second application.
Temperature reduced and improvement in discharge.

R a d i u m 49
3. _ S. M. G. Penetrating wound of foot, injury to bone, infected.
Condition standing over two months. Improvement noted after first
application. Good recovery in ten days.
4. H. McP. Extensive lacerated wound of arm; compound comminuted
fracture, infected. Dead bone in wound. No improvement
noted after two applications.
5. S. C. Lacerated wound of shoulder; infected. Condition standing
over two months. Improvement noted after first application. Small
spicula of bone easily removed second day. Complete recovery in fifteen
days.
6. P. R. Leg amputated below knee in field hospital. Infected
with gas bacilli. Amputated above knee later. Condition standing from
May 9 to July 15. Two micrograms of radium element in 60 cc. aqua;
dest. as douche t.i.d. and moist dressings of same solution. Improvement
in pain and discharge third day. As directions were not being
carried out, treatment was discontinued.
7. W. D. Bullet wound of left arm; compound comminuted fracture,
infected. Large spicula of bone in wound. Improvement in discharge
in four days. Dead bone easily removed hut necessary to operate
for large spicula.
8. P. L. Extensive lacerated wound of leg Bone injured but
not complete fracture. Infected gas bacilli. Considerable pus and
slough present. Condition standing from June 15 to July 15. Marked
improvement after second application.
9. B. P. Extensive lacerated wound of arm; infected, nongranularing
and large slough present. Condition standing July 6 to 16.
Marked improvement after second application. Complete result in ten
days.
10. C. F. Lacerated wound of face, superior maxillary injury;
infected, dead bone present. Symptoms of general infection. Condition
standing April 25 to July 16. Reaction after use of tube and no improvement
noted after third application. Could not place tube in proper
location. After operation patient made good recovery.
11. F. J. Extensive lacerated wound of arm; compound comminuted
fracture and injury to joint. Wound infected and symptoms
of general infection. Discharge of pus. Condition standing from June
25 to July 16. Marked improvement noted afted second application.
This improvement in general and local condition.
12. P. R. Large open wound of leg, infected, nongranulating.
Condition standing from March 4 to July 17. Discharge stopped after
second application. Has been given frequent applications to stimulate
granulations. Complete recovery.
13. J. H. Lacerated wound of leg. Operated for foreign body,
infected. Condition standing from June 28 to July 23. Marked improvement
after one application. Wound entirely well in fifteen days.
14. D. P. Lacerated wound of elbow, bone injured, infected. Condition
standing from July 13 to July 23. Improvement marked in
three days.
15. S. M. T. Penetrating wound of elbow. Bone and joint injured,
infected. Symptoms of general infection. Condition present over three
weeks. Improvement in general condition noted in three days. Improvement
in local condition also marked
16. U. W. Infection (?) of ankle joint. Condition standing
several months with no improvement. Running temperature like tuber-

50 R a d i u m
culosis. After second application temperature reduced, swelling and
pain reduced and patient able to walk on foot in ten days.
17. P. H. Infected bursitis of ankle joint. Operated for pus.
Condition standing for three months without much improvement. Improvement
noted after second application. Patient able to walk on foot
in two weeks.
IS. J. B. Left inguinal hernia; blood pressure 200 mm. Pulse
running 108 to 110. Urine normal, chest normal. Diagnosis not positive.
Injection of 100 microgram radium clement into median basilic
vein to note effect on blood pressure. Some reduction in blood pressure
but not marked. Concluded that high blood pressure was not circulatory.
19. L. P. Lacerated wound of back. Foreign body removed by
operation. Sinus still discharging pus and nongranulating surface. Condition
standing from June 22 to August 24. Improvement in discharge
and better granulations after two applications.
20. P. McL. Lacerated wound of knee. Immediate operation for
hemorrhage, wound infected. Some improvement noted in discharge
after second application. Pain relieved. Pocket of serofluid developed
in old incision. Operated. Later had hemorrhage from wound and again
operated. No applications after second operation.
21. J. I. Wound above right clavicle. Bone injured, small pieces
of bone removed from time to time. Infected and considerable discharge
from sinus. Standing for two months. Improvement noted in
discharge from sinus after second application.
22. Wound of left shoulder. Bone removed by operation. Infected.
Standing from May 15 to August 31. Pain and discharge
much improved after first application.
2Z. S. A. Lacerated wound of leg; operated for foreign body.
Condition standing from March 15 to September 2. Discharge improved,
no pain, and reduction in swelling after first application of rsdium (35
milligrams used on this case).
24. J. L. Lacerated wound of leg, operated for foreign body;
infection present. Sinus leading to bone. Condition standing from
April 3 to September 8- Patient said there was no pain after first application
of radium. Discharge cleared up after second application.
Patient able to walk in ten days. Complete recovery.
25. P. P- Osteomyelitis of left upper femur. Standing since
October 14. Bone removed by operation following August. Condition
at time of radium application: Three openings leading to bone and
discharging pus. In three days discharge less. In thirty days wounds
entirely healed up. (Used cross-fire method on this case, 25-, 18- and
10-mgm. tubes being employed for ten minutes.
26. J. L. Lacerated wound over left iliac crest. Bone exposed,
operated in July for foreign body. Condition standing from June 15 to
September 15. Foreign body still in wound. Gave raying from 25-mgm.
tube and on October 4. piece of shrapnel was removed by operation.
Afterwards gave small dose and wound healed and closed up entirely.
27. L. C Lacerated wound of elbow. Compound comminuted
fracture. Operated for foreign body four days after injury was received.
Operated for nerve four weeks after injury. Wound infected.
Time of treatment, sinus presented discharging pus. Foreign body still
present in wound. Condition standing from April 24 to September 18.

R a d i u m
Five days after first raying, foreign body removed. After this, sinus
was again rayed with a good result.
28. I. K. Lacerated wound of arm; compound comminuted fracture.
Infected. Patient had temperature, local swelling and edema,
discharge, etc Concluded foreign body still in wound.
29. C. S. Compound comminuted fracture of arm, infected. Large
open wound. Condition standing from August 15 to September 16.
After first application, free from pain and wound in much better condition.
30. E. B. Penetrating wound of popliteal space. Foreign body
removed and artery ligated by operation. Wound infected and considerable
discharge. Condition standing from April 30 to September 24.
After first application of 25-milligram tube, some improvement noted.
May be that foreign body is in wound. Wound closed up on October 9.
31. W. T. Compound comminuted fracture of tibia. Infected.
Sinus to bone. Condition standing from July 30 to September 27. After
one application wound closed up in ten days.
32. R. P. Compound comminuted fracture of right tibia. Infected.
Condition standing from June 20 to October 2, 1915. After first application
and in about four days, healthy granulations over entire surface
of wound.
33. C. R. Shrapnel wound of left temporal region. Bone exposed,
soft tissue undermined. Not a favorable case for radium. No
improvement after first application and no further treatment given.
34. P. D. Shrapnel wound upper part of tibia. Infected, bone
removed September 24. Sinus leading to bone and discharging. Condition
standing from July 3 to October 4. One application made and
in ten days sinus closing.
35. R. W. Gunshot wound of arm. Sinus leading to fracture-
Slight temperature, septic Discharge of pus. Condition for about three
months. In five days after first application, improvement was very
marked.
36. L. G. Gunshot wound of left arm. Amputated and reamputated
at upper third. Stump healed excepting discharging sinus. Condition
standing from May 12 to October 18. After two applications,
marked improvement in discharge and less pain.
37. C. L. Bullet wound through gluteal region, paralysis of bladder.
Infected. Bullet removed May 18. Long sinus, obstinate discharge,
considerable pain. Condition standing from March 23 to September
23. After several applications, character of discharge became less
purulent. November 3. wound filling slowly and discharge much less.
38. Y. B. Shell injury to leg. Leg amputated and reamputated.
Three discharging sinuses. ' Condition standing from June 15 to September
29. After three applications, decided improvement took place.
39. P. Y. Gunshot wound of shoulder. Two bullets removed.
Sinus three inches long. Condition standing from April 22 to September
29. After several applications wound is almost healed and no discharge
present.
40. W. T. D. Compound comminuted fracture of both bones of
arm. Nonunion. Waiting for sinus to close before operation. Condition
standing from August 22 to October 13. No improvement after
two applications. Treatment not continued.
41. P. S. Shell injury to shoulder. Foreign body removed. Dis-
51

52 R a d i u m
charging sinus to bone. After two applications, sinus closed and no
discharge.
42. H. C. Gunshot wound left side. Foreign body removed and
rib fractured. Discharging sinus. Condition of long standing. Considerable
improvement in discharge after two applications.
43. E. A. L. Bullet wound left gluteal region. Dead bone removed
by operation. Sinus extending from posterior opening to skin
surface in front. Condition standing over five months. After three
applications, sinus clean, less discharge and wound closing.
44. H. M. Leg amputated May 18. Several reainpu tat ions. Sinus
one to one half inches deep in flap. Condition standing from April 18
to October 27. Two applications radium, wound became clean and
sinus closing.
45. P. W. Gunshot wound of hip. Sinus through sacrum. Condition
standing from March 20 to November 2. Two applications of
25 milligrams radium clement; improvement very marked.
46. A. G. Gunshot wound of arm. Bone and shrapnel removed
by operation. Condition standing for five months. Improvement after
one application.
47. I. O. Infected mastoid of long standing. General condition
bad. Temperature 100° to 103° over a long period of time. Pus
dissected up tissues over large area of scalp and neck. Number of incisions
made but patient would not permit radical operation. All other
agents did not improve local or general condition. Wound douched t.i.d.
with radium solution (2 micrograms to 60 cc aqua; dest.), moist dressing
same solution applied. Given 8 micrograms four times a day by
mouth. Three days following treatment, discharge was reduced. In
seven days infection cleared up. Temperature normal and patient able
to be up.
CONCLUSIONS.
1. The application of a stimulating dose of radium rays (ten to
thirty-five milligrams of element, in tubes, from ten to twenty minues)
is the most effective agent employed up to the present time in the
treatment of wounds in what may be called the subacute or chronic stage
of infection. The same may also be said of nongranulating wounds.
2. By raying to the point of tissue destruction, the removal of
sloughing tissue, dead bone, etc. may be facilitated.
3. In raying deep sinus cases, care must be -taken to place tube at
bottom of sinus. If foreign body prevents, the case should not be
rayed until same has been removed, unless the raying is intended to
facilitate the removal of bone spicula.
4. The number of cases already reported will demonstrate that
the intravenous injection of radium is void of danger. Its effect on the
circulation, the clotting period of the blood, on the red and white cells,
and its effect in increasing the action of other agents makes it a most
valuable agent in the treatment of shock, anemia, and cases presenting
symptoms of general infection.
5. Although the opportunity for using a solution containing radium
element has not been very large, in the treatment of acute infected
wounds, enough data has been collected to demonstrate that its use in

R a d i u m 53
combination with normal saline, will give just enough stimulation to
local circulation to bring the white cells constantly into action.
6. Radium rays have no bactericidal action and the effect, when
used locally, is due to the stimulating effect of the rays.
7. Because of the long period of time radium tubes may be employed,
and the number of cases capable of being treated in twenty-four
hours, we believe we have developed the most economical method of
treatment of backward wounds. i
RADIUM IN NON-MALIGNANT CONDITIONS'
Walter B. Chase, M.D.
BROOKLYN-NEW YORK.
The quite common belief that the usefulness of radium is limited
to malignant conditions is not based on facts or experience; on the
contrary it is an unsettled problem whether or not its larger applicability
may be in benign ailments. While the general law of its use in nonmalignant
diseases is similar, in point of application the technique is
quite different. This diversity is seen in smaller doses and usually in
shorter period of application; though exceptions are found in treating
large fibromata and tubercular"glands.
Its applicability is established by recognized authority in tubercular
lymphangitis, polypoid endometritis, hemorrhagica metropathia, goitre,
lupus, urethral caruncle, keloids, and a variety of rheumatic and rheumatoid
involvements, and in local inflammatory infections. As typical
of its usefulness I have selected three cases of diverse pathogenesis, in
non-malignant conditions, compiled from the official reports of my work
during July, August and September, 1915, at the Norwegian Hospital
in the service of Drs. Delatour, Skelton and Graham. Most of this is
copied verbatim.
Case 1: J. L., aged 21, maidservant at the Norwegian Hospital.
Previous history good, only sickness being influenza in February, 1913.
She was operated upon for cervical adenitis, left side, May 29, 1914,
by Dr. Delatour. At this date, July 9, 1915, there remained a discharging
sinus, left side of neck, leading upwards and inwards for two inches.
On August 28, 1914, she was anesthetized and the sinus thoroughly
curetted by Dr. Skelton, but nevertheless the discharge persisted. Between
August 14, 1914, and July, 1915, this sinus was curetted at least
twice without an anesthetic Early in July, 1915, Dr. Graham filled
the sinus with carbolic acid without result. On July 9, 1915, I began
radium treatment; twenty-five mgms. being used as follows: a tube
containing ten mgms, was passed directly into'the sinus, and fifteen
mgms. were applied to the skin over the sinus, thereby producing "cross
fire." On July 13, the discharge was greatly diminished and on July 16,
healing had taken place. On August 10, the patient sat in a draft of
cold air. This was followed by slight discharge at site of former sinus.
August 13, fifteen mgms. .of radium were applied for fifteen minutes
over the line of sinus. August 15, sinus healed. September 3, sinus still
"Lone Island Med. Journ.. Dec, 1916. Bead bcroro the Brooklyn Surgical
Society, October 7, 1916.

54 R a d i u m
closed. Same conditions present on presentation of patient at Brooklyn
Surgical Society, October 7.1
Comment: Tubercular glands are susceptible to radium rays providing
caseation is not present—and its use by avoiding excision adds
to the cosmetic results. In lymphadenoma, confined to small superficial
areas, disappearance is frequently brought about by radium.
Case 2. Mrs. J. M., aged 40. Metrorrhagia. Patient very pale,
complains of weakness, headache, and backache. Admitted to Norwegian
Hospital, July 20, 1915. History shows she had been bleeding
for one year, and for four months before admission it had been practically
constant. On admission she was markedly exsanguinated, heart
sounds weak, respiration 2?, and pulse, 80 to 90. Otherwise normal.
Hemoglobin 40 per cent. Pelvic examination revealed a moderately
enlarged prolapsed uterus and first degree retroversion. Diagnosis:
Polypoid endometritis. July 21 to 24, severe uterine hemorrhage, so
marked as to require vagina! packing to control it. July 2$. packing
removed and twenty-five mgms. of radium introduced into the cervical
canal, which was removed after thirty-three minutes. Sensation of
numbness in lower abdomen during the application of radium. July 26,
considerable bloody vaginal discharge. July 31, enough discharge to
cause spotting. August 1 to 21, no bleeding. August 22, slight discharge.
August 23, bleeding stopped. August 24. discharged to return
for observation on request. General condition improved, hemoglobin
70 per cent. The patient began to feel better and increase in strength
from the very date she was given radium. Up to October 7, she had
not returned to the hospital.
Comment: The extreme weakness of this patient forbade any
heroic measures, and even curettage (much less hysterectomy) was
contraindicated. The reason why a larger quantity of radium was not
inserted arose from the extreme weakness which forbade any effort at
cervical dilatation. In fact she passed into a condition of syncope at
the time it was inserted. Her failure to return to the hospital gives
credence to the belief her menorrhagia was overcome.
Case 3. A. C, aged 32. longshoreman. Service of Drs. Delatour
and Graham. Admitted to Norwegian Hospital. May 27, 1915. with
compound fracture of both bones of left leg, just above ankle. On
June 7, fracture was reduced under anesthesia: plaster cast was applied
with opening over ulcerating area near ankle to permit of dressing. There
were three ulcerating sinuses at points of fracture leading down to
bone. Over the anterior portion was an area of denuded periosteum
five and one-4ialf inches long, of varying width. The discharge was
profuse and the patient weak and exhausted. July 7. twenty-five mgms.
of radium in three separate tubes was introduced into the sinuses,
remaining for fifteen minutes. Immediately after this radiation. Dr.
Graham removed about one inch of the upper fragment of the tibia
which was protruding at the ankle. July 10. fifteen mgms. of radium
applied to the sinuses for fifteen minutes. For one-half hour patient
experienced sensation of numbness from the knee down. July 12. discharge
decidedly lessened. July 14. wound granulating rapidly. Fifteen
mgms. applied to sinuses for fifteen minutes. July 20, sinuses closing
up rapidly, and patient discharged from hospital, to return from time to
time for observation and treatment. Subsequent history. Leg dressed
at Hospital, July 24, 26. and 31. There was apparently firm union at
1—Feb. 21, 1916, sinus remains closed.

R a d i u m
point of fracture and the granulation in the sinuses had almost reached
the skin level. Patient directed not to place any weight on this loot.
August 2. notwithstanding orders to the contrary, the patient appeared
at Dr. Chase's office with crutches but bearing most of weight on
injured leg. Dressed by Dr. Chase. August 7, patient came to Dr.
Chase's office using crutches for support of leg. Foot moderately
swollen and tender and on its dorsal aspect there was a pin point perforation
of the skin discharging sero-purulent fluid. Twenty-five mgms. of
radium was applied for one-half hour over the anterior aspect of foot.
August 9, 13 and 17, leg dressed at Norwegian Hospital. Sinuses on
dorsal aspect of foot healed over, but entire foot still quite swollen and
of purplish tinge. September 6, redressed at Norwegian; Hospital,
swelling of foot greatly diminished. The condition October 7, when
presented to the Brooklyn Surgical Society—save for a superficial ulcer
over instep, was substantially as last described.
Comment: Notwithstanding the forbidden and reckless use of
the leg the results of this case give hope as to the future usefulness
of the leg, and go to establish the efficacy of radium in local inflammatory
infections, notably of the streptococcus variety. Radium does not
act as a germicide, but by some occult selective influence, its modus
operandi being obscure. The literature of the treatment of these nonmalignant
inflammatory infections by radium is meagre.
Along this line Bissell, Medical Record, July 19, 1915, records
results probably unequalled by any previous writer—in fact, these results
of its use mark a new departure in the treatment of local infections
and of blood dyscrasias; notably in pernicious anemia and in the persistent
anemia following surgical injuries. This future field of radium
therapy will be watched with interest by the surgical world as it opens
new possibilities of dealing successfully with these difficult and grave
problems.
RADIUM.
A RECOGNITION OF ITS EFFICIENCY AND A PLEA
FOR MORE THOROUGH INVESTIGATION.*
By Douglas C. Mori art a, M.D.,
SARATOGA SPRINGS, N. Y.
So much has been said concerning radium in the lay press that
you may wonder whether it belongs to the armamentarium of the
regular or the quack. Personally, I feel that it is a live subject, and
that any adverse criticism from the inexperienced unbeliever, that would
affect its use where it is indicated, is unfortunate, for it certainly does
possess remedial qualities peculiar to itself.
It has been said that "radium is to be considered a force and not
a therapeutic measure;" and notwithstanding its physiological action,
this expression is certainly suggestive. Radium has been employed in
treating disease for more than ten years, but it is only within the last
two or three years that it has been more generally taken up by the
profession. A reason for this is perhaps, that the earliest specimens of
• Medical Record. Vol. 89. No. 10, pp. 410-13. Mar. 4; 1916. Read hy Invitation
before the Glens Falls Medical Society of New York. December 17, 1915.
53

56 R a d i u m
radium were disappointing in their action, for it has since developed that
they did not contain the quantity of radium that was expected. This
was due no doubt to difficulties in producing a pure product commercially.
Radium is a metallic element found in carnotite ore and pitchblende,
and first separated by Madame Curie in 1898. It belongs to the
strontium-barium group, forms salts with the mineral acids, and is the
leading element in the radioactive group whose peculiarity is atomic
instability. In the process of disintegration of radium, which never
ceases, it loses a portion of its atom and becomes a gas, which is the
radium emanation.
Radium emanation can be separated from the radium as fast as
it is formed, and a definite amount of emanation is always evolved from
a given amount of radium. The emanation from a gram of radium
(value $120,000) multiplied by thirty, would only equal a volume of
gas the size of a small pin head. When we realize that few practitioners.
employ more than 100 to 500 milligrams, and most of us work with
success vvith quantities varying from 50 to 100 milligrams, we get some
conception of its wonderful force.
In the so-called decay of radium, a particle of radium splits into
alpha rays and emanation; this emanation in turn splits into alpha rays
and secondary deposit, and from the splitting of this secondary product
come the other two classes of rays, known as beta and gamma. If this
splitting or decay, which is constantly going on, occurs in radium that
is sealed, the emanation is enmeshed in the radium itself, and gives rise
to the mechanism of general radiation and the liberation of energy.
This is the so-called "ageing" of radium, freshly prepared radium being
comparatively inert until the process has advanced thus far. As there
are no gamma rays until the third decay product, the maximum of the
gamma rays, under these conditions, does not develop for a month.
If, however, the radium is open, or in solution, the emanation is
liberated as such, and may be used by inhalation or in solution as
activated water. Thus, in any case, the action of radium depends upon
emanation, which is its radioactivity. In the one case, as in a tube,
there is a uniform activity of the rays from the splitting and successive
products; in the other case the emanation is introduced into the body,
where the splitting of the rays goes on with the same identical liberation
of rays and energy as if it were sealed. Thus the therapeutic value of
radium may be roughly divided into external and internal administration.
The three kinds of rays, to which the names alpha, beta and gamma
have been given, have well-defined characteristics and differences.
Technically speaking, alpha rays arc not rays at all. but are positively
charged atoms of helium, with a weight four times that of an atom of
hydrogen. They are liberated with an explosive force, and travel 12,000
miles a second. The energy of their liberation accounts largely for
the heat of radium, and the force of their bombardment for the injuries
to the tissues, such as superficial irritation, as well as burns of varying
degree.
The beta rays are also not rays at all. but a negatively charged
stream of electrons.
The gamma rays are not particulate matter, but a vibration of
ether, similar to ordinary light. They do not polarize, pass straight by
a magnet, and are not deflected by a prism.

R a d i u m 57
In the use of radium externally it is necessary that the rays should
be filtered to avoid superficial irritation and burns. By this we mean
simply that the passage of certain rays must be obstructed by the interposition
of some material or space that will absorb or stop the rays
that are developed which we do not want to use. Alpha rays, being
particles all traveling the same distance at the same time, are stopped by
a slight obstacle, such as a sheet of paper. Beta rays show different
degrees of penetration, being divided into soft, medium, and hard.
If one makes space the filter for these various rays, alpha rays are
cut off by a distance equal to 3 cm. of air; beta rays, by about three
times that amount; while gamma rays would reach a distance of 100
meters and still affect the electroscope, or travel 3 meters, penetrate a
man, and cause a fluorescence beyond him. The ratio of penetration of
these rays may be expressed hy 1; 100; 10,000.
For the alpha and soft beta rays, one may make simple filters of
lead, paper, rubber, or mica. Metals, however, furnish the common
filters for the medium and hard beta and gamma rays; silver, aluminum,
lead, brass, and more recently gold and platinum, are employed. One
centimeter of lead screens the hard beta rays completely; gamma rays
need 5 cm. of lead for what is practically complete absorption, although
a small fraction will still be left with 10 cm. We thus vary the quality
of the rays by filtration. Without filtration, there are 90 alpha particles
to nine beta and one gamma ray. Under strong filtration, 600,000 total
rays are reduced to 5,000 (gamma) rays.
Mention should be made -of still another class or rays which are
created when a filter of lead is used in the application of radium; they
are called secondary rays, are very irritating, and can be screened by
rubber tissue of varying thicknesses.
After the nature of the rays and the kind and amount of filtration
have been determined, the third factor in radiation is the density of
the tissue to be radiated. A knowledge of all three facts is essential
in practice; in fact, they absolutely control and determine the results
of radium treatment, when it is used externally, and when these factors
are not well understood, it is easy to account for the failures and disappointments
in its external use. It is my experience that radium is
always going to do something, but success in its use will be achieved
only after wc have learned how to use it.
In considering the use of radium, we will find that the alpha rays
must in the main be rejected therapeutically. Their discharge has been
called "the most intense liberation of power in nature." Kinetic energy
is their chief characteristic. As has been said, they account for the
heat of radium, their chemical energy is shown in catalysis, and the
rays are irritating and destructive to normal tissue. Soft beta rays arc in
much the same category; but the hardest beta rays which are much
more penetrating, are similar in effect on pathological tissue to gamma
rays. In gamma rays, it is agreed, we have the most useful therapeutic
agent of radium as they will penetrate a great distance, though as we
have said, their number is relatively small. Our problem is to get the
greatest amount of these rays in any given place. This will depend
upon the intensity (amount of radium used), the manner of filtration,
and the period or time of exposure. The intensity of an application is
greatly augmented by what is termed "cross-firing;" this is simoly the
focusing of the gamma rays from several sources upon a given district;
the burying of a tube will also increase its efficiency many times, because

58 R a d i u m
all the rays will thus become engaged; while if it lies upon the surface
this is not the case, as only the rays emitted in the direction of the
object can be effectual.
Gamma rays are shown to have a predilection for pathological cells,
in proportion to their youth, embryonic state, or degree of development;
the quantity of radium employed should be at least sufficient to affect
the normal tissue. Young connective tissue, in the vicinity of the application,
may be observed multiplying and developing vigorously. This
is the essence of the favorable action of radium on morbid tissue; normal
tissue elements are stimulated, while morbid ones wither and are
gone. All observers have seen the wonderful power of radium to
destroy growths of a simple and intermediate nature, from warts to
non-infiltrating carcinoma. Large cell growths arc simply ''blown to
pieces." New growths differ considerably as to their degree of resistance.
Epitheliomata require larger doses than some other morphological
tissue. The nearer the surface of the body the new growths are,
the easier can they be destroyed, whether benign or malignant. Growths
of the mucous membrane of the mouth require large doses and are quite
difficult to cure. The effect of radium extends only to the depth of a
fraction over an inch; therefore, a large mass to be attacked successfully
must be carefully plotted with extensive direct radiation. If possible,
a tube of radium should be placed in the tumor mass for a cross-fire.
Applicators in the form of needles are here useful. The results of
treatment may be complicated by an erythema, or even a severe burning,
and by extensive edema. This is usually due to ineffective screening,
or too long an application, where a large dose seems imperative.
Toxemia from absorption, following prolonged treatment where there
is no drainage, must be borne in mind, for I am convinced that massive
radiation was a factor in a fatal termination of one of my cases. Burns
per se are not material if the desired result has been accomplished at
the time they occur. They are ordinarily superificial. not very painful.
and heal slowly. But if the further local application of this particular
field is to be continued, then the early irritation or congestion must be
recognized and radium application be discontinued for a time, otherwise
sensitization of the skin will result and further treatment must be
delayed indefinitely. After the area is once sensitized I find it
necessary to renew treatment with much smaller dosage.
As I have said, all these mentioned factors enter into the problem
of the successful use of radium. In addition to the knowledge of the
character of the rays, the technique of filtration, the time of exposure.
etc.. we must take into consideration the amount which it is necessary
to use. its form and shape, and the location and position of the application.
We must also consider the susceptibility of the tissue involved, its
pathology, the varying degrees of resistance of the different normal and
abnormal tissue cells, as well as other chemical, physiological, and biological
factors, all of which must he understood before the therapeutic value
of this element can be fully determined. Until experience has given us
more knowledge, the results of treatment must, in many cases, be unsatisfactory;
not because radium is not capable of doing the things we
would like, but because wc have not as yet learned how best to make
it always do what we want it to.
Radium administered internally has an action startling in many
ways. Here it is used either bv inhaling the emanation, drinking the
activated waters, or water in which radium salts have been dissolved.

R a d i u m 59
or by intravenous injections; all of these methods are effective in their
proper sphere.
1 he physiological action of radium sounds not unlike a fairy tale.
It often increases Ihe red blood count '.4 of a million in forty-eight hours,
and also the hemoglobin markedly in a short time. It stimulates all cell
life, particularly that of the enzymes, thus aiding and improving
metabolism. It increases the elimination of carbon dioxide, urea, and
uric acid, and in addition is said to keep the latter in solution in the
blood. It diminishes the viscosity of the blood and greatly increases
the quantity of urine secreted. In stimulates and increases the appetite,
and aids digestion by activating the digestive ferments. It dilates the
blood vessels, through the excitation of the vasomotor nerves. Its
action in anemia is little short of marvelous, it relieves the pain and
local manifestations of gout promptly, and also the pains of neuritis.
It lowers blood pressure almost so surely as you administer it. It is a
prompt and powerful tonic and stimulant. In larger doses it often
produces a decided reaction, causing headache, nausea, lassitude, and
general body discomfort. The cases in which this reaction occurs are
thought surely to receive benefit from its use. No toxic or lasting ill
effects have been reported.
The dosage of radium is quite as important internally as externally.
Internal dosage does not seem to have been definitely determined, though
we are daily getting a more clear conception as to what can be expected
from various dosage. The men who use infinitesimal doses, and there
are a goodly number of them, are quite as enthusiastic over the effect
secured as are those who use it in larger doses; and none of them
hesitates to express his opinion of its therapeutic value. The varying
degrees of chronicity and the amount of metaliolic derangement seem
to be controlling factors as regards the amount of radium emanation
to be given. Frequently, we meet patients who exhibit a well marked
susceptibility to radium and who react to extremely small dosage. Ordinarily,
I classify my cardiovascular-nephritic cases as requiring lowdosage
and my arthritis cases as requiring high dosage. Each case must
be judged as it stands and after treatment is inaugurated its course must
be regulated by carefully checked laboratory findings.
I first became interested in radtium in 1912, when the National
Bureau of Mines announced that some of our mineral springs at Saratoga
contained radium in solution, and that others were activated by
radium emanations. The Bureau of Mines, in making this announcement,
furnished me with the explanation of the value of our mineral
spring waters, which to me had always been uncxplainable. In a paper
written in 1908 I stated that the results I had observed from the use
of the waters were surprising, and could not, to my mind, be accounted
for by a knowledge of the chemical analysis of the waters. I stated
that the natural waters at Saratoga presented unusual therapeutic properties
which are peculiar to themselves and not presented by artificial
waters made after the analyses of the chemists, and gave as a reason
that I believed that the combination of basic and acid radicals in nature's
laboratory under pressure and heat did not result in the theoretical
formula believed and accepted by the chemists who made the analyses.
I am now convinced these peculiar therapeutic properties arc due to
radium influences. We arc not in a position to announce at this time
any data relating to the limitations and efficiency of radium as a catalyzer.
Suffice it to say that it is a property of marvelous importance.

60 R a d i u m
For years I have had unusual results from our mineral spring
waters, when their use was associated with a carefully directed personal
regimen, in cases of high blood pressure, gout, obscure neuralgic pain,
arthritis, etc., the reasons for which were not clear to my mind, until
I became familiar with the physiological action of radium in various
amounts and knew that it was contained in our waters. With those
who would refer all the benefit derived by these patients to the regulated
regimen, and a protein-free diet, I would disagree. Radium, even in
such small doses as occur in our Saratoga waters, is a _ wonderful
synergist to metabolism and when it is administered, proteins do not
have to be so restricted, neither do nitrates have to be used to control
the high blood pressure of arteriosclerosis. As we increase the amount
of radium by direct administration, either by intravenous method or by
mouth, definite biochemical manifestations are noted which give us
reason to accept radium as an active therapeutic force.
A word concerning arteriosclerosis may not be amiss. The early
symptoms of this degenerative process are scldomi appreciated, because
they have not been associated with the diagnosis of the later manifestations.
The late symptoms are often confused with atheroma of the
arteries, the latter being due to advancing years and senility, while
arteriosclerosis need not of necessity be a senile condition. TJhe early
symptoms of arteriosclerosis are nervousness, irritability-, insomnia, and
a general breaking-down in a young person; these are caused by continuous
over-work, excitement, speculating, the use of alcohol, gormandizing
—in fact, the abuse of nature in every way. A large number of these
individuals soon or later, develop the late symptoms, which are characterized
as cardiovascular, cardiorenal, and myocardial degeneration, with
the concomitant high blood pressure; this latter symptom being very
popular, is the bugbear of the public generally and a meal ticket for
the profession particularly. It would seem to me that this symptom is
not correctly interpreted or well understood, and it occurs to me that
physicians seldom differentiate between a high compensating pressure
and a true hypertension. In other words, the etiology and pathology of
airterio-sclerosis are entirely ignored, and the one ambition seems to be
the relief of this one symptom, i.e. high blood pressure. In my experience,
radium never fails to control this symptom when it is intelligently
administered. I have treated these cases for many years in my
summer practice by regulating the diet, amount of exercise, etc., with the
internal and external use of our mineral waters; and usually the symptoms
arc controlled to a marked degree, without the use of nitrates; and
this result, I now believe, is due to the radium contained in our mineral
spring waters. Following up this effect I have found that with increased
radium dosage I can secure more permanent results in my cardiovascular
cases.
In the direct application of soluble radium salts, my experience
extends only over a period of about fifteen months. During this time
I have used it in emanation, in activated water, the dissolved salts intravenously,
and radium solutions by mouth in about sixty cases. My
results have been without exception amazing; so much so that those
uninformed concerning radium, or those who are skeptical as to its
value, would surely question my conclusions.
I appreciate the fact that the number of cases is too few. and the
period since instituting the radium treatment too short for the results
to be accepted as cures. Vet they serve to emphasize the statement

R a d i u m 6i
that I have made that radium is a potent therapeutic measure, when the
quantity of radium that should be used in a given case, and the conditions
controlling its use are correctly interpreted.
I have found that when a patient is to be treated by radioactive
waters or by inhalations, the best results are obtained by commencing
the treatment with the injection intravenously of at least 25 micrograms
of radium chloride; the idea is to give a goodly quantity to act
in the body in the beginning, and to maintain the saturation by replacing
the elimination of the dissolved salts, by the waters or by the inhalation
of emanation.
The amount of activated water that a patient will accept I have found
will vary from 10,000 to 100,000 mache units daily. I have usually
administered it in four doses, so divided that three are given one-half
hour after meals and the fourth on retiring.
In all cases in which I have used radium internally, I have preceded
its use by making a red blood count, noting the hemoglobin and the
blood pressure, and making a urinary examination. I have observed that
without exception there has been an increase in the red blood cells of
from 50,000 to 250,000 in ninety-six hours. Invariably the hemoglobin
has been increased. When radium is well borne, it is a marked tonic
and stimulant; the appetite has been markedly improved, as have been
the digestive processes, and the patient experiences the sense of well
being.
In one case of arthritis deformans which I here cite as a type, the
patient, a school teacher, 50 years old, was practically a helpless cripple.
Her hands were terribly deformed, the joints large and fingers thrown
out at an angle; in fact, we had a typical picture of this condition. Her
knees and ankles were swollen, the motion in all joints limited, she could
not close her jaws tightly, had difficulty in masticating her food, the
tissues of her back were in a tumified condition, and she was in constant
pain. She was given an intravenous injection of 50 micrograms of
radium chloride and then continued to use radium by drinking the
activated water. After a period of four months the pain has subsided,
she walks without limping, and closes her hands, and, as she says, bites
a thread if she wishes to when sewing. I might mention in this particular
case, that her blood pressure at the time of taking the injection was
240, the blood count 3,500,000 and the hemoglobin 80 per cent. Twentyfour
hours after its administration the blood pressure was down to 180.
Ninety-six hours after the treatment, the red blood count was 5,200,000,
the hemoglobin 90 per cent, and blood pressure 185. The quantity of
urine had increased from 30 to 60 ounces daily.
I have had eight cases of neuritis or myalgia that had existed for
months, resisting all treatment, that have been relieved by the use of
radioactive waters with a single intravenous injection at the beginning
of the radium treatment.
I have had seven cases of nephritis with albumin, casts, headache,
loss of appetite, shortness of breath, and precordial distress—one in particular
with the headache so strongly marked that the patient was incapacitated.
All cleared up so that the patients, to use their own statements,
which seemed general, "feel like a new being." I have had two
cases of gout which under emanation treatment were entirely relieved
of active symptoms.
My results from the local application of radium in malignant and
benign ign growths have been equally startling. I have been permitted to

62 R a d i u m
use the element to date in some fifty-three cases, which present conditions
varying from carcinoma of the breast to uterine fibroids. As a result I
am greatly impressed with the value of radium in gynecological practice.
The large majority of these cases gave entirely successful results—
in malignant cases futures are to be considered. Radium exerts a
destructive influence on the malignant mass in a manner more humane
than any other known agent after the knife has been withheld. It controls
pain, hemorrhage, and odor. It frequently gives a hope to the
hopeless that I would not withhold. I esteem radium as an invaluable
adjunct to surgery and I feel we are fast gaining a better conception
as to its efficiency. My recent experience from the use of radium in all
of its forms has been so uniformly promising that I actually hesitate
to report it and I would not wonder should clinicians question the
accuracy of my primary observations and ultimate results. I assure
you my convictions that evidence enthusiasm have developed against my
prejudices. Personally, I feel that we should endeavor to foster in
every manner any investigation that shall have as its purpose a thorough
study of this wonderful element. We should be able to look to some
of our great research laboratories for real data. The day is past where
we will proclaim radium and radioactive substances as agencies of
mystery with no special merit. The little we are able to unfold tells
a different story. The problem is how soon are we to know and understand
its marvelous energy?
NEW BOOKS
Radium. X-Rays. and the Living Cell. H. A. Colwell, M B
(Lond.), D. P. H. (Oxfd.>, and S. Russ, D.Sc. (Lond.). London:
G. Bell and Sons. Ltd., 1915, (Med. 8vo., pp. 334; 61 figures, 2 plates;
$4.00.) This book is an important addition to our. unfortunately too
few. authoritative texts on radium therapy. We can do no better than
quote the commendatory review of this book in the British Medical
Journal, p. 132. Jan. 22, 1916.
"Colwell and Sidney Russ, in publishing a book on Radium, X-Rays,
and the Living Cell, state that their object is to describe some of the
main experimental facts which have been established as to the effects
of the X-rays and the rays from radium upon living cells. When innumerable
papers are appearing day by day in medical journals all
over the world (a few scientific, but by far the larger proportion merely
personal records of cases and results), it is well to have a clear and
lucid account of the chemical and physical properties of these radiations,
and a rational exposition of their effects on living cells, with a
scientific explanation of the manner in which these effects arc brought
about. With these objects in view the authors have produced a work
which should do a great deal towards placing X-ray and radium therapeutics
on a more scientific basis than has hitherto been possible. In
the first chapter an important point is emphasized in dealing with the
measurement of X-rays, a point which is by no means commonly known

R a d i u m 63
even amongst so-called experts. The change of color in a prepared
pastille is a common method of measuring an X-ray dose, and yet
by a simple experiment this method can be shown to be very inaccurate.
The authors point out that a "soft" tube in a certain time will change
the pastille to the standard tint; then harden the tube, readjust the
primary current, and a new pastille suffers the same color change in
the same time. The dose, as measured by the two pastilles, is the same,
yet the clinical effects upon the tissues, seeing that the tube condition
is quite different in the two cases, must be profoundly different. The
early chapters on X-rays, secondary X-rays, the transmission of
X-rays through matter, the ionization effects, and other similar matters
should be of great value to X-ray therapeutists. They are followed by
chapters on the radio-active substances and their emanations, written
on similar lines. Dealing with the standard of radioactive quantity,
it is pointed out that the mache unit has been much abused by its too
general use, and that its uses for cases other than that for which it
was originally intended—namely, the measurement of very small quantities
of emanation in waters—is to be deprecated. Part II starts by
describing the chemical action of radium and of X-rays, and then follow
chapters on the effect upon certain low forms of animal life. The
diagrams showing the restriction of development following radium irradiation
of the ova of triton are remarkable; a description of the histological
examination of a human fetus after exposure to X-rays is
of great interest. Next we have the results of experiments on the
growth of plants and of bacteria, and note that the authors have omitted
to refer to the experiments carried out by Abbe. The latter part of
the book, well illustrated by reproductions of photomicrographs, deals
with the histological changes brought about in various organs, such
as the skin, the blood and the blood vessels, the various glandular structures,
the nervous system, and other tissues. A full account of the
changes in malignant cells follows, and emphasis is laid on the fact
that the administration of the type and intensity of the radiation most
appropriate to any particular growth is a matter of great difficulty.
The data may at present be insufficient for any sure basis of radiotherapy,
yet a large number of facts are being gleaned which should
render this possible in the near future. Short chapters on the production
of malignant disease by the rays, idiosyncrasy and dosage, the
physiological effects, and the selective and differential action of rays.
form the concluding part of the work. Two features add to the value
of the book—namely, that a very complete bibliography follows each
chapter, and that the authors in each section have placed side by side
the chapters on radium and X-rays. This method of arrangement makes
it easy to follow and to compare results, and adds greatly to the value
of the book for reference."
Reviews and Abstracts.
"Combined X-ray and Radium Treatment of Inoperable Uterine
Cancer. Bergonie and Speder (Arch. (Fclcctr. med. No. 391, 1915)
make use of a military analogy in comparing X-rays and radium
applications in the treatment of uterine cancer. The X-rays, they say,
may be likened to machine guns which, stationed on the crest of hills,

64 R a d i u m
concentrate their fire on enemy troops in the hollow, and are able also
to rake isolated detachments distributed on the futher side of the opposite
slopes. Radium, on the other hand, has the effect of bombs exploding
in the central positions of the enemy, leaving the outer ring
unscathed. The authors find that the reaction on the skin after an
exposure of five hours to the ultra-penetrating radiation of an 18 eg.
of radium placed 2 cm. away is about equal to that which follows an
X-ray irradiation for twenty minutes, the rays being filtered through 3
mm. of aluminium, the anti-cathode placed 20 cm. from the skin, and
the current being 3 ma. The X-ray intensity, therefore, is about 1,500
times greater than the intensity of the radium. The employment of
radium, however, is of considerable value when the neoplastic tissue
is of no great thickness, and the extreme penetrability of the radium
rays is advantageous from the point of view of homogeneity in the
immediate distribution of the effect. The X-rays are concentrated upon
the same mass of tissue through a number of converging ports of
entry. The anterior inferior abdominal wall is divided into four, six,
or eight fields (according to the corpulence of the subject and the
probable extent of the lesion), and the sacro-iliac region into four or
six fields. These fields receive successively an X-ray dose of 15 to 18
Holzknecht units. The rays are filtered through 4 mm. of aluminium.
and with these a very large dose may be given without a reaction beyond
that of radioepi derma litis, which requires for its evolution eight days
at most By means of a speculum further radiation is introduced by
means of the vagina, the mucosa of which has a remarkable power of
resistance to X-ray action. This means of irradiation by the vagina,
through which a total amount of 50 Holzknecht may be given, enables
one to act on the prolongation of the neoplasm in the large ligaments
and in the walls of neighboring organs. The treatment of the various
fields and of the vagina may be spread over a period of ten or fifteen
days, followed by another series of sittings at the end of a month.
The authors have treated five cases of inoperable cancer or relapses
after operation by a combined method consisting of (1) local radium
therapy, with 18 eg. of radium bromide, of which only the ultra-penetrating
radiation is utilized, the total duration of the applications being
100 to 150 hours; and (2) deep radiotherapy. The cases are too recent
to admit of a definite judgment, but in all of them within two months
there has been an improvement locally, and the neoplasm itself, which
in two cases had the character of a diffuse infiltration, has become
limited to a hard mass. In one case of cancer of the neck of the
uterus which was operable, but was treated by radiation because the
patient refused surgical intervention, no trace of the trouble has been
found for three months, and no induration is perceptible on palpating the
uterus." British Medical Journal, Oct. 23, 1915.
* * * * *
Hugh H. Young. M.D. (Baltimore). The Renaissance of Urology.
Southern Medical Journal, Vol. 9, No. 2, pp. 146-53. In speaking of
radium in urology Dr. Young says: "Radium, too, is a force of marvelous
power, the limits of which are little known, but which occasionally works
seeming miracles. We have been using radium by means of special
radium-carrying operative cystoscopes, in conjunction with the high frequency
treatment of vesical tumors, and prostatic carcinomata with really
promising results."
* * * * *

I U M
A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY. PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES.
Edtted and Published by Charles H. Viol, Ph. D., and William H. Cameron. M. D
with the assistance of collaborators working in the fields of
Radiochemistry. Radioactivity and Radiumtherapy.
Subscription S2.50 per year, or 25 cents per copy in the United States and Canada
in all other countries $3.75 per year.
Address all communications to the Editors, Forbes and Meyran Avenues,
Pittsburgh, Pa.
VOL. VII. Ji;.\K, 1916 No. 3
RADIUM IN THE TREATMENT OF CARCINOMA OF
THE CERVIX UTERI*
C. Jeff Miller. M.D., F.A.C.S..
NEW ORLEANS, l.Of'SlAN.V.
It is unfortunate that so much labor and time are required in
attesting the true vahialion of a therapeutic agent. Chemists, physicists.
physiologist, and clinicians must combine the results of their many
labois. and even after their work is completed it is often difficult to
make the final deductions properly; to eliminate faulty methods and
premature claims of over-enthusiastic pioneer investigators.
The investigation of so-called cancer cures is especially difficult because
of the length of time required to check the ultimate results.
Radium has proved no exception to the rule; in fact its novel
chemical qualities, its absolutely original physical phenomena and the
premature claims as to its wonderful therapeutic propertes have doubly
confused rather than clarifies! our knowledge of its actual virtues. It
has been used about ten years in the treatment of disease, during which
time it has been lauded in the highest terms; abandoned as useless
by some, and denounced without trial by many. The first seven years
of its use produced only scattering reports. It was in the experimental
stage and available for study by only a few clinicians, and it may he
said that the statistics of real value have been produced within the past
three years, since the methods of application and screening have been
better understood, and a larger supply of the clement has been available.
•Sundry. Gynecology and Obstetrics. XXII. IJT-U1, April. 19HS. Prexenie-1
in flu- symposium on "Cancer of the t'terus." at the meetlns of the Chicago
Gynecological Society. December 1". 1915

66 RADIXJM
From the numerous clinical data now collected, certain welestablished
facts may be gathered. First among these facts should be
mentioned the remarkable influence of radium over uterine bleeding
associated with the metropathies, fibromata, and carcinomata. This
faculty alone establishes it as an agent of the first rank in the treatment
of probably the commonest affection for which the gynecologist is consulted.
There is no longer the slightest doubt that it exerts a powerful
influence over cancer-cells. This influence is not the result of cauterization,
as many pathologists would have us believe, nor is it because of
any selective action on cancer-cells, but rather its effect on all cell life.
Its effect is well described by IJurnam, who states that "it can be
assumed that radiation deleteriously affects all living tissue, but under
this injurious influence the normal tissues are preserved because the
fluids and the protective agencies of the body are all constructed to
help the normal tissues, and that the pathologic tissues disappear because,
wcakene:! by radiation, they are unable to withstand the normal
protective mechanism of the hotly. This readily explains why a similar
growth in different individuals will react differently or not at all to
radiation; why slight radiation will effect marvelous changes in one
case and show just the opposite changes in another. It must also be
borne in mind that certain normal tissues arc more resistant than others
and that the latent period of radiation may be influenced by all of the
above-named factors and promptly points to numerous problems yet
to be solved by radiophysicists. Whether the solution of these problems
depends upon earlier treatment, larger dosage, more efficient screening.
or by combining radiation with operation or other therapeutic agents,
remains for the future to solve."
There is another point which must be kept constantly in mind by
the clinician; viz.. his duty and obligations to the already proved
principles of the surgical treatment of cancer.
Surgery is the only treatment so far known that offers a permanent
cure for cancer in the early stage of the disease. Xo discussion which
might detract from the hi«h esteem in which surgery is held should
be allowed to filter out to the inexperienced practitioner and particularly
to the public at large. Until something more satisfactory than surgery is
positively proved, we must unite in the common cause of educating
the public to the importance of early surgical treatment, remaining in
the meantime in a receptive attitude toward the efforts of investigators
to reach the common goal hy other avenues. We must agree that we
have about reached the limitations of operative technique in cancer
eradication. Xo one may venture farther than the present established
technique of breast amputation or radical hysterectomy. If we increase
our percentage of ultimate cures it will be by earlier operation or by
combining other therapeutic agents with surgery.
The most promising agent so far known is radiation, either by
special X-ray apparatus or radium. Both agents are scarcely beyond
their infancy and their wonderful properties seem to be manifold and
lead into divers ramifications.
It is net difficult to define my attitude toward radiumtherapy after
the above remarks. So far I have employed it solely as an adjunct to
surgery. I have not been satisfied with the results of radical operation,
not to mention the 60 to 70 per cent, who come so late for treatment

R a d i u m v
that even palliative measures are often useless and burdensome to the
doomed patient.
As my experience with radical operation increased, the percentage
of cases in which I advised it gradually decreased. I no longer recommend
it in the so-called borderline cases, believing that such formidable
treatment, with its primary fatalities ami subsequent morbidity, does
not give sufficient returns for the risk incurred. It was with the idea
of increasing the permanent results obtained by surgery by the combination
with radium, the conversion of inoperable into operaMe cases, ami
last hut not least the amelioration of the suffering of the hopeless eases.
that I determined to try radium.
I regret that I can offer as yet no statistics that might slum- that
my operative results have been improved by the use of radium prior and
subsequent to operation. Such conclusions must necessarily be based
upon a large series of definitely classified cases by the same operator
doing the same type of operation and following the cases for a longer
period than any one has yet been able to extend their observations.
Prophylactic raying after operations is now fairly well established on a
rational basis. The only statistics at my convenience bearing on this
point are those of Gauss, who reported that of 2\ operated upon and
rayed, 20 had remained free from recurrence up to si\- years afler
operation, while their previous experience showed that in 60 per cent.
of cases operated upon without radiologic treatment the disease showed
evidence of recurrence within one year.
I also regret that I cannot produce practical personal evidence that
preliminary application of radium will convert inoperable into operable
cases. Improvement has been so gratifying in four of my cases that
I have repeatedly urged hysterectomy, but notwithstanding my strongest
arguments, three positively declined, stating that thev had imnroved so
satisfactorily thnt thev were willing to assume the risk. The fourth has
agreed to submit to operation within a few weeks. I mav add that
many good authorities differ as to whether or not advanced cases become
operable under radium therapy. Whether or not the accompanying
parametria! involvement which disappears under radiation is of
malignant or inflammatory origin cannot be determined without operation
and offers another serious difficulty in diagnosis. There is no
doubt that radium applications prior to operation add some difficulties
to the operative technique. The widespread connective-tissue changes
would necessarily make the usual dissection exceedingly tedious ami
must be taken into consideration when it is decided to operate after
radium treatment.
It is the tendency at present to ooerate on more of these cases than
formerly, so it will he only a matter of time before the value of the
combined treatment is fully known.
The results I shall present are derived from the application of radium
in 20 cases of inoperable cancer of the cervix uteri and recurrent cancer
following hysterectomy that have come under observation since May. 1014.
All have been followed up to December 1. 1015. The list is small and the
lenirth of time that has elapsed too short to permit of practical deductions
except as to the primary results of radiumtherany. It permits
me. however, to state most emohaticallv that radium is a great boon
to patients suffering from inoperable and recurrent cancer of the cervix
uteri. I have seen laree inooerable carcinomata fixed in the pelvis entirelv
disannear within a month and the natient's general condition
correspondingly improve. Bleeding was almost invariably controlled

68 Radium
within two weeks and the foul discharge disappeared almost as rapidly.
Even in cases in which the local process did not respond the bleeding
was checked, the discharge changed in character, the pain usually decreased
and the general condition improved for a short period. Fifteen
inoperable cases were treated solely with radium. They were far advanced,
showed the usual cachexia, and several were not good risks
even for simple cauterization under anesthesia. Four have died and
two are slowly succumbing to the disease. Five are apparently free
subjectively and objectively of disease. Among the five who are apparently
well are two of the earliest cases and the others were treated
about nine months ago. The primary results were almost uniformly
good when the condition at the time of treatment is considered).
Four cases did not respond to treatment. They were far advanced,
the vagina, bladder, and rectum being involved. Bleeding was checked
and the pain reduced but they gradually lost ground and died within
two months.
The first case in this series was treated in May. 1914. She writes
Xovember 20. 1015, that she had a slight haemorrhage in March, 1915.
but it lasted only a day. She has been comfortable since but has lost
sonic weight. Four in the series showed evidence of returning trouble
about 6 months after treatment, but responded to further applications.
It is too soon to tell how long they will remain free from symptoms.
It is interesting to observe the remarkable deodorizing action of
radium. Sepsis is the commonest complication of advanced cervical
cancer and the attending foul discharge is the most disagreeable feature
both to the patient and her attendants. Ten days afler radium applications
the odor begins to disappear and the temperature, if present.
usually subsides. This effect alone has prompted several patients to
state that the treatment was worth while, whatever the final results
might be.
The relief of pain is usually as marked as the control of discharges.
Pain is usually due to the septic complication and consequently subsides
as the local process improves. The subsidence of pain, however,
does not depend entirely upon this factor, as I have seen patients
abandon opiates within 24 hours after the first application.
CASES CAUTEKIZFD PRRYtOVS TO RADIUM TREATMENT.
Six cases has been excochleated and burned one to five months
prior to radium treatment. In every instance the disease was rapidly
reappearing when radium was first applied. The first case was treated
in May. 1014. She was cachectic, suffered intensely, and had an exceedingly
offensive discharge. The bladder was involved, the rectal
wall was infiltrated and the remaining parametria! structures fixed. She
improved rapidly, gained 17 pounds in weight, and the local process
completely disappeared. She remained well until October, 1915. then
died after a brief illness. Her physician stated that no evidence of
trouble could be found in the vaginal vault. Since she had excruciating
pain in her left hip for two weeks 'before her death, it is to be believed
thai she died of metastases remote from the vaginal vault. Three of
these cases are apparently free from disease twelve months after treatment.
Just at this point it is apropos to discuss whether or not it is better
to burn or use the curette on sloughing masses before applying radium.
My experience leads me to believe that it is not the best mode of
procedure. I am positive that it required a longer time to check the

R a d i u m
local symptoms and the subsequent histories do not show that they
remained well any longer for having had the preliminary cauterization.
Preliminary cauterization requires anaesthesia and is attended by no
little discomfort and certainly retards the primary effects of radiation.
My experience is corroborated by otherSf especially Burnam, who recently
stated that he no longer cauterized and curetted sloughing masses
as a preliminary measure.
RECURRENT CARCINOMA AFTER HYSTERECTOMY.
I have applied radium to malignant areas reappearing in the vaginal
vault after hysterectomy in 6 cases. These cases are utterly hopeless
from a surgical standpoint and unfortunately are much less amenable
to radium-therapy than primary processes. In four cases the growth
promptly responded to treatment but the results cannot yet be known
owing to the short period elapsed since the applications were made.
The first case presented a fungus bleeding mass in the vault two years
after j had performed hysterectomy. Radium was used in December,
1014. She was entirely free of local symptoms when examined Deccmb.r
I, 1915. and her general health is excellent. Two other cases are
apparently well six months after treatment. In one case the mass disappeared,
but the patient died soon after from an infected kidney.
In another instance local masses have responded twice within the
past year to applications, but her general condition is gradually waning.
I have related in a general way these personal experiences to showjust
what my results with radium have been so far. As you will see
thev do not prove that radium will cure cancer, for the most favorable
cases have not been followed yet two years. They prove conclusively to
my mind, however, that cancer of the cervix is profoundly influenced
by radiation in cases that are hopeless surgically and that the results
were accomplished with a minimum of discomfort to the patients. I
may further add that the results so far are superior to any other method
I have used in similar cases.
The primary result is often beyond the hopes of its most enthusiastic
supporters. Bedridden sufferers have been given a new lease on life
and some have been improved to the extent that surgery might be beneficial
when it was originally useless. The remarkable primary results
caused many early workers to report cures which were unfortunately
only temporary symptomatic cures. The same test of time must be
applied as in surgical statistics before they are transferred to the cured
column.
One point in favor of radium which should not be overlooked in
the final analysis is that the present statistics will be based upon material
that has passed beyond surgical relief before radium i« used. If radiation
can show even a fair percentage of cures at the end of five years.
its usefulness will be fully established in a class of cases not amenable
to any other form of treatment. The chief point of interest after all
is the duration of radium treatment. The only recent available statistics
that might throw light on this phase of the subject arc those of Kelly
and Burnam. Schmitz has also published some extremely interesting
figures, but like my own. the cases can be followed only since April.
1014.
The statistics of Kelly and Burnam probably contain more cases
observed over a longer period than any other single clinic can show at
present. They report >7 clinical cures; 35 cases of original inoperable
cancer of the cervix uteri and vagina, and 18 cases of originally in-
w

70 R a d i u m
operable recurrent cancer. One cure lias lasted 6 years; 3 for over 4
years; 4 for over 3 years; 5 for over 2 years; 29 for over 1 year, and
15 for 6 months. If this list is again summarized two years hence, we
may begin to learn something of the ultimate results.
Cheron and Rubens-Duval's statistics approach approximately tho-e
ot Kelly and Burnam in number and length of time observed and practically
coincide with the latter's figuures.
TECHNIQUE.
There still exists a wide difference of opinion as to the proper
usage of radium iu treating uterine cancer. Some believe that the problem
is solved when sufficient radium can be made available to give
massive doses hitherto impossible owing to the scarcity of the agent.
Schauta. Kelly and Burnam. Krcenig. Wickham. and others believe
in massive dosage while ether equally well-known observers believe that
smalltr amounts applied for a longer period will accomplish the same
results.
\\ hat the final conclusions will be remains to be seen, but it is
generally agreed that less than 50 milligrams of the radium element
should net he employed, lest the growth be stimulated instead of causing
the necessary necrosis.
Pinch, who has large quantities of radium at his disposal, finally
decided upon a dosage of 50 to 100 milligrams. Schmitz used uniformly
50 milligrams giving 6 to 8 seances of from 10 i> 12 hours. The course
is followed by an intermission of three weeks. If examined there reveals
an apparent cure, two or three applications of 500 or 600 milligram
hours of radium element is given every second or third day.
followed by ancther interval of three weeks.
This has been practically my plan with the exception that I use
from 75 to 85 milligrams of the radium element and endeavor to give
from 3.000 to 5.000 milligram hours within a week or ten days. One
month later further applications are made according to the indications.
X'o one can doubt that cancer of the cervix can be entirely eradicated
bv radium. Unfortunately it is not the cervix per sc that controls
the ultimate termination; the outlying cancer areas in the broad ligaments
and the glandular metastases reallv control the situation. If the
penetrative powers of radium can he made to reach the outposts of the
disease, its value will be inestimable.
Bumm's widelv quoted experiments which showed that the limit of
the gamma-ray efficiency (in tissue) was about 4 cm. i* now very correctly
questioned by Burnam, who -rates that it is possible to radiate any distance
by proper distribution of the applicators, all of which goes to show
that the seemingly insurmountable obstacles are being overcome as experience
increases. To prove that cancer can be anatomically cured will
be much more difrVult than any phase of the work so far accomplished.
It will require not only long years of observation, but it will require
as well a microscopical study of serial sections of outlying tissues removed
at subsequent operations and at post-mortem findings. This is
a task stupendous in itself and can only he solved in the manner recently
illustrated fcv Schmitz. Cheron and Rubens-Duval. and others.
The scope of this paper does not permit of much more than a
statement of my personal experience. I cannot offer anv general conclusions
other than to say that radium has a wide field of usefulness.
the real value of which can be estimated only after painstaking collective
studies. It has no field absolutely to itself but is merely a therapeutic
agent which should be used in common with other vvel'-estnblished
methods of treatment.

R a d i u m
CONTRIBUTION ON THE THERAPEUTIC VALUE OF
THE INTRAVENOUS INJECTION OF SOLUBLE
RADIUM SALTS IN THE TREATMENT OF
PERNICIOUS ANAEMIA AND LEUKAEMIA.
Bv Frederick Proescher, M.D.
EPICRISIS OF CASES.
Case 1. is a morbus Biermer where the mcgaloblastosis was aisent
during the entire course of the disease. Xiwleated red cells were seldom
found in spite of the numerous examinations. The macro, micro
and poikilocytosis as well as the hyperchromasia vvith a color index 1.2
were pronounced, and the relative lymphocytosis strengthened the
diagnosis of essential pernicious anaemia. The anisocytosis of the
red cells without the accompanying hyperchromasia would rather have
suggested a diagnosis of secondary anaemia.
After the diagnosis was established the case was treated for a
little over four weeks with subscutaneous injections of cacodylate of
soda. In spite of the rigorous arsenic treatment on January S, 1913
the red cells were considerably decreased from 2.250,000, which the
first examination on Decemoer 1. 1912 showed, to 1.575.000. the color
index was increased to 1.4. 1 suggested to the attending physician that
he abandon the cacodylate treatment and advocated the subcutaneous
arsacetin treatment in the maimer described a'love. After the arsacetin
injection the red cells and hemoglobin increased gradually. April 20,
1913 the red cells were increased to 4.500.000 hemoglo'jin 11.96 gm.
(85.4%); color index .9. while the leucocyte count showed a decrease
to 1.000. May 2^. 1913, twenty day.- after the last arsacetin injection the
red cells were increased to 4.600.C00. the hemoglobin to 16.76 gm.
(119.7%); and the color index to 1.3.
If we summarize the effect of almost six months arsenic treatment
we see that under the cacodylate treatment the red cells and hemoglobin
were markedly decreased. The color index increased to 1.4. If this
was due to the cacodylate or caused by the still progressive hemolytic
process. not influenced by the cacodylate. is open to question. Whether the
arsacetin really influenced the morbid process of if the remission, independently
of the treatment set in, is impossible to decide. The numerical
increase of the red cells in spite of the rigorous arsenic treatment compared
vvith the initial findings is not very considerable, but the most
striking increase was manifested in the hemoglobin content. The
microscopical aspect of the stained blood films still showed a slight
macro and microcytosis and also a few poikilocytcs. The differential
count did not show any material changes as a marked lymphocytosis
prevailed throughout the entire arsenic treatment. The only result of
the arsenic treatment, if we can attribute any to it. is an increase in
red cells and hemoglobin. The red cell aspect still showed degenerative
signs and the leucocyte picture was not influenced at all.
Mav 2^, 1913—The patient received the first intravenous injection
of 250 micrograms radium element in the form of radium bromide.
The next three days following the radium injection the red cells were
decreased 550.^00. the hemoglobin content was also slightly lowered.
while the color index remained almost the same. The leucocytes showed
7\

72 R A D I U M
an increase from 5,620 to 7,750. May 31, 1013. the red cells were increased
again to 4,550,000 the hemoglobin 117.5%, the leucocytes increased
to 9,250. The differential count showed a decided relative
increase of the polynuclear neutrophils from 44.46% to 56.49%. The
monocytes also were increased from 1.66% to 9.64%. June 3, 1913,
the red cells reached their maximum and showed an increase to
6.050,000. the hemoglobin increased to 153.1% (21.44gm.) _while the
color index was 1.2 and the leucocytes had decreased to 6.500. The
differential count showed a decrease of the polynuclaer neutrophiles to
48.00%. The red cell aspect during the above described period showed
a slight poikilocytosis while the macro and micrccyto;is had almost
disappeared. The hyprochromnsia of the red cells was unchanged.
From June 10th until October 28. 1913 the red cells showed as a
maximum 5.000.000 and were lowered to a minimum of 3,203.003
(October 28. 1913). The hemoglobin decreased from 117.4% to
98.2%. The color index during this period was once found to be
below 1. i.e. on July 5, 1913 color index was 0.9.
The absolute leucocyte count, vvith the exception of June 10. 1913,
when it reached 17,500; (the highest count noticed during the entire
period of our observation) showed almost normal values. The differential
count showed a continuous relative increase of the neutrophile
leucocytes from 46.90% to 51.56%. Anisocytcsis. poikilocytosis and
hyperchromasia of the red cells were present in a slight degree. On
account of the decided decrease of the red cells the palient received
from Xmember 22, 1013 to December 22. 1913. another series of injections
of arsacetin. The bipod examination on March 1. 1914. showed
that the red cells had increased to 4.250 030. while the hemoglobin was
further reduced frpm ''8.2% to 94%, color index 1.1. leucocytes 8.250.
Polynuclear neutrophiles were relatively increased to 55.80%. A period
of six months elapsed until the patient presented himself for a further
blood examination. June 8, 1014 patient came in a very debilitated condition,
he was weak and markedly anaemic. The blood count on
the same day showed that the red cells had decreased to 1.3"6.000. the
hemoglo'iin to 34.1 rr. color index 1.3. leucocytes 7.003. Polynuclear
neutrophiles were relatively increased to 71.50% ; anisocytosis, poikilocytosis
and hyperchrcmasia of red cells were all pronounced. Me received
from June 10. 1014 to August 11. 1914. 8 grams of arsaceti:i. Repeated
Mcod examinations during this time did not show any appreciable effect
i". n the rel cells and heunglobin. The red cells were only slightlv
increased to 1.520.000 (Julv 10. 1914). The hemoglobin 36.3%. color
index between 1 and 1.3, there was a pronounced leukopenia with the
polynuclaer neutrophiles relatively decreasing. On July 10. 1914. 250
micrograms radium element were injected. During the next three weeks
following the radium injection no influence on Ihe red count was
noticed. Hemoglobin somewhat increased (36.3% to47%V Pronounced
hyperchromasia, color index 1.4 to 1.7, leukopenia. Relative increase in
polynuclear neutronhiles (68.50% V Anisocytosis and poikilocytosis pronouned.
100 micrograms radium clement injected on August 11. 1014.
On August 18. 1914 a slight increase in the red cells 1.656.000.
hemoglobin 38.4%. color index 1.1. Very pronounced leukopenia
(2.7501. During the next seven months a further continuous decrease
of rhe red cells was noted. On March 0. 1915 the red cells were decreased
to 1.084.000. hemoglobin 40%. color index 1.8. leucocytes 4.100.

