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PRESENTED BY 

PUBLISHER

A QUARTERLY JOURNAL DEVOTED TO THE CHEM 

ISTRY, PHYSICS ANIi THERAPEUTICS OF RADIUM 

AND OTHER RADIO-ACTIVE SUBSTANCES 

VOLUME THREE. NEW SERIES 

APRIL. 1924, TO JANUARY, 1925. 

^ ^ 

'\ v 

PITTSBURGH, PA. 

1925

CONTENTS OF VOLUME THREE. NEW SERIES 

NUMBER QNE, APRIL. 1924 

A*j-E. Harvard Pinch, F.R.C.3. A Kcporl of the Work Car- 

'.Vi'ied OlCc-al the Radium Institute. I-ondon. from January 1st, 

'•'.i$2$, -ty-•.December 31st. 1923 

jatfres tâse, M.D., F.A.C.S. The Technique of Radiation 

.STOierapy of Esophageal Carcinoma 24 

WrA. Campbell Posey, M.D. Concerning Vernal Conjunctivitis. . 35 

Rt«f. \yflHfims, Past Assistant Surgeon, Office of Industrial Hy- 

•••îenc:^'nd Sanitation. United Slates Public Health Service. 

..:J:relimSKary Note on Observations Made on Physical Condition 

of-Persons Engaged in Measuring Radium Preparations. . 43 

Vitorgc 'D.;.Culver, M.D. Technique of Radium Treatment for 

Lupus." "Erythematosus 65 

Index of Articles Relating to the Therapeutic Use of Radium 

and Radio-.\ctivc .Substances. Which Appeared in 1923 67 

New Books 96 

NUMBER TWO, H'LY, 1924 

Charles C. Norris. M.D.. and M. E. Vogt. M.D. Carcinoma of 

the Uterus (with the Report of 115 Cases) 97 

Robert H. Herbst. M.D. Blocking Lymphatics in the Control of 

Carcinoma of the Prostate Gland 113 

Ernest M. Watson. M.D. A Technique for the Application of 

Radium (Emanation) in Carcinoma of the Prostate 

no 

G. Failla, Sc.D. The Twenty-fifth Anniversary of the Discovery 

of Radium 

J2^ 

Ninth Annual Meeting of the American Radium Society 129 

New Books , 11 

Reviews and Abstracts. 

John G. Clark, M.D., and Frank B. Block, M.D. Relative Values 

of Irradiation and Radical Hysterectomy for Cancer of the 

Cervix 1 *-

George W. Crile, M.D. Carcinoma of the Uterus 141 

Thomas E. Jones, M.D. The Role of Radium in the Treatment 

of Carcinoma of the Uterus 146 

Walter S. Lawrence, M.D. On the Reasons for Choice—Radium 

or X-Ray, when Radiotherapy is Indicated 147 

R. E. Loucks. M.D., CM. Radium Treatment of Toxic Goiter 

with Metabolic Deductions 

Th. Vaternahm. M.D. Further Experiences in the Treatment of 

Arthritis with High Doses ot Radium Emanation 156 

Obituary—Harvey R. Gaylord, M.D 160 

NUMBER THREE, OCTOBER. 1924 

Robert B. Greenough, M.D.. F.A.C.S. The Treatment of Malignant 

Diseases with Radium and X-Ray. Cancer of the Cervix. 161 

Frederick M. Johnson, M.B., Tor. Radium Treatment of Carcinoma 

of the Antrum 174 

Sanford Withers. M.D., and John R. Ranson, M.D. The Treatment 

of Malignant Growths '\bout the Face 181 

Frederick S. Burns, M.D. Radium in the Treatment of Non- 

Malignant Diseases of the Skin 189 

Frank A. Pcmberton. M.D., F.A.C.S. Childhcarmg After Radium 

and X-Ray Treatment 196 

J. J. Corbctt. M.D. Radium Clinic for Treatment of Eye, Ear. 

Nose and Throat Conditions 199 

J. J. Corbett, M.D. The Effect of Radium on Glaucoma 202 

X-Ray and Radium Protection Committee. Revised Report No. 1. 207 


W. S. Flateau, M.D. Results of Radiotherapy of Cancer of the 

Uterus 213 

Arthur U. Desjardins. M.D., and Francis A. Ford. M.D. Hodgkin's 

Disease and Lymphosarcoma. A Clinical and Statistical 

Study 214 

George R. Minot, M.D., Thomas E. Buckman. M.D., and Raphael 

Isaacs. M.D. Chronic Myelogenous Leukemia: Age Incidence, 

Duration and Benefit Derived from Irradiation 217 

Burt Russell Shurly, M.D. The Removal of Tonsils, with Special 

Reference to Methods Other Than Complete Enucleation 219 

CfcttTRA!. - ADVLT 

-flVl •b,^-x*

F. W. Aston, D.Sc, F.R.S. Atoms and Isotopes. The May Leeture 

to the Institute of Metals " 

G. P Baxter. Thirtieth Annual Report of the Committee on 

Atomic Weights 3 

s'UMBER FOUR. JANUARY, 1925 

W. H. Guv. M.D., and F. M. Jacob, M.D. The Erythema Dose 

of Radium 225 

Frederick M. Johnson, M.B., lor. Treatment of Carcinoma of 

the Conjunctiva with Radium 232 

G. 1-:. Pfahler. M.D. Radiation in the Treatment of Primary 

Malignant Disease 2-*° 

Howard C. Taylor. M.D.. and Thomas C. Peighthal. M.D. End 

Results of 201 Cases of Carcinoma of the Cervix 245 


Gosta Fors?>ell, M.D. Experiences in the Permanency of Radiological 

Cure in Cancer. Caldwell Lecture. 1924 253 

I. H. V. Hevman. M.D. Results of Radiation of Cancer of the 

Cervix ...' 258 

Thomas H. Kelley, M.D. Lymphosarcoma of the Small Intestine..26 

Bradley L. Coley, M.D. Retroperitoneal Lymphocytoma Causing 

Chylous Ascites and Chylothorax 260 

Joseph L. DeCourcy, M.D. Cancer iH the Thyroid 263 

Leon II. Smith, M.D. Epithelioma of the 'Tonsil 264 

Isaac Levin. M.D. Intraperitoneal Insertion of Buried Capillary 

Glass Tubes of Radium Emanation in Carcinoma of the Cervix 

Uteri 265 

George R. Minor, M.D., and Roy G. Spurling, M.D. The Effect 

on the Blood of Irradiation. Especially Short Wave Length 

Roentgen-Ray Therapy 268 

Gordon B. New. M.D., and Fred A. Figi. M.D. Treatment of 

Fibromas of the Nasopharynx: Report of Thirty-two Cases... . 275 

W. Warner Watkins, M.D. Pathological Basis for Roentgen- 

Ray Treatment of Tonsil Disease 277 

Obituary—William Henry Beaufort Aikins, M.D 282

Q

2 Radium 

P. M. the apparatus is applied for the last time, being finally removed 

at 7 A. M.—nine hours; thus completing the prescribed period of thirty 

hours. During the periods of rest the radium is used for the treatment 

of those cases which require unscreened, or short lightly screened exposures. 

When, however, the ca-es are such as call for treatment by the 

burying of radium tubes, the tubes after insertion are allowed to remain 

undisturbed for the whole length of the exposure, and are only withdrawn 

when it has terminated. 

The services of the surgeon are being requisitioned more frequently. 

for the purpose of employing radium in the most effective manner, and 

recently reported advances in that direction comprise the treatment 

of laryngeal growths by subhyoid pharnygotomy; and of inoperable 

cancer of the uterus with extensive infiltration of the broad ligaments. 

by performing a medium laparotomy and burying the radium tubes in 

the diseased tissues from the peritoneal surface. Cases of carcinoma 

of the cardiac end of the oesophagus have also been treated by the introduction 

of radium tubes through a gastrotomy opening. It appears 

highly probable that the use of "surgery of access" will undergo a steadily 

progressive development. 

The combination of diathermy with radium has. during the past 

twelve months, yielded some highly successful results in the treatment 

of carcinoma of the tongue, mouth, tonsils and fauces, many cases of 

very advanced type being greatly benefited, the suffering much relieved. 

and the progress of the disease retarded or arrested. The customary 

procedure consists of the removal or destruction of the primary focus 

of the disease by diathermy, excision of the more easily accessible associated 

lymphatic glands, and a subsequent general radiation of the whole 

operation area with radium tubes and applicators. 

The general trend of radium therapy is in the direction of increase 

of dose, more especially at the first exposure, and the employment of 

quantities of radium element varying from 250 to 750 mgrs.. with screening 

of 2 mm. of lead, and exposure of from twenty to thirty hours' duration, 

is now by no means unusual in the treatment of such conditions 

as an extensive mammary cancer, mediastinal growths, lymphosarcoma, 

lymphadenoma. and lymphatic leukaemia. Patients so treated do experi 

ence some degree of systematic disturbance, but it is never very great. 

and rapidly disap[>ears under appropriate treatment. It is not. however. 

wise to use such a heavy dose when the radiation is directed chiefly to 

the abdominal cavity, as recent experimental researches have shown that 

the mucus-forming cells of the intestines are peculiarly susceptible to 

gamma rays. "The immediate effect of such radiation is a definite but 

transient increase of activity of the goblet cells, speedily followed by 

atrophy and degeneration. No mucus being formed the intestinal bacteria 

are enabled to invade the mucosa, causing its necrosis and desquamation. 

The bacteria may in some cases penetrate into the blood streams 

and give rise to a septicaemia. 

During the past twelve months all the radium applicators and tubes 

used at the Institute have been standardized in terms of radium element, 

as this method of recording the strength of apparatus is steadily coming 

into general use.

R a d i u m 3 

The surface applicators are of three strengths:— 

(i) "Full strength" containing 0.5 centigramme radium element 

per square centimetre. 

(2) "Half strength" containing 0.25 centigramme radium element 


(3) "Quarter strength" containing 0.125 centigramme radium element 


Similarly the initial activity of all radium emanation apparatus is 

expressed in millicuries. A millicurie is the amount of emanation in 

equilibrium with a milligramme of radium element. 

In the report of the International Committee on Chemical Klements. 

1923, it was advised that the word "radon" should replace the term 

"radium emanation." 

The use of radon is steadily increasing as its therapeutic value becomes 

more widely known and appreciated. All forms of apparatus 

are made by the laboratory staff, from the tiny millet seed sized glass 

capsules for burying permanently in malignant growths, to the flatapplicators 

with a surface area of 50 or 100 square centimetres, for the treatment 

of extensive superficial affections. 

Advice is freely given to medical practitioners in the treatment 

of disease with radon apparatus, and if precise information is furnished 

as to the nature and extent of the disease or growth, a suitable apparatus, 

correctly screened, with full instructions as to technique and exposure. 

can usually be forwarded to any address in the British Isles within two 

or three days. 

The fact that the therapeutic effect of radon and radium salt apparatus 

is identical cannot be too strongly emphasized, as some practitioners 

even now appear to retain a prejudice against the employment of radon 

apparatus, believing it to be weaker in its action than radium salts. It 

is true that radon slowly decays, its initial radio-activity being reduced 

to one-half in 3.85 days, and to one-fifth in 8.8 days; but this rate of 

decay never varies, and it is thus a perfectly simple matter to prepare 

an apparatus, the mean activity of which during a period of twentyfour 

hours, would be exactly equivalent to that of a radium salt apparatus 

of a stated strength. Supposing, for the sake of example, it is desired 

to give an exposure of twenty-four hours' duration with a radon tube. 

the activity of which will be equal to that emitted by too mgrs. of radium 

clement, a radon tube is made possessing an initial activity of between 

109 and no millicuries; by the end of twenty-four hours it will have 

fallen in value to between 92 and 93 millicuries. so that its mean activity 

for the whole of the period will be. as nearly as possible 100 millicuries. 

Radon, moreover, has one particular advantage over radium salts, being 

a gas it is highly compressible, and a curie of radon (the amount of radon 

in equilibrium with a gramme of radium element) can be contained in 

a space of only 0.5S cubic millimetre. This property permits of the 

manufacture of extremely small radon tubes or applicators, possessing 

a very intense radon activity. 

Further, radon possesses no intrinsic value, and should a radon applicator 

be mislaid or destroyed, the only pecuniary loss incurred is the

Radium 

value of the metal container. This enables radon apparatus to be sent on 

hire or loan to all parts of the I'nited Kingdom, no security or insurance 

being demanded, as would be the case if radium salt applicators were 

used. 

The report for 1921* dealt with "Radium Therapy in Gynecaeology." 

that for 1922** with "Radium Therapy in Diseases of the Alimentary 

Canal." They were so favorably received that it has been considered 

cx[>edient to devote the report for 1923 to a consideration of "Radium 

Therapy in Diseases of the "Thyroid. Thymus. Spleen and Lymphatic 

System." 

The Tables of Cases refer only to those patients who were seen 

lor the first time between ist January, 1923, and 31st December, 1923. 

and do not include any cases examined prior to those dates, though many 

such have received treatment during 1923. 

The policy of declining to treat operable cases of malignant diseases 

—rodent ulcer alone excepted- —has been rigidly adhered to. save in 

those instances where the patient has positively refused to submit to 

operation. 

The cases treated were in no instance selected, and the only ones 

refused were those in which the patients were practically moribund, or 

where the disease was of a kind for which radium therapy was manifestly 

unsuitable. 

The column "cured" refers only to cases of a non-malignant nature. 

as it would be unjustifiable to claim as "cured" cases of malignant disease 

which have been treated for the first time during the past year. 

The term "apparent cure," used in relation to cases of malignant disease, 

must be interpreted as representing a condition in which all traces 

of the original lesion or lesions has disappeared, in which there is no 

sign of any recurrence, and in which the patient is, so far as can be determined 

by a thorough and careful examination, free from anv indication 

or symptom of the disease. 

Cases have been classed under the heading "improved" only when 

the result of treatment has been to produce a definite and marked degree 

of benefit, diminution in the size of a growth, healing of ulceration and 

arrest of hemorrhage and discharge, or of relief to such subjective symptoms 

as itching, tenderness, pain, dyspncea and dysphagia. 

The strength of all the apparatus used in the treatment of cases is 

expressed in terms of radium element. 

''.951 treatments were administered during the year, of which 3.776 

were given free of all charge to necessitous patients. 

947 emanation applicators were prepared during the year, and distributed 

to hospitals and medical practitioners throughout the I'nited 

Kingdom tor the treatment of patients. 

*R«I>rlnt«d I11 KAI'H'M. July, 1922. 

**Tti>|irin»e«l in RAI'lfM. April. 1923.

Radium 

Tabu: I 

Classification of Cases 

Disease. 

 

9 

'I 

it 

li 

8 

— b 

« 

lis 

P 

/ I 

| g 

? I 

1 I 

o 

li 

si 

m 

Carcinoma, Squamous-celled: 

Glabrous skin 

Buccal, oral, lingual, and 

pharyngeal mucous membranes 

(Esophagus 

Larynx 

Vulva 

Vagina 

Uterus 

Bladder 

Carcinoma, Spheroidal-celled: 

Breast 

Thyroid 

1 

6 

1 

•> 

4 

12 

2 

1 

2 

12 

1 

10 

1 

3 

1 

4 

2 

3 

2 

1 

: 

: 

_ 

— 

9 

25 

3 

2 

1 

23 

1 

36 

3 

2 

21 

1 

1 

1 

17 

12 

— 

2 

3 

3 

2 

5 

a 

22 

74 

0 

6 

6 

2 

61 

•> 

60 

4 

Carcinoma, Columnar-celled: 

Stomach 

Intestine 

Prostate 

Ovary 

Rodent 

Sarcoma 

ulcer 

Endothelioma 

Malignant glands 

Mediastinal tumors 

Lymphadenoma 

Fibroid disease of uterus... 

Chronic metritis 

__ 

1 

— 

1 ' 2 

1 

2 7 | 1 

1 1 

— 1 | 1 I | — 

1 

| 

2 

1 

1 

1 1 

— 16 1 — 

4 6 4 

- i i 

1 1 

— I 2 I — 1 

1 1 

11 2 — 

i — 

1 2 

— 

— 

124 

S 

2 

1 

— 

1 

— 

— 

— 

— 

^_ 

— 

— 

— 

— 

— 

— 

5 

— 

17 

2 

2 

33 

15 

:'. 

6 

4 

3 

4 

5 

n 

1 

1 

i 

_ 

3 

— 

_ 

'. 

1 

10 2 

— 

— 

— 

2 

2 

— 

— 

— 

— 

— 

— 

2 

1 

_ 

— 

1 

2 

1 

2 

— 

— 

— 

•> 

6 

4i> 

3 

6 

178 

46 

9 

13 

8 

5 

i 

13 

N'xvi: 

Cavernous 

- 21 - 

"I 2(- 

— 

— 

4 

10 

12 1 5 

— 

— 

— 

— 

— 

25 

19

Radium 

Table I—Continued 

Classification of Cases 

Disease. 

Moles, warts and papillomata 

Keloids 

Dupuytren's contraction ... 

Spring catarrh 

3 . 

-- 

I! 

Il 

a 

2 

2 

1 

§1 

a 

c u 

*> 

to 

6 

8 

l 

I|| 

- -- 

t*E2 

aw 

5 

El 

a 

< 

36 

8 

1 

1 

. 

u 

> 

o 

fa 

a 

E 9 

26 

2 

6 

•6 

% 

I 

£ 

0 

y. 

1 

3 

!! 

- 

_2 

9 

54 

52 

3 

5 

7 

Tuberculosis: 

Palate 

1 

1 

2 

3 

3 

5 

4 

9 

11 

1 

7 

14 

20 

Chronic inflammations 

Chronic ulcerations 

Psoriasis 

Lupus erythematosus 

Skin disease (various) 

Iêucocyth^nia: 

Spleno-medullary 

Exophthalmic goitre 

Arthritis deformans 

Totals 

8 

1 

1 

2 

1 

2 

2 

2 

127 

5 

4 

2 

3 

3 

3 

4 

3 

4 

2 

" I 

- 2 8 

— 1 — 1 6 

! 

I f 

25 137 i 93 1323 

1 

2 

94 

— 

i 

1 

l 

10 1 23 

12 

4 

6 

4 

3 

10 

4 

4 

12 

n 

RRS 

Table II. 

Summary of Coses. 

Examined, but not treated 

Recent report not received 

Received prophylactic irradiation only 

Apparently cured 

Cured 

Improved 

Not improved 

Abandoned treatment 

Died 

Total. 

3* 

127 

25 

•37 

93 

328 

94 

IO 

23 

80S

R a d i u m 

RADIUM THERAPY IN DISEASES OF THE THYROID. 

thymus, spleen and lymphatic system. 

Apparatus 

The treatment of this group of diseases calls chiefly for the employment 

of fiatsurface applicators, and a large number of' these is required 

to obtain the best results. 

"Half-strength" applicators are the most useful, and convenient 

sizes are rectangles. 3 X 2 centimetres, containing 15 mgrs. radium element 

; and squares, 4 X 4 centimetres, containing 40 mgrs. radium element. 

But few screens are necessary, lead 0.1 mm. and 2.0 mm., silver 

1.0 mm., and platinum 0.3 mm. in thickness will give the requisite filtration 

for the various conditions. 

Screen. 

Thickness in mm. 

Lead 0.1 

." | 2.0 

Silver | 1.0 

Platinum j 0.3 

Percentage of Rays 

transmitted. 

? 

23.6 

0-37 

1.18 

2.28 

•' 

99-5 

92.8 

95-5 

97-2 

The passage of gamma rays through thick metal screens excites an 

"emergent secondary radiation" which is capable of causing considerable 

surface irritation, and it is therefore necessary to absorb this secondary 

radiation. This is best effected by the interposition of some sheets of 

black paper with lint and then rubber over all. between the outer surface 

of the metal screen ami the skin of the patient. The surface applicators 

are kept in position by means of thin strips of rubber adhesive plaster 

and a few turns of crepe Yclpeau bandage over all. Non-elastic bandages 

of linen or calico should never he employed when giving prolonged 

exposures, as their use often causes great discomfort to the patient. 

When radium is buried in growths or tissues, a screening of 1.0 mm. 

silver will be found best for general use; but when the nature of the 

case calls for the employment of numerous small tubes of radium, then 

tube screens of 0.3 mm. platinum are preferable. 

A.—Tnr; TuvRoin Gland 

The normal thyroid gland is but little affected by radium rays, and 

experimental researches on animals have produced scarcely any alteration 

in its structure or functions. It is possible, however, that frequently 

repeated prolonged screened radium radiations would, by inducing fibrosis, 

ultimately cause atrophy of its cellular elements and arrest of its 

secretory functions, as this phenomenon has been recorded as occurring 

after numerous X-ray treatments. 

Microscopical examination of sections taken from a normal thyroid 

gland shows it to be composed of a large number of closed vesicles, lined 

with a single layer of cubical epithelium and filled with a colloid material. 

These vesicles are supported by a delicate fibrous network, which 

is continuous with the capsule surrounding the gland. Between many of 

the vesicles are groups of polygonal or rounded cells—undeveloped vesicles. 

Numerous lymphatic vessels are present in the fibrous reticulum, 

and it is through them that the colloid material reaches the blood stream. 

as the thyroid gland has no excretory duct or ducts.

8 RADIUM 

The affections of the thyroid gland for the relief of which radium 

therapy is most usually sought are:— 

(i) Simple goitre--(

R a d i u m 9 

I he subjective symptoms are many, and comprise great nervousness 

and trembling, Bushings of head and face, palpitation, spasmodic dyspnoea, 

pruritus, thirst, vomiting and diarrhoea, great mental instability. 

forget fulness and depression. 

The disease often proves wry obstinate and distressing, and medical 

treatment, though of the greatest value in the relief of symptoms, has 

but little effect on the duration of the disease. In suitable and selected 

cases the operation of partial thyroidectomy is undoubtedly the procedure 

offering the best prospects of permanent relief or cure, but many 

patients emphatically refuse operation, and radium treatment is advised. 

Prolonged irradiation with the gamma rays often proves most beneficial. 

especially if there is no vomiting or diarrhoea, and the patient is not 

emaciated. Klat applicators containing from 70 to too mgrs. of radium 

element screened with 2 mm. of lead are employed, and a total exposure 

of from twenty to thirty hours' duration given. The treatment is 

sometimes followed by a definite exacerbation of all the symptoms, and 

it seems fair to attribute this to the congestion attendant upon the reaction, 

causing an increased outflow of the thyroid secretion into the blood 

stream. Such exacerbation, however, proves transient, and is usually 

followed by a gradual but steady and definite improvement in the patient's 

symptoms and general condition, and this may probably, almost 

certainly, be ascribed lo the action of the rays producing an arrest of the 

vitality and retardation in the development of actively proliferating cells. 

thus restoring the output of the cellular secretion more nearly to normal 

limits. With this there is also associated a fibrosis of the connective 

tissue of the gland, causing the organ to become firmer and smaller. The 

patient should be seen at intervals of three months, and the treatment 

repeated, if necessary, with such modification as may seem advisable. 

(3) Malignant Goitre.—Malignant disease of the thyroid gland 

may be either carcinomatous or sarcomatous. In the absence of the 

information that may be obtained from a biopsy, the clinical differentiation 

is often extremely difficult, though as a general rule sarcoma is apt 

to attack one lobe only and to grow with extreme rapidity; carcinoma 

is more likely to affect both lobes and to progress more slowly. 

The disease is one of late adult life, cases occurring before the age 

of fortv are extremely rare. Not infrequently, on eliciting the history 

of a case of malignant disease of the thyroid it is found that the patient 

bad an innocent goitre for many years. In the early stages of the disease, 

whether carcinomatous or sarcomatous, the growth is enclosed 

within the capsule of the gland, but in a very short time it perforates 

it. and invades the adjacent structures, surrounding- the carotid artery. 

involving the trachea and pharynx and paralyzing the vocal cord. Fixation 

of the growth occurs to larynx, trachea, sternum, clavicle, etc. It is 

important to note that a growth, when firmly fixed to the trachea only. 

will move with it on deglutition, but cannot be moved on it. 

Tlie majority of cases presenting themselves at the Radium Institute 

for treatment are in a very advanced state, there being a large, hard. 

firmly fixed growth affecting one or both lobes, the surface being bossy 

or irregular. Dysphagia, dyspnoea, hoarseness, neuralgia pain in head 

and neck, and paralysis of the sympathetic may one or all be present. 

In these advanced and inoperable cases radium treatment should most 

certainly be adopted. It will often arrest the progress of the disease 

in a most striking fashion, causing a great reduction in the size of the 

growth and affording much relief to the symptoms.

10 R a d i u m 

The treatment should be carried out by "cross-lire" irradiation with 

external applicators containing 150 to 250 mgrs. of radium element, 

screened with 2 mm. of lead. Exposures of thirty hours' duration related 

at intervals of six weeks are necessary. The employment of 

radium tubes buried within the growth is strongly to be deprecated, as 

this procedure is almost inevitably followed by a rapid fungation of the 

growth through the skin incisions. It is important to preserve the surface 

of the skin intact as long as possible, as the presence of fungation 

and ulceration adds greatly to the patient's distress. 

B.—The Thymus Gland. 

During fcetal life this gland is largely developed. It increases during 

the first two years of life, remains stationary until about the tenth year. 

then commences to atrophy and to undergo fatty degeneration. So long 

as it exists it appears to perform the function of a true lymphatic gland; 

it is also thought by some to furnish an internal secretion which is a 

stimulant to the general metabolic processes of early life. When atrophy 

does not occur at the usual time, and the gland persists or becomes hyperplasic 

it may be associated with:— 

(i) Thymic Asthma.—Although there is much difference of opinion 

as to whether the pressure of an enlarged thymus upon the trachea 

may produce dyspnoea, and many cases of thymic asthma prove, upon 

enquiry, to have been attacks of laryngismus stridulus; yet the balance 

of evidence is in favor of an enlarged thymus sometimes so constricting 

the trachea as to produce a true pressure dyspnoea. 

(2) Lymphatism-Status Lymphatic us.—The existence of this condition 

is occasionally only rendered evident when sudden death has occurred 

during anaesthesia, and the autopsy reveals the presence, hitherto 

unsuspected, of an enlarged thymus. 

In a large number of cases of true status lymphaticus there are. 

however, indications of a hyperplasia of the lymphatic structures generally, 

the patients having enlarged tonsils, adenoids, enlargement of 

the glands in cervical, axillary and inguinal regions, and possiblv of the 

thyroid, spleen and liver. When the existence of an enlarged' thymus 

gland is suspected a definite diagnosis should he made by ordinary physical 

methods and an X-ray photograph, and since the gland serves no 

useful purpose in adult life and its persistence may be a possible source 

of danger, the adoption of measures to hasten its atrophy are quite justifiable. 

With this object in view "cross-tire" radiation of the area with 

Hat applicators containing 50 to 100 mgrs. radium clement screened with 

2 mm. of lead should be adopted. The total exposure should be of from 

fifteen to twenty hours' duration, preferably given in three or four equal 

periods on successive days. The gland rapidly shrinks and a second 

series of exposures is rarely, if ever, necessarv," 

C.—The Spleen-, 

This organ is a great blood filter,purifying the blood in its passage 

through it. taking up panicles of foreign matter, micro-organisms and 

effete red blood corpuscles. The cells of the splenic pulp are strongly 

phagocytic, as also are the endothelial cells which line the walls of the 

cavernous spaces in the reticulum. 

Physiologists are agreed that the spleen possesses a powerful ln-emo-

Radium 

n 

lytic function, and there is abundant evidence, both microscopical and 

clinical, to support this view. Some authorities contend that the spleen 

also possesses a homogenetic power, but that this property is only evoked 

in response to severe hemorrhages or other special stimuli. 

Chronic enlargement of the spleen from congestion is met with in 

hepatic cirrhosis, and in chronic cardiac and pulmonary affections. It 

also occurs in certain constitutional conditions, syphilis, rickets, malaria. 

and lardaceous disease, but in none of these affections is radium therapy 

of any practical value. There are. however, three diseases, in all of 

which there is great enlargement of the spleen, and in which radium 

treatment is indicated, as it rapidly induces a considerable shrinking in 

the size of the organ with an associated improvement in the patient's 

general condition. 

i. Splcnomeijaly—Simple.—A gradually progressive enlargement 

of the spleen, unaccompanied by ana-mia or leucocytosis. and with practically 

no symptoms beyond the discomfort occasioned by the size and 

weight of the organ. 

The effect of radium radiation in a case of simple splenomegaly is 

usually very striking. A spleen which before radiation reaches down 

into the left iliac fossa rapidly recedes under appropriate dosage, and 

at the end of six weeks or two months may not be palpable below the 

costal margin. The radiation of the enlarged organ i> best accomplished 

by means of numerous "half strength" Hat surface applicators containing 

from 200 to 400 mgrs. of radium element, screened with 2 mm. of 

lead, the total exposure being of from twenty to thirty hours' duration. 

2. Splenic Anaemia—fiaiiti's Disease. A chronic enlargement of 

the spleen, with marked anemia, but without any leucocytosis. The disease 

shows a great tendency to hemorrhages, and is followed after a 

period of years by cirrhosis of the liver and ascites. 

In ibis condition radium usually induces a definite decrease in the 

size of the spleen, with some slight improvement in the color index. 

The disease is. however, a steadily progressive one. and the remission 

usually proves but temporary, a repetition of the treatment being called 

for at intervals of from four to six months. 

Radiation is carried out with "half strength" surface applicators. 

screened with 2 mm. of lead, and total exposure of from twenty to thirtyhours. 

The amount of radium employed varies with the size of the 

spleen, but generally quantises of from 100 to 200 mgrs. of radium 

element are necessary. 

3. Spleno-Medulhry Leukaemia.—This affection is much more 

common than lymphatic leukemia. The principal clinical features are 

a gradual enlargement of the spleen, with associated changes in the blood 

and bone marrow, followed in the later stages by multiple hemorrhages 

and progressive anemia. Microscopical sections cut from the affected 

spleen show its pulp to be closely packed with leucocytes, but there are, 

in addition, many marrow cells "myelocytes." both neutrophilic and eosinophilic. 

The Malpighian bodies arc usually hypertrophied. In acute 

cases, or in the early stage of the disease, the organ is soft, but as the 

condition becomes chronic a fibrosis and thickening of the reticulum 

occurs. Examination of the Wood shows ;* great increase in the number 

of the white blood corpuscles, the count varying from 200.000 to 1.000.-

12 Rapitjm 

ooo per cubic millimetre. Cases have been recorded in which the number 

of the leucocytes has exceeded that of the red blood corpuscles. A differential 

count of the white blood corpuscles reveals some striking features. 

'The lymphocytes may be reduced to 5 per cent or even less. The 

polymorphonuclears are relatively diminished; the eosinphilcs are increased. 

Myelocytes, both neutrophilic and eosinophilic, are present in 

large numbers, and may form 25 per cent to 50 per cent of all the white 

corpuscles. Nucleated red blood corpuscles and poikilocytes are also 

present in varying numbers. There is generally a moderate reduction 

in the number of the red blood corpuscles, the total rarely falling below 

2,000.000 per cubic millimetre. The hemoglobin is usually diminished 

in a slightly greater proportion, giving a color index of from 0.7 to 0.9. 

Hemorrhages are common. Epistaxis is of frequent occurrence. Bleeding 

from the jaws, hematemesis, cerebral and retinal liemorrhages. extensive 

purpura, and multiple ecchymoses are met with. The disease usually 

proves fatal in two or three years, though some cases of recovery 

have been recorded. 

Radium is unquestionably of great value in the treatment of spienomedullary 

leukemia. The immediate result in the improvement of the 

blood condition is very remarkable. It is often possible to record a definite 

decrease in the white cell count three days after the termination of 

the exposure, and this decrease may be steadily maintained for four or 

five weeks, at the end of which time the number of leucocytes may be 

reduced to between 20,000-50,000 per cubic millimetre. There is usually. 

in addition, a concomitant rise in the hemoglobin content, the anemia 

is lessened, and the tendency to hemorrhages diminished. The patient's 

general condition is also improved, appetite and strength returning. If 

the disease is of comparatively recent origin, there is a great decrease 

in the size of the spleen, the organ rapidly shrinking to almost normal 

dimensions, and permitting the performance of splenectomy, if this be 

considered desirable. If the condition is of long standing, and the spleen 

has previously been subjected to much treatment with X-rays, but little 

actual decrease in its size is likely to be effected by radium, as extensive 

fibrosis of the splenic interstitial tissue will have taken place. The radiation 

employed in the treatment of spleno-mcdullary leukemia should be 

wholly of the gamma type. "Half strength" flat surface applicators, 

screened with 2 mm. of lead, are used, and containing from 100 to 400- 

mgrs. of radium clement according to the size of the spleen. The total 

radiation should be of from twenty to thirty hours, and, when possible, 

this should be spaced over two or three days, as by so doing the possibility 

of inducing some slight systemic disturbance is much lessened. 

Patients vary greatly in regard to the amount of disturbance experienced. 

possibly the most constant feature is a feeling of nausea (which in very 

susceptible patients may induce actual attacks of vomiting), with headache 

and a slight rise of temperature. These symptoms arc, however, 

quite transient, and disappear within twenty-four or forty-eight hours. 

The patients need to be kept under careful observation and periodic 

examinations of the blood should be made. A steady progressive increase 

in the leucocyte count should be regarded as an indication for further 

radium treatment. This is. however, rarely necessary at lesser intervals 

than four months, and in favorable cases a period of six or nine months 

may elapse between exposures. In very advanced cases accompanied by 

severe anemia, transfusion of blood may advantageously be employed 

between the radium treatments.

Radium 13 

D.—Diseases of the Lymphatic System. 

1. Chronic Lymphadenitis may be 

(a) Syphilitic. 

(b) Pyogenous. 

(c) Tuberculous. 

(a) Syphilitic Lymphadenitis.—This condition is not amenable to 

radium therapy, and should be treated with the appropriate specific 

remedies. 

(b) Pyogenous Lymphadenitis. In the early and acute stages of 

this condition, with congestion and swelling of the glands, erythema 

of the overlying skin, and much local tenderness, radium treatment is 

not called for. When, however, the acute symptoms have subsided, leaving 

enlarged and chronically inflamed glands, radium treatment may 

be employed with the object of inducing or accelerating their resolution. 

"Half strength" applicators, screened with 2 mm. of lead, should 

be disposed over and around the enlarged glands in such fashion as to 

obtain a maximum "cross-fire" irradiation. The total exposure should 

be of from twenty to thirty hours' duration, repeated, if necessary, at 

intervals of six weeks or two months. The result is usually very good, 

the affected glands steadily shrinking in size and ceasing to trouble the 

patient. 

(c) Tuberculosis Lymphadenitis.—This condition is peculiarly prone 

to occur in the cervical glands, and. if not treated promptly, often proceeds 

to caseation of the affected glands, which break down, implicate 

the overlying tissues, forming chronic indolent sinuses surrounded byareas 

of bluish ill-nourished skin. Healing of the sinuses takes place 

very slowly, and leaves an irregular puckered scar. The affection is most 

generally met with in young subjects, and the parents are often strongly 

averse to surgical measures for cosmetic reasons. 

In the early stages of the disease, when the glands arc relatively 

small, tliscretc. and but little tender, appropriate radium treatment will 

usually speedily reduce their size and number, and arrest the progress 

of the disease. If caseation or suppuration has occurred, it is. however, 

imperative that before radium treatment be given the contents of the 

glands should be removed, either by aspiration, or free incision and 

drainage. 

Some judgment must be exercised in the treatment of tuberculous 

adenitis, and the strength of apparatus, screening and length of exposure, 

modified according to the nature of the individual case. When the 

covering skin is not implicated, "half strength" applicators, screened 

with 2 mm. of lead, and exposures of from twenty to thirty hours' duration 

give the best results; but when chronic sinuses exist and the skin 

is infiltrated or ulcerated, screening of 1 mm. of silver or 0.1 mm. of 

lead is preferable, the length of the exposures being shortened accordingly. 

The action of radium rays in the treatment of tuberculous adenitis 

is probably of a two-fold character. Numerous experiments have been 

made with regard to the action of radium rays on tubercle bacilli, and 

it has been found that exposures of at least one hundred hours' duration 

with full strength applicators unscreened, are necessary to produce a 

lethal effect. Such exposures are outside the range of practical therapy. 

and for this reason radium irradiation cannot he used for the distinct 

purpose of killing tubercle bacilli. It has, however, been noted that cul-

14 Radium 

tines of tubercle bacilli which have received a relatively short irradiation 

have their vitality greatly inhibited, and that subcultures made from 

them grow much*more slowly than controls, and exhibit numerous involution 

forms. It is probable, therefore, that the radiation of tuberculous 

glands weakens the vitality of the contained tubercle bacilli, and 

enables their destruction to be more readily accomplished by the phagocytic 

cells. Eurther. the radium irradiation acts as a stimulus to the production 

of fibroblasts,with the consequent development of an encircling. 

constricting, and protective fibrosis. 

2. Lymphadenoma. Hodijkin's Disease.— This condition is characterized 

by" a progressive hyperplasia of the lymph glands, accompanied 

by anemia, and occasional development of secondary lymphoid nodes 

in the spleen, liver and other organs. 

It is commonest in young adults, and affects men more than women 

in the proportion of 3 to 1. In a few cases the onset appears to be 

determined by chronic irritation, and very occasionally it follows directly 

upon a tuberculous adenitis. 'The attack is usually s'ow and insidious. 

but in some instances is more marked, with rigors and intermittent 

pyrexia. 

Any group or groups of lymphatic glands may form the starting 

1'oint of the disease, but it is most prone to develop in the cervical axillary 

or inguinal glands, in the order named. When affecting the deepseated 

glands in the thorax or abdomen, pressure symptoms may be the 

first phenomenon noted, the patient suffering from paroxysmal dyspncea, 

cyanosis, cedema of feet, and pain in some of the nerve trunks, etc. The 

g'ands are usually firm, elastic, painless, and not tender, freely movable 

and not adherent to the skin. In the later stages the glands tend to adhere 

to each other, and to form large lobulated masses. They do not 

suppurate. Microscopically the changes observed in the glands arc those 

of a simp'c hyperplasia, an increase in the number of lymphoid cells. 

and an associated thickening of the reticulum. The spleen is usually distinctly 

en'arged and often contains secondary lymphoid growths. The 

liver also may be similarly affected. The kidneys, lungs, and in very 

rare cases the skin, may be the site of the metastatic lymphoid deposits. 

There are no blood changes, which may be regarded as pathognomonic 

of lymphadenoma. The anemia is of the secondary type, appearing in 

the later stages of the disease, and rarely being of extreme degree. The 

color index usually ranges between 0.7 and 0.9. There is but seldom 

any very definite lymphocytosis. 

The course of the disease is very variable. It may prove fatal in 

three or four months, or it may run as many years. There are often 

prolonged periods of quiescence, but cachexia or anemia gradually develops, 

and the patients die from asthenia. In some case death is induced 

by pressure effects in the mediastinum, on the trachea, or the spinal cord. 

This affection usually exhibits an exceedingly favorable response to 

radium therapy, more especially when the superficial glands only are 

affected and no enlargement of the spleen, liver or mesenteric glands 

is appreciable. 

The position of the enlarged glands generally renders the application 

of "cross-fire" radiation practicable, and if this method of treatment be 

conducted with suitable sized "half strength" applicators, screened with 

2 mm. of lead, and exposures of twenty to thirty hours' duration, the 

glands rapidly dimmish in size and number, this effect being often clearly 

perceptible to the patients themselves within a week of the exposures.

Radium 15 

I he duration of the remission varies very widely. In some cases the 

disease will remain quiescent for twelve, fifteen or eighteen months, in 

others a repetition of the treatment may he found necessary at intervals 

of six months, but none the less radium treatment is to be advocated, as 

it will prolong the patient's life considerably, and postpone the appearance 

of a secondary anemia and its accompanying symptoms. 

3. Lymphosarcoma.—This is a variety of of round-celled sarcoma 

originating in lymphoid tissue. It is most commonly met with in the 

superior mediastinal region and in the cervical lymphatics, but it also 

occurs in the lymphatics of the intestinal canal. The tumors grow with 

great rapidity and speedily infect the neighboring lymphatic glands. 

When commencing in the mediastinum, pressure symptoms quickly 

develop, dyspnoea, dysphagia, congestion of face and neck, pleural effusion, 

etc.. Incoming evident. When the cervical glands are the starting 

point of the disease the investing skin becomes adherent and discolored, 

and in later stages it may ulcerate and fungation of the growth occur. 

The tumors speedily becomes fixed by reason of the direct extension of 

the disease to the neighboring structures. Microscopical examination 

shows the growth to be comi>osed of small round cells, with an abundant 

delicate intercellular fibroid network. The disease is highly malignant, 

and. unless treated, rapidly progresses to a fatal termination. 

It is in the treatment of lymph-sarcoma that the most spectacular 

results of radium therapy are to be seen. The lympho-sarcoma cell i* 

l>eculiarly susceptible to gamma radiation and its degeneration rapidly 

occurs. Lympho-sarcomatous masses appear, literally to melt away under 

the action of radium and patients who ha\e presented themselves for 

treatment with enormous lympho-sarcomata of the mediastinal and 

cervical regions producing dyspnoea, dysphagia, congestion of face and 

neck, etc., their condition on admission being grave in the extreme, responds 

in a fashion that is often amazing. The masses commence to 

shrink within a few hours of the application of the radium, and within 

a week or ten days the symptoms of pressure ami obstruction are greatly 

relieved, and the change in the patient's appearance is most remarkable. 

The rapid degeneration and absorption of the lymphosarcomatous cells. 

however, necessarily produces an autotoxemia. and the systemic disturbance 

is generally considerable, sickness, lassitude, headache, and a 

rise of temperature being pronounced features. The patient should be 

kept strictly .it rest, and laxatives and diuretics judiciously administered, 

until the symptoms have subsided. If is not necessary or advisable to 

treat lymphosarcomata by the burying of radium tubes in the substance 

of the growths. The tumors exhibit a great tendency to fungation when 

once any breach of the covering skin has occurred, and for this reason 

the surface should be kept intact as long as is possible. "Cross-fire" 

radiation will do all that is required, and it is justifiable, in view of the 

extreme malignancy of the disease, to use a very large quantity of radium 

—400 to 700 mgrs'of radium element, screened with 2 mm. of lead, and 

a total exposure of thirty hours have been employed in some extreme 

cases with most gratifying results. 

It appears better to give an intensive dose at the first ex|iosure 

rather than smaller doses of successive intervals. In a few instances the 

remission has been of very long duration, the patient keeping in comparatively 

good health for one or two years. Patents are, however, instructed 

to report at regular and frequent intervals for examination, so 

that if any remission occurs it may be dealt with promptly.

16 R A D I U M 

4. Lymphatic Leukaemia.—This disease is characterized by a general 

lymphatic enlargement affecting principally the superficial groups of 

glands, and usually associated with some degree of enlargement of the 

spleen. The affected glands are soft, discrete and movable. They do 

not tend to adhere to one another, to suppurate, or to involve the overlying 

skin. 

-1 lie total number of white blood corpuscles is increased and may 

rise to 500,000 per cubic millimetre, the average count is about 120.000 

ot 150.000 per cubic millimetre. This increase is almost entirely due to 

an augmentation of the lymphocytes, which may form over 90 per cent 

of the white blood corpuscles. The red blood corpuscles are diminished 

in number, usually from 2,000,000 to 3.000,000 per cubic millimetre. 

Hemorrhage from mucous surfaces, purpuric eruptions and severe 

ecchymoses following on slight injuries are seen, though these phenomena 

arc not so frequently met with as in splenomedullary leukemia. The 

spleen is usually a little enlarged, and there may be slight swelling of the 

liver. The general symptoms are pallor, weakness, wasting, pains in the 

joints, and intermittent pyrexia. The disease generally runs an irregular 

course, with exacerbations and remissions, but most cases prove fatal 

within two or three years. 

Cases of lymphatic leukemia of acute type are occasionally met 

with, but they are extremely rare. The patients are usually young adolescents. 

The onset is very sudden and anemia progresses with extreme 

rapidity, there being great destruction of the red blood corpuscles, and an 

enormous increase in a number of the lymphocytes, so that examination 

of stained film may show the lymphocytes to l>e almost equal in number 

to the red corpuscles. The affection rapidly proves fatal, and neither 

radium therapy or any other method of treatment appears to be of the 

slightest use. 

Lymphatic leukemia is of much less frequent occurrence than splenomedullary. 

It tends to run more chronic course and the late anemia 

is not so profound. Radium treatment is very effective in improving the 

condition of the blood. In a typical case of lymphatic leukemia the 

lymphocytes may constitute 80 to 90 per cent of the white blood corpuscles. 

The lymphocyte is probably, almost certainly, the most susceptible 

of all cells to radium, and for this reason radiation of the enlarged 

glands is speedily followed by a very definite decrease in the total number 

and percentage proportion of the lymphocytes, the count not infrequently 

falling to between 10.000 and 20.000 i>er cubic millimetre in alx>ut a 

month. Willi this fall there is usually associated an improvement in the 

general symptoms, and the patient's health is decidedly benefited. It is. 

however, extremely difficult to predict how long the improvement will 

last. In a few cases the disease will remain quiescent for a year or eighteen 

months, but. as a general rule, indications of a relapse appear in 

between four and six months, and a repetition of the treatment becomes 

imperative. The ultimate prognosis is bad. but the adoption of radium 

treatment usually effects a considerable prolongation of the patient's life. 

Treatment is administered by means of suitable sized "half strength" 

applicators, screened with 2 mm. of lead, and applied in contact with the 

surface of the affected glands. The total quantity of radium used is dependent 

upon the number and size of the glands treated, but generally 

amounts of lietween 100 and 3cx> mgrs. radium element will suffice. The 

total exposure should be of from twenty-four to thirty hours' duration. 

5. Lymphaiu/eii'ma. Capillary and Cavernous.—These lesions are

R a d i u m 17 

simitar in structure to the vascular angeioma or naevi, but as the dilate.! 

vessels and cavernous spaces are filledwith lymph instead of blood, they 

are yellow rather than blue or purple in color. The cavernous variety 

of lymphangioma is often found in cases of congenital enlargement 

Of tongue and lips- microglossia and macrochilia. 

A few cases of macroglossia have been treated and good results obtained. 

The procedure adopted has been a "cross-fire" radiation with 

"half strength" applicators of suitable size and shape, screened with 

o.i mm. of lead, three exposures, each of from thirty to forty-five minutes' 

duration being given on three successive days. The series of exposures 

has to be repeated at intervals of six weeks over a period of a year 

or even longer. Improvement occurs very slowly, but if the treatment 

is persevered with, the result is usually most satisfactory. 

6. Cystic Hygroma.—This type of growth most frequently occurs 

in the neck. The mass is composed of a number of dilated lymph spaces. 

cut off from the general lymphatic circulation, which are lined with 

endothelium and filled with clear lymph. The tumor often attains a 

very considerable size. 

'These growths, if occasioning discomfort or disfigurement, are best 

removed by dissection. If of small size, and the patient is averse to 

removal by excision, the cyst may be aspirated, and a tube containing 

20 to 30 mgrs. of radium element, screened with 1 mm. of silver, introduced 

into the cavity for twenty-four hours. This will excite a mild 

degree of inflammation, followed by an adhesive fibrosis, which will 

produce obliteration of the cyst. . 

7. Endothelioma. Perithelioma.—These growths may originate in 

the endothelium of the lymphatic vessels. Their miscroscopic appearances 

exhibit very great diversity. In a typical section, the main characteristics 

are numerous and closely-set flattened spaces containing irregular 

groups of cells of polygonal or cuhoidal epithelium. Definite 

mucoid degeneration is often apparent. In perithelioma, the proliferated 

endothelium is arranged in whorls, or in a radial manner around the 

lymphatic capillaries. The whorls are separated by a loose stroma. 

In the treatment of these tumors radium irradiation with gamma 

rays is often of the greatest value, more especially when given after 

removal of the growth by operation, as any recurrence is always a local 

one; and the fact that these growths spread only by direct extension, 

and do not form metastases, enables the radiation to be concentrated 

over a comparatively limited area, and thus powerfully to affect any 

isolated extensions of the growth which the surgeon may have failed 

to eradicate. If the growth be inoi>crable. it should be treated by the 

actual insertion of one or more tubes of radium, according to size and 

shape of tumor, screened with 1 mm. of silver, into its substance, supplemented 

by "cross-fire" irradiation with external applicators screened 

with 2 mm. of lead, an exposure of from twenty to thirty hours' duration 

being given. 

When the growths occur in connection with the parotid or submaxillary 

glands the burying of radium lubes in their interior should 

not be lightly undertaken, as if the track of a tube be in contact with 

any normal secreting gland tissue, a fistulais likely to form shortly after 

the operation, which will defy all efforts to close it and will form the 

starting point of a progressive intractable ulceration. 

8. Secondary Tumors.—These are much more common than primary 

growths, and are more often met with in the lymphatic glands

18 RADIUM 

than in anv other organs of the body. All forms of carcinoma—basalcelled 

epithelioma (rodent ulcer) excepted—give rise to them, and they 

also occur in connection with melanomata. and sarcomata of the tonsil. 

thyroid and testis. 

A small primary focus, the detection of which is difficult, is frequently 

responsible for the presence of large masses of affected glands. 

At times it is impossible to discover the primary growth, though the 

hardness and fixity of the secondary lymphatic masses are strongly suggestive, 

if not absolutely indicative of malignant disease. 

The treatment of secondary malignant growths of the lymphatic 

glands is mainly surgical, most operations for the treatment of malignant 

disease being planned on a scale which provides for a wide removal 

of the associated lymphatics. In many cases, however, radium treatment 

is employed as an adjunct to surgery, a prolonged screened radiation 

being given over a wide surrounding area, with the two-fold object 

of bringing about the degeneration of any scattered or isolated loci of 

the disease; and of arresting the permeation of malignant cells through 

(he lymphatics. 

When the removal by dissection of malignant glands is impossible 

or inadvisable, radium treatment may be adopted, as it will often cause 

a considerable diminution in their size and arrest the spread of the infection 

to neighboring glands. When the masses are superficial, ami 

in easily-accessible situations, treatment with buried radium tubes. 

screened with t.o mm. of silver or 0.3 mm. of platinum, is to be advocated. 

When deeply situated, or attached to important structures, blood 

vessels, or nerves, the pro'onged screened radiation from "full strength" 

applicators is to be preferred. 

It is impossible to lay down any hard-and-fast rule as to dosage; 

the amount of radium used, screening employed, and exposure given. 

having to be adjusted to the requirements of the case. Speaking in general 

terms, however, when buried tubes are used the exposure should 

vary from eighteen to twenty-four hours. When prolonged radiation 

from external applicators is adopted the screening should be 2 mm. of 

lead and the tola! exposure of from twenty to thirty hours. If benefit 

result, the treatment may be repeated at intervals of five to six weeks. 

I desire to express my very great indebtedness to my colleagues. Dr. 

Philip (iosse and Dr. Oskar Teichman, for much generous help in the 

compilation of this report. Much valuable information has been obtained 

from the case sheets of the evening clinic, for the conduct of which 

they have been responsible. 

REPORT OF THE RESEARCH DEPARTMENT 

By J. C. Mottram, M. B., D. P. H.. Director 

During the year five papers have been published:— 

(1) "On the general effects of exposure to radium on metabolism 

and tumor growth in the rat. and the special effects on testes and pituitary," 

by J. C. Mottram and W. Cramer. Quart. Jourl. Exp. Physiol 

xiii. 209-226. 

Several observers have recorded an increased growth in animals 

subjected to small doses of radiation for long periods of time. This 

communication analyzes this finding in detail. It is shown that this 

increased growth is an increase in weight, and that this is due to a general 

increase of the adipose tissues of the body. This, in turn, is sec

Radium 19 

ondary to changes in the testes and pituitary gland. In the testis there 

is found atrophy of the seminiferous tubules, with hypertrophy of the 

interstitial cells, and following this change in the testes changes'occur in 

the pituitary in all three parts of the gland. The dependence of these 

changes was established by. in one case, radiating the whole animal, in 

another case by radiating only the testis, and in a third set by irradiating 

only the pituitary. The observations show that the two component tissues 

of the testis, the spe mitogenetic tissue, and the interstitial tissue, 

have two distinct and independent metabolic effects on the organism. 

The observations represent probably the actual basis of the general 

changes stated by Steinach to occur after implantation of testicular tissue 

in his operation for rejuvenescence, and give a possible explanation 

of the symptoms complex of dystrophia adiposogenital is. 

The rats which have been rendered obese by exposure to radiation 

were found to be more resistant to tumor inoculation than control animals. 

(2) "Some observations upon the Histological changes in Lymphatic 

Glands following exposure to radium." Amer. .lonr. Med. Science, 

1923, clxv, p. 469-480. 

This paper shows how an analysis of the changes which occur in 

lymphatic glands following radiation brings out the relationship of the 

various cells found there. It shows how the lymphocytes which are 

constantly (lowing into the gland by the afferent lymphatics are devoured 

by macrophages, how fresh lymphocytes are formed by the division of 

lymphoid myeloblasts, bow probably the myeoblasts are replenished bv 

the gradual conversion into these cells of the macrophages as they 

phagocytose the lymphocytes, so that a continuous cycle of change takes 

place, the lymphatic glands taking in and destroying lymphocytes on one 

side whilst manufacturing them on the other side, the various cells, endothelial 

cells, macrophages, and myeoblasts being part of the machinery 

within. 

It is clear, therefore, why a lymphopcenia following radiation is followed 

at a later date by a compensatory lymphocytosis. 

(3) "Some effects of exposure to radium upon the alimentary 

canal." Proc. Roy. Soc. Med., xvi. 41-44- Large doses of radium or 

X-rays quickly produce desquamation and necrosis of the intestinal 

mucosa. Observations were therefore made to discover what arc the 

first histological changes in the alimentary canal and at what period 

after radiation they occur. It was found that very small exposures interfered 

with the normal production of mucus by the alimentary tract. Two 

days after exposure the secretion of mucus was greatly increased, but 

this was onlv temporary, for after four days the mucus ceased to be 

poured out. This stoppage of mucus allows the bacteria of the colon 

and cecum to invade the mucosa, and this is followed by the desquamation 

and necrosis as observed. 

These results indicate the necessity of protecting the alimentary 

canal frpm radiation during the treatment of patients, especially when 

large penetrating radiations are being used, as in deep X-ray therapy. 

The paper points out how the anemia and thomboposnia which often 

follows exposure to X-rays or radium may [possibly be connected with a 

bacterial invasion of the blood stream occurring in the intestinal tract as 

a result of injury there. 

(4) "Some effects of Exposure to Radium on the Blood Platelets." 

Proc. Row Soc. Med.. IQ23. vol. xvi. 9-13.


In a previous paper it was shown that exposure to radium is followed 

by a great diminution of the platelets in the blood. In this communication 

the subsequent changes in the platelet numbers are dealt with. 

It was found that the thrombopcenia is followed by a rise in the number 

of platelets almost to double their normal numbers. The high platelet 

count is, however, only maintained for a few days, after which it gradually 

falls so as to again reach the normal level in about fourteen days. 

These observations were made upon the rat. Repeated small doses of 

radiation gave rise to a primary rise in the platelet numbers, but this was 

only maintained for a few days. Moller is of opinion that the anemia 

following radiation is the result of hemorrhages into the tissues conditioned 

by the diminished platelet numbers. If, however, micro-organisms 

findtheir way into the blood stream from the alimentary canal, as 

indicated in No. 3. they will suffice to account both for the thromboixenia 

and the anemia. Moreover, the anemia following radiation begins 

to manifest itself many days before the occurrence of hemorrhages 

into the tissues. The thrombopcenia requires to be profound before these 

hemorrhages occur. 

(5) "On the behavior of platelets in Vitamine A. deficiency and 

on the technique of counting them." by Cramer, Drew and Mottram. 

Brit. Journ. Exp. Path., 1923, iv, p. 37-44. 

This sets out further observations and confirms the deep thrombopcenia 

of vitamine A. deficiency. Further, just as the thrombopcenia 

following radiation appears to be secondary to an intestinal lesion, so 

the thrombopcenia of vitamine A. deficiency is associated with a profound 

intestinal lesion of an atrophic nature. 

This information is a further indication for the giving of a diet rich 

in vitamine A. to all patients undergoing radium or X-ray treatment. 

more especially in those cases where the abdomen is likely to be radiated. 

The paper also answers certain criticisms made by Bedson and Zilva 

with reference to our findingsof thrombopcenia in vitamine A. deficiency. 

REPORT OF THE CHEMICAL AND PHYSICAL LABORATORY 

By W. L. S. Alton. F. I. C. Director 

The work of the Laboratory for 1923 is summarized in a table giving 

the figuresfor 1922 and 1923: 

1923 1922 

Number of bottles of radon solution distributed 2,756 3.676 

Total output in litres 689 919 

Number of radon tubes and applicators prepared 947 887 

Activity of above in terms of radium bromide 84.650 85.644 

grms. grms. 

Activity in millicuries 45-37° 

Number of radium applicators prepared 7 14 

Number of measurements of radio-activity 32 IO 

The use of the term radon and the standardization of all radon applicators 

in millicuries is discussed in an earlier section of this report. 

The number of applicators made is the highest yet attained, and 

the demand for them is such that the strictesl economy of all tubes in 

circulation and ever;- cubic centimetre of radon gas mixture is necessary. 

In this connection improvements have been effected in the tubefilling 

apparatus (Report, 1920). chiefly in the direction of saving any


radon which was not finding its way into the condensation bulb. An 

examination of the apparatus in the dark revealed bright areas in and 

near the stopcocks, due to absorption by tap grease, and further bright 

areas in the pump capillary, due to radon being pumped off when the 

pressure became low. It was considered that a piece of pressure tubing 

was also responsible for losses, and this has been replaced by phosphoric 

FlOr.2 

Fiq.3 Fig. 4 

acid, and the gases pumiwd off daily are put back into the circulation 

and refraclionated. . 

Figs. 1-4 show some screens which have been made in the workshop 

in conformity with the wishes of the medical staff. Fig. i shows 

an applicator sometimes used in cases of recurrences at the vaginal vault 

after hysterectomy for carcinoma of the uterus. I he body A. is made 

of aluminum for the sake of lightness, the convex-faced radon container 

B is made of thin German silver, and is screened with a hood ot lead

99 Radium 

2 mm. thick; the whole applicator is bound together in a very compact 

manner with strapping and rubber tissue. 

Figs. 2 and 3 show tubes used for oesophageal work. The screens 

in each case are of silver 1 mm. thick, while in the case of Fig. 3 there 

is an additional sheath of vulcanite for the purpose of dilating the str.cture. 

Fig. 4 shows a screen sometimes used in cases of carcinoma of 

the rectum. The walls arc of lead 2 mm. thick, and the usual rubber 

sheathing is also provided. All these screens are filled with radon tubes. 

and the dose can be varied at will. 

A slide rule for radon applicators has also been devised, giving 

facilities for determining the activity of an applicator at any period of 

its existence, as well as its mean activity oxer a period of exposure. The 

acquisition of a further quantity of radium sulphate in the autumn of 

this year for the purpose of adding to the number of applicators used 

in the In>titute made it necessary to review the progress made generally 

in the preparation of radium applicators since the foundation of the 

Institute in 1908. The majority of the applicators in use at present 

were modeled on the early French pattern, i. e., amber varnish was employed 

as the medium for fixing the radium salt to shallow metal trays. 

Owing to their frailty, and the destructive effects of radium salts on 

any organic compound, these applicators have needed frequent repair 

and additional coats of varnish, until >ome of them no longer serve as a 

source of soft beta ray radiation. An applicator of this type, belonging 

to a hospital, was seen recently, from which the plaque of varnish and 

radium had become detached. An examination of the underside was 

\erv illuminating, the varnish had undergone considerable local erosion 

and had turned into a porous friable mass. Little doubt is expressed 

that there had been a steady evolution of carbon dioxide for a considerable 

time, and it was probable that this gas in escaping took with it some 

of the radon to which the activity of the plate is eventually due. 

A similar type of applicator, made with dental vulcanite and described 

in the Report for 1917. has proved to be much more robust in 

construction, and specimens made in that year and subsequently have 

given very little trouble. They are. however, beginning to shrink, and. 

being made of organic matter, are open to the same objections as have 

been cited in the case of the varnish applicators. It is necessary, then. 

to seek some method in which organic materials are not employed. The 

ideal applicator is one which combines strength with the thinnest possible 

self-screening, in order that a wide range of radiation may be available. 

The earlx forms of radium capsules, consisting of an ebonite cell 

with a mica screen held down by a brass screw cup. were an attempt to 

attain this ideal, but usually the radium salt in the fonn of radium bromide 

was badly distributed in the cell, giving a very uneven source of 

radiation. In addition, radon leaked continually, and so maximum activity 

was never attained. 

From the United Slates came the idea of radium sulphate with a 

glaze in flat gold trays to form an enamel-like surface. This type of 

applicator is very efficient as well a* permanent, though accidents have 

been reported where the applicator has been dropped on stone floors 

and the enamel splintered. 

In Denmark, applicators have been made by mixing radium sulphate 

with kaolin, and utilizing the porcelain plaques thus obtained. If these 

are thin, they must be rather fragile, and. if thick, absorb a large proportion 

of trie soft beta radiation.

R A D I U M 23 

The applicators made for the Medical Research Council by Mr. 

Harrison tllcw, and used by Dr. Mottram in this Institute for several 

years, have given very little trouble, and it was decided to make similar 

applicators, employing, however, much thinner covering screens. After 

some experiments it was found to be possible to solder silver foil. .03 

mm. in thickness, so as to make gas-tight applicators, the soldering of 

thin aluminum foil not being practicable. As a fixative for the radium 

sulphate in the applicator, sodium silicate was chosen, as this substance 

is not hydroscopic, stands heat well, has considerable adhesive properties, 

and was considered not to give off any gas under the influence of radium 

radiation. The applicators were prepared in the following manner:— 

Shallow trays of nickel-plated German silver of the required dimensions 

are accurately leveled on a surface plate, and the edges given a preliminary 

coating of solder. Layers of mica are added until the trays are 

full to the edge, in order to give support to the thin silver screen, and 

the weighed amount of radium sulphate, mixed into a paste with water 

and sodium silicate, spread over the surface of the uppermost mica sheet. 

Tins paste is carefully dried and eventually treated to 2000 C. in order 

to drive off all traces of water, when the film is seen as an enamel-like 

layer, the radium sulphate being particularly evenly distributed. Meanwhile, 

a piece of silver foil has been cut. rather larger than the applicator, 

and has also had a thin coating of solder applied to its edges. This foil 

is laid on a piece of hard wood, and the applicator, with the addition 

of another piece of mica (.001 mm. in thickness) to act as a kind of 

cover glass between the radium layer and the silver, laid face downwards 

on the prepared screen. A screw clamp is used to keep the applicator 

firmly pressed against the screen, and by means of a silver soldering 

iron the smallest possible amount of solder is run round the applicator. 

When this has been done, applicator and screen are heated with a Bunsen 

burner until the solder melts, and the screw clamp quickly tightened, 

so as to make intimate contact between the edges of the applicator and 

the silver foil. It is necessary to have a small vent hole drilled in the 

back of the trav. in order that the molten solder is not drawn in as the 

applicator cools. This vent hole is sealed with a spot of solder, which 

is afterwards smoothed with a file. The edges of the foil are trimmed 

with a pair of scissors, and a protection hand of solder run round the 

applicator to safeguard the screen from being detached when handled. 

Although the radium sulphate is subjected to considerable heat in this 

process, there docs not appear to be material loss of radon, several applicators 

giving 95 per cent of their maximum activity when tested within 

an hour of their completion. Radium sulphate appears to absorb radon, 

provided there be no other gas present, and every effort should be 

made to keep organic substances and moisture from the interior of any 

radium applicator. 

Some applicators of this type have been in use for three months 

and arc giving satisfactory clinical service, though through contact with 

either the rubber sheeting used, or possibly from unscreened use on 

patients, the silver screening became rather heavily sulphided. This 

has been removed and a thin layer of lacquer applied, but it would seem 

as if other screening material may prove more advantageous. Experiments 

are being conducted with rustless steel, and also with nickel alloys. 

but are not sufficiently advanced to be reported upon. 

In addition, a platinum tube. 0.3 mm. wall, containing 25 milligrammes 

of radium element, was made, and added to the stock of plat-

2-1 Radium 

inum tubes in use. These tubes have their stoppers screwed and goldsoldered, 

and in view of the many losses of radium which have occurred 

during this procedure, a word of caution may be uttered in this respect. 

The soldering necessitates the temperature of the oxy-hydrogen blowpipe. 

and notwithstanding that the main length of the tube is cooled 

in water, the crimson flame coloration of the radium spectrum is sometimes 

seen. Radium sulphate is considered to be a particularly nonvolatile 

body, and it must be assumed that organic material, either dust 

or i>ossibly traces of oil left from the boring of the platinum tube, have 

reduced the sulphate to sulphide. However, if precautions are taken, 

and. in addition, all moisture excluded during the filling of th; tube, the 

operation of soldering can be carried out satisfactorily. 

The opinion is expressed that the future construction of all applicators, 

either flat applicators or tube applicators, will be based mainly 

on the extend e use of unit tubes with an activity of t to 5 milligrammes 

of radium element, constructed of thin-walled rustless steel, nickel, or 

even brass, and distributed according to the need of the moment. 

In conclusion, grants of emanation have been made for lecture purposes, 

and demonstrations of the apparatus used at the Institute can be 

given u|K>n application. 

THE TECHNIQUE OF RADIATION THERAPY OF 

ESOPHAGEAL CARCINOMA* 

By James T. Cask. M. D.. F. A. C. S.. Battle Creek. Michigan. 

In few situations does a malignant lesion present greater difficulties 

in the technique of radiation application and dosage, or less probability 

of completely destroying the neoplastic tissue than in carcinoma of the 

esophagus. I'nfortunately, the attention of the patient is not drawn to 

his trouble until dysphagia appears: and this is therefore the earliest 

clinical symptom, usually the one which brings the patient to the physician. 

Vet esophageal carcinoma furnishes a large proportion of erroneous 

diagnosi- or failure to diagnose, owing to the absence of the symptom 

of dysphagia. This was shown in the statistics published some years 

ago by Richard Cabot, after reviewing the incorrect diagnoses in a large 

series of cases at the Ma»achusctts General Hospital. 

Koentgenobgically. the earliest sign of esophageal carcinoma may 

be due to the obstruction of constant grade one would expect from the 

organic stenosis attending the malignant lesion. The writer has found 

many cases of esophageal carcinoma where the firstsigns of obstruction 

were apparent long before there existed any actual narrowing of the 

esophageal lumen, the hindrance being due to a spasm set up at the level 

of the early malignant lesion, or just above it. a considerable time before 

the infiltrating process had brought about actual stenosis. This is especially 

true of those cases of carcinoma of the lesser curvature high up in 

the stomach involving the cardiac orifice. It often happens that these 

obstructions are at firstconsidered spastic because the administration of 

antispasmodics temporarily relieves the dysphagia. Occasionally an extracsophageal 

malignant mass will be accompanied by a spasmodic ohstruc- 

• Reprinted by permission from the American Journal of Roeu teen alow «•>•( 

Radium Therapy, x. S59-S66. November 1?.'3. Read at the Eighth Annual \I*,.!inof 

The American Radium Society. San Francisco. Calif., June 25-26. 1933. """*•

Radium 

zd 

tion in the esophagus. The writer has in mind particularly one case in 

which the esophageal obstruction was by post-mortem shown to be due 

to a carcinoma of the lesser curvature of the stomach, with extensive 

infiltration of the glands about the cardiac orifice and some infiltration 

of the cardia; yet the site of the obstruction in the esophagus, as determined 

both by sounds and by the roentgen studies, was two or three 

inches higher than the infiltrated area, and it had all the earmarks of a 

spastic hindrance. We therefore make routine use of antispasmodic 

medication, both in the study and the treatment of esophageal lesions 

thought to be malignant. One of the most important technical problems 

to be overcome in radium treatment of esophageal cancer is the 

delivery of an adequate dose of homogenous radiation into the depths 

of the tissues. The investigations of Fricdrich. supplemented and corrected 

by Schmitz working in Friedrich's laboratory, show how rapidly 

the efficiency of radiation from a radium capsule diminishes at a short 

distance from the applicator; so that unless one does considerable damage 

through overdosage to the tissues actually in contact with the radium 

applicator, he will not deliver an efficient dose into the depths of the 

lesion, say only two centimeters beneath the mucous membrane, and certainly 

nothing like an efficient dosage along the normal lines of extension. 

If the lumen of the stricture suffered sufficient dilation to permit 

from S to 15 mm. of uibher tissue wrapped around the radium in its 

usual metal container, the added distance from the radiant source to 

mucosa would greatly improve the depth dosage, though much prolonging 

the time of application. Yet„ one hesitates to dilate a malignant 

stricture at all. and in the light of our present knowledge he surely will 

not do so any more than is absolutely required for introducing some form 

of radium applicator, fearing that the instrumentation may do more 

harm than the radiation does good. The radiologist is thus by circumstance-; 

limited to an unequally distributed, non-homogeneous radiation. 

if he depends upon radium alone: therefore the natural tendency to supplement 

the radium application by external applications of radium by 

packs applied at some distance from the skin, or by deep roentgen irradiation, 

or by both. 

Another serious problem is an accurate visualization of the lesion. 

as interpreted from the x-ray and clinical findings. Some have recommended 

the routine study of these patients by means of the csophagoscope. 

but such instrumentation is extremely distressing to some patients 

and. for various reasons, quite impossible in others. 

It is not easy to make an accurate map of the infiltration or ulceration 

in any given case, and yet an error of estimation amounting to only 

a centimeter or so makes a great difference in the result. The above 

considerations emphasize the obvious need of the greatest possible accuracy 

in the mental picture formed of the lesion under attack, the need 

of abundant filtration and a maximum of distance from radiant source 

to lesion, none of which ideals are capable of satisfactory realization. 

at least in the present state of our attainments. 

Radiim Methods 

Various methods have been devised and employed by all of us in 

the attempt accurately and efficiently to place the radium. 

I. Radium-bearing Sound Guided by a Thread. By the wellknown 

technique, a thread several feet in length is employed. Fight or 

ten inches of this stout but very fine thread is enclosed in an ordinary


5-gr. capsule and swallowed. Careful "feeding" of the thread aided 

by hypodermic injection of atropine to the point of securing marked 

dryness in the throat, plus the frequent sipping of small amounts of 

warm water, will, in most cases, carry the thread through the stricture 

and on along the digestive tube distally until traction on the thread reveals 

the stout resistance offered to attempts at withdrawal. 

In other cases success has followed the use of atropine to the point 

of marked dryness of the mouth followed by a little paraffin oil. The 

thread once in place, it i> a relatixely simple matter to give the patient 

a >wallow of a barium mixture, not too opaque, to permit accurate screen 

observations of the site of the lesion, and to thread over the silken guide 

Fig. 1. Gastrostomy tube introduced Into the stomach in 

s*ueh direction that a duodenal sound passed through this 

tuhe will lie directed into the pylorus. 

the radium-bearing sound, the construction of which will be taken up 

further on. When through with the silk thread, it is withdrawn by mouth 

as far as possible and cut off. the remainder passing on into tlie intestine. 

Not the least difficult of the steps of this procedure is the maintenance 

of the radium in proper |>osition. once it has been p'aced under 

the guidance of the tluoroscope. The writer prefers to put a mattress 

and other comforts on a horizontal fluoroscojie and leave the patient 

lying quietly in the position assumed during the sounding. The distal 

end of the radifer-»us sound is attached to the check by adhesiye plaster. 

first bending the sound over the teeth in such a way as to mark securely 

the proper location. It is well to alter the position of the sound, deliberately 

attempting to place it a little too far at the first and a little short 

of the lesion at the third change. 

2. The Radiferous Sound Canalising the Stricture under Fluoroscopic 

Guidance. This method, already long before devised and prac-


ticed by various radiologists, was reviewed and improved by Mills at the 

St. Louis meeting of this Association. Mills deserves special recognition 

(or the very ingenious modifications of the sound, permitting the terminal 

radifcrous end to be bent in only one of four directions, while the 

remainder of the sound is susceptible of any sort of angulation. This 

small but very important addition to the instrument jiermits canalization 

under screen control of practically every organic stricture to be met: 

yet occasionally one sees a case in which the method is impracticable. 

Sometimes the stricture is too tight for passage; again sometimes the 

patient proves to be unable to tolerate the esophageal and pharyngeal 

manipulations; the instrumentation of the lesion, with more or less traumatism, 

as in the thread method, is prejudicial to success; and finally 

many patients experience the greatest distress in maintaining the sound 

so long in the esophagus because of the hurt to the pharynx and mouth. 

Fia. 2. Representation of the duodenal sound passed throush 

the gastrostomy tuhe and on Into the duodenum for duodenal 

feeding. 

3. Gastrostomy, Pins Thread Method. A gastrostomy may be performed, 

under local infiltration anesthesia, the technique being such that 

an efficient valve-like gastrostomy opening results. It is the writer's custom 

to perform this operation in such a way that the gastrostomy tube 

points toward the pylorous, care being taken to use a rather large tube, 

sufficient to permit the passage through it of an ordinary duodenal tube 

without its metal tip. Almost immediately after the operation, if not 

at once, a duodenal tube is passed through the gastrostomy tube, on 

through the pylorous well into the duodenum, the position being verified 

by x-ray observation. It is not required to move the patient to the fluoroscopic 

room; a bedside x-ray equipment is quickly moved to the patient's 

room, and little trouble is caused by slipping a film beneath the 

sick one. to make the necessary x-ray exposure. Duodenal feeding is 

begun at once. The operation successfully performed, a thread is pre-


1 tared, as in the first method described, and one end of it. in a capsule. 

swallowed. A fine thread may be employed, a stouter one being drawn 

down, once the end of the finer one has been recovered from the stomach 

through the gastrostomy opening. Formerly the writer used an ordinary 

shoe-button hook or a strabismus hook, or Kellogg's ligament 

hook, to fish up the thread, but a simpler way recently presented itself. 

Fig. 3. Thread a— a passed from the moulh through the 

esophagus, past the malignant stricture, and out through 

the gastrostomy opening. 

With an ordinary washout 3-4 oz. syringe, fill the stomach with water; 

then, leaving the syringe attached to the tube, withdraw the tube, syringe 

and all. The thread readily floats out through the opening with the 

escaping fluid. By gentle traction the fine thread is pulled down, drawing 

with it a much stouter guide thread. When the stout thread is in 

place, from mouth to gastrostomy opening, the lower end of the thread

R a d i u m 

2d 

is passed through the gastrostomy tube, which is again introduced into 

the stomach. Under the traction required to pull down the radium applicator 

attached to the upper end of the thread, damage may be done 

to the lining of the stomach by the "sawing" of the thread unless this 

tube be in place. The inner end of the tube may even be pulled up into 

the lower end of the esophagus, which is additional insurance against 

"sawing" the mucosa. It is important to maintain a thread attachment 

Fig. 4. This thread it* then passed through the gastrostomy 

tube, which is reintroduced into the opening Into the 

stomach. Traction upon the thread .1 — o' in the direction 

of a' pulls the Inner end of the gastrostomy tube up to 

the Inferior border of the stricture thus preventing sawing 

ot the thread upon the soft tissues at the cardia. The 

r.tdlferous capsule is then drawn down the esophagus into 

the stricture under x-ray guidance and the taut thread 

held In position by the forceps 'V' clamped on the gastrostomy 

tube close to the akin. 

to the radiferous capsules through the mouth, for one may need to alter 

the position either upward or downward. On one occasion the extra 

silk thread served for removal of the capsule when the other end of the 

thread broke. Among the advantages of this thread method when combined 

with gastrostomy may be mentioned: 

(a) The ability to begin abundant feeding at once and to maintain 

good nutrition through the gastrostomy opening.


(6) The greatly lessened discomfort to the patient during the 

radium treatments. 

(

R a d i u m 

3i 

(.uisez. etc.). The latter recently reported several cases in which apparent 

cure has lasted nearly three years, where radiferous needles have 

been placed in and about the esophagus lesion under the direct control 

furnished by esopbagoscopy. In the exi>erience of the writer and 

his colleague there are many objections to esophagoscopv in these patients, 

who are weakened, old. and often in such a state of distress thai 

•-•sophagoscopy cannot be tolerated. Kven when accomplished, the implantation 

of needles is thoroughly done only around the upper jiole of 

:hc stricture, and there is the ever present danger of perforation, either 

immediately or after a few days. One case has been reported where 

death occurred from a small perforation into the aorta. In the employment 

of this technique "seeds" of radium emanation are preferable to 

any other form of radium applicator. 

1 his method has the obviously great advantage of permitting accurate 

vision of the lesion and the progress of the treatment. Undoubtedly 

the method will appeal to the men who have had special training 

vt esophagoscopv. 

Purely Roentgen Method 

L'ndcr modern roentgenotherapeutic voltage, long focus-skin distance, 

large fieldsand heavy filtration,the administration of a highly 

efficient dosage of roentgen rays to the neighborhood of the esophageal 

lesion is feasible. The writer employs four fields,as a rule centering 

the radiation as nearly as possible u]khi the carefully mapped out objective. 

The dosage upon the skin is variable, the intention being to 

deliver to the lesion considerably more than a full erythema dose (120- 

130 per cent E. S. D.). Our effort has been to deliver this tlose within 

about four days* time; but the observation of Kegaud and his colleagues 

give good ground for the belief that the same dose given in from ten 

'o twelve days' time is more efficient, while being much less distressing 

to the already weakened, undernourished patient. Surely the roentgen 

method has the advantage of avoiding all intraesophageal manipulation. 

This, according to Simone Labord. is a reason for preferring the roentgen 

method to the exclusion of intraesophageal radium, for fear that 

radium treatment of esophageal cancer sometimes actually shortens the 

patient's existence. 

Combination Roentgen ami Radii'm Method 

A combination of the external application of roentgen radiation 

with the intraesophageal application of radium appears to the writer 

to be the ideal method. This belief is borne out by our clinical results 

which show greatest prolongation of life, although our results are no 

better than those reported by Mills a year ago. We have performed 

gastrostomy on three-quarters of our patients, and have given them by 

ibis means alone a marked degree of palliation. 

Comment 

In our work we prefer the method of gastrostomy under local anesthetic, 

followed in ten days by the placing of the thread, and three or 

four days later by the firstapplication of radium. A series of roentgen 

applications through four fields is then given, ifit has not already preceded 

the operation. On about the twentieth and twenty-fifth days further 

radium is applied, and a program of watchful waiting instituted. 

In the preparation of the radium applicator, whether for use by the sound 

or by the thread and gastrostomy method,it is our custom to use two.


and at times three, capsules, placed end to end, a too mgm. in the middle. 

and a 50 mgm. capsule on either end. Tbe whole is contained in the 

usual 1 mm. of brass filter and wrapped with plastic rubber of the thickness 

estimated feasible in the given case, using the maximum amount 

of wrapping. Near the upper end of the preparation, a cuff of rubber 

is wrapped in such a way as to form a guard against the slipping of the 

preparation entirely below the stricture. Of course, in some cases it is 

impossible to canalize the narrowed lumen with even the ordinary applicator 

in its brass cover, to say nothing of additional rubber; in such 

cases we content ourselves with the silver filterfor the firsttime, usually 

finding that it is possible, after the lapse of a few days, to use the more 

bulky applicator. 

Renewed roentgen applications and radium treatments are given when 

circumstances warrant, but it is our intention and hope to give all the 

radiation necessary during the firstattack. We hope so to perfect our 

calculations and our technique that this may be realized; but to date we 

have found it necessary to continue treatment into the second or third 

series. 

The method preferred by the writer includes, then, the following: 

1. Careful x-ray survey of the lesion, realizing how much of the 

deformity in the esophageal lumen may be due to associated spasticity. 

2. Preliminary deep roentgen treatment. 

3. Gastrostomy, followed at once by duodenal feeding. 

4. Ten to fourteen days later placing of thread from mouth, 

through stricture, and out of gastrostomy opening. 

5. Intraesophageal radium treatment by aid of this thread under 

careful fluoroscopic screen control, endeavoring to administer all necessary 

radiation during firstattack. 

6. Careful periodical review of case from month to month with 

repetition of radiation therapy as needed. 

Discission 

Dk. Henry Sen.muz, Chicago. III.—The treatment of cancer of the 

esophagus has been anything but encouraging in the hands of most of 

us. The reasons for this are: First, the trauma which is usually caused 

by the insertion of the radium dose, and second, the impossibility of applying 

the correct radium dose. I feel that we can congratulate Dr. 

Case upon the method he has demonstrated. It appeals to me as the 

most rational of which I have heard. The danger in the use of radium 

in the esophagus i> the local destruction caused by the radium. The 

trauma results in increased difficulty in swallowing, interferes with nutrition 

and decreases the strength of the patient alarmingly. I have 

not seen any case in which we have had even tenqiorarily good results. 

The patients have been worse off after the application of radium than 

before. 

The method advised by Or. Case insures proper feeding and enables 

one to place the radium capsule correctly and for a length of time 

necessary to insure results. Finally, the added radiation of the \-ray 

enhances the efficacy of the treatment. 

Dr. San ford Withers, Denver, Colo.—-I am heartily in accord 

with the use of gastrostomy to relieve the continual massage of the esophagus 

by the passage of each bolus of food. 

For placing the radium in such cases I model a sort of shoulderlike 

disc of wax on the capsule or wire guide to prevent the radium

R a d i u m 

:j:$ 

from going below the stricture. The radium capsule and bard wax disc 

are covered with paraffin to give a smooth nonconductive coat. 

Dr. H. H. Bowing, Rochester, Minn.— I do not know whether our 

results are any better than those of Dr. Case, but certainly they are 

better than those of Dr. Schmitz. These patients get a wonderful amount 

of relief from the dilatation alone. 1 recall one patient who returned 

to his work and lived for three years. His only symptom, when last 

seen, was a chronic cough, and the x-ray examination of the chest showed 

multiple metastatic areas. If we had given him irradiation we would 

have credited this improvement to the treatment. We can probably 

give the majority a longer lease on life with treatment than without it. 

We use the string method described by Dr. Case. With the string 

in position the sound may be passed along its course with the least chance 

of injury to the diseased esophagus. We always begin with a small olive. 

and increase the size until we get one that enters with some difficulty; 

then we know we have an olive that will help to hold the radium applicator 

in position. The applicator itself is about 7.5 cm. long and it will 

hold two tubes of radium. 

The upper end of the applicator is fittedwith a large olive that will 

not go beyond the obstruction. The smaller olive will just go through 

the tumor and will not be regurgitated; the large olive is fittedwith a 

whalebone bougie. The latter has previously been marked in order rhat 

the depth of the lesion from the incisor teeth is known. When the applicator 

is in position we can withdraw the whalebone bougie and to this 

we have attached several strands of strong fish line. We are absolutely 

sure the patient will not swallow the applicator and that it can be withdrawn. 

The patient can tolerate the applicator without any signs of 

difficulty, but I have found that there is a great amount of trouble with 

excessive salivary secretion; this is distressing and can be controlled 

with morphin and atropin. 

We are not satisfied with our results, but I know we can apply the 

radium in the esophagus with some assurance that it will stay put. and 

the patient can wear the applicator for twelve hours or longer without 

much discomfort. 

Dr. W. H. B. Aikins, Toronto. Ont.—The appliance described in 

detail by Dr. Case may, I trust, result in greatly modifying the hitherto 

unfavorable results so far obtained in the treatment of carcinoma of 

the esophagus; and we look forward to hearing from him to that effect. 

Prof. Lars Edlini;. Lund, Sweden.—I have treated a small number 

of cases of carcinoma of the esophagus. I think not more than 10. 

In those I had a good result in 3 cases; in 2 I have observed a very 

good result; 2 cases I have observed after about two years in each case. 

One case was treated four years ago and that patient lived for at least 

two years afterward. I have heard that she has since died, but I do not 

know just how. The other case was treated three years ago and I sawthat 

patient last March, when she was quite well. 'The third patient was 

treated early this year and is still alive, feeling well and can cat. The 

tumor was in the upper third of the esophagus and that, of course, makes 

the treatment very much easier, especially in regard to combining the 

x-ray treatment which has been used in all cases. 

I have used for the puq>ose of applying the radium a common sound 

made of two catheters placed together so as to have the length requited 

I have a joint in the upper end so that the radium tube may be placed 

within the capsule. The radium tube is of lead with 1 mm. of gold. The


capsule is placed under control of the x-ray and attached to the side of 

the face by a stitch and at the border of the teeth also by a stitch. There 

has licen no special difficulty in holding the radium in place in these cases, 

but of course the patient is much distressed by the saliva. Because of 

that I have always used atropin. with very good results. The dosage 

used has been 45 mgm. and the time of treatment over twenty hours. 

In one or two instances the patient could not hold it. and then I repeated 

the dosage. 

Dr. Henry J. Cli.mann, Santa Barbara, Calif.—I would like to take 

advantage of this opportunity to show- a way of improvising when one 

has not the apparatus Dr. Bowing spoke of. A patient was presented 

who had refused gastrostomy. The size of the olive tip that would go the 

length of the stricture had been determined by means of the x-ray. The 

next larger olive was put on the rod and the lower end of a catheter 

containing the radium capsule was slipped over it. The thread was run 

through the tip of the catheter and the outfit inserted as far as it would 

go. The olive stopped at the stricture and the catheter end with the 

radium then lay within the stricture, held by the olive above. This might 

be found useful if a more efficient type of apparatus was not available. 

Dr. Henry P. Beirnk, Quincy. HI.—If you get the linen thread the 

harness makers use you can hold a mule with it. You can wax it down 

to any size you wish and never lose your radium. 

As a temporary dilator I have had patients swallow an ordinary 

shoe button, taking it with the food and letting it make its own dilation. 

Two or three days later it can be pulled out and no harm done. This is 

a home-made affair, of course, but in one case the patient was able to 

cat more food and the clinical results were better. ' 

Dr. Case (closing discussion).—The gastrostomy, I realize, is objectionable; 

but under local anesthesia there should be no fear as regards 

life, and I think it is a valuable procedure. The patient's nourishment is 

then assured. We have a means of feeding him that is available in spite 

of anything which may happen to the esophagus. The point one speaker 

brought out about diverting the food from the traumatized area is very 

important. 

In employing radium, it is highly necessary to take account of the 

amount of rubber tissue filtrationplaced outside the brass capsule. We 

know that the intensity of radiation diminishes inversely as the square 

of the distance of the radium from the tissue, and therefore it is necessary 

to use as much rubber as possible outside the metal applicator. 

Every additional millimeter of rubber means additional distance and adds 

that much more chance of not traumatizing the other parts and of getting 

more uniformly distributed homogeneous dose of the radium itself. 

I should have added that the gastrostomy tube should be left in place 

while traction is being made on the lower end of the thread to pull the 

radium iinvi n die (-.nph.-iiius to the proper site above and in the stricture; 

and with a .forceps clamped upon it, the thread may be held in place. 

When we cannot use additional rubber on account of the small size of 

the lumen of the stricture. we use the smallest applicator and leave it in 

only a couple of hours. In a few days we can put in a larger applicator. 

We should not assume the full tlose given until we c=»n put in an applicator 

with at least a half centimeter of rubber around it. 

If the patient refuses a gastrostomy. I then prefer the method 

brought out by Dr. Mills last year. In that way I have been able to 

canalize strictures which would not permit the passage of even the


smallest olive. I hesitate very much to attempt to pass an olive in these 

cases, for the reason that we sometimes, under the fluorescent screen. 

see the wall of the esophagus above the stricture balloon out in a dangerous 

manner. The slightest additional pressure would surely make a 

perforation. Under the screen guidance, however, we are able to avoid 

this danger. 

In most cases an adequate dosage will not be administered with the 

use of a single applicator. I have been using three, with a 100 mgm 

applicator in the middle and one of 50 mgm. above and a similar one 

below. 

CONCERNING VERNAL CONJUNCTIVITIS* 

Some Phases CONNECTED with Its Clinical Kkatukks. Deration, 

Prognosis and Treatment 

By Wm. Campbell Posey, M. D., Philadelphia. Pa. 

Vernal conjunctivitis manifests such a determined tendency to recur 

annually with the advent of warm weather, that one naturally questions: 

Is there no self-determination of this disease, no hope for its running 

itself out after a certain number of years, and if so, is there any fixed 

span of time in which this is accomplished ? The observation of a considerable 

number of cases over a long period should be of assistance 

in answering such a query, and with this in mind a review was made of 

all my private cases affected with this disease which had been under 

observation sufficiently long to be of value in such an investigation. 

This analysis revealed that in mild cases, those characterized clinically 

by the typical discoloration of the conjunctiva and the appearance 

of Rattened granulations upon that membrane, with but slight >>r 11*> 

bulbar involvement and with cessation of symptoms in cold weather. 

the disease often disappears after a period of from S to 10 years, very 

rarely in the four or six years mentioned by Saemisch in his classic 

article. In the severer types, those cases in which there is a persistence 

of the symptoms, though in less aggravated form, through the winter 

months, with the presence of large hard and ofttimes rounded granulations 

studding the conjunctiva, with or without limba! involvement, it 

was ascertained that despite almost continuous alleviating treatment. 

the disease may continue for twenty years or even longer. 

This is in accordance with the exi>erience of others. In a monograph 

upon vernal conjunctivitis which I read before the Section on 

Ophthalmology of the American Medical Association in Xew Orleans 

in 1903. reference was made to a case observed by Weeks in the annual 

recurrences of 17 years and another by Schwenk of 18 years. Saemisch 

cites a case he had followed for 23 years. In this instance, one of the 

palpebral type, with annual recurrences in the cold weather, the disease 

had appeared at 12 years of age. In the latter years of Saemisch's observations, 

the palpebral prominence grew less and less distinct until 

they were no longer discernible, the conjunctiva becoming smooth and 

covered with a whitish network of scar tissue permeated with a fine 

vascular tissue. 

•Reprinted by permission from the Atlantic Medical Journal, xxvii. ilS-219. 

January, 1921. Read before the Section on Eye. Far. Nose and Throat FMseases 

of (he Medical Society of the Stale of Pennsylvania. Pitt&hurKh Session. October 

2. 1923.


1 have observed one of my cases almost every year since 1899. a 

period of twenty-four years, another since 1902. a period of twenty-one 

years, another thirteen years, all occurring in healthy males. Another 

case, a female, with rather poor health, has been seen more or less frequently 

during the past 16 years. In all of these the disease appeared 

in early childhood and assumed the severe type. The first case presented 

the pericorneal involvement suggestive of phlyctenular disease 

which is so frequently observed in vernal conjunctivitis. In the two 

cases next alluded to, both cornea? had suffered epithelial denudation 

and some interstitial involvement when they were brought to me. so that 

paring down of the large, round, hard granulations which had irritated 

the cornea and given rise to this condition was necessitated. 

Though a cursory glance might pronounce the conjunctiva in these 

cases, after these years of inflammation, to be normal, a closer examination 

reveals a slight atrophy of that membrane, as indicated by an 

abnormal smoothness and the presence of a finely reticulated superficial 

membrane of blood-vessels. Furthermore, the advent of spring each year 

is usually attended by a slight renewal of subjective symptoms of irritation, 

such as lacrimation. itching, with at times a catarrhal discharge, 

provoked by a mild conjunctivitis. 

The notes on two of my cases, those of a father and son. are of 

interest as bearing upon two factors of the disease, namely, the influence 

of heredity and the striking refractive changes which may be occasioned 

by vernal conjunctivitis of long standing. 

Case /.—X. M. F.. age ^, stated that vernal conjunctivitis first 

appeared at 11 years of age; that the symptoms were very severe for 

several years, but in consequence of regularly continued treatment, had 

pretty much disappeared by his twentieth year; that vision had been 

much affected in the right eye, for as a young boy he could shoot well 

with that eye. whereas in later years he had been compelled to have recourse 

to the left eye in that pursuit. 

At the time of my first examination, although in the spring of the 

year, the conjunctiva was normal and both eyes free from irritation. 

Both cornea were, however, slightly hazy and conical. Refraction was 

as follows: 

O.D. — S. 3.5 D. O — C 6.D. ax. 950 = 5 35 

O.S. + S.2.75 D. O — C. 9.D ax 92' _.: = 5 9 

Case II.—X. M. F.. Jr.. aged 7 years, son of the foregoing. Vernal 

conjunctivitis firstap|>eared in both eyes at five years of age. and at the 

time of my examination. April 12. 1910, symptoms of that disease in an 

acute form were present, the conjunctiva being discolored and covered 

with large, hard, rounded granulations. There was some slight pericorneal 

injection but the cornea? were clear. The usual alleviating local 

treatment was prescribed. Several months later, the granulations having 

increased in size and threatening the cornea from pressure, these excrescences 

were pared down with a sharp knife. For several years there 

was scarcely a time when the eyes were free from irritation,"the svnip 

toms persisting through the cold weather and defying all treatment. In 

April. 1912, two years after my first observation, refractions under 

atropin was as follows: 

O.D. — S. 1.25 O + C. 2. ax. 75 = 5 7K- 

O.S. — S. 0.75 O + C3. ax. 90° = 5 9

R A D I U M 37 

Since that date the patient has been under my more or less constant 

supervision, and year by year there has been a gradual amelioration of 

his symptoms. So far a> has been |>ossible. everything which might act 

as an excitant to the ocular mucous membrane, such as dust, smoke ami 

extremes of heat, has been avoided. Locally, solutions of adrenalin. 

weak percentages of cocain and dilute acetic acid have been of greatest 

avail. Any involvement of the bulbar tissues has been combated with 

solutions of atropin and yellow oxid salve. At no time has there been 

more corneal involvement than a slight haze of the periphery of the membrane, 

this being most marked in the left eye. When seen a few months 

ago, refraction was as follows: 

O.D.V. with + C. 2.25 ax. 700 = 5/5 

O.S.V. + S. 0.25 D. O + C. 7.5 ax. 180* = 5/6 

Wilder, Stevenson. Jackson. Gilford and Tiffany have also reported 

cases in which heredity seemed to play a role. 

In the April number of the American Journal of Ophthalmology. 

i'& 

O.S. unchanged 

1922 O.D. — S. 0.62 O + C. 4- ax. 95" = 5/5 

O.S. unchanged 

This patient finished school, graduated from the Dental Department 

of the University of Pennsylvania, and is a very busy dental practitioner. 

using his eyes hard.


Frequency and Distribution 

Gonzales, writing from Mexico and quoting the observations of other 

colleagues from that country, without citing statistics regarding the 

frequency of vernal conjunctivitis m Mexico, gives the impression that 

this form of conjunctivitis occurs there much more commonly than is 

the case elsewhere. Juan Santo> Fernandez, on the other hand, in the 

not far distant island of Cuba, where it is wann through all the year. 

states that out of a total of Oi.ooo eye cases observed by him. there were 

but six instances of vernal conjunctivitis, all of which came from Cuban 

cities. Freingold. in Xew Orlean-. reports the disease of rare occurrence 

in that locality. In a characteristically able paper based u|>on the study 

of 44 cases observed over a period of 15 years and an experience gained 

by 10 years of earlier observation of scattered cases in Philadelphia. 

Jackson concluded that the disease is more common in the very elevated 

region of the western L nited States than elsewhere in our country. 

In my paper of 1903. which contained a -ummary of the experience 

with the disease of leading ophthalmologists from all parts of the Cnited 

States, it was ascertained that though vernal conjunctivitis existed in all 

parts of our country,it was always rather a rare condition, occurring in 

a proi>ortion ranging from one case of vernal conjunctivitis to every 

200 to 500 of conjunctival disease. My observations during the past 

twenty years lend to the corroboration of these figures. It would appear 

that the same frequency maintains in Furopean countries. Xeither would 

I change the figurespublished in my earlier paper regarding sex liability 

to the disease, as affecting 855? of male and but 15*^ of females. The 

apparent immunity of certain regions may doubtless be explained by its 

failure of recognition in such localities. Thusit is scarcely to be credited 

that, in 191.000 cases treated in Petrograd over a period of fiveyears* 

there occurred but one case of vernal conjunctivitis. 

Prognosis asp Treatmest 

Xow that radium is more generally available, the prognosis in vernal 

conjunctivitis may safely be asserted to lie much more favorable 

and the likelihood of limiting the course of the disease greatly enhanced. 

This phase of the subject was so admirably treated by Shumwav before 

this Society four years ago that any extended review of the use of radium 

in vernal conjunctivitis is unnecessary at this time. I shall, however, 

refer briefly to a case in which the application of radium while curative 

of the disease, provoked unfortunate sequells. 

J. E. P., now 24 years of age. has been under my observation for 

the past fiveyears. He had had competent ophthalmic oversight since 

the disease firstaffected his eyes when he was but fiveyears of age. the 

ocular inflammation coming on after a prolonged case of pneumonia. 

The usual alleviating collyria have been prescribed but each season th^ 

svmptoms recurred, some years with greater severity than others. 

At my firstexamination the findingscharacteristics of vernal conjunctivitis 

of the palpebral type were observable in each eye. The granulations 

were large and prominent, but flat,and in the right eye there 

was some involvement of the perilimbal tissues, especially to the nasal 

side, at which point, the cornea was also faintly hazed. Cnder atropVthe 

refraction was: 

O.D. + S. 1.50 = 5 15 

O.S. + S. 0.75 O + C. 1.37 ax. 65 ° = 5/6


In addition to the local treatment usual in such cases, the patient was 

referred to Dr. H. K. Pancoast for radium therapy, four treatments 

being applied over a period of the two succeeding months. Considerable 

reaction was evoked by this treatment, and several weeks following the 

last application styes appeared in the lids which persisted for several 

months and were followed by a dropping out of many of the cilia, none 

of which have ever returned. The radium, however, has exercised a 

very beneficial effect upon the disease, greatly lessening the symptoms 

in the four years succeeding. Last summer, the eyes were but slightly 

injected and the conjunctiva smooth and free from granulations. Refraction 

was as follows: 

O.D. + S. 1.5 O + C 0.62 ax. 1700 = 5/5 

O.S. h C 0.S7 ax. do" = 5/5 

Arnold Knapp tells me that be. too, has seen unfortunate sequel l« 

after radium, though his case happened to be one of trachoma. He 

writes: 

"The case received a radium treatment on April 15th. with a very 

severe reaction 2 days later and pain beginning 4 weeks later. The lids 

were red, conjunctiva was congested, cornea? dull and vascularized like 

a keratoglobus. Vision was reduced to movement of hands. This condition 

has persisted for 3 years, and the question of enucleation has come 

up. The diagnosis of trachoma was uncertain, as the right eye had not 

been affected. Was first seen in 1919. The upper palpebral conjunctiva 

was red. fleshy,with irregular, gray follicles with a well-marked pannus. 

The radium caused the loss of the eyelashes and of the eyebrows, and 

the thickening and reddening of the lids, with the changes in the conjunctiva 

and cornea just described. 

"I forgot to say that the patient was treated for some time with 

tuberculin, on the sup|>osition that the condition was tuberculosis, and 

as the process did not improve, radium was advised." 

In both of these cases it is not unlikely that the sequella? arose from 

a too protracted or powerful application of the radium. In any event. 

in a number of other cases treated for me by Dr. Pancoast no such serious 

consequences arose. In closing, I shall read a recent communication 

to me from Dr. Pancoast regarding his ex|>erience with radium in 

vernal conjunctivitis. 

"I have received your letter requesting a statement in regard to our 

views concerning the treatment of vernal conjunctivitis. The results 

under radium treatment with us have been, on the whole, very satisfactory. 

We do not use x-rays for the purpose because radium can be much 

more easily controlled and especially the penetration. 

"Our method is to evert the lids and treat the entire conjunctival 

surface which is involved and at the same time protect the eyeball against 

any unnecessary exposure. If the bulbar conjunctiva is involved, one 

must be very careful in regard to the dosage because of the reaction 

which results, and the dose is usually an amount less than that for the 

lids. The reaction to radium is rather intense and we always prefer to 

treat cases during the quiescent period of winter rather than to add the 

discomfort of a radium reaction to that which the patient already has 

from the activity of the disease. It is very important not to give too much 

treatment and to get too much cicatrical tissue. The main difficulty encountered 

in cases in which the lids alone are involved is in removing 

the condition from the region of the upper border of the cartilage in 

the upper lid.

10 

R a d i u m 

holder with comparatively little filtrationin order to get as much beta 

ray effect as possible. The holder is attached to a handle so that the 

hand of the attendant does not have to be ex|x>sed. 

"A method which has been used elsewhere and which i> recommended 

is the use of a considerable amount of radium emanation for a 

few seconds over the involved area of the lids and in this way a number 

of cases can be treated at one time. One, of course, must be very careful 

about the dosage where such a large amount of emanation is used. The 

advantages of this method are in the saving of time and in getting a pure 

beta ray effect. We believe that it is much betier to give a safe application 

than to attempt to control the disease at one sitting. It is necessary 

that the reaction subside following each application before the next 

application is made." 

Disci'ssiox 

Dr. Edward Jackson, Denver. Colo.—As is customary. Dr. Posey 

has >o well covered the subject that there remains perhaps only a general 

comment on certain points that seem more important. 

In the firstplace, there is reason to believe that the failurei diagnose 

vernal conjunctivitis in some localities i- due to lack of observation. 