R a d i u m ;.*
If we summarize the influence of the radium upon the blood picture
we come to the following conclusions:
After a latent period of approximately six or eight days during
which time the red cell count was somewhat lowered, a marked increase
of the red cells and ihe hemoglobin was noted. During the next six weeks
observation the red cells remained at almost their normal number and
once the proportion of the hemoglobin and red cells, as indicated bv the
color index (0.9), was found normal. We can safely say that "such
an increase is not due to a spontaneous remission, but must be attributed
to the influence of the radium upon the erythrocytes, but this extraordinary
increase was only temporary as a few days later the red cells
decreased to subnormal while the hemoglobin, which was also considerably
lowered, was still abnormally high as the color index indicated.
It is striking that during this blood crisis only ; fcw nucleated red cells
were found. The microscopical aspect of the stained blood films still
exhibited a slight degree of anisocytosis and the hyperchromasia was
pronounced.
How long the approximately normal red cell picture was retained
cannot be stated, since no blood examination was made during the next
three months. July 19 to October 28, 1913 the general condition of the
patient was good and he was able to attend fully to his work. A blood
examination at the end of October, 1014. showed that the red cells were
considerably decreased with a high color index while the hemoglobin was
about normal. Another series of arsacetin injections increased the red
cells again, while the hemoglobin still declined. Whether this remission
was due to the arsacetin or was spontaneous in its nature, is difficult to
decide.
On January 3, 1914 the patient was in a fairly good condition.
still able to work. Unfortunately during the next six months the
patient did not return for further blood examination and we did not
see the patient before June 0. 1014 in an extremely weak and anaemic
condition. Further injection of arsacetin and radium were without any
.ifluence upon the blood picture. In spite of the extremely low red cell
count the patient lived almost a year, dying August 10, 1015, of
exhaustion.
Case Xo. 2.—This case illustrated a kryptogenetic infection (generalized
infectious lymphadenitis of unknown origin) with a pernicious
anaemic blood picture. The absolute count showed a very marked reduction
of the red cells and hemoglobin with a color index 1.2. no leukopenia.
Differential count showed a relative lymphocytosis and a slight
"reizungsmvelocytosis."
The microscopical aspect of the stained blood films showed anisocytosis.
hypo and hyperchromasia and reduction of the blood platelets
and many ervthroblasts and gigantoblasts. The patient was treated
with radium only and received no other medication. He received 400
micrograms radium element intravenously (April 14. 1914). During the
next four weeks the red cells and hemoglobin showed a steady increase.
showing on Aoril 13. 1914 an increase from 1 376.000 to 2.800.000 and
the hemoglobin from 27.7% C3.38 gm.) to 70.3% (9.84 gm.). while the
color index was still above 1. The leucocytes were first lowered and at the
end of four weeks increased. Another injection of 100 micrograms on
May 13. 1914 showed two days later a still somewhat higher red count
(3.i52'.00O) while the hemoglobin was a little lowered. The color index
was i. The relative leucocyte count showed the following: The poly-

74 R a d i u m
nuclear neutrophiles were slowly increased from 13.89% (April 14, 1914;
to 36.5% (May 1, 1914) but decreased again to 21.75%. The polynuclear
eosinophils as well as the lymphocytes showed only a slight variation.
The neutrophiles. myelocytes and myeloblasts disappeared entirely. The
leucoblasts and monocytes were markedly diminished. The erythroblasts
and gigantoblasts showed no marked fluctuation. The microscopical
aspect of the red cells showed at the end of the four weeks observation a
slight anisocytosis, hyperchromasia and polychromasia of the red cells.
The rapid and steady increase of the red cells was without doubt
supported by the radium. Of course a spontaneous remission which
may have in time corresponded with the radium treatment cannot be
entirely excluded.
It is to be regretted that no further observation of this case was
possible. The attending physician. Dr. Pettit, reports the patient
to be in fairly good condition and working, but unwilling to present
himself for further examination, thereby leaving this interesting case
incomplete.
Case No. 3.—This leukaemia case was the first one treated with
massive doses of radium element intravenously. He received 2.700
micrograms equal to 7,290.000 mache units in 13 months. The first
blood count on July 1. 1913 showed 4,087.500 red cells. 12.84 gm.
hemoglobin (91.7%). color index 1.1, leucocytes 222,500. The stained
blood films showed a mixed cell leukaemia of a myeloid-myeloblastic
type.
The patient received from July 1st to July 7. 1913, 400 micrograms
radium element, in 100 microgram doses, given every two days. Twentyfour
hours after the first injection the red cells showed an increase of
1.637.500. The hemoglobin was only slightly increased (2.3%) while
the white cells were increased to 272.500. After the second injection
the red cells were lowered about 756.000 while the hemoglobin was still
further increased to 14.36 gm. (102.6%), and the leucocytes increased
to 280.000. After the third injection the red cells and the hemoglobin
remained almost the same while the white cells were lowered to 245.000.
After the fourth iniection the red cells showed a very slight decrease
of about 15.000. while the hemoglobin was lowered from 13.6 gm.
(99.7%) to 8.96 gm. (64%). The white cells showed a slight increase
from 245.000 to 265.000, the color index which was before the radium
injection about 1.1 was lowered to .6. Four days later (July 12th),
after 400 micrograms radium element had been given, the red cells
increased to 8.350.000. the hemoglobin to 15.24 gm. (108.9%). color
index .6, wdiile the white cells were 231.200. The red cells in two
days showed an increase of 4.262.500. It is remarkable that no abnormal
increase of nucleated red cells was noticed. Between July 5. 1913 and
August 17. 1913 the red cells slowly decreased from 8,350,000 to
5.300.000. the hemoglobin was also lowered from 15.24 gm. (108.9%) to
13.44 gm. (96%). The white cells showed a steady increase from 242.500
to 350.000. On December 20. 1913 the patient received another injection
of 100 micrograms radium element. No blood count was made during
the next three months.
In conclusion we can say that after a period of twelve days during
which a slight increase and decrease of the red cells and a more marked
decrease of the hemoglobin had been noted, no destructive effect upon
the leucocytes could be observed. On the contrary it seems that the
leucoevtes were rather stimulated, resulting in a quite considerable

R a d i u m 75
increase. The effect upon the erythrocytes, which were temporarily
enormously increased, was most striking. Three mouths after anotner
injection of 100 mictogram radium element, a blood examination was
made (March 16, 1014) showing that the leucocytes were still increasing
lo 365,000. The red cells were on the same day 3,025.000, hemoglouin
12.56 gm. (89.7%), color index 1.1. We decided therefore, to give
a massive dose of radium at once, to see if a destructive effect upon
the leucocytes could be accomplished. Tjie paiient received on March
16. 1914, 1.000 micrograms radium element intravenously. A blood
count made two and a half hours after the injection, showed that the
leucocytes were decreased from 365.000 to 260,003. The red cells were
somewhat increased, while the hemoglobin was unchanged. During the
neM four weeks the leucocytes slowly decreased to 97,500 (April 18.
1914). A slight stimulating effect upon the red cells and hemoglobin
during this period was also noted. "April 4. 1914). Increase of red
cells. 697.000, hemoglobin 1.74 gm. (12.4%). The temporary decrease
of the leucocytes was followed by an increase again ami on May 0,
1914 the leucocytes were 182,400. On both May 9. 1914 and on May
16. 1914 he received 100 micrograms radium element. During the period
of May 9th to June 13. 1914. a slight increase in the red cells was noticed,
while the hemoglobin remained almost constant. The leucocytes were
lowered from 220.000 to 122.400.
On June 13, 1914 the patient again received 1.000 micrograms
radium element intravenously. Four days later the red cells were somewhat
lowered from 4.736.0Q0 to 4.424,000 while the hemoglobin was
increased f'rom 11.96 gm. (85.4%) to 14.36 gm. (102.6%). The
leucocytes showed only a reduction from 117.600 to 109.600. The
white cells were only once lowered (July 18. 1914) to 91.000. making a
total reduction after the injection of 2.700.030 mache unils of only
26.600. Five weeks later the leucocytes were again increasing to
240.000.
For an analysis of the changes of the leucocyte picture after injection
of radium we will divide the observation time into five periods;
the first period includes the time from July 1. 1913 to December 20,
1913. after 400 mcrograms radium were given. The second period
includes the time from December 20, 1013 to March 13. 1914. after 100
micrograms radium had been given. The third period from March 13.
1014 to May 2. 1914. after 1.000 micrograms radium were given. The
fourth period from May 9. 1914 to June 6. 1914. after 200 micrograms
radium were given. The fifth period from Tune 6. 1914 to August 20.
1914. after the second injection of 1.000 microgram radium element.
In the first period we noticed that the polynuclear neutrophiles were
increased from 1841% to 42.05%. No change was noted in the polynuclear
eosinophils, bascphiles. metamyelocytes, leucoblasts. large
lymohocytes, medium and ni'crolvmphocvtes. The neutrophil myelocytes
were reduced from 3393% to 3.33%. The mye'oblasts were
increased from 4.1% to 10.33'?-. The large lymohocytes were decreased.
T^e small Ivmphocytes were first increased and then decreased again.
The monocytes disappeared entirely.
In the second period the Dolynuclear neutrophiles were still increased
to 45.37%. The metamyelocytes and neutrophil myelocytes were
decreased. The myeloblasts were markedly reduced, disapoeared and
increased again to 1.33

76 R a d i u m
In the third period the polynuclear neutrophiles were increased lo
51.37%. The polynuclear eosinophils, basophiles and myeloblasts
showed little variation. The neutrophil and eosinophil myelocytes
disappeared almost entirely. The leucoblasts and the large lymphocytes
were decreased. The medium lymphocytes disappeared entirely. The
small lymphocytes were decreased and increased again. The micro
lymphocytes and monocytes disappeared almost entirely.
In the fourth period the polynuclear neutrophiles still increased to
63.33%. The polynuclear eosinophils and basophiles, leucoblasts. large
lymphocytes and microlymphocytes showed little variation. The
eosinophil myelocytes had entirely disappeared. The metamyelocytes
were increased and decreased. The neutrophil myelocytes increased,
the myeloblasts and the medium lymphocytes were decreased and the
small lymphocytes increased.
In the fifth period the polynuclear neutrophiles decreased from
59.1% to 37.bfo. The polynuclear eosinophils, basophiles, myeloblasts.
and large lymphocytes showed no appreciable change. The metamyelocytes
decreased. The neutrophil myelocytes entirely disappeared and reappeared
again. The eosinophil myelocytes which had entirely disappeared
increased up to 1%. The small lymphocytes and microlymphocytes
decreased and increased again. Monocytes disappeared and
reappeared.
If we summarize the effect of the radium upon the leucocyte picture
we come to the following conclusion: It seems that radium exerts a
pronounced stimulating effect upon the polynuclear neutrophiles in small
divided doses and in large doses. We see that during the entire period
of observation the polynuclear neutrophiles were steadily increasing
and once almost reached their normal number, but remained al>ove
their initial count at the end of the investigation. On the other hand
we see that the eosinophil and neutrophil myelocytes, as well as monocytes
are very radio sensitive, as they were markedly reduced after the
small doses and disappeared after the large doses and reappeared later
on in a very small percentage. The polynuclear eosinophiles, basophiles,
seem to be the most radio resistant leucocytes. The metamyelocytes,
leucoblasts, large lymphocytes, medium and micro lymphocytes seem
to exhibit a variable resistance to radium.
On August 31, 1914 the patient received a cross fire radiation of
600 milligrams of radium to both femurs for three and a half hours
each. The blood count taken on September 12. 1914 showed 182.000
white cells and on the 19th of September 158.000. On September 26th
there were 210.000 leucocytes, 5,344.000 red cells and 14.04 gm. hemoglobin.
From September 26th to November 4, 1914 the patient received
eleven X-ray treatments. A blood count on November 4th showed that
the leucocytes were lowered to 167.000. Another leucocytes count taken
on November 30. 1914 showed 117.600. Until the death of the patient.
January 15. 1915. no other blood counts were made.
The two massive doses of 1.000 micrograms radium element each.
showed a marked temporary reduction of the leucocytes, but with no
reduction to the normal. The leucocytes were increased two months
later to their former number. No appreciable effect was noticed during
this period upon the red cells. As to the effect of the large doses of
radium upon the relative leucocyte picture, the only marked influence
was upon the neutrophil myeolocytes and polynuclear neutrophiles.

R a d i u m
While the myeolocytes showed a continuous decrease and sometimes
entirely disappeared, the polynuclear neutrophiles showed a steady increase
and once reached almost normal value. (63.33%) but this effect
was only temporary as with the elimination of the radium the polynuclear
neutrophiles were decreased and myelocytes were increased
again. The radiation vvith radium as well as the radiation with X-ray
did not show any marked effect upon the leucocytes. It seems that
the effect of small doses of radium given at greater intervals produced
radium resistence so that further doses of radium lave littlle or no
effect upon the blood picture. It further seems that the radium resistence
makes also a resistence against the X-ray as we have seen that
the X-ray radiation which otherwise exerts a most powerful effect on
the leucocytes had very little influence upon the radium resistant blood
cells.
(To be concluded in the next number.)
REVIEWS AND ABSTARCTS.
Frank U. Simpson, M.D. (Chicago). Radium in the Treatment
of Lymphangioma Circumscriptum. Report of a Case. Journ. A. M.
A., Vol. LXVI, No. 13, Man 25, 1016. "History.—LX., woman, aged
21, first came under my observation at the Cook County Hospital in
April, 1914. She presented a tumor of the skin involving principally
the right buttock and the inner surface of the right thigh and covering
an irregular surface measuring approximately 8x15 centimeters."
".The tumor had been present since her earliest recollection."
"It was composed principally of irregularly grouped wart-like projections
more than a centimeter high at the most elevated parts and of
a dirty yellowish color."
"On close inspection, the tumor was seen to be composed of innumerable
thick-walled vesicles on which had developed in places a
thickened hyperkenatotic epithelium giving the wart-like appearance
noted before. Parts of the tumor, however, were more flat and were
bluish black, being evidently made up of Mood vessels. Lying beyond
the main portion of the growth were many discrete, thick-walled,
yellowish vesicles containing clear scrum. When these were pricked a
clear serous oozing took place which sometimes lasted for hours."
"From between the verrucous projections which composed the bulk
of the growth a serous oozing occurred at times spontaneously, this
being one of the symptoms for which relief has been sought."
"Occasionally a few new vesicles had appeared at the periphery,
persisting so that a considerable increase in the size of the growth since
childhood had been noticed."
**The clinical diagnosis was lymphangioma circumscriptum (lymphangiectodes,
T. and C. Fox) and hemangioma. For microscopic
study a small vesicle was excised, sectioned and stained with hematoxylin
and eosin and vvith polychrome methylene blue."
"Dr. B. Barker Beeson has kindly furnished me with the following
notes made from a study of the sections:

78 R a d i u m
"Microscopic Examination.—Epidermis: The stratum corneum is
somewhat thickened in places but no evidences of parakeratosis arc
present. The granular layer is also slightly increased in size. A
marked acanthosis or proliferation of the rete malpighii is a prominent
feature, and, plus the hyperkeratosis, give* to the section a verrucous
appearance. Throughout, the basal layer is normal."
"Corium: In the papillary and subpapillary layers one finds dilatation
of the lymphatics and blood vessels, the former being especially
well marked. A round-cell infiltrate surrounds the blood vessels. The
number of connective tissue cells is also somewhat increased. Here and
there, near the dilated lymphatics, scattered mast cells are to be seen."
"That the tumor would yield to radium was expected from the
success already obtained in the treatment of many pure angiomas of
the skin and from my observations of the general effects of this agent
on the skin and other tissue>."
"When I first undertook the treatment, in April. 1914. the effect
of radium on tumors of this type had not to my knowledge "jeen studied.
Even earlier than this, however. Dr. Robert Abbe, of New York, had
begun the treatment of lymphangiomas vvith radium, and in August,
1015. he published an account of the results obtained in four lymphangiomas
of the tongue and two of the skin."
"These are apparently the first cases of this type recorded in
which radium was used."
"The success following radium treatment is so striking that a brief
account of the technic which I employed may be of interest."'
"Treatment.—The most prominent part of the tumor was attacked
first. Radium varnish applicators of one-quarter strength were usually
employed. Four applicators of this type covering an area of 16 sq. cm.
were applied unscreened for a period of one hour a day on four successive
days. A series of four similar courses about four to six weeks
apart sufficed to level the surface of the most prominent portions of the
growth. As the tumor decreased in height the treatment consisted of
an hourly seance each day (0.1 mm. lead screens being used over the
face of the applicators) for five successive days. Two series of treatment
of this sort at intervals of six weeks sufficed to cause complete
retrogression of the growth."
"In the less infiltrated parts a linen 'toile' (one-twentieth strength)
was sometimes used."
"With this applicator screened with 1/100 aluminium a series of
applications of an hour each day on five successive days, repeated four
times, at intervals of about six weeks, sufficed for decolorizing and
removing these areas."
"The treatment was carried out more or less irregularly for various
reasons, but the reduction of the growth, the alleviation of all symptoms
and a «ood cosmetic appearance were obtained rather easily."
"Owch-skix.—In view of the difficulty which is frequently experienced
vvith ether methods of treatment, the use of radium in these
rare and interesting cases would seem to be the method of election.''
Richard I . Sutton, M.D. (Kansas City. Mo.) Radium in the
Treatment of Synovial Lesions of the Skin, lourn. A. M. A.. Vol.
LXYI. Xo. 8. pp. 565-6. Feb. 10. 1916. "It is"probable that the true

R a d i u m 79
nature of synovial lesions of the skin was first discovered by Sidney
Jones and G. II. Makins of London, but it is to the late James Xevins
Hyde that the general profession is indebted for a classical description
of the disorder. In the first edition of his treatise in diseases of the
skin, he states thai lesions of this type
"Occur in the form of wart-like projections from the skin, pseudovesicles,
and bullae, always over the sites of bursae connected
with tendons, traversing the small articulations of the hand and foot.
They are seen over the metatarsophalangeal articulations; and in the
hand most frequently over the dorsal face of the articulation between
the distal and adjacent phalanges of the index finger and thumb. The
hrst form is that of a roundish, corneous, pea-sized wart with a yellowish
center, of long duration, usually insensitive unless roughly handled.
When punctured there exudes a syrupy, yellowish, or grumous fluid,
which continues to form after repeated puncture. Split-pea sized
vesicles, and bullae as large as a 50-cent piece, often exceedingly painful,
are also seen, especially on the feet, with simply an epidermic roof
wall. Each lesion contains the same yellowish or whitish fluid, occasionally
mingled with masses like sago grains. In every case the contents
of the lesions are supplied by a synovial bursa beneath the skin.
with which the lesion is either directly connected, or in communication
by a short sinus."
"More recently Liugenfelter has described a typical example of the
affection occurring on the dorsal aspect of the third phalangeal articulation
of the second digit of the right hand, in a woman aged 51. The
lesion had been present fdr fourteen months. Pain of a sharp, stabbing
character, radiating in all directions, was present at rather frequent
intervals, and was usually succeeded by a throbbing ache. In a discussion
of Lingenfeller's communication. Ormsby called attention to
Hyde's earlier investigations and report, and, in addition, described
four cases which had come under his observation during the past eight
years. Three of his patients were women, between the ages of 46 and
50, the olhcr being a man, aged 66. The microscopic and cultural
findings were negative in Ormsby's cases. He says that an arthritic
diathesis is strongly suggested."
"The lesions are extremely resistant to treatment. Hyde recommended
complete excision or destruction of the secreting cyst wall.
Lingen felter employed the Roentgen ray with success. Ormsby also
found the use of this agent curative in two instances, although he was
compelled to resort to supplemenal electrolysis in a third instance. On
account of the patient's inability to remain in the city, energelic
treatment was given with electrolysis, with apparent success, in his
fourth case."
RFP01JT OF C.VSES.
"During Che past year I have encountered two examples of the
disorder."
"Case 1.—The first was in a married woman, aged 58, referred to
me by Dr. C. F. Menningcr of Topeka. Kan. The lesion, a smooth,
rounded, pea-sized, fluctuant tumor, was located over the distal phalanx
of the right index finger, and had been present eighteen months. It
had been incised and drained on two different occasions, but each time
the cyst had refilled, with syrupy, straw-colored fluid, as soon as the
wound healed. There was intermittent pain, of a sharp, lancinating
character. Treatment bv electrolysis was refused because of the

R a d i u m
attendant discomfort, and as the patient could remain in the city for
only a few hours, frequent applications of tincture of iodin, with compression
by means of a small pad and bandage, were advised."
"In a recent letter, the patient say- that the lesion is much reduced
in size, and that the pain has disappeared. It is probable, however,
that permanent relief will be secured only by the adoption of more
radical remedial measures."
"Case 2.—The second case occurred in a graduate nurse, ageil 26,
referred to me by Dr. J. Park Xeal of this city. The lesion was located
over the metacarpophalangeal joint of the index finger, and had been
present five months. Clinically it corresponded to the first form
described by Hyde—a roundish, pea-sized, fluctuant nodule, having a
depressed, yellowish center. Owing to frequeit and repeated cauterization
and the use of picric acid and similar agents, the surrounding skin
was inflamed and eczematous. Following puncture considerable
amounts of gelatinous, grumous fluid could be expre-sed through the
opening. T'lhe patient said that the lesion varied in size at different
times. When greatly distended, it gave rise to much pain and discomfort."
"Because of the encouraging reports of Lingenfelter and Ormsby
following Roentgen-ray therapy, it was decided to try only radium in
this case. The fractional dose method wias used, a one-fourth strength
applicator, unscreened, being applied for one-half hour on eight successive
days. Following the subsidence of the reaction, it was found
that Ihe lesion, with the exception of a small central cicatrix, had entirely
disappeared. At this time, five months having elapsed, there
is no sign of recurrence. -The surrounding area of dermatitis responded
readily to frequent applications of calamine lotion and zinc oil."
Walter C. Stevenson, M.D.. B.Ch., D.P.H. (Dublin. Ireland). A
Method of Recording Radium Doses. Illustrated by a series of eleven
cases treated with one set of radium emanation capillaries in needles.
Archives of Radiology and Electrotherapy. No. 186. pp. 270-276. Jan.
1916. A paper read before the Section of Surgery. Royal Academy of
Medicine in Ireland, November 5th, 1015.
"It is an obvious advantage in treating patients with radium to have
a uniform method of recording the dose. Only by adopting some
convention in this respect can confusion be avoided, and the experience
of one worker be utilized as a guide to others who are undertaking
this kind of treatment."
"It is convenient to speak of the 'dose of radium." though the
therapeutic effects are not due to radium or emanation, but to the beta and
gamma rays given off by their descendants, radium B and radium C,
during their conversion lo radium C and radium D respectively. It is immaterial
therefore whether the local source of the therapeutic rays is
a radium salt or radium emanation. For our purpose the difference is
principally that radium is practically a constant source of therapeutic
rays, while the quantity of therapeutic rays from emanation decreases
at the same rate as the emanation decays. The quantity of
radium is estimated by an. eleetroscooe which takes cognizance only
of the rays from radium C. One millicurie of radium emanation and
one milligramme of radium element are in equilibrium. They will d;s-

R a d i u m X]
charge an electroscope at the same rale and give off the same quantity
of therapeutic rays. In both cases there is the same amount of emanation,
radium A, B and C present. It is necessary to remember, however,
that emanation, when it is pumped off from the parent radium and sealed
in a tube, takes four hours to reach its maximum activity, that is it
takes four hours for the radium C, which is in equilibrium with the
emanation present, to collect. After four hours the emanation and
radium C remain at equilibrium, as both decrease at what may be
regarded, for practical purposes, as the same rate."
"It*would be convenient, and avoid the possibility of confusion, if
the quantity of therapeutic agents were at all times specified in terms
of the element radium or in millicuries. Then X milligrammes of
radium or X millicuries can only indicate the same definite quantity
of therapeutic rays. At present this is not the case. The activity of
radium or emanation is frequently given in terms of one of the radium
salts. It is therefore necessary to know what standard is in use in
measuring supplies from different sources. For instance, the international
radium standard is Ra CI,. The standard used in the Radium
Institute. London, is hydratcd radium bromide (Ra Br, 2HtO).
Emanation is now supplied in Dublin in millicuries, though at the time
I was carrying out my investigation on the practicability of the use of
radium emanation needles, the Royal Dublin Society used my radium
bromide standard in estimating the dose they were good enough to
supply to me for the purpose. The following quantities of radium and
its salts, and the amount of emanation in equilibrium with each, have
the same activity, as can be calculated from their atomic weights.
100 mg. Ra (Pure radium element).
147.4 mg. Ra CI, 2H, O.
131 5 mg. Ra C',.
142.5 m.g. Ra SO,.
187.0 mg. Ra B

82 R a d i u m
attendant tissues, is different from the optimum arrangement for treating
a carcinoma of a dry squamous epithelium, with its attendant tissues.
The experiments show that maximal effects on the epithelial cells and
minimal effects upon the associated tissues are produced in the case
of a columnar cell growth, when the quantity of radium is relatively
great and length of exposure of the tissue is relatively small, but is
produced, in the case of a dry squamous cell growth, when the quantity
of radium is smaller and the length of exposure to the rays is increased."
"However. I think there is a good deal to be said for the terms
milligramme-hours or millicurie-hours. It saves circumlocution, and
is quite explicit provided:—
1. The milligrammes are stated in terms of pure radium element.
2. Emanation is stated in millicuries.
3. The quantity factor and time factor are recorded in the order
indicated by the term milligramme-hours.
4. The dose is registered in the form of an equation/'
"Thus, when a patient received 12X10=120 mgh., it is clear
that he had ibeen treated by 12 mg. of Ra buried in the tissues for ten
hours. If the radium is used on the surface the result is divided by 2,
as at least half the rays arc wasted, and the dose is recorded thus:—
12/2 X 10 = 60 mgh. While in a structure where the whole circumference
is radiated, as in an annular cancer of the rectum, 12/1 X 10 =
120 mgh., explains the dose and the method. It would be an advantage
also *o record the amount of screening. This might be done thus, 12 X 10
= 120 mgh/1.5 mm. Pbi as the dose is diminished by the rays intercepted
by 1.5 mm. thickness of lead."
"The term "millicuric-hours' makes it plain that emanation is the
source of radiation. The definition of a millicurie leaves no doubt as to
the standard used. When using emanation, however, as its activity
decreases comparatively rapidly, the quantity factor of the dose must
be calculated from an emanation table. It is about the mean of the
initial and final amount of emanation present. It is more accurate and
usually more convenient to stale the quantity as that present when half
the exposure is over. It is obvious that when a dose runs into days
it would be better to take the mean of the quantities present
at every six or twelve hours interval. I find the millicurieJhour a
particularly convenient method of recording the dose when using emanation
needles—as the needles arc standard bore and thickness—namely.
. 7 mm. in bore and 4 mm. in thickness, and the screening is always the
same, .4 mm. of steel. The capillaries also are of standard capacity
and length, one cubic millimeter and 1.5 centimeter respectively. Therefore,
each capillary of a set will contain approximately the same
quantity of emanation."
"The number of needles or foci of radiation is recorded in brackets.
'Phus. 12 (4) 10= 120 mch. indicate that four needles containing an
average total of 12 millicuries, or 12 millicuries at half the period of
treatment, were inserted into the tissues for ten hours, and it is obvious
also that each of the four foci contained 3 millicuries. Incidentally I
may mention that when using the needles the roughest outline sketch.
which is made in two or three minutes, graphically shows the relative
position of the needles, their distance apart, and the size, shape, and
locality of the area treated. By this means, with the minimum waste
of time and energy, a complete record of the dose and treatment is

R a d i u m
secured, an essential for future reference. When sufficient, such record,
accompanied by an account of the histological and clinical results of
treatment are available, it will enable the question of dosage in radium
therapy to be placed on a scientific basis."
"In planning the treatment to be undertaken by the use of capillaries
I find it an advantage to proceed on certain lines. Cases where there is
evidence to slow that short exposure vvith a large amount of radium
gives the best results, are treated first. Again. I endeavor to use fresh
capillaries in such position as in the throat and mouth, where a long
exposure is trying to the patient. In my experience secondary malignant
glands seem to benefit most by small quantities. With the glands
too the risk of over-exposure is thus lessened. Small growths, where
the needles are inserted very close together, can legitimately be dealt
with small quantities, and rodent ulcers are particularly benefited by
long exposure with small quantities. It is usually safer to use small
quantities also where a dose is being repeated."
"Besides illustrating dosage, the following account is intended to
furnish an example of the amount anil variety of work that can be
accomplished by a single set of emanation capillaries. The cases, eleven
in number, and all inoperable are not selected, but are simply those
which happened to be ready for the dose of radium at the time 1 was
able to procure it. They were treated by nine capillaries containing
radium emanation which reached its maximum activity of 37.7 millicuries
at 4.1 p.m. on the 4th June last, and which was supplied to me
by the Royal Dublin Society Radium Institute. I may mention, one
patient with malignant tonsil I had arranged to treat, died while I was
waiting for it. and the second, a rodent ulcer, failed to keep his
appointment."
".The series is typical of the routine I have adopted, and well
illustrates the economical use of the valuable therapeutical agent. I am
not at present concerning myself vvith the efficiency of the method.
described before, and employed by me for over a year and a half.
in which a number of glass capillaries containing emanation are buried
in the tissues included in the lumen of fine exploring needles. Besides
being extensively used in Dublin, radium emanation capillaries in needles
are now. Professor Joly informs me. largely employed at the Manchester
Radium Institute, which is under the direction of Professor Rutherford;
and I know arrangements have been made by Dr. Russell to have them
supplied at the Glasgow Radium Institute, where Mr. Fleck is in charge.
Judging by the results that have been shown here, and published by
others who have followed this technique. I think it may be claimed
the procedure has a good deal to recommend it. It has been proved. I
take it. that the method is not fraught with undue risks of over-exposure
and sloughing owing to inefficient screening and secondary rays from
the metal, as was suggested at the British Medical Association Meeting
last vear. I have already pointed out in this section that screening
in radiotherapy is only a means of securing uniformity of radiation.
which uniformity is secured in this method, with the minimum waste
of therapeutic rays, toy the sub-division of the dose into "multiple foci
of illumination.' as suggested by Professor Joly."
"The following is a summary of the patients treated, and contains
particulars of disease, time of radiation, and dose. Tfhe dose is recorded
as suggested in the beginning of this paper. For instance. 36.04 (9) 10 =
360.4 mch. indicates that the mean quantity of emanation employed or
s.;

84 R a d i u m
the amount of emanation at half-time in the treatment was 36.04 millicuries,
that nine needles or foci of radiation were used, and the duration
of the exposure was ten hours, while 360.4 millicurie-hours conveys an
idea of the dose administered, and is a convenient record of the total
amount of ionization effected."
"Summary.—Patient (1). Recurrent cancer of rectum. Time—
5 p.m., 4/6/15. Dose—36.04 (9) 10 = 360.4 mch.
Patient (2). Cancer of root of tongue and epiglottis. Time—
2 p.m., 5/6/15, to 1 a.m., 6|6|15. Dose—3.404 (1) 11=37.44 inch.
Root of tongue and epiglottis. Time—1 a.m. to 10 a.m., 6/6/15. Dose—
9.45 (3) 9 = 85.1 mch. Total, 112.54 mch.
Patient (3). Epithelioma palate. Time—2 p.m. to 7 p.m., 5/6/15.
Dose—20.86. (6) 5 = 104.3 mch.
Patient (4j. Sarcoma cheek, right nostril, and naso-pharynx. Xose.
Time—2j).m., 5 |6 |15, to 11 a.m., 6 |6 |15. Dose—6.56/1 (2) 21 = 137
mch. Naso-pharynx through palate. Time—1 a.m. to 10 a.m., 6/6/15.
Dose—12/61 (4) 0=113.48 mch. Cheek. Time—8 p.m., S/6/15, to
10 a.m., 9/6/15. Dose—11.23 (6) 14= 157.5 mch. Total—407.78 mch.
Patient (5). Carcinoma ethmoidal cells, maxillary antrum and
orbit. Time- -1 p.m., 6/6/15. to 2 p.m., 7/6/15. Dose—24.51 (9) 25 =
612.78 mch.
Patient (6). Epithelioma vulva and glands in groin. Time—5
p.m., 7/6/15, to 8 a.m.. 8 |6 115. Dose—20.43 (9) 15 = 306.4 mch.
Patient (7). Malignant glands neck. Time—2 p.m., 8/6/15, to
2 p.m., 0/6/15. Dose—5.51 (3) 24 = 132.2 mch.
Patient (8). Epithelioma tongue. Time—2 p.m. to 6 p.m., 8/6/15.
Dose—2.2 (6) 4 = 48.8 inch.
Patient (9). Sarcoma chin. Time—2 p.m. to 9 p.m., 9/6/15. Dose
—10.06/2 (6) 7 = 35.21 mch.
Patient (10). Epithelioma of tongue with glands in neck. Time—
3 p.m., 12/6/15. to 2 p.m., 13 |6 |15. Dose—7.35 (8) 23 = 169 mch.
Patient (11). Cancer rectum. Time—3.m„ 13/6/15, to 2 p.m.,
14/6/15. Dose—6.1/1 X 23 = 130.3 mch."
"Patient (1) had been operated on about a year previously for
cancer of the rectum. Some nodules had developed near the anus
causing partial obstruction. These nodules diminished greatly in size
as a result of my treatment. The capacity of the bowel was considerably
increased, and the patient was able to evacuate the rectum more freely.
so that colotomy was deferred, and is still not necessary. (26th December.
1915.)"
"Patient (2) had a greatly infiltrated epiglottis which threatened to
choke him. The tissue was so friable that only one needle \% inches
long could he made to remain in position. Tto overcome this difficulty
I inserted needles 2% inches long into the root of the tongue and the
epiglottis from the surface, entering them just below and in front of the
angle of the jaw. and guiding them into position by the aid of my finger
in the throat. The capillaries, of course, were at the point of the
needles. As a result of treatment Dr. Richard Hayes verified that the
tumor of the epiglottis had melted away and the whole condition of the
part was very much improved. This patient had a number of glands
in the neck, and was in a very critical condition when I saw him. For
a time the glands became smaller and the throat improved. He died
about four months later with well marked cachexia."

R a d i u m 8s
"Patient (3) had been treated twice previously by Dr. Murphy, of
St. Vincent's Hospital, and myself. The original ulcer of the palate had
completely disappeared. This treatment was undertaken for some extension
along the fauces and apparently was successful in causing it to
disappear."
"Patient (4) had a tumor at the junction of the upper jaw and
cheek, which was about the size of a pigeon's egg, and which greatly
disfigured his face. His right nostril was almost completely blocked,
and two or three days previous to treatment he had had a very severe
haemorrhage from this, as a result of which he was quite blanched. His
naso-pharynx was also choked up with the growth. I first put two
needles loosely into his right nostril, later four right through the soft
palate into growth of the naso-pharynx. and later still six needles were
inserted from inside the mouth into the tumor of the cheek. Tliis was
the second dose administered in the last region. This boy has not been
treated since. His nostril and naso-pharynx have become quite clear.
and Dr. Richard Hayes, who kindly examined him for me, found that
the growth had completely disappeared from these regions. TJiere is
still a slight swelling of the cheek. The patient considers himself well.
and he looks healthy. Up to the present I have considered it unnecessary
to give him further treatment. This patient, whom you have seen here
to-night, was this morning examined by Dr. Hayes and myself. A
swelling was found near the right Eustachian tube. This has not affected
his hearing, but wiil require further treatment. His right nostril is
perfectly clear, in fact larger^than normal, as the turbinated bones have
atrophied."
"Patient (5) has been operated on by Dr. Murphy, of St. Vincent's
Hospital. He had considerable swelling of the right cheek over the
antrum of Highmore, and proptosis of the right eye, evidently due to
growth in the orbit. Six needles were inserted into the orbit, three
along its inner margin, three along its lower margin, and three into
the antrum through the cheek. As a result of this and a previous dose
a marked depression developed over the anthrum Highmore due to
atrophy of the growth. The tumor of the orbit diminished, and the pain
was greatly relieved. He returned to work. When I last saw the patient
there were a couple of sinuses in the position where two needles had
been. This patient refused further treatment, and I believe his condition
has become considerably worse."
"Patient (6) had an inoperable fungating epithelioma of the vulva
which caused her great pain and discomfort, and bled frequently. She
was treated in April, and improved so markedly that Dr. Alfred Smith.
of St. Vincent's Hospital, was easily able to remove the growth. Dr.
Smith kindly wrote to me, saying. "The progress of the case was most
interesting. I look forward with much concern as to the ultimate result;
there is no doubt as to the clinical cure, the future can only determine
its permanency. She came to my ward a physical wreck. She returned
home without any trace of the tumor, feeling and looking well." The
present dose was intended as a prophylactic one. I am sorry to say this
patient has now, after six months, apparently seme return of her trouble,
and is coming up from the country for further treatment."
"Patient (7) was in a very bad way with ulcerated glands of the neck.
and I do not think his condition was materially improved by the treatment
on this occasion. A few months before he improved so much that
he had gone back to work and neglected to a.ttend me."

86 R a d i u m
"Patient (8) had a very chronic squamous tpithelioma of the tongue,
which Professor McWeeny—to whom I am much indebted for examining
this and a number of other specimens—says has an extremely marked
tendency to undergo keratinisation. This patient has been much impioved
by radium treatment. The glands under the jaw are much less evident.
The mouth and tongue which were originally very foul have become
clean. Treatment, especially any large dose, seems to cause th? melting
away of the tissue without producing a distinct slough. lie has lost
over half of the anterior third of his tongue."
"Patient (9) has a sarcoma of the chin which had ulcerated throu?h
the skin. The tumor had considerably diminished with previous radium
treatment. The needles in this case were inserted in line into a sterilized
piece of lint and used by surface application on the ulcer."
""Patient (10) appealed t> derive great benefit from the treatment.
but unfortunately I have since lost sight of him. When 1 first saw him
he was hardly able to swallow fluid, a week after treatment he was able
to eat meal. He stated that all the pain and soreness had gone from
the root of the tongue where the disease was situated. Five needles
were used in the glands; three long ones were inserted in the root of the
tongue from the surface of the neck, in the same manner as in patient
(2)."
"Patient (11) was an advanced case of cancer of the rectum. The
treatment was employed to check the constant hemorrhage, which it
succeeded in doing to some extent. Soon afterwards he returned to
the country. In this case the capillaries were fixed in the top of a
thermometer case by paraffin, which was in turn surrounded by thin lead,
and the whole tied in the finger of a rubber glove."
"To sum up. it will be seen that these capillaries were utilized for
ten days, till their activity was reduced from 37.7 millicuries to 6.2
millicuries. Eleven patients were treated and fourteen doses were administered.
The parts treated were:—the orbit, the antrum of Highmore,
the nose, the naso-pharynx. the check, the anterior part of the
tongue, the root of the tongue, the palate and fauces, the epiglottis,
glands in the neck and the groin, the vacina. and the rectum. The
capillaries were used in short needles and in long needles; they were
buried in the tissues separately, employed for surface application, and
collected into a single tube, according to the requirements of each case.*'
"In conclusion. I do not think an account of any work with radium
in Dublin is complete without expressing the indebtedness of the medical
profession in this city to the Royal Dublin Society for the arrangements
they have made fo supplying radium emanation for the relief of suffering
in the poor as well as in the rich. We who have used the capillaries
recognize how much we owe to the skill and ungrudging labour of Mr.
Moss, the Registrar, who. besides being the first to make them, had to
devote a great deal of time in devising and setting up the apparatus for
charging them vvith emanation."
Richard Weil. M.D. f New York). The Treatment of Parotid Tumors
bv Radium. The Journal of Cancer Research. Vol. 1. No. 1. p. 121-2.
[anuary. 1916. (Proceedings of the American Association for Cancer
Research. Eighth Annual Meeting, held in St. Louis. April 1, 1915).

R a d i u m 87
Full article appears in Jour. Am. Med. Assn., Vol. LXV, pp. 2138-10,
December 18, 1915. "Dr. Weil reported a case of parotid tumor which
had been successfully treated with radium in the Memorial Hospital
of New York. A number of other favorable results vvith tumors of the
parotid have been reported, but in no instance has the microscopic
character of the tumor been described. In the present case, a small
piece removed for examination was diagnosed by Dr. Ewing a>
adenoid cystic epithelioma. The appearance corresponds to that frequently
described as cylindroma. The sections shovv cells resembling
epithelium, and arranged in cords which have extensively infiltrated
and destroyed the muscle bundles. No tissues characteristic of the
"mixed tumors" were discoverable. The patient was a female aged
thirty-eight. The tumor, which had been slowly growing for seven years,
was seated in the parotid region and involved the entire lower half of
the car, and of the upper part of the neck behind the ear. It was
firmly adherent to the deeper structures and in part to the skin. There
was complete facial paralysis on the right side. The radium (10 mgm.
radium bromide screened with 1 mm. lead) was inserted into the tumor
through an incision, eighteen such applications being made. At the
end of six weeks the tumor had practically disappeared. L'p to the
present time, after an interval of more than one year, there has been
no evidence of recurrence. The facial paralysis, liovvever, has not been
benefited."
Discussing the above paper Dr. F. C. Wood said: "I have long
been interested in this group of tumors and have seen, probably, some
one hundred and twenty of them. Some years ago I examined all the
specimens preserved in the laboratory of the College of Physicians and
Surgeons, New York, and found that only about fifty per cent, of these
had recurred, even with the imperfect operative procedures which were
then employed, most of the tumors dating back twenty or thirty years."
"I think that almost all these tumors might be successfully removed,
were it not for the difficulty of operating so as to avoid culling the
facial nerve. This tumor is of a type which is relatively harmless. I
have followed up a number of them of similar morphology, observed in
St. Luke's Hospital during the last few years, and have found no
recurrence. I have seen other cases, however, which did very badly
under radium treatment. The carcinomata. squamous cell epitheliomata.
and sarcomata which occasionally arise in salivary gland tumors after
they have existed for a good many years, are of an entirely different
type, extremely malignant, and not at all susceptible to radium therapy.
This case of Dr. Weil's is certainly very interesting, and illustrates the
necessity for careful microscopical study of tumors before the application
of radium. Growths containing cartilage are. as a rule, resistant
to radium, though in general no more malignant than the basal cell
epitheliomata of the face, which, as we all know, can often be treated
more efficiently with radium than in any other way."
In closing Dr. Richard Weil said: "I should like to say that the
tumor reported was one which cannot be accurately described as malignant,
in spite of certain histological features. It invaded and infiltrated
the neighboring tissues, destroyed a large part of the car. was densely
adherent, and had apparently infiltrated and destroyed the facial nerve.
Yet, on the other hand, it was slowly growing and did yield to radium."

88 R a d i u m
James Ewing. M.D. (New York;. Pathological Aspects of Some
Problems of Experimental Cancer Research. The Journal of Cancer
Research, Vol. 1, No. 1. pp. 83-85. January, 1916. (Read in the
Symposium on Cancer Research of the Second Pan-American Scientific
Congress, Washington, D. C, January 5, 1916). "On the therapeutic
side, experimental cancer research still presents itself practically emptyhanded.
The exclusive and quite energetic pursuit of the principles of
serum immunity has accomplished practically nothing, except to show
that the malignant tumor process can probably noi be controlled by
investigations along the lines which have proven effective in bacterial
diseases. Vaccination by means of tumor derivatives has been practiced
on an enormous scale all over the world and has failed to justify itself.
It has had some paradoxical success but has probably done more harm
than good. No one has been able to improve upon Vidal's feeble showing
for anticancer sera. Chemotherapy has never had any tangible
basis in the tumor field, and from Weil's review it would seem to have
even less claim to serious notice than lias vaccination. Under these
circumstances, I venture to raise the question whether it is not time to
abandon this unprofitable territory and seek for help in entirely different
directions. It may be the artificial alterations in the course of metabolic
processes in the body, as suggested by recent dietary studies, may prove
capable of influencing favorably the course of some malignant tumors.
I freely confess the hope that the vegetable kingdom may be found to
contain some agent that will specifically affects the cells of some tumors.
It is the genius of vegetable products specifically and powerfully to
affect different organs, tissues, and functions of the animal body, as
exhibited by digitalis, strychnine, morphine, etc. \\ hy should not some
vegetable agent attack the delicately balanced nutrition of tumor cells?
It would be extremely disconcerting, and even mortifying, if some
vegetable alkaloid or glucoside were found to do mere for cancer than
all the theories of serum immunity, but the demonstration, if made,
would have to be accepted."
"At present, the only laurels in cancer therapy are being carried off
by physical agents. X-ray and radium, and it seems to be only the
difficulties of accessibility and dosage which stand in the way of the
successful application of these agents to all localized and some general"
ized tumors. Cancer research should note that progress in the development
of the X-ray is almost exclusively in the hands of elaborately
equipped and far sighted business corporations, from whom one department
of medicine receives orders when and how to proceed. This
situation is somewhat different, since the study of physics and therapeutics
of radium rests vvith Government organizations, universities, and private
institutions endowed with a supply of this precious metal. It is not
too much to hope that when the early stages of cancer are recognized
as a proper field for the use of X-ray and radium, as has already occurred
in the opinion of some competent authorities, much of the present fear
of the disease, especially of the most deplorable post-operative recurrences,
will be removed. In such an event, some of the present problems
of cancer research will retain only an academic interest."
Howard A. Kelly. M.D. (Baltimore). Some Radium Achievements.
American Journal of Surgery. Vol, XXX. pp. 73-77, 1916. "What will
radium do, and what will radium not do.' are two burning questions in

R a d i u m
the medical world today, the former of which I will try to answer
briefly here:"
"what radium will do in the future with increased study and experience,
is a different and a more difficult question. Those of us who
are using radium every day in the treatment of cancers and of sarcomata.
and of fibroid tumors and of uterine hemorrhages, hope for a great
extension of the field of utility in this new field of radio-iherapeutics,
as great it may "be or even greater than the growth we have witnessed
in the field of the X-ray, which at first had no known therapeutic value,
but is now rendering such splendid service. Let me answer then ihis
great question, "What is radium doing today?" Radium is useful in
one way or another in almost every therapeutic field. I cannot therefore
do more than set down a few of its notable achievements in the
limits of a single article, giving here and there an illustration which
will speak louder than any assertions 1 may make."
"First and foremost, let me emphasize this great fundamental fact,
which applies to radium as well as to surgical operations, that is to say
the earlier the case is seen the better are the results."
"We have treated over two thousand cases with radium, but. a'as,
many of these have only come in the very last stages of their disease,
but a short distance from the end of the journey. This was due to the
fact that to the popular imagination there appeared to be something
magical in radium vvith its mysterious physical properties. Nor did it
do on the other hand to send out a general warning to our professional
friends to stop sending these very advanced cases, for here and there
even in this group occasionally one would get well."
"Radium is not a remedy to be used all by itself. He who applies
it must first of all have a broad medical experience and must be prepared
to use every adjunct in making a diagnosis; let mc briefly recapitulate
some of our daily efforts. A careful history is followed by a
careful examination of the patient from head to fool. Secretions are
examined and in all cases (unless there is a special reason given to the
contrary) a Wasserniaim test is made. Occasionally a 'cancer' is proven
in this way to he a gumma and obscure nervous symptoms arc cleared
up. X-ray pictures are taken in all cancers of the breast and of the
neck and in Hodgkin's disease and in lymphosarcomata. not to mention
the systematic examination of the intestinal tract. A most careful
pathological study is made of all available tissues before and after
radiation."
"Let me now briefly recount some of the radium successes. I think
the story cannot be too often told vvith thankfulness that radium cures
basal-celled skin epitheliomata, especially those about the face, in over
ninety per cent, of the cases when seen early. Surgery will do this
too. but what shall wc say to the mutilation caused by surgery when a
wide excision is made, to the risk of return when the surgeon is overeager
to avoid deformity?"
"When the disease extends on to and involves the mucous membrane
of the nose or mouth or when it extends back of the ear and becomes
adherent to the mastoid, although there may be marked improvement,
the final results arc not nearly so good. Of the mastoid group we have
not yet seen a single cured case."
"Cancer of the lip. if taken early, can often be eradicated; late
cases are difficult to handle."
so

90 R a d i u m
"Where the glands of the neck are involved they ought to be removed
surgically."
"Of cancer of the tongue we have had several apparent cures, but
all early cases."
"In cancer of the breast the best use to make of radium is to deal
with recurrences. It never replaces surgery in operable cases. Some
remarkable results we have seen in utterly inoperable cases, and in large
recurrent nodules fixed to the chest wall."
"Perhaps the best group of cases are the lymphosarcomata. Here
radium would justify the outlay and labor involved even if it did no
more than secure the remarkable results we are constantly witnessing
in the disappearance of great tumor masses and in saving the lives of
men in imminent danger of choking or starving to death, from ihe
pressure of their conglomerate neck tumors."
"Out of twenty of our cases, thirteen had been operated upon and
all were advanced and most of them desperate risks (with one exception)
and yet we were able to give entire relief to 6*5*y6. We do not
believe that surgery is justifiable any longer in this group, for here
surgery is at its worsi with its practically invariable recurrences and
radium is at its best with its rapid dramatic cures."
"Several massive abdominal sarcomata have also shown an equally
remarkable improvement."
"I would like to consider three classes of cases in the gynecological
field: fibroid tumors, bleeding uteri, and cancers of the neck of the
womb."
"We have treated a large series of fibroid uterine tumors vvith these
results in general. The menstruation can be stopped in about even*
case, the tumor can he checked in its growth, caused to shrink and even
to disappear. In young women it is often possible to preserve menstruation.
Our treatment is given by simply inserting the emanation
of the radium on the end of a uterine sound well within the uterus.
This causes no more pain than an examination of the patient. The
progressive diminution of the tumor goes on for weeks or months.'*
"Our position, then, regarding fibroids is this: If pressure svmptoms
are urgent or if -there are complicating conditions such as lateral
inflammation or ovarian cysts, operate. In all other cases use radium.
It is astonishing how many patients we see with serious complicating
conditions such as Bright'? or heart disease, or diabetes which would
render operation extremely hazardous or impossible. In these latter
radium is. of course, supreme."
"Bleeding uteri can also always be checked and in this way a radical
operation avoided. This is one of the greatest of all the boons conferred
hy radium."
"Xow as to the great question of cancer of the cervix of the uterus.
What can be done here? I give the statistics of 213 cases which Drs.
Burnam. Lewis and I have seen and treated, lumping them all together."
"These 213 cases were treated with radium between January 1.
1000. and January 1. 1915. Of these cases fourteen were operable and
109 inoperable or inoperable recurrent cases."
"Of the fourteen operable cases ten patients were operated on and
treated prophylactically with radium. Of these two have remained
well for more than three years: one for more than two years; four for
more than one vear; and three for more than six months. In four cases

Jf\APIUM Ol
of the operable group, on account of some general" contra-indication,
to operation, radium alone was used. All of this group are living and
well; two for over three years and two for over one year."
'The total number of inoperable and inoperable reeunent cases
is 199. of which 53 patients have been clinically cured, 100 markedlv
improved and thirty-seven not improved."
"Our series includes thirty-five cases of originally inoperable cancers
of the cervix uteri or vagina in which the patients are clinically
cured; two cases for over three years; four cases for over two years;
D cases for over one year; 10 eases for over six months. It also includes
18 cases of originally inoperable recurrent cancers in which the
patients are now clinically cured; in one case for over six years; in
one case for over four years; in eleven cases for over two years; in ten
cases for over one year; in five cases for over six months."
"Excluding the ten operable cases in which we both operated and
used radium, there are 203 cases left; in 57 of these 203 cases the
patients are clinically cured. Of the >7 clinical cures, one has lasted
for six years; three for over four years; four for over three years;
five for over two years; 24 for over one year; 15 for over six months.''
"Our rules, then, arc:
" (H Operate on every operable case, estimated as a good risk
as heretofore "
"(2) Radiate from four to six weeks after the operation."
"{3) Do not operate on borderline cases, but use radium first.
for the disease practically always returns after operation in these cases.
while many are curable with radium."
"(41) Radiate all the advanced inoperable cases, for many of these
too are curable, or can be shrunken down so as to become good risks."
"(5) Where there are metastases up into the abdomen, radiation
mav give great relief and a temporary return to apparent good health
but it will not cure."
"I el me conclude by urging two things, first, that it is not enough
to radiate and lei the case go when apparently cured that is to say
when all obvious disease is gone. AH radiated cancerous cases must
be kept under occasional observation for some years. A slight relanse
is not infrequent and as a rule responds rapidly to another application
of radium. Finally let me insist that while honing for the great boon
of a cure, we too constantly lose sieht of the fact that even if radium
never cured a single case it would still be one of our greatest therapeutic
agents, and that it often gives such remarkable prolonged relief from
pain, checks discharges, causes a cessation of foul odors and brings
about a relief and general imnrovemeivt with better soirits ami appetite.
and renewed interest in the affairs of life, a relief which is inexpressibly
valuable even if it lasts only a few weeks or months."
"Radium then has come as a most potent agent to enlarge a sphere
of control over the worst of all diseases It will do manv things we
have never been able to do before, although it is by no means a specific.
except in lympho-sarcomata."
« s * « *
Francis E. Park. M.D. (Stoneham. MassA The Treatment of
Disease by Injections of Deen-Sea Water and Radium. Med. Rec,
Vol. 89. pp. 7S2-3. Anr. 29. 1916,
For a period of about fifteen years. Rene' Quinton. the originator
of the treatment of disease by injections of deep-sea water, rendered

92 R a d i u m
isotonic with the fluids of the body by the addition of spring water,
has been carrying on in Paris his great humanitarian work. During
this period he has saved thousands of lives, especially those of infants.
His methods were the object of a great deal of ridicule at first, but as
time wore on and the uniformly splendid results of his treatment
became known, more and more respect was accorded it, until, at the
time I visited him, three years ago, it was customary to find his clinic
crowded by physicians from all over Europe.
My attention was drawn to this method by reading a paper written
by Dr. Robert Simon of the University of Paris and published in the
"International Medical Annual'' of 1010. In this such strong and
apparently well-substantiated claims were made, that I was induced to
try the remedy in a very grave case that was under my care at that
time, and with such striking results that I gave it a wide and searching
trial, and now, after Wxe years of constant use. can say unhesitatingly
that nowhere in medicine, so far as my knowledge goes, have we such
a potent, yet safe, general tonic.
In Quinton's book, "L'Eau de Mer, Milieu Organique," there
is a very careful analysis and study of the water of the ancient ocean
as revealed in deep deposits in mines. The elements revealed there
are easily divided into groups. In the first, which contains in bulk
more than half of all the others combined, are chlorine and sodium. In
the next the amount is very smalt, (but still present in appreciable
quantities, and the minerals are sulphur, magnesium, potassium, and
calcium. In the next group the amount present is exceedingly minute
but still demonstrable chemically, and comprises bromine, silicon, carbon,
azote, iron, iodine, manganese, phosphorus, and lithium. Then there
is a fourth group, in which the presence of the elements can be determined
only by means of the spectroscope; this contains boron,
arsenic, copper, silver, gold. zinc, strontium, barium, cesium, rubidium,
aluminum, lead, and now later investigations add to the above list,
radium.
According to Quinton's researches, all of these elements, in practically
the same proportions, have been demonstrated in the body fluids
by competent chemists. It was this remarkable coincidence, coupled
vvith his belief that the first living organism was found in the warm
waters of the primordial ocean, that led him to the conclusion that if
life originated and developed in such a medium, then the same solution
applied to diseased cells, that are in structure similar to the original
one. could not fail to be beneficial, by furnishing them a pabulum which
they could easily assimilate, and thus regain their lost energy.
It is hardly the place here to follow the steps by which he was
ultimately led to apply his theory in practice; suffice it to say that the
evolution occurred, and as a result we find to-day in Paris two large
clinics where this work has been carried on for many years in the most
careful and scientific manner possible, vvith all the data for this period
open for inspection. The results obtained cover such a wide variety
of diseases that one is at once forced back to the very essence of things.
in order to reach an adequate explanation of the effects observed, for
not only do we see desperately sick enteritis cases recover in a marvelous
manner, but various other conditions extending even to chronic skim
lesions as psoriasis and eczema.
At the time I visited Professor Quinton. in 1913. he was holding
to his original belief, that in the deep-sea water was some element of

R a d i u m 93
life, which he called "marine plasma," for he had found the vital
force in it was very unstable. He could neither hoil the water nor
keep it more than a few days without a total loss of its healing power.
I suggested to him at that time my belief that he was dealing vvith a
weak emanation of radium, but we could not agree. Within a few
months, however, Professor Joly's paper appeared claiming his discovery
of rich deposits of radium in the deep-sea dredgings, and his
subsequent assertion of the radioactivity of the whole ocean body. Thus
we had in the administration of freshly prepared solutions not only a
natural food, but also the dynamic force of radioactivity i-.. stimulate
the activity of the cells and increase their power of absorption.
So much for the prologue, now for the story; what will it do:
In the first place I will slate how it is prepared, and then as briefly
as possible outline the conditions where it has proved of benefit.
The water is obtained out in the open ocean, in a region free from
the contamination of sewage, and out of the track of vessels. 1 use a
sterile glass bottle of a gallon capacity, and vvith a very small neck.
This is dragged rapidly down to the depth of about 100 feet by a heavy
weight attached to the rope and several feet below the botlle. It remains
at that depth for fifteen minutes, and is then drawn to the surface and
sealed. In my laboratory it is diluted with pure spring water in the
proportion of three parts of the sea water to Uve of the other, and in
order to make it permanently radioactive, 5 micrograms of a solution
of radium barium bromide is added to every 1,000 cc. of the mixed
solution. It is then passed through a porcelain filter, and afterwards
sterilized by heat. The dose varies from 10 cc. to 200 cc.
It can he injected vvith any large syringe which can be sterilized,
but the best way I believe is by means of an apparatus which I have
devised, patterned somewhat afler that used in Paris. The accompanying
illustration. I think, explains itself. It consists of (

94 R a d i u m
to grow warm and show signs of life. The improvement was most
marvelous, for an experience of over twenty years assured me that the
case was hopeless. Since then I have learned always to expect a recovery
in these conditions when treated in this manner.
As a general tonic after a severe sickness, I believe it is without
a peer, while time and again 1 have been able to build up a surgical
case that on account of general debility was apparently hopeless, so
that in a very prion time my patient was able to undergo a major operation
successfully. Again I use it as a routine practice in the convalescence
following all my severe surgical work, and am sure that I derive
great benefit from it. In simple anemia and chlorosis, and as an adjunct
to thorium X in the treatment of the pernicious type it is of proved
worth.
In various skin affections, especially psoriasis and chronic eczema.
Quinton has done some very remarkable work, and has a collection of
photographs of cured cases that cannot be duplicated. My own experience
in this line has been small, but my results have Twen equally
striking.
In elderly patients the effect of the treatment is very gratifying;
in fact, they seem to respond a good deal as do the children, and were
it not for taking up too much space I could narrate some very interesting
illustrative cases.
Another class of disease where 1 employ it as a most satisfactory
routine treatment, is neurasthenia, and every medical man can test this
very nicely in his own experience. There are always times in our
busy life when the work comes so fast that wc are tired out. and it iliard
to keep going. This is the condition that has sleered so many
of our profession into the use of alcoholic stimulants and drugs. The
effect of the solution in this condition is simply magical, as I can
testify from many personal experiences. In my own case I pass, in
about twelve hours, from a condition of exhaustion, to one of perfect
well being, and this condition persists.
As for contraindications. I know of none. In the five years thai
I have employed it. and I use it very largely. I have never seen the
slightest harm come from its use. barring a small number of abscesses
in the early days, that were directly traced to a septic needle.
In conclusion. I believe that the medical world owes a debt of
gratitude to Prof. Rene' Quinton which as yet it but little realizes, hut
some day will to the uttermost, as the treatment becomes more generally
known,
R I. Schoenenberger and S. William Schapira (New York).
Application of Radium in the Bladder for Carcinoma, with Report of
two cases. Journ. Am. Med. Assn. LXIII. pp. 1852-3. Nov. 21. 1014.
To review at this time the various surgical conditions to which
radium has been applied would be without gain, in view of the very
recent development of our knowledge and use of this new element.
which is being brought to our attention almost daily. We believe, however,
that in reporting our cases, we are prcseining for the first time
a complete history of the action of radium as applied in the bladder
in cases of carcinoma, accompanied as they are by cystoscopic examinations
before and after application, microscopic examinations of the
tumors and end-results.

R a d i u m 95
After a careful review of the literature we find very few cases
in which radium was applied in the bladder in cases of carcinoma. One
case is reported hy Cauhape in which he applied radium to the bladder
for carcinoma of the prostate with cure in nine months. These applications
were made with radium aitached to a catheter and introduced
into the bladder per urethram. Twenty-five mg. of radium were used
and the applications made every -three days, each application lasting
two hours. Wickham and Degrais in their latest work do net mention
the use of radium in the bladder. The Radium Institute of London
in 1912 reported two patients trealcd with results not noted, ami also
two patients for prophylactic treatment, reported as improving. The
Royal Infirmary of Edinburgh reported no bladder cases in 1912. The
foregoing constitutes about all the information that we could obtain,
demonstrating that in only one authenticated case, (that of Cauhape I is
there any definite report as 'to ihe nature of the tumor, amount of radium
used, length of application and end-result.
Vne two cases that have come under our observation are as
follows:
Case 1. M. J. T.. aged 3-4. consulted us. September 23, 1013.
Family history shows that father probably died of carcinoma of stomach.
Patient gives history of hematuria for about i\ve vears. occurring at
intervals of about three months until recently, when attacks became very
much more frequent. There had been no pain until shortly before the
patient's visit to us. At this time the patient complained of hematuria
and sharp pains in right inguinal region radiating to pelvis. Examination
showed patient to be in fair physical condition. There was a left
bubonocele. In right inguinal region a mass about the size of an
orange could be felt. This mass was hard, immovable and extended
down into the pelvis. There was edema of the right thigh. Cystoscopy
showed a tumor, about the size of an English walnut, situated in the
trigon. midway between its center and the opening of the left ureter
in the bladder. The tumor was friable. The right ureter was obstructed,
but showed urine escaping. ICxamination of metastatic growth, microscopically,
showed the tumor to be carcinoma.
October 7, 1913, a suprapubic cystotomy was done. A tube containing
15 mg. of radium was attached to the lower end of a Freyer
tube and introduced into the bladder in direct contact with the tumor
and allowed

06
R a d i u m
urination day and night for about eighteen months. During the last
three months he has had pain in the region of the bladder and perineum
accompanied by frequency and hematuria. He has lost about 40 pounds
in the last three months. His appearance is cachectic He was discharged
from the German Hospital, after ten days' observation, as having
an inoperable case. Residual urine was 12 ounces, bloody and ammoniacal.
I Hood-pressure from 190 to 170. Blood examination: White
cells. 18.000; polynuclears, S3 per cent.; lymphocytes 11 per cent.;
eosinophils, 1 per cent. Rectal examination shows large hard prostatic
tumor. Cystoscopy shows large bleeding tumor slightly to left of left
ureteral opening; smaller tumor near the right ureteral opening; also
large eroded and bleeding tumor at site of prostate. The entire mucous
membrane of the bladder appears infiltrated. Diagnosis: Carcinoma of
prostate and bladder.
Patient entered hospital January 6, and a permanent catheter was
introduced for drainage and irrigation preparatory to operation, suprapubic
cystotomy, which was performed January 8. A tumor the size
of an egg at the site of the left ureteral opening was removed. A tumor
on the right side, somewhat smaller, was also removed. A V-shaped
section was removed from the prostatic tumor. The prostatic growth is
considered by us to have been the primary focus in this case. The
section taken from the prostate also provided better drainage through
the urethra. The same procedure in the use of the radium was pursued
as in Case 1. The bladder was closed in three weeks. The same unaccountable
pyrexia occurred as in Case 1. Patient was discharged from
the hospital February 5. about four weeks after operation. At this time
the patient was passing clear urine four times a day and every three
hours at night at our direction to prevent distention of bladder and
reopening of suprapubic wound. Patient gained 26 pounds in weight
in two months. Cystoscopy, April 22, showed bladder mucosa apparently
normal. the surfaces from which tumors had been removed appearing
as small pale, depressed areas. All of the surfaces appeared to be
covered by normal mucous membrane. Rectal examination showed
prostate greatly diminished in size and of normal consistency. Residual
urine. 3 ounces.
The pathologic report of Case 1 is from the laboratory of St Francis
Hospital; the pathologic report of Case 2. is from the laboratory of
the City Hospital.
Conclusions: 1. We may without danger, even without discomfort
to the patient, place in the bladder as much as 15 mg. of radium
and allow it to remain as long as twelve hours.
2. We believe that we have shown that radium has the power
to remove a tumor of the bladder (carcinoma) and of the prostate within
a period of two months. It has also been demonstrated in Case 1 that
radium has had a very decided effect in reducing the size of a metastatic
growth associated with carcinoma of the bladder.
3. No difference seems to have been evident in the result whether
or not part of the tumor was removed. In Case 1 no part of the tumor
was removed, while in Case 2 a considerable portion of the tumors was
excised.
4. We are of •the opinion that the peculiar pyrexia associated in
both cases was due to an absorption following the destructive influence
of the radium on the tumors. A thorough investigation did not disclose
anv other cause.
* * * * *

I U M
A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY, PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES.
Edited and Published by Charles H. Viol, Ph. D., and William H. Cameron, M. D.
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Radiochemistry, Radioactivity and Radiumtherapy.
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In all other countries £3.75 per year.
Address all communications to the Editors, Forbes and Meyran Avenues,
Pittsburgh, Pa.
VOL. VII. JULY, 1916 No. 4
UTERINE HAEMORRHAGES:
WITH SPECIAL REFERENCE TO ACTINOTHERAPY.*
By Henry Schmitz, A.M., M.D.. F.A.C.S., Chicago.
GENERAL CONSIDERATIONS.
There are two kinds of uterine haemorrhage: the one which is
periodical and associated with the menses is termed menorrhagia
(monthly bleeding) ; the other occurring at irregular intervals and
independent of the menstrual flow is known as metrorrhagia (uterine
bleeding). The two conditions may be easily differentiated or it may
not be possible to discriminate one from the other. But this is not of
any clinical importance, as the one may be a degree of the other and
we may term both "uterine haemorrhage." Whether the menstrual flow
is too profuse, lasts too long, or is too frequent should be determined
by a careful interrogation of the patient, taking into consideration the
number of napkins used, the character of the blood (whether arterial or
coagulated), the duration of the flow, and finally the determination of
the onset of each haemorrhage.
KTIOLOGY.
The causes of uterine haemorrhage are (1) accidents of pregnancy,
labor, and puerperium; (2) functional derangements of the genital
organs without any demonstrable pathology; (3) diseases of the generative
organs with a demonstrable pathology; (4) general constitutional
or systemic diseases; and (5) vascular disturbances.
The accidents of pregnancy, labor, and pucrpenum belong to the
domain of obstetrics and will not be considered in this paper. Such
•Sur-

98 I^ADITJM
disturbances are abortions, either threatened or incomplete, extra-uterine
pregnancy, placenta previa, premature detachment of the placenta,
atony of the uterus during or following the placental stage of labor, injuries
of the uterus, retained oval membranes, subinvolution, etc. If a
uterine haemorrhage unexpectedly occurs in a married woman, the
possibility of an abortion or extra-uterine gestation should always be
considered.
The functional disturbances of the genital organs depend in all
probability on a dysfunction of the internal secretion of the ovaries and
other ductless glands. We know from animal experimentation and
clinical observation that hormones of certain ductless glands either
inhibit or stimulate ovarian internal secretion; for instance hyperpituitarism
causes amenorrhoea, and finally sterility and atrophy of the
genital organs. Hyperthyroidism is usually accompanied by amenorrhcea,
while hypothyroidism is often associated with uterine haemorrhages. In
other words, increased activity of the thyroid gland leads to a decreased
activity of the internal secretion of the ovary, and decreased thyroid
gland activity results in an hyperfunction of the ovary.
The diseases of the uterus and adnexa accompanied by uterine
haemorrhages are: (1) Circulatory disturbances resulting in a hyperplasia
of the genital organs. They are brought about by (a) trauma and
subsequent scar formation, as lacerations of the cervix, inflammatory
cicatrices from necrosis and gangrene, haematorma, and haematocelc; (b)
displacements and deformities, as flexions, versions, rotations, torsions,
inversion, prolapse, and hernia formation; (c) tumors, leading to an
obstruction of the blood and lymph virculation; (d) obstinate and
habitual constipation; and (e) active hyperemia from perversions of
sexual and marital life. (2) Inflammations of the pelvic organs as
gonorrhceal, septic, and tuberculous infection. (3) New-growths of
the uterus as carcinoma, sarcoma, chorio-epithelioma, myoma and
adenomyoma.
General constitutional or systemic diseases are the anaemias (while
chlorosis causes oligomenorrheca or amenorrhcea); chronic poisoning;
acute infectious diseases, as cholera, smallpox, malaria, typhoid, and
scarlet fever, also scurvy, rheumatoid diathesis and haemophilia.
Vascular disturbances are the result of chronic cardiac, hepatic, and
nephritic disease.
Out of 643 consecutive gynecological cases that came under my
observation at the St. Mary's (199) and Willard (444) hospitals, 135
or 21 per cent were accompanied by uterine haemorrhage due to an
underlying genital disease. The diseases associated with uterine haemorrhage
are:
Carcinoma uteri 19 cases or 14.1 per cent
Chronic adnexitis 16 cases or 11.8 per cent
Hyperplasia of the endometrium 13 cases or 9.7 per cent
Myomata uteri U cases or S. 1 per cent
Hyperplasia of myometrium 11 cases or 8.1 per cent
Retroflexio uteri 11 cases or S.l per cent
Abortion 10 cases or 7.4 per cent
Descensus uteri ..._ 9 cases or 6.7 per cent
Oophoritis and ovarian tumors 8 cases or 5.9 per cent
Chronic cervicitis with lacerations 6 cases or 4.4 per cent

R a d i u m 99
Haemorrhagic metropathy 6 cases or 4.4 per cent
Extra-uterine pregnancy 5 cases or 3.7 per cent
Endometritis post-abortum 4 cases or 3.0 per cent
Subinvolution of uterus 4 cases or 3.0 per cent
Sarcoma uteri 2 cases or 1.5 per cent
Fifty-six out of these 135 cases are characterized by a proliferation
of uterine tissue. Thirty-two or more than one-half of the 56 arc
caused by new-growths and of these 19 are the result of carcinomatous
formations. If we add to these 56 cases the 6 cases of haemorrhagic
metropathy or essential haemorrhages, we obtain a total of 62 cases
which formerly indicated repeated curettages and finally hysterectomies
to relieve the patient. The cancers and myomata, of course, were
always extirpated if operable.
DIAGNOSIS.
A correct diagnosis of the underlying disease in uterine haemorrhages
is of the utmost importance. It can only be rendered by a
microscopic examination of the endometrium or excised pieces of uterine
tissue. A careful general and special pelvic examination will be a
valuable adjunct. Carelessness in diagnosis leads to procrastination
which has often changed a favorable into a hopeless prognosis. Incipient
malignancy can only be recognized in this manner. At this
stage the malignancy is localized and can be easily and completely
eradicated, and an anatomical cure is thus assured.
THIvATMlCNT.
It is not my object to discuss the treatment of the immediate arrest
of uterine haemorrhages at the time of their occurrence or describe the
technique of a curettage or of a hysterectomy. The purpose of this
study is to call your attention to the curative action of actinotherapy
or radiotherapy in treating uterine haemorrhage. If wc subtract from
the 62 cases mentioned above the 21 cases of malignancy, we have left
41 cases of uterine haemorrhage which had existed for a long period of
time and resisted all usual treatment. Formerly the majority of these
women had to be hysterectomized to bring about a cessation of the
haemorrhage. Six patients were treated vvith the massive roentgen rays
and 12 with radium. The accompanying table gives all the data
necessary.
Technique. A course of X-ray treatment consists of 6 seances
each of about one hour's duration, given on six succeeding days. Watercooled
tubes of a diameter of 7 inches and a hardness of 7 to 9 Heinz
Bauer are charged with a current of 2 to 3 miltiamperes. The focal
distance of the tube from the patient is 21 cm. The rays are filtered
through an aluminum plate of 3 mm. thickness. Six different fields,
each 5 cm. square, are drawn upon the suprapubic regions. Thirty to
forty X are applied to each field. The amount of X used is determined
by a Holzknecht radiometer. The applications are preferably made
during the week following the cessation of menstruation. Usually one
such course of treatment suffices to produce amenorrhcea. If this should
not occur, a second course is given after three weeks, which invariably
brings about the desired result. Concomitant symptoms are mild. They
usually consist of nausea or diarrhoea, but are of a transient nature.
Only the gamma rays of radium are employed in the treatment of
uterine haemorrhages. The alpha and beta rays are arrested by a lead

100 R a d i u m
Case |
No.;
Name | Age
la 1 | Mrs. 0.
1
!!a | Mrs. S.
1
3a : Mr*. T.
1
4* | Mrs. G.
1
5a 1 Miss M.
1
•Sa | Mrs. K.
1
i I Mrs. N.
iti
47
if
40
i,
iii
ii
42 | .Mr... P.
1
44 | Mrs. E.
1
53 i | Mrs. B.
1
!5 I Mrs. M
I E. C.
ft t MlisTT-
1
~53 FMUs C.
I
~S"5 | 1 Mrs. P.
1
97 1 Mrs. B.
3S
3S
Civil
SMt*
M.
«"
M
s.
M.
M.
o
IV
ill
"«>
TS~
Dura (Ion
of
Hemorrhage
len years
Four years
Six years
Three years
Severa 1~
years
years
four
months
Six months
One year
Diagnosis
Myomata"
uteri
Myomala
Uteri
Hyperplasia
uteri
Sfyomata
ulerl
Hyperplasia
ulerl
II>perpla*
uteri
Myom.t.
uteri
Metropathia
rh an lea
hemor-
Decisis
_
"April if.
19H
June 30,
1915
5o
.1"
li,
:-.*
II, VI
"
Six years
Three
months
Ttiree
-'-\ months . i .11
years
Myomata
uteri
Myomata
uteri
Hyperplasia
Metropathia
uteri
hemor­
38
65
M
M
I'll Two years
V Ten years
rhagica
Myomata
uteri
Myomat
102 I Mrs. P. 32
1
137 1 Mrs. b. 1 «
1
1
142 ! Mrs. S. I io
i 1
M.
M.
M.
Ml
TV"
One year
'I'lii- - years
Eighteen
days
uteri Cystoma
ovari
Myomata
uteri
Myomata
uteri
filter of the thickness of 2 mm.; the secondary or Hyperplasia
Sagnac rays, forming
in the heavy metal filter, which resemble the soft beta uteri rays of radium.
are absorbed by a pure para rubber filter of 1 mm. thickness. The
average amount of milligram hours of radium element necessary to
cause amenorrhcea is 1.000. If 50 milligrams of radium element are
employed, it will take twenty hours to obtain this milligramage. The
patient is prepared as for any operation: one-quarter of a grain
of morphine is given hyperdermically about one-half hour prior to the
time the application is to be made. The field around the vagina is
rendered sterile, the cervical canal dilated, the endometrium is curetted
for diagnostic purposes, and the radium capsule is then placed in the
uterine cavity. A small chain or silk thread is left attached to the capsule
to facilitate its removal. On an average 1,000 milligram hours
suffice to bring about amenorrhcea. If the patient should still flow at a
subsequent
weeks.
period, the application may be repeated after four to six
1 repeat the necessity of a diagnostic curettage to exclude malignancy
before the treatment with the roentgen or radium rays is begun.
The indications for this treatment followed by inc are as follows:
Essential uterine haemorrhages and hyperplasia of endometrium and
myometrium. In a patient of 35 years or older, failure of medicinal

CaBe
No.
1A
2a
8a"
4a
5a
M
*
42
44
63
72
§2~~
•3
IB
n
—102
• 137
142
Kind of
Treatment
x-ray
200.x
X-ray
3U0-X
X-ray
260-X
X-ray
joo-x
X-ray
210-X
X-ray
30»-X
Kadlum
looo mgh.
Hadturn
12

102 RA.PITJM
CONCLUSIONS CONCERNING THE VALUE OF
RADIUM-THERAPY IN PERNICIOUS
ANAEMIA.
By Frederick Proescher, M.D.
For the critical discussion of the value of radium in pernicious
anaemia, a brief recapitulation of the present status of the pathogenesis,
diagnosis and therapy of this disease will be given.
The opinion as to the clinical classification of essential pernicious
anaemia and its differentiation from other severe anaemias having a
pernicious anaemic blood picture, has changed considerably during the
last decade.
According to our present knowledge, the essential pernicious
anaemia (Addison-Biermer) is a clinical entity characterized by its progressive,
sometimes remittent but fatal course of unknown etiology.
The former opinion of Ehrlich and Lazarus that the megaloblastic hyperchromatic
blood picture (Ehrlich's embryonic blood picture type) caused
by a primary disease of the haemopoetic system which is frequently
found in this disease and in the most pronounced form, and which
should be characteristic of the pernicious anaemia only, is abandoned
today. Numerous observations have shown that the blood changes
regarded as specific may be temporarily or entirely absent during the
entire course of this disease. On the other hand a pernicious anaemic
blood picture may be observed undoubtedly in curable and incurable
diseases of known etiology as ankylostomasiasis, botricephalus-infection,
carcinoma, syphilis, malaria, etc. All pernicious anaemias, including
the anaemia which accompanies the morbus Biermer, are all secondarily
symptomatic, not primarily essential. Primary essential anaemias
do not exist. The anaemia in Biermer's disease, clinically an entity, is
the most pronounced symptom and is only secondarily symptomatic.
Moreover, all pernicious anaemias are not primary bone marrow
diseases or primary myeloid anaemias. The apparently primary bone
marrow anaemias (myelo-anaemias) are caused by a metaplasia of the
bone marrow and arc, therefore, secondary or primary hacmolytic or
haemotoxic anaemias, like the secondary anaemias. This theory supported
by the fact that all banal secondary anaemias may change into a
pernicious form proves the latter also to be of secondary nature.
With Pappenheim, I distinctly separate the clinical pernicious
anaemia, morbus Biermer, from the pernicious anaemic blood picture.
The first is an etiological unknown (kryptogenetic) group of diseases,
with a specific clinical course. The latter is a very ominous symptom
of different severe toxic anaemias which accidentally received its name
from anaemia perniciosa. The pernicious anaemic blood picture is a
final and severe symptom of a toxic anaemic regeneration without specific
cause, (Schilling-Torgau). The severity of the anaemia depends on
the individual resistence to the intoxication (hemotoxin) in which
resorption and a partially acquired immunity play an important role.
The primary hemotoxin may either be of a serogen or histogen nature
(increased local destruction in spleen).
Biermer anaemia, a specific form of the pernicious anaemia, is of
unknown origin, probably autotoxic while the botriocephalus anaemia,
and carcinoma anaemia if they show the pernicious anaemic blood picture,

^APITJM 103
are of known etiology. In the case of leukanaemia we do not have a
combination of Biermer's disease with leukaemia, but a pernicious
anaemia caused by a hyperplasia of the myeloid component of the bone
marrow (myeloid anaemia.)
For the diagnosis of pernicious anaemia a careful clinical observation
together with repeated blood examinations is necessary to establish
the diagnosis of pernicious anaemia during life, (but the diagnosis can be
made wilh certainty only post-mortem. The following points are
essential for the diagnosis: Characteristic progressive remittent clinical
course; exclusion of syphilis, carcinoma, malaria, helminthiasis by specific
therapy; presence of a megaloblastic hypcrchromatic or hypochromatic
blood picture with leukopenia, lymphocytosis and decrease in blood
platelets, if only of temporary duration. The difficulty in establishing
the diagnosis of essential pernicious anaemia is obvious, and it is, therefore,
not surprising to find in the literature a great number of so-called
cures of pernicious anaemia, which are in reality nothing else than
temporary remissions, but no permanent cures. On the other hand,
there are cases recorded where in a curable disease a pernicious anaemic
blood picture was found, but a morbus Biermer was diagnosed, which
disappeared either spontaneously or under the usual treatment.
AH experienced clinicians are convinced that the essential pernicious
anaemia is incurable and as long as we are in the dark as to its
etiology, the treatment is merely symptomatic. The main therapeutical
effort is to increase the red cells or in other words, to stimulate the
erythroplasia component of the bone marrow in order to overcome the
pathologic destruction of the red cells. As stated above, the essential
pernicious anaemia is secondarily haemotoxic, the destruction of the
red cells going on extramedullary. The bone marrow, or more exactly,
the erythrogenesis is not directly affected. As long as the bone marrow
is not exhausted, we may overcome or balance the abnormal destruction
by an increased output of red cells.
Of the various therapeutic agents, which stimulate the erythropoesis,
iron and arsenic in its various inorganic and organic compounds, are
the most valuable. Until the haemostimulating properties of the radioactive
substances were discovered, arsenic played the main role in stimulating
the red cell formation. Iron as well as arsenic has a direct
stimulating effect upon the bone marrow. After the administration of
iron Fr. Muller found in animals artificially rendered anaemic an
increase in nucleated red cells in the bone marrow. Bettmann and
Stockmann found the same for arsenic. Bettmann's careful investigations
have shown that arsenic in toxic doses displays two different
actions. First: The resistence of the circulating red cells is lowered
and the cells therefore, are more rapidly destroyed. Second: The bone
marrow shows an over production of premature red cells of increased
resistence and the absolute amount of the circulating red cells is considerably
increased. In large doses the destructive effect upon the red
cells surpasses the stimulating effect and a marked anaemia is the consequence.
In conclusion we can say that in minimum and slowly
increasing doses the destructive effect upon the circulating red cells
is not only completely compensated but surpassed by the production
and increased output of newly formed red cells brought into the circulation.
Since Bramwell in 1877 advocated arsenic for the treatment of
the progressive anaemia, this drug is used more than any other agent

104 Rapitjm:
and as in many cases it has been the sole therapeutic agent, it has gained
prestige as a specific. With a few exceptions most authors are inclined
to believe that arsenic has a startling beneficial effect as the beginning
of recovery corresponds with the administration of this drug. The
statistics published by Pauley and Fuerbringer seem to speak in favor
of the arsenic treatment. Twenty-iwo cases treated by Padley showed
16 recoveries (?) two improvements and four deaths. Fuerbringer
treated fifty-seven cases with the following results. Four relatively
recovered, 16 improved, 10 unimproved, and 27 died. The great contrast
in both statistics is evident and arouses skepticism that the 16 cases
reported recovered were not essential pernicious anaemias. Fuerbringer's
statistics show no recovery and speaks merely for a symptomatic but
not for a specific influence of arsenic.
A disease with such a variable course, where spontaneous remissions
from the most alarming symptoms to rn apparent recovery may
be observed, lead the inexperienced observer to the most optimistic view
as to the therapeutic value of any symptomatic treatment, 'jut in
spite of the still doubtful influence of the are* lie upon the course of
the pernicious anaemia, we cannot entirely dispute its favorable influence
in some cases. It is not my intention 'o discuss the various
arsenic compounds used in the treatment of this disease. I prefer of all
arsenic preparations the arsacetin for subcutaneous -ind intravenous injection,
as well as per os. The arsacetin is of all arsenic compounds
the most tolerated and I have used it entirely in the List five years without
any untoward results such as we experience by the use of inorganic
arsenic preparations, and the cacodylates. The solutions can be repeatedly
sterilized without deterioration. The methods of preparation and the
dosage were described under case Xo. 1. (This Journal, June. 1916, p. 71).
The increased haemoglobin content of the erythrocytes as well
as the great amount of iron stored in the organs, especially in the
liver, shows that there is no lack of iron and makes an iron medication
unnecessary. The iron therapy is absolutely without any effect in pernicious
anaemia.
The treatment of pernicious anaemia with radioactive substances,
especially with thorium-X, is of recent date (Plesch, Bickel, Gudzent
Klemperer and H. Hirschfeld). Plesch was the first who apparently
successfully treated a case of pernicious anaemia with thorium-X. The
erythrocytes in this case were only .540.000. After the first intravenous
injection of 20.000 mache units, which Plesch designated as "Reizdosis."
the red cells increased twenty-four hours later to 1,200.000. on the second
day to 1.300,000. On the fifth day the patient again received 20.000
mache units. The blood count on the thirteenth day showed 2.300.000
and on the twenty-third day 3.000.000 red cells. During the treatment
the pathological forms of the red cells disappeared and a normal red
cell picture was restored. Bickel reported a case of pernicious anaemia
in which he obtained a most remarkable result by treatment with
thorium-X drinking water, after arsenic treatment had been unsuccessful.
The case showed 960.000 red cells. 50% hemoglobin, and 3.800
leucocytes. The patient received 5.000 mache units daily in form of
thorium-X drinking water in three portions after each meal for four
weeks. Five weeks later a remarkable improvement was noted. The red
cells had increased to 6,000,000. the hemoglobin to 90%. and the
leucocytes to 8.000.

R a d i u m
Hirschfcld and Klemperer (1) treated five cases of pernicious
anaemia with intravenous injection of thorium-X and noticed a temporary
improvement only in one case. The other cases did not respond to
the treatment at all.
In the following tables the five cases of Hirschfcld and Klemperer
are given: (Amounts of Thorium-X injected intravenously are expressed
in terms of radium bromide).
Case Xo. 1.
Amounts of Thorium-X
Date 1912 injected intravenously. Hemoglobin % R. Cells. //'. Cells.
June 13
June 18
June 19 0.05 nig. Radium bromide
equals 40,000 M.U-
60 2.700.000
2,800,00
5,800
4,000
June 22 0.04 mg. Radium bromide
equals 40.000 M.U-
July 4 0.03 mg. Radium bromide
equals 30,000 M.U.
July 12
July 17 0.05 mg. Radium bromide
equals 50,000 M.U.
65 4,100.00
July 19
4,400,000
June 3
June 7 20,000 M.U.
June 8
June 12
April 4
May 2
Mav 21
May 24
May 28
June 1
June 2
June 11
June 19
June 15
June 24
Tuly 12
July 17
Case Xo. 2.
Case No. 3.
Thorium-X-Inject ion
0.02 mg. Radium bromide
equals 20.000 M.U.
0.02 mg. Radium bromide
equals 20,000 M.U.
0.02 mg. Radium bromide
equals 20,000 M.U.
0.02 mg. Radium bromide
equals 20,000 M.U.
0.05 mg. Radium bromide
equals 50.000 M.U.
1.350.000
July 18
i\T Der Jelzlse Stand der Thorlum-X Theraple ml< elsrenen neobachtiinsen
bel l'euk»nie and Anaemia. G. Klemperer unci Hlnich leld. Die Theraple der
Gegenwarl. 1912.
25
23
25
35
45
30
30
105
1.300,00 7,400
900.000
550.000
1.200,000
1,850.000
1.730.000
1.440.000
1,620.000
1,740.000
1,620.000
1.020.000
950,000

106
May 21
June 19
June 22
RAPITJ* I
Case No. 4.
0.02 mg. Radium bromide
equals 20,000 M.U.
40
25
1,660,000
780,000
4,000
June 26
20 428,000 3,000
July 3 0.04 mg. Radium bromide
equals 40,000 M.U.
July 7
470,000 4,300
June 24
Case No. 5.
25 1,000,000 4,000
June 28 0.03 mg. Radium bromide
equals 30,000 M. U. 20 1.050.000 3,000
July 3 0.12 mg. Radium bromide
equals 120,000 M. U.
July 9 20 800,000 4,880
At the time of the publication of the above table Klemperer and
Hirschfeld stated that out of a total of seven cases treated, three were
successful and four unsuccessful.
Since the publication of Klemperer and Hirschfeld a number of
other authors have reported their results with thorium-X in pernicious
anaemia. Most of these case reports confirm to a greater or less degree
the observation of these authors. I wish to refer only to the work of
Arneth (2) which is by far the most thorough, since a complete analysis
of the blood picture was made, especially the leucocyte changes, based
on his well known method. The analysis of the blood picture of a
pernicious anaemia case twice treated with arsenic, the first treatment
responding, while the second failed, and finally given a series of injections
with thorium-X is shown in the following table: (Next page).
After the injection of 350,000 mache units of thorium-X tfie red
cells increased over 3,000,000, the hemoglobin to 70%, but both were
later somewhat lowered. The leucocytes following the first injection
were increased from 1,000 to 2.000 and after three weeks they reached
their normal number, 5000 to 6000.
Under the influence of thorium-X the leucocytes were increased
from 500 to 600%. At the same time the leucocyte picture was
restored to normal. Relatively the lymphocytes decreased from 40%
to 19% and the neutrophile leucocytes increased from 53% to 70%
The eosinophiles which were abnormally high were slightly decreased
and the mononuclear and transitial forms which were entirely absent
reappeared.
Arneth concludes that thorium-X influences the blood picture only
in a quantitative way. It decreases and increases their production, but
in proper dosages does not effect either the white or red cells directly.
Thorium-X in pernicious anaemia is a leucocytacticum of a special kind.
The normal leucocyte picture is restored by a general movement of the
nuclear picture towards the right.
According to the opinion of Klemperer and Hirschfeld, thorium-X
has no advantage over the arsenic treatment, as the latter will bring
on a remission in about the same percentage of cases as thorium-X.
On the other hand they believe that thorium-X will be of value in some
(2)~ Thorium-X bei pernicloser Anaemia Arneth. Berliner kllnische Wochen-
BChrlft. 19U, No. 4. p. 163.

Rapitjm
Date. Thorium-X Hemoghbin
Doramad. Time A.M. Erythrocytes. per cent. Leucocytes.
16.6 35 9:45 1,904,000 42 1,000
17.6 .. 11:00 1,760,000 47 1,000
19.6 30 11:00 1,428,000 53 2,000
21.6 .. 10:15 1,844,000 55 1,400
23.6 35 11:00 1,896,000 57 2,600
25.6 .. 11:45 2,224,000 56 3,500
26.6 30
28.6 .. 10:30 2,304,000 62 3,000
30.6 35 11:00 2,424,000 58
30.6 .. 5:45 P.M. 2,176,000 59
4.7 11:20 2,384,000 57 4,000
8.7 11:30 2,536,000 62 5,200
12.7 35 11:30 2,336,000 65 5,400
16.7 11:00 2,408,000 66 6,700
23.7 30 11:00 2,472,000 68 6,200
28.7 10:45 2,424,000 70
2.8 30 1:00 P.M. 2,360,000 64
9-8 30 12:00 2,504,000 70
14.8 30 1:00 P.M. 2,952,000 70 4,400
20.8 30 11:30 3,064,000 70 4,200
26.8 30 11:00 2,016,000 66 4,100
5.9 11:30 2,400,000 62 6,400
12.9 10:30 2,624,000 62 8,200
19-9 11:00 2,336,000 62 5,800
DIFFERENTIAL count.
.{ till ' i
4 osi t I & » sprig
A < j o z a c J j 5 o h
16.6 1,000 58 3 38 1
28.6 3,000 48 5 2 45
16.7 6,700 77 2 0.25 19 0.5 0.75
2.8 63 2 1 34
26.8 4,100 75 1.6 23 0.4
19.9 5,800 69 0.9 0.3 29 0.3 0.3
BLOOD PICTURE OF RED CELLS.
16.6. Three normoblasts (polychromatic) per 300 leucocytes; in each of
three to four fields, one polychromatic erythrocyte, few basophilic erythrocytes
(orthochromatic); slight poikilo—and anisocytosis, many microcytes, few megalocytes.
28.6. Slight anisocytosis and a few poikilocytes, no nucleated red cells.
16.7. Very slight anisocytosis and a few poikilocytes.
2.8. Poikilocytosis and anisocytosis in a very slight degree, few megalocytes.
26.8. Anisocytosis almost disappeared; a mere trace of poikilocytosis.
19.9. A mere trace of anisocytosis, normal erythrocytes, very few megalocytes
still present.
107

108
R a d i u m
cases in which arsenic is without influence. They advise treating pernicious
anaemia first with arsenic in the form of sodium arsenate or
arsacetin. If no effect is noted they advocate the use of tartarus stibiatus
(1 to 5 mgm. daily). If 'both drugs are without effect they advise the
use of thorium-X as the ultimum refugium (20 to 40,000 mache units
daily). As to the specificity of the thorium-X in pernicious anaemia
they express no opinion.
Arneth believes that thorium-iX possesses to a certain degree the
quality of a specificum for pernicious anaemia, as it temporarily restores
ihe blood picture to normal. Whether or not pernicious anaemia can
be definitely cured with thorium-X has as yet not been proven.
At present it is impossible to come to a definite opinion as to the
real therapeutic value of the thorium-X treatment in pernicious anaemia.
In the majority of the cases a complete analysis of the blood picture
with the exception of the case of Arneth was not undertaken and
furthermore the observation time in all the cases was too short to
reach any definite conclusion as to the advantage over the arsenic treatment
and the specific influence of the thorium-X in pernicious anaemia.
If we compare the action of radium with thorium-X in the treatment
of pernicious anaemia we notice that both have the same qualitative
action, but quantitatively the radium seems far superior to thorium-X.
A study of the tabulated cases of Klemperer and Hirschfeld as well as
the case of Arneth and both our cases, demonstrates that a single dose
of radium produces either the same or a more pronounced effect upon
the blood picture than several injections of thorium-X. The leucocyte
picture is influenced in the same way as with thorium-X. The slow
decay of the radium exerts a more prolonged and on the other hand
a more mild action upon the erythrocytes than the rapid decay of
thorium-X. According to the investigation of Seil, Viol and Gordon,
on the elimination of radium in human beings, from 55 to 65% of the
radium intravenously injected remains in the body for four or five days
following the injection. The daily rate of elimination of the injected
radium 10 days later, is less than 1%. About 35 to 45% of the radium
is fixed in the body, mainly in the long bones in form of an insoluble
salt giving for a long period a low but fairly constant concentration
of radium emanation. The following table demonstrates the distribution
of radium salt 108

R a d i u m 109
7. Para thyroid
g'and 0.12 " 0.035 " Trace? "
8. Bone marrow
lumbar region 9.18 " 3.73 " .01780 " 0.00480
9. Intestines 17.7 " 5.10 " .000700 " 0.00014
10. Thyroid gland.. 13.3 *' 2.74 " .000700 " 0.00026
11. Kidney 15.0 " 3.41 " .000090 " 0.00003
12. Stomach 15.5 *' 3.30 " Trace?
13. Lung. 4.77 " 0.82 " .00163 " 0.00200
14. Pancreas 7.12 " 1.38 " .00059 " 0.00043
15. Spleen 11.83 " 2.90 " .00196 " 0.00067
16. Retroperitoneal
gland 26.6 " 11.80 " .00141 " 0.00013
The largest percentage of radium was recovered from the bone
marrow. The affinity of the radium to the bony structures makes it a
haemostimulant "par-excellence."
Thorium-X on account of its exceedingly short life time is never
deposited in the bones. Its toxicity does not permit its injection in
doses greater than 20 or 40,000 mache units. According to Arneth
these doses should never be exceeded either in pernicious anaemia or
in other disease, as the effect of large doses cannot be judged beforehand.
Messeth has reported two deaths in pernicious anaemia after the
injection of 100.000 mache units intragluteal. If thorium-X has no
effect in small doses given in short intervals, it should .never be used
at all. as we have no other substances which counteracts thoriuin-X.
The animal experiments of da Silva Mello with thorium-X have shown
that after a small but not fatal dose of thorium-X which causes no
marked change in the blood picture the animals may die after the effect
of thorium-X has entirely subsided. The autopsy findings in such
animals are entirely negative. The accumulative effect of the thorium-X
is further demonstrated by the animal experiments of da Silva Mello
that after the injection of a second hut not fatal dose of thorium-X in
an animal which is still under the influence of the first injection a more
intense action will be noted than if both doses were given at once
In addition to this. thorium-X has a more injurious action upon the
erythrocytes. Medium sized doses may cause a marked anisocytosis and
a polychromatophilia of the erythroeyctes.
Radium on the other hand is a much less toxic agent. In fatal
and superfatal doses given to animals it never produces an anisocytosis
of the red cells and a complete leukopenia. It is not accumulative and
doses up to one milligram (2.700.000 mache units) in either small or
massive doses are without danger. We have thus far no death record
after the injection of large doses of soluble radium salts. According
to v. Koordcn. radium is superior to •thoriuim-X in the treatment
of anaemia. It has a more selective action upon the erythropoctic component
and a less injurious effect upon the leucocytes and myeloid
tissue.
The advantage of radium over arsenic does not need to be
emphasized. The toxicity of the arsenic no matter what preparation is
used makes it desirable to replace it by an atoxic haemostimulant. A
fraction of a milligram of soluble radium salt exerts a far more powerful
effect upon the erythropoetic system without any untoward symptoms
than arsenic even" in large doses. Comparative investigations in the
future have to decide if the present arsenic therapy will be replaced
by radium.

no R a d i u m
Reviews and Abstracts.
Stephen Rushmore, M.D. (Boston). Progress in Gynecology.
Boston Medical and Surgical Journal, CL-XXIV, No. 8, pp. 277-282,
Feb. 24, 1916. "Cancer and Radium. Much has been written on the
use of radium in the treatment of cancer of the uterus, but the known
results can be stated briefly. Ransohoff (Lancet-Clinic, Vol. cxiii,
p. 289) advocates its use in inoperable cases, where it gives great relief.
Some of these cases may prove later to be cured. He does not accept
Kroenig's dictum that it should be used in every case to the exclusion
of operation, though all acknowledge that the five-year limit only will
show the final test."
"The line of treatment laid down by Ransohoff is in accord with
the practice of most operators at the present time—to operate in cases
in which the growth seems eradicable. While not in favor of preoperative
radiation on account of material increase in the difficulty of
operation, he advocates post-operative treatment as a prophylactic
measure against recurrence. If radium is effective for three and onehalf
centimeters only, even this range of applicability would cover
most of the operable cases. If the carcinoma has advanced more than
this distance the case is a border-line case, one of those which the
surgeon so often wishes he had not attempted when he gets down to
the growth."
"The report of the Radium Institute of London is to be recommended
to those who desire detailed information and conservative views.
An abridged report has been published giving a summary of the work
of the past year. Pinch (Brit. Med. Jour., 1915, Part I, p. 367) the
medical superintendent, says cancer of the uterus is very favorably
affected by radium, both in inoperable and in operable cases, though
it is not proper to speak as yet of a cure. Post-operative recurrences
in the vagina are also favorably influenced. But if extensive operation
has been carried out. great care is necessary in the post-operative use
of radium, employing smaller amounts and thicker screens. Unless
these precautions are observed, a severe and extensive destructive
reaction may follow. This may be attributed to operative interference
with the trophic nerves in the pelvis. If radium has been applied to
the vagina, douches should be used night and morning for six weeks,
at least, to prevent adhesive vaginitis. In some extremely susceptible
cases a transient proctitis has been noted after the intravaginal treatment.
For details of technic. reference must he made to original
sources."
"Von Scuffcrt's (Strahlen Ther. Vol. iv. p. 740) experience in
the treatment of cancer with radium, has been chiefly with reference
to the treatment of cancer of the uterus, and he aims to give a fair
statement of the present status of radium therapy as far as it is concerned
with cancer. No method hitherto described gives as satisfactory
immediate results in cancer of the uterus, whether the case is operable
or inoperable. As to cures, no judgment can as yet be expressed."
"There can be no doubt that many inoperable cases can be so influenced
that no evidence of carcinoma can be detected after treatment,
and a number of such patients are now living one or two years after
treatment who are clinically as if no cancer had ever been present.
Among cases treated in the earlier period when radium was first used

R a d i u m in
there are a few free for over five years. Yet it is also to be noted
that especially in the cases first treated the effect was very superficial
owing to the technic, and that it is recognized now that the depth of
the penetration is an important factor."
"If the disease has advanced to the glands, operation offers the
hope of cure in some cases in which radium does not, for cases with
such glandular metastases have survived operation for more than five
years without recurrence, and tests of the penetration of radium indicate
three and one-half centimeters as its limit. Bumm found glands with
uninjured cancer cells after radium treatment. Bumm has also raised
the question as to the injury or depression of vitality of cancer cells
without evident microscopical injury, by reporting a case in which
carcinoma nests were found up to the line of excision, yet Ihe patient
was well one and one-half years after operation with no evidence of
carcinoma in or near the scar. But, if radium did not give quite as
many cures, would it still not counterbalance the high operative mortality?
Only time can tell. When we consider local effects, the limit
of penetration of three and one-half centimeters gives at least as good
a chance for cure as does operation."
"Through recent refinements in technic, the effects of radium in
the body may be controlled so that there seems to be a so-called elective
or specific action on carcinoma cells, though there is objection to the
use of these terms in this relation. The progress which has already
been made technically gives promise of still further improvement along
the lines of lessening the dangers and increasing the efficiency. With
deep penetration the danger is to the intermediate tissues."
"Allman (Strahlen. Trier., Vol. iv, p. 625) reports his experience
in the treatment with radium, of inoperable carcinoma of the uterus,
with results which are gratifying, when we consider the discouraging
nature of this hopeless group. He comments adversely to the use of
cholin, which has been so strongly recommended by some, on account
of the disagreeable constitutional symptoms of which the patients
complain."
"Cheron and Rubens-Duval (Strahlen. Ther., Vol. v. p. 80) report
similar favorable results in a series of one hundred fifty-eight
inoperable cases, one of which was cured (histological examination).
One hundred and fifty-five showed regression, some of which are
clinically cured, though less than five years. There were two in which
treatment failed completely. These writers prefer massive doses, as
do Kroenig and some others."
"The histological changes in the carcinomatous tissue arc studied
by Degrais and Bellot (Strahlen Ther.. Vol. v. No. 1). whose article
contains some microphotographs of the progressive destruction and
final disappearance of the epithelial cells in the midst of connective
tissue growth."
"Runge (Med. Klin.. Vol. x, pp. 19, 59, 192) presents the replies
to an TJmfrage' or questionnaire, which was sent to a number of
German gynecologists. The questions were:
(1) How do you regard radiotherapy for metropathies? (a) X-ray;
(b) Radium or mesothorium.
(2) How do you regard radiotherapy for myomata? (a) X-ray;
(b) Radium or mesothorium.
(3) How do you regard radiotherapy for cases of cancer of the
female genitalia, and particularly in cancer of the uterus? (a) In-

112 R a d i u m
operable; (b) Operable; (c) Recurrence; (d) Prophylactically after
radical operation.
(4) What combination do you use in the radiotherapy of cases of
uterine cancer? (a) X-ray alone, total dose given; (b) Radium or
mesothorium alone, total dose given; (c) Combination of X-ray and
radium or mesothorium, total dose given.
(5) What filtration of rays do you consider best, (a) for X-ray,
(b) for radium or mesothorium.
"Sixteen replies to the questionnaire were received and may be
briefly summarized."
"For metropathies at about the time of the climateric, X-ray gives
excellent results in the hands of all who have tried it. Radium or
mesothorium seems to be no better, not indicated, or more dangerous,
though few had used them for this condition."
"For myomata, the results in general are very good if bleeding
is the only symptom and no complications are present. But Fraenkel
considers radiation more dangerous than operation, and von Herff says
radiation is to be employed only if operation is contraindicated. Kroenig
recommends radiation except in cases of younger women in whom
enucleation is possible. In general, radium and mesothorium are not
used for myomata."
"Radiation gives immediate results, which are favorable in most
cases of inoperable cancer. Some replies are enthusiastic, others withhold
judgment though all advocate giving it a trial."
"For operable cases all operate, except Kroenig, who operates only
in selected cases (methods of selection not stated); Bumm, who says
radiation gives certain local cure, and Pankow, who says that up to
the present time, at least, radium has given good results."
"Results with recurrence are generally negative or unfavorable,
though all try radiation if operation is impossible. Local recurrences
do much better than glandular."
"Though prophylactic radiation is used by all (post operative),
the general opinion is that not enough is known about results here
to form a basis for judgment. In one reply it is said the questionnaire
was sent out at least a year too soon."
"Myomata of the Uterus and Radium. Abbe (Med. Rec. Vol.
lxxxvii, p. 379) reports a small series of cases of myomata of the uterus,
which he had treated with radium (fifty to one hundred milligrams)
at varying intervals, and had observed for a number of years. The
tumors have diminished in size and in some cases almost disappeared,
while in others no trace of the tumor remains on palpation. In one
patient the mass filled the pelvis. Abbe has not seen harmful results
with the technic he has employed, and now regards radium as the
treatment of choice in all cases except pedunculated fibroids."
"Kelly (Surg. Gyn. and Obst.. Vol. xx, p. 271) presents some
additional cases of fibroid of the uterus treated with radium with
most satisfactory results. The size and position of the tumor seem
to make little difference with the result, though the larger tumors show
somewhat less tendency to disappear. The preferred method of application
is intrauterine. The question of dosage is not yet solved satisfactorily,
but in the later cases Kelly has had a tendency to use massive
doses for shorter intervals, as he thinks this is less likely to disturb
ovarian function."

A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY, PHYSICS AND
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in all other countries $3.75 per year.
Address all communications to the Editors, Forbes and Meyran Avenues,
Pittsburgh, Pa.
VOL. VII. AUGUST, 1916 No. 5
EXOPHTHALMIC GOITRE*
WITH SPECIAL REFERENCE TO THE ETIOLOGY AND
TREATMENT WITH RADIUM.
By W. H. B. Aikins, M.D., Toronto, Ont.
Exophthalmic goitre is referred to in literature under several
different names, including Graves's disease, Basedow's disease, and
Parry's disease, and the designation of hyperthyroidism has recently
been applied to it by some observers. This latter term, however, can
scarcely be regarded as an appropriate one, as it is now generally
assumed that hyperthyroidism, although it probably plays a certain role
in the causation of the disease, is not by any means the only etiological
factor. The designation of exophthalmic goitre also has the disadvantage
that the assumption on which it is based, namely, that exophthalmos
and enlargement of the thyroid are invariably present, has
now been shown to be without foundation, as one or both of
these symptoms may be absent in an otherwise typical case; but it has
been so generally adopted that I propose to use it.
In spite of the fact that there is probably no condition in regard
to which such extensive investigations, both clinical and experimental.
have been made during the last few years, and notwithstanding the
amount of literature which has accumulated upon the subject, the
etiology of exophthalmic goitre still remains obscure, although considerable
light has been thrown upon it. The two chief theories which have
been advanced may be considered under the following headings: 1. The
glandular theory; 2, the neurogenic theory.
•New York Medical Journal. Vol. CIV. pp. 19-53. 1916: also Canadian Practioner
and Review, Augusf. 1916.

114
R a d i u m
1. The Glandular Theory. The theory of Micbius was for a long
time very generally accepted as a sufficient explanation of the symptoms
of exophthalmic goitre. It assumes that it is due to a primary functional
disturbance of the thyroid, resulting in the production of an excess of
secretion, which saturates the organism, and causes the symptom complex.
Many writers now consider it probable that abnormalities of the
•other endocrinous glands, such as the thymus, suprarenals, hypophysis
and ovary, also play a more or less important part in the etiology of the
•condition.
2. The Neurogenic Theory. The neurogenic theory does not negative
the glandular theory, but is complementary to it, there still being
difference of opinion whether the glandular or the neurogenous disturbance
is to be regarded as the primary one. Feeding with thyroid
substance, both experimentally and by the administration of thyroid
tablets in man, sometimes produces the typical symptoms, while in other
eases it fails to do so, even if continued for a prolonged period. This
indicates that the disease cannot be regarded as a pure hyperthyroidism,
but that, in addition to an abnormal secretory function of the thyroid, a
predisposing factor of some kind is essential, and the facts which are
now at our disposal lead to the assumption that this predisposing factor
is to be sought for in a primary defect or injury to the central nervous
system. This hypothesis is confirmed hy the comparative frequency of
the disease in neurotic persons and those with a neuropathic heredity,
as manifested by the occurrence of diseases such as insanity, hysteria
or epilepsy in other members of the patient's family. The predominance
of symptoms referable to the nervous system in the clinical picture is
also confirmatory. Bumsted (1) emphasizes that fact that direct inheritance
of the disease itself is not so uncommon as is generally supposed.
He cites Rosenberg's case, in which the patient's grandmother.
father, two aunts, and two sisters had suffered from exophthalmic goitre,
and Oesterreicher's statement that in a family of ten children eight
suffered. Bumsted himself has had four sisters under his observation
during the last five years. Two of them have severe exophthalmic goitre
and a third early symptoms, while the fourth manifested symptoms when
she had been for some time at home with her sisters after leaving school.
Although it has not yet been definitely proved, it appears probable
that abnormalities of the other endocrinous glands play a part in the
production of the symptoms. This applies more especially to persistence
and hyperplasia of the thymus, which has been observed in a
large proportion of the cases which have been examined post morthem,
and is described by the French writers as rejuvenescence of the thymus.
Capelle and Bayer (2) found enlargement of the gland in forty-three
of sixty autopsies (seventy per cent.). Matti (3) in seventy-five per
cent, of 133 autopsies. Berry (4) in 100 per cent, of the autopsies that
he has made, and Klosc (5) goes so far as to say that exophthalmic
goitre never occurs without enlargement of the thymus. Capelle and
Bayer believe that in most cases the symptoms result from abnormal
function of the thyroid, which is supplied by the sympathetic nervous
system, and the thymus which is supplied by the vagus. Some writers
explain the symptoms, not by disease of the thyroid, but of the thymus,
and Garre (6), who now operates on the thymus in every case, states
that its removal causes the disappearance of Carre's characteristic blood
picture. Hart (7) is inclined to ai»ree with this opinion, and believes
that the thymus of itself is capable of causing the symptoms usually

R a d i u m 115
ascribed to the thyroid. He therefore assumes secondary disease
the thyroid, due partially to persistence of the thymus and partially to
constitutional anomalies, above all, lesions of the nervous system. On
the other hand, Kocher (8) says there is no proof that typical exophthalmic
goitre can be induced by the thymus alone without hypersecretion
of the thyroid, but that it is possible that hyperplasia and
persistence of the thymus predispose to it. He finds that an enlarged
and persistent thymus is particularly common in certain districts and
certain families, in which it is seen both with and without symptoms of
exophthalmic goitre. He accordingly regards it as merely a regional
familial late involution, dependent upon congenital or possibly constitutional
peculiarities, and not as a direct cause of the disease.
There seems reason to believe that other internal secretion glands
have some influence. In exophthalmic goitre Kocher found general
hyperplasia of the lymphoid organs and proliferation of ectopic lymphoid
tissue, involving the suprarenals, and ovaries, and more rarely the pancreas.
The frequency of pigmentation of the skin suggests the possibility
of an influence of the suprarenals, while the greater frequency of the
disease in women points to the influence of ovarian secretion. It is a
well known fact that there is a predisposition to the onset of exophthalmic
goitre at puberty and the cessation of menstruation, and to
exacerbations of the already existing disease during menstruation and
pregnancy.
While there is evidence that an excess of thyroid secretion is of
importance in giving rise to the symptoms of exophthalmic goitre, there
seems reason to believe that it does so only if some predisposing factor
is present, and that this primary predisposing factor consists in an
injury to the nervous system. The secretion of the thyroid gland consists
of iodine, an albumin body, and a group of proteins, and described
collectively as iodothyreoglobulin. This combination appears to possess
specific characteristics, which none of its constituents possesses in itself,
either alone or in combination with one of the others. Oswald, who has
made extensive investigations in this connection, states that iodothyreoglobulin
increases nerve tonus and the excitability of the nervous
system, and also favors metabolism and degeneration of the albumin
and fat. These properties explain the clinical pictures of myxedema
and hyperthyroidism, thyroid secretion in the former being reduced or
abolished, and in the latter increased. Oswald (9) points out the significance
of the fact that symptoms of exophthalmic goitre do not invariably
develop in response to saturation of the organism with iodothyreoglobulin,
and therefore concludes that the exothyroid contributory
factor must be something more than a mere predisposition. Oswald does
not regard the saturation of the organism with iodothyreoglobulin as
primary, but as a result of increased innervation of the gland and excessive
flow of blood through it, in which the nervous system plays the
primary role. A so called vicious circle is thus established, the excessive
amount of secretion poured out increasing still further the tonus and
excitability of the nervous system, and the latter in its turn reacting on
the thyroid, and intensifying its innervation and thereby its secretory
activity.
Constitutional diseases, such as diabetes, gout, and obesity, are not
infrequently present in these cases, and careful inquiry will often elicit
the information that the patient has for a long time suffered from servere
nervous and psychical disorders, sometimes dating back to childhood.

116 R a d i u m
We find that long (before the appearance of the typical symptoms the
patient has been nervous, unduly excitable, irritable, and "difficult," and
has perhaps suffered from cardiac troubles. A very common statement
in the anamnesis is that there is intolerance for cocaine, as manifested
on the extraction of a tooth. The general conclusion seems to be that,
whatever part the thyroid and other internal secretion glands play in
the setting up oi the pathological process, injury to the nervous system
is by far the most important etiological factor.
Exophthalmic goitre may follow acute diseases, such as typhoid,
rheumatism, diphtheria, and especially influenza. Bialokur reports its
occurrence in twenty-seven of 337 cases of pulmonary tuberculosis, and
its stimulation in the early stages of the symptoms of the latter disease
has sometimes led to an erroneous diagnosis. It is not uncommon in
chlorosis. McCarrison's (10) extensive researches in relation to endemic
goitre, in the course of which he obtained good results from vaccines
prepared from organisms isolated from goitre, suggest the possibility
that the enlargement of the thyroid in exophthalmic goitre may also be
due to some nonspecific infection.
Treatment. The treatment of cases of exophthalmic goitre is always
difficult, and demands a maximum of good judgment on the part of the
physician if he wishes to obtain a successful result without referring
them to the surgeon for thyroidectomy. It is a mistake to assume that
the condition is practically incurable by medical treatment, and after a
careful study of its results in the hands of various writers, including
Hale White (11) and Mackenzie (12), Solis Cohen (13) concludes that
there is a reasonable prospect of recovery in about seventy-five per cent.
of the cases, which is about the same proportion as that allotted to
surgery in the hands of competent surgeons. At the same time there
is no doubt that for some cases surgery is imperative, and in ibis respect
each case should be judged on its own merits. Whatever the treatment
adopted, it is exceptional for all the symptoms to disappear completely,
but most authorities agree that we are justified in speaking of cure if
the general condition and strength are maintained, and the symptoms
are relieved to such an extent that the patient is able to resume hec ordinary
occupation.
The brief account which has been given of the various hypotheses
in regard to the causation of the disease makes,4.t obvious that in the
treatment it is essential to adopt measures tending to reduce excessive
vascularity of the gland, thereby diminishing secretion and the tendency
to hyperthyroidism. With this object in view it is absolutely necessary
to secure for the patient the most complete bodily and mental rest
obtainable under the circumstances, thus removing the stimulating effect
on the thyroid of exercise and excitement. In some of the slighter cases
a simple rest and isolation cure alone may relieve the symptoms, and
if persevered in for some considerable time result in subsidence of the
enlargement of the gland. During the first stage of the treatment rest
should be so complete that it should not even be disturbed by the administration
of medicaments. The length of time during which it is
advisable for the patient to remain in bed varies in accordance with the
progress of the case. The best guide in this respect is the condition
of the pulse. When it has remained regular and practically normal
for three or four weeks, the patient may be allowed to rest on a sofa
in the room for an hour or so daily, and subsequently increase the amount
of exertion very gradually day by day. The benefit of the rest cure

R a d i u m ll-
is likely to be greater if it is possible to take it in the country, preferably
m a bracing climate, and away from the ordinary surroundings
of the patient. **
Defective nutrition is commonly associated with this disease and
therefore a liberal and nutritious diet, similar to that often recommended
in pulmonary tuberculosis, is frequently indicated. Foods rich
in extractives should be avoided, the diet consisting chiefly of milk and
cereals, together with fruit and the more easily digested vegetables. It
should be borne in mind, however, that gastric hyperacidity is present in
not a few of these cases, and that under such circumstances it is advisable
to forbid acid fruits.
Medicaments. As regards the medicaments which have been
recommended, their name is legion, and the most contradictory opinions
are given by different writers as to the efficacy of most of them. Opinions
differ as to the advisability of giving hypnotic drugs, such as veronal,
sulphonal. and trional. Some writers recommend them for the purpose
of procuring sleep and lessening excitability, while others emphasize the
fact that in neurotic cases of this description the drug habit is easily
formed, and not so easily given up. Williams (15) thinks that the only
sedative drug permissible is aspirin. The benefit sometimes derived
from belladonna is due rather to its property of controlling glandular
secretion than to its sedative qualities.
Of the bromides the only preparation which lias been found useful
is hydrobromide of quinine, Ivhich is highly recommended by Miller
(16), Forschheimer (17) and others. Bumsted states that with it he
has been able to cure several cases which had previously proved refractory
to all other forms of treatment, including operation, and that one
of its advantages is that it can be taken for months together without
bad effects. In my own practice I have found that the most effective
drug treatment is the administration of this preparation in the form
of capsules or cachets, each containing five grains of hydrobromide of
quinine and one grain of ergotin. the dose being given three times daily.
Leigh Watson (18) reports beneficial results from the injection of
one to four c. c. of a thirty to forty per cent, solution of quinine and
urea in fifty cases of exophthalmic goitre, the dose being repeated every
third day. Two severe cases remained free from symptoms eighteen
months after the last injection, and sixteen have been free from symptoms
for one year.
On the assumption that exophthalmic goitre is more common in
districts in which the water is deficient in lime, treatment by the
administration of calcium sal's has been recommended. Campbell (19)
states that during the last eighteen months he has been in the habit of
treating his cases in this way, and has had better -results than from any
other form of medication. He does not suggest that it should be the
only treatment, but that it should be combined with any other form of
treatment selected. He gives a dose of ten grains of chloride of calcium
daily.
In view of the liability to digitalis toxemia in toxic conditions of
the thyroid, many writers emphasize the desirability of avoiding the
use of this and other cardiac drugs, except in cases in which special
indications, similar to those in organic disease of the heart arc present.
Weiland (20) points out that such indications are absent in the cases in
which some surgeons recommend a dose of digitalis before operation.

118 R a d i u m
and that they should therefore be included in the category in which the
drug is contraindicated.
Organotherapy. Some writers state that they have obtained satisfactory
results from administration of extract of the thymus gland, but
the reports as regards treatment hy organotheraphy, including the administration
of thyroid substance, are on the whole not very favorable,.
and do not compare with the brilliant results obtained in cretinism and
myxedema from organotherapy. Serum from thyroidectomized sheep
and milk from thyroidectomized goats are sometimes used in the forms
of preparations known as rodagen, thyroidectin, and antithyroidiin, and
have been found useful in some cases.
Roentgen Rays. The fact that X-rays are known to have a selective
effect upon glandular tissue, justifies the assumption that their use may
be beneficial in exophthalmic goitre, and they have accordingly been
extensively used, both alone and in combination with surgery. Satisfactory
results are reported by several writers, and Kienbock (21),
Nagelschmidt (23) and others go so far as to say that no operation for
this condition should be undertaken without preliminary treatment by
X-rays, and that if this procedure were universally adopted it would be
likely materially to reduce the operative mortality of exophthalmic goitre.
Belot (23) is of the opinion that even in the so called abortive cases
in which struma is absent, the rays have a favorable influence on excessive
and dysfunction (deficient or perverse function) respectively of
the glands of internal secretion, even if these abnormalities are not
associated with appreciable enlargement. Dr. Dawson Turner (24)
reports successful cases, in which application of the X-rays was followed
by diminution in the size of the thyroid and subsidence of the symptoms.
This retrogressive process was associated with atrophy of the secretory
epithelium and interstitial and extracapsular fibrosis.
Radium Treatment. Clinical experience shows that many cases donot
respond satisfactorily to any of these methods, and in these refractory
cases I have found the employment of radium to be of decided benefit.
Abbe, of New York, first used radium successfully in exophthalmic
goitre, and his favorable experience of its results has been repeatedly
confirmed by other writers. The experiments of Victor Horsley and
Finzi (25) show that the most constant changes after the application
of radium affect the blood and lymph vessels. My 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 th.it it can be
applied without noise or excitement, while the patient remains in bed.
The following cases will serve as examples of the benefit to be derived
from the use of radium rays in exophthalmic goitre:
Case 1.—Mrs. M., aged thirty-one years; married; two children.
Five years before coming to ine. she noticed enlargement of the thyroid
and had used local applications, probably iodine, with no effect. A month
before she consulted me the growth had increased to such an extent that
it was spreading to the lateral lobe. She had suffered from difficulty in
breathing, and discomfort on speaking or swallowing. Recently her
appetite had been bad. and she had felt tired, nervous, and disinclined

R a d i u m hs>
for work. On examination, the thyroid was found to be definitely
enlarged and pulsating, especially its middle and right lobes, the neck
being fifteen inches in circumference. The pulse rate was 88, accelerated
on slight exertion. The condition appeared to be an early stage
of exophthalmic goitre.
Three thyroidectin tablets, each containing five grains, were given
daily, and in addition a radition of 100 mg. hours was given with a
large radium plaque. A week later the circumference of the neck had
diminished to fourteen inches, the pressure symptoms were better, and
the patient felt better. Five weeks after the beginning of the treatment
the neck was thirteen inches in circumference, the tumor had almost
disappeared, the patient no longer complained of nervousness, and she
has remained well ever since.
Case 2.—A young unmarried woman of twenty-one years had for
a year been so nervous, excitable, and changed in disposition -that her
parents feared for her mental condition. A physician was consulted,
but apparently he did not suspect the real nature of the disease. When
she first came under observation, she was in a highly nervous condition,
with marked tremor, cardiac rapidity, and enlargement of the thyroid,
the circumference of the neck being fourteen inches. The treatment
adopted was rest in bed, with an ice bag applied over the heart, and the
administration thrice daily of a quinine hydrobromide capsule (five
grains hydrobromide, ergotin, one grain). The thyroid gland was subjected
to a heavy exposure to radium rays. Three months later the
neck was only twelve and one-half inches in circumference, and the
tachycardia and nervous symptoms had disappeared. Further radium
treatment has since been given; she has now continued well for1 more
than two years, and has been able to resume her normal life.
Case 3.—In this case, in a young woman, the circumference of the
neck was sixteen and three-quarter inches. When first seen, signs of
"Hyperthyroidism were not marked, there being slight tremor, but no
tachycardia. She was not treated by absolute rest until severe tachycardia
suddenly developed, the pulse rate going up to 160. when she was
at once put to bed with an ice bag over the prccordia. Radium was
applied to the thyroid, and in three months the neck measured only
twelve and one-half inches, the pulse rate at the same time becoming
normal. She has remained well ever since, that is for over three years.
Case 4.—A married woman, aged thirty-five years, was referred
to me by Dr. G. W. Smith, of North Bay. She had suffered for the
previous five months from exophthalmic goitre, which developed six
months after the removal of the ovaries. The thyroid gland was only
slightly enlarged, but there was well-marked tremor, and the pulse rate
was 140. She had been treated at home by rest in bed, suitable diet and
medication, together with other ordinary recognized measures of treatment,
but without result. As a last resort she was sent to me for
radium treatment. I prescribed absolute rest in bed, with an ice bag
over the precordium. and the administration thrice daily of hydrobromide
of quinine (five grains, with one grain ergotin). In addition
heavy radiation was instituted of the thyroid. The improvement was
marvellous. Within two weeks the pulse rate had dropped to 75. and
nervousness had almost entirely disappeared. The patient was kept
v.nder observation for six weeks, when she went home in apparently
normal health. When seen again, about six months later, there had

120 R a d i u m
been no return of the symptoms of hyperthyroidism, and 1 am informed
that she continues well.
Case 5.—A girl of nineteen years, referred to me by Dr. Clarke, of
/Jowmanvillc, Ontario, who presented the typical picture of Graves's
disease. The thyroid was fairly prominent, the circumference of the
neck being fourteen and one-half inches. There was well marked
exophthalmos, the pulse rate was 120, and the patient was very nervous.
No benefit had resulted from all the ordinary measures of medical
treatment, which had included the administration of hydrobromide of
quinine and ergotin and of Moebius's serum, together with absolute rest
tor some months. She was kept in bed with an ice bag over the
precordium, the quinine and ergotin being continued. In addition
an exposure of seventy mg. hours of radium was given over the thyroid.
She went home and was not seen again for five weeks. At the end of
this time the pulse rate was still 120, but the circumference of the neck
was reduced to thirteen inches. She was further radiumized, and when
seen again, two months later, the pulse rate had dropped to 76, tremor
had disappeared, and the exophthalmos was scarcely noticeable.
This patient was last seen in September, 1915, when she had improved
sufficiently to be able to do light housework. The neck measurement
remained thirteen inches, and the pulse rate was 80. The effect
of radium in this case was most marked, as before its employment no
improvement whatever had resulted in the patient's condition.
Case 6.—An unmarried woman, aged forty-five years, manifested
symptoms of exophthalmic goitre in March, 1915. She complained of
a "sick nervous feeling," and marked tremor. The pulse rate was 130.
There was considerable improvement after a rest cure, but the slightest
exertion brought about a return of the symptoms. She first consulted
me early in October, 1915, when there was definite exophthalmos and
tremor, the pulse rate rising to 120 on the least exertion. There was
marked prominence of the left lobe of the thyroid, the neck measuring
fourteen and one-half inches. Hydrobromide of quinine and ergotin
were given, with an ice bag over the heart. Radiation was applied over
the thyroid. After receiving the treatment she returned to her home in
the country. When next seen, on November 2nd, she looked and felt
\ery much better. The neck measurement was half an inch less, the
pulse at no time exceeded 90, and the nervousness had disappeared.
Further radiation was given.
In January, 1916, the patient returned for observation. The pulse
was only 76 a minute, even and regular. The left lobe of the thyroid was
still somewhat prominent, but the symptoms of hyperthyroidism had
disappeared completely.
Case 7.—In this case all the recognized symptoms of severe hyperthyroidism
were present, with the exception of enlargement of the
thyroid gland. The patient was a married woman of twenty-seven
years. Protuberance of the eyes was first noticed after an attack of
influenza in the spring of 1913, and subsequently dyspnea and palpitation.
During the following winter, the symptoms diminished somewhat
in severity, but after an attack of tonsilitis in March, 1915, she began
to have attacks of vomiting, suffering from palpitation, and was easily
excited or startled the action of the heart becoming very rapid. In June,
1915, she was kept in bed for five weeks, when her pulse became normal.
When seen in August, 1915, there was no enlargement of the thyroid.