I know of several men who. after they recognized a case, saw several 

others in a short period, in regions in which they had previously been 

practicing without recognizing any. It is easy for those who devote 

much of their time to trachoma and have not had their attention called 

to vernal conjunctivitis, to make a diagnosis of trachoma in these cases. 

especially in the more aggravated form; while the cases that are not 

severe arc usually passed over as conjunctival hypermia and not much 

importance attached to them. 

The diagnosis I think can usually be made from the history, certainly 

after the first year or two of the affection. There are a few cases. 

but they are very few. that seem to be as bad in the winter as in the 

summer. Questioning as to the recurrence from season to season will 

generallv bring out the fact that it first began in the spring, or summer. 

and has been worse during the warm weather. Seasonal influence is 

very striking in some cases. A few years ago I watched a case during 

the latter part of the summer, giving palliative treatment, but without 

very great relief. The vision was disturbed more than I have seen in 

any other case of vernal conjunctivitis. His vision was running about 

one-half, or as low as one-third of standard vision. Within three days 

after the firstfrost in autumn, he came in showing normal vision, without 

any further treatment or any other change to account for it. 

I have seen another case in which the man gave a history of one 

or two years of conjunctivitis. He went to work in a mine soon after 

the attack came on in the early summer and worked there through the 

summer, and for a few weeks was entirely free from any evidence of 

vernal conjunctivitis. He then began to work above ground, had another 

attack, and was told to go back to underground work. 

I have seen several cases relieved by removing from Colorado to 

other localities. The evidence of Dr. Gonzales, of Mexico, points in 

the direction of my experience, that it is not the heat so much as the 

dust and dryness that determine the occurrence of vernal conjunctivitis. 

The experience of Dr. Feingold in regard to heat is conclusive. Perhaps 

in a cold, dry country there may be more freedom from the trouble 

than where it is hot and dry. Certainly cases have been relieved by a 

climate marked by a relatively low summer temperature and a good


deal of moisture in the atmopshere. On the Pacific coast relief is found 

in the climate of Puget Sound, but in the upper Mississippi Valley, or 

Canada or the Lake region we can expect cures. 

To my mind radium has solved the problem of the treatment of 

vernal conjunctivitis. I have never seen it fail. 1 have seen it tried 

on cases that have gone on for ten or fifteen years, and one particularly 

that had been under my care for six or eight years, in which the very 

striking results from radium application were illustrated. It is probable. 

as Dr. Posey has pointed^ out. that an overdose accounts for bad symptoms 

that may occur. The dose required is very much less than that 

needed for malignant growths. Perhaps thirty to fifty millicuries for ten 

or fifteen minutes. That is ten to twenty millicurie hours against one 

hundred and over for carcinoma. So a worker with radium who has 

not been instructed and has not done anything with a case of vernal 

conjunctivitis is very likely to give an overdose. 

Dr. Edward A. Shumway. Philadelphia. Pa. -Perhaps as a result 

of the paper 1 read before the Section on Pediatrics of this Society. 

1 have had an op|H>rtunity of seeing more than an ordinary number of 

these cases. 1 wrish to corroborate all of Dr. Posey's statements. I 

am quite sure that the diagnosis is not always made. The first case I 

ever saw was in Prof. Fuch's clinic in Vienna, and when I got hack to 

New York I recognized a case which had been treated at one of the 

prominent hospitals as trachoma, as being unquestionably a case of 

vernal conjunctivitis. 

As to heredity. I have never seen a case occurring in father and 

son. I have seen two boys in one family affected, but in a mild degree. 

and they did not require treatment with radium. 

Certainly radium should only be employed in the very severe tvpes. 

The ordinary cases that are seen with a conjunctivitis, with an intense 

itching that comes on in summer time, can be treated in other ways and 

made comfortable until it gradually disapi>ears in the course of years. 

However, in the severe types there is no question that radium is by all 

means the most efficient remedy. But it should be used carefully. In 

the early days, when we had little experience. I have seen cases where 

there was permanent loss of lashes. In those early cases the radium 

was applied in one position, but now it is applied in various places across 

the lid so it is not placed in close contact with the lashes, at any one point. 

for more than a few minutes. I have seen one case of corneal involvement, 

a corneal ulcer, but evidently the disturbance was not from the 

radium, but from the pressure of the growth on the lid. I have never 

found it necessary to cut off a growth since we have been using radium. 

The radium causes such a quick disappearance of the hard masses, that 

even in the severe types three or four applications will suffice to clear up 

the condition. As Dr. Posey says, however, the conjunctiva is not normal 

after these treatments; there will be a certain amount of atrophy 

of the membrane as in the late stages of trachoma. 

For the milder tyi>es we have always used a solution of adrenalin 

with a boric acid solution and find that sufficient. This year we have 

had a great deal of satisfaction with a preparation made by Schieffelin 

& Company, in New York, upon which the American Medical Association 

has not yet placed its sanction, and that is estivin, which Schieffelin 

& Company say contains a special extract of rosa gallica. This is particularly 

valuable in hay fever, they claim. In my experience it has no 

effect on hav fever, but it has a remarkable effect in early types of con-

42 HADITJ M 

gestion of the eve which are associated with the appearance or grams 

such as timothy in the country, and in the congestion and uncomfortable 

itching which occurs in types'of vernal catarrh it acts very favorably. 

Dr. Hesry K. Pasoust. Philadelphia, Pa.—To us the most important 

point in connection with a case at the beginning is the diagnosis. 

Personally. I am not competent to make a diagnosis of vernal catarrh 

in all cases. I have known of at least one case being diagnosed trachoma 

by one ophthalmologist, by another vernal catarrh, and sent to me for 

treatment. It was treated for vernal catarrh, but if the condition was 

trachoma the treatment might succeed, though more radiation is necessary. 

In our early cases inexperience might have resulted in lack of 

care in not keeping the radiation distributed evenly over the lid. This 

is especially difficult with children who are struggling. The entire lid 

wherever involved -hould be treated evenly. The applicator should never 

be held in one place unless it is a special one made of the same size and 

shape as the lid. 

It is practically impossible to assure the patient that the lashes will 

not come out following treatment. We all know that hair follicles are 

extremely susceptible to radiation. Even erythema doses will cause falling 

of hair anywhere, and in case of the eyelid the follicles are extremely 

close to the surface and the radiation must reach them. After our first 

experience we have always told the patient that the lashes are likely to 

fall out. but in our experience they usually grow back. The two cases 

that have been mentioned here are the only ones I know of in which 

the lashes have not returned. 

It is very important not to persist in the treatment too long, because 

of the certainty of scarring of the lids, which is undesirable. If we do 

not get the result we desire within a reasonable time and with a few 

applications, we would rather stop than to treat the case further. 

We always prefer to treat patients during the cold season in order 

that the reaction, which is unavoidable because of the nature of the 

treatment, may not add to the discomfort of the patient during the sea- 

>on of activity. The principle of radiation treatment requires a reaction 

and if we get no reaction we get no result. 

The treatment of the bulbar conjunctiva is something that I always 

go about with a great deal of fear and trepidation, because the reaction 

in the eyeball, even though it may be slight, causes a great deal of discomfort 

to the patient and one never knows how severe that reaction 

will be. We never would give the same dose over the eyeball that we 

would over the lid. The dosage which Dr. Jackson has given you is 

practically the same as is used by everyone, whether it be expressed 

in terms of millicurie hours or milligram hours. The whole secret is the 

use of the beta radiation with very little filtrationin order that you 

may not get too much penetration over a very thin structure. 

Dr. Posey i in closing). -It is a great source of satisfaction to hear 

from these gentlemen that the results from radium are so favorable. 

There is no doubt that the failure to recognize this condition has 

been widespread. Twenty years ago. when I sent my letter to 500 ophthalmologists 

all over the country asking them how manv cases thev 

had seen. I remember the Professor of Ophthalmology in a well-known 

medical college sent back word that vernal conjunctivitis was verv common 

in his region, and that they saw hundreds of cases in the spring 

of every year, he of course mistaking vernal conjunctivitis for acute 

catarrhal conjunctivitis.

R a d i u m 

•1:5 

PRELIMINARY NOTE ON OBSERVATIONS MADE ON 

PHYSICAL CONDITION OF PERSONS ENGAGED IN 

MEASURING RADIUM PREPARATIONS* 

By R. C. Williams, Passed Assistant Surgeon, Office of Industrial 

Hygiene and Sanitation. United States Public Health Service. 

This re|>ort presents the observations made during a period of about 

a year and a half, from January. i«>jj. to July, 19^3. on the physical 

condition of the persons employed during that time in the radium section 

of the I'nited States Bureau of Standards. Washington. D. C. The 

reasons for making this study were twofold: (1) The necessity for 

periodic supervision of the physical condition of persons engaged in the 

constant handling of radium, in order properly to safeguard their health; 

(2) as a matter of scientific interest, to note the physical effects upon 

radium workers of continued exposure to radiation. 

Practically all the radium that is sold for medical or scientific pur- 

]>oses by manufacturers or commercial firms in the United States is 

sent to the United States Bureau of Standards for measurement; thus 

the employees of the radium section of the Bureau of Standards daily 

handle radium in varying amounts up to 750 milligrams. The total 

amount that may he on hand at the Bureau of Standards at any one 

time varies from 0.5 gram to 4 gram.* Radium bromide is the salt that 

is most frequently handled. 

It is not the purpose of this re|H>rt to review the literature dealing 

with the physical effects on radium workers of continued exposure to 

radiation, but rather to record as a preliminary note the matters that 

have come under our observation. Acknowledgment is here made of 

the excellent cooperation and valuable assistance given during this study 

by Mr. W. H. Wadleigh. chief of the radium section. Through the 

courtesy of Dr. G. W. McCoy, director of the Hygienic Laboratory of 

the United States Public Health Service, all of the blood examinations 

were made by workers at the Hygienic Laboratory. 

It has been well known for several years that persons exposed to 

large amounts of radiation frequently experience harmful physical effects. 

Various general symptoms, such as headache, malaise, weakness. 

undue fatigue, unusual need of sleep, increased excitability, fretfulness. 

irritability, disordered menstruation, attacks of dizziness, etc.. were said 

to be caused by long and repeated exposures to radio-active substances 

(l); but more recent experimental and clinical evidence shows that 

these general symptoms are perhaps not so frequent in occurrence nor 

so important as danger signals as are the now well recognized blood 

changes. 

The polymorphonuclear leucocytic and the lymphocytic blood content 

of radium workers is decidedly lower than that of normal individuals. 

Even among workers with the least exposure to radiation there 

was no evidence of leucocytosis. This contrasts with the fact that, in 

small animals, alternate periods of radiation and freedom from radiation 

will, under certain conditions, produce profound leucocytosis, and the 

leucopenia following a single dose of Roentgen rays is often followed 

by leucocytosis (2). 

•Reprinted !»' permission of the Surgeon Gi-m-i.il, rrom I'ul ni.in IlKallli Reports, 

iXXTlll. No. 51. 300T-302S. December II, 1923.


The low polymorphonuclear blood content commonly found and the 

anemia of an aplastic type affecting the much exposed workers point 

to an interference with the output of blood cells from the bone marrow. 

Among X-ray workers there is rarely any evidence of such an effect. 

though a small fall in the number of circulating polymorphs and a mild 

anemia have been noted in a few cases. It would seem that the penetrating 

gamma rays are able to reach the bone marrow, whereas the 

relatively soft X-rays used clinically fail in this respect (3). 

An initial fall in the number of circulating lymphocytes occurs in 

the blood soon after exposure to radiation. The experimental and observational 

data bear upon one another to the extent of showing that 

both X-rays and gamma rays may be expected to cause lymphocytes 

to disappear from the circulation. Changes in. the red blood cells have 

also occurred after a single gamma ray exposure; they are not of a pronounced 

character, however, unless the radiation is very prolonged {4). 

There is a constant occurrence of a marked polynuclear leucopenia. 

The recovery from the leucopenia is very slow. There is agreement in 

respect to the destruction of lymphocytes. Destructive changes in hone 

marrow have also been described (5). 

A thrombopenia was found to be a lesion common to vitamine-A 

deficiency and exposure to radium (6). 

Undue exposure to the X-rays or radium is associated at times with 

a moderate leucoplakia. a relative lymphocytosis, a relative polycythemia. 

and occasionally an eosinophilia. A low blood pressure, which does not 

seem to be associated with any other definite symptoms, is quite common. 

The skin changes found in the earlier workers are not increasing 

and are being avoided entirely by the later ones because of increased 

knowledge and increased protection (7). 

A diminution of the number of polynuclears of 1 and 2 nuclei and 

an augmentation of the polynuclears of 4 and 5 nuclei were noted (8). 

The small variety of mononuclears is especially sensitive to radiation, 

as measured by their disappearance from the peripheral circulation 

after exposure of the animal to radiation (9). 

The lymphocyte is the most radio-sensitive cell in the animal organism. 

The change in the numerical relationship of the two types of white 

cells is not accompanied by noticeable change in the total leucocytic 

count (10). 

The red cells seem to be diminished in numbers in the radium workers. 

The hemoglobin content of the blood is less affected, so that the 

color index is high. This finding, combined with the fact that there is 

no evidence of red cell regeneration, and with the associated polynuclear 

leucopenia, points to an interference with the production of red cells 

and polynuclears in the bone marrow. It would seem that the penetrating 

gamma rays of radium react and injure the bone marrow, whereas 

the less penetrating rays exhibit their effects chiefly upon lymphocytes 

and lymphoid tissues, which are not protected by a covering of bone (11). 

With increased protection for radium workers, evidence is found of 

a return of the altered blood condition of the workers to the normal. 

In the case of the red cells, the polymorphs, and the hemoglobin, the 

return to normal was complete; only a mild lymphopenia persisted (12). 

Three deaths were reported in 1921 as occurring among persons employed 

in handling radium at the London Radium Institute (5). These 

fatal cases were accompanied by anemia, which has occurred from time 

ot time among radium workers. Taking into account the great rarity


of aplastic pernicious anemia, it is reasonable to conclude that ex|Kisure 

to radium was an important etiological factor. 

From the available literature on this subject it appears that continued 

exposure to radiation usually produces the following harmful 

effects: 

I. Pain, sensitiveness, or anesthesia of the skin of exposed lingers 

or hand. 

2. Burns or destruction of the skin and underlying tissues. 

3. Effect upon the blood and blood-making organs—usually a profound 

leucopenia affecting both the |tolymiclears and lymphocytes; a 

decrease in blood platelets; also a milder anemia accompanied by a high 

color index. The reduction of the lymphocytes seems to be definite and 

regular; the effect upon the polynuclears is irregular. 

4. Sterility. 

5. The inhibition of the absorption of fat in the intestinal canal. 

This has been demonstrated experimentally (13). 

The extent of the effect of the exposure to radiation depends upon— 

(a) Amount of radium to which the subject is exposed. 

(b) Length of time of the exposures. 

(c) Frequency of the exposures. 

(rf) Proximity of the radium to which the subject is exposed. 

(e) Amount and character of protection afforded against radiation. 

(/) Character of the rays to which the subject is exposed. 

The following is quoted from J. C. Mottram (11) regarding the 

biological action of radium: 

"Surveying the biological action of radiation, one of the first generalizations 

which may be made is that the various tissues differ widely 

in their susceptibility; some—for instance, nerve cells—show no changes 

after relatively large exposures, whereas others—for instance, reproduction 

cells—are altered by small amounts of radiation. The following 

tissues arc especially sensitive: skin, blood vessels, connecting tissues. 

hair follicles, reproduction cells, lymphoid tissues, and blood cells. Experimental 

evidence goes to show that the last three are more susceptible 

than the others, so much so that these tissues would be especially chosen 

for examination in searching for the earliest effects of radiation. There 

is no doubt about the sensitiveness of the reproduction cells. The sterility 

of X-ray workers who have good health in other respects is very 

clear evidence. As regards the blood changes, it may be mentioned 

that experiments on rats have shown that, by their blood changes, X- 

radiation could be detected where a photographic plate gives no record. 

For this reason, and also because the blood changes have been the subject 

of large investigation, it may be concluded that they will serve as 

an excellent indicator for the biological effects of radiation. The present 

state of our knowledge would lead to the conclusion that in the absence 

of blood changes the worker had received no more than a harmless 

amount of exposure to radiation." 

Most of the articles appearing in the literature deal with the harmful 

effects of continued exposure to radiation upon persons handling 

radium for therapeutic purposes. As this study was made upon persons 

who are engaged in measuring the gamma radiation of the radium s.dts

46 Radium 

examined, it is believed desirable to describe briefly the methods employed 

in their work. 

The packages containing the radium that is sent to the Bureau of 

Standards for examination and measurement come by registered mad 

or express. They are delivered to the shipping room and then brought 

to the packing room of the radium section, where the packages are opened 

by the employees. Approximately one-third of the radium received is 

in sealed glass tubes from I to 2 centimeters in length and about 2 millimeters 

in diameter, ami the remainder is in sealed metal needles from 

lyi to 2]/> centimeters in length and about 1J/2 to 2j4 millimeters in 

diameter. The persons who do the unpacking stand behind cast-iron 

screens which are placed upon a table at the height of the chest so as to 

protect the workers as much as possible. 'Tbis use of the cast-iron screens 

was instituted a short time prior to the beginning of this study and was 

continued during the lime of the study. The hands and arms of the 

workers are extended around the screens. The applicators containing 

the radium are removed from the containers in which they arrive and 

examined closely. To avoid any contamination of the surface of the 

applicator which may have been acquired during the process of manufacture, 

the preparations are washed thoroughly with soap and water 

by means of a small brush and dried with cotton held in forceps. They 

arc then put in larger glass containers, marked for identification purposes, 

and placed in wooden boxes about 6 inches long, 3 inches wide. 

and 3 inches high, with a lead lining about one-half inch thick. During 

this process the preparations are handled entirely with forceps. (See 

Plate I.) The boxes containing the radium are carried in a fiber bucket 

to the safe where all this material is kept. 

Radium that is being sent out from the Bureau of Standards is 

handled in a similar way. The unpacking and packing of radium require 

the services of two or three |>ersons for about one hour daily. 

The chief exposures and sources of exposures to radiation during 

unpacking and packing appear to be— 

I. Exposure of hands, arms. neck, and head. In unpacking and 

packing, the use of rubber or lead-rubber gloves has not proved satisfactory. 

The sense of touch alone can not be relied upon; hence it is 

necessary to see the package and radium containers, and consequently 

there is also an exposure of the head and neck. 

2. Sometimes radium tubes are received in a broken or leaky condition. 

In such cases, when the package is opened, exposure involving 

the breathing of radium emanation is very considerable. In case of 

broken or leaky tubes the radioactive gas is spread through the room. 

Unless there is proper ventilation of the room by means of electric fans 

after such occurrences, persons working in the room are exposed to 

radiation for a considerable time, and from within the lungs as well as 

from without. 

When ready to undertake the measurements on a given tube of 

radium, the following is the process through which the worker must 

go: He must visit the safe where all the radium is kept, open the door, 

and, according to a check list, remove the lead-lined wooden boxes containing 

the preparations desired. (See Plate I.) The boxes are then 

carried to a smaller safe in an adjoining room, from which the preparations 

are taken one at a time for actual measurement. The individual


preparations are taken to the electroscope, or instrument where the 

measurement readings are made, in a wooden carrier having a long 

handle. In taking the radium from its place in the safe and placingit 

in the wooden carrier, forceps are used for picking up a particular tube 

from among several others. 

During the actual measurements the tube contianing the radium 

that is being measured is placed upon a support about on a level with 

the face of the operator and at a distance of about 3 feet. (See Plate 

II.) The process of making the readings consumes about seven minutes. 

After the readings have been completed, the radium is placed in 

the wooden carrier box and returned to the safe. The return of the 

radium tube to the safe must then be noted on the check list. 

The principal exposures and sources of exposure to radiation during 

this process are as follows: 

1. Exposure when standing before the open safe for the purpose of 

finding, identifying, and checking the particular tube desired. 

2. Use of fingers on forceps in taking tube from container and 

placing it in wooden carrier box. 

3. Exposure when tube is being placed upon instrument for reading. 

4. Exposure the same as 1 and 2 when the tube is being returned 

to the safe after the readings are completed. 

For the purpose of future identification at any time during which 

the bureau retains the radium, accurate weighings are made of the 

applicators containing radium; also, measurements of the external dimensions 

are made with a comparator. (See Plate II.) During this 

process the radium is kept, as much as possible, behind lead screens. 

In order to obtain some idea as to the actual amount of radiation 

to the person exposed during the operation above mentioned, and as to 

the part of the body that is most frequently exposed, an experiment 

was made in which standard dental films were worn in various locations 

on the body for varying lengths of time. A penny was glued to the 

proper side of each film, and the films were worn on the forehead, neck. 

chest, and both inguinal regions. These films were worn daily by em, 

ployees of the section while engaged in their routine work. 

For the first experiment five films were worn by each person, as 

follows: On forehead, neck, chest, right inguinal region, and left inguinal 

region. Seven persons took part in this experiment, which lasted for a 

period of two days. During this time the amount of radium to which 

each person was exposed varied from 10 milligrams to 500 milligrams, 

and the time of exposure varied from 15 minutes to 2j/< hours. None 

of the films which were worn for two days showed any evidence of exposure 

to radiation. 

Then, in order to obtain a basis upon which to consider the effect 

upon films of exposure to radiation, several films were exposed to various 

amounts of radium for varying lengths of time. The amount of radium. 

the distance of the film from the radium, and the time of exposure were 

as follows: 

10 mg. at 5 cm. for 5 minutes. 

25 mg. at 5 cm. for 5 minutes. 

50 mg. at 30.5 cm. for 30 minutes. 

75 mg- al 4° cm- f°r 45 minutes. 

15 mg. at 60 cm. for 2

48 IÂDITJM 

Positive results of exposure were obtained in all films thus used. 

A film was exposed at a distance of 60 cm. for 5 minutes before an 

open safe containing 500 milligrams of radium. Between the film and 

the radium was interposed a one-half-inch lead screen. The results of 

this exposure were negative. 

A second experiment of wearing films was made. This tune the 

films were worn on the five locations previously mentioned, by six persons 

for three days. During this time they performed their regular routine 

work. The amount of radium handled and the length of exposure 

during this time varied within the limits named for the first experiment; 

that is. from 10 milligrams to 500 milligrams in amount and from 15 

minutes to 2>< hours in time. The films from three persons in this experiment 

showed positive evidence of exposure to radiation. 'The three 

films that were positive were those worn upon the forehead. 

The preceding experiments seemed to show that the forehead was 

the most exposed part of the workers, as the films worn on the other 

parts of the body were at all times negative; and so in the next experiments 

with the wearing of the films it was decided that they should be 

worn only upon the forehead. The films were now worn by six persons 

for four days. The amount of radium to which they were exposed at 

this time varied from 10 milligrams to 750 milligrams daily, and the 

length of time from five minutes to three hours. During the time these 

films were worn, regular routine duties were performed. All the films 

used in this experiment showed positive evidence of exposure to radiation. 

It would therefore seem, from the results obtained from the wearing 

of films as above described, that "employees of the radium section in 

the course of their regular routine work receive sufficient radiation to 

record positive findings upon the dental X-ray films. It would also appear 

that the head is the part of the body that is exposed to the greatest amount 

of radiation, except, of course, the hands and forearms. 

Having thus considered the possible hazard of exposure to radiation 

in the work process of the group of persons under discussion, and having 

further established by experiments that all members of the group 

receive upon at least one part of the body (the forehead) suflicient radiation 

to produce positive evidence of exposure on dental films, the next 

step in the investigation was a consideration of the general physical condition 

of the persons thus exposed to radiation. 

Accordingly, in the beginning of the study every worker in the 

radium section was given a complete physical examination. Eight persons 

were employed in this work at that time. A former employee who 

had been working with radium for six and one-half years past was also 

examined. During the period covered by this report several employees 

left the section and one or two new ones came in for a short time. Onlv 

five employees were continuously under observation for the entire period 

of the year and a half which this report covers. Table I gives a summary 

of the results of the physical examinations made at the beginning 

of the study:

R a d i u m 49


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»2 R a d i u m 

The summary of physical examinations made at beginning of study 

shows four males and five females. No serious defects were found in 

any of the group. Two of the males had symptoms of the skin of the 

fingers and hands which are suggestive of the effects of radiation. One 

male attributes his nervousness and digestive disturbances to continued 

exposure to radiation. He states that members of his family, without 

actually knowing whether be had been exposed to radiation or not. could 

accurately tell by his increased nervousness and irritability that he had 

been exposed to radiation. Two females had enlarged thyroid glands. 

The cardiac findings in all the females are thought to be functional. Menstruation 

in the females had not been disturbed by exposure to radiation. 

One female (No. 5) had recently returned from two months* sick 

leave. A physician had made a clinical diagnosis of anemia and nerve 

fatigue. At the time of the physical examination made during this study. 

she still felt nervous and depressed. It will be noted that in all the cases 

except in No. 4. No. 5. and No. 8 there seems to be a rather low blood 

presstire. Case No, 5 had only recently returned from sick leave when 

this reading was made. Case No. 8 works writh radium only one day a 

week, thus leaving case No. 4 as the only one whose blood pressure 

apparently was not lower than it normally should be. These blood pressure 

readings were made with a Tycos instrument, the auscultatory 

method being used. 

The physical examinations, therefore, seem to show that, of the nine 

persons examined, only two presented any signs of the effect of radiation 

upon the skin, and that exposure to radiation apparentlv produced a 

lowering of blood pressure in the majority of cases. It was thought that 

there might exist a relation between the decrease of red or white blood 

cells in certain members of the group and the low blood pressure, but it 

appears, upon careful study, that such was not the case. (See Table III.) 

The next step in the investigation was an examination of the blood 

to determine whether any changes could be noted. An examination of 

the blood of the employees of the section made on February 6, 1922. "ave 

the results shown in Table II.


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Radium 55


In the studies made by Mottram, anything less than an 8 per cent 

variation was considered "no change." Applying this standard to the 

blood examinations tabulated above, we find that all in the group were 

below normal in polymorphonuclear neutrophiles. Two (No. 3 and No. 

5) were below normal in small lymphocytes. All save one (No. 8) were 

above normal in large lymphocytes. Three persons (No. 4. No. 6. and 

No. S) were below normal in total white cells. Two persons (No. 5 

and No. 6) were below normal for total red cells. Thus we find that 

three persons (No. 5. No. 6. and No. 8) had a deviation from normal 

in more than one of the cellular constituents of the blood. 

Following the initial examination and blood counts, other blood 

counts and blood-pressure readings were made at intervals varying from 

two weeks to two months, covering a period of about a year and a half. 

The accompanying graphs show results of these several blood counts. 

It will be noted that cases No. 10. No. 11, and No. 12 appear in the 

graphs. These represent employees who entered the section after the 

study had begun. A record of their physical examinations will be found 

in the summary shown in Table I, except No. 10, upon whom no physical 

examination was obtained before he left the section. Again applying 

the standard that anything less than 8 per cent variation is considered 

"no change." we find that there were changes and variations in the blood 

picture as follows: 

For the polynuclear neutrophiles there was a tendency to be somewhat 

below normal, although the last count shows all save one within 

allowable limits. All members of the section show a decrease belownormal 

in the number of small lymphocytes. The large lymphocytes vary 

and most oi the time are above normal, but the last two counts show ;i 

decline in all the members of the section. The total white cells vary 

also; the last count show four persons below normal limits, two dropping 

to 4.900. The last count of total reds shows three below the allowable 

limit. In the studies to be made henceforth it is planned to run a 

control group for blood counts. It appears probable that there are appreciable 

individual differences in the resistance to changes in the blood. 

Table III. showing blood-pressure records, is of interest. The readings 

were made by the auscultatory method; a Tycos instrument was 

used most of the time. On one or two occasions a mercury instrument 

was used. From this table it is evident that most of the workers in the 

radium section have a rather low blood pressure, both systolic and diastolic, 

as compared with the commonly accepted normal, and that these low 

blood pressures have continued persistently during the entire period of 

this study. 

A summary of the physical examinations of the employees of the 

radium section made at the expiration of a year following the beginning 

of the study shows nothing of special significance. Specimens of 

semen from No. 1 and No. 2 examined during the study showed motile 

spermatozoa. There were five males and seven females. The menstrual 

function of one female worker is noted as disturbed since working with 

radium. It is also noted that every female employee of the section save 

one is recorded as having an enlarged thyroid. Two of the female employees 

had only recently entered the section; hence the enlargment of 

the thyroid gland in their cases certainly could not be attributed to the 

work with radium. No connection between enlargement of the thyroid 

and the work has been noted in this study.

R a d i u m 

57 

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Radium 

Unpacking and packing radium. 

At the radium safe: Keprenenlhig (I) taking Inventory, and (?) removal or 

radium to nnd fn»m safe for storage, measurements, and packing.


Measuring radium by meane of the gamma ray electroscope—the standard 

method used for all but exceedingly weak pienarntluns. 

Making measuiemirts of length, diameter, nnd weight of radium tuV.es. 

needle--, and planncs for purposes of future identification.


Conclusions 

i. At least two persons, one an employee at the time of the study 

and one a former employee, who were examined during this study, presented 

symptoms showing evidence of the effect of radiation upon the 

skin of the fingersand hands. 

2. Employees are exposed to radiation, as is evidenced by positive 

effects upon dental films worn by employees in regular routine work. 

3. Apparently certain blood changes had occurred in the workers; 

notably, a tendency in the polymorphonuclear neutrophiles to remain 

Slightly below the lower normal limit, and a diminution in the small 

lymphocytes, while the large lymphocytes apparently ran somewhat 

higher than normal. The total white cells had a tendency to decrease 

in number, as also had the total red cells. 

4. A low blood pressure, as compared with the usually accepted 

normal, was noted in practically all the employees of the section. 

Recommendations 

On the basis of this study it is recommended— 

1. That blood examinations and blood pressure readings be made 

at regular intervals on all employees of the radium section. 

2. That complete physical examination of all employees of the section 

be made at regular intervals. 

3. That all new employees of the section, before beginning work. 

be given complete physical examinations, including examination of the 

blood. 

4. That in the handling of radium, all employees of the section 

utilize to the greatest possible extent all practicable protective devices. 

such as screens, lead-lined carrier boxes, and handling forceps. 

5. That all rooms in which radium is handled be adequately and 

thoroughly ventilated. The use of electric fans for this purpose appears 

to be highly desirable. 

6. That all employees of the section be warned to reduce to a minimum 

the amount of unavoidable unprotected exposure to radiation, and 

not to remain in the vicinity of radium longer than is necessary. 

7. That in the packing and unpacking of radium in connection with 

the receipt and dispatch of shipments, all boxes, wrapping paper, and 

other equipment be assembled, arranged, and prepared so as to expedite 

lhe work and thus reduce the amount of unavoidable exposure to radiation. 

8. That all employees of the section be allowed to work only five 

days a week, and that at least a two-day period intervene between the 

two holidays of each week, these not to be considered annual or sick 

leave. 

9. That all employees of the section be required to take 30 days' 

annual leave each year, preferably, whenever at ail practicable, in twoweek 

periods at six-month intervals.

R a d i u m 

6i 

Bibliography 

I. Gudzent and Hadberstaedter: Deutsch mcd. W'chnschr.. March 

26. 1914, p. 633. 

2. The leucocytic blood content of those handling radium for 

therapeutic purposes. By J. C. Mottram and J. R. Clark. From the 

Research Department, Radium Institute, London. Archives of Radiology 

and Electrotherapy, March i, 1920. pp. 345-350. 

3. Histological changes in the bone marrow of rats exposed to the 

gamma radiations from radium. By J. C. Mottram. From the Research 

Department. Radium Institute. London. Archives of Radiology and 

Electrotherapy. 1920-1921. vol. 25. p. 197. 

4. Some contrasts in the effects of X-rays and radium upon blood 

cells. By Sidney Russ. Brit. Med. Jour. 2: 268. 1921. 

5. The red cell blood content of those handling radium for therapeutic 

purposes. By J. C. Mottram. From the Research Department. 

Radium Institute. London. Archives of Radiology and Electrotherapy. 

1920-21, vol. 25. 

6, On blood platelets, their behavior in vitamin-A deficiency and 

after radiation. By Cramer. Drew, and Mottram. Proc. Roy. Soc. B.. 

vol. 93. pp. 449467. 

7. Effects of the X-rays and radium on the blood and general 

health of radiologists. By G. E. Pfahler. Am. Jour. Roentgenol. October, 

1922. 

S. Modifications et hemoleucocytaires sans rinfluence de 1'enianation 

du radium. Rabattu et Richard. Jour. Med. Francaise, Paris. 1913. 

P- 234. 

9. Observations upon the action of radium and X-rays on the mononuclear 

leucocytes of the blood of rats. J. C. Mottram. From the 

Research Department. Radium Institute. London. Jour. Roy. Soc., Med. 

Pathological Sect. February, 1922. 

10. Action of radium and the X-rays on the blood and bU.odforming 

organs. By Isaac Levin. The Am. Jour, of Roentgenology. 

February, 1922. 

11. The use of blood counts to indicate the efficiency of X-ray 

and radium protection. By J. C. Mottram. Brit. Med. Jour. 2:269. >02i. 

1 j. The effects of increased protection from radiation upon the 

blood condition of radium workers. By J. C. Mottram. Archives Radiology 

and Electrotherapeutics. May. 1921. vol. 25. 

13. Vitamines, exposure to radium and intestinal fat absorption. 

By Mottram. Cramer, and Drew. Brit. Jour. Exp. Pathology. Vol. 3. 

Xo. 4.

62 RADIUM 

Appendix 

In the following tables are given the chronological records of the 

blood counts of the individual workers: 

SUBJECT NO. 1. 

lied colls. 

While cell*. 

Total 

number. 

Men. 5-5 >? 

I million : 

Normal.. women 

4^,-S 

million 

1921, 

Feb. 6.. 

Apr. 10. 

July 26. 

5.430,500 

4.900.000 

4.880.000 

4.11O.U0O 

4.200.000 

Sept. 7.. 4.260.000 

Nov. 11. i.TGn.noo 

Dee. 19.. 4.580.000 

1923. 

Ji.n. 3.. 5.080,000 

Feb. .13 4.570.000 

Apr. 24.. 5.030.000 

1H22. 

i-vi>. •;.. 

Apr. 10. 

4,306.000 

4,960,000 

4.510.000 

5,120.000 

June July 7.. 14 June Aug- '&• 23. 

Sept. 28. 5.050.O0U 

Nov. 11. 3.800.000 

Drc. 13. 3,$>S».000 

1113. 4.190,000 

Jan. 2.. 4,890.000 

Feb. 13.. 5,010.000 

Apr. 24. 4.450,000 

July 19. 4,510.000 

1932. 

Feb. 6... 4.050.000 

i.Goo. 

Apr. 10.. 4.SOU. 

1,260.000 

July 6.. 4,900.000 

July 26. 3,900.000 

AUK. 15- 5,050.000 

Sept. 6.. 4.370.000 

Nov. 11. 3,930,000 

l>ec. 19.. 4.440.000 

11-23. 

Jan. 2.. 4,520.000 

Feb. Apr. 24. 13. 

4.265,000 

4,810,000 

July 19. 4,500.000 

Haemoglobin 


Ited cells, 

SUBJECT NO, 4. 

White cells. 

Total 

number. 

Hin-ml"Flobln 

iT.°'' 

quittt). 

Total 

number. 

Polymorphonuclear*. 

Neuropillea. 

Lymphocytes 

Kosti- Biinoph- 

aoph- Small. Large. 

ilea. He*. 

Large 

mononucivart, 

Men. 5-5 K Men, 

Normal.. million; 90-110 7.500 i;:.-70 

women I wo- 

1-3 o.L'5-,5 2o-3» 8-6 

4'i-S men. 

million. 80-100. 

% 

'• 

Feb. 6.. 4.590.000 

f.000 57.5 i.:. 

4 

Apr. 10.. 4.600.00O 

•1.800 

51 l.S •:•• 13 

June H 4.950.000 

f.100 

50.8 1.4 

33 8 

July 6. 5.100,000 

t.SOO 63.2 1.2 

26.4 4,4 

July 86 4.205.000 

MOO 

56 .4 .36 37.2 3 

Aug. 18. 4.810.000 

f.400 

47. 3 .3 42 8 

10.5 

Sept. 1923. 2S. 

Jan. Nov. 2. 11. 

13. 

1>CC. Feb. 19. 

24. 

Apr. l»f 

July 

4.440,000 

4.970.000 4,680,000 

4.460.000 4.680.000 

4.470.000 

4.020,000 

1922. 

Feb. 6.. 3,700.000 

Apr. 10. 4,400,000 

June 1 I 4.080,000 

Aug. 15. 4.000,000 

Sept 6. . 1.010. 

Sept. 28. 4.720.000 

Nov, 11. 3,870,000 

Dec. 19. 4,080.000 

1923. 

Jan. 2.. 1.330, 

Feb. 13. 4.175.000 

1922. 

Feb. 6. 

Apr. 10 

June 14 

July 6. 

Nov. 11 

3,595,000 | 

4,300.000 

4.410,000 

5.000,000 

3,940.000 ! 

1922. ' 

Feb. 6..I 4.370,000 

Apr. 10.[ 4.520.000 

July 6.. 5,200.000 

June 14.) 4,780.000 

July 26.1 4.456,000 

1922. 

Feb. i; . 4,100,000 

Apr. 10. 

.Inly 

4,600.000 

36. 

Aug. 15. 4.666.000 

Sept C.. 4.500.000 

4,250.000 

90 

92 

100 

92 

ion 

90 

90 

95 

85 

80 

90 

95 

90 

95 

95 

95 

95 

90 

100 

80 

100 

7.000 

M60 

7.340 

1.460 

;.40ti 

7,400 

9,000 I 

8.000 

7.200 

8,950 

7.600 

7.310 7,840 

6.400 8.000 

59 I 81 

54.8 63.7 1.61 3 

60 . 1.7 

67.5 I • 

1 

SUBJECT NO. 

65 

64.5 

5| 

57 

52.4 

60 

65.5 

65.5 66.4 

3.6 

1.6 

2 

4 

3.2 

.41 

3.4 .5 

l.S l.s 

0 

.6 

i -„•;. 


5.200 61.2 

6,200 

S.6 

61 5 

7.500 

1.6 

63.6 

5,200 

.8 I 

68 

6,640 

D 

subject 67.S no. 

85 6,100 

90 6.400 

100 7.100 

100 5.200 

96 5.500 

4.800 

7,000 

5,250 

6,600 

4,400 

63 •1.5 

60 2 

66.8 1.6 

66 

56.2 Z 1.6 

SUBJECT NO. 

62 0.6 

S3.5 . .5 

S0.5 4 

S3 11 

60.8 .4 

1 

0 

1 

0 .4 

.3 

24.8 

25 7.5 

16.3 17.5 

13 

11 3 

16 

20.5 

27 

:;n 

23 

24 

18 9.2 

10.5 14.4 

28.5 

24.4 

26 

15.6 

27 

27 

24.4 

*"-« 

31.8 

J » 

0 .5 t 24 30 

1 .8 1 26.4 24 

! 

14.5 13.3 

164 

8 

3.5 

6.5 

s.;, 

7.8 

8 

5.6 

11.7 

11.6 

15 2.4 

7.2 

3.2 

3.8 

6 

5 

3.2 5.6 

5.4 

•I 

3 

4,5 

3 

6.8 

1-2 2-t 

o.;. 

6 

I 2 

1.4 

:: 2 

5.7 

13.S 

If, 

13.7 

6.8 

1.5 

3.25 

1.4 

1.42 

4 

6.6 

12.6 

4.8 

1 

;: :'. 

1 

2 

2.8 

2.7 

3 

2 

3.5 | 

4 

2.5 

6 

2 

1.6 

2.63 

.8 

24.7 

LI 

.6 

2 i 

3.5 

2.5 

2.25 

1 

2.4 

2.05 

02.8 

1.6 .5 

2 

3 

1.6 .8 

1.8 

0.6 

0 

.4 

.4 

.4 

".T 

1.2 

.11 

0.4 

.6 

.4 

0.5 

0 

1.6 

.3 

4 I 

1 .i 

2.5 : 

4



Red eel la. 

White cells. 

Normal. 

Tolal 

number. 

Haem- 

>globin 

(Toliui«t>. 

Men. 5-5 % 

million : 

90-110 

women women, 

P..-;. 

million. 

80-100. 

Feb. 6.. 4,745,000 

May 22 . 

May 29.. 3,390,000 

June 12. 4.660.000 j 

July 10. 

Aug. 15 4,620,000 ' 

July 19.. 4,900.000 

8,600,000 

4.730.000! 

I 

1922. I 

July 26..! 5.050,000 

Aug. 15.. 4.200.000 

7.50-I 

7.200 

4,000 

4,500 

7.000 

5.100 

7,000 

l.S 90 

7.200 

5,600 

Polymorphous 

65-70 

Total 

number. 

Neutrophil*. 

Boalnoph 

Ilea. 

% 

51 l.S 

56 2 

61 2 

63.6 4 

62 L 

G5.8 

SUBJECT Nu li 

12.7 

84 

1-2 0.25-.5 20-30 

Nym|(hl,cv(„ 

Basoptl- 

Small. 

lie* 

% 

0.5 

2 

3 

.8 

i.s 


* 

21.5 

26 

14 

23 

20 

34 

'" 

Large = 

nuclear*. 

Large. 

e. 

2-6 

11.5 

5 

20 

5 

5.2 

9 

2.2 

0.3 24 I 3.3 

6 

l-'J 

« 

2 

3 

4 

2.S 

13 

1 . 

2-1 

41 

« 

S 

a 

c 

=> 

.% % 

8.5 0.5 

5 

2 

3 

1.6 

l.S 

1.3 2,7 

1922. 

4.230.000 

Kept. 6. | 4,500.000 

Sept. 28 : 4,180,(100 

4.070.000 

Nov. 11. | 

Dec. 19.| 4,100,000 

1923. | 4,160,000 

l.lln.000 

Jan. 2.: 3,920.000 

Feb. 13. 

Apr. 24. 

July 19. 

1923. 

Apr. 24..; 4,640.000 

July 19..I 4.49U.O0O 

1 

95 

5.250 

85 7.000 | 

1 

90 5,940 : 

96 7.100 | 

95 

95 

80 

85 

6.660 1 

4,680 

4.280 

6.790 | 

r.6.4 

61 

C3 •: 

67.7 

61 

61.8 

69.5 

76-7 

0.3 

1,29 

1.4 

1 ( 

1.2 

.8 

.5 

.5 



86 

24 

16.8 

11.7 

10 

14.8 

13.5 

11 

1923. 

July 19.. ;..

R a d i u m 

TECHNIQUE OF RADIUM TREATMENT FOR LUPUS 

ERYTHEMATOSUS 

By GEORGE D. Culver, M.D., San Francisco, Cal. 

Dermatologists regard failure to cure lupus erythematosus as in 

the natural course of events, and among them it gives rise to no unfavorable 

criticism. With the general profession, however, it is different, 

for the disease is regarded as a superficial affair and failure in treatment 

is looked upon as an indication of the weakness of dermatology 

as a specialty. As for the laity, an unfavorable issue is particularly 

unfortunate, as the lesions are almost always on the face, more frequently 

in women, and they constitute a continual reminder of our 

deficiencies. 

The reputation of radium in the management of lupus erythematosus 

was one of the factors that stimulated our investment, and before 

long the purchase for this use was regarded as of doubtful value. This 

doubt was really due to faulty technique. A later method proved much 

more satisfactory. 

Half or full strength plaques of radium have proven best, screened 

with sufficient metal and additional distance screening, as with rubber 

or paper, to eliminate all the alpha particles and many of the less 

swift beta ones. To illustrate: A plaque two centimeters square, containing 

ten milligrams of radium clement, is screened with 0.2 to 0.4 

millimeters of lead and eight to twelve layers of writing paper, or 1 

to 2 millimeters of rubber. The plaque is left in place for from two 

to two and a half hours, covering a little beyond the edge of the lesion. 

This exposure is followed by some redness and often by superficial 

necrosis, which, however, is late in appearing—about eight or ten days 

after the exposure. The superficial necrosis heals quickly. 

The prolonged irradiation probably acts on the deeper blood vessel 

walls, and on the endothelial cells. 

There is still another effect produced. As is well known, radium. 

if unscreened or only lightly screened, gives rise to jwrmanent capillary 

dilatation. Employed in the above way. however, it not only has not 

caused this disfiguring capillary dilatation, but many of the capillaries 

resulting from the disease and from previous, more lightly screened 

irradiations have disappeared. 

It was not until the latter part of the year 1920. after having used 

radium for nearly live years, that I began to employ the heavier screening 

mentioned above, and the longer exposures; and not until the earlier 

part of 1922 that 1 was completely convinced of the marked superiority 

of this method. The results are far beyond anything attained by any 

other local means within my experience. 

Of course, the use of radium does not preclude measures looking 

to the general health of the patient and the employment of other remedies 

locally, such as pure alcohol vigorously rubbed in, or an alcoholic 

lotion consisting of: 

Salicylic acid 100 Essence of Lavender 10.00 

Acid boric 10.00 Spts. vini rect. (95%) ad 240.00 

which Dr. Corlett once kindly suggested for use in acne, and which is 

excellent. Hutchinson's lotion in different strengths of dilution also 

acts well. Frequently the hyperkeratoses clear up after the use of


trichloracetic acid. As is well known, salves do not act well in this 

disease. 

The main local treatment, however, is now with radium. It almost 

never fails to accomplish some good with each application, and where 

possible to repeat the irradiations at intervals of from six weeks to two 

months it is ihe exceptional instance that will resist its effect and fail 

to disappear. 

Local treatment in the past was by no means an entire failure. However, 

the disease was far from being a joy to treat. It was not a simple 

matter to judge therapeutic results, as lesions would disappear without 

treatment or in spite of it. Only by grouping stubborn cases has it been 

possible to reach a satisfactory conclusion as to what to expect from 

irradiations with radium. 

In a group of ninety-eight cases of lupus erythematosus, dating 

back seventeen years, just half that number have been treated with radium 

irradiations, and of the forty-nine, thirty-eight have come under supervision 

at some time since the firstof 1920. that is, during the last four 

years, and since using radium more heavily screened. Twenty-six of 

the ihirty-eight show excellent effects from the radium irradiations as 

described above, and sixteen of this number show quite satisfactory end 

results. Of the remaining portion of the thirly-eight cases some are 

those recently acquired who are under treatment and others have continued 

their nomadic tendencies. 

One finds gratification in having a method of procedure that is so 

effective as to hold as nomadic a group of patients as those afflicted 

with lupus erythematosus. It is also a satisfaction not to dread their 

visits. 

Citation of individual cases would be a time consumer without 

sufficient recompense. One instructive instance may be mentioned, that 

of a woman forty-one years old, who in 1912 had had lupus erythematosus 

three years. I first saw her in September of 1912, and from time to 

time until February of 1916. when she quite justifiably sought help elsewhere. 

June 5. 1922. more than six years later, she maneuvered through 

another member of her family to get me to call at her home, because her 

face was so extensively covered with active lupus erythematosus patches 

she dreaded appearing in the office. She would appear on the street 

only when so heavily veiled her face could not be seen. Irradiations 

were immediately begun. Four plaques of radium (one 2x2 centimeters 

square plaque containing 10.86 milligrams of radium, another of similar 

strength somewhat larger, and two 25 milligram plaques of the size of a 

ten cent piece, the weaker plaques being screened with 0.2 lead and twelve 

layers of paper, the two stronger plaques with 0.4 lead and sixteen 

layers of paper), "ere applied for two hours. Fourteen sittings with 

not more than tour applications in any one place, have so nearly freed 

her from eruption that only indefinite areas indicate further treatment. 

Her lupus erythematosus was of the type that left scarring in all 

situations, and on the scalp denuded the patches of hair. It affected 

the eyelids, extending on to the edges, the lips extending on lo the mucous 

membranes, with other patches running into the nostrils and also affected 

the meati of the ears. 

Most of the dilated capillaries that were present have disappeared. 

This case was the type that in the past I should have desired someone 

else to have the responsibility of treating. That, however, is not now 

the attitude of mind I feel in reference to even the most discouraging 

picture.

R a d i u m 

B7 

INDEX OF ARTICLES RELATING TO THE THERA 

PEUTIC USE OF RADIUM AND RADIOACTIVE 

SUBSTANCES WHICH APPEARED IN 1923* 

Actinomycosis—Of head and neck, report of 107 cases. (G. B. New and 

F. A. Figi) Surg. Gynec. Obst. 37:617-6^5. Nov. '2$ (illus.) ; 

also Radium, ii. N. S.. 257-271. Jan. '24. 

Adenoids—X-ray and radium treatment of infected tonsils and adenoids. 

(E. U. Wallerstein) Virginia M. Monthly, 50: 177-180. 

June "23. 

Aikins. W. H. B.—Radium in Sarcoma, J. Radiol. 4:44-46. Feb. '23. 

—Some results of radium treatment in sarcoma, Canadian M. A. J. 

U: 654^656. Sept. "23. 

—Use of radium in treatment of leucemias and Hodgkin's disease. 

Am. J. Roentgenol. 10:853-858. Nov. '23. 

Anderson, F. W. and Bowing. H. H.—Treatment by radiation of cancer 

of rectum. Am. J. Roentgenol. 10:230-239, March '2$. 

Anemia—Aplastic, professional roentgen anemia. (K. Faber) Ugesk. f. 

Laeger 85:8-10. Jan. 4 '2^; ab. J. A. M. A. 80: 592, Feb. 24, '2$. 

Angle, E. J. and Owen, L. J.—Radium Therapy, Nebraska M. J. 8: 236- 

240, July '2%. 

Aris, I*.—Tremolieres, F., and Colombier, I*.—Irradiation of spleen in 

treatment of pulmonary tuberculosis. Fresse med. 31:637. July 

21, '23. 

Arthritis- Treatment, Radium emanation in arthritis, rl. \ aternahsn > 

Med. Klinik 18:1493-1495. Nov. 19. '22. 

Ayres. S.. J.—Radium in the treatment of subungual verrucae, Arch. 

Demit. & Syphilol. 5:748-749, June '22; ab. Radium, ii, N. S.. 

317, Jan. '24. 

de Backer. P.—Technic of deep radium therapy, J. de Radiol, et d' 

electrol. 7: 20-32. Jan. '23. 

Ilagg, H. J. and Bailey. H.—Effects of irradiation on fetal development. 

Am. J. Obst* & Gynec. 5:461-473; May '2^; also Radium, ii. 

N. S., 109-119. July '23. 

—and Edwards. D. J.—Lesions of corpus striatum by radium emanation 

and accompanying structural and functional changes. Am. 

J. Physiol. 65: 162-173. June '23; also Radium, ii, N. S., 308- 

316, Jan.'24. 

and Little, C. C.—Occurrence of 2 heritable types of abnormality 

among descendants of X-rayed mice. Am. J. Roentgenol. 10: 

975-989, Dec. '2^. 

Bailev, Harold and Bagg, H. J.—Effects of irradiation on fetal development. 

Am. J. Obst. &"Gynec. 5:461-473. M*>' '23; also Radium, 

ii. N. S.. 109-119. July '21- 

—and Ilealv. \V. P.—Follow-up results of 908 cases of uterine cancer 

treated by radium. Am. J. Obst. & Gynec. 6: 402-406, Oct. '23; 

also Radium, ii. N. S., 277-284. Jan. '24. 

•Thislist has been prepared using as the main basis Hie titles given In the 

Quarterly Cumulative Index to Current Medical Literature, vol. 8 1923. published 

bv the American Medical Association. Most of the articles will be rouund listed 

under the name of the author or authors, and under the **'bJect. all in alphabetica 

order. Only those articles on the x-ray have been included which refer to general 

effects of x-rays on tissues, etc.. clinical papers not being listed— Editors


Barker, W. C—Report of Committee on Radiography. Radiotherapy and 

Apparatus; problem of deep roentgen therapy. Am. J. Elect roth. 

& Radiol. 40: 377-382, Dec. '22. 

Baumgartner, H.—Radium in treatment of lupus of nasal mucosa. 

Schweiz. mcd. Wchnschr. 53:775-777. Aug. 16. '23. 

Baylor, J. W. and Crowe, S. J.—Benign and malignant growths of nasopharynx 

and their treatment with radium. Arch. Surg. 6:429- 

488, March "23. 

Beers. N. T.—Radium applicator for small lesions. Am. J. Roentgenol. 

10:643-645, Aug. '23; ab. Radium. Jan. '24. 

Buettner, O.—Radium treatment of uterine cancer. Schweiz. med. 

Wchnschr. 53:105-108, Feb. 1, '23. 

Bigger. I .A., Jr.—Radium treatment of chronic myelogenous leukemia, 

Virginia M. Monthly, 50:543-547, Nov. '23. 

Bissell, F. S.—Concerning modern radiation therapy and its indications 

in treatment of certain benign and malignant conditions, Minnesota 

Med. 6:646-652, Nov. '23. 

Blacker, G.—Treatment of menorrhagia by radium. Lancet 1:421-424, 

March 3. '23. also in Arch. Radiol. & Electroth. 28:47-55. 

July '23. 

Bladder—Cancer, a new method of applying radium through cystoscope, 

(L. Buerger) J. Urology. 9:227-247. March '23 (illus.). 

Cancer oi urinary bladder cured by radium (C, Burnam & G. 

Walker) J. A. M. A.. 80: 1669-1670, June 9. '23 (illus.). 

—Carcinoma of bladder, treated by radium needles inserted into tumor 

mass through vaginal wall (R. H. Herbst) S. Clinics N. America 

3: 1077-1081. Aug. '23 (illus.). 

— Mcsothorium in treatment of bladder cancer. (F. Legueu. F. Marsan 

& P. Flandrin) J. d'urol. 16:81-84. Aug. '23. 

— Report of cases of malignant growths of bladder treated by resection 

and radium. (H. G. Rugbee) J. Urologv 10:159-171. Aug. 

•23 (illus.). 

—Results obtained by various methods in treatment of tumors of bladder. 

(H. H. Young & W. W. Scott) New York M. J. 118:262- 

268, Sept. 5, '23 (illus.). 

—Treatment of cancer of bladder by radium implantation (G. G. 

Smith) J. Urology 9:217-226. March '23. 

—Treatment of carcinoma of bladder, (W. Neill, Jr.) Southern M. J. 

16:292-297. April '23. 

—Hemorrhage, radium treatment of hemorrhage, M. A. Bioglio) 

Ri forma med. 39:800-801. Aug. 20, '23. 

—Radium applied through a cystoscope. (L. Buerger) J. d'urol. 

14:409-418, Nov. '22 (illus.); also in J. Urologv, 9:227-247. 

March '23. 

—Tumor, method for introduction of radium needles into tumors of 

bladder, (J. II. Cunningham) Boston M. & S. T. 188:816-818. 

May 24. '23 (illus.). 

—Radiothcrapv in bladder tumors. (C. Goosmann') Am. I. Roentgenol 

10:804-806, Oct. '23 (illus.). 

Blood, coagulation—Action of roentgen rays on coagulation of blood, 

(Pagniez. Ravina & Solomon) J. de radiol. et d'electrol. 7: 153- 

157, April '23. 

Bonta. M. B.—Radium in treatment of leukemia. Ann. Clin. Med. 1 ; 155- 

156, Nov. '22.


Bower, J. O. and Clark, J. II.—Resistance of thyroid gland to action o 

radium rays, results of experimental implantation of radium 

needles in thyroid of dogs, Am. J. Roentgenol. 10:632-643, 

Aug. '23. 

—Action of buried radium on diseased thyroids in man. Am. J. Roentgenol. 

10:875-880, Nov. '23. 

Bowing. H. H.- Radium and roentgen-ray treatment of chronic lymphatic 

and myelocytic leukemia, M. Clinics N. America 7:233- 

239. July '23. 

—And Anderson, F. W.—Treatment by radiation of cancer of rectum, 

Am. J. Roentgenol. 10:230-239. March '23. 

Breast—Cancer. 

— Biological considerations in radiotherapv. (M. J. Sittenfield), New- 

York M. J. 118:487-490. Oct. 17.''23. 

—Carcinoma of breast, its combined treatment, surgerv, X-rav and 

radium. (W. J. Cassidv) J. Michigan M. Soc. 22:8^-85. 

Feb. '23. 

—Radium in carcinoma of breast, necessarv preoperative routine, (G. 

S. Willis) New York M. J. 117:453-457. April 18. '23. (illus.). 

—Results and technique in treatment of carcinoma of breast by radiation, 

(B. J. Lee) Am. J. Roentgenol. 10:62-67, Jan- "23- 

—Treatment of recurrent inoperable carcinoma of breast. (Lee. B. J. 1 

J. A. M. A. 89: 1574-1576. Nov. 4, '22; ab. Radium, ii. N. S.. 

168. July '23. 

Brooks, C. D. and Clinton, W. R.—Radium treatment in cancer of cervix. 

J. Michigan M. Soc. 22:80-83. Feb. '23. 

Bryant. F.—Report of 146 case sof skin affections treated with radium. 

Boston M. & S. [. i88:So5-8

70 Radium 

inoculated into X-rayed area. (W. Nakahara) J. Exper. Med. 

38:309-314. Sept. '23 (illus.). 

—Progress and results in cancer control, (Hoffman, F. L.) Boston 

M. & S. J. 188: 221-225, F^. '22, '2$: also in Radium, ii, N. S.. 

33-3&- April '23. 

—Radiotherapy, combination of X-ray and radium therapy in treatment 

of superficial malignancies of face. (S. D. Neely) J. Oklahoma 

M. A. 16:212-214, July '23. 

—Effect of X-rays and radium rays in malignancy, (H. Swanberg) 

Illinois M. J. 43: 205-208, March '23. 

—Irridation of cancer, (E. Opitz) Med. Klinik 19:1215-1216, Sept. 

9. '23; ab. J. A. M. A. 81 : 1993, Dec. 8, '23. 

—Limitations in radiotherapy of cancer. (F. C. Wood) New York 

State J. Med. 23:446-449. Nov. '23. 

—Malignant disease and its treatment by X-rays, radium and electrocoagulation, 

(G. E. Pfahler) Northwest Med. 22:432-436, Dec. 

'23 (illus.). 

—Present fieldfor use of X-rays and radium in treatment of malignant 

neoplasms. (Stone, W. S.) Am. J. Roenigeno'. 9: 502-507, 

Aug. '22; ab. Radium, ii, N. S.. 153-159; July '23. 

—A British medical association lecture on the problem of radium 

therapy of cancer, (Burrows, A.) Brit. M. J. 33-34. July 8, 22; 

ab. Radium, ii. N. S.. 172-173, July '23. 

—Radium: its uses in treatment of cancer. (Hanford. C. W.) Cincinnati 

J. Med. 4:391-396, Oct. '23; also in Radium, ii, N. S., 

297-302. Jan. '24. 

—Conclusions after six years' use of radium, (Newell. E. D.) Southern 

M. J. 16:706-708, Sept. '23; also in Radium, ii, N. S.. 302- 

305, Jan. '24. 

—Principles of radiotherapy of carcinomata especially of uterine and 

mammary carcinomata. (E. Opitz) Am. J. Roentgenol. 10:312- 

319, April "23. 

—Radium therapy in cancer at Institute of Radium. Paris, (M. W. 

Thewlis) Rhode Island M. J.. 6:39-42. March '23. 

—Indications for radium treatment, summary of results, (L. A. Pomeroy) 

Ohio State M. J. 19:324-327. May '23 (illus.). 

—Problem of malignant disease, with special reference to radium 

therapy, (H. M. Moran) M. J. Australia 1:632-634, June 9. '23. 

—Radium and thorium in treatment of cancer. (Kupferberg) Munchen. 

med. Wchnschr. 70:6-7, Jan. 5. '23 (chart). 

—Radium therapy of cancers. (S. Laborde) J. de radio), et d'electrol. 

6:45'"453- Oct. '22. 

• Radium treatment of cancer. (J. Markl) Cas. lek. cesk. 62: 1049- 

1054. Oct. 6, '23. 

—Radium in treatment of malignant tumors of nose and throat, (J. R. 

Ranson) Laryngoscope 33:883-888. Nov. '23 (illus.). 

•—-Radium treatment of new growths without direct application of 

radium (J. C. Vaughan). Indian M. Gaz. 58:467-470. Oct. '23. 

—Treatment: see also Cancer, radiotherapy, radium therapy, roentgenotherapy. 

—Problem of radium and surgerv in treatment of cancer, (A. Strauss) 

Ohio State M. J. 10:85-89. Feb. "23 (illus.). 

—Recent cancer therapy. (F. C. Wood) Canad. M. A. J. 13:151-159, 

March '23.


—Treatment of malignant disease by means of the new higher voltage 

shorter wave length roentgen rays, radium and eiectrothermic 

coagulation, (J. T. Stevens) J. M. Soc. New Jersey 20:415- 

422, Dec. '23. 

—Immunity. im|K>rtant points from radium therapist's standpoint regarding 

cancer immunity. (C. Chase) Am. J. Roentgenol. 10: 

167-168, Feb. '23. 

Cannon. D.—Application of radium to gynecology as practiced by Vienna 

school. Irish J. M. Sc. p. 20-27. March '23. 

Canti. R. G. and Donaldson, M.—Carcinoma of cervix treated with 

radium, Brit. M. J. 2: 12-16. July 7. '23. 

Cappelli. L.—New system for radium applications. Policlinico (sez. 

prat.) 30:242-243. Feb. 19, '23, 

Caspari. W.- Theories as to aciiim of rays. Deutsche med, Wchnschr. 

49:269-271, March 2. '23. 

Cassidy. W. J.—Carcinoma of breast, its combined treatment, surgery. 

X-ray and radium, J. Michigan M. Soc. 22:83-85. Feb. '23. 

Castration—Radium castration and dosage. (P. W Siegel) Deutsche 

med. Wchnschr. 49: 47-49, Jan. 12, '23. 

Chase, C—History chart for radium therapy. Am. J. Roentgenol. 10: 

163-166, Feb. '23. 

—Two important points from radium therapist's standpoint regarding 

cancer immunity, Am. J. Roentgenol. 10: 167-168. Feb. '23- 

Chemical Elements—Report of international committee on chemical elements, 

1923. J. Amer. Chem. Soc. 45:867-874. April '23; also 

in Radium, ii, N. S., 210-217. Oct. '23. 

Chevallier and Cluzet—Inhalation of thorium emanations, Paris med. 

13:105-108, Feb. 3. '23. 

Clark, J. H. and Bower, J. O., Resistance of thyroid gland to action of 

radium rays, results of experimental implantation of radium 

needles in thyroid of dogs. Am. J. Roentgenol. 10:632-643. 

Aug. '23. 

•Action of buried radium on diseased thyroids in man. Am. J. Roentgenol. 

10:875-880. Nov. '23. 

Clark. W. L.—Role of radium needles in treatment of neoplastic diseases, 

Am. J. Roentgenol. 10:204-208. March '23. 

Cleland, F. A. and Low, D. M.—Uterine hemorrhage. Canad. M. A. J., 

13:790-794, Nov. "23. 

Clinton. W. R. and Brooks. C. D.—Radium treatment in cancer of cervix. 

J. Michigan M. Soc. 22:80-83. Feb. '23. 

Cluzet and Chevallier Inhalation of thorium emanations, Paris mi-d. 

13: 105-108, Feb. 3. '23. 

Coliez. R— Physical bases for irradiation of uterine cancer by combined 

radiotherapy. J. de radiol. et d'electrol. 7:201-216. May 

'23- 

Conjunctivitis, vernal—Spring conjunctivitis with giant elevations cured 

by radium. (M. Marin Amat) Siglo med. 71:234-236, March 

10, '23. 

Cooke. W. L.. Review of 6 months' experience with radium, J. M. A. 

Georgia, 12:54-56. Feb. '23. 

Cordes. F. C. and Franklin. W. S.—Lupus vulgaris with ocular extension. 

Am. J. Ophth. 6:573-578. July '23. 

Corscaden, J. A.—Limitations of radiotherapy in management of fibro-


myoma of uterus, Am. J. Obst. & Gynec. 6:42-50. July 23'; 

also Radium, ii, N. S., 218-225, Oct. '23. 

Crowe, S. J. and Baylor. J. W.—Benign and malignant growths of nasopharvnx 

and their treatment with radium, Arch. Surg. 6:429- 

48S, 'March "23. 

Culver, G. D.—Series of angiomas in babies, Arch. Dermat. & Syph. 

8:769-775. Dec. '23. 

Cunningham. J. H.—Method for introduction ot radium needles into 

tumors of bladder. Boston M. & S. J.. 188:816-818, May 

24, '23. 

Curtis, A. H.—Problems concerning infections of cervix, body of uterus 

and fallopian tubes. J. A. M. A. 80: 161-162. Jan. 20. '23. 

- Radium therapy in gynecology, Wisconsin M. J. -'': -j'^-'.Q1'. 

April '23. 

—Pathology and treatment of chronic Icucorrhoea. Surg. Gynec. Obst. 

37:657-660. Nov. '23; ah. Radium. Jan. '24. 

Daels. F.—Radiation of true pelvis with help of drainage tubes, Arch. 

Radiol. & Electroth. 27: 257-268, Feb. '23. 

Daland. E. M.—Radium treatment of keloids, Surg. Gynec. Obst. 36:63- 

68. Jan. '23; also Radium, ii. N. S-. 17-24. April '23. 

Dean. A. L., Jr.—Results of skin tests made to determine an objective 

dose for radium radiations, Am. J. Roentgenol. 10:654-661. 

Aug. '23. 

Degrais. P.—Beta rays of radium, Presse med. 31: 145-146. Feb. 14. '23. 

Dennis. W. A—L'se'of radium in benign hypertrophy of prostate, Minnesota 

Med. 6:9-13. Jan. '23. 

Dessauer. F.—Cause of action of X-rays and gamma rays of radium 

upon living cells, J. Radiol. 4: 411-415, Dec. '23. 

Diathermy—Roentgen-ray epithelioma cured by diathermy, (H. Bordier) 

Presse med. 30: 1083-1084, Dec. 16. '22 (illus.) ; ab. J. A. M. A. 

So: 588. Feb. 24. '23. 

— Roentgen-ray epithelioma cured by diathermy. (H. Bordier) Paris 

Med. 12: 469-471, Nov. 25. '22 (illus.); ab. J. A. M. A. 80:283. 

Jan. 27. '23. 

Donaldson. M. and Canti, R. G.—Carcinoma of cervix treated wilh 

radium. Brit. M. J.. 2: 12-16. July 7, '23. 

Edwards, D. J. and Bagg, H. J. Lesions of corpus striatum by radium 

emanation and accompanying structural and functional changes. 

Am. J. Physiol. 65: 162-173, June '23; also Radium, ii, N. S-, 

308-316. Jan. '24. 

Enzymes- -Effect of radium and X-rays on enzyme action, (S. C. Roth 

& J. J. Morton) Am. J. Roentgenol. 10:407-408, May '23. 

—Effect of radiations from radium emanation on solutions of trypsin. 

(R. C. Hussey and W. R. Thompson) J. General Physiol. 5: 

647-659. May '23 (charts). 

Esguerra. A.. Monod. O. and Richard. G.—Preparation of forms for 

radium treatment of head and upper part of neck. J. de radiol. 

et. d'electrol. 7:49-60, Feb. '23. 

Esophagus, cancer—Present status of radium in laryngeal and esophageal 

cancer in United States, (H. H. Forbes) J. Larvngol. & Otol. 

38:1-8, Jan. '23. 

—Cancer of oesophagus, report of case treated with radium and X- 

ray: autopsy: remarks. (M. F Porter) J. Indiana M. A.. 16: 

281-282. Sept. '23.


—Carcinoma of oesophagus. (P. P. Vinson) Am. J. M. Sc. 166:402- 

414. Sept. '23 (illus.). 

—Further observations on radium treatment of cancer of oesophagus 

with review of 44 cases so treated. (R. W. Mills & J. B. Kimbrough) 

Am. J. Roentgenol. 10: 148-161, Feb. '23 (illus.). 

—Radium treatment of cancer of oesophagus, (J. Guisez) Presse med. 

31:193-195. Feb. 28. '23 (illus.); ab. J. A. M. A. 80:1491, 

Slay 19, '23. 

— Radium treatment of cancer of oesophagus. (Kurtzahn) Arch, f 

klin. Chir. 121:725-753. '22 (illus.). 

—Technique of radiation therapy of oesophageal carcinoma (J. T. 

Case) Am. J. Roentgenol. 10:859-866. Nov. '23 (illus.). 

Radium needle- for esophagoscope. 1 S. Yankauer) Arch. Surg. 

6:288 (pt. 2), Jan. '23 (illus.). 

Ethmoid Sinus, cancer—Basal cell carcinoma of orbit and ethmoid: 

operation; radium application. (J. Green. Jr.) Arch. Ophth. 

52: 75-79. Jan- '23- 

Eye, effect of radiant energy on—Physiological effects of radiant energv. 

especially upon human eye, (C. Sheard) New York State 

J. Med. 23:292-300. July '23 (illus.). 

Orbital changes produced l>v radium in cancer of upper jaw, (A. 

Knapp) J. A. M. A. 81: 1849-1851, Dec. 1. '23. 

Eymer. H.—Radium treatment of benign gynecologic bleeding, Klin. 

Wchnschr. -': 1761-1764, Sept. 1;. '23. 

Failla, G.—Ionization measurements. Am. J. Roentgenol. .10:48-56, 

Jan. '23. 

—and Quimby. E. H.—Economics of dosimetry in radiotherapy, Am. 

J. Roentgenol. 10:944-967. Dec. '23. 

Fernau. A.—Standard units for radio-active substances, Wien. klin. 

Wchnschr. 36:355"35- May 17. '-,3- 

Fetus—Effects of irradiation on fetal development, (H. Bailey & H. J. 

Bagg). Am. J. Obst. & Gynec. 5:461-473. Ma>' '23! a,so 

Figi. F 

Radium, ii. N. S.. 109-119, July '23. 

A. and New, G. B.—Actinomycosis of head and neck. Surg. 

Gynec. Obst. 37:617-625, Nov. '23; also Radium, ii. N. S., 

257-271- Jan. '24. . 

File, W. P.—Radium as an adjunct to surgery in uterine conditions. J. 

Oklahoma M. A. 16: 182-184. June '23. 

Flatau, W. S.—Results of radiotherapy in cancer of uterus. Zentralbl. 

f. Gynak. 47: 737"743- May 12, '23. 

Forbes. H. H.—Radium in laryngeal and oesophageal cancer. J. Laryngol. 

& Otol. 38: 1-8, Jan. '23. 

Forsdike. S.—Treatment of severe and persistent uterine hemorrhage 

by radium. Proc. Roy. Soc. Med. (Sect. Obst. & Gynec.) 16:69- 

So. June '23; also in Lancet 1: i3C9-'3"- Junc 3°- '23- 

—Treatment of severe uterine hemorrhage by radium. Brit. M. J. 

2:409-411, Sept. 8. '23. 

Franklin, W. S. and Cordes. F. C—Lupus vulgaris with ocular extension. 

Am. J. Ophth. 6: 573*578. July '23. 

v Franque, O.—Treatment of uterine cancer. Munchen. med. Wchnschr. 

70:676-678. Mav 25, '23; ab. Radium, Oct. '23. 

Gagev, J.—Radium for a hospital service. J. de radiol. et d electrol. 

7: 182-184. April '23.

74 RADIUM 

Gaslro-intestinal Tract, diseases—Some effects of exposure to radium 

upon alimentary canal. (J. C. Mottram) Arch. Radiol. & Electroth. 

28:28-31. June '23 (illus.). 

Gay lord, H. R. and Stenstroem, K. W.—Comparative measurements 

between radium and X-rays concerning energy absorbed at 

depth. Am. J. Roentgenol. 10:56-62, Jan. '23. 

Gibson, A. L., Harvard's hospital for radium therapy. Mod. Hosp. 20: 

526-529, June '23. 

Glasser, O.—Newer investigations of gamma-rav dosage of radium, J. 

Radiol. 4: 386-388, Nov. '23. 

Goin, Lowell S.—Treatment of uterine bleeding in young women. 

Radium, ii, N. S., 305-307, Jan. '24. 

Goiter—X-ray and radium treatment of goiter. (G. W. Grier) Atlantic 

M. J., 26:516-523. May '23; ab. Radium, Oct. '23. 

Toxic thvroid with pathological findings after radium treatment, 

(R. E. Loucks) J. Radiol. 4:276. Aug. '23. 

Radium treatment of toxic goiter with, metabolic deductions, (R. E. 

Loucks), Am. J. Roentgenol. 10:767-776, Oct. '23. 

Goltz. H.. Cori, C. F. and Pucher. G. W.—Biological reactions of X- 

rays; effect of radiation on nitrogen and salt metabolism, Am. 

J. Roentgenol. 10:738-745, Sept. '23. 

Gonads—Irradiation of sex glands and its effect on progeny. (L. Numberger) 

Monatschr. f. Geburtsh. u. Gynak. 63:7-18, May '23. 

Gottlieb. C.—Use of isodosis curves in X-ray therapy showing inaccuracy 

of Dessauer charts. Am. J. Roentgenol. 10:896-901. 

Nov. '23. 

Graves. R. C.—Cancer of prostate relieved by radium, Boston M .& S. 

J.. 189:486. Oct. 11, '23. 

Graves. W. P.—Cancer of cervix uteri. Boston M. & S. J. 188: 1006- 

1008, June 21. '23; also in Radium, ii, N. S., 185-188, Oct. '23. 

Grier, G. W.—X-ray and radium treatment of goiter, Atlantic M. J.. 

26: 516-523, May '23; ab. Radium. Oct. '23. 

Guy, W. H. and Jacob, F. M.—Comments on radium technic, Atlantic 

M. J.. 26:453-45*>. April '23. 

—Erythema dose of radium. Tr. Sect, Dermat. & Syphilol. A. M. A. 

' p. i?i-}77< '23- 

Gynecology, radiation—Application of radium to gynecology as practiced 

by Vienna school, (D. Cannon) Irish J. M. Sc. p. 20-27. 

March '23. 

—Radiation of true pelvis with help of drainage tubes. (F. Daels) 

Arch. Radiol. & Electroth. 27:257-268, Feb. '23 (illus.). 

—Radiotherapy in gynecology. (Recasens) Presse med. 31:705-708, 

Aug. 15. '23; ab. J. A. M. A. 81: 1476. Oct. '27, '23. 

—Radium as substitute for hysterectomy; series of operated cases 

reviewed with this question in mind, (C. W. Woodall) Am. J. 

Obst. & Gynec. 6:734-736, Dec. '23. 

—Results of radium in gynecology, (A. F. Maxwell) California State 

Jour. Med. 21: 155-158. April '23; also Radium, ii, N. S.. 128- 

i33- July '23- 

—Role of radium in gynecology, (W. W. McCuislionl Texas State 

J. Med. 19:397-398, Nov. '23. 

—Special features of radium therapy in gynecology, (A. H. Curtis^ 

Wisconsin M. J. 21 :


—Uses of radium in diseases of women, (G. S. Cameron) Canad. 

M. A. J. 13:872-876, Dec. '23. 

—Uses of radium in malignant and non-malignant conditions; with 

particular reference to fieldof gynecology, (F. L. Shrover) 

Ohio State M. J. 19:498-503, July '23. 

Hall. U. D.—Use of radium in treatment of cancer of cervix. J. M. A. 

Georgia 12:45-51, Feb. '23. 

Hand, tumor—Epithelioma of back of hand (D. W. Montgomery & G. 

D. Culver) New York M. J. 118:674-676. Dec. 5, '23 (illus.). 

Hanford, C. W.—Radium: its uses in treatment of cancer. Cincinnati J. 

Med. 4:39*-396. Oct. "23; also in Radium, ii. N. S., 297-302. 

Jan. '24. 

Haret and others—Nomenclature of radiotherapy, (committee report) 

J. de radiol, et delectrol. 7: 185-186. April '23. 

Heaiy, W. P. and Bailey, H.—Follow-up results of 908 cases of uterine 

cancer treated by radium. Am. J. Obst. & Gynec. 6:402-406, 

Oct. '23; also Radium, ii, N. S.. 277-2S4. Jan. '24. 

Heiner, M.—Indications for radium treatment. Med. Klinik, 19:612-613, 

May 6, '23. 

Hemolysis—Biological reactions of X-rays; effect of X-rays on rates 

of specific hemolysis. (K. F. Cori. & G. W. Pucher) J. Immunology 

8:201-209, May '23 (chart). 

Herbst, R. H.—Papilloma of prostatic urethra, treated with radium and 

fulguration. S. Clinics N..America 3: 1071-1075. Aug. '23. 

—Carcinoma of bladder, treated by radium needles inserted into tumor 

mass through vaginal wall, S. Clinics N. America 3: 1077-1081. 

Aug. '23. 

Heredity—Occurrence of 2 heritable types of abnormality among descendants 

of X-rayed mice. (C. C. Little & H. J. Bagg) Am. 

J. Roentgenol. 10:975-989. Dec. '23 (illus.). 

Hess, V. F.—On physical principles of alpha ray therapy. J. Radiol. 

4: 78-79. March '23. 

Hirsch, H.—Roentgen ray sickness and cachexia. Deutsche med. 

Wchnschr. 48: 1646-1647. Dec. 8, '22. 

Hodgkin's Disease—And lvmphosarcoma, clinical and statistical study. 

(A. U. Desjardins & F. A. Ford) J. A. M. A. 81:925-927. 

Sept. 15. '23 (charts). 

—Use of radium in treatment of leucemias and Hodgkin's disease, 

(W. H. B. Aikins) Am. J. Roentgenol. 10:853-858. Nov. '23.. 

Hoffman, F. L.—Progress and results in cancer control, Boston M. & 

S. J., 188: 221-225. Feb. 22, '23; also Radium, ii. N. S.. 33-38. 

April '23. 

Hogler. F, and Muller. L.—Cure of trachoma by radium. Wien. klin. 

Wchnschr. 35:954"955. Dec. 7, '22. 

Holden. G. R.—Immediate effect of radium treatment upon symptoms 

of uterine cancer. J. Florida M. A. 10:3-5. July '23. 

Hubbard. J. E.—Radium in inoperable carcinoma of uterus, W. Virginia 

M. J., 17:473-478. May '23. 

Hussey. R. G. and Thompson. W. R.—Effect of radio-active radiations 

and X-rays on enzymes; effect of radialions from radium emanation 

on solutions of trypsin. J. General Physiol. 5:647-659, 

May '23. 

—Effect of radioactive radiations from radium emanation on |>epsin 

in solution, J. General Physiol. 6: 1-5. Sept. '23.

76 Radium 

- Effect of radioactive radiations and X-rays on enzymes; unit of 

measure of activity for radium emanation, J. General Physiol. 

6:7-11, Sept. "23. 

Injuries— 

—Effects of X-rays and radium on blood and general health of radiologists, 

(Pfahler, G. E.), Am. J. Roentgenol. 9:647-656. Oct. 

22; ab. Radium, ii, N. S., 159-168, July '23. 

—Treatment of primary and latent injuries of skin from radium and 

X-rays, (Schmitz, H.), Radiology 1:34-38, Sept. '23; also 

Radium, ii. N. S.. 271-277, Jan. '24. 

—Lesions of the corpus striatum bv radium emanation and accompanying 

structural and functional changes, (Edwards D. J. and Bagg, 

H. J.)( Am. J. Physiol. 65: 162-173, June '23; also Radium, 

ii, N. S., 308-316, Jan. '24. 

Intestines, effect of roentgen rays—Intestinal reaction to erythema dose, 

(C. L. Martin & F. T. Rogers) Am. J. Roentgenol. 10: 11-19. 

Jan. '23 (illus.). 

Isotopes—Report of international committee on chemical elements, 1923. 

J. Amer. Chem. Soc. 45:867-874, April '23; also in Radium, ii, 

N. S., 210-217, Oct. '23. 

Ivy, A. C. and others—Studies of effect of X-rays on glandular activity, 

J. Radiol. 4: 189-199. June '23. 

Jacob. F. M. and Guy. \V. H.—Comments on radium technic, Atlantic 

M. J. 26:453-456. April '23. 

—Erythema dose of radium, Tr. Sect. Dermal. & Syphilol.. A. M. A. 

pp. 171-177. '23- 

Jacoby, A. and others—Studies of effect of X-rays on glandular activity. 

J. Radiol. 4: 189-199, June '23. 

James. W. D. and James. A. W.—Epithelmoata- Prophylactic and curative 

measures. International J. Surg., March '23; also Radium, 

N. S., 205-210, Oct. '23. 

Jansen, H.—Copenhagen Radium Emanatorium, Ugesk. f. Lacger 85: 

759-761. Oct. 25, '23. 

Jaw, cancer—Orbital changes produced by radium in cancer of upper 

jaw. (A. Knapp) J. A. M. A. 81: 1S49-1851. Dec. 1, '23. 

Johnson. F. M. and Quick, D.—Statistics and technique in treatment of 

malignant neoplasms of larynx, Am. J. Roentgenol. 9:599-606, 

1-9, April '23. 

Judd, E. S. and New. G. B.—Carcinoma of tongue, Surg. Gynec. Obst. 

36: 163-169. Feb. '23. 

Kelly, H. A.—Radium therapy with special reference to diseases of female 

pelvis, Theraueptic Gazette 46:761-767. Nov. 15, '22; 

also in Radium, ii, N. S.. 25-32, April '23. 

—and Ward, G. E.—Radium therapy in carcinoma of rectum. Surg. 

Gynec. Obst. 37:626-634. Nov. '23; also Radium, ii, N. S.. 

285-294, Jan. '24. 

Keloid, treatment—Radium treatment of keloids, (E. M. Daland) Surg. 

Gynec. Obst. 36:63-68. Jan. '23; also Radium, ii. N. S., 17-24, 

April '23. 

Treatment of Keloids with radium. (L. R. Taussig) California 

State J. Med. 21: 520-522, Dec. '23. 

Kennedy, W. H.—Cancer of cervix. Kcntuckv M. J. 21 :i6i-i64 March 

'23-


Kimbrough. J. B. and Mills, R. W.—Radium in cancer of oesophagus, 

Am. J. Roentgenol. 10: 148-161. Feb. '23. 

King, Howard—Three years' experience with radium, J. Tennessee M. 

A. 16:292-296, Dec. '23. 

Knapp, A.—Orbital changes produced by radium in cancer of upper 

jaw, J. A. M. A. 81 : 1849-1851, Dec. 1. '23. 

Kotzareff. A. and Mollow. M.—Action of radium on uterus, Gynec. 

et Obst. 6:244-273, Oct. '22. 

Kurtzahn, H.—Radium in cancer of esophagus. Arch. f. klin. Chir. 121 : 

725-753. '22- 

Laborde. S.—Radium therapy of cancers. J. de radio], et delectrol. 6: 

45|"453- Oct. '22. 

de Laborie, B. and Lory—Technique of application of radium in low 

neoplasms of rectum, J. de radiol, et d'electrol. 7:493-496. 

Nov. *23. 

Lacassagne, A.—Histological emanation of radiosensibility of cutaneous 

and membraneous epithelial cancers. Paris med. 13:376-379. 

April 28, '23. 

Landham, J. W.—X-ray vs. radium in treatment of uterine hemorrhage. 

Southern M. J. 16: 550-554. July "23. 

I-ane, L. A.—Study of tonsil question with preliminary report of roentgen 

ray and radium therapy in pathological tonsils, Minnesota 

Med. 6:97-104, Feb. '23. 

Lange. L. and Fraenkel. M.—Action of roentgen rays on tubercle bacilli. 

Klin. Wchnschr. 2:1161-1162, June 18, '23. 

Larkin. A. J.—Radium needles in malignant growths of tongue: the time 

factor, Am. J. Roentgenol. 10:734-735, Sept. '23; ab. Radium. 

Jan. '24. 

Larynx, cancer—Present status of radium in laryngeal and oesophageal 

cancer in United States, (H. H. Forbes) J. Laryngol. & Otol. 

38:1-8. Jan. '23. 

- -Radiotherapy in carcinoma of larynx -with special references to 

radium needles through thyroid membrane. (Pfahler, G. E.) 

J. Radiol. 3:511-516, Dec. '22; also Radium, i, N. S., 284-295. 

Jan. '23. 

—Statistics and technique in treatment of malignant neoplasms of 

larynx. (Quick. D. and Johnson. F. M.) Am. J. Roentgenol. 

9:599-606. 1-9. April '23. 

Lassueur, A.—Radium in dermatology. Schweiz. med. Wchnschr. 53: 

836-842. Sept. 6. '23. 

Iîwrence. H.—Radium therapy, experimental research work in, including 

death, retardation of growth, prolongation of life, determination 

of sex. sterilization and artificial parthenogenesis reproduction 

without the male. M. J. Australia 1:463-471. April 

28. '23- 

Leddy. E. T. and Weatherwax, J. I.—Standardization of ionization 

measurements of intensity and measurements of scattered and 

secondary X-rays effective in producing an erythema, Am. J. 

Roentgenol. 10:488-497, June '23. 

Lee. B. J,—Results and technique in radiation in carcinoma of breast, 

Am. J. Roentgenol. 10:62-67. Jan. '23. 

—Treatment of recurrent ioperable carcinoma of breast. J. A. 

M. A.. 89: i574-"576. Nov. 4, *22; ab. Radium, ii, N. S-, 168, 

July '23.


Legnew, Marsan, F„ and Flandrin, P.—Mesothorium in treatment nf 

bladder cancer, J. d'urol. 16:81-84, Aug. '23. 

Leroux, R. and Roussy, G.— Radium treatment of cancer of uterine cervix, 

Rev. de chir. 60:499-508, '22. 

Leukemia, myelogenous—Radium treatment of chronic myelogenous 

leukemia, with report of 5 cases. (I. A. Bigger, Jr.) Virginia 

M. Monthly 50:543-547, Nov. '23. 

—Treatment—Radium and roentgen-ray treatment of chronic lymphatic 

and myelocytic leukemia, (H. H. Bowing) M. Clinics 

N. America 7:233-239, July '23 (illus.). 

—Radium in treatment of leucemias and Hodgkin's disease. (W. H. B. 

Aikins) Am. J. Roentgenol. 10:853-858, Nov. '23. 

-—Radium in treatment of leukemia (M. B. Bonta) Ann. Clin, Med. 

1:155-156, Nov. '22. 

Leukorrhea. etiology and treatment—Pathology and treatment of chronic 

leucorrhea. further clinical and laboratory study of this subject. 

(A. H. Curtis) Surg. Gynec. Obst. 37:657-650. Nov. '23 (illus.) ; 

ab. Radium, Jan. '24. 

—Problems concerning infections of cervix, body of uterus, and fallopian 

tubes, (A. H. Curtis) J. A. M. A. So: 161-162, Jan. 

20, '23. 

Levin. I. and Lcvine, M.—Action of buried tubes of radium emanation 

on neoplasias in plants. J. Cancer Research, 7: 163-170. April 

'22. 

Lcvine, Michael and Levin, I.—Action of buried tubes of radium emanation 

on neoplasias in plants. J. Cancer Research, 7:163-170. 

April '22. 

Lip. cancer—Cancer of lip, its treatment by radium and surgerv combined. 

(C K. Wall) J. M. A. Georgia 12:67-69. Feb. '23. 

—Radium treatment of carcinoma of lip, (L. Taussig) M. Climes N. 

America 6:1579-1586, May '23 (illus.). 

Little, A. D.—Use and abuse of radium. J. M. A. Georgia 12: 180-181, 

May '23. 

Little, C. C. and Bagg. H. J.—Occurrence of 2 heritable types of abnormality 

among descendants of X-rayed mice. Am. J. Roentgenol. 

10:975-989, Dec. '23. 

Loeb, L.—Effects of roentgen rays and radioactive substances on living 

cells and tissues, J. Cancer Research 7:229-282, Oct. '22. 

—A Report of the work carried out at Radium Institute. London, 

from January 1st. 1922. to December 31st, 1922, (Pinch A 

E. H.) Radium, ii, N. S., 39-67. 

Lorenz, E. and Rayewsky. B.—Measurements of absorption coefficient of 

water and aluminum for hard X-rays, Am. J. Roentgenol. 

10:880-896. Nov. "23. 

Loucks, R. E.—Radium therapy in ophtho-oto-larvngologv. J Michigan 

M. Soc. 22:63-64. Feb. '23. 

—Toxic thyroid with pathological findings after radium treatment 

J. Radiol. 4:276. Aug. '23. 

—Radium treatment of toxic goiter with metabolic deductions, Am T 

Roentgenol. 10:767-776, Oct. '23. 

Lupus, treatment—Radium in treatment of lupus of nasal mucosa (H 

Baumgartner) Schweiz. med. Wchnschr. 53:775-777, Aug.

R a d i u m 

7^ 

Lymph Nodes—Histologic changes in lymphatic glands following exposure 

to radium, (J. C. Mottram) Am. J. M. Sc. 165:469- 

479, April '25 (illus.). 

—Treatment of tuberculous cervical adenitis by radium. (E. S. 

Molyneux) Brit. M. J. 2:865-866. Nov. io.''23. 

McCuistion, W. W.—Role of radium in gynecology Texas State J. Med. 

>9:397-398. Nov. '23. 

McLean, S. and Ruhson, R. II.- Treatment of vascular nevi with radium. 

Am. J. Dis. Child. 25:466-469, Feb. 17, '23; also Radium, ii. 

N. S.. 225-235. Oct. '23. 

MacNeal. W. J. and Willis. G. S.—Skin cancer following exposure to 

radium. J. A. M. A. 80:466-469, Feb. 17, '23; also Radium, 

ii, N. S., 119-127. July '23. 

Mallet. L.—Combined radiotherapy of cancer of uterine cervix. Presse 

med. 31 : 289-291, March 28, '23. 

—Rational bases of radium therapv. Progres med. 38:239-242. Mav 

19. '23. 

Markl. J.—Radiopunclure of tumors, Cas. lek. cesk. 62:47^-477. May 

5- ^3. 

—Radium treatment of cancer. Cas. lek. cesk. 62: 1049-1054. Oct. 

6. '23. 

Marsan, F.. Flandrm. P., and Lcgueu. F. Mcsothorium in trealment 

of bladder cancer, J. d'urol. 16:81-84. Aug. '23. 

Matthews. H. B.—Effects of radium rays upon ovary. Am. J. Obst. & 

Gynec. 6:614-618. Nov. '23; ab. Radium, ii. N. S.. 323-326. 

Mavor, J. W.—Biological effects of X-rays. Am. J. Roenigenol. 10:968- 

974, Dec. '23. 

Maxwell, A. F.—Results of radium in gynecology. California State J. 

Med. 21:155-158, April '23; also Radium, ii. N. S.. 128-133. 

July ^23. 

—Classification and relative value of various methods employed for 

internal administration of radium emanation and radium salts, 

(Cameron, W. H. and Viol, C. H.) Radium, ii, N. S., 136-148, 

July '23. 

Menorrhagia, treatment—Treatment of menorrhagia by radium. (C. 

Blacker) Lancet 1 :421-424, March 3. '23. 

Medical Use of Radium— 

—Treatment of menorrhagia bv radium. (G. Blacker) Arch. Radiol. 

& Elect roth. 28:47-55. Jub' '23- 

Mills, R. W. and Kimbrough, J. B.—Radium treatment of cancer of 

esophagus. Am. J. Roentgenol. 10: 148-161, Feb. '23. 

Mineral Waters—Radioactivity in Manzanares' mineral water. (J. M. 

de Castillo) Siglo med. 70: 509-510. Nov. 25. '23; cont. 70: 586- 

587, Dec. 16. '22 (illus.); cont. 71:28-30. Jan. 13. '23; cont. 

71: 57"58. Jan. 20, '23; cont. 71: 147-148. Feb. 17, '23. 

Mollow, M. and Kotzareff. A.—Action of radium on uterus. Gynec. et 

Obst. 6: 244-273, Oct. '22. 

Molyneux. E. S.—Treatment of tuberculous cervical adenitis bv radium. 

Brit. M. J.. 2:865-866, Nov. 10, '23. 

—Radium as curative agent for tuberculous glands. Lancet, pp. 804- 

805, Oct. 14, '22; ab. Radium, ii, N. S.. 253-256, Oct. '23. 

Monod, O.. Richard G. and Esguerra, A.—Preparation of forms for 

radium treatment of head and upper part of neck, J. de radiol. 

et d'electrol. 7:49-60. Feb. '23.


Moran, H. M.—Malignant disease, with special reference to radium 

therapy, M. J.. Australia 1:632-634, June 9, '23, 

Morrow, H. and Taussig. L.—Statistics and technique in treatment of 

malignant disease of skin by radiation. Am. J. Roentgenol. 10: 

212-218, March '23. 

—Radium therapy of vascular ncvi. Am. J. Roentgenol. 10:867-871. 

Nov. "23. 

Morton, J. J. and Roth. S. C.—Immediate effect of radium and X-rays 

on enzyme action. Am. J. Roentgenol. 10:407-408, May '23. 

Mottram. J. C.—Effects of exposure to radium on blood platelets. Proc. 

Roy. Soc. Med. (Sect. Pathol.) 16:9-13. Jan. '23. 

—Histological changes in lymphatic glands following exposure to 

radium. Am. J. M. Sc. 105:469-479, April 23. 

—Effects of exposure to radium u]>on alimentary canal. Arch. Radiol. 

& Electroth. 28: 2S-31. June '23. 

Mouth, cancer—Carcinoma of floorof mouth. (D. Quick 1 Am. J. Roentgenol. 

10:461-470, June '23 (illus.). 

— Radio-therapeutic technic of face and mouth, (W. A. Weed i Southern 

M. J. 16: 102-104. Feb. '23. 

Mtiller. L. and Hdgler, F.—Cure of trachoma by radium. Wien. klin. 

Wchnschr. 35 : 954-955- Dec. 7. '22. 

Munoz del Castillo, J.—Radioactivity of Manzanares'waters. Siglo Med. 

70:509-510. Nov. 25. '22; cont. 70:586-587. Dec. 16. '22: cont. 

71:28-30. Jan. 13. '23; cont. 71 : 57-58. Jan. 20. '23: cont. 71: 

147148. Feb. 17. '23. 

Xakahara. W.—X-ray effects: histological study of fate of cancer grafts 

inoculated into X-rayed area, J. Exper. Med. 38:309-314. 

Sept. '23. 

Nasopharynx, tumor—Benign and malignant growths of nasopharynx 

and their treatment with radium, (S. J. Crowe & J. W. Baylor) 

Arch. Surg. 6:429-488. March '23 (illus.>. 

Xeely. S. D.—Combination of X-ray and radium therapv in treatment 

of superficial malignancies of face, J. Oklahoma M. A. 16:212- 

214, July '23, 

Xeill, W. Jr.—Diagnosis and treatment of carcinoma of cervix. W. Virginia 

M. J. 17:258-263. Jan. '23. 

—Treatment of carcinoma of bladder. Southern XI. I. 16-292-297 

April '23. 

—Instrument for implantation of bare radium emanation tubes into 

tissues. Am. J. Roentgenol. 10:871. Nov. 23. 

Nevus—See also Tumor, angioma—Radium therapv of vascular nevi, 

(H. Morrow & L. R. Taussig) Am. J. Roentgenol. 10:867-871 

Nov. '23. 

—The treatment of vascular nevi with radium. (Rufison. R. H. and 

McLean. Stafford^ Am. J. Dis. Child. 25:359-370, Mav '23; 

also Radium, ii. X. S., 225-235. Oct. '23. 

N ew G. B. and Figi. F. A.—Actinomycosis of head and neck. Surg. 

Gynec. Obst. 37:617-625. Nov. '23: also Radium, ii, N. S„ 2>?- 

271. Jan. "24. 

—and Judd. E. S.—Carcinoma of tongue, Surg. Gvnec Obst *6- 

163-169, Feb. '23. ' •* ' 

Newell. F D—Conclusions after six years" use of radium. Southern 

M. J. 16:706-708, Sept. 23; also Radium, ii. X S 102-30= 

Jan. '24. ' ° •* J'

R a d i u m 

si 

Nicolich—Carcinoma of prostate cured by radium, Policlinico (Sez. 

prat.) 30:494-495. April 16, '23. 

'Nogier, T.—Treatment of uterine fibromyomas by radium, J. de radiol. 

et d'electrol. 6:477-479, Oct. '22. 

—Necessity for permanent control of radium tubes and needles. J. de 

radiol. et d'electrol. 6:479. Oct. '22. 

Nose, tumor—Radium in treatment of malignant tumors of nose and 

throat. (J. R. Ranson) Laryngoscope. 33:883-888, Nov. '23 

(illus.). 

Nuzum. F. R. and Ullmann, H. J.—Bacteriology of irradiated tonsils. 

Am. J. Roentgenol. 10:396-398, May '23. 

Opitz, E.—Dosage and curative action of roentgen and radium rays. 

Arch. f. Gyniik. 117:223-230. Dec. '22. 

—Dosage of roentgen and radium rays. Klin. Wchnschr. 2:243-24". 

Feb. 5, '23. 

—Principles of radiotherapy of carcinoma, especially of uterine and 

mammary carcinomata, Am. J. Roentgenol. 10:312-319. April 

—Biologic processes in irradiated cancer. Monatschr. f. Geburtsh. u. 

Gynak. 61:232-247, Jan. '23. 

—Causes of favorable action of rays in cancer of uterus. Munchen 

med. Wochenschr. 70:1299-1300. Oct. 19, '23. 

Orndoff. B. H. and others—Studies of effect of X-rays on glandular 

activity, J. Radiol. 4: 189-199. June '23. 

Otolaryngology—Indications for radium therapy in ophtho-oto-laryngology. 

(R. E. Loucks) J. Michigan M. Soc. 22:63-64, Feb. '23. 

Ovary 

Effects i" radium upon rabbit ovaries, ill. A. VVeis) Surg 

Gynyec. Obst. 36:373-382, March '23 (illus.). 

Effects of radium rays upon ovary. (Matthews. H. B.) Am. J. Obst. 

& Gynec. 6:614-618, Nov. '23; ab. Radium, ii. N. S.. 323-326. 

Owen, L. J. andAngle, E. J.—Radium therapy. Nebraska M. J.. 8:236- 

240. July '23. 

Pares—Radium therapv of epitheliomas of skin. J. de radiol et delectrol 

6:487-488. Oct. "22. 

Perrola. A.—Radium treatment of inoperable cancer of uterine cervix. 

Rev. franc, de gynec, et d'obstet. 18:321-329. May 25. '23; ab. 

Radium. Jan. '24. 

Pfahler, G. E.—Malignant disease and its ireatment by X-rays, radium 

and electrocoagulation, Northwest Med. 22:432-436, Dec. '23. 

—Radiotherapy in carcinoma of larynx—with special reference to 

radium needles through thyroid membrane. J. Radiol. 3 : 511-516. 

Dec. '22; also Radium, i. N. S., 284-295. Jan. '23. 

—Effects of X-rays and radium on blood and general health of radiologists. 

Am. J. Roentgenol. 9:647-656, Oct. '22; ab. Radium. 

ii, N. S.. 159-168, July '23. 

Philips. H. B.—Rontgen rays and radium therapy of hypertrophied 

prostates. New York M. J. 118:272-275. Sept. 5, '23. 

Pinch. A. E. H.—A Report of the work carried out at Radium Institute. 

London, from January 1st. 1922, to December 31st. 1922; also 

Radium, ii, N. S-. April '23. 39-67. 

Pomeroy. L. A.—New radium chart. Am. J. Roentgenol. 10:229. March 

'23- 

—Indications for radium treatment, summary of results. Ohio State 

M. J. 19:324-327. May '23.


Polak. J. O.—Notes on the clinical value of radium in management of 

uterine hemorrhage. Med. Rec. 101:493*494. March 25. 22; 

also Radium, ii, N. S., i33-'36. Jul>* '23- 

Porter, M. F-—Cancer of esophagus, report of case treated with radium 

and X-ray; autopsy: remarks. J. Indiana M. A. 16:281-282. 

Sept. '23. 

Potassium—Biological action of potassium and its radio-activity, (H. 

Zwaardemaker) J. Pharm. & Exper. Therap. 21:151-159. 

March '23 (charts). 

Prostate, cancer—Carcinoma of prostate cured by radium. (G. Nicolich) 

Policlinico. (sez. prat.) 30: 494-495- April 16, '23. 

—Case of cancer of prostate relieved bv radium. (R. Graves) Boston 

M. & S.J. 189:486, Oct. ii, '23. 

Roentgen rav and radium therapv of hvpertrophied prostates, (H. 

B. Philips) New York M. J. 118:272-275. Sept. 5, '23. 

—Use of radium in treatment of benign hypertrophy of prostate, (W. 

A. Dennis) Minnesota Med. 6:9-13. Jan. '23. 

Quick. D.—Carcinoma of Moor of mouth. Am. J. Roentgenol. 10:461- 

470, June '23. 

—Relative value of unfiltcred radium emanation in deep therapy, J. 

Radiol. 4:318-322. Sept. '23. 

—and Johnson. F. M.—Statistics and technique in treatment of malignant 

neoplasms of larynx. Am. I. Roentgenol. 9:599-606. 1-9. 

April '23. 

Treatment of malignant neoplasms of tonsils. J. Radiol. 31173"' 7^- 

May '22; also Radium, ii. N. S., 97-109. July '23. 

Qnigley. D. T.—Treatment of superficial cancer. Am. J. Roentgenol. 

10: 161-162, Feb. '23. 

Quimbv, E. H.—Simple nomogram for determination of radium skin 

doses. Am. J. Roentgenol. 10:574-578, July '23. 

—and Failla. G.—Economics of dosimetry in radiotherapy. Am. J. 

Roentgenol. 10:944-967. Dec. '23. 

Radiation—Effects of roentgen rays and radioactive substances on living 

cells, and tissues, (L. Loeb) J. Cancer Research 7:229-282, 

Oct. '22. 

Radioactive substances—Report of international committee on chemical 

elements. 1923, J. Amer. Chem. Soc. 45:867-874. April "23; 

also Radium, ii. N. S., 210-217, Oct. '23. 

Radioactivity—Of Manzanares* waters. (J. Muiioz. del Castillo) Siglo 

med. 70: 509-510, Nov. 25, '22; cont. 70: 586-587, Dec. 16, '22; 

cont. 71: 28-30, Jan. 13. '23; cont. 71: 57-58. Jan. 20, '23; cont. 

71 : 147-N8. Feb. 17, '23. 

—Radioactive substances in soluble form, (S. Lomholt) Hospitalstid. 

65:865-875. Dec. 20. '22 (charts); cont. 65:897-912. Dec. 27, 

'22; ab. J. A. M. A. 80: 51S. Feb. 17, '23. 

—Radio-activity of medicine, (S. Russ) Lancet 2: 1314-1317. Dec. 

15. '23-. 

—Standard units for radio-active substances. (A. Fernau) Wien klin. 

Wchnschr. 36:355-356. May 17. '23. 

Radiotherapy—Certain biological principles of radiation therapv, (S. 

Withers) Am. J. Roentgenol. 10:776-781. Oct. '23. 

—Present status of radio-therapv, (H. W. Van Allen) Boston M. & 

S. J. 189:5-8. July 5. '23.


Radium— 

—Large deposits of radium ore discovered in Africa. Press notice 

from Geological Survey, Nov. 17, '22; also Radium, i. 308-309. 

Jan. '23. 

—Radium from Ferghana in Russian Turkestan. Radium, ii. N. S., 

241-243. Oct. '23. 

—Acute constitutional symptoms due to radiations, (H. Rolleston) 

Brit. M. J. 1: 1-4, Jan. 6, '23. 

—Apparatus. Radium needle for esophagoscope, (S. Yaukauer) Arch. 

Surg. 6:288. (pt. 2), Jan. '23 (illus.). 

—Efficient method of applying radium within mouth, (E. W. Ruggles) 

J. A. M. A. So: 1374-1375. May 12. '23 (illus.). 

—Forceps for cleaning radium needles and tubes. (J. S- Ullman) Am. 

J. Roentgenol. 10:989. Dec. '23 (illus.). 

— Instrument for implantation of bare radium emanation tubes into 

tissues. (W. Neill, Jr.) Am. I. Roentgenol. 10:871. Nov. '23 

(illus.). 

—Measures advised for protection of radiologists. Seniana med. 1:567- 

570. March 22, '23. 

— New device for retubing radium emanation, (W. Stenstroem) Am. 

J. Roentgenol. 10:311-312. April '23 (illus.). 

—New holder for radium needles, (J. R. Ransom) J. Radiol. 4: 170- 

171, May '23 (illus.). 

—New instrument in radium therapy, I. de radiol. et d'electrol. 7:456- 

457. Oct. '23 (illus.). 

—Preparation of forms for radium treatment of head and upi>er pari 

of neck, (A. Esguerra. O. Monod. & G. Richard) J. de radiol, 

et d' electrol. 7:49-60. Feb. '23 (illus.). 

—Radium applicator for small lesions. (N. T. Beers) Am. J. Roentgenol. 

10:643-645, Aug. '23 (illus.). 

—An instrument for application of radium to tonsils (Stewart, C. W.) 

Radium, ii. N. S.. 149-150, July '23. 

—Radium emanation slide rule for use in fieldof therapeutics, (J. 

Ransom) Am. J. Roentgenol. 10:735-736. Sept. '23 (illus.). 

- -Recent developments in protective methods and appliances as used 

in radium therapy, (C. F. Burnam & G. E. Ward) Am. J. 

Roentgenol. 10:625-632. Aug. '23 (illus.). 

—Cancer of skin following exposure to radium. W. J. MacNeal and 

G. S. Willis) J. A. M. A. So: 466-469. Feb. 17. '23 (illus.); also 

Radium, ii. N. S.. 119-127. July '23. 

—Castration and dosage. (P. W. Sicgel) Deutche. med. Wchnschr. 

49:47-49. Jan. 12, '23. 

—Cause of action of X-rays and gamma rays of radium upon living 

cells. (F. Dessauer) J. Radiol. 4:411-415, Dec. '23 (illus.). 

—Chart, new radium chart, (L. A. Pomeroy) Am. J. Roentgenol. 

10: 229. March '23. 

—Copenhagen Radium Emanalorium. (H. Jansen) Ugesk. f. Laeger 

S5:759-76L Oct. 25. "23. 

—Dermatitis. Observations on radium dermatitis. (M. S. lliomson & 

C. P. G. Wakeley) Arch. Radiol. & Electroth. 28:153-158. Oct. 

'23 (illus.)- 

—Dosage of radium, (D. Turner) Brit. M. J. 1:100-101. Jan. 20. 23. 

—Dosage and curative action of roentgen and radium rays. (Opitz) 

Arch. f. Gynak. 117:223-230. Dec. '22.


—Dosage of roentgen and radium ravs, (E. Opitz) Klin. Wchnschr. 

2: 243-247, Feb. 5, '23; ab. J. A. M. A. 80: 1492. May 19, '23. 

- Erythema dose of radium, (W. H. Guy and F. M. Jacob) Tr. Sect. 

Dermat. & Syphilol., A. M. A. pp. 171-177, '23. 

—Ionization measurements, (G. Failla) Am. J. Roentgenol. 10:48-56. 

Jan. '23 (illus.). 

-Newer investigations of gamma-ray dosage of radium. (O. Glasser) 

J. Radiol. 4:386-388, Nov. '23 (illus.). 

—Results of skin tests made to determine an objective dose for radium 

radiations. (A. L. Dean) Am. I. Roentgenol. 10:654-661, Aug. 

23 (illus.). 

—Simple nomogram for determination of radium skin doses. (E. H. 

Quimby) Am. J. Roentgenol. 10: 571-578. July '23 (charts). 

—Dystocia due to cicatricial stenosis of cervix following an intracervical 

application of radium, (H. Vignes & L. Cornil) Progres 

med. 38:315-3'/. June 30, '23 (illus.). 

—Effects of radio-active radiations and X-rays on enzymes; effect of 

radiations from radium emanation on solutions of trypsin (R. 

G. Hussey & W. R. Thompson) J. General Physiol. 5:647-659, 

May '23 (charts). 

—Unit of measure of activity for radium emanation, (R. G. Hussey & 

W. R. Thompson) J. General Physiol. 6:7-11. Sept. '23. 

—Effect of radium on uterus, (A. Kotzareff & M. Mollow) Gvnec. et 

Obst. 6: 244-273. Oct. '22 (illus.) ; ab. J. A. M. A. 80: 282. Jan. 

27, '23: 

—Effect on tissues, corpus striatum of radium emanation and accompanying 

structural and functional changes, (D. J. Edwards & 

H. J. Bagg) Am. J. Physiol. 65: 162-173. June '23 (illus.) ; also 

Radium, ii, N. S.. 308-316, Jan. '24. 

—Effect of radium upon normal nervous tissue. (J. E. Sweet) Pennsylvania 

M. J. 26:399-401, March '23. 

—Effects of irradiation on fetal development. (H. Bailcv & H. J. 

Bagg) Am. J. Obst. & Gynec. 5:461-473, May '23. ' 

—Histological changes in lymphatic glands following exposures to 

radium. (J. C. Mottram) Am. J. M. Sc. 165:469-479, April 

•23 (illus.). 

—Effects of radium upon rabbit ovaries. (H. A. Weis) Surg. Gvnec. 

Obst. 36:373-382. March '23 (illus.). 

—Effects of X-rays and radium on blood and general health of radiologists 

(Pfahler. G. E.) Am. J. Roentgenol. 9:647-656. Oct. 

'22; ab. Radium, ii, N. S.. 159-168, July '23. 

—Effects of blood, hemolytic action of radium emanation, (A. C. Redfield 

& E. M. Bright) Am. J. Physiol. 65:312-318. Julv '23 

(chart). 

—Effects of exposure to radium on blood platelets. (J. C Mottram) 

Proc. Roy. Soc. Med. (Sect. Pathol.) 16:9-13. Jan. '23 (charts). 

—In various diseases: See Radium therapy; and under names of diseases. 

—Intravenous injections of pure radium solution (on phvsical principles 

of alpha ray therapy). (V F. Hess) J. Radiol. 4: 78-79 

March '23. 

—Necessity for permanent control of radium tubes and needles. (T. 

Nogier) J. de radiol. et d'electrol, 6:479, Oct. '22.

a d i u m 85 

-Physical conditions of persons engaged in measuring radium preparations, 

(R. C. Williams) Pub. Health Rep. 38:3007-3028. 

Dec. 21. '23 (illus.); also Radium, April '24. 

-Rational distribution of radium for a hospital service, (J. Gagey) 

J. de radiol. et d'electrol. 7: 182-184, April '23. 

-Therapy: See also under Cancer; Gynecology; Tumor; and under 

names of various organs, regions and diseases. 

-A note on first 6 months' work of radium institute at Ranchi (T. C. 

Vaughan) Indian M. Gaz. 58:58-61, Feb. '23. 

-Comparative measurements between radium and X-rays concerning 

energy absorbed at depth. (H. R. Gaylord and K. W. Stenstrocm) 

Am. J. Roentgenol. 10:56-62, Jan. '23. 

-Conclusions after six years' use of radium, (E. D. Newell) Southern 

M. J. 16:706-708, Sept. '23; also Radium, ii. N. S., 302-305. 

Jan. '24. 

-Experimental research work in radium therapy, including death, 

retardation of growth, prolongation of life, determination of sex, 

sterilization and artificial parthenogenosis production without 

the male, (H. Lawrence) M. J. Australia 1 :463-471, April 28, 

'23 (illus.). 

-Harvard's hospital for radium therapy. (A. L, Gibson) Mod. Hosp. 

20:526-529, June '23 (illus.). 

-History chart for radium therapy. (C. Chase) Am. J. Roentgenol. 

10: 163-166, Feb. '23 (charts). 

-Indications for radium treatment, (M. Heiner). Med. Klinik, 19: 

612-613, May 6, '23. 

-Indications for radium treatment, summary of results, (L. A. Pomeroy) 

Ohio State M. J. 19:324-327, May '23 (illus.). 

-Indications for radium therapy in ophtho-oto-laryngology, (R. E. 

Loucks) J. Michigan M. Soc. 22:63-64. Feb. '23. 

-New system for radium applications, (L. Chappelli) Policlinico 

(scz. prat.) 30:242-243, Feb. 19, '23. 

-Radiation of the true pelvis with help of drainage tubes, (F. Daels) 

Arch. Radiol. & Electroth. 27:257-268, Feb. '23 (illus.). 

-Radium in dermatology, (A. Lassueur) Schweiz. med. Wchnschr. 

53:836-842. Sept. 6, '23. 

-Rational bases of radium therapy, (L. Mallet) Progres med. 38:239- 

242, May 19, '23. 

-Recent developments in radium therapy, (F. E. Simpson) Illinois 

M. J. 44: 327-329- Nov. '23. 

-Relative value of unfiltered radium emanation in deep therapy, (D. 

Quick) J. Radiol. 4:318-322. Sept. '23 (illus). 

-Report of 146 cases of skin affections treated with radium. (F. 

Bryant) Boston M. & S. J. 188:803-809. May 24. "23 (illus.); 

also Radium, ii, N. S., 188-20t, Oct. '23. 

-Report on radium therapy, (E. J. Angle & L. J. Owen) Nebraska 

M. J. 8: 236-240, July '23. 

•Reviewr of 6 months' experience with radium, (W. L. Cooke) J. M. 

A. Georgia 12:54-56, Feb. '23. 

-Some comments on radium technic, (W. H. Guy & F. M. Jacob) 

Atlantic M. J. 26:453-456. April '23. 

-Technic of deep radium therapy, (P. de Backer) J. de radiol.et 

d'electrol. 7:20-32. Jan. '23 (illus.).


—Therapeutic use of beta rays of radium. (P. Degrais) Presse me 

31:145-146. Feb. 14, '23; ab. J. A. M. A. 80: 1653. June 2. '23. 

—Three years' experience with radium. (H. King) J. Tennessee M. 

A. 16:292-296, Dec. '23. 

—Use and abuse of radium. (A. D. Little) J. M. A. Georgia 12: 180- 

181, May '23. 

—Use of radium in treatment of disease. (D. Turner» Brit. M. J. 1 : 

464-465. March 17, '23 (chart). 

Ransom, J.—Radium emanation slide rule for use in fieldof therapeutics. 

Am. J. Roentgenol. 10:735-736, Sept. '23. 

Ranson, I. R.—New holder for radium needles. J. Radiol. 4: 170-171, 

May '23. 

—Radium in treatment of malignant tumors of nose and throat, Laryngoscope 

33 = 8S3-8SS. Nov. '23. 

Rayewsky. B. and Lorenz. E.—Measurements of absorption coefficient 

of water and aluminum for hard X-ravs, Am. J. Roentgenol. 

10:890-896, Nov. '23. 

Rays—Alpha rays in psoriasis (S. Lomholt) Hospitalstid. 65:865-875. 

Dec. 20. '22 (charts) ; cont. 65:897-912. Dec. 27, '22; ab. J. A. 

M. A. 80:518. Feb. 17, '23. 

—On the physical principles of alpha ray therapy. (V. F. Hess) J. 

Radiol. 4:78-79, March 23. 

Rectum, cancer—Clinical study of radium therapy in carcinoma of rectum, 

(H. A. Kelly and G. E. Ward) Surg. Gynec. Obst. 37: 

626-634. Nov. '23 (illus.); also Radium, ii, N. S.. 285-296. 

Jan. '24. 

—Radium treatment of rectal cancer. (C. Schmitti Xeoplasmes 2: 

166-171. July-Aug. '23 (illus.) ; ab. J. A. M. A. 81: 1396. Oct. 

20. '23. 

—Treatment by radiation of cancer of rectum. (H. H. Bowing and 

F. W. Anderson) Am. J. Roentgenol. 10:230-239. March '23 

(illus.). 

—Tumor, Technique of application of radium in low neoplasms of 

rectum, (Lory & B. de Laborie) J. de radiol. et d'electrol. 

7:493-49". ^'ov. '23 (illus.). 

Regaud. C.—Sensibility of bone tissue to radiation. J. de radiol. et d'electrol. 

6:485-486. Oct. '22. 

—Principles of treatment of epitheliomas by irradiation; applications 

to epitheliomas on skin and in mouth, J. de radiol. et d'electrol. 

7: 297-322. July "23. 

Richard. G.. Esguerra. A. and Monod, O.—Preparations of forms for 

radium treatment of head and upper part of neck. J. de radiol. 

et d'electrol. 7:49-60. Feb. '23, 

Robinson. C. F.—Radiation treatment of tonsils. New York M. I.. 117: 

39-40. Jan. 3. '23. 

Roentgen Ray—Effects. Blood changes under roentgen rav treatment. 

(K. Hein) Arch. 1. Gvnak. 116:291-316. Nov. '22 (illu* 1 • ab 

J. A. M. A. So: 590. Feb. 24. '23. 

—Action of deep roentgen radiation on blood. (M. Mouquin) Medicine 

4:473-474. March '23. 

—Action of roentgen rays on coagulation of blood. (Pagniez Ravina 

and Solomon) J. de radiol. et d'electrol. 7: 153-157. April '25. 

—Action of roentgen ray on early pregnancy. (B. A. Archangelskv)

R a d i u m 

ST 

Arch. f. Gynak. 118: 1-17, March '23, ab. J. A. M. A. 80: 1348. 

May 5. '23. 

—Action of roentgen rays in inflammation. (C. Kemp) Deutsche 

Ztschr. f. Chir. 176:272-280, '22 (chart); ab. J. A. M. A. 

80:967, March 31. '23. 

—Alleged stimulating action of roentgen rays. (G. Ilolzknecht) Munchen 

Med. Wchnschr. 70:761-762, June 15. '23; ab. J. A. M. A. 

81: 1155, Sept. 29,'23. 

—Alleged stimulation by roentgen rays; comment on Holzknccht's 

article. (L. Freund) Munchen. Med. Wchnschr. 70:1202. Sept. 

21, '23. 

—Biologic action of roentgen rays. (G. Miescher) Schweiz. med. 

Wchnschr. 53:485-49'' May 17, '23. 

—Biological effects of X-rays. (J. W. Mavor) Am. J. Roentgenol. 

10:968-974. Dec. '23 (illus.). 

—Biological reaction of x-rays; effect of radiation on nitrogen and 

salt metabolism, (C. F. Cori, G. W. Pucher and H. Goltz) Am. 


•—Biological reactions of X-rays; effect of X-rays on rates of specific 

hemolysis, (K. F. Cori and G. W. Pucher) J. Immunology 8: 

201-209. May '23 (chart). 

—Biological reaction of X-rays; influence of X-ray treatment on compliment 

content of blood of.cancer patients, (C. F. Cori and 

H. De Niord) Am. J. Roentgenol. 10:830-834, Oct. '23. 

—Blood concentration after roentgen rays, (F. Klewitz) Klin 

Wchnschr. 2: 171, Jan. 22. '23. 

—Blood with deep roentgen ray therapy; hydrogen-ion concentration, 

alkali reserve, sugar, and non-protein nitrogen. (E. F. Hirsch 

and A. J. Peterson) J. A. M. A. 80: 1505-1507. May 26. '23. 

—Cause of action of X-rays and gamma rays of radium upon living 

cells, (F. Dessauer) J. Radiol. 4:411-415. Dec. '23 (illus.). 

—Effect of radioactive radiations and x-rays on enzymes; effect of 

radiations from radium emanation on solutions of trypsin. (R. 

G. Hussey and W. R. Thompson) J. General Physiol. 5:647- 

649. May '23 (charts). 

—Effect of roentgen rays on respiration of skin, (O. Gans) Deutsche. 

Med. Wchnschr. 49: 16, Jan. 5, '23; ab. J. A. M. A. 80:882, 

March 24, '23. 

—Effect of X-rays of different wave-lengths upon some animal tissues; 

proof of differential action, (S. Russ) Lancet. 2:637-640. 

Sept. 29, '23 (charts). 

—Effects of irradiation on fetal development, (H. Bailey and H. J. 

Bagg) Am. J. Obst. and Gynec. 5:461-473. May '23. 

—Histological study of fate of cancer grafts inoculated into X-rayed 

area, (W. Nakahara) I. Exper. Med. 38:309-314, Sept. '23 

(illus.). 

—Immediate effect of radium and X-rays on enzyme actions, (S. C 

Roth and J. J. Morton) Am. J. Roentgenol. 10:407-408, May 

—In explanation of action of X-rays; is it necessary to assume functional 

and growth stimulation? (F. Pordes) Arch. Radiol. & 

Electroth. 28:89-93. Aug. '23. 

—Influence of irradiation of ovary on subsequent fecundation and

88 Radium 

pregnancies, |A. Lacassagne and H. Coutard) Gynec. et Obst. 

7: 1-25. Jan. '23; ab. J. A. M. A. 80:1274, April 28. '23. 

—Irradiation of sex glands and its effect on progeny. (L. Nurnberger) 

Monatschr. f. Geburtsh. u. Gynak. 63:7-18. May '23. 

—Is effect of irradiation local or general? (L. Seitz) Monatschr. f. 

Geburtsh, u. Gynak. 63: 103-no, June '23. 

—Studies of effect of X-ravs on glandular activity (A. C. Ivy. B. H. 

Omdoff. A. Jacoby and J. E. Whitlow) J. Radiol. 4:189-199. 

June '23 (illus.). 

—What causes healing action of roentgen rays? (G. Holzknecht) 

Arch. Radiol. & Electroth. 28:85-89. Aug. '23. 

—Use of isodosis curves in X-ray therapy showing inaccuracy of 

Dessauer charts. (C. Gottlieb) Am. j. Roentgenol. 10:896-901. 

Xov. '23 (illus.). 

Roentgenotherapy, dosage—Dosage and curative action of roentgen and 

radium rays (Opitz) Arch. f. Gynak. 117:223-230. Dec. '22. 

—Economics of dosimetry in radiotherapy, (G. Failla and E. H. Quimby) 

Am. J. Roentgenol. 10:944-967. Dec. '23 (chartsL 

—Further studies in radiation dosage. (F. C. Wood) J. Radiol. 4: 343- 

344- Oct. '23 (charts). 

—Ionization measurements. (G. Failla) Am. J. Roentgenol. 10:48- 

56, Jan. '23 (illus.). 

—Isodose charts. (O. Glasser) Am. J. Roentgenol. io:45-407- May 

'23 (charts). 

Roth. S. C. and Morton, J. J,—Immediate effect of radium and X-rays 

on enzyme action. Am. J. Roentgenol. 10: 407-408. May '23. 

Roussy. G. and Leroux. R.—Radium treatment of cancer of uterine 

cervix. Rev. de chir. 60:499-508. '22. 

Roux-Berger. J. L.—Associated surgery, roentgen-ray and radium treatment 

of cancer. Paris med. 13:269-274, March 24. "23. 

Ruggles. E. W.—Efficient method of applving radium within the mouth. 

J. A. M. A. So: 1374-1375. May 12, '23. 

Rulison. R. H. and McLean, S.—Treatment of vascular nevi with radium. 

Am. J. Dis. Child. 25:359-370. May '23; also Radium, ii. X. S.. 

225-235. Oct. '23. 

Russ, S.—Effect of X-rays of different wave-length upon some animal 

tissues; proof of differential action. Lancet 2:637-640. Sept. 

29. "23. 

—Radio-activity of medicine. Lancet 2: 1314-1317. Dec. 15. '23. 

Saidman, J. and Robine. R.—Combined radiotherapv of lymphadenitis. 

Bull, et mem. Soc. med. d. hop. de Par. 47:622-625. April 

27. '23- 

Schaedel. H.—Radium in treatment of uterine affections. Zentralbl. f. 

Gynak. 46: 1918-1921. Dec. 2, '22. 

Schmitt. C.—Radium treatment of rectal cancer. Neoplasmes 2: 166-171. 

July-Aug. '23. 

Schmitz. Henry—Technique of treatment of carcinoma of cervix uteri 

with combination of X-rays and radium rays. Am. J. Roentgenol. 

10:219-229, March '23. 

- I reatment of carcinoma of uterus, with special reference to surgery. 

X-rays and radium. Northwest Med. 22:77-81. March '23. 

—Histologic and clinical studies of cervical carcinomata treated with 

gamma and X-rays, Xorthwest Med. 22:232-237. July '23; also 

Radium, ii, N. S.. 177-184. Oct. '23.


Scholten, G. C. J.—Results at Doderlein's clinic with irradiations of 

uterine cancer, Miinchen. med. Wchnschr. 70:300-301. March 

9, '23; ab. Radium, Jan. '24. 

Shaw, William Fletcher—Treatment of Uterine Fibroids: operation or 

radiation? Brit. M. J. 1:1005-1006, June 16. '23. 

—Carcinoma of female urethra, with notes of 2 cases treated with 

radium, J. Obst. & Gynec. Brit. Emp. 30:215-219, '23. 

Shroyer. F. I.—Uses of radium in malignant and nonmalignant conditions: 

with particular references to fieldof gvnecologv, Ohio 

State M. J. 19: 498-503. July "23. 

Shurly, B. R.—Removal of tonsils, with special reference to methods 

other than complete enucleation, J. A. M. A. 81:800-803. Sept. 

8, '23. 

Siegel, P. W.—Radium castration and dosage. Deutsche med. Wchnschr. 

49=47-49. Jan- "2, '23. 

Simpson, F. E.—Radium emanation ampoules in treatment of cancer of 

tongue, Illinois M. J. 44: 139-142, Aug. '23. 

—Recent development in radium therapy, Illinois M. J. 44:327-329. 

Nov. '23. 

Siredey, A.—Radium treatment of metrorrhagia. Paris med. 13:113-120. 

Feb. 3, ^23. 

Skin, cancer—Skin cancer following exposure to radium, (W. J. Mac- 

Neal and G. S. Willis) J. A. M. A. 80:466-469, Feb. 17. '23 

(illus.); also Radium, ii. N.-S., 119-127. July '23. 

—Statistics and technique in treatment of malignant disease of skin 

by radiation, (H. Morrow and L. Taussig) Am. J. Roentgenol. 

10:212-218, March '23 (illus.). 

—Tumor: Radium therapy of epithelioma of skin (Pares) J. de radiol. 

et d'electrol. 6:487-488. Oct. '22. 

—Re(>ort of 146 cases of skin affections treated with radium (Bryant. 

F.) Boston M. & S. J.. 188: 805-809. May 24, '23; also Radium, 

ii, N. S.. 188-201, Oct. '23. 

—Epitheliomata- -Prophylactic and Curative measures, (fames, W. D. 

and James. A. W.) International J. Surg., March '23; also 

Radium, ii, N. S.. 205-210, Oct. '23. 

Smith. G. G.—Treatment of cancer of bladder by radium implantation. 

J. Urology 9:217-226, March '23. 

—Cancer of prostate. Boston M. & S. J. 188:621-625. April 26, '23. 

Stenstroem, K. W.—Device for retubing radium emanation. Am. J. 

Roentgenol. 10:311-312, April '23. 

—and Gaylord, H. R.—Comparative measurements Ijetween radium 

and X-rays concerning energy absorbed at depth. Am. J. Roentgenol. 

10:56-62, Jan. '23. 

Stern, M. A.—Experience with radium in treatment of certain fibromas 

and metrorrhagias, Journal-Lancet. 43:466-469, Sept. 15. '23. 

Stevens. J. T.—Treatment of malignant disease by means of the newhigher 

voltage shorter wave length roentgen .'rays, radium 

and electrothermic coagulation. J. M. Soc. New Jersey 20:415- 

422, Dec. '23. 

Stewart, C. W.—An instrument for application of radium to tonsils. 

Radium, ii, N. S., 149-150, July '23. 

Stone. W. S.—Present fieldfor use of X-rays and radium in treatment 

of malignant neoplasms. Am. J. Roentgenol. 9:502-507, Aug. 

'22; ab. Radium, ii, N. S., 153-159. July '23.


Strauss. A.—Radium and surgery in cancer, Ohio State M. J. 19:8 

Feb. '23. 

Swanberg. H.—Effect of X-rays and radium rays in malignancy. Illinois 

M. J. 43:205-208. March '23. 

Swanson. C—Removal of angiomata with radium. J. M. A. Georgia. 

12: 181-183. May '23. 

Taussig, L. R.—Radium treatment of carcinoma of lip, M- Clinics X. 

America 6: 1579-1586. May '23. 

—Treatment of keloids with radium. California State J. Med. 21: 520- 

522. Dec. '23. 

—Carcinoma of tongue and its treatment with radium. Arch. Dermal. 

& Syphilol. 6:424-427. Oct. '22; also Radium, ii. X. S-, 9-17. 

April '23. 

—and Morrow. H.—Statistics and technique in treatment of malignant 

disease of skin by radiation. Am. J. Roentgenol. 10:212- 

218. March '23. 

—Radium therapy of vascular nevi. Am. J. Roentgenol. 10:867-871, 

Xov. '23. 

Thewlis. M. W.—Radium therapy in cancer at Institute of Radium, 

Paris, Rhode Island M. j. 6:39-42. March '23. 

Thompson. W. R. and Hussey. R. G.—Effect of radioactive radiations 

and X-ravs on enzymes; effect of radiations from radium emanation 

on solutions of trvpsin. J. General Phvsiol. 5:647-659. 

May '23. 

' 

—Effect of radioactive radiations and \-rays on enzymes: effect ot 

radiations from radium emanation on pepsin in solution. J. 

General Physiol. 6:1-5. Sept. '23. 

—Effect of radioactive radiations and X-rays on enzymes: unit of 

measure of activity for radium emanation. J. General Physiol. 

6:7-11, Sept. '23. 

Thomson. M. S. and Wakeley. C. P G.—Radium dermatitis, Arch. 

Radiol. & Electroth. 28:153-158. Oct. "23. 

Thorium—Cancer treatment. Radium and thorium in treatment of cancer. 

(Kupferberg) Munchen. med. Wchnschr. 70:6-7. Jan. 5. '23 

(charts). 

Inhalation of thorium emanations (Cluzet and Chevallier) Paris 

med. 13: 103-108. Feb. 3. '23: ab. J. A. M. A. So: 1417. May 

l2' -3- ... . . . . ' 

— Subcutaneous injection of thorium X in chronic rheumatism. (M. 

P Weil) Medecine 4:687-691. June "23. 

Throat Tunior>. Radium ill treatment 01 malignant tumors of nos? 

and throat. (J. R. Ranson) Laryngoscopy 55:885-888. Nov. 

'23 (illus.). 

I hyroid—Effect of radium on. Resistance of thyroid gland to action 

of radium rays, results of experimental implantation of radium 

needles in thyroid of dogs. (J. O. Bower and J. H. Clark) Am. 

J. Roentgenol. 10:632-643. Aug. '23 (illus.). 

Radium treatment of toxic goiter with metabolic deductions, (R. 

E. Loucks) Am. J. Roentgenol. 10:767-776. Oct. '23 (charts). 

Tongue—Cancer. Radium emanation ampoules in treatment of cancer 

of tongue. (F. E. Simpson) Illinois M. J. 44 M39-142. Aug. 

•23 (illus.). 

—Radium needles in malignant growths of tongue: the time factor.


(A. J. Larkin) Am. J. Roentgenol. 10:734-735, Sept. '23; ab. 

Radium, Jan. '24. 

—Carcinoma of tongue and its treatment with radium (Taussig. L.) 

Arch. Dermat. & Syphilol. 6:424-427. Oct. '22; also Radium. 

ii., N. S., 9-17, April '23. 

Tonsil—Radiotherapy. Present status of radiation treatment of tonsils, 

(C. F. Robinson) New York M. J.. 117: 39-40. Jan. 3, '23. 

—Bacteriology of irradiated tonsils. (H. J. Ullman and F. R. Nuzum) 

Am. J. Roentgenol. 10: 396-398. May '23. 

—Prompt aciion of radium radiations in treatment of small or large 

infected tonsils and lingual tonsils, (F. H. Williams) Boston 

M. & S. J., 188: 497. April 5. '23. 

—Radium treatment of hy|iertrophied tonsils. (V. H. Williams) Paris 

med. 13: 110-113. Feb. 3, 23; ab. J. A. M. A. 80: 1417. Mav 

12, '23. 

—Study of tonsil question with preliminary report of roentgen ray 

and radium therapy in treatment of pathologic tonsils. (L. A. 

Lane) Minnesota Med. 6:97-104. Feb. '23. 

—Use of radium to induce atrophy of faucial tonsils—histologic evidence. 

(W. A. Wells) Laryngoscope 33:681-690. Sept. '23 

(illus.). 

—X-ray and radium treatment of infected tonsils and adenoids. (E. 

U. Wallerstein) Virginia M.•Monthly 50: 177-1S0. June '23. 

—Treatment of malignant neoplasms of tonsils (Quick, D.) J. Radiol. 

3: 173-178. May '22; also Radium, ii. N. S.. 97-IC9, July '23. 

Trachoma—Treatment. Cure of trachoma by radium, (L. Muller and F. 

H6g!er) Wien klin Wchnschr. 35:954-955, Dec. 7, '22; ab. 

J. A. M. A. 80: 441. Feb. 10, '23. 

Trypsin-—Eftcct of radioactive radiations and X-rays on enzymes; effect 

of radiations from radium emanation on solutions of trypsin. 

(R. G. Hussey and W. R. Thompson) J. General Physiol. 5: 

647-659, May '23 (charts). 

Tuberculous Glands--Radium as curative agent for tuberculous glands. 

(Molyneaux, E. S.) Lancet. S04-S05, Oct. 14.'22; ah. Radium, 

ii. N. S., 253-256, Oct. '23. 

Tumor—Angioma. Nevus vasculous (strawberry mark). re|>ort of case 

cured by radium therapy. (H. Swanberg) J. Radiol. 4:284. 

Aug. '23 (illus.). 

—Removal of angiomata with radium. (C. Swanson) J. M. A. Georgia 

12: 181-183. May '23. 

—Treatment of vascular nevi with radium. (R. H. Rulison and S. 

McLean) Am. J. Dis. Child. 25:359-370, May '23 (illus.). 

—Epithelioma, Principles of treatment of epotheliomas by irradiation: 

applications to epitheliomas on skin and in mouth. (C. 

Regaud) J. de radiol. et d'electrol. 7:297-322. July '23. 

—Radium therapv of epitheliomas of skin. (Pares) J. de radiol. et 

d'electrol. 6:487-488. Oct. '22. 

—Statistics and technique in treatment of malignant disease of skin 

by radiation. (H. Morrow and L. Taussig) Am. J. Roentgenol. 

10:212-218. March '23 (illus.). 

—Fibromyoma. Treatment of uterine fibromyomas by radium. (T. 

Nogier) J. de radiol.et d'electrol. 6:477-479, Oct. '22. 

—Lymphosarcoma. Behavior of lympho sarcomata under radium treat-


mem. 1 D. I. Harries and E. R. Williams) Practitioner ill :29i- 

294. Oct. '23. 

—Hodgkin's disease and lymphosarcoma, clinical and statistical study. 

(A. U. Desjardins and F. A. Ford), J. A. M. A. 81:925-927. 

Sept. 15. '23 (charts). 

—Radium treatment. Action of buried tubes of radium emanation on 

neoplasias in plants, (I. Levin and M. Levine) J. Cancer Research 

7: 163-170, April '22 (illus.). 

—Radium needles in treatment of tumors. (J. Markl) Cas. lek. cesk. 

62:473-477- Mav 5. 23 (illus. V 

—Role of radium needles in treatment of neoplastic diseases. (W L. 

Clark) Am. J. Roentgenol. 10:204-208. March '23. 

—Uses of radium in malignant and non-malignant conditions: with 

particular reference to field of gynecology. 1F. I. Shroyer) 

Ohio State M. J. 19:498-503, July '23. 

—Sarcoma. Radium in sarcoma. (W. H. B. Aikins) J. Radiol. 4:44- 

46. Feb. '23. 

—Results of radium treatment in sarcoma. ' W, H. B. Aikins) Canad 

M. A.J. 13:654-656. Sept. '23. 

Turner. D.—Dosage of radium, Brit. M. J. I: 100-101. Jan. 20. '23. 

—Use of radium in treatment of disease, Brit. M. J. 1:464-463. 

March 17, '23. 

Ullman, J. S.—Forceps for cleaning radium needles and tubes. Am. J. 

Roentgenol. 10:989. Dec. '23, 

I'llmann. H. J. and Nuzum. F. R.—Bacteriology of irradiated tonsils. Am. 

J. Roentgenol. 10:396-398. May '23. 

Urethra—Tumor. Papilloma of prostatic urethra, treated with radium 

and fulguration, (R. H. Herbst) S. Clinics X. America 3:1071- 

1075. Aug. '23 (illusA. 

lTcru>—Action of radium on uterus. (A. Kotzareff and M. Mollow) 

Gynec. et Obst. 6:244-273. Oct. '22 (illus.); ab. J. A. M. A. 

80: 282. Jan. 27. '23, 

—Cancer. Diagnosis and treatment of carcinoma of cervix. (W. Ncill, 

Jr.) W. Virginia M. J. 17:258-263, Jan. '23. 

—Cancer of cervix. (W. H. Kennedy) Kentucky M. J. 21: 161-164. 

March '23. 

—Cancer of cervix uteri. (W. P. Graves) Boston M. & S. J. 188: 

1006-100S. June 21. '23; also Radium, ii. N.S.. 185-188. Oct. '23. 

—Causes of favorable action of rays in cancer of uterus. (E. Opitz > 

Munchen med. Wchnschr. 70: 1299-1300, Oct. 19. '23; ab. J. A. 

M. A. 82: 74. Jan. 5. '24. 

—Fifty cases of carcinoma of cervix treated with radium. (M. Donaldson 

and R. G. Canti) Brit. M. J. 2: 12-16. July 7, '23 (chart). 

— Follow-up results of 90S cases of uterine cancer treated bv radium. 

(H. Bailey and W. P. Healy) Am. J. Obst. & Gynec. 6:402- 

406. Oct. '23; also Radium, ii. X. S.. 277-284. Jan. '24. 

—Histologic, and clinical studies of cervical carcinoma treated with 

gamma and X-rays. (H. Schmitz) Xorthwest Med. 22:232- 

' - 237, July '23 (illusA ; also Radium, ii. X. S.. 177-1S4. Oct. '23. 

—Immediate effect of radium treatment upon symptoms of uterine 

cancer. (G. R. Holdcn) J. Florida M. A. 10:3-5. Ju'>' -3- 

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16: 113-115, Mav '23,


—Xecessity for combined radium and deep roentgen therapy. (L. 

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. '23 (illus.). 

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319. April '23. 

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J. Oklahoma M. A. 16: 182-184, June '23. 

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Virginia M. J. 17:473*478. May '23. 

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March 9, '23; ab. Radium. Jan. '24. 

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—Salient poinls in diagnosis and treatment of cancer of uterus. (A. 

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(Kelly, H. A.) Therapeutic Gazette. 46:761-767. Nov. 15, '22; 

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hemorrhage. (Polak. J. O.) Med. Rec. 101:493-494. March 

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Radium, ii. N. S., 305-307, Jan. '24. 

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cervix. (H. Schmitz) Am. J. Roentgenol. 10:781-792. Oct. 

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of X-rays and radium rays. (H. Schmitz) Am. J. Roentgenol- 

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31:461-463. May 23, "23.. 

—Treatment of carcinoma of uterus, with special reference-to surg-. 

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81. March '23 (illus.). 

—Treatment of uterine cancer. (O. v. Franque) Miinchen med. 

Wchnschr. 70:676-678, May 25. '23; ab. Radium, ii. N. S., 

248-252, Oct. '23.


—Use of radium in treatment of cancer of cervix, (O. D. Hall) J. M. 

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and metrorrhagias. (M. A. Stern) Journal-Lancet, 43:466-469. 

Sept. 15, '23. 

—Fibromyoma, Limitations of •radiotherapy in management of fibromyoma 

of uterus. (J. A. Corscaden) Am. J. Obst. & Gynec. 

6:42-50. Julv '23 (illusA; al*o Radium, ii. X. S.. 218-225. 

Oct. '23. 

—Treatment of uterine fibromyomas by radium. (T. Nogier) J. de 

radiol, et d'electrol. 6:477-479. Oct. '22. 

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(M. A. Stern) Journal-Lancet 43:466-469, Sept. 

!5- '23- 

—Hemorrhage, Radium as adjunct to surgery in uterine conditions, 

(W. P. Fite) J. Oklahoma M. A. 16: 182-184, June '23. 

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39:800-801. Aug. 20. '23. 

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Klin. Wchnschr. 2: 1761-1764. Sept. 17. '23. 

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Southern M. J. 16:550-554. July '23. 

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various methods employed for internal administration of radium 

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Walker. G. and Burnam. C.—Cancer of urinary bladder cured bv radium. 

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J. M. A. Georgia i2:i»7-69, Feb. '23.

RADIUM 95 

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96 RADIUM 

NEW BOOKS 

Albert Bachem. Ph. D. Principles of X-ray and Radium Dosage. 

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casse as treated in the light of the most recent developments of deep 

roentgen therapy. 

The important work of Kroenig and Friedrich on the Principles of 

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Considerably more space in the book is devoted to the discussion 

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whereas in the case of radium, the quality of the rays is constant, and 

ray intensity is the important factor in determining dosage and clinical 

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As far as it may be set down with the present knowledge of skin 

erythema dose (and it may be remarked parenthetically that these data 

are largely due to the workers in the physical department at the Memorial 

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radium, placed at different distances from the skin surface. In the 

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series. 1923) Paul B. Hoeber. Inc., Xew York, 1924. xii. 293 pp. with 

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in press, a review of the book will appear in the July issue.

A QUARTERLY JOURNAL DEVOTED TO THE CHEMISTRY. PHYSICS AND 

THERAPEUTICS OF RADIUM AND RADIOACTIVE SUBSTANCES 

Copyright 1924 by Radium Chemical Co. 

Edited by Charles H. Viol. Ph. D., and William H. Cameron. M. D.. with the assist 

collaborators working in the fieldsof Radiochemistry. Radioactivity and Radiumtherapy. 

Address all communications to the Editors. Forbes and Meyran Avenues, 

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Annual Subscription $2.00. Single Copies 50 Cents. 

VOL. 3, New Series JULY, 1924 No 2 

CARCINOMA OF THE BODY OF THE UTERUS (WITH 

THE REPORT OF 115 CASES)* 

By Charles C. Norris, M. D*. and M. E. Voct, M. D. 

Philadelphia. Pa. 

With the advent of radium, the study of carcinoma has received a 

great stimulus, and perhaps in no variety greater than that which occurs 

in the uterus. Probably owing to the unsatisfactory results secured by 

operative intervention and probably also to the greater frequency of the 

neoplasm, this interest has been rather centered about cervical cancer. 

The following study embodies the results obtained by operation and 

irradiation in a series of 115 consecutive carcinomata of the body of the 

'uterus, especially emphasizing the end-results. 

Carcinoma of the uterus may be divided into that form which originates 

in the cervix and that which springs from the fundus. These 

are different tumors, histologically and clinically, and a definite line 

should he drawn between them. Carcinoma of the fundus is less common 

than that of the cervix. Among 12.514 gynecologic patients observed 

during the last 23 years at the University Hospital, there have 

been 115 cases of fundal carcinoma. During a like period 346 cases 

of cervical carcinoma have been observed among 756 cases of carcinoma 

of the genital tract. Thus in our series, carcinoma of the fundus constituted 

about 15.2 per cent of all cancers of the genital tract and about 

25 per cent of all uterine cancers. Frank1 places the former figure between 

10 to 15 per cent; Peterson2 18.8 per cent; and Wilson3 11.2 per 

cent. 

It is an established fact that chronic irritation is a distinct predisposing 

factor towards cancer. Cervicitis, especially in cervices which 

"Reprinted by permission from The American Journal or Obstetrics and 

Gynecology, vll. 55


have been the seat of laceration, is extremely frequent, whereas true 

chronic corporeal endometritis is infrequent, and if we exclude the 

tuberculous type, quite rare. It is probable that these facts have a definite 

bearing on the greater infrequency of fundal than of cervical carcinoma. 

The combination of genital tuberculosis and carcinoma has 

been recorded bv a number of observers (Xorris.* D'Halluin and 

Dalral5). 

Carcinoma of the fundus is generally a disease of advanced life occurring 

on an average somewhat later than carcinoma of the cervix. The 

following presents the age in decades in our series: 

20-30 

31-40 

41-50 

51-60 

61-70 

71-80 

1 case (29 years of age) 

14 cases 

18 " 

57 

21 '* 

4 "* 

The average age in this series was 53.29 years; 100 of the 115 cases 

or 86.9 per cent were 41 years of age or over, and 82 or 71.3 per cent 

were 51 years or older, the greatest number. 49 per cent, occurring between 

51 and 60 years. Peterson states that 73.2 per cent of his patients 

were between 55 and 65; Koblanck* 50 per cent between 50 and 60; 

Cullen: and Wilson observed similar findings. 

Carcinoma of the cervix is rare in nulliparous women, 26 per cent 

of carcinoma of the present series occurring in spinsters. It would appear 

that childbirth plays little part in the etiology of this neoplasm, 

and that the disease is relatively as frequent in the nulliparous as in the 

m u It i parous. 

The most important symptoms are hemorrhage and discharge. The 

hemorrhage usually begins in the form of "spotting.*1 generally small 

in amount. It may follow trauma, but this is not as constant as in 

cervical carcinomata; in the latter the vascular, friable cancer is from 

its location, less protected. The hemorrhage becomes more frequeunt 

and profuse as time goes on. This rather rapidly progressive character 

of the bleeding is characteristic of all malignant uterine neoplasms. 

Rarely until the later stages is the amount of blood lost sufficient to 

produce a marked alteration in the blood picture. It should be emphasized 

that the bleeding produced by carcinoma of the fundus is a 

metrorrhagia. Menstruation, if still present, is probably in no way affected 

and occurs regularly and is usually of the normal duration. Oc- 

•Since compiling these statistics, we have observed a cane of adenocarcinoma in 

a younic woman, twenty years of age. The case was referred to the gynecologic ward 

of the University Hospital with a diagnosis of incomplete abortion. Carcinoma «f 

the fundus was diagnosed from the curettlngs and hysterectomy revealed an early 

cancer in the fundus not more than 1.6 cm. in diameter. Despite the early stage 

of this tumor, a small metastasis had occurred In one ovary. This case offers an 

opportunity to study the rapidity of growth of adenocarcinoma. The curettage was 

performed September 21sl, and owing to various difficulties, among them that the 

patient had left the city, hysterectomy was not performed until six weeks later. 

At ih.- time of curettage, the tumor must have been extremely small as practically 

all the tissue removed was norma) except a small shred a few millimeters in 

diameter, which showed a typical picture of carcinoma. When the uterus was 

removed, the tumor was easily recognizable macroscopleally and measured 1.6x1 cm. 

There was little penetration of the myometrium. The neoplasm had evidently 

originated from the surface epithelium and was of the variety sometimes spoken of 

as adenomaligum.. The Sampson theory of perforating cyst Is applicable to this 

case ovary curettage tractions, as and an dislodges the was explanation ovarian of about carcinoma metastasis of the why size cells, such that (or would the an Imolanatlon) early postoperative be expected specimen was pain under produced upon produces the the circumstances. 

metastasis. surface uterine of con 

The the


casionally a carcinomatous hemorrhage may accidentally occur a day 

or two before or after the normal period, and thus simulate a prolongation 

of the normal How but. as a rule, it is definitely intermenstrual 

in type. 

Owing to the age at which carcinoma of the fundus usually develops, 

the irregular bleeding of the cancer is often attributed to the 

menopause or to a recurrence of the menses. A slight amount of bleeding 

frequently follows straining at stool, and this is often attributed by 

the patient to hemorrhoids. The origin of the hemorrhage can be easily 

determined by instructing the patient to insert a small piece of cotton 

or gauze into the vagina prior to defecation and examining same shortly 

after the bowels have moved. The discharge is thin, irritating, often 

bloody and malodorous. The foul odor depends upon the amount of 

degeneration which has occurred on the surface of the cancer. Some 

authors state that discharge is usually the first symptom, and this may 

be true. A small amount of discharge is. however, less noticeable than 

a small amount of bleeding and for this reason, the latter is the more 

important symptom. 

An analysis of our case histories shows that in Si per cent of our 

patients, hemorrhage was the first symptom, and in the remainder discharge 

was noticed prior to the bleeding. Hemorrhage, however, occurred 

in all at a later date, whereas in a few of our early cases discharge. 

while perhaps present in small quantity, probably was not noticed bv 

the patient. In carcinoma of the fundus, hemorrhage is worth about 

75 points in the diagnosis, and discharge about 25; whereas in carcinoma 

of the cervix, the symptom of hemorrhage is of even greater diagnostic 

value, probably being worth 90 points and discharge 10 points. Hemorrhage 

and discharge are the only subjective symptoms of much value; 

pain, cachexia, loss of weight, etc.. generally indicate an advanced anil 

hopeless condition. 

The ini|H>rtance of early diagnosis cannot be overestimated. The 

subjective symptoms during the early stage are by no means characteristic. 

In our series, less than 25 per cent were early cases. A study 

of the present scries proves that two factors stand out dominantly as 

reasons for the advanced stage in which most of these cases were when 

first observed. The first is that the lesion is painless during the early 

stage. Nothing will bring a patient to a physician more quickly than 

pain, and the absence of this symptom during the early stage of all 

uterine cancers is an important and unfortunate factor. The second 

reason that patients are prone to disregard the early symptoms is that 

the menopause itself is usually irregular; probably not one woman in 

ten passes through this period of life without some irregular bleeding. 

Many women, therefore, disregard the slight irregular bleeding or slight 

discharge which are the only symptoms of the cancer during its early 

stage, under the belief that the hemorrhage is the result of the menopauuse 

and, if she inquires among her friends, this opinion is almost 

sure to be confirmed. 

The reason that this misapprehension is so firmly established in the 

lay mind and so difficult to eradicate, is that in 90 per cent of women 

the irregularities are due to some benign condition, and as a result the 

belief becomes more firmly fixed. Carcinoma of the fundus often develops 

after the menopauses and after the woman has gone through a 

more or less prolonged period of irregular bleeding, and under such

100 Radium 

circumstances the hemorrhage is often attributed to a return of the 

menstrual flow. Furthermore, carcinoma develops at a period when 

various minor lesions are prone to cause bleeding. 

It is obvious, therefore, that the great majority of irregularities 

are not the result of cancer, and for this reason this danger symptom 

is often disregarded during the period when its observance would be 

of most value. The disinclination to submit to a gynecologic examination, 

combined with the good general health often enjoyed by the patient 

during the early stage of cancer of the uterus, are also contributing 

factors in "letting the condition go for a while and seeing if they will 

not get well." 

To the experienced physician the symptoms previously described 

are always suspicious, and the condition is very properly viewed as 

malignant until proved otherwise. This proof, however, is not always 

easy. The ordinary pelvic examination is generally entirely negative. 

In 65 per cent of our early cases, the uterus was normal in size, showing 

definitely that increase in size of the uterus is by no means a constant 

condition. The curette of course offers a practically certain means 

of diagnosis. 

The test suggested by Dr. John G. Clark, while less certain, is of 

great practical value. This is applicable to all suspicious cases and may 

be safely employed as an office procedure. It consists in cleansing the 

external genitalia, vagina and cervix thoroughly with an antiseptic solution 

and then passing under sight a sterile sound to the fundus of the 

uterus and gently manipulating the point of the instrument over the 

entire endometrial cavity. If a friable, vascular growth such as carcinoma 

is present a small trickle of blood will be observed. A satisfactory 

means of employing this test is. after the cleansing of the vagina, 

to introduce a Sims speculum and partially fillthe vagina with bichloride 

solution. 1-2000. so that the cervix is immersed in a lake of the liquid. 

l/nder sight a sterile sound is then introduced and gently raked over 

the entire endometrial cavity. We all know how a few drops of blood 

from a nose bleed will discolor a bas;n of water, and in the same manner 

a few drops of blood will be easily demonstrated in the clear solution 

in the vaginal lake. In employing this test, the cervix should not 

be grasped with a tenaculum. 

As it is possible that other pathologic conditions may cause bleeding 

from this test, the nonappearance of blood from the cervix indicates 

strongly that no cancer is present. One of the writers has employed 

this test frequently and has never seen it fail when a carcinoma has 

been present, Ewing has suggested taking smears from the fundus of 

the uterus, and by this means has been able to demonstrate in a proportion 

of cases the presence of carcinoma cells or fragments of the tumor. 

A combination of the Clark and P.wing tests may be easily employed and 

is of great practical value. Neither of these tests is conclusive in all 

cases, and the surgeon will have to depend upon the microscopic examination 

of the curettages for the final and positive diagnosis in the 

majority of the early cases. 

Absolute asepsis is essential in the employment of either the Clark 

or Kwing tests. The great advantage of the Clark test is that it mav 

be employed as an office procedure; it involves no loss of time and requires 

no s[>ecial skill or expensive apparatus. We feel sure that if 

this test were more widely employed, many early cases of carcinoma

R a d i u m 101 

would be detected which would otherwise remain unrecognized until the 

disease became advanced. 

To the experienced physician, a tentative clinical diagnosis in a 

patient who has passed the menopause, and in whom there has been 

an absence of bleeding for some years prior to the development of the 

cancer, is generally easy. When symptoms develop at the time of the 

menopause, the clinical diagnosis is much more difficult. 

In our entire series, the clinical diagnosis was correct and positive 

in 57 per cent of cases. Carcinoma of the fundus was suspected in 

an additional 23 per cent of cases, and in 19 per cent the cancer was 

unsuspected. An analysis of 58 cases in which a diagnostic curettage 

was performed, shows even more forcefully the importance of a histologic 

examination. In this series 36.8 per cent were correctly and 

positively diagnosed clinically; in an additional 37.9 per cent the malignant 

character was suspected, and in 25 per cent the clinical diagnosis 

was benign. In addition, many cases clinically suspected of being carcinoma 

were proved benign or a result of curettage. 

Of the 20 cases in which the clinical diagnosis was benign but proved 

malignant, 15 were associated with myomata. Thus in 75 per cent of 

the unsuspected cases the symptoms of the cancer were masked by those 

of preexisting myomata. Myomata are the most common uterine neoplasms 

and their association with cancer is by no means infrequent. 

In our 115 cases oi carcinoma, _•; were associated with myomata. In 

the early stages the bleeding produced by these two forms of neoplasms 

is generally quite distinct; the myoma producing menorrhagia, and the 

carcinoma metrorrhagia of the type previously described; but often in 

the later state of the myoma, the bleeding becomes markedly irregular 

and these are the cases in which error is especially likely to occur. 

The association of fundal carcinoma with myomata is an interesting 

one. and despite the amount of research which has been done upon the 

subject, it is still questionable whether or not mvomata are a predisposing 

factor towards cancer. In the present scries, carcinoma of the 

cervix is about three times as frequent as carcinoma of the fundus. 

Noble" found carcinoma of the fundus more frequently than of the cervix 

among 5.000 myomata. in the proportion of 75 to 63. Williams* found 

carcinoma of the fundus in 1.4 per cent of his myoma cases. Our statistics 

show 115 fundal carcinoma as compared with 1.983 myoma, a 

proportion of a little more than one fundal carcinoma to every 17 

myoma. 

The aforementioned figures demonstrate the im|>ortance of a diagnostic 

curettage in all suspected cases, and also emphasizes the importance 

of a preliminary curettage prior to all irradiation of myomata. 

For the performance of a successful histologic diagnosis from curettings, 

it is essential that the pathologist possess a thorough knowledge of the 

changes which take place in the normal endometrium during the menstrual 

cycle at different ages, as well as the changes produced by pregnancy. 

He should be furnished with such data from the history of each 

case as are necessary. Recently a number of papers have appeared in 

Ihe gynecologic literature decrying the operation of curettage as a routine 

procedure. This has no bearing on diagnostic curettage. Were 

diagnostic curettage to be eliminated from the number of justifiable operations, 

few early operations for fundal carcinoma would be performed 

and many benign lesions would be treated as malignant.

102 R a d i u m 

A diagnostic curettage should be a thorough one as the carcinomatous 

lesion may be small. Obviously, it is impossible for the pathologist 

to make a correct diagnosis of carcinoma from a very small fragment 

of tissue, provided this presents a typical picture; a larger quantity of 

material, however, greatly facilitates the laboratory diagnosis, and in a 

series of cases, materially increases the proportion of correct conclusions. 

The accuracy with which histologic diagnosis may be made in a 

large series of cases has occasionally been questioned, and Deaver and 

Reimann1" have even gone so far as to recommend abdominal hysterotomy 

in suspicious cases. In the laboratory of gynecologic pathology 

at the L'niversity Hospiial, a diagnosis of carcinoma of the fundus has 

never been made from cureltings which, when the uterus was subsequently 

removed, did not confirm the histologic findings. Nor. so far 

as our knowledge goes, has a case which was diagnosed benign by the 

pathologist, ever been shown to be malignant. Some of our cases in 

which a diagnostic curettage has been performed and a benign diagnosis 

made from the histologic findings, have not been traced and may 

therefore have been mistakes by the pathologist, but in view of the 

fact that a very thorough follow-up system is in force, even this appears 

doubtful. Cases can. however, be imagined where a cancer may develop 

in the crevice of a uterine cavity, the seat of one or more submucous 

myomata, in which it would be impossible for the curette to reach the 

carcinomatous tissue, but these must be extremely rare. 

One case occurred in which a woman presented herself, having a 

large nodular mass in the pelvis, and who had been bleeding irregularly 

and profusely for a long period of time. The diagnosis was myoma 

of the uterus and the patient was referred for irradiation. A curettage 

had been performed in a neighboring city and a histologic diagnosis of 

polypoid endometritis made by another pathologist. This case presented 

all the clinical characteristics of a myoma, and on account of the poor 

general condition of the patient, due to her hemorrhages, it was decided 

to apply radium. At the time of the irradiation, a curette passed lightly 

over the endometrial cavity failed to secure any tissue, probably due to 

the fact that the former curettage had been performed but ten davs 

previously. This patient failed to improve, sought surgical assistance 

elsewhere and at hysterectomy some time later a carcinoma of the fundus 

was discovered. In this case it was impossible to secure tissue on account 

of the former curettage. 

Despite this case, we believe that accuracy in histologic diagnosis 

of curettings is possible in nearly ioo per cent of cases. Carcinoma 

of the fundus may originate upon the surface of the endometrium and. 

at this stage, it is theoretically possible for a curettage to remove the 

entire lesion. A number of cures by curettage are on record and mav 

undoubtedly occur. Ladinsky" has collected 22 such cases; also Frank1'2 

and \\ cincr.13 Such instances must, however, be extremely rare. It is 

hardly probable that such early carcinomata would produce svmptoms. 

and unless the curettage is performed for some other cause, "it is unlikely 

that such cases would be observed. Specimens from such cases 

should be subjected to an extremely rigid pathologic examination, for 

the possibility of a misinterpretation of the histologic picture must be 

considered. It is not improbable that an endometrial polyp which was 

undergoing carcinomatous degeneration might be entirely removed by 

curettage and thus result in a permanent cure. This would be espe-

R a d i u m 103 

cially likely if the carcinomatous area were confined to the distal extremity 

of the polyp. 

One of the writers (Norris14) has elsewhere drawn attention to the 

limits of microscopic diagnosis. Occasionally doubtful histologic pictures 

will be observed which will be interpreted differently by even the 

most experienced pathologists. As a general rule, such specimens are 

usually benign. If the curettage has been a thorough one. there is rarely 

room for doubt in the class of cases under discussion. Was such a case 

to occur, it would be wise to be governed by the clinical evidence present. 

Certainly a second diagnostic curettage would be indicated, in any 

event, should there be a recurrence of symptoms. In the performance 

of diagnostic curettage in cases suspected of being carcinoma of the 

fundus, care must be observed not to perforate the uterus; this is a cpiite 

possible accident in advanced cases. (Schottlander and Kermauner1*'i. 

We have dwelt somewhat upon the question of early diagnosis because 

we feel that it is the keynote to situation, and provided proper 

treatment is instituted, carcinoma of the fundus is generally considered 

a relatively hopeful form of cancer, especially when compared to carcinoma 

of the cervix. Many authors place the percentage of cures as 

high as 60 to 75 per cent. This has not been our experience. A careful 

study of our cases, while it shows better results than those secured in 

the cervical form of cancer, is by no means satisfactory. Only 44 per 

cent of 115 patients are alive today, and some of these are alive with 

recurrences and, in others, recurrence will develop. 

Carcinoma of the fundus is obviously a more favorable form of 

cancer than is the cervical variety. The cervix is surrounded by vital 

structure—bladder, rectum, ureters, etc.—and extension into any of these 

renders a favorable end-result unlikely. Because the cervix is intimately 

associated with adjacent structures, extension is more likely to occur 

and makes a wide removal more difficult. When the cancer originates 

in the fundus, it is surrounded by a thick muscular envelope—the myometrium 

; the fundus is free on both the anterior and posterior surface 

and the upper portions of the broad ligament are easil) removable The 

lymphatics of the fundus are abundant. Metastases and rapidity of 

growth of carcinoma of the fundus appear to vary somewhat according 

to the age of the patient and the type of the tumor. The duration of 

symptoms is about twice that of cervical cancer. 

F.wing16 states that the lymphatics of the corpus begin at the endometrium, 

pass upwards and outwards and leave the uterus in four or 

five trunks just beneath the tubes, pass through the broad ligaments. 

anastomising with the ovarian plexus and about the ovarian artery in 

the pelvic ovarian ligament, to end in the lumbar nodes above the bifurcation 

of the aorta; from the middle of the corpus, other vessels mingle 

with those from the cervix, reach the iliac nodes, parametrial. iliac, hypogastric, 

sacral, lumbar and inguinal, form the regional nodes of the uterus. 

Beyond these there is a wide communication with each other and with 

vessels of the bladder, rectum, kidneys and abdomen. 

In many cases individual susceptibility of the patient also seems to 

be an important factor in the question of metastasis and rapidity of 

growth. Many efforts have been made to correlate the malignancy of 

the carcinoma with the histologic type of cancer. Practically all carcinomata 

of the fundus of the uterus are of the glandular type, although 

we have encountered one squamous-celled carcinoma in this locality in

104 R a d i u m 

a specimen forwarded to us by Dr. John L. Atlee. of Lancaster.'7 Especially 

noteworthy in this effort is the recent research of Mahlc.'•" He 

states that cellular differentiation appears to be the most important factor 

in determining the malignancy in any given case. We have carefully 

reviewed our specimens with this conclusion in mind, and while we 

agree with Mahlc's statement, we have observed a number of contrary 

findings. Our experience has been that, as a general rule, those tumors. 

the cells of which exhibit a marked tendency towards mitosis, a marked 

tendency to break through the basement membrane, are the most rapid 

in growth. Such tumors are naturally surrounded by a more well-defined 

zone of inflammatory reaction than are more slow-growing neoplasms. 

This inflammatory reaction consists largely of lymphocytes. Marked 

irregularity in the size of the tumor cells anil hyperchromatosis are also 

generally present in extremely malignant form of tumors. 

The chief point in prognostic value is the integrity of the myometrium. 

In some specimens, the myometrium is hy]»ertrophied. but this 

is unusual, although edema is generally present in advanced cases. The 

macroscopic examination offers a rough, but fairly accurate, guide to 

the advancement of the case, and on cut sectionsit is usually possible to 

determine moderately accurately, the extent of the growth. In two 

specimens we have observed subperitoneal involvement, due to extension 

along the blood vessels from small tumors. Fwing has recorded a 

similar experience. The macroscopic appearance may be intensified hy 

making a thin slice of tissue antl floodingit with polychrome methylene 

blue No. 13; the tissue is then rinsed in distilled water and examined 

with the naked eye. antl with a magnifying glass, according to the 

method suggested by Terry.19 As a general rule, the younger the patient 

the more malignant the tumor. 

The duration of the symptoms prior to treatment naturally bears 

a definite relationship to the prognosis. 

An analysis of all our 3-year cases shows the following: 

THE Relationship of the Duration of Symptoms to Prognosis 

Duration of Symptoms No. of Cases Percentage of 3 Year 

Patients Alive 

6 months or less 24 57. 

7-12 months 32 31.2 

1 year or more 28 17.8 

In 59 or 71 per cent of these cases the duration of symptoms was 

between 5 and 18 months. In over 15 per cent, the symptoms had been 

present for two years or more. 

The treatment of choice for adenocarcinoma of the fundus of the 

uterus consists in panhysterectomy and bilateral salpingo-oophorectomy. 

Whether or not preliminary or postoperative irradiation, or both, will 

be found advisable is still a mooted point. In the Gynecologic Clinic 

of the Hospital of the University of Pennsylvania, preliminary irradiation 

has not been resorted to routinely, and postoperative irradiation 

has been employed only in selected cases, usually when the tumor was 

found to have been in an advanced stage. The Werthcim operation has 

not been performed as a routine procedure, although as extensive a 

hysterectomy as is possible for the individual case has been performed. 

For those cases in which the carcinoma is too advanced for hysterectomy.

R A D I U M 105 

radium irradiations are an excellent palliative procedure antl in some 

cases appear to be curative. The dosage employed has generally been 

2400 mgh.. and in a few cases postoperative irradiation by means of 

deep x-ray. From the study of our end-results, we are led to favor the 

routine postoperative irradiation in all cases that offer any ho|>e of 

cure. The following table presents the results in all cases, including 

those too advanced for any form of treatment: 

Total number of cases 115 

Percentages of cases traced 

91.31 per cent 

Percentage of mortality from all causes 56. per cent 

Percentage alive 44. per cent 

We realize the fallibility of an arbitrary statement regarding 3-year 

or 5-year cures, but for purposes of comparison and study, have adopted 

the 3-year standard. We are aware that recurrences may occur in some 

of our 3-year cases which now appear well, but have emploved this 

period in order to secure groups of sufficient size to warrant the deduction 

of at least tentative conclusions. Weibel viewing Wertheim's 

cases, found that all recurrences occurred within three years. The chief 

value of statistics relating lo carcinoma are those showing the endresults. 

In compiling statistics relating to cancer, two points are of 

paramount importance; the first is the number of 3 or 5-year cases 

which have been observed and the number which are alive; and the 

second vital point is what methods have been resorted to to secure the 

results. Comparison of operative statistics may be misleading unless 

accompanied by figures relating to the |>trcentage of operandi ty. One 

surgeon may operate upon 90 per cent of his carcinoma patients and 

another upon onlv 10 per cent; the latter will probably be able to show 

a much higher percentage of 5-year cures among his operative cases 

and a lower operative mortality, whereas the former may actually have 

more 5-year patients alive. 

The following table presents the results of all our three-year cases 

traced without regard to the form of treatment or the advancement of 

the disease, and includes cases too advanced for either irradiation or 

operation: 

Total number of 3-year cases 87 

Percentage alive 34-8 

Percentage alive, no recurrences 27.9 

Percentage alive with probable recurrence 6.9 

Percentage of cases dead, all causes 65.1 

The following table shows the 3-year results in those cases upon 

whom hysterectomy was performed. These, in general, are the earlier 

cases: 

Total number 3-year hysterectomies 57 

Percentage alive 37-5 

Percentage alive, no recurrence 3°-5 

Percentage alive, probable recurrence 7. 

Percentage dead, all causes 62.5 

Cullen records 60 per cent of his cases alive, but some of these were 

operated only one year previously. Wilson-' records only 24 per cent

106 R a d i u m 

of absolute cures. Sixtv-five per cent of our 3-year cases were subjected 

to hysterectomy, and this list contains a relatively large proportion 

of moderately advanced cases. 

The following table shows the results secured in a series of hysterectomies 

performed for early moderately fundal carcinoma; 

Total number of early 3-year cases 26 

Percentage alive 54- 

Percentage alive, no evidence of recurrence 4-? 

Percentage dead, all causes 4°- 

Whercas this group is too small from which to draw definite conclusions, 

we believe that 50 to 60 per cent of ultimate cures may be 

expected from this class of cases. This group includes only cases in 

which no metastasis was discovered at operation, and in which the 

growth was macroscopically limited to the fundus, and in no instance 

was there less than 1 cm. of macroscopically normal myometrium between 

the tumor and the serosa. 

Preliminary irradiation has not been routinely adopted in the present 

series. The following table shows the results secured in a small 

series of cases in which this treatment was adopted, the dosage varying 

from 1200 to 2400 mgh. 

Three-vear cases treated by radium irradiation followed by hysterectomy 

: 


Percentage alive 5°- 

Percentage mortality, all causes 5°- 

Total number of 3-year cases treated by curettage and radium irradiation 

alone: 


Percentage 3-year cases alive 45- 

Percentage 3-year cases alive, no recurrences 35. 

Percentage 3-year cases alive, probable recurrences 10. 

Percentage 3-year cases dead, all causes 55. 

The number of cases comprising this group is too small from which 

to draw definite conclusions. Small group statistics are unreliable as 

a few cases alter results so markedly. The majority of cases constituting 

this group were too advanced to permit of radical operative intervention. 

In addition, however, it includes a few extremely early cases 

and. because of this mixture, it is somewhat unsatisfactory as a means 

of comparison to the preceding groups. Whereas the figures in this 

table emphasize the value of radium irradiation, and are actually superior 

to those secured by hysterectomy in the proportion of 45 per cent 

alive after three years, as against 37.5 among those submitted to radical 

intervention. At the risk of repetition, we would warn from drawing 

too definite conclusions from such a small number of cases as this table 

comprises. Nearly all of the patients in this group were temporarily 

improved by the irradiation, and in the majority of those who ultimately 

succumbed, life was prolonged and made more comfortable. For these 

patients, irradiation by radium is the greatest palliative ever placed 

before the medical profession, and offers a chance for cure even in those 

cases too advanced for operation. Bailey and Healy- record unsatisfactory 

end-results from irradiation in this class of cases. Thev state

R a d i u m 107 

that in nearly every instance, cases subjected only to irradiation, evidence 

of the disease reappeared within a year. 

Three-year cases too advanced for any form of treatment or who 

refused oi>eration 10 

Three-year cases too advanced for treatment 6 

Three-year cases who refused treatment 4 

Dead 10 

A comparison of the hysterectomy mortality based upon all deaths 

occurring during the patients' stay in the hospital compared with that 

following radium irradiation shows the following results of the entire 

series of 115 cases: 

Hysterectomies 68. 

Deaths 5. 

Peritonitis 3. 

Pulmonary embolism 1. 

Myocarditis 1. 

Operative mortality, all causes 

7-3cA 

Radium irradiations 32. 

Deaths 2. 

Myocarditis 1. 

Pulmonary embolism 1. 

Operative mortality, all causes 6.2% 

In considering the relative mortalities from these two forms of 

treatment, the advanced stage of the cancer in many of the patients 

submitted to irradiation must be considered. Radium was employed 

in the majority of cases merely as a palliative. Wc would venture to 

state that had irradiation only been employed upon all cases, the operative 

mortality would have been materially lessened. Of the entire series 

of 115 cases, but seven were too advanced for any form of treatment. 

and an additional 8 cases refused to submit to treatment. 

From the Crocker Institute, Wood and his coworkers have amply 

demonstrated the factor which is played by trauma in the dissemination 

of cancer. Many cases of fundal carcinoma present only vague symptoms 

during the early stages of the disease. The necessity of diagnostic 

curettage in these cases is obvious. The question, however, arises as 

to the part which curettage may play in the dissemination of carcinoma 

in this type of case and with a view to at least throwing some light on 

this phase of the problem, we have studied the cases in which hysterectomy 

has been performed alone or immediately followed by curettage. 

and compared these results with those secured from a group of patients 

in which a curettage was previously performed. In the latter group 

are included only cases in which the curettage was performed at least 

24 hours or more prior to the hysterectomy. 

Three-year hysterectomies only, or D. and C. immediately followed by 

hysterectomy. 

Number of cases 35 

Percentage alive 37.5 

Three-year hysterectomy preceded by curettage 24 hours or more previously. 

Number of cases 22 

Percentage alive 40.9

108 Radium 

The results in this series are actually in favor of those cases which 

have been submitted to a preliminary diagnostic curettage in the rate 

of 40.9 to 37.5 per cent. In considering these figures, it must be borne 

in mind that those cases which were submitted to an immediate hysterectomy 

were, as a group, more advanced, as naturally a diagnostic 

curettage would not be i>erformed except in the case of a doubtful clinical 

diagnosis. At all events, this study seems to prove that a preliminary 

curettage is not markedly detrimental to the ultimate outcome. 

It is at least possible that a routine irradiation following the diagnostic 

curettage would even improve the results in the latter group. Certain)v 

had a diagnostic curettage not been performed, the diagnosis would 

have been delayed in many of the cases of carcinoma and the benign 

lesions could not have been excluded. 

Whereas a panhysterectomy is indicated in all cases of carcinoma 

in which the litems i- to be removed, this has occasionally not been possible, 

or in a few insiances the malignant character of the lesion was 

not recognized until the specimen reached the laboratory. The latter 

has been the case in a few specimens in which the uterus was removed 

for myomata and a fundal carcinoma subsequently discovered. A comparison 

of these groups shows the following results: 

Total number of 3-year hysterectomies 57 37-5% alive 

Total number of 3-year panhysterectomies 40 43-3% alive 

Total number of 3-year supravaginal hysterectomies. .. 17 24.2*^ alive 

These figures indicate the importance of removing the entire uterus 

in this class of cases. 

\\ ith only 34.S per cent of three-year cures in our series, the necessity 

of early recognition of carcinoma is apparent. To attain this end 

in anv group of cases, it will be found necessary to resort to diagnostic 

curettage in a relatively large proportion of cases. Even excluding the 

possibility of dissemination of the carcinoma by the curettage, any preliminary 

operation which occurs a day or two prior to the second operation 

has many drawbacks; the added discomfort, the mental effort upon 

the patient and the fact that anesthesia has to be administered a second 

time, all mitigate against this procedure. In a proportion of cases, however, 

this cannot be escaped. In a few cases when the amount of material 

secured at the curettage is large, a few of the larger portions of 

the specimens may be utilized for the freezing method. In general, 

frozen sections have not proved as reliable in our hands as paraffin preparation, 

and this is particularly true in the case of curcttings. When 

only a small amount of curettings is secured, it is safer to rely upon 

a rapid paraffin method by which a practically certain diagnosis mav 

be made in twenty-four hours. On the other'hand. if the amount of 

tissue is considerable, one or two large pieces may be utilized for the 

freezing method. If these are found positive for carcinoma, it is safe 

to recommend that the hysterectomy be performed at once; if. however. 

the results secured by the freezing method are doubtful or negative] 

the final histologic diagnosis should be delayed until the paraffin sections 

have been examined. In passing, it mav be stated that a careful 

macroscopic examination of curettings which have been thoroughlv 

washed, placed in a small flat glass dish containing clean water and examined 

with a magnifying glass in a good light, is of distinct value 

Frank-3 states the gland recurrences in the lumbar, inguinal iliac

R a d i u m 109 

liver and lung metastasis are most common and that wound implantations 

in the perineal scar after Schuchard's incision, have been repeatedly 

reported (Hirsch" and Milner"). True vaginal metastases have 

been observed by Hellendahl.*6 In only two of our cases have metastases 

been observed in the ovaries and in only one in the tube. Whereas we 

are unable to give accurate figures,the majority of the recurrences have 

been pelvic. A possible explanation of this may be found in the theory 

of the origin of perforating hemorrhagic ovarian cyst advanced bv 

Sampson." If we accept that epithelial cell from the normal endometrium 

may be swept out through the fallopian tube and produce implantation 

growths in the ovary and adjacent structures, it is at least possible 

that a similar condition may occur in the cases of carcinoma cells 

originating within the uterine cavity. In only one instance have we 

observed a metastasis to the uterus from an ovarian carcinoma. This 

case is not included in our series. 

Carcinomatous degeneration may occur in endometrial polyps. 

Among 104 endometrial polypi, we have observed three such instances. 

These have not been included in the aforementioned study. All the 

three are alive and with no evidence of recurrence. In the case of carcinomatous 

degeneration of an endometrial polyp, the most important 

points to determine from a prognostic viewpoint, are the condition of 

the pedicle and whether or not an implantation growth has occurred. 

One of our cases is so unique as to require special mention. The specimen 

consisted of a double fundus, one of which was small and atrophic. 

the other was the seat of intramural myoma, the size of an orange, and 

contained a large tongue-shaped polyp* the distal half of which was the 

seat of an adenocarcinoma. In the posterior wall of the vagina was a 

squamous-cell carcinoma 6 cm. in diameter. This is the only case in 

which carcinoma has been observed in malformed uteri, and the only 

case in wrhich multiple carcinomata have been present. 

CONCLUSIONS 

I. Carcinoma of the body of the uterus is less frequent than cancer 

of the cervix. A possible explanation of this fact is that chronic cervicitis 

is a common lesion, whereas true chronic corporeal endometritis 

is relatively infrequent. 

2. Carcinoma of the fundus is a disease of advanced life. Over 

71 per cent of patients, constituting the series under discussion, were 

51 years of age or older. 

3. Childbirth plays little part in the etiology of this neoplasm. In 

the present series 26 per cent were spinsters. 

4. Hemorrhage and discharge are the most important symptoms. 

In 81 per cent hemorrhage was the first symptom. Pain, cachexia and 

loss of weight generally indicate an advanced and inoperable tumor. 

5. With only 25 per cent of cases presenting themselves in the 

early stage and only 34.8 per cent of three-year patients alive, the importance 

of early diagnosis may be recognized. 

6. Absence of pain and the nonrecognition of the significance of 

irregular bleeding account for the majority of advanced cases. 

7. The histologic examination of curettings offers an almost certain 

means of diagnosis, even in the early cases. 

8. The Clark test which consists in the passage of a sterile sound 

is of great practical value. Absence of bleeding following this test goes

110 R a d i u m 

a great way towards excluding carcinoma. The test is an office procedure, 

and its more general adoption will result in the recognition of 

many early cases. 

9. In the present series, the clinical diagnosis was correct and positive 

in 57 per cent of cases; the cancer was suspected in an additional 

23 per cent, and in 19 per cent the cancer was unsuspected. 

10. In 75 per cent of the unsuspected cases, the symptoms resulting 

from cancer were masked by those produced by preexisting myomata. 

The combination of adenocarcinoma of the body of the uterus 

and myoma is a frequent one; 20.8 per cent of the present series of cancers 

were associated in these tumors. 

II. The chief point of prognostic value is the integrity of the myometrium. 

12. The duration of the symptoms has a direct ratio to the percentage 

of permanent cases. In cases in which symptoms were present 

for six months or less. 56.5 per cent were alive at the end of three years; 

when symptoms were present 7 to 12 months 31.2 per cent, and when 

symptoms hatl been present over one year, but 17.8 per cent were saved. 

13. The treatment of choice is panhysterectomy and bilateral salpi 

ngoophorectomy. 

14. Postoperative irradiations by radium of deep x-ray are of distinct 

value. 

15. Radium irradiation is the greatest palliative and results in 

greater comfort to the patient and prolongation of life. 

16. Radium irradiation offers a hope of cure even in cases too advanced 

for operation. 

17. The percentage of three-year hysterectomy cures was 37.5 

per cent, whereas in a like series, the irradiation resulted in 45 per cent 

of three-year cures. The result is probably due to the small number of 

cases comprising the irradiation group. A large group would probably 

show hysterectomy giving the better results. 

18. The percentage of three-year hysterectomy cures in the early 

cases was 42 per cent. 

19. The operative mortality from hysterectomy was 7 [>er cent and 

from radium 6 per cent. 

20. The total mortality from all causes in the entire series of 115 

cases was 56 per cent. 

21. The total number of three-year cases was 86; of these 34.8 

per cent are now alive. 

22. Carcinoma of the fundus must be considered a relatively malignant 

form of cancer. The teaching that 60 to 75 per cent of these cures 

be permanent cures is. in our experience, fallacious. 

23, Preliminary curettage plays little part in the dissemination, 

and its value as an early diagnostic procedure far outweighs any disadvantage 

accruing from its employment. Without diagnostic curettings. 

the majority of early cases would be overlooked or many nonnal 

uteri sacrificed. 

24. Carcinomatous degeneration occurred in less than 3 per cent 

of endometrial polypi. All are alive. In these cases the important points 

are the condition of the pedicle of the tumor and whether an implantation 

growth has occurred. 

REFERENCES 

(1) Frank, R. 7".: Gynecological and Obstetrical Pathology, D.

Radium 

in 

Appleton Co., 1922. (2) Peterson, R.\ Surg.. Gynec, and Obst., 1919, 

xxix, 544. (3) Wilson, Eden and Lockycr: New System of Gynecology, 

London. 1917. ii. 478. (4) Norris, Chas. C.: Gynecological and Obstetrical 

Tuberculosis, D. Appleton Co., 1922. (5) D Holluin and Dalral: 

Bull, et mem., soc. anat. de Paris. July, 1910. (6) Hoblanck: Veifs 

Handbuch tier Gynakologie, Wiesbaden,' 1908, 3. ii, 672. (7) Cullen, 

T. S.: Cancer of the Uterus. N. Y., 1900. (8) Noble: Jour. Am. Med! 

Assn., 1906, xlvii. 1881. (9) Williams: Boston Med. and Surg. Jour., 

1908, clix, 465. (10) Deaver, J. B. and Reiman, S. P.: Am. Jour. Med. 

Sci., 1921. Ixi, 661-663. (n) Ladinsky: Surg. Gynec. and Obst., 1915, 

xx. 325. (12) Frank, R. T.i Am. Jour. Obst.. 1916, Ixxiv, No. 3. (13) 

Weiner: N. Y. Med. Jour.. 1917, cv, 1079. (14) Norris. C. C: 

Am. Jour. Obst. and Gynec, Jan.. 1923. (15) Sehottlander and Kermaxtncr: 

Uterus Karzinom, Berlin, 1912. (16) Ewing, /.: Neoplastic 

Diseases. Phila. and London, 1919. (17) Norris, C. C.: Primary Squamous 

Celled Carcinoma of the Body of the Uterus. Am. Jour. Obst., 

1907, lvi. No. 6. (iS) Mahle, A. E.: Surg. Gyn. and Obst., March, 1923. 

{19) Terry, B. T.: Jour. Am. Med. Assn.. July. 1923. (20) Weibcl: 

Arch. f. Gynak., 1913. c. 135. (21) Wilson. Eden and Lockycr: New 

System of Gynecology, London, 1917. (22) Bailey, H. and Healy, W 

P.: Am. Jour. Obst. and Gynec., 1923, vi, 402. (23) Frank. R. T.: 

Gynecological and Obstetrical Path., N. Y. and London. 1922. (24) 

Hirsch: Ztschr. f. Geburtsh. u. Gynak.. 1911, xlix. 742. (25) Milner: 

Arch. f. klin. Chir.. 1904, 74. (26) Hcllendahl: Hegar's Beitr. z. Geburtsh. 

u. Gynak., 1902, v. 6. (27) Sampson. /. A.; Arch. Surg.. 1921, 

iii, 245- 

DISCUSSION 

Dr. W. R. Nicholson.—There should be no question, it seems to 

me, that all competent gynecologists will agree that radical operation for 

carcinoma of the cervix is a thing of the past. I am happy to say that 

for the past four years I have not done a so-called radical operation for 

cervical carcinoma. Some years ago I did use the Percy cautery, but 

after half a dozen cases, was convinced of the futility of the procedure. 

Since that time I have used the same instrument as a preliminary step 

to the use of radium, but I have come to the conclusion that aside from 

the removal of the sloughing mass, for the introduction of radium, there 

is no indication even here for operative procedure. 

I personally believe that when one can diagnose carcinoma of the 

cervix, by either inspection or palpation, the case is beyond operation. 

I do not believe that the presence or absence of demonstrable areas of 

extension should enter into the question of operability. I believe that 

the Wertheim operation, done according to the published technic of its 

author, has failed to increase the span of life of those suffering from 

carcinoma of the cervix. By this I mean that the primary mortality 

and immediate secondary mortality is so high that the number of days 

of life lost by the women who have been operated upon, are greatly in 

excess of the number of days of fifegained by the so-called successful 

cases. In other words, I feel perfectly hopeless regarding the operative 

treatment for carcinoma of the cervix, and believe that at present we can 

only hope that radium and deep x-ray treatment will offer some chance 

for these patients.

112 R a d i u m 

With regard to carcinoma of the fundus. I. of course, have a yendifferent 

feeling. If I had to elect a site for carcinoma in a woman. I 

would most certainly choose the fundal portion of the uterine cavity. 

My ex|>erience has been that if the patient is seen within a few months 

of her first symptoms she has a very good chance of complete cure by 

an ordinary panhysterectomy. Of course the use of deep x-ray has to 

be considered in certain of these cases; as for instance, a woman upon 

whom I operated three years ago. and in whom the extension of the 

disease was more widespread than I had expected. In this case I am 

certain that a small portion of the cervix was of necessity left in situ. 

The repeated use of x-ray and radium, by Dr. Pfahler. has resulted in 

the complete disappearance of anything which can be considered pathologic 

as far as the vaginal examination is able to reveal. 

On the other hand. I have within the last few days advised against, 

or rather, acquiesced in the decision of a patient against hysterectomy, 

because the carcinomatous condition of the fundus was of three years' 

standing, and because the feel of the uterus impressed me with the belief 

that there was beginning |>eritoneal extension. She will have x-ray and 

radium. 

I wish that Dr. Norris had been a little more definite in stating 

how he differentiates cases suitable for panhysterectomy, and I hope 

lhat when he publishes his paper, this point will be fully covered. There 

is one thing in his paper which to my mind, from the standpoint of cure, 

is more important than anything else and that is the question of bleeding 

at the time of menopause. If it could be impressed upon all women that 

at the time of the menopause, any increase of bleeding is a danger sign. 

and that its occurrence means that a most thorough examination should 

be made by a competent gynecologist, with a uterine curettage if necessary, 

there is no question that the statistics of cervical carcinoma could 

be improved beyond anything for which we can hope at ihe present time. 

It has always seemed to me to be extremely unfortunate that women 

are not instructed a* to what constitutes menstruation, in order that thev 

might know that a mere discharge of blood from the genitalia is not necessarily 

a menstrual [>enod. I'nfortunately, otherwise intelligent women 

have absolutely no conception of what menstruation really is. and as is 

well known, there is a firmly entrenched belief that the' menopause i< 

usually ushered in by hemorrhage. Of course the difficulty is that in 

a good many instances benign hemorrhage does occur as a symptom. 

I believe that it it would be possible, by the teaching of physiology in 

the higher grades oi the common schools, and bv a nation-vvide propaganda, 

to enforce this one fact upon the women "of America, we would 

see a tremendous improvement in the cancer mortality in the next twentvhve 

years. 

Finally. I would simply mention the only adverse criticism of these 

two papers, which is the advice to use the sound in the office as a diagnostic 

means of detecting the possible presence of fundal carcinoma It 

is all very well to have trained men. under the stringent precautions outlined 

by Dr. Norris. use this procedure, but I think it a grave mistake 

to advocate its use bv the profession at large, as the ordinary nonhealing 

practitioner has absolutely no know ledge of what constitutes asepsis.

R a d i u m 113 

BLOCKING LYMPHATICS IN THE CONTROL OF 

CARCINOMA OF THE PROSTATE GLAND * 

By Robert H. Hi:ri:st. M. D.. Chicago 

We do not know any more about the cause of cancer of the prostate 

than we do about cancer occurring in other organs. We do know, however, 

that at least 20 per cent, of all neoplasms of this gland are malignant. 

Hg. 1.—Bladder turned downward and rectum cut off; 

posterior wall of bladder, seminal vc*iele> and prostate 

flanil visible, with lymph channel' on surface of prostate 

Mining four main trunks and draining into lymph node* 

about the iliac vessels and promontory of the

114 Radium 

bladder neck for cancer, all carrying with them a high immediate mortality 

and little success in control of the cancer. 

The employment of radium in irradiation of carcinoma of the prostate 

is comparatively recent. Minet.' in 1908, using the urethral route. 

irradiated the surface of the prostate by means of an elbow catheter 

with the beak hollowed out to receive the radium tube. 

From this time until 1915. we find a number of reports by Desnos,* 

Pasteau, Wickham and Degrais.1 Cauhape.' Schuler.* LeFur.* and 

Young,1 all applying radium to the gland either in the prostatic urethra 

or in the rectum or in both. In 1915. Barringer* began irradiating the 

gland by passing long needles through the perineum into the carcinomatous 

lobes. About this time 19 began embedding needles containing 

radium into the malignant gland through the suprapubicallv opened 

bladder, believing that ihts route gave better access to the involved area 

and allowed more accurate irradiation. From this time the literature 

Fi|f. 2.—Lateral view, showing lympl ••• . - of prostate, passing up 

through supiaprostatic space, bounded in front by the bladder, behind 

by the RCttim. and on either side by the seminal vessels. 

has been crowded with case reports and descriptions of methods of irradiation. 

Janeway" buried emanation tubes in the prostatic cancer bv 

inserting them through the perineum and through the rectal wall. 

Kohscher" advocated suprapubic cystotomy and electrocoagulation of 

the tumor mass before applying the radium. Morson1- performed perineal 

section and buried radium tubes in the prostate. Bugbee" reported 

good results from needling the prostate through a suprapubic opening. 

Thomas and Pfahler" handled bladder and prostatic cancer by a 

combination of surgical care, electrocoagulation, radium exposures and 

roentgen-ray treatments. Marion" pushed a hydrocele trocar through 

the perineum directly into the cancerous prostate. 'The obturator was

R a d i u m 115 

removed, and the radium capsule, attached to a wire, was passed through 

the cannula into the prostate. Bumpus" used radium needles inserted 

through the perineum and. after subsidence of the reaction, again applied 

radium to the gland from the rectal side. Hinman17 inserted radium 

into the prostate urethra, used needles for embedding, and applied 

it to the rectal side by means of a bag that contained collargol for the 

protection of the rectal wall. 

After a careful review of the literature, supplemented by my experience, 

I conclude that the treatment of carcinoma of the prostate resolves 

itself into a consideration of the following problems: (i) the 

control of the cancer; (2> the relief of urinary retention, and (3) the 

obtaining of the best possible function after the cancer has been controlled. 

In order 10 accomplish these purposes. I believe that it is essential 

to open the bladder suprapubicallv. 

METASTASES 

About one-third of all patients who seek relief for cancer of the 

Fig. 3.—Insertion of radium needles under trigon into siipraprostatlc 

area, through which the lymphatic* from the prostate gland pass upward 

into the pelvis. 

prostate show demonstrable bone metastases. A certain fair percentage 

have involvement of the pelvic and abdominal lymph glands (not, as a 

rule, demonstrable), and a small percentage have viscera! metastases. 

So we can safely estimate thai more than one-half of all the patients 

wrho seek relief for this rather common condition are beyond control. 

This brings up the question: How may we discover these patients earlier, 

before they have developed metastases? Unfortunately, the symptoms 

in most cases are delayed until after the metastases have developed, so 

that the only hope for the future is that the cancer will be found in the

116 Radium 

course of a routine physical examination. A rectal examination should 

be a part of every physical examination, but unfortunately is frequently 

omitted. One would not think of subjecting a female to a general physical 

examination without a bimanual vaginal examination. Is there a 

better way of examining the male pelvis than a bimanual rectal examination? 

If this was practiced as a routine, more cases of prostatic cancer 

could be discovered before metastases have developed. 

In order to carry out accurate irradiation of the malignant prostate. 

one must have a knowledge of the gross pathology of this disease, and 

of the lymphatic drainage of the prostate gland. 

Fukase1* has shown that rudimentary lymph nodes are present in 

the normal prostate, appearing as small aggregations of lymphocytes 

located beneath the glandular and duct epithelium. These drain into 

lymph channels on the surface of the gland, which finally unite into four 

main trunks, one from the anterior surface and three from the lateral 

Fig. 1.—Lateral virw. showing needles embedded into area under 

trigon ihrough which lymphatics pais. 

and posterior surfaces (Fig. i). All four trunks pass upward, through 

an area bounded behind by the rectum, in front by the trigon and on 

either side by the seminal vesicles, and finally drain into the lvmph nodes 

about the iliac vessels (Fig. »). It is this supra prostatic area which 

must receive early attention if we may hope to prevent metastases. 

Careful, painstaking and accurate embedding of radium into this region, 

even though apparently uninvolved. will have a tendency to lock off the 

lymphatics at this point and prevent the spread of the disease into the 

pelvic lymphatics and beyond our control. This is the equivalent of going 

well beyond a cancerous growth in excision.

R a d i u m 

in 

PATHOLOGY 

Pathologically, the disease may assume three different forms: i. 

As a scirrhous cancer beginning in the posterior lower segment of the 

gland. In this type the disease has a tendency to follow Denonvillier's 

fascia and by way of the lymph channels to invade the pelvic lymph 

nodes. This is a rather malignant form of the disease, with a tendency 

toward the early development of metastases. 2. A combinalion of benign 

hypertrophy of the upper superior segment and malignancy of the lower 

posterior part of the gland. 3. Adenocarcinoma, a less common form 

of tumor, in which the entire gland is involved. This type, as a rule. 

is smooth and symmetrical, but harder than the benign adenoma. 

SVM1TOMS 

The symptoms of cancer of the prostate are often postponed until 

late in the course of the disease. This is particularly true of the type 

that develops in the posterior segment of the gland and spreads upward 

behind the bladder: These patients usually have no urinary symptoms, 

and the pain produced by metastases is the first symptom to attract their 

attention. The symptoms may be thus classified: (1) those produced 

by the growth of the gland; (2^ those due to obstruction; (3) those 

produced by metastases; (4) general symptoms common to malignancy. 

The local symptoms arc few, such as pubic pain, pain in the perineum, 

and a sensation of fullness in the rectum. The symptoms due to urinary 

obstruction arc frequent, imperative urination, pain along the urethra 

radiating out to the end of the penis, pyuria, and hematuria. This last 

sign is often considered diagnostic of malignancy, but is not uncommonly 

found in benign hypertrophy. The symptoms of metastases are pain in 

the back, radiating down into the thigh, often due to pressure of enlarged 

lymph nodes on the nerve roots as they come from the spine. The pain 

in the back may also be caused by bone metastases. Cachexia, anemia. 

loss in weight, and weakness arc the general symptoms common to all 

forms of cancer. 

A hard, nodular, asymmetrical, fixed or frozen gland with obliteration 

of the interlobular sulcus is the description of the rectal findings 

in a typical case of cancer of the prostate. However, these findings may 

vary. In the early stages of the disease it may be difficult to find any 

changes on the rectal side of the gland, or only a small nodule may be 

palpable. The small nodules are found more readily by palpating the 

gland on a sound placed in the urethra. 

In the advanced cases, a hard infiltration may be felt, extending 

upward above the gland and along the course of the seminal vesicles. In 

the adenocarcinoma type, one may feel a large, symmetrical gland resembling 

benign hypertrophy, but the consistency is much harder. 

On cystoscopic examination little may be found, especially in the 

type developing in the posterior segment. An elevation of the trigon 

due to infiltration of this area may be the only change noted. In more 

advanced cases, nodules projecting up into the bladder, at times ulcerated, 

may be seen. Trabeculation and injection of the bladder wall aro found 

in all cases in which retention exists. 

DIAGNOSIS 

The diagnosis from benign hypertrophy ordinarily is not difficult, 

especially if the rectal and cystoscopic findings are at all characteristic.

us 

R a d i u m 

The discovery of a small, hard nodule in any part of the gland should 

be looked on with suspicion and followed up carefully. Metastases maydevelop 

from such a nodule without any other changes occurring in the 

gland. The differentiation from the hard, fibrous prostate may offer 

some difficulty and may not be possible without microscopic sections. 

There are cases in which all characteristic signs and symptoms are absent 

and malignancy is not suspected until after the microscopic examination. 

TREATMENT 

We have the same problem in the relief of urinary retention in 

cancer of ihe prostate as we have in benign hypertrophy. Unless the 

upper urinary tract is protected by drainage, these patients will succumb 

to infection and destruction of the kidney as they do in benign hypertrophy. 

I believe that this drainage is best accomplished by suprapubic 

cystotomy, which also gives an opportunity for the accurate embedding 

of radium into the area above the prostate through which the lymphatics 

pass (Figs. 3 and 4). The same accuracy cannot be accomplished by 

directing needles through the perineum, and I believe that the accurate 

embedding into this area is the important step in the control of the malignant 

prostate. When once this area is locked off, there is less danger 

of the cancer cells spreading through the lymphatic channels to the pelvic 

lymph nodes. This may be likened to excising a tumor with a scalpel. 

and going beyond the limits of the growth through healthy tissue. Suprapubic 

cystotomy also gives an opportunity for removal of the benign 

upper segment of the gland when associated with malignancy of the lower 

segment. This benign area is not influenced by radium, and. if allowed 

to remain, prevents good urinary function when once the cancer is controlled. 

The benign lobe, as a rule, can be enucleated without much difficulty. 

If it is found adherent to the lower posterior segment, it can 

usually be separated by blunt dissection and scissors. 

It seems obvious that a suprapubic cystotomy gives the opportunity 

to accomplish best the three problems that confront us in malignancy 

of the prostate gland: i. e.. control of the cancer, relief of urimrv retention, 

and the establishment of good urinary function after the cancer 

has been controlled. When the lymphatics leading from the prostate 

gland have been blocked by the action of radium, the malignancy in the 

gland proper may be taken care of by introducing needles through the 

perineum, supplemented by urethral and rectal applications. Roentgenray 

therapy is undoubtedly of some value in conjunction with these 

other methods. 

The failure to control ihe disease in the past has been due. at least 

in some instances, to the haphazard introduction or application of radium 

to the malignant prostate. A knowledge of the lymphatic circulation. 

together with the establishment of good drainage of the urinary' tract, 

is essential to success in the control of the disease. Accuracy, coupled 

with attention to detail, is as important in the control of cancer of the 

prostate as in any other surgical procedure. 

REFERENCES 

1. Minet: Proc. verb. A. franc, d'urol. 13:629-646. 1910. 

2. Desnos: Bull. med. 28:231. 1914. 

3. Pasteau, Wickham and Degrais: Second conference internationclle 

pour I'etude du cancer. Paris. 1910. p. 707; other papers. 1911. 1913.

4. Cauhape: Thesis. Paris. 1911. 

R a d i u m 119 

5. Schuler: Wien klin. Wchnschr. 27:22, 1914. 

6. LeFur: Paris chir. 6:456-464, 1914. 

7. Young, II. H.: The Use of Radium in Cancer of the Prostate 

and Bladder. J. A. M. A. 68:1174 (April 21) 1917; South. M. J. n :i20 

(Feb.) 1918. 

8. Barringer. B. S.: The Treatment by Radium of Carcinoma of 

the Prostate and Bladder, J. A. M. A. 67:1442 (Nov. 11) 1916; Radium 

in the Treatment of Carcinoma of the Bladder anil Prostate, ibid. 68: 

1227 (April 28) 1917. 

9. Herbst. R. H.: Cancer of the Prostate. J. A. M. A. 72:1610 

(May 31) 1919. 

10. Janeway, H. H.: Am. J. Roentgenol. 7:325 (July) 1920. 

11. Kolischer. Gustav.: Am. J. Surg. 34:323 (Dec.) 1920. 

12. Morson, C.: Brit. J. Surg. 8:36 (July) 1920. 

13. Bugbee, H. G.: Radium in Cancer of the Prostate, J. Urol. 6: 

459 (D«.) 1921. 

14. Thomas, B. A., and Pfahler. G. E.: Tr. Sect. Urol. A. M. A., 

1921, p. 268. 

15. Marion, G.: J. d'urol. 7=335 (Aug.) 1918. 

16. Bumpus. H. C: Diverticula of Posterior Urethra, M. Clin. N. 

Am. 3:707 (Nov.) 1919. 

17. Hinman, Frank: Newer Methods for Radium Treatment of 

Prostatic and Vesical Cancer. J. A. M. A. 72:1815 (June 21). 1919. 

18. Fukase, N.: Surg., Gynec. & Obst. 35:131 (Aug.) 1922. 

A TECHNIQUE FOR THE APPLICATION OF RADIUM 

(EMANATION) IN CARCINOMA OF THE PROSTATE* 

By Ernest M. Watson, M. D.** 

Buffalo. N. Y. 

Since Pasteu and Degrais in 1913 made use of radium as a therapeutic 

agent in cancer of the prostate, there has been an increasing 

interest and a wide endeavor to determine the extent and limitations 

of this element in the management of the malignant prostate. Their 

method was to use a small quantity of the radium element sealed in a 

small glass tube, contained within a metal sheath and the whole fastened 

inside of the end of a soft rubber catheter which was allowed to 

remain within the urethra for the duration of the treatment (i. e., ]/•— 

1-2 hours). The end of the catheter which contained the radium was 

calculated to lie along the prostatic urethra and, when projwrly placed. 

the emanating rays would enter the middle, two lateral anterior and 

perhaps the posterior prostatic lobes. 

•Reprinted by permission from the Bulletin of the Buffalo General Hospital. 

January, 1924, 

"•h'rom the Department of C.'roloRy, New York State Institute for tli* Study 

of Malignant Disease.

120 R A D I U M 

In an effort to bring the radium in closer proximity to the prostatic 

mass and to secure a more uniform distribution of its active principle. 

Barringer in 1915 began the use of "radium needles." which were 

long hollow structures containing at their poinis a cavity which held 

a certain number of milligrams of radium element. These were inserted 

into the prostate gland through the perineum and allowed to remain 

there for several hours. The number of needles used and the 

length of time they remained in ihe gland depended upon the extent 

of the carcinomatous enlargement, and the strength of radiation desired. 

Later Young, in an attempt to increase the dosage of radium applied to 

the carcinomatous prostate and to more accurately apply it. devised several 

radium holders—or carriers, some of wh:ch were more accurately 

inserted along the urethra, coming to rest in the prostatic portion while 

J 

Figure I 

Trocar with l>tiirator In place, through wlilcl the; radium 

needles are passed. 

i; Radium n.-cdles at the end of which Is carried the 'sped" 

containing the radium emanation. 

others were inserted per rectum, coming to lie in close approximation to 

the posterior lobe of the prostate, which portion is generally conceded 

to be the site of predilection for the origin of carcinoma in this region. 

These so-called radium carriers all made use of small amounts of the 

radium element for their therapeutic efficiency. 

Due to the increased facilities in handling the emanation of radium 

founded upon Duane's researches antl particularly to the knowledge 

that their therapeutic potency is equal to that of the clement radium itself, 

a more general use of this form of application is now being made. 