R a d i u m i-i
but the eyes were prominent, and the pulse ranged from 84 to 120.
Radiation was given over the thyroid, and in October she reported that
she was much better, the pulse was steadier, and she had gained in
weight. In January, 1916, after further treatment, she was able to take
short walks and do light house work without disturbing the pulse,
nervousness had nearly disappeared, and instead of having become a
confirmed invalid she had become a normal young woman.
Hydrotherapy.—Hallevorden ',26), whose article is based on 100
cases, has had excellent results ffrom the hydrotherapeutic method recommended
by von Winternitz, which consists of packings and demibaths.
The treatment is always agreeable to the patient, and the pulse usually
goes down on the application of the packing. With it he gives daily
cold applications to the neck and back, and also to the heart if cardiac
symptoms are prominent. The avoidance of exhausting and depressing
baths is advisable. In slighter cases 'benefit is often derived from indifferent,
salt or gaseous baths of comparatively low temperature. If
fever is present, it should be treated by tepid full baths or cool full
baths, in accordance with the indications. Tight collars and tight lacing
should always be avoided.
Conclusion.—In conclusion, I should like to refer briefly to the
psychological aspect of the condition, and its significance in relation to
treatment. In view of the fact which is now generally accepted, that
injury of some kind to the nervous system is—even if not a primary
factor—at least a very important factor in the etiology of exophthalmic
goitre, and that as a rule symptoms referable to it predominate in the
clinical picture, it follows that one of the essential objects in our treatment
is to endeavor to relieve these nervous symptoms, and that therefore
psychotherapy plays an important role. This being so. it is obvious that
it is highly desirable that physicians who have not had much experience
with neurotic and neurasthenic people, and consequently do not
understand them and have no sympathy with them, should refrain
from undertaking the medical treatment of cases of this kind, in which
the psychic element is such an important feature.
Bibliography.
1. C. V. R. BUMSTED: Medical Record, Ixxxvii. 1915, p. 467. 2
CAPELLE and BAYER: Beitrage cur klinisehe Chirurgic, Sept.,
1913. 3. MATTI: Zeitschrift fur Chirurgie, cxvi. 4. BERRY:
Lancet, 1. 583, 1913. 5. KLOSE: Annals of Surgery, 1912, p. 143.
Beitrage fur klinisehe chirurgie lxxvii. 601, 1912. 6. _ GARRE:
Verhandlungen d. Deutschen Gcscllschaft fur Chirurgie. 27, 1911. 7.
HART: Medisinische Klinik, xi, 1915, 388. 8. A. KOCHER: Virchotv's
Afchiv., April. 1912. Arcliiv. fur klinisehe Chirurgie, cxiv, 924,
1914. 9 OSWALD: Zur Thcorie der Schilddrusenfunktion, Berliner
klinisehe Wochenschrift. Hi. 430, 1915. 10. McCARRISON: Aetiology
of Endemic Goitre. 11. HALE WHITE: Proceedings of Royal
Society Medicine, March, 1912, Surgical Section, p. 81. 12. MACKEN­
ZIE: Ibidem. 13. SOLIS COHEN: Cited by Bumsted. 15. LEON­
ARD WILLIAMS: Practitioner, xciv. 94, 1915. 16. MULLER:
Cited by Bumsted. 17. FORSCHHEIMER: Therapeusis of Internal
Diseases iii. 18. LEIGH WATSON: Quinine and Urea Injections
in Exophthalmic Goitre, Journal A. M. A., lxv, 1102, 1915. 19. H.
CAMPBELL: Exophthalmic Goitre. Clinical Journal, xhv, 329. 1915.
20. WEILAND: Behandlung der Morbus Basedowii, Thcrapie der-

122 R a d i u m
Gegenwart, lvi, 187, 1915. 21. KIENBOCK: Cited by Weiland. 22.
NAGELSCHMIDT: Cited by Weiland. 23. BELOT: Transact,
internal. Congress, London, 1913. Rad. Sect, Part 2, 43. 24. DAW­
SON TURNER: Radium in Treatment of Hyperthyroidism, Report
British Association, May, 1913. London, 672, 1914. 25. VICTOR
HORSLHY and FINZI: Cited by Dawson Turner. 26. HALLE-
VORDEN: Theraple der Gegenwart, liv, 347, 1913.
Reviews and Abstracts.
H. K. Pancoast, M.D. and William Alfred Sawyer. The Results
of the Use of Radium for Two Years at the University Hospital. The
Penna. Med. Journ. No. 10, XIX, pp. 800-801, July, 1916. Abstract of
a report presented before the Philadelphia County Society, May 24, 1916.
"The report is made with the full realization that the results to date are
but tentative; time alone will develop their ultimate value. A few of the
cases were treated with radium and with the X-ray; many were inoperable;
in others operation and radium were employed conjointly. We have classified
our cases as (1) those cured or apparently cured; (2) those benefited;
(3) those not benefited. It is felt that there is a class of cases in
which a definite cure can be effected; another in which it is safe to say
only that an "apparent cure" has resulted or that the patient is benefited.
We have not in this summary taken into account the dosage or frequency
of radium applications as that is of importance chiefly to the radiotherapeutist,
and as radium in the hands of any but those making a study
of it is dangerous we have properly left out the methods and technic of
application. The report deals with 240 cases, both benign and malignant
lesions, treated from May, 1914. to May, 1916; Sixty-nine have
been treated by Dr. John G. Clark in the department of gynecology and
it is from his report that we quote his results; all of the others were
treated by Dr. H. K. Pancoast. Of these 240 patients treated, there
are "apparently cured," or cured, 96; benefited, 57; not benefited, 35refused
treatment or failed to return, 30; dead, 22."
"It is worthy to note that 30, or approximately 13 per cent, of the
patients treated, failed to return or continue treatment for one cause
or another. Some did not realize the need of subsequent application,
the first treatment having benefited them to such an appreciable extent.
Others, because of the slowness of the treatment, became discouraged*
and ceased taking treatment. Gynecologically, the therapy is at present
only a palliative measure. The two-year period is not yet over. Dr.
Clark's results are good and show splendid possibilities. It is obvious
that in some cases radium is of undoubted value. Local lesions may be
eradicated, symptoms relieved, life prolonged, or the individual restored
to normal health. There is yet much to know concerning its use and
perhaps an ever-widening field of efficacy."
"Dr. Henry K. Pancoast, in discussing: In the treatment of malignancy
by any means now known it is essential to consider, in connection
with the case, every known means of treatment adapted to the
ease and then to select the particular method or methods most efficacious.
One objection made to the radium treatment has been that cases have
been treated promiscuously and without good judgment. The result*

R a d i u m 123
of the radium treatment in carcinoma of the rectum have been disap-
Pointing, in the vagina, far better. In cavities or canals constantly functionating,
the use of radium or of the X-ray is not so satisfactory as
in those which are not. A preliminary colostomy is essential lo the
satisfactory treatment of a rectal case with radium. When the lesions
are low down metastasis is more probable than when located higher up.
In lesions of the mouth methods to remove sloughing tissue are indicated
in combination with the radium treatment. In the treatment of brain
tumors and of many growths of the neck I think radium can be used
to better advantage in cross-firing than can roentgen radiation. Radium
is of particular advantage in the treatment of naevi and in growths of
rather superficial venous supply; care must be taken to prevent sloughing
and scarring. In growths with deeper and pulsating vessels other
methods than radium are necessary."
"Dr. John G. Clark: I think the future will demonstrate that we
shall have fewer, perhaps, of operable cases in the sense of the desire
to operate in the more extensive cases, than in the past, and, therefore,
shrinkage of the number of surgically operable cases, and an increase
of the number which will use radium. In the last two years of our
work radium has been a special boon to many of the cases within the
inoperable zone. The relief of hemorrhage and of pain and the healing
of local ulcerated areas have amply demonstrated its value as a palliative
remedy. We have had two or three cases in which the results
would seem to be almost miraculous. We must, however, wait until the
expiration of the given time before we can speak definitely of results.''
"Dr. Charles H. Frazier: It would seem that tumors of the brain
should lend themselves to some such treatment as that of radium, since
so many are inoperable from one cause or another. Tumors of the
brain in many instances grow very slowly, and if we have at our command
a remedy which will keep the growths under control we have a
very useful means of prolonging life. I shall refer only to the six
cases of malignant tumors of the cerebellum which Dr. Sawyer mentioned
in his paper. One case was a fibrosarcoma, believed to be inoperable.
A 50 mg. tube of radium was introduced in May. Silk was
tied to the tube which was removed through the wound. The patient
returned in July for a second treatment but failed rapidly. As Dr.
Pancoast has said, fibrosarcoma does not respond well to radium. A
second case interested us very greatly; in operating to examine the cerebellar
pontine angle no evidence of the tumor could be found. A cerebrospinal
fistula had developed at the site of the wound, the subarachnoid
space became infected and the patient died of meningitis a year after
the original operation."
"This leaves four cases in which the patients are still alive. The
first case is that of a child, ten years of age, who when first seen was
bedridden and almost blind. The lesion was a deep-seated cerebellar
tumor. After exploratory incision operation was thought to be impossible
and radium treatment was instituted, and the patient returned
twice for treatment. The child is now able to be up and about the
house and is greatly improved, although there are still marked symptoms
of cerebellar disturbance. A second case is that of a woman of forty
years, operated upon two years and two months ago. when a tumor in
the right cerebellar fossa was removed. Several applications of the
X-ray and radium were made; the patient entirely recovered and has

124 R a d i u m
had no recurrence. This result I attribute to the use of the X-ray and
radium combined. The third case is that of a boy of fifteen brought
from the South. The tumor was exposed in the right cerebellar pontile
angle and the case regarded as hopeless. Two tubes of radium, 35 and
50 mg. were inserted and allowed to remain from 12 to 8 o'clock the
following morning. The patient was bedridden and almost blind from1
optic atrophy. He was brought back to the University Hospital a year
after operation for a second treatment of radium, when he had but few
symptoms of cerebellar disorder. 1 communicated with the boy's mother
a few days ago and learned that he now goes to business and apart
from his blindness, which might have been prevented by earlier operation,
he seems to be entirely well. The fourth case is that of a young
woman of thirty-five, treated seven months ago for inoperable cerebellar
tumor. Staggering has largely disappeared and the patient is able to
walk by herself and has gained in weight and strength. I am reminded
of a fifth case in which I believe that for the time being radium had
some effect. While this is but a short series the results certainly justify
a continuance of radiotherapy in this particular field."
Henry Schmitz, M. D., (Chicago). The Action of Gamma Rays
of Radium on Deep-Seated Inoperable Cancers of the Pelvis. Bulletin
of the Chicago Medical Society, XV., No. 42, June 24, 1916.
Dr. Henry Schmitz said that radium therapy of malignant tumors
in any part of the body demands the discussion of the following points:
1. The technic of the application of radium. 2. The evidence of the
histological changes caused in the tumor tissue. 3. The clinical results,
it also must include employment of all accessory means, which
will facilitate the action of radium. 4. The application of the massive
Roentgen rays. 5. The use of surgical procedures to facilitate or aid
the intensity of the gamma rays of radium.
The technic of the application of radium must consider: 1. The
amount of radium element used. 2. The method of screening. 3. The
extent of the time of exposure of the rays and the tumor mass. The
quantity of radium necessary to destroy growths that reach two to three
centimeters into the uterine, rectal, vesical and pelvic cellular tissues,
should be at least fifty milligrams of radium element. If the capsule
cannot be brought into direct contact with the tumor, then a sufficient
intensity of the rays must be obtained by the use of the larger amounts
of radium element.
The experiments in the human body were carried out in recurrent
breast cancers, characterized by the formation of multiple nodules. A
nodule was removed under local anesthesia and subjected to a microscopic
examination to determine its pathological nature. Then the gamma
rays of fifty milligrams radium element were applied for four hours to a
given nodule, for six hours to another nodule, for eight hours to a third
one, for ten hours to a fourth, for twelve hours to a fifth one, and so
forth. After ten to fourteen days, i. e., when the latency of the action
of the gamma rays reaches its height, the nodules were removed. He
potcd particularly the distance of the growths from the skin surface. The
removed tissues were subjected fo microscopic examinations. In this

R a d i u m 125
manner he repeatedly demonstrated the fact that the gamma ray of 50
milligrams radium element destroyed carcinoma tissue within a distance
of one centimeter from the skin surface after a continued application of
twelve hours, i. e., 600 milligram hours or milligramage.
The schedule of a course of radium applications, based on these
facts, is as follows: The duration of a course of treatment varies
from twelve to 108 hours, when fifty milligrams of radium element are
employed, depending on the extent of the cancer into the tissues. The
course is divided into seances of twelve to twenty-four hours, the interval
between the sittings being from twelve to thirty-six hours. He endeavors
to invariably give the total amount estimated within one week.
If 100 milligrams of radium element are used, then the duration
of the treatment is correspondingly reduced. Should it be impossible
to apply the radium directly to the tumor mass, then longer exposures
or larger amounts must be used to correct the reduction of the intensity
of the rays caused by the increase in distance. The law of inverse
squares must be applied in consideration of these facts.
He has, fortunately, seven cases in which an abdominal panhysterectomy
was performed after a clinical cure of the cancer by the
use of radium rays was obtained.
He gave the clinical results of thirty-five inoperable, twelve recurrent
and fifteen operable uterine carcinomata; seven inoperable, and
three operable rectal cancers, and five inoperable, two recurrent and
one operable carcinomata of the ibladder. The total number is eighty.
They were treated between April 1, 1914, and April 1. 1916.
The results of the radium treatment differ, depending, first, on the
organ involved, and. second, on the stage of the disease. The prognosis
is best in vesical cancers, less favorable in uterine malignant growths and
least favorable in rectal carcinomata. The value of the treatment
varies, depending on the operability, inoperability or recurrence of the
disease. The time elapsed in all the cases enumerated is too short to
permit a discussion of the curative action of radium.
Conclusions: 1. The therapeutic action of radium depends on
the use of a correct technic, which must be based on a careful physical
examination of the patient and the physical properties and the biologic
action of the element.
2. The use of massive Roentgen rays, according to multiple field
and crossfire methods, in conjunction with radium therapy, to destroy
metastases, is an imperative necessity.
3. Certain surgical procedures must be used in radium therapy to
assist the action and facilitate the application of the rays.
4. The action of X-ray on cancer tissue is specific and suggests
positive proof of the possibility of destroying malignant tumors by the
application of radium.
5. The results of radium therapy in inoperable and recurrent cancers
surpass those of any other known therapeutic agent.
6. The prophylactic use of radium rays in operable carcinomata
increases the percentage of operability and probably the efficacy of the
operative procedudes.
DISCUSSION.
Dr. A. J. Ochsner said he has had an opportunity of observing the
work Dr. Schmitz has been doing with radium, and up to the first of
May Dr. Schmitz has treated eighty of his cases of inoperable carcino-

126 R a d i u m
ma. Of this number, there were sixty-two uterine, ten rectal, and eight
vesical cancers. Clinically, he is absolutely certain that there are now
living among these eighty a number who would have died months ago
if radium treatment had not been resorted to. There were cases in
which there was such a degree of invasion of the surrounding tissues
as to make the destruction of the cancerous tissue impossible by any
other means than radium, and a certain number of these patients are
alive today, consequently it was worth while to have made use of this
method. As the work progresses he observes a considerable improvement
in the results, because at the beginning of this treatment the technic
had not been so thoroughly worked out as at present.
All the histological specimens he had seen and examined personally
and the impression one gets is that radium has a very intense beneficial
effect upon cancer.
Dr. Carl Beck said the paper of Dr. Schmitz covered very accurately
the present status of radium therapy; that his results are better than
those of most observers, due to the fact, perhaps, that Dr. Schmitz carefully
studies and selects his cases. He would object to the use of the
word cured in the statistics of Dr. Schmitz. Dr. Ochsner had not used
the term cured. Observation shows the effect of radium upon the
cancer cells, but before we can speak of a cure we have to be much
more certain than the doctor could be of his results. Carcinoma is not
a local disease, and when we have inoperable carcinoma of the uterus
we cannot speak of a local disease any more. All those who have had
experience have observed carcinoma away up in the abdomen and in
distant regions, and, therefore, any local effect that radium might have
upon the cancer would he limited to great improvement locally and
not universally. We could not speak of a definite cure. While he has
observed great improvement in many cases, he could not say that he
had ever seen demonstrated a cure except in some of the superficial
epitheliomata and superficial rodent ulcers which have been regarded
by many practitioners as non-malignant.
Dr. Blaine said the term cured, as pointed out by Dr. Beck, should
be used very sparingly when we speak of results in the treatment of
carcinoma, whether it be by the Roentgen ray, radium, or by other
methods. In his experience with a large number of these cases, he is
frequently asked. What is your percentage of cures? There are none.
He has no percentage of cures, but wc undoubtedly do benefit more
than half of our cases, putting it conservatively.
Dr. Schmitz, in closing, said he did not want to convey the impression
that he was speaking of the curative action of radium. He
did not refer to the results as clinical cures. It is impossible to speak
of an anatomical cure until five years have elapsed and the patient has
remained well. Patients suffering with generalized carcinoma cannot
be treated satisfactorily with radium or X-ray, and for that reason only
those parts of cancer would necessarily be influenced by the radium
to which the radium rays can be sent,
Joseph B. Bissell, M.D. (New York). Bone Sarcoma Treated bv
Radium. New York Med. Journ. CIV. No. 1. pp. 3-5, July 1. 1916.
(Patients and photographs presented before the Surgical Section,

R a d i u m 127
Academy of Medicine, May 5, 1916). "These patients are presented
as examples of results which sometimes follow the application of radium
to sarcomatous tumors of the long bones."
"Case 1. W. T., nineteen years old, had been in several hospitals
and clinics and under various treatments before coming under my
care. He first noticed this growth nearly two years ago. He had had
experience with considerable doses of X-rays as well as Coley's serum.
Two pathologists had reported upon specimens taken from the tumor.
They concurred that it was an osteosarcoma of the spindle cell variety,
arising from the periosteum. According to the skiagraph the growth
involved the whole circumference of the left femur at its middle third.
The early pictures before treatment with radium presented the characteristics
of a sarcoma. The last picture, taken since the application of
radium, is reported by Dr. Meyer, of Bellevue Hospital's X-ray staff.
to resemble a chronic periostitis. The patient had in addition a severe
radium burn on the limb, extending deeply into the muscle of the inner
side. This burn extended almost completely around the leg. It had
taken a long time to heal and was still troublesome. Considering, however,
that the tumor had practically disappeared under treatment, the
patient was not making more than the ordinary complaints about the
inconvenience of the condition. At the beginniug of the radium treatment,
the circumference of the leg over its largest point was 53.25 cm.,
the right leg at the same point being thirty-five cm. for contrast. The
affected leg over the site of the original tumor is now 40.25 cm. in
circumference, and part of this measurement is probably due to the
swelling of the soft parts from the radium burn. This boy had rather
large doses of radium, and for a comparatively long time. The average
amount used was about 400 mgm., and for the first four or five times
the exposure was twenty-four hours in length each time. Various
kinds of screens were used and every endeavor was made to protect
the skin from burns. There was a space screen of an inch and a half
from his skin to the material screens, which consisted of from three to
five mm. of rubber, and two mm. of brass or lead, depending upon the
special applicator used, beside the original silver container, one mm.
in thickness, and the glass tube containing the radium.''
Photographs show the improvement from the time the patient
came under Dr. Bissell's care up to the present, when the last photograph
was taken. A skiagraph shows the improvement in the condition
of the bone between the same dates,
"Case II. Isador S., five years old. first noticed a tumor in the
upper third of the left humerus about a year ago. X-ray pictures, soon
after, showed evidences of a rarefied swelling of the bone. Later on
this was seen to be a sarcomatous infiltration, subperiosteal in origin.
The diagnosis was confirmed by the examination of a section by the
pathologist. The following measurements were made in May, 1915.
before applying the radium treatment:
"Over the greatest size of the tumor, twenty-two cm.; at its lowest
portion, seventeen cm.; one inch above the greatest diameter, eighteen
cm. Fifty mgm. of radium were applied around the bone in five containers
of ten mgm. each. They were applied at equal distance points
and remained on about two hours. They were applied close to the skin
with three mm. lead screens covered with 0.5 mm. rubber. In a week's
time this application was repeated, also two weeks later. The measure-

128 R a d i u m
merits taken early in July after these three applications were as follows:
Over greatest diameter, eighteen cm.; below fifteen cm.; and above
sixteen cm. Nothing more was done until the following September,
when two similar applications were made, two weeks apart; the patient
in the meantime continuing to improve until at this time there was
very little difference between the arms. The child's general health was
good. He had no pain or trouble of any kind relating to this tumor.
Following the foregoing treatments there were no radium burns and
the tumor almost disappeared. Palpation of the arm at the site of the
tumor showed that there remained several irregular ridges parallel
with the long axis of the bone. Late in November the tumor began
to grow again; the patients general condition became affected; he had
slight chills, rise of temperature, loss of appetite, complained of pains
in his arms and chest, and seemed otherwise ill. An X-ray picture of
his chest showed what was thought to be metastatic deposits in the
mediastinum. In order that he might get the benefit of further radium
applications, he was taken into the Radium Sanitarium and one hundred
and fifty mgm. of radium was applied to his arm for twelve hours.
Preceding this, a section was taken of the tumor, the pathologist
reporting that it was a spindle cell sarcoma. A second X-ray interpretation
showed it to be subperiosteal. Another skiagraph, several weeks
later, showed no such pathological condition in the chest as described
above."
"The tumor is still rather marked, although somewhat smaller than
when the patient first came to the hospital. Several applications of
radium of 150 mgm. each, for twelve or fourteen hours at a time, have
not deoreased it very much. He has a pronounced necrosis about an
inch in diameter, of the soft parts of the arm. due to an X-ray burn.
His general health at present appears to be about normal."
"These two patients are taken for contrast. One has apparently
entirely recovered from the growth, the other has improved but slightly.
The pathological condition, the character and position of the tumors,
as well as the treatment carried out. are similar, yet the results are
apparently opposite; although it may be said for the little boy five
years old. that under a former series of radium applications the tumor
has also practically disappeared. In spite of this seemingly poor result I
believe that radium properly applied is the correct treatment. The only
alternate is amputation at the shoulder joint, with almost certain early
return of the tumor, either in the scar or in some other part of the
body."
"At the Radium Sanitarium and laboratories we are constantly
learning more about the pathological, histological, chemical, and clinical
results of the action of radium and other agents upon the various malignant
tumors in the human body. In some of its aspects malignant
disease seems general or constitutional rather than local. It would not
be surprising if in a short time such a theory proved to be a fact, and
new growths, now regarded as limited, surgically removable, and curable,
were' recognized, after all, as only symptoms or indications of a widely
disseminated dyscrasia not permanently eradicable by the knife alone."

A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY, PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES.
Edited and Published by Charles H. Viol, Ph. D., and William H. Cameron, M. D.
with the assistance of collaborators working in the fields of
R ad i ©chemistry. Radioactivity and Radiumtherapy.
Subscription $2.50 per year, or 25 cents per copy in the United States and Canada
in all other countries $3.75 per year.
Address all communications to the Editors, Forbes and Meyran Avenues,
Pittsburgh, Pa.
VOL. VII. SEPTEMBER, 1916 No. 6
RADIUM AND SYMPTOMATIC BLOOD PRESSURE.*
By Douglas C. Moriarta, M.D.,
SARATOGA SPRINXS- N. Y.
I have two thoughts which I wish to present for your discussion
to-day:—high blood pressure and its significance, and the use of radium
for its relief.
The more I see of patients who have a symptomatic blood pressure,
the more I am convinced that we do not give them the careful attention
they require. These people are invariably moody and nervous, and the
knowledge that their blood pressure is high is a constant menace to
their health, as they live continuously in a state of apprehension. They
are happy if the pressure is down 5 mm. to-day, and morose if it
happens to be up 5 mm. to-morrow; notwithstanding the fact that this
deviation from day to day is not more than the actual error of manipulation.
They are usually uninformed as to the cause of the symptom,
and apparently it has never been taken into consideration whether their
individual index is a normal one for them or not.
So I believe that our patients should be taught the cause and
significance of an increased blood pressure. This would allay the
natural perturbation that is felt when they are informed of the presence
of this symptom. As a rule, much of the nervousness and apprehension
would not have occurred, or will disappear, when their condition is
explained and they understand that a high blood pressure is only a
symptom, and not a disease, per se. They should know that their increased
pressure is probably a normal index for their pathological state;
•M^lcal Record. Vol. 89, No. 21. PP. 865-68. May 13. 1916.
Read before the Saratosa County Medical Society, May 8. 1916.

130 R a d i u m
that its presence is essential if nature is to keep a balance in the performance
of her functions; and that, while it is a symptom of a morbid
condition, it is necessary, and one that will be present until the exciting
cause is controlled. The best illustration we have of this statement is
the number of people who go about perfectly happy, with a constant
high blood pressure, until they discover that their pressure is high.
I do not intend to minimize the importance of this symptom, nor
to suggest that it is not an anxious one. But I must deprecate the
unfortunate influence which this knowledge seems to have upon our
patients when they are simply told that their blood pressure is increased,
without some explanation.
Consequently, when we are estimating the blood pressure of a patient
and find that it is relatively high, we should go more into detail; tell
him that it is the exciting cause and the pathological condition which
are of importance and not the registered measure. He should be told
that it is an index to either a functional or an organic derangement;
that if the trouble is organic, the increased pressure is necessary, and
is nature's method of balance; while if the trouble is functional, an
effort will be made to control it by removing or correcting the exciting
cause; and that this knowledge must be had, and this conclusion reached,
in every individual' case that carries an increased blood pressure, and
that it is the only criterion.
It is a common observation that both physicians and patients are
inclined to the continuous use of drugs to relieve high blood pressure.
This is not good practice and should be avoided except to relieve some
temporary condition.
It is well to lay particular stress upon the fact that patients often
have a high index which is a normal one for the existing condition; that
it is essential to their well-being and must not be interferred with. On
the other hand, when we do meet high blood pressure which is a true
hypertension, the welfare of the patient will be enhanced when it is
controlled. In other words, no patient should be judged by comparison
with any other patient, but only after a study of his individual case.
In this way only will a safe working conclusion be reached.
So I urge that we explain to our patients that their increased blood
pressure is an indication of a more or less complex condition, which
may have been developing over a period of years; that it may be functional
and involve the toxins of the alimentary tract; or it may be
organic, involving the kidneys, heart; and blood-vessels. Explain that
such a condition frequently occurs in a hard-working person who has
an exacting business, which has been carried on under constant
nervous strain, without periods of rest. Such an individual has. perhaps,
been in the habit of eating quickly and irregularly, often being
over-fed with rich, highly-seasoned, nitrogenous food. When to this
are added tea. coffee, tobacco, and alcoholic stimulants. the individual,
while still young in years, is old in fact. Thus, as Bishop states, "that
which in early life was a case of indigestion, after many years of suchliving,
has developed into a nephritis with a high blood pressure." Perhaps
the condition may not have progressed so far as this; or it may
have gone still farther, and degenerative changes may have occurred
in the heart, kidneys, and blood-vessels. In the latter case if compensation
gives out. we will probably have a secondary low blood pressurewhich
is of serious omen.

R a d i u m m
I shall not attempt to describe the early, progressive, or late
symptoms of arteriosclerosis, as I simply wish to call attention, at this
time, to the baneful effect upon the patient's mental condition, of
symptomatic blood pressure, when the reason for the presence of this
symptom is not fully understood. The successful management of such
a case is possible, I believe, only when the patient thoroughly understands
its significance.
I have been treating patients with symptomatic blood pressure for
years with our mineral waters, particularly those who have come to
Saratoga for their health, and with uniformly good results. It has,
of course, been necessary to correct the exciting cause, so far as
possible, by a carefully regulated regime and not by the use of drugs.
I have learned to value the Saratoga mineral waters as a therapeutic
agent very highly. I am not unmindful of the benefit of a regulated
life, such as is followed when one is taking a cure. I fully appreciate
the "few-protein" diet of Bishop and the vegetable protein diet of
Kellogg; and I recognize the importance of clearing the intestinal tract
and increasing elimination by the use of salines and the alkalies, as
well as the advantages of the omission of tea, coffee, alcohol, and
tobacco, and the benefit to be derived from the use of mineral-water
baths. Yet I imagine I see an effect beyond all these when one uses
our Saratoga mineral waters therapeutically. I have also noted that
they had a remote effect, i.e. a general betterment which was noticeable
months after taking a course of treatment at the Springs. It has always
seemed to me that the improvement I noted in my patients when using
these waters could not be entirely accounted for by their chemical
analyses, and that their action was unusual; and I have for many years
expressed myself to that effect. I now believe this remarkable action
to be due to their radium content.
It has been my experience that the blood pressure of a patient
taking the cure will drop from 20 to 60 mm. of Hg. in a period of
from four to six weeks, almost without fail. Of course, I exclude in
this statement those in whom advanced cardiovascular or renal degeneration
exists. All etiological conclusions concerning symptomatic blood
pressure point to perverted metabolism as the primary cause, regardless
of the terminal pathological symptom. Physiologically we are taught
that radium stimulates the individual normal cell to increased action.
or corrects a perverted cell action by its influence on the enzymes. It
also affects the nervous system and produces dilation of the bloodvessels.
Clinically we know, beyond possibility of contradiction, that it
increases very promptly the red blood cells, increases elimination from
the kidney, in the quantity of both the water and the solid content of
the urine; it also acts as a stimulant to peristalsis, thus being a mild
cathartic and increasing in this way elimination from the alimentary
tract; and it invariably produces a sensation of general well-being.
Possibly small quantities of radium act as synergists, or perhaps the
reverse is the case. In anv event, mineral waters containing radium
salts, or those that are radioactive, have their therapeutic possibilities
materially increased.
The objection has been made that a few mache units of radium
contained in a liter of our water could not act as I believe it does.
It is. however, a recognized fact that radium possesses an almost incomprehensible
catalytic power, even in infinitesimal doses; larger doses
do undoubtedly possess added therapeutic possibilities.

132 R a d i u m
After studying the reports of the physicians of the European spas
and those from the London Radium Institute, I learned that they
generally believed larger doses of radium emanation to be essential to
the best therapeutic results; and that while their waters contain radium
in larger quantities than our Saratoga mineral waters, yet they had
found it helpful to fortify the action of the waters by the further use
of radium element. I was impressed with their results, and decided to
adopt their methods—this plan of treatment, therefore, I put into
effect early in the spring of 1915.
I experienced quite some difficulty in adjusting my equipment for
activating water and for inhalation purposes. I have, however, finally
succeeded in arranging a very satisfactory outfit which answers my
purpose admirably. I have for your cosideration some photographs of
the apparatus which I trust will prove of interest. The features of
more particular importance to which I desire to draw your attention
are to following:
1. The subceiling effect, which reduces the cubic air space without
the sensation of stuffiness.
2. The electric fans, which keep the air in motion, thereby making
the treatment more agreeable.
3. The separate compartments within the einanatorium, together
with an improved arrangement for distributing the emanation, make
it possible to vary the quantity administered.
4. The provision which makes it possible to freshen the air in
the emanatorium by the introduction of oxygen.
5. The arrangement for the removal of COj from the atmosphere.
6. The apparatus for activating water is arranged so that there is
very little lost space—therefore we have a high percentage of efficiency.
The entire outfit, although composed of several units, is so constructed
that all or any part of the emanation can be thrown into either
of the treatment rooms; this also applies to the apparatus which activates
the waters.
During the past year I have treated fifty-six cases in which there
was an increased blood pressure with radium emanation in addition to
our mineral waters plus a regulated regime- These cases may be said
to be too few to warrant the formation of an opinion concerning the
possibilities of radium, particularly as over half of these patients were
under observation only from four to eight weeks; nevertheless I do
JCr/y*r£G rsr^e
tiurtcr

R a d i u m 133
believe that my experience has taught mc that radium possesses valuable
therapeutic properties. It will be interesting for you to know that
in varying degrees there was in every one of the cases a lowering of
blood pressure index and an increased red blood count. I desire to
bring to your attention a few brief case histories that may serve to
illustrate the above conclusions. My findings as a whole show that
radium emanation lowers symptomatic high blood pressure, and I might
add that even in cases showing advanced structural changes in the
kidncy.heart, and blood-vessels I have found it helpful.

134 R a d i u m
Case I.—Mrs. F.; extremely nervous temperament; has always
lived well; has a cocktail before dinner, and often a highball or wine
with dinner. Has suffered with colonic stasis and its concomitant
toxemia for several years; is anemic, sallow, and has a red blood count
of 4,000,000, the blood pressure varying from 150 to 160 mm. She
was ordered to drink radioactive water daily containing 15,000 m.u. in
divided doses. At the end of a month her complexion cleared up; red
blood count increased to 4,600,000, with a reduction of the blood
pressure to 140 mm. and a general sense of well-being.
Case II.—Miss M., housewife, complained of severe neuralgic
pains, malaise, loss of appetite, disturbed sleep, and torpid bowel; distressed
breathing on going upstairs. Blood pressure 230; urine negative
on repeated examinations, except that the specific gravity varied from
10O4 to 1010. Red blood count 3,400,000. She was given 50 micrograms
radium element intravenously, followed by a second injection three
weeks later of 25 micrograms, with 1 liter (100,000 m.u.) of activated
water daily. At the end of four weeks her blood pressure was 180.
with a red blood count of 5,400,000, and there was a feeling of general
betterment At the end of eight months her blood pressure is 165;
she has had no remedies other than periods of taking the activated
water.
Case III.—Mr. B., age 76, merchant in active life. Complained
of shortness of breath and precordial pain on slight exertion; no other
symptoms. Blood pressure 230. Urine showed fine granular casts,
no albumin; specific gravity 1004-1006. This patient was given 25,000
m.u. of activated water daily in four divided doses. After a distressing
reaction it was discontinued, and tried again after forty-eight hours
with 15,000 m.u. daily. This was also found to he too large a quantity,
and finally 6000 m.u. per day were tolerated, which were later increased
gradually until 30,000 were given in twenty-four hours. This resulted
in a lowering of the blood pressure to 185, with a decided relief from
the symptoms that had appeared on exertion.
Case IV.—Mr. S., age 74, master carpenter, was seen in consultation.
Patient had intense dyspnea on the slightest exertion, was unable
to lie prone, had constant cough, with mild edema of the lungs. Both
legs were edematous nearly to the trunk; he had a ruptured compensation
and a secondary low blood pressure of 105. The urine was loaded
with albumin; small and large granular casts were present. He was
given 50 micrograms of radium clement intravenously, with 25 micrograms
one week later; also I liter (100,000 m.u.) of activated water
daily. In forty-eight hours his dyspnea was relieved and he was able
to lie prone; edema of the legs entirely cleared up and he was decidedly
more comfortable for a period of two weeks, when he suddenly died.
Case V.—Mr. D., age 56, in active life; has suffered from glycosuria
for three years past. This condition is absolutely controlled by a
regulated diet and life, except that he has a constant blood pressure
of 158 to 165. This patient was given 40,000 m.u. of radium emanation
in activated water daily which caused a distressing reaction. Eventually
he could tolerate activated water containing 20,000 m.u. daily, and continued
to take that amount for two months, with the result that his
blood pressure was reduced to 120 mm. and remained under 130 for
a year.
Case VI.—Mrs. K.. housewife. 60 years old, an active, high-strung,
nervous woman. Complained of continuously painful muscles, and

R a d i u m 135
that she was not up to her regular duties—headache, malaise, loss of
appetite, and disturbed sleep. Bowels regular. Blood pressure 190.
Urine negative. I gave her # liter of radioactive water (50.000 m.u.)
daily. After a period of four weeks blood pressure was 175 and she
stated she had not felt so well in years.
Case VII.—Mr. S., janitor, age 60; hard-working, closely confined
man. Is anemic and sallow, has digestive disturbance, and it not able
to continue his duties. Blood pressure 185; hemoglobin 65; red blood
count 4,800,000. Was given daily a liter of radioactive water, containing
100,000 m.u., for six weeks with a complete restoration of his
well-being. Blood pressure 170; hemoglobin 80; red blood count
5,600,000.
I am aware that the indications for the use of radium emanation
could not be determined from these few cases. This is so for two
reasons: first, the small number of cases, and second, there is such
a paucity of knowledge concerning the proper dosage.
^ I inaugurate a course of treatment with either radiocative waters,
radium emanation by inhalation, or an intravenous injection of radium
in the form of a soluble salt. The radioactive waters are given in doses
ranging from 25,000 to 100,000 mache units of emanation per day. in
divided doses after meals and at bedtime.
Radium emanation by inhalation is given daily in the emanatorium
for a period of two hours— this daily treatment is further fortified by
prescribing a varying amount of radiactive water taken at the beginning
of the sitting and at the end of the treatment. The ordinary emanation
content of my emanatorium shows 250 mache units of emanation per
liter of air.
Radium element in the form of the soluble salts is given intravenously
in selected cases either at the commencement of the treatment or
after the response to the radioactive waters or the radium emanation
hy inhalation has not been sufficiently effective. As a rule, I follow
the first injection with a second in two weeks, and vary the quantity
from 10 to 15 micrograms of radium chloride. Administration of radium
intravenously is always followed up with a course of waters and inhalation.
I would sound a note of warning, or at least urge precaution, in the
use of large doses of radium emanation at the commencement of the
treatment of any patient, as I have many times observed a special
reaction from radioactive waters, such as severe headache, malaise,
digestive disturbances, and a rise in temperature. When this supervenes
the treatment should be discontinued for a day or two. after which the
course can be resumed with about one-fourth of the original dosage and
gradually increased until the desired result is secured. In this manner
of procedure almost any amount of radium emanation can be administered.
There are other clinical points of importance which should be
considered, but the time at my disposal will not permit their discussion.
BIBLIOGRAPHY.
Bartholow: American Medicine. June, 1915.
Bissell: Mfdicai. Record. July 11. 1914.
Cameron: Transactions Pennsylvania State Medical Society, 1913.
Colwell and Russ: Radium. X-Ray, and the Living Cell.

136 R a d i u m
Comstock: New York Medical Journal, Jan. 6, 1912.
Delano: American Medicine, June 15, 1915.
: Medical Record, July 24, 1915.
Ferris: Medical Record, July 18, 1914.
Field: Medical Record, Jan. 22, 1916.
Moriarta: Xew York Medical Journal, Jan. 6, 1912.
: Medical Record, March 4, 1916.
Saubermann : Archives of the Roentgen Ray, January, 1912.
Thomas: Medical Record, April 1, 1916.
Proescher: Radium. January, 1916.
Viol: New York Medical Journal. March 1, 1915.
511 Broadway.
Reviews and Abstracts.
Joseph B. Bissell, M.D. (Xew York). Special Radium Needles in
Use at the Radium Sanitarium of.New York. American Medicine, XI,
No. 7, pp. 520-1, July. 1916. ''While in England last summer, the writer
observed some very interesting results in the treatment of new growths
in various parts of the body by the insertion of radium emanation in the
body of the tumor. This emanation is inserted by means of very small
glass capsules pointed at one or both ends, filled with emanation. These
tiny glass bulbs (or seeds) are placed in the tumor by means of hollow
needles whose calibre is large enough to carry the seed The needle,
usually four to six inches long, is driven into the tissue of the tumor
until it reaches approximately the center, then the glass containing the
emanation is pushed down through the hollow air stem. A small obturator
is used for pushing the bulb home. The needle and the obturator are
withdrawn, leaving this glass bulb behind in the tissue. The patient
either remained at the sanitarium during the treatment or returned to
his home at a distance. As radiation takes place in every direction from
the element as a center, this method of treatment seems a most attractive
one, and is theoretically perfect as to the location of the application."
"In the service of Mr. Pinch, of the London Radium Institute, this
treatment appears to have been quite successful. The same method is
being carried out at the Huntington Cancer Research Laboratories in
Boston by Dr. Duane, and also at the General Memorial Hospital in New
York City."
"An objection to this treatment, a purely economical use of
course, is that in order to obtain the emanation and use it frequently,
a considerable amount of radium must be Jcept continually in solution.
Only 16 per cent, of the emanation of radium in solution is obtained
in the first twenty-four hours. In the next twenty-four hours
14 per cent. It takes four days to obtain 50 per cent. For t>he emanation
to equal the amount of radium in solution or to reach equilibrium
requires twenty-eight days. A good deal of time is thus required to
procure the emanation. In a very active service, this is a great drawback.
Another possible objection is that the little seeds left deeply
seated in the tumor may become a possible source of irritation and in-

R a d i u m 137
fection. Unlike the radium itself, the emanation has not a long life,
its effect decreasing very rapidly. It reduces itself 50 per cent, in
3.85 days, and in twenty-eight days its usefulness has entirely gone."
"It occured to the writer, that a series of hollow needles filled
with varying amounts of radium would have the same effect as the
insertion of the little glass seeds, and that this effect would be more
thorough and exact, and permanent as long as the needle remained in
position. The amount of the element thus supplied can be more accurately
measured by using the radium itself than hy the use ot :hc
unstable emanation. The needles may be used as well for radium applications
in other oases, exactly as if the radium was in the ordinary
brass, silver, glass, hard rubber, or other containers."
"Last summer under my direction seven such needles were made.
five containing approximately eight mgm. of radium and two, five
mgm. each. The needle consists of a sharp pointed steel ^old-plated
hollow tube with a ring at the end opposite to the point. The ring
and the blunt end of the needle are firmly and smoothly soldcied to
the hollow part after it has been filled with radium. The steel wall is
0.3 mm. thick, and the gold about 0.01 mm. Iridium points are preferable,
and in my next needles I expect to make use of them, but this
time the iridium was not easily obtained without some loss of time,
and I was in a hurry to make use of the needles for a special case
which was then waiting. They are especially adapted to tumors of
the thyroid, various isolated enlarged glands, as well as for the various
tumors of the breast. 'So far I have used them for two carinomatous
glands of the neck, two cases of isolated glands, and one case of
sarcoma of the humerus involving the whole circumference of the
bone, as well as in the tuberculous glands in the axilla."
"The needles can, of course, be inserted in the tissue of the circumference
of a large tumor at equal intervals, radiation thus taking
place in all directions from each needle as a center. This is theoretically
at least, a very desirable way of getting the effect of the radium."
Frederick L. Hoffman. LL.D., The Mortality from Cancer
Throughout the World. The Prudential Press. 1915. Radium and Radiotherapy,
pp. 209-212. "A thoroughly qualified statistical inquiry into
the results of cancer treatment would make an extremely valuable contribution
to the cause of cancer research. A large amount of statistical
information has been published on the results of surgical operations, but
the methods of statistical analysis have, as a rule, been crude and often
not free from serious technical objections. In the case of the nonsurgical
treatment of cancer the statistical considerations are even more
involved, and the conclusions advanced arc less to be relied upon as
impartial and accurate. The underlying reason is to be found in the
widely varying and statistically ill-defined principles of medical and surgical
practice; in other words, it is extremely difficult, if not practically
impossible, to reduce the cases considered to an absolutely comparable
basis. For illustration, one institution may treat largely inoperable
cases as a matter of charity or positive necessity; another institution
may treat only such cases as upon thorough examination warrant an
exceptionally favorable prognosis: yet the first of the two might actually
be better administered and yield relatively more favorable results than

138 R A D I U M
the second. It is therefore obvious that statistical conclusions regarding
methods of treatment require to be accepted with extreme caution."
"These observations apply with special force to radiotherapy as a
possible solution of the apparently hopeless problem of an effective
cancer cure by other means than radical surgical interference. The
subject of radium, however, has attracted so much attention within the
last few years that it has seemed advisable to include a brief discussion
of it, regardless of the rather doubtful value of the statistical evidence
available at the present time. The opinion has been expressed by Mr. A.
E. Hayward Pinch, the medical superintendent of the Radium Institute
of London, that "No useful purpose would be served by a minute
analysis of the statistics, for, as observed by the British Medical
Journal, "the stages and extent of the disease vary so much
from case to case that only a very large number would warrant the use
of the statistical method." Subsequently, however, some very interesting
statistics have been published by the Institute, which will presently be
discussed in some detail. It requires to be kept in mind that the modern
surgical treatment of cancer is unquestionably much more effective than
the surgical practice of the past and that the results obtained are in
almost precise relation to the previous duration of the disease, or, in
other words, to the attained size and degree of infiltration of the cancerous
mass into the adjacent tissue through the regional lymphatic glands.
The average surgical results, under normal conditions, have been summarized
by Dr. Isaac Levin, in the following statement:
"Only in carcinoma of the lip the radical cure by the aid of the
so-called block dissection of the tumor and the regional lymph glands
is as high as 70 to 83 per cent. In carcinoma of the breast Halstead, who
is one of the best operators of this condition, reports that 38.8 per cent.
of the cases which were operated remained well for three years and over.
Since not all the cases examined were operable, probably not more than
30 per cent, of the cases of carcinoma of the breast can be cured by
surgery alone. In regard to carcinoma of the uterus, Wertheim, the
greatest authority on the surgical treatment of this condition, states that
about one-half the cases which come to him are operable and of these
about one-half are cured by the operation, consequently about 25 per
cent, of the cases of carcinoma of the uterus may be cured by operative
treatment. Wm. J. Mayo, who is one of the most brilliant operators in
the world, reported recently on 996 cases of carcinoma of the stomach.
Of these 344 cases only were operable, and of the latter 25 per cent.
remained cured five years and over after the operation. In other words,
about 9 per cent, of cases of carcinoma of the stomach can be cured by
surgery alone in the hands of a Mayo and probably an even smaller
percentage in the hands of most other surgeons. In all rather less than
30 per cent, of cancer patients can hope to be cured by the aid of surgery
alone."
"It must be admitted that these results are disappointing, considering
the high degree of surgical efficiency on the part of those who are
rightfully considered the master minds of the surgical profession, but
Dr. Levin is far from being justified in his conclusion that "It is also
safe to assume that there can hardly be expected any further progress in
surgical treatment of malignant tumors," for the self-evident reason that
in the past the large majority of the cancer patients obtained surgical
treatment at a time when the cancerous growth had probably reached

R a d i u m
the inoperable stage. These observations seem called for in view
of the reasons advanced in behalf of the radium treatment as a substitute
for surgical interference, even though evidence is wanting to prove
that radiotherapy would be applicable to the large majority of deepseated
cancers, which cause the major portion of the aggregate mortality
from malignant disease."
"Radiotherapy is a branch of physiotherapy, which includes treatment
by heat, light, electricity and radio-activity A brief outline of the
principles of physiotherapy in its relation to cancer is obtained in the
treatise on "The Cancer Problem," by William Seaman Bainbridge, who
refers to the discovery of Roentgen rays in 1895, which were also
first employed in the the treatment of malignant disease. Elsewhere in
this work reference has been made to X-ray dermatitis, or skin cancer,
due to the action of the rays, met with among Roentgen-ray workers. In
moderate forms of cancer, however, the application of X-rays has been
beneficial in treatment, but the statistical data are far from sufficient and
conclusive. The discovery of radium and radio-activity by Mme. Curie
dates from 1898-1900. The general principles of radiotherapy have been
elaborately set forth in a work by Wickham and Degrais, translated by
Dore, with an introduction by Sir Malcolm Morris. The therapeutic
results discussed in the work are illustrated by a large number of colored
photographs of cases before and after treatment. Most of these cases
represent external or superficial cancers, and but a few are derived from
gynecological experience. In a subsequent treatise on radium, as employed
in the treatment of cancer, angiomata, keloids, etc., the same
authors present much additional evidence, but again most of the illustrations
are of superficial cutaneous cancers, which would naturally be
most likely to yield satisfactory results."
"The statistical interpretation of the facts presented by these and
other authors on radiotherapy is as yet far from convincing. The first
annual report of the Radium Institute, published in the British Medical
Journal, under date of January 25, 1913, includes 657 cases, but of
these a large number were not malignant disease. Of the carcinomata
and sarcomata not a single case was reported as cured; but out of 447
cases treated, 44, or 9.8 per cent., were reported as apparently cured;
137, or 30.6 per cent., as improved; and 52, or 11.6 per cent., as having
died." (The author fails to add that practically only inoperable cases of
malignant disease were treated.—Ed.)
"A review of the recorded observations on individual cases warrants
the conclusions that radium is unquestionably an effective method
of treatment in superficial cancers, particularly in the earlier stages of
the disease. The results of the treatment, however, are largely dependent
upon the quantity of radium used. Failures are more likely to be
attributable to the insufficiency in the amount of radium available than
to any other cause, at least in patients in a far-advanced sta§e of the
disease. These conclusions, however, appjy, as yet. almost exclusively to
superficial cutaneous cancers, which cause but a small fraction of the
aggregate annual loss of life. There has not been sufficient time to
observe the after-effects of radium treatment in a large enough number
of typical cases. The statistical experience data have also not as yet been
subjected to an extended critical analysis, with a due regard to the
organs and parts of the body affected or the specific types of the disease
and the degree of cancerous involvement. Nor has the question of joint
results in operative and radium treatment combined received adequate
139

140 R a d i u m
attention. There would seem to be much ground for accepting the conclusion
that the best results, at least in internal cancers, are likely to be
obtained, first, by surgical interference, and, second, by subsequent
radiotherapy."
• p * * *
Howard C. Taylor, M. D. The Radical Operation for Carcinoma of
the Uterus. Abstract of a paper presented oefore the Section on Obstetrics
and Gynecology, New York Academy of Medicine. Trans, of
N. Y. Acad, of Med., Am. Journ. of Obstetrics, LXXIV, 144-6, July,
1916. "Dr. Taylor said that his treatment of carinoma of the cervix uteri
was as follows: (1) For the favorable cases, a patient in a good general
condition, an abdominal wall without an excess of fat. and no associated
pelvic lesion to increase the operative risk and a limited growth, he advised
the radical operation. (2) For a limited growth in a patient who
was a bad risk on account of general or local conditions, he advised
usually a simple abdominal hysterectomy, occasionally a vaginal hysterectomy.
(3) For the so-called inoperable case, he advised radium, X-rays
and the cautery. In this class because of the favorable reports that were
published following the use of radium, X-rays and the cautery, he included
cases that formerly he submitted to operation. If after the use
of radium, X-rays or the cautery the case became operable he removed
the uterus."
• # * * «
A Martin (Berlin). Radiotherapy in Cancer of the Uterus, Jahreskurse
fuer arztliche Fortbilding, July, 1915. American Journal of Surgery,
XXIX, No. 10, October, 1915 and XXIX, No. 11, November, 1915.
"The influence of the radioactive substances on the histological structure
of tumors is the same, no matter what form of radio-energy is employed;
thus the studies of Aschoff with X-ray, Haendly and Weinbrenncr with
mesothorium, Doederlein with mesothorium and X-ray, Exner, Wickham,
Degrais, and Bellot with radium, have all shown practically the
same effect on the tumor cells. In general the formula suggested by
Bergonnie and TVibondeau for the sensitiveness of cells to rays has been
verified by the other investigators. Thus it has been shown, that the
cells are the more sensitive to the ray: !, the greater their reproductive
activity; 2, the longer their karyokinetic phase, that is, the more remote
they are from their mature state; 3, the less defined their morphology
and formation."
"Von Hansemann and Schottlaender have shown that there is nothing
specific in the effect of the ray on the histological picture. The pictures
often show changes frequently seen in rapidly growing or rapidly
disintegrating tumors, but this can be seen only by examining pieces for
diagnosis and comparing them to the extirpated tumor or to excised
particles which latter show these pictures. The effect on normal tissues
is practically the same as on pathological tissues; at first there is hypertrophy
; then necrosis of cells and bacteria; followed by absorption; then
replacement by scar tissue. This is the same in both animals and plants,
as well as in human and animal tumors (Keyserling). These changes are
induced by the so-called irritation doses (Reizdosen). Sachs warns
against these milder doses because they may stir up to greater activity
the deeper-lying carcinoma cells instead of being inhibited in their growth
and even destroyed, as are the more superficial lying cells;—they may

R a d i u m
even take on an increased activity. Von Franque has demonstrated this
in a convincing way: All. rays decrease in effect in proportion to the
square of the distance from the ray-source. Certain amounts of the ray
are absorbed by the exposed tissues; of the gamma ray, of mesothorium, of
radium. 40% ; of the roentgen-ray 30^>, for one centimeter of tissue layer
(Kectman). The limit of the penetrating effect of the ray does not seem
to exceed ten centimeters. Tart of the residual X-ray may penetrate still
further; according to Lazarus, as much as a meter in depth."
"A selective effect, in the sense that only carcinoma cells are destroyed,
has not been demonstrated for any kind of ray. There is, however,
a certain tendency of the ray to destroy carcinoma cells—to replace
connective tissue by stimulating increased activity. Upon normal epithelial
cells, there was practically no effect. If the ray intensity is not sufficient,
the carcinoma may even be stimulated to greater, more active prolifr
eration, which sometimes becomes very intense. If the ray intensity is
excessive, the neighboring tissues may also be destroyed. Asehoff, Kroenig
and Gauss have reported necrosis due to burning of the intercostal
muscles in a case of mammary carcinoma, of the superficial layers of lung
and of small areas of liver (found at autopsy). Possibly, this will not
occur with the employment of the newest apparatus. Bumm, however,
says this danger has been practically eliminated."
''Clinical manifestations.—Frequently there is noticed a swelling and
hyperemia (inflammatory signs) of the tumor. Secretion is increased;
suppuration and hemorihage. decrease, in fact cease altogether; the secretion
becomes oderlcss and serous. This also disappears in a few
weeks, occasionally more rapidly, at times more slowly. The proliferation
gives way to shrinking. The ulcerated mass becomes epidermalized.
The vaginal portion takes on a normal form. Sloughing is evidence of
excessive dosage. By and by the vaginal vault becomes narrower, the
vaginal portion disappears, giving the impression of senile atrophy of the
genitals. Infiltrated parametria begin to show hard indurations. Pains
disappear with surprising rapidity. Amenorrhea and shrinking of the
ovaries result. The ova cells are more noticeably sensitive to the ray than
carcinoma cells."
"This local change, is as a rule, accompanied by a remarkably rapid
improvement in the general condition. Cachexia and anemia disappear;
the body weight increases under better nutritional activity; general efficiency
and capacity for work return."
"In another series of observations the opposite condition obtained,
whether with smaller or larger doses, lassitude, weakening, febrile state,
nausea, vomiting, anemia, due to the direct effect of the ray on the red
blood cells."
"Kolde and Martens observed when large doses were used, a decrease
of one million to the cubic centimeter with diminution in hemaglobin
and erythrocytes (Schauta). This is probably due to the absorption
of toxic proteid-by-products from the affected carcinoma, which
may have a jeopardizing effect on life."
"The bladder is often badly affected—ardor urina: is ushered in.
enuresis also; mucous discharge and tenesmus are frequently observed.
These disappear when small or moderate doses are used. These untoward
symptoms have obviated by improved technic. Stricture of the
rectum which necessitates artificial anus, recto-vaginal fistula (two cases
of Bumm's reported at the Halle Congress died of urinary infiltration
141

142 R A D I U M
following bladder necrosis and suppuration). Heyncmann showed cystoscopically
that in more than two-thirds of all the cases there was
bulbous edema of the bladder walls and the ureter orifice. In two cases
there was extension of the carcinoma upon the bladder wall. 1 he danger
of stricture should be borne in mind. Bucky reported an autopsy of a
case 5 months after intensive raying. There were ulcers on the buttock
several centimeters deep; also over the mons veneris. At the same time
an extensive cervix carcinoma had broken through into the bladder.
Halban reports a fatal hemorrhage from an erosion of the hypogastric
vein 27 days after inserting 27 mg. of radium into a recurrent tumor of
the parametrium. But the filter capsule instead of being of lead should
be of brass."
"Cheron, Rubens-Duval use platinum and gauze surrounding it (30
layers of gauze). There is no question that a large part of the injury is
due to imperfect apparatus. These are avoided by improved technic."
"Technic. The dose of radium and mesothorium has been worked
out chiefly by Doederlein. The minimum dose, according to him. should
be for carcinoma of the uterus, 27 mg. of radium element or mesothorium.
In very large cervical cancers occasionally 100-150 mg. were inserted. This
is left in situ for twenty-four hours, at first is repeated at two weekly
intervals, later at three to four weekly intervals. The filter used was
brass lined with rubber To prevent injury of the vagina and rectum
the filter capsule was placed into an appropriate portion of a kolpeurynter
adapted to the size and elasticity of the vagina. The bag was filled
with lysoform in each case. A thorough excochleation of the cancer is
made before the radium or mesothorium application. The results are
better in the more superfical growths. The infiltrating types of cancer
are as resistant and unfavorable as they are to surgical operations."
"In February, 1915, Doederlein reported twelve cases of inoperable
cancer which were entirely well one year after cessation of treatment."
"The Schauta Klinik, Vienna, uses radium in operable cases and in
operable cases that refuse surgical treatment. Excochleation by means
of the Paquelin cautery is done at the beginning of the treatment. Then
27 mg. of radium is introduced for twelve hours, with intermission of
twelve hours to several days. Tlhe first series consists of five applications
after three weeks to a month a second series of four or five applications
is begun, and if necessary is followed by a third series of five sessions.
The dose decreases after each series. Where superficial effects are
desired, the filter is lead, in certain small tumors the filter is of gold,
while for deeper effects platinum or brass is used."
"Of thirty-four cases treated by this technic, eighteen completed
the full course of treatment. One died of pyemia with multiple lung
abscesses—the carinoma was no longer macroscopically visible. Three
women remained unimproved; fourteen were considered to be primarily
cured. Nine cases were carcinoma of the cervix, two of carcinoma of
the body, two of carcinoma of the rectum, and one carcinoma of the
vagina. In no case were untoward symptoms noticeable, i. e., outside of
Slight temperature elevation, mild cystitis and transient loss of appetite
and disturbance of the bowels, as well as backache and abdominal pain.
In general, the discharge and hemorrhage ceased promptly, the pains
rapidly improved, the general condition, blood-picture and body-weight
improved. No fistula? were observed. The course of treatment lasted
l',4 to 2*4 months. Observation of these patients up to the time of
publication was 6 to 10 months."

R a d i u m 143
"The Schauta Klinik does not regard their technic as by any means
perfected. They also employ ar prophylactic measure radium in 27 mg.
doses about 10 days after carcinoma operation. The application lasts
10 hours and is repeated at intervals of a month."
"G. Klein has combined the use of mesothorium or radium with the
intravenous injection of chemical substances such as enzytol and radium
barium selenat (Merck) with the Roentgenization. Enzytol appears to
lead to skin-burns because of its sensitizing effect on the skin. The
future will best determine the value of such combined treatment. Of
Klein's series of 100 cases (25 operable uterine carcinoma, 59 inoperable
uterine carcinoma, and 16 breast carcinoma); 28 were so far cured,
partly primary, partly secondary; 30 were improved, 11 were worse. 23
died, of whom the terminal end in 8 cases is unknown. Klein finds his
method contraindicated in very large cancer or sarcoma of the body of
the uterus, and even dangerous in mammary carcinoma, with massive
infiltration of the axillary glands which probably involve the large vessels
and nerves."
"The expense of the treatment, according to Sachs, to the practitioner
of the individual case receiving 7,000 X approximates about
$750. Van der Welde confirms these figures out of his own experience.
He also notes that the difference in expense as claimed by the manufacturers,
and so encountered by the practitioner, is a vast one."
"The end result: So far one may speak only of primary results
with Roentgen and radiotherapy. With the increased, very large doses
it may be possible to achieve secondary and permanent results. By
means of radium and mesothorium treatment, post-operative in 58 cases
of uterine cancer, Scherer succeeded in keeping 48 cases free from
recurrence three years after operation. The permanent results will
naturally improve the smaller is the primary operative mortality. Thus
Schauta's very satisfactory results with his improved radical vaginal
cancer extirpation the past six years was only 4 per cent."
"Operation vs. Raying of Operable Uterine Cancer.—Some authors
have stopped operating operable cancers of the uterus and have begun
with actinotherapy. Thus Amann, Klein and others claim satisfactory
results without first extirpating the uterus. Hofmeier, however, has had
at least one most disastrous effect from a combined primary treatment of
an adeno-carcinoma of the cervix with radium and Roentgenization.
The tumor in this case was favorable for operation. After three weeks'
treatment, during which 2.000 mg. hours of radium and 250 X of
Roentgen-rays were given, Hofmeier was obliged to operate and found a
great activity of the growth. Despite further radium treatment and
Roentgenization. in all 30,000 mg. hours and 2,630 X during a period of
four weeks following operation the metastases were overwhelmingly
widespread. Fehling takes a very cautious attitude towards primary
radiotherapy, and Von Pratique shares the same feeling."
"There is a great number of women alive today who owe their life
and well-being to ray-therapy. In operable cancer of the uterus actinotherapy
has proven of undoubted benefit; in operable cases a similar
therapeutic value of the X-ray. radium and mesothorium remains yet to
be established."
* * * * *
Clarence W. Lieb. A.M., M.D. The Nauheim Treatment as Given
at the Glen Springs. The Canadian Practitioner and Review. XLI,
No. 4, pp. 145-154. April. 1916. "The following chart shows that, in

144 R A D I U M
addition to their valuable mineral constituents, The Glen Springs (New
York) arc radio-active;
Springs. Mache Units per Liter of Water.
Nauheim (Brine No. 1) 68.
Brine No. 2 13.
Deerlick 2.89
Salubria .64
Kissingen Trace
"Dr. J. S. Shearer, of Cornell, who tested The Glen Springs for
their radio-activity, says in a recent report: "Samples No. 1 (Salubria)
and No. 4 (Deerlick) are quite similar to Saratoga Springs, while
Sample No. 2 (Nauheim) seems to be three times as active as the
highest American Spring previously reported."
"The value of 68 Mache Units for Sample No. 2 shows the radium
emanation in equilibrium with the dissolved radium salt, hence this
amount of emanation may be obtained from each liter of water every
thirty days or half this amount every 3.85 days. As the salt is in
solution the water may he boiled down or otherwise evaporated and
will show concentration of the radium content."
"From the above it will be seen that the Nauheim Spring at Watkins,
N. Y., contains nearly three times the amount of radioactivity of
the next highest radio-active spring in this country and over twice as
much as the strongest spring at Carlsbad or Neuheim, springs long
noted for their therapeutic power."
"It has been demonstrated that the development of diseased processes
in tissues has been checked by radium rays and under certain
conditions regeneration established. It is a notable fact that most
springs which for years have been conspicuous for their therapeutic
value are radioactive and vice versa that the most radioactive springs
of which we know have long been famous for their "healing powers."
"It is a fact familiar to all that the use of mineral waters has
produced much of the charlatanism in medicine and that there has been
altogether too much ceremony and ritual about their use. It would
only be contributing to this regretable chapter in medicine to exploint
The Glen Springs without well founded claims. The results obtained.
however, by the use of this water have impressed many observers
as being out of all proportion to that which can be explained by the
mineral content of the water or its mere physiological application. The
discovery of the high radium emanation from the Nauheim Spring,
and the fact that it contains radium salt held in solution, thus furnishing
a constant source of emanation and not a mere transient ebullition
of this gas, may account for their remarkable healing powers which
until recently, have only been proven empirically. It is the purpose of
this paper, however, to discuss the use of these waters only as they
are used in connection with circulatory disturbances, yet it must necessarily
follow that a water containing such a potent element as radium
salt in solution in addition to its other valuable mineral constituents
must be a very important adjuvant in producing those tissue changes
which it is the end and aim of the Nauheim treatment to effect. There
is good experimental evidence confirming this deduction, even when
artificial radio-active fresh water is used."
* * * * *

A MONTHLY JOURNAL DEVOTED TO THE CHEMIS­
TRY, PHYSICS AND THERAPEUTICS OF RADIUM
AND OTHER RADIO-ACTIVE SUBSTANCES
VOLUME EIGHT
OCTOBER, 1916 TO MARCH, 1917.
PITTSBURGH, PA.
1917.

CONTENTS OF VOLUME VIII.
NUMBER ONE Page
Henry Schmitz. An Additional Contribution to the Therapeutic
Value of Radium in Pelvic Cancers, 1
Robert Abbe. Radium Efficiency in Non-Malignant Surgical
Conditions, 21
Reviews and Abstracts.
George M. Mackee. Progress in the Treatment of Skin
Diseases, 28
NUMBER TWO
Joseph Ransohoff and J. Louis Ransohoff. Radium Treatment
of Uterine Cancers, 29
D. Bryson Delavan. Radium in the Field of Laryngology, ... 33
Reviews and Abstracts.
Henry Schmitz. The Action of Gamma Rays of Radium on
Deep-seated Inoperable Cancers of the Pelvis, 37
Russell H. Boggs. The Treatment of Epithelioma of the
Lower Lip, 39
George Erety Shoemaker. Primary Carcinoma of the Urethra,
Retention of Urine from Obstruction, Restoration of
Function by Radium, 42
J. Wesley Bovee. Notes on the Past, Present and Future of
Gynecology, Obstetrics and Abdominal Surgery, 44
NUMBER THREE
Frank E. Simpson. Radium Therapy. Remarks on the Use of
Radium in Deep-seated Malignant Disease and in Dermatology,
45
Edward B. Heckel. Report of a Case of Melanosarcoma of the
Orbit, Treated with Radium 50

William H. Cameron, Radium in French Military Surgery, ... 54
The American Radium Society, 58
Reviews and Abstracts.
J. T. Geraghty. Treatment of Bladder Tumors, 60
NUMBER FOUR
John G. Clark. Results Obtained by the Use of Radium in the
Treatment of Cancer of the Uterus, 61
Russell H. Boggs. The Treatment of Leukoplakia by
Radium, 69
Reviews and Abstracts.
William H. Dieffenbach. Reports on Cancer Patients Treated
with Roentgen or Radium Rays Remaining Clinically
Cured After More than Three Years 71
NUMBER FIVE
John M. Lee. Radium in Surgery and Gynecology, 77
Palmer Findley. Radium Treatment of Cancer of the
Cervix, 89
"Damned With Faint Praise", 94
Reviews and Abstracts.
Thomas C. Kennedy. Radium Treatment of Epithelioma, .... 97
_-"- NUMBER SIX.
«V Joseph B. Bissell Radium in Various Surgical Conditions, ... 1
-1 Reviews and Abstracts.
•< M. L. Heidingsfeld. Radium Treatment of Rhinophyma and
Hypertrichosis, 105
Benjamin S. Barringer. The Treatment by Radium of Carcinoma
of the Prostate and Bladder, 106

A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY, PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES.
Edited and Published by Charles H. Viol, Ph. D., and William H. Cameron. M. D
wilh the assistance of collaborators working in the fields of
Radlochemlslry. Radioactivity and Radiumtherapy.
Subscription $2.50 per year, or 25 cents per copy in the United States and Canada
In all other countries $3.75 per year.
Address all communications to the Editors, Forbes and Meyran Avenues,
Pittsburgh. Pa.
VOL. VIII. OCTOBER, 1916 No. 1
AN ADDITIONAL CONTRIBUTION TO THE THERA­
PEUTIC VALUE OF RADIUM IN
PELVIC CANCERS'
By Henry Schmitz, A.M., M.D., F. A. C. S., Chicago.
In accordance with the statement made in my previous articles (1
and 2)—"The Action of Radium on Cancers of the Pelvic Organs,"
and "The Primary Results of Radium Treatment in Uterine and Rectal
Cancers"—in which reports were made as to the use of radium in 41
cases of cancers of the pelvic organs. I submit below a review as to
the present status of these cases and include in addition the histories
of cases which have come under my care up to April 1. 1916.
The total number of cases of malignant disease of the pelvic organs
treated to date is 8Q; 62 of these are uterine. 10 rectal, and 8 vesical
cancers (see Table 1).
The clinical results of radium therapy depend upon the method of
application. My technique has been changed repeatedly as I have
gained experience in the course of two years, and therefore I believe
it would not be amiss to describe my present method of applying radium.
TECHNIQUE USED IN RADIUM THEPAPV
The therapeutic action of radium depends on (1) the amount of
radium element. (2) the method of screening, (3) the extent of the
time of the exposure, and (4) the distance maintained between the:
radium and the tumor mass.
J, Surgery. Gynecology and Obstetrics. XXIII 191-202. August. 1916. Inaugural
thesis. Chicago Gynecological Society. June Z3. n»*.