As a means of satisfactorily using this form of emanation therapy 

in carcinoma of the prostate, a method has been devised which for the 

past three years has been used with some success. Bv this technique 

it has been possible to accurately deposit within the prostate gland, seminal 

vesicles, and trigone. 1500-2000 millicuric hours of radium. This 

can be accomplished under novocaine anaesthesia, in about 8-10 minutes. 

Xo prolonged instrumentation of urethra, rectum or perineum

R a d i u m 121 

is necessary by this means and the absence of any continued distress to 

the patient is very appreciable. 

This procedure is most readily accomplished with the patient in the 

Fi.a.RKlI 

Cross section of pel\ls and prustatic region showing the trocar 

passed through the midpoint In ihe perineum up to Ihe prostate. 

The finger in the rectum serves as a guide. 

lithotomy position. The region of the perineum is shaved and the skin 

is cleaned with iodine. A point along the median raphe about \)/z inches 

Figure III 

Cross section of the pelvis and prostatic region showing the trocar 

passed up to the prostate, ihe obturator withdrawn and 

the radium needle passed into the substance of the 

prostate gland.

122 R a d i u m 

in front of the rectum is chosen, and at this site several cubic centimeters 

of Yi of i

Radium 123 

is injected into the tissue in front of the prostate and into the gland itself. 

A satisfactory anaesthesia is usually secured in about 3-5 minutes. 

With a gloved finger in the rectum as a guide, a medium sized 

trocar is then inserted in the midline of the perineum up to the prostale. 

An instrument with a firm handle, and obturator with a sharp 

cutting edge has been found most desirable. The obturator is then 

withdrawn and through the hollow trocar the needles, each carrying a 

small glass tube or "seed" of emanation, are inserted and the seed deposited 

within the substance of ihe prostate gland. Without removing 

ihe trocar 15-20 "seeds" of emanation can readily be placed in different 

portions of the gland with a minimum of discomfort. The needles 

are directed to different portions of the gland by simply changing the 

axis of the trocar anteriorly, posteriorly, or laterally. The "seeds." varying 

in strength from 0.6-1.0 millicuries each, are placed about 1 cm. 

apart throughout the entire gland as indicated. 

Figure VI 

Chart showing prostatic and vesicular enlargement with 

of induration

124 R a d i u m 

commissure is involved,it is possible by greatly depressing the handle 

of the trocar, to direct the needles upward so that with the aid of a sound 

placed in the urethra (held by an assistant) and its tip inserted just beyond 

the external sphincter, this portion of the gland directly beneath 

the symphysis may be thoroughly "seeded." 

The work of Murphy. Maisin and Sturm has shown very strikingly 

the resistance of tissue to tumor transplants after X-ray treatment, and 

also the diminished chances of positive "takes" of an X-rayed tumor 

compared to one not so treated With these facts in mind, in addition 

to the "seeding" of cancer of the prostate, the periprostatic structures 

and areas immediately adjacent thereto should receive from So-ioo^ 

of an erythema dose of deep X-ray. 

BIBLIOGRAPHY 

Barringer. "The Treatment by Radium of Carcinoma of the Prostate 

and Bladder." Jour. A. M. A.. Vol. Ixvii. Xo. 20, p. 144-*. Xov. 11, I910- 

Duane, (a) "On the F.xtraction and Purification of Radium Kmanation." 

Physical Review. V. S.. Yol. v. Xo. 4. p. 31 >. April. 1915. (b) 

"Methods of Preparing and I "sing Radio-Active Substances lî the 

Treatment of Malignant Disease and of Estimating Suitable Dosages." 

Boston Med. & Sin-. J»ur.. Vol. 177. XV 23. \>. 787. Dec. 6, 1917. 

Murphy, Maisin and Sturm. "Local Resistance to Spontaneous 

Mouse Cancer Induced by X-rays." Jour. Fxper. Med.. Yol. xxxviii. 

Xo. 5. p. 645. Xov. 1, 1923. 

Pasteu and Degrais. "Radium in Cancer of the Prostate." Jour. 

of Urology. 1913. 

Watson and Ilcrger. "Certain Criteria of Management in Prostatic 

Carcinoma." Xew York State Jour, of Med.. Yol. xxiii. Xo. 7, p. 309. 

July. 1923. 

Young and Frontz. "Some Xew Methods in the Treatment of Carcinoma 

of the Lower Urinary Tract with Radium." Jour, of Urology. 

Yol. i. Xo. 6. p. 505. December, 1917- 

THE TWENTY-FIFTH ANNIVERSARY OF THE DIS 

COVERY OF RADIUM 

Bv G. Failla. Sc.D.. Memorial Hospital, Xew York City. 

The discovery of radium by the Curies was officially announced to 

the world in a paper read before the Academy of Sciences of Paris on 

December 26. 1898. The twenty-fifth anniversary of this momentous 

event in the progress of science was appropriately celebrated in Paris 

on the initiation of the Curie Foundation. The writer happened to be 

in Paris at the time, and was kindly invited to take part in the celebration. 

The principal ceremony took place at the Sorbonne and was presided 

over by President Millerand. The program was as follows: 

(1) La Marsellaise, played by the band of the Republican Guard. 

(2) Allocution by M. Paul Ap|»ell. rector of the Academy of Paris 

and president of the Curie Foundation.

R a d i u m 125 

(3) Polonaise Number 4 (Chopin), played by the band of the Republican 

Guard. The sentimental appropriateness of ibis selection i> 

obvious since Poland is Madame Curie's native country. 

(4) The presence of Professor Lorentz, who came from Leyden 

to take part in the ceremony, caused a change in the program. President 

Millerand called on the eminent Dutch physicist lo speak at this 

point. In very good French he brought out clearly the inij>ortance of 

radioactivity in modern physics, its relation in the unification of chemistry 

and physics, and the part played in the determination of atomic 

structure. 

(5) Conference by M. Jean Perrin, "Radioactivity and Its Importance 

in the Universe." Professor Perrin compared the advent of 

radioactivity to the conquest of fire by primitive man. He then reviewed 

the salient points of the discovery and of the properties of radioactive 

substances, emphasizing the transmutation of one element into another 

and mentioning the possibility of being able to do this at will in the 

future. 

(6) Reading of the significant passages in the scientific communcation 

of the Curies in which the initial discoveries relative to radioactive 

bodies were originally announced to the Academy of Sciences. 

Very appropriately these excerpts were read by M. Andre Debierne. 

who was associated with the Curies in the early days of the work, and 

has continued his collaboration with Madame Curie. To the physicist 

this was the most dramatic part of the program. It gave a vivid picture 

of the different steps which culminated in the discovery of radium. 

(7) Some Fundamental Kxperiments. These were made by M. 

Holweck and Mile. Irene Curie of Ihe Curie Laboratory. They were 

executed most successfully and impressed the audience greatly. The 

first was the discharge of a gold leaf electroscope by radium radiations. 

demonstrating the ionizing property of the rays. The second illustrated 

the random emission of alpha particles. In this experiment use was 

made of a radio-telephony amplifying system and loud speaker to "announce" 

the arrival of one alpha particle in a suitable ionization chamber. 

A so-called "radium clock" was then shown. The last experiment 

consisted in allowing radium emanation to diffuse into a glass tube 

coated with zinc sulfid which became phosphorescent, due to the bombardment 

of the alpha and beta particles. 

(8) Conference by Dr. Antoine Beclere. "Radium and Medicine." 

In his address. Dr. Beclere outlined the rapid progress of radium therapy 

and the important place which it now occupies in the treatment of malignant 

disease. Le Temps of December 27. 1923, quoted the following 

vivid passage: 

"Formerly surgery was the only means to combat cancer. To-day 

there is a happy competition between radium and X-rays and the surgeon's 

knife. These radiations represent so many bistouris. or rather 

invisible arrows, wonderfully sharp anil piercing, which riddle the whole 

diseased region and. without bleeding or mutilation, without injuring 

the skin, they kill in a deep-seated organ the cancer cells, leaving the 

neighboring normal cells intact." 

(9) President Millerand called on Madame Curie to talk. She 

arose amid enthusiastic applause, and was evidently deeply moved. In 

a very low voice she spoke of her work, paying tribute to the genius of 

Pierre Curie. Speaking of the discovery of radium, she said:

126 R a d i u m 

"It was a most modest enterprise undertaken by two humble beings 

anxious to serve. Started in the old school of physics where we could 

not find proper facilities, we were worried with difficulties which at 

times seemed insurmountable. We continued in spite of difficulties in 

order to realize an ideal which made us slaves to science. The discovery 

of radium was made under the most precarious conditions in a humble 

building that has since become legendary. Of the benefits which resulted 

therefrom one of us did not profit. Pierre Curie left us several 

years before the creation of the laboratory which bears his name. But 

we know that the rule of his life was to go on with his work no matter 

what happened, and according to his own fine expression 'to make of 

life a dream and of a dream a reality.' It is gratifying to know that 

by an unhoped-for good fortune, our discovery has helped to relieve 

human suffering." 

(10) Address by M. Leon Berard. minister of public instruction. 

M. Berard said he could not speak of the discovery of radium as a scientist, 

but he was happy to bring to Madame Curie the enthusiastic homage 

of the French Parliament. He spoke of the philosophical aspects of the 

great discovery, and paid tribute to science and the unselfish devotion 

to the search for truth of scientists such as Madame Curie. 

(ii) Allocution by President Millerand. President Millerand recalled 

the visit which he. in the capacity of minister of commerce, paid 

to the poorly equipped laboratory in which the Curies were carrying out 

their pioneer work, soon after the announcement of the discovery of 

radium. He mentioned the profound impression which M. and Mme. 

Curie made upon him. In conclusion he said: 

"The Government of the Republic, and Parliament as faithful interpreters 

of the people's thoughts, have already offered Madame Curie 

a concrete national recompense.* May she receive it with the solemn 

homage which we pay her to-day as a sincere token of the universal 

sentiments of enthusiasm, respect and gratitude in which she is held." 

(12) A march played by the band of the Republican Guard ended 

the ceremony. 

One of the touching episodes of the afternoon was the presentation 

to Madame Curie of a winged Victory in bronze, by a representative 

of the student body of France. Also the Belgian students were represented 

by a delegation of 120 who arrived in Paris unexpectedly. They 

offered their tribute in flowers. 

It is hardly necessary to say that the elite of the intellectual aristocracy 

of France were present en masse. Seats had been reserved on the 

stage for them and the representatives of foreign learned societies and 

institutions. From America, in addition to the writer, there were Professor 

Noyes. representing the American Chemical Society, and Dr. 

Gendreau. representing the I'niversite de Montreal (Canada). 

Official Inauguration of the Curie Foundation 

Since the Curie Foundation is practically unknown in this country, 

it is perhaps well to give a brief outline of its historical development. 

In 1922 the University of Paris and the Pasteur Institute in close cooperation 

founded the Radium Institute. In the years 1912-1914 two 

•This refers to th

R a d i u m 127 

modern laboratories were built, to be devoted separately to chemical and 

physical researches and to biological studies of radiation. The former 

is an intrinsic part of the University of Paris and is directed by Madame 

Curie. The latter bears an analogous relation to the Pasteur Institute 

and is under the directorship of Dr. CI. Regaud. The war came before 

the laboratories were even fully equipped and their work came to a standstill 

until the end of 1918. At this time, however, the work was taken up 

with renewed zeal, and rapid progress has been made. 

Since the Pasteur Pavillion is devoted to purely scientific investigations, 

the need soon arose for a suitable place in proximity to the laboratory 

where patients could l>e treated properly. It was to supply this 

need that the Curie Foundation came into existence. It is a private 

organization which has undertaken to supply means to the Radium Institute 

for scientific research, and particularly for the therapeutic applications 

of radium and X-rays. The foundation was recognized of public 

utility by official decree in May, 1921. and has enjoyed since the support 

of the government. 

The president of the Board of Directors is M. Appell. rector of 

the University of Paris; the vice-presidents are Dr. Roux. director of 

the Pasteur Institute, and Madame Curie; the treasurer is Dr. Henry 

de Rothschild, one of the founders; the secretary is Dr. Regaud. director 

of the laboratory of radiophysiology of the Radium Institute. 

The foundation has at the present time a dispensary adjoining the 

Radium Institute, a department at the Pasteur Hospital, and a department 

at the Medico-Surgical Clinic. The dispensary consists of two twostory 

buildings. One, the Rothschild Pavillion. is devoted to radium 

therapy, and the .other to X-ray therapy and diagnosis. No wards or 

rooms for the hospitalization of patients are available here, so thai patients 

needing hospital care must be taken by ambulance to the two abovementioned 

departments in other institutions. This is a serious disadvantage, 

which is felt keenly by the staff, and steps are being taken to 

correct it. The two buildings are very well arranged and equipped. For 

radium therapy 2,700 milligrams of radium element arc available. A 

considerable part of this is in solution for the preparation of emanation; 

the rest is used in fixed needles or tubes. The X-ray equipment consists 

of six high voltage machines of the latest design, from which a total 

of eight X-ray tubes can be run simultaneously. 

It will be of interest to American women who donated one gram of 

radium to Madame Curie to know that this radium is kept in the Curie 

Laboratory and used exclusively for experimental work by Madame 

Curie and her co-workers. Before she received this gift she had practically 

no radium, because in 191S she had given the Curie Foundation 

the gram which she had prepared herself from Bohemian ores. This 

was in accordance with her husband's wishes, for they had agreed that 

they should get no personal material advantage from their discovery. 

Other contributions to the supply of radium at the Curie Foundation 

were made by Dr. Henri de Rothschild and by the French government. 

A number of fellowships, of the value of 12.000 francs each, are 

available annually. They are awarded to properly qualified research 

wrorkers to carry out in the laboratories of the institute investigations

12S 

Radium 

relative to ihe biological actions of the radiations or to the radio-treatment 

of cancer. 

Indigent patient- are examined and treated gratis; to others a reasonable 

charge is made, payable to the foundation. The medical staff 

cannot collect fees from patients treated as private patients. 

The Curie Foundation had functioned for a considerable time, but 

the formal inauguration was reserved for the morning of December 

26. M. Paul Strauss. Minister of Hygiene, presided over the meeting. 

M. Appell spoke first. He praised particularly the minister of hygiene 

for his efforts in organizing in France a systematic fight against cancer 

by the establishment of regional centers, of which the Curie Foundation 

is the most conspicuous one. He thanked Madame Curie for her generous 

gift of one gram of radium, and all those who had made financial 

contributions. Finally, he praised Dr. Regaud. whose disinterested devotion 

to the work has made its rapid development possible. Dr. Regaud 

then explained the practical functioning of the foundation. 

Professor Bergonie. one of the pioneers of radiation therapy, paid 

a tribute to Madame Curie and recalled with emotion that it was in his 

laboratory in Bordeaux that she deposited her radium in Septemlwr. 

1914. at the time when it was feared Paris would be captured by the 

Germans. 

M. Strauss took this occasion to thank all those who had cooperated 

with him in his efforts on behalf of the cancer patient. He announced 

then that Parliament had voted unanimously five million francs 

for ihe purchase of radium. 

A tour of inspection through the two buildings concluded the program. 

Dinner Given by Dr. Henri dk Rothschild in Honor of Madame 

Curie 

The Rothschild family have been interested in radium since the 

beginning of the work. In the early days they were influential in securing 

some of the Bohemian ores needed by ihe Curies. Dr. de Rothschild 

has established a fund of 200.000 francs for the Curie Foundation and 

has contributed 400.000 francs for the purchase of radium. The celebration 

of the twenty-fifth anniversary of the discover)' of radium was 

completed in the evening by a dinner at his house, given in honor of 

Madame Curie. There were probably ntore than one hundred guests, 

including high government officials and the leading men of science in 

France. Madame Curie was very happy and cheerful the whole evening. 

In spite of the strenuous day she had had. she remained until a 

late hour.

R a d i u m 129 

NINTH ANNUAL MEETING OF THE AMERICAN 

RADIUM SOCIETY 

The ninth annual meeting of the American Radium Society, under 

the presidency of Dr. James T. Case, of Battle Creek, Michigan, was 

held June 9th and 10th, 1924. at the Drake Hotel, Chicago. Following 

a business session, scientific papers were presented on Monday as follows: 

William H. Schmidt, M. D., Philadelphia, Pa. Indications for the Use 

of Radium and Other Methods in the Treatment of Cancer. 

Gordon B. New, M. D., and F. A. Figi, M. D.. Mayo Clinic, Rochester. 

Minn. The Treatment of Fibromas of the Naso-Pharynx: A Report 

of Thirty-two Cases. (Read by Dr. Figi.) 

G. W. Grier, M. D., Pittsburgh. Pa. The Treatment of Malignant Disease 

in the Mouth. 

Henry K. Pancoast, M. D., Philadelphia, Pa. Some Observations on 

the Treatment of Carcinoma of the Larynx, 

C- Augustus Simpson, M. D., Washington. D. C. Radium in the Treatment 

of Tonsils. 

Bernard F. Schreiner, M. D.. Buffalo, X. Y. Results After Radiation 

of Cancer of the Uterus. 

Ernest C. Samuels, M. D.. New Orleans, La. Radiation in the Treatment 

of Carcinoma of the Uterus. 

George Adams Leland. Jr.. Bosion. Mass. Massive Dose Radium Treatment 

in Carcinoma of the Cervix. 

Albert Soiland, M. D.. Los Angeles, California. The Treatment of 

Inoperable Cancer of the Pelvis by Radium. 

Lawrence A. Pomeroy, M. D.. and Frank Milward. M. D.. Cleveland. 

Ohio. Radium in Lesions of the Female Urethra. 

G. E. Pfahler, M. D.. Philadelphia, Pa. A Safety Device for the Care 

of Radium Contained in Needles and Capsules. 

Henry Schmitz, M. D., Chicago, III. Radiation Treatment of Breast 

Carcinoma. 

Of particular interest in the Monday session was the symposium on 

the treatment of cancer of the uterus by radium. The papers in this 

symposium were unusually interesting and the discussion and papers 

brought out the now generally accepted feeling that radiation treatment 

of carcinoma of the cervix may be considered preferable to surgery. 

The annual dinner of the Society was given Monday evening and 

over one hundred and sixty members and guests were in attendance 

in the French room at the Drake Hotel. After the dinner, a brief address 

was given by the President, Dr. Case, introducing the speakers 

of the evening. Dr. Howard Kelly, of Baltimore, spoke on "That Which 

Is Assured in Radium Therapy." Professor Claude Regaud, of Paris, 

France, read a paper on the "Biological Aspects of Radium Therapy," 

in which he gave his views on the mode of the action of radiation on 

cells. The last talk was given by Dr. James Ewing. of New York City. 

and in a very brilliant, yet philosohpical, talk Dr. Ewing discussed the 

question. "Is Radiation an Epoch in Cancer Therapy?" leaving his

130 Radium 

hearers profoundly impressed with his masterly summary of the present 

status of radium in cancer therapy and fairly convinced that radium 

treatment in this condition does constitute an epoch. 

On Tuesday following a business session, papers were presented 

as follows: 

G. Failla, Sc. D., Memorial Hospital, New York City. A Brief Analysis 

of Some Important Factors in the Biological Action of Radiation. 

William L. Clark, M. D., J. Douglas Morgan, M. D., and Eugene J. 

Asnis, M. D., Philadelphia, Pa. Objections to the Use of Radium 

Emanation in Bare Tubes, With Clinical and Histological Observations. 

(Presented by Dr. Morgan.) This paper was discussed 

very fully by Drs. Regaud, Ewing and Quick. While admitting most 

of the disadvantages cited against the use of bare radium emanation 

tubes by the essayists, and while inclined to agree in part with some 

of the theoretical considerations adduced against the bare tubes by Dr. 

Regaud, Dr. Ewing closed his discussion by saying that after all it was 

the best clinical results which would have to be a most important factor 

in determining the usefulness of the several methods, and he invited 

Dr. Clark and his associates, and Dr. Regaud to give their statistics in 

order that the results might be compared with those from the Memorial 

Hospital where the bare tube method has found its greatest development. 

Dr. Hugh H. Young. Baltimore, Md., read a paper on "Survey of Results 

Obtained with Radium in Carcinoma of the Prostate and 

Bladder." 

Burton James Lee, M. D., New York City. Technique and Results in 

the Treatment of Mammary Cancer by Radiation. 

Tuesday afternoon a clinical meeting was held in the Clinical Amphitheater 

of Mercy Hospital; the following demonstrations were given: 

Professor C Regaud, Paris, France. Clinical Results of Radiation 

Treatment. 

Emil G. Beck, M. D., Chicago, 111. Carcinoma of the Jaw and Cheek. 

Charles W. Hanford. M. D., Chicago, III. Third Report of Cancer of 

the Esophagus 'Treated with Radium. 

H. L. Kretschmer. M. D.. Chicago, III. Treatment of Carcinoma of 

Prostate with Radium. 

Frank E. Simpson, M. D., Chicago, III. Treatment of Cancer of the 

Tongue by the Implantation of Bare Glass Ampoules Containing 

Radium Emanation. 

Harry E. Bundy. M. D„ Chicago. III. Value of Radium and X-Ray in 

the Treatment of Benign L'terine Hemorrhage. 

For the succeeding year the president will be Dr. W. S. Newcomet, 

of Philadelphia, and the following officers were elected at Chicago: 

Douglas Quick, M. D., Xew York. President-Elect 

Albert Soiland, M. D., Los Angeles. Cab, ist Vice-President. 

E. C. Samuels. New Orleans, Second Vice-President. 

Edwin C. Ernst, M. D„ St. Louis, Secretary. 

Robert E. Loucks, M. D.. Detroit. Treasurer. 

James T. Case, M. D.. Member of the Executive Committee.

R a d i u m 131 

Several distinguished workers in the fields of radioactivity and 

radium therapy were elected to honorary membership in the American 

Radium Society, among these being Professor Sir Ernest Rutherford, 

of Cambridge University, England, and Dr. James Ewing, of the Memorial 

Hospital and Cornell Medical School, New York City. The list 

of honorary members of this Society already includes such distinguished 

names as Dr. Robert Abbe, New York City, Dr. Howard Kelly, Baltimore, 

Dr. Francis Henry Williams, Boston, three of America's radium 

pioneers, Dr. Claude Regaud, Paris, and Madame Curie. 

The meeting was the largest and most successful which the Society 

has thus far held and great credit must be given the local committee on 

arrangements and particularly its chairman. Dr. Henry Schmitz. Other 

members of this committee included: William Lee Brown, Sr., M. D., 

Harry E. Bundy, M. D., Herman L. Kretschmer. M. D.. H. N. McCoy, 

Ph. D.. F. E. Simpson, M. D., C. W. Hanford, M. D., Emil Beck, M. D. 

NEW 

BOOKS 

Radium Report of the Memorial Hospital, New York (Second 

Series, 1923). Paul B. Hoeber, Inc., New York, 1924. 305 pages, 55 

illustrations. $5.00. 

It is the general opinion that the work with radium as carried out 

at the Memorial Hospital in New York is second to none. The report 

of this work as given in the newly issued volume is therefore of the 

greatest interest and utmost value to all medical men who would make 

a just assessment of the value of radium in the treatment of malignant 

growths and learn of the limitations and the future possibilities of radium 

treatment. 

Ilie nineteen chapters of this second report of the Memorial Hospital 

comprise articles as follows: 

I. The Present Status and Scope of Radium Therapy at the Memorial 

Hospital, by H. H. Janeway. 

II. Technical Principles Employed in Radium Therapy at the Memorial 

Hospital, by H. H. Janeway. 

III. Malignant Tumors of the Intraoral Group, by Douglas Quick. 

IV. Carcinoma of the Rectum, by Douglas Quick. 

V. New Growths of the Parotid Gland, by Douglas Quick. 

VI. New Growths of the Eyeball and Orbit, by Douglas Quick. 

VII. Malignant Tumors of the Skin, by Douglas Quick. 

VIII. The Use of Radium in Cancer of the Female Generative Organs, 

by Harold Bailey and Edith Quimby. 

IX. Vulval and Vaginal Cancer Treated by Filtered and Unfiltered 

Radium Emanation, by Harold Bailey and Halscy J. Bagg. 

X. Follow-up Results of 908 Cases of Uterine Cancer Treated by 

Radium, by Harold Bailey and William P, llealy. 

XL Technique and Results in the Treatment of Carcinoma of the 

Breast by Radiation, by Burton J. Lee. 

XII. Treatment of Recurrent Inoperable Carcinoma of the Breast by 

Radium and Roentgen Rays, by Burton J. Lee. 

XIII. Results of the Treatment by Radiation of Primary Inoperable 

Cancer of the Breast, by Burton J. Lee.

132 R a d i u m 

XIV. Carcinoma of the Prostate, by Benjamin S. Barringer. 

XV. Radium Treatment of Carcinoma of the Bladder, by Benjamin 

S. Barringer. 

XVI. Radium Therapy of Teratoid Tumors of the Testicle, by Benjamin 

S. Barringer and Archie L. Dean, Jr. 

XVII. Epithelioma of the Penis, by Benjamin S. Barringer and Archie 

L. Dean, Jr. 

XVIII. The Present Field for the Use of X-Rays and Radium in the 

Treatment of Malignant Tumors, by William S. Stone. 

XIX. An Analysis of Radiation Therapy in Cancer, The Mutter Lecture, 

by James Ewing. 

In the foreword it is stated: "Two main considerations have led 

to the delay in issuing the second report. The foremost of these has 

resulted from the rather numerous changes in technical methods which 

were found necessary in the development of the work while the treatment 

of various forms of carcinoma was in the experimental stage. The 

second consideration was the great desirability of having a longer period 

of observaiion of cases treated before attempting to form judgments 

regarding the efficiency of the methods used. 

"Owing to present uncertainties in both these particulars, no mention 

is made in this report of several diseases, the radiation treatment 

of which is at present occupying much of the attention of the medical 

staff. For the forms of carcinoma discussed in this second report, it is 

the belief of the staff that no radical changes are likely soon to occur 

either in the methods employed or in the character of the results obtainable 

by radiation, and it is therefore thought best to issue the report 

at this time. 

"Several of the contributions included in the report, as well as many 

others by members of our hospital staff, have already been published in 

various medical journals where they have been accessible for one or more 

years. Others have been prepared especially for this publication." 

The first article on "The Present Status and Scope of Radium 

Therapy at the Memorial Hospital" was written by Dr. Janeway shortly 

before his death and was later somewhat revised. In the second article, 

also by the late Dr. Janeway. detailed description is given of the "Technical 

^Principles Employed in Radium Therapy at the Memorial Hospital." 

The next fifteenchapters are devoted to the discussion of radium 

treatment of various malignant growths, including exact data on the 

methods and dosage used and the results attained. 

In chapter XVIII, Dr. William Stone makes a masterly general 

summary of the "Present Field for the Use of the X-ray and Radium 

in the Treatment of Malignant Tumors." In opening. Dr. Stone says: 

"Roentgen rays and radium in the treatment of malignant tumors are 

still accepted reluctantly by the surgeon, except as palliative agents in 

the advanced stages of the disease. Their application before the patient 

is in an incurable stage appears to be an insufficiently tested method. In 

the case of X-rays it is particularly so. for, before the recent advent of 

the high-voltage machine. X-ray therapy had become so overshadowed 

by the results of radium that it had lost somewhat of its early reputation. 

"It seems, therefore, to he an opportune time to review this work. 

as it has been presented to the writer during a service of seven years at 

the Memorial Hospital. During this period more than io.ooo cases of 

neoplastic disease have been under his observation, to the majority of

R a d i u m 133 

which X-rays or radium have been applied. We feel that we have now 

arrived at a position in this work from which we may discuss the surviving 

old, the established new, and the still experimental." 

And in closing, he says: "In conclusion, in addition to supplanting 

the operation as the method of choice in a number of fields of malignant 

neoplasm, the use of irradiation has so limited the field of applicability 

of the radical operation in numerous others that it is becoming 

a questionable procedure. In uterine cancer, it is entirely eliminated. 

and in mammary cancer it is a question of accurate diagnosis. 

"The use of irradiation, therefore, has made necessary greater refinement 

in diagnosis than heretofore. 

"To this end, the patient's interests are best conserved by obtaining 

the conjoined knowledge of the surgeon and the radiologist. In fact, 

cancer therapy has become an institutional problem requiring, for the administration 

of physical agents, more clinical experience and knowledge 

of surgical pathology than does operation." 

In the last chapter of the Report, Dr. Ewing gives "An Analysis 

of Radiation Therapy in Cancer." This article is the Mutter Lecture 

for 1922. Dr. Ewing considers the question, "Do radium and x-rays 

exert a selective action in tumor cells?" and after carefully weighing 

the evidence concludes that the action of radiation is both specific and 

selective. He says: "We have thus reviewed three main principles of 

radiation therapy which appear to be fundamentally different, and each 

of which is selective, specific and tends to support natural processes of 

defense. These are: 

"1. Autoiytic degeneration, observed mainly in the group of embryonal 

tumors. 

"2. Caustic destruction, employed in the treatment of resistant 

adult squamous carcinoma by bare radium emanation tubes, active deposit 

of radium and heavy doses of hard gamma and X-rays. 

"3. Growth restraint, illustrated in the slow recession of resistant 

tumors under deep radiation and in the treatment of chronic inflammatory 

hyperplasias." 

Next are considered the following important topics with the conclusions 

warranted by a careful weighing of the clinical or other evidence. 

(a) Does radiation ever stimulate tumor growth? 

(b) The effects of "deep radiotherapy" with radium and X-rays. 

(c) Adjuvants to deep radiation therapy. 

(d) The influence of radiation therapy in the knowledge and conception 

of tumors. 

(e) The methods and indications for radiation therapy. 

(f) The influence of radiation therapy on the cancer problem. 

This article is a most profound and lucid statement of the physiological 

basis of radiation therapy with a classification of tumors, and 

an estimate of the value of the various forms of radiation used in the 

many types of malignancy treated at the Memorial Hospital. 

A careful study of this Report will be of inestimable value to those 

engaged in radiotherapy, and the reading of the philosophical and masterly 

summaries by Drs. Stone and Ewing will give those who seek it 

an eminently fair and comprehensive estimate as to the value of radiotherapy.

134 Radium 

Pierre Curie, by Marie Curie. Including also Autobiographical 

Notes. Translated by Charlotte and Vernon Kellogg, with an Introduction 

by Mrs. William Brown Meloney. Illustrated. 242 pages. The 

MacMillan Company, Xew York, 1923. 

In her preface Mme. Curie says, "It is not without hesitation that 

I have undertaken to write the biography of Pierre Curie. I should 

have preferred confiding this task to some relative or some friend of his 

infancy who had followed his whole life intimately and possessed as 

full a knowledge of his earliest \ears as of those after his marriage. 

Jacques Curie, Pierre's brother and companion of his youth, was bound 

to him by the tenderest affection. But after his appointment to the University 

of Montpelicr. he lived far from Pierre, and he therefore insisted 

that I should write the biography, believing that no one else better 

knew and understood the life of his brother. He communicated to me 

all his personal memories and to this important contribution, which I 

have utilized in full. I have added details related by my husband himself 

and a few of his friends. Thus I have reconstituted as best I could 

that part of his existence that I did not know directly. I have, in addiiton, 

tried faithfully to express the profound impression his personality 

made upon me during the years of our life together." 

Mrs. William Brown Meloney, well known as the Editor of the 

Delineator, in an introductory chapter tells of her visit to Mme. Curie 

in Paris in 1920. As a result of this visit Mrs. Meloney was instrumental 

in raising a fund contributed by the women of America to purchase 

a gram of radium for Mme. Curie, the presentation of which was 

made to Mme. Curie at the White House by President Harding on May 

20, 1921. During the American travels. Mrs. Meloney repeatedly requested 

Mme. Curie to write the story of her life and this little book 

about her husband, and the notes about herself, is the result. 

In the story of the life of her husband. Mme. Curie pays tribute 

to the devotion to science that characterized Pierre Curie. She paints 

his disdain for worldly honors that caused him to refuse the decoration 

of the Palmes academiques and the I-egion d'Honncur. She tells of 

spending money given her for her trousseau to buy two bicycles, upon 

which the newly wedded couple made many happy trips in and around 

Paris. She tells of her husband's successful researches and his gradual 

advancement—with the continual struggle for something like adequate 

research laboratory facilities. Then when she had begun that interesting 

work on the measurement of the radioactivity of minerals, which 

showed their abnormally high activity, she tells how her husband helped 

in the tedious and yet fascinating work, which led to the discover)' of 

polonium and radium in 1898. Their simple and happy family life, the 

two daughters, Irene and Eve. are touched on.—the greater and greater 

recognition accorded their work, including the joint award to Becquerel 

and themselves of the Nobel Prize in 1903. and in 1905 membership for 

Pierre Curie in the Academy of Sciences, the tenancy of a newly created 

professorship in the Sorbonne. With all these honors went a continued 

struggle for better experimental facilities, the need of which is vividly 

shown in some of the illustrations which depict the crude means used 

by the Curies in their firstlarge scale work of extracting radium from 

the residues of pitchblends from St. Joachimsthal in Bohemia. Then 

the tragedy of April 19. 1906, when the life of Pierre Curie was cut off 

untimely as a result of being struck by a truck while crossing the street.

R A D I U M 135 

In the autobiographical notes, Mme. Curie tells of her parents and 

family, her ambitions, her coming to Paris, and the meeting of Pierre 

Curie, their common tastes and sympathies, which led in July, 1895, to 

their marriage. In a later part she tells of her work in the training of 

X-ray workers during the war, and the re-establishing of her teaching 

and research work in Paris after the close of the war. In the last two 

chapters Mme. Curie tells of her American trip and the concluding 

sentence of her notes is one of appreciation: "I got back to France with 

a feeling of gratitude for the precious gift of the American women. 

and with a feeling of appreciation for their great country tied with ours 

by a mutual sympathy which gives confidence in a peaceful future for 

humanity." 

The writer of this review cannot refrain from noting a correction 

to a statement made on p. 235, where Mme. Curie, in speaking of the 

presentation of the radium made at the White House, says: "The radium 

itself was not brought to the ceremony. The President presented me 

with the symbol of the gift, a small golden key opening the casket devised 

for the transportation of the radium." As one who assisted Mr. 

James C. Gray, the President of the Standard Chemical Company of 

Pittsburgh, by whom the radium was refined and prepared, in the carrying 

of the precious burden from Pittsburgh to the White House, and 

after the presentation ceremony, to the United States Bureau of Standards. 

I know the actual radium was enclosed in the metal container 

which, housed in a mahogany chest whose golden key Mme. Curie received 

from the President, stood on a pedestal in the space between the 

audience and the chairs reserved for the President. Mme. Curie, and 

the other speakers and immediate members of Mme. Curie's party. 

REVIEWS AND 

ABSTRACTS 

John G. Clark, M. D„ and Frank B. Block, M. D., (Philadelphia, 

Pa.) Relative Values of Irradiation and Radical Hysterectomy for Cancer 

of the Cervix. Am. J. of Obstet. and Gynec, vii, 543-550, May. 

1924. 

"Surgical statistics the world over demonstrate the fact that there 

is scarcely an anatomic situation which offers a more discouraging outlook 

for operative intervention than cancer of the cervix. It is not, therefore, 

surprising that many excellent surgeons have largely side-tracked 

the radical abdominal operation in favor of irradiation, since the low 

percentage of operability and the high rate of mortality have not proved 

a very alluring fieldfor such a strenuous endeavor. In our own hands. 

in the Gynecologic Department of the University Hospital, notwithstanding 

the most assiduous endeavor, we were never able to achieve a salvage 

of more than 33 per cent of five-yearcures, in a relatively small number 

of operable cases, which had been culled from a much larger group of 

hopeless cases. Several reports from other sources have demonstrated 

a higher percentage of curability, while some have dropped below this 

point. It was not difficult, therefore, to 'swap horses' when the surgical 

race had been so poorly run by the first nag, and the second offered a 

hope for at least as good if not a better issue." 

"In our initial employment of radium, we proceeded with great cau-

136 RADIUM 

tion, applying it only in hopelessly inoperable cases, but when this agent 

began lo yield such startling palliative results, we widened its scope of 

administration to the zone of borderline cases, acting on the principle 

that irradiation, which is accompanied with almost no mortality, would 

work quite as effectively as a hazardous operation with its large percentage 

of rapid recurrences and infrequent cures. Again, after advancing 

our standard the results did not cast discredit upon this innovation, 

and for the last three years the choice of a radical operation 

has been limited to the absolutely favorable type, and they have been 

so few in comparison with the number of hopeless and borderline cases 

as to be almost negligible. It has been our endeavor to maintain as judicial 

an equilibrium as possible, not too hastily abandoning the old and 

not too unreservedly taking on this newer therapeutic method. After 

all. as our experience has taught, and statistical reviews fully confirm, 

there is no accurate or scientific method of determining the exact extent 

of any cancerous process, for not only does operability vary remarkably 

among surgeons of the highest merit, but even in one's individual 

experience, this instability is noted. What we might define as a 

borderline case at one time may be classed as inoperable at another." 

"There really is but one way of classifying cures in cancer, and 

that is. upon an actual basis of gross numbers. The question is. how 

many cases of cancer have you seen, and how many have vou cured? 

Were the physician to attempt to define what is a curable, a borderline. 

or an incurable cases of pneumonia, typhoid fever, or any of the numerous 

diseases which he encounters, he would hopelessly muddle statistics, 

and we are persuaded after a perusal of many articles on cancer, 

based upon this differential standpoint, that the results are glaringly 

chaotic. To put this matter in a nutshell, all cases of cancer recorded 

in our clinics should be included as a whole and not subdivided into 

classifications so subject to the large factor of human mutability. How 

better may one confirm this observation than by pointing to the accompanying 

compilation of the surgical results of ten skillful specialists? 

Thus Peterson in 380 cases considered only 15.7 per cent as operable, 

whereas Graves in a series of 189 cases, operated upon 65 per cent. If 

such a wide difference occurs in the hands of two men of special skill. 

what may one expect from the surgical world at large? As we view 

this situation, we consider such an attempt to define surgical limits as 

practically useless. As an example of exaggerated caution, a writer has 

recently defined the curable case of cancer of the cervix as one which 

can only be recognized microscopically. This refinement of selection 

would essentially reduce operability to a vanishing point, and of course 

is the view of a surgical pessimist. The point which we wish to make 

is that mass statistics rather than differential values are. in the final run. 

the only safe basis upon which to rest our estimate of curability. Furthermore, 

the surgical mortality following the radical operation is even 

of wider variability, for in the accompanying table, the lowest mortality 

recorded is 5 per cent, whereas the highest is 26.6 per cent. Also, what 

one surgeon designates as a radical abdominal operation when compared 

with the extensive dissection of another surgeon might quite properly 

be classified as a simple panhysterectomy. And so goes the fallacy of 

statistics which are built upon such shifting sands." 

"The object of our paper is to compare surgical and irradiation 

statistics viewed from the standpoint of cures, and the mortality attributable 

to therapeutic intervention. In Table II the most recent results

R A D I U M 137 

of radical operations from ten excellent clinics are epitomized, and a 

mere glance at these columns sets forth the ever intrusive human equation. 

Thus Martzloff's report from the Gynecological Clinic of the Johns 

Hopkins Hospital shows a 14.2 per cent mortality and only a 26.6 per 

cent salvage—a poor exhibit in comparison with many other reports. 

Knowing the method followed in compiling these statistics, we are confident, 

however, that none can be more strictly fair or more accurate. 

For instance, there has been a change of viewpoint in recent years among 

pathologists as to what constitutes malignancy in certain questionable 

changes. Taking into account this fact, Martzloff first reviewed the 

original microscopic slides of all cases diagnosed as cancer in the gynecologic 

laboratory, and chose only those which were unqualifiedly malignant, 

discarding all questionable cases, and still others which a decade 

ago were designated as malignant, but which are today otherwise classified. 

Upon this scientific diagnostic basis his clinical structure was 

erected. Just as the personal equation varies both in the perfection of 

surgical skill and judgment, so likewise may the ability and accuracy 

of the pathologist be measured. It has been our experience that even 

the best genera! pathologist is inclined often to pronounce glandular 

changes in the cervix as malignant, while another specializing in gynecologic 

microscopy will unhesitatingly take a benign view of the same case. 

This element of error is strikingly illustrated in a decision as to what 

constitutes a deciduoma malignum. Thus into all statistical reports in 

which there is a close microscopic question as to malignancy, an error 

may he introduced, which always favors a larger percentage of cures. 

For fear of dooming a patient because of an error of judgment, not 

infrequently the pathologist, when in this dilemma, acts upon the principle, 

when in doubt classify the specimen as cancer. For this reason 

we call especial attention to Martzloff's report, because there has been 

such a rigid sifting out of all questionable microscopic material. In 

the study of Table II, the widely varying viewpoints as to operability 

and the great divergencies between the surgical mortality and the fiveyear 

cures of several reporters is so vividly evident as to require no 

further comment. Such wide discrcpcancies in results can scarcely 

occur in any other domain of surgical endeavor." 

"Statistics on Treatment of Cervical Cancer.—The Radical 

Abdominal Operation.—About ten years ago Jacobson compiled statistics 

on this subject. At a later date his work was included in the statistics 

of Janeway published in 1919 (Surg., Gyn., and Obst., 1919, xxix, 

242). The latest collected statistics are those of Duncan (Jour. Am. 

Med. Assn., 1921, lxxvii, 604), which include Jancway's work (Table 

I)." 

"A review of the literature for the past three years by Skeel (Am. 

Jour. Obst. and Gynec, 1922, iii, 252) demonstrates the obvious fact 

that the mortality rate declines with experience. He estimates that of 

every 100 cases of cervical cancer applying for treatment only 50 are 

operable. On an average, there will be a primary mortality of five (10 

per cent), recurrences in 25 (50 per cent), five-year cures in 20 (40 

per cent), while 50 will die without operation. He believes a radical 

operation lacks justification with such results if any other less hazardous 

measure offers an equivalent. Judged by this very fair standard, we 

have compiled the recent statistics from ten surgical clinics, and a glance 

at Table II will show how remarkably accurate is Skeel's estimate."

138 R a d i u m 

Carcinoma of Cervix 

Abdominal Operation 5027 

Percentage 

Carcinoma of Cervix 

Vaginal Operation 1205 

Percentage 

Name of 

Reporter 

Table I 

Cases Cured for Five-Year Period 

of of Cases 

Number Opera- Primary of Cases Applying 

of bility Mortality Cases Operated for 

Cases 

Traced Upon Treatment 

1720 

34.21 

654 

58.1 

Table II 

1090 

18.23 

192 

9.35 

35.41 

29-67 

Radical Operation for Carcinoma of Cervix 

Journal 

Total 

Applying 

Operability 

Per 

Cent 

19.32 

17.74 

11.27 

9,26 

Number Primary 5-Years 

Oper- Mortality Cures 

ations 

Martzloff Bull. Johns Hopkins 

Hosp., 1923, xxiv, 141. 387 46 % 178 14.2% 26.6% 

Maver Zentralbl. f. Gynak., 

1920, xliv, 617. 

725 65.3% 457 20.3% 39.3% 

Cobb Jour. Am. Med. Assn., 

35 14.3% 57.1% 

1920, lxxiv, 14. 

Graves Surg. Gynec. and Obst, 

189 64 % 119 5.0% 34.2% 

Bonney 

1921, xxxii, 504. 

100 20.0% 42.3% 

Brit. Med. Jour., 1921, 

ii, 1103. 

380 15.7% 60 26.6% 40.9% 

Peterson N. Y. State Jour. Med., 

443 

1920, xx, 313. 

40.0% 177 6.78% 51.4% 

Schweitzer Zentralbl. f. Gynak., 

1921, xlv, 289. 

Davis Ann. Surg., 1922, lxxvi, 

85 

371 

37.6% 

70.6% 

32 

224 

9.3% 

19.6% 

40.0% 

33.5% 

395. 

157 

49.0% 

Giesecke Arch. f. Gynak., 1922, 

"The ratio cxv, of 435. operability varies from 15.7 per cent to 70.6 per cent, 

but Bumm the oft Zentralbl. repeated statement f. Gynak., that low operability means high percentage 

of cures 1919, does xliv, not pt. invariably 1, 1. hold since Peterson has the lowest 

operability (15.7 per cent), but his percentage of cures (40.9 per cent) 

is about the average, as stated by Skccl. Furthermore, his primary mortality 

is highest (26.6 per cent), which would indicate that he performs 

a very' extensive operation. In the entire series, the primary mortality 

varies from 5 to 26.6 per cent. Totalling the statistics we find that in 

'•539 abdominal operations, there were 608 five-year cures, or 39.5 per 

cent curability. This then represents the present curability of cervical 

cancer in the hands of the most experienced surgeons throughout the 

world. The percentage of cures is slightly higher and the primary mortality 

is a bit lower than Janeway found a few years ago." 

"In the compilation of statistics on radiotherapy of cervical cancer, 

for purpose of comparison, we encounter some difficulty. While radium 

is widely used, and there is much literature upon this subject, there are 

but few reports which deal with five-year cures—not because they do 

not occur, but because this innovation is yet in its infancy. Heyman

R a d i u m 139 

reports 26 cases, 85 per cent of them inoperable, and seven, or 29 per 

cent, have been cured over fiveyears. We have taken from Bailey and 

Hcaly's report, not yet published, only the cases treated by their new 

technic in the Memorial Hospital of New York, which have passed the 

five-year test. These surgeons have had available for use maximum 

amounts of radium. In this Table, there are 160 operable cases treated 

by radium five years or more ago with 69 or 43.1 per cent cures. Of 

the inoperable cases, there were 41S subjected to irradiation with 38 

or 9 per cent five-yearcures." 

Bumam 

Table III 

Radiotherapy in Carcinoma of Cervix 

N. Y. State Jour. Med., 

1920, xx, 316. 

Flatau* Zentralbl. f. Gynak., 

1923, xix, 737. 

Bailey and Jour. Am. Med. Assn., 

Healy 1923, Ixxxi, 65. 

Schmitz Northwest Med., 1923, 

xxii, 77. 

Bumm Zentralbl. f. Gynak., 

1919, xliv, pt. 1, 1. 

Series 1913 

•Denou 

Operable Borderline Inoperable Recurrent 

Inoperable 

50% 

50% 

->-

140 R a d i u m 

erations reported from the Gynecological Clinic of the University Hospital 

in 1913. yielded only a 33 per cent curability with an 8 per cent 

incidental mortality. In 22 cases treated by radium with no primary 

mortality, 27.2 per cent passed the five-yearperiod. When we add a 

6.7 per cent of five-yearcures in the inoperable classit will be seen that 

the results are practically equivalent to those obtained by the radical 

operation. On the other hand, in estimating the relative values of these 

two plans of treatment on a basis of hospital economics, the efficiency 

of the two classes of patients immediately after treatment, the checking 

of distressing symptoms, and the reduction of morbidity, the argument 

is manifestly in favor of the irradiation series. However, the distressing 

fact is still quite evident that while irradiation is of inestimable value 

as a therapeutic agent and removes from the surgical domain the great 

majority of cases of cancer of the cervix, we arc not as yet in sight of 

a real and efficient remedy for this disease in by far the overwhelming 

majority of cases." 

"We have classed as operable those cases in which the disease had 

not extended beyond the cervix or the body of the uterus. The inoperable 

cases were those in which the disease had extended into the broad 

ligaments, vagina, had invaded the vesical or rectal walls, or had metastasized 

to remote glands. Also, under this head were placed all cases 

the records of which did not show in accurate detail the extent of the 

growth. 

Table IV 

Radium Treatment of Carcinoma of Cervix. Cases Applying for 

Treatment in the Gynecologic Department of the University 

Hospital Between January i, 1914, and January i. 1919 

(Compiled by Dr. Robert Kimbrough) 

Total Xo. Operable 122 Cases) Inoperable Recurrent Totals- 

Cases 5-Year Cures (118 Cases) Inoperable Year 

5-Year Cures (4 Cases) 5- Cures 

Year Cures 

!44 27.2^ 6.7% 25% 10.4% 

"As to the relief of symptoms, we find the results about the same 

as reported in previous paper on this subject issued from the Gynecological 

Department of the University Hospital. In conclusion we again 

reiterate our oft repeated statement that radium is a palliative remedy 

of inestimable value in the great majority of hopeless surgical cases 

and of absolute curative value in a small percentage. While it challenges 

most favorable comparison with the radical abdominal operation nevertheless, 

we take no issue with the skillful specialist who still adheres 

to the radical viewpoint, provided he supplements his operation with 

postoperative irradiation. As to antcoperative irradiation, we arestill 

doubtful and await with interest the report from those clinics in which 

this prophylactic plan is employed. To discard or fail to use this newer 

remedy as an adjunct to surgical measures in the face of such statistics 

as are now available should lay the objector open to a charge of serious 

negligence." "

R a d i u m 141 

George W. Crile, M. D., (Cleveland. Ohio). Carcinoma of the 

Uterus. Am. J. of Obstet. and Gynec, vii, 528-535, May, 1924. 

"The American College of Surgeons has attacked as one of its first 

problems for intensive study the treatment of carcinoma of the cervix; 

and the uniform presentation of data collected from various clinics 

covering all phases if incidence, types of tumors, symptoms and operability 

and the results of various methods and combinations of methods 

of treatment should throw urgently needed light upon this outstanding 

problem." 

"A study of the literature for the past two years, in the hope that 

we might glean therefrom comparative statistics, shows such a divergence 

of opinion, and such a divergence of plan of presentation of statistics 

that it is practically impossible to draw any final conclusions. In this 

presentation, therefore. I shall, in the main, confine myself to a report 

of preliminary studies of carcinoma of the cervix and the fundus which 

have come under the observation of my associates and myself. This 

study is still in progress and the results reported here and the deductions 

drawn therefrom are to be considered as the results and deductions 

of the moment which may possibly be altered by our later investigations." 

"The results of our statistical studies at the present time are given 

in Table I: 

T ABLE 

End-Results—Carcinoma of the Uterus 

Total number of cases 

Not treated 31 

Cases available for study of operability, 

mortality, etc 

j 

Radical operation 60 

Palliative No operation—radium and X-ray only. 1108 5'2 

Operative deaths—radical operation 

Operative mortality—'radical operation.. 

Operability (radical operation) 

Cases heard from 

Radical operation 

No Palliative operation—radium and X-ray only. 

Number of cases surviving 3 years (heard 

from) 


Palliative operation 

No operation—radium and X-ray only. 

Number of cases surviving 5 years (heard 

from) 


Palliative operation 

Percentage of 3 year survivals—all 

operations 

Percentage of 3 year survivals—radical 

operations 

Percentage of 5 years survivals—all 

operations 

Percentage of 5 years survivals—radical 

operations 

• 

42 

47 

50 

Cervix Fundus 

16 

•4 

3 

14 

3 

251 

220 

4 

6.7% 

27.37< 

139 

23 

17 

22.5% 

38.1% 

19.1% 

33.3% 

15 

70 

17 

36 

6 

3 

12 

2 

0 

10 

1 

106 

91 

14 

11 

6 

8.6% 

76.9% 

44 

34.1% 

33.3% 

26.8% 

I 27.7% 

All Cases— 

Fundus and 

Cervix 

357 

46 

130 

125 

56 

84 

52 

53 

28 

6 

8 

24 

4 

311 

10 

7.7% 

41.8% 

189 

37 

28 

25 % 

33.3% 

20.6% 

28.6%

142 R A D I U M 

"Operability.—Radical operations were performed in 60 of the 220 

cases of carcinoma of the cervix regarding which we have sufficient 

data for study. On the basis of this figure the operability in this series 

was 27.3 per cent. Among 91 cases of carcinoma of the fundus, a radical 

operation was performed on 70. making an operability of 76.9 per 

cent." 

"Although various reporters have published operability percentages, 

it is obvious that their figures cannot be used as a basis of comparison 

unless the judgment of each reporter as to the standard of operability 

is known." 

"Of particular interest in this discussion of operability- is the short 

duration of symptoms and the extent of involvement at the time of operation. 

Thus, among the cases of cancer of the cervix, in three cases 

in which the symptoms had been recognized for less than a month, two 

were diagnosed as inoperable and the vagina was involved in one. In 

36 cases in which the duration of symptoms had been less than a year, 

30 were inoperable and the vagina was involved in six. These figures 

emphasize certain points to be made later regarding earlier recognition 

of carcinoma of this organ." 

"Incidence.-—Our figures show the highest incidence of both carcinoma 

of the cervix and carcinoma of the fundus between the ages 

of 50 and 60 years. This is later than the findings of most reporters 

who place the highest incidence between the ages of 40 and 45 years. 

As to the occurrence in married and unmarried women, but six of our 

cases of cancer of the cervix occurred in single women. A similar relation 

exists in the case of carcinoma of the fundus, our series showing 

78 cases among married women as contrasted with 10 among unmarried. 

These figures, combined with the lack of recognition of early symptoms, 

emphasizes the" importance of Kelly's suggestion that '(1) The 

physician attending a woman at labor should, six or eight weeks later, 

make an examination and find out what lesions remain,' and '(2) Every 

woman who has borne children should have a careful gynecological examination 

at least once every year until she is 55 years old.' as in view 

of the' symptomless early stages only by direct examination can one 

surely catch the very firststages of carcinoma of either portion of the 

uterus. This point is emphasized also by the fact that among our cases 

hemorrhage or other discharge was noted as the first symptom in 122 

out of 132 cases of carcinoma of the cervix in which the first symptom 

was noted, and in 60 of the 68 cases of carcinoma of the fundus in 

which the first symptom was noted. It will require a very long period 

of propaganda and instruction of the public and medical profession at 

large to assure that every' woman above the age of 40 will surely look 

upon any abnormal discharge from the uterus as a suspicious symptom 

upon its first appearance, especially during the period of the menopause." 

"Predisposing Causes.—The preponderating incidence of carcinoma 

of the uterus in married women, especially in women who have bome 

children, indicates that laceration and irritations of the cervix are certainly 

to be considered as primary predisposing causes. Poeltse reports 

that chronic endocervitis preceded cancer in 34 out of 48 cases. Ewing 

maintains that polypoid myomas of the cervix are usually malignant 

at all ages and that the presence of a myoma in this region, therefore, 

is to be considered as a definitely premalignant condition."

R a d i u m 143 

"In carcinoma of the fundus, Ewing believes that myomata are the 

first causative factors, an opinion apparently borne out by W. J. Mayo, 

who states that 'cancer of the cervix occurs 15 times as frequently as 

cancer of the body of the uterus, but in myomatous disease, cancer of 

the body of the uterus is found five times as frequently as cancer of 

the cervix, chronic irritation of the uterine tumors increasing the incidence 

75 times.' These opinions would seem to be strengthened by the 

fact that uterine myoma is estimated to be present in 50 per cent of all 

women over 50 years of age. Any local congestion or chronic endometritis 

aids the development of carcinoma. Cullen has reported perhaps 

the earliest squamous-cell carcinoma of the cervix which has been 

reported, its occurrence being discovered by an examination of the scrapings 

in a case curetted for hemorrhage due to hyperplasia of the endometrium 

and a small submucous myoma. Kelly and others urge the importance 

of most painstaking examination of all curetted material by 

someone sufficiently expert to recognize the presence of cancer cells." 

"As for the type of carcinoma, our findings to date coincide with 

those reported by Ewing, squamous-cell carcinoma predominating among 

our cases of carcinoma of the cervix, and adenocarcinoma among the 

cases of carcinoma of the fundus." 

"Diagnosis—Early Recognition.—In addition to the comments made 

above, it may be noted that cervical carcinoma yields earlier symptoms 

than does carcinoma of the fundus and that the symptoms of carcinoma 

of the fundus are more subjectively urgent; that is, in carcinoma of the 

fundus pain sometimes occurs due to^ distension of the muscular wall. 

whereas unfortunately pain is one of the latest symptoms of carcinoma 

of the cervix. A leucorrhea or hemorrhage discharge which may be 

intermittent or persistent and becomes increasingly fetid in character is 

usually the primary symptom." 

"Extension.—Two striking characteristics of carcinoma of the fundus 

and of the cervix noted by Ewing seem thus far to be borne out by 

our own observations, that is. the tendency of uterine carcinomata to 

remain localized. Cullen found the nodes free in practically all cases 

examined by him. Ewing gives the reports of various observations 

showing lymph nodes free in a large percentage of the fatal cases of 

cancer of the fundus. Carcinoma of the cervix, while it extends early 

to contiguous structures, also is usually limited to the pelvis, its extension 

to the bladder, as one would expect, being of the most frequent 

occurrence. Very few cases of carcinoma of the vagina due to recurrence 

from the uterus or cervix arc reported in the literature. In our 

own series we have one case of carcinoma of the vagina following a 

hysterectomy for a fibroid tumor, the only case we have noted." 

"Treatment.—In our judgment, in any patient past the menopause 

who has either a continous or intermittent uterine discharge of any 

character, complete hysterectomy should be performed without delay 

and without hesitancy. We are told by some writers that uterine discharge 

is significant only when it is fetid and mixed with blood, but we 

do not believe that ihe character of the discharge should delay our treatment 

if the childbearing period is past. We urge strongly against curettage 

in these cases, as, if cancer is present, it will tend to disperse and 

disseminate the cancer cells. In these cases vaginal hysterectomy is 

performed and this can be done readily and successfully even in comparatively 

senile patients. A vaginal hysterectomy is performed also

144 R A D I U M 

in a case of definite diagnosis of cancer of the fundus with the following 

precaution to prevent sowing the field with cancer cells,—alcohol 

gauze is firstpassed well within the cervix which is clamped off with 

heavy clamps." 

"Because of the favorable results of radium and deep x-ray therapy 

in operable cases and the indications of its value in all stages of carcinoma 

of the cervix, we are. at present, not using surgery in any of these cases. 

We are, however, holding our final judgment in abeyance until a sufficient 

time shall have elapsed for a definite comparison of the three 

and five-year results of radiation in early cases to be made. Fundus 

carcinoma is still treated surgically—except those in which metastases 

involve areas beyond the field of operation. These cases are treated 

by radium and deep x-rays." 

"In the case of suspected carcinoma of the cervix a section is first 

made for microscopic diagnosis. If the diagnosis was confirmed, our 

method in the past has been to destroy the local growth with the cautery 

and to pack the vagina with alcohol sponges which were left in place 

overnight. The following day an abdominal hysterectomy was performed 

with a wide dissection of the parametrium and the broad ligaments, an 

iodoform drain being place well within the wound. These procedures 

applied to the certainly operable period, the operation being followed 

promptly by radium." 

"Surgery vs. Radium and X-ray.—As to the comparison of the operative 

mortality and the length of life after operation combined with 

radium, with the results of radium treatment alone, few final statistics 

of value have thus far been published since the majority of reporters 

give results in but limited series of cases for longer periods, the periods 

in the majority of the reports extending over two or three years only." 

"Bumm reports 78 cases treated by radiation in 1913, 77 in 1914. 

and 127 in 1915. From this large experience he recommends operation 

in all cases of cancer of the cervix or fundus, in which the condition 

of the patient permits. This is in marked contradistinction to the judgment 

of J. G. Clark, who reports the extreme opposite opinion that radiation 

is always the method of choice in the treatment of carcinoma of the 

cervix, an opinion apparently shared by the Mayo Clinic as indicated 

in a communication by Dr. W. J. Mayo to Dr. Skeel: 'The Wcrtheim 

type of operation has today only a very small field of usefulness. Personally. 

I have not done one in three years. Radium is taking the place 

of the extensive operation for the cure of carcinoma of the cervix with 

the exception of very early cases and it is possible that it will soon be 

the method of choice in all cases, either alone or combined with operation. 

For carcinoma 01 the body of the uterus, total hysterectomy is 

the operation of choice.' " 

"Schmitz' figures are shown in Table III. 

Apparent Cures 

1914-1919 inc. 

1914-1918 inc. 

1914-1916 inc. 

Table III—Schmitz 

from Radium Treatment for 2, 3 and 5 Year 

Periods 

Operable 

7M% 

60.0% 

66.654 

Borderline Inoperable Recurrent 

54-5% 27.()r,'r 2.2fU 

55-6% 21.756 0.0% 

40.0% O.O^r 0.0*0

R a d i u m 145 

" 1 he principal objections urged against the radical operation are 

the postoperative sequelae, as well as the high mortality and the limited 

number of five-year survivals. Among the sequelae should be especially 

noted, cystitis, peritonitis, and fistulae of various types. Since some of 

these sequelae result also from the use of radium in expert hands, since 

we are by no means as yet assured of a radical cure by the means of 

radium alone, since without operation the suffering of the patient with 

carcinoma of the fundus is progressive and the outcome certain, it would 

seem that since surgery in combination with postoperative employment 

of radium and x-ray gives the assurance of saving a large majority of 

the patients who present themselves in the operative stage, and of palliating 

suffering and prolonging the life with a fair prospect of ultimate 

cure in doubtful cases, we should hesitate to abandon such certainties 

for the uncertainties still presented by the use of radium and the x-ray 

without surgery in cases of carcinoma of the fundus, and should consider 

the advisability of abandoning surgery in cases of carcinoma of 

the cervix as still sub judice." 

"Our own operative mortality following radical operation alone, or 

followed by radium, has been 6.7 per cent in 60 radical operations for 

carcinoma of the cervix, 8.6 per cent in 70 radical operations for carcinoma 

of the fundus. Lincoln Davis gives a mortality rate of 9.3 per 

cent for radical operations for carcinoma of the cervix. Mortality rates 

published by other operators vary from 6 to 18 per cent, the latter figure 

being given by Janeway's figures for the Wertheim operation." 

Table* IV 

Various Statistics Regarding Operation and Operative 

Mortality of Carcinoma of Cervix 

Cullen 

Lincoln Davis 

Graves 

Janeway (Collected Statistics) 

Cobb 

('rile 

Operative 

Mortality 

IS-I % 

9-3 7o 

5.0 % 

18.2370 

11.167*0 

6.7

146 R A D I U M 

cinoma of the fundus which are apparently inoperable may become operable 

after a period of rest and the application of selected therapeutic 

measures. 

"5. Extensive correlation of ihe experience of individual observers 

is essential to the establishment of a correct basis of judgment as to 

the relative merits of surgery, radium and of the x-ray in the treatment 

of carcinoma of the uterus—whether of the fundus or of the cervix." 

Thomas E. Jones, M. D., (Cleveland. Ohio). The Role of Radium 

in the Trcaimcnt of Carcinoma of the I'terus. Am. J. of Obstet. and 

Gynec, vii, 541-542. May. 1924. 

"Carcinoma of the Cervix.—The cases of carcinoma of the cervix 

which have been subjected to radium therapv- during the past four years 

can be roughly classified into three groups: 

"I. Inoperable cases treated with radium alone. 

"II. Cases subjected to treatment with both surgery and radium. 

"III. Cases treated with both radium and deep x-ray therapy." 

"In the treatment of the cases in group I—the inoperable cases— 

radium therapy yields excellent results. At first we were unwilling to 

treat early cases of uterine carcinoma with radium, but secured excellent 

results in the treatment of the inoperable cases. Thus, among nine cases 

treated over three years ago, four cases— 45 per cent—are now apparently 

well. Even should any of these cases die during this year they 

have been able to live in comfort and their economic status has been 

assured for at least 5 per cent of the normal term of life—during the 

period in which a mother is an important factor in family affairs." 

"In the second group,—treated by both surgery- and radium.- very 

bad results were secured and this combined treatment has been discarded." 

"The third group, in the treatment of which both radium and deep 

x-ray therapy have been used, shows the best results, although since 

this combined method of treatment has been in use less than a year we 

have no available statistics upon which to base a discussion of end-results 

—three or five year cures." 

"Method of Treatment.—The method of application of radium 

changes from time to time with increasing experience and with individual 

cases, for it is impossible to treat all cases alike. Often it is 

feasible to use needles, while in other cases their use is not possible. I 

think, however, that needles should be inserted wherever possible because 

by their use a more homogeneous radiation is secured." 

"It has been our custom to place 75 mg. in the cervix screened with 

1 mm. of brass, 50 mg. against the cervix and 75 mg. (in 9 needles) 

inserted at various points in the cervix, the treatment being continued 

for periods varying from 12 to 16 hours. In from three to four weeks 

the patient is treated again by placing 125 mg. screened with 1 mm. of 

brass against the cervix for from 12 to 15 hours. Thus, each case receives 

a total dosage varying from 4000 to 4S00 mg. hours. After the 

second treatment the patient is discharged, but comes in again for observation 

three months later." 

"Nausea is the one complicating factor to be considered. This is 

not invariable, as some patients are nauseated and others are not. We

IUM 147 

have found no means of obviating this condition. There is no foundation 

for the popular use of alkalies. That there is no acidosis is shown 

by the fact that the potential alkalinity of the blood is increased after 

radiation." 

"We have not seen a single fistula,either rectal or vesical, in the 

cases treated with radium alone. They have occurred only in the cases 

treated with both surgery and radium. Proctitis with a slight stricture 

has occurred in only one case." 

"It should be borne in mind that in discussing the relative merits 

of surgery and of radiation in the treatment of carcinoma of the cervix 

the basis of comparison must be the morbidity and the end-results,— 

three and five year 'cures'—as immediate mortality in these cases pertains 

only to surgery. No immediate mortality can be attributed to radium 

therapy. We are convinced of the value of radium in inoperable cases of 

carcinoma of the cervix; we believe that accumulating evidence will 

give equally positive evidence of its value in early cases." 

"Carcinoma of the Fundus.—On account of the excellent results 

of the surgical treatment of carcinoma of the fundus, up to the present 

time I have not advocated radiation in these cases. During the past year. 

however, in three cases we have seen a recurrence in the upper end of 

the vagina six months after a complete hysterectomy, and all three of 

these patients died less than one year after operation. This fact suggests 

that further investigation is demanded perhaps a trial in cases 

of carcinoma of the fundus, in which there may be some contraindication 

to operation, such as old age. or cardiovascular disease, or objection 

to operation on the part of the patienf." 

Walter S. Lawrence, M. D.. (Memphis, Tenn.). On the Reasons 

for Choice—Radium or X-Ray, when Radiotherapy is Indicated. The 

Urol, and Cutaneous Rev., xxviii, 294-296. May, 1924. 

"Among many men who arc using one or both of these agents, there 

seems to exist still considerable haziness of thought as to the relative 

merits, the likenesses and differences of the two. Some seem to be quite 

convinced that radium is far superior to the X-ray. while others are 

equally sure that the X-ray, especially now that we have high voltage 

X-ray. is quite as good as radium in every way, while still others believe 

that radium and the X-ray act exactly alike and can be used interchangeably. 

Needless to say, all three of these viewpoints are in error." 

"In what is to follow I wish to call attention to certain principles 

underlying the nature and distribution of radiation from these two 

sources. Due consideration of these principles will enable us to choose 

promptly and rightly one or the other agent in any given case, and will 

also lead inevitably to the conclusion that in certain cases both agents 

should be used, one supplementing the other." 

"Let us consider first the nature or quality of the radiation from 

each of these two sources, and second the distribution of this radiant 

energy within the tissue when used as they ordinarily are used in the 

treatment of disease." 

"Not considering the alpha particles which have no penetration, 

about 99% of the output of radium is composed of beta rays of low 

penetration, being comparable to X-rays generated by a current of 40 to

148 R a d i u m 

75 K. V. The remaining \fc is made up of gamma rays of very great 

hardness, being far more penetrating than the hardest X-rays." 

"Now so far as has ever been accurately determined—though there 

is still some doubt on this point—the effect of hard and soft rays on 

both normal and diseased tissue is the same. And this is what wc would 

expect to be true when we bear in mind certain similar physical effects 

brought about by either hard or soft rays. Both are active ionizing 

agents, both promote certain chemical reactions, likely by way of ionization 

atomic disruption causing in turn molecular changes. Both cause 

certain not fully explained color changes in glass and other substances. 

Any apparent differences in tissue reaction to hard or soft rays may 

easily be explained by differences in absorption and differencess in distribution 

within the tissue; for if living tissue is subjected to. and absorbs 

a given amount of radiation, tissue reaction will be the same 

whether the wave length be short or long. It would seem then that the 

problem of the radiologist is to deliver radiation, hard or soft, in sufficient 

quantity to bring about those tissue changes which we know can be 

brought about. If soft radiation can be delivered, well and good, but 

if it cannot be delivered on account of its natural limitation, which is 

its lack of penetration and consequent absorption by normal tissue overlying 

the diseased tissue, then wc must resort to some other means of 

getting the desired amount of radiation to the point of disease." 

"If radium can be placed on, or into the diseased tissue, well and 

good, but if it cannot, then its natural limitations brought about by the 

comparatively small amount of radiation given off by available quantities 

of radium, coupled with the action of the law of inverse distance squares. 

come into play, and it is readily seen that we cannot deliver the required 

amount of radiation by radium, and must in turn resort to some other 

means. This would not be true if we possessed this agent in unlimited 

quantities. Since the rays from radium are highly penetrating, it would 

then only be necessary to select such a quantity as would give off sufficient 

radiation to produce the desired effect in the tissue even after suffering 

the reduction brought about bv the square of a considerable distance." 

"The rays from a high voltage X-ray tube possess ihe required penetration 

and also the required volume after suffering distance reduction, 

but not radium in the quantities now available." 

"An experimental comparison of what may be termed the volume 

of rays given off by an X-ray tube, as compared with the output of say 

50 m.g. of radium, may lend some convincing evidence to the truth of 

the above statement. If 50 m.g. of radium bromide be placed upon a 

piece of blotting paper, which will filter out the alpha rays and at the 

same time give a distance of about 1 m.m.. and the paper placed on the 

surface of the skin, an active erythema will be produced in two minutes. 

About the same degree of erythema could be produced by even 

low voltage X-rays. 5 m.a.. unfiltered. in the same time at a distance 

of 15 cm. or 150 m.m. The square of one is to the square of 150 as 1 

is to 22.500. And this means of course that the intensity of the X-ray 

radiation is 22.500 times that of the radium radiation. This also means 

that if the radium were placed at the same distance from the skin as 

the point of origin of the X-ray. that is, 150 m.m. instead of 1 m.m.. the 

time required to give an erythema dose would be. not two minutes, but 

22,500 times two minutes, or 45.000 minutes, which is thirty-one days

R a d i u m 149 

and six hours. Now in the above experiment we were using the radium 

practically unfiltercd, getting the full effect of the beta rays as well as 

the gamma rays. Since the volume of beta rays giver, off by a given 

quantity of radium is 100 times that of the gamma rays, we may assume 

that at least 99% of the erythema effect was produced by the beta rays. 

This being true, if we should filterthe radium rays heavily, as is done 

in all attempts to get deep effects from radium, we would have only one 

per cent of the previous radiation left, so that to get the same degree of 

erythema it would be necessary to continue the application 100 times as 

long, or 200 minutes. If we should attempt to treat a growth one inch 

or 25 m.m. below the surface by laying the radium capsule on the skin, 

the radium itself would be about twelve times as far from the diseased 

tissue as from the skin. It would therefore be necessary to make the 

exposure 144 times 200 minutes, about 20 days, in order to get a mild 

erythema dose to the point desired. In doing this the skin would receive 

about 150 times an erythema dose. If now to improve this surface 

depth ratio we should withdraw the radium to 15 cm. or six inches 

the distance at which the X-ray dose was given in the first experiment. 

and allow 2 m.m. for the thickness of the radium filter, that is, the 

actual distance of the radium from the skin in the surface application, 

the distance in the second position would be 75 times that in the first 

and the time required to give an erythema dose would be equal to the 

square of 75 or 6,525 times the 3 hours required in the firstcase, which 

gives a total of about 16.000 hours, nearly two years, and even then 

the point one inch below the surface would have received less than threefourths 

of a full dose. With these figures before us it may be stated 

that there is no such thing as deep therapy by means of radium in quantities 

at present available." 

"The discharge of radiant energy from 50 or 100 m.g. of radium is 

vastly inferior in amount or intensity to that given off by an active X-ray 

tube. This may possibly be roughly visualized by comparing the discharge 

from radium to the discharge of bullets by a squad of riflemen 

firing rapidly in the same general direction, and the discharge from the 

X-ray tube to the discharge from a battery of machine guns in action. 

At a given distance from the riflemen a small tree would receive an occasional 

bullet resulting in material damage, while at the same distance 

from the machine guns it would receive a solid spray of lead which in 

a few moments would reduce it to powdered bark and splinters." 

"Now which ever of the present theories as to the way in which 

radiation produces its results, we may favor, we come face to face with 

this fact: That in order to produce these results in the most marked 

degree wc must produce a certain density of radiation within the irradiated 

field. If the 'point-heat' theory of Dessaucr should be correct, 

it would seem that a considerable intensity of irradiation within the 

field is necessary in order that a sufficient number of cells may be struck 

a sufficient number of times within a given period—otherwise a sufficient 

number of heat-points will not be developed to kill the cells." 

"If we favor the theory of ionization and believe that by atomic 

disruption new combinations are formed and in this way chemical changes 

are set up within the tissue, this still would bring us to the conception 

of a rather richly irradiated field; for if only an occasional ion were 

knocked off from an occasional atom, these would likely recombine with 

their recoil atoms and matters shortly be 'as they were.' "

150 Radium 

"Or if Crile's rather attractive theory appeals to us and we believe 

that radiation effects are simply cell charge disturbances brought about 

by ionic bombardment, still we must conceive of a rather high rate of 

bombardment, otherwise only a few cells would be disturbed which would 

hardly result in tissue death." 

"A full appreciation of the distribution of radiation within the tissue 

will help us to reconcile some of the apparent differences in tissue reaction 

to hard and soft rays and also differences in reaction to X-rays 

and radium rays. When we have considered these differences we will 

be ready to select our means of attack. X-rays or radium rays, short wave 

length, or long in any given case, and make our selection without fear 

of error." 

"It has been said that a radium burn heals more readily than an 

X-ray burn of the same degree. This is likely true, or at least it should 

be on theoretical grounds. If the erythema dose is exceeded in the case 

of radium and a burn results, the greater part of the injury is received 

by the surface layers of the skin, for on account of the rapid falling 

of intensity from the law of inverse distance squares, the 2nd m.m. of 

skin would receive only one-half of an erythema dose, which would not 

materially damage it even though the first m.m. had received a double 

erythema dose resulting in a pronounced burn. If. however, a burn 

results from X-rays of considerable penetration, on account of the relatively 

great distance of the target from the skin, the deeper layers of the 

skin and even the near subcutaneous tissue will receive approximately 

the same dose as the surface. The resulting burn will be a much more 

serious injury and the reparative processes will be much longer delayed. 

On the other hand, if an X-ray burn should result from the administration 

of very soft X-rays, 30 to 60 K. V., the surface layers of the skin 

only will be materially damaged—not from distance falling off as in the 

case of radium, but from lack of penetration. Here from quite different 

causes, the distribution of radiant energy within the tissue will be approximately 

the same, and we shall see a radium burn caused by rays of 

extreme penetration and an X-ray burn caused by rays of very slight 

penetration behave in practically the same way—both are superficial— 

both will heal readily and likely with no scarring." 

"It has been said that superficial port wine marks have been more 

successfully- treated by radium than by the X-ray. I suspect that this is 

true. But if true, in my judgment, it is so largely on account of faulty 

selection in the type of X-ray. This is a surface condition and should 

be treated either bv radium at close range, or by very soft X-rays unfiltered." 

"Having now tried to establish the fact that whatever differences 

may exist between the action of radium rays and X-rays, hard rays 

or soft rays, are due largely to differences in distribution within the 

tissue, let us now put this into practical application in the selection of 

the proper agent of the proper tvpe of ray in certain diseases and conditions." 

"1st Any surface lesion of small extent may be treated by either 

radium or soft X-rays, unfiltercd. with equal prospect of success." 

"2nd. Any large or multiple surface lesion should be treated with 

soft X-rays rather than radium, as a time-saving measure." 

"3rd. Any malignancy within a body cavity so situated that a 

radium capsule may be placed against it, and at the same time be kept 

at a safe distance from normal tissue, or any such lesion that can be

R a d i u m 151 

thoroughly transfixed by radium needles, should be treated by radium. 

In such cases the intense local action of radium is far superior to the 

widespread more general action of the X-ray." 

"4th. Certain of these cavity cases have become extensive with 

glandular involvement. These should be treated with radium within 

and also high voltage X-ray by cross fire from without." 

"5th. Malignant papilloma of the bladder would at first thought 

seem to be particularly suitable for treatment by radium. But the difficulty 

of application is so greal that most of these cases will do better 

by deep X-ray therapy." 

"6th. Nowhere have the results of radiotherapy been more brilliant 

than in cancer of the cervix. In quite early cases a sufficient application 

of radium within the cervix will likely bring about a complete 

and lasting cure. In more advanced cases radium alone may cure; but 

all of these cases would be safer if the X-ray from without were added 

to the radium from within. Many of the advanced cases even with a 

so-called 'frozen pelvis' may be saved by large doses of radium within 

and equally large doses of high voltage X-ray from without." 

"7th. Cancer of the lower lip can possibly be treated better with 

the X-ray. The dose should be large, the whole lip thoroughly saturated 

with fairly penetrating filtered X-rays, while the glandular region should 

be treated by rays of greater penetration." 

"8th. All deep seated or wide spread malignancies not in body 

cavities should be treated by high voltage X-ray and not by radium." 

"9th. Strictly speaking, there is no such thing as deep therapy 

by means of radium. For if it be attempted to withdraw the radium 

to such a distance from the skin as would tend to equalize the surface 

dose and depth dose, the time of application for one dose begins to run 

into months and years—beyond a reasonable time limit." 

"10th. Neither the X-ray nor radium can accomplish all that can 

be accomplished by radiotherapy. These agents should be regarded 

more as supplements than substitutes." 

R. E. Loucks, M. D.. C. M. (Detroit). Radium Treatment of Toxic 

Goiter with Metabolic Deductions. Am. J. of Roentgenology and Radium 

Therapy, x, 767-776, October, 1923. 

"In order that the true significance of a pathological condition or 

dysfunction of the thyroid gland may be understood, it is absolutely 

necessary that the anatomic relation with physiologic function and normal 

metabolism should be known, with a comprehensive understanding 

of its relation to the other endocrine glands. 

Anatomically the gland consists of two lobes connected across the 

second and third ring of the trachea by an isthmus. The posterior surface 

is in contact with the thyroid and cricoid cartilages, the inferior 

laryngeal nerve, the inferior constrictor of the pharynx and the lateral 

borders of the trachea and esophagus. The outer surface is covered 

with the superficial muscles of the neck and the external jugular vein. 

The outer border of each lateral lobe is in close proximity to the carotid 

sheath containing the common carotid artery, the internal jugular vein 

and the pneumogastric nerve. The significance of this relation is apparent 

when dealing with any one of the enlargements of the gland."

152 Radium 

"The physiological function appears to control the iodin and calcium 

balance and split up iodin products into thyroxin (Kendall) which 

acts as a hormone stabilizer to the whole endocrine chain. The one or 

the many hormones have specific function in cerebration of the brain 

cells, increasing the activity of nerve transmission and regulating the 

heat mechanism; in fact, they are the main activators of metabolism." 

"Normal metabolism signifies a harmony in all the functions of the 

living body that go to make up a 'well being.' A physiological activation 

is not by any means a pathological hyperactivity." 

"The question arises: When is a hyperactive thyroid a pathological 

disease* The answer: When symptoms of toxicity are manifest, either 

objectively, subjectively, or by laboratory calculations." 

"Suffice to note that a toxic goiter may be: 

"i. A primary exophthalmic. 

"2. A toxic adenoma. 

"3. A toxic adenoma with exophthalmos." 

"1. The objective symptoms are manifest in the exophthalmic 

type by (a) the prominence of the eyeballs, giving a staring expression 

and a facies of mental alertness, (b) a lagging of the upper lid in looking 

down so that it apparently covers more than its half of the eyeball 

when closed. At times the lids cannot cover the ball completely but 

leave a slit allowing the conjunctiva and cornea to become injected 

from exposure, lack of palpebral lachrvmation and massage. A strip of 

white sclera shows be:ween the cornea and lower lid when the eye is 

open, (c) There may also be winking, tardiness of external ocular 

muscles and decreased lacrymation. (d) At times a red tremulous 

tongue is found and also teeth notched on the lateral borders." 

"The primary exophthalmic type may not show any noticeable 

change either in size or figure of the gland, while the adenomatous type 

presents variations in size, from the large prominent uneven mass to 

small lobulated cystic out-croppings on the lobes or isthmus." 

"Pulsations of the thyroid arteries are common and a bruit may 

at times be heard over either lobe. The radial pulse varies from 90 to 

160 and often registers much less than the apex beat, as each wave does 

not have time to be carried independently." 

"The heart may be enlarged in all diameters and if the case is of 

long standing there is evidence of myocardial degeneration, as elicited 

by the degree of fibrillation and the character of the murmurs present. 

The precordial impact may be diffuse, and have enough force to cause 

a heaving of the chest wall with each contraction of the heart. Pulsation 

of the superficial arteries of the fingers and toes is common." 

"The systolic blood-pressure in primary exophthalmic cases is at 

first raised, but gradually returns to normal or goes below normal after 

the firstcrisis. Should a spontaneous cure succeed, it remains low; but 

should a second crisis occur it again rises and remains high until the 

termination of life, unless treatment controls the toxicity. The diastolic 

blood-pressure is usually low. giving a much increased pulse pressure." 

"Trophic symptoms occur as a brownish yellow pigmentation of 

the skin, thinning of the hair and longitudinal striae of the nails." 

"Mental disturbances are common in the late or verv active cases 

and vary from a state of constant fear and apprehension to that of a 

decided psychosis." 

"2. Subjectively, the individual complains of nervousness, general

R a d i u m 153 

weakness, palpitation, insomnia, pulsation in the ears when lying down, 

sweating of the hands and feet and, at-times, general hyperidrosis. Frequently 

digestive disturbances occur, such as nausea, loss of appetite 

and diarrhoea; menstrual irregularilics in females; pain and pressure 

in the neck with a sensation of choking, or an irritable cough, and general 

feeling of 'fag.'" 

"3. Laboratory calculations arc most conclusive in the toxic state. 

Du Bois has standardized basal metabolism in the normal individual 

and Plummer has proven by extensive studies that thyroxin in excess 

raises the metabolic rate. Therefore, a sufficiently high metabolism 

is pathognomonic of thyroid hyperactivity and is one of its most important 

diagnostic features." 

"With hyperactivity of the thyroid, there is marked increase in cellular 

activity and carbon dioxid output, with a speedy demand for larger 

oxygen consumption. To determine the metabolic rate it is necessary 

only to measure the amount of oxygen consumed for a given period of 

time, and make calculations in calories per hour, by comparing the intake 

to certain physiological standards for body surface, tempcra'.ure 

and barometric pressure." 

"Urinalysis reveals kidney changes in direct relation to cardivascular 

degeneration and digestive disturbance. Scanty, high-colored urine 

signifies concentration due to evaporation and skin elimination. Albumen 

and casts are indicative of kidney dysfunction and contraction. 

The presence of sugar indicates diminished carbohydrate toleration." 

"The blood picture may reveal a decreased number of erythrocytes 

with lessened hemoglobin content or an increased heat production. If 

the blood sugar rises slowly there is a compensatory function of the 

kidney that holds the balance, and there is no glycosuria. Should this 

tolerance be broken by increased carbohydrate ingestion, the kidney 

excretes sugar." 

"An editorial in The Journal of the American Medical Association 

for April 14, 1923 (page 1071) after discussing the roentgen rays and 

surgery in the treatment of exophthalmic goiter, says: 'In the light of 

the present-day evidence, the choice of therapeutic procedure presents, 

indeed, a difficult perplexity.''' 

"We are positive that no one treatment will control all cases of 

toxic goiter, but that after defining and correlating the symptoms and 

classifying the case pathologically, the indication for treatment should 

be manifest." 

"Furthermore, special consideration must be given to the associate 

or subsidiary symptoms before and after treatment. It is generally 

agreed that rest and quiet are helpful factors. An ice bag may be applied 

to the gland and precordium. Plenty of easily digested food, tepid 

baths and alkaline drinks are equally important. Digitalis as a therapeutic 

splint to an irregular, rapidly beating, dilated and decompensated 

heart, will sometimes tide over a catastrophe. Blood transfusion is indicated 

in a low cell count, 30 per cent or lower hemoglobin and general 

edema, and more especially when the toxemia has been profound enough 

to produce a severe psychosis. Bromides and ergot have their place in 

assisting in the control of certain symptoms." 

"It was through the efforts of the surgeon that we began to realize 

the importance of the present conception of the disease. For this reason. 

therefore, surgical findings in toxic goiter should be held in the highest 

regard."

154 

R a d i u m 

"Without consideration of the surgical mortality in the most skilled 

clinics, we must consider this great danger in other centers; also the 

fear, apprehension, hospitalization and financial cost to the individual, 

not forgetting the possible return of all symptoms." 

"Leniency must be used in the criticism of scientific men who. ignoring 

radium entirely, assert that all treatments have failed except 

surgery. It must be remembered that prejudice and inexperience will 

warp the soul of the most sublime." 

"Radium therapy for toxic goiter as standardized and given to 

this Society by the author two years ago, at the Boston meeting, merits 

your serious interest. After seven years of experience with the element, 

the last three under the most exacting scrutiny by means of laboratory 

methods and clinical findings, I conclude that toxic goiter can 

be cured by radium and that it is not a surgical disease." 

"Of the 1S0 cases I have treated, only 10 were subjected to a second 

radiation. Four of these had large cystic adenomata and the toxic activity 

was not completely controlled after the firsttreatment. The other 

6 were given the second treatment with the hope of further reducing 

the enlarged gland. Three cases, in a state of extremus from myocardial 

degeneration with general edema, died. One insane patient died from 

starvation before the treatment had time to benefit the toxemia." 

"Improvement is noted within the first ten days after treatment. 

but about the third week all the old symptoms may return, due to the 

radium reaction. This active stage varies in different individuals. Some 

express disappointment in not feeling bad, while others are nauseated 

for a few days." 

"Within four weeks the nervous tremor has commenced to subside, 

the appetite has improved and the heart has slowed down twenty 

or thirty beats. After two months all the symptoms are much better 

and most individuals gain a few pounds in weight. The improvement 

is gradual, as shown by the cases reported when the metabolic rate has 

been taken every three months after treatment." 

"Some cases are free from all symptoms after six months, while 

others with large adenomata of long standing and with extensive myocardial 

change take twelve to eighteen months to show a normal metabolic 

rate with a normal heart action." 

"The enlarged gland gradually decreases in size in direct relation 

to the amount of cystic formation present. All hypertrophy or hyperplasia 

is reduced to normal while the cystic type is reduced about onehalf 

in size. The exophthalmus in many of my cases has been controlled 

after three years. However, all do not respond so favorably." 

"There has been no evidence of myxedema in any of the cases 

treated. Metabolic readings have been made over a period of two and 

a half years and all have remained normal." 

"Many toxic adenoma cases give a history of pregnancy, childbirth 

or miscarriage initiating the toxic activity. In these young women they 

run an active and rapid course, so that the symptoms are grave in a 

very few months. Sixteen of these cases have been treated, and 10 

haye had second and third pregnancies since treatment without any 

evidence of thyroid toxemia. Two showed activity at the beginning of 

lactation but were controlled by means of the ice bag." 

"Two of our cases had two operations each and 8 had one each 

for thyroidectomy. Four others had ligation of the thyroid arteries 

on one side and 2 had both superior thyroid arteries tied off. They

R a d i u m 155 

had all been benefited for a period of six months to two years, but the 

remaining portion of the gland had hypertrophied and soon became 

active. On account of parathyroid glands, discretion in the technique 

of treatment of postoperative cases must be used." 

"None of my cases have shown any symptoms of parathyroid dysfunction 

after treatment." 

"For the last two years all cases with infected tonsils associated 

with a toxic thyroid have received treatment over the tonsil area conjointly 

with that of the thyroid gland. One case had a gall-bladder 

drainage and two had operations for chronic appendix six months after 

ihe thyroid treatment." 

"Abdominal support is given all cases that show visceroptosis by 

roentgenography. It has been shown experimentally that stimulation 

of the cervical sympathetic nerves in animals produces exophthalmic 

goiter, and that thyroid secretions lower the threshold to sympathetic 

stimulation, so that a vicious circle is established." 

"It is a question whether radium therapy breaks the vicious circle 

by diminished gland secretion, thus restoring the balance by some specific 

effect of the rays on thyroxin itself, or whether radium acts mechanically 

by blocking the blood supply." 

"The rapid control of the toxic symptoms after treatment would 

support the hypothesis of a change in the character of the secretion. 

Diminished secretion due to cellular change would come later, while 

thrombosis of the smaller arterioles and capillaries would come last 

of all." 

"Corroboration of the objective and subjective symptoms by laboratory 

standards will verify the findings and establish the diagnosis. 

The basal metabolic rate in thyroid toxicity proves more than clinical 

findings, as it registers the degree of severity as shown by the variation 

in records. A _f-6o case indicates greater activity, toxicity and severity 

tha one of -f-20. This known difference in rate is a helpful factor in 

the prognosis of the case." 

"Radium Treatment.—At least 100 mgm. of clement arc used (more 

often I use 130) in four tubes, each tube being screened in one mm. 

of brass and 1 mm. of gum rubber. To obtain distance, the screened 

tubes are placed 1 cm. apart on a gauze pad 2 cm. in thickness." 

"The gauze pad is made with a loop of adhesive tape at each end 

so that it can be adapted and tied over an uneven surface without strapping. 

The radium pad is placed over one lobe for eight or ten hours 

and then over the other for an equal time, depending on the size of 

the lobe and the amount of radium used. If the isthmus is enlarged the 

pad can be arranged to cover one side of it at each application without 

overlapping and endangering the trachea." 

"This technique in treatment will give an active hyperemia in the 

blonde type of individual. The susceptibility of some people (especially 

if there is a vasomotor disturbance like sweating) has to be considered; 

so that judgment must always be used at all times." 

"It is well to advise the use of the ice bag in hourly periods each 

day, over the gland, for a few weeks following the treatment. This 

insures rest and controls circulatory and cellular activity. As mentioned 

before, subsidiary treatment is important after radiation to control arising 

symptoms of insomnia, tachycardia, indigestion, diarrhoea, etc, until 

the. therapeutic effect of the radium has been established." 

"Conclusions.—1. A high systolic and a low diastolic blood pres-

156 R a d i u m 

sure show a normally balanced pulse pressure in some cases before the 

metabolic rate becomes normal." 

"2. Three months after treatment the metabolic rate was found 

to be normal in many cases that had been active." 

"3. A high systolic blood pressure in the late stages of a toxic 

adenoma is conclusive evidence of myocardial or renal degeneration 

whenever it is not reduced 20 or 30 per cent after the normal metabolic 

rate has been re-established." 

"4. The basal metabolic rate proves and estimates the degree of 

thyroid activity and also furnishes conclusive evidence of toxic control 

after radium therapy." 

Th. Vaternahm. M. D. (Frankfurt. A. M.). Further Experiences 

in the Treatment of Arthritis with High Doses of Radium Emanation. 

Medizinischc Klinik. xviii. 1477-79. Nov. 23, 1922. 

While at firstin the application of radon in diseases of the joints, 

doses were employed which corresponded approximately to the natural 

healing factors, soon the multiple—even a thousand times this amount, 

has been given with good results, partly on account of the small and 

slow progress of the cure. Falta was the first who emphasized the necessity 

of stronger applications of radon and according to him and to 

v. Noorden. theraputic effects with higher doses are obtained on account 

of the stronger physiological effect which large doses of radon 

can exert, where in many cases small doses do not do anything. Falta 

assumes that only in giving stronger doses a larger part of the emanation 

passes the lungs, enters the left heart, and the general circulation, 

thus being conducted to all tissues of the body. 

In a previous communication from our Institute. Strasburger and 

Werner have reported that very good results in arthritis have been 

obtained by treatment with drinking waters containing tip to 300,000 

M. L". (mache units)* and these experiences have been further confirmed 

according to our observations in the last years. More recently we have. 

by a further increase of the doses, obtained surprising results in cases 

where we could see. with the light dose so far used, little or no improvement, 

even with repeated treatment. The amount of radium in our Institute 

which gives us daily about 15.000,000 M. U., enables us to give 

to our patients, in suitable cases, very strong doses up to 1.000,000 M. U. 

and more in the usual way. Starting with low doses of a few thousand 

M. U. we gradually increase and stop for some time at our usual maximum 

dose of 300.000 M. U. If then, no appreciable effect can be observed, 

we go cautiously, giving during the next two to three weeks up 

to 1.000.000 M. U,, let the patient drink this new maximum for 10-12 

days, and then go slowly down again. The whole drinking treatment 

extends over about 6-8 weeks. In order not to obscure the judgment 

on the success, no other treatment, medical or physico-therapeutic, is 

given simultaneously. 

The treatment with such high doses of emanation made it necessary 

to look for eventual harmful consequences. Several times previously 

we made the observation of albumin in the urine, even when small doses 

were given. This was soon proven to be without foundation. Falta found 

in his many cases treated, partly with very high doses, never an irri- 

•1 milllcurie per llier cqunls about 3.700.000 M. U. conocntralio". Ed.

R a d i u m 

i57 

tation of the kidneys in the healthy, nor the growing worse of an existing 

albuminuria, and also, we could not state in any of the carefully 

checked cases changes of the urine. According to experience a transient 

leucocytosis in the blood was to be ex]

158 R A D I U M 

Treatment has been given to cases of primary chronic polyarthritis. 

rheumatism, both dry and exudative forms; secondary chronic polyarthritis 

and genuine arthritis deformans. 'The majority of the patients 

were treated ambulatorily and were females. 

The primary chronic polyarthritis reacted most conspicuously on 

increased doses. Cases which behaved refractorily in previous treatments, 

according to Falta, with 300.000 to 400.000 M. U., showing a 

decided improvement after increasing the doses and then without execplion. 

both the exudative as also the dry form, the latter which is in general 

much less susceptible to emanation treatment, Falta observed also 

in malignant forms a considerable improvement after application of very' 

high doses. 

Case 1. Mrs. M.. 52 years old. Beginning of the disease in 1919 

with pains and thickening of the joints of the fingers and in the course 

of a few months wrists, and in the last weeks the joints of the jaw were 

attacked. Treatment with salicylates, hot air, radium up to 300,000 M. U. 

resulted in success. May 20. 1922. Doughly thickening at the middle 

and especially at the base joints of the fingers, the back of the hand, 

the wrist, and also of the left knee. Making of a fistdifficult, imperfect; 

also movement of the middle joints of the fingers. Limited movement 

of the left knee joint. Mouth can only be moderately opened, chewing 

therefore difficult and painful. All joints sensitive to pressure. Condition 

from X-ray picture, atrophy of the metacarpal bones. Spaces 

at the base joints of the fingers and the hand partially obliterated. 

Radium drinking treatment from May 20th to July 28th. dose gradually 

increased to 1.000.000 M. XJ. June ~th, 300,000 M. U. Mouth 

can be opened a little better. Otherwise, status the same. Additional 

doses of 270.000 M. U.. reaction lasting three days and giving increased 

pains in hands, feet and left knee. Dose reduced to 200.000 M. U.( increasing 

again. 

June 15th. After stopping eight days at 300,000 M. XJ. no change 

in status. Increase of dose lo 1,000.000 M. U. 

June 20th. 500.000 M. I". Movement of knee joints longer and 

without pain. Base joints of fingers decreased considerably, making 

of fist in the left hand possible. Left knee better moving. 

July 2nd. 700-000 - U. Increase in movement. Swelling of back 

of hand and joints of fingers further decreased. 

July 15th. 1,000.000 M. U. Left knee normal and without pain 

when moving. Patient has made a three-day excursion and has walked 

very much better. 

July 28th. Treatment finished. Joints of jaw free. Fingers decreased 

except moderate thickening of base joints. Also back of hand. 

Fist about normal. Now and then a little pain in joints of the feet. 

Left knee, not much swelling; movement free. Patient feels better and 

is again busy with houscwrork. 

Case 2. Miss L., 26 years. Illness existed about 11 years, starting 

with pains and increased stiffening of joints of fingers and toes, hip 

and knee. Since 1914 has been growing worse. Hot air, salicylates and 

treatment with medical bath without success. 

August 26th. 1921. Status: fingers, knee, toes and joints of feet 

swollen. Fourth and fifth fingers right, in contracted position. Other 

fingers hardly active and cannot be moved without great pain. Patient 

must be in lying position most of the time and is incapable of anv work.

Radium 159 

Can walk only with a cane. At night often sleepless on account of pain. 

Radium drinking treatment up to 1,000,000 M. TJ. 

September 8th. 80.000 M. U. Reaction was rigidity in neck and 

increased pains in all joints. Patient must stay in bed. treatment was 

discontinued one day, starting again with 50.000 M. U. 

October 15th. 370,000 M. U. Patient can sleep at night. Otherwise, 

no change in status. 

October 25th and November 5th. treatment discontinued at request 

of patient. 

November 20th. 760,000 M. U. The last few days patient is almost 

free from pains. The swelling has decreased. Patient can walk better 

and feels stronger. 

December 17th. 1,000.000 M. U. for 15 days. Knee and joint 

of hip free, without pain. Swelling decreased at joints of fingers and 

toes. Better mobility. Patient is out of bed during the day. 

January 9th, 1922. Treatment finished. Joints of fingers still 

very little swollen, fist on both hands almost possible. Knees show still 

a moderate thickening, as do the joints of the feet. Patient is almost 

entirely free from pains, feels stronger, can walk without a cane and 

again do her housework. 

Case 3. Mrs. H.. 48 years old. Beginning 9 months ago with pains 

in the left shoulder. Movement limiied in joint of shoulder and relative 

stiffness. First radium emanation drinking treatment from August 

16th to October 13. 1921. Pains were considerably reduced, the mobility 

somewhat improved. After a few weeks, however, the same condition, 

as before the treatment, recurred. 

Treatment with hot air, massage and exercise without success. 

Jan. 19, 1922. Status: no swelling of left shoulder joint. Mobility 

very limited. Arm can be lifted actively as well as passively up to horizontal 

only. Mobility towards the back almost entirely impossible. 

Wasserman reaction negative. Diagnosis, arthritis of the left shoulder 

joint. Emanation drinking solution up to 1,000,000 M. U. 

Jan. 31. 250,000 M. U. Status the same. 

Feb. 16. 520,000 M. U. Patient can lift arm better. Mobility 

towards the back unchanged. 

March 3. 800,000 M. U. Reaction is increased, pains in shoulder. 

Discontinued two days. 

Started again with same dose. 

March 10. 1,000,000 M. U. Conspicuous improvement. Arm almost 

normal and mobility to back. Can be lifted to the head so the patient 

can arrange her own hair. 

March 16. Treatment finished. Mobility of left arm entirely normal 

and without pain. 

Secondary chronic arthritis could also be treated with large doses. 

Cases of genuine arthritis deformans are, on account of their character, 

the most difficult to influence by radium emanation. According 

to Falta and others, most of the pains could be somewhat relieved by 

treatment with emanation. Also here, even in serious cases, we could 

obtain surprising results. These cases concern patients who had been 

treated once or several times with emanation drinking treatment up to 

300,000 M. U. without success.

160 R a d i u m 

If we review our results we can state that in comparison with the 

values found by Werner, about 70% of the cases (Werner 55?&) were 

influenced, while 30^ (Werner 45%) did not give any results even with 

treatment with very high doses. 

We do not. however, want to say that only very high doses, as 

mentioned before, have an effect. Against this speak the good experiences 

which we have had with others when treating with average or small 

doses. According to Strasburger, the number and degree of success 

did not increase in arithmetical proportion with the strength of the 

doses, but as he thinks in nuich smaller progression. However, where 

small doses did not give any result, treatments with higher doses should 

be given. 

Our observations show that diseases of the joints, which have been 

treated with doses that according to our present opinion are high, show 

only small results can be successfully influenced by flooding the organism 

of the body with radium emanation by further increase of the doses 

up to 1.000,000 M. XJ. and more. 

Harvey R. Gaylord, M. D. 

OBITCARY 

Dr. Harvey R. Gaylord. Director of the State Institute for The 

Study of Malignant Disease, at Buffalo, X. V., died at Watkin's Glen, June 

22nd. Dr. Gaylord was born in Saginaw, Michigan, in 1872, and was 

graduated in medicine from the University of Pennsylvania in 1893. He 

served as an instructor in pathology for three years at the University of 

Goettingen, and began his service with the Xew York State Institute 

at Buffalo as an assistant to the late Dr. Roswcll Park. In 1914 Dr. 

Gaylord secured a quantity of radium in order that he might study its 

use in the treatment of cancer. Later he was instrumental in having 

the State purchase two and a quarter grams of radium for use at the 

State Institute in the treatment of indigent cancer patients from Xew 

York State, and as far as this quantity permitted, from other States. 

Dr. Gaylord and his associates have also made intensive and careful 

studies in the use of massive doses of short wave length x-rays in the 

treatment of cancer. 

Dr. Gaylord's keen and energetic personality was a great factor 

in the successful conduct of the State Institute under his direction, and 

in his passing the State of New York has lost a faithful and valuable 

servant, and Radiotherapy will mourn for one who has done much to 

advance this science.