2 R a d i u m
The quantity of radium at my disposition is 100 milligrams of
radium element in the form of radium barium sulphate of a purity

J^ADIUM
The method of screening is simple as gamma-rays only must be
used in pelvic organs. The alpha-rays are arrested by the glass capsule.
in which the radium salt is contained. The beta-rays are absorbed by
1.2 millimeters brass, silver, or lead. Brass screens were used as they
are cheaper and cleaner than the other metals. The secondary or Sagnac
rays formed in the metal screens are arrested by a para rubber tube
of 2 millimeters thickness or about six to eight layers of No. 2 gauzesurrounded
by a rubber finger Obtained from a discarded surgical glove.
The screens are built so that the radium capsules may be arranged in
tandem or twin formation. The tandem is used intra-uterinely, rectally,
or vesically, while the twin is employed on large surfaces as a crater in
Variety of Cancer
Carcinoma uteri Inoperabile
Carcinoma uteri operabile
Carcinoma uteri recurrms
Total
Carcinoma recti
Carcinoma vesicae
Grand total
TABLE I—PELVIC CARCINOMATA
Treated with Radium from April 1, I'll, to April 1, 1916
•_
a
II
35
12
15
62
10
S
•so
Primary
Subjective
>
t
3
23
11
10
44
6
7
57
Result
18
>
2
5
3
12
1
S
1$
4
1
23
Primary
Objective
R-sult
«
2
21
11
10
42
6
5
53
>
I
e
3 14
i
5
20
4
3
27
3
1
c
n
7
4
22
2
3
27
Present Condition
the cervix. The local conditions found present, therefore determine the
arrangement of the capsules (see figs. 1 and 2). We are especially careful
to protect normal tissue from the gamma-rays by suitably formed
lead plates protected with heavy rubber sheeting to arrest any secondary
rays that might form in the lead. We choose lead sheeting for this
purpose as it is pliable and can be cut with scissors to any size or shape
desired.
The rays of radium strike the tissues with a greater uniformity
of intensity the further the distance between the capsule and the tissues,
as the rays become almost parallel or homogenous. This principle
is advocated by Dessauer in massive roentgen raying (6). The
advantage thus gained is more than lost by the decrease in the intensity
of the rays (7). We attempt to bring the capsule as close to the tissues
as possible.
>
2
c
3
4
2
2
S
3
2
13
%
5
20
3
9
32
5
3
40

R a d i u m
Crossfiring should be employed whenever possible (8). If a carcinoma
is found in the anterior rectal wall, a radium capsule should
be inserted in the rectum and another one in a corresponding position
within the vagina; if in the posterior rectal wall, in the rectum and
between the anal or perineal fold; if in the posterior vesical wall, in
the bladder and vagina; if in the anterior vesical wall, in bladder and
suprapubically, and so forth.
MAftp
Fig. 1. Application of radium to cervix and vagina. Tubes in "twin" applicator.
Special radium carriers are required for rectal and vesical applications.
For the former I use a cup with a perforation in the center and
held in place by double rubber bands fastened to a belt around the abdomen.
The radium carrier is attached to a brass rod which is surrounded
by rubber tubing. The latter arrests also the secondary rays.
The length of the rubber tubing is determined by the distance of the
growth from the cup. The brass rod passes through while the rubber
tube rests on it. The carrier by this arrangement remains movable and
therefore becomes automatically adjusted to any position the patient
might assume. In vesical cancers I place the radium capsule in a
urethral catheter. Two fenestra are made in the catheter beneath the
radium capsule. As vesical cancers are usually located in the trigone,
the position of the catheter within the bladder is indicated by the
escape of urine through the tube. The latter is then secured in place
by adhesive plaster. A rubber tube attached to the catheter directs the
urine into a bottle. Continuous drainage is thus secured, making possible
long continued applications of radium within the bladder.
After the first course of radium treatment the patient is requested
to return weekly for re-examinations. The latent action of radium
reaches its height within 21 days. Should the patient not exhibit at
this time a marked improvement in the local condition, indicated by a
decrease in the size of the tumor, another course like the first one is
given. If the patient shows a marked improvement, then the second
seance is postponed for another three weeks. Further applications are

R A D I U M
l&*it»*> caJiiMlt
"'".
Pig. 2 Radium inserted in cavity of uterus, "tandem" arrangement.
thereafter given when indicated by a persistence or a reappearance of
the tumor. The patient is requested to return for examination every
four weeks after a clinical cure has been obtained.
Strictest asepsis must be observed in the application of radium.
Instruments and applicators must be rendered sterile by boiling. The
field of operation must be prepared as for any operation. The surgeon,
also must prepare as he would for the performance of any
operation and protect the hands with sterile rubber gloves.
THE USE OF MASSIVE ROENTGEN RAYS IN CONJUNCTION WITH RADIUM
TREATMENT,
We cannot determine by bimanual examination whether the
regional lymphodes are or are not metastatically invaded by the carcinoma.
Therefore, we apply massive X-rays to the glands through the
anterior abdominal wall by the multiple field crossfire method of Gauss.
Wc use Coolidge and water-cooled roentgen tubes. As the vacuum or
hardness obtainable in the water-cooled tubes is higher than in the
Coolidge, we prefer the former. However, the use of the roentgen
tube involves a greater expenditure in the time of the exposure, but
the higher vacuum obtainable insures a greater penetration. This, after
all, determines the preference for the water-cooled tube.
Thirty to fifty erythema doses are necessary to destroy a malignant
growth within 20 centimeters of the surface of the abdominal wall. It
. IuWcwJ.j-,
ft.lt fitttr_,-n?.

J-. -
5*
12
2t
24
26
29
SI
32
31
6 R a d i u m
requires seven times this amount, that is 350 erythema doses to remove
metastases near the posterior pelvic walls, which are about 10 centimeters
distant from the suprapubic region (9). The roentgen tube
should have a hardness of twelve to thirteen and a half, as determined
by a Wehnelt penetrometer. It should carry a critical current of 4 to 5
milliamperes. Its constancy must be maintained by a continuous flow
of cold water around the anode and an interruption of the current for
a half second out of every second while in use to keep the tube cool,
and thereby retain the hardness for an indefinite length of time. The
distance of the anode from the body should be 21 centimeters. The
rays should be filtered through a three-millimeter aluminum screen, to
exclude the soft rays. Under these conditions 10 to 12 erythema doses
may be obtained per hour. If three seances of one hour each are given
daily, 10 to 14 days are necessary to reach an amount of 350 erythema
doses. If we use six fields as portals of entrance, we must apply about
60 erythema doses to each field. Bumm does not hesitate to apply 100
to a field (10).
The time of exposure can be reduced by using a Coolidge tube.
Hospital
Number
Augustana
3S223
Augustana
3977S
SI. Mary's
24096
St. Mary's
23967
Augustana
(0202
Willard
27036
Augustana
39321
Augustana
39(69
Name of
Patient
Mrs.
Pauline H.
Mrs.
Kmilio K.
J. McC.
Mrs.
R. M.
Mrs
M. R
Mrs.
John S.
Mrs.
Ingeborg T.
Mrs.
L. W.
TABLE XL- CARCINOMA UTERI INOPERABLE
r
Age
66
47
62
(3
50
,3
36
civil
Stat©
w.
11
43
M.
•w.
M.
M.
M.
M
Para
o
0
ir
t
111
I
t
0
First Symptom
June. 1912
Hemorrhages
Jan.. 1914
Hemorrhages
For three mos.
Hemorrhage
For one-half yr.
Menorrhagia
Sept.. 1913
Hemorrhages
Jan.. 1910
Hemorrhage
For six mos. discharge.
For 1 mo
Hemorrhage
Pain and
Hemorrhage
Result of Examination
Cancerous ulcer involving vagina.
Very cachectic.
Ulcer left side of cervix in
volving left vaginal wall.
Uterus fixed.
Cervix forms a crater. Uterus
firmly fixed. Mass In llg
lata.
Cervix and vagina one crater
extending Into llg. card.
Ulcer right half cervix extending
into right llg. latum
and vagina.
Uterus a mere shell, firmly adherent
to rectum. Rectovaginal
fistula.
Crater of cervix invading nostvaglnal
wall.
Cervix ulcerated. Vaginal
vault Invaded. Infiltration

k
12
22
24
2ft
22
31
32
— 34
Date of
Fir-t
Symptom
June,
1912
Jan..
1914
Jan..
1914
1912
Sept..
1913
Jan.,
1910
11-1-13
Dec.
1913
R a d i u m 7
L. G. Cole states that an erythema dose may be attained in one minute
with a three-millimeter aluminum filter. The entire application of 350
erythema doses could, therefore, be made within 6 hours.
THE POSSIBILITY OF INCREASING THE INTENSITY AND PENETRATION OF THE
GAMMA-RAYS OF RADIUM BY EXCOCHLEATION AND
CAUTERIZATION OF THE CANCER GROWTH.
The extent of the intensity and penetration of the gamma-rays of
radium may be increased by the removal of the cancer-tissue by the
sharp spoon and the cautery iron. This procedure is especially practicable
in the proliferating, cauliflower growth of the cervix. Cauterization
has been performed in every case in our series in which such
a procedure was not contra-indicated. The result is a decided reduction
in the extent of the new-growth, a corresponding increase in the penetration
of the rays, and a decrease in the duration of the exposure to
the gamma-rays. It is a purely economical question and has no other
influence on the result of the radium treatment.
Date of
Treatment
5-30 to9-24-l(
5-12 to 7-5-14
(-18 to 8-16-14
1-2 toft-11-14
7-20 to 27-14
ft-7 to 8-5-14
(-( to 6-17-14
1-1 to 9-9-14
4-1 10 7-31-14
1
10375
6320
7600
7876
3100
9260
8312
9013
8700
i
Primary
Result
1 •
7-3-14 Subjectivo
cure
Good
Good
Good
Good
Good
Good
Good
Date and
Character
Surgery
11-13-13
.autery
•*.22-14
Cautery
3-1S-14
Cautery
3-8-14
Cautery
7-l(
Abd. Hyst.
8-6-14 Abd. Panhysterect
1910
(autery
3-5-11
Cautery
l-2i
Abd. Hyst.
3-19-lt
Cautery
6-11-11
Abd. Hyst.
Present Condition
Died March. 1915
Died Jan.. 1915
6-17 became worse. Now
refractory. Died.
Died from invasion of rectum.
Died 11-20-14.
Oct, 10, 13- Colostomy. Died
Dee. 14. Meiastos'sL^er
4-1-16 Well
Dl.d Aug. 1911. Care.
vesicae.

35 | Augustana Mrs.
1 (0568 w.
39
(»
46
:,*.
65
73
SO
SI
*3
Augustana
11305
Augustana
41221
Wash. Bvd.
8902
Mrs.
Lillian R.
Mrs.
A. N. S.
Mm
M. R.
We«,l Side Mrs.
28985 M.
Augustana
419K
Post
Graduate
48
39
53
63
48
1
Mrs. 1 49
R. T.
1
Mrs.
Julia H.
1 (3
Augustana Mrs.
42538 Charlotte L.
Norwegian
Deaconess
St. Mary's
27649
88 1 St Mary's
I 27973
1
_
110
1
St. Mary's
28355
St. Mary's
28467
St. Mary's
28866
130 1 St. Mary's
1 290(9
1(3 j Augustana
' (3556
'28 | Augustana
44110
Mrs.
Johanna W.
Mrs.
,.s.
!
55
63
C5
Mrs. | 5$
Nellie DeR. 1
Mrs.
Anna V.
Mrs.
Jadwiga G.
Mrs
A. W. B.
36
50
Mrs. i 48
B. T.
Mrs. 1 47
•' E P.
Miss | 41
M. F.
' 1
R a d i u m
TABLE II — C>:':r.'i,-:..
M.
30
M.
9
M.
3.
M.
M.
2(
M.
27
M.
30
W.
w.
M.
37
M.
M.
16
M.
32
M.
M.
S
XIII
II
[
O
0
III
XV
0
VI
V
11
VIII
V
V
I
o
For fi\e mca.
Menorrhagia
July. 1914 .
Hemorrhages
Mess involving uterus, vagina
parametria Myocarditis with
d i *co m p en sat lo n.
Cervix, large indurated ulcer
extending to vagina all
around
June. 1914 lufcer Involving cervix and
Menorrhagia vagina all around.
Oct.. 1913 1 Advanced cachexia. Entire
Hemorrhage i pelvis, Including vagina form
1 one mas'.
Mar.. 1914
Hemorrhage
For two years pair
in pelvis.
"^or three years.
Discharge
Uterus size of fist. Mass extends
to left bony pelvis.
Advanced case
Crater involving cervix, vagina
and llg. card.
Crater Involving cervix and
ant. vaginal wall. Advanred
cachexia.
For three mos. Cervical stenosis due to tumor.
Hemorrhages Pyometra.
For two years.
Discharge
Ulcer of cervix, involving
vesicovaginal septum and
llg. card.
Muss involving cervix and lie.
[ card.
Mass Involving cervix and
right parametrium.
Uterus mere shell, adherent
all around. Advanced cachexia.
0cl- '914 Crater involving entire uterus*
Hemorrhage and vagina.
Dec. 1914
Hemorrhage
Deo.. 1914
II r"orrluiKP
For one month
Dyiuria
Advanced cachexia. Crater Involving
vagina, uterus, rec-
Advanced cachexia. Crater cer-
Ulcer of cervix. Uterus fixed.
Ulcer involving cervix and upper
half of vagina.

35
3,
40
Feb.,
1914
July
1913
June,
1914
46 1 Oct..
I 1913
50
66
73
80
81
83
88
98
110
US
120
Mar..
1914
Jan. fi,
1914
Jan..
1912
Jan..
1915
Two
years
Oct.,
1914
Four
years
Dec.
113 Dec.
1914
1
128 |
1
7-19 to 8-9-11
10-17 10 22-14
10-19 to 11-1-14
2-9 to 11-1915
11-6 to 12-3-14
11-27 to 11-30-14
1-21 to 24-15
2-6-16
3-12 to 26-16
3-15 to 3-1915
3-20 to 4-26-15
4-15 to 5-5-15
5-18 to 27-15
6-10 to 8-24-15
6-4-15
7-8-15
7-23 to 8-29-15
9-20
8-28-15
3-29-!•=
R-17 lo 8-26-15
9-16 to 1-31-16
3760
(000
6800
1200
8S50
(150
R a d i u m
Refractory
Refractory
Good
3500 1 Good
4800
2925
1700
4550
5660
3050
3400
2(00
1750
3350
1050
2100
300
100&_
1925
4675
1
Refractory
Refractory
Refractory
Good
Negative
Good
Well
5-26-16
Well
Immediately
Int. vag
fistula
Refractory
Refractory
Well
Good
10-7-14
Cautery
9-26-14
Cautery
None
1-6-1916
Cautery
l-in-1915
Cautery
-t-l*-1915
Bxcochl cation
--16-1915
Cautery
4-15
Cautery
Veiy advanced

1(1
no
1(7
~1
152
161
162
166
168
17*
10 R A D I U M
Augustana Mrs.
44801 Anna R.
Willard Mrs.
29S5S Katie M.
Post- Mrs.
Graduate Mamie S
Augustana
46181
St. Mary's
30939
Augustana
46549
Augustana
45516
Miss
S. A. S.
60
48
tacl:
M.
W.
—|
58 W. I
46
1
Mrs. 1 70
Dora H.
Mrs.
E. B.
Mrs.
E. B.
Augustana Mrs.
46129 iP. M.
St. Mary's Mrs.
31395 M. LaR.
178 I St. Mary's Mrs
! 31638 I'. G
52
10
53
49
I 31
9.
M.
S3
M.
32
M.
35
M.
33
It
M
10
n—Continued.
O For three months
Dysurla
o
VII
V
II
O
For three years
Hemorrhages
Purulent at timer
bloody, discharge
Oct.. 1915
Pain
Discharge
Discharge
Discharge
Hemorrhage
Involvement of cervix, entire
vagina and vesicovaginal
septum.
Advanced cachexia. Crater
involving cervix and vagina
Uterus fired in a mass involving
parametrll. Cervix ani
vagina present ulcer.
Involvement of cervix and
entire vagina.
Ulcer involving cervix, and
vaginal fornlces. Uterus fixed
Ulcer involving cervix and
vagina, extending Into parametrll.
Crater Involving cervix, extending
into left parametrium.
Uterus has sloughed entirely.
Vesicovaginal fistula.
Hemorrhage ; Crater involving vagina, cervix
and infiltrating parametrll-
O .Hemorrhage Ulcer of post-cervical Up extending
into fornix; infiltrating
rectum.
It is advisable to perform a colostomy in rectal cancers. This renders
the seat of the carcinoma dean, prevents absorption of septic and
putrefactive material, gives the patient an invaluable relief, and makes
the use of radium less obnoxious.
In vesical cancers in the male a suprapubic cystotomy should be
done. The radium may then be inserted through the suprapubic tube.
Injury to the posterior urethra is avoided, the use of operating cystoscopes
becomes obsolete, and the objections on the part of the patient
are obviated. However, the catheter procedure, as before mentioned.
may also be used after a preceding dilatation of the urethra.
THE CUNICAI, RESULTS.
Tables II. Ill, IV. V, and VI give the clinical history and result
of every case treated, I have discussed the histological action of radium
on carcinoma-tissue in one of my former monographs (1). The reader
is kindly referred to the same.
The results of the radium treatment differ depending (1) on the
organ involved, and (2) on the stage of the disease. The prognosis is

141
140
147
152
161
162
165
Three
months
Three
years
July.
1916
Oct.
1916
Jan. 9, 1-17
1916
Feb..
1915
Six
weeks
10-27 to 31-15
12-27 to 29
8-16 to 24-15
11-12 to 3-18-16
1-21 lo 12-15-15
12-3-15
12-24 to 3-11-16
1-19 to 3-15-16
1-26 to 2-10-16
3-3 to 3-18-16
1200
2600
2100
3225
3800
2250
2900
600
3700
2000
1800
R a d i u m 1!
Good
Good
Good
Good
Good
Good
Good
i1-11-16
Cautery
1-14-16
Good Cautery
2-16-16
Good
Good
Died Jan.. 16. Post-morten.
examination negative, N •
carcinoma.
*-10-15 3-25-16. Well. Working.
Cautery Gained 60 lbs. in weight.
(-2-16 Fulguration
of bladder papilloma
Abd. Hy»t
(-13-16
Panhyster
ectomy
4-1-16. Well. Resumed her
work.
3-25-16. Genitals negative.
Bladder papilloma.
Refused further treatment.
5-1-16. Well
7-12-16. Recurrence.
168 16
1-30 to 3-14-16 3550 Good
10-15-16
|
months
Cautery
172 1 June. 2-20 to 24-16 ' 1700 Good 8-2-15
| 1914 3-20-21 1850
Cautery
lis | 1 Dec..
1 1915
J
1
3-2 to4-1916
3-27
2400
1000
Good
| 1 —
best in vesical, almost equally favorable in uterine and vaginal, and not
so favorable, even poor, in rectal carcinomata. The value of the treatment
varies, depending on the operability, inoperability, or recurrence
of the disease. The time elapsed in all the cases enumerated is too
short to permit a discussion of the curative action of radium. However,
I have two cases which succumbed from an intercurrent disease
after the inoperable uterine cancer had been clinically cured by radium
rays. The result of the treatment, based on microscopic examinations,
will be discussed at the end of this paper.
Inoperable carcinomata. Eleven clinical cures were obtained in 35
inoperable uterine, none in 6 inoperable rectal, and 3 in 4 inoperable
vesical cancers. A clinical cure implies a complete subjective and objective
cure of cancer as far as it can be determined by an exact palpation
and a micropscopic examination. Fourteen clinical cures were obtained
in 45 inoperable pelvic cancers, i. e., 31.1 per cent. This percentage
would have been much more favorable if hopeless cases had
not been included. However, not a single case was refused the treatment.
Seven uterine, 4 rectal, and 1 vesical, i. e.. 12 cases, which are
included in these 45 cases were far-advanced and in a terminal stage.
The 31.1 per cent clinical cures would be raised to 42.4 per cent by deducting
the twelve terminal cases from the total number of 45.
Has large vesicovaginal fistula.
5-5-14. Free of pain.
4-30. Ulcer has healed. No
indurations anywhere.

13
1
21
23
28
37
n
77
79
4
12 R a d i u m
Hospital
Number
Augustana
40717
St. Mary's
24058
Augustana
39516
Augustana
40270
Augustana
40(56
Augustana
1161 2
Augustana
(2319
St. Mary's
27533
St. Mary's
27590
i
105 1 Wlllard
I 29857
_ 1 L
116 I Augustana
43718
124 Augustana
44099
125
135
176
182
Augustana
(4095
Augustana
4(503
Augustana
(5966
St. Mary's
319(4
Mrs.
A. H.
Name of
Patient
Mrs.
M. K.
Mrs.
McQu.
Mrs.
Caroline
TABLE III. —CARCINOMA UTERI RECURRENS.
*
<
29
63
Mr*. 1 46
T. M. P.
Mrs.
D. W. H.
Mrs.
Mary M.
Mrs.
Mary H.
Mrs.
Ann C
Mrs.
Harrlette E.
Mrs.
Ellen C
Mrs.
(tiristin.- V.
,.
42
33
:,
1
IS4
:
Mrs. 1 47
Lulu C
!
Mrs. 1 26
Mary M.
Mrs.
Caroline Y.
Mrs.
Mrs. Cath.F.
1 5\>
I 52
!
1
Civil
State
w.
AT.
9
yrs.
M
M
M.
M.
22
M
W.
M
W.
M.
13
M
M.
8
W.
w,
Para
t
0
0
III
II
t
III
IV
r
o
HI
IV
II
First Symptom
June, 1910
Discharge
Since 1912
Pain
April. 1913
Character of Recurrence and
of Operation
Reeurrens: Nodule in fornix
Panhysterectomia vaginals.
Abdominal supravaginal amputation.
Involvement of entire
vagina-
Abdominal hysterectomy. Involvement
of vagina, vulva,
perineum.
May. 1913 ' Involvt-ment of vaginal vault
Since Aug.. 1912 ! Abdominal hysterectomy. Mass
Discharge in right parametrium.
Since April, 1914
Haemorrhage
Abdominal hysterectomy. Involvement
of scar in broad
ligament
Slnoe June. 1913 I Abdominal hysterectomy. Mass
Haemorrhage Involving scar and right
parametrium.
Haemorrhage Vaginal panhysterectomy. Involvement
of parameirii.
Mar.. 1913 Vaginal hysterectomy. involve-
Haemorrhage ment of vagina.
Percy cautery. Abdominal pan-
Aug., 1913 hysterectomy. Crater in-
Haemorrhage volving left parametrium.
Haemorrhage
For one month
Haemorrhage
For 2 years
Abdominal
Tumor
Crater in vaginal vault
Vaginal panhysterectomy. Ulcer
In vaginal vault
tbdominal panhysterectomy for
papilloma ovarii. Parametrll
Involved.
1 Vaginal hysterectomy. Vesicovaginal
fistula, vaginal vault
Ovarian Abdominal oophorectomy. In-
Papilloma volvement of parametrll and
vaginal vault
Oct.. 1914 Crater and ulcer In left vagi-
Sanguineous dis- nal vault extending downcharge
«iril

u
13
21
23
28
37
48
71
77 1
1
79
105
116
121
125
135
176
1S2
Date of
First
Symptom
June,
1910
1912
April.
1913
May.
1913
8-12
1912
May.
1913
June.
1913
Mar.,
1913
Oct..
1913
2-15-16
1-8-13
Dec.
1914
Oct..
1914
Jan.,
1910
9-l«
13
Oct.
1913
May.
1913
8-12
1912
Date Of
Operation
11-22-13
Oct 1.
1913
Aug. 21.
1914
Mar.,
1914
6-19
15
Mar.
26-15
1-8-15
8-1-15
Dec.
1914
Apr. 14.
1915
June,
1914
Dale or
Recurrence
Immediately
Immediately
Jan.,
1914
Mar..
14
9-2-14
Jan..
1914
Immediately
Immediately
July.
1915
One
month
Immediate
R a d i u m 13
I
Radium
Immediate Present Condition
Date and Amount
Result
7-23-14 tO
11-30-14
12000
4-16 to 5-28-14
5700
4-26 to 5-13
3275
6-13-K to6-lS
2275
7-10 to 13-14
3500
11-22 to 11-21
220
2-15 to 5-13
8200 "
3-5 to 3-19-15
(075
3-10 10 4-5-15
3900
6-1 to 11-16
3950
8-5 to 11-29
210H
7-9 to 11-11-15
7100
8-13 to 12-20-15
5575
8-13 to 9-5-16
235')
9-21 to 26-15
2050
2-28. 1000
3-13. 1100
3-29-16
2000
Good May 15. Died from iniercurrcnt
disease
Good Died Sept 21-14. Exhaustion.
Refractory bled. Vagina, vulva and
perineum were inxolted.
10-14.
Good
Refractory
At first
Sub. cure
Refractory Died.
I
5-13-16
Good
4-25-16
Cautery
6-19-15
Abd. Hyst
Good at
first
Good at
first
Good
Good
Did not return for treatment
Died August, 1911. Exhaustion.
Died from exhaustion r.nd
sepsis tollowing cautery.
Died with vesicovaginal fistula.
Nov., 1915.
8-28-15. Returns with recurrence.
Non-refractory.
Died.
Well. 5-16-15.
Vesicovaginal fistula, 10-
1915. 11-1916. haemorrhages.
Died.
December became rapidly
worse. Died. (-10-16
Had vesicovaginal fstula
after operation. Refused
to return.
3-11-16. Panhyerectomy. abdominal.
Apr. 28-16. Subjectively
well.

h
7
14
Hospital
Number
Augustana
41218
Mrs.
E. B.
Name of
Patient
TABLE IT
8
<
64
17 1 Augustana Mrs. 1 39
40944 R.
..
82
90
Ml
106
Augustana Mrs.
39755 Hilda F.
St. Mary's
27560
St. Mary's
27982
W11 lard
29417
St. Mary's
27770
117 | Augustana
| 43551
133
,«
174
41
li
IS
St Mary's
29442
Augustana
44615
Wlllard
Wash. Bvd.
896S
Hospital
Number
Augustana
39516
Mrs.
Belle J.
Mrs
Jos. St. A.
Mrs.
G. B. P.
Miss
D.
Mrs.
Hat tie H.
Mrs.
M. P.
Mrs.
E W.
Mrs.
K. H.
Mrs.
I»aac B.
Name
of Patient
u
1
36
49
63
37
39
35
48
13
52
R a d i u m
CARCINOMA UTERI OPERABLE
•
5
« Para First Symptoms
M
42
yrs.
M.
1
O
V
15 II
1
26 V
33
S.
M.
M.
14
W.
M.
1
II
O
VII
v
VI
o
Menorrhagia
discharge
discharge
Menorrhagia
For one year
discharge
Microscopic
evidence
For six months
discharge
For eight months
haemorrhages
Tumor formation
vulva for 5 years
Haemorrhage
since 4-16-15
Discharge 5 mos.
Haemorrhage 1
month
Uterine
Haemorrhage
Menorrhagia
TABLE V.—CARCIHOHA RECTI
•
M
<
Mrs. 1 32
Anna D.
1
S 9
55
M
Para
II
First Symptom
14 months
Rectal hemorrhages
Result of Examination
Cauliflower growth of cervix.
involving entire vaginal vault
Uterus fixed posteriorly.
Nodule size of hickory nut on
anterior cervical lip.
Ulcer involving cervix and
posterior vaginal fornix.
Negative
Cervix-crater extending into
vaginal fornioes. fixed to
cardinal ligaments.
Cervix-crater Invading vesicovaginal
septum and right ligament
latum.
Nodules all through vulva.
especially clitoris. Inguinal
lymphnodes Involved.
Uleertlon of entire cervix.
Uloer of entire cervix Invading
rectovaginal septum.
Ulcer involving cervical canal.
Not Invading surrounding
tissues.
Adnexa negative. Uterus freely
movable. Ulcer involving
cervix.
Ulcer In fundus uteri. Bilateral
adnexitis.
Result of Examination
Involving perineum. Tumor
obstr. Rectum 2 Inches up.

7
17
33
92
90
101
106
117
133
134
174
u
41
18
Date of
First
Symptom
Jan..
1914
Jan..
1914
Apr..
1913
Oct.,
1914
Aug..
1914
Jan.,
1909
April,
1915
Nov.,
1915
Date of
First
Symptom
1901
9-25
1914
8-26
1914
4-20 to
21-14
3-16
1915
4-16
1915
5-20
1916
6-20
1915
6-18-15
R a d i u m 15
TABLE IT—Continued.
Date of Radium jf = S
Operation Treatment '-=0
"3
10-1-15
Abd. pan.
2-14
1916
10-29
1914
Date and Character
of any
Surgery
Nov., 1913
Colostomy
6-1-15
1914
10-10 to 24-14 | 5200
9-16 to 11-17-14
6-11-15
5-15 to 30-11
3-21 to 3-28
1915
5-23 to 31
1915
5-23 to 30-15
Since received
6-30-16
7-1S-15
9-19-16
9-23 to 27-15
11-8-15
2-22 to 25-16
10-21 to 23-14
11-11 t o 13 -14
TABLE V—Continued.
Date
of treatment
o
9900
1
1
6775
2400
3526
2550
4000
4000
7375
3000
1050
2400
2350
600
1750
4150
Immediate
Result
Refractory
Result to Date
Died Jan., 1915. from hemorrhage.
8-26. Abdominal panhysterectomy.
Vesicovaginal
fistula. Died Feb,, 1916.
4-20 Cautery. 4-24 Abdominal
panhysterectomy. Primary
result good. Ab-
• •"•i"U:d.
Well. Mar.. 1916.
Well, Feb., 1916.
2-15-16. Vesicovaginal fistula.
Good physical condition,
otherwise.
Cacinoma vulvae.
3-26-16 well.
6-20. Panhyst

20
18
70
99
131
153
157
163
173
Ii
19
59
16 R a d i u m
St. Mary's
25176
Augustana
40349
Wiltard
28901
Augustana
43245
Augustana
44323
Augustana
45160
German
Deaconess
Augustana
45S93
Willard
r
Hospital
Number
Augustana
(0(05
Mr
Ed. J. J.
Mrs.
Lillian J.
Mr.
A. M.
Mr.
Joe St
Mr.
R. A. H.
Mrs.
Mrs.
H. Sch.
Mrs.
Glen W.
Mr.
John P. K.
Name of
Patient
Mr.
John E.
St. Mary's ;Mr
26857 Anthony St
69 1 St. Mary's Mr.
1 27096 Francis T.
1
107 1 Norwegian
! Deaconess
150
151
Mr.
Alb. F. B.
...
V
T
56
70
61
47
82
TABLE V—Continued.
M
M.
M
M
M.
M
M.
22
M.
M
ill
11
Roctal
Haemorrhages
Pain in rectum.
Constipation
Haemorrhages
For three years
Hae mo rrh ages
12-15
For 3 months
Haemorrhages
TABLE VI.—CARCINOMA VESICAE.
<
"
1
1 58
..
> «
It
St Mary's iMr. | 40 ; S.
30484 Harley D.
I
St. Mary's 'Mrs. 1 55 M.
30489 E. T. H.
1 j
M
«
Para
C
Ulcer 2 inches by 1 inch about
1 Inch above sphincter.
Rectum obstructed by tumor
about 2 in. above sphlnc'.er.
Circular ulcer about 1 inch
wide and 2 inches above
sphincter
Stricture of rectum about IJi
above sphincter
Ulcerating mass extending up
to sigmoid
Ulcer Infiltrating perineal
body, involving vag ra! mucosa
Irregular ulcerating mass Involving
rectum and vaginal
septum
Tumor involving posterior vaginal
wall
Papllomatous mass in lower
rectum
First Symptom Result of Examination
Dysurla Tumor involving trigone and
Haematuria extending Into prostate
Dysurla
Ischuria
Dysurla
Haematuria
Tumor of abdominal
wall
Pain radiating to
left kidney
Haematuria
Recurrens. Papilloma origin:
Trigone
Papilloma
Recurrens. Tumor of bladder
involving abdominal wall
Tumor at left ureteral opening.
Vesical stone
Tumor of bladder wall invading
vesicovaginal septum.
Recurrens

20 | One
! year
1
38 |
1
70 Dec. l,
1914
99
131
153
157
163
173
Is
I
19
69
69
107
ISA
151
Three
years
Three
months
Date of
First
Symptom
1911
1903
1909
7-2-1914
Res. of
Rectum
Colostomy
Refused
Colostomy
8-1914
Colostomy
7-29 to
10-31-14
7-29 to
8-8-14
2-12 to
date
5-19 to
7-30-15
10-4 Colostomy 9-11-15
9-3 Resection
12-23-15
Colostomy
12-15
Kraske
2-5-16
Resection
Date and Character
of any
Surgery
7-17-14 Perineal
Cystotomy
1903 Cystotomy
1910 Cystotomy
1-25-15
Cystotomy
Inoperable
12-3-1915
Cystotomy
5-10-15 Removal
of tumor
12-6 to
1-25-16
12-31 to
2-14-16
1-21 to
3-16-16
2-17-16
3-11-16
R a d i u m
Date of
Treatment
8-3 to
9-1 1914
12-31-14
1-24-15
1-31-15
5-18 to
5-30-15
12-3 to 25 to
1-2S-16
12-2 to 9
12-23 to 26
1125
1T875
4200
2100
3950
2825
1100
250
600
V
o
3150
2(50
1150
2(00
1900
2100
200
2000
2300
Recovered
Refractory
At first good
result
Refractory
Subjectively
good
Refractory
Prophylactic
Good
Immediate
Result
Improved
Bladder
Improved
Well
Refractory
Good
Good
Good
Died July, 1916.
Metastasis of liver.
Severe rectal tenesmus prevented
further treatment.
Died 11-28-14.
Mar. 16. Patient cachedi-
Died.
Advanced case.
3-22-16
Reports rect. vag. fistula
subjectively very good.
4-25-16. Reported in an improved
condition.
1-29-16. Reported well. Examination
negative.
Rectovesical fistula closed
Present Condition
Dud Dec. 1914.
12-31-1914. Suprapublic cystotomy.
Died 1915. If*
tastasfs femur.
11-1915. Well.
Died. 6-1915. Advanced! y
cachectic.
Bladder functionates normally.
Cystoscopy negative.
2-l(-16. Reported In good
condition. Recurrens.

156
170
1* R a d i u m
German Miss
Deaconess Helen P.
Augustana
46647
Mrs.
Mllly St.
1
f
TABLE
S.
M.
30
VI—Continued.
O
II
Dysurla. Frequent
urinations
Vesical
tenesmus
Recurrens; mass involving left
bladder wall, post, -another
ant.
Tumor involving neck of bladder,
entire urethra, and vesicovaginal
septum
The time elapsed since the beginning of the treatment in the fourteen
clinical cures is as follows:
Case No. Months Remarks
32 24 Hysterectomized
98 11
113 10
128 6 Died from an intercurrent disease
141 4 Died from an intercurrent disease
140 9
117 6
162 4 Hysterectomized
165 4 Hysterectomized
168 3
178 2
69 14
150 4
170 4
The favorable and palliative action of radium in inoperable cases
is truly remarkable. There does not exist another remedial agent in our
entire therapeutic and surgical armamentarium the application of which
is followed by better results. Radium will bring about these results
without any immediate or remote dangers to the patient provided the
strictest asepsis and a perfect technique are employed.
Recurrent carcinomata. The prirpary results m recurrent cancers
are as follows: Fifteen recurrent uterine, 1 recurrent rectal, and 3 recurrent
vesical carcinomata were treated. Four of the uterine cancers
are clinically well. The recurrent rectal cancer was in an advanced
stage at the beginning of (he radium treatment and remained refractory.
One vesical cancer (107) was in a terminal stage when referred for
treatment, one (157) was clinically cured, and another one (156) had
remained refractory. The bladder was apparently improved by the
radium applications but a metastatic tumor in the right lateral pelvis does
not respond to the most powerful roentgen raying. Five of the 19
recurrent cases are clinically cured, i.e., 25.8 per cent. If the five advanced
and hopeless cases are subtracted from the above total, then
the per cent of clinical cures would be 35.7.
The elapsed time since the beginning of radium treatment in the
clinically cured recurrent cases is:
Case No. Months
105 10
125 8
135 7
176 2
151 5

170 Three
weeks
2-24-25 Partial
Cystectomy
Oct. 1916
Hysterectomy
R a d i u m 19
12-30 to 1-5
1-29 to 3-5
1-29
3-16-16
2550 [Good
2100 I Poor
1400 i
600 Good
4-1-16. Mass Involving e
tire right parametrium.
Tumor disappeared.
The prognosis of radium treatment in recurrent cancers is, therefore,
not as good as in the inoperable cases. Especial care is necessary
in these cases to avoid injury of neighboring organs and contiguous tissues
by the radium rays.
Operable carcinomata. The application of radium following radical
excision of the uterus and adnexa for carcinoma is a purely prophylactic
procedure. Carcinoma-cells that have become spilled throughout
the wound area during the progress of the operation, or carcinomatissue
that has been inadvertently left behind may, thereby, be effectually
destroyed. This fact has induced surgeons to increase the percentage
of operability of their cancer cases because of the possibility of
subsequent radium application after the radical operation. Cases No.
90, 101, 106, 133, and 188 were really inoperable cases. Singularly
enough the first three have done remarkably and are well, while the
last two have not been benefited by the surgery and radium.
An opinion as to the value of radium in operable cases cannot be
rendered. The improvement or cure must be credited to surgery. Otherwise
the time elapsed since the operation is too short to permit an expression
as to a permanent or anatomical cure. When these cases arc
followed up carefully and the character of malignancy is considered
from the microscopic specimen and the local condition during operation,
then the conclusion must be drawn that radium favorably influenced ihe
primary result of the operation. Medullary epithelial-cell cancers occurring
especially in young individuals may be given a respite for years,
where formerly without the X-ray and radium they could not even be
benefited by an operation and rarely left the hospital alive. The time
elapsed since the operation and radium treatment is as follows:
Case No. Months
32 13
90 12
101 »
106 10
117 .-.- 10
134 7
174 2
41 18
163 6
173 ; 2
Cases 162 and 165 succumbed tq an intercurrent disease after a
clinical cure of the uterine carcinoma had been obtained. The first case
died from sepsis following an appendectomy and abdominal panhysterectomy.
Microscopic examination of tissues removed from the uterus did
not show carcinoma. Case 165 died suddenly from a dilatation of the
heart. The pelvic organs, para- and perimetrium, the pelvic parietal
peritoneum from the brim downward, also rectum, bladder, and urethra

20 R a d i u m
were removed post-mortem and en bloc. Microscopic examinations
of all the tissues were made. None of the sections showed carcinomacells.
This result is not interpreted as an anatomical cure of cancer,
yet it demonstrates the remarkable changes caused by radium in carcinoma-tissue.
Those parts which before treatment showed cancer-cells
were now free from macroscopic and microscopic evidence of the disease
(11).
SUMMARY.
1. The therapeutic action of radium depends on a correct technique,
which must be based on a careful physical examination of each
patient.
2. The result of radiumtherapy in inoperable and recurrent cancers
surpasses those of any other known therapeutic agent.
3. The prophylactic use of radium in operable cancers increases
the percentage of operability and probably the efficacy of the operative
procedure.
REFERENCES:
1. J. Am. M. Ass., 1915, lxv, 1879.
2. Surg. Gynec. & Obst., 1915, xx, 363.
3. Wood and Prime. The action of radium on transplanted tumors
of animals. Ann. Surg., Phila., 1915, 751.
4. Hoehne and I.inzcnmeyer. Untersuclumgen uebcr die Lage der
Ovarien an der Lebenden mit Ruecksicht auf Roentgenbehandlung.
Strahlentherapie, i, 141.
5. Dominici. H. Die Receptivitaet der normalen und pathologischen
Gewebe fuer die Radiumbehandlung. Strahlentherapie.
iii, part 11, p. 388.
6. Dessauer, Friedrich. Die physikalischen und technischen
Grundlagen der Tieferrbestrahlung. Strahlentherapie, 1912,
i, 310.
7. Gauss and Lemke. Roentgentiefcnthcrapie. Berlin: Urban und
Schwarzenberg, 1912. p. 99.
8. Wickham and Degrais. Radium Therapic, p. 48. Berlin:
Julius Springer, 1910.
9. Bumm, E., und Warnekros, K. Heilung ticfliegender Karzinome
durch Roentgenbest rah lung von der Koerperoberflaeche
aus. Muenchen. med. Wchnschr., 1914. lx. 1601.
10. Schmitz, Henry. Massive X-raying in gynecology. Surg., Gvnec.
& Obst., 1914, xviii, 576.
11. Kelly, Howard A. Am. J. of Surg., 1916, xxx., 73.

R a d i u m 21
radium efficiency in non-malignant surgical
conditions*
By Robert Abbe, M. D.,
New York.
Senior Surgeon, St. Luke's Hospital.
It will refresh our minds to divert attention from the popular hue
and cry after a cancer cure by radium, by considering a few of the interesting
list of non-malignant troubles which this remarkable agent has
helped. It will be consistent with the aim of this most practical society
that its members should be informed on practical results.
One interesting demonstration of the prompt curative action of radium
and its permanent benefit is in vernal catarrh, in a disease considered
intractable by oculists, as well as physicians. This affection of the eyelids
is a conjunctivitis recurring each spring, and often lasting through
the year when it has become established. The lids are hot, swollen, red
and itchy. Photophobia often compels the patient to stay in a semi-dark
room. The lids gum up and are glued together in the mornings with a
sticky, often mattery secretion. On everting the upper lid there is seen
a mass of granulation tissue standing far out from the under surface,
and often grouped in bunches. This condition does not occur in thr
sulcus above the cartilage of the lid. By this it can be differentiated
from trachoma.
1 have treated in all ten cases which were recurrent for many vears
and can assert that the improvement always begins soon after the first
treatment. Most cases had had extreme treatment by slicing off ihe
masses, cauterization, and caustics before I saw them, and had become
the betes noircs of the oculists.
A uniform benefit and ultimate cure follow the judicious use of
radium. Technically, a fifteen minute application of a tube of strong
radium under the eyelid, moved back and forth, with a lead device to
protect the cornea, repeated every month or two. constitutes the simple
and rapidly helpful method. With a drop of cocaine, the most sensitive
eye feels no pain. The cases I have so treated have now remained cured
up to ten years, as shown in the case tonight. The method of its action
is specific, in altering the hypertrophied cells of the mucous surface,
which have made a veritable tumor structure.
The second interesting condition in which radium lias no rival is
in reducing lymphoid tumor tissue such as is found in tumors of the
tongue called hemolymphangioma, and in other parts of the body. I
have reported a series of these in a paper read before the American
Surgical Association last spring, and will not even quote further from
it here, but merely say that it is a triumph in a small group of formerly
hopeless cases. Its selective action on the lymphoid cell growth is emphatically
specific.
This overgrowth of one element of skin structure in the scheme of
tumor formation is not unlike papillary warty growths which subside.
like all vocal cord papillomas as you have seen tonight in the brilliant
and permanent restoration of voice with perfect vocal cords five years
after apparently hopeless conditions.
•Medical Record, Vol. 9o. No. 2. July "th. 19IS. pp. 17-50. Read at „ mretin?
of the New York Clinical Society. April 2Sth. 1!*I6.

22 Radium
Fig, 2. Best method of exposing the
under surface of the eyelid to strong
radium; this Is pla*ed In a groove at
the end of a long lead cylinder covered
By a celluloid holder. The cornea Is
protected by the lead beneath the groove
holding the radium tube.
Fig. 1. Typical vernal catarrh;
this inveterate case had resisted
every variety of scientific treatment
by specialist*, bul was cured by
radium.
Fig. 3. This patent with
papilloma of the larynx remains
perfectly cured after
one radium application, anil
.•^ing with perfect voice five
years after the treatment.

R a d i u m
Fig. 4. Chronic abraded ulcer of the lip.
Warts, in places delicate as the edge of the eye lid. or the tender
vermilion of a child's lip. or the coarse skin of the sole of the foot, or
under the finger nails, or in the scalp, where scars are not desirable,
radium has cured for me a hundred times with usually no scar. 1 would
class this with specific action inasmuch as a retrograde of wrong-growing
cells takes place after this atomic bombardment, causing them to
return to normal growth.
Lcucoplakia. considered as a simple overgrowth of surface cells
of the tongue or mucosa lining the cheeks is not unlike the keratosis of
the skin, heaping up in places and making a veritable new growth, :>iten
precancerous and tending to extend downward and become a cancerous
invasion. This is seemingly as capable of cure by radium within the
mouth as it is in skin hyperkeratosis, whose disappearance can he predicted
with as much certainty as the treatment is easy. In the mouth,
however, the time and method of application require much more judgment
and skill to attain good results. It is associated with a transient
painful irritation which is essential to success. We face the fact, however,
that before radium was available no cure was known. Mr. Builin
once told me that "if radium would cure leucoplakia. it would do what
neither cutting out. or shaving off. or caustics, or cautery had ever done
in his hands.'"
An allied condition of the lips presents another phase of the successful
use of this energetic agent. There is occasionally seen a weak
spot of the skin of the lip. a chronic thin surface ulcer or abrasion. The
skin refuses to heal, or if it heals with a thin surface, it quickly breaks
down and chronic abraded nicer remains, not with cut-out edges, but. as
ice freezes, with a thin blue edge always looking as if it might heal.
There seems in these cases to be a lack of force in the epithelial cells
at the edge. It often lasts for years, and is in striking contrast to the
hypertrophic conditions on the lip. both of which I illustrate, and both
are equally well cured by radium. The same is true of the chronic
painful crack of the lip.
23

24 R A D I U M
Fig. 6. Small typical true keloid of the chest; It had been cut out. and
returned, as they all do. before coming to me for radium treatment. This cured
It with « smooth skin scarcely depressed.
It seems paradoxical that the same agent can cure an overgrowth
keratosis and a deficient growth, as in these abrasions, and until we
know why cells grow, we may not explain it. Some satisfaction, however,
may be had in a hypothesis which I offered some years ago which
argues backward from the known output of beta radiation of radium.
an enormous charge of negative electron particles driven into the disorderly
growing cells. Inasmuch as there follows a retrograde change
in the overgrown cells, it must be due to something supplied to them
by this treatment. If, hypothetical!)-, we surmise that the vital force
actuating a normal cell growth, is a balance of electric action established
within it, and we conjecture that a riotous overgrowth may be
due to loss of balance, may it not be that the preponderance of positive
or negative charge is responsible for the disturbance which is corrected
by the new supply of nascent negative electrons. Science is about ready
to concede that the actuating force of nerve and cell activity is electrical,
and singularly enough this new agent is almost wholly a discharge
of material particles each bearing a charge of electricity, some positive
and some negative. It is not easy to explain, for instance, the recovery
of the destructive myeloid tumor of the jaw, which I showed you tonight,
as a fortuitous reassembling of disordered cells to orderly rearrangement
to form a normal jaw again which has endured for twelve
years. This I would designate specific action. In what the specific
action consists, we can only speculate.
By contrast, there is an action of radium which is curative by irritation
only, as in nevus. The endothelium of veins or arteries undergoes
hyperplasia and partly or wholly obliterates the lumen, so as to

R a d i u m
Fig. «. Extensive keloids following two years after an acid burn.
induce a gentle fibrosis and cure of the birthmark. Patience and discretion
are needed to keep a velvety skin and not produce a cicatricial
atrophy from overtreatment.
The active irritation of these intense penetrating rays is absolutely
necessary to a successful result, in any of its many uses. This provokes
a kind of inflammation, except that it has no bacterial origin.
Especially noticeable is this in keloids, one of the most useful fields of
its work. It was Wickham of Paris in his early work who first showed
me cases of keloid cured by radium, and told me there was no difference
between so-called true and false keloid; both were equally easy
to cure. I have verified this in a great number of patients. Cases
which no surgeon would dare cut out are perfectly cured by inducing,
first, a sharp radium inflammation which transforms the hard keloid
masses of cells and fibrous tissue. This is followed by an atrophy of
the mass as the inflammation of the fourth week subsides. This is
especially grateful in the so-called true keloids of the front of the
chest, often seen in young women, which recur with terrifying certainty
when cut out, but which invariably leave a thin, flexible cicatrix after
radiumizing properly.
In the terrible case of face keloid from acid burns, which you have
seen tonight, the condition two years after the accident was one of pro-
25

26 R a d i u m
gressive very dense hard masses much as if leather were drawn tight
over a golf ball. Several sharp radiumizations were induced in all, and
each was followed by marked softening and atrophy until now they
are all soft and pale and nearly flat.
! - *\
F :
^k
^
^^^^^"•-^B
- M
1
' •
/ % 1
^ A
Fig. 7. Same patient as shown in Fig. 6. after radium treatment.
But I come at last to speak of the most extraordinary of all the
remarkable effects of radium known to me—its cure of the disease
known as uterine fibroids. It is fair to call this a disease by itself
because it has no exact counterpart that I know of, in the body. It is
essentially a tendency of the muscular structure of the uterus to grow
tumors made up of the same muscle structure. One, or many, they
are myomata; some old and fibrosed, some young and of juicy cell
structure. Those growing close beneath the lining membrane of the
cavity usually induce severe hemorrhages, often very grave. For forty
years surgery has had but one answer to the appealing sufferer—"Cut
them out, usually with the whole uterus also." It would be difficult
to compute the hundreds of thousands so treated in the hospitals of the
world.
The surgical results must include not only a great majority of satisfactory
cures, btit also deaths by hundreds from operative risks and
the several sequels of pelvic abscess, abdominal wall abscess, hernia of
the scar, cystitis from catheterization, femoral phlebitis, and so on.
Add to this the four or six weeks of hospital care—which in private

R a d i u m 27
means often a continual surgical attendance of many weeks more, where
the patient is often more frail. The absence from work or home duties,
in women who can ill spend the time, completes a long list of essential
incidents associated with the customary surgery of uterine fibroids.
Fig. 8. To Illustrate the action of
radium on a large uterine fibroid. A.
tumor before the application of radium;
B, tumor ten months later.
Let us imagine, now, that a remedy for all this is found in so simple
a treatment as the introduction of a small tube of radium into the
uterine cavity, without ether, for two hours on two or three occasions,
without entering a hospital, and that, following this, the excessive
hemorrhage stops and the tumors progressively shrink until they disappear.
Is this possible? It is not only possible, but has come to the
point of complete demonstration. Accumulated cases now show that it
may be depended on for permanent cure, with apparently no risks, no
delay, no hospital, small cost to the patient in time and money; and to
the surgeon, small cost of time. It sounds like a Munchausen tale.
It is one of the most beneficent actions of this unique agent.
My experience with it dates back to 1905, which is the first case
as far as I know in which it was used to arrest a hemorrhage and for
its hoped for good effect on the tumor. That and another which followed
soon after were recorded by me in 1906. and have been watched
ever since. The tumors shrank year after year until they remained but
very small, inert buttons on the uterus. Since then I have applied it in
more than thirty cases and have yet to see a case which did not shrink.
some completely, some rapidly—all in large measure. It may truly be
called a specific for uterine fibroids, and must supplant operative treatment
as fast as conviction and the accession of radium come to operators.
Its special value shows in the many cases of violent hemorrhages
from fibroid disease. Here the uterine lining is overgrown and highly
vascular, or stretched out thin and bleeding from open mouthed veins.
The contact of radium with these blood vessels seals them up by occlusive
inflammation, due to the active beta rays, while the penetrating
gamma rays go through the whole disordered cell mass, and produce a

JS
Radium
retrograde change in the conduct of each cell so that it begins its retreat
at once, and the growth's shrinkage is measurable in from two to six
months.
The very large tumor in a desperate case of hemorrhage, published
by mc last June, has shrunk from a diameter of ten inches to four, in
ten months, and will disappear probably within a year. Meanwhile the
exhausting hemorrhages ceased in six weeks and have never recurred.
The patient has enjoyed perfect health since. This may be said of all
the cases treated.
One patient whom I have shown you tonight with the most extensive
lupus erythematosus of the entire face, ears, and side of the neck.
and of his hands, was cured by one thorough radium treatment. This
case does not stand alone.
It is probable that every case will yield to proper radiumization,
judging by five cases of this disease on the face which have yielded excellent
results which seem permanent. The first case was of a man who
had typical patches on both checks. He remained cured after my
treatment in 1904.
Time has limited me in this paper to speaking of only a few of
the non-cancerous cellular growths in which the action of this comparatively
new agent—radium—has a character of its own.
Reviews and Abstracts.
George M. Mackee, (New York). Progress in the Treatment of
Skin Diseases. N. Y. Med. Journ., Vol. CIII, No. 10, pp. 441-4. March
4, 1916. "Radium is now being extensively employed in the treatment
of skin diseases. There is a decided misunderstanding relative to the
comparative value of radium and the X-ray. It should be remembered
that there are rays emitted from radium that have varying characteristics,
which is also true of the rays from an X-ray tube. The gamma
rays of radium are of all degrees of penetration. Some will pass
through almost anything if afforded sufficient time. Then there are
gamma rays that possess very little penetrating power. The rays emitted
from an X-ray tube, practically speaking, are analogus to the gamma
rays of radium, but there is a greater degree of latitude in the penetrability
of the gamma rays. In addition, in the case of radium, it is
possible to utilize the very marked therapeutic effect of the beta rays.
The bela rays produced in the X-ray tube cannot be used because they
will not penetrate the glass wall of the tube. Now there are some
dermatological conditions that respond more readily to the gamma rays
of very low penetration and to the beta rays than to the more penetrating
rays from an X-ray tube. It is this difference that accounts
for the superior efficacy of radium, compared with the X-rays in certain
dermatoses. Therapeutic experiments with exceedingly "soft" gamma
rays, and with the beta rays obtained from the X-ray tube, are now
being conducted, and the indications are that the results will be identical
wilh those obtained with radium. Radium has produced very superior
results in the treatment of deep seated vascular naevi. but it is not so
efficacious in the port wine mark. It is of use in leucoplakia and lupus
erythematosus. In these conditions it is at present superior to the
X-ray. In inaccessible locations radium can be used to advantage, but
where extensive surfaces are to be treated the X-rav is indicated."

I U M
A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY, PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES.
Edited and Published by Charles H. Viol, Ph. D., and William H. Cameron, M. D.
with the assistance of collaborators working in the fields of
Radiochemistry, Radioactivity and Radiumtherapy.
Subscription $2.50 per year, or 25 cents per copy in the United States and Canada
in all olher countries $3.75 per year.
Address all communications to the Editors, Forbes and Meyran Avenues.
Pittsburgh, Pa.
VOL. VIII. NOVEMBER, 1916 No. 2
RADIUM TREATMENT OF UTERINE CANCERS*
By Jos:*pii Ransohoff, M. D., F. R. C. S. (Eng.)
AND
J. Louis Ransohoff, M.D.,
Cincinnati, Ohio.
The mortality of radical removal of (he uterus for cancer, that of
the body excepted, is so high and the end result so gloomy that we would
all welcome a method of overcoming the disease, if without instituting a
hazardous operation it would offer at least an equally good end-result.
Whether radium treatment can do this, the next few years must determine.
Whatever else may be said of it, it does not immediately jeopardize
life; it at least is safe. The discovery of the unique qualities of the
ultra-penetrating gamma rays by Dominici marked an epoch in radium
therapy. His principle of filtration permits the use of large quantities of
radium without destructive effects on healthy tissues. It also permits
the deep action of the rays without interfering with the viability of superficial
tissues covering deep-seated lesions.
While it is not within the scope of this paper to discuss the scientific
principles of radium therapy, a few words may not be out of place.
Numerous microscopic observations have shown that radium has a
definite selective action on neoplastic tissue. For instance, a cancer of
the uterus treated by radium shows definite histologic changes. During
the first two weeks there is increase in size and vacuolization of the
nuclei and numerous atypical mitoses are found. This is followed by
•Annals of Surgery, LXIV, pp. 298 303 Read before the American Surgical
Association, May 10. 1916.

30 R a d i u m
change in form, enlargement, and vacuolization of the cancer cells; retardation
and finally cessation of nuclear division. The last stage is the
destruction of the cell. This is accompanied by infiltration of leucocytes,
the formation of new connective-tissue cells, and gradual replacement of
neoplasm by fibrous tissue. There is always an obliteration of the bloodvessels,
probably due to a proliferation of the intima. This in itself
tends to the destruction of the highly organized neoplastic cells by interference
with nutrition. It is one of the most potent factors in the radium
cure of uterine fibroids. The metamorphosis of the cancer cells is always
interesting, and at times unusual. Occasionally one may see in typical
cancers of the cervix a tendency to cornification. In clinically cured
cases of uterine cancer there are at times seen nests of changed, but undestroyed,
cancer cells, imbedded in dense fibrous tissue. Whether or not
these cells are capable of further growth and dissemination has not as yet
been determined.
Whether the action of radium on neoplastic tissue is specific, or
whether it is due to the great cell richness of the latter is merely an
academic question. All things being equal, the action of radium on any
tissue is in proportion to the abundance of nuclei. This has been well
shown by Keetman and Harting,4 who have shown that radium depends
for its action on the denser substances in the nuclei of the cells. For this
reason, the more closely the tissue approaches the embryonal type, the
more amenable it will be to the radium treatment. This accounts for the
remarkable results achieved in the treatment of lymphosarcoma. Also,
the comparative obstinacy of periosteal and chondrosarcoma to radium
action.
The uterus presents an unusually fertile field for radium therapy,
partly from the histologic structure of uterine cancer, but particularly
because of its unusual accessibility. The radium can be brought into
immediate contact with the neoplastic tissue where it can exert its direct
influence. The primary results of radium therapy in this field have even
exceeded the hopes of a few years ago. The reports grow more and
more encouraging.
According to the report of the London Radium Institute, of 1914,
uterine cancers yield most gratifying results, and the effect of radium in
operable cancers is far in advance of those obtained by any known surgical
or medical treatment.
Degrais2 has a number of cases apparently well after four and five
years, Rubens Duval,3 in a report of five years' experience, recounts a
most interesting case of inoperable cancer of the uterus, which died of
some intercurrent affection several years after radium therapy. Autopsy
showed a complete anatomical cure. Of 158 cases reported, radium had
a beneficial action in 155. In 93 the improvement was classed as phenomenal,
while in 46 there was a probable cure.
Degrais and Belot have seen no case of cancer of the uterus in
which some benefit has not been given by radium therapy. The question
of the entire replacement of radical operation by radium therapy maysoon
come up for final solution.
The mortality of the Wertheim operation is from 15 to 25 per cent.
in the hands of the best operators, and far greater in those of the average
surgeon, and the percentage of cases which are in condition to undergo
this operation is not very large. Probably the greater number of those

R a d i u m 31
who undergo the Wertheim operation suffer from recurrence within the
first year after operation. Many operators have taken the mid-ground
in the treatment of operable cancers of the uterus. For instance, Pozri8
has given up the extensive Wertheim operation, even in border-line
cases, and treats them with radium alone. In operable cases, a simple
vaginal hysterectomy is done, followed by prophylactic radium application.
The consensus of opinion of all operators is thai operation after
radium therapy is exceedingly difficult. For instance. Kelly* says in the
conclusion of his article, "in border-line and inoperable cases we advise
the use of radium, as operative measures are impossible in this group. If
the growth disappears, it can only be determined whether or not hysterectomy
is advisable by trying out both methods This as yet has not been
done in a sufficient number of cases to arrive at any definite conclusion.
We do feel, however, that when clinical cures have occurred in operable
case*, operations are probably best not carried out."
In a personal communication Kelly stated that inoperable and borderline
cases clinically cured by radium should not be subjected to operation.
The reason for the difficulty of operation in cases after radiation is
easily understood from the fact that there is a great deal of fibrous
tissue deposited which makes clean dissection extremely difficult and
dangerous.
We have recently seen a striking example of this diction. In September,
1915, we saw a woman, aged forty-three. Five years before, a
supravaginal hysterectomy had been done for fibroid. In June, 1915, she
began to pass clots of blood. There was a great deal of backache. Examination
shows cervix fixed and occupied by hard cancerous nodules.
There was a marked infiltration of the left broad ligament. Under radium
treatment the mass melted away, the bleeding stopped, and the pains disappeared.
In March, 1916, against our advice, a vaginal removal of the
cervical stump was attempted. The operation was exceedingly difficult
and incomplete. The specimen removed showed a great deal of fibrous
tissue and some few nests of embedded cancer cells. From the time of
operation the pains recurred and the wound did not heal. Manifestly,
as we have stated before, anything like a complete operation is impossible
after extensive radium treatment. Whether this condition would have
remained permanently well is doubtful. Her condition, however, was
certainly only made worse by operation.
The results of Kroenig and Doederlein" are only too well known to
require more than mention.
The immediate local results of radium are phenomenal. Within a
week of the first application the hemorrhage is. as a rule, arrested and
the foul discharge stopped. We have not had a case in which we were
not enabled to arrest both the offensive discharge and the hemorrhage
within from one to three weeks. The cauliflower vegetations which frequently
fill the vagina seem to melt away. The improvement of the general
condition of the patient is astounding. Pain is sometimes relieved
within a few days of the first application. The most difficult cases in
which to effect a benefit arc those which recur after a Wertheim operation.
The fibrous tissue scars are so dense as to seem almost impervious
to radiation. However, even these cases can be benefited, but wc have no
cure lasting more than a year. The pain in these cases is more difficult

32 R a d i u m
to relieve than in those that are primary. The tissues are dry and densely
infiltrated with scar tissue.
Out of 25 cases treated in this series, 11 arc still well. Of these 3
have been well for two years, 6 from one to two years, and 2 from six
months to a year. Of the 11 clinical recoveries, there were 3 operable
and 8 inoperable. Of the 3 operable cases one is well after two years,
and 2 over one year. Though the cases are few, this is in itself an
interesting observation, as a recurrence after operation usually occurs
within the first six months.
A few of the results obtained seem to warrant individual report.
Case I.—Mrs. S., aged forty-five, was brought to the Jewish Hospital
in an ambulance, in what seemed to be the last stage of a secondary
anaemia. Red count 2.400,000, marked pcecilocytosis, hccmglobin 40 per
cent., weight 72 pounds. The vagina was completely blocked by exuber
ant masses springing from the cervix. There was, however, no involvement
of the vesicovaginal or rectovaginal septum. March 15, 1915, contrary
to our usual custom, in order to more promptly control the hemorrhage,
the mass was curetted away, and cauterized with the actual cautery.
One hundred milligrammes of radium were buried in the crater.
On March 20. the hemorrhage was entirely stopped. Radium treatment
was repeated four times between that and May 17. After the last treatment
there was some rectal irritation. She was sent home and told to
return for treatment in about two months. Nothing more was heard from
her until April, of this year. when, in answer to inquiry, she stated she
was in excellent health, weighed 110 pounds, normal weight 125. and that
she did her own housework. Aside from a slight rectal irritation she was
in excellent health. She has been perfectly well for over a year.
In all of these cases classed as inoperable, the uterus was firmly fixed
in the pelvis, and there was marked hemorrhage and more or less putrid
discharge. In all of these cases one of the most noticeable phenomena
was the increased mobility of the uterus after the first few treatments.
After more extensive radiation, the uterus again becomes more or less
fixed by the new-formed fibrous tissue.
In one case we have had a recovery after a comparative incomplete
series of treatment.
Cask II.—Mrs. H.. aged seventy-one. seen first May 1, 1915. Has
had slight^ hemorrhage from the uterus for a year and a half. For the
past seven months very severe. Examination shows a carcinomatous degeneration
of the entire cervix, with complete fixation of the uterus.
Four treatments were given in all, and at the end of that time the cervix
was normal and uterus movable. The patient refused further treatment.
She is still well, allhough more than a year has passed since the last
treatment.
In our experience there has been no single case in which the radium
treatment was not followed by some benefit. One of our earliest cases
came into the hospital in what seemed the last stages of septic infection.
The vagina was filled with great masses of carcinomatous tissue, and the
odor of the discharge was terrifying. After three radium applications of
24 hours each, the discharge stopped, the foul odor disappeared and the
patient began to gain in weight. She died five months later of a large
perinephric abscess, but there was no return of the vaginal involvement.
Cases approaching this in severity arc numerous in our series, and

R a d i u m 33
show that practically no case is too far advanced to be at least temporarily
helped by radium treatment. In cases where there is involvement of
the recto- and vesicovaginal septa great care must be exercised because
of the danger of fistula formation.
Parenthetically we may here allude to an unpleasant sequel of radium
therapy which we have seen in a few of our clinically cured cases. It is
a pain in the rectum which occasionally becomes quite severe. It probably
results from scar tissue, but this, it must candidly be said, is only a
surmise.
There are, of course, many methods of applying radium to cancers
of the uterus, according to the contour of the growth. We vary our
methods, using for this purpose either a disc-like brass filter or one
cylindrical in shape. The former is reserved for cases in which there is
a broad ulcerating surface, and the latter for those in which there is a
disposition to crater form.
SUMMARY.
1, Radium is the method of choice in the treatment of inoperable
and border-line cases.
2. Of the three operable cases treated with radium a clinical cure
has been effected in each case.
3. Cases clinically cured by radium should not be subjected to
hysterectomy, as the operation is difficult and dangerous.
BIBLIOGRAPHY.
'Keetman and Harting: Berl. Wochr., 1913, vol. xxxix, p. 1806.
3Degrais, P.: Ann de Gyncol. ct d' Obst., 1915, Wid. xi, p. 609.
3Duval, Rubens: Strahlentherap, 1914. vol. i.
*Kelly: Jour. Amer. Med. Assn., 1915, vol. Ixv. p. 1874.
5Kroenig: Deutsch. Med. Wochenschr.. June 26, 1913.
RADIUM IN THE FIELD OF LARYNGOLOGY*
By D. Bryson Delavan, M. D.(
NEW YORK.
The past year has brought distinct advances in the knowledge of the
use of radium, in no department with more encouraging results than in
ours. Today many observers are studying its effects in an ever increasing
variety of disorders, some of which are far beyond the limits of
previous conjecture. Additions are being rapidly made to the number
of conditions in which the treatment is effective, and substantial encouragement
is being given to the hope that there has been found in radium
a truly valuable therapeutic agent. Several of our institutions, notably
the General Memorial Hospital, New York, have been fortunate in
acquiring amounts of radium large enough to meet all of the probable
demands of treatment, while those in whose hands it has been placed for
•Medical Record. XC. 50-52. July S. 1916. Read before the American Larynrologlcal
Association at Us thlrty-eitrhth meeting. Washington. r>. C. May 10. 1316.