A QUARTERLY JOURNAL DEVOTED TO THE CHEMISTRY. PHYSICS AND 

THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES 


Edited by Charles H. Viol, Ph. D., and William H. Cameron. M. D.. with the assist 

collaborators working in the fieldsof Radiochemistry, Radioactivity and Radiumtherapy. 

Address all communications to the Editors. Forbes and Meyran Avenues. 

Pittsburgh, Pa. 


VOL. 3, New Series OCTOBER, 1924 No. 3 

THE TREATMENT OF MALIGNANT DISEASES WITH 

RADIUM AND X-RAY-CANCER OF THE CERVIX* 

By RoBiiki B. Gbfenougii, M. D., F. A. C. S., 

Boston, Chairman 

Report of Ihe Committee ol Mallgnani Diseases with Radium and X-ray, appointed by the 

American College ot Surgeon* 

The result of treatment of cancer of the cervix of the uterus was 

selected as the first subject for investigation. Abstract cards were prepared 

by the committee and the co-operation of the established clinics 

in the various cities represented was sought and obtained. To the many 

individuals who have taken part in the investigation, and especially to 

those junior men who look on the laborious task of transferring the clinic 

records to the abstract cards, the thanks of the committee are due. Without 

their interest and cooperation the investigation would have been 

impossible. 

The cases selected for study were all treated in the years 1914 to 

1919 inclusive. Each clinic was requested to provide a record of the 

cases of cancer of the cervix which entered the hospital within that 

•Reprinted by permission from Surgery. Gynecology and Obstetrics. BXU, 18-2G. July. 1924. 

The accompanying report Is that of a conuniltee appointed In February, 1932. and Includes the 

data collected up to February 1. 1924. The membership of the commltlee Is as" follows: C. F. 

Buraam, Baltimore; G. W. Crlle, Cleveland: William Dunne, Boston; J, SI. T. Finney. Baltimore: 

Burlon J. Lee, New York; H. K. Pancoast. Philadelphia; H. Gideon Wells. Chicago: Francis 

C. Wood, New York; R. B. Greennugti. chairman. Boston. 

The chairmen of the local committees are: J. M. T. Finney. Baltimore; R. B. Grcenough, 

Boston; Harrey R. Gaylord, Buffalo; Albert J. Ochaner, Chicago: George W. Crlle. Cleveland: 

C. Jen* Miller. New Orleans; Charles H. Peck, New York; John G. Clark, Philadelphia; Charles 

H. Mayo, Rochester; Aleiander Primrose. Toronto.

162 R a d i u m 

period, whether treated by operation, by radium, or by any other method.' 

It may be said that the results here recorded represent a considerable 

number of the clinics which are believed to be well equipped in every 

way to deal with this disease, either by radiotherapy or by radical operative 

measures. 

The problem before the committee was to collect data in regard 

to cases of cancer of the cervix treated by operation, by radium or X-ray, 

or by any other method, or combination of methods. In order to make 

possible a fair comparison of the results of treatment, it was necessary 

that the same rigid conditions should obtain in determining the results 

of all methods of treatment as have been agreed upon by the surgical 

world to be necessary in reporting the end-results of the operative treatment 

of cancer in its various situations. It was also necessary, especially 

when dealing with the cases treated by radiation, to obtain a classification 

of cases according to the extent of disease present at admission 

to the hospital, so that early favorable cases treated by operation 

should not be compared directly with advanced cases subjected to radiation 

only as a palliative measure. Such a classification of cases, based 

upon the clinical findings on admission and corrected when possible by 

subsequent operative findings, has been procured. 

The correction of the clinical classification of cases by subsequent 

operative findings undoubtedly leads to a more correct estimate of the 

actual conditions, but it should be recognized that cases which are not 

subjected to operation are not reclassified, and this fact therefore works 

somewhat to the disadvantage of the cases treated by radium or other 

non-operative procedures. 

Before presenting the statistical result of the investigation, a few 

comments upon the conditions seem to the committee to be appropriate. 

In order to obtain a sufficient number of case records, and in order to 

have a sufficiently long period after operative treatment to estimate the 

end-results on the arbitrary 3 year basis, it was necessary to set the period 

of investigation for the calendar years iOi-t-15-16-17 and 18. In 1923 

this was extended to include the vear 1010. 

During this period, which includes the years of the war, hospital 

services were somewhat disorganized, clinical work on these problems 

was interrupted, and hospital records were not always kept as fully up 

to dale as could he desired. The radical operative treatment of cancer 

of the cervix had been fairly well standardized, and was in general use 

-The committee ha* collected 1.210 case word* for analysis. These records come from 

the following hospitals: 

I, Free Hospital for Women. Boston. Dr. W. P. Graves. 

2. Huntington Hospital, Boston. l)r G. A. Leland. 

3. .Massachusetts General Hospital. Boston, Dr. Lincoln Davis 

1 Augustaoa Hospital. Chlcaso. Dr. Henry Sebmitz. 

o. Cook County Hospital, Chicago. Dr. Henry Schmitz. 

6. German-Ararrlran Hospital. Chicago. Dr. Hen'v Schmitz. 

.. Post-Graduate Hospital, Chicago. Dr. Henry Schmitz. 

S. St. Mary's Hospital. Chicago, Dr. Henry Schmlu. 

*- St. Joseph's Hospital. Chicago. Dr. Henry Sclmiltr 

10. Washington Boulevard Mospital, Chicago, Dr. Henry Schmitz 

11. Frances Wlllarrt Hosoilal. Chic»=o, Dr. Henry Schmitz. 

IS. RoostrMl Hospital, Snr Y-trk. Dr. Howard C. Taylyor 

13. University Hospital. Philadelphia. Dr. John G. Clark 

14. Philadelphia General Hospital. Philadelphia. Dr. Charles P Norris 

is. Scranton Hospital, Scranlon, Pa.. Dr. J. M. Wainmrlght. 

16. Fresbjterinn Hospital. New York. Dr. James A. Corscaden. 

li. Toronto General Hospital, Toronto. Dr. Alexander Primrose 

21. 22. 

IS. 

19. 20. Jefferson Lakeside 

Howard 

Woman's Memorial 

A. 

Hospital, Hospital. Kelly Hospital. 

Philadelphia. Cleveland, New York. York, 

Baltimore, 

Dr. Dr. George Win, G-nrtr B. 

Dr. 

A. P. W. 

Curtis 

Gray Anspach Heale.v, Crlle." Ward. 

F. Burnam.

R a d i u m 163 

in operative clinics. Radium therapy, during these years, however, was 

in a state of constant experimental modification. The dosage employed 

was as a rule less than in these same clinics at the present time, 1924. 

and the application of radium was less accurately accomplished. Repeated 

treatments were employed in many cases in contrast to the single, 

massive dose administered under anaesthesia and with all the conditions 

of a surgical operation, such as is the usual technique at the present 

time. It may be said that it is the general opinion of radiotherapists 

that the results of radium therapy during the period under discussion 

were far less favorable than are those to be anticipated from the technique 

now employed. Since the results of the present method, however, 

cannot be judged for at least 3 years to come, it is believed wise lo 

consider what was then accomplished and to await the end-results of 

the preseni methods as they mature. We must admit, however, that 

as between radium and radical operation, these conditions are to the 

disadvantage of radium in no small degree. 

During the period concerned in this investigation, high voltage, short 

wave length X-ray therapy was not in common use. and no cases were 

recorded in which X-ray was employed except as an adjunct to other 

methods. To judge of the value of X-ray from these data is therefore 

quite impossible. 

The standard surgical report of end-results in cancer cases furthermore 

demands pathological evidence of the presence of cancer. In operative 

cases this is readily obtained, as the tissue removed is submitted 

entire to the pathologist. In many cases suitable for radiotherapy, however, 

the removal of tissue for a biopsy cannot be accomplished without 

adding to the discomfort of the patient, or prolonging the operation. 

and for these reasons is occasionally omitted by the surgeon who feels 

himself quite competent to make a diagnosis on clinical evidence alone. 

Such cases, while in all probability actual cases of cancer, are of no 

value in this investigation, as they fail to fulfill the prescribed conditions, 

and thus must be omitted as inconclusive. There were 32 such 

cases in this series; S in which hysterectomy was followed by radium 

and 22 in which radium alone, or combined with cauterization, was employed. 

All of these cases are alive and well and their omission on account 

of lack of pathological evidence of cancer lowers the percentage 

of "cures" by radium in comparison with hysterectomy. We believe 

that due weight should be given to these facts in estimating the value of 

the different methods of treatment. 

Attention should be called to the use of the word "cure" in the following 

pages. The term is used as the most convenient one to express 

the fact that the case in question is reported free from evidence of disease 

at a period 3 years or more subsequent to treatment. It is not meant 

to imply that subsequent recurrence of the disease may not take place. 

It is the purpose of the Committee to obtain later reports on all these 

cases. 

While the total number of case records is already large, constant 

additions to this number are to be expected, and supplementary- reports 

will be prepared from time to time and presented by the committee. 

When the total number of cases is divided into the different classes, however, 

and when these numbers are again subdivided into smaller groups, 

according to the method of treatment employed, the numbers of cases 

in each group arc much diminished, to such an extent, indeed, in certain

164 

Radium 

groups as to make possible serious error, if too much weight is placed 

upon variations of slight degree in the percentages obtained.1 The 

committee does not wish to be accused of failing to recognize these facts, 

but draws attention to them that no misunderstanding of the conditions 

may occur. Such as they are, however, and pending the receipt of additional 

records which may tend to overcome this objection by providing 

larger number of cases in each group, the results are here reported. 

TABULATION OF RHSt'LTS 

It was necessary to reject 3S1 records of the total number of 1,210. 

The reasons for discarding these records are stated in the Table I. 

Thirty-two cases were rejected as they lacked pathological evidence 

of the presence of cancer; these cases were, however, all alive and well 

more than 3 years after treatment. 

Twenty-five cases were rejected because less than 3 years had 

elapsed from the time of the last treatment; these cases also were alive 

and well. 

Five cases, however, were accepted as three year "cures" in which 

a period of 3 years had not elapsed after the last treatment with radium. 

These were all cases in which the original treatment was given more 

than 3 years before, and the later radium treatment was given, without 

evidence of recurrence, only as a prophylactic measure. One of these 

was a case of hysterectomy with postoperative prophylactic radiatioD. 

one. cautery and radium, and three were treated by radium alone. 

Kight hundred and twenty-nine cases remain as satisfactory for 

study. 

TABLE I.—REASON'S FOR RltJFCTINC 381 RECORDS 

Total cards received I.2IO 

Discards: 

Untraccd 159 

Xot cancer of cervix 10 

Xo treatment 56 

Xo pathological diagnosis 32 

Under 3 years 25 

Re-entries — duplicates 23 

1913 and 1020-1021-1922 43 

Xo data to classify 13 

Otherwise inconclusive 20 

— 38l 

Satisfactory for study 829 

'By ihe courtly of Professor K. B. Wilson of the Harvard School of Public Health the 

following explanatory footnote has been added lo Ibis report. 

The mathematical formula eomnnnb used by statisticians to Indicate Ihe influence of 

chance In determining percentage relations Is e\prc*sed as "standard deviation." Tills terra is 

meant to indieat" that chance fluctuation* would be expected to He, at least I wo thirds of the 

time, within the assigned limits. 

The formula l( as follows: Let N represent the numher of cases recorded and F the fraction 

"cured." The "standard deviation" would be \'F n-Fi-rN. Taking the figures from Table III. 

as applied to Cl**< l.A: X = 123: F = 3S 123 or .4*. The -standard deviation" would then be 

V.2SX.:2-M2^. This Is .04-f. 

In terms of percentage this indicates that at least two-thirds of the time the chance, fluctuations 

of the !S per cent -ecorded In TaMc III would lie between 21 per cent, and 32 per cent. 

The "standard deviation" has been calculated In this way for the percentages given In these 

tables and Is noted In the text In reference to those tables where It Is a matter of significance. 

Another ionuula "probable error." is sometimes used by statisticians. "Probably error" 

Is two-thirds of "standard deviation" and Indicates that one-half of the time the fluctuations 

due the "Standard more to chance rigorous deviation" would test. He has within been the used assigned In this flgures. paper in preference lo "probable error" as being

a d i u m 165 

In Table II we have divided the 688 primary cases into the four 

groups: 

i.A—Early favorable 

i.B—Border-line 

i.C—Broad ligaments involved 

i.D—Advanced cases 

There were 123 cases of recurrence after hysterectomy; the hysterectomy 

in these cases having been done in some other institution. None 

of these cases appears in the 688 primary cases above recorded. 

There were 18 cases in which cancer of the cervix developed in the 

stump left after a supravaginal hysterectomy for fibroid. 

' TABLE II.—DIVISION OF PRIMARY CASES 

688 

Primary cases: 

1.A—Early favorable 123 

i.B—Border-line 120 

i.C—Broad ligaments involved 310 

i.D—Advanced cases 135 

Recurrent after hysterectomy 123 

Cancer of cervical stump 18 

Total . * 829 

Table III records the results of treatment in the different classes 

of cases. As would be expected, the greatest number, as well as the 

greatest percentage of "cures," occur in the early and favorable cases. 

There were 9 "cures" of recurrence after hysterectomy and there 

were 2 "cures" in cancer of the cervical stump. Ninety-four cases of 

the whole number, or 11 per cent., were "cured" of their disease. It 

should be repeated that in all of these tables the word "cure" is used 

advisedly to indicate only a period of 3 or more years elapsed without 

evidence of disease. It is the intention of the committee to obtain later 

reports on all these cases. 

TABLE III.—RESULTS OK TREATMENT IN DIFFERENT CLASSES OF CASES 

Primary cases: 

Cases "Cures" Per cent. 

Class 1.—A 123 35 28 

Class 1.—B 120 22 18 

Class 1.—C .*. 310 24 7 

Class 1.—D 135 2 1 

688 83 8 

Classes 2 and 3—Recurrent after hysterectomy.. 123 9 7 

Class 4—Cervical stump 18 2 n 

Totals 829 94 11 

All of the cases of this series entered the hospital in the calendar 

years 1914-1919 inclusive. 

Table IV indicates the number of years that have elapsed in the 

"cured" primary cases. It is to be noted that cures of 6 or 7 years' dura-

166 R a d i u m 

tion have been obtained by hysterectomy with or without radium, and 

by radium, or radium with palliative operation. 

TABLE IV.—NUMBER OF YEARS ELAPSED IN "CURED" PRIMARY CASES 

Duration 

Yrs. Yrs- Yrs. 

Yrs. 

4 5 5-6 6-7 

3—4 5 6 3 

Hysterectomy alone 5 1 

4 

Hysterectomy and radium 1 3 1 

Radium and hysterectomy .... 2 r» 1 

Radium alone 12 1 I 

Radium and X-ray 

I 

6 5 

Radium and cautery 2 

1 

Radium and amputation 

1 

Cautery and ligation 

Yrs. 

7-* 

Total 23 23 14 83 

Table V indicates the actual numbers of cases, and the percentage 

of the total number, which were "cured" by different methods of treatment. 

It will be seen that radium alone or with X-ray. was responsible 

for 37 "cures" or 4.4 per cent, of the total number; and radium and 

X-ray, with or without a palliative operation, gave 56 "cures" or 6.6 per 

cent, of the total cases treated. This is to be taken merely as an indication 

of the absolute value of radium in the treatment of this series of 

cases of cancer of the cervix. It is not in any way an indication of the 

relative value of radium as compared to hysterectomy. 

TABLE V.—ACTUAL NUMBER OK CASES AND PERCENTAGE OF TOTAL NUMBER 

"CURED" P.Y DIFFERENT METHODS OF TREATMENT 

829 Cases—94 "Cures" 

"Cures" Per cent. 

By hysterectomy alone 19 2.2 

By hysterectomy supplemented by radium. 18 2.1 

By radium alone or with X-ray 37 4.4 

By radium and palliative operation 19 2.2 

By cautery alone 

o 

By cautery and ligation of internal iliacs. ... 1 o.l 

Total 94 11 

Table \T shows the result* of different methods of treatment in 

688 primary cases regardless of the extent of their disease. It is to be 

noted that the percentage of "cures" by hysterectomy alone (26 per 

cent.) is the same as the "cures" in cases where preoperative or postoperative 

radium is employed. The operative mortality of 16 per cent. 

following hysterectomy is also to be noted. 

There were 146 hysterectomies performed in the 688 primary cases. 

One hundred and twenty-seven were pan-hysterectomies after the Wertheim 

technique. Xine were recorded merely as abdominal hysterectomies. 

In 6 cases only a supravaginal hysterectomy was done, and in 

4 cases vaginal hysterectomy was performed. It is a notable fact that 

3 of the 4 vaginal hysterectomies resulted in cure. 

Fifty-two cases were treated by cautery alone, and in 92 cases cau- 

2 

3 

4 

3 

Total 

19 

8 

10 

M 

4 

16 

X 

1

Hajmu.m 167 

tery was used in combination with radium or X-ray. In many of the 

hysterectomies also cautery was used as a preliminary measure, either 

prior to, or as a first step in, the radical operation. In 24 of the cautery 

operations the record stated that the Percy technique was followed. Five 

of these cases appear in the list of cures, but in 4 of them the cauterization 

was supplemented by radium treatment, and in the other one a 

hysterectomy was done. No one of the 52 cases in which cautery alone 

was used resulted in cure. 

TABLE VI.—RESULTS OF TREATMENT REGARDLESS OF EXTENT OF DISEASE 

Cases Cures" Per cent. 

Hysterectomy alone 74 19 26 

Hysterectomy with radium 70 18 26 

Hysterectomy with X-ray 2 0 

146 hysterectomies 

16 

23 operative fatalities 

10 2S 

Hysterectomy with postoperative radium 40 

8 27 

Hysterectomy with postoperative radium 30 

37 25 

Hysterectomy with or without radium 146 

40 hysterectomies with preoperative radium 

4 operative fatalities : 10 

Table VII îve- »>vaq nirther details of the results of treatment. 

It is to be noted that the preoperative use of radium in 40 cases, followed 

by hysterectomy, gave approximately the same percentage of "cures" 

(25 per cent.) as when radium was used in postoperative treatment 

(27 per cent.). It is to be noted also that the 40 cases of preoperative 

radiation did not appear to increase the hazard of operation to any great 

extent as it was found that only 4 fio per cent.) of these cases died 

of operation 

TABLE VII.—FURTHER PETAI1.S 01* TREATMENT 

Cases 

Radium alone 363 

Radium and X-ray 20 

Radium and cautery 91 

Radium with or without X-ray or palliative 

operation 478 

Cautery alone 52 

Other methods 12 

478 radium applications 

1 operative fatality .. 0.2 

The main purpose of this investigation may be said to have been to 

obtain a classification of cases with reference to the extent of the disease 

in order that a fair comparison should be possible of the results of 

different methods of treatment in similar cases. 

Table VIII indicates the results of treatment in the i.A group of 

early favorable (operable) cases. 

Hysterectomy without radium gave 14 "cures" in 41 cases (34 per 

cent.) There were 8 operative fatalities, a mortality of 19 per cent. 

and the use of radium either before or after operation did not appear 

to increase the percentage of "cures." 

Radium alone gave 15 per cent., and radium combined with X-ray, 

cautery or other minor operative procedure, gave 6 "cures" or 42 per cent. 

24 

•1 

ib 

45 

1 

Per cent. 

6 

20 

17 

9 

8

168 Radium 

The numbers, however, are small and it is probable that we get a 

more accurate idea of the prospect of cure if we combine the cases 

treated with radium, either with or without the use of the cautery, getting 

11 "cures" in 44 cases, or 25 per cent. Roughly stated, in early 

favorable cases, hysterectomy gives 1 chance in 3 of cure, with an operative 

mortality of 1 in 5, where radium, with or without the cautery, 

gives a chance of cure of 1 in 4 without mortality. 

If to these percentages we apply the statisticians' correction for 

"standard deviation" we find ihat the 34 per cent, "cures" by hysterectomy 

should be recorded as ~ 7.4 and the 25 per cent, for radium with 

or without cautery or X-ray 1 should he *- 6.5. Thus chance alone might 

bring about a variation for the hysterectomy percentage from 26.6 per 

cent, to 41.4 per cent, and lor the radium cases from 18.5 per cent, to 

31.5 per cent. It is readily seen that these bounds actually overlap and 

the difference in percentage is not of serious statistical significance. 

TABLE VIII,—RESULTS OF TREATMENT IN CROUP I .A 

\.A—123 Cases 

Ca»;s -Cures" Per cent. 

Hysterectomy without radium |i 14 34 

8 operative fatalities .. 19 


Pre-operative radium 13 4 3° 


Postoperative radium 15 5 33 

Xo fatalities 

Hysterectomy with or without radium 69 23 33 

Radium alone 30 5 16 

Radium and palliative operation and X-ray 14 6 42 

Radium with or without palliative operation and 

X-ray 41 11 25 

The i-B group represents the so-called border-line cases, those in 

which the disease has begun to involve the vaginal wall or ihe cavity of 

the uterus, but without extension into the broad ligaments (Table IX), 

Hysterectomy alone gave 25 per cent, "cures" in 16 cases. The 

operative mortality ran as high as 31 per cent. Hysterectomy with 

radium gave 33 per cent, "cures" in 15 cases. The cases in which 

radium was used before operation, while only 6 in number, gave 3 

"cures." or 50 per cent. 

Radium alone gave only 10 per cent, of cures. Radium with palliative 

operation gave a showing equal to that of the hysterectomies with 

or without radium, and radium with or without a palliative operation, 

gave 13 "cures," or 16 per cent. 

It would appear that in the border-line cases the prospect of cure 

by hysterectomy is less; the use of radium before operation may possibly 

improve the outlook, and the operative mortality is higher than 

in the l-A group. 

Although the numbers are small, it would suggest that the use of 

radium supplemented by a palliative operation, gave the greatest prospect 

of cure and without operative ri»k. The calculation of the "standard 

deviation." however, indicates that the difference of percentage is not 

of great significance, viz.. hysterectomy with or without radium. 29 

per cent.'-- 8; radium with palliative operation. 33 per cent. ~ 3.

R a d i u m 

169 

TABLE IX.—RESULTS OF TREATMENT IN GROUP I.B 

\ 

i.B—120 Cases 

.. -*i i' Cases "Cures" Per cenl. 

Hysterectomy without radium 

lO 

6 operative fatalities l£ 

Hysterectomy with radium i^ c j» 

Preoperative radium (j -0 

i operative fatality ,a 

Postoperative radium o 2 22 

No fatalities \ 

Hysterectomy with or without radium 31 o 29 


Radium with palliative operation 21 7 »? 

Radium with or without palliative operation 77 j^ iD 

Table X combines the groups I.A and i.B, giving larger numbers to 

deal with. Roughly stated, hysterectomy without radium cures 1 in 3 

with an operative fatality of 1 in 4. 

Radium with a palliative operation cured about 1 in 3, and radium 

with or without palliative operation about 1 in 5, 

If we calculate the "standard deviation" in these percentages we 

get: 

Hysterectomy, with or without radium 32 per cent.—4.6 

Radium, with or without palliative operation 19 per cent.—3.5 

TABLE X.—RESULTS OF TREATMENT IN CROUPS I.A AND I.B COMBINED 

l.A and i.B (combined) 


Hysterectomy without radium 57 18 31 



Preoperative radium 19 7 36 



No fatalities 



Radium with palliative operation or X-ray 35 13 37 

Radium with or without palliative operation. .. .121 24 19 

Table XI gives the results of treatment in the i.C group where the 

disease was believed to have infiltrated the broad ligaments. 

There was 1 "cure" (7 per cent.) and 2 operative fatalities in 13 

cases treated by hysterectomy alone. The addition of preoperative or 

postoperative radiation increased somewhat the percentage of "cures" 

(16 per cent.); the numbers, however, were rather small. 

Radium alone cured 12 cases, and radium with palliative operation 

7 cases; the numbers treated, however, were large and the percentage 

small.

170 R a d i u m 

TABLE XT.—RESULTS OF TREATMENT IN GROUP I.C 

i.C—311 Cases 


Hysterectomy without radium 13 ' 7 

2 operative fatalities 15 

Hysterectomy vv ith radium 2;", 4 16 

Preoperative radium 19 3 '6 

Xo fatalities 


Xo fatalities 



Fatalities I .. }4 

Radium and palliative operation or X-rav $2 7 13 

Radium with or without palliative operation. .. .2.(1 19 7 

Table XII shows the advanced and supposedly hopeless cases. Six 

cases were operated upon, with or without radium, without success. 

Only 2 cases appear in ihe three year "cures." 1 treated by radium alone, 

and 1 by radium and cauterization. It is obvious that these two cases 

at least were erroneously classed as "hopeless." This is in all probability 

due to the difficulty in distinguishing fixation of the uterus due 

to cancerous infiltration of the broad ligaments from a similar infiltration 

of an inflammatory character. 

TABLE XII.—RESULTS OF TREATMENT IN GROUP I.D 

'O—135 Coses 

Cases "Cures" Per eenL 

Hysterectomy without radium 4 0 o 

Hysterectomy with radium 2 o o 


Radium alone 8S 1 1.1 

Radium with palliative operation 27 1 3 

Radium with or without pallialive operation 115 2 1.7 

Table XIII shows the duration of life in the cases not cured. It 

will be seen that no material difference exists as between the different 

methods of treatment. 

In the early favorable group radium alone gave a slightly longer 

average of life, but in the less favorable cases this is not so apparent. 

Four cases in the I.B group treated by hysterectomy averaged 27 

months. These numbers, however, are so small that little reliance should 

be placed upon this isolated observation. 

TABLE XIII.—DURATION- OF LIFE IN CASES NOT "CURED" 

Hysterectomy alone 

_, . Cases Months 

Class I.A 18 21 

Class i.B _j 27 

Class i.C q » 

Class i.D ,.

R a d i u m 

m 

Radium alone 

Class i.A 25 28 

Class i.B 47 ,4 

Class i.C .67 M 

Class i.D 78 9 

Radium, cautery. X-ray 

Class i.A 

Class i.B 12 9 

Class i.C 40 13 

Class i.D 22 9 

Rectovaginal and vesicovaginal fistula; occur spontaneously in cases 

of cancer of the cervix. There were S such cases in the entire series 

of primary cases ^Tablc XIV). 

The danger of fistula formation is apparently increased by any 

method of treatment, thus hysterectomy alone gave 5.5 per cent.; cautery 

alone 5.6 per cent.; radium alone 5.7 per cent.; and cautery and radium 

7 per cent. 

It would appear that the danger of fistula formation should not 

weigh heavily in the choice of methods of treatment. 

TABLE XIV.—RECTOVAGINAL AND VESICOVAGINAL FISTULAE 

Cases Fismlae Percent. 

Spontaneous 688 8 1.1 

After hysterectomy alone 74 4 5.^ 

After cautery alone 52 3 5.6 

After radium alone 363 21 5.7 

After hysterectomy and radium 70 4 5.6 

After cautery and radium 91 7 7.0 

Other methods 3S o 

47 

The value of radium as a palliative measure in the treatment of incurable 

cases is generally admitted (Table XV). That life is materially 

prolonged by the use of radium is hard to prove. 

Local healing of the disease in the cervix or vagina was noted, 

however, in 75 cases which failed of cure. This, of course, means relief 

from the offensive discharge and haemorrhages which are characteristic 

of the advanced stages of the disease. 

Table XV indicates the methods of treatment which resulted in 

local cure. The small group of cases in which radium and X-ray was 

used is perhaps most striking. Of 20 cases, 4 were "cured" of their 

disease and 6 obtained local healing. Thus in 50 per cent, of this small 

group the local lesion was destroyed. 

TABLE XV.—LOCAL RESULTS OF TREATMENT 

Local 

Cases "Cure*" HeallnB 

Hysterectomy alone 74 *9 3 

Hysterectomy and X-ray 2 0 I 

Hysterectomy and radium 70 18 13 

Radium alone 3°3 24' 37 

Radium and X-ray 20 4 6 

Radium and palliative operation 95 17 14 

Cautery alone $2 o 1 

Other methods 12 1 o

172 R a d i u m 

Table XVI shows that the cases which showed recurrence after 

hysterectomy gave 7 "cures" by radium alone, and 2 "cures" by radium 

and cautery. Of iS cases in which cancer of the cervix developed after 

a previous hysterectomy for fibroidonly 2 were "cured" and those by 

radium alone. 

TABLE XVI.—RESULTS OF TREATMENT IN RECURRENCE AFTER HYSTERECTOMY 

Cases -Cures" Per cenL 

Recurrent after hysterectomy 123 9 7 

By radium alone 7 

By radium and cautery 2 

Cancer of cervical stump 18 2 11 

By radium alone 2 

An estimate of radium dosage in millicurie or milligram hours alone 

is misleading. The amount of filtration and the distance must also be 

considered. It is an interesting fact, however, that the average amount 

of local or contact radiation employed in the successful cases was 5,004 

millicurie hours, irrespective of deep ^radiation or X-ray applied externally 

(Table XVIII), Such an amount of radiation can be obtained 

only by very prolonged treatments 14 to 8 days) when radium tubes 

of only 25 or 50 milligram are used. The smallest dosage of radium 

used in the "cured" cases was as follows: 

Millicurie 

Hours 

Class A 1.700 

Class Ii 1.725 

Class C 2,200 

The largest dosage in a "cured" case was 16.000 millicurie hours 

given in twenty-nine treatments. 

In general, during this period there has been a distinct tendency 

to abandon the many times repeated small dosage local treatment, in 

favor of the single massive dose of radiation administered under an 

anaesthetic and with all the conditions of a surgical operation. In certain 

well equipped clinics this is further supplemented by heaw v-radiation 

or X-ray.1 

TABLE XVII.—RADIUM DOSAGE (LOCAL) 

Aierafe 

Millicurie 

57 cured primary cases 5.004 

i.A Class—16 cases 3-354 

i.B Class—iS cases 5.S96 

i.C Class—23 cases 5-45^ 

Table XVIII shows the different varieties of cancer in S3 "cured" 

cases. It is apparent that no uniform method of classification has obtained 

wide acceptance in the clinics here represented. It is of interest, 

however, to note that the milder forms of the disease—adenocarcinoma 

'At the suseestion of one of the numbers of the Committee, the followlnc statprafM Is made. 

to supplement the report: 

Much variation Is found in the technl.me employed in radium therapy Id this series of casesmethods 

were constantly chanclne in the period covered; and It Is probable that durlnr this 

lime methods have been materially luiprortd. It Is the purpose of the Committee to submit a 

later report, dealing with the details of treatment with radium, but It must be r. n : ihit 

nothing short of the very best of radium treatment, as well as the best of suri^c-al sfcui ôvild 

be considered adequate In dealing with this disease.

R a d i u m 173 

and papillary carcinoma—are not by any means the only ones to be cured, 

whatever agency is employed. 

It is also of interest to note that of all the cases in which hysterectomy 

resulted in a "cure,'' in only 2 was evidence presented that the 

disease had extended beyond the uterus itself, and in these two cases 

the pelvic lymph nodes were not diseased but cancer was found by microscopical 

examination, in the parametria! tissue adjacent to the cervix. 

TABLE XVII!.—VARIETIES OF CANCER IN 83 "CURED" CASES 

Total 83 

SUMMARY 

, "Cures" 

Adenocarcinoma 8 

Adeno-acanthoma 

i 

Carcinoma 14 

Epidermoid carcinoma 5 

Squamous cell carcinoma 42 

Solid carcinoma 1 

Cylindrical cell carcinoma 1 

Epithelioma 7 

Papillary carcinoma 4 

i. As a result of the study of the case records submitted to the 

committee certain conclusions may be drawn. We would again emphasize 

the fact that this is to l>e regarded only as a preliminary report, 

and that it is the purpose of the committee to collect further data and 

extend the time beyond the minimum period of 3 years, so that knowledge 

of the more remote end-results of these cases may be obtained. 

The figures available to the committee arc submitted and such conclusions 

drawn as seem justified by the results. 

2. Of 829 cases of cancer of the cervix 94 were free from disease 

3 or more years after treatment. More than half of these "cures" were 

obtained by the use of radium and X-ray without radical operation. 

There were no "cures" by cautery alone. 

3. In 243 cases of the i.A and i.B group (early favorable and 

border-line cases) hysterectomy alone cured in 1 in 3, with an operative 

mortality of 1 in 5. Radium with palliative operation (cautery) cured 

about 1 in 3, and radium alone (or with palliative operation) about 1 in 

5. Under these conditions it may be said that the choice between operation 

and radium in the treatment of early and favorable cases of cancer 

of the cervix is an open one. It is to be borne in mind that the results 

of treatment by radium used with the technique of the present day, are 

not yet available but that it is generally believed that they will be better 

than the figures here presented. 

4. In more advanced cases (i.C and i.D) the "cures," either by 

radiation or by hysterectomy, were very few. 

5. The duration of life in the unsuccessful early cases is somewhat 

greater after radium than with operation. 

6. The formation of rectovaginal and vesicovaginal fistula? occurred 

with nearly equal frequency with all methods of treatment. 

7. Radium, with or without X-ray or palliative operation, was 

the most important agency in the destruction of local disease in cases

174 R a d i u m 

which failed to obtain a "cure." The value of radium as a palliative 

measure in advanced cases is beyond dispute. 

8. In the treatment of recurrent cases after hysterectomy, and in 

cancer of the cervical stump, radium is to be preferred to other methods. 

9. A sufficiently large dosage of radium is necessary to obtain 

destruction of the local lesion. The treatment of cancer of the cervix 

with inadequate amounts of radium should not be encouraged. 

10. A uniform classification of the pathological varieties of cancer 

of the cervix is much to be desired. 

RADIUM TREATMENT OF CARCINOMA OF THE 

ANTRUM* 

By Frederick M. Johnson, M. B., Tor. 

Surgeon in Charges of Radium Department. Steiner Memorial Clinic, 

Atlanta, Ga. 

Formerly of the General Radium Service, Memorial Hospital for Cancer 

and Allied Diseases, New York. 

The problem of treating malignant tumors of the maxillary antrum 

seems to have passed the stage of radical surgery. Numerous operations 

have been devised and performed. Depending on the boldness and 

skill of the surgeon conservative excision of the growth and radical resection 

of the upper jaw have been advocated. But an investigation of 

the results indicates that such efforts have failed to cure and in many 

instances have actually hastened a fatal termination. For example, 

Scudder (1) who is a very experienced operator, states that even the 

most painstaking surgery rarely succeeds, and that it is the exception 

rather than the rule to find cured cases with authenticated laboratory 

reports, Bloodgood (2). more recently, was unable to find in his records 

of 30 years one solitary case of proven carcinoma of the antrum, cured 

by excision of the upper jaw. This persuaded him to replace the cutting 

operation by the cautery, by which method one patient has been made 

free of disease for 5 years. Martens (quoted by Scudder, 1) has collected 

40 cases from the literature, of which only two were well for any 

length of time following operation. But the ultimate hopelessness of resection 

of the superior maxilla is not the complete story, because from 

the European clinics comes the tale of an operative mortality of 15 to 

.30 per cent. Koenig's (quoted by Scudder. 1) experience at the Gottingen 

clinic was even worse, for in 48 total upper jaw resections there 

were 19 operative deaths (39 per cent.). 

With the introduction of radium it was hoped that at last wc had 

at our disposal an agent on which reliance could be placed, if used in 

conjunction with conservative surgery. But it appears that the factors 

which caused surgery to fail hinder in the same manner the newer forms 

-of treatment. These conditions arc: 

1. Carcinoma of the antrum is locally a highly malignant disease. 

•From the Ccneral Radium Service of the Memorial Hospital, Xew York City. Reprinted by 

permission from Surgery. Gynecology nnd Obstetrics, axrill, 819-822, June. 1924.

R a d i u m 175 

It grows rapidly, infiltrates widely, and invades bone readily, but the 

lymph glands are rarely involved. 

2. Accurate and early diagnosis is rendered difficult by the fact 

that cancer in itself does not produce specific clinical signs and symptoms, 

and it is only when a luinor is produced that mechanical disturbances 

appear. Bu this appearance is slow and insidious when the growth 

is in a hidden cavity like Ihe antrum, and the diagnosis of the disease 

is often too late for successful treatment. 

3. As in the case with all cancers of the mouth and nasal passages, 

inflammatory processes may predominate, and an incomplete diagnosis 

of empyema of the antrum, or simple polyp, may delay proper recognition 

of the essential disease, until the neoplasm is hopelessly advanced. 

Numerous contributions on experience with radium therapy have 

been made to the current medical literature during the last few years. 

While many of these are nothing more than single case records, a general 

review of them indicates that distinct advances are being made. New 

(3) reports from the Mayo Clinic that in carefully selected cases he 

opens the floor of the antrum with a hot soldering iron, thereby destroying 

the growth by heat. Radium is used later as indicated. He claims 

that the results are much better than with jaw resection and mentions 

three cases clinically free of disease for 13 months, 15 months, and 17 

months. 

Our experience in the use of heat in antral cases has not been satisfactory 

enough to warrant its adoption as the method of choice. It 

is true that a bulky portion of the neoplasm is destroyed quickly. On 

Ihe other hand microscopical evidence indicates that in surrounding tissues 

there is produced a paralysis of blood vessel walls and a dilatation 

of lymphatic spaces. Moreover, there is an inhibition of lymphocytic 

infiltration, the presence of which is now thought to be of the greatest 

service in local cancer restraint. The cautery, therefore, produces an 

effect which is diametrically opposed to that of radium. Unless we are 

fortunate enough to kill every cell of the cancer during the heating 

process, we fear that the effect of ihe cautery on the outlying tissue 

would tend to spread the disease. 

Ochsner (4). Blaisdell (5), Greene (6). and Patterson (7) have also 

contributed recent articles on the management of such cases by radium. 

Carcinoma of the antrum is not an uncommon disease. Ewing 

states that at the Memorial Hospital during the years 1916-17, out of 

1,892 cases of cancer of all type admitted. 35 (1.84 per cent.) involved 

the maxillary sinus. He recognizes the following types: 

1. Papillary carcinoma, some of which are malignant transformations 

of papillomata. 

2. Carcinoma of basal-cell type. They are often designated as 

adenoid cystic epitheliomata, endotheliomata, or cylindromata. 

3. Squamous-cell carcinoma which arises by metaplasia from previously 

altered lining epithelium. 

4. Cylindrical-cell carcinoma which forms a bulky tumor and is 

unusually malignant. It is adenocarcinomatous in type. 

5. Round-cell carcinoma of atypical structure which is often designated 

as sarcoma. 

6. Dental tumors which not infrequently develop in the antrum. 

They include the squamous and glandular types of adamantinoma. 

The exact point of origin of carcinoma of the antrum is usually

176 IÂDIU M 

never determined. Many undoubtedly arise from the mucous membrane 

of the sinus itself. F.pithelial rests in connection with a toothsocket 

may account for some. Phillips (9) has recorded in detail 16 

cases which were described as burrowing cpilheliomata. They grew 

from a tooth-socket and developed upward in the direction of least resistance, 

filledthe antrum, and then burst through the alveolus after 

the extraction of the teeth for the relief of pain. Others spring from 

the mucous membrane of the ethmoid region and after occluding the 

nasal passage spread along ihe orbital plate. Certain it is thru no matter 

where the seat of origin, the soft friable inflamed growth readily 

fills the cavity, and as development continues erodes the bony walls 

which are confining it. Thus the orbital contents and the capsule of 

Tenon may become involved, producing a prominent and faulty moving 

eye. Or pressure may be exerted on the thin facial wall, in which event 

perforation occurs near the infra-orbital foramen, producing a swelling 

of the cheek and later ulceration. The more extensive cancers advance 

through the posterior wall into the pterygoid fossa rendering the prognosis 

hoiieless. In many cases the alveolus and palatine process are 

the last to be destroyed, and a mushroom like tumor sprouts through into 

the mouth, being thereby the means of finallyforcing the sufferer to seek 

treatment. 

As has been indicated, antral cancers may produce signs and symptoms 

referable lo the nose, orbit, or teeth long before the presence of 

an associated tumor is suspected. Therefore rhinologists, opthalmologists, 

and dentists have the first opportunity of making a diagnosis 

and instituting appropriate treatment. Too often our records reveal 

one or more intranasal operations on recurring polyps which of course 

are secondary to the malignant disease; or a dental surgeon extracts 

molar teeth because of pain, with the result that the sockets do not properly 

heal, but become filled with a new tissue which for a time is believed 

to be "proud flesh." Again an antral empyema is suspected, and 

a very conservative opening is made in the anterior wall for irrigation 

purposes. 

The first symptom in many cases of this series was persistent pain 

or burning over the cheek, due to irritation of the fifth nerve. Later 

this pain was referred to the teeth or forehead. There was usually 

temporary relief when the tumor perforated. Nasal obstruction was a 

common first symptom, and was accompanied by a purulent and later 

a blood-stained discharge. The average duration of such symptoms 

before the patients were firstseen at this clinic was 7 months. Tenderness 

over either the antrum on percussion, or the palate on pressure, 

was frequently present. Radiographic examination was of great value 

in revealing a definite antral opacity, and if the tumor was large, there 

was a distortion of the turbinates and septum. If any doubt exists 

after such findings, an exploration from below is certainly advisable. 

This is strongly advocated bv Moore (10). 

In general, the plan of treatment that has been developed at the 

Memorial Hospital, includes the pre-operative, the operative, and the 

postoperative use of radium. 

Pre-operative Treatment. The antrum and accessory sinuses are 

subjected to a maximum "pack"' treatment from a distance of 6 centimeters. 

The "pack" is a flat brass box with walls 2 millimeters thick, 

.and an area of 77 square centimeters. It contains silver capsules of glass

R a d i u m 177 

emanation tubes. The dosage given is about 9,000 millicurie hours, which 

will produce a slight skin erythema. The lymphatic glands of the neck 

are exposed in the same way. With such heavy filtrationonly the deeply 

penetrating rays arc effective. When the available emanation was limited, 

we have recently substituted X-radiation in the pre-operative phase 

of treatment. Although theoretically not as efficient, it nevertheless 

has a distinct field of usefulness, especially in clinics that are equipped 

with only a small amount of radium. 

Operative Treatment. Before the tumor area is touched, a 10 centimeter 

skin incision is made under local anaesihesia along the anterior 

border of the sternocleidomastoid muscle. 1 he lymph-bearing tissue 

close to the internal jugular vein and in the posterior submaxillary space 

is exposed and examined. If there is any suggestion of metastases, a 

complete neck dissection is at once performed. If not, unfiltercd emanation 

tubes arc inserted, and the external carotid, lingual, and facial 

arteries are ligated. By tying the latter two vessels, the establishment 

of a vigorous anastomotic circulation is much delayed. Although such 

a careful observer as Bullin (11) did not approve of a preliminary ligalion, 

we believe from experience thai 1: is a wise procedure for two reasons. 

First, the danger of serious hemorrhage from the primary growth 

is much reduced both during the second stage of the operation and at 

a later date when the radium slough separates from the antrum; and 

second, the starving effect on the tumor is a distinct aid to any method 

of radiation treatment. We have performed the operation of ligation 

in well over 400 cases of oral and associated cancers with no bad results. 

Matas (quoted by Scudder, 1) refers to two fatalities from 

cerebral embolism, but there seems to be no danger if the point of ligation 

is well above the origin of the superior thyroid, and the lingual and 

facial arteries are tied separately. 

The antral operation is performed at the same sitting or postponed 

a few days, depending on the patient's condition. It is essentially an 

operation to expose the growth for radiation. The method of approach 

varies with the local condition. 

1. Many cases present signs of increased intra-orbital pressure 

and a swollen cheek with the swelling most prominent adjacent to the 

inferior rim of the orbit. The palate and alveolus indicate no evidence 

of invasion. The cancer has. therefore, followed the orbital plate, and 

not the antral floor. The logical operation is to make an opening closest 

to the bulk of the growth, namely through the floor of the orbit. _ At 

first wc hesitated to sacrifice a functioning eye. but we now believe 

that in many instances our hesitancy was the cause of ultimate failure. 

In a few patients with the eye remaining in situ, the severity of the radium 

inflammation in adjacent tumor tissue forced us to remove it subsequently. 

These patients would have been spared much suffering if 

we had been less conservative at the outset. 

2. In another group there are no orbital signs and symptoms, and 

the external tumor is well below the eye. The alveolus and palate are 

however swollen and perhaps destroyed. The cancer has therefore grown 

downward, and is best reached through a large window made below. 

3. A third and smaller group may require an opening through 

both the orbit and the alveolus. These are very advanced cases, but we 

feel that in selected patients, there is the possibility of clinical cure or 

palliation.

178 R a d i u m 

Radium is applied bv tying unfiltered emanation tubes in the end 

of an ordinary rubber finger cot. and packing it centrally or toward any 

wall depending on the needs of the case. As a rule about 35 to 40 millicuries 

are used for periods varying from 4S to 60 hours. This dosage, 

of course, produces an intense caustic effect, but we believe that nothing 

less will suffice. In 6 to 10 weeks slough and destroyed bone are gradually 

cast off. As may be inferred, we place our main reliance on the 

destructive qualities of radium, and not on cauterization or curettage. 

Postoperative Treatment. During the weeks following the operation, 

constant attention is given to the radiated area. Frequent irrigations 

are absolutely necessary on the part of the patient, because when 

the radium slough commences to form a very disagreeable odor is given 

off. I-oose string)' necrotic tissue and fragments of destroyed bone 

should be gently removed. If a large sequestrum forms, many weeks 

may elapse before it loosens and separates. While in place, it is a constant 

source of annoyance, because of pain and suppurative discharge. 

Excessive granulation tissue may form about it, giving the false picture 

of a recurrence. After the effect of the operative treatment subsides, 

careful observation is made for possible neoplastic nodules that 

have not completely regressed. If any such areas arc present, and they 

appear to be enlarging, emanation tubes or filtered needles are applied. 

But caution should be used in order not to treat unnecessarily, because 

it is our experience that regression may continue, even though outward 

radium effects have disappeared. 

This series of cases from the Memorial Hospital records comprises 

24 carcinomata of the antrum. Of these 12 were in females and 12 in 

males. 

The age incidence is as follows: 

Decade 

Cases 

Fourth 3 

Fifth 10 

Sixth 5 

Seventh 4 

Eighth 2 

Before being referred to the hospital 11 cases were surgically treated 

for wrongly diagnosed empyema. Five sought the attention of a dentist 

who extracted teeth for the relief of pain. Two cases were operated 

on intranasal'y one or more times for obstruction. One patient had a 

complete resection of the upper jaw with a large recurrence. 

Cervical nodes were present only three times. In one case on account 

of patient's poor general condition, emanation tubes were inserted 

and no attempt made to do a complete neck dissection. In all 

except four instances, roentgenographs examination revealed the destruction 

of one or more of the walls of the antrum. It may. therefore, 

be concluded that the cases taken as a group were far advanced. 

The results of treatment are briefly as follows: 

Four cases were unimproved. These were hopelessly advanced. 

All were in poor general condition, and died before the results of radiation 

could be determined. 

Four cases are showing a satisfactory response to the operative 

treatment. 

Eight cases were improved locally and generally, although they were

R a d i u m 179 

never at any time free of malignant growth. The duration of palliation 

extended in one instance to 4 years. 

Four cases present no clinical evidence of disease for varying periods, 

as follows: 2 cases for 1 year; 1 case for V/2 years; 1 case for 

5 years. 

In addition, 3 cases were free of disease for 1 year, 3 years, and 4 

years, but later failed to return to the clinic, so it must be assumed that 

they finally succumbed to cancer. 

The last case of the group was free of disease for 61/* years, but 

after neglecting to come for observation for several months, returned 

with a large recurrence projecting from the roof of the antrum. This 

is being treated at the present time. 

Two case records are given in detail: 

Case i. (26387.) W. B., female, age 59. came for treatment 

in November, 1918, giving a history of neglected teeth. Following the 

extraction of some troublesome molar roots, a swelling of the gum appeared, 

which was followed in a few months by the protrusion of the 

eye on the same side. At first pain was severe, and was situated in 

the cheek and forehead. Two months before coming lo the hospital 

an ulcer developed in the root of the mouth, close to the site of the previous 

dental extraction. The pain was then temporarily relieved. 

Examination revealed that the patient was weak and anaemic. The 

left cheek was swollen and red. The left eye was more prominent than 

the right. The nasal passage was completely occluded, and occupying 

the entire half of the hard palate was an irregular ulcer 3 by 4 centimeters 

in area, A note on the record says: "This is a very advanced 

case in a woman of poor general condition. Treatment should be directed 

toward a palliation and not a cure." Microscopic diagnosis was 

epidermoid carcinoma. She was treated by embedding unfiltered emanation 

tubes directly in the growth through the palate. Radium was 

used in November, 1713, February. 1919. and April, 1919. Following 

this local condition was satisfactory until March of 1922, when a further 

radium application was made because of evidence of active tumor growth. 

The patient died in July, 1922, from chronic sepsis and circulatory failure. 

No autopsy was obtained. This case is of interest as showing that 

a long palliation may be obtained by the use of radium without operative 

interference. 

Case 2. (23737.) M. S-, male, age 47, came to the hospital in 

September. '1916. His illness commenced 3 months earlier with the 

appearance of a small lump on the alveolar process of the right upper 

jaw. The right side of the face soon became swollen. A dentist vyas 

consulted who removed a tooth. The socket never healed. Examination 

on admission to hospital showed that the patient was in good general 

condition. An egg-shaped ulcerated mass 3 by 3 centimeters projected 

from the alveolus and palate. Externally there was a discoid swelling 

of the cheek, the skin of which was red. Nasal examination revealed 

that the ethmoid area was not involved. There were no palpable nodes 

in the neck. The late Dr. Janeway ligated the neck vessels, removed 

what was left of the floor of the antrum, and applied unfiltered radium 

emanation. After a few weeks, large portions of slough and dead bone 

came away, leaving a healthy cavity. There were no further manifestations 

of the disease until January. 1923. when a recurrence was noted 

close to the floor of the orbit. This was treated by packing a finger

180 R a d i u m 

cot of emanation tubes close to the tumor tissue. In a few weeks the 

cancer area sloughed away exposing the floor of the orbit. A small 

discharging fistulaformed below the lower eyelid, communicating with 

the anterior antral wail, a portion of which was destroyed. This caused 

a considerable degree of orbital inflammation, and for a while we believed 

that the eye was in danger. However, in June the sequestrum loosened, 

and was removed through a small window made in the cheek surrounding 

the fistula. It proved to be the orbital plate with a large portion 

of the anterior wall. At the present time there is no evidence of new 

growth. This illustrates that it is hardly wise to consider a case cured 

even after nearly 7 years. The patient is to be congratulated so long 

as no recurrence appears. 

Summary 

1. Cancer of the antrum must be recognized in the early stage 

before any method of treatment will produce uniform and favorable 

results. The opportunity is given to rhinologists and dentists, but facts 

indicate the tardiness with which they make an accurate diagnosis. 

2. Conservative surgery combined with radium promises to give 

better results than does the radical operation. 

3. Palliation for a large number of hopelessly advanced cases is 

possible through the conservative use of radium. 

4. The successful application of radium depends on an adequate 

exposure of the area. As a rule an oral approach is best, but if conditions 

demand it the eye should be removed and the floor of the orbit 

opened. 

Bibliography 

1. Scvdder. Tumors of the Jaws. Philadelphia: W. B. Saunders 

Co., 1912. 

2. Bloodgood. See Greene, Am. J. Roentgenol., 1922, September. 

3. New. J. Am. M. Assn.. 1920. May 8. 

4. Ochsner. Ann. Surg., 1922, September. 

5. Blaisdell. Boston M. & S. J.. 1921, November 10. 

6. Grefxe. Am. J. Roentgenol.. 1922. September. 

7. Patterson. Proc. Roy. Soc Med.. Sect. Laryngol., 1922, June. 

8. Ewixc. Neoplastic Disease. Philadelphia: \V.xB. Saunders 

Co., 1919. 

9. Phillips. J. Laryngol., Rhinol. & Otol.. 1898. xiii. 325. 

10. Moore. Prcc. Roy. Soc. Med., Sect. Laryngol.. 1917. 60. 

11. Bctltn. The Operative Surgery of Malignant Disease.

R a d i u m 181 

THE TREATMENT OF MALIGNANT GROWTHS 

THE FACE* 

By Sanford Withers, M. D.. and John R. Ranson, M. D. 

Denver, Colorado 

ABOUT 

This paper will deal exclusively with the treatment of superficial 

malignancies about the face and almost entirely with the treatment of 

growths of epithelial origin of which 95 per cent'occur above the clavicle 

and of this number, roughly 95 per cent, consist of basal-celled epitheliomas. 

It is not the purpose of this discourse to review all of the possible 

methods of treatment, for very little new work has been contributed to 

the older methods of dealing with these conditions, but we wish to emphasize 

the importance of certain physical agents in the treatment of 

malignancies, as these methods have only recently come into prominence. 

This discussion in connection with the slides accompanying this 

paper will illustrate the practical use of surgery combined with radiation 

methods. In the subject matter we will, therefore, confine ourselves 

to more or less theoretical considerations which determine the radioresistance 

or susceptibility of known pathological conditions. 

Time is all too short to give the resume of this subject that had 

been contemplated. We shall, therefore, be content to present certain 

important fundamental principles of radiation therapy. 

The use of radium in the treatment of malignant growths about 

the face is gradually assuming a more and more important place in surgery. 

Its use bids fair to become the method of choice in the treatment of 

many of these conditions. Unfortunately the proper evaluation of these 

agents has been made more difficult by exaggerated claims, and by their 

improper use by incompetent men. 

It was observed years ago that certain tissues were resistant to large 

doses of radiation, while others were quite susceptible and underwent 

resolution with small units of beta, gamma, or x-rays. 

HISTOLOGICAL CHARACTERISTICS WHICH DETERMINE SUSCEPTIBILITY TO 

RADIATION 

In general there are six histological characteristics which determine 

tissue susceptibility to radiation: all are of a cellular nature. 

1. It has been observed that the more embryonal or undifferentiated 

the type of cell, the greater is its radio-susceptibility; and conversely, 

the more differentiated, highly-specialized the type of cell, the 

greater is its radio-resistance. 

2. It is easily demonstrated that cells in the process of dividing 

are eight to fifteen times more vulnerable to radiation than in the resting 

condition. 

3. Cells containing large amounts of chromatin in the nucleus are 

more easily killed than those containing little chromatin. McCarty of 

the Mayo Clinic has repeatedly called attention to the fact that the 

degree of malignancy of any epithelial growth can be estimated from 

•Reprinted by permission Irom Colorado Medicine, Dd, 92-ilT. April. 1921. Read al Ihe 

annual meeting ol ihe Colorado State Medical Society, September 4. 5,t>, 1923.

182 Radium 

Case I. Carcinoma involving the inner two-thirds of the lower eyelid. Duration 2 years. Treated by family physician 

who made applications of some caustic solution. 

This case received 500 milligram hours, applied to the surface of the growth in standard silver lubt>s (O.S millimeters 

thick) covered with 1.0 millimeter of rubber. 

The picture on ihe right: Showing complete retrogression of ihe tumor with only a slight scar which was soft and 

pliable. 

the above three factors, and he has arbitrarily established the standard 

of four grades, depending upon the degree of differentiation of the 

malignant cells, the number of mitoses seen, and the presence of atypical 

chromatin masses. It is singularly true, then, that the more malignant 

the growth according to McCarty's classification, the greater is its radiosensibility. 

4. It is common knowledge that the endothelial lining of blood 

and lymph vessels is very radio-sensitive, and that tumors having an 

abundance of thin-walled, delicate capillaries react much more quickly 

and favorably to radiation than corresponding tumors having a scanty 

blood supply. 

Ca&C 2. Carcinoma Involving the inner can thus of the left eye and the medial three-fourths of the ciliary margin of the 

upper lid. It was first noted four years previously but had never been treated. 

This growth received a total of 900 milligram hours applied on the surface. The radium waa contained Id 25 milligram 

silver tubes0."> millimeters thick corcred with 1.0 millimeter of rubber. 

Too picture on ihe right: Results of treatment, remaining clinically cured after t«« years. Showing absence of scar 

formation or deformity. 5. Tumors having small amounts of intercellular connective tissue 

react much more quickly and favorably to radiation than new growths 

with a well formed supportive structure. 

6. Secreting cells are in general much more radio-sensitive than 

non-secreting cells, particularly if such cells produce crystalloid or crystallizable 

material containing inorganic salts. 

The presence or absence of any one of these characteristics to a 

marked degree enables one to predict that the growth will or will not 

react favorably to radiation properly applied. 

The radio-susceptibility of cells does not in any way depend upon 

the anatomical location, but depends entirely upon the histological picture 

presented. For example, a lymphoid hyperplasia which is made 

up of hyperchromatic undifferentiated cells is almost as vulnerable to 

radiation as sex cells and will undergo retrogression with mild radiation

R a d i u m 183 

Cast 3. Carcinoma at Ihe Inner cauthus with ulceration extending 5 millimeters along the conjunctival 

surface of Uie upper eyelid and 2 millimeters along the lower Hd margin. 

A pterygium covered the medial quartet' or the globe to the margin of the pupil. 

Pour years previous Ihe growth had been curetted and the base cauterized. Tills treatment was 

repeated three years later, since which time the carcinoma developed rapidly. 

Twenty-five milligrams of radium in a standard Silver tube applicator covered with 0.5 millimeters of 

paraffin was applied for four hours. 

The picture on the right: It was noted two months later that there was no clinical evidence of Ihe 

carcinoma or the pterygium. The scar is soft anil pliable, allowing per feci function. 

whether it be a lympho-sarcoma, a Hodgkin's gland, an hypertrophied 

Peyer's patch, a thymic or tonsillar hypertrophy or tuberculous cervical 

adenitis. 

LOCAL CONDITIONS WHICH INFLUENCE THE REACTION TO RADIATION 

One of the most important reactions following radiation is the intense 

infiltration of cells and serum which accompanies the inflammatory 

Case *. Case of multiple carcinomas. There are a great number of senile keratoses about the face. 

This case had been treated with cancer paste nine months previous to admission. The caustic had opened the upper 

nares. 

There was applied to Ihe large carcinoma of the rlghl lemple 100 milligrams of radium In silver tubular applicators 

covered with 0.5 millimeters of rubber applied for a total of 33 hours about the margin. 

Two V, milligram tubes were packed against the growth at the Inner canthu* of the rlghl eye for 3 hours. 

The picture on the right: One year later there was no clinical evidence "f carcinoma present. It was evident that 

the keratoses 

reaction. 

in Ihe vicinity 

This 

of the 

zone 

lesions 

of 

had 

lymphocytes 

disappeared, duo 

and 

lo the 

plasma 

Incidental 

cells 

Irradiation. 

constitutes the 

first barrier to neoplastic invasion, just as the pyogenic membrane about 

an infection tends to wall it off. The presence of a round-celled infiltration 

about a malignancy, whether it occurs as a part of the natural body 

resistance (Broders) or whether it is stimulated by radiation, is one of 

the first steps in causing the retrogression of neoplastic elements. 

The study of the blood vessels and connective tissue of tumors 

has furnished us with data that deserves to be emphasized. When a

184 RADIUM 

Case 5. Lara* carcinoma (prickle cell type) of the temple associated with multiple basal celled carcinomas and many 

keratoses. One of these small growths can be seen lo the photograph just anterior to ihe right ear below the large 

growth of the temple. Duration six months since the last operation . . 

When first wen there was a large foul ulcerating cau'lllowcr mass B»_. by . \i centimeters and raised above the surface 

about 2^ centimeters. . 

This growth «a* given 3,100 milligram hours of radium by inserting needles deeply Into Ihe tumor margins. 

The picture on the right: Shows a complete retrogression of Ihese growths. The scars are soft and pliable, but dimpled, 

due to Ihe removal of normal tissue by previous operations »*d the caustic applications. 

Case C. This Is an example of the slow growing, infiltrating variety of prickle cell carcinoma of the lower lip. 1*1* 

type of growth Is less radio-sensitive than Ihe more rapidly growing, raullflowerllko epitheliomas, but offers a better 

prognosis because ol Its relatively late metastasis. 

In the treatment of this growth there was given approximately l.flOO milligram hours of radium about Ihe margin. 

Due care was taken to protect the ulcerating area from Intense radiation, which would have resulted Id a breaking 

down of this area. 

A dental compound Impression was made of the lower Up and chin and radium tubes and needles were held In position 

in (he dental compound, crossfirlng the margins of Ihe growth from boUi the mucous membrane and skin surfaces. 

When lasr heard from (one year agol the patient was olive and well without recurrence of the carcinoma more than 

Ihrec years after treatment.

R a d i u m 185 

Chm 7. Showing condition on admission thirty days after an attempted operative removal of Ihe growth that involved 

the cheek and antrum. 

This growth prorcd to be a large, rouod-ccllcd sarcoma ami its immediate and permanent (to dale) retrogression well 

illustrates the very radio •sensitive nature of such rapidly growing tumors. 

Beside iho involvement of the lymph glands In Ihe subnaxill-ry triangle, there was hard, firm masses In both 

tonsillar fossae and a small nodular growth (not broken down) In the soft palate. 

This patient was radiated from the zygomas to Ihe clavicles (both sides) giving approximately 30.000 milligram hours. 

M attempt was made 10 radiate Intensively, as such a procedure would have done much damage to normal structures. 

It was estimated that the mass In the cheek did not reecho more Ih.in 12 to 15 per cent, of an erythema skin 

dose. All radiation was filteredthrough 3 millimeters of brass at one Inch from the skin. 

biopsy shows adult connective tissue of normal appearance with very 

little acute inflammatory reaction, and ihe presence of capillaries of 

which the walls appear well formed, and the occurrence of a perivascular 

infiltration of round cells and eosinophiles, one observes almost always 

a favorable outcome from radiation or surgical treatment of such epithelial 

growths, as this appearance is an evidence of a certain amount 

of norma! tissue resistance to the neoplastic invasion. This picture can 

be markedly changed th'-ough '.he administration of ether or chloroform 

anaesthesia or through profound loss of blood. (Crile; Chase), resulting 

in a connective tissue whose fibrils have lost their affinity for stain, and 

vessels the walls of which appear altered: an infiltration of the polynuclear 

neutrophil type only, which shows that the bodily resistance to 

the malignant invasion has been markedly diminished. In the presence 

of this changed picture one cannot expect a favorable outcome by any 

method of treatment. 

The repair of an irradiated area is brought about through the deposit 

of white fibrous tissue. This scar tissue formation is similar to the 

repair that takes place in other traumatized areas and is a function of the 

absorbed radiation. 

Accompanying the radiation there is produced a local obliterative 

endarteritis. This closing of the blood vessels and lymph spaces by the

186 R A D I U M 

combined action of the arteries, perivascular round cell infiltration and 

scar tissue formation, effectively incarcerates any persistent neoplastic 

elements. 

We wish to point out that when an area is subjected to repeated 

doses of irradiation, the same normal cells are radiated, but not the 

same malignant ones. Hence the normal tissue elements become successively 

less radio-resistant through the cumulative changes that have 

made the malignant cells more radio-resistant; and in those cases where 

a cure is sought, and not palliation alone, an attempt should be made to 

give the entire dose at a single sitting to avoid having to give a second or 

third dose of greater intensity with the consequent greater damage to 

normal tissue elements. 

Reactions to radiation are not only qualitative but quantitative,, when 

all of the factors involved are taken into consideration; but this statement 

does not permit of the interpretation that there is. or can ever be, 

established a standard carcinoma or sarcoma dose, since no two growths 

have identically the same cell structure or surrounding normal tissue 

stroma permitting an identical reaction. 

CONCLUSIONS 

I. That the cellular reaction to radiation depends upon the amount 

of radiant energy absorbed, whether it be primary or secondary in origin. 

2. That susceptibility to short wave length therapy is a cellular 

characteristic depending upon a definite histological structure. 

3. That the normal tissue reaction to radiation and neoplastic invasion 

depends to a large degree upon the well-being of the body as a 

whole. 

4. That there is sufficient data to predicate on a priori grounds 

those tissues or tumors which will prove radio-resistant or radio-susceptible. 

5. That the use of radium or x-ray is just as radical and rational 

a procedure as the use of other physical agents in the treatment of neoplastic 

conditions. 

6. That 'he use of radium or x-ray in a given condition should 

require an equal amount of surgical judgment, a more complete knowledge 

of the pathology present and a broader bio-physical training than 

the corresponding surgical ablation demands. 

DISCUSSION 

A. J. Marklpy, Denver: This paper of Drs. Withers and Ranson 

seems to be a verv definite contribution to our knowledge of the 

proper method of dealing with malignancies about the face, particularly 

as it insists upon and brings out succinctly the necessity of determining 

absolutely beforehand what the character of the growth is with which 

you are dealing and in that way giving a prognosis of what your outcome 

is lo be. We have known for a great many years that the basal 

cell epitheliomas are relatively benign, and that any proper procedure. 

proper surgery-, or use of paste and caustics, that would completely eradicate 

a basal cell epithelioma would be productive of satisfactory results, 

insofar as the disease itself is concerned; but lacking knowledge of the 

character of the epithelioma with which you arc dealing, you are alwavs

R a d i u m 187 

courting disaster by not determining in advance whether it is a basal cell 

epithelioma; and that is not always readily determined clinically. Dr. 

Ranson has brought forth the necessity of making careful microscopic 

study before you institute procedures to bring about its cure. Now, 

if you want to use radium, you want to use it not only locally, but in all 

anatomically related lymph glands. The surgeons have long since learned 

that procedure, and it is only because radium gives better cosmetic results 

that it is to be preferred. Now. it is perfectly possible to take a 

curet, or a knife, or caustic, or paste, and eradicate a basal cell epithelioma, 

wherever it may occur. But the tendency of anyone working about 

the face is to save as much tissue as possible, and wc are always trying 

to keep within the best possible procedure, and not eradicate them all. 

With the use of radium, this can be obviated, because you can use it over 

a wider scope of territory than any excision would permit, and for this 

reason radium is undoubtedly the method of choice in dealing with basal 

cell epitheliomas wherever they may exist. The use of radium, however, 

in the case of the prickle-cell variety, is not always the method of choice. 

because of the impossibility of being sure of eradicating the base by 

radium alone. We know that many times it is very, very resistant to 

radium, as Dr. Ranson has pointed out in his paper. Therefore, the 

amount of radiation required to destroy some prickle-cell epitheliomas 

is so excessive as to require the use of a dosage which would be destructive 

to an extent which would contraindicate its usage. Now, I 

have had the opportunity of observing for the last two or three years 

the work of Dr. Ranson and Dr. Withers along these lines, and 1 have 

been very much impressed, as I know they have, by the surgical dictum 

that has long since been laid down, that the hope of every cancerous 

individual is an early diagnosis, and that applies no more to the use of 

radium than it does lo the use of surgery, and we must forever be* on 

the lookout to impress our patients with the necessity of applying for 

diagnosis at the earliest possible moment. 

I should like to emphasize again the necessity of determining, as 

absolutely as it is possible to 'lo, the character of the growth with which 

we are dealing, and that can only be done by a very careful microscopical 

examination. That was brought out very clearly in the last picture the 

doctor showed. One of those cases presented epithelioma of the ear. 

Clinically that was a typical basal epithelioma which responded very 

promptly to small doses of radium, but within three months it was evident 

that it was a prickle-cell epithelioma. Now, it is possible that enough 

radiation cannot be employed in this case to eradicate the glandular 

involvement, but that would have been done at the expense of a very 

serious loss of tissue and function in the region involved. Here it is possible 

to lay down a law that may be subject to some exceptions, but there 

are very few exceptions. If you take any individual and draw a line 

from the angle of the mouth to the upper tip of the ear, it can be accepted 

almost without qualification that any growths that occur below that line 

are almost certain to be prickle-cell in their character, and procedure 

should involve a treatment of the anatomically related lymph glands. 

Epitheliomas below the lip are almost invariably prickle-cell in their 

character, and no procedure is proper, or is fulfilling the duty and obligation 

of the physician to his patient, that does not involve, however 

small the initial growth may be, a proper radiation of all the anatomically 

related lymph glands. Above that line, almost without exception,

188 R A D I U M 

the epithelioma new-growths arc of the basal cell type; and while it is 

proper to determine microscopically that this is so, the procedure may 

be then whollv local. The use of radium on a small prickle-basal-cell 

epithelioma of the upper lip, or the nose, or the eye. is a very minor 

procedure. In my early days in the treatment of cases, I did think that 

I was accomplishing a great deal, and that I had made quite an achievement, 

if I brought about the cure of a small basal cell epithelioma about 

the eyelid, as I looked upon it as a proper procedure. I may save some 

amount of disfigurement in curing such a cancer, but I do not in any way 

place it as properly treating an epithelioma cell. The removal of the 

local growth itself in ihe cancer of the lip is a very insignificant achievement. 

It is what happens in the glands below that determines the future 

prospect of life and happiness and comfort of those patients, and I am 

very pleased to have Dr. Ranson outline to you the proper procedures 

in cases of this kind and to emphasize what should always be borne in 

mind in dealing with cases of this kind. 

N. B. Newcomer, Denver: I have enjoyed the paper very much. 

The subject was covered thoroughly in every way except that, to my 

mind, there was not enough stress put upon the difference between radium 

treatment of those conditions and the x-ray. Of course, I realize that 

he was discussing radium more than x-ray. You know* in a glandular 

involvement you must treat the drainage area. To treat a large drainage 

area with radium within the growths, is almost an impossibility. The 

laws that govern the radiation of tissues by radium are the same as 

those that govern the radiation of tissues by x-ray. The dose will vary 

with the square of the distance. It seems to me that this ought to be 

explained >o that people can understand it. Take for instance Hodgkin's 

disease. This is a deep proposition, three, four and five centimeters 

in depth, and to take care of this properly you must use a deep 

x-ray machine. Of course, I realize 1 am speaking from the point of 

view of one who is combating cancer anywhere. If you are going to 

take care of the cancer, you must take care of the extension. The doctor 

says there is no definite dose for any cancerous lesion, yet it is malignant 

and you will be pretty safe if you give it all it will stand, and 

anything short of that is folly. With a ten-inch machine 16.2 per cent. 

will be delivered half-way through an average body of twenty centimeters, 

while with a two-hundred thousand volt machine 42.5 per cent. 

will be delivered half-way through the body. 'This is an important thing 

to consider, because you cannot just treat the surface and cure the 

growth, but you must deliver an erythema clear through the structure, 

and you cannot do it with a light machine. With this addition to the 

doctor's paper. I thank you.

R a d i u m 189 

radium in the treatment of non-malignant 

diseases of the skin * 

By Frederick S. Burns, M. D. 

Boston, Mass. 

After this Society had paid me the honor of asking me to read a 

paper on the use of x-ray and radium in non-malignant disease of the 

skin, consideration of the prospective papers led me to the opinion that 

the inclusion of x-ray therapeutics would inevitably involve a paper of 

greater length than is appropriate to ihe occasion; moreover, the use 

of x-rays in skin diseases is now a ripe subject, it already possesses a 

voluminous literature and its present status is well formulated in standard 

text hooks, so that to review a subject already ably presented by 

many would be a needless redundance. 

The use of radium in non-malignant skin disease, however, is still 

a theme with a large field ahead for development and the present status 

of therapeutic indication and technique is far from crystalized; and even 

a cursory examination of the subject should satisfy one that subtraction 

of malignant disease from participation in the field of radium therapy 

of cutaneous disease yet leaves an extensive and promising domain for 

work. 

It is not the intent of this paper to give a discourse on the history 

and physics of radium. This purely scientific side of radium has been 

dealt with by physicists and the facts concerning radioactive elements, 

so far as known, are best read in their words. Nevertheless, in order 

to correlate the peculiar properties of radium radiations and their effect 

on living tissues to their practiacl use on the skin, one may be allowed 

to refer to the essential peculiarities of radium activity and to their biochemical 

reactions. 

When beta or gamma rays impinge on matter, secondary radiations 

are produced which vary with the density of the obstructing material 

and the intensity of the primary rays. Beta rays give rise to secondary 

gamma rays which in turn produce tertiary beta rays. Primary gamma 

rays produce secondary beta rays of marked penetrating power. The 

production of secondary rays in tissues is thought to be the origin of the 

biologic effect of radioactive energy. Beta and gamma rays possess 

wide variations in their penetrating power. The index of absorption of 

these rays by different metals has been quite accurately computed. Colwell 

and Russ have also determined that the intensity of hard beta rays 

is reduced to about six per cent, of the initial value after passing through 

one centimeter of epithelial tissue. 

As a general rule, the absorbing power of a given substance for 

different rays increases in proportion to its density. The intensity of 

radiation is further reduced by distance, in accordance with the inverse 

square law. i.e., doubling the distance reduces the intensity to onefourth. 

These facts provide the physical basis for filtration by means of 

which a selection of rays for superficial or deep action is possible. Filtration 

is of prime importance in radium therapy of the skin: for not 

alone is the amount of radium used a factor but. also the quantity and 

•Reprinted by permission from tin Boston Medical and Surgical Journal, exel, 16-20. July 

3. 1924.

190 R A D I U M 

quality of radiation that actually penetrates diseased tissue. For it is 

evident that only absorbed rays can exert biologic action. 

The skin requires radiation for both superficial and deep effects. 

On account of the high percentage of soft beta rays from unfiltered 

surface applicators, such rays arc employed for superficial effects only 

in processes with slight thickening. In order to influence pathologic 

conditions involving a depth of one centimeter or more, filtrationis requisite 

that superficially absorbed rays may be eliminated and also in order 

to utilize the more penertating ones. Without this filtration,the upper 

strata will be dosed with soft beta ravs before tl-.c desired amount of hard 

rays can be absorbed by deeper structures. In lesions of greater thickness 

than one centimeter, or in those situated more than one centimeter 

below the suifacc. gamma radiation should always be employed. 

By proper filtrationall beta rays can be removed and a homogeneous 

gamma radiation be obtained. Filtration in this manner gives a quite 

uniform intensity of action for a distance of several centimeters. 

Broadly speaking, all of the biologic effects of radioactive substance, 

when applied externally, are due to radiations and are manifested by 

disturbances termed reactions. 

In the use of radium for non-malignant diseases of the skin constitutional 

reactions do not occur, for the reason that only small amounts 

are required. 

Wickham and Deg.ais were the first to point out that changes in 

viral tissues may take place by the surface application of radium without 

the supervention of visible irritation. Hence, this action has been 

called selective. Inasmuch as all layers of the skin are affected to some 

degree, the term differential has been proposed by other writers to indicate 

that the energy of radium affects some tissues more than others. 

It has been suggested bv Colwell and Russ. however, that the tissue 

irradiated is of as much importance as the rays, and these authors have 

proposed the term selective .ib-orption. this term implying that certain 

structures absorb radium rays more than others, i. e., the more the rays 

are absorbed, the more the tissue is affected. In general highly differential 

structures are more sensitive to radium than connective tissue, and 

pathologic embryonic structures react more sensitively than fixed normal 

ones. 

Selective action, therefore, may be defined as that response by tissues 

to radium whereby retrograde metamorphosis may be induced in 

one tissue without such change in ethers. 

The term selective reaction means that under the influences of radium 

abnormal structures may be caused to undergo retrograde change 

without visible appearance. 

The range of biologic action of radium extends from stimulation to 

destructive necrosis. It is at present thought that increased metabolic 

activity by stimulation can. bv over stimulation, produce necrosis through 

exhaustion. Cells most susceptible to such destruction are embryonic 

cells, endothelial cells, and cells undergoing rapid division, e. g., those 

of malignant disease. 

In the human skin the cells of the germinal layer, hair papillae, the 

sebaceous and sweat glands, the endothelial cells of blood vessels, and 

fixed connective tissue cells are radiosensitive; while the non-nucleated 

elements, as the hair, and elastic and collagenous connective tissue, are 

only slightly susceptible.

R a d i u m 191 

Histologic changes in sensitive tissues consist essentially in nuclear 

swelling and hyaline degeneration, with early and persistent inflammatory 

reaction, seen mainly in the papillary layer and consisting of perivascular 

thickening and oedema. 

In passing it may be noted here that direct bactericidal action on 

bacteria in tissue by radium, without serious damage to the tissues, cannot 

be obtained. 

According to MacKee, in most cutaneous diseases amenable to irradiation, 

the therapeutic* effects arc explainable probably through inhibitory 

action on cell division. Highman and Rulison have also made an 

interesting contribution to this point, offering explanations based on the 

histopathology of various dermatoses and, although their paper dealt 

primarily with x-rays, much of it applies to radium as well. 

Histologic changes occurring in the skin from irradiation have been 

described by Dominici, Barcat, Halkin and others. Dommici and Barcat 

have described their investigations auite accurately. These authors 

made their investigations with six mgm. of radium bromide contained in 

a varnish plaque. In the firstseries of experimenters no filter was used; 

the radiation consisted, therefore, of mixed beta and gamma rays. Ten 

applications of five minutes each were given on successive days, guinea 

pigs being used. Reaction appeared ten days later, consisting of erythema 

followed by ulceration and crusting. 'The crust came off between 

the fifth and six week and the healed area appeared as a depigmented, 

smooth, supple scar. Examination of the radiated tissue ten days after 

exposure snowed evidence of inflammation. The nuclei of the epithelial 

cells were enlarged and intercellular oedema was present. After thirty 

to forty days two phases were noted: first,that of embryonic regression 

and, later, that of fibrosis. During the first phase the epidermis was 

restored, but the hair follicles and glandular structures were permanently 

destroyed. The corium had lost its normal appearances and connective 

and elastic tissues were replaced by many connective tissue cells. 

Smooth muscle fibres and small blood vessels underwent similar regressive 

changes to embryonic type. In the second phase, fibrous connective redeveloped. 

Formation of the fibrous scar differed, however, from usual 

sclerotic tissue. From normal areolar tissue it was distinguished by 

regularity of the connective tissue bundles and by the forming of lines 

parallel with each other and with the surface. From the usual cicatrix 

it differed by marked regularity of the scar tissue and by absence of 

fibroid perivascular rings and vascular dilation. After seven months 

the connective tissue was mainly replaced by cellular elements, but the 

same regularity and parallel arrangement remained. 

A second scries of experiments were carried out with the same 

amount of radium (viz., 6 mgm.) screened with five mm. of silver 

which filtered out the hard beta rays, making gamma rays responsible 

for the changes. Fourteen hours after exposure there were 

found an enlargement of nuclei of the cells of the epidermis and congestion 

in the corium. After three days there was a superficial but temporary 

destruction of the epidermis. The corium displayed changes 

not differing from those occurring after an exposure of fifty minutes 

to the unscreened radium. 

From these experiments the following practical inferences may be 

drawn: first,that by accurate filtrationthe effects of either beta or gamma 

radiation may be utilized; second, that for superficial action on the skin

192 R a d i u m 

beta rays exert the chief effects; third, that whenever gamma radiation 

is desired, the inflammatory and destructive activity of beta rays should 

be eliminated completely. 

Of benign tumors of the skin removable by radium the following 

are at present recognized as the most important: keloids, vascular and 

pigmented naevi. lymphangiomata, benign cystic epitheliomata, synovial 

cysts and rhinoscleroma. 

Irradiation of keloids, keloidal scars and cicatricial bands gives excellent 

results not only for cosmetic effect but for the more important 

relief of annoying, redundant thickenings and contractures which may 

cause all degrees of impediment to motion. The influence of radium 

and x-rays, under given technique, on these conditions seems to be identical. 

The use of radium is best restricted to small keloids and hands 

of scar tissue, for the reason that x-rays can be applied to much larger 

surfaces. MacKee, who has had wide experience in the use of both 

radium and x-rays, has not observed any difference in their action on 

keloids. On the other hand. Simpson, Abbe and others favor the use 

of radium in the treatment of keloids over x-rays. 

An important point in the treatment by irradiation of all keloids 

is to establish the diagnosis and to undertake treatment as early as possible 

in the formation of the growth. 

Depressed scars, e. g., such as those caused by varicella, cannot 

be removed by radium. 

The technique of treatment of keloids considers mainly the size 

and duration of the lesion. Of first im|x>rtance is the necessity for irradiating 

keloids to the extreme depth of their bases, Treatment of a 

keloid should be regarded as complete only when no palpable thickening 

remains. For small keloids, one-qquarter or one-half strength flat 

applicators may be used. Screened with one-tenth mm. of lead or fourtenths 

mm. of aluminum applied next the skin, exposure of two to four 

hours may be given. In children this dosage should generally be reduced 

one-half. 

Usually after the removal of keloids by radium the skin is soft and 

elastic, and shows only a smooth atrophic surface. Subsequently telangiectasis 

is avoided by proper screening. 

Vascular naevi as a class yield well to radium. However, of the 

haemangiomatous birth marks the flat port wine stain is the most difficult 

in which to obtain satisfactory cosmetic appearances. Small port 

wine marks may be removed with one-quarter or one-half strength applicators 

with light screening of one-tenth mm. of aluminum. It is difficult 

to treat larger lesions of this type evenly with radium, and the edges 

of the applicators are apt to leave markings difficult to avoid even by 

the most careful overlapping of the edges. Better results in the large 

port wine naevas arc obtained vviih the water cooled ultra violet rav lamp. 

The group of cavernous angiomata give especially satisfactory results 

under radium. In these the selective action of radium is necessary. 

One-half and full strength applicators may be used screened with onetenth 

mm. of lead with exposures of one to two hours; the dosage depending 

on the thickness of the vascular tissue to be broken down. 

In cavernous tumors with great redundance of tissue, Wickham and 

Dcgrais recommend crossfiring by insertion of needles within different 

portions of the growth. 

The deeper angiomata require considerable gamma radiation to bring

R a d i u m 193 

about their involution and, for this type, radium in tubes, radium emanation 

or full strength applicators should he employed, filtering out at least 

fifty per cent, of hard beta rays, either hy brass or lead filters or by 

metallic filters combined with distance filtration. 

F.xcepting port wine marks, as mentioned above, treatment of vascular 

naevi by radium at present gives results superior to any other 

method. Most writers agree as to the excellent results obtained in vascular 

naevi; antl MacKee. who always balances carefully x-ray versus 

radium, advises radium in this lesion. 

On pigmented naevi radium has no selective action. Their removal 

by radium is consequently through the caustic and exfoliative effect of 

the softer beta rays. Being situated superficially in the skin, rays of 

slight penetration only are required and, of these, small amounts suffice. 

With care, excellent results can be obtained in both small and large 

pigmented lesions. Minute pigmented naevi are best removed by other 

methods, such as freezing by liquid air or carbon dioxide and by electrolysis. 

In the treatment of pigmented naevi by radium an average dose 

of two to three mgm. hours screened with rubber only is a safe and 

usually successful technique. As in the treatment of larger vascular 

naevi. it is necessary to observe great care in overlapping, in order to 

avoid remaining pigmented lines. 

Lymphangiomata.— tumors that have been notably stubborn to all 

other methods of removal, yield well to radium. Lymphangioma cavernosum. 

because of the greater depth of tissue, is more difficult to destroy 

than lymphangioma circumscriptum, a comparatively superficial growth. 

Simpson, Abbe and MacKee have reported cases of both types treated 

by this means. The writer has succeeded in destroying six examples 

of the circumscribed variety. The method of treatment is similar to 

that for cavernous haemangiomata. 

Multiple benign cystic epitheliomata are lesions of considerable interest 

to the dermatologist because of their usual situation on the face, 

their disfiguring appearances, and. further, on account of the difficulty 

in destroying them without replacement bv cicatrices almost as unsightly 

as the growths themselves. To call radium a panacea for this affection 

is scarcely an exaggeration, for it accomplishes their removal in almost 

miraculous fashion and with practicality no scarring. 

Cases of synovial lesions of the skin cured by radium have been reported 

by several writers. These lesions have been difficult to cure by 

surgery, cauterization or electroylsis. so that to be able to remove them 

by radium is a most acceptable aid, Ormsbv and Sutton mention good 

results from the irradiation of these cysts. 

It is of interest to the writer to report here the cure of three small 

wens by radium. The content of the cysts was first evacuated and the 

surface then treated with ten mgm. hours screened with four-tenths mm. 

aluminum. 

There is a group of affections that for the purposes of this paper 

may be classed as of inflammatory and uncertain etiology and are symptomatically 

healed by radium. 

Lupus erythematosus has always been a difficult diseases to manage 

therapeutically and the legion of remedies recommended for its alleviation 

is an almobt certain index of their inefficacy in general. Of late, however, 

two remedies have become outstanding in the treatment of this

194 IjAPIUM 

affection, viz., carbon dioxide snow and radium. The use of these agents 

is confined strictly to the fixed, or discoid expressions of lupus erythematosus. 

Radium has become a valuable method of treating lupus erythematosus 

and many writers have reported favorable results from its use. 

Simpson has reported fifty cases of the discoid type, all more or less 

benefited. The writer is able to report twenty-seven cases treated by 

radium, in all but five of which the lesions healed. Tendency to recurrence, 

however, is common and irradiation appears to exert no influence 

on the course of the disease. 

In psoriasis, lichen planus and chronic eczema, radium finds a limited 

fieldof usefulness. 

Small, isolated papules of psoriasis, especially those situated on 

exposed surfaces, can be healed readily. The dosage should not exceed 

one to two mgm. hours with rubber screening only. 

Small areas of corresponding size of chronic eczema and lichen 

planus are also healed readily; a similar dosage to that employed in psoriasis 

being used. But on the general course or cure of these affections 

radium has no influence. 

Superficial hypei trophies of the skin curable by radium are keratosis 

senilis, verrucae, callosities and. in some instances, clavi. 

Of skin affections, exclusive of malignant disease, radium in the 

removal of keratosis senilis probably finds its most important place. For 

the cure of these potentially malignant lesions radium is little short of 

magical and the cosmetic results after healing are equally satisfactory. 

In order to avoid undue atrophy and subsequent telangiectasis only small 

amounts of radium should be used. 

In the writer's experience of over a hundred cases of keratosis senilis 

treated with radium, a safe and efficient dosage is two to five mgm. hours 

with rubber screening Fnllowiin; the reaction, the keratosis is exfoliated 

and spontaneous healing ensues. 

The dangerous and painful keratoses that develop in atrophic skin 

resulting from x-ray dermatitis will almost always disappear under the 

action of the beta rays of radium. MacKee. who has had wide experience 

as a roentgenologist as well as in the use of radium, refers to his 

gratification in having removed by this means the keratoses from the 

hands of a number of pioneer x-ray workers. Tousey, Abbe, Degrais 

and Belot speak with equal interest of the value of radium for x-ray 

keratoses; and the latter also refers to the cure of several epitheliomata 

by same means. 

The writer has treated seven cases of x-rav keratoses, all of whom 

were physicians excepting one, who was an x-ray technician. The lesions 

occurred on the hands and face. So far as is known all keratoses 

treated were healed. 

The phenomenon of cure of keratoses due to radiodermatitis by 

radium has been referred to as an apparent paradox; an appropriate 

term, for the situation is only apparent, not real. In fact, the situation 

is the same whatever the cause of the keratosis, whether due to physical 

or chemical agents. Cells are compelled to adapt themselves to newconditions 

and, in so doing, they take on new peculiarities and power 

of independent growth. 

Fundamentally, a prc-epitheliomatous keratosis is the same whether

R a d i u m 195 

due to x-ray, sunlight or other causes promoting degeneration. If radium 

can cure keratoses and early cutaneous epithelioma the result of actinic 

rays, one may assume that it may be equally efficacious in similar lesions 

caused by the results of x-ray exposures. 

On account of the peculiar a;rophy resulting from radiodermatitis, 

a note of warning should be given with reference to the treatment of 

accompanying keratoses. Soft beta rays ami small dosage should be 

given, on an average about two-thirds the amount that would be used 

in an ordinary senile keratosis. 

As clavi and callosities consist mainly of epidermic thickening they 

can usually be removed bv soft beta rays. 

Because of their papillomatous nature and the discomfort and inconveniences 

they cause, verrucae are frequently an affection of importance. 

Plantar warts in particular often occasion pain and impediment 

to walking. Radium serves as a very successful agent in removing 

all varieties of warts. Small filiform warts and multiple flat warts, 

however, are belter destroyed by electro-dessication for. by this method. 

many lesions may be removed at one sitting. 

As an antipruritic remedy radium has been used with some success 

in localizing itching of the anus and vulva. In such local pruritus 

radium has a similar effect to x-rays, but with the disadvantage that 

affected areas cannot be as completely radiated as by the latter except 

at the expense of considerable time. 

It is worth while to mention the use of radium for the removal of 

superfluous hair only in order to condemn it. The possibility of producing 

atrophy and telangiectasia of the skin is scarcely justifiable for 

a condition of purely cosmetic importance. Better results, without danger, 

can be accomplished by electrolysis in the hands of a skillful operator. 

Although the chief interest of radium therapy of the skin is in the 

treatment of malignant disease, nevertheless it possesses a field of usefulness 

in other dermatoses which has gradually developed to a point of 

importance. 

Radium therapy of the skin demands two essential qualifications: 

first, the training of a dermatologist: second, special training in the technique 

of radium as applied to the skin. 

REFERENCES 

Colweix and Ri;ss: Radium. X-rays and the Living Cell. 

Wickham and Deorais: Presse Medicate, 1006. 

MacKee, G. M.: X-ray and Radium. 

Dominici and Bapcat: Compt. Rend. Soc. de Biol., 1908. 

Hai.kin. H.: Archiv. fur Derm, und Syph.. Ixv, 201. 

Simpson, F. K.: Radium Therapy. 

Ahbe. Robert: Med. Rec. N. Y., lxxxviii. 215. 

Orhsiiy: Diseases of the Skin. 

Sutton : Diseases of the Skin. 

Tousey, S.: Jour. Am. Med. Assoc, Ixiv. 1394. 

Foerstf.r, O. H.: Archives of Derm, and Syph., Jan., 1924, p. 38.

196 R A D I U M 

CHILDBEARING AFTER RADIUM AND X-RAY TREAT 

MENT* 

By Frank A. Pemderton, M. D., F. A. C. S., 

Boston, Massachusetts 

The writer has been questioned so many times by physicians in 

regard to the danger of causing poorly developed, deformed, or backward 

children or even sterility in fertile women by the use of radium 

and X-ray for therapeutic purposes that it seems probable the known 

results are not common knowledge. These methods of treatment maybe 

used during the childbearing age to relieve uterine bleeding caused by 

functional derangement of the ovary and fibromyomata which is not 

amenable to simpler measures. At present they are not used in the 

fibromyoma cases if a myomectomy is feasible because operation removes 

the pathological cause. Their effect is on the ovary, the uterus, 

and, in the case of radium especially, the endometrium. We may dislegard 

the last two in this discussion because permanent changes are 

probably not produced in them if an artificial menopause is not brought 

on and they are not fundamentally concerned in fertility as are the 

ovaries. 

Radiation may cause a temporary or permanent amenorrhea or 

oligomenorrhcea. In the cases under discussion only a temporary amenorrhea 

at the most is desired and the dosage is so regulated that it is 

rare to cause more than that. The cause of the amenorrhea is generally 

believed to be the effect of the radiation on the ovaries. Radium placed 

inside of the uterus does have a local effect on the endometrium which 

reduces flowing but it undoubtedly also affects the ovaries. 

The action of radium and X-ray is essentially the same. The result 

of radiation in the ovary is well established by the examination of animal 

and human ovaries after treatment. Most investigators (3, 4, 5, 7) agree 

on the important points. The action on the follicles of the ovary is what 

we are interested in as they contain the ova. The maturing graafian 

follicles are more susceptible to radiation than the primordial which is 

very important as will be seen. In a well developed follicle the changes 

consist in a degeneration and destruction of the ovum and the membrana 

granulosa, preventing the follicle from going on to maturity and 

leaving a small cyst (7). In less advanced follicles the ovum is destroyed 

but the single layer of granulosa cells is preserved (5). If the 

dose has not been large enough to cause a menopause, however, the 

primordial follicles remain intact, capable of maturing normally. Theoretically 

then it is possible to use such a dose of radiation that mature 

follicles may be destroyed and primordial follicles not damaged. This 

is what seems to occur clinically. Following treatment the patient mav 

menstruate normally, have a scanty flow, or amenorrhea for a few 

months depending on the size of the dose. If amenorrhea occurs with 

this small dosage it is followed by a re-establishment of menstruation 

except in rare unusually susceptible cases. Ovulation and menstruation 

are believed to be definitely related to each other. Therefore fertility 

is possible. That this is clinically true will be shown later. 

The other important consideration is the possibility of the fertili- 

•Rcprinti-: by limitation frum Surctrj, Gynecol ot> "i"1 Obatctrka. BCXlX, 207-209.

R a d i u m 197 

zation of a partially damaged ovum. Theoretically this might result 

in a deformed or poorly developed child or a so-called blighted ovum. 

There appears to be no data in regard to this point. Xo one has made 

a report of the examination of ihe products of conception in miscarriages 

from such cases. The percentage of miscarriages is greater in 

radiated than in normal mothers, as will be shown, but this was in a 

small series of cases. It requires further investigation. On the other 

hand, no one has reported the birth of a deformed child and only a 

few under-developed ones are found. 

The results of radiating fertilized eggs and the fetus in utero are 

quite different, however, l.'nterherger (?) has shown that the offspring 

from fertilized butterfly eggs which have been radiated produce adults 

only two-thirds as large as normal and the next generation is even 

smaller. Experiments on cold-blooded animals have shown malformations 

and lack of development after radium or X-ray treatment of the 

eggs or fetus (i). There arc a few similar observations on warmblooded 

animals such as those made by Forsterling and Colin, who found 

backward development in guinea pigs whose mothers were radiated 

during pregnancy (1). There are a few reports of similar cases in 

humans. 

Reports of children bom from mothers previously radiated for 

functional or fibroid bleeding arc few and mostly incidental to other 

subjects. 'The largest group of cases that we have seen is reported 

by Werner {

198 R a d i u m 

was 34. Four of them report pregnancies after the treatment as follows 

: 

31-249, age 24. had a miscarriage in March. 1919. She received 

600 milligram hours of radium on August 5. 1019. Her menstruation 

began in November. 1919. She bore twins in March, 1921, both normally 

formed, one of which died 4 days later from unascertained causes. 

The other is living and well, 2\A years old. 

28-367, age 21. had had no pregnancy previous to radiation. She 

received 200 milligram hours of radium on November 7, 1917. Her 

menstruation began 3 weeks after treatment, was regular for several 

months and then irregular, the longest interval being 5 months. She 

bore a normal baby on September 28, 1919, which is now well and strong 

4 years later. 

29-111. age 34. had borne eight children previous to the treatment. 

She received 400 milligram hours of radium on January 16, 1918. She 

had eclampsia resulting in a premature birih at 7X' months on January 

30, 1922. The child lived two days, 

34-162, age 24. had had no previous pregnancy. She received 200 

milligram hours of radium on April 5. 1922. for membraneous dysmenorrhea. 

She became pregnant and miscarried at about 3 months on 

January i. 1922. 

There are doubtless other cases reported which the writer has not 

been able to find because they were reported incidentally under other 

subjects. 

Radiation of the fetus during pregnancy gives quite different results 

as has been shown by animal experiments. Werner (9) cites two 

cases in which one patient was X-rayed and the other treated with radium 

placed in the vagina during pregnancy because of a mistake in the diagnosis. 

The child bom to the first was nomial at birth but 6 pounds 

under weight at 6 years. The child from the second was small but perfectly 

formed at birth and about 1 year backward in physical development 

at 3'/; years of age. Steiger (6) says that this procedure may cause 

abortion during the early months of pregnancy but not in the later. 

Aschenheim (ii reports a case in which a mother was X-rayed during 

the third to six month of pregnancy on the diagnosis of fibromyoma. 

The child was a microcephalic imbecile with optic atrophy and cloudiness 

of the lens of the eye. the latter being characteristic of changes in 

the eye of experimental animals. 

It is evident that a patient can be treated with radium or X-ray and 

bear normal children subsequently. We have no data on whether or not 

such treatment decreases the chance of becoming pregnant in women who 

wish children and it would be difficult to get reliable information. It is 

probably true that deformed or undeveloped children are not likely to 

follow such treatment. A damaged ovum is not capable of being fertilized 

or, if it is.it probably results in a blighted ovum which comes away 

by miscarriage. It docs seem thai the chance of a miscarriage is greater 

than in untreated women. It is important to examine the products resulting 

from such miscarriages to find out if the fetus is absent or deformed. 

Care should be taken not to treat pregnant women, because it may 

cause a poorly developed or deformed child. More reports arc needed 

to decide all these questions. 

(The writer is greatly indebted to Dr. W. P. Graves for permission

R a d i u m 199 

to report his cases antl to Mr. R. H. Smithwick for looking up the cas 

for him.) 

REFERENCES 

Asciienhkim. Strahlentherapie. xi. 789. 

Ferrari and Lafont. Bull. Soc. d'obst. et de gynec. de Par., x, 828. 

Heiman. Strahlentherapie, xi, 731. 

Kolzaheff and Mollow. Ciynec. et. obst. Paris, vi. 244. 

Lindic, Strahlentherapie xi, 720. 

Steiger. Schweiz. med. Wchnschr., li, 10S4. 

Tsukaiiara. Ztschr. f. Geburtsh, u. Gynaek. Suttgart, Ixxxv, 36. 

Unterdergir. Monatschr. f. Geburtsh. u. Gynaek., Berlin, lx. 164. 

Wernfr, Muenchen. med. Wchnschr., lxviii, 757. 

RADIUM CLINIC FOR TREATMENT OF EYE, EAR, 

NOSE AND THROAT CONDITIONS.* 

J. J. CORDETT, M. D. 

Ophthalmic Surgeon, Boston City Hospital 

(From the Radium Clinic of the Eye, Ear, Nose and Throat Departments 

of the Boston City Hospital) 

At the Boston City Hospital, there was started in August, 1922, a 

clinic for radium treatment of some eye, ear, nose and throat conditions. 

There is one outstanding and conspicuous feature about this clinic, 

namely, that easily 98% of the cases in which radium is used are nonmalignant. 

This contrasts very markedly with the general use of radium 

to date, and with the accepted and prevalent idea carried in the lay or 

non-medical mind. The name of radium has been so intimately linked 

with that of cancer thatit has almost become a synonym for malignancy; 

and yet, as radium becomes better understood and its uses more diversified, 

it will not be at all surprising if its application is not productive of more 

good in the non-malignant field. Its success will be measured not alone 

by whatit accomplishes in a physical way, but in an economic way as well. 

When the idea of such a clinic came to mind,it was accompanied 

by much doubt as to whether the project could be successfully carried out. 

Members of the executive and staff were approached and their cooperation 

enlisted. As a result of their enthusiastic efforts, there were 

provided cases upon which the work has been done to demonstrate the 

use of radium. 

Of course, the clinic is still in its infancy, and the work done to 

date is limited. In a short period of two and one-half months, several 

groups of cases were treated. These cases were shown at the Dry 

Clinics as part of the program arranged for the American College of 

Surgeons at the Boston City Hospital. As stated at the time, the cases 

were shown not with the idea of proving what radium would or would not 

do, but rather to call attention to the lines along which the work was 

being done. 

To demonstrate the use of radium on tonsils, four cases of the hypertrophied 

variety were selected. The tonsils were of the large, spongy 

type that meet in the middle line. In each throat, one tonsil was treated, 1:1 

Reprinted by permission from the Boston Medical and Surgical Journal, exc 

1082-1084. June 19. 1924.

200 R a d i u m 

order to show the difference between the treated and the untreated 

tonsil. The difference was very apparent. The treated tonsils were 

much shrunken and more firm, while the untreated tonsils showed only a 

slight change, undoubtedly due to stray gamma rays: Four 12.5 milligram 

needles were buried in the tonsil for fifteen minutes, once a 

week, for six consecutive weeks. 

Two of these cases were interesting, one from a systemic, the other 

from a local point of view. A man 38 years old. tailor, whose right tonsil 

was treated, offered the information that the pain in the right shoulder, 

from which he had suffered for several months, had entirely disappeared. 

He had received massage, electric treatments, and various internal remedies 

without relief. The interesting feature lies in the fact that the left 

shoulder which had been as painful as the right was not relieved by the 

treatment of the right tonsil, and showed signs of relief only after the 

left tonsil had been treated. The other case, a boy 14 years old, had 

difficulty in articulating, owing principally to the enormous size of his 

tonsils which met in the middle line. His speech was conspicuously 

muffled. After three applications of 50 milligrams of radium for fifteen 

minutes in each tonsil, there was a decided improvement in his speech, and 

now his articulation is quite normal. 

Before beginning the treatment of tonsils by imbedding the needles 

into the substance of the tissue, other methods were tried. The needles 

were held against the oral side of the tonsil in some cases, and in others, 

applied externally, being screened in brass and hard rubber, and separated 

from the skin by 2 cm of gauze. Observation led to the conclusion that 

the quickest and most effective manner to use radium was in the form 

of needles plunged into the body of the tonsil and allowed to remain. 

Fifty milligrams of radium have been used for periods varying from 

fifteen minutes to one hour without any serious reaction, and repeated at 

weekly intervals. 

It may not be amiss to state some of the impressions derived from 

the use of radium on tonsils. When anticipating the treatment of tonsils, 

radium should be given only secondary consideration. It is simply an 

instrument added to the armamentarium of the laryngologist. and should 

be used in selected cases. When the tonsils are diseased, or producive of 

systemic complications due to absorption from local infection, enucleation 

is the quickest and most effective method of treatment. If. however, 

operative treatment is contra-indicated, radium is the second choice, 

and may be resorted to with considerable confidence. 

There are three classes of cases in which tonsillectomy is not 

desirable and in these radium may be used with success. These are (a) 

the physically unfit; (b) the mentally unfit; (c) the commercially unfit. 

Patients in class A will be met in the clinic and private practice. Patients 

in class B and C will be met practically at all times in private 

practice. 

In class A will be found patients with organic changes which make 

them poor operative risks; patients whose histories point to haemophilia; 

suspicious cases of status lymphaticus in children; and adults of advanced 

years in whom all other possible foci of infection have heen ruled out. 

Radium in these cases will give good results. 

Class B includes the patient whose next door neighbor might have 

had a hemorrhage after tonsillectomy, or who has heard the gruesome 

story of someone who bled to death after a tonsil operation. Any complication 

whatever, whether a co-incidence, or a direct result of tonsillectomy, 

is apt to come to the mind of one who is anticipating such a step, and

201 

very often will result in a decision against the operation. The patient 

who dreads anesthesia more because of the loss of consciousness than 

of the anesthetic itself, or because he has heard of a death which occurcd 

while tonsils were being removed, the patient never regaining consciousness, 

welcomes the suggestion of radium treatment. 

Class C includes the busy man who cannot stop long enough for such 

a thing as an operation and convalescence from the same. He has been 

advised by his physician and his physician's consultants that his tonsils 

alone remain the only source of the infection which is causing his physical 

discomfort. He is physically fit. has all the courage in the world (and 

some to spare), he dreads or fears nothing. He would take ether with 

the same indifference as he would take a drink of water, but he simply 

cannot take a week or ten days away from his business for the sake of 

the operation. Such a man typifies class C. and he may look with confidence 

for relief from radium. 

Enough work has been done with radium to warrant the recommendation 

of its use in such cases as are suggested in these three classes. 

and with the hope of getting good results locally and syslemicallv. But if 

the condition of the patient warrants it, advise surgery first and hold 

radium as a second choice. Radium does not remove tonsils. It transforms 

them into small, firm fibrous lumps of tissue. In this shrinking 

process, the toxic material contained in the crypts must be squeezed out. 

and the tonsils rendered inert as sources of infection. 

Aside from epitheliomata, the most interesting nose case which has 

come to the clinic was one of hemangioma of the septum. The patient 

came to the Nose and Throat Out-Patient Department, and pressure was 

applied to control the bleeding. There was temporary relief but the patient 

returned the next day and the nose was still bleeding. The patient 

was admitted to the House and suture applied. This gave temporary 

relief, but after two days, there was more bleeding. The patient was 

then referred for radium treatment. Examination showed a tumor 

starting from the muco-cutaneous margin of the septum and large enough 

to completely occlude the left nostril. There wras a slight oozing of blood. 

Twenty-five milligrams of radium were applied for fifteen minutes. In 

two days, the same dose was repeated. One week later, the dose was 

given for a third time. At the end of three weeks, the tumor was 

shrunken to one-half the size of a buck-shot. There was no bleeding 

from the day of the firstapplication of radium. 

As the clinic has progressed, the number and variety of cases have 

markedly increased. The clinic has now been in operation about one 

year and a half. For the first few months, there was no restriction as 

to the type of case as long as it was of interest to the Eye, or the Ear. 

Nose and Throat Departments. Volume and variety were the two 

features developed, the idea in mind being to weed out the cases that 

would not respond to radium treatment. The volume increased so rapidly 

and the variety became so great, that during the past six months, it became 

necessary to restrict both volume and variety of cases. 

Corneal scars and cataracts became the principal conditions upon 

which work was concentrated. At the April meeting of the New England 

Ophthalmological Society, held at the Massachusetts Charitable Eye 

and Ear Infirmary, seven cases were shown. Three of these were 

cataracts, one a congenital and the other two incipient senile cataracts. 

The vision of the eyes was taken with and without glasses, before and 

after the treatment with radium. Both cases showed an improvement of

202 R A D I U M 

vision without glasses, and with glasses, could be brought to 20/20 

normal. This had not been possible before the radium was applied. 

The congenital cataract was in the right eye of a boy 3l/t years old. 

The cataract could be seen by the unaided eye. The pupil appeared gray 

instead of black. There was no fundus reflex. Incidentally, there was 

a convergent squint in the same eye. After treatment, the pupil appeared 

black; there was a clear fundus reflex; the retinal vessels and optic disc 

could be seen with the Ophthalmoscope. The eye was refracted and a 

+ 1.00 Cyl. Axis 90 was prescribed. The convergence was overcome by 

the wearing of glasses. It is now eight months since the last treatment. 

The view of the fundus is still clear and the eye remains straight with the 

help of glasses. 

In the four cases of corneal scars, there was a definite improvement 

in the vision after treatment with radium. Two of the very thinnest 

scars, (nebulae of the cornea) entirely disappeared. The other two 

showed a very definite thinning out. There was a definite improvement 

in vision in each of the four cases shown. 

Conclusions: That in certain selected cases of cataract, radium gives 

a definite help. 

In cases of corneal scars which are not too dense, mostly nebulae of 

the cornea, a clearing up of the scar, and an improvement in vision can 

be demonstrated. 

That radium has a very definite action on tonsillar tissue which is far 

reaching in its systemic results. 

That when tonsils cannot be removed by surgery, radium is the next 

choice. 

THE EFFECT OF RADIUM ON 

J. J. Corrett, M. !).. Boston 

GLAUCOMA* 

To say the least, the use of radium is extremely fascinating. In most 

cases, the results come slowly, but occasionally the unexpected happens. 

Then one feels fully compensated for the effort and time put into the 

work. 

The writer wishes to call attention to what he considers a spectacular 

result of radium treatment in one of the most serious of pathological eye 

conditions, namely, glaucoma. Three cases will be described. 

I. Patient, A. C, male, 62 years old. consulted me on April 27, 1923. 

The patient stated that the vision had been failing in the right eye for 

over a year. He had been under treatment with other oculists and, on 

April 25th. the eye became suddenly blind. The eye felt sore but the 

pain was not severe. 

Examination showed the right eye to be markedly injected, the cornea 

hazy in the lower half, the pupil dilated, the anterior chamber shallow. 

The tension was about +3. A view of the disc was impossible on account 

of the hazy cornea. There was no light perception. Patient also stated that 

he had refused operation recommended by one of the oculists previously 

seen. His attitude was rather extreme since he said he preferred to be 

blind to having an operation on his eye. 

This course of reasoning followed: This man's right eye is totally 

blind. He has nothing to lose since he refuses the most probable method 

of recovering sight. Why not try radium? No hami can be done by 

'Reprinted by permission from ihe Boston Medical and Surgical Journal exc 

1124-1126. June 26, 1924. ' """

R a d i u m 203 

the cautious use of radium. If there is any recovery of vision, the patient 

will have gained, and a new agent will be available for the treatment of 

glaucoma. The radium was applied to the right eye for one hour. Not 

having absolute confidence in radium, the patient "was given Eserin and 

Dionin for local use. He was advised to limit his liquids, use hot applications 

and take frequent large doses of epsom salts. 

The patient returned on April 30 and the vision of the right eye was 

20/50 normal; tension +2. Radium was applied for one hour and ihe 

patient was advised to continue the treatment outlined above. 

The patient returned on May 5th and the vision of the right eve was 

20/30 normal; tension +2. Treatment continued. Radium applied. 

The vision of the patient on June 8 was 20/50 normal, improved 

to 20/30+2 with a correcting lens, (+.50 Sph. +.50 Cyl. Axis 90). 

Aug. 2$. V. O. D. 20/50-1, radium applied. 

Oct. 9, V. O. D. 20/50+2. radium applied. 

Dec. 11, V. O. D. 20/100. improved to 20/50 with a correcting lens 

(+.50 Sph. +.50 Cyl. Axis 90). Radium applied. 

Jan. 25, V. O. D. 20/70. On this date, tension was taken by McLean 

Tonometer and registered 40. The patient at all times has kept up the 

local eye treatment, and it will be noted from the above records of 

vision that as the interval increased between the dates of application of 

radium, that there was a tendency of his vision to diminish. This would 

tend to emphasize the importance of radium in the treatment of this case. 

2. J. W., male, 46 years, appeared at the Eye, Out-Patient Department 

of the Boston City Hospital on Monday, June 4. The patient stated that 

after boarding the New York train on Saturday night, June 2, he felt a 

pain in the righteye and the vision began to disappear. When he reached 

Boston on the next morning, he had to be taken in a taxi to the home of 

friends because of loss of vision. 

Examination showed the patient's right eye to be markedly injected, 

the anterior chamber shallow, the pupil dilated, and the tension increased 

to about +3. The cornea was hazy. It was impossible to see the opticdisc. 

The patient could count fingers at one foot. Radium was applied 

to the right eye for one-half hour and no other treatment was prescribed. 

The patient returned on June 6th and the vision was 5/200. Radium 

was again applied, at this time for one hour. 

On June 7th, haziness of the cornea clearing, eye getting softer. 

tension about +2, pupil still dilated, eye still red, vision 20/70 normal. 

Patient was anxious to returii to New York and in order to speed his 

recovery, Dionin and Eserin were prescribed with hot applications. 

June 9th, the vision was 20/70 normal, tension about +2, pupil still 

dilated, eye still red. 50 milligrams of radium applied for one hour. 

June nth. cornea clear, disc showed cupping, tension +1, pupil still 

dilated, injection of globe subsiding, vision of the right eye 20/50 normal, 

improved with a correcting lens. (—.50 Cyl. Axis 180) to 20/30 normal. 

The patient left the office in a happy state of mind and naturally very 

much pleased with the recovery of his vision. 

He returned the next day stating that the pain had returned on the 

previous night. After some interrogation,it was learned that the patient 

had taken an automobile ride after leaving the office on the day before. 

Vision of the right reduced to 10/200, eye markedly injected. 

The sudden disappearance of the vision after the automobile ride 

has become more significant since emphasized by an experience with the 

condition described in case three. It is probable that the exposure of the 

eye during the ride precipitated another attack of his glaucoma.

204 R a d i u m 

The patient received a telegram from his wife to return to New 

York immediately. He was advised to consult an oculist at once. 

Several attempts were made to trace the patient through relatives in 

Boston. Finally it was learned that the patient had been operated on by 

a New York surgeon and operation was followed by intra-ocular hemorrhage. 

Judging from the description received over the telephone, the patient 

probably has light perception only. 

3. A. C, male, 59 years old. 

History: Pain in left eye four years ago with failing vision. Consulted 

a reputable oculist in Boston several months after the onset. 

Operation was advised and refused. After the consultation, the patient 

noticed a halo of colors surrounding the lights and continued to lose his 

vision, until, finally,the left eye became totally blind. 

Two years ago, noticed circles in front of the right eye. Eye got red 

and the pain was more severe. Started treatment under Christian Scientist 

as soon as the right eye began to bother. 

The vision in the right eye had been gradually failing until Dec. 23, 

at which time the patient had a severe attack of pain and a sudden loss 

of vision. On Chrstimas day, the patient stated he could not see the food 

on his plate. 

The patient came to the Boston City Hospital on Jan. 4th, 1924, led 

by his wife because of his inability to see. Examination revealed the following: 

Right eye hard and red, cornea hazy, pupil dilated, anterior 

chamber shallow, view of the fundus impossible on account of hazy cornea. 

Tension by McLean Tonometer. 100. Light perception. Left eye 

hard and red, cornea so hazy that it appeared infiltrated, pupil dilated, 

anterior chamber shallow, view of the fundus impossible, no light perception, 

tension by McLean Tonometer, 100. 

In the two cases previously described, at some time in the course 

of the treatment, myotics were used, so that they could not be considered 

purely cases of unmixed radium treatment. 

The treatment of this case was started with radium alone. Fifty 

milligrams of radium were applied for one hour to the right eye, and 

ioo milligrams of radium for one hour to the left eye. 

The Interne was advised to take tension at intervals of two hours 

on the day of the application of radium and until three records had been 

made. There was no variation in the tension of either eye. 

On the next day. the patient returned to have his tension taken. The 

right eye showed a tension of 80 and the left eye a tension of 74. The 

tension was taken again two days later and found to be 65 in the right 

eye and 70 in the left eye. On this date, radium was again applied to both 

eyes. 

On January 7th, the cornea of the right eye was clear, the cornea 

of the left eye showed infiltration. Vision of the right eye, fingersat one 

foot. Radium was again applied for one hour. 

On Jan. nth, the vision of the right eye was 20/60. improved with 

a correcting lens, (+.50 Cyl. Axis 180) to 20/40+3. It was now possible 

to see a thin linear scar extending from 7 o'clock to the center of 

the cornea. There was also a slight thickening of the anterior capsule 

of the lens and a more dense area near the lower margin of the lens. Up 

to this date, nothing had been used in the right eye locally, nor was there 

any general treatment for the patient's condition. 

He was treated with radium and radium alone. His vision had been 

improved in one week from light perception to 20/60 normal, and, with 

a correcting lens, to 20/40 normal.

IUM 205 

On Jan. 14th. which was a very cold day. the patient walked a distance 

of two or three miles to the hospital. There was.marked epiphora 

but no pain. The vision was reduced to 20/100 normal. Radium was 

again applied. 

When the patient returned to the hospital again. Jan. 18th, the vision 

was still 20/100, tension of the right eye 75, the left eye 80. 

On Jan. 28th. the vision of the right eye was 10/200 normal and 

the tension 90. The patient was admitted to the hospital and myotics 

started. He has been kept under observation and his vision brought back 

to 20/100 normal in the right eye and the tension to 85. 

It has been observed since he has been in the hospital that a dose 

of 100 milligram hours gives relief for about five days when there is a 

return of pain, a decrease in vision, and an increase in tension. 

The above cases were reported at the meeting of the New England 

Ophthalmological Society on Tuesday evening, Feb. 19. 1924. Cases 

one and three were shown and case two simply reported. These cases 

were shown with the idea of demonstrating that radium is an agent which 

can be used to reduce intra-ocular tension. 

It should not be inferred that radium is considered a panacea in the 

treatment of glaucoma, that it is the sole agent to be used in the treatment 

of glaucoma, or that it is to be used as a substitute for myotics or 

operation. These cases show very definitely that radium will reduce the 

intra-ocular tension in glaucoma, and incidentally may improve the vision. 

After a thorough search of the literature, it was found that the only 

instance in which radium was used in the treatment of glaucoma was reported 

by Wickham and Degrais in their book on "Radium Therapy."* 

In the latter part of December, 1906, a patient suffering from glaucoma, 

at the hospital of St. Jean De Dieu at St, Barthelemy, near Marseilles, 

was sent to Wickham and Degrais in Paris for radium therapy 

relative to glaucoma. The description of the case follows: 

"We have ourselves tried it in a case of glaucoma, which we quote 

bere, not because of the result obtained, which was in no way remarkable, 

but because of the technique. . . The patient was completely blind in the 

left eye. and partially blind in the right eye. The eye on this side could 

distinguish some shadows. The diagnosis of the ophthalmologist at the 

institution was 'inoperable glaucoma,' of several years' standing." 

Notice how in detail, the description of this case corresponds to the 

condition of the case described in case three. 

Quoting further: 

"The treatment, commenced on January 23rd, 1907. was repeated 

every day until February 5th, inclusive. . . . The patient returned to Marseilles 

on February 12th. During the course of treatment he seemed to 

see unaccustomed lights, and felt much encouraged. On March 26th M. 

deM wrote to us that there seemed to be improvement; but since 

then the patient's condition has become the same as before treatment. 

We give this instance only because it marks our firstattempt at filtering 

radium rays through a lead sheet." 

It will be seen that the authors describe the above case primarily 

to demonstrate the technique which would enable them to use radium in 

deep therapy, and which, in so far as they knew, had never before been 

used. Their report on the case mentioned in no way, nor even suggested 

•From "Radium Therapy" by Wickham and Degrais tFunk & Waenalls). part 111. 

chapter ix. pp. 277-278.

206 R A D I U M 

that radium produced a reduction in the intra-ocular tension; nor did it 

make, in any way. any definite record of improvement in vision. 

The amount of radium element used was 26.8 milligrams, and the 

time of application twenty minutes daily for fourteen consecutive days. 

Their method of application was such as to have the benefit of crossfiring, 

This dosage is comparatively small both from the point of view of 

the individual dose and the aggregate. Each separate dose was 8.9 milligram 

hour and the total dosage for the entire treatment was 124.6 milligram 

hours. Probably this is wherein the treatment failed. 

If the optic nerve had gone on to atrophy, radium or any other element 

could not be expected to restore its function. When eyes have been 

glaucomatous for over one or two years, totally or almost totally blind 

for a period varying from two to fifteen days, and the vision can be 

brought back, even temporarily, who knows when the optic nerve begins 

to atrophy and to what degree it is atrophied in these cases of glaucoma? 

In so far as can be determined by a study of the literature to date, 

the cases of glaucoma above described by the writer, afford the only instances 

and the firstrecords of a reduction of intra-ocular pressure with 

an improvement of vision by the use of radium. 

When an agent of this kind can bring the vision of an eye from total 

blindness to 20/70 normal in four days as in case one; and when the 

vision of an eye can be improved from what is practically total blindness 

to 20/60 normal in seven days by radium alone, then this agent is certainly 

a factor to be reckoned with and given due consideration in the 

treatment of glaucoma. 

In case one, the patient had been under the care of trained men who 

undoubtedly gave all the help possible by the use of myotics. It is reasonable 

to assume that the Eserin and Dionin prescribed on the day that 

the radium was applied, added nothing to the drug action which had previously 

been prescribed by the other men. It points very forcibly to the 

fact that the snap-back in the patient's vision must have been due to something 

which had not previously been received in the way of treatment. 

'There is no desire on the part of the writer to convey the idea that 

radium is the last and only word in the treatment of a glaucoma, but it 

must be admitted that it has the power to produce this all important effect, 

namely, the lowering of intra-ocular tension. There is still much 

to be learned as to how radium acts, how extensive and permanent its 

results. 

Another very important phase of the subject to be worked out is 

dosage. It is very necessary to determine whether the best results will 

be obtained by large doses given at longer intervals, or small doses given 

at frequent intervals. The impression from observations thus far leads 

the writer to believe that there is more good to be obtained from one 

large dose than from several small doses. In treating this condition, the 

alpha and beta rays should be screened with brass and hard rubber, and 

the radium placed 2 cm. from the eye, this screening making available the 

gamma rays without any danger of burning. 

It is not unreasonable to assume that radium will become a valuable 

pre-operative adjunct to the treatment used by the Ophthalmic Surgeon 

when he desires to lower the intra-ocular tension in cases of glaucoma, 

previous to operation. Instead of resorting to paracentesis of the cornea 

-or sclerotomy, he may, by the use of radium, be able to lower the tension 

sufficiently to render his operative procedure safe.

CONCLUSIONS 

207 

That in some cases of glaucoma, radium definitely lowers the intraocular 

tension, and this lowering of intra-ocular tension is sometimes 

accompanied by an improvement in vision. 

That the action of radium on intra-ocular tension in glaucoma, suggests 

a fieldfor worth-while investigation. 

X-RAY AND RADIUM PROTECTION COMMITTEE- 

REVISED REPORT No. 1* 

Sir Humphrey 

MEMBERS 

(December, 1923) 

CHAIRMAN 

Rolleston, K.C.B.. President of the Royal College of 

Physicians. 

Sir Archibald Reid, K.B.E.. C.M.G. (St. Thomas's Hospital). 

Dr. Robert Knox (King's College Hospital). 

Dr. G. Harrison Orton (St. Mary's Hospital). 

Dr. S. Gilbert Scott (London Hospital). 

Dr. J. C. Mottram (Pathologist to the Radium Institute). 

Dr. G. W. C. Kayc, O.B.E. (National Physical Laboratory). 

Mr. Cuthbert Andrews. 

UONDRARV SECRETARIES 

Dr. Stanley Melville (St. George's Hospital!. 

Prof. S. Russ (Middlesex Hospital). 

ADDRESS 

Care of Royal Society of Medicine, Wimpole Street, London, W.i. 

The X-ray and Radium Protection Committee presents a revised 

edition of its preliminary report firs)issued in July, 1921. 

The new report contains a considerable number of alterations and 

additions based largely on the experience of the National Physical Laboratory 

in its inspection work carried out for the last two years or more 

in co-operation with the committee. 

Copies of the report may be had on application to the Director, 

National Physical Laboratory, Teddington, Middlesex. 

INTRODUCTION 

The danger of over-exposure to X-rays and radium can be avoided 

by the provision of efficient protection and suitable working conditions. 

The known effects on the operator to be guarded against are: 

1. Visible injuries to the superficial tissues, which may result in 

permanent damage. 

2. Derangements of internal organs and changes in the blood. These 

are especially important, as their earlier manifestation is often unrecognized. 

'Rcprinlcd from The Uritish Jpunn.il of Radiology, xxix. 19-27. Jnnu.iry. 1921.

208 R a d i u m 

GENERAL RECOMMENDATIONS 

It is the duty of those in charge of X-ray and radium departments 

to ensure efficient protection and suitable working conditions for the 

personnel. 

The following precautions are recommended: 

I. Not more than seven working hours a day. 

2, Sundays and two half-days off duty each week, to be spent as 

much as possible out of doors. 

3. An annual holiday of one monlh or two separate fortnights. 

Sisters and nurses, employed as whole-time workers in X-ray and 

radium departments, should not be called upon for any other hospital 

service. 

PROTECTIVE MEASURES 

It cannot be insisted upon too strongly that a primary precaution 

in all X-ray work, whether with stationary or portable sets, is to surround 

the X-ray bulb itself as completely as possible with adequate protective 

material, except for an aperture as small as possible for the work in hand. 

The protective measures recommended are dealt with under the following 

sections: 

I. X-rays for diagnostic purposes. 

II. X-rays for superficial (low-voltage) therapy. 

III. X-rays for deep (high-voltage) therapy. 

IV. Electrical precautions in X-ray departments. 

V. Ventilation of X-ray departments. 

VI, X-rays for industrial and research purposes. 

VII. Radium therapy. 

It must be clearly understood that the protective measures recommended 

for these various purposes are not necessarily interchangeable; 

for instance, to use for dee]' therapy the measures intended for superficial 

therapy would probably subject the worker lo serious injury. 

It should be further pointed out that the protective values of certain 

materials are much affected by a change in the voltage applied to 

the X-ray tube. This applies particularly to materials in which lighter 

elements than lead furnish the chief protection. The importance of 

obtaining a National Physical Laboratory test in this connection is emphasized. 

In the case of protective slabs or plasters made up of a mixture 

of materials, the difficulty of securing uniform mixing should be 

met by a generous margin of safety in estimating the required thickness. 

I. X-RAYS FOR DIAGNOSTIC PURPOSES 

1. Screen Examinations 

(a) The X-ray bulb should be enclosed completely as possible 

with protective material equivalent to not less than 2 mm. of lead. The 

material of the diaphragm should be equivalent to not less than 3 mm. 

of lead. The design of the diaphragm should be such as to permit it to 

be completely closed. The simpler rectangular forms of diaphragm 

will, in general, be found preferable to the iris type. 

In the case of installations which are incapable of generating peak 

voltages exceeding 70,000, the lead value of the tube enclosure may be 

reduced to 1.5 mm. and of the diaphragm to 2 mm.

R a d i u m 209 

(b) The fluorescent screen, attached as a permanent fitting to 

screening stands, etc., should be fitted with lead glass equivalent to not 

less than 2 mm. of lead. In all positions the lead glass should be large 

enough to cover the area irradiated when the diaphragm is oi>ened to its 

widest. Eor screens of smaller area, the lead glass should be mounted 

in a frame of protective material which overlaps the screen and is of 

adequate width and thickness to afford protection in all positions of the 

screen. In* the case of portable screens considerations of weight militate 

against the recommendation of a degree of protection greater than 1 mm. 

of lead. As far as jiossible, the glass should be of uniform thickness 

and free from striations and air bubbles. 

(c) To afford protection from scattered radiation in the case of a 

couch, a protective screen, mounted on the carriage and of material 

equivalent to not less than 2 mm. of lead, should be employed between 

the operator and the X-ray box. In addition, a device such as a "collar" 

of protective material between the tube box and the underside of the 

couch is effective. In the case of a screening stand, an "apron" of protective 

material should be attached to the lower edge of the screen, and 

panels of protective material mounted on each side of the patient. 

(d) Protective gloves should be of lead rubber (or the like) and 

afford protection for both back and front of hand (including fingers 

and wrist). The protective value should be not less than */j mm. of lead. 

Gloves should preferably be lined with leather or other suitable material. 

(As practical difficulties militate at present against the recommendation 

of a greater degree of protection, all" manipulations during screen examination 

should be reduced to a minimum. > 

(e) In those cases where the necessity is felt for even greater protection 

for the operator, goggles and aprons may advantageously be 

worn. The glass of the goggles should have a lead value not less than 

Yz mm.; aprons should have lead values not less than 1 mm. 

(/) A minimum output of radiation should be used with the bulb 

as far from the screen as is consistent with the efficiency of the work in 

hand. Screen work should be as expeditious as possible. 

2. Radiographic Examinations ("overhead" equipment.) 

(a) The X-ray bulb should be enclosed as completely as possible 

with protective material equivalent to not less than 2 mm. of lead. This 

figure may be reduced lo 1.5 mm. in the case of installations which are 

incapable of generating peak voltages exceeding 70,000. 

(b) The operator should stand behind a protective screen of material 

equivalent to not less than 2 mm. of lead. In general, such screens 

should not be less than 3 ft. 6 in. wide and 7 ft. high and should extend 

to within 1 in. of the ground. If a window is provided, its lead equivalent 

should not be less than 2 mm. Its dimensions need only rarely 

exceed 9 in. by 6 in. 

II. 

X-RAYS TOR SUPERFICIAL (LOW-VOLTAGE) THERAPY 

It is difficult to define the Fine of demarcation between superficial 

and deep therapy. . . c 

For this reason it is recommended that, in the reorganization ol 

existing or the equipment of new, X-ray departments, small cubicles 

should not be adopted, but that the precautionary measures suggested 

for deep therapy should be followed.

210 

'The definition of superficial therapy is considered to cover sets of 

apparatus giving a maximum peak voltage of 100.000 (15 cm. spark gap 

between points; 5 cm. spark gap between spheres of diameter. 5 cm.). 

Cubicle System. 

Where the cubicle system is already in existence it is recommended 

that: 

1. The cubicle should be well lighted and ventilated, preferably 

provided with an exhaust electric fan in an outside wall or ventilation 

shaft and suitable air inlets. The controls of the X-ray apparatus should 

be outside the cubicle. 

2. The walls of the cubicle should preferably not take the form of 

partitions, but should extend from floor to ceiling. If partitions are 

adopted, they should be not less than 9 ft. in height and extend to floor 

level. 

3. The walls (and where necessary, the floor and ceiling) of the 

cubicle should be of material equivalent to not less than 2 mm. of lead. 

Windows should be of high quality lead glass of equivalent thickness. 

They need only rarely exceed 9 in. by 6 in. in dimensions. Care should 

be taken that the protective materia! overlaps at joints. 

4. The X-ray bulb should be enclosed as completely as possible 

with protective material equivalent to not less than 2 mm. of lead. This 

figure may he reduced to 1.5 mm. in the case of installations which are 

incapable of generating more than 70.000 volts. 

III. X-RAVS FOR DEEP (ItlGlI-VOLTAGE) THERAPY 

This section refers to sets of apparatus giving peak voltages above 

100.000. 

1. Small cubicles are not recommended. 

2. A large, lofty, well-ventilated and lighted room should be provided, 

preferably provided with an exhaust electric fan in a suitable air 

duct. 

3. The walls (and where necessary, the floor and ceiling) of the 

room should provide protection equivalent to not less than 3 mm. of 

lead. Windows should be of high quality lead glass of equivalent thickness. 

They need only rarely exceed 9 in. by 6 in. in dimensions. Care 

should be taken that the protective material overlaps at joints. 

4. The X-ray bulb should be enclosed as completely as possible 

with protective material equivalent to not less than 3 mm. of lead. 

5. A separate enclosure should be provided for the operator, situated 

as far as possible from the X-ray bulb. All controls should be 

within this enclosure, the walls and windows of which should be of material 

equivalent to not less than 3 mm. of lead. 

IV. ELECTRICAL PRECAUTIONS IN X-RAY DEPARTMENTS 

1. Wooden, cork, lino or rubber floors should be provided; existing 

concrete or similar floors should be covered with one of the above 

materials. 

2. Stout metal tubes or rods terminating in spheres should, as far 

as possible, be used instead of wires for conductors. Overhead conductors 

should not be less than 9 ft. from the floor level. The connecting 

leads from the overhead conductors to the X-ray tube should be 

brought down in positions as remote as possible from the operator and

R a d i u m •, 211 

patient. The provision of thick-walled insulating tubing to shield the 

more adjacent pans of the connecting leads is recommended. Thickly 

insulated wire is preferable to bare wire. Slack, looped or low hanging 

wires should be avoided. Small spring tapes should be replaced by rheophores 

of robust design with heavily insulated wire. 

3. All metal parts of the apparatus and room should be efficiently 

earthed. 

4. All main and supply switches should be very accessible and distinctly 

indicated. It should not be possible to close them accidentally. 

Wherever j>ossible double-pole switches should be used in preference to 

single-pole. Fuses no heavier than necessary for the purpose in hand 

should be used, together with quick-acting double-pole circuit breakers. 

The possibility of unemployed leads to the high-tension generator should 

be prevented by interlocking switches or the like. 

5. Alternative spark gaps (preferably of the sphere type), should 

be provided. They should be furnished with cm. or inch scales, together 

with a voltage scale. The spark gaps should be situated in positions 

where they can easily be read and adjusted while the tube is in operation. 

V. VENTILATION OF X-RAY DEPARTMENTS 

I. It is strongly recommended that the X-ray department should 

not be below the ground level. In general, ceilings should not be less 

than 11 ft. in height. The presence of steam piping and the like must 

he allowed for. Damp rooms should be avoided. 

2. The importance of adequate ventilation in both operating and 

dark-rooms is supreme. Artificial ventilation is recommended in most 

cases. With very high potentials coronal discharges are difficult to avoid, 

and these produce ozone and nitrous fumes, which arc prejudicial to 

the operator. Rotating rectifiers often require the provision of a special 

ventilating duct or like measure. I'ncnclosed rectifying spark gaps are 

better replaced by enclosed types. If vacuum valves are used, the fact 

that they may produce X-rays should not be lost sight of. 

All rooms, including dark-rooms, should be capable of being readily 

opened up to sunshine and fresh air when not in use. The walls and 

ceilings of all rooms, including dark-rooms, are best painted some light 

hue. 

VI. X-RAYS FOR INDUSTRIAL AND RESEARCH PURPOSES 

The preceding leconunendations will probably apply to the majority 

of conditions under which X-rays are used for industrial and research 

purposes. 

VII. RADIUM THERAPY 

The following protective measures are recommended for the handling 

of quantities of radium up to one gram: 

1. In order to avoid injury to the fingers the radium, whether in 

the form of applicators of radium salt or in the form of emanation 

tubes, should always be manipulated with forceps (preferably wooden) 

or similar instruments, and it should be carried from place to place in 

long-handled boxes lined on all sides with i cm. of lead. 

2. In order to avoid the penetrating rays of radium all manipulations 

should be carried out as rapidly as possible, and the operator should 

not remain in the vicinity of radium for longer than is necessary. 

The radium when not in use should be stored in an enclosure, the

212 R a d i u m 

wall thickness of which should be equivalent to not less than 2 cm. of 

lead. 

3. The handling of emanation should, as far as possible, be carried 

out during its relatively inactive state. In manipulations where emanation 

should be very carefully guarded against, and the room in which 

it is prepared should be provided with an exhaust electric fan. 

GENERAL 

The governing bodies of many institutions where radiological work 

is carried on may wish to have further guarantees of the general safety 

of the conditions under which their personnel work. 

1. Although the committee believe that an adequate degree of 

safety would result if the recommendations now put forward were acted 

upon, they would point out that this is entirely dependent upon the loyal 

co-operation of the personnel in following the precautionary measures 

outlined for their benefit. 

2. The committee would also point out that the National Physical 

Laboratory, Tedding ton. is prepared to carry out exact measurements 

upon X-ray protective materials and to arrange for periodic inspection 

of existing installations on the lines of the present recommendations. 

(Sec Report No. 2.) 

3. Further, in view of the varying susceptibilities of workers to 

radiation, the committee recommend that wherever possible periodic 

tests, e. g., every three months, be made upon the blood of the personnel, 

so that any changes which occur may be recognized at an early stage. 

In the present state of our knowledge it is difficult to decide when small 

variations from the normal blood-count become significant. 

REPORT NO. 2 

In view of the widespread uncertainty and anxiety as to the efficacy 

of the various devices and materials employed for the purposes of protection 

against X-rays, the X-ray and Radium Protection Committee 

strongly advise that the Heads of X-ray departments of hospitals and 

other institutions should safeguard themselves and their staffs on this 

score by recommending to the hospital authorities the adoption of the 

following precautions: 

1. The various protective appliances should be inspected and reported 

on by ihe National Physical Laboratory (N.P.L.), Teddington. In 

the event of an adverse report, early steps should be taken to carry out 

the recommendations of the Laboratory. The laboratory is prepared. 

wherever possible or expedient, to engrave (or otherwise suitably mark) 

the N. P. L. monogram and year of test on such appliances as provide 

the full measure of protection laid down in the Revised Report No. 1 of 

the Protection Committee. It should be pointed out that, in the case of 

materials which may deteriorate, e. g.. lead rubber, such inspection should 

be periodic, say, every twelve months. 

2. Within the committee'? recent experience, the working conditions 

of X-ray departments, .\ g., lay-out of installations, degree of scattered 

radiation, ventilation, high-tension insulation, etc.. arc often unsatisfactory. 

It is recommended that such conditions be inspected by 

the N.P.L. and that early steps be taken to give effect to such alterations 

as may arise out of their report. It is advised that, in the planning of new

R a d i u m 213 

radiological departments, advantage be taken of the facilities available at 

the N.P.L. 

3. Manufacturers of X-ray apparatus arc also invited to assist in 

reassuring the public by actively co-operating with the committee in its 

recommendations. It is suggested that protective materials or equipment 

should not be sold or incorporated into an installation unless accompanied 

by a specification based upon an N.P.L. certificate or report 

stating, in terms of the equivalent thickness of lead, the degree of protection 

afforded. 

In the interests of both the trade and profession, it is urged that 

manufacturers should put themselves into a position to be able to guarantee 

that their apparatus complied completely with the recommendations 

of the committee. 

4. The committee recommend that the various instruments dealing 

with the measurement of current (ammeters and milliammeters) and 

voltage, be standardised by the N.P.L. With reference to the measurement 

of secondary voltage, the commiltee recommend that everv installation 

should be provided with adequate means for enabling this to 

be easily effected, e. g.. by kilovoltmeter, sphere-gap voltmeter or the 

like. 

5. The committee would further urge that Heads of X-ray departments 

should insist upon complete N.P.L. inspection of imported materials 

and apparatus. 

REVIEWS AND 

ABSTRACTS 

W. S. Flatau, M. D. (Nurnberg, Germany). Results of Radiotherapy 

of Cancer of the Uterus. (1) Zent-alblatt fuer Gynaekologic, 

Nov. 19, 1923. (2) do. May 12, 1923, abstr. in J. A. M. A., Sept. 1, 

'923. P- 790. 

Author examines his material from the simple point of view as 

proposed by Menge. He treated with rays, from December, 1913, to 

February, 1922, a total of 310 cases of cancer of the cervix, of which 

101 operable, 52 or 50% of which are living, and 209 inoperable, of 

which 22 or g.5% are living. These 22 would have been absolutely lost 

without radiation (immovable uterus), which in this respect alone shows 

the superiority of radiotherapy. He uses the combined radium-x-ray 

treatment, the standard method for the past three years. Of 68 radiated 

cases 22 were operable, 17 or 8o

214 R a d i u m 

funds—fail to appear for the second or third series, which fact explains, 

in part, the large number who remain uncured. Radiotherapy must be 

intensified if it is to compete with operative treatment. Flatau, therefore, 

sets up three requirements for a standardized method: (i) The greatest 

possible homogenization and hardening of the ray cone; (2) irradiation 

of the whole pelvis (uterus, ligaments, lymph paths, lymph glands, connective 

tissue) in one large field, and (3) simultaneously (or immediately 

preceding or following) a combination of excentrically applied and 

'incentrically' active distant roentgenization and an 'incentrically' applied 

and excentrically active radium treatment. Flatau has been applying 

such a standard method for nearly three years and now gives a preliminary 

report of his results. He uses 50 mg. of radium within the cervix 

for forty-eight hours; 50 mg. of radium vaginally for twenty-four hours; 

immediately preceding or immediately following this treatment he applies 

an irradiation of the whole pelvis with the aid of four distant fields, one 

dorsal, one ventral and two lateral. Out of 22 operable cases, 80 per cent 

arc still living; 5 are dead or have been lost sight of; out of 46 inoperable 

cases, 22 per cent are still living; 34 are dead or have left the community. 

The results of operative treatment, Flatau holds, cannot compare 

with these, and as regards the inoperable cases, the 12 patients 

alive and well today is so much net gain. lie emphasizes, however, 

that radiotherapy requires a skilled and experienced operator to the 

same extent as surgery. The ingestion of a teaspoonful of sodium chlorid 

immediately following irradiation has been found to exert a markedly 

prophylactic action as regards after-effects of irradiation." 

Arthur U. Desjardins, M. D., and Francis A. Ford, M. D. (Rochester, 

Minn.) Hodgkin's Disease and Lymphosarcoma. A Clinical and 

Statistical Study. Jour. Am. Med. Assn., lxxx, 925-927, Sept. 15, 1923. 

"Hodgkin's disease and lymphosarcoma, while not common conditions, 

are not rare. Since attention was attracted to this type of disease 

by the reports of Hodgkin in 1832, and especially by the contributions 

of Samuel Wilks in 1856 and 1865, much effort has been expended 

in attempts to determine the etiology, with but little success. Owing 

chiefly to the work of Dorothy Reed, the pathology of the Hodgkin's 

type of lymphoma is well established. In general, this is also true of 

lymphosarcoma, but many cases are encountered in which it is not easy 

even by careful microscopic study positively to differentiate it from 

certain allied conditions. Many forms of treatment, medical and surgical, 

have been tried. Various drugs have been advocated from time to 

time, but, aside from brief and transient improvement in certain cases, 

the fatal course of the disease has not been greatly impeded. Nor has 

surgical excision of notably involved groups of glands been successful, 

and it is seldom considered at the present time." 

"The only form of treatment that exerts noteworthy influence on 

such morbid states is irradiation by means of roentgen rays and radium, 

used independently or in combination. The intelligent employment of 

such treatment often yields striking results even in cases in which complications 

of a more or less serious nature are impending. Many patients 

are completely restored to normal health, while others are only partially 

improved. Even in the presence of extensive mediastinal glandular 

involvement, with or without pleural effusion, it is often possible to 

cause such adenopathy to disappear and the fluid to be absorbed. Un-

R a d i u m 215 

fortunately, the improvement is not permanent; it may continue for 

months or even for two or three years or more, but sooner or later recurrence 

in the same, or in some other, region occurs, and is usually fatal." 

"There can be no question that systematic treatment by irradiation 

is of the greatest service in such conditions, and many patients can be 

kept in relatively good condition for a variable period of time; but 

whether or not their lives are actually prolonged has not been determined. 

In undertaking to study this subject, wc immediately realized that it 

would be worthless to ascertain the average length of life of patients 

treated by irradiation without preliminary investigation of the average 

duration of the disease without systematic treatment. In order to obtain 

such information, to serve as a basis for a later study of the actual effect 

of irradiation treatment on the longevity of such patients, the histories 

were consulted of all patients registering at the Mayo Clinic for 

the five-yearperiod, between 1015 and 1920, in whom a definite diagnosis 

of Hodgkin's disease or lymphosarcoma had been made on the basis 

of microscopic examination of excised glands. Besides studying the 

average duration of the disease in these two groups of patients, it seemed 

desirable to take advantage of this opportunity to gather from the histories 

as much clinical information as possible, it is the results of this 

study that we now present." 

"That approximately 11 per cent, of each group of patients were 

living three years or more was not unexpected, but we were rather surprised 

by the information gathered from a review of these living patients." 

"A detailed review of these cases will not be given, since the value 

would be considerably diminished by the fact that in several instances 

complete information concerning subsequent treatment was not available. 

In some cases, "block" dissection (excision) of enlarged cervical 

or axillary glands was followed by more or less systematically repeated 

roentgenization; in other cases, rather indifferent roentgen-ray treatment 

followed the excision of one or more glands for microscopic study. 

In some cases, a biopsy was followed by roentgen-ray treatment or injections 

of Coley's fluid, or both, and in others the biopsy was not followed 

by treatment. In only a few cases was the irradiation treatment 

given in a manner that would now be considered adequate." 

"The only conclusion, therefore, that may be drawn from these 

cases are, either that the relatively long life of the patients was due to 

treatment, or that the condition happened to be unusually chronic, or 

both factors may have occurred in combination. It is probable that an 

etiologic factor of low activity, and a comparatively high resistance. 

combined with an inhibitory influence exerted by the treatment, prolonged 

the existence of the patient." 

"From the data, it is seen that the male is 2.3 times more susceptible 

to Hodgkin's disease than the female, while lymphosarcoma attacks 

the male 4.4 times more often than it does the female." 

"In Hodgkin's disease, the dyspnea or shortness of breath, when 

present, was always associated with, and caused by, mediastinal adenopathy. 

Venous engorgement and edema are classified together, because 

some of the histories made it impossible to separate them; in some instances, 

the condition was frankly called venous engorgement, while in 

others apparently the same condition was described as edema. This 

occurred only in cases in which there was marked mediastinal involvement 

and pronounced circulatory obstruction. Pruritus, general or local.

216 R a d i u m 

is not as common as we have believed it to be. More careful investigation 

might have elicited this complaint in a larger number of cases. Usually, 

it is general, and causes the patient much distress; it undoubtedly 

has a toxic basis. In one case, itching occurred only in the skin over 

the glands, which was red and edematous. In another, pruritus was 

present only for a short time after the onset of glandular enlargement. 

It had been our impression, afler studying many cases of Hodgkin's 

has a toxic basis." 

"In general, the discussion of Hodgkin's disease applies equally 

to lymphosarcoma. Indeed, the most noteworthy fact is the close parallelism 

of the symptoms in bolh groups, a parallelism which has led many 

observers to believe that the two conditions are, to say the least, very 

closely related. Toxic pruritus occurs only one-third as often in cases 

of lymphosarcoma as in cases of Hodgkin's disease; however, since in 

our cases of Hodgkin's disease it was present in only 9 per cent of 135 

cases, the difference between 9 per cent and 3 per cent hardly constitutes 

a very important point in differential diagnosis. 

"In both Hodgkin's disease and lymphosarcoma, pain is a frequent 

symptom and may be of two types. One is due to pressure phenomena. 

such as enormous mediastinal adenopathy; in some cases abdominal pain 

was complained of, and was probably due to pressure by masses of enlarged 

glands. In the late stages of the disease, pain in various bones 

and joints is quite common. It is not constant in any one location, but 

moves from one bone or joint to another. Examination of such painful 

bones or articulations has failed to disclose anything that might account 

for such pain." 

"On reviewing the histories, we were impressed by the frequency 

with which the adenopathy seemed to have a more or less definite relation 

to common chronic lesions around the mouth and throat, such as 

bad teeth, diseased tonsils and naso-pharyngeal infection. Unfortunately, 

in many cases the information available was not sufficiently explicit 

to warrant definite conclusions." 

"Moderate leukocytosis is common in Hodgkin's disease, but less 

so in lymphosarcoma. In one case of Hodgkin's disease, there were 

83.cx.Kj leukocytes, and eosinophils represented 8S per cent of the total; 

in another, the leukocytes numbered only 3.000. In lymphosarcoma. 

leukocytosis was noted in but twelve cases, in one of which the count 

reached 2J7.000. with 93 per cent of lymphocytes." 

"More definite knowledge of metastatic dissemination in Hodgkin's 

disease and lymphosarcoma would have been of distinct value. Unfortunately, 

by clinical examinations alone, it is impossible to avoid overlooking 

some of the less prominent manifestations of the disease. Moreover, 

necropsy findings were available in very few of these cases. In 

the 135 cases of Hodgkin's disease, definite metastatic lesions were noted 

in but six instances; in four, it was pulmonary; in one case, there was 

a subcutaneous tumor between the eyes; and in one. the liver was involved. 

In the lymphosarcoma group, metastatic foci were noted in the 

lungs in three cases, in the cecum and left kidney in one; in the suprarenal 

in one; in the liver in four; in the right tibia in one; in the sternum 

and right fibula in one; in the abdominal wall in one, and in the chest 

wall in four. Such information is of little value except to indicate possibilities." 

"The data here presented will enable us later to determine the effect 

of systematic irradiation treatment as now practiced. We do not

R a d i u m 217 

know whether such comparison will show definite prolongation of life. 

but we do know that such treatment may keep the disease under complete 

or partial control for varying periods, and that at the present time 

it is the most effective means of bringing relief to the unfortunate victims." 

Average Duration of the Disease From the Onset of Symptoms iii 

Seventy-Three Cases of Hodgkin's Disease and Fifty-Five Cases 

of Lymphosarcoma in Which the Date of Death Is Known 

Hii'i^tilU'r- I'l'-. .,: • Lymphosarcoma 

Decade of 

Incidence 

o to 10 3 

ii to 20 4 

21 to 30 24 

3' to 40 23 

41 to 50 10 

51 to 60 8 

61 to 70 1 

Total 73 

Average Duration 

of Dlbi-uee 

Wars -Months Cases 

4 O 4 

2 9 4 

_• 11 U 

-• 7 5 

I 8 12 

2 3 14 

3 0 3 

— — — 

j 7 55 

of Disease 

Av rragc Duration 

Wars Months 

I 4 

4 I 

l l 1 

5 4 

1 8 

2 7 

0 4 

-— — » 5-5 

Patients Living 

Hodgkin's Disease 

lymphosarcoma 

Patients Per Ceni. Patients Per Cent. 

One year or less 9 12.7 20 37.0 

Two years or less 19 26.0 13 24.0 

Three years or less 19 27.0 4 7-4 

Four years or less 10 13.7 8 14.S 

Five years or less 9 12.7 3 5.5 

More'than five years 7 9j8 6 n.o 

******** 

George R. Minot. M. D., Thomas E. Duckman, M. D.. and Raphael 

Isaacs. M. D„ (Boston). Chrome Myelogenous Leukemia: Age Incidence. 

Duration, and Benefit Derived from Irradiation. The Journal of 

the American Medical Association. Ixxxii, 1489-1.94. Mav 10. 1924. 

(From the Medical Service of the Collis P. Huntington Memorial Hospital 

of Harvard University.) 

"Irradiation treatment of chronic myelogenous leukemia was first 

undertaken by Senn in 1903. using long wave length roentgen rays. It 

was not until after Rcnon. Degrais and Desbouis. in 1913, and Ordway, 

in 1917, reported the effect of radium on the disease that adequate irradiation 

was given at all frequently so as to produce very often marked 

alleviation of symptoms. In recent years and with the advent of short 

wave length roentgen-ray therapy, constantly greater numbers of these 

patients in an increasing number of localities are receiving intensive 

irradiation with great benefit. The reports by Ordway. Peabody. Giffin,

218 Radium 

Vogel, Wood and Rohenthal are among those that indicate the value of 

this form of treatment." 

"It is recognized that irradiation frequently brings about striking 

remissions of the disease, so that patients who are often in a distressing 

and sometimes an apparently serious condition can be returned to a useful 

and functionally efficient existence. However, there is very little 

information in the literature concerning such facts as the duration of 

chronic myelogenous leukemia and the length of time irradiation enables 

these patients to remain efficient. Enough time has passed since the inauguration 

of intensive irradiation to evaluate the end-results of a series 

of cases, and this is the particular purpose of the present communication. 

It is not our object to discuss here the most suitable method of treatment, 

but simply to present in a statistical manner certain aspects of the 

disease and the results of irradiation therapy." 

"Material Studied.—The data have been compiled from the records 

of 166 typical cases of chronic myelogenous leukemia. At least one of 

us has seen and studied continuously no of the cases. We have studied 

only the records of the remaining fifty-six cases. Nineteen of the patients 

are living, and the data are incomplete on seventeen cases, so that 

thirty-six are not available for statistics concerning the end-results. For 

the latter purpose there are 130 cases; seventy-eight of these patients 

have received intensive irradiation, chiefly from radium, and fifty-two 

have been given no form of irradiation. These two groups are comparable 

because there is no distinction that can be detected in the character 

of their disease. A considerable number of the seventy-eight patients 

have not received treatment of the degree or frquency, or in the 

manner that would seem todav most suitable, but all have had what is 

usually considered at least an effective amount of intensive irradiation 

therapy: an amount that produced distinct improvement in a very high 

percentage of the case*. Thirty-six of the fifty-two patients who form 

a control series to the seventy-eight irradiated patients suffered from 

chronic myelogenous leukemia prior to the date of introduction of intensive 

therapy. Sixteen of the fiftv-two developed their disease in the 

last ten years. They received no irradiation because of either refusal 

of therapy or an incorrect diagnosis until they eniered the hospital in a 

terminal state. 'The latter patients do not represent acute cases since 

some had their disease four years, and lived for about as long a time 

on the average as did all ihe other patients." 

"SUMMARY, i. Of 166 patients with chronic myelogenous leukemia, 

seventy-eight treated by irradiation and fifty-two not so treated 

are known to be dead. The latter serve as a control group to the 

former." 

"2. The ratio of ihe percentage in each decade of life of these 

166 American cases and of 247 British cases, reported by Ward, to the 

percentage of living persons of like age. indicates that after about 30 

years of age it remains nearly constant, the ratio being at a point around 

2; falling for the decade 65-75 10 about 1.5, which is ihe same as for the 

decade 25-34. The ratio is highest for the ages 35-44, when the actual 

number of cases is greatest. Below 25, the disease is rare." 

"3. About 60 per cent, of cases of chronic myelogenous leukemia 

occur in males, and 40 per cent, in females." 

"4. The insidious onset of the disease makes early diagnosis difficult. 

On the average. 100 patients did not consult a physician until about

R a d i u m 219 

eight months had elapsed after the first symptoms appeared. The length 

of time between the appearance of symptoms and diagnosis was on the 

average 1.4 years for 148 cases." 

"5. Irradiation has had little effect on prolonging the life of these 

patients. I he early institution of irradiation as yet does not promise an 

important increase of life expectancy. The average duration of life 

after the first symptom of the disease in fifty-two nonirradiated patients 

was 3.04 years, and in seventy-eight irradiated patients 3.5 years. Of 

these 130 patiems, 42 per cent, lived from two to four years, and 12 per 

cent, more than five and up to ten vears.'-' 

"6. Continued, properly administered irradiation produces symptomatic 

benefit, which is often marked, and offers to the patient the best 

guarantee of the longest possible preservation of his working capacity. 

As the disease progresses, efficiency decreases, in spite of continued 

therapy." 

"7. All but 5 per cent, of Ihe seventy-eight patients were benefited 

sufficiently by radium or roentgen ray to remain able and useful for 

varying |>eriods of time. At least 50 per cent, became temporarily symptomatically 

well. This is in contrast *o the fact that but 6 per cent, of 

the fifty-two nonirradiated patients had moderate remissions." 

"8. The duration of efficient life as compared to the length of life 

after diagnosis or beginning irradiation, cither early or late, shows that 

on the average it is at least 30 per cent longer in irradiated patients. 

This percentage time of useful and able existence and the degree of efficiency 

are both much greater when treatment is begun before than after 

the middle of the disease." 

"9. The actual duration laverage 1.6 years for seventy-eight patients) 

of useful life after ihe first irradiation is pro|X>rtional to the 

duration of the disease." 

"10. The statistics given enable one to forecast the probabilities of 

the duration of life and the general ability of the patient with chronic 

myelogenous leukemia. 'The forecast can be made more accurately if 

information, not discussed here, concerning the clinical state, the blood. 

the metabolism and the irradiation is properly evaluated." 

* * * * * * 

Burt Russell Shurly, M. D. (Detroit). The Removal of Tonsils, 

with Special Reference to Methods Other than Complete Enucleation. 

Journal of the American Medical Association, lxxxi, 800-802, Sept. 

8, 1923. 

"A perusal of tonsil literature during the last quarter century, with 

its many examples of radicalism and conservatism, with its illustrations 

of hundreds of new, now useless, instruments, with its story of frequent 

imaginative results and methods without logic is. nevertheless, a 

tale of scientific progress. The useless procedures, to supply a demand, 

that promised absorption of pathological tonsils such as arsenical paste. 

iodin. electrolysis, and the galvanocautery, received a long trial, failed, 

and are now only memories of early laryngology. During this period 

there was a prevalent idea among the laity that the removal of tonsils 

lessened the powers of sexual function. Today we are again asked to 

meet and classify the value of new methods of absorption, to establish 

the proper therapeutic indications, and to tabulate the results from the 

use of radium or the roentgen ray." 

"While it is true that hundreds of cases are now under treatment

220 R a d i u m 

by these methods, which, in my opinion, should have tonsil enucleation, 

it is only fair to meet this problem on a scientific basis and inquire and 

observe as to the true value and indications of the procedure. It is the 

duty of the laryngologist to operate on all patients that he conscientiously 

believes require this service. It is also his duty to classify and 

refer those that may obtain better and safer relief by means of the roentgen 

ray. We have no quarrel with the roentgen-ray expert, if he can 

prove a better result than ours. On this scientific studv alone we must 

stand." 

"It is unfair to take advantage of the fear by the laity of anesthesia. 

operative procedure and the hospital to draw cases to roentgen-ray men 

unless a scientific statistical demonstration beyond experiment can justify 

the method." 

"When Witherbee published his report of results in the treatment of 

tonsils by the roentgen ray. I immediately sent my roentgenologist to 

Xew York to learn the technic and apply the method in a series of cases 

and obtain, if possible, an opinion of its value." 

"The problem of enucleation in indicated cases must necessarily 

be viewed from three standpoints: the laity, the general practitioner 

and the pediatrician or other specialist. The laity must consent to the 

operation. This is often purely a psychologic problem, and depends on 

the successful result with a friend or a member of the family. The 

general practitioner may be for or against operation as influenced by 

fortunate or unfortunate personal experience on those among his clientele. 

He may have decided notions in opposition to certain methods of 

technic. The pediatrician demands finer details of classification as to 

the selection of the class of cases, age and time; he may require a special 

preparation of the patient. The judgment of the specialist is therefore 

limited in a number of referred cases, but he may he allowed to follow 

his own methods among those who come directly to him." 

"The roentgen-ray method is therefore adapted to bad operative 

risks and to an increasing class with pathologic tonsils who. from fear 

or under the instruction of some medical mind, friend or cult, will not 

consent to operation. The dangers, the mistakes, the fatalities and the 

poor results have indeed had their influence in the demand for a procedure 

with safety. Operation may not be performed purely as a prophylactic 

operation. This state of mind is somewhat of our own making 

The furore for tonsillectomy, the craze to remove tonsil remnants, the 

poor work in the removal of adenoids by the general surgeon, and those 

unprepared, the constant reoperation without a more careful physical 

survey have discouraged many people, and these faults must be remedied." 

"The contraindications and choice of anesthesia demand more attention. 

Too many patients with active pulmonary tuberculosis are operated 

on under ether, and too many pulmonary abscesses, as an infection 

from the inspiration of septic material, develop under general anesthesia." 

"Tonsillectomy is a major and hospital operation. These and many 

other reasons have created a public demand for greater caution. So 

great has the furore for operation become that laymen have recommended 

it extensively to those who are feeling bad. It is therefore nccessaryto 

guard conscientiously the contraindications and produce a belter 

attitude within and without the profession toward its true and wonderful 

value."

R a d i u m 221 

"The selective and destructive action of the roentgen ray on cellular 

tissue was observed by Hemicke, in 1905. J. B. Murphy, in 1914, reported 

a series of animal experiments showing a disappearance of lymphoid 

tissue without injury to organs. The Rockefeller Institute took 

up the problem with the hope that irradiation would replace surgery. 

Its firstreport claimed that the size of the tonsil was reduced greatly 

in some cases, that the tonsil became smoother and more firm. These 

effects were observed to increase over a period of several months, and 

it was reported that the result approximated the senile tonsil. The 

crypts opened for better drainage, and even Streptococcus hemolyticus 

disappeared. Adenoid treatment was almost negative. 'These rather 

startling reports created great interest, and many observers have been 

at work. The technic of Witherbee was adopted, and cases in which 

irradiation was employed by Hickey, Evans and Gift, the latter of my 

hospital staff, have offered an opportunity for observation and continued 

interest." 

"I cannot agree with the enthusiasm of the roentgenologist. I incline, 

rather, to accept the reports of the series at the Massachusetts 

General Hospital under Barnes and McMillan." 

"There is no evidence to show that the infection of the crypts is 

removed by the roentgen ray, although a preliminary report by Hickey 

on diphtheria carriers proved some marked results. Unless the tonsil 

can be sterilized, it remain a menace to the system, and as a method 

to succeed surgery, the roentgen ray fails. I believe that the roentgenray 

man is over-enthusiastic and radical." 

"My experience with radium is very limited. It possesses the advantage 

of direct exposure to the tonsil without a wider area, although 

more liable to burn. Williams reports good results with 50 mg. of 

radium bromid. The use of these methods by experts is certainly within 

the zone of safety. That infected tonsils should come out must be an 

unvarying rule unless valid contraindications exist. The results speak 

for themselves. No argument or statistical study is necessary. The 

judgment and experience of the surgeon alone can decide this question." 

"There are without doubt a limited small number of cases that are 

bad operative risks—the bleeder; the patient with advanced pulmonary 

tuberculosis, cardiac disease, nephritis or diabetes; the hysterical patient 

with imaginative 'throat trouble'; the borderline case in which the relationship 

to a tonsillar condition or focal infection is questionable; the 

neurotic, the senile and those suffering from the complex of fear. These 

patients should be given the trial of irradiation. They should receive 

much suggestive and real benefit. This treatment as a therapeutic aid has 

a well defined place, and that classification should be made by the internist 

and laryngologist." 

"There are numerous questions that must be answered before radical 

statements are justifiable. How many treatments are best: three, six 

or fourteen"' How long will the results last? What microscopic changes 

result in the different types of tonsil after treatment? What kinds of 

infections are modified and which destroyed? If irradiation kills all 

lymphocytes and lymphoblasts of the germinal layer producing atrophy, 

are not some reproduced?" 

* * * * * * * * 

F. W. Aston. D. Sc, F. R. S. Atoms and Isotopes. The May Lecture 

to the Institute of Metals. London. Eng.. delivered June 4, 1924. 

The following summarizes Dr. Aston's lecture:

222 R A D I U M 

That matter is discontinuous and consists of discrete particles is now 

an accepted fact, though it is not obvious to the senses on account of 

the extreme smallness of the particles. Some idea of their size and 

numbers can be gained by the hypothetical division of a piece of matter 

into smaller and smaller pieces until the ultimate atom is reached. For 

this purpose a model decimetre cube of lead is taken and cut in such a 

manner that after each operation a similar cube of half the linear dimensions 

and one-eighth the volume results. Modern science shows 

that this operation can be repeated no less than 28 times before the ultimate 

atom of lead is reached, and that the number of atoms in the original 

cube is so enormous that placed in a string as close together as they 

are in the lead they would extend over six million million miles. Again, 

if an ordinary evacuated electric light bulb were pierced with an aperture 

such that one million molecules of the air entered per second, the pressure 

in the bulb would not rise to that of the air outside for a hundred 

million years. 

Dalton in his atomic theory postulated that "Atoms of the same 

element are similar to one another and equal in weight." a simple and 

definite conception which has been of inestimable value in the development 

of chemistry. A little later Prout suggested that the atoms of 

all elements were made of atoms of a primordial substance which he 

endeavored to identify with hydrogen. If Dalton and Prout were both 

right the chemical atomic weights should all be whole numbers, hydrogen 

being unity. Chemical evidence was against this, and Prout's theory 

was abandoned for the time. We cannot test the truth of Dalton's postulate 

by chemical methods since these require countless myriads of atoms, 

and. therefore, only give a mean result. 

The weights ot individual atoms can be investigated by means of 

the analysis of positive rays and the early experiments of Sir J. J. 

Thomson suggested that one element neon—had atoms of two different 

weights but the method of analysis was not accurate enough to prove 

the point. The requisite accuracy has been obtained by means of an 

instrument called the ""mass-spectrograph." In this the charged atoms 

in a beam of positive ray* are sorted out according to their weight by 

means of magnetic and electric fields so that they strike a photographic 

plate at different points. V mixture of atoms of different weights will 

give a series of focussed lines called a mass spectrum and the relative 

weights of the atoms can be calculated from the position of their lines 

to an accuracy of 1 in 1.000. 

As the result of this analysis it has been shown that neon (Atomic 

Weight 20.20) is a mixture of atoms of weights 20 and 22. these constituents 

have identical chemical properties and are called "isotopes.' 

Chlorine (At. Wt. 35.46) is a mixture of isotopic atoms of weights 35 

and 37. About half the elements so far analyzed turn out to be mixtures 

and some are very complex. Thus krypton has six, tin at least 

seven, and xenon possibly nine constituent isotopes. Recently by means 

of the method of "accelerated anode rays" the work has been extended 

to many metals and already some fifty of the eighty-four known nonradioactive 

elements have been analyzed into their constituent isotopes 

or shown to be "simple." 

Most important of all is the fact arising out of these measurements 

that all true weights of atoms can be expressed as whole numbers to a 

very high degree of accuracy. This remarkable generalization known 

as the "whole number rule" has removed the last obstacle in the way

R a d i u m 223 

of a simple unitary theory of matter. We now know that Nature u 

the same bricks in the construction of the atoms of all elements, and 

that these standard bricks are the primordial atoms of positive and negative 

electricity, protons and electrons. 

According to the nucleus theory of the atom first suggested by Sir 

Ernest Rutherford, which has led to such wonderful advances recently 

in the hands of Professor Bohr, all the protons which are much heavier 

than electrons, are packed with some of the electrons in a central 

nucleus or sun round which circulate the remaining electrons like planets 

in orbits. The protons and electrons are so minute compared with the 

atom itself that it is difficult to indicate their numerical relations. If we 

were to construct a scale model of the atom as big as the dome of St. 

Paul's we should have some difficulty in seeing the electrons, which 

would be little larger than pin heads, while the protons would escape 

notice altogether as dust particles invisible to the unaided eye. Experimental 

evidence leaves us no escape from the astounding conclusion 

that the atom of matter, as a structure, is empty, empty as the solar 

system, and that what we measure as its spherical boundary really only 

represents the limiting orbits of its outermost electrons. 

All the chemical and spectroscopic properties of an atom depend 

on the movements of its planetary electrons, and these in their turn 

depend on the positive electric charge on the central nucleus. In the 

case of isotopic atoms the net positive charge on their nuclei is the same. 

giving identical chemical properties, but the total number of protons 

is different, giving different atomic weights. 

Transmutation of one clement to another can only be achieved by 

the disruption of the nucleus. This requires enormous forces, but by 

the bombardment of atoms by swift alpha particles Rutherford has succeeded 

in breaking up the nuclei of several of the lighter elements. This 

transmutation only takes place as the result of a direct hit on the nucleus. 

the chance of which is only one in many millions. The quantity of matter 

is indeed almost inconceivably small, but it is the first step towards 

the release and control of the so-called "atomic energy." We know now 

with certainty that four neutral hydrogen atoms weigh appreciably more 

than one neutral helium atom, though they contain the same units, 4 

protons and 4 electrons. If we could transmute hydrogen into helium 

matter would, therefore, be destroyed and a prodigious quantity of energy 

would be liberated. 'The transmutation of the hydrogen contained 

in one pint of water into helium would set free sufficient energy to propel 

ihe Maurctania across the Atlantic and back at full speed. With such 

vast stores of energy at our disposal there would be literally no limit 

to the material achievements of the human race. 

G. P. Baxter. Thirtieth Annual Report of the Committee on 

Atomic Weights. J. Am. Chem. Soc. xlv, 523-533, March. 1924. "The 

first report of the new International Committee on Elements gives tables 

of isotopes, and of radioactive elements and their constants." (J. Am. 

Chem. Soc. xlv, 867, 1923, reprinted in Radium, ii, N. S., Oct. 1923.) 

Of interest to students of radioactivity are the data on the atomic weight 

of the radioactive lead from the uraninite of the Belgian Congo, and 

also the more recent data regarding isotopes. "Radioactive Lead.— 

Honigschmid and Birckenbach and Richards and Putzeys have determined 

the atomic weight of lead obtained from minerals associated with

224 Radium 

the deposit of uraninite in the Belgian Congo. Weights are corrected 

to vacuum. CI = 35.458. 

Atomic Weight of Lead 

Honigschmid and Birckcnbach 

Congo Lead 

Wt.of PbCl- 

G. 

'>-53

A QUARTERLY JOURNAL DEVOTED TO THE CHEMISTRY, PHYSICS AND 

THERAPEUTICS OF RADIUM AND RADIOACTIVE SUBSTANCES 


Edited by Charles H. Viol, Ph, Q., and William H. Cameron. M. D., with the assis 

collaborators working in the fieldsol Radiochemistry. Radioactivity and Radiumtherapy. 

Address all communications to the Editors, Forbes and Meyran Avenues. 



VOL. 3, New Series JANUARY, 1925 No. 4 

THE ERYTHEMA DOSE OF 

RADIUM* 

By W. H. Gi'y, M.D.. and F. M. Jacob, M. D., Pittsburgh. 

A perusal of the literature reveals a tendency by most authors to 

utilize the term "erythema dose" as a quantitative una in radium dosage. 

Such terminology is convenient but lacks definition, as evidenced by 

the wide range of dosage that is interpreted as the erythema dose. 

Standardization is rendered difficult, as the skin of different parts of 

the body and of different persons reacts differently to equivalent applications; 

furthermore, different tyjies of applicators entailing variations 

in the shape and area of the source of radiation, as well as variations 

in the quantity of radium used and the type and quantity of filtration. 

complicate the problem. Using tubes, plaques and needles a scries of 

experiments were performed during several years in an attempt to gain 

some definite information bearing on the erythema dose. As will be 

mentioned later, the difficulties in estimating this unit on skin surfaces 

are almost insurmountable; so that our work has been, after many trials. 

practically confined to the scalp, producing temporary and permanent 

epilation comparable to the Holzknecht roentgen-ray unit at skin distance 

"(temporary epilation) and the erythema dose (permanent epilation). 

In the course of our work, many interesting phenomena were 

noticed that were entirely foreign to the main issue, which will be detailed 

below. 

bi:ta ray applications 

A, Unfiltered Plaque Applications on the Skin.—From the standpoint 

of the dermatologist, an important technic is the method of obtaining 

beta ray by the use of bare or lightly screened plaques. It will l>e 

noted that different plaques of equivalent size and radium content varied 

•Reprinted by permission (mm Iho Arrhlres of I>erni«lolopy and Sy philology, Ix, 73-80, January. 

1924. Read before (he Section on Dermatology and Syphllohrgy al Ihe Sereniy-Konrlh 

Annual SeMlon of the American Medical As.focl.itIon, San Francisco, Juno, 1923.

226 R A D I U M 

~ V 1 

Fig. 1.—A, Ino-ltour application of ;>P mg. of radium fully screened after two weeks: B, 

:ifier ineniy-one days, showing ihciiia »nt* epilation without erythema:

R a d i u m 227 

in their beta ray activity, as evidenced by variations in the degree of 

reaction when all other factors were equal. This is probably accounted 

for by variations in the thickness and structure of the holding substance 

In unscreened applications, which are necessarily short to obtain a good 

cosmetic result, the amount of gamma ray delivered is almost negligible. 

Simple experiments along this line confirm clinical impressions that reactions 

conform closely in outline to the shape of the applicator, the 

degree of reaction being, within certain limits, in proportion to the 

milligram hour dosage. In these experiments, half and full strength 

plaques were used, and in unfiltered applications they were in direct 

contact with the skin. Parallel rows of unscreened plaque applications 

and those in which i mm. of rubber was used as screening demonstrated. 

especially in blond persons, that a thin non-metallic filter is indicated 

in all surface applications. Reactions under the metallic edges of naked 

applicators were intensified and in longer applications had a tendency 

to produce a line of telangiectasia, depigmentation and atrophy. With 

unscreened half strength plaques, applications as short as one minute 

produced erythema, which, however, was transitory and produced no 

Fig, 2,- —Timjmrary epilation nith gamma ray, 

permanent change. Beginning at six minutes, a primary hyperpigmentation 

and later atrophy with depigmentation was produced only along 

the lines corresponding to the metallic edge of the applicator. This may 

be explained by the well-known fact that a thin layer of some nonmetallic 

substance, such as rubber, will entirely remove the secondary 

rays that are formed when metallic substances are subjected to radiation. 

Interposition of 1 mm. of rubber between plaques and skin surfaces 

prevented aggravated marginal reactions. Further reference in this paper 

lo unscreened applications will be understood to entail the use of a thin 

nonmetallic screen. All applications of half strength plaques from five 

lo thirty minutes produced ervthema of corresponding graded intensity. 

Thirty minute applications of half strength applicators produced in most 

instances heavy reactions with depigmentation, telangiectasia and atrophy. 

This was particularly true in cases of tender surfaces of blond skins. 

A fifteen minute application of a full strength plaque eight years ago on 

a tender skin shows well defined atrophy antl telangiectasia. Therefore. 

it is suggested that half strength plaques should not be applied for longer 

than one half hour when good cosmetic results arc paramount. One need, 

however, only refer to one's clinical experience to demonstrate that

228 R A D I U M 

much longer applications may be made when the plaque is placed on 

pathologic tissue whose destruction is of vital importance. It will be 

seen that the erythema dose of beta ray can with difficulty be standardized. 

B. Unscreened Plaq.tc Applications on the Scalp.—Half strength 

flat plaque applications were made to the scalp to determine the time 

required to produce temporary and permanent epilations. As was expected, 

light haired persons were found to be more susceptible; but furiher 

variation in different scalps occurred that could not be accounted for. 

ihus making our results rather indefinite. \\ c soon learned, however, 

that an erythema produced with beta rays on the scalp was not necessarily 

followed by even temporary epilation. Ten minute applications 

of half strength flat applicators produced definite erythema, but did not 

cause the hair to fall. Fifteen minute applications produced erythema 

and temporary epilation. A half hour application produced a heavvrcaction 

with exudation, and resulted in permanent epilation. Thus. 

while the erythema dose of beta rays proves to be a variable amount. 

the experimental work is deemed worth while because it demonstrates 

the necessity for close attention to certain technical details. 

CAM MA RAY APPLICATIONS 

.,'. Fdtercd Applications tn Skin Surfaces.—For the sake of uniformity 

these experiments were performed with equivalent filtration,the 

Fig. 3. -Pcunanent cpiUt'en onr-half hour, CBV-hllf strength plaque. 

amount being that necessary to absorb practically all beta rays. Tubes 

were screened with 0.5 mm of silver. 1 mm. of bras*, and 1 mm. of 

uibber. Interposed between plaque* and the surface were 1.2 mm. of 

brass and 1 mm. of rubber. Thus the minimum focal distance was nearly 

ihe same. \\ e attempted to ascertain the ''erythema dose" of gamma 

rays on the glabrous skin surface-, but we were obliged to abandon this 

project because of the wide divergence of results in checking experiments 

and lack of clean cut reactions with varying dosage. A tube conlaining 

50 mg. of radium clement was applied to the skin of the back. 

•ising a focal distance of 5 mm for two. three and four hours, respectively. 

This was paralleled on either side by applications of 23 mg. and 

100 mg.. respectively, the lime being varied to obtain equivalent dosage. 

The degree of reaction corresponded fairly closely, there being some 

difference* due probably to the method of grouping the element in the 

lube*; but the reactions were not sufficiently clean cut to enable us to 

draw definite conclusions as to minimum dosage to produce erythema

R a d i u m 229 

or the gradation of reaction corresponding with increased dosage. We 

were able to demonstrate to our own satisfaction that an erythema may 

be produced by gamma ray applications, and that a considerable increase 

in dosage does not materially increase the degree of primary reaction. 

We were unable to determine what degree of reaction should be called 

an erythema. Variations m skin texture and pigmentation added to our 

difficulties. Maximum dosage was also difficult to determine because 

one's idea of dosage limitations necessarily vary with the type and location 

of the lesion. A second degree bum may be expected from an application 

of 200 mg. hours at 2.5 mm. on the average skin of the covered 

parts of the body. Where cosmetic results are of importance, the single 

application had best be kept below 150 mg. hours at the same distance, 

dosage at greater distances being governed by the law of inverse ratio 

of proportion. Greater dosage may of course be indicated by the necessity 

for complete destruction of malignant tissue. By increasing the focal 

distance and changing the time according to the law of inverse ratio of 

proportion, other factors being equal, we obtained practically the same 

degree of reaction, but of greater area and more uniformity. We believe 

that unless the pathologic condition is of limited extent, applications 

had best he made with, for instance, a focal distance of 10 instead 

of 5 mm. This advantage is enhanced by the fact that as the focal dis- 

Flt. *.—Temporary epilation—four hours. 55 mg., fully screened, 5 mm. distance. 

tance increases the disproportion between surface and depth dosage decreases. 

GAMMA KAY APPLICATIONS TO THK SCALP 

The Plaque.—The application of 10 mg. of radium element to the 

scalp in the form of half strength fiat applicators filtering with 1.2 mm. 

brass and approximately 1 mm. rubber for four hours did not produce 

an erythema, but resulted in an epilation in twenty-one days. Regrowth 

was complete two months later. This was the minimum filtered application 

to produce epilation. Similar applications for six, seven, eight and 

nine hours produced epilation without erythema, and as the length of 

the application increased regrowth was more lardy, some occurring as 

late as the fifth month after epilation. The eight and nine hour applications 

resulted in a depilalion that did not entirely regrow. A ten hour 

application resulted in a faint erythema and practically complete permanent 

depilation. 

Tubes: To obtain further information regarding the erythema dose 

of the gamma ray on the scalp. 50 mg. of radium was incased in 0.5 mm. 

of silver, 1 mm. of brass and 1 mm. of rubber, and this was applied

230 R a d i u m 

directly to the scalp for varying lengths of time. A gradual series of 

reactions from delayed temporary epilation to permanent epilation with 

erythema were obtained, the severity of the reaction depending on the 

length of :imc that the radium wa* applied. Again we noted the hypersusceptibility 

of the blondes. A two hour application resulted in a sharply 

defined reaction. An area of erythema 6 mm. in diameter appeared, in 

which depilation occurred on the eleventh day. The area of depilation 

spread slowly until on (he twenty-first day it was complete and measured 

21 mm. in diameter. This epilation was temporary with the exception 

of the area of the erythema. It will be noted that with equivalent 

milligram hour dosage, reactions were much less with the plaque 

than with the tube, but .were of correspondingly greater extent 

Having approximated an erythema dose of gamma rays comparable 

to the erythema dose skin distance (i!j Holzknecht units) of roentgen 

rays, we made several experiments varying the distance and obtaining 

equivalent dosage according to the law of inverse ratio of proportion, 

producing temporary epilation, and we quickly learned that the effect of 

gamma rays of radium is not exactly comparable to unfiltered roentgen 

rays. In the case of the latter, the margin of safety is about 25 per 

cent; with radium it is much greater, at least twice as great. This suggests 

a field of usefulne** in scalp depilation for such conditions as tinea 

and favus. 

Fig. 5.—Temporary epilation—two ho-ns.3l» mg.. f.llj screened, 5 mm. distance. 

KADIl'.Vl NF.ED'ES 

With radium applied by the subcutaneous melhod the skin erythema 

dose is, obviously, not of great importance. The method is principally 

used because heavy dosage may be administered directlv to pathologic 

tissues, without producing surface reactions. In surface work dosage 

is limited by skin tolerance; many times this amount of radiation mav 

be administered advantageously by ihe insertion of radium directlv into 

diseased tissue. If one places needles approximately 15 mm. apart and 

is careful that the radium is a corresponding distance beneath the skin. 

ihe possibility of >crious skin reactions may \*c disregarded with the 

dosage ordinarily required. When dosage is "heavy, tissue necrosis occasionally 

occurs, but this depends not on skin tolerance, but on the subcutaneous 

tissues. Xeedlt* containing 10 mg. of radium element may

R a d i u m 231 

be left in malignant tissue as long as from eighteen to twenty-four hours. 

but had better not remain longer than from three to four hours at the 

edge of such a lesion. It is to be remembered in estimating dosage when 

needles are used that the entire energy output is utilized, and that therefore 

a 10 mg needle for one hour may be credited with approximately 

40 mg. hours as compared to surface application*. 

END RESULTS 

In no case in winch an erythema was not produced did atrophy or 

telangiectasia result. Furthermore, not all applications which produced 

erythema resulted in these changes. A fair percentage of "erythema 

dose,"' however, or larger applications of gamma rays did result in atrophy 

and telangiectasia. We were with difficulty able to foretell the endresult 

of applications, knowing only that nonpigmented skin was likely 

lo react unfavorably. Seemingly trivial erythema was at times followed 

by extensive ectasia and atrophic scarring, and. on the other hand, strong 

reactions were at times not produccive of undesirable end-results. The 

view that radium reactions may to a great extent be disregarded, we 

Fig. 6.—.1. practically WUlraleal reactionswith varying dosage of gamma raj : fi.end result. 

believe to be enoneous. However, we have gained the impression thai 

erythemas produced by gamma rays of radium are less frequently followed 

by telangiectasia and atrophy than ihose produced by presumably 

similar quantities of roentgen rays. If this is true, it can probably best 

be explained on the basis of relatively greater absorption by the skin of 

roentgen rays than of gamma rays of radium. Frythemas produced by 

beta rays van- materially in their end-results. At times strong reactions 

with exudation and crust formation leave a practically unmarked skin; 

in other instances, mild erythemas produced bv comparatively short 

applications produce unsightly end-result*. We would urge, therefore. 

that caution be used in applying radium in any form to or through a skin 

surface to the extent of an erythema lest undesirable end-results eclipse 

the unquestionably excellent results which may be obtained in selected 

cases with smaller dosage. 

7026 Jenkins Arcade.

232 R a d i u m 

treatment of carcinoma of the conjunc 

TIVA WiTH RADIUM * 

By Frederick XI. Johxson. M.B.. Tor. 

Surgeon in Charge of Radium De|>artment. Steiner Memorial Clini 

Atlanta. C.a. Formerly of the General Radium Service 

Memorial Hospital fcr Cancer and Allied Diseases. 

Xew York. 

The encouraging results that have been obtained at the Memorial 

Hospital in the treatment Ot a small series of conjunctival carcinomas 

has prompted the writer to review the disease and to emphasize the 

advantage of radium therapy. 

Wickham and Degrais' were probably the first to use radium as a 

curative agent in this tvpe of growth. The pioneer in America is Collins.* 

who in 10,15 treated one case with success. Wessely.' in 1919, 

obtained a clinical regression with mesothorium. and New and Benedict,* 

in 1020, reported two cases of epithelioma of the limbus which were controlled 

satisfactorily. Albers-Schonherg/ in 1020. as others had done 

before, used a physical agent in the form of X-ray. With these exceptions 

the treatment of choice has been local excision of the growth with 

basal cauterizaion, and in advanced cases, enucleation or exenteration. 

An essential aid to the radiation therapv of any tumor is a correct 

appreciation of the extent oi involvement, by means of inspection, palpation 

or other method of investigation. In conjunctival carcinoma, 

such an estimation i* comparatively easy. Most cases, when first seen. 

are obviously limited to the tissue of origin, antl only in the late stages 

is the anterior chamber penetraled. De Schweinitz and Shumway* stated 

that perforation has occurred in $7.6 per cent of eyes removed at operation. 

However, this proportion i< relatively too high, because it includes 

only the very advanced neoplasm* which demanded radical treatment. 

By other*, perforation is considered a rare occurrence and confined 

to matured and badly treated case*. (Axenfeld.: Wintersteiner,8 

Cirecft'.') It is evident, therefore, that the cornea and sclera offer a considerable 

resistance to invasion, especially if Bowman's membrane is uninjured 

by surgical trauma. 

There is uniform agreement on the frequency with which the 

growth arises in ihe very vascular limbus conjunctivae (Saemisch,1* 

Hcilbrun"V and more frequently in the nasal, than in the temporal portion 

(I.icsko'-). It is through ihe limbus. that penetration of the globe 

most commonly commences. The oldest portion of the tumor is at this 

point, antl the lymphatic channels surrounding the anterior ciliary vessels 

are natural paths of communication. 

CLINICAL DIAGNOSIS 

The recognition of the disease usually offers little difficulty, although 

Lagrange1' in a historical note, refers to the fact that for many years 

there was confusion with analogous lesions, and terms such as "vicious 

fungus" antl "excrescences of flesh'" were used. He has described a very 

early case, that presented itself as a minute ulcerated phlyctenule which, 

'Reprinted by rerm!«*i«n (n>ni A met lean lounial or npluhalmoloey. Ser. 3. III. ."89-59S. 

Aiipiist. 1M4, F("iii Ihe Grncral K idiom Serrlcv ot the Memorial Hospital. Xew York Cliy.

R a d i u m 233 

during repeated cauterization, grew slowly lo assume its mature character. 

A fully developed lesion may be no.larger than a small pea. and 

is always situated on the external surface of the membrane (Panas1*). 

During its further growth, which is usually a surface extension, it may 

attain a size sufficient to push the eyelids far apart, and appear between. 

as a greyish red. finely nodular mass, often blackened bv hemorrhage. 

With large cancers, Ihe surface is always much greater than the base. 

Many are therefore distinctly pedunculated, and overhang a considerable 

area of sclera and cornea. Ulceration may develop; a thin slough then 

covers the surface. Ordinarily the growth is single, but distinct lobes 

may he distinguished. Slight bloody discharges are caused by irritation. 

True hemorrhages are rare. 

As has been mentioned, the tumor more often arises from the limbus 

than from any other portion of the globe. A few spring from the 

palpebral conjunctiva, and secondarily spread to the sclera. A peribulbar 

type is recognized, which extend* completely around the cornea in an 

annular fashion (Ucydcr1*). Visual disturbance* mechanically appear 

when the pupillary area is covered. 

Lagrange13 has studied in detail the direction of cellular growth 

during the process of perforation. He describes in classical language 

the advance of cell columns, through lymphatic channels. Schlemm's 

canal is the objective. When this is occupied, younger and more vigorous 

cells enter the anterior chamber and, with all resistance killed, involve 

finallyintrinsic and extrinsic orbital structures. Saemisch10 makes 

the interesting observation, which is not unknown in other fields of 

oncology, that a preliminary inflammation in the uveal tract may precede 

actual tumor ingrowth. 

The occurrence of metastatic deposits is infrequent. Profeta10 has 

tabulated 51 cases, in 3 of which regional lymph glands were involved, 

5.5 per cent. The preauricular glands are first affected, and the submaxillary 

group later. (Parsons'1). 

The rale of growth of carcinoma of ihe conjunctiva is by no means 

uniform and constant. For a long period the neoplasm may barely show 

an increase in volume, and then suddenly, often under stress of trauma. 

flare up and destroy at a very rapid rate. 

MICROSCOPIC DIAGNOSIS 

During its passage from the free edge of the eyelid to the cornea. 

ihe character of the conjunctival epithelium changes in different parts 

of the sac. Thus at the border of the lids, and for a few millimeters 

over the tarsi, it resembles ihe epidermis in being stratified squamous. 

Towards the fornices. and passing on to the sclera, a somewhat altered 

stratified type is found, consisting of four or five layers of cells, the 

deeper of which are small and spheroidal, and the superficial elongated 

or conical. The latter, however, may be somewhat flattened, in which 

case, they resemble closely stratified squamous epithelium. Near the 

margin of the cornea, another transformation occurs, and the superficial 

cells become progressively flattened,thereby conforming to the stratified 

squamous type, which is regularly found close to the palpebral margin. 

It is this normal variation that produces confusion in the terminology 

of the epithelial tumors arising in the conjunctiva. For the sake of 

clarity and uniformity, F.wingV* classification of epidermoid carcinoma 

of the skin might welt be used. 

The following groups would he recognized:

234 R a d i u m 

i. Acanthoma—characterized by the presence of adult squamous 

cells, pearl formation and cornification. Such cases are reported in 

detail by Saemisch"' and de Sihweinitz." A pavement cell epithelioma 

is described by Lagrange." in which the cells are large and grouped in 

columns, with no pearl formation. It i* an acanthoma with recessive 

adult characters. 

There are two main types of acanthoma which give very* different 

clinical pictures. 

fa) For many, a distinct papillomatous stage is recognized. (Freytag.IQ 

Rutschmann,-*0 Pasetti-'). They are not ulcerated originally, and 

advance slowly, but influenced bv irritation the growth is active and involvement 

of the layers of sclera and cornea occurs. Such papillary 

growths may be multiple (Luedde-r). Continori describes two types. 

depending on the predominance of epithelial, or connective tissue elements. 

As instances of the clinically benign course of papillary tumors, 

Licsko" cites three cases in which the growth had been present for 10 

years, and in one instance for 32 year*. Cases Xos. 1, 3. 5 and 7 of our 

series were clinically 01 this type. 

(h) Other acanthomas grow rapidly, ulcerate early, and have no 

dislinct papillary stage. They recur promptly after local removal, and 

metastases may supervene. The entire loss of adult epithelial character 

may give lo the tumor an indifferent or round cell appearance, which 

leads to the diagnosis of sarcoma (Saemisch'0). Cases Xos. 2, 4 and 6 

belr.ng lo *his group. 

a. Basal Cell Carcinoma. This is undoubtedly a rare tumor, and 

cannot be distinguished clinically from acanthoma. Cases have been 

reported by Krompccher*' and Clover." Licsko.13 who has studied this 

type, states that the histology is not different from basal cell carcinoma 

elsewhere. They recur frequently after operation, but as an evidence 

of their relative benignity more permanent cures are obtained with this 

type than with acanthoma. An adenoid type i* reported by Bohm.-* and 

probably arose from ihe glands of Krause or Henle. close to the fornix. 

Our records contain no cases of this variety of tumor. 

ETIOLOGY 

There seems to be no great difference in the incidence of the disease 

between the sexes. It is an affliction that seldom appears before 

the fifth decade, although Heilbnuv1 cites a case in a child of five following 

a lime burn, and Greeff?; in a child of six as a sequel of xeroderma 

pigmentosum. In seven cases collected by Rogman.1- the ages ranged 

from 20 months to 37 years. The youngest case in our series is a girl 

bf 13 years, and the oldest a woman of 84 year*. 

Many possible etiologic factors have been described—a pterygium 

i Wiener and Alt80), a nevu> 'Offret50'*, a dermoid (Duclos"), an inflammatory 

epithelial overgrowth (Hohne3-). A contact cancer from 

the lower lid has been noted on the cornea (Fymann13). One of our 

cases, Xo. 7. gave a definite history of injury by a particle of steel J 

vears before the development of a tumor. 

Saemisch'0 enumerate* three reasons why the limbus is the site of 

predilection: 

1. Fpithelial transformation occurs at this point. 

». A liberal blood supply.

R a d i u m 235 

3. The presence of occasional normal irregularities in the development 

of the epithelial layer in the form of invaginated processes. 

TREATMENT 

For the treatment of lesions of the conjunctiva, we have taken advantage 

of the large amount of emanation that is produced daily at the 

hospital, about 600 millicuries. Ordinarily it is collected in capillary 

glass tubes which are used in many ways. But once in three weeks, a 

day's supply is gathered in a small glass bulb-* measuring about 5 millimeters 

in diameter. This is sealed with paraffin in a steel cone, that 

surrounds the bulb on all sides excepl one. A flexible wire handle is 

attached to facilitate manipulation. One side of the bulb, therefore. 

emits unfiltered rays, which are made effective by simply holding the 

applicator against the lesion. 

Dosage is entirely regulated by individual cases. As a rule, 250 

millicurie minutes will cause complete regression of tumor tissue 3 millimeters 

thick, over an area of 0.7 square centimeters. It has been our 

custom to treat about 4 areas at one time. Three weeks are allowed 

to elapse before completing the radiation. The first noticeable effect 

occurs in about 8 days, with the appearance of a slight conjunctival inflammation. 

The growth gradually dissipates in a very remarkable 

fashion, and in 3 to 4 weeks has completely regressed. There is no 

more convincing example of the selective action of radium for certain 

types of tumor formation. If the dosage has been correctly estimated, 

there is no gross tissue destruction, and consequently no subsequent 

scarring. In none of our cases have* metastases occurred, and we have 

not considered the prophylactic radiation of gland bearing areas. It 

would appear that the production of metastatic foci is in a large measure 

dependent upon curettage, cauterization, or other forms of surgical 

injury. It is undoubtedly an embolic process, and such operations would 

favor the loosening of malignant cells. The bulb treatment is a gentle 

process, and is so free of trauma, that the preliminary use of cocaine is 

unnecessary. 

CASE RETORTS 

Case i. Female, age 25. was referred for treatment on September 

19, 1917. When 13 years old. a red spot appeared on the eyeball and 

remained stationary for ten years. It then grew quite rapidly and 2 

months prior to admission was removed surgically, and proved to be 

acanthoma. 

At the time of treatment, the recurrence measured ixjtf cm., and 

was elevated 2 millimeters. It was pale pink in color, finely granular 

and was adherent at the limbus. There appeared to be no intraorbital 

extension. 

Treatment. Two silver filteredtubes were held over the lesion. 1 

millimeter distant, on four occasions, during a period of 6 months. The 

dosage averaged 35 millicurie hours each treatment. 

Comment. This was the first case of this type treated at the Memorial 

Hospital with radium. The bulb was not yet devised. Accuracy 

of application was here impossible, and complete regression was obtained 

only after 6 months. No scarring was produced, however, and 

at the present time, after an interval of 6 years, there is no recurrence. 

The advantage gained by the use of the bulb is two-fold: 1. It is 

a means of verv accurate application with a short exposure period. 2.

236 R a d i u m 

I he rays are unfiltered. and therefore *oft beams give the desired superficial 

effect before a harmful quantity of hard rays enter the orbit. The 

truth of the latter statement is now becoming apparent. Within the last 

few weeks we have learned that ihe lens of the radiated eye in case 

Xo. i is developing an opacity,* which is so unlike an ordinary' cataract, 

that we must conclude that the amount of ]>enetrating beta and gamma 

rays is an important ctiologic factor. Case Xo. 2 is additional evidence. 

Dr. Arnold Knapp, consulting ophthalmologist, is now investigating this 

problem, in order to definitely prove or disprove the relation. 

Case Xo. 2. Male, age 73. was referred to the -clinic June 23rd, 

1920. for a growth of the conjunctiva that commenced as a pink nodule 

about one year before. Dr. Knapp examined the case and considered 

it acanthoma. The tumor measured i!jxi cm., and covered the medial 

half of the cornea, extending for about 1 cm. on to the sclera. It was 

a firm consistence, greyish-red in color, slightly ulcerated and fixed to 

the limbic area but not involving the anterior chamber. Vision was partially 

obstructed. 

Treatment. Two silver tubes were placed 1 mm. from the lesion. 

A dosage of 03 millicurie hours was given. Regression was complete in 

six week*. 

Comment. Two years later there was no evidence of tumor. However. 

Dr. Knapp examined the patient at this time and discovered opacities 

in the lens and a partial optic atrophy. In six months, the vision 

was entirely destroyed in this eye by a well developed glaucoma, the 

pain of which was relieved by an operation that had no effect on vision. 

Case Xo. 3. Male, age 39. was first observed on May 28th. 1920. 

His previous history was no; significant. The eye lesion commenced 

five years before, and grew very slowly. Six weeks prior to coming 

to the hospital an operation was i>crformed. There was a prompt recurrence 

in ihe scar. The lesion measured 1x0.5 cm*., and overlapped the 

limbus on the lateral half of the eye. It was papillary in type and not 

ulcerated. An examination of ihe tissue removed at operation, showed a 

papillary acanthoma. 

Treatment. One silver tube was applied for a dosage of 50 millicurie 

hours. Following this ihe patient was lost lo the clinic for nearly 

2 years. When next seen, on April 25th. 1022, there was a small recurrence 

on the cornea, close to the site of the original tumor. This was 

treated on two occasions with the unfiltered bulb, causing a prompt regression 

which has lasted for 1 2 '3 years. Vision is perfect. 

Comment. In spite of careful application of the silver tube, sufficient 

accuracy was not obtained to produce a permanent regresison. This 

difficulty has been obviated by the introduction of the bulb. 

Case Xo. 4. Male, age 62. About one year before applying for 

treatment, a pink growth appeared on the eye. This grew so rapidly 

that vision was gone completely in about eight months. Then several 

operation* were performed, but all were unsuccessful. Microscopic 

diagnosis was acanthoma. Patient now (July 7th, 1921) presents a 

greyish-white finely nodular tumor, measuring J< cm. in diameter, and 

•Bjce. "orkln? 'n ihe Memorial Hospital researchlaboratory, has reported on

R a d i u m 237 

situated at the limbus, just medial to the cornea. There is no evidence 

of intraocular growth. 

Treatment. Using the unfiltered bulb a dose of 324 millicuries 

minutes was given over each of two areas. In six weeks the growth 

had disappeared, leaving a slight scar at the site of the previous operations. 

This patient has remained well for a period of 2j4 years. 

CASE No. 5. Male, age 40. came for treatment August 16th. 1922, 

stating that a red spot had been present on the eve, as long as he was 

able to remember. Two unsuccessful operations were performed seven 

years ago. At the time of admission, the lesion was 1x2 cms. in size, 

and was placed on the sclera o( the upper inner quadrant. It was firm, 

red and nodular, and gave off a blood tinged discharge. The cornea 

was encroached upon for a distance of 3 millimeters. This tumor was 

slightly pigmented in one area. The anterior chamber was not involved. 

Biopsy was performed before coming to the clinic. Dr. Fwing examined 

a section, and pronounced it acanthoma. 

Treatment. The bulb was used on two occasions. Each treatment 

consisted of 400 millicurie minutes divided over two areas. There was 

complete regression five weeks after the second treatment. Patient has 

remained clinically well for i)/> years. 

Case Xo. 6. Female, age 85, came to the hospital on May 1st. 1923. 

because of a growrth on the conjunctiva of the right eye. This had commenced 

nine months before, growing slowly at first, but lately has enlarged 

rapidly with the apriea ranee of superficial ulceration. The tumor 

measured 2x1 cms., was situated on the sclera just lateral to the cornea. 

It was firm and not definitely adherent. On May 4th four areas were 

treated with a total dose of 800 millicurie minutes. It was planned to 

complete the treatment in three weeks. Unfortunately, the patient at 

this stage went to the clinic of an Ophthalmic Hospital, where she was 

admitted, and on May 17th the eye was removed. On October 27th. she 

was again admitted because of pain in the eye socket. It was then found 

that there was a recurrence as large as a small hazelnut, involving the 

soft tissue of the orbit. On October 30th. an exenteration was performed, 

and a week later she was referred to the Memorial Hospital for 

postoperative radiation. Her recent progress has been entirely satisfactory. 

The tissue removed at the second operation contained acanthoma. 

Comment. In view of the fact that this was originally a case early 

in growth, and favorable in expected radium response, it is a matter of 

great regret that the Eye Hospital surgeons saw fit to operate upon one 

so advanced in years. In so doing, we believe that the growth was 

mechanically spread to the orbital structures. The difficulties of successful 

radiation, thereby, have been greatly increased. 

Case No. 7. Male, age 47, came under observation on August 15th. 

1923. Four years before, while at work, a fragment of steel entered 

the right eye. The foreign body was easily removed, and no unfavorable 

symptoms developed^ About 2y2 years later, a growth appeared 

on the conjunctiva, which has gradually increased, causing a decided 

interference with vision. Examination showed a red. granular, flat. 

slightly ulcerated neoplasm involving the entire lateral half of the sclera. 

and growing on the cornea for a distance of 5 millimeters. Much of 

the tumor was covered by the upper eyelid, and was freely movable 

with the conjunctiva. The anterior chamber was not invaded. A minute

238 Radium 

section of tissue removed at this lime was reported as papillary epidermoid 

carcinoma (acanthoma). The lesion was treated in two stages 

with the unfiltered bulb, and on X'ovember 21st, just three weeks after 

the last radiation, there was no clinical ev idence of disease. On January 

4th. 1924. we noted the absence of any gross scar tissue. The sight is 

now normal. 

Comment. Most writers are agreed that in spite of the relatively 

i>enign course of untreated cases, there are distressing recurrences in 

countless patients after attempted surgical interference. If the cases 

were carefully observed during a long period after operation, the numbers 

would still further be increased, because most of the accounts are 

published a few days after healing of the wound. According to Licsko'*, 

recurrences appear usually within one to ten months: the earliest was 

noted twelve days, and the latest seven years, after operation. His morlaliiy 

in 7\ patients was 27 per cent. 

It is the opinion of only those who helieve that a carcinoma cannot 

reach to the deep part* that prognosis is good. Partisans of an optimistic 

prognosis expose themselves to an aftermath of regrets (Lagrange1"). 

Recurrence occurs with extraordinary regularity. (Saemisch'0). 

Such statements coupled with individual case reports lead to one 

conclusion; that a slow growing, well restrained tumor is practically 

never removed by simple ablation, which is performed one, two. or even 

ihree times for prompt recurrences: that such operations induce with 

great constancy, orbital penetration, which necessitates more extensive 

operation*, which in many instances fail to preserve life. The cases 

of this series are no exception. They demonstrate only too clearly the 

unfavorable results of operations that are practiced. The contrast with 

what we have accomplished with radium therapy is unmistakable. 

It wa* fortunate that intraorbital extension in our cases was the 

exception and not the rule. It is inconceivable, that radiation of any 

lype would successfully eradicate a cancer in the anterior chamber without 

destroying the function of the eye. A lesion of such magnitude 

should be treated with the hope of saving the life, and not the eye. Exenteration 

would be indicated, combined with preoperative and postoperative 

radiation. 

Xone of the cases treated with the unfiltered bulb have developed 

lens opacities. It is the method of choice. The dangers of filtered 

radium must be recognized. 

siwimarv 

Epidermoid carcinoma of the conjunctiva is a local disease, restrained 

in its growth hy the fibrous outer layer of the eveball. 

Surgery usually fails lo cure and actually assists the local and regional 

spread of the disease. 

Radium therapy gives promise of being a curative agent in cases 

not involving intrinsic ocular structures. When perforation has occurred, 

a combination of surgery and radium is indicated. 

Evidence is accumulating which makes it appear that heavily filtered 

radiation may produce opacities in the len*. Unfiltered radiation 

is therefore the agent of choice.

R a d i u m 239 

REFERENCES 

1. Wickham ami Degrais. Radium Therapy. 1912. 

2. Collins. Archives of Ophthalmology, vol. 44. p. 577. 

3. Wessely. Munch, med. Woch., 191 j. p. 681. 

4. New and Benedict. Am. jour. Ophthalmology. 1920. vol. 3. 

p. 244. 

5. Albers-Schonberg. Munch, med. Woch., 1920. 528. 

6. De Schweinitz antl Shumway. Trans. Amer. Ophthalmol. Soc, 

1913. vol. 13, part 2. pp. 508-515. 

7. Axenfeld. See 6. 

8. Wintcrsteiner. See 6. 

9. Greeff. See 6. 

10. Saemisch. Handbuch der gesamten Augenheilkunde, 1904. vol. 

5. part 1, pp. 677-71S. 

11. Heilbrun. Archiv Ophthalmol.. 1910, vol. 77. pp. 541-552. 

12. Eicsko. Archiv. fur Augenheilkunde, 1922, vol. 91, pp. 1-10. 

13. Legrange. Traite des Tumeurs de Poeil de 1'orbite et des annexes, 

vol. 1, pp. 102-190. 

14. Panas. See 13. 

15. Hevder. \rchiv. fin* Augenheilkunde. 18S7. 

16. Profcta. Clinica Oculistica, 1911. vol. 12, pp. 793-807. 

17. Parsons. See 6. 

18. Ewing. Neoplastic Diseases, 1st Edition, 1919. 

19. Freytag. Archiv. fiir Ophthalmol.. 1915, vol. 90, p. 367. 

20. Rutschmann. Ein Eall von einem Epithelioma fibrosum conjunctivae 

bulbi (Papillom) mit Cystenbilding. Inaug. Diss. 

Kiel. 1911. 