34 R a d i u m
adminstration are gaining experience in its application and learning how
it may best be utilized and controlled.
Some contributions have been made to the literature of the subject
in general, but in the department of the diseases of the upper air passages
little has yet appeared. This is not surprising. The study of
radium is in its infancy. Few investigators at present are ready to issue
formal reports of their work, wisely refraining from announcing results
until their deductions can he placed upon a stable basis of well proved
fact. Any attempt to drag it before the medical public at the present
time would be premature. What is needed is not publicity, but rather
the development of scientifically proved data upon which, and only
which, reliable reports of progress are possible. The securing of such
data requires long-continued and painstaking study of the action of
radium, under conditions favorable for accurate observation, in the
hands of men especially qualified for the work. When these conditions
have been fulfilled, and not until then, we may hope for the beginning of
a literature at once valuable and instructive. Meanwhile, however, even
the most conservative observers are willing to admit that encouraging
progress is being made. Were the actual experiences of different institutions
demoted to the study of radium to be quoted the truth of the above
statement would be plain.
A few fragmentary contributions and reports have appeared, some
of which are worthy of notice. From these it is again evident that the
progress being made in the knowledge of radium efficiency in nonmalignant
surgical conditions and in certain nonsurgical affections of the
upper air passages continues to be gratifying. This is shown by the
work of various observers in the United States, particularly by that of
Dr. Robert Abbe, of Xew York, and by the reports of the two leading
British institutions, the Radium Institute of London and the Royal Infirmary
of Edinburgh.1
Thus the London Institute reports excellent results in the treatment
of "vernal catarrh," patients treated for it by radium having in a large
proportion of cases been cured without recurrence, although under observation
for a series of years.
In the treatment of naevus by radium remarkable results are being
obtained.1 The most brilliant of these are seen in young children where
conditions of unusual severity in the vicinity of the lips and nose, far
beyond the limits of surgical relief, are being successfully reduced.
Rhinoscleroma, according to Kahler.3 has been treated with good
effect. Good results have been obtained from the application of radium
in goiter and in tubercular glands.1 For the latter Bissell,5 of New York,
is particularly impressed with its value. Under his observation proper
radium treatment has often and completely restored such glands to their
normal functions. Abbe believes that leucoplakia of the tongue is not
unlike a keratosis of the skin, often pre-cancerous and tending to extend
downward and become cancerous. He considers that it is as capable of
cure by radium as is the skin keratosis. Delavan6 has called attention to
the same thing. Serra7 reports a successful case.
Much attention is also being given to the study of radium as applied
to new growths in general and many highly interesting and important
facts are being obtained. This is especially true of growths of a nonmalignant
character. In the treatment of' nasopharyngeal fibroma the
use of radium has proved encouraging, particularly so" in view of its sue-

R A D I U M 3S
cess in the treatment of fibromata in other parts of the body.8 Abbe2 has
shown a case of myeloid tumor of the jaw, completely cured.
In the treatment of non-malignant intralaryngeal growths many
highly interesting results have been obtained, tumors of various histological
structures having disappeared, in a number of cases with complete
restoration of the singing voice. The treatment of papilloma of the
larynx by means of radium is one of the most interesting phases of its
use. In view of the success already attained with it, as well as with
warty growths in general, the outlook for it is most promising.
Weil9 reports a parotid tumor (adeno-cystic-epithelioma) of seven
years' standing, which was treated for six weeks by the insertion of
radium into it. The growth disappeared, and at the end of two years
has not recurred. Freudenthal7 reports a case of fibrosarcoma of the
right antrum cured. He also reports a case of sarcoma of the tonsil, in
which the growth disappeared and remained in abeyance for six years.
Then it recurred and the patient died. In another similar case the growth
disappeared for six months.
In this highly specialized department, laryngology, radium promises
to occupy a wide and important field.
While the treatment of these various lesions has been attended with
interesting results, the final value of radium in certain of the more
serious affections has yet to be proved. Especially is this true of its use
in carcinoma, for while a considerable number of cases have been placed
under treatment it has been claimed by some that the effect of radium
has in certain instances been'unsatisfactory; and even in some in which
its influence has been temporarily beneficial the good effect has not
always been lasting, or else too little time has elapsed to prove its final
value. In a few cases it is said that not even temporary benefit has
resulted, while in some of these the advance of the disease seems to have
been hastened. Again, while parts of the region exposed have undoubtedly
improved, other parts have retrogressed. Admitting that these several
objections may contain more or less of truth it is. nevertheless, encouraging
to know that the causes of more than one of them are understood
and that diligent effort is being made to discover the means by
which they may be prevented.
In this connection, recent British experience and opinion is interesting.
The report of the Radium Institute of London1 states that "epithelioma
of the buccal, lingual, and pharyngeal mucous membranes usually
proves refractory and disappointing in its response to radium," but, it is
significantly added, "under new methods of application better results may
be expected. Thus far. the treatment docs not seem to have much effect in
arresting the disease."
The report of the Royal Infirmary1 gives a far more sanguine outlook.
Thus: "While in advanced malignant cases a cure may not have
been effected, yet in practically all treated more or less benefit was produced,
through the relief of pain, the cessation of discharges, the healing
of ulcerative surfaces, the removal of local growths, and the prolongation
of life.
"Malignant disease of the posterior nares, buccal cavity, pharynx
and larynx seems less amenable to radium, but this may be from the difficulty
of administering a sufficient dose in such positions.

36
R a d i u m
Several cases that have come under my own observation have
shown effects worthy of notice. Two of them were epithelial carcinoma,
originating in the left side of the throat close to the wall of the larnyx
and, as far as could be ascertained, extra-laryngeal. Both patients were
men in the early fifties, hitherto in perfect health, active, vigorous, and
of excellent antecedents. When first seen, the disease in both had invaded
the interior of the larynx, the left lateral wall of the pharynx, the
pyriform sinus, the tonsil, and the base of the tongue. In both, ulceration
was present and there was marked aphonia and dysphagia. Operation
was impossible. Both were subjected to the radium treatment at the
same institution and large doses were applied. In both the results have
been materially the same.
The first effect of the radium locally was an almost immediate control
of the secretions of the throat. From having been abundant and
fetid they promptly ceased. Following this the areas of ulceration
rapidly diminished in extent, and in the less severe of the two cases they
disappeared; while in the other case they seemed to do so, although it has
not been possible to prove this, owing to the difficulty of examination.
The swellings which had appeared over extensive areas of the affected
parts decreased markedly, and the infiltrated tissues were reduced in
size, became soft to the touch and more natural in appearance. Accompanying
these changes extraordinary improvement took place in the
various functions of the throat. Thus, the voice became clearer, anil
deglutition, which before the application of radium had become almost
impossible, showed such improvement chat both patients were able to
swallow without pain and to largely increase the variety of their food.
Together with these local changes, the improvement in general was
remarkable. Digestion became normal and sleep more prolonged and
restful; while with the improved nutrition a steady increase of strength
was apparent and a rapid return to an almost normal condition of good
spirits. One of these patients, a physician, was able to resume his office
practice and for two months remained steadily at work.
These patients, as well as all who have seen them, admit that even
if from now on the progress of the disease should ultimately be unfavorable
the benefit already gained in the relief of suffering and the added
comfort afforded, would well repay them for any inconvenience the
radium had caused. This is an important concession, for the superficial
burn sometimes resulting from radium may be an unpleasant feature.
Compared, however, with the results of any serious surgical operation, it
is but a slight annoyance. And yet how gladly will the patient, submit
himself to the knife and to weeks and perhaps months of disability and
suffering following its use for the sake of cure, quickly forgetting all the
harrowing details of his surgical experience and even its resulting mutilations
in the joy of being restored to life and health! Any method which
will cure carcinoma, at the same time leaving the normal parts intact, with
no worse penalty than a slight superficial burn, should surely be welcomed
with acclaim.
The present is no time for the adverse criticism of radium. The
study of the radium treatment of carcinoma is but just begun. Some, at
the very threshold, are already discouraged, and are announcing themselves
as unwilling to believe in its efficacy. To these we may repeat
that the knowledge of the use of radium in general is still in embryo.
The failure to gain uniformly reliable results in carcinoma is

R a d i u m 37
due to the imperfect knowledge of the methods by which the radiations
can be controlled, of the amounts of radium which should
be used, and of the correct duration of the exposures. The allimportant
basic principle has certainly been proved, namely that, under
proper application, radium mill destroy a superficially located cancer cell.
Granting this proposition, it is by no means impossible that with increased
knowledge of its action, and skill in its application, deeply seated
cells may be successfully reached and destroyed, while at the same time
the surrounding tissues arc effectively protected.
Already, results worthy of profound consideration have been obtained.
Far from being discouraged, there is every reason why persistent
and continued effort should be made to finally solve the existing
problems and give to the world a cure for one of its most grievous
scourges. Fortunately, there are some who, in the face of many difficulties
are earnestly and hopefully striving to obtain this end. Let such gain
inspiration from Trudeau" that noblest of humanitarians: "Optimism is
a mixture of faith and imagination, and from it springs the vision which
leads one from the beaten paths, urges him to effort when obstacles
block his way, and carries him finally to achievement when pessimism can
only see failure ahead. Optimism may, and often does, point to a road
that is hard to travel, or to one that leads nowhere; but pessimism leads
to no road at all. * * * *
"Let us not therefore quench the faith nor turn from the vision
which, whether we own it or not, we carry * * * * and thus inspired
many will reach the goal," as* have all whose hopeful imaginings and
courageous efforts have been the basis of every noble success the world
has ever seen.
REFERENCES.
1. British Med. Journal, June, 1915.
2. Abbe: Oral communications, 1916.
3. Wiener klin. JVoch., 1905.
4. Journal-Lancet, 1915.
5. J. B. Bissell: Oral Communication, 1916.
6. Trans. Amer. Laryngolog. Assn., 1915.
7. Rcznsta Espan. de Urol, y Dermatol., August, 1915; Laryngoscope.
April, 1916.
8. Delavan: Medical Record, June IS, 1915.
9. Journal Amer. Med. Assn., December 18, 1015.
10. N. Y. Med. Journal, July 3, 1915.
11. President's Address, Eighth Congress of American Phys. and
Surgs., Washington, 1910.
Reviews and Abstracts.
Henry Schmitz, M. D., F. A. C. S., (Chicago). The Action of
Gamma Rays of Radium on Deep-seated Inoperable Cancers of the Pelvis.
Medical Record, XC, 100-105, July 15, 1916. This article covers in part
the same ground as in Dr. Schmitz' article, "An Additional Contribution
to the Therapeutic Value of Radium in Pelvic Cancers," which appeared
in the August, 1916, number of Surgery. Gynecology and Obstetrics.

3S R a d i u m
'The Histological Findings.—The histological changes may be
divided into four stages:
"The first stage is characterized by an enlargement of the carcinoma
cells, a hypcrchromatosis and a pyenosis of the nuclei. They are evident
in all the cases examined. These changes usually occur within about ten
days after the first application of radium.
"In the second stage we observe caryolysis, caryorrhcxis, cytolysis,
and cell detritus. They are seen as early as from the first to the third
week of the treatment.
"The third stage shows an absorption of the cellular and -nuclear
debris by phagocytosis. Macrophages and microphages are concerned in
this step. It takes place as soon as the cells begin to degenerate.
"The fourth stage is the stage of connective-tissue proliferation and
scar formation. It completes the histological cure of cancer. The places
left vacant by the dead carcinoma cells are immediately filled by young
fibroblasts derived from the connective-tissue stroma of the tumor. The
fibroblasts become differentiated. The fourth stage appears usually after
the first to the third month, but may occur much sooner.
"A discrepancy frequently exists between the clinical results and
the histological findings. For instance, in case 26 of our series there was
evidence of a completely destroyed cancer tumor, yet the patient succumbed
to a bowel invasion, proving that some cancer cells either remained
uninfluenced by the radium or regenerated after the subsidence
of the action of the rays. Therefore, certain questions arise which call
for definite answers before we may positively state that radium rays
cause a degeneration and ultimate death of cancer tissue and a simultaneous
proliferation of connective tissue.
"1. Are we able by microscopic examinations to differentiate the
nccrobiotic changes in the carcinoma cells brought about (by natural and
artificial conditions from those caused by the influence of radium rays?
Cells under necrobiotic changes in the course of their existence. Heat
caustics, and alcohol, brought in contact with the tissues, mav produce
the same changes, as is well known. However, the absence of cell degeneration
as evidenced in the first section, and the general and extensive
changes as seen in the subsequent specimens after their exposure to the
gamma-rays, and the regularity of their occurrence in all the tissues
microscopically investigated, even in those not previously cauterized,
permit us to state that they must be caused by the action of the gammarays.
"2. Can we. by examination of small pieces of tissue removed from
the growth, determine the extent and intensity of the action of radium
rays? We cannot from such an examination, but could do so from serial
sections from all the organs removed either intra vitam during operation
or, preferably, post mortem.
"I have, fortunately, seven cases in which an abdominal panhysterectomy
was performed after a clinical cure of the cancer by the use of
radium rays was obtained. CCases 26. 29. 32. 64. 128. 162 and 165.)
Serial sections were made from the tissues removed. A microscopic
examination revealed that the cytolytic changes were generally present
throughout the tumor. This does not prove that distantly located foci
were not left behind. As a matter of fact, patients 26 and 29 died subsequently
from cancer. This shows hat viable cancer cells were left

R a d i u m
behind somewhere in the pelvis. Bumm examined tissues acted on by
gamma-rays and removed afterwards during post mortem examinations.
He estimated that the intensity of the gamma-rays sufficient to destroy
carcinoma tissue extended into a radius of four centimeters. Within this
area of intensity, carcinoma cells were not found present. Beyond it,
however, typical unchanged cancer cell nests were still found to exist.
In other words, extensive carcinoma growths are only partially destroyed
by gamma-rays. This area of destruction, however, has a diameter
of eight centimeters and enables us to reach tissues which a knife
could never remove.
"3. Is it possible by such microscopic examinations to state
whether a carcinoma cell has perished or whether it might not regenerate
after the action of the radium ceases? The following citation will
illustrate the answer to this question. Cheron and Rubens-Duval treated
a patient suffering from an inoperable carcinoma of the cervix with
radium during November, 1910, and January, 1911. The patient was
apparently cured. She died from an intercurrent disease (a cerebral
softening) during April. 1912, fifteen months after the beginning of the
radium treatment. All the internal organs and! tissues were removed
post mortem, and a careful serial histological examination of all the
tissues did not reveal a single carcinoma cell at any place of the organism.
A complete anatomical cure by radium rays had been demonstrated.
"I have made a similar observation in a case of Mrs. A. R., Augustana
Hospital, number 44801, serial number 141, who was treated with
3,600 milligram-hours radium clement from October 27 to October 31,
1915, for an inoperable cancer involving the cervix and the entire vagina.
An examination made December 27, proved the patient clinically cured.
She died suddenly during the latter part of January, 1916, from heartblock.
The pelvic organs wilh the para and perimetrium and parietal
peritoneum and lymphnodes, including the sacral, were removed en bloc.
A most careful examination of stained sections in series did not reveal
any cancer cells or nodules.
"Our investigations demonstrate the uniformity and general extent
of the necrobiotic changes brought about in the carcinoma cells by the
action of the gamma-rays. Bumm's researches fix the extent of the area
within which a carcinoma will become destroyed, and Cheron and Rubens-Duval's
case proves the capability or efficiency of the radium rays
to bring about an anatomic cure of cancer."
* * # w *
Russell H. Boggs, M. D., (Pittsburgh). The Treatment of Epithelioma
of the Lower Lip. Interstate Medical Journal, Vol. XXIII. \*o. 5,
1916. Epithelioma of the lower lip, however innocent in appearance, is
nevertheless cancer, and often shows a degree of malignancy that is not
usual in epithelioma in other situations. It seems to be rather a regional
than a local lesion. The lymphatics which drain it should In every case
receive the same attention as the visible lesion. Until recently the best
routine treatment has been early surgical removal of the ulcer and lymphatics.
Until the introduction of the roentgen rays and radium there
was no alternative treatment. Severe caustics would occasionally destroy
the growth, but the resulting scar was large and retracted and the percentage
of recurrence was very high. Even after clean-cut operation,
results were sufficiently bad to lead the more careful surgeons to refer
39

40 R a d i u m
these cases for post-operative radiotherapy as a prophylactic against recurrence
from lymphatic trunks that had been overlooked. Today the
general practitioner frequently refers these cases to the roentgenologist in
the first instance rather than to the surgeon.
To the mind of some, the open question is whether they are justified
in referring these cases for radiotherapy. In deciding this question let us
consider the circumstances under which we have won our present position.
In the quite recent past, the radio-therapeutist was necessarily
untaught and inexperienced, for he was a pioneer. His supply of radium
was insufficient, and his apparatus unstable. He was compelled to adopt
the fractional dose instead of the massive single dose, universally regarded
as superior by men of experience with both. Even with the fractional
dose he was guided by the possibilities of his apparatus rather than
by his opinion as to the amount of radiation necessary. In other words,
he concerned himself rather with technique than with the principles of
therapeutics. He was limited to the worst possible class of cases,—namely,
those for which surgery had done its best or worst. Under these
circumstances it is no wonder that we all saw cases said to have had
innumerable roentgen exposures without the slightest sign of reaction.
that we saw roentgen ulcers treated in place of an epithelioma, which had
long been cured, and that we saw epitheliomas stimulated to more rapid
growth and metastasis rather than improvement by the ray. Yet even
so, radiotherapy demonstrated its superiority by not infrequent cures of
recurrent or otherwise inoperable cases.
How different is the oicture today. With radium, the powerful
transformer and the Coolidge tube, the therapeutist administers with
precision the single massive dose that his experience tells him is necessary.
He concerns himself not only with technique, hut also with the
type of lesion and with the individual. He sees early cases in which a
diagnosis is yet questionable; he sees cases a trifle more advanced after
radical operation, in which he administers prophylactic radiation, as well
as in hopelessly inoperable cases. He not only sees more cases in a year
than any individual surgeon of equal standing and reputation, but he
works earnestly over many cases long after ihey have been abandoned
by family physician, dermatologist and surgeon. ' He is in the best possible
position to compare different methods of treatment from the standpoint
of ultimate results. In short, he has a broader clinical knowledge
of the subject than any other man. Should he. therefore, still be relegated
to the position he quite properly occupied ten years ago as an
adjunct to the surgeon?
It is quite frequently said at medical meetings that every cancer is
curable at some stage by operative removal. This is perhaps a tactful
thing for the roentgenologist to say. It pleases the surgeon and induces
an agreeable mood of reciprocation. The onlv objection to this statement
is that from the practical standpoint it is not true. If there is such
a stage it is one that escapes the notice not only of the physician but of
the patient himself. The untimely death from cancer of the longue of
one of the ablest of the present generation of Pittsburgh physician* i*
sufficient evidence of this. But. if further support is needed. I could
quote figures collected by Murphy, and published in his clinics, showing
that of the most favorable class of cases (those submitted to radical
operation when there was a< yet no evidence of glandular involvement)
52 per cent. died, finally, a cancer death.
Guided by these considerations, the writer believes radiotherapv, bv

R a d i u m
means of radium and the modern roentgen tube, at present constitutes the
best routine treatment of epithelioma, both at the early and late stage.
Experience leads me to take a firm conviction that whatever position you
may take today you will all ultimately agree with me in this respect.
There has been much haggling surgery of lip cancers; and it is
hoped that this paper may not encourage haggling radiotherapy in the
same field. The inexperienced, with recklessness solidly founded on
ignorance, may bum a case; but he is scarcely more dangerous than the
slightly experienced and over-cautious radiotherapeutist giving insufficient
dosage which may stimulate the growth exactly in the same degree as an
incomplete operation.
Epithelioma of the lower lip was discussed before the American
Dermatological Society, many taking part, and it was concluded that
epithelioma of the lower lip could be successfully treated by radiotherapy
provided the cases were selected by an expert, and the operator
was qualified. All agreed it was a perfectly legitimate method of treatment,
but that it was a method liable to abuse if it were not restricted to
its proper field. We all know that lately many have been purchasing
.v-ray machines and radium tubes, and are giving all kinds of treatment
without much knowledge of the subject. The six or eight weeks' course
of instructions will teach many, so that they can make a few good plates.
But their interpretation in terms of radiotherapy is another proposition.
That radiation, applied by a trained and skillful radio-therapeutist,
will destroy epithcliomatous tissue has been definitely proved, and in
cases of epithelioma, far advanced, it is the only weapon at hand for
science. Miraculous as are its results in some recent cases, it cannot be
expected to compensate for neglect of prophylactic treatment; precancerous
changes, so well recognized clinically, must be regarded seriously,
and in cases in which excision is advisable, radiation comes almost as an
indispensable adjunct. Anyone who does not realize that he is treating
a serious condition is not competent to carry out any method of treatment
of epithelioma of the lower lip. Beside, he should have had experience
before he assumes the responsibility by himself.
The technique, whether using radium or the roentgen rays, must
be varied somewhat for the individual case. Scientific dosage should be
regarded from two points of view—that of physics and that of therapeutics.
Physical dosage may be fairly exact. Therapeutic dosage cannot
be indicated with the same certainty. It not only depends on experience
gained with a certain technique, but it also proceeds from a knowledge
of the clinical character of the epithelioma and of the susceptibility
of the patient. I prefer to use radium locally in epithelioma of the lower
lip and ray the adjacent glands with a Coolidge tube. When using
radium, a capsule is placed inside, one on top, and another on the outside
of the lip. By so doing the whole area is thoroughly radiated. One
advantage of radium is that it produces a more intense reaction which
disappears much more rapidly than a reaction of the same degree produced
by the roentgen rays. Usually the first reaction is sufficient to
heal a lesion of moderate extent. The resulting scar must be healthy,
pliable, without any retraction and without scalincss before a case is considered
clinically cured. The treatment of the adjacent glands is most
•important and should never be omitted, no matter how small the lesion-
Partial removal of an epithelioma is to be condemned.
In an article. "The Local Application of Radium. Suppplemented by
Roentgen Therapy," which I read before the American Roentgen Ray
41

42 R a d i u m
Society, September, 1915, I explained in detail the value of the combined
use of radium and the roentgen rays, which is applicable in the treatment
of epithelioma of the lower lip.
Any method in the treatment of epithelioma must be one which completely
eradicates every cancerous cell. Experience has taught us that an
epithelioma in this situation is rather a regional than a local lesion. For
this reason early surgical removal, wide and radical, has proved inefficient,
because a recurrence takes place in over 50 per cent, of the cases,
when there are no palpable glands at the time of operation, and in over
75 per cent, when there is any glandular involvement. All precancerous
lesions should be removed by some method without leaving any scar
whatever. Many believe the results by radiotherapy (meaning radium
and the roentgen rays) are equal and even better than those by surgery,
and that the removal should only be done in selected cases. There arc a
number of radio-therapeutists who have had sufficient experience in
epithelioma of the lower lip whose results justify them in considering
radiotherapy a perfectly legitimate method of treatment.
George Erety Shoemaker, M.D., F.A.C.S.. (Philadelphia). Primarv
Carcinoma of the Urethra, Retention of Urine from Obstruction,
Restoration of Function by Radium. Surgery, Gynecology and Obstetrics
XXII, No. 6. pp. 730-731, June. 1916. "The occurrence of
primary carcinoma of the urethra is so rare that all cases should be
reported, and especially the influence which radium may exert on their
relief is of interest."
"L. S. McMurtry, after a search of the scanty literature, calls
the urethra the 'rarest location' for primary carcinoma. Many cases
reported are merely extensions from other commoner localities and
will not bear analysis."
"Bringing previous searches down to date, he was able in his
paper before the American Surgical Associtaion, to find but 26
cases, beginning with one reported by Madame Boivan in 1828."
"F. von YYinkel, says that such carcinomatous neoplasms are
of extremely rare occurrence, and those reported have usually spread
from the external genitalia or the vagina. He saw two primary cases
and says that in both a pavement epithelioma had undoubtedly "started
in the urethral mucosa. The second patient had urethral and vesical
calculi and died of uraemia. He refers to four cases published by
Melchiori and one by Roberi in 1869. Their observations were that
periurethral cancer appeared as nodules in the vestibule and extended
thence in the cellular tissues along the urethra, without, however,
affecting the walls or the mucous membrane of the canal, the nodules
being at first hard, painless and non-ulcerating. In the earlier stage,
they do not extend to the depth of more than half the length of the
urethra; in the second stage, they reach the pelvic fascia and the neck
of the bladder.
•'Sielman mentions one case of carcinoma of the urethra as
being considerably rednced in size, with relief of the accompaning
dysuria. by application of X-rays. An interesting example of what
radium may accomplish is reported bv Legueu and Cheron of
Paris."
"A woman aged 26; pavement epithelioma; at first involving the
urethra, which was destroyed producing incontinence; extension to

R a d i u m
vagina. Radium applications by Cheron with disappearance of growth.
Two and a half years later, death under operation for implantation of
ureters in bowel. Autopsy; no microscopical malignancy."
"The writer would record his only experience as follows, all others
seen being instances of involvement by extension."
"Mrs. W., multipara, a full blood Virginia negress, aged 50 years,
applied at the Presbyterian Hospital because of overdistention of the
urinary bladder with complete retention. Beginning about five months
before (July, 1915), there had been some difficulty in urination
gradually succeeded by dribbling. For more than a week bladder distention
had been extreme, and on admission culminated in inability to
pass any urine at all. There had been no bleeding or pain, except that
due to the bladder condition."
"No ordinary sized catheter could be introduced, owing to a
nodular infiltration in and around the urethral canal. The urethra
felt through the vagina like a hard fixed ridge of the size of a lead
pencil, extending from the meatus back nearly to the base of the
bladder. The orifice was retracted, its edges hard, irregular, nodular
and ridge-like. The vaginal surfaces were normal in color—the surfaces
of the urethral mucous membrane were reddish but not ulcerating.
There was no involvement of the cervix or uterus; the vagina and the
vestibule showing only senile changes, except close to the urethral canal.
There was no tumor. A No. 6 ureteral catheter was passed with some
difficulty. It was tied in and the bladder thus gradually drained. In
the first 24 hours 173 ounces«or nearly 11 pints of urine were thus
obtained and some was lost."
"Bladder drainage and rest in bed caused sufficient subsidence of
swelling to enable a No. 12 soft catheter to be passed after some days.
but retention persisted."
"Surgery was inadvisable as the removal of the entire urethra up
to the neck of the bladder would have been necessary, with resulting
incontinence. Radium was therefore advised. Dr. William S. Newcomet
carried out this portion of the treatment, while the bladder
paralysis and cystitis resulting from overdistention were being treated
in the writer's service at the Presbyterian Hospital."
"The patient was transported to and fro, from time to time, to
the Department for Radiotherapy of the Jefferson Hospital, where an
applicator of proper size and efficiency was to be found. Between
December 14, 1915 and January 4, 1916. nine applications in all were
made, of three hours each. The quantity used was 20 milligrams of
radium element."
"The first few drops of urine were spontaneously passed December
24. The quantity gradually increased until by January 15 the bladder
was completely emptied by the patient in a normal manner. There was
no leakage, no pain, and no bleeding. A No. 19 flexible catheter could
now be passed."
"The urethra still retained its pencil-like feel. There was a short
split in the lower portion of the meatus, doubtless due to traumatism
of the rigid tissue. The radium produced a pallor of the mucous
membrane both about the urethra and in the vaginal entrance, a form
of radium burn, but there had been no loss of substance or ulceration."
"A small piece was afterwards removed at the edge of the meatus
and examined in the laboratory of the Presbyterian Hospital by Dr.
Damon B. Pfeiffer, pathologist."
43

44 R a d i u m
"Microscopical report: Squamous celled carcinoma."
"The Wassermann test for syphilis was negative, and there was
no specific history."
"The inguinal lymphatics were not enlarged, but when their removal
was advocated, the patient disappeared, considering herself well."
* * * * •
J. Wesley Bovee. M. D. (Washington). Notes on the Past, Present,
and Future of Gynecology, Obstetrics, and Abdominal Surgery.
Surgery, Gynecology and Obstetrics, XXIII, No. 3, pp. 290-6, Sept.
1916.
"The treatment of cancer of the uterine cervix continues to receive
the very ernest attention of gynecologists, and special activity in
the general subject of cancer during the past three years has been
enthusiastically aided by this society. Thus far the cause of cancer
has not been found and no doubt this must be discovered before we
may reasonably expect to gain a mastery over this dreadful disease.
Its behavior, as influenced by radium and long-continued, slightly elevated
temperature, as advocated by Percy, is of interest. The use of
certain rays from radium seems to retard its progress and, perhaps,
completely destroys it while other rays from it are thought to induce
the disease. If the latter be a fact we may well refuse to believe, for
the present, that cancer is of microbic nature. Even the Percy method
emphasizes this doubt for it should stimulate microbic activity; yet its
retarding influence on the progress of cancer of the cervix is attested
by many careful and reliable observers. But neither of these two agents
can be regarded as a specific for this disease for they are both notably
limited in their radius of action. Whether radium has deeper penetrating
power as a cancer destroyer than the Percy heating method is a matter
of doubt and the cases reported by Boldt throw grave doubt on the
penetrating power of Percy's method used for this purpose. This latter
method is based upon the application of a low elevation of heat to
the involved tissues. And yet for this purpose is employed an instrument
so hot that it has constantly to be moved to prevent overheating and the
heat is gauged principally by the sense of touch through the uterine wall,
which varies greatly in individuals. If this method is proved a specific
against the active agent of cancer, is it not to be the sole agency in the
treatment and cure of cancer in the breast, bladder, vagina, vulva, and
rectum? If it has a positive specificity for two inches then no part of
the human body will be inaccessible to its beneficient influence."
"It would appear then, that our hope in cancer of the uterus continues
to consist of surgery, as early as possible, universal education on
this subject, the employment of radium and high or higher temperatures
and unremitting search for the true etiology of it. Radium offers benefit
to other forms of neoplasms, particularly to the bleeding uterine
fibroid, according to several credible observers. Nevertheless it is vet
but an empiric agent, not available to more than a very small percentage
of patients suffering from the many conditions in which it is extolled
and not without its evil effects, such as corrosion of tissue. While we
may believe enthusiastic faith has had much, far too much, to do with
the reported results of radium application, we cannot fail to recognize
that this agency, when properly harnessed, has great possibilities in the
treatment of pathological conditions, I believe it is deserving of being
absolutely divorced from charlatanary and commercialism. Its exploitation
has been unfortunate."

A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY, PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES.
Edited and Published by Charles H. Viol, Ph. D., and William H. Cameron, M. D.
with the assistance of collaborators working in the fields of
Radtochemistry, Radioactivity and Radiumtherapy.
Subscription $2.50 per year, or 25 cents per copy in the United States and Canada
in all other countries $3.75 per year.
Address all communications to the Editors, Forbes and Meyran Avenues,
Pittsburgh, Pa.
VOL. Vni. DECEMBER, 1916 No. 3
RADIUM THERAPY*
Remarks on the Use of Radium in Deep-Seated Malignant
Disease and in Dermatology.
Frank E. Simpson, M. D.,
CHICAGO.
Those who are interested in knowing the truth about radium and its
possibilities should not fail to read the several reports issued in the last
three years by the London Radium Institute. These reports are among
the most solid contributions to radium therapy that have been published
in any language and they tend to clear the field of much exaggeration
from which radium has suffered.
A few words may first be said with reference to malignant disease.
At the present time the general opinion among radium therapeutists is
that operable cancers should not be treated by radium but should be
operated on by the surgeon.
When malignant growths are inoperable, however, radium has
proven of the greatest value, first, in rendering the growth operable,
secondly, in occasionally bringing about recovery without operation. In
the report of the London Radium Institute for 1914 several cancers of
the rectum are referred to which were treated by pre-opcrative radiation.
Considered as inoperable before radium was resorted to. these
tumors were so much diminished in size that their removal by the surgeon
was successfully accomplished. I have treated with radium numerous
inoperable malignant tumors in various situations. These include
cancers of various parts of the mouth, of the esophagus, rectum, bladder,
uterus, breast, etc.
Reprinted from the Illinois Medical Journal, August. 191B. Read before the
66th annual meeting of the Illinois State Medical Society at Champaign, May
18. 1916-

46 Raditjim
While it is difficult to make broad generalizations it is fair to say
that a few cases have apparently recovered for periods of from one to
three years; many cases have been benefited and the life of the patient
has been prolonged; a few cases have received no marked benefit.
At some future time I shall make a statistical report of all of these
cases.
I wish now to refer briefly to a few cases which illustrate some of
the points mentioned.
Case 1. (Carcinoma of cheek, lip and antrum. Recurrent.)
I first saw J. O., male, aged 44, on January 2, 1915. The primary
Fig. I. Epithelioma of Right Ear. Photograph taken February, 1916.
growth had started as a cancer of the buccal mucous membrane about
a year prior to my observation of the case. He had been operated on
several times, but the growth had recurred after each operation. The
last recurrence had been regarded as inoperable by several distinguished
surgeons. Two days before I saw him he had consulted the Mayos at
Rochester, Minn., and had been told there also that the growth was inoperable.
Between January 2 and January 15, 1915. he received vigorous
radium treatment at my hands and on April 15 I exhibited this
patient before the Chicago Medical Society (North Side Branch) as a
case that had made a clinical recovery under radium. When I last heard
from this patient he was still in good health. This case is reported more
fully in the Chicago Medical Recorder for July, 1913.

I N D I U M 47
Case 2. Epithelioma of the posterior wall of the soft palate. This
growth was regarded as inoperable by Dr. E. H. Skinner and Dr. Hall
of Kansas City, who sent him to me.
This patient was given an exposure of ten hours in fractional doses
by passing 50 mg. of radium through the anterior nares until it came
in contact with the growth. The radium treatment was supplemented
by x-rays applied by Dr. Skinner externally over the neck. A clinical
recovery followed in this case in about eight weeks and the patient still
remains in good health.
Case 3. (Cancer of the breast. Recurrent.)
Three years prior to my observation the left breast had been radi-
Flg- 2. Patient in Fig. 1 After Treatment with 150 mg. Kadlum Element (1
mm. Screen) for 20 Hours In Fractional Doaes. Photograph Taken May. 1916.
cally removed by Dr. W. C. Wood of Decatur, and Dr. W. A. Melton
of Warrcnsburg. When I first saw her in July, 1914. there were three
groups of nodules, the size of filberts, on the chest wall and in the left
axilla.
These were regarded as inoperable by Dr. S. C. Plummer of Chicago
and Dr. Melton. Treatment was begun with radium in July, 1914.
Six treatments were given with 50 m. g. of radium element.
Two months later the nodules had disappeared, she had gained
fourteen pounds in weight and seemed clinically well. Seven months
later (March, 1915) a slight recurrence took place and she was given
six more treatments with 150 mg. of radium element. Two months

48 R a d i u m
later (May, 1915) she seemed entirely well. Seven months later (December,
1915) the patient had a severe attack of intercostal neuralgia.
Although nothing superficial could be made out, deep carcinoma was
suspected and two treatments with 200 mg. radium clement was given
over the painful areas. She recovered from the attack, gained in weight
and resumed her occupation. About four months later (April, 1916)
another attack of intercostal neuralgia occurred. Owing to various
circumstances it has been impossible to carry out adequate treatment and
the future of this patient is of course problematical.
Fig.
1915.
Vascular Bluish Red Nevus, of Forehead. Photograph Taken March,
This case is cited to illustrate both the remarkable relief which
radium sometimes gives, the certain prolongation of life, and also the
uncertainty of the eventual outcome in malignant disease of this type.
There are two chief reasons for the failure of radium treatment in
malignant disease. The first and foremost lies in the very nature of
carcinoma or sarcoma, i. c., in the frequent malignant infiltration of the
tissues far beyond the area in which radium is effective, or to which
radium can be applied. Unless new ways are devised of applying
radium we cannot expect that more than a certain small percentage of
inoperable malignant disease of internal organs will be permanently
relieved. A second cause of failure lies in faulty technic. i. e., in methods
of applying radium which are entirely inadequate. Frequently the
amount of radium is too small. Not less than 50 mg. and occasionally

R a d i u m 49
200 or more mg. radium element are essential in dealing with serious
malignant conditions.
The distance into the tissue to which radium rays will effectively
penetrate is still open to question. Following certain histologic studies it
was widely accepted that a depth of 2 or 3 cms. is the farthest that effective
therapeutic effects from radium may be anticipated. On the other
hand, certain clinical effects that have been observed make it probable
that radium rays may be effective at a much greater distance. For example,
under radium treatment, the subsidence of severe symptoms, such
Fig. 4. Patient In Fig. 3 After Treatment with
1/10 mm. Screen) for 12 Hours In Fractional Doses.
ber. 1S16.
10 mg. Radium Element
Photograph Taken Decem-
as cough and dyspnea, due to pressure effects of a tumor in the mediastinum
has been observed by Wickham, Hayward-Pinch, and others. A
similar effect has been observed from the use of x-rays.
Radium in the vault of the vagina will easily fluoresce a piece of
willemite applied to the abdomen, while photographic plates over the
head will be darkened. This leads to the belief that the estimation of
the exact depth to which radium effects extend is a complex problem and
not entirely solved at the pre.-enf time.
A somewhat neglected but important field is the use of radium as a
post-operative measure to prevent relapse after the removal nf a malignant
tumor. It is, of course, difficult to estimate the extent to be derived
from this measure.

so R a d i u m
The London Radium Intsitute states that in a series of cases in
which operation was performed for malignant disease and in which recurrence
would probably have taken place in a large percentage of cases,
recurrence actually took place in only 19 per cent. This is believed to have
been due to the post-operative radiation which was carried out.
My own experience in treating post-operative cases is favorable.
My present plan is to begin post-operative radiation immediately after
the operation wound heals. This plan has succeeded in some cases in
apparently preventing a recurrence which might otherwise have b-en
expected.
Turning now to certain diseases of the skin, cancer of the skin furnishes
a brilliant field for radum therapy. I have now treated over 200
cases of epithelioma with radium and failure to bring about recovery
has been rare. Failure, as a rule, occurs only in the very extensive
cases, in which great loss of issue has taken place and repair is almost
impossible.
Cancer of the skin furnishes one exception to the general state
ment that operable cancers should be operated on. In many cases
radium therapy alone or combined with surgery is superior to surgery
alone. Especially is this true in the rodent ulcer type of epithelioma.
In these cases resolution is usually prompt under radium, the scar is
surprisingly good, while recurrence is uncommon.
Angioma. In certain types of angioma (birthmarks) radium occupies
a unique field. It is especially valuable in the angiomas of children.
because of its painlessness and the case of application. In certain
cases the cosmetic result is superior to that obtained by any other
method.
Keloids furnish another sphere in which the use of radium is attended
with success. In certain types of tuberculosis, lupus erythematosus,
sycosis vulgaris, intractable pruritus (as of the anus) and some
other affections of the skin, radium has proven of signal service to the
dermatologist.
In certain diseases of the skin it offers an alternative method to
x-rays, while in a limited number of affections it holds a unique position.
(Lantern slides of various diseases showing the results obtained
from the use of radium were then exhibited by the author.)
REPORT OF A CASE OF MELANOSARCOMA OF THE
ORBIT, TREATED WITH RADIUM*
Bv Edward B. Heckkl, M. D., F. A. C. S.,
PITTSBURGH, PA.
(From the Service of the Allegheny General Hospital.)
The subject of the following observation was seen first on April
16, 1912. The patient a man of forty-eight years of age. There was no
history of any eye injury; general good health had always prevailed.
•Archives of Ophlhalmology. XLV. *65-S. 1916. Read at the meeting of the
American Ophthalmological Society. Washington, D. C, May 9, 1316.

R a d i u m 51
The right eye had never annoyed him; the left eye, however, was and
had been blind for twelve years; the condition then present had commenced
thirteen years before; "it simply got weak."
Inspection showed the right eye negative in every respect with a
corrected vision of 20/20, w. -f 075 D. C. ax. 180°. The left eye: the
cornea flat, yellowish, and opaque with some blood-vessels in its substance.
It appeared like an eyeball which had undergone a sloughing of
the cornea following a purulent conjunctivitis, although the patient denied
any inflammatory condition of the eyeball at any time. The eyeball
was somewhat shrunken and soft. An immediate enucleation was
advised, but was refused by the patient, as he had heard "the removal of
one eye would injure the other."
The patient returned, however, on September 9, 1913, for an enucleation
of the left eyeball, because it had become painful. The right
eye had remained as when first seen in April, 1912. The enucleation was
done September 10, 1913. Quite a large dark staphylomatous mass was
found protruding down and backward from the region of the equator
of the eyeball. The eyeball with the projecting mass was carefully removed
and the specimen sent to the pathological laboratory, where it
was examined by Dr. Haythorn, the pathologist, and pronounced a
melanosarcoma.
The orbit healed promptly and the patient told of the diagnosis and
probable prognosis and that, very likely there would be a return of the
neoplasm. As the patient was very desirous of wearing a prosthesis,
permission was granted with a full explanation that the presence of the
foreign body might act as a source of irritation. He was also cautioned
that if at any time any pain or discomfort developed, or if the orbital
contents seemed to increase, or if the prosthesis should appear to bulge
forward, to report at once, as this would in all probability mean a return
of the neoplasm.
He wore the prosthesis with comfort and satisfaction until March,
1914, or about six months after the enucleation, when he returned. At
this time he presented the appearance shown in Fig. 1. The orbital
contents had decidedly increased. The prosthesis was pushed forward
and downward with a distinct bulging of the upper and lower lids.
Palpation revealed the orbit to be quite well filled with a spongy mass
limited only by the bony walls of the orbit.
Previous experience with orbital exenteration for malignant disease
of the orbit decided the writer to try radium in this case. Consequently
on March 27, 1914, a deep incision was made into the orbit,
practically bisecting it in its horizontal meridian, and fifty-three milligrams
of radium element in a silver capsule, screened by 2mm of lead
and covered with a rubber tube, inserted into the orbit in its anteroposterior
diameter and held in place by means of a light compress and
bandage and left in place for eleven and one half hours.
The presence of the radium with its screening was somewhat painful
but did not cause any great discomfort. There was no febrile reaction.
On April 13th, or seventeen days after the exposure to the radium
rays, a distinct mass could be palpated in the center of the orbit. This
mass was dissected out on the following day and proved to be strongly
pigmented and 3 X 2Vo X 2cm in size. This was sent to the laboratory
and the same diagnosis was made as was made of the enucleated eye,
melanosarcoma. The orbit was lightly packed and two days later fifty-

52 R a d i u m
-=
t
I
0
u
<
*a
-
to
60

R a d i u m
three milligrams of radium element, screened as before, was inserted
and allowed to remain in place for thirteen and one-half hours. The
orbit did nicely after this with a slight sloughing discharge. The orbit
was kept clean and healed promptly. It showed no evidence of any return
of the neoplasm, at least there was no increase in the orbital contents,
and after a few months presented the appearance shown in Fig. 2.
In November, 1914, the orbit became somewhat painful, especially
at night, and there was a slight increase in its contents, especially along
the nasal side. Palpation revealed a soft mass.
On December 7, 1914, quite a bit of strongly pigmented material was
removed by curetting, and four days later fifty-three milligrams of
radium element, screened as before, was inserted and left in place for
twelve hours. This as before was followed by some sloughing from the
orbit. The patient did nicely for six months or until June, 1915, when
the orbit again became painful and palpation revealed a movable mass
within the orbit. On June II, 1915, the orbit was again curetted and
one hundred milligrams of radium element, screened as before, was inserted
and left in place for fourteen hours. This, as before, was followed
by a sloughing from the orbit. The orbit continued to do nicely
and when the patient was seen on July 12, 1915, he complained of
nothing except a burning sensation which he had not observed before.
The patient was not seen again until December 22, 1915, when
the socket was partly filled, clean, and quiet and the surrounding structures
quite normal, as shown in Fig. 3. This photograph is slightly misleading
as in reality there was quite a depression while the photograph
makes the orbit appear quite full. The patient, however, appears pale
and anaemic. He stated that he had lost 25 lbs. in weight but felt quite
well. There was no pain or discomfort about the orbit. His blood was
examined at this time by Dr. Haythorn with the following result:
Red cells, 4,716,000; leucocytes, 6360. Hg. 80%. Differential;
neutrophiles, 63.5%; eosinophiles, 4.5%; basophiles, 1%. Mononuclear:
small 9%; large, 12.5%. Transitionals, 1.5%. Unclassified, 8%.
The patient was seen last on April 25, 1916. The orbit has remained
quiet, no pain or discomfort and no increase in its contents. His general
health, however, has been rather poor: he has lost some weight and was
confined to his bed during the entire month of February. He now weighs
114 lbs. his normal weight being 150 lbs. His physician, Dr. Midgley,
under date of May 5, 1915, tells me "that there is very extensive involvement
of the liver, spleen, and pleura and probably of the bowels."
The value of radium, if used in sufficient amount, in malignant disease
of the orbit is, in the opinion of the writer, 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 up to
within the last three months or during a period of two and one-third
years. The experience of this case has also suggested to the writer the
use of the electric-cautery knife, at a cherry-red heat so as not to carbonize
the tissues, for the removal of the malignant mass from the
orbit instead of the knife, as has been suggested by others for the removal
of malignant tissue from other parts of the body, so that when a
similar case presents itself the writer will pursue the following technic:
Make an incision through the skin of the lids about 5mm from the free
border of lids, completely encircling the palpebral fissure, then dissect the
skin only of the lids back to the bony orbital wall, then with an electric-
53

54 R a d i u m
cautery knife, at a cherry-red heat, by repeated punctures directed toward
the apex of the orbit and as closely 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
necessary or advisable. The writer is strongly convinced that one application
of one hundred milligrams of radium element is of more value
than several applications of a less amount.
The writer is indebted and hereby expresses his appreciation and
gratitude to Dr. Wm. H. Cameron of Pittsburgh for the generous loan
of the radium used in this case.
RADIUM IN FRENCH MILITARY SURGERY*
By William H. Cameron, M. D.,
PITTSBURGH.
In the March, 1916, number of the Pennsylvania Medical Journal.
I published an article on "Radium in Military Surgery." * * In the article
I gave a summary of the results obtained with radium in the treatment
of backward wounds, sinus cases, etc., at certain English hospitals.
Recently I have been in communication with a well-known medical
officer of the French army and he takes me to task for not giving due
credit to certain French surgeons for the work they have been doing
along this line. This apparent lack of courtesy was not intentional. I
made careful inquiries regarding the subject during my visit to France
in August, 1915, but could find nothing that would lead me to think that
such work was being carried out in the French hospitals.
The following extracts translated from an article by Medical Adjutant
J. Barcat, published in Le Progres Medical, May 20, will, I trust,
be of interest and at the same time avoid any controversy that may occur
in the future.
I trust that Mr. Rene Brocard, who very amiably put me in touch
with Dr. Cameron, and the latter, who very obligingly sent me a resume
of his observations in London, will excuse this manner of protest which
I can not help expressing for the benefit of the French school, whose
reputation can not be ignored ....
Each of the French radiotherapeutists, in a measure as circumstances
have permitted, has not failed to benefit our wounded by the precious
resources which radium offers. Thus to cite examples which we know,
Dr. Dominici lending his masterly experience and his applicators to
those chiefs of the hospital service in Paris who desired them, notably
that eminent" master of neurology, Dr. Babinski, and to Dr. Possi and
Dr. Delaunay, etc.; Dr. Degrais, collaborator from the first of the lamented
Wickham, giving his assistance as a trained specialist to the
medical head of one of the great Parisian formations, and his applicators
to his assistant, Ansclme Belot. officially at the head of a radium
therapy service in the Grand Palais; Mme. Laborde also director of another
official service for the application of radium at the same Grand
Palais.
•Pennsvlvanfa State Medical Journal. XIX. 906-S, Sept.. l$i*i.
••Reprinted In RADIUM. May. 1916.

R a d i u m 55
As to our other Parisian colleagues specializing in this branch of
physicotherapy of whom we have no news (Drs. Foveau de Courmelles,
Cheron, Chevrier, Guisez, Haret, Mme. Fabre, Dr. Delammarrc, etc.)
doubtless it is not their fault, but rather that of circumstances if they
have not disinterestedly placed their experience and their applicators in
the service of our wounded.
Radium possesses biological and therapeutic properties which have
been well known for some time, chiefly through the works of the French
school. It is these properties which make possible its applications in the
treatment of certain war wounds.
About 1910, Dominici {Presse Med., Mch. 16, 1910,) Chevrier (Tr.
Med., March 19, 1910) demonstrated its general action on the organism
when introduced in the form of a radiferous solution or serum. This
action is upon the oxidation processes, the hematopoiesis, and on the
leukocytic defense which it increases. The nervous system likewise is
influenced, the effect being tonic and sedative. Chevrier also, in the
same work, shows the acceleration produced by radioactive dressings of
low activity in the cicatrization of wounds; and with Dominici (see tne
Precis de Radiumtherapie of J. Barcat, 1912, published by Maloine) we
have shown the stimulating action of small doses upon tissues, its decongestive
and resolving effect on subacute and chronic inflammations, effects
which seem to result as much from its biochemical and stimulating
action on the affected tissues as to the sedation which it exerts on nerve
terminals, as well as the hindering influence, direct or indirect, which it
exerts on bacterial agents.
While incapable of completely sterilizing the different bacteria it at
least attenuates their virulence and their toxins (Danysz, Phisalix,
Wickham, Dominici and Barcat, M. and Mme. Fabre, Tizzoni and Bougiovanni)
and this action is not negligible, as Dr. Cameron seems to
think.
The properties which we have just enumerated would indeed indicate
its employment in the treatment of war wounds which have become
chronic, either by atony of the tissues or by their profound infection
(osteomyelitis).
For a long time also (Foveau de Courmelles, Congres de Berne,
1902; A. Darier, Clin. Ophthalm., 1905) wc have known the analgesic
effects of radium in neuralgias, its good effect on the restoration of the
motor function of nerves, and that paralysis and painful neuritis are
frequent complication in the war wounds.
Besides the action of radium on keloid (Williams, 1904) and on
vicious cicatrices (Wickham and Degrais, 19081 would indicate its application
in the treatment of these same complications of war wounds.
To give concrete examples of the valuable role which radium
therapy plays in war surgery we will at first analyze briefly Dr. Cameron's
work and we will then report some interesting observations which
Dominici has communicated to us as well as some others already published
by Mme. Laborde. We regret that circumstances depending on
the war do not permit us to add some personal observations.
(Brief summary of Dr. Cameron's article concluding as follows:—)
In conclusion, the work of Dr. Cameron is very interesting, but it
is not complete since his experiments have not been carried on with keloid
or vicious cicatrices, nor the neuralgias. Among the observations of Dr.
Dominici we will omit those dealing with chronic wounds since Dr.
Cameron has given us a sufficient number of examples, and the keloids

56 R a d i u m
which follow wounds since they do not present anything in particular.
We will give in detail, however, certain of those relating to nerve lesions,
a new chapter, since the cases previously known referred to neuralgias or
neuritis of toxic or infectious origin. The author has used only his
method of the uItrapcnetrating rays: the tubes of .5 mm. wall thickness,
screens of 1.0 to 1.5 mm., and 5 to 6 mm. of gauze or light screening
material.
Traumatic neuritis may give rise to trophic disturbances, sensory
or motor.
Trophic Disturbances: We will cite a case in which the cicatrix,
following the amputation of the first phalanx of the medius, was the site
of trophic troubles with discharge. A system of applicators consisting
of three tubes containing a total of 57.8 mgm. of radium element was
applied about the finger for a single application of one hour. In three
weeks the aspect of the cicatrix had become normal.
Sensory Disturbances: Cases in which the analgesic action of
radium plays a part are most numerous. Dominici divides them into
separate groups: First, simple neuritis; second, neuritis accompanied by
a conjunctivovascular inflammatory thickening; third, neuromas.
Simple Neuritis: Neuritis in non-cicatrized wounds. Following
are examples:—
Wounded soldier, bed No. 9, Hospital Broca, service of Dr. Pozzi.
Perforation of the leg by a ball which injured the internal popliteal
sciatic nerve. Sharp pain preventing sleep in spite of the normal course
of cicatrization. Two tubes each containing 16 mgm. of radium element
and one containing 25.7 mgm. of radium were applied for one hour
at three points, the two orifices of the trajectory and the posterior
face of the leg. Immediate relief permitted sleep the following
night. The next day a second application of eight hours on each of the
same spots. The dressings which followed revealed a slight crisis, followed
soon by progressive sedation with complete healing by the third
week.
Wounded, bed No. 6 (same service). Quite similar case, in which
complete healing was obtained at the end of fifteen days after two applications
at eight-day intervals of only one hour on each point, using a flat
applicator containing 26.6 mgm. of radium element.
Wounded soldier in the service of Dr. Babinski (Salpetriere). A
ball wound in clavicular and subclavicular region injuring the brachial
plexus and particularly the origin of the ulnar and median, the whole
course of which in the upper part of the member is painful. The same
flat applicator used in the preceding case was applied for twenty minutes
at each point along the course of the nerves. Immediate amelioration
followed by a little relapse. A second application similar to the
first made three weeks later did not prevent the recurrence of pain. A
third application made on the eighth day with applicators containing in
the total 139.3 mgm. of radium clement resulted in immediate relief,
interrupted by a slight relapse, which soon gave way to complete
healing.
Wounded soldier, bed No. 17. Hospital Broca. Fracture of the
neck of the femur by the explosion of a grenade, with a lesion of the
sciatic giving rise to terrible pain in the lower member, especally in the
foot. Flat applicator containing 26.6 mgm. of radium element was applied
to the foot for two hours without immediate result. Next day

R a d i u m 57
the applicator was moved all along the nerve two hours at each point.
Pain persisted during forty-eight hours and then progressive sedation
resulting in a healing three weeks later.
Neuralgia Persistent after the Cicatrization of the Wound: Example,
wounded soldier G (service Dr. Babinski). Normal cicatrization
of the wound on the inner side of the right arm and after three and one
half months the patient felt sharp pains along the ulnar nerve. A flat
placque (28 sq. cm. area) containing 8.4 mgm. of radium element was
applied for twenty-four hours; slight exacerbation on the following day
and progressive improvement. On the twentieth day a second application
of the same placque was made for fourteen hours; slight relief
and improvement which ended in a healing after five weeks (Dominici-
Heitz).
Wounded soldier L. (same service). Reported by Dominici and
Heitz. A ball wound in the lumbar region. Two and one-half months
afterwards in spite of complete cicatrization, sharp pain in the lower
member preventing sleep. Same flat applicator containing 8.4 mgm. of
radium element was applied in various spots in the lumbar region (total
of seventy-four hours in seven days). Improvement from the second
day and a relapse on the eighth day soon followed by progressive
sedation until cured, seventeen days after starting treatment.
Neuritis accompanied by an inflammatory thickening of the neurilemma
or of the neighboring conjunctivovascular tissue. Example:—
Lieutenant G. (service of Dr. Babinski). Ball wound due to perforation
at the root of the arm on the inner side. Sharp pain along the
ulnar and median. Thickening, painful to the touch along the vascularnervous
paquet of the axilla in the upper third of the arm. A system of
applicators containing in the total 48.2 mgm, of radium element was
moved over this zone fifteen days giving a total of three and one half
hours at each point. Later a flat applicator containing 16 mgm. of
radium element was applied so as to give each point three hours of irradiation.
Each seance followed by an exacerbation, increasingly feeble,
which did not prevent a progressive sedation, with complete healing in
six weeks.
Neuroma: Dominici and Heitz have had occasion to treat two
cases of which one was refractory, and the other, still under observation,
has diminished to one half its original size.
Motor Troubles: Two cases which Dominici has communicated to
us are not as good as the preceding relative to sensory disturbances.
Two cases showed no improvement.
Vicious Cicatrices: Mme. Laborde particularly has studied this
point and her work is all the more interesting since in the two observations,
already published (Acad, of Science, Aug. 9, 1915), she has
been able to demonstrate the efficacy of the ultra-penetrating radiation
on nonkeloidal cicatricial tissue, which Wickham and Degrais had declared
amenable only to destructive doses, that is to say vigorous applications
of the soft and moderately soft rays. In the following, these
two observations are cited:—
Capt. B., wounded by a grenade at level of the fold of the elbow.
the resulting cicatrix forming a fibrous band which limited the extension
of the forearm to an angle of 110° at most. This band formed a pad
which was deep, 7 cm. long and 2 cm. in width, which by compression on
the median had produced a partial degeneration. During one month.
after five applications of one and one half hours each, given about eight

5s R a d i u m
days apart, with a system of applicators containing 37.8 mgm. of radium
element, screened by 0.5 mm. of platinum, 1.5 mm. of rubber and
two thicknesses of gauze, the zone of fibrous tissue disappeared, extension
of the arm was almost complete, and the electric reaction of the
nerve is almost normal.
Sergeant C. Fracure of the neck of the humerus by a grenade with
complete paralysis of the biceps, probably due to a lesion of the muscles
and skin which presents a reaction representing almost complete degeneration
and which seems bound at the level of a scar, which forms a
linear furrow adherent to the bone in the anterointernal region of the
arm below the origin of the pectoralis major. Six applications of one
hour made with the same applicators at eight-day intervals. Six days
after the second application voluntary contractibility reappeared at the
same time as the faradic excitability, excitation by the galvanic current
giving a less gentle effect.
Conclusions: From the preceding examples one may judge of the
importance of the service of radium in war surgery. Atonic wounds;
chronic fistulas in connection with the bone, or slight sequestrations of
which, according to Cameron, favor the spontaneous expulsion; keloids
following traumatism; vicious cicatrices; traumatic neuritis, all appear
as indications well established and, it may be said, most valuable.
THE AMERICAN RADIUM SOCIETY
During the annual session of the American Medical Association in.
Detroit in June, a group of medical men interested in radium therapy,
met at dinner and discussed the desirability of forming a national organization
of radium therapeutists. With this in view the following
temporary officers were elected:—Dr. W. H. B. Aikins, of Toronto,
temporary president, and Dr. R. E. Loucks, of Detroit, temporary secretary.
Committees on Membership and on the Constitution were appointed
and the Secretary was instructed to bring the matter
to the attention of radium therapeutists and qualified physicists who
have specialized in radioactivity, in inviting them to attend a dinner
which was to be given in Philadelphia, Thursday evening, October 26th,
at the Rittenhousc Hotel, during the meeting of the Clinical Congress of
Surgeons of North America.
Following this dinner, which was well attended, those present proceeded
to the organization of the society. Dr. H. K. Pancoast, m
charge of the dinner, introduced the acting president. Dr. W. H. B.
Aikins. It being the unanimous opinion of those present that such a
national organization of radium therapeutists was desirable in the interest
of advancing the study of radium therapy, a motion to organize
a permanent society was passed and the report of the committee on theconstitution
and by-laws was called for. After a first reading, by Dr.
Henry Schmitz, chairman of the committee, a constitution and by-laws
were adopted. The name chosen for the organization is The American.
Radium Society.

R a d i u m 59
The objects of the society are to promote the scientific study of
radium-therapeutics, and to seek to maintain a high ethical standard
among those using the radioactive substances therapeutically. Active
membership in the society is to be limited to those holding a medical degree
from a reputable medical school, and qualified for membership in
the American Medical Association or the American Institute of Homeopathy,
or its equivalent, together with a sufficient experience in radium
therapy. Qualified physicists specializing in the study of radioactivity
are eligible for associate membership.
Following the adoption of the constitution and by-laws permanent
officers were elected to serve for the next year as follows:—
President, Dr. W. H. B. Aikins, Toronto.
Vice President, Dr. R. H. Boggs, Pittsburgh.
Recording Secretary and Treasurer, Dr. R. E. Loucks, Detroit.
Corresponding Secretary, Dr. H. K. Pancoast, Philadelphia.
Members of Executive Council, Drs. J. M. Lee, J. B. Bissell, Howard
Fox, and the officers.
The Membership Committee to pass upon the qualifications of applicants
and make recommendations to the Society at the Annual Executive
Sessions:—
Dr. W. H. Cameron, Chairman, Pittsburgh.
Dr. H. K. Pancoast, Philadelphia.
Dr. J. B. Bissell, New York.
It was decided to hold the next Executive Session in New York
City, preceding the Annual Session of the American Medical Association,
June 4th, 1917.
Following the organization and election of officers, Dr. Charles H.
Viol, of Pittsburgh, addressed the society on "Radium Radiations from
the Physical Standpoint".
Active members of the American Radium Society.
W. H. B. Aikins, M. D., Toronto, Canada.
C. E. Alliaume, M. D., Utica, N. Y.
J. B. Bissell, M. D., New York, N. Y.
R. H. Boggs, M. D., Pittsburgh, Pa.
W. H. Cameron, M. D., Pittsburgh, Pa.
J. T. Case, M. D., Battle Creek, Mich.
Howard Fox, M. D., New York, N. Y.
S. C. Glidden, M. D., Danville, 111.
T. C. Kennedy, M. D., Indianapolis, Ind.
J. M. Lee, M. D„ Rochester, N. Y.
Isaac Levin, M. D., New York, N. Y.
H. W. Longyear, M. D.. Detroit, Mich.
R. E. Loucks, M. D., Detroit, Mich.
W. N. Magill, M. D., Providence, R. I.
C. Jeff. Miller, M. D., New Orleans. La.
II. K. Pancoast, M. D.. Philadelphia, Pa.
D. T. Quigley, M. D.. Omaha, Neb.
M. J. Rosenthal, M. D., Fort Wayne, Ind.
F. E. Simpson, M. D., Chicago, 111.
Henry Schmitz, M. D., Chicago, III.
W. A. Weed, M. D., Birmingham, Ala
Associate Member.
Charles H. Viol, Ph. D., Pittsburgh, Pa

60 R a d i u m
Reviews and Abstracts.
J. T. Geraghty, M. D. (Baltimore). Treatment of Bladder Tumors.
N. Y. Med. Journ. CIV. Oct. 28th, 1916. pp. 838-40. Read before the
New York Academy of Medicine, April 27th, 1916. "Radium. During
the past eighteen months, we have treated about fifteen tumors
with radium alone or with radium in combination with fulguration. Our
experience has not been sufficient to draw definite conclusions regarding
the ultimate value of this method. It has been employed most frequently
on malignant papillomata in combination with fulguration, and the
effect of the radium has been most striking. In three cases in which
fulguration has been employed over long periods of time, and which
had resisted very stubbornly all efforts to entirely destroy them, radium
seemed entirely to change their nature. In all three cases after receiving
600 mg. hours of radium applied directly against the tumor, the latter
disappeared with astonishing rapidity on resuming fulguration. When
possible, the radium is applied directly against the tumor by means of
the Young radium cystoscope, using a tube with an opening on one side,
so that the beta rays can be applied directly to the tumor while
the rest of the bladder wall is screened. The combination of radium and
fulguration in this type of case seems to promise much. So far, we have
not succeeded in definitely eradicating the papillary or other infiltrating
types of carcinoma."
"Conclusions. The experience in our clinic in recent years indicates
clearly that benign and malignant papillomata should be treated
by fulguration; excision or resection should not be practised except
where intravesical treatment is impossible or very difficult. Radium has
been a great aid in the treatment, particularly of the malignant papillomata,
and our best results have been obtained when the radium was placed
directly against the tumor. When the tumor is a papillary carcinoma, resection
should be practised by a technic which will reduce to a minimum
the dangers of implantation or recurrence. Radium as yet has not given us
results in this type of tumor sufficiently encouraging to warrant our employment
of it in preference to resection in cases which are considered
operable. Following resection, cystoscopy should be performed at an
early date, and at frequent intervals, especially for the first year, and if
recurrences are noted, they can occasionally be successfully treated by a
combination of fulguration and radium. Unfortunately, as already
stated, a large percentage of cases are first seen with the disease so extensive
that nothing more than palliative measures can be adopted."
* * * » *
George M. Mackec, M. D. (New York). Progress in the Treatment
of Skin Diseases. N. Y. Med. Journ. CIII, Mar. 4, 1916, pp. 441-4.
"Radium is now being extensively employed in treatment of skirt
diseases It has produced very superior results in the treatment
of deep seated vascular naevi. but it is not so efficacious in the port
wine mark. It is of use in leukoplakia and lupus erythematosus. In
these conditions it is at present superior to the X-ray. In inaccessible
locations radium can be used to advantage, but where extensive surfaces
arc to be treated the X-ray is to be indicated."