21. Pasetti. Ann. di Ottalmol.. 1912, vol. 91. p. 602. 

22. Luedde. Am. Jour. Ophlhalmology, 1914. vol. 31. p. 65. 

23. Contino. Archiv. fiir Augenheilkunde, 1912. vol. 68, p. 4- 

24. Krompecher. Der Basalzellenkrebs, Jena, 1005. 

25. Coover. Am. Jour. Ophthalmolgoy. Sept.. 1920. vol. 3. p. 683. 

26. Bohm. Klin. Monatsblatter fiir Augenheilkunde. 1917. 

27. Greeff. See 12. 

28. Rogman. See 6. 

29. Wiener and Alt. Am. Jour. Ophthalmology, 1910. p. 361. 

30. Offret. Ann. d'Oculistique, 19*2, vol. 147. P- 3°3- 

31. Duclos. Ann d'Oculistique, 1912, vol. 147. p. 35. 

32. Hohne. Klin. Monatsblatter fiir Augenheilkunde. 1914. vol. 52. 

p. 400. 

33. Eymann. Klin. Monatsblatter fiir Augenheilkunde, 1915. vol. 2, 

p. 339- 

34. For a detailed description of ihe bulb see Quick and Johnson, 

Am. Jour. Roentgen., vol. 9. No. 1, Jan.. 1922.

240 Radium 

RADIATION IN THE TREATMENT OF PRIMARY 

MALIGNANT DISEASE* 

Bv in our treatment by radiation and in our understanding of carcinoma. 

Excluding the su|>erficial epitheliomata of the skin and the carcinomata 

of the uterus, comparatively few primary cancers have been 

referred lor radiation treatment. The number is increasing, but it is 

still too small to make statistics of much value. The rapid development 

of radiotherapy has led to a great variation in technique. With our 

more modem methods, we are undoubtedly obtaining better results than 

ever before, yet for statistical purposes, the results are too recent to be 

of value. For instance, during my visit to the Frauenklinik of the University 

of Erlangen during the past summer. I was told that they had 

treated lietwcen seven and eight thousand cases of carcinoma of the 

uterus since 191'i. and that during this time they had operated upon 

only one case. The fact thai only one case out of over seven thousand 

was o|>eratcd upon in a gynecological clinic, in itself would speak for 

good results, but Professor V. intz told me that he was unwilling to 

publish his siatistics until his present technique has been passed through 

•Reprinted hy per minion from the Atlantic MeJlc.il Journal, xsvlli. 76-80. Xov em 

Head by Invitation before tin- American Association tor Cancer Research. Friday. March SO. 19!3, 

at Boston. M.i-v (Released for publication »i»•• i• S. l!»St. because the Journal of Cancer Re- 

M'.irch hat been triiipor.irily In iiispcnilun.)

Rajpium 241 

the test of five years, which would require two years more. Professor 

Opitz. in Freiburg, seemed equally enthusiastic and stated that he was 

becoming more gratified over the results each year. 

I shall give my impressions of the value of radiation in the treatment 

of the various classes of malignant disease, and must emphasize 

that it is only my opinion or impression. 

Basal Cell Epithelioma of the Skin, if treated by radiation primarily 

and before it has extended to the deeper tissues, such as muscle. 

fascia, cartilage, or mucous membrane, should yield successful results 

in at least 90 per cent of the cases, and if one adds electrocoagulation 

there should be practically 100 per cent of cures. McKee's1 statistics of 

unselccted cases of basal cell epithelioma show clinical cures amounting 

to 90 per cent, with relapses amounting to 15 per cent. Most of the 

recurrences, however, responded to further treatment, so that the original 

90 per cent is not materially reduced. 

Squamous Cell Epithelioma of the Skin yields very much less satisfactory 

results. In my experience, these lesions generally involve the 

temporal region, the region of the car and of the back of the hand. They 

give rise to metastasis, and this fact must always be taken into consideralion 

and treatment given to ihe neighboring lymphatics. Burrow's statistics 

show 9 of these cases well at the end of a year out of 51 cases 

treated. Pinch has 10 clinical cures out of 74 cases treated. Hazen 

reports on the x-ray treatment of prickle-cell epithelioma as follows: 

number of cases. 10; clinical cures. 7; permanent cures. 4. 

It is my custom now to destroy these lesions primarily by electrocoagulation, 

then to treat the local area, and the lymphatic area by the 

x-rays. If metastases are present. I add ihe insertion of radium needles 

into the palpable lymph nodes. With this combination of treatments, I 

feel confident that the cures as indicated by the above statistics can be 

tripled. 

Epithelioma of the /.>/>.—If treated before there are palpable lymph 

nodes, 90 per cent to 05 per cent of the cases should recover, providing 

the local disease is thorough!v destroyed by electrocoagulation, and the 

surrounding tissues and lymphatic areas are thoroughly treated bv deep 

x-ray therapy or by sufficient gamma radiation. My own statistics* should 

very properly be criticised because the cases have not passed the fiveyear 

period, but I believe that not more than 5 per cent error need be 

allowed. In my opinion, if there are palpable lymph nodes, one of two 

procedures should be followed. There should be a preliminary radiation 

by short wave x-rays, or sufficient gamma radiation over the local 

tissues and the lymphatic drainage areas. Then in two or three weeks 

the local disease should be destroyed by electrocoagulation, and radium 

should be inserted into the lymph nodes. Whether excision or electrocoagulation 

is used, there should be some additional radiation employed. 

Epithelioma of the Tongue and Mucous Membrane of the Mouth.— 

Because of the early and extensive metastases to one or both sides, very 

much will depend upon the stage at which the patient is brought for 

treatment. On a basis of my personal observations only. I believe that 

best results will be obtained by preliminary radiation with the short wave 

x-rays, or with sufficient gamma rays applied in the sublingual region, 

and by cross-fire upon the base of the tongue. Then at the end of about 

three weeks the local disease may be destroyed by electrocoagulation. 

if it can be done completely, or radium may be inserted into the diseased 

and surrounding area.

242 RADIUM 

Carcinoma of the Accessory Sinuses will sometimes yield to radiation. 

Recently a young man of twenty-one years was referred to me 

by Dr. John B. Deaver. Dr. Ralph Butler and Dr. K. Bauer, with carcinoma 

involving especially the ethmoid region. A section examined 

by Dr. Stanley Reimann showed prickle-cell carcinoma, with a chain 

of metastatic lvmph nodes extending down the left side of the neck. So 

far as any of'us can tell, all evidence of the disease has disappeared 

under thorough cross-fire with the high voltage x-ray*. This will serve 

as an example of what will likely be the method of choice in the future 

in treating carcinoma and sarcoma of the accessory sinuses. 

Carcinoma of the Larynx will sometimes yield to radiation. I have 

found the introduction of radium into the tumor, through the thyrohyoid 

membrane, to be helpful.* It is advisable to do a tracheotomy in advance 

so as to prevent complications. Then a preliminary course of 

x-rays covering even- part of the disease should be given. Radium 

needles can afterward be inserted through the thyrohyoid membrane 

into the diseased area, and ten milligram needles can be left in place 

about six hours. Wc have been at least favorably impressed with this 

line of action. 

Carcinoma of the Esophagus.—Heretofore, these cases have been 

looked upon as hopeless. The brilliant work done by Drs. Mills and 

Kimbrough' gives us some encouragement in their radiation treatment. 

Their general result* are: 

Cured o 

Total 45 

Palliative result good 12 

Palliative result fairly good 12 

Palliative result fair 14 

Palliative result poor 4 

Palliative result negative 3 

Xo cures are recorded, but one patient lived three and a half years. 

dying finallyof tuberculosis and exhaustion. This was one of the cases 

rated as "palliative good." It is significant that only three cases failed 

to obtain some palliative result. Dr. Mills referred to one case that. 

three months previously, was thought to have about three weeks to live. 

and who. at the time of the report, was walking twelve miles a day as 

an inspector. Some additional help may also be obtained by treating 

with high voltage x-rays. 

Carcinoma of the Breast.—The treatment of primary carcinoma of 

the breast with radiation is not new, and the primary cases referred for 

treatment have been nearly always very far advanced; but when one of 

these advanced cases is cured we feel that a great deal has been accomplished. 

Possibly we may some day be able to consider fairly the relative 

value of surgical extirpation and treatment by radiation primarily. 

but this will be possible only when the surgeon and radiologist can see 

patients together, preliminary to treatment. The diagnosis should then 

be made by them jointly; or better, a diagnosis made without reference 

to treatment. The patients should be carefully classified and then a considerable 

number of each class treated by each method. The operations 

should be performed by a thoroughly competent surgeon and the radiation 

should be given by an equally competent radiologist. Such an ideal 

arrangement is most difficult to obtain, but until such conditions prevail.

R a d i u m 243 

comparative statistics will be of little or no value, and theory and individual 

impressions must be our guides. 

Knowing the early and widespread metastases that may develop 

in carcinoma of the breast, surgeons have operated as early and as thoroughly 

as possible. Yet too many failures have resulted. Deaver says. 

"We can never be sure that every malignant cell has been removed,-however 

early and well localized the disease seems to be at the time of operation, 

nor do the most complete operative procedures in such cases 

insure freedom from recurrence. When the disease is localized to a 

small area of the breast and the case is in other respects a suitable one 

for operation, we may be led to hold out the hope of surgical cure; only 

to have the patient die of early metastatic involvement of the viscera." 

So, too, we have great difficulties with radiation. We certainly cannot 

cure cancer by radiation excepting in those areas where we can deliver 

enough of the rays to destroy the malignant cells, either directly 

by the effects of the rays on the cancer cells, by the indirect action of 

the rays in stimulating the connective tissue, or |>erhaps by stimulating 

the development of some substance in the tissues which destroys the 

cancer cell. 

All of us have seen recurrent cancer of the breast disappear, and 

1 have patients that have remained well ten and twelve years. We have 

also seen widely distributed metastatic disease disappear. It would seem, 

therefore, that if these same patients had been treated early -before 

operation—by radiation, the primary disease should also have disappeared 

more easily. We have also seen primary cancer of the breast 

disappear, but in such cases there is always the thought in the minds 

of some that the lesion probably was not carcinoma. 

Certainly, if we can hold out a reasonable hope of cure by radiation. 

patients will present themselves for treatment much earlier, and I believe 

that such hope can be entertained. It is my present custom, so far as 

1 am able, to get a surgeon's opinion and cooperation in each case. Then 

I have been telling the patient, the family physician, or the family, that 

with our present knowledge one of two procedures should be followed: 

(i) There should alwavs be a roentgenogram of the chest made 

to rule out metastasc*. (2> There should be a thorough preliminary 

course of radiation given to the breast and to the lymphatics leading 

from the breast. The amount of radiation given should be just under 

an erythema dose with the high voltage rays, or at least with rays filtered 

through six millimeters of aluminum. Such a treatment will usually 

require two weeks. At the end of this time we should either do a complete 

surgical removal, or should implant radium needles throughout the 

tumor. 

I am not sure which of these two procedures is best. By combining 

roentgen ray treatment with surgery, il would seem that we are getting 

all the possible good from surgery, and adding an extra precaution 

against recurrence or metastasis. It does not. however, eliminate the 

fear of operation which makes the patients come late. I am inclined 

to believe that, when we have perfected our technique, the radiation 

treatment will be the method of choice. It may be possible even to avoid 

the use of the radium needle's. When this is possible, we shall have 

eliminated all fear and will surely get the patients at an earlier stage. 

Whether the patient is operated upon or whether the radium needles 

are used, there should be a second course of deep x-ray treatment given. 

Primary Cancer of the Uterus.—This subject has been more thoroughly

244 R A D I U M 

discussed from the standpoint of ihe radiation treatment than any other, 

and the enthusiasm has come chiefly from the gynecological clinics, both 

in Europe and America. In Europe, enthusiasm has centered about 

treatment by high voltage x-rays, and in a number of the largest clinics 

operation for carcinoma of the uterus has been entirely replaced by 

radiation treatment. In America, radium has played an important role. 

and such capable observers as Drs. John G. Clark. Schmitz, Bailey and 

others, have almost abandoned operation in favor of radiation. The 

following conclusions by Clark with regard to radium arc justified: 

"Results of irradiation in cancer of the cervix may remove this class 

of cases from the surgical field,although wc have not yet completely 

yielded this point Cases of cancer of the fundus, unless too far advanced, 

or unless there is a critical surgical contra-indication. should be 

submitted to hysterectomy, followed from fourteen to twenty-one days 

later, by a light irradiation of Ihe vaginal fornix."' 

CONCLUSIONS 

i Primary carcinoma should yield as readily to radiation as recurrent 

or metastatic disease. 

2. Inoperable primary carcinoma can sometimes be made operable 

by thorough preliminary radiation. 

3. Preliminary' radiation in an operable case will devitalize the carcinoma 

and should make recurrence antl metastasis less likely. 

j. Basal cell epitheliomata of the skin yield in practically all instances, 

especially if radiation be combined with electrocoagulation. 

5. Primary squamous cell carcinoma should be treated by preliminary 

surface radiation, local destruction by electrocoagulation, and the 

insertion of radium locally and into the adjacent tissues. 

6. A preliminary conference between the surgeon and the radiologist 

will probably be followed by the most satisfactory results to the 

palient. 

REFERENCES 

1. McKee: X-Rays antl Radium. Treatment of Diseases of the 

Skin. Lea & Febiger. Philadelphia. 1921. 

2. Pfahler: Cancer of ihe Lip Treated by Radiation or Combined 

with Electrocoagulation and Suigical Procedure. Radiol.. 1922. III. 213. 

3. Pfahler: Radiotherapy in Carcinoma of the Larynx with Special 

Reference to Radium Xeedles Through the Thyrohyoid Membrane. 

Radiol.. 1922. III. 511. 

4. Mill* & Kimbrough: Further Observations on the Radium Treatment 

of the Esophagus with a Review of Forty-four Cases so Treated. 

Roentgenol.. 1923. X. 148. 

5. Pfahler: Radium Combined with X-Ray Treatment in Carcinoma 

of ihe P.reast. Roentgenol.. 1021, VIII. 661. 

6. Pfahler: Radiotherapy in Carcinoma of the Breast. Surg.. 

Gynec. and Obst., 1922. XXXV, 217. 

7. Clark and Kcene: The Treatment of Cancer of the Pelvic Organs 

with Moderate Irradiation. Roentgenol.. 1922. IX. 80S.

R a d i u m 245 

end results of 201 cases of carcinoma 

of the cervix* 

Bv Howard C Taylor. M. D.. and Thomas C. Pi:k;iitai., M.D. 

Xew York City. 

(From the Gynecological Service of the Roosevelt Hospital) 

The following is a report of 201 consecutive cases of carcinoma of 

the cervix, admitted to the Gynecological Service of the Roosevelt Hospital, 

during the period from 1910 to 1020. inclusive-eleven years. 

During this time there have been a number of changes in the procedure 

of handling these cases and. since 1917. radium has been used extensively 

in the great majority of instances, either alone, or preparatory to 

and following operative removal. For this reason, a study of the end 

results is not complete without showing their relation to the type of procedure, 

and the groups shown in the tables which follow are so arranged 

as to bring out this relationship. 

Xo attempt will be made to study these cases with reference to symptoms, 

signs, or other points of interest in their histories, except to give 

the age of incidence, state in life, and the relation to child-bearing. Likewise, 

the pathology will be discussed only as to type and location of 

growth, with special reference to its bearing on the end results, particularly 

in those cases which show no recurrence, after three years. 

Age of Incidence.—-The exact age is known in 182 cases, and an 

analysis by decades shows the following- Two cases between ten and 

twenty vears, one being twelve and the other nineteen years of age; 7 

cases between twenty and thirty; 36 cases between thirty and forty; 76 

cases between forty and fifty; $3 cases between fifty and sixty; 5 cases 

between sixty and seventy and three cases over seventy,—these being 

seventy-one, seventy-two and seventy-five years of age. 'Thus it will 

be seen that 90 per cent of the cases fell between thirty and sixty years. 

and 70 per cent of the cases between forty and sixty years. The average 

age is forty-five and one-half, the youngest being twelve and the oldest 

seventy-five years. The age seems to bear little, if any. relationship to 

recurrence for the average age of cases free from growth, after three 

years, is forty-one. which is practically the average age of incidence. 

State in Life, and Relation to Child-Bearing.—Of the 201 cases, 192. 

or 95.5 per cent were married, while o. or 4.5 per cent were unmarried. 

Likewise 181 cases, or 94.3 per cent bore one or more childern. while 11, 

or 5.7 per cent were nulliparae. With such a preponderance of these 

cases falling among the muciparous women, one naturally is forced to 

the conclusion that child-bearing is a definite causative factor in carcinoma 

of the cervix; but when one considers that the majority of 

women at forty-five.—the average cancer age shown above—are married 

and have borne one or more children, this conclusion loses some of its 

importance. 

Pathology.—Of the cases included in this report, biopsy with pathologic 

report, from sections, was obtained in 102. while in 9 cases the 

diagnosis was only established clinically.—but in each of these latter 

the disease was so far advanced as to be practically unmistakable, and 

was grossly of the squamous variety. Of the specimens examined in the 

'itnnrintfsl bv permission from American Journal of Olislelrics and Gynecology, vlll. 28S-297, 

1924.

246 R a d i u m 

laboratory, 9. or 3 per cent proved to be adenocarcinoma, the remainder. 

183. or 95 per cent, being squamous in character. All the cases which 

have shown no recurrence, after three years, were of the squamous group. 

As to the age and type of growth, the youngest case, 12 years, showed 

adenocarcinoma, while the ages of the other cases, in this group, all 

ranged between forty and fifty years. 

A study of the location and extent of growth on admission furnishes 

several points of interest. These facts have been established, in all 

but the few classed as inoperable, by pelvic and rectal examination 

under a general anesthetic, and. in the cases where excision was done, 

by direct observance at operation and subsequent study in the laboratory. 

In only 48 cases the lesion was confined to the cervix alone; in 40. it 

had extended into the vaginal walls, while in 103 it was decided that 

the surrounding parametria! tissues were involved. Of the 16 cases alive 

over three years without recurrence. 11 showed cervical involvement 

only; four showed extension to the vaginal walls, and one case beginning 

extension into the parametrium. Of the cases in which recurrence 

took place after three years, all but one originally had involvement of 

cervical tissue only. Thus, in these cases traced, a favorable prognosis 

depended very materially on whether or not the growth was limited to 

the cervix. 

Type of Procedure.—As stated previously, the type of procedure in 

handling these cases of carcinoma of the cervix has varied considerably 

from time to time during the eleven years covered by the report. Before 

the use of radium cases were divided into two groups,—the operable 

and the inoperable.—the latter being treated onlv palliatively, or with 

chemicals such as acetone. The operable group had either the classical 

Wertheim type of operation, or a complete hysterectomy, with rather 

wide excision of the broad ligaments; and both of these were, as a rule. 

combined with cauterization cf the cervix. The latter was accomplished. 

in some cases by the actual, or hot, cautery, and in others by the Percy 

method. In an intermediate group of cases excision was not attempted. 

but the cervix alone was subjected to cauterization by one of the two 

methods mentioned above. 

After the adoption of the use of radium in 1917. a number of cases 

were still treated by these procedures, but soon thereafter the presentday 

methods were develo|>ed as follows. Extremely early cases are still 

considered operabie and receive radiation with the clement both before 

and after excision. A varying period of from two to six weeks is 

allowed to elapse between the primary radiation and hysterectomy, and 

here a modified Wertheim, with exposure of the ureters in their lower 

course, or a rather wide complete hysterectomy is done. Postoperative 

radiation in the healed vaginal vault is begun before the patient leaves 

the hospital, and is continued later, if the original extent of the growth 

seems to warrant it. The average preoperative application of radium 

is 2400 milligram-hours within ihe cervical canal and growth.—while the 

average postoperative dose is 1000 milligram-hours. The element itself 

is used in silver and brass capsules.—one 50 and two 25 milligram tubes. 

At present the inoperable cases are treated by repeated radiation of the 

growth,—the primary application usually being 2400 milligram-hours: 

and those following depending upon subsequent examination, and the 

possibility of vesicovaginal aid rectovaginal fistulae. 

Table I show* the 201 cases grouped according to the type of op-

R a d i u m 247 

Operation 

Hysterectomy 

Wertheim-cautery 

Wertheim-radium 

Total Wertheim type 

Hysterectomy 

Complete cautery 

Complete radium 

Total complete type 

Total hysterectomies 

Hot cautery alone 

Percy cautery alone 

Radium alone 

Total operations 

Inoperable (previous 

Total Cases 

Table 

to 1917 

1 

Total 

41 

10 

5i 

34 

12 

4(1 

97 

17 

!() 

50 

174 

27 

201 

Total Traced 

21 

9 

30 

20 

7 

27 

57 

9 

8 

15 

89 

5 

94 

erative procedure, as well as the number in each group which could be 

traced with sufficient accuracy as to be considered of value in establishing 

end results. 

There were 97 hysterectomies, 51 of them Wertheim and 46 complete. 

Only 30 per cent of the former and 27 per cent of the latter could 

be traced. Seventeen cases were cauterized with actual or hot cautery 

only, while on ten the Percy method alone was used. We have been 

able to follow nine of the former and eight of the latter. Fifty cases 

received radiation only, of which the outcome is known in fifteen. The 

remaining 27 were of the inoperable, advanced group, and were seen 

previous to the use of radium. 

End Results.—Of the 201 cases treated, only 94 could be traced, 

and ihe end results discussed below are based upon this total. 

Operative Cases, with No Recurrence, or Free from Growth Three 

Years or More After Operation.—Sixteen casesfall into this group and 

are shown below in Table II. The only cases considered here, as possi- 

Table 11 

Cases With Xo Recurrence in Relation to Operative Procedure 

Operation 



Total Wertheim 



Total complete 


"Percy cautery alone 

Total 

Percentage (Excision 

Tolal 

Traced 

21 

9 

30 

20 

7 

27 

57 

S 

65 

3 4 | 5 6 

| Years Years 1 Years Years Years 

1 

1 li 1 

1 1 1 8 1 

1 

1 1 1 1 

l | 1 2 

2 | 2 | 5 

> 1 1 

2 :; 6 

1 

4.5 1 4.5 | 11.4 

1 

1 

1 1 

1 

S 

Years 

1 

VearJ T,,,i" 

l 5 

1 3 

1 1 1 

1 1 1 3 

1 4 

1 

2 | 2 115 

1 1 

1 |2 ]2 |16 

1 

2.3 | 4.5 

cases) 

57 

2.3 

4.5 ; 34.0 

•This case has ligation of internal iliacs also. 

Note: As 13 of these cases died postoperatively, percentages are figured on 

total of 44.

218 R a d i u m 

bilities. are those in which some tyj>e of hysterectomy was done; except 

for one case of Percy, cauterization of the cervix and ligation of the 

internal iliacs. m which there was no evidence of growih four years 

after operation. This case has not been traced since 1920. and all attempts 

to locate it have been unsuccessful. 

It will be seen that 2 cases have gone between three and four years 

without recurrence: 3 cases between four and five years; 5 cases between 

five and six years; 1 case between six and seven; 1 between 

seven and eight year*: 2 l>ctwcen eight and nine years, and 2 between 

nine and ten years. Kleven, or more than two-thirds, of these cases arc 

over five years. 1 hus. of the 57 cases traced, which had some type of 

hysterectomy. 13 are known to l>e alive without recurrence more than 

three years, or a total of 34 per cent for succe-sful results in the operalive 

cases. A correction of percentage is necessarily made as 13 of this 

group died postoperatively in the hospital. 

The table also shows the type of operative procedure, and here the 

results indicate practically as much success, where complete hysterectomy 

.vas chosen, as where the more extensive Wertheim was done. If any 

operative group can be said lo have shown mo>"e success than the others. 

it was where one of the two types of hysterectomy was combined with 

radiation. This fact vv>uld seem to justify ihe present method of treatment 

described above for operative cases, that is. wide complete hysterectomy, 

with prcojierative and postoperative radiation. 

Operative Cases ti-i'h Known Recurre-iee.—Here again only cases in 

which some form of hysterectomy was done are considered, and they are 

summarized in Table III. 

Table III 

SuowiNt; Time of Reci rrencg in Re:,atio\ to Operative Procedure 

Operation 



Total Wertheim 



Total complete 

Total 

Traced 

21 

•1 

rso 

20 

7 

27 

«'• 1 

Month* Y>;ir 

3 2 

2 0 

0 4 

3 3 

1 

1 3 

IS 2 

M'nuh*| Years 

1 

2 

0 3 

1 

1 

n 

3 4 

Yea re Years 

*J> 1 

•'. 

1 

1 

1 

1 

1 

5 

Years 

0 

2 

2 

Total 

10 

6 

16 

Total hysterectomies 57 9 7 

2'.' 

Percentages of total1 44. ! 20.5 ! 15.9 4.5 I 6.8 9.1 4.5 4.5 65.9 

Percentages of re-' 

' i 

l 

currences 31.0 I 24.0 7.0 : 10.0 14.0 7.0 7.0 

Note: Recurred in 3 years 25 (S5 per cent); over 3 years 4 (14 per cent). 

Percentages are figured on a total of 44. 

All these showed recurrence within the pelvis.—the majority in the 

remaining parametria! tissue*; a few locally in the vaginal walls, and 

only one to some distant organ.—in this case to the parotid gland. Xine 

cases had recurrence in six months, seven more in twelve months, two 

more in eighteen months, three between eighteen months and 2 years: 

four more in three years; iwo more in four years, and two more in five 

years. Thus, of the 57 operative cases traced, 20. or 66 per cent are 

known to have had recurrence, and of these 35 j>er cent recurred within 

one year. SVi per cent within three years. 14 per cent between three 

10 

3 

13

R a d i u m 

'IV.) 

and five years, and no cases going over five years have shown recurrence 

to date. 

This table also shows the type of operation in relation to time of recurrence.—but 

little if any conclusion can be drawn from this comparison. 

Sixteen cases had had Wertheim and thirteen complete hysterectomy. 

Lfp to three years, fifteenof the former and ten of latter had 

shown recurrence, while after three years one Wertheim and three 

complete hysterectomies developed further lesions. Comparison of these 

figures with the total cases traced for each operative group, shows approximately 

a 50 per cent recurrence in each. 

Deaths.—Table IV gives a statistical study of all deaths, showing 

ihe relation between ihe time of death and the type of treatment, whether 

excision, cauterv or radium atone. 

Table IV 

Showing I*ime 01 D -:atii is Relation tt Operative Procedure 

Operation 

Total 

6 1 18 2 3 4 

Traci-d p, o.j Mm. Yr. 

Yrs. Yrs Yrs. Yrs. ITotai 

Wertheim-cautery 21 6 3 2 

2 2 1 1 10 

Wertheim-radium 9 

1 2 1 

1 

1 6 

Total Wertheim 30 6 | 4 4 1 0 3 2 2 I 16 

Complete cautery 20 7 2 2 1 2 1 9 

Complete radium 7 

1 

1 1 

3 

Total complete 27 7 2 z 2 2 1 2 1 I 12 


57 13 6 6 3 2 4 4 3 28 

1 

Percentages 44 13.3 13.6 i 13.6 6.8 4.f !1.0 9.0 6.8: 63.6 

Hot cautery alone 9 

4 1 1 2 1 

Percy 

8 

4 2 

1 | • !? 

Total cautery 17 

1 8 3 1 3 0 1 0 1 16 

Radium alone 15 6 2 2 2 2 0 0 1 14 

Total 

89 13 I 20 11 6 7 '> 6 3 I 58 

Percentages 76 7.5 1 26.3 14.5 i.U 9.2 7.9 6.6 3.9 76.3 

Note: Of the 27 inoperable cases treated palliatively. only 5 could be traced, 

and all died within six months. 

Of the 57 caês which had hysterectomy, thirteen died postoperatively 

in the hospital, antl arc analyzed as a special group below; six died 

within 6 months, six more within a year, five more in two years, eight 

more in four years, and three more in six years. The last three had 

shown recurrence in Iwo. three and five years, respectively, but life was 

prolonged until the sixth year in each case by radiation. Thus of the 

57 cases mentioned above 41 left the hospital, and of these 28, or 63 

per cent died of cancer within six years,—21 or 75 per cent of the deaths 

occurring within three years. One additional case, free from growth 

four years after operation, died of pneumonia. One other patient, developing 

recurrence five years after excision, is still living two years 

after the recurrence was noted, but is in very poor health. Of the cases 

leaving the hospital, approximately jus*, as many died of cancer following 

Wertheim as following complete hysterectomy. 

Seventeen cases were traced which had been treated with the hot 

and Percv cauterv. Of these all but one were dead within three years. 

and 70 per cent of these deaths occurred within one year. 

Onlv fifteen cases treated by radium alone could be traced, and of

250 R a d i u m 

these fourteen were dead within three years.—60 per cent of these deaths 

occurring within the first year. The remaining case is still alive, three 

years after first radiation, but the growth is well advanced and the patient 

has a rectovaginal fistula. 

Of the twenty-seven advanced inoperable cases that received nothing 

but palliative treatment, only five could be traced, and all of these 

died within six months. 

Thus a summarization shows a grand total of 76 (or 80 per cent) 

deaths due to cancer, out of the 91 cases traced. 

Postoperative Deaths.—An analysis of the thirteen cases dying in 

the hospital, after operation, follows: 

From 1911 to 1920, there were 07 hysterectomies. 51 of Wertheim 

and 46 of the complete type. Thirteen of these cases, or 13.3 per cent. 

died postoperatively in the hospital. All of these deaths occurred between 

1911 and 1915. during which period 6j of the hysterectomies 

were done. From 1016 to the end of 1020. 33 cases had hysterectomy 

1,17 Wertheim and 16 complete) but in none of these did death result 

from operation. Of the seventeen cases treated by the hot cauterv- and 

len bv Percy cauterv, none have died in the hospital. Likewise, there 

have been no fatal results from treatment by radium, cither alone or 

combined with hysterectomy, there having been fifty of the former and 

twenty of the latter, in the period covered by the report. Thus, of the 

174 cases having some type of operative procedure, in 13 only (or 7.5 

per cenO can it be said that death resulted from operation. 

In these postoperative deaths, the average age of the patient was 

forty-eight. One case died on the table, and six others died within 

seventy-two hours; two died from pneumonia (one in the fourth and 

the other on the fourteenth day) ; one death on the eighth day was due 

lo ileus; and in ihree other cases (one on the eighth, one on the eleventh 

and one on the eighteenth dav^ death resulted from circulatory com- 

Recurrence 

in 

6 months 

1 year 

18 months 

2 years 

3 years 

4 years 

5 years 

Total 

Taplf. V 

Siiowino Reiation of Death to Recurrence 

Total 

li 

1 

2 

3 

4 

2 

29 

6 

Months 

6 

5 

1 

2 

2 

16 

1 

Years 

1 

1 

1 

2 

1 

1 

Died After Kecummcr in 

IS 2 3 

Months ; Year* ;\car* 

2 1 

2 

(1 alive H 

1 

! 

1 

1 

1 

2 

4 

| Years 

I 

p 

1 

1 

1 

plication. Six had had Wertheim and seven the complete type of operation. 

In four the growth was confined to the cervix; in three the vaginal 

walls were also involved, while in six there was beginning extension 

10 the parametrium. 

Relation of Death to Recurrence.—In Table V. the relation of time 

of death to recurrence is shown. Of the 29 cases, showing recurrence 

at various periods from six months lo five years. 16, or 55 per cent, were 

dead six months later, while 7. or 24 per cent lived only one year, making 

a total of 23. or 79 per cent, who died within twelve months. Thus 

the length of time between operation and recurrence has no relation to.

R a d i u m 251 

or effect upon, the time of death after recurrence; as the cases where 

carcinoma reappeared three, four and five years after operation, died 

just as soon as those in which the postoperative free interval was of 

much shorter duration. Two patients died three years, and one four 

years after recurrence, while one is still alive, four years after the 

growth reappeared. But all four of these cases have been extensively 

radiated,—this accounting in some measure for the prolongation of life. 

Radium Cases.—Since 1917. seventy-two cases have been treated by 

radiation, either alone or combined with some type of excision. Fifty 

cases, having been considered inoperable, have had radium only, while 

twenty-two were radiated in conjunction with hysterectomy. Wertheim 

was done in ten. and complete hysterectomy in twelve of these twentytwo 

cases. Eight of them received radiation before, four after, and ten 

before and after operation. The average amount before was 2000 milligram-hours, 

and the average postoperative application was 1000 milligram-hours. 

In the group of fifty cases treated by radium alone, ihe 

smallest total amount used was 1200 milligram-hours (this case failing 

to return for further treatment;, while the largest amount was 7200 milligram-hours, 

in four applications. The average total application was 

4000 milligram-hours. 

Of the twenty-two operative-radium cases only sixteen could be 

traced. Of these seven, or 44 per cent have remained without recurrence 

-one three years, one four years, three five years, one six years, and one 

seven years. The remaining nine, or JO per cent have all developed recurrence,—three 

in six months, two in one year, one in eighteen months. 

two in two years, and one in three years. Of these nine, all are dead.— 

six dying within six months, two within twelve months, and one. four 

years after the recurrence. 

The latter case is of particular interest. Six years ago the patient 

had a Wertheim hysterectomy, with 2400 mghr. radiation before, and 600 

mghr. after operation. Two years later recurrence developed as a small 

nodule in the anterior vaginal wall near the urethra. In the past four 

years since its reappearance the growth has been radiated three times 

for an additional 2150 mghr.. the last application having been about one 

year ago. Within the past six months an indurated, ulcerated area developed 

on the anterior vaginal wall, and metastatic masses have been 

noted within the pelvis. The patient's death has been reported within 

the past few weeks. Undoubtedly radiation very materially prolonged 

life in this case. 

Of the fiftycases of advanced carcinoma of the cervix treated with 

radium alone, unfortunately only fifteen have been traced. This is due 

to the fact that the majority of them were trcatcil during the recent 

war period f from 1917 to 1919). when the follow-up system was greatly 

handicapped by a limited personnel, and by the frequent change in the 

patient's address. 

Fourteen, or 00 per cent of those traced have died of cancer, six 

within six months; two more within a year; two more in eighteen 

months; two more within two years, and Iwo others lived three years. 

The remaining one. while still alive three years after the firstradiation. 

is in fair health, but has a rectovaginal fistula, and the growth is well 

out into the parametria! tissues. This case has had 5200 mghr. radiation, 

in four applications. Two others had fistulae.—one rectovaginal 

and one vesicovaginal.

252 Radium 

Thus 60 per cent of these advanced cases died within twelve months. 

and of the others only one had lived more than three years. All showed 

marked regression of the growth locally within the cervix and vaginal 

walls, the majority shrinking down so that their offensive discharge and 

bleeding were completely controlled. In many the lower parametrial 

involvement also showed some recession, and their general health was 

materially benefited for a time. Further spread of the growth outward. 

usually marked by deep pelvic and sciatic pains, could only temporarily 

be controlled, for at this stage additional radiation was usually limited 

by the danger of vesicovaginal and rectovaginal fistula. At present these 

cases are also receiving cross-fire x-radiation of the pelvis, in addition 

to radiation within the cervix, so that future reports will undoubtedly 

show even Iwtter control of ihe parametrial involvement. 

Sl'MMARlF.S 

Total number of cases .201 

Inoperable palliative 27 

Total operative cases 174 

Total hysterectomies (Wertheim 51) 97 

Total cautery cases 27 

Total radium cases 50 

Total cases traced (lnoperablc-5) 94 

Xo recurrence or free from growth 

16 34','c 

Recurrence, but not dead I 2% 

Died, postoperative 13 -(/, 

Recurrence, and dead 28 63^ 

Recurrence in less than three years 23 57$ 

Recurrence after three years 4 9^ 

Alive three years, without hysterectomy 2 6% 

(Radium cases—1: Cautery. 1.) 

Dead, without hysterectomy 30 94^ 

Total dead in less than three years 

68 72c/e 

Total dead after three years 8 9^0 

In ihe past three years. 1921 to 1023. an additional group of 46 cases 

of carcinoma of the cervix have been treated, Thirtv-one were of the 

advanced type and had radium alone, while fifteen were considered sufficiently 

early to have hysterectomy after radiation. These end results 

are not included in this report, as the usual ihree year period has not 

elapsed, but the percentage of ihose free from growth to date is most 

promising, and should l>e even higher than the figuresgiven above for 

the preceding ten years. 

COXCI.fSlONS 

1. Advanced Cases.—This group, when treated by radium alone 

shows much better result- than were formerly obtained bv any other 

nonoperative palliative procedure, or by such operative measures as the 

use of the actual or Percy cautery. The growth locally in the cervix 

and vaginal walls can be controlled, so that the patient is infinitely 

more comfortable than formerly: and the parametrial involvement caii 

for a long period be held in abeyance.--especially if radiation is combined 

with external x-radiation. Treatment with radium in such cases 

is a safe procedure: for in none of the Si cases radiatedin the past seven 

vears, has death resulted from its use.

R a d i u m 253 

2. Early Cases.—This group, when subjected to hysterectomy. 

shows 34 per cent free from growth three years or more after operation; 

25 per cent free five years or more; and where hysterectomy was accompanied 

by radiation 44 per cent had no recurrence three years or more. 

and 31 per cent five years or more after the removal. These results compare 

very favorably with the figures reported bv those clinics where 

radium is available ii: large amounts, and radiation alone is the adopted 

method of treatment. Thus, where radium can be used in limited 

amounts only,—such as 100 milligrams of the element, -and the method 

of application must necessarily be limited also, hysterectomy plus radiation 

is still the method of choice in earlv cases. Here too the safety 

of such procedure, from the standpoint of postoperative mortality must 

be emphasized. None of the thirty-seven cases of hysterectomy, combined 

with radiation, have died as a result of operation. 

As x-radiation will also be included hereafter in the operative procedure 

of this group, future end results should show an even higher percentage 

of five year cures. 

REVIEWS AND 

ABSTRACTS 

Ciosta Forssell. M. D.. (Stockholm. Sweden). Kxperiences in the 

Permanency of Radiological Cure in Cancer. Caldwell Lecture. 1924. 

The Amer. J. of Roentgenology and Radium Therapy, xii, 301-311, October, 

'24. 

"The interest in radiological scientific work is nowadays to a great 

extent in dealing with the problems concerning the mode of action of 

loentgen and radium rays and with the many important and difficult 

problems in the therapeutic technique." 

"To me, however, it seems also of dominant interest to consider 

the experiences we have gained in the past years, so that the development 

of radiotherapy may henefit by our practical experience. Radiotherapy 

has now been practiced for nearly thirty years, and the technique 

in its essential parls has been developed for at least ten years. At present, 

however, the situation is such that there are certainly a great number 

of publications on the immediate results of radiological treatment 

in malignant tumors, bu* very few statistics on the finalresults in radiologically 

cured cases which have been carefully followed during a long 

period of observation. Also the immediate results of radiotherapy vary 

much in different institutions, and the indications for radiotherapy are 

judged very differently. No theoretical speculations can here decide the 

matter—onlv practical experiences which have been critically examined. 

Under such circumstances it seems to me that the time has come for 

everybody who has large material at his disposal lo try to draw the balance 

of the results obtained. I will now. to the extent of my power, try 

lo carry my straw to the stack." 

"The most important practical questions which present themselves 

for our consideration in this field arc, then:" 

"Within which groups of malignant tumors has radiotherapy been 

able to effect a clinical cure':" 

"To what extent has it been possible to secure a cure within these 

groups of tumors*'" 

"What is the degree of permanency of this cure?"

254 RADIUM 

"What factors seem to favor or to counter-influence a permanent 

cure:" 

"The material I am going to lay before you originates from the 

Radiumhemmet in Stockholm, a small hospital of thirty-two beds for 

the radiologicaltreatment of cancer. The Radiumhemmet was founded 

in 1910. and is maintained bv private subscription and supported by the 

Swedish Government and the city of Stockholm. At Radiumhemmet 

we have a well-organized department for ihe supervision of patients who 

are carefully followed the firs: few years after ihe cure, and are then 

summoned for examination at long intervals." 

"The greatest strength of this system of after-examination lie* in 

the fact that the Swedish Government, by an act of Parliament, pays the 

traveling expenses of the poor patients 10 and from the hospital; and 

bv means of this, personal examination and control have been rendered 

possible in most cases." 

"There are several grouj > of malignant growths that nowadays 

might be subjected to an examination regarding the final results; but 

only within three large groups of carcinoma, i. e.. cancer of the skin of 

the face, cancer of the lips, and cancer of the uterine cervix, do we possess 

a sufficiently large number of cases which have been observed for 

a sufficiently long period of time, to be able to make an examination of 

the finalresults." 

"It does noi come within the scope of this lecture to give an account 

of the technique employed." 

"I will only mention that in these groups 01 cancer practically all 

cases have been treated with radium. Only a few cases have in addition 

had roentgen treatment; and we use. as a rule, radium rather than roentgen 

rays in all cases of tumors in which a direct radiation can be applied, 

and always radium in our treatment of growths situated in a cavity. 

When radium is :o be applied directly on skin or mucous membranes. 

we alwavs employ prostheses of 'dental mass.' and a very careful application 

after the methods described in English by I.. F.dling in Volume I 

of the Acta Radiologka. We use a powerful screenage. generally from 

2 to 4 mm. of lead, and a radium dose computed according 10 the tumor. 

The radium treatment is concluded within a relatively short time. \\ e 

employ roentgen rays in cases of large tumors, in treatment of glandular 

matestases. and in postoperative treatment, as well as in deeply situated 

tumors." 

"I have examined the results with regard to different modes of 

growth and different topographical extension of the tumors, and have 

also compared the results in primary tumors and in recurrences. Further, 

I have examined the cure in different histological forms of tumors. 

as well p.s in cases with or w ithout enlarged, regionary glands. Further 

still. I have examined the influence of age on the cure. And finally. I 

have devoted my attention to the frequency and latency of the recurrences 

as well as their response to repeated radiological treatment. I 

have also tried to examine the real permanency of the cure obtained I 

now wish to give vou a brief account of my result* with regard to the 

influence of the mentioned factors on the radiological cure and its permanency." 

"My report on skin cancer comprises all those cases which were 

treated at "Radiumhemmet" during the period from 1910 to 1915 inclusive. 

The entire material has been after-examined twice, in 191S and 

1923. In preparing my material I have divided my cases into two main

R a d i u m 255 

groups: the superficial tumors, by which I mean tumors that are restricted 

to the skin and the subcutaneous tissue, and are freely movable against 

the subjacent tissue; and infiltrating tumors, by which I understand tumors 

infiltrating and fixed to the subjacent iissue. The prognosis is essentially 

different in these two groups." 

The details of the clinical results given by Dr. Forssell are too extensive 

to lend themselves to abstracting, and the reader is referred to the 

original article for these data on radium treatment of skin cancer, cancer 

of the lower lip, cancer of the uterine cervix, and cancer of the thyroid 

giand. 

"A comparison between the results in those of our own cases in 

which radium therapy alone has been employed and the cases where a 

combined radium and roentgen therapy has been administered as well 

as a comparison between the results in our cases, mostly treated with 

radium alone, and the results obtained at other institutions where roentgen 

treatment only or a combined radium-roentgen therapy has been used. 

have long ago convinced me that the treatment with radium only, as a 

rule, is to be preferred in carcinoma of the cervix when there are no 

extensive glandular metatases. I have found this observation of mine 

confirmed by the latest statistics. I am inclined to generalize this opinion 

so far thai I consider a radium treatment is to be preferred to a roentgen 

treatment in circumscribed malignant tumors, if the turner is accessible 

for a direct and sufficient irradiation with radium. The chief reason 

for this is the comparatively limited effect of the radium radiation, which 

is neither attended with ihe same amount of risk to the surrounding 

tissue, nor has the same injurious effect on the whole individual, as has 

the deep roentgen irradiation. In the treatment of cavities, such as the 

uterus and the bladder, mouth and pharynx, radiumtherapy has also a 

very great advantage over roentgen treatment." 

"My general impression is, that in all other forms of cancer (possibly, 

with the exception of cancer of the ovaries) as a rule, only those 

tumors have remained cured which were of a comparatively limited 

size." 

"But if complete freedom from symptoms is secured, it seems that 

the cure, in several different forms of cancer, is permanent." 

"Recurrences following operations arc. as a rule, less responsive to 

irradiation than primary tumors. In recurrences following radiological 

treatment the result is still less favorable." 

'"I must point out in this connection that 1 have had no experience 

with implanted emanation-seeds, a method which has been so successfully 

developed in the United States. According to American reports this 

method has gained large fields,especially in the treatment of cancer of 

the tongue, bladder, prostate and rectum." 

"In several forms of cancer in which a permanent cure cannot be 

secured with our technique of today, radiotherapy has to a great extent 

produced lasting improvement and temporary freedom from symptoms 

m inoperable cancer. Radiotherapy is unrivalled as a palliative measure 

in cancer." 

"Our experience has shewn that neither in carcinomata nor in sarcomata 

is the success of radiotherapy in malignant growths principally 

determined by the radiosensibility of the characteristic cell type." 

"There are probably few. if any, malignant tumors where the radiosensibilitv 

itself of the individual cells is not sufficiently great to assure 

a cure, if the clinical character of the case otherwise makes a cure pos-

256 

Radium 

sible. The most radiosensitive form of tumor may have the least chance 

of permanent cure if a rapid generalization is characteristic of the tumor 

in question, as for instance, in the lymphosarcomata. Rapid growth of a 

tumor possibly renders it more radiosensitive, though less curable. On 

the other hand, a tumor of but little radiosensibility, as the squamouscell 

carcinoma, is, as a rule, cured permanently by a fully satisfactorytechnique, 

if it is still local and confined to the soft parts." 

"The biological character of the tumor and its stage of development 

determine the final result !o at least the same extent as the degree of its 

radiosensihility." 

"A high radiosensibility in conjunction with a limited growth and 

well-nourished surroundings gives, of course, the best condition for a 

permanent cure." 

"In this assembly I do not need tn emphasize that the final as well 

as the primary care mainly depends on the technique used, or rather on 

the skill and experience of the radiologist." 

"A most interesting problem is the -ause of recurrences following 

radiological cure of growth, and to what extent the radio-therapeutic 

technique is responsible for their appearance." 

"I cannot here enter fully into this problem. I only want to point 

out that, in my opinion, most recurrences are not new tumors, but are 

developed from remainders of the primary tumor that have been overlooked 

or impossible 10 find. Many 'recurrences' are. in my opinion, due 

to the fact that the case has been wrongly interpreted as being cured. I 

have often noticed cases of skin cancer considered as cured, in which 

small typical rests of the tumor have been found on the border of ihe 

tumor area. From such rests the 'recurrences' arise. Many an unsuccessful 

'reatment i>. on the other hand, due to the treatment of late, reactive 

swellings, wrongly interpreted a* cancer. This repeated treatment 

often results in necrosis. If any rests of the growth are then present. 

a radiological cure is. as a rule, impossible." 

"We must bear in mind that the treatment may induce a chronic 

dermatitis, which may lead to cancer. Personally, I have not seen a 

single case in which recurrences of a cancer could be supposed to have 

been caused by changes following radium irradiation. On the o'her 

hand. I have observed 5 cases of cancer on the basis of a roentgen dermatitis, 

none of which occurred in a scar following roentgen cure of a 

tumor." 

"Our experience from postoperative irradiation of cancer of the 

breast has taught us that latent metastases may increase rapidly if the 

body is debilitated by too strong an irradiation. In this way the technique 

of irradiation may be to blame for the development of metatases." 

"Neither can the eventuality be precluded that, under certain circumstances, 

metastases may develop when a tumor is breaking down. 

following irradiation." 

'"We certainly hope, either by influencing the endocrine apparatus 

or by means of immunization, to reach through radiotherapy a general 

effect on the organism, and thereby to cure even extensive or disseminated 

growths. Hut. at the same time, we must point out quite clearly 

that wc cannot as yet count on a permanent cure in anv other cases but 

those in which a limited growth is still accessible to a certain appropriate 

dose. Further we must emphasize that it is equally as important not to 

hurt the healing power of the organism, as it is to reduce the resistance 

of the tumor."

R a d i u m 257 

"I am becoming more and more convinced lhat the normal resistance 

of the surrounding tissue is at least as important in radiological 

cure as the degeneration of the cancer cells themselves, produced by the 

irradiation." 

My opinion is that radiotherapy, in favorable cases, bv weakening 

the tumor, gives the normal mcchani.vi of cure a chance of overcoming 

the disease.'' 

"In spite of ail its technical improvements, radiotherapy is still a 

mainly local treatment. In all our practical work we must bear this in 

mind, and scrupulously avoid giving up the solid ground of our previous 

experience, even when facing the most important technical progress." 

"INDICATION'S FOR RADIOLOGICAL TREATMENT IX MaLICKAXT 

Growths.—My report states the fact that a radiological treatment of 

growths has been successfully applied, not only in cases of inoperable 

tumors, but also to a large extent in operable cases. We have further 

seen that in certain groups of cancer, a permanent cure has been obtained, 

and that in those groups the percentage of cured cases is quite 

comparable with the results obtained by surgical intervention." 

"Now the question arises: Is radiotherapy under any circumstances 

to be preferred to surgical intervention, and. if so. what are the indications 

for ihe radiological treatment in malignant growths?" 

"In my opinions, the simple answer to this question is this: Radiotherapy 

is to be applied only in those cases in which it is obviously superior 

to surgery." 

"In doubtful cases, radiotherapy is indicated, if previous experience 

makes a cure or a material improvement probable." 

"If this be nol the case, radiotherapy should not be employed, even 

in inoperable cases." 

"When radiotherapy can secure a permanent cure in inoperable 

cases, it is generally not the size of the growth, but its topographical 

situation, which prevents operation- for instance, when in the pharynx, 

the thyroid gland, or the parametrium. In certain operable cases a bad 

general condition is the indication for irradiation." 

'"In some inoperable cases, where we cannot rely upon radiotherapy 

alone, this therapy may he employed to change the tumor into an operable 

one, and then an operation can be performed successfully." 

"The point, however, is to do the operation at the right time." 

"In operable cases radiotherapy can be considered only when it will 

yield a materially betler result than will surgery." 

"We meet with this condition, above all, in the borderline cases of 

carcinoma of the uterine cervix, in which the operation is attended with 

great risk; further, in the operable cases of cancer of the uterine cervix 

and of the thyroid gland. In these latter cases, at least, the same result 

is gained by radiotherapy, with less mortality and morbidity than by 

operation." 

"Furthermore, radiotherapy is greatly indicated for social reasons 

in those tumors in which an operation involves a mutilation of the face. 

but where radiotherapy is able to cure definitely, leaving but very little 

scar. Cancers of Ihe skin, ihe face and the lips belong to this category. 

The radiological results in these cases arc quite comparable with those 

obtained by surgery, and the patients gain integrity of face, often of great 

importance for their social position." 

"Finally. I will mention that in my opinion, the majority of the

258 

sarcomata, except cares in which an amputation is considered necessary. 

are also suitable for radiotherapy. If the sarcoma does not disappear 

entirely, the remainder of the growth should be resected and postoperalive 

treatment instituted. This latter procedure should also be resorted 

to, if the sarcoma is not reduced under radiological treatment within a 

short time." 

"Postoperative treatment i>. in my opinion, indicated in cancer of 

ihe ovaries, as in most cases of sarcoma; possibly also in cancer of the 

uterus, cancer of ihe breast, and other malignant growths." 

"The crux is just to choose the right method of treatment, while 

at the same lime paying strict attention to the clinical picture of each 

individual case, and not to strain the method beyond its limitations. The 

ability to limit the treatment bespeak* the master." 

"I have tried, as far as it is possible on the basis of our experience, 

to evaluate the permanent results of radiotherapy in cancer. It is 

with a sense of great responsibility that I have considered myself in duty 

bound to assert the superiority of radiotherapy in the treatment of certain 

operable tumors, which, in the general opinion of the medical profession, 

have hitherto been regarded as confined to surgery. I consider that 

the welfare of the patient demands that radiotherapy should be recognized 

and employed in even' case where it can yield a better result than 

other methods of treatment." 

"But I must accentuate the fact that irradiation of operable tumors 

is not to be allowed, unless an experienced radiologist with sufficient 

technical resources is in charge of the treatment. Otherwise, all operable 

cases must be operated upon." 

"To those who watched the first tottering steps of radiotherapy,ii 

gives a singular and proud feeling to see its present development. The 

simplest results that we are now witnessing in the radiological treatment 

of malignant growths would, twenty-five years ago. have been 

regarded as pure witchcraft. We may enjoy this success, but we must 

realize our limitations and remember that it is still only an inconsiderable 

number, perhaps 15 per cent at the most, of all malignant growths 

lhat we are able to cure permanently, w hethcr by radiotherapy or by 

surgery. There are enonnous problems in this field still waiting to be 

solved—great difficulties to be overcome." 

"From all I have learned, I feel convinced that the radiologists of 

ihe United States will be found in the front rank in this battle against 

one of the most terrible enemies of humanity," 

J. H. V. I lev-man. M. D.. (Stockholm. Sweden). Results of Radialion 

of Cancer of the Cervix. Jour. Obstet. & Gynec. of the Brit. Fmp.. 

xxxi. 1, 1024. 

"The literature of today contains many articles regarding the use 

f radium in cancer of the uterine cervix. \ close scrutiny, however. 

shows a real scarcity of rejxirts of the results of any large series of cases 

of cervical cancer treated by radium after the crucial five-year period 

has passed, but because of the length of time over which the work has 

been conducted it is particularly interesting to note a report of the cases 

treated at 'Radiumhemmet.' Stockholm, anil which deals only with cases 

of carcinoma of the cervix. In cases of carcinoma of the uterus radiological 

treatment only i- practiced The patients are referred for treat-

R a d i u m 259 

ment of 'Radiumhemmet' almost exclusively by surgeons or gyneco 

gists, mostly from hospitals and gynecological clinics." 

"Tkchnic—-As a rule, only three applications of radium are made. 

The second application is made one week after the firsi and the third 

application three weeks after the second. If possible, radium is applied 

at each treatment both in the vagina and the uterus, the length of time 

of each application being twenty-two hours, using from 33.7 to 40.1 mg. 

in the uterus each lime, making a total dosage of about 2220 to 2640 mgm. 

hours. In the vagina 70 mgm. is used three times, making a total dosage 

of about 4500 mgm. hours. The radium is always filteredthrough 3 to 

4 mm. of lead. During the last three years a more concentrated treatment 

has been tried, the number of applications being reduced to two, 

thirty-two and twenty-four hours respectively. In such cases the total 

vaginal dose has been limited to 4000 mgm. hours. All operative interference 

at the commencement of the treatment, such as cauterization 

or excochleation, is absolutely contraindicated and ihe treatment is never 

repeated within the firstsix months. If. six months after the three applications 

already mentioned, the growth has not disappeared or if there is 

a recurrence, the treatment may be repeated, though preferably not until 

a year after the firsttreatment and only one application is then made. 

Clinically healed patients, as well as patients with a suspected 'reactive' 

inflammation, are not treated again until a recurrence has been definitely 

proved. If there is a local recurrence and the growth is operable, hysterectomy 

is performed. If there are extensive glandular metatases 

roentgen irradiation is used in conjunction with the radium treatment. 

It is also used if severe pains persist'after the radium treatment and if 

there is a recurrence in the parametria." 

"Results.—This report covers ihe period of eight years from 1914 

lo 1921, during which time 303 cases of cancer of the cervix were primarily 

treated. From 1914 lo 1918 the inoperable and borderline cases 

constituted 91.2 per cent of the series, but from 1919 to 1921 these cases 

constituted only 68.4 per cent. One-third of the patients were under 

forty-six years of age; 19.1 per cent were forty years of age or under. 

In the statistics which follow, all the patients who have died have been 

counted as dying from cancer " 

"Operable or Borderline Cases.—191.1-191& 40-5 per cent free 

from symptoms after 5 years; 1019, 47.3 per cent free from symptoms 

after 4 years; 1920. 60.0 per cent free from symptoms after 3 years; 

1921, 5S.3 per cent free from symptoms after 2 years." 

"Inoperable Cases.—1914-1918. 16.6 per cent free from symptoms 

after five years. Of the remainder 20 to 25 per cent, varying with 

the year were free from symptoms after three years. Heyman has observed 

that if local recurrence occurs, as a rule it does so within one 

year, but glandular recurrence and metatases may supervene after years 

of apparently good health. Pain, anemia and fever nearly always indicate 

the presence of cancer in the pelvis. The complications due to radium 

treatment are chiefly rectal, which appear, as a rule, six months after 

the treatment, and are due to overdosage and include tenesmus and haemorrhage. 

Since 1915 he has not had a case of fistula,while 5 patientr* 

died of diffuse peritonitis and sepsis as the result of the treatment, and 

one from pulmonary embolism. The primary mortality in this series is 

1.19 per cent."

260 R a d i u m 

Ihomas H. Keiley, M. D.. (Chicago*. Lymphosarcoma of the 

Small Intestine. Jour. A. M. A., Ixxxii. 7S5-7S6. March 8, 1924. 

"The comparative rarity of lymphosarcoma of the intestine prompts 

me 10 report a case that came under my observation some months ago." 

"Report of Cask.—The patient, a woman, unmarried, aged 34. was 

admitted to the Illinois Central Hospital. Jan. 24. 1923. with a history 

of pain in the epigastrium and lower left quadrant. The onset occurred 

seven weeks previously with sudden, cramplike pain over the entire abdomen. 

A physician who was called prescribed a cathartic, which, however, 

gave no relief. The pain gradually decreased in severity and finally 

localized a- a dull pain in the left lower quadrant. The patient was nauseated 

at the onset but did not vomit. Bowel movement had no influence 

on the pain. The history was otherwise unimportant." 

""On examination a hard, irregular mass was palpable superficially at 

the level of the navel on the left side. The mass extended downward 

to the lower quadrant, and there was marked tenderness over this region. 

1 he form of the mass could not be made out because of pain on deep 

palpation." 

"Roentgen-ray examination of the intestinal tract revealed shadows 

suggestive of many constrictions in the lumen. There was a narrowing 

of the duodenum in the second part; and. a few inches below this, an 

anterior narrowing of ihe lumen was present. There were about six 

areas in the small intestinal tract where the bowel was dilated, followed 

by narrowing of the lumen. The colon also showed narrowing in a 

number of areas, and the haustrations were very irregular and scattered. 

"Operation was performed. January 27. Five distinct tumors about 

a foot apart were found in the -mial! intestine. The loop of bowel containing 

these tumors was resected, and an anastomosis was made with the 

ascending colon." 

"The paUirlogic examination was made by Dr. H. Gideon Wells, 

who reported: ' The noticeable feature in this case is the extensive eosinophil 

infiltration of the mucosa. The tumor encircles the entire segment 

of the intestines in which it is located, (t is not more than 1 cm. in thickness 

at any point and extends along the bowel for a distance of 2 inches. 

The mucosa is slightly hemorrhagic. The diagnosis i< lymphosarcoma." 

"The patient made an uneventful recovery and is still living at the 

lime ihis report is made, nine months after operation." 

"Comment.—The treatment consists in the removal of the growth. 

the section of the bowel in which it originates, and anv accessible metastases. 

When a large portion of the intestine is involved,it is a question 

whether or not radical operation is advisable. Because of the beneficial 

effect of radium on lymphosarcoma in other portions of the body. Fisher 

(Ann. Surg.. May. 1919) suggests its use as a postoperative agent in 

all lymphosarcomas of the intestine. DeXoyelles (Ann. Surg.. Aug.. 

1922) also favors "he use of radium as a palliative measure, but believes 

that the difficulty of making a preoperative diagnosis and of securing a 

suitable technique for radium application will long he serious obstacles." 

Bradley I., t.'.iley. M.I)., (Xew York'. Retroperitoneal 1 ,\ mpliocytoma 

Causing Chylous Ascites and Chylothorax. Jour. A. M. A.. 

Ixxxii. 2031-2032. June 21. 1924. 

"The comparative rarity of true lymphocytoma is generally recognized. 

The case that came under mv care was characterized bv such

R a d i u m 261 

unusual symptoms and presented such peculiar features that it seems 

justifiable to report it in full." 

"History.—L. D,, a married woman, aged 48, had always lived on 

Long Island, and had been in perfect health until the onset of the present 

illness." 

"Two years before I saw her. she began 10 feel weakness and discomfort 

in the abdomen, which she attributed to an umbilical hernia. 

which, she states, had been present fifteen years. During this time, the 

abdomen had been large and pendulous. Associated with the feeling 

of discomfort, she had noticed dyspnea for the past eight months. There 

was a slight, intermittent, dull pain in the left upper quadrant. Her 

appetite, which had hitherto been excellent, began to fail, and there was 

some loss of weight. There were no other digestive symptoms except 

gaseous eructations, which came on after eating. There were no symptoms 

referable lo the genitourinary system. The family history was 

negative for malignant disease. The patient remembered no previous 

illness. She had always been in excellent health. She had not had any 

surgical operations." 

"The bowels had always been constipated until six months before. 

since which time the bowels had moved daily. The stools were apparently 

normal. Nocturia occurred once or twice. The patient felt 

full after a small meat. The appetite seemed to be failing. She did 

not sleep well. Six months before she weighed 220 pounds (100 kg.); 

four months before. 175 pounds (80 kg.); she had lost weight since; 

the annum: was not known." » 

"The menses had been regular until one year before, when the interval 

began lo be prolonged from two to four months. There had been 

complete cessation for the last six months. Presumably the patient wras 

approaching the climacteric at the time of onset of the present illness. 

She had been married twenty-seven years and had five children, four 

of whom were living and well. There had been no miscarriages." 

"Aug. 27, 1922. ihe patient consulted the family physician. He advised 

gastro-intestina! roentgen-ray examination, which was done with 

inconclusive findings. Ihe patient was then advised to enter a hospital 

for observation and was admitted to St. John's Hospital. Brooklyn, September 

2. under the care of Dr. George F. Sammis." 

"The abdomen was not distended, rigid or tender; there was a fair 

amount of abdominal fat. Percussion over the left iliac region revealed 

definite dullness and resistance, and the outline of a mass that had a wave 

of fluctuation as of fluid. There was an umbilical hernia the size of a 

lemon. Percussion over the liver revealed slight increase of dullness. 

The extremities were normal." 

"A few days later an exploratory laparotomy was' performed by 

Dr. Sammis. who found a thin, creamy fluid in the abdominal cavity. A 

large mass, fairly smooth, apparently involved the posterior peritoneum, 

the entire mesenteiy of the upper abdomen, and extended into the left 

pelvis. The uterus and the right ovary seemed to be normal. The tumor 

was studded with petechial hemorrhages. The omentum was ligated 

and the hernial sac removed. The wound was closed in layers; one rubber 

tissue drain was inserted. Not any of the mass was removed, because 

of its extensive involvement of the entire mesentery; the possibility 

of aggravating the condition, should it be malignant, and the impossibility 

of its removal, because of interference with the blood supply 

of the intestine."

262 Radium 

"Examination.—I saw the patient about four weeks after her uneventful 

convalescence. At this time she was suffering from severe 

dyspnea and orthopnea. She was well developed and well nourished. 

and evidently was chronically ill. The principal findings were signs of 

fluid at the right base extending posteriorly up a> far as the scapular 

spine, i. c.. dullness approaching flatness, loss of fremitus and distant 

voice sounds, the breath sounds being absent. The abdomen was rotund. 

not markedly distended, and presented a linear midline scar extending 

for a distance of 3 inches, its midpoint being ihe center of a line from 

the pubic symphysis to the ensiform cartilage. The umbilicus was absent. 

To the left of the incisional scar, an ovoid mass about 9 cm. in 

diameter, movable, firm but noi stony hard, was indistinctly felt. The 

mass could be slightly shifted. Percussion over it gave a dull tympany. 

Palpation did not elicit tenderness. There was no engorgements of the 

superficial veins, no swelling of the extremities, and no glandular enlargements." 

"Treatment and Course.—The following day. by thoracentesis. 5 

pints of fluidof a milky character was withdrawn. This fluid was examined 

by Dr. Ewing and pronounced true chylous fluid. Following ihe 

aspiration, the patient experienced relief from the distressing respiratory 

symptoms. However, a gradual progressive enlargement of the abdomen 

followed which necessitated aspiration ten days after the chest aspiration. 

at which time 6!? quarts of fluid was withdrawn, the nature of which 

was identical with that obtained from the right chest. Keaccumulation 

of fluid in the abdomen necessitated tappings at frequent intervals during 

the next thirteen months. The intervals at first varied from seven 

to ten days. There was a long period in which lappings were unnecessary, 

from March 9 to June 29, M23. F.dema of the lower extremities 

was never present." 

"March 6. 1022. there were signs of fluid in the right chest, and a 

second right thoracentesis was performed, yielding lj^ quarts of milky 

fluid. March 19. 2 quart* was removed from the left chest. From October. 

1922. to Xovcmber. 1023, I performed abdominal paracentesis thirtyfive 

times, a total of 231 quarts being removed. 'Thoracentesis was resorted 

to three limes, with a total of 6'i quarts." 

"Five weeks after the first aspiration, the patient was removed to 

the Memorial Hospital, where an exposure of 16.000 millicuries hours of 

radium at 10 cm. distance was given with the pack placed directly over 

ihe abdominal mass. This treatment resulted in a marked decrease in the 

size of the mass as made out by palpation, though the rate of the accumulation 

of fluid was not lessened, "îx weeks later, a second radium pick 

treatment was given in the same manner, with a dosage of 1S.000 millicurie 

hours at the same distance. Following this treatment, the abdominal 

mass diminished in size." 

"Two months later the accumulation of fluid suddenly diminished. 

and for fifteen weeks no tappings were needed. Coincident with the 

cessation of rcaccuinulatic-n of the fluid there was a marked improvement 

in the general condition, strength returned, and the patient was up 

and about and doing light housework." 

"The ihird radium treatment was given in the same manner. May 

8. 1023. the dose being 1S.000 millicurie hours." 

"Seven weeks after the third treatment, the alxlomen began to swell 

very gradually, until June 29. 1923, when aspirations were begun again. 

Xo further radium treatments were given, and the patient's general con-

R a d i u m 263 

dition continued satisfactory despite repeated lappings, until September 

i, when she began to fail and grew progressively weaker with loss of 

appetite and severe pain in the abdomen associated with severe 'dragging 

down' feeling. She died. December 5." 

"Postmortem Findings.- T-.xamination, limited to the abdomen, was 

performed six hours after death. There was about 4 quarts of greenish. 

opaque, milky fluid free in the peritoneal cavity. The peritoneum was 

greatly thickened. A firm, cordlike adhesion attached a loop of ileum 

10 the lower right anterior parietal peritoneum. The transverse colon 

and most of the jejunum was involved in a meshwork of adhesions, some 

fibrinous and velamentous, others firm and fibrous. The pelvic organs 

were normal. The liver was not greatly enlarged, and seemed normal 

save for extensive cloaking in adhesions. The stomach, duodenum and 

spleen and kidneys seemed normal." 

"A fleshy tumor mass occupied the posterior portion of the abdominal 

cavity, which was retroperitoneal and extended from the brim of the 

pelvis upward, apparently fading out at Ihe level of the attachment of 

ihe diaphragm. It extended somewhat farther on the left side than on 

ihe right, and completely invested the aorta and vena cava. The thoracic 

duct was not definitely identified, but was necessarily involved. The 

mass was reddish, homogeneous and firm. There were no hemorrhages 

into its substance, and it was not densely hard or nodular. At several 

points in the adjacent retroperitoneal space, small, ovoid, yellow, encapsulated 

bodies were seen. They shelled out readily, and seemed like 

inspissated fat. There was a similar ovoid (discoid) tumor mass, approximately 

S by 10 cm. in diameter and 4 cm. in thickness, growing 

between the leaves 01" the mesentery of a loop of high ileum. The mass 

resembled closely the retroperitoneal tumor, but was nol directly contiguous. 

It was removed for a specimen. One of the yellow bodies 

mentioned above was removed from the under surface of the right lobe 

of the liver." 

"Microscopic examination by Dr. James Swing revealed that the 

tumor was composed of a diffuse growth of small lymphocytes. These 

grew diffusely, infiltrating all tissue actively, and without any inflammatory 

or fibrous reaction. There was little tendency to necrosis. The 

walls of the blood vessels were infiltrated. The process was a true lymph - 

ocytoma. It fell in the group of true pseudoleukemia, except that the 

process was locally aggressive and malignant. It was a true tumor of 

lymphocytes." 

* * * c * * * 

Joseph L. DeCourcy, M. D„ (Cincinnati). Cancer of the Thyroid. 

Annals of Surgery, Ixxx. 551-554. October. 1924. 

"Treatment.—All adenomata should be removed as soon as diagnosed. 

Surgery offers a 100 per cent cure in adenomata of the thyroid 

with'a mortality of less than 1 per cent in all cases. If toxic, of course 

proper judgment should be used as to ligation, time to operate, etc. X-ray 

and radium have no [dace in the treatment of adenomata, in my opinion, 

and are more apt to do harm than good." 

"If the above treatment were carried out. cancer of the thyroid would 

be reduced to a minimum. When cancer has advanced, however, to a 

stage where a clinical diagnosis is possible, then the method of treatment 

becomes problematical. At present I feel that the outlook is hopeless 

and that they will do just as well if left alone. I may be wrong. I do

264 Radium 

not. however, believe that surgery is indicated. Possibly needling with 

radium, at present, offers the best means at our disposal. Deep X-ray 

therapy may find its place in the treatment of thyroid cancer but I feel 

that it may do damage in the destruction of the parathyroid bodies." 

"Technic for Xecdlhtg w;t'; Radium.—The wound is opened and the 

muscles separated as in the firststep of a thyroidectomy. The needles 

arc then inserted into one lobe of the mass, each needle being about half 

inch apart. The wound is left open and the needles removed in 12 hours, 

the following morning, or twelve hours later, the wound is closed. The 

patient is then kept under obsenation for four weeks. Csually after 

iwo or three weeks the mass becomes oedematous and there is some danger 

of strangulation. About the fourth week the other lobe is needled." 

"Following this treatment should be given a prolonged course of 

X-ray therapy." 

* * * * * * * 

Leon H. Smith. M. P.. (Buffalo, X. Y.i. Epithelioma of the Tonsil. 

X. V. State T. Med., xxiv, 2S0-202. March 7. 1924. Abstracted from 

The Eye. Ear. Xose and Throat Me>n:hly, iii. 37S. August, 1924. 

"Leon H. Smith, at the last annual meeting of the Medical Society 

of the Stale of Xew York, read a paper on epithelioma of the tonsil 

based on the study of .10 patients who had been treated at the Buffalo 

State Institute for 'he Study of Malignant Disease. The cases were 

divided into the four following groups; (1) Cases with the new growth 

confined to the tonsil and excellent general condition (4 cases); (2) 

cases with early cervical metastases and good general condition (10 

cases); (3) cases with well-marked metastases and poor general condition 

(14 cases); (4) hopeless cases with advanced toxic cachexia (12 

cases). Thirty-six of the paiienis were males and 4 females. The ages 

ranged from 2S to £2. the average l>eing 55. As regards the earlier 

medical history, only 12 sta'ed that they had had previous attacks of 

sore-throat or tonsilitis; -5 per cent admitted excessive indulgence in 

tobacco, and only three had not used nicotine in any form. Ten had 

well-marked dental caries, and -even moderate dental caries accompanied 

by pyorrhcea. In three there were upper and lower plates. In 

only two patients was the Wassermann reaction positive. The chief 

complaints were sore-throat and discomfort which were present in at 

least 30 per cent. A biopsy was performed on each patient, care being 

taken to remove only a small portion of tissue if dental caries or oral 

sepsis was present. In the differential diagnosis the following conditions 

had to be excluded: Gummata. tuberculoma, napiloma. sarcoma, and Vincent's 

angina. The |H>ssibility, however, of the coexistence of syphilis 

or tuberculosis widi cancer should not be overlooked. The earlier patients 

were treated by X-rays, but the results in the vast majority were 

unsatisfactory, retrogression of the neoplasm and improvement of the 

general condition being only temporary. Puring the last three years a 

combined method of treatment has been adopted. Radium emanation 

in glass beads is inserted into the growth where they arc allowed to 

slough out or remain encysted, and deep X-rays or the new radium pack 

are applied to the cervical regions. Apart from cases of a fulminating 

type- patients in whom the symptoms had lasted one to three months 

only were favorable subjects for treatment. After the lapse of three 

months ihe cases became more refractory to treatment and after six 

months altogether inoperable. Seventeen patients in the present series

R a d i u m 265 

died from hemorrhage, two from general sepsis, four from suffocation 

due to edema of the glottis, and three from profound toxemia. In conclusion, 

Dr. Smith emphasizes the importance of early diagnosis and 

the prompt institution of radiation therapy." 

Isaac Levin. M.D.. (Xew York City). Intraperitoneal Insertion 

of Buried Capillar)' Glass Tubes of Radium Emanation in Carcinoma 

of the Cervix Uteri. The Amcr. J. of Roentgenol. & Radium Therapy. 

xii, 352-357. October, 1924. 

"Radium and roentgen therapy is beginning to acquire such a preeminent 

position in the treatment of carcinoma of the cervix uteri that 

recently surgeons themselves arc beginning to abandon radical panhysterectomies 

in favor of irradiation. Ochsner states that during the 

last four years he has turned over to treatment with radium and roentgen 

radiation all cases of carcinoma of the cervix, even those not advanced.'' 

"The methods which the writer has employed in the treatment of 

carcinoma of the cervix have changed from time to time. They consisted 

at first in intravaginal and intracervical application of filtered 

radium combined with roentgen therapy of the pelvic region. At present 

the method of radiotherapy in these cases consists in the intratumoral 

insertion of buried capillaries of radium emanation accompanied by high 

voltage roentgen therapy of the pelvis." 

"During the last five years the writer has done a considerable amount 

of experimental and clinical investigation of this method of intratumoral 

insertion of glass capillaries of radium emanation. The method will 

play a prominent part in the future development of radiotherapeutics in 

cancer and it will therefore not be amiss to state here briefly the writer's 

conception of the mechanism of the biological action of these capillaries 

of radium emanation. Unlike the metal filtered radium the thin glass 

wall of the capillaries filtersoff only the alpha rays and allows the free 

passage of both the beta antl gimma rays. Consequently the main difference 

between the action of ihe glass capillaries of radium emanation 

and the filtered radium, whether used as a flat applicator or a metal 

needle, consisis in the fact that in the latter only the gamma rays are used, 

while in the former the beta rays are also employed." 

"It is difficult to separate the beta rays from the gamma rays in 

order to study the biological action of the former, though Abbe recently 

made an attempt in this direction. However, the biological and therapeutic 

results obtained by the action of gamma rays alone and by the 

combined action of beta and gamma rays differ to such an extent that 

certain conclusions as to the aciion of the beta rays can be drawn." 

"In cooperation with Michael I.evine. the writer employed this 

method experimentally on normal and neoplastic tissues of animals and 

plants. The capillary glass tubes were inserted into normal liver, spleen 

and bone marrow of rabbits, into the muscles and testicles of rats and 

mice, into normal young plant tissue, into crown galls of geranium and 

into club roots of cabbage." 

"A gross and microscopic analysis of the irradiated tissues was 

made. The zone of tissue immediately surrounding the glass capillary 

was in a state of complete necrosis. The second zone showed characteristic 

gamma ray irradiation changes in the protoplasm and nuclei of

266 

R a d i u m 

the cells. This latter zone was more extensive in tumor than in normal 

tissues." 

' In addition to the experimental investigations, the writer subjected 

to microscopic study tissues obtained on clinical material at various 

intervals after the insertion of the glass capillaries. In general, the clinical 

results are vary significant. Pathological conditions, which do not 

yield to large quantities of filteredrays, respond readily to the beta rayaction.'" 

"Microscopically, human tissues examined one to two weeks after 

the insertion of the capillaries >how the same condition as in animal and 

plant tissues, i. e., a narrow zone of necrotic lissue and a second larger 

zone which shows the effect of gamma radiation. In material studied 

six to eight weeks after the insertion of the capillaries the necrotic tissue 

is found to be completely absorbed and the second zone of tissue is replaced 

by connective tissue. Ihe ultimate clinical result is replacement 

of all or most of ihe cancer tissue by dense connective tissue scarring. 

Progressive necrotization and sloughing takes place when too large a 

dose has been used, and particularly in ulcerating tumors." 

"A superficial analysis of the results obtained may produce the impression 

that the action of the beta rays on the first zone of tissue is 

identical w ith the action of a simple caustic agent. A closer study of 

the phenomena involved, however, shows that ihe mechanism of the 

action of beta rays differs widely from the caustic effects of heat or 

chemical agents and is qualitatively analogous to the action of the gamma 

rays. Moreover, the whole sequence of the tissue changes reported above 

may result from the action of large amounts of gamma ravs." 

"The biological action of the gamma rays of radium and of the analogous 

roentgen rays must depend in the ultimate analysis of the intraatomic 

action of these rays on the atoms of elements. This action, in 

accordance with the present day conception of physics, is as follows:" 

"Gamma rays and roentgen rays are rays of light of very small 

wave lengths. When they enter an atom of matter they disturb the 

electronic equilibrium and free a certain number of electrons of the 

influence of ihe positive nucleus of the atom. These free electrons travel 

in a certain direction wiih a given velocity and as a result produce within 

the Cher scattered or characteristic roentgen ravs. The results will 

be the same whether the original agents are the gamma rays or the roentgen 

rays." 

"A biological effect of the ray* on tissues means a change in the 

structure of the tissues and must be a result of changes in the atoms 

of the tissues. A gamma raj entering the tissues sets into motion a number 

of electrons. The latter produce secondary roentgen ravs which 

influence the other component parts of the tissue. Beta ravs are themselves 

electrons in motion and when they enter the tissue they must 

produce analogous secondary roentgen rays, because they have a velocity 

similar to the velocity of ihe electrons produced in the tissue bv the 

gamma rays of radium. Consequently biological action of the gamma 

and beta rays must be analogous. The difference is quantitative and is 

due to the fact that the ratio of beta and gamma rays in a unit of radium 

is about loo to I. Five millicuries of radium emanation distributed in 

10 capillaries will destroy 10 cu. mm. of carcinoma. To produce the 

same effect by surface application, the gamma rays of 500 millicuries 

would have to be employed. The statement made by physicists that the 

biological effect of 1 millicurie of radium emanation buried in the tissues

R a d i u m 267 

equals 132 millicurie hours of surface application of filtered radium takes 

into account only the action of the gamma rays and disregards the action 

of the beta rays and their secondary x-rays." 

"The outstanding fact in the whole field of therapy, by surgery or 

radiation, of cervical cancer is that the results become poorer the more 

the process advances into the broad ligaments, the other pelvic structures 

and regional lymph nodes. That surgical removal must fail in all 

of these cases i» self evident, since dissection must be done within an 

area infected with cancer cells and serves only to disseminate these cells 

through the opened lymph and blood channels. The failure of the present 

methods of radiotherapy, on the other hand, must be due to the fact 

that the radiations do not reach with the necessary intensity into all the 

distant areas involved in the process. 'That radium in any form introduced 

through the vagina cannot influence a carcinoma high up in the 

pelvis unless the quantities are so large that normal vital organs are injured 

is an established fact. Large quantities of radium, placed over 

the abdomen in combination with vaginal irradiation, may influence a 

certain number of cases. For a time it was hoped that by the aid of the 

high voltage roentgen-ray apparatus and tubes much better results would 

be obtained. But even with all these methods combined not more than 

20 per cent of the clearly inoperable cases with involvement of the broad 

ligaments and the regional lymph nodes can be influenced. It is thus 

self evident that a constant search for any additional method of radiotherapy 

is more than justified. 

"For ihe last four years the writer,,has done a considerable amount 

of clinical work with the intratumoral insertion of buried capillary glass 

tubes of radium emanation introduced through a laparotomy wound. 

For instance, when a carcinoma of the recto-sigmoid juncture is situated 

so high that die upper margin cannot lie reached through the anus, 

a laparotomy is performed. The patient is placed in a steep Trendelenburg 

position and if a radical surgical removal of the tumor cannot be 

done then the radium emanation capillaries are introduced through the. 

l>eritoneal covering into the tumor mass of the rectum or sigmoid. If 

necessary', a colostomy is done at the same sitting. The capillaries used 

for intraperitoneal insertion are sterilized either by boiling or by immersion 

in alcohol iodine and must contain not more than between 0.2 

to 0.7 mc. of radium emanation. Following the intraperitoneal insertion 

of the capillaries, there may lake place a severe reaction with high temperature 

which subsides in a few days. This reaction, in the experience 

of the wriler, takes place only in those cases in which the tumor is ulcerated, 

like carcinoma of the rectum or cervix, and is most probablydue 

to the combination of bacterial infection and radium necrotization;. 

The writer employed the method of intraperitoneal insertion in tumors 

of the ovaries, retroperitoneal tumors and hypernephroma and saw no 

reaction following the insertion. On the other hand, a severe reaction, 

as will be shown later, mav follow insertion into the tumor of the cervix 

through the vagina without a laparotomy. In the majority of cases there 

is no reaction and the patients make an uneventful recovery." 

"The present report is based mainly on the work done in cooperation 

with Dc. Gustav Seeligmann at his Gynecological Service of the 

Lenox Hill Hospital, New York, For the last two and a half years Dr. 

Seeligmann and the writer have treated all cases of carcinoma of the 

cervix either by radiotherapy and surgery. Different methods were 

tested and finally the following general scheme was followed. A thor-

268 R a d i u m 

ough examination of the patient is made ami if it is determined that the 

carcinoma is confined to the cervix and the vaginal wall then radium 

emanation capillaries are inserted through the vagina, and this is followed 

by a course of high voltage roentgen therapy. In cases in which 

the broad ligaments arc involved and there are fixed pelvic masses palpaled, 

a laparotomy is performed. The patient is placed in a Trendelenburg 

position and the capillaries are inserted into carcinomatous tissue 

wherever it is found, i. e.. the broad ligaments, the spaces between bladder 

and uterus, between uterus and rectum, into the regional lymph nodes 

ami also into the supravaginal portion of the cervix. The operation, as 

stated above, is in some cases followed hy a severe reaction with high 

lever which generally subsides in a few days. In other cases no reaction 

follows ihe intraperitoneal insertion of the capillaries and the patients 

make an uneventful recovery. The presence or absence of reaction does 

not depend upon the extent of the growth or the amount of radium emanation 

used and. as stated above, is due to a combination of Iwicterial infection 

and radium reaction. After the patients have recovered completely 

from ihe effects of the operation, they receive a course of high 

vollage roentgen therapy." 

"This investigation has not been continued long enough nor on a 

sufficient number of cases to allow one to draw final conclusions as to 

its value. It is presented as a preliminary report of an additional method 

of radiotherapy of carcinoma of ihe cervix. It is fairly easy of execution 

for any trained surgeon and the risk to the patient is not very great. 

On the other hand, the method is capable of placing the source of radiation 

in intimate contact with carcinomatous tissue everywhere. In combination 

with correct high voltage roentgen therapy it ought to improve 

considerably the therapeutic results in the advanced inoperable conditions, 

particularly when the broad ligaments and the spaces between the 

ulerus and the bladder and the uterus and the rectum are involved. 

Since. a> stated above, in this type of cases with the best methods of 

radium and roentgen therapy emploved at present less than 20 per cent 

may be benefited, it is imperative that this additional method of intraperitoneal 

insertion of buried capillary glass tubes be given a thorough 

trial." 

* * * * * * * 

George R. Minot, M. D., and Roy G. Spurling. M. D.. (Boston). 

The Effect on the Blood of Irradiation, Hspecially Short Wave Length 

Roentgen-Ray Therapy. The American Journal of the Medical Sciences, 

clxviii. 215-241. August. 1924. (From the Medical Service of 

the Collis P. Huntington Memorial Hospital of Harvard University.) 

"The physiological effecis of exposure to roentgen-rays and radium 

are assuming increasing importance in clinical medicine; particularly 

with the advent of the use of apparatus of high voltage delivering short 

wave lengths. It has long been recognized that desirable theraputic irradiation 

produced slight blood alterations, and that excessive irradiation 

produced profound changes in the hematopoietic system. There has 

been a general impression that a profound effect on the blood, which 

might lead to disasirous results, would become prevalent with the administration 

of the new short wave length therapy." 

"Resume of the JMeratnre. In order to evaluate ihe known effect 

of irradiation on the blood, a brief review of the literature is given below. 

For the benefit of those who wish to study the subject in detail, 

an essentially complete bibliography is appended."

R a d i u m 269 

"The data in the literature on the effects of irradiation on the blood 

are confusing, owing chiefly to the utilization of many different kinds 

of apparatus delivering different degrees and qualities of light. Details 

regarding the amounts of irradiation utilized have often been omitted. 

hence only generalized statements are made below concerning the blood 

changes after irradiation with either roentgen-rays or radium." 

"It has become generally accepted that biological reactions after 

exposures to roentgen-rays and radium are essentially the same, the 

degree of reaction depending upon the quality of irradiation taken into 

the organism. The location of the exposure appears not to create a 

fundamental difference in the alterations that occur in the blood. Levin 

states, however, that radium causes less general disturbance to the blood 

and hemopoietic system than does corresponding doses of roentgen-rays. 

It is also his belief, from animal experimentation, that the effect of irradiation 

on the blood is dependent upon the square surface of entry of 

irradiation into the organism to a far greater extent than upon the size of 

the dosage administered." 

"Heineke, in 1904, made the firstcareful histological studies of the 

blood and blood-forming organs following roentgen-ray exposures. His 

experiments were made upon small animals. He demonstrated that the 

lymphoid tissue of the body was primarily affected, and that there developed 

a degeneration of lymphoid follicles in the spleen and lymph 

glands, and a diminution in the number of lymphocytes in the circulating 

blood. He also found that there was a marked diminution in the number 

of white cells after heavy irradiation, beginning after the second day, with 

a predomination of polymorphonuclear neutrophiles. After several days 

Ihe lymphocytes almost entirely disappeared, while the absolute number of 

polymorphonuclear and large mononuclear forms showed scarcely any 

change. From his studies on the bone-marrow he found that the white 

cells, with few exceptions, were destroyed. This destruction of white 

bone-marrow cells was apparent in three hours after exposure, and 

reached its height after eleven hours. The destructive process terminated 

afler five or six days. Heineke noted that the injured bone-marrow was 

capable of regeneration, which commenced before the destructive action 

ceased and was completed by the end of the third or fourth week. He 

suggested that the diminution in the circulating lymphocytes is referable 

directly to the selective destruction of the lymphogenic tissue by roentgenrays. 

These observations on the hemopoietic system have been confirmed 

by Warthin, Aubertin and Beaujard. and others. It has also been shown 

that if the irradiation is sufficient! actual complete aplasia of the marrow 

occurs with its characteristic peripheral blood picture." 

"During the next few few years, following this pioneer work of 

Heineke, reports of intensive studies of the circulating blood after irradiation 

appeared in the literature. Practically all the recorded observations 

were made on small animals with only an occasional observation 

on patients. Aubertin and Beaujard were apparently the first to report 

that prior to leukopenia there developed a primary transient leukocytosis. 

They found that the leukocytosis was due almost entirely to an increase 

in the polymorphonuclear neutrophilies. Since their report many have 

observed that an initial leukocytosis occurs in both animals and man after 

any amount of irradiation in contrast to the leukopenia which develops 

only after relatively large doses. The height of this leukocytosis apparently 

varies in animals and man; in animals an increase of 100 per cent 

in the number of circulating leukocytes is common, while in man the

270 R a d i u m 

increase seldom amounts to over 50 per cent. The leukocytosis usually 

starts about two hours after roentgen-ray treatment, and has reached 

its height in twelve hours. It persists, on the average, for not longer than 

twenty-four hours. The height of the leukocytosis does not seem to be 

dependent u|K>n the character of the irradiation. When radium is used 

the leukocytosis lasts longer than when roentgen-rays are used; often 

forty-eight hours. This longer duration may be due to the fact that 

radium is often applied for a much longer period of time than the 

roentgen-rays." 

"All observers have found that following the leukocytosis there often 

occurs a marked decrease in the number of white blood cells, especially the 

lymphocytes. This decrease amounts to an actual leukopenia if sufficient 

irradiation is used. In experimental animals the while cells have been 

recorded as low as 1000 per cu.mm.. requiring five to fifteen days before 

they return to normal numbers. This degree of reduction of the white 

cells rarely has been observed in man following customary therapeutic 

doses of irradiation, though excessive irradiation may lead to such a 

reduction. In the early literature, counts of 4000 white cells per cu.mm. 

are occasionally recorded in man. but such counts were only transient 

and the normal level was reached in a few days. This contrast between 

the effects of the rays on animals and man is but one of degree and can 

be accounted for by the proportional difference in ihe size of the doses 

used. However, since the more recent clinical reports of the effect on 

the blood of large doses of radium and roentgen-rays. leukopenia of 

greater degree and of longer duration than formerly recorded, is being 

observed following treatment. Leukopenia, following intensive treatment. 

has been recorded as persisting from three to five weeks, and Heim states 

that it may be even eight lo twelve weeks before the white cells return to 

normal. The advent of the high voltage machine delivering rays of short 

wave length is not wholly responsible for the recent increase in the frequency 

of leukopenia. This is because larger doses of irradiation have 

been employed with all forms of apparatus during the last three to four 

years. The blood changes now being observed following intensive irradiation 

are quite comparable to those observed in small animals many 

years ago. because the large doses now being used therapeutically approach 

quantitatively the doses originally employed in animal experimentation. 

It is noteworthy that information in the literature is scant concerning the 

ease with which leukopenia is produced by second courses of treatment." 

"To prove whether the leukopenia produced by irradiation is due to 

a direct effect on the circulating blood or to a suppression of activity 

of the bone-marrow. Benjamin *•/. al., performed some ingenious experiments. 

They showed that it is ]>ossiblc to produce the characteristic 

changes in the circulating blood (leukocytosis followed by leukopenia) 

not only by irradiation of the blood-forming organs, but also by irradiation 

of the isolated blood. A cardinal difference in the effect of irradiation 

of the two tissues is that regeneration occurs with astonishing 

ease in the latter instance, while after the bone-marrow is exposed seven 

to ten days are required for regeneration. They conclude that the transient 

changes occurring in the blood during the first twenty-four hours are 

accompanied by a destruction of leukocytes in the blood stream while 

the more prolonged alterations are due to injury of the hemopoietic 

system." 

"It has been well established that the lymphocytes are the most sensitive 

of all the blood cells to irradiation. Since Heineke demonstrated in

R a d i u m 271 

animals a diminution of the number of circulating lymphocytes and a 

destruction of lymphoid tissue following exposure to roentgen-rays. this 

phenomenon has been investigated by many, especially Mottram and 

Murphy. The results show clearly that while relatively large doses of 

irradiation cause a marked decrease in the number of circulating 

lymphocytes, distinctly small doses act as a stimulus to the lymphogenic 

organs and cause a lymphocytosis. The degree of lymphopenia is not 

necessarily proportional to the degree of leukopenia. Quite comparable 

lo the effect of small doses of roentgen-ray or radium irradiation is the 

effect of the similiar light rays from the sun, as it has been shown by 

Aschenhcim. Clark, and others, that there occurs a relative and actual 

increase in the number of circulating lymphocytes after exposure lo direct 

sunlight." 

"The percentage of jiolymorphonuclear neutrophiles varies in inverse 

proportion to the percentage of lymphocytes at all times following irradiation. 

The absolute numbers of polymorphonuclears are increased. 

except with leukopenia, when they may l>ecome reduced to 50 per cent 

of their original number, however, their percentage still remains high." 

"Coincident with the drop in the lymphocytes, the polymorphonuclear 

eosinophils undergo a decrease. None may be observed when leukopenia 

develops. Later they increase over a period of days to weeks, reaching 

often above normal and sometimes as high as 15 per cent, then returning 

to normal m a similar period ot time. Vubertin and Beaujard found in 

animals on the fourth day following exposure an increase of eosinophils 

that persisted for two to three weeks. Later observations on man by 

Heim. Masieri, Schroeder. and Koenigsfeld, indicate that eosinophilia 

is a late rather than an early manifestation of the effect of irradiation, the 

primary rise occurring some weeks after exposure. Peterson and Saelhof 

found eosinophilia (5 to 20 per cent.) developed for a number of days 

following irradiation over the livers of dogs. I'hey did not observe such 

an increase in eosinophiles after exposure of other organs." 

"No constant changes in the character or number of polymorphonuclear 

basophiles have been observed following irradiation." 

"After irradiation little or no change in the numbers or character 

of the large mononuclear cells has been discovered by most observers. 

Wetterer, Band and Xcmnick are the only ones to report that many of 

these cells appear in the blood stream after irradiation." 

"Various observers (Aubertin and Beaujard and others) have noted 

following irradiation of animals two types of histological changes in 

the white cells of the peripheral blood; one to be interpreted as due to 

destruction and premature death, and the other indicative of youth. 

Leukocytes showing evidence of histolysis of the nucleus and cytoplasm 

with abnormal granulations have been frequently recorded in animals 

in the first week after exposure. During this period of time fragmented 

white cells were observed often, and sometimes in abundance. These 

changes occurred especially in the polymorphonuclear cells, hut "mononuclear 

ce!ls"(Morris includes lymphocytes) also exhibited such alterations. 

Coincident with the many degenerating cells there appeared in the blood 

stream an increased numlter of immature ones. These consisted for the 

most part of young polymorphonuclear neutrophiles although an occasional 

myelocyte was observed. The occurrence of degenerating and 

immature' cells in man after irradiation has been referred to but little." 

"There are relatively few observations recorded on the effect of irradiation 

on the blood platelets. Helber and Linser and Duke found that

272 R a d i u m 

there was a decided decrease in the number of circulating blood platelets 

in small animals following heavy irradiation, while smaller doses apparently 

stimulated their production and caused a rise. Similar observations 

of the effect of radium are recorded by Mottram. Buckley and Guggenhcimer 

among others have observed over ioo per cent increase in the 

number of blood platelets in man following erythema doses of roentgenrays." 

"The effect of irradiation on the red cells and hemoglobin is not so 

clearly defined in the literature as the effect on the white blood cells. 

It is evident that important changes do not occur after customary therapeutic 

irradiation unless repeated many times. Some have reported that 

if considerable anemia exists then the red cells arc adversely affected. 

Heineke. in his earliest observations, found no change in the number or 

form of the red cells or the amount of hemoglobin during the firsttwelve 

days after exposure to the roentgen-rays. During the third week he 

found that there was a slight decrease in both of these elements. His 

later observations in the clinic failed to support this view, however, as 

he found a decided increase in the red cells and hemoglobin in patients 

after roemgentherapy. It is evident from reports that fluctuations in 

the hemoglobin and red cells occur after irradiation, but confusion arises 

owing to a lack of a distinction between the effects of irradiation and 

changes in the blood due lo improvement of the patient. The current 

opinion seems to be fairly evenly divided between those w ho believe that 

there is an increase and those who recognize a decrease in the number of 

red cells and ihe percentage of hemoglobin, and those who believe there 

is no appreciable change in these two elements after irradiation. It seems 

probable that this difference of opinion may be due to variation in the size 

of ihe dose of irradiation used, as well as variations in the health of different 

patients. It is well known lhat prolonged and excessive exposure 

to irradiation may lead to anemia, an ill-effect that never has been observed 

after a single exposure. Xucleated red corpuscles have been noted 

in the circulating blood of animals, but not in man when the bone marrow 

was essentially normal, following large doses of irradiation. X*o distinct 

or constant alterations in the size, shape, or staining qualities of the red 

blood corpuscles have been obsened in man or animals following therapeutic 

irradiation." 

"The blood picture of those people chronically exposed to irradiation. 

as roentgen-ray and radium workers, is extremely variable and does not 

directly concern us here. Suffice it so say. that the blood picture may be 

one that indicates varying degrees of marrow insufficiency, while occasionally, 

if the exposure is sufficient, actual aplasia may develop." 

"Cases Studied and Methods. From the above resume of the literature, 

it is evident that there is ample information indicating that sufficient 

irradiation of an) part of the body leads to lymphopenia and leukopenia. 

In spite of.the lack of comprehensive data in the literature, it would 

appear that the degree and duration of the lymphopenia and leukopenia 

are more marked and longer with a larger than a smaller dose; that 

though the degree may be the same with different doses, the duration 

will be longer with the larger dose. The effect of the amount of surface 

area irradiated has been shown to play an important part in alteration 

of the blood in animals, but in man little attention has been given to this 

factor. Investigations reported below were undertaken with a view to 

determine the degree and duration of changes in the while cell count 

produced by desirable therapeutic doses of short wave length roentgen-

R a d i u m 273 

rays as contrasted with roentgen-rays of longer wave length in patients 

not suffering from any fundamental disorder of the hemopoietic system. 

In addition to the white cell count, observations on all the formed elements 

of the blood were made to determine what changes occurred and lo 

learn how further to evaluate alterations of the blood in regard to safe and 

efficient treatment." 

"The data presented were obtained on 42 patients with various 

forms of malignant disease. These cases have been divided into three 

groups dependent upon the amount of irradiation given. The first two 

groups consists of 20 cases, each of these patients was studied before and 

after one course of treatment received from one of two different roentgenray 

machines, delivering many long and some short wave lengths. Both 

of these machines represent types of apparatus which are commonly in 

use for therapeutic purjxises at the present time. Of these 20 patients. 

S were given from one machine and 4 from another a smaller dose of 

roentgen-ray than that received from the latter apparatus by the 8 remaining 

individuals. The maximum dose given to any of the 12 former 

patients, who compose the first group, was 424 m.a.m., while the minimum 

dose was 144 m.a.m.; 3mm. of aluminum and one sole leather filter was 

used. The treatment was given in two pans with an interval of four 

days between each part. The surface area of hotly exposed (portal of 

entry) was on an average 434 sq. cm." 

"The character of the larger treatments given the S patients who 

comprise ihe second group was as follows: The total dose varied between 

630 and 1050 m.a.m.; 4 inmNof aluminum and one thickness of 

sole leather was used as filter. The total treatment in each case was 

divided into four or five parts. In 6 of the 8 patients the total treatment 

was completed in the course of one week. In ihe other two. however, 

the total treatment was prolonged over two and a half weeks. The 

square body surface irradiated averaged 525 sq. cm." 

"The 22 patients composing the third group were studied before 

and after receiving 36 i^cparate courses of roentgen-ray treatment from 

a new form of apparatus delivering great quantities of very short wave 

length roentgen-rays. This machine was operated at an equivalent voltage 

of 220,000 and the target placed 31 inches from the body of the 

patient; J-^ mm. of copper was used as a filter. The total dose of any one 

course of treatment varied from 338 m.a.m. to 1050 m.a.m. Twenty-five 

of the treatments were given to 15 of these patients: each one of which 

was completed within a period of twenty-four hours and usually in less 

than seven hours. The remaining 7 patients received 11 treatments which 

were divided into four parts and given on four successive days. The 

surface area of the body irradiated averaged 040 sq. cm. for the 36 treatments." 

" 1 he follow ing blood examinations were carried out on each of the 42 

patients comprising the three groups. Prior to irradiation, one and sometimes 

more determinations were made of the total and differential white 

cell count, red cell count, hemoglobin percentage and platelet count of estimation 

of the numbers of platelets. The detailed character of the formed 

elements was recorded With the exceptions noted below these observations 

were repeated each day for six days following the conclusion of treatment. 

The exceptions were that red cell and platelet enumerations were made 

daily on but 13 patients, and every few days on the others. After six 

days the patients were discharged from the hospital, and then the different 

blood examinations were repeated in most cases at least once each week,

274 Radium 

or four to five weeks or until the blood findings were similar to those 

observed prior to irradiation." 

"Si'Mmarv. A study has been made of ihe blood of 42 cases, chiefly 

of cancer before and after 56 roentgen-ray irradiation treatments. Particular 

attention was given to the observations on 22 of the patients given 

36 intensive short wave length treatments. The other irradiations were 

milder. Cases of disease of the hemopoietic tissue are not included and 

the statements below require modification when applied to such conditions." 

"The most important effect of customary therapeutic doses of 

irradiation on the blood elements is to decrease the number of while cells, 

especially lymphocytes, so that leukopenia and lymphopenia may occur. 

Preceding the decrease in the white count a transient increase develops. 

due to increment of polymorphonuclear neutrophiles. Very small doses 

of irradiation may permit a lymphocytosis. 

"When a customary iherapeutic dose of short wave length roentgenrays 

is given, it causes the white count to reach its lowest point about 

six days later; at that time leukopenia (a count below 5000 per cu.mm.) 

is more often present than not. A decrease below normal of the absolute 

numbers of bone-marrow white cells, which is indicative of marrow 

depression, is not unusual. Leukopenia lasts on the average about 

nine days, but may persist for over four weeks, liven if the white count 

remains above 5000 per cu-mm., the white count often does not return 

to its pretreatment level for a momh. If treatment is given again before 

the number of cells have remained for some time at their original level. 

leukopenia of a greater degree and duration is produced than after the first 

treatment. 

"The fall in the lymphocytes is greatest in the firsttwenty-four hours. 

but they continue to drop for about three days. These cells rise with the 

white count, but do so proportionately more slowly. Subsequent treatments 

may keep the lymphocytes fewer in proportion to the white count 

than fo'lovving the firstirradiation." 

"The new short-wave-length roentgen-ray therapy, suitably given. 

produces no changes in the blood that are of a different character from 

from those occuring afier milder yet intensive irradiation. However, it 

does produce more rapid, marked and persistent changes than milder 

treatment, and if the treatment consists of merely moderate long-wave 

exposures it may not even cause a decrease of white cells." 

"An eosinophilia. of often 7 and as high as 23 per cent, is usual two 

to three weeks after short-wave-length irradiation. It appears to develop 

particularly following repeated exposures." 