A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY, PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIOACTIVE SUBSTANCES.
Edited and Published by Charles H. Viol, Ph. D., and William H. Cameron, M. D.
with the assistance of collaborators working in the fields of
Radiochemistry, Radioactivity and Radiumtherapy.
Subscription $2.50 per year, or 25 cents per copy in the United States and Canada
in all other countries $3.75 per year.
Address all communications to the Editors, Forbes and Meyran Avenues,
Pittsburgh, Pa.
VOL. Vin. JANUARY, 1916 No. 4
RESULTS OBTAINED BY THE USE OF RADIUM IN
THE TREATMENT OF CANCER OF THE UTERUS*
At the University of Pennsylvania Hospital.
Bv John G. Clark, M. D.
of Philadelphia, Pa.
The treatment of cancer of the uterus—that will-o'-the-wisp of
surgery—has for the last three decades been a bone of contention as
regards the best method of circumventing the growth by surgical
methods. The various forms of hysterectomy have been thoroughly
tested, beginning, first, with the simple vaginal method, a large series of
cases thus treated having been reported from American and European
clinics. The final summary of results, however, after a probationary fiveyear
period, showed the treatment to be lacking in effectiveness, first,
because it was applicable to only a relatively small number of cases, and,
second, because the percentage of ultimate cures it yielded was lamentably
small. Then came Schuchart's more radical vaginal hysterectomy,
which, in the hands of a few experts, among the foremost of whom is
Schauta, has given a larger rate of ultimate cures; it is, however, a very
difficult operation, and is attended by a larger mortality, and is followed
by serious vesical and ureteral sequela:. Because of these objections,
this method has received only limited approval from gynaecologists.
Following this, the extended or more radical abdominal method came
into vogue, and until three years ago continental gynecologic literature
was replete with the reports of cases from many clinics; these contained
both favorable and adverse criticism. About three years ago these
•Reprinted from Annals of Surgery, LXIV. 602-612. November, 1912.

62 R a d i u m
reports suddenly ceased, to be almost entirely superseded by the consideration
of ladium and mesothorium as new and promising therapeutic
agents.
This brief discussion of the rapid change of events in the surgical
treatment of cancer leads to the inevitable conclusion that the surgical
world is still very much at sea as regards the most effective method of
dealing with this disease. A decided surgical advance has been made, but
the progress is in no way commensurate with the effort that has been
expended, for even in carefully selected cases the best series of radical
operations still yields less than 50 per cent, of recoveries.
As a convincing evidence of the limitations of surgical applicability,
wc offer the results of experience. In less than two years we have treated
49 cases of inoperable cancer of the uterus with radium, and during the
same period only 12 cases have been considered as within radically operative
limits. During the preceding ten years the number of radical operations
performed was about 60. In other words, for 50 cases subjected
to operation, at least 250 have been abandoned as hopeless. This personal
observation has convinced us, more than ever before, of our grave
shortcomings as regards the surgical treatment of uterine cancer.
Although the radical operation has given the best ultimate statistics,
so far as the number of permanent cures is concerned, experience has
proved that beyond doubt, it is also attended with an unavoidably high
primary death-rate; that it is followed by serious post-operative sequela;
which are difficult to cure, and that when these are irremediable, they
leave our patients in a very wretched condition. Since the American
Gynaecological Society so thoroughly reviewed this subject four years
ago, I have found no reason to alter my views as expressed at that time
after a study of my own cases. The conclusions then reached were as
follows:
1. The operation, in expert hands, notwithstanding its high primary
mortality, has given the greatest percentage of permanent cures of any
therapeutic procedure thus far suggested for cancer of the cervix.
2. While the foregoing conclusion is true, the general adoption of
the operation, in view of its dangers and difficulties, is not to be advised
until the primary mortality can be reduced to a much lower percentage
by a simplification or a perfection of details.
3. The abandonment of the extensive glandular dissection is justified,
because this detail adds to the hazards and does not sufficiently increase
the percentage of permanent cures.
4. The cardinal advantage of the operation lies, first, and above all,
in the excision of an extensive cuff of vagina and the widest possible
removal of the parametrial tissue.
5. There is no middle-of-the-road policy in cancer of the cervix.
The surgeon would better perform a simple vaginal hysterectomy or a
high amputation of the cervix with extensive cauterization than to attempt
the radical operation if he is not prepared effectively to execute
its details.
6. The earnest endeavor, by many specialists, with the improved
ultimate cures in a few hands, offers the hope that a further simplification
and perfection of details in this operation may yet make it more
generally available.
The therapeutic problem involved in the successful treatment of
carcinoma of the cervix is based upon the stage of invasion of the newgrowth.
The results of the radical operation have proved condusivelv

R a d i u m
that, with very rare exceptions, the hopeless cases are those of the metastatic
type. All the methods now being employed, arc therefore, directed
toward the radical elimination of the local cervical and vaginal disease
process. If the growth has invaded the parametrium to a point beyond the
outer limits of the ureters, or if it has found lodgement in the iliac
glands, the case must, with rare exception, be regarded as hopeless, so far
as surgical extirpation is concerned. This statement may be challenged,
but in that case the burden of proof falls upon the challenger. No operaion
as yet suggested has been more generally misapplied than has the
so-called radical abdominal operation. This may be proved to one's own
satisfaction by examining the specimen exhibited, as a rule, as the
product of this operation. This criticism is directed not alone to the
work of other surgeons, but applies with equal force to my own. There
can be no more difficult surgical procedure than the radical operation for
the removal of a cancerous uterus, for the efforts of the operator are
impeded on all sides by insuperable limitations.
To attempt to compare the statitics of the various operators is a
difficult or impossible task. In one clinic the greatest risks are taken,
and an attempt is made to operate on hopeless cases in the belief that a
dangerous hazard is always warranted, because thus an occasional brand
may be snatched from the burning. Conversely, another surgeon, with
less temerity, and possibly with better judgment, will operate only on
cases that promise to reward his efforts and that are unmistakably within
his surgical domain. The latter operator will, therefore, have fewer cases
than the former, and, of course, his series will show a correspondingly
higher rate of permanent cures. Then, too, the variation in skill of
different surgeons plays an important role in the estimate of results. Because
this skill varies so widely, and is so largely dependent upon the
temperament and physical equipment of the surgeon, the standardization
of the radical operation for cancer, whose degree of effectiveness is
defined within the widest anatomic limits under the most hazardous of
surgical liabilities, must remain forever upon shifting sands. In many
operations the limited nature of the disease and its accessibility are such
that more or less fixed principles of procedure may be evolved, and in
these cases skill and judgment do not influence the operative results so
profoundly.
In the anatomic division of cancer of the uterus this point may well
be demonstrated, for in carcinoma of the fundus the statistics of various
surgeons do not differ to any marked degree, because extirpation of the
uterus generally suffices to give good results. So long as the growth is
confined to the fundus, recurrence does not take place in more than 50
per cent, of cases, provided even a simple hysterectomy is performed.
The rule, therefore, that calls for removal of the uterus and its adnexan
may, in the hands of a mediocre operator, be productive of a mortality
incidence and a permanent percentage of cures approaching closely those
of his more skilled colleague.
We are all fairly well satisfied with the results of operation in cancer
of the fundus, whereas no one regards the operative treatment of cancer
of the cervix with any great degree of optimism. To attain a higher
measure of success, some more efficient means than the scalpel must
be employed. That this remedy has not as yet been discovered is
shown by the fact that almost every surgeon who has made a special
study of this question very properly advocates the same principle
here as has been adopted in cancer of every other part of the body
63

64 R a d i u m
that is accessible to radical surgical measures. Notwithstanding the
remarkably good results that have followed the use of radium, I still
adhere to the dictum that the uterus and all possible adjacent tissue, if
the growth is very limited in its extent, must be extirpated. Beyond this
point, however, I have grown quite conservative. My first recession occurred
eighteen years ago, after visiting Sanger's Clinic. I found that
this very clever surgeon and clear thinker had even then abandoned hysterectomy
as a palliative measure in widely extended cancer, on the
ground that practically no hope of cure could be offered the patient, and
that removal of the uterus actually intensified her subsequent suffering.
Following a hysterectomy, if carcinomatous tissue is left in the parametrium,
the patient's post-operative state is likely to be worse so far as
pain is concerned, for it is usually severer and, therefore, more prolonged
than if the uterus is allowed to remain in situ. With the removal of the
uterus, the elastic broad ligaments and parametrium retract and cling
closely to the pelvic wall, coming in contact with the large pelvic bloodvessels
and the sacral plexus. If the growth remains in this situation
the condition is infinitely more painful than if it is held in suspension
away from the pelvic wall by the broad ligaments, and therefore, more
slowly reaches the periosteum and ganglionic roots.
The crux of the situation, therefore, as our experience has taught,
is to attempt surgical measures only in the clearly operable cases, leaving
the large remainder to secure relief from therapeutic efforts, which give
as good or, as we now believe, even far better results from the use of
radium.
In the inoperable cases, I believe the Percy cautery holds out a distinct
hope; nevertheless. I do not share the great degree of optimism
shown by the inventor of his method as regards the cases of widespread
extension. In using the cautery, as in performing the radical operation.
the anatomic barriers are the same, and I am firmly convinced that its
general adoption will be followed by even a larger number of serious and
wretchedly disabling sequela;, so far as the rectum, bladder and ureters
are concerned. This cautery should be used only by the skilled specialists,
for it is not safe in the hands of the novice. Even in skilled hands
accidents are prone to occur in many instances. Moreover, one cannot
get away from the fact that the Percy method is most radical, involving
an abdominal section, ligation of the internal iliac arteries—a procedure
that may be quite difficult in some cases—and the prolonged exposure of
the patient to the slow desiccation of the tissues. This method must,
therefore, be regarded as on trial, and it is to be hoped that its enthusiastic
sponsor will publish a full account of cases up to date. We should
know the mortality percentage and the degree of morbidity following the
operation in order fairly to estimate its full value. Because of the fact
that a sufficient quantity of radium was at our disposal at the University
Hospital, we have followed this line of treatment almost exclusively,
and we have had, therefore, but a limited experience with the desiccating
method.
Under the best of clinical conditions, wc are forced to throw into the
surgical discard by far the largest proportion of cancer cases registered in
our clinics. If we are still holding a very conservative opinion as to the
final results following the Percy method, what, it may be asked, is our
attitude toward the Roentgen ray treatment and the use of radio-active
substances ?

R a d i u m
In thi^ country the X-ray has not had sufficient trial to give it a place
of even tentative value. To Bumm's Clinic, from which very favorable
preliminary reports were issued, wc looked for an elaboration of technic
that would serve as a standard for comparison with radium and mesothorium.
The Great War has, however, put an end to all investigation in
the gynecologic clinics of Germany, and it is only from the hospitals of
the continent, where there is an abundance of material and also a willingness
to risk much, so far as individual patients are concerned, to work
out a theoretic principle, that wc may expect authentic reports of hazardous
novel procedures. The roentgenologist cannot be depended upon for
convincing reports, for his cases are drawn from widely divergent
sources, &nd too often the clinical diagnosis is accepted and no microscopic
control attempted.
As to radium, I am convinced from our experience at the University
Hospital that it offers the most helpful outlook of any remedy thus far
presented in the palliative and occasionally the curative treatment of the
border-line and inoperable cases. In the Gynecologic Clinic of the University
of Pennsylvania during the past two years, 44 cases of carcinoma
of the uterus, vagina, and urethra have been so treated. Practically all
of these would, according to our past standards, have been classed as
inoperable and, therefore, would inevitably have been doomed.
As regard the effect of radium when applied in too large amounts
and too often, Schauta's experience is enlightening. In his first series of
13 patients, from 50 to 100 mgs. of radium were applied uninterruptedly
for from three to eleven days, and repeated in similar dosage after an
interval of from twelve to twenty-two days. His results were most
disastrous; one patient died of pyonephrosis; S showed steady loss of
weight, with diarrhcea, tenesmus, fever, vomiting, headache, and reduction
in blood count. The autopsy findings showed severe necrosis and
fistula; with diphtheritic and purulent inflammations of the rectum and
bladder, sigmoiditis, and ulcerative processes in the pelvic coils of the
ileum. One striking point, however, noted at the autopsies was that in
not a single instance was a trace of local carcinoma found. In the method
of its application, however, the remedy proved far worse than the disease,
but this investigator established beyond question that radium radiations
wer^ absolutely destructive to cancer cells.
In a second series of 11 cases the dosage was smaller and the interval
of application shorter, but in spite of this some of the patients presented
the group of disagreeable symptoms just noted, but in four a local cure
was effected.
In his third series of cases the dosage was regulated as follows:
From 30 to 50 mg. of radium, filtered through 1.1 mm. of gold. 1 mm.
of platinum, and 0.75 mm. of brass, were applied in from 5 to 8 exposures
of twelve hours each, at intervals of from one to several days; an
interval of rest of three to four weeks was then allowed to elapse, followed
by a second but shorter exposure, and in some cases, after another
interval of two to three weeks, a third series of applications was employed.
Eleven patients were thus treated; of these. 3 were somewhat improved
anO the remaining 8 were apparently cured. In no instance were
fistula; or necrosis produced, and the weight and general condition of the
patient showed marked improvement.
As an evidence of the widespread skepticism concerning these newer
remedies, and in spite of this very favorable personal experience, Schauta
65

66 R a d i u m
declares that, although he will use radium in advanced cases, he will still
continue to employ Schuchart's radical method of performing vaginal
hysterectomy in the clearly operable cases, reserving radium as a postoperative
prophylactic agent.
With a less intensive method than that at first employed by Schauta,
we have thus far had but one patient in whom a fistula developed; this
followed a radical operation in which 50 mg. of radium were left within
the vaginal cuff for eight hours, another application being made in six
weeks. In this case there was no apparent retardation of the growth;
on the contrary, within two months great sloughing holes appeared in
the rectum and bladder. Whether these were caused by the radium or
were due to the rapid growth of the carcinoma we were unable to determine.
In practically every case radium has been applied for twenty-four
hours, and the patient has usually returned home the next day. So far as
any immediate effect is concerned, in no instance have we witnessed any
untoward symptom beyond a fleeting degree of nausea, and this but
rarelyj only in one case did a high temperature develop, and this was in
a case in which the Percy cautery had been applied extensively, and was
followed by a twenty-four hour application of radium. In our series of
cases there have been, with these two exceptions, no disagreeable effects.
Fortunately, we have not had to pass through the experimental stage of
this treatment but have, profited by the mistakes of the early workers.
Thus far we have found an 85 to 100 mg. dosage quite satisfactory. It is
possible that still better results may be achieved by larger amounts. For
information on this score, however, we must turn to Drs. Kelly and
Burnam.
We have adhered strictly to one rule, namely, never to attempt an
operation on any case that has been healed locally by radium. It appears
to us a most unwise surgical policy to subject a patient to the grave
hazards of a radical operation, after the radium has acted beneficially, in
a fatuous attempt to secure still more effective results. With further
experience we may modify this rule, but up to the present we have not
seen the slighest evidence in favor of so apparently unwise a policv.
Radium, as is shown in our series of cases, is by no means a universal
panacea for cancer, even when the growth is strictly localized. There is
no way of determining which case will be benefited by its use. There is
beyond a doubt a certain percentage—how small or how great we cannot
tell from our experience—in which cancerous growths are not retarded
by radiotherapy; indeed, occasionally it would appear that there is a
positive acceleration of growth. That many cases show an astounding
improvement and local cure cannot be gainsaid. In our series several
instances occurred in which the results achieved were so remarkable as
to be almost incredible. Whether in these cases the fire is but smouldering
and may break out sooner or later with renewed violence time alone
will tell.
In the discussion of these cases the question of hospital economics
must not be lost sight of. The length of stay in the hospital following
a radical operation will average at least three weeks; whereas, after the
application of radium not more than three days will be required. When
complications arise after radical operations thev arc usuallv serious,
entailing much suffering. Such patients, on returning home, are likely
to remain semi-invalids for several weeks, and when, as is frequently the
case, there is a rapid continuation of the disease, they become a heavy

R a d i u m 67
burden to ;. poor family. In the comparison of statistics, this difference
between the two classes of patients is greatly in favor of those treated
by radium a fact that tends to incline us strongly to the use of radium
in border-line cases, which we formerly subjected to a radical operation.
It would also appear to be a self-evident fact that the post-operative
effects of the Percy method must fall far short of those of the radium
cases. I cannot here enter into a discussion of ultimate curative results,
even though at present they may appear most promising, for wc are on
the very threshold of a therapeutic innovation that may, in the end,
prove of less value in effecting a cure than the radical method of performing
a hysterectomy.
Removal of the uterus in cases of cancer of the fundus has yielded
such goods results that I do not feel we are justified in taking any chances
with radium, not even in the border-line cases. Our attitude toward the
cervical and fundal growths is diametrically opposite. In border-line
cases of cancer of the cervix wc invariably employ radium. In advanced
cases of cancer of the fundus we invariably perform a hysterectomy. A
pessimistic view dominates our outlook in the surgical treatment of the
cervical growths if the pathologic process is at all advanced, whereas
fundal growths may be viewed with a cheerful optimism, even when the
cancerous process is extensive. As a palliative agent, we may assert with
full assurance that we have never obtained results with any other method
that have even approached in beneficence those secured by radium. The
cloud, however, that hangs over the remedy is the danger of unbridled
optimism.
The following three tables are appended, as they give the final
results in the radical operation for cancer of the fundus and the palliative
results in cases treated by radium during the last two years. A very
close oversight is being kept of the radium cases, and we expect from
time to time to give reports on all of these cases.
The Radical Operation for Carcinoma of Cervix.
Operative deaths (peritonitis) 5
Died from continuance in 3 months 1
Died from continuance in 6 months 3
Died from continuance in 10 months 1
Died from continuance in 11 months 1
Died from continuance in 12 months 3
Died from continuance in 15 months 1
Died from continuance in 16 months 1
Died from continuance in 18 months 5
Died from continuance in 2 years 6
Unable to trace 10
Alive and no sign of continuance:
One year i 2
One and one-half years 3
Three years 0
Four years; 2
Five years 1
Six years 6
Seven years I
Eight years 1
Total number of cases 53

68 R a d i u m
Post-operative Sequelae
Suppuration of abdominal incision S
Cystitis -}
Peritonitis (recovery) 3
Ureteral fistula; 2
Vesical fistula; 3
Phlebitis 1
Laceration of rectum (fistula) 1
Pleurisy 2
Rectovaginal fistula 2
Average stay in hospital 21 days at least
Panhysterectomy for Carcinoma of Fundus
Operative deaths (one patient died one week after operation
from a general metastasis of chorioepithelioma. Death
occurred from widespread involvement of the lungs with
the malignant process. Other patient died from peritonitis>
2
Well over six years 5
Well over five years 1
Well over four years 1
Well over three and one-half years 2
Well over two and three-fourths year 2
Well over two years 2
Well over one year 1
Died from continuance of disease in 3 months 1
Died from continuance of disease in 7 months 1
Died from continuance of disease in 1 year 1
Died from continuance of disease in 3 years 1
Died from continuance of disease in 5 years 2
Died in two and one-half years from mastoid abscess (complete
autopsy revealed no microscopic trace of cancer
either in pelvis or in the abdominal lymph glands) 1
Unable to trace 3
Total number of cases 26
Use of Radium in Inoperable Cancer of Cervix, Vagina and
Urethra1
Deaths following treatment 0
Died from continuance in 1 month 4
Died from continuance in 2 months 1
Died from continuance in 3 month* 1
Died from continuance in 4 months 1
Died from continuance in 6 months 1
Died from continuance in 7 months 1
Died from continuance in 8 months 1
Died from continuance in 9 months 1
Died from continuance in 10 months 1
Died from continuance in 11 months 1
IThis table Is a complete record of case* treated by radium up lo the time
of this paper going to print. September 15, 1316.

R a d i u m 69
Alive 22 months 2
Alive 21 months 1
Alive 16 months 1
Alive 14 months 1
Alive 12 months 2
Alive 11 months
Alive 10 months.
1
Alive months.
. 1
Alive months,
. 5
Alive months.
2
Alive months.
1
Alive months,
5
Alive months.
4
Alive months.
15
Alive month. •
4
Not traced
10
Total number of cases ,69
History of Patient after Application of Radium
Relief of hemorrhage (complete)
Recurrence of hemorrhage in 3 weeks
Recurrence of hemorrhage in 4 weeks
Recurrence of hemorrhage in 6 weeks
Recurrence of hemorrhage in 2 months
Recurrence of hemorrhage in 3 months
Recurrence of hemorrhage in 4 months
Recurrence of hemorrhage in 8 months
Relief of pain (complete) 2
Relief of pain for 2 months 1
No relief of pain 18
No symptomatic relief 12
Local healing of ulcerative area (of this number, 2
died subsequently of internal metastasis) 26
Rapid extension of growth, coincident vesicovaginal
and rectovaginal fistuale 5
Immediate untowards result 0
Average stay in hospital—about 3 days.
THE TREATMENT OF LEUKOPLAKIA BY RADIUM*
By Russell H. Bocgs, M. D., Pittsburg, Pa., Roentgenologist,
Allegheny General Hospital; Dermatologist and
Roentgenologist, Pittsburg, Columbia and
St. Francis Hospitals.
Radium has proved a very useful agent in the treatment of leukoplakia,
which has been very resistant to most forms of treatment. It is
-Texas Medical Journal. XXXII. 224-fi. November. 1916.

70 R a d i u m
a forerunner of epithelioma in many instances and should receive just
as prompt and efficient treatment as precancerous lesions on the skin.
Leukoplakia is a disease which attacks the mucous membrane of
the tongue, the inner surface of the cheeks, gums, lips, roof of the mouth
and rarely the vagina and genitals. It is characterized by one or more
whitish patches, often more or less thickened. The surface is smooth,
roughened or somewhat papillomatous, and there may be an encircling
hyperemia. The course is chronic and ulceration and malignant changes
frequently occur. In some cases the lesions, after reaching a certain
stage, remain stationary for a long time. The process is one of proliferation
of the cells of the rete malpighii with cellular infiltration in
the papillary layer of the corium. When examined closely, these lesions
are found to be made of a hyperkeratinized epithelium, being covered
by adherent and more or less dense pellicle, removable only by artificial
means and closely applied to the inferior stratum of the mucous.
Views on buccal leukoplakia have given birth to a series of hypotheses
that have been enunciated one after the other during the last few years.
It is generally conceded that there are two forms of leukoplakia; first,
the true idiopathic, the cause of which is unknown and which alone
leads on to an epithelioma in the form of the so-called smoker's cancer;
and the false, which is a form of tertiary syphilis, always more or less
sclcro-gummatous, and, according to some authorities, is never followed
by cancer. Some authorities, to the contrary, state that there are two
principal factors in the production of cancer of the mouth and in most
instances they are both present, namely, syphilis and the use of tobacco.
Without denying the great frequency of tertiary syphilis of the mouth
and its possible transformation into cancer, there is no question of the
existence of the non-syphilitic leukoplakia, chronic from the onset, followed
'by epitheliomatous degeneration. It makes its appearance almost
exclusively in men between the ages of forty and sixty. It is different
from the syphilitic lesion, and as a matter of fact should be treated as a
superficial epithelioma. Syphilitic leukoplakia is accompanied bv induration,
fissures and later by scarring and white fibrous tracts. The diagnosis
may be confirmed by a Wassermann. I feel sure that many of
the syphilitic lesions of the mouth later become cancerous, but this type
of malignancy does not respond readily to any form of treatment. It
has been shown in the past that the treatment of true leukoplakia has
not been satisfactory from the irritating methods of cauterization. When
first seen the lesions are very superficial and it is not necessary to use
a method which will destroy tissue at a depth more than one or two millimeters.
On account of the successful results which I have obtained in
the treatment of epithelioma with radium and on account of its easy
application to the mucous membrane of the mouth, I decided to employ
radium in my first case, almost three years ago. The results'were so
satisfactory that I have been treating all cases of true idiopathic leukoplakia
as well as a few cases of syphilitic leukoplakia ever since. The
latter have not responded nearly so well, but accomplishes more even in
the luetic type than any other local form of treatment we possess today,
because I believe in many instances we have an epithelioma situated in
syphilitic tissue and will not respond to one form of treatment alone.
In true leukoplakia we must abstain from giving iodides or compounds
of iodine, the effects of which are deplorable. Many of the cases have
had such treatment before they were referred, which only aggravated
the condition. It is necessary to make an early diagnosis since all ir-

R a d i u m 71
ritating treatment is contra-indicated. It is a waste of time to use gargles
and inert medication.
In -the treatment of leukoplakia the best results are obtained by the
rays of low penetration, as it is not necessary to have a reaction deeper
than one or two millimeters. I have been using one-half a millimeter
of silver, several layers of gauze and a finger cot as a filter. This allows
a large amount of the beta rays to be used in the treatment. Whether
this is absolutely essential I am unable to state, but, by using this amount
of filtration, the time of exposure can be considerably reduced. Using
a tube containing 25 milligrams of the element, one to two hours is
usually sufficient for each lesion depending upon its stage and extent. On
the tongue, on account of the papillae, it requires a slightly larger dose than
on the buccal membranes, but I always attempt to clear up the lesion
with the smallest amount of irritation possible. This is contrary to my
usual procedure in epithelioma of the skin or carcinoma of the cervix
or uterus, where intensive radiation is given as quickly as possible. This
coincides with many observers and is the principal reason why results
are so unsatisfactory from irritating caustics.
In this connection let me cite a case to illustrate the usual course of
many of the leukoplakias. Mr. M., age 50, had a leukoplakia on the
left inner side of the cheek. It was treated by caustics, first by his
dentist, again by his family physician, and a year later was removed
surgically and the pathological report was epithelioma. It recured, and
a second operation was performed. Three months after his last operation
he was referred for radiotherapy with a large infiltrated growth in
his mouth, which was broken down and very offensive, and he was
scarcely able to open his mouth. The glands were involved and he was
suffering a great deal of pain. Radiotherapy relieved the pain, killed
the offensive odor and checked the disease, but he died eight :ionths
later. These are the cases thai should have early radium therapy instead
of inert irritating treatment. We all have witnessed precancerous
lesions in the mouth following similar sad experiences, seeing the disease
progress under inefficient treatment. Epithelioma in the mouth is always
a serious condition if the disease is advanced and the results produced
by radium will, in the future, bring patients early so they can be
treated in the precancerous stage. Leukoplakia in the past has been
considered a trivial lesion and from the description in text-books it is
not any wonder that it is so considered by many.
In conclusion, radium has proven to be an efficient form of treatment.
Leukoplakia is frequently a forerunner of epithelioma and should
always be seriously considered.
Even when leukoplakia has become epitheliomatous, radium is the
best form of treatment we possess today and some remarkable results
have been obtained, but a guarded prognosis must always be given if the
disease is advanced and there is glandular involvement.
Reviews and Abstracts.
William H. Dieffenbach, M. D., (New York City). Reports on
Cancer Patients Treated With Roentgen or Radium Rays Remaining
Clinicially Cured After More Than Three Years. Journ. Am. Inst.

72 R a d i u m
Homeop. IX, 43CM36, Oct., 1916. This brief report is presented as an
effort to reply to the many recent contradictory statements as to the
value of radiotherapy in malignant conditions.
Physicians who have tested radiology for a period of years, have, in
spite of malicious and misinformed detraction, definite convictions as to
the value of radiotherapy in malignant disease and have the proofs of
their convictions in the living patients.
True it is that no specific or panacea for the treatment of cancer
exists today, but equally true is the statement that properly dosed radiotherapy
can positively inhibit cellular activity and in some cases cure and
in others retard malignant invasion.
In making these positive statements the writer does not wish to
minimize the value of surgery or remedial measures in the treatment of
cancer. Some of the most remarkable results noted were due to the
combination of surgery plus radiotherapy, and further progress can undoubtedly
be achieved by the conjoined utilization of constitutional,
surgical and physical therapeutics in the cure and control of this scourge
of mankind. The following histories are cited:
Case I. Mrs. L. G., aet. 35. Patient of Dr. Baruch, New York
City.
Date of entry, April. 1904.
Diagnosis: Osteosarcoma of the lower jaw.
Patient was examined by the late Dr. W. T. Bull, who refused to
operate. Patient was referred for radium treatment as a last recourse
and for the past twelve years has been under treatment and observation.
Radium has inhibited the growth, has prevented metastasis and. although
there is still a deformity of the jaw remaining, the lesion is quiescent.
Case II. Miss O. Patient of Dr. W. G. Crump, New York City
Date of entry: January, 1905.
Diagnosis: Cancer of cenix and posterior fornix.
This patient was operated upon twice and there were two recurrences.
After the second recurrence radium was given a trial by means
of a coated rod of 25.000 activity which was placed in the vagina against
and about the recurrence for one hour weekly for one year. During my
absence in Europe, Dr. William Harvey King continued the treatment.
using a ten milligramme glass tube for one hour weekly. The nodules
contracted and no recurrence has been noted for eleven years. Patient
is a professional nurse and is active in her work today.
Case III. Miss G.. aet. 64. Patient of Dr. Johnston, Brooklyn.
Date of entry, April, 1905.
Diagnosis: Epithelioma involving concha of the ear.
Operation with removal of concha was advised, but refused. This
patient was treated with radium and after six months no vestige of the
tumor remained. She was exhibited before the New York County Society
in 1910 as a cured patient and has had no recurrence after eleven
years.
Case IV. Hon T. B., aet. 58. Patient of the late Dr. James P.
Tuttle, New York City.
Date of entry, 1906.
Dr. Tuttle had diagnosed carcinoma of the rectum and advocated
radical operation but frankly stated that he could not guarantee a cure.
A large fee was demanded and the patient considered the combination
unsatisfactory. Some political friend suggested a trial of radium. A

R a d i u m 7$
specially coated rectal bougie was made, 25,000 activity, and applied in
the rectum for two hours weekly for several months. This checked :he
hemorrhages and improved the symptoms so that the patient paid for
the bougie and continued treatment at home. I had considered, not
having heard from this patient for years, that he had joined the great
majority and was surprised to receive a note last year that he was a
candidate for sheriff in a neighboring county. Inhibition of this lesion
can be claimed for fully ten years.
Case V. Mr. C .E. C, aet. 72. Patient of Dr. H. C. Reynolds,
Passaic, N. J.
Date 1907.
Diagnosis: Epithelioma of cheek.
Developed epithelioma of right check in 1904. The growth was
excised and recurred in two years. Was referred for radium treatment
and a series of massive doses were given in monthly treatments. There
had been no recurrence for eight years. This patient was shown before
the New York County Society for 1910 as a cured case.
Case VI. Miss F. H., aet. 44. Patient of Dr. E. St. John, Savannah,
Ga.
Date: October 29, 1909.
Diagnosis: Carcinoma of left breast.
There was a marked induration of the left upper quadrant with
involvement of the left axilla and also one nodule in the right axilla
subsequently. Operation was advised but refused by patient. These
lesions were treated by means of a large placque 4x4 inches coated vith
radium of 25,000 activity. This large placque was fastened over the
various areas involved and kept i'h situ five days at a time. Severe
dermatitis supervened but as the patient was anxious to return home,
treatment was repeated once a month for three months.
Patient visited New York City in 1913, four years after the original
treatment, and no mestatasis and no evidence of the lesion was present.
Heard from the patient in 1915; she was still in good health.
Case VII. Mrs. B., aet. 64.
Date: June, 1909.
Diagnosis: Inoperable carcinoma of left breast with contracted
nipple, which was invisible.
This patient had been refused admission to the Chapin Home for
the Aged on account of the cancer of the breast and was one of the
first patients in whom injections of solutions of radium gelatin was
tried. The lesion was injected with half an ounce of radium gelatin
solution, 25,000 activity, in June, 1909. A second injection of the same
quality and quantity solution was made in January, 1911, when evidence
of recurrence and further involvement was noted.
This lesion is quiescent at present. The nipple is still invisible
and the tissue about it contracted into a hard sclerotic mass covered
with telangiectasis. There has been no mestastasis; the patient is ttey
well and has been accepted at a Methodist Home for Respectable Indigent
Females. Seven years have elapsed since the first injection.
Case VIII. Mrs. S. T., aet. 73.
Date: January, 1910.
Diagnosis: Carcinoma of right breast with metastasis in right axilli
and left axilla.

74 R a d i u m
This patient was referred to me as inoperable. Has had massive
doses of radium over isolated nodules and massive general thoracic exposures
of Roentgen ray. The lesions have sclerosed and patient is in
apparently good condition after six years.
Case IX. Mrs. B., aet. 60.
Date: June 13, 1910.
Diagnosis: Recurrent cancer of left breast and axilla.
This patient had a Halstead operation of the left breast Feb. 9,
1910, and recurrence in June, 1910. Swelling of left arm and metastasis
in left axilla. This is one of the few of this character who has been
benefited. Had monthly massive Roentgen rays and was treated for two
years. No evidence of metastasis is present after six years.
Case X. Mr. C. D. M., aet. 61. Patient of Dr. Broughton, Brooklyn.
Date: March 21. 1911
Diagnosis: Recurring epithelioma.
Presented an epithelioma involving right lower eyelid and cheek.
Had been cauterized twice and operated four times. Recurrence after
each treatment. Radium given in 100 milligram hour doses sclerosed
the whole area and there has been no recurrence for over five years.
Case XL Mrs. S. P., aet. 58. Patient of Dr. T. H. Lemmerz,
Jersey City, N. J.
Date: April 2, 1911.
Diagnosis: Inoperable Cancer involving greater part of left ear
and tissues adjoining.
Patient was taken to hospital and massive doses of radium applied,
2,100 milligram hours divided over the entire surface. After one
month, massive Roentgen ray was applied for several months in succession.
The whole lesion sclerosed, the ear was saved and it is difficult to
tell at the present time where lesion was located. No recurrence in five
years.
Case XII. Mr. F. C. aet. 69. An emergency case treated in conjunction
with the late Dr. Bukk G. Carleton and Dr. Sprague Carleton.
Date: December, 1911.
Diagnosis: Cancer of the bladder.
This patient had. on and off. suffered from hematuria and had the
misfortune to break his catheter in the deep urethra while performing
his usual cystic lavage. Drs. Carleton were called in consultation and
Dr. Sprague removed the broken catheter through an endoscope. Some
days subsequently hematuria set in very profusely and various treatments
suggested by Dr. Carleton failing to check the bleeding, a suprapubic
incision was made and the bladder incised. Both Doctors Carleton
diagnosed a large fungoid mass almost filling the bladder cavity and
after deliberation concluded that operation was not feasible, the age and
condition of the patient being considered. A prognosis of fatal termination
of what both surgeons considered an inoperable carcinoma was
made.
With this prognosis before him the writer concluded to test the
efficacy of massive dosage of radium rays and a tube of 10 milligrams
of pure radium was placed at the end of a catheter and through the incisions
was introduced into the bladder. After 720 milligram hours
hemorrhages ceased and the radium was removed. The patient, almost
exsanguinated, soon showed signs of improvement, but after one week,
hemorrhages set in again. The process was repeated and the tube remained
in the bladder for 720 milligram hours again. The patient im-

R a d i u m
proved and resumed his business activities, passing his urine through a
catheter in the abdominal incision and same emptying into a specially
constructed rubber bag fastened between the groins. This patient lived
for over four years after this treatment and died in January, 1916, from
pneumonia.
This, it is believed, is the first case of cancer of the bladder cured
through suprapubic cystotomy and massive radium radiation, for the
patient at the age of 74 died of an acute disease, not involving in any
way the original lesion.
Case XIII. Mrs. W., aet. 59. Patient of Dr. A. E. Austin,
New York City. Treated in conjunction with Dr. E. Lathrop of
Buffalo and Dr. W. G. Crump, New York City.
Date: October, 1912.
Diagnosis: Recurrent papillary epithelioma involving left labia.
This patient presented a second recurrence of a fungating mass
growing from the labia about the size of a large lemon with involvement
of the glands of both inguinal regions.
Following pre-operative radium treatment of the tumor and both
groins for several weeks, Drs. Lathrop and Crump excised the tumor
mass and the inguinal glands and cauterized the open wounds. This
was followed by implantation of tubes and discs of radium in the incisions
of both inguinal regions, the radium being kept in the wounds for
three days. The discs were subsequently shifted at three hour intervals
along the whole periphery of the incisions of the labial and inguinal
tissues until the whole area had been covered and rayed. This postoperative
raying had for its object the destruction of any remaining malignant
tissue which the knife and cautery may have failed to reach. In
October this patient will have remained free from recurrence for four
years. The combination of surgery, cautery and pre-and postoperative
radium treatment has in this instance changed an apparently inoperable
case into a clinically cured one.
Case XIV. Mrs. F. Patient of Dr. Stella Q. Root, Stamford,
Conn. Treated in conjunction with Dr. W. G. Crump.
Date: October 27, 1912.
Diagnosis: Carcinoma of bladder.
Surgical removal by Dr. Crump was followed by postoperative
treatment with 30 milligram hours of radium through the incisions,
over the site of the lesion. No recurrence after three and one-half
years.
Case XV. Mr. H., aet. 61. Patient of Dr. Jas. Ackerman, Asbury
Park, N- J-
Date: February 20, 1913.
Diagnosis: Fungating epithelioma.
This lesion involved the whole nose and so deformed the patient
that he had to give up his business. Massive radium treatment 100
milligram hours over each area produced sclerosis. No evidence of the
disease is now visible after more than three years. Nose looks normal.
Case XVI. Mrs. B. Patient of Dr. James E. Burt, New York
City.
Date: 1913.
Diagnosis: Recurrence along the scar after hysterectomy for
cancer.
75

76 R a d i u m
This recurrence was treated by placing a tampon containing 100
milligrams of radium in a glass tube, screened by many layers of adhesive
plaster, and leaving it packed in the vagina for 24 hours, thus giving
2,400 milligram hours. This exceedingly heavy dose has produced
sclerosis and has prevented metastasis and recurrence. Patient is well
after three years.
In selecting a few clinically cured patients from the list of histories,
the writer was impressed with the fact that a much greater number
of recurrent and terminal cases treated by him have succumbed than
have been cured. The fact was also revealed that in the list of doctors
who referred these patients a relatively large number have also died
during the period quoted.
Ordinary cases of epithelioma are so frequently and readily cured
that they are not cited.
Many interesting lesions have been lost track of and cannot be reported
upon and the patients are presumably dead. This report is therefore
made in no spirit of exultancy or superiority. It is hoped that with
increased knowledge of dosage and improved remedial and dietetic treatment,
the value of radiology as an adjuvant in the treatment of malignancy
will be greatly extended.
From experience gained, it is especially urged that when surgery
removes the products of malignancy, postoperative radiation be utilized
as a positive and valuable aid in the prevention of transplantation, recurrence
and matastasis.
Co-operation of the surgeon, prescriber and radiologist will, in my
judgment, based on clinical experience, achieve better results than are
at present secured by one method dogmatically pursued by itself. In
making this statement the writer has in mind the dictum of the physician
who read the recent report of the "American Association for the
Control of Cancer," in which the unqualified claim is made that "surgery
at the present time is the only method to be employed in the treatment
of malignancy."
This statement is unfair and dangerous to the patient and directly
reflects upon the integrity of many workers who have claimed virtue>
particularly for Roentgen and radium rays. Many thousand cured
cases of epithelioma, recurrences of cancer after operation and occasional
inoperable conditions can be collected from current literature to
prove the contention that co-operation of various methods are required
for the best results.

A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY, PHYSICS ANI
THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES.
Edited and Published by Charles H. Viol, Ph. D., and William H. Cameron, M. D.
with the assistance of collaborators working in the fields of
Radiochemistry, Radioactivity and Radiumtherapy.
Subscription $2.50 per year, or 25 cents per copy in the United States and Canada
in all other countries $3.75 per year.
Address all communications to the Editors, Forbes and Meyran Avenues,
Pittsburgh, Pa.
VOL. VIII. FEBRUARY, 1917 No. 5
RADIUM IN SURGERY AND GYNECOLOGY*
By John M. Lee, M. D.*, Rochester, N. Y.
I will speak of radium-therapy to-day from the standpoint of the
surgeon rather than from that of the radiologist; and I am more
strenuous on the side of early surgical treatment of cancer than is
usually the case with most doctors. It has always seemed to mc that
one ought not to wart three or four months before he operates on suspected
cancer even if the disease may remain local that long; but that he
should remove the tumors as soon as they are discovered and long before
a clinical diagnosis can be made. Care should be taken to make the
incisions so that they can be neatly closed if the disease is found to be
benign. If there is the slightest doubt as to the character of the tumor,
a section of it should be submitted to a competent pathologist equipped
to make a miscroscopic examination at once, and to determine the diagnosis
while the surgeon is yet with his patient at the operating table. By
use of the freezing microtome, this requires but a few minutes. If the
tumor is found to be benign, the wound may be closed; oh the other
hand, if it is malignant, a radical operation may be performed,—for example,
as is now done in cancer of the breast.
Where the tumor is discovered very early, and a pathologic diagnosis
is made, the character of the growth may permit the surgeon to
remove the breast alone without danger of a return, and thus avoid the
maiming which comes from the radical operation. Eighty per cent, of
cystic breast tumors become malignant sooner or later and they too
should have thorough surgical treatment.
•Surgical and Gynecological Society, The Journal of tde American Institute
of Homeopathy. Vol. IX. No. 6. December 191S, pp. 5S9-616.

78 Radium
Some believe that medicine should be employed for a considerable
time before the patient is sent to the surgeon. In my judgment this is a
dangerous view to take, as the infection may be disseminated and the
patient rendered hopeless during this short period. Cases should be
treated by the internist, but not until after the focus of infection has
been extirpated. Then the patients should be returned to the careful
prescriber for his more efficient treatment. Surgeons are too busy, generally,
to look after this branch of the work; and naturally and rightfully
it belongs to the more competent internist. It is also much better
for the surgeon and his patients for them to be handled by the medical
wing of the profession provided they will sound the alarm early where
there are recurrences and again provide surgical treatment.
Even when all these measures are carried out, many of the cases
will finally become hopeless and inoperable. Then, tumors may develop
in sites in which operations cannot be performed or even considered,
and under the present careless regime the majority of the cases are inoperable.
It is these classes of cases that we shall consider during the
short time at our disposal.
Fig. 1.
It was four years after the discovery of radio-surgical-therapy, before
any scientific attempt was made to screen out rays objectionable to
the treatment of cases which required deep penetration; and but little
progress was made until 1907. Up to this time, often more harm than
good was done, by the agent, as too profound reaction, even surface
necrosis, developed long before the hard beta and gamma ravs could be
applied, for a sufficient length of time to effect deep seated lesions. Thin
rubber protectees were finally placed over the applicators, for cleanliness;
these supplemented the hard varnish which held the radium in
place, and the two together screened out the alpha and soft beta rays.
Brilliant results were now secured in the treatment of nevi and superficial
epithelioma (Fig. 1), but the deeper seated maladies could not yet be
safely reached. When, however, the physics of radium was finally carefully
studied and better understood, proper sc-eenage became at once the
desideratum to efficient use of the ultra penetrant rays and at once the

RAPITJM 79
longest step was taken toward the proper use of the agent in deep seated
lesions. Such freshly prepared apparatus requires several months to
elapse before reaching full power, due to the accumulation of radium
emanation; then its activity is constant for many years, since the radioactivity
of radium diminishes by only 1 % in about 25 years; therefore
its curative value is but slightly altered in time. In this particular
it is unlike the ordinary x-ray tube, which changes its therapeutic
value, constantly, even many times during a single treatment.
This stability and varied qualities of the radio-activity from radium element,
give us fixed points from which to estimate our dosage; this is a
most important factor. But there are others of almost equal importance.
These are:
1. Amount of the element used, screenage and time of exposure.
2. Age and physical condition of the patient.
3. The histology and pathology of the tissues to be rayed.
4. Site of the growth or disease.
5. Blood pressure, blood constituents, particularly the proportion
of leukocytes, and more especially the lymphocytes.
6. Co-existence of syphilis, tuberculosis or nephritis.
The amount of radium to be used depends upon the depth of the
diseased tissues to be reached and it should be increased inversely with
the square of the distance. The screenage follows closely the same law,
and it should be increased correspondingly with the dosage and the time
of exposure diminished.
The "toiles" of the French, and the films and other appliances of
the Americans, are especially useful in the treatment of skin diseases;
for they may be made to cover an arm or a leg at once, and they possess
the further advantage of even and accurate applications to uneven and
irregular surfaces. A one-twentieth strength film applicator, several
inches square, is of great value in the treatment of port-wine birthmarks.
In lichenoid forms of eczema, or acute inflammatory dermal affections,
no screens are needed other than the varnish which holds the
radium in place. Here the beta rays are largely relied upon to do the
work, and they.are most efficient; but great care must be taken, else
too long exposures develop inflammatory reaction, which should not
often occur.
The local effects of radium applications, make their appearance in
from a week to twelve days, in the form of dermatitis. This is the
reaction of the tissues; blisters may form and desiccation result; the
process is progressive for a few days, though at about the third week,
the part heals without scarring, and the tissues are left soft and normal.
In other instances the reaction is not perceptible macroscopically though
it is always present in the tissues, and sometimes systemic depression
develops. This process may be minimized by careful screenage and
dosage but there is always some reaction from efficient application, no
matter how careful one may be, or what technic he employs.
The age and physical condition of the patient are factors that must
be carefully considered: In the young the tissues are more susceptible
to the rays, and care must be taken else the dosage will be unneccessarilv
severe. Here, as everywhere, the needs of the patient must be
carefully scrutinized, and the rays especially indicated employed; and
those known to be objectionable, screened out. In skin lesions all the

so R a d i u m
rays may be needed from ten milligrams of radium element for two or
three minutes; or, all the alpha and the soft and medium beta rays
screened out for use in deep lesions as sarcoma, carcinoma, etc. Frequently
the gamma rays alone are employed. Five hundred milligram
hours radiation, from radium element may be considered a fair dose;
though three times that amount may be borne with but little depression
or local reaction, if the patient is in fair condition ami the apparatus is
screened with .5 millimeter silver; .5 millimeter brass; gauze pads of
graduated thickness up to an inch, owing to the depth of the disease;
and .1 millimeter rubber tissue, next to the skin. The amount of radium
element required for such an applicaton may vary from 25 to 500
milligrams of radium element. If the dose is smaller, the time of exposure
must be lengthened; and if larger, shortened to get the required
number of milligram hours of exposure. As yet it is not known whether
smaller doses and longer exposures, or larger doses and shorter exposures,
yield better results. One should not attempt general work, however,
with much less than one hundred milligrams of radium element
though it should be divided up in applicators of various amounts of
radium element, from ten milligrams in the varnish apparatus to several
twenty-five milligram tubes. It is better for the beginner to start his
practice with ten milligrams in a varnish applicator, and confine his work
to superficial lesions; then, as his experiece permits, gradually increase
his holdings in the radium, until he has a sufficient amount of the element
to enable him to reach deep-seated disease.
Care must always be exercised, else harm comes from the use of
this most valuable remedy. If the dosage is too small and too long applied,
the growth under treatment may be stimulated and aggravated; or
if applied as a prophylactic over a healing wound, from a recently removed
malignant disease, furuncles and indolent swellings which exude
a thick sanious pus may develop. It may require four or five weeks
for these to heal; in several ca>es in which this condition developed, the
patients remain well after three years.
When the radium is placed in the ends of long rubber tubes as applicators
and carried down to the bottom of the wounds from which
malignant tumors have .been removed, the applications must be shortened
else too much destruction of tissue will follow. In a case of round cell
sarcoma of the femoral canal, the femoral vein was encircled by the
growth, and a section of it was necessarily removed. Twenty-five milligrams
of radium element were carried down to the bottom of the wound.
in the drainage tube, and allowed to remain for eight hours. This ap"
plication was too long; a watery, purulent discharge came through the
drainage tube opening for three weeks, when four inches of the femoral
vein with the ligature still securely tied to its end. sloughed, and I drew
it out of the wound. The patient was discharged at the seventh week
with the wound healed, and attends to her duties as a housewife. Her
foot and leg to the knee are somewhat swollen, though they do not give
her pain nor much inconvenience, and there are no signs of a return
of the disease after twenty-six months.
The exposure was too long and I have reduced it in subsequent
cases of both sarcoma and cacinoma. which involved the jugular veins
of the neck. There were three of these patients and they were all
treated substantially the same. The jugulars were tied in two places
and divided between the ligatures above the growths. Then the clavicles
were divided, and the muscular attachments severed, when necessary, to

R a d i u m ri
permit retraction of the cut ends of the clavicles in all cases to make
room in which to work. The tumors were carefully dissected from
above downward, and the hemorrhage controlled: when the jugulars
were reached near their origin, they were again tied and the tumors removed.
In all these cases 25 milligrams of radium element screened by
0.5 millimeter silver, 1 millimeter lead, and 2 millimeters of the rubber
drainage tube were left in contact with the deep wounds, to act for four
hours. The discharge was thin and after a day or two, straw colored,
which continued for two weeks, at which time all the wounds closed, except
one, and this finally healed, and good results were secured in all
the cases. One year has elapsed since the treatment of the last patient,
and one-half and two years respectively, in the other two . In my judgment
from two to four hours is about the proper length of time tubes
should be buried in the tissues.
I am aware that some surgeons deprecate the use of radium in this
way, but I would not undertake the treatment of such hopeless cases as
these, unless I could employ radium to supplement the use of the knife.
_ In the prophylactic treatment of cancer, the technic should be
varied to suit the needs of each case; If it be a large wound like that from
removal of the breast, several radium tubes should be screened by lead
or brass tubes, then crowded into the end of a rather thick-walled rubber
drainage tube, and laid in the bottom of the wound from its lower
angle to the upper border of the axilla. The tubes should not
be placed in contact with large vessels. After they have acted for
not be placed in contact with large vessels. After they have acted for
a sufficient time they should be drawn into a new site, and so on until
all the surfaces of the wound have been carefully rayed. From one to
two hours with a dosage of 75 milligrams of the element, will be sufficient
for wounds of this character. Of course this rubber tube is used
solely for the application of the radium; drainage must be provided with
another tube carried through the usual site.
When secondary deposits of cancer arc removed from the axilla or
other sites, two hours radiation with 25 milligrams radium element
will be sufficient. In case of operation for cancer of the cervix, the
rectovesical flaps should be carefully closed, .ind the vaginal wound left
open; then when the abdominal wound is sutured, 25 milligram tubes
should be laid in the wound and maintained in position with gauze packing
for two hours, then removed.
If for any reason it seems unwise to employ the above method
radium should be used in larger dosage, with distance screenage and
longer exposure, after the wounds have healed; or, at the latest, when
the first manifestation of recurrence appears. It is not in this class of
cases that the age and physical condition of the patient are important
factors; for this work is borne with impunity, and the local effect alone
must be guarded. But in the extensive deposit of cancer, the hitherto
hopeless cases, caution as to dosage must be used. The surgeon must
proceed with great care after fifteen thousand milligram hours radiation
have been administered during a period of three months. Some patients
will stand much greater dosage than this, and others will succumb from
toxemia due to the great mass of cancerous debris liberated in the system.
The histology and pathology have much to with this condition,
since regression is more-rapid in some kinds of malignant tumors than
in others; the squamous cell and the spine cell varieties, particularly,
are more difficult to bring into satisfactory condition than other forms

82 R a d i u m
of carcinoma, and the same disease in some tissues is more readily influenced
by radium than in others.
Again, the condition of the blood must always be determined
for it affords the best indication as to whether the case should be started
on small or large doses. Sometimes the leukocytes are down 2000 in
cancer, and as they are the chief scavengers of the system, we are at once
greatly handicapped in the use of the agent, therefore, progress must
be made slowly and with small doses.
I once had a patient with cancer of the rectum with a leukocyte
count of 1900, increase to 6200 in the short period of four weeks, and
nothing was done except to use the radium cautiously in the meantime.
In another case, the blood pressure was 210 and the patient died of
apoplexy before regression of the growth could be effected. I now know
that the treatment of that patient should have been begun with intravenous
injection of radium, and her blood pressure reduced, and her
general condition improved before her system was taxed too much by
the elimination of the toxic emanations from the growth.
The co-existence of cancer and syphilis must be recognized, else appropriate
treatment cannot be employed. Tuberculosis complicates cancer,
and frequently lupus degenerates into a malignant type of that
disease, and demands the most vigorous treatment. If the kidney is involved
the chief channel of elimination in all these conditions is greatly
impaired, and one must proceed with moderate dosage, and endeavor to
throw part of the work of elimination on other organs. Even then the
treatment of such cases is anxious and uncertain.
Nevi of all kinds are acted upon with great satisfaction. The portwine
stains, hairy pigmented blemishes of the face, and cavernous vascular
nevi when extended over large areas, were all beyond remedial
agency prior to the introduction of radium. Today they may be treated
with great success. Restoration of the tissues is produced by the agent,
with little or no real destruction of the normal tissues. When coarse
hair and thick, unsightly discolored skin are present, the hair is permanently
removed and the skin is left soft and pliable. Short exposure
of a few minutes, with the unscreened varnish applicator removes the
various tinted stains, though the skin over the sites of the growths is
slightly whiter than that which surrounds them.
The action of radium is so remarkable that even after four years of
experience, I am often surprised at the extent of its inhibitive and restorative
effect on neoplasms, both benign and malignant.
Although Martin of Berlin dissents, nearly all other writers credit
radium with a selective action for diseased tissues. The few who object
to this peculiarity of the element's curative powers explain their theories
on pathologic, histologic or other grounds, but all this does not elucidate
the problem as the diseased cells disappear with hut little injury to the
healthy ones which surround them. This is especially marked in most
forms of malignant tumors, in which it changes the cells back to more
nearly the embryonic type from which they developed. This selective
action, no matter how it may be explained, is not so pronounced in
growths of epithelial tissue as it is in those of connective structures;
neoplasms, here particularly, are about six times more readily acted
upon by radium than the normal tissue which surrounds them. In many
cases, the growths soften shrink and disappear without destruction of
the normal tissue, in such a short period, sometimes two weeks, that the
whole process seems incredible, even to the initiated. In other

R a d i u m g3
cases, the pain, hemorrhages, and foul discharges cease, and the
part cicatrizes and leaves a soft, yielding scar, without contraction, deformity
or unsightliness. Sometimes regression to a marked degree is
secured, and the case progresses no further. This fibrosis of the neoplasm
may be allowed to remain inactive, or, be excised and the wound
rayed or not, as conditions indicate. Again, inoperable tumors may
undergo sufficient regression to permit ready removal, and thus bring
the patient into good condition.
Radium is a most useful remedy in joint disease, of both specific
and rheumatic origin. I am convinced that on two occasions, resection
of the knee joint was rendered unnecessary by intravenous injections of
fifty micrograms of radium element, repeated several times two weeks
apart.
In genito-urinary diseases, the remedy is of service, especially 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, for drainage. In such cases, the dosage
must be greater than in inoperable cancer of the cervix and vagina.
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. Various forms of ulcers and hemorrhages of
the bladder are favorable conditions to treat. Management of hypertrophy
of the prostate, is fast coming into "this field; and a number
of cases of cancer of this organ have been clinically cured, and remain
well after one and two years.
On the mucous membrane of the buccal cavity, roof of the mouth,
tongue, gums and pharynx, much skill and patience are required to obtain
successful results. One of the greatest aids to secure the tubes in
proper position on these sites is No. 20 copper wire. It may be ben*
to form little eyelets through which silk ligatures may be passed, then
securely tied about the rubber and other screens at each end of the tubes,
and firmly bound to the wire. This applicator may then be placed over
the diseased part and bent over the face, chin or forehead and held in
place by adhesive plaster and bandage. If the above apparatus is neatly
and efficiently adjusted, it meets the indications much better than is
possible by relays of nurses.
The tongue cases, especially, are exceedingly obstinate, and those
who have effected cures have accomplished the feat, only by the expenditure
of much time, thoroughness and patience (Fig. 2.) These cases
are generally spine celled, and where feasible surgery should be combined
with radium-therapy. In patients who could not be treated by
operation, I have relied upon large dosage of well screened tubes
stitched to the tongue, and allowed to remain for from twenty to
twenty-four hours. Reaction was somewhat painful and protracted, but
good results were finally secured.
The most remarkable regression I have seen in malignant tumors
treated by radium, has been in the round cell sarcoma of the neck,
parotid gland and face. One case, particularly, was almost miraculous
in the rapidity with which the tumor disappeared. A single application
caused the pain to subside and the parts to assume nearly Bhcir normal
appearance in the short period of ten days, and in two weeks there was
but little to show that such a deadly disease had existed. It is better
to combine good surgery with radium-therapy, if possible, in sarcoma

84 R a d i u m
and carcinoma, though the surgeon should not disgrace his art by the
performance of operations on too advanced cases unless he can supplement
his work by suitable radiation.
In cervical adenitis, or even Hodgkin's disease, where not too widely
disseminated, radium yields excellent results. When most of the
lymphatic centers as the neck, axilla, or groins are involved, the growths
had better be removed, then the sites and mediastinum, if involved, rayed
with heavy dosage and distance screenage.
Fig. 2.
I have seen marked benefit in mediastinal tumors which resulted
from carcinoma of the breast. Of course, the cases were not curable
on account of general infection, but the growths were greatlv reduced,
and the patients breathed freely and were made comfortable. The life
of one of these has been prolonged for three years. There was general
infection when the breasts were extirpated, and metastatic growths have
;ince appeared in one of the women. They developed on her neck, chest,
supraclavicular region, scalp, both axilke, left orbit and mediastinum.
Her eye was removed, and the orbit and all other wounds raved at the
time of the operations. The large flat growth of the scalp was not removed,
but it regressed completely by the use of the ravs. All these applications
of radium were satisfactory, but its greatest triumph was in
the regression of the flat growth on the scalp, and the great diminution
of the size of the mediastinal tumor. In both of these hopeless cases
life has been prolonged two or three years, and the patients made comparatively
comfortable. I now have three other cases of mediastinal
tumor under treatment and the progress is remarkable; the disease has
subsided where rayed and the tissues look in the radiograph as though
they had been cut out with a knife and a sharply defined border left.
Four cases of malignant disease of the neck and larynx have come
under the care. The first was a very advanced case and she was a long way
toward recovery when she died suddenly of pulmonary embolism. The

R a d i u m
second refused tracheotomy and succumbed before regression could be
secured; the third, tubercular larynx, is improving; and the fourth.
malignant goiter of the squamous cell type with marked involvement of
the thymus, cervical glands and larynx, is also improving satisfactorily.
His case was inoperable and he was obliged to have emergency tracheotomy
done. When he was received his eyes bulged, he breathed through
the tube alone, and he could scarcely swallow. Now the trachea tube is
kept corked and he breathes through the larynx; his eyes are improved
and he can swallow freely.*
Fig. 3.
Until radium was brought into use, malignant tumors of the antrum
of Highmore and the nasopharynx were incurable. The ghastly extirpation
of the superior maxillary, afforded relief for but a few months or
years at the most. And, as I recall my cases, it is evident that the benefits
derived from the operation are not such as to warrant its further
continuance, as raying of the growths serves the patients much better.
If operation is finally decided upon radium-therapy should also be employed
; and where the pathology of the growth is favorable, raying alone
will yield better results than operation. (Fig. 3.) This is especially
true in sarcomata of the nasopharynx; they are always fatal without the
use of radium, and with it the results are astonishingly satisfactory. At
first I could not bring myself to believe this, and in several cases I
combined surgery with radium-therapy. I now know this to have been
a mistake, at least, until radium had been tried; and I believe it will be
a long time before I shall use the knife again in these cases, for the
large growths disappear promptly and many patients remain well.
Sarcomata and epitheliomata of the tonsils in several patients have
yielded excellent results. They arc inoperable usually, and while most
of the cases yield promptly to radium, some of the pathologic make-ups,
as the spine cell carcinoma, require much skill and thoroughness to bring
them under control. In one of my first cases, a vigorous powerful man,
'He has since died though his life was prolonged and he was rcUeved of
pam.
S5

86 R a d i u m
with more money than judgment, jerked his head backward through t
supporting hands of the nurse, and at the same time yanked the mucoussmeared
and slippery braided silk thread out of my hand, just as I was
about to seize the tubes in the pharynx with forceps, and swallowed 175
milligrams of radium in three well screened tubes. He refused immediate
gastrotomy, and the tubes were passed through the alimentary
canal at the average rate of nine inches per hour. No injury followed
and he said: '*None of the crowned heads of Europe have anything
over me in luxurious repasts, for I have had the only distinction of the
consumption of a $20,400 meal."
Disease of the thyroid gland offers very' favorable^ results with
radium treatment. Like the application of the remedy in most other
sites, proper screens, dosage, and careful study of technic are necessary
to secure the best results. The remedy should be used in malignant
growths either in connection with surgery or alone. Exophthalmic
goiter with thymus involvement does not respond to radium as satisfactorily
as to operation; yet the cases are greatly improved, and a number
of cures have been reported. I can add one to the list. Thyroid carcinomatous
growths of the colloid type regress under the action of
radium and frequently clinical cures are made. With most recurrences
after operation, cures may be expected by the use of radium.
In malignant tumors of the breast, radium is a valuable remedy,
especially in recurrences; and I have a number of patients who have
remained well three years after several unsuccessful operations had been
performed. Inoperable cases should have the benefit of radium, and
those suitable to the knife, both surgery and radium.
In the treatment of rectal diseases, radium is a valuable aid; it may
be used alone or combined with surgical procedure, and it is. in many
ways, of great advantage to the patient; some clinical cures have been
made. Polypi, whether in the rectum or bladder, are readily cured by
radium, without much annoyance, and there is no scarring or danger.
Adenocarcinoma is generally curable, but the squamous cell variety of
cancer is more intractable; still we have had clinical cures in some of
these cases.
Radium, in the treatment of uterine hemorrhages which persist after
several curettages, is a most valuable addition to our present equipment.
Great care must be exercised, especially in young women, however, lest
amenorrhea and sterility be produced. It acts in a similar way on men
if too large dosage be applied to the testes, as they may become impotent
if due care is not observed.
Among the most favorable sites for the use of radium is the cervix
uteri and vagina, in both operable and inoperable cancer. Some surgeons
have progressed so far in radio-surgical-therapy, that they believe raying
of malignant diseases of those organs, at any stage, is preferable to
operation; but I cannot agree with them in this practice. It is my judgment
that where all the growth can be removed, it is better to perform
hysterectomy; and immediately ray all the tissues of the incision or, if
this cannot be done, keep the patient under observation, then if there is
recurrence cause regression by thorough raying
I have seen some of the most brillant results in the treatment of
cases of inoperable cancer in this site. Dangerous hemorrhages, excruciating
pain, and disgustingly fou! odors have been made to dissappear,
almost at once; and birth canals and cervices that were involved

R a d i u m 87
from the_ meatus urinarius to the internal os, to such an extent that
the vagnia was closed, regress, and the tissues become soft and yielding,
and the cervix assumes more nearly its normal appearance during a single
month of treatment. But where the disease extends into the rectum, bladder
and broad ligaments, it requires more time; and the treatment of these
cases is not so satisfactory as where the disease is confined to the vagina
and the cervix; still the results in some of these most pitiable cases are
surprisingly good.
In fibroid tumors of the uterus, the action of radium is exceedingly
gratifying. Nine-five per cent of the cases are cured, and the balance
undergo such regression that the tumors are no longer a source of discomfort
to the patients. (Fig. 4).
Fig. 4.
OUR •*3HI">
fj IR|*7Mlltt
>nta ±

R a d i u m
be diagnosed early, if this becomes a general rule. Some operator: state
that they never have cured a cancer of the uterus by operation. I thinkthat
by operating, and then using radium, many cases will he cured, and
that many cases in incipiency will not have to have the uterus removed
entirely. Cauterization is all that is needed, and then the application of
radium will effect a cure. In my experience of a year and a half I have
had a number of cases of epithelioma disappear absolutely aficr three,
four or rive weeks under radium. There has occurred in a number of
cases metastasis to the liver, to the stomach, and general peritoneal involvement.
I have gotten in the habit since July of last year of having
the Coolidge tube applied over the abdomen after the cancer has disappeared
from the local application of radium, using first the curette, or
cauterization if the cancer is large, then the use of radium until the
growth is entirely gone, and then in six weeks three minutes of the
Coolidge tube on the right side over the ovary, and then en the left side
once in a week's time, going up two inches more in a week's time, and then
two inches more, giving six, eight or ten treatments. This method will assist
materially in curing clinically many cases of cancer of the uterus.
Dr. Ashcraft: If Dr. Lee has had any experience with radium in the
treatment of tumor of the urinary bladder, I would like to hear what his
results have been. In cancer of the urinary bladder, operation offers
the only hope. Some time ago, I wrote to the Ixindon Xadium fn*titute
and asked them to send me a report of all cases of tumor of the urinary
bladder treated by radium. There were not any ca-.es reported. Dr.
Howard Kelly is one of the most enthusiastic supporters of radium. In
an article published in the Journal of Surgery a month or so ago. he
claims that after trying all methods of treatment, hi has decided that
cancer of the urinary bladder is not amenable to radium. In the early
stages of bladder tumors, fulguration is decidedly the treatmem of choice.
I do not wish to criticise radium, but its value in my line of work is questionable.
I know of only one exception. Dr. Ayres reported a case, in
which he had applied radium through a cystoscope. Up to the time that
he reported this case his results were very satisfactory. He told me
afterwards that the patient had returned to him, and died from diabetes.
Dr. Lee (closing the discussion): Pathological examination in all of
these cases is the thing desired. We are equipping our hospital to do
this work very thoroughly. Incisions of cancerous tissue may cause
dissemination of the disease. This may be equal'y true when icmoving
specimens for microscopic examination and uniess the dicsase is so situated
that a section can be taken without much trauma, it is safer not to
remove tissue for pathological purposes.
I have not had sufficient experience with the treatment of cancer
of the bladder to enable me to speak with any degree of authority as to
the usefulness of radium in this site.
When wc work on such tissues as the lung, the neck or other
deep parts of the body, we must increase the dosage and screenage. If
we treat the chest we should use an inch of gauze screens faced with
rubber over the other screens and then we must increase the dose of
radium. The rule is that in deep penetration tt)3 dosage must be increased
inversely with the square of the distance. The doctor from Cincinnati
who has had such good results will find that if he increases his dosage
and screenage he can reach tumors of the pelvis, the mediastinum or
other deep tissues.

R a d i u m
RADIUM TREATMENT OF CANCER OF THE CERVIX*
Palmer Findley, M. D., F. A. C. S.,
Omaha, NEBRASKA.
The value of radium in the treatment of cancer of the cervix is not
as yet established. It is extolled by a few and condemned by many, but
the vast majority in the medical profession, of this and other countries,
has no settled convictions on the value of radium in therapeutics. Certain
it is that radium should be given an extended trial because enough
is known of its therapeutic action to justify its use in all cases in which
surgery cannot be invoked. My modest contribution to the cause rests
in the following abstracts of nine case reports, together with such clinical
deductions as seem warranted.
The radium was administered by Dr. D. T. Quigley of Omaha,
who has supplied the following notes on his methods of application:
"The radium instruments used in this series of cases are four tubes,
each containing a small fraction under 16 mg. radium element, one
square applicator containing approximately 16 mg. radium element and
a square containing 5 mg. radium element. The squares were used on
the abdomen, just above the pubic bone, as cross lire.
"The tubes used in the.cervix or in the vault of the vagina were
encased in J4 mm. silver.
"In cases where the wall between the vagina and rectum, or between
the bladder and vagina were so thin as to make it dangerous to use the
silver tubes alone, they were further encased in tubes of 1 mm. brass,
and in some cases the brass was further covered with 1/3 to 1/2 inch
gauze; this to get distance filtration; and the whole was covered with
rubber dam.
"The squares were always covered with 1 mm. brass screens, as
only very penetrating beta and gamma rays are of use here.
"In every case the most accurate approximation possible was made
between the tubes and the diseased area."
When desiring to apply radium immediately after an abdominal
hysterectomy, a half inch pure India rubber tubing is stitched to the
vault of the vagina. The anchored end is closed with sutures and is
made to protrude about one inch into the pelvis. The tube is long
enough to extend beyond the vulvar outlet. The radium is attached
to a stiff wire and passed the length of the tube. In this manner the
radium is placed partly within the pelvis and partly in the vagina. The
radium is readily removed and can be replaced in subsequent treatments
with no inconvenience to the patient.
Case I. Mrs. W.. age 58. no pregnancies, entered Clarkson Hospital,
October 10, 1914. There was a foul vaginal discharge which
later became bloody and was acompanied by pelvic pain and moderate
loss of flesh.
Examination revealed an advanced cancer of the cervix and extensive
infiltration of the parametrium.
Treatment. Cervix curetted, cauterized and acetone applied. Acetone
applied three times in the following ten days. Two weeks later the
following applications of radium were made:
•American Journal of Surgery, Vol. XXX. No. 11, Xov. 1916. p». 337-9.

90 R a d i u m
Six treatments, 12 hours each 32 mg. in silver tubes, together with
20 mg. cross fire on abdomen, 1 mm. brass screen.
I examined the patient two months later and found the uterus freely
movable, entire absence of exudate in the pelvis, and the vault of the
vagina perfectly healed. Eighteen months later she was again seen hy
Dr. Quigley who reported a cancer on the posterior wall of the rectum
but no evidence of recurrence in or about the uterus. The patient dietof
the cancerous bowel about eighteen months from the date of the first
application of radium.
In this case the disappearance of the pelvic exudate, together with
all local manifestations of the disease was most gratifying. It is noted
that to the time of her death (about eighteen months af^er the first aplication
of radium) there was no evidence of recurrence in or about the
uterus.
Case II. Mrs. P., age 48, 1-para, complained of a watery discharge
beginning June 1913. Later she was distressed with pain in the
vagina and left side of pelvis. No alteration in the menstrual flow.
There was found a cauliflower cancer of the cervix with marked infiltration
of the left broad ligament.
The cervix was curetted and cauterized and acetone applied. The
acetone applications were repeated seven times at intervals of three to
ten days. The discharged disappeared but the pain persisted.
November, 1914 radium was applied as follows:
Two treatments 36 hours each,
Sixteen treatments 12 hours each;
32 mg silver tube;
20 mg cross fire on abdomen.
1 mm brass screen.
In this case the large number of treatments were given because of
the difficulty in controlling the pain and the repeated recurrence of the
growth at the vault of the vagina.
Indeed it may be said that the radium had little control over the
development of the growth in the excochleated cervix, nor did it lessen
the pain. I doubt if the patient's life was prolonged or her suffering
lessened by the radium. She died in uremic coma about six months
after the initial application of radium.
Case III. Mrs. L., age 56, 0-para, complained of a heavy dragging
sensation in the pelvis for the preceding two months and for three years
antedating her admission to the hospital, she had a foul, odorous vaginal
discharge. Menopause established at 42 years of age. On admission to
the Clarkson Hospital, July 1915, she was found to have an advanced
cancer of the cervix with extensive infiltration of the left broad ligament
and utcrosacral ligaments.
The cervix was curetted and cauterized and acetone applied. At
the end of ten days the cellular exudate had largely disappeared and a
radical abdominal hysterectomy was performed. Radium was applied
at the end of the operation as follows:

R a d i u m 9\
July 12 17 hours 32 mg
July 15 11 hours 32 mg
July 17 12 hours 32 mg
July 20 14 hours 32 mg
Total 54 hours 32 mg
Five months later the patient developed intestinal obstruction. The
abdomen was opened and the entire peritoneal cavity was found invaded
with carcinoma. The patient died soon after the secondary operation.
Case IV. Mrs. T.. age 78, Ill.-para, enteied the Clarkson Hospital,
July 1915. For several years she had suffered from articular rheumatism
and cardiac incompetency. For the six months preceding admission there
had been a bloody vaginal discharge. Examination revealed far advanced
cancer of the cervix. The cervix was curetted and cauterized and acetone
applied. Radium was later administered in the following manner:
July 14 24 hours 32 mg
July 18 12 hours 32 mg
July 22 15 hours 32 mg
Total 51 hours 32 mg
20 mg cross fire on abdomen.
1 mm brass screen
No improvement was observed and patient died in about three weeks,
from what her attending physician called heart failure.
Case V. Mrs. IT., aged 46. was referred to me April 10, 1915 two
weeks after amputation of the cervix. A diagnosis of cervix carcinoma
had been made by two competent pathologists. A radical abdominal
hysterectomy was performed and radium applied as follows:
April 17 12 hours • 32 mg
April 18 10 hours 32 mg
April 28 7 hours 32 mg
April 29 14 hours 32 mg
May 10 13 hours 32 mg
Total 56 hours 32 mg
First two treatment 20 mg cross fire on abdomen.
1 mm brass screen.
The patient suffered intensely from an irritable bladder. Later she
developed pulmonary embolism but slowly recovered and lived for about
one year. The condition of the pelvis at time of death not known.
Case VI. Mrs. H., age 50. II-para, admitted to the Clarkson Hospital
September 8. 1915, when radium was applied to a recurrent vaginal
cancer. An abdominal hysterectomy had been performed some months
before. Radium applied as follows:
September 8 16 hours 62 mg
September 9 16 hours • 62 mg
October 22 14 hours 62 mg
October 24 18 hours 62 mg
February 26 12 hours f>2 mg
February 27 28 hours 62 mg
Total 104 hours 62 mg

•)1 R a d i u m
20 mg cross fire on abdomen.
1 mm brass screen.
Infiltration in the vaginal walls and parametrium disappeared under
the influence of radium for a period of four months and then reappeared.
Subsequent treatments failed lo effect the growth to any noticeable degree
and were abandoned.
Case VII. Mrs. B.. age 50. Ill.-para, was admitted to Clarkson
Hospital September 12. 1915. She had passed the menopause at 47
years of age. For three month- she suffered from the pelvic and bloody
vaginal discharge. There was also cardiac decompensation and extreme
anemia.
She had an early cancer of the cer\i\. A total abdominal hysterectomy
was performed and radium applied in the following manner:
October 24 18 hours 62 mg
October 26 17 hours 62 mg
Total 35 hours 62 mg
20 mg cross fire on abdomen
1 mm brass screen
There was no evidence of recurrence ten months after the radium
treatments.
Case VIII. Mrs. A.. 55 years of age. V.-para. entered Clarkson
Hospital September 20. 1915. Menopause passed at 52 years of age. Complained
of pelvic pain and bloody vaginal discharge for three months.
Diagnosis, cancer of cervix with no palpable extension beyond the cervix.
Radical abdominal hysterectomy performed and radium applied as follows:
October 4 15 hours 62 mg
October 6 16 hours 62 mg
Total 31 hours 62 mg
Abdominal wound failed to unite. Patient died of exhaustion eleven
weeks after operation.
Case IX. Miss C. age 23. 0-para. admitted to Clarkson Hospital
July 13. 1915.
Diagnosis: advanced cancer of cervix.
Treatment. Initial curettage and application of acetone; 50 mg of
radium were applied for a total of 84 hours at three intervals and at the
end of three weeks a radical abdominal hysterectomy was performed.
Following operation 50 mg radium was applied for a total of 30 hours
in three intervals.
Examination at intervals disclosed no evidence of recurrence until
June 1916. when patient returned with a swelling in the right iliac fosca
and great pain radiating down the right leg. The abdomen was opened
and a group of large glands found. A rubber tube was anchored to the
margin of the abdominal incision and its distal end closed with sutures

R a d i u m 93
and placed to the side of the glands. 50 nig radium was carried to the
bottom of the tube and left for 4 hours. These exposures with radium
were repeated twice. The results are as yet unknown but it was hoped
that the pressure pains might be relieved by reducing the size of the
glands. The pain had not been relieved three weeks after the treatments.
CLINICAL DEDUCTION.
First:—It will be observed that cases III., V., and IX., which were
regarded as inoperable, became frankly operable after the application of
the curette, cautery and radium. In each instance no enlarged lymph
nodes or infiltrated tissues were observed when hysterectomy was performed.
In case IX. the scrapings from the cervix were of a highly
malignant type but Dr. Schultz. the pathologist, who made careful search
for cancer cells in the removed uterus, was able to find only a nest or
two of degenerated epithelium. The logical conclusion is that in radium
we have a most valuable agent in transforming an inoperable case into
one that is operable. However, we mus* not imply that such cases are
curable. Many of them we know are not cured and the time limit has
not yet been reached for pronouncing any of them permanently cured.
Second:—Case II. was not favorably influenced by the radium. There
was recurrence in the vault of the vagina very shortly after three successive
applications of radium. Here, as in another instance in my experience,
radium failed to destroy completely the near lying cancer cells.
Third:—In cases II., IV., VI., VIII., pain was only partly or not at
all relieved by radium. In case I., and VII., the pain was promptly relieved.
In case V. the pain intensified but was largely accounted for by
irritable bladder.
Fourth:—Cases VII., and IX, suggest the importance of applying
radium on the operating table following hysterectomy. It is maintained
that in so doing implantation of cancer cells at the seat of operation may
be prevented. Case V. suffered intensely from an irritable bladder.
She was probably overdosed. Case VIII. developed a vesicovaginal
fistula which promptly healed spontaneously—she too was probably overdosed.
It would seem advisable to limit the number of mg hours in
post-operative cases to one-half or one-third the usual dosage.
Fifth:—The rapidity with which the general peritoneal cavity was
invaded in case III. suggests that the radium might have had a stimulating
effect upon the cancerous growth.
Sixth:—In cases IV. and VIII. the patients failed to react well to
the radium treatments. They developed a toxic condition and it was
thought that death might have been hastened by the action of the radium.
Here again it is possible that they were overdosed.
Seventh:—Two of the nine patients are still living; one after a
period of fourteen months, the other ten months. In one there is no
evidence of recurrence and in the other (case IX.) the enlarged lymph
nodes in the right iliac region, which have lately developed, are highly
suggestive of recurrence.
Eighth:—Finally it is fair to conclude that radium has a place in
the treatment of cancer of the cervix. It is our most effective means of
relieving distressing symptoms, it prolongs life in nearly all instances,
it converts many inoperable cases into operable cases, but as yet we can
say nothing of the curability of these cases.

94 R a d i u m
"damned with faint praise'
"Radium as Cure for Cancer is Failure says Head of Crocker Fund
of Columbia University."—Cincinnati Enquirer, Dec 18, 1916.
* * • • *
"Report Radium Fails as a Cure for Cancer. George Crocker
Special Research Fund Spends Another Year in Fruitless Quest for
Method to Combat Dread Disease. Many Experiments are carried on
by Investigators."—New York Telegram, Dec. 18, 1916.
* * * * *
"Radium Not Cancer Cure. Result of Exhaustive Tests on Rats,
Mice and Guinea Pigs Announced."—Macon, Ga., Telegraph, Dec. 18,
1916.
* • • • *
"Cancer Cannot be Cured With Radium—Wood. Experiments Show
life Can Be Prolonged by Treatment. Says Expert."—Dayton, O., Journal,
Dec. 18, 1916.
* * * * *
"Finds Radium Dangerous in Cancer Cases. Dr. F. C. Wood Reports
Under Some Conditions It Spreads Rather Than Reduces Growths.
Sanctions Use Only When Operations Are Impossible, and Then Only
Under Strict Limitations."—New York American. Dec. 18, 1916.
* * * * *
"Says Radium Is Failure As Cure For Cancer."-— Milwaukee Sentinel.
Dec. 18, 1916.
• * * * •
"Radium Fails as Cancer Cure, Columbia Director Reports. Tumors
Stimulated by Small Doses, While Growths Disappearing After Use of
Larger Quantities Are Only Quw>r:cnt—Recommended to Ease Tain."
—Pittsburgh Gazette Times, Dec 1?. 1916.
* * * * *
"Cancer Grows By The Use '_>i Radium. Dr. Wood. Head of
Crocker Research, So Reports to President Butler. Large Quantities
Neaded. Otherwise Portions ot Tumor May Be Stimulated and Harm
Done to Patient."—New York Times. Dec. 18, 1916.
* * * * *
"Says Radium For Cancer Is Failure. Used in Small Quantities It
Aggravates According to Research Expert."—Philadelphia Press. Dec.
18, 1916.
* * * * *
"Radium Not Cancer Cure. Found to Be a Failure After Exhaustive
Tests on Rats, Etc."—Rochester, N. Y Chronicle, Dec. 18, 1916.
* * * * *
"Cancer Tests Failure. Dr. Wood Reports He Is Unable To Cure
Animals With Radium."—Columbus, O.. Journal, Dec. IS, 1916.
* * * * *
"Radium Cancer Cure Is Failure. Doctor Says. Specialist Claims
Use of Small Quantities is Detrimental to Patient."—South Bend. Ind.
News-Times, Dec. 18, 1916.
* * * * *
"End Of Radium Theory."—Philadelphia Bulletin, Dec. 18, 1916.
* * * * *
'Radium Failure For Cancer."—St. Louis Republic, Dec. IS, 1916.

R a d i u m 95
"Radium Not A Cancer Cure. Successful as a Palliative Only in
Cases on Which Operation Is Not Possible—May Make Patient More
Comfortable—Dangerous If Used in Small Quantities."—Boston Transcript,
Dec. 18, 1916.
* * * * *
"Find Radium Failure As Cancer Cure."—AKoona Pa.. Times. Dec.
18, 1916.
* * * * *
"Radium A Failure As A Cancer Cure."—Wheeling, W. Va., Intellingencer,
Dec. 18, 1916.
* * * * *
"Find Radium Is No Cure For Cancer. Also Fails in Tumor Cases,
Experts Discover."—Springfield, Mass. Union, Dec. 18, 1916.
* * * * *
"Radium Fails To Relieve Cancer. After Exhaustive Tests, Much-
Heralded "Cure" Is Discarded."—Binghamton, N. Y., Herald, Dec. 18,
1916.
* * * * *
"Cancer Often Stimulated by Use of Radium."—Rochester, N. Y.,
Herald, Dec. 18, 1916.
* * * * *
"Radium Fails as Cure For Cancer and Tumors."—Greenville, S.
C, Dec. 18, 1916.
* * * * *
"Radhim Not A Cure For Cancer—Verdict. Use of Small Quantities
Only Aggravates the Case."—Reading, Pa., Times, Dec. 18, 1916.
* * * * *
"Radium Failure As Cancer Cure."—Parkersburg, W. Va., News,
Dec. 18, 1916.
* * * * *
"Calls Radium Failure As Cure for Cancer."—Lafayette, Ind.,
Journal, Dec. 18, 1916.
* * * * *
"Radium Only A Palliative. Cannot Cure Cancer, Says Expert
After Long Research."—Philadelphia Record, Dec. 18, 1916.
* * * * *
"Radium Declared No Remedy For Cancer. Columbia University
Doctor Says Small Amounts May Even Cause Cancer to Grow."—Columbus,
Ind., Republican, Dec. 18, 1916.
* * * * *
"Radium Failure As Cancer Cure."—Portland, Me., Press. Dec. 18,
1916.
* * * * *
"Radium Failure In Cancer Cases. Good As Palliative Only, Says
Savant After Exhaustive Tests on Rodents."—Birmingham News, Dec.
18, 1916.
* * * * *
The quotations given above are the headlines of articles which appeared
in the daily press throughout the country, the articles dealing
with a report of the director of the Crocker cancer research fund.
Medical men arc not prone to debate medical subjects in the columns
of the daily newspapers. The newspaper versions of Dr. Wood's report
have not found a cordial acceptance by those who are in position to realize

96 R a d i u m
the value of radium in the treatment of cancer as evidenced by the letters
and interview, which wc reproduce below:
"Radiums Uses in Cancer Cases. Dr. Frazier Thinks Prevailing
Pessimism as to Its Utilitv Unjustified and Unfortunate in Its Effects."
—Philadelphia Public Ledger, Jan. 6, 1917.
"To the Editor of Public Ledger:
"Sir—The editorial of the issue of the Public Ledger for January
4th on 'Radium and Cancer Cures' I read with interest, and was glad to
see the publicity given the statement of Doctor Ewing, of the Cornell
Medical School, which, to a limited degree, qualifies the wholesale condemnation
of radium so widely advertised in the newspapers of late.
"There is no doubt that the greatest hope of a cancer cure, for the
present at least, lies in removal with the knife in the early stages of the
growth, and the public needs still to be convinced that surgery cures a
certain percentage of cancers, large or small, according to the seat and
duration of the lesion. At the same time there are and always will be a certain
number of cancers which because of their location or because of
delay and proscrastination are not seen by the surgeon in the operable
stage and should be treated by radium or the X-ray for three reasons.
First because it prolongs life and relieves suffering in many cases, secondly,
because it effects a cure in an occasional case, and thirdly, because
it is inhuman and cruel to brand people so afflicted as hopelessly ill and
beyond the pale of human aid."
"I happen to know that the pessimism recently and widely expressed
in the newspapers has had a demoralizing effect upon patients under
treatment with radium, and for this reason I was glad to see the qualifying
note sounded in your editorial. I have had an opportunity to follow
many of the cases under treatment in the X-ray and radium department
of the University Hospital under the immediate care of the director,
and not only have radium and the X-ray proved of value in the superficial
cancers of the skin, but in cancers of large dimensions and deeper-seated.
In many of these cases not only is the condition ameliorated
and life prolonged, even in the deadliest forms of cancer, but there have
been a smaller number of cases in which the growth has entirely dispeared.
There should be no fear of the knife on the public's part; the
popular tradition that the knife "spreads the cancer" should be dismissed
as absolutely without foundation, but those who otherwise have not a
ray of hope let us encourage to believe that there remains a rcmedv which
promises a measure of relief and an occasional cure.
(Signed) Charles H. Frazier."
Philadelphia. January 5. 1917."
"Still Believes Radium Effective For Cancer. Cincinnati Physician
Says His Opinion Is Lmchanged."—Cincinnati Times-Star, Dec. 20 1916.
"Cincinnati doctors are interested in telegraphic reports from New
York to the effect that Dr. Francis Carter Wood, head of the Crocker
Cancer Research fund, declares that the use of radium as a cure :.^r
cancer is a failure. A Cincinnati surgeon who told a convention of surgeons
at the Hotel Gibson of the encouraging results he had achieved
with the use of radium in certain forms of cancer cases, said in this connection
Wednesday to the Times-Star: 'JU(lging from the dispatches it
seems to me that the views of Dr. Wood, regarding the usefulness of
radium in the treatment of cancer, are too pessimistic'"

R a d i u m 97
'"Are you as hopeful as to the possibilities of radium as you were
when you addressed the convention of surgeons on the subject?' "
" 'Yes. Since then, as before that, some cases have died and some
cases have been cured. Radium is not going to cure every case but
there are certain cases in which it give good results. Radium treatment
should not take the place of surgery.""
"The Other Side Of The Radium Cure."—Boston Herald. December
2, 1916.
"To the Editor of the Herald:
"Newspaper interpretation of medical subjects, vital to the interesis
and health of the community, should be peculiarly conservative and '.veil
advised. To me your editorial comments on radium in cancer on
Wednesday morning of this week seem especially open to criticism on
this score.
"Briefly stated, your summing up of the findings of the Crocker
cancer commission of Columbia University unqualifiedly placed radium
in the discard as a "cure," damned it with faint praise as a palliative,
and noted with the cheerful abandon of 'life' opportunity given the
medical profession to make 'the patient's condition worse than if he had
been left alone.' Suoh is the pessimistic side of the picture based on
truth but, unfortunately for your readers, only half the truth. Simply
because radium cannot act as a 'cure' in inoperable or hopeless cases
of systemic cancer is no reason why readers should be instructed to regard
it as a discarded fad to the utter disregard of countless cases of
early malignant disease that this remedy has saved."
"Point out rather to your readers the significance of the recent purchase
of many thousand dollars' worth of radium by the Huntington
Hospital of this city as an example of how useful it is in experienced
hands. Tell them of its curative effects beyond that of any other remedy
in epitheliomas or cancers of the skin. Lay your emphasis on howradium
can absolutely prevent cancers of the skin if people could be
taught to have the early pre-cancerous possibilities such as keratoses.
warts, moles, etc..removed before degeneration starts. By such statements
it seems to me you would be doing the greater services to the community
and more rightly interpreting the findings of the Crocker cancer
commission on radium.
J. Harper Blaisdell, M. D."
45 Bay State road. Dec. 21.
Reviews and Abstracts.
Thomas C. Kennedy, M. D„ (Indianapolis, Ind.), Radium Treatment
of Epithelioma. The Journal of the Indiana State Medical Association,
Vol. IX., July, 1916, p. 298. Care must be taken not to allow
radiation beyond what the normal tissues will stand. In the beginning of
my experience with radium, I was fearful of the effects of massive
dosage and began with great caution. Never having seen any

98 R a d i u m
untoward effects from the use of radium applied through a filter,
and not getting the desired effect in some of the more obstinate
cases, I cautiously began the use of it unscreened, using only the
air as a filter space. Although finding a greater resulting erythema,
which at first seemed alarming, there was a more speedy cure.
Following the application there is an erythema of the tissues surrounding
the lesion. In two cases there was a dermatitis so severe that it simulated
erysipelas. About three days after the application of the radium
to ulcerating surfaces, a soft crust forms, under which there is a slight
discharge. The patient is cautioned not to disturb the scab in any way.
but let it alone until it loosens and comes off, which occurs in two or
three weeks. When this scab comes off, a smooth, white scar remains.
The cosmetic effect in every case has been far better than I have ever
seen after surgery or the use of caustics.
In the treatment of epithelioma of the nose, eyelids, etc., I have almost
entirely abandoned the use of metal screens, and simply use the
10 mg. applicator of radium (20 mg. radium sulphate, containing 10 mg.
pure radium element) using the air space of l/i inch. In some of
the more refractory cases, I apply it directly to the lesion. In cases of
epithelioma of the tongue, it is necessary to use from 40 to 60 mgs.,
which is screened with a metal filter.
The relief from pain is frequently noticed after one treatment, and
after two or three treatments there is usually a distinct change in the
lesion. The discharge is checked, if there is an ulcerating surface, with
a perceptible shrinking of the lesion. It has been the custom of the
profession to advocate operation for all skin cancers, but as practically
all of them can be cured with radium it should be tried before resorting
to an operation.
In superficial lesions, radium is applied in a sealed glass tube. If
Alteration is deemed necessary, the tube is placed from \k to 1 inch from
the lesion, giving the "air space" filter. The glass tube is wrapped in a
small piece of gauze and held to the place with a small strip of adhesive
plaster. As a rule, the first treatment is for one hour. I am firmly
convinced that all epithelioma, wholly on the cutaneous surface, can be
cured with radium, if it is at all amenable to treatment. In other words,
any epithelioma of the skin, that does not yield to radium, cannot be
cured by any other known methods. While in two extreme cases there has
been no marked improvement, there has not been a single case stimulated
by the use of radium as has been noted by others. An exceptionally
small per cent of cases of epithelioma of the tongue are benefited by
surgery, and oftentimes arc made worse, glandular involvement ensuing
rapidly. Frequent disappointments are met in the surgery of cancer,
and men who have had large experience with radium do not claim it as
a cure-all. It can no longer be questioned, that, in the treatment of
cancer of the face, radium is undoubtedly the method of choice.
It is only by experience, that we can tell whether to use a large
amount of radium, thoroughly screened, or, to use a lesser amount,
either screened or unscreened. As a routine practice, 10 mgs. of radium
is used, screened with the "air space." In some cases, the application is
made direct to the lesion. In a very small per cent of the cases it will
be found necessary to use 40 mgs., or even 50 mgs., but these are exceptional.
The cases herewith reported were treated with 20 mgs.
radium sulphate, 50 per cent, strength, containing 10 mgs. radium etc-

R a d i u m 99
ment. In speaking of the amount of radium used, it should refer t
radium element contained, as it is used in the form of a salt, of varying
strength. Only a few typical cases will be reported here, as it is deemed
unnecessary to report many cases in detail.
Case 1.—Miss V., referred to me by Dr. Denny, of Madison, Ind.
Maternal aunt died of cancer of uterus at 60 years of age. Another
maternal aunt died of cancer of face. Father died of Hodgkin's disease
at the age of 75. Mother died of pneumonia. As near as she remembers,
in 1897 she noticed a small ulcerated spot on the right side of forehead.
She first received treatment in 1901 with caustic paste. Under
this treatment it healed and remained apparently well for several
years. Treated again in 1906 but did not get well. Was treated again
with caustic paste in 1907. The ulcerated spot did not heal, but a very
large scar was produced by the treatment. In 1908 was treated with
X-ray about 1 dozen times, and in 1909 took a few more treatments,
and again in 1910 without results. In October, 1911, carbon dioxid snow
was used without healing. When I first saw her she had a large scar
about the size of a dollar on the right side of her forehead. There was
a crust in the center of the scar about the size of a quarter, which was
very sore, tender and painful, and there was a tendency to bleed on
touching it. Radium was applied for a period of one hour each alternate
day for two weeks, then applied once a week for about two months.
Lesion entirely healed and she apparently is cured.
Case 2—A. J. B., Columbus, Ind., surgeon, age 66. No family
history of cancer or tuberculosis. Father died at the age of 74 of organic
heart disease. Mother died at the age of 86 of double pneumonia.
Patient had an erosion of tongue for several months which refused to
heal. Silver nitrate 40 grs. to the oz. was applied without results. The
tongue was so sore he could not masticate his food and had lost weight.
Troubled with constipation. He was treated every alternate day for
two weeks with radium, and then at intervals of once a week. The lesion
began to heal after a few treatments, and was apparently cured after
two months.
Case 3—Mrs. D., age 65, referred to me by Dr. Osterman, of
Seymour, Ind. No cancer or tuberculosis in family. A scaly spot appeared
on the right side of her nose about 5 years ago. It was treated
with salves, powders, and I think from the description, also with caustic
paste, without results. When I first saw her, there was an ulcerated spot
on her nose about the size of a dime, which bled on touching it. She
has had 16 applications of radium of one hour each, and is clinically
cured.
Case A—Mrs. T„ age 52, referred to me by Dr. F. C. Heath of this
city. Mother died of cancer. About 18 years ago a small lump appeared
on right lower eyelid. She consulted a physician who informed her it
would not amount to anything. About 5 years ago it began to break
down. Paste was applied about 3 years ago but it got worse. About
1 year ago she began treatment with X-ray and continued for about 6
months. Lesion seemed to get some better but never healed. The eye
was very painful and there was destruction of the inner border of the
lower lid. Eyeball red, inflamed and tender. She was advised by one
man, to have the lower lid operated, which she refused. Several others
declined to give any treatment. Pathological examination showed it to
be an epithelioma. Radium was applied for two hours and. was re-

100 Radium
pealed at the end of a week. This seemed to aggravate the condition,
and the period of application was reduced to one hour. The application
was made once a week, for a period of three months. The ulcer
has completely filled in with new tissue. There is a slight granular condition
which persists, but it is diminishing gradually. The eyelid shows
but little of its former destruction. She is still taking an occasional
treatment.
Case 5—Mr. P.. aged 80, referred to mc by Dr. Sims of Frankfort,
Ind. Had large mole on left side of upper lip for years. About
two years ago it became inflamed, discharged pus and formed a crust
over the top. Painful at times. Pathological examination showed it to
be an epithelioma. Application of radium was made at intervals of one
week, and after 15 treatments, he is apparently well.
Case 6.—Mr. K., age 54, engineer. Father died of cancer of the
ear at the age of 82. He had an epithelioma over the left malar bone,
which was removed with paste in December, 1913. It recurred in January,
1915. Increased gradually until at the time I saw him, it was as
large as a dime. Application of radium was made at intervals of one
week for about two months, and then at intervals of about once a
month. After the third treatment there was a relief from pain and beginning
retrogression of the lesion. He is clinically cured.
Case 7.—Mr. K., age 67, brother died of cancer of the rectum. One
aunt died of cancer of the breast. He first noticed a slight lesion on left
cheek in August, 1914. This increased until it was about one-half inch
in diameter, ulcerating, with a tendency to bleed and covered with a
thick crust. Three treatments with radium of one hour each, at intervals
of about 10 days, healed the lesion, and there has been no recurrence.
Patients who have been clinically cured should be kept under observation
for several months, and they are instructed to the effect that
the slightest recurrence of the lesion the treatment must be renewed at
once.
Conclusion. Radium is not a cure-all by any means, but it will
cure every case of epithelioma that is amenable to treatment.
Those who are skeptical about the results obtained from the use of
radium are the uninformed.
Radium, intelligently used, is a painless, safe and efficient method of
treating malignant skin lesions. It is the treatment of choice in epithelioma
of the face, and the cosmetic effects are better than with other
known method of treatment. This means much to the patient.
The number of treatments varies. Improvement usually is noticed
after two or three treatments, and frequently after the first.
The analgesic action of radium is very marked and frequently noted
following the first application.
It is claimed by competent physicists that there is a decided difference
in the physical properties of X-ray and radium. Radium has cured
cases in which the X-ray has failed.

I U M
A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY, PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES.
Edited and Published by Charles H. Viol, Ph. D., and William H. Cameron, M. D.
with the assistance of collaborators working in the fields of
Radioed em istry. Radioactivity and Radiumtherapy.
Subscription $2.50 per year, or 25 cents per copy in the United States and Canada
in all other countries $3.75 per year.
Address all communications to the Editors, Forbes and Meyran Avenues,
Pittsburgh, Pa.
VOL. VIII. MARCH, 1917 No. 6
RADIUM IN VARIOUS SURGICAL CONDITIONS*
By Joseph B. Bissell, M. D.
NEW YORK CITY.
It is designed in this short paper to consider the use of radium in
some of the usual surgical diseases, not including cancer. Besides the
many important physical and chemical qualities of radium already in
general knowledge other unutilized properties are constantly being developed
in the different research, physiological and chemical laboratories
throughout the world. Consideration of the subject offers interesting
speculation aside from the effect upon malignant tissue. In fact it i«
not so certain that the action of radium may not cause changes in other
pathological conditions, both medical and surgical, of greater importance
than in cancerous growths. This is not to depreciate its action in attacking
local manifestations in morbid changes in human structures and
functions. Nor is it to minimize the role of radium in cancer. In
certain forms of malignancy the results of radium treatment are so
satisfactory and so striking as to seem almost miraculous. This statement
is not confined to the superficial skin cancer alone, but relates to
pathological growths involving the deeper tissues, and in some cases,
even to extensive malignant infiltrations in widely different parts of the
body.
As a therapeutic agency, the writer has made use of this remedv
in several hundred non-malignant cases in Bellevue and St. Vincent's
Hospital, in the Radium Sanitarium of New York, and in private practice.
The results have been instructive, interesting, sometimes puzzling,
and frequently gratifying. I have tried to make our knowledge of the
varying properties of radium fit the indications for treatment.
•New York State Journal of Medicine, Vol. 16. No. 12. Dee. 1916. Bead at
the Annual Meeting of the Medical Society of the State of New York at Sartoga
Springs, May 17. 1916.

102 R a d i u m
The destructive, the absorbing and the constructive properties of
radium, as well as some if its abstruse chemical actions are also taken
into consideration; for instance, knowing by experience of the stimulating
effects of some of its rays, endeavor was made to use this quality
in sluggish suppurating ulcers and sinuses associated or not with
diseased bone. In this short but rather discursive paper numerous
unconnected pathological states are considered and treated without
reference to their relationship to each other or to any single disease
condition. The application of radium has varied from the treatment
of unhealthy and unhealed ulcers of different types to fibroids of the
uterus, and from a keloid of the scalp 10 the cure of a callosity on :he
toe. In the course of these wide excursions results are obtained which
give rise to thought and consideration and assist us in determining more
definitely the uses and utilities of this element.
Following are the cases:
Miss B., thirty years of age. She has an inflamed, thick, hard
corn on right little toe. It has been present over a year. Radium applied
twenty minutes each time, with no visible reaction. No screening.
After six applications, four or Uve days apart, the corn entirely
disappeared, without local irritation to the neighboring skin.
Air. B., twenty-nine years old. December 16, 1914. Has an inflamed
corn on the ball of left foot, at least one and a half inches long,
and one inch wide. It is exquisitely tender on pressure. He walks
with difficulty and with the aid of a cane. The callosity has been
cauterized and cut out repeatedly, but always returned. Ten milligrams
of radium applied for fifteen minutes at the first application. Five days
later a large amount of callous was removed in the center of the corn,
and into this hole thus left a tube containing twenty-five milligrams of
radium, unscreened except for the silver casing, was applied for fifteen
minutes. The surrounding tissues were protected by one millimeter
lead screening, covered with two millimeters of rubber. This procedure
was used several times at six-day intervals. Subsequent examination
showed patient to be entirely relieved. He was able at the end of
a few weeks to return to his business as superintendent of a mine.
Mrs. C. dcR., May 13. 1915. Fibroid of uterus. Fifty-one milligrams
of radium applied in the cervix for five hours. June 20. fifteen
milligrams applied for ten hours. September 1, report from doctor in
charge finds on examination that the growth has markedly decreased in
size. Symptoms of hemorrhage and pain and pelvic discomfort have
ceased, and three months later the growth was so small that an operation
was unnecessary
Mrs. S. M. H„ forty-seven years old. April 3, 1915. Fibroids.
One tumor, size of a small orange on the anterior surface of uterus.
Large fibrous os. April 3, fifty-one milligrams of radium, in one tube,.
applied in the cervical canal for twenty hours. Complains of considerable
nausea during the application. On the fourth day after the application
patient developed what was thought to be grippe, with headache,
sore throat, cough, and temperature running to 104. April 10, last night,
however, the temperature was only 99.8 and she came to the sanitarium
this morning for another application. Cervix is congested, tender,
swollen, bleed's easily and she has a rather profuse discharge. Fifty
milligrams applied as before. Complains again of nausea. No pain except
a backache. Tube removed at 9 P. M., after a ten-hour application.
April 12. her doctor telephoned this morning that she had a!

R a d i u m xoa
temperature of 105.6, severe headache, rectal tenemus, slight diarrhoea,
frequent and painful urination and other symptoms of local irritation.
She had a very 'stormy time following this, with temperature, chills,
bloody urine, pain in kidneys and ureter region, all symptoms of a
hemorrhagic pyelitis. This condition lasted about three weeks then
slowly disappeared. When examined May 10, only a vestige of the
anterior fibroid remained and the os was soft and patulous, with no
evidences of fibroids. In this case there was a severe infection extending
up one or both ureters from a radium burn of the uterus. She had
also a moderate proctitis probably of a similar origin. Eventually the
patient made a complete recovery from these conditions.
Marie D.. twenty years of age, telephone girl. April 3. 1915.
Keloid, one inch in diameter on the right breast. This followed a
scald four years ago. Fifteen milligrams applied in varnish applicator
for thirty minutes. April 11, slight blister and swelling over the
lesion. Twenty-five milligrams of radium in tube applied for ten
minutes. April 19, varnish applicator five milligrams and tube of ten
milligrams, applied with rubber screening for ten minutes. June 27,
1915, the keloid is about half its former size, and very much thinner.
Applied two five millimeter varnish applicators over the soft keloid for
twenty minutes. In September, when she reported for final examination,
there was only a thin white scar remaining.
Angeline F., seventeen years of age; milliner. November, 1915.
A keloid scar four inches long, half an inch wide, at some points elevated
a quarter of an inch. It runs directly across the left cheek from
her ear. Radium applied twenty to thirty minutes, once a week, fifteen
times. Keloid has softened and only the soft scar remains when
she ceased treatment, February 15, 1916.
N. McC, female, thirty-seven years of age, seamstress. February
22, 1915. Second toe of right foot amputated for osteomyelitis. The
wound did not heal because of dead bone. On admission to the hospital
she had an indolent sinus from which protruded flabby granulations.
This sinus had been irrigated every day with various solutions
without any improvement until March 7. when ten milligrams of radium
were applied in the sinus for ten minutes. The three following days the
discharge was very much less, the granulations became smaller and the
pain, swelling and tenderness disappeared at the end of a week. March
18. a second application of radium was made for ten minutes. Improvement
continued and on April 4 patient was discharged cured.
H. D. L., fifty years old, single; brushmaker. Admitted to St. Vincent's
Hospital, August 5, 1915. He had a history of osteomyelitis of
the right knee, twenty-five years before. Now an acute arthritis of
the knee, which had lasted two weeks. At present the knee is twice as
large as the opposite one, red swollen and tender, has several fluctuating
points, and is discharging profusely from a sinus on the upper side of
the leg just above the joint. August 6, several incisions were made into
the soft points and large quantities of pus discharged from these incisions.
Temperature 104 and pulse 150. August 25, there were several
sinuses about the joint discharging sero-purulent fluid so copiously that
the dressings have to be changed twice a day. X-ray picture at the time
shows septic infection of the knee joint, involvement of the lower end
of the femur, patella and tibia; cartilage destroyed. August 27, the
destruction of the joint was apparently so complete and the extension
into the bony structure so marked that amputation of the leg at the

104 R a d i u m
upper third of the hip was advised. Patient refused operation. 100
milligrams of radium applied in the different sinuses, in five tubes, for
ten minutes. At the end of three or four days after this application
the discharge was very much less, redness and pain greatly improved,
and the knee was markedly smaller. September 8, radium applied as
above, after which the discharge continued to diminish, pain decreased
and the swelling about the joint also lessened. The discharge clearea
up so rapidly that on October 1 several of the sinuses were healed, and
there was only a slight discharge remaining. Dressings were changed
only every third or fourth day instead of as previously, twice daily.
October 25, another application of radium was given for twenty minutes.
As only one sinus was still discharging, a tube of twenty milligrams of
radium was put into this sinus, the remainder of the 100 milligrams of
radium being strapped around the joint at equi-distant points.
November 25, discharge practically absent; last sinus closed; knee joint
seems to be ankylosed, but no longer tender or with fluctuating points.
Patient was up and about the ward on crutches. November 25, a
point of fluctuation appeared just below the patella. This was incised,
small pocket of pus evacuated and it was healed by December 7. January
7, 1916, patient discharged cured, with ankylosed, but useful knee
joint. He is able to go about his business with the help of a cane.
S. B., forty-three years of age, male, married, laborer. Admitted
to hospital July 8. 1914. A few days previous patient had been injured
by having his knee caught between a car and a packing box. On examination
his right knee was swollen, red, hot and tender. A small punctured
wound is seen on the lateral internal aspect. Pressure causea a
copious discharge of purulent, oily like material; evidently the injury
communicates with the joint. Leg flexed and very tender to the touch.
Has had chills; temperature, 104. pulse, 140. July 11, wound enlarged
and tube inserted for drainage. Joint fluid and pirs discharging through
tube. Diagnosis acute purulent sinovitis. Knee and the patient's general
condition became steadily worse, and as the joint seemed to be
pretty well disorganized, amputation was advised and refused. Several
points of suppuration were opened and drainage tubes inserted into the
joint. A week later, after amputation was again refused. 100 milligrams
of radium in divided doses were applied through the tube in the
knee joint for twenty minutes. Within a few days the knee began to
show signs of improvement. September 7. radium applied again as
above for ten minutes. September 23, marked improvement. There
is very little tenderness and the knee is resuming its normal shape, but
is still flexed at an obtuse angle of about twenty degrees. All the
sinuses are healed except two. and from them there is very little discharge.
Radium applied in these two sinuses and around the circumference
of the knee for about ten minutes. October 8. radium applied
to the only remaining sinus for ten minutes. October 20. all sinuses are
healed, and on November 30. after remaining in the hospital in order
that the stiffness and pain on attempt at motion should he treated by
baking, he was discharged cured, with ankylosis at about an angle of
twenty degrees-
Rose E.. seven years of age; came into the hospital Julv 14. 1915,
with a swelling over the first metatarsal bone of the foot. No history"
of injury. There are three small sinuses in this region. The X-ray
shows an osteitis in the first and second metatarsal bones. She was
treated in the usual surgical manner up to September 6. with no im-

R a d i u m
provement. September 8, radium applied for ten minutes, and again on
September 25, for ten minutes. After the first application swelling
began to subside, the ulcers around the sinuses began to contract and
heal up and the discharge to decrease. October 1, radium again applied
for ten minutes. October 15, only one sinus remained, the ulcers have
healed up, 'swelling is much less, and there is no discharge. Without
further treatment of any kind this patient continued to improve and
was discharged November 1 as cured. The case was apparently one of
tubercular osteitis.
These uses of radium, with one exception, are not new. In 1910,
Dr. Wickham of Paris, reported over sixty cases of fibroids treated in
the way just described. Following treatment, hemorrhage and discharge
ceaised, pain and discomfort disappeared and the tumors themselves
diminished in size or were entirely absorbed.
The removal of benign growths like callosities or keloids is of
course known to irs all, and is a very satisfactory and frequent result
of the use of radium. The exception spoken of above is the local usage
of radium in bone and sinus work, and as far as I know is original
with the writer. In a recent issue of the Pennsylvania Medical Journal,
Dr. W. H. Cameron* described the effects of radium applied locally to a
number of patients in the army camps in England. These soldiers for
the most part were suffering from sluggish ulcers, indolent infected
wounds and unhealed sinuses. They were treated in the manner instituted
by the writer personally at these English camps last summer,
and Dr. Cameron expressed satisfaction at the results obtained after he
had made a satisfactory personal examination of many of these men.
REVIEWS AND ABSTRACTS.
M. L. Heidingsfeld, M. D. (Cincinnati, O.). Radium Treatment
of Rhinophyma and Hypertrichosis. (Presented before the Academy
of Medicine of Cincinnati, May 1, 1916). The Lancet-Clinic, Vol. 116,
No. 13, Sept. 23, 1916, pp. 305-7.
"This man, fifty-five years of age, is presented on account of his
unusual condition and to show the result of radium treatment, The
patient presented himself for the first time, February 26, 1916, when
the present cauliflower excrescence on the crest of the nose was possibly
half again as large as it is at present. The case is a very marked
and extreme type of rhinophyma, which is essentially an adenoma of
the sebaceous glands of the skin. It is at the present time approximately
the size of a large English walnut. Before radium was used
in these cases, surgical ablation gave good results. There was, however,
always a considerable degree of disfigurement from such a procedure.
In several of these cases I have used radium, which has not only cleared
up the condition but has produced almost perfect cosmetic results. This
patient is presented in a preliminary way, after five applications of
radium."
"Mrs. A. R., is presented not only as a case of extreme hypertrichosis,
but also in order to demonstrate the effects of radium in cor-
•See also Radium. VII. 46, May, 1916.
105

106 R a d i u m
reeling this unpleasant disfigurement. The patient was treated for the
first time on March 6, and three applications have been made with the
result that whenever radium lias been applied, the hair has been completely
and apparently permanently removed."
"When tiie patient first presented herself, there was a heavy growth
of hair over the chin and neck, almost as marked as that in an adult,
fully developed male. Most of this has already been scccessfully removed
and the patient is shown at this partial stage of recovery, in order
to best illustrate the success of radium treatment in this condition. It
is painless, rapid and effective in character, and the cosmetic result is
far better than that which can be accomplished by the only other reliable
method of treatment, namely, the needle and galvanic current."
Discussion.
"'Dr. C. J. Bboeman: Referring to the case of hypertrichosis, I
have quite a number of cases of this kind under treatment. .Wishing
to receive an opinion concerning them from men with large experience
in both .r-ray and radium work, I wrote Dr. Kelly concerning the
radium treatment, and he turned the matter over to his assistant, Dr.
Burnam, who wrote me, saying that radium could be used with perfect
safety. He failed to mention whether he himself had ever used it to
treat such a case, or whether he had obtained any results. I then wrote to
Dr. McKee, of New York, with regard to the propriety of using the
.r-ray in this condition; his reply was never to use the x-ray in such
cases."
"If the patient presented to-night has been permanently cured, then
radium has certainly proven a wonderful remedy. I have treated a
number of cases in which radium has previously been used without
effect and I am now using the electric needle on one case in which
radium seemed to make the condition worse. The cosmetic effect,
however, is not as good as that exemplified in Dr. Heidi ncspeld's
case, and, I think, there is some question as to whether the case is permanently
cured."
"Dr. Heidincsfield (in conclusion:) Of coures, the fundamental
question regarding radium is whether or not the results obtained from
its use are permanent. Not six months or even a year is sufficient to
determine a cure. Radium has been used a great many years by some
men, who claim they have not had permanent results. The tendency
to return is very much in evidence. On the other hand, there are some
who claim to have had very satisfactory results."
* * * * *
Benjamin S. Barringer, M. D. (New York). The Treatment by
Radium of Carcinoma of the Prostate and Bladder. Preliminary Report.
Journ. A. M. A., Vol. LXVII, No. 20, pp. 1442-45, Nov. 11,
1916.
"In October, 1915, at the Memorial Hospital, we began treatment
by radium of cases of carcinoma of the prostate and bladder. At this
early date obviously no final results of our treatment can be predicted.
In certain cases, however, our primary result's have been good. This,
together with the fact that the technic of the application of the radium
particulary in prostate carcinomas, is new, encourages us to give this
report."
"Problems presented by bladder and prostate carcinomas are so
entirely different that they will (be considered separately."

R a d i u m 107
CARCINOMA OF THE BLADDER.
"The cases considered in this paper are not papillomas which may
have undergone at one place or another carcinomatous degeneration, but
rather flat sessile tumors, sometimes cauliflower, sometimes hard, some
times multiple, generally sloughy in part. The cystoscopic picture or
the rectal feel may suggest an indurated base. Microscopically they
show carcinoma. Fulguration does not particularly affect this tumor."
"Technic of Using Radium.—There arc a number different facts
connected with these tumors which have determined our method of
treatment."
"1. These patients often have a great deal of pain both connected
with and between urinations. We have tried not to increase their pain and
discomfort; in other words, if we do not succeed in curing, we can at
least say that we have not made them materially worse. We have not
been altogether successful in this. The extent of the carcinoma, the
presence of urinary retention, the involvement of the prostatic urethra,
and other factors, seem to make it more or less impossible to determine
accurately the amount of pain a patient will have from radium treatment."
"2. In the first case in which we used radium, the bladder was
opened suprapubically and the radium attached by hooks to the tumor.
It took this man nearly three months to get out of the hospital. He
had sloughs in his suprapubic wound for a long time and his physical
condition at present is the worst of any of the patients treated. For
this reason I have at least temporarily given up this method."
"3. I believe that the problem of destroying carcinoma of the
bladder by radium is, in most cases, largely one of accuracy in applying
the radium to the growth. This has been the experience of those who
have used radium treatment in uterine carcinoma. Therefore we have
not used irradiation by means of rectal tubes or suprapubic application,
but have tried to place the radium on the growth in the bladder. I have
tried to use the radium in such quantities and over such periods of time
that undue sloughing and burning of the normal portion of the bladder
will not result."
"The method which I use at present is as follows:
From 100 to 200 millicuries of radium screened with 0.6 mm. of
silver and 1.5 mm. of rubber are put up so as to form a capsule about
1 inch long and one-eighth inch in diameter; to this is attached a long
stout double linen thread. A direct cystoscope is introduced into the
bladder, the capsule put through its sheath and the cystoscope withdrawn,
leaving the radium in the bladder. The linen thread attached
to the tube runs through the urethra and appears at the meatus. In
women one may reintroduce a 'small cystoscope and see if the radium
lies on the tumor. The patient remains in bed during the application.
This perhaps rs a crude and inaccurate way of applying the radium. On
the other hand, a large majority of bladder carcinomas are in the base, and
the tube of radium cannot be very far from a carcinoma in this position;
certainly much nearer than a rectal or suprapubic tube would be. If
the carcinoma is located on one side of the bladder, the patient is told
to turn slightly toward that side while the radium is applied. The patient's
generally have been able to urinate without trouble during the application.
Some have held theiir urine until the end of the irradiation, at
most eight hours, and then urinated or were catheterized after the

108 R a d i u m
radium was removed. The urine possibly to some extent screens the
vault of the bladder (all of my patients to date have had carcinoma of
the base) and also lifts the bladder mucous membrane of the vault away
from the radium. Whatever may be the reason, the normal bladder
mucous membrane seemis very resistant to radium burns when the radium
is used in this way."
"Duration of Radium Burns.—There is much variation in the effect
of any given dose of radium. The radium does not, as a rule,
change the appearance of the tumor; that is, a red cauliflower tumor
generally remains red after the radium burn, but it appears to be softer,
and fulguration of the tumor has a much greater effect than before
the irradiation. On the other hand, sloughing sometimes occurs and
presists even for a number of months. My rule is not to reapply radium
until a patient has entirely recovered from the effects of the first application."
"Danger of tlie use of Radium.—I have lately heard of one case
in which radium was used, quantity, time on screening not known, in
which the patient some two and one-half months after the irradiation
died of a ruptured bladder. This case emphasizes the fact that if the
tumor is at all extensive it is very difficult by the cystoscope to tell exactly
the amount of bladder involved. Cystographs may help some. It
is possible that further experience will indicate that, in extensive carcinomas,
we should do a suprapubic observation of the exterior of the
bladder. If we find that the carcinoma has penetrated the bladder,
radium treatment is probably both useless and dangerous."
REPORT OP BLADDER CASES.
"Nine bladder tumors have been irradiated."
"Extent of Growth.—In one of these cases the growth was absolutely
inoperable. In another case the growth should be classed as a
prostatic carcinoma with secondary invasion of the bladder. In five
other cases the extent of the growth indicated that total cystectomy
would have been the only operation to offer anything. In another case
partial cystectomy, with the reimplantation of the left ureter, would have
been possible, while in another the growth itself possibly could have been
removed."
"Microscopic Examination.—In six of the nine cases the diagnosis
of carcinoma has been confirmed by the micoscopic examination of
pieces taken from the growth. I believe that in all cases the diagnosis
must be confirmed by the microscope. But when once confirmed the
cystoscopy and the rectal feel give us much more trustworthy data as to
the extent of the tumor and the prognosis in a given case than does the
microscope."
"Result of Treatment.—One patient died three months after irradiation.
This patient had an extensive inoperable carcinoma of the bladder
base; three patients have been too recently treated to make any report.
Another patient is definitely getting worse. This is the patient in whose
case the radium was applied through the suprapubic opening in October.
1915. I have never been able to examine this patient with the cystoscope
to see the effect of the radium on the bladder, but he is losing weight
and having more frequent and more painful urination. In two other
cases the symptoms arc about the same, and the patient's general condition
is slightly improved, but the carcinoma still persists. One of these
was treated with radium about three months ago, and the other was

R a d i u m 109
treated several times, beginning in October, 1915. In two of the nine
cases the growth has disappeared. One has only recently been examined
cystoscopically, notwithstanding the radium was applied in February,
1916. In the other the growth has been absent (by cystoscopic examination)
for three months. These last two cases are of enough interest to
report in some detail."
"Case 1.—C. T., man, aged 59, came to Dr. Keyes in January, 1916,
and stated that since June, 1915, he had had occasional attacks of painless
hematuria. In July, there had been two bloody emissions, though
lie had been impotent for ten years. At that time a papilloma was found,
and since then he has been fulgurated four times—October 22, November
1, December 9, and January 11. Because of the return of the
growth it is suspected to be carcinoma. Dr. Keyes reports a sloughy ulcer
about the left ureteral orifice with definitely carcinomatous looking lumps
in the edge. A piece was removed which Dr. Ewing reports as diffuse
carcinoma, and the growth was burned again with the high frequency
current. Three weeks later, 214 millicuries of screened radium were
left in the bladder for seven hours. After the irradiation the patient
went to his home and had various ups and downs, an attack of grip, etc.
Three days after the irradiation and for a period of two weeks, he arose
five to six times at night to urinate, but had no special burning on urination.
From that time on the frequency has diminished. He was
examined cystoscopically. May 2, 1916, at which time no trace of the
original tumor could be detected. The entire bladder was slightly congested,
and there were a few bullae about the bladder orifice. He is the
picture of health, and there is no hardness felt ini the prostate or the
base of the bladder."
"Case 2.—C. A. G.,woman, aged 69, had painful and frequent urination
for one year, three or four times at night, and by day every three
to four hours. She has been passing bloody urine for some time. She
was examined cystoscopically some months before I saw her, and a diagnosis
made of inoperable carcinoma of the bladder. Cystoscopy revealed
a large red cauliflower tumor with small necrotic areas on the
left side of the bladder base. I had some difficulty in determining its
full extent. It probably was as large as half a dollar and sessile. It
was directly over the left ureteral orifice, which could not be seen. Dr.
Ewing reports carcinoma. I burned the tumor twice with high frequency
current, but this had little or no effect on it, and I considered it useless
to continue. January 4, I put 100 millicuries of screened radium in the
bladder and left it in eight hours. The patient went out of town the
next day and at the end of three days had severe bladder pain with
increased urinary frequency so that she urinated every hour. Two days
later she was absolutely normal as to pain and urinary frequency."
"February 4, cystoscopy revealed that the tumor was gone. The
ureter was in plain sight and covered with normal mucous membrane.
The patient had a little pedunculated papilloma of the bladder neck,
which was burned. Dr. Keyes confirmed my examination. April 28.
cystoscopy revealed that there was still no tumor. She had a slight
cystitis (caused by retention of urine due to a cystocele)."
"Whether the carcinoma in these cases will return or not. no one
can say. I believe that the fact they have reacted so quickly to radium may
indicate that we have eradicated the growth. Only time will tell, however."

no R a d i u m
CARCINOMA OF THE BLADDER.
"The problem involved in the diagnosis and treatment of carcinoma
of the prostate is different from that of carcinoma of the bladder. In
the first place is the difficulty in diagnosis. An extensive carcinoma
which runs up into the vesicles can usually be exactly and positively
diagnosed by palpation. On the other hand, a carcinoma as extensive
as this is probably beyond the hope of cure. If the carcinoma, as far as
can be determined by palpation, is confined to the limits of the prostate,
then the diagnosis by palpation alcne is sometimes not only difficult, but
impossible.
In a recent case which I treated with radium there were two positive
diagnoses, including my own, which was possibly biased, one of
"very suspicious," one of merely "suspicious" and two indeterminate.
As Geraghty has pointed out, palpation of the median lobe on a sound
introduced into the urethra is of assistance. It has been suggested that
enough of the prostate for microscopic diagnosis can be obtained by the
introduction of a trocar through the perineum into the suspected
prostate. In one of my cases part of a carcinomatous lobe was removed
and the diagnosis made from this. Such a procedure, however, is not
ideal, as it might make the carcinoma grow more rapidly. If one treats
cases which one is sure are carcinomas of the prostate, but in which a
microscopic diagnosis has not been made, and makes such patients temporarily
or permanently better, one will, of course, run a risk of dealing
with cases which were not carcinomatous."
"Treatment.—The operation after Legueu, Young and others apparently
succeeds in curing the disease in a certain number of cases.
The operative mortality is probably between 10 and 20 per cent., and
the cured cases very few. Aside from the mortality, one objection to
the operation is the fact that many patients are left with partial or
complete incontinence. Because the results of an operation are unsatisfactory,
radium has been employed in attempts to destroy the growth.
Irradiation has been both rectal and urethal. Pasteau and Degrais1 report
a number of cases in which the radium in the prostatic urethra or
bladder gave a marked diminution of the size of the prostate and a decided
improvement in symptoms. One patient three and one-half years
after treatment by radium was is excellent health, with a small regular
movable prostate and clear urine. This carcinoma had extended through
into the bladder. Geraghty, applying radium by way of the urethra, has
been able to relieve the symptoms of frequent urination, tenesmus, etc,
in a number of cases, buthasbeen unable to cause any appreciable diminution
in the size of carcinoma."
"Technic of Application of Radium.—Because the carcinoma starts
in the interior of the prostate gland, and radium by urethra or rectum
often causes intense irritation. I have applied the radium differently. A
needle 4l/2 inches long and about 18 gage has been used. From 50 to
100 millicuries of radium have been placed in the end of this needle
for a distance varying between % inch to VA inches according to the
indications of the individual case. The patient is placed in a lithotomy
position, a finger introduced into the rectum and the perineum between
the urethra and rectum is anesthetized with novocain (1 per cent.).
1. PiiBteau and Desrnls: Radium in Cancer of the Prostate. Jour, d'urol..
September, 1013.

R a d i u m
I have frequently inserted the needle without anesthetization, causing
very little pain. The radium needle is then plunged into the perineum
between the urethra and rectum, and, guided by the rectal finger, the
end of ithe needle is passed into the middle of one or the other of the
carcinomatous lobes.2 After the needle is introduced, the patient frequently
does not feel its presence. The needle is left in place from
four to six hours. If one wishes to irradiate the other lobe, the needle
is pulled out of the first lobe and introduced into the second and left
there the proper time. The ease of this procedure is obvious. I was
nearly dissuaded from using this method by reports of necrosis following
the use of unscreened radium. I have now used the needles in the
prostate fifteen times, and to date have had no radium sloughs. These
patients are apt to have burning and pain beginning the week after the
radium is used and lasting from one to two weeks. During this time
the prostate swells, and the maximum effect of the radium on the growth
is not to be looked for until two or three months. Some patients,
notably those with the carcinoma extending into the vesicles, have a great
deal of pain. Neither the pain, however, nor the urinary disturbance
are as great as when the radium is used in the bladder. And curiously
enough radium in the urethra 'seems to cause or increase an already
present residual urine; while this needle method, as far as I have observed,
does not. There is a certain class* of borderland cases in which
the carcinoma has broken through into the bladder neck and in which
the cancinoma has broken through into the bladder neck and in which
radium in the bladder neck. I think these cases should be started with
prostate needles, as the reaction is often little or nothing."
REPORT OF CASES.
"Extent of Lesion.—Five patients have been treated by the needle
method.3 In but one of these cases was a specimen obtained for pathologic
examination. In this case the bladder was opened suprapubically,
and one lobe of the prostate removed and found to be carcinomatous.
In two of the cases there was every extensive carcinoma of the prostate
with involmcnt of the vesicles. In another case there was but little
involvement of the vesicles, but a large hard irregular unmistakable carcinomatous
prostate. In the fifth case there was a doubt of the diagnosis.
Dr. Keyes and I thought it to be carcinoma. Another surgeon said
that it was "very suspicious," still another "suspicious." and two refused
to give an opinion."
"Number of Treatments.—In one case I inserted the needle four
different times; in the. four other cases I used the needle only once. The
largest dose of radium that I have used in a needle is 102 millicures for
four and one-half hours in one lobe, and the same needle was changed
to the other lobe, and remained there four hours. I have never seen
a slough from the use the needle, although I prefer to begin with small
doses at first, from 50 4o 75 millicuries for six hours."
"Results of Treatment.—One patient died two months after the
irradiation. He had an extensive carcinoma of the prostrate and vesicles.
The immediate cause of his death I do not know. One of the patients
has been too recently irradiated to determine the result. The other
three patients have improved symptomatically."
2. The needle In the prostate also serves 10 exclude prostatic stone, the
one condition hard to differentiate from carcinoma.
3. A sixth patient was treated hy radium inserted In tlie rectum. In this
case there was considerable irrltabllltv and urinary retention, and the patient
finally died uremic. I have not Included him in the foregoing series.
m

112 Radium
"One who was irradiated in December, 1915, directly after suprapubic
exploration (by another surgeon) I have been unable to reach to
examine. I have heard indirectly, however, that he is up and doing
a good day's work. This is all I know about him."
"The second, a possible borderland case, was treated Feb. 8, 1916.
He had just before the irradiation an acute retention of urine. For six
months prior to this he had a night urinary frequency (from two to four
times). The radium needle caused absolutely no pain and no urinary
disturbance. When seen, May 3, 1916, his prostate was considerably
reduced in 'size. He had gained a few pounds in weight, he had no
night frequency and was doing a full day's work. During this time he
had no urethral instrumentation."
"The last patient is decidedly better symptomatically, and his prostate
is so much reduced that if I did not know his history I would have
much difficulty in convincing myself that he had any carcinoma. He
was first seen in November, 1915. He gave a history of night urinary
frequency of from six to eight times for four months, and some pain
running down his right thigh for five years. There had been no erections
for one and one-half years. He weighed 116 pounds. He had
lost about twenty pounds. Both lobes of the prostate were large, irregular,
stony, hard, with slight extension up toward the vesicles. The
prostate was so hard that the possibility of prostatic stones was thought
of. A roentgenogram excluded this. He had no residual urine. Radium
was used in November, 1915. A month later he reported that he had
a number of vigorous erections which "gave him hope." The prostate
at that time was at a maximum swelling. January 14, the weight was
126. The prostate was much reduced. Dr. Keyes said: "It is more
the slight irregularity of the prostate than anything else that suggests
carcinoma." "
"I again irradiated the patient, January 18. February 7, he was
not up at all at night. He weighed 132^4 pounds. February 22, I irradiated
again. April 4, I irradiated once again. When last seen, April
21, his frequency had gone from none at all at night to twice at night
because of the radium of April 4. He has a small hard lump in the
left lobe and a narrow, hard ridge along the outer margin of the right
lobe. The prostate is very flat. This man has gained about 16 pounds
in weight. From getting up at night six or eight times, he has had a long
period just before the last radium burn of getting up not at all at night.
His prostate is markedly reduced in size, but I believe still has carcinoma
in it. For six months his carcinoma and the symptoms caused
by it have markedly regressed."
SUMMARY.
"By means of radium we have caused the rapid and complete disappearance
of two bladder carcinomas out of nine treated. These cases
were carcinomatous by cystoscopic appearance and microscopic examination.
Time only will tell whether these patients are cured."
"In one case of prostatic carcinoma, treated for six months, the
carcinoma and the symptoms have markedly regressed. In another case,
treated three months (possibly borderland) the symptoms have improved.
Of three other patients treated, one is dead, one has only recently
been treated, and one is doing a full day's work but could not be reached
for examination."

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