"After irradiation the blood contains many degenerated white cells. 

especially in the firstthree days. There is scant mention in the literature 

of this feature of the blood in man. larger doses produce greater 

numbers of these cells than smaller doses. After short-wave-length 

therapeutic irradiations the degenerated cells often amount 10 25 per 

100 formed white cells." 

"Some increase of immature white cells may be observed, especially 

at about the time the white count begins to rise, after large doses of irradiation." 

"A slight increase of the platelets soon after irradiation is common. 

They are depressed less readily than the white cells, but following the 

transient rise they are often found slightly decreased and rarely markedly. 

Combined with leukopenia they may be an indication of greater marrow

R a d i u m 275 

depression than a decrease of only the bone-marrow white cells. About 

four days after intensive irradiation and prior to a definite rise in the 

white count, the platelets rapidly increase and remain elevated above 

normal for days to weeks." 

"Important changes in the count of ihe red blood corpuscles and 

hemoglobin |>ercentage do not occur as a result of mild or intensive therapeutic 

irradiation. Changes in the number of immature cells occur." 

"The clinical condition of the patient will influence the degree and 

duration of the blood changes after irradiation, but anemia per sc does 

not seem to be of any great importance. The white cells of patients 

whose clinical condition is similar, given the same dose in the same manner, 

show considerable variation. On the average, patients with higher 

white counts before irradiation will develop leukopenia and marked lymphopenia 

less often than those with lower counts." 

"Much more important than the condition of the patient in determining 

the influence of irradiation on the blood is the size, intensity and 

character of the dose; larger doses producing greater blood changes than 

smaller ones." 

"The amount of surface area irradiated is a factor of great importance 

in determining the tlegree and duration of the decrease of white cells. 

The greater the surface area exposed to a given amount of irradiation the 

more profound, on the average, is the effect on the white cells. Secondary 

radiation, which is greater with larger than smaller doses, with short 

wave than long wave lengths, and with a larger than smaller portal of 

entry, probably plays a role in the production of the blood changes." 

"Depression of the activity of lymphatic tissue and bone-marrow are 

probably undesirable states, yet may occur for even weeks after irradiation 

without any obvious detrimental effect. In spite of the production 

of leukopenia and lymphopenia, the benefits derived from radiation appear 

to offset these changes." 

"Prior to irradiation, particularly if one dose has been given, the 

blood should be examined. A white count alone will usually suffice to 

indicate the state of the hemopoietic organs. If 5000 per cu.mm. or more. 

irradiation may be given without producing serious harm to the blood 

forming tissues. It is not ideal to give irradiation when leukopenia is 

present, but it may be done without disaster. With leukopenia, especially 

when marked, repetition of treatment probably becomes a more serious 

event." 

"Before treatment is given to a patient with leukopenia, a complete 

study of the formed blood elements should be made, for it may reveal 

a greater degree of marrow depression than that shown by leukopenia 

only, and thus induce one to decide against irradiation. In order to determine 

whether or not to treat a patient with a given degree of leukopenia, 

one must decide whether the benefits of treatment will offset the 

disadvantages of an increased depression of the homopoietic tissue. This 

latter condition may become of relatively little importance and be distinctly 

less harmful than permitting a lesion to go untreated." 

* * * * * * 

Gordon B. New. M D., and Fred A. Figi. M. D., (Rochester. 

Minn.). Treatment of Fibromas of the Nasopharynx: Report of Thirtytwo 

Cases. The Amer. J. of Roent. & Radium Therapy, xii. 340342. 

October. 1924. 

"The tyPC of treatment lo be selected for new growths is thai which 

will give the best end-results in each particular case. It is usually neccs-

276 Radium 

sary to combine methods of treatment in order lo obtain the best results: 

we believe, however, that certain of *hese methods are of major importance, 

and the others are of minor importance in the treatment of a 

given case." 

"Tumors of the nose, throat, and mouth may be classified in three 

groups for the employment of the major form of treatment: (i) mmors 

best suited to surgical procedures; (.2) tumors best suited to cautery 

or diathermy; and (3) tumors best suited to treatment with roentgen 

and radium radiation. In Groups 1 and 2. radium or roentgen radiation 

is used in conjunction with the other methods. In our experience, fibromas 

of the nasopharynx should be placed in Group 3. Radium is the 

treatment of choice." 

"During the last fourteen years. 1910 to 1923 inclusive, we have 

examined at the Mayo Clinic 32 patients with fibromas of the nasopharynx. 

This group includes only the hard fibromas. The ages of the 

patients varied from ten to thirty-one years, ihe average being eighteen 

and one-half years." 

"The duration of symptoms previous to examination was from two 

months to six years. Five patients had had symptoms for less than one 

year, nine for more than two years." 

"'Twenty-three of the 32 patients in our series had been operated 

on from one 10 twelve times before their examination in the Clinic. The 

average number of operations was between three and four. Two patients 

said that they had had 'multiple' operations; these operations were 

not included in the average. Five patients had not been treated previously. 

Treatment had consisted of internal medication, the application 

of caustics, fulguration, and roentgen radiation. Two patients had 

been treated with radium." 

"Fibromas of the nasopharynx present a typical clinical picture; 

ihev have a definite life cycle, starting to grow about puberty, and continuing 

active until the age of about twenty-five years. The tumor is 

more amenable to treatment in older patients, since there seems to be 

a spontaneous retrogression after the age of twenty-three or twentyfive 

years. The tumor, which is hard, may be pedunculated or have a 

broad sessile base. It may have several atiachments due to ulceration. 

and mav fillthe greater part of the nasopharynx. In 10 of our series 

the tumor was confined to the nasopharynx alone, and in 13 it had extended 

to both nostrils. The antrum was involved on one side in 2 cases, 

and the palate in 3. The tumor had apparently originated in the right 

side of the nasopharynx in iS cases, in the left side in 9. in the median 

line in 3. and in one case the point of origin was not determined." 

"Fibromas of the nasopharynx are microscopically benign and clinically 

malignant. This type of tumor does not metastasize, but may, 

owing to its location and extension into the skull, cause death. In some 

of the earlier cases, tissue was removed for microscopic examination; 

this proved to be fibroma, fibro-angioma. or fibromyxoma. In a fewcases 

the specimen was reported inflammatory, due to the reaction from 

repeated previous operations and treatments. In the last four years no 

attempt was made to obtain tissue on account of the bleeding which 

accompanied such procedure, and the diagnosis was based on this history, 

the hardness of the tumor, the age of the patient, and the clinical 

picture." 

"Ihe surgical treatment of fibromas of the nasopharynx is usually 

attended with a high mortality and frequent recurrences, necessitating

R a d i u m 277 

repeated operations. The severe hemorrhage which accompanies such 

operations makes them hazardous."' 

"The patients in our scries, who were treated previous lo our use 

of radium in these cases (1910-1915), were operated on by the avulsion 

method, both through the nose and the nasopharynx. During these years 

S patients were observed; 5 were operated on and 2 died; we were unable 

to trace the other 3 patients; 3 patients were examined only, and 

not treated." 

"From 1915 to January 1, 1924, twenty-four patients with fibromas 

of the nasopharynx were examined. Twenty-three were treated with 

radium. The treatment was applied by three methods. In the first or 

early cases, a T-shape lead applicator with a 50 mg. tube of radium in 

the trough of the T was held in various positions against the tumor in 

the nasopharynx. The original dose was usually a 50 mg. tube for from 

ten to fifteen hours. It was difficult to apply ihe radium accurately in 

this manner, ami there was severe reaction in ihe structure around the 

tumor. In 2 cases the palate was perforated. Such complications are 

now prevented by protecting the posterior surface of the palate with a 

lead retractor made of 2 mm. of lead covered with a rubber finger cot, 

and by more accurate dosage." 

"In the second group of cases, steel points, containing the radium 

emanation or the element, were inserted directly into the tumor. Three 

or four points were usually inserted, depending on the size of the tumor, 

about the same amount of radium being used as in the initial dose." 

"In the third group of cases emanation seeds, averaging 0.5 to 1 

millicurie each, were implanted directly into the tumor, the number depending 

on the size of die tumor. This method has been used in recent 

cases only. Such treatments are repeated in from six weeks to two or 

three months, depending on the reaction and the result of ihe previous 

treatment. The dosage of the secondary treatments varies greatly, depending 

on the progress of the case. The number of applications required 

in the cases now cleared up. varied from two to nine, averaging 

between five and six. The length of time our patients were under treatment 

before the condition cleared entirely varied on account of the distance 

some of them lived from the Clinic, and the difficulty in returning; 

the average length of time was fourteen and two-tenths months. 

Several patients had been operated on elsewhere with much bleeding. 

The radium seems to have controlled this immediately. The crusting 

and scabbing secondary to radium treatment may be cared for symplomatically 

bv the use of oil sprays, potassium iodid internally, and so forth. 

Kleven (733 per cent) of patients were less than twenty-three years 

of age when cured, and four (26.6 per cent) more than twenty-three 

years of age when cured." 

* * * * * * * 

W. Warner Watkins. M. D.. (Phoenix. Ariz.). Pathologic Basis 

for Roentgen-Ray Treatment of Tonsil Disease. Jour. A. M. A., Ixxxiii, 

f3°5-'307i Oct. 25. 1924. 

"Most of the discussions on the subject of the irradiation of tonsils 

are conspicuous for two things; first,the absence of participation by 

general practitioners or internists, the people most interested, and second, 

the almost frantic arguments by laryngologists and surgeons in support 

of tonsillectomy, these ranging from the naive suggestion that Nature 

intended ihe tonsils to be removed because they atrophy later in life,

278 R a d i u m 

lo the statement that the mere presence of streptococci in the tonsillar 

crypts is sufficient indication for removal, since we never know where 

these supposedly iniquitous organisms are headed for." 

"The discussions have not tended to clarify the situation in the eyes 

of the people most concerned; that is. the general practitioners, internists 

and pediatricians, into whose hands the welfare of the unfortunate possessor 

of enlarged tonsils first comes. Further, I believe that the work 

of serious and unbiased workers in radiation and laryngology justifies 

the contention that there are types of pathologic changes of the tonsil 

which are amenable to radiation treatment and which should be so treated 

by preference; that proof of this is available to any one who really desires 

to weed it out of ihe mass of current literature, and that a simple 

and categorical statement can now be made that will serve as a fairlyaccurate 

guide to the general practitioner, internist or pediatrician, in 

designating whether a given case of tonsil disease is to be irradiated or 

operated on." 

"There is much in the literature on this subject that is very confusing. 

For those who can select with discrimination from the mass of 

material that has been published, there is a fairly plain path leading toward 

what will be the final truth in this matter." 

"The first publication of note in the American literature was the 

enthusiastic report of Withcrbee. in 1920. This was not the first mention 

of this method, however, for Regaud, in 1913. projiosed the treatment 

of enlarged tonsils, by irradiation, but war conditions distracted attention 

from his suggestion. Following Witherbee's report, many enthusiastic 

workers began to bring forth reports and several serious investigators 

set deliberately to work to check up the published results, and see 

where the actual iruth might lie. At the same time, a concerted cry 

went up from the laryngologists all over the country against this method, 

and every possible weak point in the treatment has been seized on and 

magnified out of all proportion to its importance. Thus, we can find 

reports that the irradiated tonsils do not remain sterile, an assertion that 

was soon abandoned by roentgen-ray workers, because they observed it 

first and found the jKunt of no importance. It has been asserted that 

the tonsils do not become fibrous as Witherbee first reported, and there 

has been the equally loud declaration that they become so fibrous that 

they cannot later be removed by operation. It has been stated that the 

parotid is injured: that the thyroid is destroyed, with resulting myxedema. 

and that the pituitary is airophied and acromegaly produced. One ambitious 

report has been brought forth in which the investigator submitted 

the entire bodies of rats to the roentgen ray up to the skin tolerance 

dose and found that mutations resulted, and on the liasis of this the investigator 

asserted that irradiating the tonsils of children would do so 

much damage to brain cells that mutations might result in iheir offspring. 

This report gave no adequate explanation of the relation between the 

brain cells which are. in ihe well formed genus Homo, some distance 

away. Altogether, the early prophecy of a keen observer among roentgenologists 

has been abundantly justified, that the irradiation of tonsils 

would make very slow headway, because it would be strenuously opposed 

by a very strongly entrenched and well organized specialty of medicine." 

"On the oilier hand, roentgenologists have unwisely rushed into this 

logomachy, adopting the mistaken policy of quoting statistics: therefore. 

one can find figures showing that tonsillectomy is the chief cause of 

lung abscess: that 55 per cent of the tonsillectomies fail to remove the

R a d i u m 279 

tonsil completely, and, when it is removed, that 50 per cent of the patients 

still have chronic throat infections; that tonsillectomy simply allows 

the bacteria lodging in the throat to drain into the cervical lymph 

nodes and filter more rapidly down into the apex of the lung; that tonsillectomy 

does this, or fails to do ;hat. In other words, we have followed 

the general trend and quoted statistics and case reports ad nauseam, 

neglecting our final and unanswerable argument—the pathologic 

basis for our contentions. The general practitioner wants the fundamental 

reason for any new treatment. A few brief fads will represent this 

foundation on which we must stand. They may be grouped under: (1) 

ihe anatomy and physiology of the tonsil; (2) the demonstrated and biologically 

controllable effect of the roentgen ray on tonsillar tissue, and 

(3) the pathologic conditions in which such a known effect, scientifically 

produced, will remedy the condition present." 

"The tonsil is essentially a mass of differentiated lymphatic tissue, 

surrounded by a fibrous envelop, which holds it in position. The free 

surface of the tonsil is covered by the mucous membrane epithelium 

of the throat, this epithelium dipping into the substance of the tonsils 

in several places, to form the familiar cypts. These crypts are formed 

just as if one had taken a sharp pointed instrument and punched the 

mucous membrane into the tonsil; there arc from ten to twenty of these 

infoldings of the cpitheliium in each tonsil. Within the tonsil, there 

arc two distinct kinds of cells: the main mass of ordinary lymphatic* 

cells, and a number of small islands, called the germinal nodules, in 

which the cells are more highly differentiated, actively dividing and 

phagocytic, evidently designed to attack, destroy and digest invading 

organisms. The network of lymph vessels enters the tonsil from the attached 

side and the lymph flow is directed toward the free surface, so that 

lymph and leukocytes arc being continually discharged on the free surface 

of the tonsil and into the crypts. The crypts are lined with epithelium 

similar to that on the free surface, except that it is thicker in the 

crypts; this epithelium is everywhere seen to be invaded by leukocytes 

and lymphatic cells, with germinal nodules protruding into the epithelium 

in a number of places.' 

'The tonsils guard the gateway to the respiratory tract and furnish 

ihe first protection against bacterial invasion." 

"The direction of ihe lymph flow in the tonsil and the discharge 

of this protective lymph with phagocytic white cells on the surface of 

the tonsil is the first defensive measure of the tonsil." 

"The crvpts. lined with epithelium, are bacterial filters,the membrane 

being thickened in the crypts and designed to hold back bacteria 

Within these crvpts. the Ivmph and leukocytes supplied from within the 

tonsil kill off tlie bacteria that invade these openings, the debris being 

washed to the surface. If the destruction becomes rapid, or retention 

within the crypts abnormal, the crypts narrow and till up with the familiar 

plugs. * When bacteria penetrate the epithelium, they are met by 

the phagocytes, which are one of the characteristics of tonsillar epithelium." 

"The third function of disintegration, destruction and absorption of 

bacteria within Ihe tonsil is a function that has been established within 

recent years. Ihe histologic and anatomic structure of the tonsil, and 

all the research work of the last few years, point directly to this function 

as an important one. if not the paramount one. of the tonsil and other 

lymphatic tissue of the throat. Whether this disintegration takes place

280 R a d i u m 

within the crypts, or whether it is performed bv the germinal nodules 

when bacteria invade the stroma of The tonsil, the result is the same." 

"Having in mind the anatomy and the established physiology of the 

tonsil, are we not forced to conclude that the tonsil is an important functional 

organ, which should be conserved, if possible, through the period 

when its functional activity is needed, unless it becomes so destroyed 

by disease that ft is no longer possible of restoration to usefulness? Is 

the effect of radiation on the tonsil such 'hat i* can accomplish this conservation, 

without sacrificing the tonsil entirely?" 

"Action of Roentgen Ray on* Tiss'je.—Biologisis tor years centered 

their researches in the roentgen ray on the action on the simplest 

types of cells, those which are least differentiated, so that we know today, 

more accurately ihan wc know much which we daily apply, what is the 

effect of roentgen rays on the lymphoid cells and what will be the results 

when a tonsil, composed of lymphoid cells, is irradiated. The effee" of 

roentgen rays on lymphoid cells is ?s uniform as that of arsphenamin 

on syphilitic lesions, and can be applied as accurately and with less danger 

of complications or effects due to idiosyncrasies. Exactly the same principles 

apply in treating tonsillar disease as are used in the treatment of 

the spleen in leukemia, in which the dose is graduated so accurately that 

lliere is a gradual dissipation of the lymphatic cells of the spleen and a 

gradual formation of fibrous tissue, except that in the tonsillar disease 

there is not the malignant reformation of these calls. Irradiation of the 

tonsil can be so graduated by the intelligent radiologist as to effect a partial 

destruction or dispersion of the abnormal mass of lymphoid cells, or 

a complete destruction, with fibrous tissue formation. Of course, the 

cervical lymph glands in the path of the ray and the lymphatic tissue 

of the pharynx are affected also, but this is usually desirable." 

"The arguments about injury to the thyroid or ihe pituitary, or 

permanent injury to the skin arc as foolish as would be the argument that 

surgical removal of ihe tonsils should never be undertaken because lung 

abscess sometimes results, or the pharyngeal pillars are injured." 

"The question to be answered by the clinician is. In what class of 

cases is it desirable to use a conservative method, which will cause the 

tonsil to return to its normal size and function, or to a condition of 

atrophy hut with a preservation of the major portion of its functional 

efficiency? In this connection. 1 might mention that the most significant 

fact in the investigations by Waters and his associates in Baltimore 

was the observation of the pathologist that, in the irradiated tonsils, there 

was a marked atrophy of the lympho'd elements, but the germinal nodules 

of the tonsils remained unaffected; in brief, the radiation cleared the 

battlefield of all untrained non combat ants and all the dead and dying. 

leaving the highly trained army and the munition factories undisturbed 

to carry on the war. Before reviewing briefly the types of pathologic 

conditions calling for treatment. I will consider what is to be regarded 

as a normal tonsil. This cannot be discussed in detail, but I simply wish 

to record the belief ihat this must he judged from clinical appearances 

and not by bacteriological investigations. If there has been one thing 

established by all the investigations on the tonsil, it is that the bacteriologic 

findings and the clinical condition of the tonsil have no definite 

relation, and the results of treatment by radiation or by surgical methods 

are not to be judged by bacteriologic findings. One can take cultures 

ihat will yield Streptococcus httnetyticus from all tonsils, if one keeps 

trying. Their presence in the crypts, so far from meaning, per se, thai

Radium 281 

Ihe tonsil is dangerous and requires radical treatment, indicates that the 

tonsil is performing its function and holding back these organisms, else 

they would be inside the tonsil and beyond the reach of the aspirator. 

Cultures furnish only confirmatory evidence of clinical symptoms." 

"Pathology of the Tonsil.—There may be. in the tonsil: 0) 

hypertrophy, (2) acute infection, (3) chronic infection, and (4) malignancy. 

"Malignancy will not be considered here, since 'here is no argument 

over the indications for irradiation in ihat condition." 

"Hypertrophy of the tonsil, or a simple increase in bulk, if it calls 

for any treatment because of mechanical factors, is beller irradiated than 

subjected to tonsillectomy; irradiation can be so graduated as to bring 

about a reduction to normal size The very presence of hypertrophy. 

without actual infection, indicates some degree of status lymphaticus. 

of which the wise surgeon fights shy." 

"Acute tonsililis may he either follicular or interstitial. In the pure 

follicular type, the infection is confined to the crypts and mucous membrane, 

without invasion of the stroma, and, therefore, without swelling 

of the tonsil. In the pure interstitial type, there is invasion of the lymphatic 

stroma and massing of the lymphoid cells within the tonsil, with 

consequent swelling of the organ. As a matter of fact, ihe infection of 

purely one type or the other is not seen, and we have both infected crypts 

and a swollen tonsil. The acute tonsilitis either promptly subsides or 

passes into the chronic stage." 

"In the chronic tonsilitis. pure types may he encountered. The 

chronic follicular tonsilitis. with infection of the crypts, is accompanied 

by infiltration of the cpilhelium by round cells, multiplication of the epithelial 

layers and exudation into the crvpts or on the surface of the tonsil. 

The crypts may gradually fill up wilh debris, or may become constricted 

by swelling of the mucous membrane lining them, or by formation 

of cheesy plugs." 

"Chronic interstitial tonsilitis may be an infection of the stroma. 

producing reaction in the lymphoid elements, and swelling of the tonsil; 

this is the hyperplastic type. On the other hand, when the infection is 

gradual, and fibrosis can keep pace with the inflammatory destruction 

of the tonsilar stroma, we have the fibrous type. In the hyperplastic type, 

ihe increase in mass crowds on the germinal nodules, narrows or obliterates 

the crypts, and hampers drainage of toxic products from the interior 

of the tonsil. Destruction and lack of drainage may cause abscess 

formation within the tonsil or around it." 

"With due regard for exceptions. I would say that the following 

lypes of pathologic changes are amenable to irradiation and should be 

so treated by preference:" 

"(a) Simple hypertiophv. whether accompanied by adenoids or 

not, because these enlarged tissues can be made to shrink back to a normal 

or atrophic condition so readily and gradually that there is no danger 

and no discomfort to the patients." 

"(b) Chronic interstitial tonsillitis of the hyperplastic type can be 

made to subside under irradiation so quickly and effeclively that, in Ihe 

absence of grave emergencies, there is no comparison between the irradiation 

and tonsillectomy. The crowding mass of lymphoid cells are 

quickly dispersed, the mass of the tonsil rapidly shrinks, the crypts open 

up and become shallower, and ihe infection subsides. If it is then desired

282 R a d i u m 

to carry the treatment further and cause a permanent atrophy of the 

tonsil, with fibrosis of its lymph stroma, this can be accomplished." 

"(c) In the chronic fibrous interstitial tonsillitis, and in the chronic 

follicular tonsillitis with little >>r no hyperplasia, the conditions are not 

so remediable, and the results will depend entirely on how much lymphoid 

tissue there is present to be shrunk by irradiation, and how effectively 

the crypts can I* obliterated by such shrinkage. It is my opinion that. 

as a rule, such tonsils, if dangerous to the general health, had better be 

removed." 

"id) When there is evidence of retained pus within the tonsil, or 

internal to it. tonsillectomy is the preferable treatment." 

"In the absence of emergency factors, the question of irradiation 

or surgery could almost be decided on the basis of presence or absence 

of enlargement of the tonsil, because if there is enlargement, this will 

mean hypertrophy or hyperplastic inflammation for all practical purposes. 

Unless some other type of treatment is called for by the clinical condition 

of ihe patient, then, a hypertrophy or hyperplastic pathologic type. 

in the absence of suppuration, can best be handled by irradiation." 

"Covcl'.'Sions.— I. The tonsil is an important organ and should be 

conserved when possible, through the adolescent period." 

"2. Irradiation has a known and well established effect on the essential 

tonsillar tissue." 

"3- Irradiation of the tonsil can be applied effectively, accuratelv 

and with safety to the tonsil." 

"4. When the pathologic changes are of the hyperplastic type, in 

which atrophy of the tonsil and reestablishment of drainage is the consummation 

to he desired, irradiation is indicated." 

"J>. When irremediable damage has been done to the tonsil, or when 

atrophy and reestablishment of drainage is apparently not to be expected, 

irradiation is not the treatment indicated, but surgery, if clinical conditions 

call for radical treatment."' 

OBITUARY 

WILLIAM H. B. A1KINS. M.B.. M.D.CM. 

( On October 2. 1924. William H. B. Aikins. of Toronto, one of Canada's 

most outstanding authorities on the treatment of cancer, died of 

angina pectoris in his office, at the age of 65. Death came suddenly as 

he was proceeding with his afternoon office routine, the only warning 

having been transient symptoms of heart trouble experienced a week 

before. 

Dr. Aikins was the son of the late Hon. I. C. and Mary E. J. Aikins, 

and was horn at "Richview," Feel County. Ontario, on August 22. 1859. 

In 1881 he was graduated from the University of Toronto, with the 

degree of M.B.. and from the Victoria University with the degree of 

M.D.CM. He took his L.R.C.P. in London in 188*1 and spent two years 

in post-graduate study* in New York. Edinburgh, Paris and Vienna.

R a d i u m 283 

WILLIAM H. B. AIKINS, M.B.. M.D.CM

284 Radium 

After passing the examination of the General Medical Council of the 

I. nited Kingdom in London, he registered in Ontario in November, 1883, 

and since ihat time until his death practiced in Toronto. 

His natural geniality and kindliness, added to his thorough training, 

insured success as a practiiioner, and these same qualities endeared 

him to'hosts of friends who now mourn the loss of his friendly smile, 

the warm clasp of his hand and his cheerful converse. 

lie was married in 1887 to Miss Augusta Hawkesworth-Wood. In 

1888 he became treasurer of the Canadian Medical Association, which 

position he held for several years. lie was actively connected with many 

charitable institutions of Toronto,—the Hospital for Incurables (for 

over -jo years), the House of Providence. Toronto General Hospital and 

the Grace Hospital. He was secretary for Canada at the International 

Medical Congress at Lisbon. 1906, and also at the International Congress 

at Budapest, 1909. and the London Congress in 1013. He was a Senator 

of the University of Toronto, representing the graduates in Medicine, 

for fifteenyears. 

Dr. Aikins was one of the American pioneers in radium therapy 

and the leading exponent of this work in Canada. At the Detroit meeting 

of the American Medical Association in 1916. Dr. Aikins was one 

of a small group of medical men inlerestcd in radium therapy, who met 

to discuss the advisability of a national organization of radium therapists. 

As a result, an organization was effected with Dr. Aikins as temporary 

president, and on October 26. 1016. at the meeting of the Clinical 

Congress of Surgeons in Philadelphia, following a dinner attended by a 

number of men interested, a permanent organization was effected and 

Dr. Aikins was elected the first president of the American Radium 

Society. Dr. Aikins was always in attendance at the Society's annual 

meetings and contributed valuable papers, as well as taking an active 

part in the discussions. His passing will he mourned by the Society 

.which he helped to found. 

Dr. Aikins is survived by his widow, a brother. Sir J. A. M. Aikins, 

Lieutenant-Governor of Manitoba, and three sisters, Mrs. J. K. Graham, 

Mrs. J. W L. Forster, and Miss Clara Aikins. of Toronto.

DEVOTED TO THE CHEMISTRY, PHYSICS 

AND THERAPEUTICS OF RADIUM AND 

OTHER RADIO-ACTIVE SUBSTANCES 

VOLUME ONE. THIRD SERIES 

APRIL AND OCTOBER, 1925 

PITTSBURGH, PA. 

1925

CONTENTS OF VOLUME ONE, THIRD SERIES 

NUMBER ONE, APRIL. 1925 

Announcement .' 1 

George C Wilkins. M. D.. F. A. C S. Radium Treatment with 

Observations Upon Its Action in Selected Cases 2 

William H. Cameron. M. D. Radon Implants. Tubes and Needles 

in the Treatment of Malignant and Non-Malignant Conditions. . 9 

George Gilbert Smith. M. D., F. A. C S. X-Ray and Radium 

Therapy in Urology 23 

William L. Harris, M. D. Closure of Bronchial Fistula of Twelve 

Years' Standing by I'se of Radium 31 

Index of Articles Relating to ihe Therapeutic Use of Radium and 

Radio-Active Substances, Which Appeared in 1924 33 

NUMBER TWO, OCTOBER. 1925 

Mr. Albert R. Raymcr. President, Standard Chemical Company, 

Pittsburgh. Pa 65 

William P. Graves, M. D. Contraindications to the Use of 

Radium in Gynecology 67 

William Sidney Smith. M. D.. F. A C. S. Gynecological Conditions 

Treated with Radium Alone or Combined with Surgery.. 76 

John Osborn Polak. M. D.. and George W. Phclan. M. D. Treatment 

of Cancer of ihe Cervix. Shall It Be Radium or Operation:- 

86 

John G. Clark. M. D. Irradiation Treatment of Myopathic 

Haemorrhage 91 

Harry H. Bowing. M. D. Significant Cellular Changes Observed 

in Irradiated Tissue. Especially of Cancer of the Rectum 03 

B. S. Barringer. M. D. Radium Removal of Carcinoma of the 

Bladder 09 

William H. Kennedy, M. D. Epithelioma of the Lip 113 

Reviews and Abstracts 

G. E. Pfahler. M. D. Radiation Therapy in Deep Seated Malignant 

Disease 122 

Obituary 

James C. Gray. M. A.. LL. D 

I25 

Title Page and Index. Vol. 1. Third Series 1 27

PUBLISHED SEMI-ANNUALLY AND DEVOTED TO THE THERAPEUTICS 

OF RADIUM AND RADIO-ACTIVE SUBSTANCES. 


Edited by Charles H. Viol. Ph. D., and William H. Cameron. M. D, with the as 

collaborators working in the fields of Radiochemistry. Radioactivity and Radium therapy. 

Address all communications to the Editors. Forbes and Meyran Avenues. 

Pittsburgh. Pa. 


THIRD SERIES APRIL, 1925 No. 1 

ANNOUNCEMENT 

Beginning with this number, Radium will be issued semi-annua 

the firstpart appearing in April and the second part in October. Radium 

appeared as a monthly publication from April, 1913. until April, 1922, 

since which time it has been issued quarterly. In the earlier years of 

its publication, the literature on radiumtherapy was scant and scattered 

—appearing largely in the European journals -and Radium served the 

useful purpose of bringing the best of this literature to its readers. 

v 

Large-scale production of radium has come about in America since 

the pioneer American production, in 1913. of high purity radium salts by 

the Standard Chemical Company of Pittsburgh. It is now conservatively 

estimated that 100 grams of radium—half of the world's total radium 

produced to date—finds therapeulic employment in America, and American 

medical journals now contain the most of the articles published on 

radiumtherapy. 

In changing to a semi-annual publication, it will continue to be the 

policy of the editors of Radium to present to its readers articles which 

represent authoritative work in the field of radiumtherapy and in the 

allied fields of radioactivity and radiochemistry fso far as these have a 

bearing on the therapeutic use of radium), with attention devoted particularly 

to those articles which are less likely to reach the medical man 

who docs not have access to a large medical library. 

The Editors.

2 R a d i u m 

radium treatment, with observations upon 

its action in selected cases* 

By George C. Wilkins. M. D„ F. A. C. S„ Manchester, X. H. 

As a therapeutic agent, radium is one of the most valuable aids to 

Surgery, and I believe it should always be considered in this relation. 

While not overlooking the fact that radium has been employed successfully 

as a therapeutic agent in many non-surgical diseases, one must 

associate its principal uses as being applicable to conditions primarily 

classified as surgical. Some former surgical procedures have been supplanted 

by radium treatment, in many conditions the assistance given 

by radiation enables the surgeon to perform operation- more successfully, 

and in other pathological conditions, notably in advanced malignancy, 

radium has given a measure of relief and longer life, where 

surgery could offer nothing, though unfortunately, many patients in this 

group have, in the past, been subjected to hopeless operations through 

mistaken judgment, or excess of zeal. 

If, then radium should be classified as a surgical therapeutic agent. 

does it not seem reasonable to maintain the position that radium should 

be used chiefly by the surgeons. A surgeon, by the very nature of his 

training and daily practice, by his clinical knowledge of anatomy, pathology 

and ihe technique of operative procedures, should be able to use 

greater skill in the method of application and better judgment in determination 

of dosage, than one not so trained. Furthermore, he stands 

in a more authoritative position when it is necessary to decide between 

the relative merits of surgery or radiation in the treatment of a given 

case. I have seen no reason yet to change this opinion held several years 

ago. when I first began lo use radium a- an adjunct to surgery. 

epithelioma of the skin 

In the treatment of epitheliomata of the skin, radium is the treatment 

of choice, even when the deeper tissues have become invaded. 

When the deeper tissues are involved, radium needles, imbedded i cm. 

apart, beneath the area involved will cause destruction of the growth. 

slowly to be sure, but effectually. In less advanced cases, surface applications 

of the radium is sufficient. It may be argued that excision with 

the knife has achieved successful results in the past. True, but radium 

can be used successfully, with practically no scarring, about the lids, 

canthi, and on the tougher, unyielding tissues about the nose, where it 

is difficult to perform excision without deformity. If it is the better 

agent for removal of growths in locations difficult of access, then why 

is it not the better agent elsewhere? Furthermore, epitheliomata of the 

skin treated by radium are less likely to recur than when removed by 

excision. The same line of argumem applies to the treatment of keratoses 

of the skin. Of the skin epitheliomata I have treated, 10% have 

been for recurrence after surgical removal. 

•Reprinted by iwrmlssion (mm Ihe Boston Medical nnd SurgU-.-il Journal. Vol. 191, 

pp. 1014-1018. Nov. 27. 1951. Read be for? tbe merlins of the New England Sumieal 

Society at HaiHor.1. i>nn.. September 26 and 21. 1921.

R a d i u m 3 

ORAL CANCER 

The next paper will cover several phases of oral cancer and I will 

only state my conviction that the knife has no place in the treatment 

of cancer within the mouth. The knife adds to the danger of recurrence, 

by carrying cancer cells into the tissues, and by cutting across 

lymphatics and blood vessels; and there is the ever present tendency to 

leave too much tissue behind in the attempt to achieve a good plastic 

result. I believe the best results can be obtained by thorough electrocoagulation 

of the cutnc involved area first, under a local or general 

anaesthetic, followed immediately by the insertion of radium deeply 

throughout the destroyed tissues. When accurately applied, the heat 

generated in the tissues by electro-coagulation effectually seals the lymphatics 

and blood vessels immediately surrounding the area of destruction. 

The treatment must be thorough and wide, ami the dosage heavy, 

disregarding subsequent bone destruction and the temporary very painful 

reaction lasting from two to six weeks. When a considerable area 

of the tongue or floor of the mouth is to be destroyed, a preliminary ligation 

of the lingual artery should be performed. 

The following are illustrative types of oral cancer difficult or impossible 

to remove surgically on account of their location, but which have 

been successfully eradicated by employing the combination of electrocoagulation 

and radium: 

Mr. CC was referred to me November i. 1920, vvith a tumor 1 cm. 

in diameter lying on the right side of the fraenum of the tongue, and 

involving the mucous membrane of the floor of the mouth. A small 

white area was noticed at the site of the present tumor in February. 1920. 

In June, firstnoticed increase in the thickness. On November 1. two 

i2-5 mg. needles were buried in the tongue, and one 25 mg. tube screened 

vvith lead and rubber, placed on the surface for cross-firing. This remained 

in place three hours, and then treated the next day for the same 

length of time. On November 22 the slough had separated and the area 

had nearly healed. On this dale two needles and one tube, totaling 50 

mg., screened with lead and rubber, were placed over the area for one 

and one-half hours. Also the glandular area on the outside of the neck 

was radiated for six hours on each side vvith the same dosage. In April, 

1921, there was no sign of recurrence at the same place, but on the floor 

of the mouth. J.^ cm. to the right, was a recurrence with two or three 

small indurations. This area was then treated vvith electro-coagulation, 

following which four needles were buried in the floor of the mouth for 

four hours. There is no sign of recurrence at the present time. 

Mr. GF. Age, 65. For eight months had been aware of a sore in 

the mouth, which constantly increased in size, considerable tenderness, 

but no pain. On examination a gray ulcer with elevated edges, size of 

a 25-cent piece, involving the left soft palate, anterior pillar, and edge 

of the tongue. Underneath this ulcer was deep infiltration with fixation. 

Treatment: April 19. 1922, under clher anesthesia, electro-coagulation 

of the entire area, paying particular attention to the base of induration 

and the involvement of the tongue, following which four 12.5 mg, 

needles were buried 1 cm. apart, deeply, and one 25 mg. tube covered 

with gauze and rubber was sutured to the surface that had been cauterized. 

This arrangement of needles and tube furnished perfect crossfiring. 

The tube was removed in six hours and the needles in 12 hours.

4 R a d i u m 

In March, 1924, practically two years after ihe treatment, there was no 

sign of recurrence. Patient died of pneumonia at this time. 

Miss HH. November 25. 1922. Referred on account of growth 

at the junction of the upper lip in the alveolar membrane in the median 

line. It had been increased in size in the past six months until it was 

impossible for her to wear her dental plate. About a month previous 

to my examination an attempt had been made to remove the growth. It 

had been cauterized and curetted. At 'he time of my examination there 

was a mass 2 cm. wide and 1 cm. thick pushing out the upper lip. and 

firmly fixedto the bone. Patient was given an anesthetic, and the entire 

area treated by electro-coagulation, following which four 12.5 mg. radium 

needles were buried for eight hours. For three months the patient suffered 

a great deal of pain, but six months later the pain had ceased. At 

this time there could be seen an area of devitalized bone. .5 cm. in diameter, 

surrounded by normal pink mucous membrane. There was no induration, 

and now. nearly two years later, there is no sign of recurrence. 

Pieces of sequestrum have been removed from time to time, and there 

is a small permanent opening between the sulcus beneath the lip and 

right nares. 

Mr. TR. September 12, 1923. For seven years a gradually increasing 

area of leukoplakia on the inside of the right cheek, opposite 

the molars, and involving the sulcus between the cheek and alveolar 

membrane. During the past nine months this had become thickened. 

rough and furrowed, and finally developed granular processes on its 

surface. At the time of examination area involved was 4 x 2.5 cm. on 

the cheek, the narrowest point being at the junction of the buccal mucous 

membrane and the ramus of the jaw. The mucous membrane over 

the alveolar process of the last three teeth was also involved. Treatment: 

Molar teeth were removed by a dentist, following which the entire area 

above described was treated with electro-coagulation under procaine 

anesthesia, following which six radium needles were buried throughout 

the entire area for 10 hours. This treatment was followed by considerable 

pain for about tvvo months and was accompanied bv sloughing of 

the tissues which had been treated, together with some destruction of the 

alveolar process. On December 21. 1923. the cavity left after removal 

of the slough was radiated with 75 mg. of radium, screened with 2 mm. 

rubber, for two hours, and the glandular area immediately beneath the 

jaw was radiated over two 2-inch area with 75 mg. of radium, screened 

with 2 mm. brass, 2 mm. rubber, and 2 cm. of cork. After this there 

was progressive healing. Sequestrum was removed from the jaw about 

July 1st. 1024. This entire area in the mouth now looks clean and 

healthy. 

In cancer of the mouth, perhaps more than elsewhere, should one 

refrain from any form of treatment, particularly radiation, when the 

disease has obviously advanced beyond a reasonable chance of cure. It 

does, however, require nicety of judgment, and considerable experience 

to be able to decide whether or not a patient can receive real benefit 

from some form of treatment. My failures in oral cancer I believe have 

been due to my inability to accurately judge curability, but fortunately 

each failure has taught its lesson. 

Cancer of the lip, unless involving a considerable portion of the 

deeper structures, can be treated as well with radium, probably more 

effectually, and with less deformity. The lymphatic area should receive 

external radiation coincidently. It is unnecessary to remove the cervical

lymph nodes in even case, but when metastases are present or suspicioned. 

they should be removed and radium buried in the depths of 

the wound, or through the open wound radium emanation mav be implanted 

in the glandular area. In only two of my lip cases have subsequent 

metastatic nodes developed. These were removed and a radium 

tube applied in the cavity for several hours. In one case, there has been 

no recurrence after two years, and in the other case, there have been 

two recurrences lower in the neck. In larger involvements of the lip, 

I believe the classical surgical procedure on the lip and neck should be 

performed, followed by thorough radiation of the entire area. 

WS presented himself 1921 with cancer involving the entire lip. 

vvith metastatic nodes on either side of the neck. Preoperative radiation. 

followed in five days by a V incision involving the whole lip, removal 

of glandular area on both sides of neck, through a collar incision, and 

a plastic Burow operation to form new lip. After healing, the lip and 

neck were radiated twice. This man, three years later, has no recurrence. 

ORBIT. RECURRENT UREAST AND NECK 

In 1920. I removed a protruding and pulsating mixed cell sarcoma 

from the orbit of a woman 70 years of age. On account of some benign 

tumor, the eye had been removed thirty years previously, by Dr. Maurice 

Richardson. Without ihe help of radium, and vvith only surgical removal 

of the sarcoma, one would expect recurrence. As early as possible after 

removal of the sarcoma, ihe orbit was thoroughly radiated and after a 

period of four years, she presents no symptoms of recurrence. 

Accessible nodes recurring after breast operations respond very satisfactorily 

to radiation with buried needles and in my experience no recurrences 

have appeared in the same vicinity; which is contrary to the 

rule in surgical removal. 

Three patients have lieen successfully treated vvith radium for recurrences 

after the surgical removal of cervical cancer just below the 

ear. These patients have all been without signs of further recurrence 

for two years or more. 

CANCER OF THE CERVIX 

Much has been written about the treatment of cancer of the uterine 

cervix, operation versus radium. I think all will agree that the border 

line cases will show as many cures with radium as with operation. All 

will agree that the somewhat advanced cases will show better results 

with radium, while in the really advanced cases surgery can do nothing, 

while radium will relieve pain for a time, will stop hemorrhage and prolong 

life. The only real argument, then, concerns the early cases, and 

the recent preliminary report of the committee appointed by the American 

College of Surgeons, to investigate this subject, of which committee 

Dr. Greenough is chairman, reveals many interesting figures. It 

would appear from this report that a patient with favorable cancer of 

the cervix has a 1 to 4 chance of cure by operation, and a 1 to 3 chance 

vvith radium. Unfortunately, however, ihe report shows that the patient 

who is treated by hysterectomy must assume a I to 5 chance of 

dying from the operation itself. This operative mortality is too high 

to be passed over without giving it thoughtful consideration. Also keep 

in mind the fact thai these figures refer to the favorable cases, which 

are. unfortunately, few in number.

R a d i u m 

Out of thirty-nine cases. I have used radium alone on all but two. 

because in a little over four years I have seen only three early cases, 

and one of these had incipient tuberculosis. All other cases had involvement 

of the parametrium or vaginal walls. I cannot feel that patients 

coming to me differ materially from the average met with by other surgeons. 

Six cases have been quite advanced, with solid fixation and constant 

pain. This last group was ireated for the purpose of stopping 

haemorrhage or discharge. Realizing the fact that sufficient time has 

not elapsed to present definite figures and percentages on the results of 

treatment in this series of cervix cases. I will, however, call attention 

to the fact that of these unselected cases, many of them advanced, fifteen 

of the thirty-nine are without symptoms, living their ordinary lives. 

and showing no recurrence of activity, covering periods of from one to 

four years. Ten have died of cancer, ail having been advanced cases. 

and two fairly favorable case* have died, one from nephritis, and the 

other from diabetes. There is a definite fieldof usefulness for radium 

in the treatment for vaginal recurrences after hysterectomy. These recurrences 

are usually accompanied by much bloody discharge with odor. 

Thorough radiation of the vagina will reduce or remove the new growth, 

and cause cessation of the discharge. I have treated six cases of this 

type, and the treatment resulted in relief from symptoms for periods 

ranging from five to fourteen months. It is of interest to note that in 

even- fatal case, that had been previously treated with radium, there 

never developed the foul discharge always associated vvith terminal cancer 

of the uterus. This is characteristic of radium treated cases, and it 

surprises one to observe the extremely small amount of discharge present 

and the comparative absence of odor. When I compare these intermediate 

results, if I may so term them, with my results in treating cancer 

of the cervix before the advent of radium. I feel that definite progress 

has been made. 

The successful treatment of cancer of the cervix is. in a great measure, 

due to the central location of the cemcal canal in the pelvis. The 

radium ravs reach for several centimeters in all directions, and owing 

to ihe natural resistance of the tissues of the cenix to destructive radiation, 

it is possible to give large doses from within the cenical canal. 

These patients are treated without an anaesthetic, the radium is placed 

in the cervical canal; or when the growth is more on one side, I bury 

needles in the new growth and place a tube in the canal. The radium 

remains twenty-four hours. After a twenty-four hour interval, another 

similar treatment is given. The complete dosage is 5400 milligram hours. 

There is usually, though not always, some local discomfort and cystitis 

for about 10 days, haemorrhage and discharge cease

adiation up to 2400 milligram hours is also of undoubted value. Please 

picture to yourselves, however, a woman fifty-eight years old, weighing 

two hundred and fifty pounds, and unable to lie flat on account of asthma. 

I think few of you would care to accept the responsibility of advising 

pan-hysterectomy on such a person 1 did not. I used intrauterine 

radiation up to 7200 milligram hours. Bloody discharge ceased in a week. 

The uterus contracted in size and she is without symptoms today. The 

treatment was one year ago. and I am not expecting cure, but hope for 

it. Out of seven cases of adeno-carcinoma I have treated, two have 

been too fat to advise operation, and two were so stout that the difficulties 

and dangers attendant on removing the entire uterus led me to 

combine operation and radium. A preoperative radiation was given, 

followed 011 the iSth and 20th days vvith radium in the cervix for 24 

hours each day. Of the seven cases of this type, all are living and all 

but one are well in varying periods from three months to 31/ years. 

One patient on whom I did a pan-hysterectomy, preceded and followed 

by radium. 3l/2 years ago, has a recurrence in the vagina. 

NON-MALIGNANT EXCESSIVE FLOWING 

Of the numerous non-malignant diseases that have received more or 

less benefit from radium treatment, I will bring to your attention three 

pathological conditions which are essentiality surgical in character, but 

in which, in properly selected cases. I believe radium should be substituted 

for, or should be used in .conjunction with surgery to produce 

the best results. I refer to menorrhagia. the smaller uterine fibroids, and 

tubercular adenitis. Nineteeen patients with eNcessive flowing due to 

hyperplastic, interstitial, or polypoid endometritis, or senile degeneration 

have all been cured permanently by radium treatment. This was accomplished 

after one short treatment except in one case. This one patient 

required a second treatment six months later. The treatment in each 

case lasted 3 to 6 hours, using only 50 mg. of radium. This dosage is 

usually not sufficient to disturb normal menstruation. When it does, the 

cessation is for only one or two periods. These patients are all anaesthetised, 

and before the radium is applied, the uterus is curetted, the 

curettings being examined later. The hyperplastic type is more prone 

to recur, and usually does if curetting alone is depended upon. The ages 

of the seventeen patients treated ranged from 15 years to 73. It should 

be borne in mind thai radium should not be used in the uterus where 

there is an associated pelvic inflammation, even though the inflammation 

be of the chronic type, for radium will stir into activity the dormant 

organisms. 

FIBROMYOMA OF THF. UTERUS 

The benign fibromyomas of the uterus respond well to radiation, 

the radium being placed within the uterine cavity, usually for two twentyfour 

hour periods, the dosage depending upon the size of the tumor. 

There are certain contraindications, however, that must be observed. 

Tumors larger than a four months' pregnancy and all pedunculated tumors 

should be removed surgically. As has been stated before, radium 

should not be used for the treatment of fibroids during the child-bearing 

period, as the dosage necessarily used will induce artificial menopause. 

Eight cases have come within the prescribed limits, and all have been 

cured with two treatments. A definite change is observed in six or eight 

weeks, and from that time on. the retrogression in size of the tumor is

8 

RADIUM 

gradual and continuous. On two occasions, I have radiated to stop 

haemorrhage, and proceeded with operation after the patient's condition 

had improved sufficiently. 

TUBERCULAR ADENITIS 

In ihe past ten years the surgical treatment of tubercular adenitis 

has undergone a very conservative change. Surgeons no longer perform 

mass dissections, which always leave an unsightly scar and frequently 

some paralysis. It is customary now to incise the broken down node, 

curette and allow nature to heal. Surgical removal of nodes is frequently 

followed by recurrence in adjacent glands. In 1921 Dr. Russell 

Hoggs, of Pittsburgh, stated that 90$* of the cases of tubercular adenitis 

could be cured with radiation. When the nodes are firm and have not 

become caseous, the application of radium externally in less than erythema 

dose will cause a gradual shrinkage of the nodes, due to an absorption 

of the lymphatic tissue and production of fibrous tissue. Usually, 

two treatments si.x weeks apart are sufficient to bring about the 

desired result, and this with a few hours hospital confinement, no operation, 

and no scarring. Furthermore, the cure is more certain than with 

surgery. I have cured a dozen tubercular glands appearing in one man 

after three operations hat! been performed. I have treated successfully 

with radium. 19 cases of tubercular adenitis. When the nodes have become 

caseous or liquefied, surgery must be employed, but I have found 

radium to be of the greatest value in inducing more rapid healing. The 

method of treatment is as follows: if time allows, the glandular enlargement 

is firstradiated externally as above described. If the gland demands 

immediate opening, the external radiation is applied later. Under 

gas anaesthesia, a very small incision is made, a curette is introduced. 

and the abscess cleaned out gently. A tube of radium containing 50 or 

75 mg. is placed within the cavity for abo:it one hour and then removed. 

This results in quicker healing and much less discharge than occurs without 

the use of radium. Old tubercular sinuses heal quite rapidly if a 

small tube of radium is applied in the sinus, but only when the bottom 

of the sinus can be reached. 

I truly believe that radium is the treatment of choice in tubercular 

adenitis, but we must remember the responsibility of checking the disease 

in the primary stage, and treat the glands as soon as they are discovered. 

It is to be remembered that large cervical glands may be due 

to sarcoma. Hodgkin's disease, and leukemia, and that radium therapy 

is still the best form of treatment for multiple glandular tumors. 

CONCLUSIONS 

It will appear from a review of the selected types of cases above described, 

that the patient afflicted with any of these conditions will receive 

the utmost benefit if treated with a combination of surgery and radium. 

With some patients the surgical treatment may predominate, while in 

others, for instance, in patients with menorrhagia, surgical procedures 

merely serve as a means to facilitate the radium treatment. With parametrial 

involvement in carcinoma of the cervix, radium is to be preferred 

over surgery, and in tubercular adenitis, radium is the best therapeutic 

agent. It is possible to cure cancer in some conditions where surgery 

has failed, and also in some locations where the technical difficulties or 

surgical procedures contraindicate operation, ll is also possible with

R a d i u m 

o 

radium to relieve patients of distressing symptoms during their last 

months, where recurrences have followed surgical procedures, and it will 

usually relieve the patient who has delayed too long in seeking treatment. 

Jt is desirable that all cancer patients may have available the four tried 

and recognized methods of trea'ment. surgery, electro-coagulation, X-ray, 

and radium. 

RADON 

IMPLANTS, TUBES AND NEEDLES IN THE 

TREATMENT OF MALIGNANT AND 

NON-MALIGNANT CONDITIONS* 

WILLIAM II. CAMERON. M.D. 

The technic suggested in this article must, of course, be general in 

scope, for the "Amount of Radon* Used" and the "Time of Application" 

depend largely on the general condition of the patient, the condition 

of the local lesion, the radiological resistance of the lesion and the susceptibility 

to radiation of the tissue harboring, and the normal tissue 

surrounding, the lesion. 

For the most part the technic is based on the employment of implants** 

containing from 0.5 to 2.0 millicuries, needles of 10.0 millicuries 

and tubes of from 25 to 50 millicuries. 

In order Ihat the relation of Radon to Radium be thoroughly understood, 

Charles H. Viol. Ph. D.. has added an appendix on the subject. 

For the convenience of the operator desiring to construct a more individualized 

and therefore a more definite technic, I have added a chart for 

estimating the number of implants to employ in a given case; a diagram 

of the factors that should be given consideration, and an illustration of 

the instruments employed in the work. 

GENERAL RULES TO BE OBSERVED. 

Rule A. Time of Application. When speaking of tubes this article 

is, for the most part, based on the use of 50 millicuries of radon. 

When a larger amount is mentioned the minimum time allowance is. as a 

rule, used. 

Rule B. Skin . Ireas. When skin areas are multiplied beyond a 

certain number (say 5 or 6) it is customary to reduce the time given each 

area. 

Rule C. Tube Screening. Unless otherwise stated, radon tubes 

are screened with 0.5 mm. silver. 1.0'mm. brass and from 1.0 mm. to 

5 mm. rubber or 1.5 mm. aluminum. 

Rule D. Distance Screening. The distance between the radon 

tube and the part to be rayed will be stated in the body of the article. 

The materia! used must be non-metallic, such as paper, rubber, gauze. 

felt, wood, molding compound, etc.. etc. 

•Radon ia the name suggested in 1323 by the International Committee on 

Chemical Elements to be used in place of the term Malum emanation. 

••IMPLANTS are the small glass tubes of radon of 3 to 4 mm. length and 

0.3 mm. diameter, which, without any metal screening, are embedded in the tumor 

mass. Larger lubes of radon of approximalely 13 mm. length and *0.S mm. diameter 

are employed in hollow metal needles and In metal tubes In the same way that Ihe 

corresponding radium applicators are used.


Rule E. Embedding Implants. Implants containing from 0.5 to 

2.0 millicuries are embedded one per each cubic centimeter of diseased 

tissue. Implants are not embedded in the wall of hollow organs, directly 

on thin bones, or against the wall of large vessels. 

Rule F. Embedding Metallic Xeedles. When non-corrosive alloy 

or platinum needles (containing 10 to 12J-J millicuries 1 are used, each 

needle should, if possible, be surrounded by at least 10 mm. of diseased 

tissue. 

Rule G. Xeedles Used as Tubes. When using non-corrosive alloy 

or platinum needles bunched (to form tube applicator) they must be 

screened as given under rule C. 

Rule H. Sterilization. When tubes are placed in cavities, or 

needles, or implants embedded, surgical cleanliness should always be observed. 

Radon containers should not be placed in bichloride solution, as 

mercury salts may amalgamate and ruin most of the metal screens used. 

Rule I. Uaginal Packing. When radon is placed in the vagina, 

cervix, or uterus, the vagina is packed with gauze, not only to hold the 

tube in place but to push the rectum and bladder as far away as possible 

from the radon. 

Chronic Leucorrhea 

Endocervicitis 

In cases of this character it must be remembered that overdosage 

will cause some disturbance of the menstrual function and an excessive 

dose may damage the ovary. Cases occurring in women of the childbearing 

period should receive the minimum dose. The contraindications 

are acute gonorrhea and pus in the tube or ovary. One treatment is usually 

sufficient to control the lesion and the full effect will not be noticed, 

perhaps, for 60 to 90 days following the treatment. The dosage ranges 

from 25 to 50 millicuries in a tube (see rule C) placed in the cervix. The 

time of application is from 3 to 12 hours. The treatment mav be repeated 

in 60 to 90 days if necessary. Rules H and I must be strictly 

observed. 

Uterine Hemorrhage (simple) 

Menorrhagia 

In treating cases of this character one should keep in mind the fact 

that radiation will have an effect on the menstrual function and that 

cases occurring during the child-bearing period should receive the minimum 

dose, unless the hemorrhage is so severe that the patient's life is 

in danger. The radon is placed in the uterine canal, the dose ranging 

from 25 to 50 millicuries in a tube (see rule C) and the time of application 

being from 3 to 12 hours. If the radon is placed shortly before 

the expected period, the bleeding may be more profuse than otherwise 

and the next two or three periods may be entirely absent. It is understood 

that in cases of uterine hemorrhage occurring in women beyond the 

age of 35, a diagnostic curettement should be made, this in order to 

determine the possibility of malignancy as the cause of the hemorrhage. 

The contraindications for the use of radon in this condition are acute 

infections in the tubes or ovaries. (See rules H and I.)


Uterine Fibroids 

The contraindications for the use of radon in this condition are 

very large fibroidsthat can be removed surgically, pedunculated fibroids 

and the presence of acute infections in the tubes or ovaries. The patient 

must be examined by the operator before radiation, this in order to determine 

the exact size of the growth—the diminution in the size being 

the factor as to future treatment. From 50 to 100 millicuries in a tube 

is advised. (See rule C.) The time factor is from 24 to 35 hours. If 

the general condition of the patient is bad or if the blood count shows 

anaemia, the treatment should be divided into two or three periods, allowing 

an interval of 24 hours between. After the initial treatment the 

patient is examined every 30 days and as long as the patient is progressing 

favorably, hemorrhage checked, and decrease in size is noted, no 

further treatment is given. A second treatment is given in 60 days if 

conditions are not clearing up as rapidly as the operator thinks necessary. 

Very large fibroids may be rayed and a favorable result obtained if for 

any reason the patient cannot be operated. In cases that have been depleted 

by excessive hemorrhage radon may be employed to check this 

symptom, and then the patient may be operated in 30 to 60 daysif such 

a procedure is advisable. (See also rules H and I.) 

Uterine Cancer 

(Radiation followed by operation) 

In early cases of cancer of the fundus it is customary to ray, this 

to be followed by complete removal in three to four weeks. Radon in 

a tube of 50 to 100 millicuries is employed (see rule C). The radon is 

placed in the fundus, the time being from 24 to 36 hours. If the patient's 

general condition is good, the total radiation may be administered in one 

application; otherwise, the dose should be divided into two or three 

applications with 24 hours intervening. Rules II and I must be strictly 

observed in these cases and. in addition, the patient's bowels must be 

thoroughly emptied before radiation is started, and the bladder not permitted 

to become distended while the radon is in place (see rules H 

and I.) 

Uterine Cancer 

(Inoperable) 

There are a number of methods employed for this condition and 

they are all more or less effective. Considering that these patients are 

always very much below par and that palliation is the object for which 

radiation is employed, it is suggested that the di tided dose method be 

used. 50 to 100 millicuries in one tube (see rule C) for 24 to 35 hours 

is used. The radon is placed in the uterine canal and rules H and I are 

strictly observed. 

Cervix—Cancer 

Almost every operator has a favorite technic which accounts for 

the diversity of methods described in the literature. The best results 

are undoubtedly obtained by carefully studying the individual case and 

applying the technic best suited to the particular symptoms found. In 

early cases, a cure should be aimed at. while in the inoperable type palliation 

is the best that can be hoped for. In the beginning cases one 

operator secures very excellent results by the use of a specially devised


cross-fire applicator. By the use of this applicator 50 millicuries is 

placed in the cervix and 50 millicuries held against the cervix, this giving 

a cross-fire of 100 millicuries. the radon being in place for 25 hours. 

Another technic suggested is by placing 50 millicuries against the cervix 

for 15 hours. Ten days later four 10 or i»Jj millicurie needles are introduced 

directly into the cervix for 10 to 15 hours, and when the needles 

are removed they are bunched (sec rule G) and placed high up in the 

cervix for 15 hours. Rules H and I must be strictly observed. The patient's 

bowels should be thoroughly emptied before radiation, and the 

bladder should not be permitted to become distended while the radon 

is in place. In cases of low vitality 50 millicuries in a tube (see rule C) 

placed in the cervix for three or four applications of 10 to 12 hours each 

is recommended, vvith 24 hours between applications. 

Bladder—Cancer 

The technic in cancer of the bladder depends for the most part on 

the choice of the method of approach used by the operator. If a suprapubic 

incision is to be made the lesion may be treated by a surface application,—that 

is. by* holding a tube of 50 to 100 millicuries against the 

lesion for a total of from 10 to 15 hours, the tube being screened as per 

rule C A spoon with a long handle that can be bent to the proper contour 

makes a good applicator, the radon being fixed in the bowl. The 

lesion may also be treated by the introduction of radon needles containing 

from 10 to i2j/$ millicuries and when these needles are employed, rule F 

is carried out. the needles being left in place for not longer than six to 

eight hours. When the lesion is treated by means of an operating cvstoscope 

radon implants of l/i millicurie are employed, it being possible to 

introduce these implants into the lesion by means of a specially devised 

implanting instrument, through the operating cystoscope. In using these 

implants the information given in rule E must be followed. When the 

lesion is in the trigone it is possible to treat the patient by using 50 or 

100 millicuries, screened with silver and brass (see rule CI and placed 

in the end of a soft rubber catheter. The total radiation from 12 to 15 

hours is given which must necessarily be divided into three or four hour 

periods, permitting the patient to rest at least 10 to 12 hours between 

these periods. 

Bladder—P.vpillomata 

These lesions are usually treated through an operating cystoscope 

and implants of J^ to 1 millicurie used. Rule E must be observed when 

this method is employed. Some operators prefer to fulgurate the papilloma 

and then hold for a short period of time a tube containing at least 

25 millicuries on the base of the lesion, the tube screened as per rule C. 

Prostate—Ca x c e r 

The best method of treating this lesion is by the use of special 

radon needles containing 10 to i2j/£ millicuries, introduced into the gland 

through the perineum. Two needles arc placed as far up in the gland 

as possible, and when placed should be not less than one half inch apart. 

Every four hours the needles are pulled outward about x/z inch. When 

the bladder has been opened radon implants of 1 millicurie each are embedded 

throughout the diseased tissue and rule 1*1 is followed out as far 

as possible. On account of the susceptibility of the rectum, it is advisable 

not to place radon in the rectum for cross-fire purposes as recommended

R a d i u m 

i3 

by some operators. X-Ray pictures of the lumbar region should be taken 

before radiation, since with metastases here the treatment can only be 

palliative. 

Prostate—Simple Enlargement 

The method of introducing needles as described under cancer of the 

prostate is carried out vvith the exception that the needles are moved outward 

-J4 to one inch every two hours. 

Rectum—Cancer 

From a mechanical standpoint and due to the fact that most cases 

submitted for radiation are advanced, cancer of the rectum presents 

many difficult problems. If the patient's general condition permits, it 

is advisable to do an exploratory laparotomy to ascertain if possible the 

exact condition of the pelvic glands. If the condition found justifies 

radiation, implants of i.o millicurie each arc introduced throughout the 

mass from above (see rule E) and a colostomy is done. On the other 

hand,if there is evidence of extensive involvement, the initial discomfort 

produced by operation and radiation is not justified. In early cases a 

colostomy is done. If possible a strong silk thread is introduced in the 

opening and brought out the rectum. A special double-eyed brass 

screen containing a tube of at least 50 millicuries radon is securely fastened 

on this thread and pulled into position. The brass screen must 

be covered by rubber. When the radon reaches the upper part of the 

growth it is permitted to stay in this location for about six hours. It is 

then moved downward about an inch and is at this location for six hours. 

etc., etc., until each one inch of the growth is rayed. It may be possible 

to reach the growth from below. In this case the brass screen mentioned 

above is placed in rubber tubing of a wall thickness of 2 to 5 mm. If 

the growth is lower down and can be seenit may be possible to introduce 

radon implants (see rule E) vvith the aid of a special proctoscope. In 

women it may be possible to cross-fire. The tube is used in the rectum 

as per the above suggestion and then moved to the vagina. When in 

the vagina the screened tube (rule C) must be surrounded with at least 

an additional l/iinch of gauze and the anterior wall pushed away as far 

as possible by additional packing. In this positionit is held for 12 hours. 

Breast—Cancer 

In the operable type the present practice is to combine radon, x-ray and 

complete removal. Before operation the axillais rayed with radon, 50 millicuries 

screened as noted in rule C, and in order to protect the skin, distance 

screening of J^ to 1 inch in all directions is used (rule D). This 

tube is held in the axilla for a period of 12 hours. After raying the axilla 

any distinct nodule that may be present is rayed through the skin. The 

skin over the nodule is divided into one inch square areas and the tube 

when removed from the axilla is held over each area from four to six 

hours (see rule B). The entire surface of the chest is then rayed with 

x-ray. Three or four weeks later a careful dissection of the gland and 

involved lymphatics is done and, after the incision is healed, the entire 

chest is rayed with x-ray. In case doubtful tissue remains after operation, 

25 millicuries, screened in 1.0 mm. brass, is placed in the axilla before 

the wound is closed. This tube is placed in the end of a rubber 

drainage tube 2 to 4 mm. wall thickness, and it is moved Y2 inch every 

two hours until the radon is out of the axilla. It is always advisable,

14 Radium 

no matter how early the case may present itself, to take pictures of t 

chest in order to ascertain if involvement of the chest has already taken 

place. If such be the case, surface radiation only should be used (as 

described above). 

Tongue—Cancer 

The best method for treating cancer of the tongue is undoubtedly 

by the embedding of radon implants containing not more than x/2 millicurie 

each, the number of implants employed depending, of course, upon 

the extent of the lesion. (See rule E.) At the same time that the implants 

are introduced, the draining lymphatics on the infected side must be 

rayed (see technic for raying malignant glands). The reaction following 

the introduction of implants in the tongue is very severe and painful 

and the patient should be warned what to expect. If sloughing occurs 

it is advisable to remove by fulguration. Before operating the mouth 

should be as clean as possible, all source of irritation removed, and after 

the introduction of the implants the mouth should be kept as sterile as 

possible. 

Inside of Cheek—Cancer 

This is handled by the cross-fire method,—that is. by holding a tube 

of at least 25 millicuries, screened as per rule C, held against the-lesion 

for at least eight hours. While the tube is being held in place some 

method should be used to keep the tongue as far away from the tube as 

possible. After raying the inside the tube is placed opposite the lesion 

on the skin surface. In addition to the screening mentioned a distance 

of at least l/2inch (sec rule D) is maintained between the tube and ihe 

skin surface. In this location ihe tube is held from six to eight hours. 

Lower Lip—Cancer 

Involvements of the mucous surface require early and vigorous 

treatment. It is nearly always possible to cross-fire the lesion and for 

this purpose a tube containing not less than 25 millicuries is employed 

(see rule C). To hold the tube in place a cast of molding compound 

(Kerr's) is made so that the lip will be extended as far outward as possible. 

The upper surface of the cast must be thick enough to push the 

upper lip well out of the way. The tube is held at least "4 inch away 

from the surface of the lesion and skin surface. First the tube is placed 

on the upper surface from four to fivehours, then directly opposite the 

lesion for the same length of time and then on the under surface, making 

in all from 12 to 15 hours' radiation. In addition, the draining lymphatic 

region is rayed (see malignant glands). Advanced cases are rayed 

by surface radiation.—that is, holding a tube of at least 25 millicuries 

(see rule C) % to y2 inch away from the skin surface and moving it 

to a new location every two to three hours until all the indurated area is 

rayed. It is advisable to ray these advanced cases asit is just possible 

that it may have been a basal cell growth, in which case a great amount 

of palliation may be had. In these cases also, the draining lymphatic 

region is rayed (see technic for raying malignant glands). 

Antrum—Cancer 

As a rule the best technic to employ in this condition is a combination 

of surgery (cautery or fulguration) and radiation. If the case is not 

too far advanced an entrance is made into the antrum and as much of 

the diseased tissue as possible destroyed by fulguration. After reaction


from the operation has subsided a tube containing not less than 50 millicuries, 

screened as per rule C, is placed through the opening directly into 

the antrum and permitted to remain in place from 10 to 12 hours. Packing 

should be introduced so ihat the radon will not be in direct contact 

with the bony wall of the antrum. 

Antrum—Sarcoma 

The technic suggested in this condition is to make a direct opening 

into the antrum and embed implants of one millicurie each throughout 

the mass. Attention is called to rule E. 

Posterior Nasal Space 

Cancer and Sarcoma 

The technic consists in embedding \A millicurie implants throughout 

the mass or the introduction of radon needles containing 10 to I2j^ millicuries. 

The rules E and F are adhered to in this work. 

Fii;rmas 

Wwohakyw 

Implants of 0.5 to 1 millicurie each are embedded (see rule E). The 

treatment may be repeated in from two to three months if necessary. 

According to Xew of Rochester, Minn., the crusting and scabbing resulting 

from the radon treatment may be cared for by using oil sprays, 

with potassium iodid internally. 

Larynx—Cancer 

Cancer of the larynx is a very unsatisfactory lesion to ray. Implants 

of J4 millicurie each may be used when the growth is of sufficient size 

to permit their introduction (see rule E), or by the use of a tube containing 

250 to 300 millicuries, screened vvith silver, brass and thin rubber, 

held directly on the lesion for a short period of time. In raying these 

cases one must always remember the close proximity of cartilaginous 

tissue, and that it may be necessary on account of reaction to do an 

emergency tracheotomy. 

Esophagus—Cancer 

Unless these cases are seen very early, palliation is all that can 

be expected. Case's technic is recommended. In brief, this technic is 

as follows:—The stomach is opened and by the use of a tube the patient 

is fed directly into the duodenum. Four or fivedays later a strong silk 

thread is swallowed and brought out through the opening in the stomach. 

The next day a tube containing not less than 50 millicuries in a specially 

devised double-eye screen, covered with hard rubber or molding compound, 

is pulled through the mouth and held in direct apposition. The 

exact location, size of the lesion, etc.. must have been previously studied 

by means of the x-ray and fluoroscope,and a total of at least 8 hours' 

radiation should be given. Many surgeons are treating these lesions by 

the direct application through the csophagoscope of a specially devised 

spiral spring semi-flexible applicator. Fifty to 200 millicuries (see rule 

C) are employed and because of the short length of time this applicator 

may be held in place, the larger amounts are recommended. 

Sarcoma—Slowly Growing Types 

As a rule, a tumor of this group is best handled by a combination 

of surgery and radiation. The skin surface over the lesion is divided

i6 

R a d i u m 

into one inch square areas (see rule B) and the tube, screened as per 

rule C, is held ^ to I inch away from the skin (see rule D), and is held 

over each area from 4 to 6 hours. Three weeks later the growth is removed,if 

possible. Should suspicious tissue still remain radon needles of 

from 10 to i2y2 millicuries each (see rule F) are embedded throughout 

the suspicious tissue, placing them especially in the line of lymphatic 

drain. Implants of 1.0 millicurie may also be employed in this work 

(see rule E). 

Sarcoma—Rapidly Growing Types 

As a general thing these patients belong to the radiological group 

and are rayed through the skin. Radon implants or radon needles may, 

in readilv accessible growths, be buried throughout the mass (see rules 

E and F). When raying through the overlying skin the technic is to 

divide the skin area into one inch square areas and with 50 millicuries, 

screened as per rule C, and vvith l/2to 1 inch distance (rule D), each 

area receives at least 6 hours' radiation. As the number of areas multiplies 

the time factor over each area should be reduced. In 30 to 60 

days these cases may require another application. 

Sarcoma—Bone 

As a group these cases are best handled by combined methods. The 

skin surface overlying the lesion is rayed as per the plan outlined under 

the heading "Sarcoma—Slowly Growing Types." Three weeks later an 

incision is made to expose the lesion and as much of the growth as possible 

is removed by fulguration or cautery. Implants of one millicurie 

each are then embedded through the remaining mass (see rule E). If 

the lesion U on the lower extremities Ihe pelvis IS raved with x-ray and 

the chest is rayed if the lesion is located on the upper extremities. On 

account of the frequently distant developments that may take place, these 

cases should have skeleton pictures taken. If such distant nodes are 

found surgical measures should not be taken and palliative radiation only 

given. 

Malignant Glands 

In all malignancies of the virulent type where glandular involvement 

usually follows, the entire draining lymphatic region is rayed. This 

procedure is routinely carried out even though there is no evidence of involvement 

in the glands present. The entire glandular area is mapped 

out into one inch square areas and the radon is held one inch away from 

the skin surface. With 50 millicuries in one tube, screened as per rule 

C. ray over each area from 6 to 10 hours. It is the operator's choice 

whether or not he will remove the gland after radiation. The operation, 

however, should not be done sooner than three weeks after radiation. 

If, at this time, there is still doubtful tissue present that cannot be easily 

removed, radon implants (see rule E) are embedded throughout, giving 

special attention to that portion of the involvement in the direct line of 

lymphatic drainage. 

Tubercular Glands 

Adenitis 

The skin surface over the involved area is divided into one inch 

square areas and a 50 millicurie tube is held x/2to 1 inch away from the 

skin (see rule D), each area receiving 2 to 4 hours. Considering the fact 

that these glands may subsequently have to have three or four applica-

R a d i u m 

n 

tions, the distance screening must not be omitted, this in order to av 

cosmetic damage such as telangiectasis, skin fibrosis,or bronzing. These 

patients should be examined every 30 days and as long as the condition 

is improving, no further treatment is given. If. however, in 60 days' 

time the condition is not markedly improved, a second application is given. 

If the glands contain fluctuatingpus. this pus must be drained before 

radiation is started. 

Spleen—Enlargement 

To reduce the size of the spleen the skin surfaces over the enlarged 

organ is divided into squares two inches on a side, and a 50 millicurie 

tube (see rule C) is held at one inch distance from the skin (see rule D) 

from 2 to 4 hours over each area. Subsequent treatments depend on the 

white cell count, and as long as this count is decreasing no furiher radiation 

is given. It must be remembered that palliation is all that can be 

expected from these cases. 

Tonsils—Enlarged; Infected 

Three methods are in use for this condition: first,external radiation 

at the angle of the jaw. A 50 millicurie tube (see rule C) is held at 

the angle of the jaw for 12 hours in adults. The tube is held one inch 

away from the skin surface (see rule D).. The time factor is reduced 

about half for children under 12 years of age. Each tonsil receives the 

same amount of radiation. If the tonsils are not sufficiently reduced in 

•60 days' time another application of 6 hours is given. The second method 

is the introduction of one or more radon needles containing 10 to i2j^ 

millicuries directly into the tonsil (see rule F). for 1 toi'/2 hours. Third, 

the introduction of implants directly into the tonsils. The number of 

implants depends on the size of the tonsil. (See rule E.) The third 

method will result in a rather severe reaction with a possibility of a severe 

infection. 

Thyroid Gland—Exophthalmic Goiter; Toxic Goiter 

T'oxic goiter is the only type rayed. Patients should be thoroughly 

studied before radiation. Metabolic findings,pulse rate and nervous 

symptoms form bases of this study as future treatments depend on their 

improvement or non-improvement. As a general rule the gland is divided 

into one inch square areas (see rule B) and 50 millicuries, in tube 

form, screened as per rule C. is employed from 2 to 4 hours over each 

area. A distance of one inch is also maintained (sec rule D). Subsequent 

treatments depend on symptoms and metabolic rate. As long 

as these symptoms continue to improve no further radiation is given. 

In any case a second treatment is not given before three or four weeks. 

If, after two treatments have been given, no improvement is noted, treatment 

is discontinued. It must be remembered that too much radiation 

•will cause a myxedema. 

Thymus Gland—Enlarged 

These are very favorable cases. The chest over the mediastinal 

region is marked off into four 1 inch areas. Fifty millicuries in a tube 

(see rule C) is used over each area for two to fivehours at l/2to 1 inch 

distance (see rule D). The second treatment is given in 3 weeks if 

necessary.

is 

R a d i u m 

Angiomas—Cavernous 

In raying angiomas it is well to remember that the skin is very susceptible 

to radiation, and may easily be damaged, thus interfering with 

the cosmetic result obtained. The skin surface is divided into one inch 

square areas and 50 millicuries in a tube (see rule C) is held over each 

area from 2 to 4 hours. A distance of y2 to 1 inch is employed (see 

rule D), As long as the tumor is reducing in size no further treatment 

is given. If, however, progress becomes stationary a second application 

is given. Cases should be examined 10 days after the firsttreatment and 

then at least every 30 days for 6 months. By this method progress is 

slow but it produces the best finalcosmetic and curative results. 

Spring Catarrh 

Vernal Conjunctivitis 

A bare glass tube of 10 millicuries held in a thin-walled celluloid 

holder (to permit beta rays) is used. The lid is everted and the tube 

slowly moved over the area involved. The entire treatment lasts about 

20 minutes. Treatment should not be repeated as long as the reaction 

from the firstapplication is present. Four or six applications may be 

necessary. 

Keloids and Scars 

The skin surface over the lesion is mapped out in areas of about 

one inch square. A tube of 25 or 50 millicuries (see rule C) is held from 

2 to 6 hours over each area. A distance of from y2 to 1 inch is maintained 

(see rule D). The time factor depends on the thickness of the 

lesion,—the thicker the lesion, the longer the time over each area. If, 

after two such applications (3 to 4 weeks apart) no improvement is noted, 

the case is not likely to be improved by radiation. 

Skin Cancer 

(Basal Cell) 

The treatment of skin cancer presents many variations. The location 

of the lesion, the length of time standing, the amount of induration 

present, the size and the character of the underlying tissue must be given 

special attention. As a rule, however, such lesions may be controlled by 

a 25 millicurie lube screened as per rule C. giving each 10 mm. square area 

from 4 to 6 hours' radiation. When periosteum or bone is involved proceed 

as above and in two weeks' time fulgurate the underlying bone if 

possible. 

Subacute and Chronic Skin Lesions 

Many superficial skin lesions in the subacute or chronic stage are 

greatly benefited by radiation and, for the most part, are treated by beta 

rays. For this reason the ideal applicator is one that gives a maximum 

beta radiation such as the radium clement half strength 2x2 cm. flatglazed 

type. Such applicators cannot be very well made when radon is used 

since it is difficult to uniformly spread a great number of small radon 

tubes over the plaque area and the cost of a radon plaque of this type 

would be almost prohibitive.


APPENDIX 

RADIUM AND RADON 

By Charles H. Viol. Ph. D. 

Radium atoms undergo a radioactive transformation which results 

in the loss from the atom of a doubly positively charged helium atom, 

the alpha ray, antl there remains an atom of a new gaseous element, 

radon, (radium emanation). This change of radium goes on very slowly, 

about one millionth of the radium atoms changing in a day. so that it is 

only after 1700 years of such change that half of the atoms in any quantity 

of radium will have transmuted. 

Radon atoms likewise undergo a radioactive change with the loss 

of an alpha ray, and the production of an atom of the substance, radium 

A. Radon changes much more rapidly than does radium, half of any 

quantity of radon transforming in 3.85 days, half of the remainder changing 

in the next 3.85 days, etc. 

Radium A atoms undergo a radioactive change with the loss of an 

alpha ray and the production of an atom of radium B. When Ra B 

atoms transform there is projected from each atom a single negative 

electron, the beta ray or particle, and the swift beta rays in their escape 

from the atom throw other electrons in the atomic structure into forced 

vibrations, resulting in the production of high frequency electro-magnetic 

waves, the gamma rays, which are physically analagous to X-rays, ultraviolet 

and visible light, differing from these, however, in having a shorter 

wave length. 

The Ra B atom after the loss of ihe beta particle forms an atom 

of the new element radium C, which in its radioactive transmutation 

emits the swifter beta rays and gamma rays of the shortest wave length, 

rays of the greatest penetration. 

From this it can be understood why both radium preparations and 

radon preparations can each be used in a similar manner in the treatment 

of disease, since each of the substances gives rise to the decay 

products Ra B and Ra C. which are the source of the beta and gamma 

rays that the therapist actually employs in affecting tissues. 

The greater radioactivity of radon results in a smaller quantity of 

this substance having the same activity as a large quantity of radium, 

six millionths of a gram of radon (a curie) equaling in gamma ray 

activity a gram of radium. The measurement of both radium and radon 

is made by the comparison of their gamma ray (Ra B and Ra C) activity, 

using a radium preparation as a standard. The millicurie of radon is 

that quantity which exhibits the same gamma ray activity as a milligram 

of radium, measurement being made only when the radon and radium 

each have attained their maximum activity (corresponding to the accumulation 

in the preparation of the maximum of Ra B and Ra C). While 

a millicurie of radon has the same initial gamma ray activity as a milligram 

of radium element, the more rapid decay of the radon results in 

a falling activity, one-sixth being lost in 24 hours, one-half in 3.85 days.


and 99.5% in 30 days. Hence, special methods of estimating radon 

dosage are necessary "where prolonged applications of this substance are 

made. Tables for this purpose are supplied with radon preparations. 

A Chart to Aid in the Estimation of the Number and the 

Distribution of Radon Implants 

The chart is drawn with squares one centimeter on a side and wi 

concentric circles increasing in diameter by centimeters. In practiceit 

has been found desirable to use 0.5 to 1.5 millicuries per cubic centimeter 

of malignant tissue. This makes it desirable to have all the implants 

spaced 1 centimeter apart in a given plane and, in larger growths, to have 

the planes in which implants lie, one centimeter apart. It is necessary that 

the implants embedded near the border of the growth be placed 5 millimeters 

from the adjacent normal tissues to avoid undesirable reaction. 

The diagram is useful to estimate the number of implants required in 

a given plane of the tumor. By drawing as accurately as possible, and 

to scale, the outline of the tumor in the plane in which implants are to 

be placed, using thin or "onion skin" paper and laying this outline of 

the tumor over the diagram given below, the tumor area can readily be 

charted into squares of approximately one square centimeter each. By 

trying several arrangements of the outline over the diagram, a position 

can usually be found which will secure the greatest number of whole 

centimeter squares. When this position is found, lines correspondingto 

the centimeter squares may be drawn in the tumor outline, and from 

the number and position of these squares, the number and position of 

the radon implants may be estimated. 

V 

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/ i t ( ( 

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Radium 21 

BASIC AND CONTBIBUTING FACTORS CONSIDERED IH THE APPLICATION OF RADIUM 

BY 

VILLIAX H.CAMERON.M.D.,PITTSBURGH,PA. 

SOURCES OF THE RAYS 

PROPERTIES BETA BAYS 

KINDS OF RAYS 

PHOPERTIE3 GAMMA RAYS 

SIOPST 

CLINICAL 

X-RAY 

ACUTE INFECTIOUS 

C0NTRA-INDICA7I0B3 TBIAL RADIATION 

?L&HINAI, CAflCEH 

fe^s 

f 

DUMCULATED FIBROIDS 

LYMPHOMA ' 

LYMPHOCYTOUA 

LniPHOSABCOUA 

MYELOMA 

E11BRYOXAL TUH0B3 

BASAL-CELL 

CELLULAB ANAPLASTIC 

BOOMD-CELL 

AUTOLYTIC 

DIFFUSE CARCINOMA 

DEGENERATION 

CAUSTIC DESTRUCTIOB — 

AGE OP PATIENT 

PAST-PRESENT HISTORY- 

PBIMABY OR BECUHBENT CASE 

BLOOD FINDINGS 

COMPLICATIONS 

VESSEL WALL (INNER COAT) 

LYMPHOID 

MUCOUS MEMBRANE 

TISSUE 

GLANDS 

BCBE MARRO* 

• 

COBHEA 

PBEVIOUS TBEATMENT — 

SITUATION OF LESION- 

BADIUU ELEMENT ' 

SURFACE RADIATIOS- 

CAV1TX RADIATION— 

ANAESTHETIC 

TUBES A NEEDLES 

SECES3ABY SURGERY- 

BAY BESPOIISE 

OF VABIOUS NEOPLASMS 

NAMED IH OBDER OF 

SUSCEPTIBILITY 

ADULT 7 

AUT.OP BADIUM OB RADON (TOTALIS. 

AMT.EACH TUBE-BEEDLE-1MPLA3 3T— \l 

TIME OP APPLICATION 

SURFACE AREA USED- 

IMMEDIATE 

NORMAL-SKI 

SIMPLE ERYTHLMIA 

DESQUAMATION 

ABNORMAL-SKIM 

VESICATION 

SUPEBFICIAL ULCERATION 

DEEP ULCERATION 

NORMAL-MUCOUS MEMBRANE 

GBAYISH-ffHITE DISCOLORATION 

SLOUGH—AFTER BURIED BADIATIO 

PBYSIOLOGICAL EFFECT 

THAT MAY BE PRODUCED 

POIBTS IN ESTIMATING 

VIRULENCE-LESION 

AHD 

RESISTANCE OF PATIENT.—• 

TO DISEASE..* X RAIUaJiOuJ 

BAY RESISTANCE 

OP 

SUBBOUNDIBG TISSUE 

NAMED IB OBDEB OP 

SUSCEPTIBILITY 

POIBTS ALTERING 1 LOCAL 

BESISTAHCE OF TISSUE 

SELECTIHG POINT SOURCE 

AND 

TYPE OF APPLICATOB 

TO SECURE BEST 

HOMOGENEOUS RADIATION 

FBEPABATIOB 

MECHANICAL 

OF 

POSITION 

PATIENT 

TUBES ETC.* AUXILIABIE 

DOSE 

AFTER EFFECTS 

IMMEDIATE 

All J 

PROGRESSIVE 

END RESULTS 

ABNORMAL-MUCOUS COMPLETE ABSOBPTIOB MEMBRANE AVORABLE-PALLIATION 

SLOUGH--AFTEB COMPLETE FIBROSIS SUBFACE — RADIATION_ 

FAVORABLE- SLOUGH-SCAB FORMATION 

DE3N0PLASTIC 

BSE FIBROIDS 

TUMOBS 

CABC1NOUA SIMPLEX 

FIBROCABCINOMA 

SQUAMOUS 

ÂDENOCARCINOMA 

FIBROBLASTIC SARCOMA 

OSTEOSARCOMA 

NEUBOSARCOMA 

GBOJTH RESTRAINT 

-TISSUE CONVERSION 

-METASTASIS 

-EXTENT OP LE3I0N 

-SITUATION OF LEGION 

TYPE OF LESION 

SKIN 

MUSCLE 

-CAHTILAGE 

-NERVE 

•PERIOSTEUM 

• BONE 

•BLOOD SUPPLY 

•LYMPHATIC DRAINAGE 

RADON (RADIUM ENAIJATIOH) 

•BUBIED RADIATION 

-CROSS-FIRE 

-FIELD 0? RADIATION 

Tîmplants t & SCREENS 

Sj~~-CAUTEJtY 01 IB X-RAY 

TIME OVER EACH AREA 

SCREENING 

DISTANCE USED 

ART.BURIED CM.OF TISSUE 

PROGRESSIVE-CELL 

SLIGHT SPELLING 

HYPERCUHOBATISM 

VACULAB DEGENERATION 

BBEAKING CHROMOSOMES 

HYDROPIC SPELLING 

SOL. OF CYTOPLASM 

ROGRESSIVE STROMA 

SEROUS EXUDATE 

HYPEREMIA 

GROWTH HES CAPILLARIES 

OUT'AANDERING LEUCOCYTES 

FORMATION FIBROUS TIS3U1 

PALLIATION 

CIRCULATION RETARDED 

PARTIAL FIBROSIS 

YUFH DRAINAGE CHECKED

22 R a d i u m

RA.PIUM 23 

X-RAY AND RADIUM THERAPY IN UROLOGY.* 

By George Gilbert Smith, M. I).. F. A. C. S.. Boston. 

(From the Huntington Memorial Hospital) 

Any discussion of the place of radiation in a specialty such as urology, 

in which widely varying types of pathological lesions occur, necessitates 

a recognition of the different forms in which radiation may be 

employed. It may not be amiss, therefore, to review briefly the physics 

of radium and the roentgen ray, and to establish first a clear conception 

of the different ways in which these measures may be used. 

At the Huntington Memorial Hospiial the total supply of radium 

is kept in solution in a flask. From ihe solution of radium a gas is constantly 

being given off; this gas is purified and led into a glass capillary 

tube less than a millimeter in diameter. Different lengths of this tube. 

with varying quantities of the gas imprisoned within each segment, are 

sealed off by heat. The gas is radium emanation (radon) ; it contains solid 

particles of Radium A, Radium B and Radium C. From these substances 

are given off the different kinds of rays. The emanation therefore has 

the radioactive property of radium, and supplies the same source of Beta 

and Gamma rays as does the clement Radium; the difference lies in its 

vastly greater rapidity of disintegration. Kmanation loses 50% of its 

potency every 3.S5 days, whereas radium itself loses one-half its radioactivity 

in something under 1700 years. For practical purposes, the 

emanation is the better form in which to employ the radioactive principle, 

because it is more capable of subdivision into very minute quantities. 

It is, we may say. more flexible, and the danger of losing the source of 

our radioactivity is done away with. The maximum amount of emanation 

accumulated from 1 milligram of radium over a considerable period 

of time is termed a millicurie. 

From the radium emanation and its products are given off three kinds 

of "rays." The Alpha rays arc positively charged material particles, 

really helium atoms, liberated from the radioactive substances with an 

initial velocity of 9000-12000 miles per second. These rays, since they 

arc absorbed by the thinnest layer of metal or by a sheet of note pajier, 

never got beyond the glass which contains the emanation. Consequently 

they are of no practical interest when radium is used in any sort of 

container. 

Beta rays are negatively charged electrons of varying degrees of penetration. 

The softest Beta rays approximate the Alpha rays; the hardest 

or swiftest have one hunderd times the penetrating power of Alpha rays. 

Yet even the hardest Beta rays are absorbed to a large extent by 1 centimeter 

of epithelial tissue. To get any effect from these rays, therefore, 

the source of radiation must be applied closely to the tissues upon which 

an effect is desired. 

Gamma rays are not particles or electrons, but are undulations of 

the ether, or electro-magnetic waves, similar to X-Rays. but of shorter 

wave length and consequently of greater penetration. An idea of their 

penetrating power is given by the fact that the hardest Gamma rays will 

penetrate even a foot of lead without being entirely absorbed. 

•Rcprinled by permission from The Boston Medical and SurRical Journal. Vol. 192. 

335-3*0, Feb. 19, 1925.


X-Rays are similar in character lo these Gamma rays, as has been 

stated. The rays produced by the ordinary low voltage machine (90,000 

volts) are of somewhat longer wave length, and are absorbed more easily 

and i>cnetrate less deeply. The rays from the recently devised high voltage 

machine (140-200,000 volts) are of shorter wave length than those 

from ihe machines of lower voltage, and penetrate to a greater depth. 

Both gamma rays and X-rays follow the law that the amount of 

energy received at any given point varies inversely as the square of the 

distance between that point and the source of the rays; this law does not 

take into consideration ihe absorption of the rays by the tissues through 

which they pass nor the scattered rays coming into the beam from without. 

To summarize, we have two widely different forms of radiation. 

One involves the use of the Beta rays, which do not penetrate much 

more lhan one centimeter. Within that radius, these rays are very powerful, 

being eight limes as active as the Gamma rays given off at the 

same source. To secure the services of the Bela rays, one must employ 

unscreened or slightly filtered radium emanation or element, and must 

apply the source of Ihe rays closely to the tissues to be treated. This 

method of using radium is confined lo surface growths, such as the superficial 

epitheliomata of the penis, or Ihe tumors in which the unscreened 

radium can be buried. 

Stevenson, of Dublin, in 1914, first used radon by implantation; 

the tubes were contained in steel needles which were plunged into the 

center of the tumor and removed after a few hours. Duane of the Huntington 

Hospital, who devised an apparatus for collecting emanation, 

modified this method by burying tiny ampules of emanation of one or a 

few millicuries each within the growth; these ampules or "seeds" become 

inert by the end of one month, and are thrown off with the slough which 

results from their activity. When a number of such seeds are buried 

in a tumor, each seed produces an oval shaped area of necrosis about 1 

cm. in diameter. In addition to this local, necrotizing effect, there is 

also considerable effect produced by the action of the Gamma rays from 

ihe whole number of seeds; ibis action is more widespread than that of 

the Beta rays. 

When it is desired lo radiate a tumor lying beneath healthy tissue, 

an entirely different problem is presented. Wc aim then to pass rays 

into the tumor in sufficient strength to exert a therapeutic effect, vet 

the rays must not be powerful enough to destroy the intervening healthy 

tissue. The accomplishment of ihis object would he impossible if it were 

not for Ihe fact that tumor tissue is more susceptible to radiation than is 

normal tissue and can be radiated through areas of normal tissue; by 

this means the tumor receives radiation with every treatment whereas 

each section of overlying tissue receives radiation but once. This phase 

of the question will be taken up a little later. It should be clear that 

in the employment of radium for such a purpose—namely, the radiation 

of deep-lying tumors.—the Beta rays must be filtered out and only the 

Gamma rays used. This end is gained by the enclosure of the source 

of radiation within a capsule of lead, platinum, silver or other metal thick 

enough to filteroul the rays that are not wanted. 

Silver screens of 0.1 mm. thickness absorb 50% of the Beta rays. 

Silver screens of 0.5 mm. thickness absorb 96% of the Beta rays. 

Silver screens of 1.0 mm. thickness absorb


Since, by the impaction of rays upon the filter, a few secondary 

Beta rays are formed, the whole apparatus should be separated from the 

surface of the body by six lo ten centimeters of air, or by gauze or rubber 

placed about it to prevent the metal screen from touching the skin. 

Inasmuch as the Gamma rays constitute only a small percentage of 

the radiation much larger amounts have lo be employed in order to get 

any effect. 2000 to 401X) mc. hours are given at one exposure. Such 

treatments are known as radium packs. Since the introduction of the 

high voltage X-Ray machine. X-Ray treatments have largely superseded 

these radium packs, thereby releasing large quantities of radium for 

those purposes for which the X-Ray could not be used. 

'Ihe effect of radiation upon living tissues opens a very interesting 

and still undecided question. Ewing3 says that "changes occurring under 

radiation are not duplicated under any other conditions and indicate a 

specific and selective action of radium upon tumor cells." That this 

action is frequently not the same in apparently similar tumors in different 

individuals must be admitted. The caustic action of the Beta rays 

is so intense that all tissues, both normal and malignant, undergo complete 

necrosis when exposed for a comparatively short time. When deep 

radiation is employed, however, either by means of the radium pack 

or X-Ray, there is great difference in the degree to which apparently 

similar tumors respond, and also in the amount of reaction shown by 

the individual who is radiated. 

F.wing believes that lumors of embryonic type, such as testicular 

tumors, arc much more susceptible than those of the adult-celled type, 

such as squamous carcinomata. Very cellular, rapidly growing tumors 

of any type are more suspectible than the slower growing scirrhous 

forms. The portion of the cell first affected is the nucleus; this part 

is especially vulnerable while in process of cell division. There is still 

much controversy as to whether a deep-lying tumor can be killed by 

radiation which has to penetrate several inches of healthy tissue before 

it reaches the growth. Certain German roentgenologists have formulated 

a theory of a "killing dose" for carcinoma and another for sarcoma; the 

former consists of a dose which is 90-1 io?£i of the erythema dose, whereas 

the sarcoma dose is somewhat less. Not infrequently the "killing 

dose" for the carcinoma is a killing dose for the patient. Ewing believes 

that we cannot expect to kill a cancer by external radiation; it is necessary, 

he thinks, to employ the caustic action of the radium by exposing 

the tumor and implanting in il unscreened radium. Metastases of certain 

types, however, may be pretty effectually destroyed by external radiation. 

The beneficial effects of deep radiation Fwing believes are due 

chiefly to interference with the circulation of the tumor. The endothelial 

cells of the blood and lymph vessels are especially susceptible to 

radiation; ihe destruction of Ihe circulation of blood and lymph prevents 

the tumor cells from getting nourishment and interferes with the carrying 

away of waste products. In support of this theory Ewing describes 

deep lying tumors in which, after radiation, the center became necrotic. 

while healthy cancer cells were found in the periphery. There is also a 

stimulation of connective tissue formation; this prevents extension of 

the growth, and even if individual cells survive, they become enmeshed 

in connective tissue. Ewing insists that wc must employ radiation 

secundum naturam; a cachectic individual will not respond to radiation 

under any circumstances. He believes ihat by slow disintegration of ihe 

tumor through circulatory interference substances are liberated which


increase the patient's resistance. For these reasons, he is opposed to the 

theory of a killing dose, and says that excellent results have been obtained 

in the Memorial Hospital, New York, by means of low voltage X-Ray 

treatments, given frequently. 

This is a brief outline of the rationale of radiation, and of the faclors 

which must be considered before one decides upon the proper method 

of radiation therapy for any particular tumor. 

In urology ample opportunity is given for the employment of all 

types of radiation. Let me mention its possible uses, with a few illustrations. 

We will begin with the less serious and more superficial conditions. 

Radiation in urology is employed only in cases of malignant disease, with 

one exception. The exception is the clinical entity known as fibrosis 

of the corpora cavernosa. This condition is due to the formation in the 

shaft of the penis of areas of dense connective tissue, almost cartilaginous 

in consistency. These areas sometimes give rise to pain, especially 

during erection. The etiology is sometimes leutic. sometimes traumatic, 

sometimes unknown. In the small series of 6 cases which we have treated 

at ihe Huntington Hospital the Wasserman was negative in four, not 

taken in two. Three cases had a definite history of injury, such as striking 

the penis against some sharp edged piece of furniture. In all of the 

six cases, symptomatic relief followed one or more applications of radium. 

As to the induration itself, the result in one case is unknown; in one. the 

induration was not diminished although the pain had disappeared; in 3, 

ihe area of fibrosis became definitely less, and in one case it practically 

disappeared. 

Justification for the use of radium in the above condition may be 

found in the statement of Simpson, who quotes Thies as saying that white 

fibrous connective tissue, when exposed to the rays, underwent destruction. 

Yellow elastic fibres, however, are resistant to radiation. Ewing 

also says that a cessation of activity of proliferating connective tissue 

is often produced by radiation. In treating fibrosis of the penis, wc have 

de[>ended largely upon Gamma radiation, for fear of causing ulceration 

of the skin by ihe Bela rays f\vo or three needles of emanation. 

screened by 1 or 2 mm. silver and 0.5 cm. gauze, are fastened to the penis 

by adhesive plaster in such a way as to subject the area of fibrosis to a 

cross-fire. A total dosage of 200 inc. hours of radium so screened has 

caused moderate erythema and occasionally superficial ulceration of no 

importance. Consequently the application should be no greater than 

this. The treatments may be repeated every six weeks or two months. 

Epithelioma of the Penis.—Early cases of this type of malignancy 

are well suited for radium treatment. Careful selection of the cases 

must be made, however. Frequently preliminary circumcision is necessary. 

If the growth is then seen to involve only the superficial structures 

of the glans penis, it should be radiated. If it appears to have broken 

through the fibrous covering of the glans. and invaded the blood spaces 

beneath, amputation should be done. Of the 7 cases in which we believed 

radium justifiable, in none have metastases in the groins appeared. All 

have responded to radium treatment. 'Three have entirely healed, so 

Ihat the glans penis shows no suspicious areas. In four, some sort of 

lesion persists, either a radium ulceration or a small area of enisling 

which may perfectly well be due to radiation, but which necessitates occasional 

visits to the hospital for observation. The earlier cases were 

treated too heavily, with Ihe result that rather deep ulcerations were pro-


duccd which were covered with a dry, fibrous,persistent slough. In the 

treatment of these growths, the caustic effect of the Beta rays is desired. 

Unscreened needles are applied over the affected area. We have found 

ihat from 7-10 mc. hours will suffice to cause a superficial slough which 

removes the growth without destroying too deeply the underlying tissue. 

This dosage is best given by applying a fairly heavy dose for a few minutes, 

rather than a small dose for a longer period. [CO millicuries for 

10 minutes, for example, produces aboul the right amount of reaction. 

In more advanced cases, the question arises as to ihe value of radiation 

following amputation. In the very limited experience we have had 

with such cases, radiation has not accomplished much. For example. 

a man of 59 had complete emasculalion and dissection of the groins on 

September 30, 1922. The glands from both groins showed invasion by 

Ihe growth. In December of the same year he had two l/2 erythema 

doses at 170 kilo volts (a fairly high vo'.tageV but he died in June. 1923, 

of "metastatic carcinoma of bladder." (Town clerk's report.) Another 

man had a partial amputation of the penis for epidermoid carcinoma in 

June. 1924. The groins were not dissected, as there appeared to be no 

involvement of the glands. He was given three X-Ray treatments at 

lower voltage (120 K V) on July 9th. September 12th, October 6th. In 

spite of this a mass of glands developed in the left groin. This mass 

was removed surgically in November. Microscopic examination showed 

a large amount of connective tissue stroma thickly strewn wilh large 

oval, rather vacuolated nuclei. These were not arranged in the manner 

typical of epidermoid cancer, and their appearance suggested sarcoma 

rather than carcinoma. They appeared to be healthy enough, however, 

in spite of the radiation. 

Tumor of the Testicle.—There can be no question as to the proper 

treatment for the primary tumor. Orchidectomy should be done as soon 

as the diagnosis can be made. Unfortunately metastasis in these cases 

is early. The growth recurs in the glands that lie along ihe iliac artery 

and the aorta. Hinman, aroused by the poor results of simple orchidectomy, 

advised careful dissection of ihe lymphatics from the renal vein to 

the inguinal ring. In some cases so extensive an operation is unwise, 

or may be thought unnecessary liecause of the early discovery of the 

tumor. In such cases, deep radiation of the abdomen is worth while. 

for it is well known that the metastases of these tumors are especially 

suspectible to radiation. We have had one very encouraging case of this 

sort at the Hunlinglon Hospital. 

J. E., age 27, came to the clinic in December, 1921. He had been 

operated by his doctor for tumor of the testicle, and presented a scar in 

the left groin and a mass of glands three inches in diameter on the inner 

wall of the left pelvis. The left testis was absent from the scrotum. His 

doctor did not state in his letter that he had not removed the testicle, so. 

seeing that the gland was missing,it never occurred to mc that orchidectomy 

had not been done. Wc therefore started to radiate the metastases. 

December 17, 1921, the patient was given a radium pack of 3S04 

mc. hours over the left groin. 

January 12. 1922. the mass had decreased to one-third its original 

size. Another radium pack of. 3216 mc. hours was given. 

February 9. The mass had entirely disappeared. Weight 115^ lbs. 

In March I learned from the patient that his testicle had always 

been intra-abdominal, and Ihat it had not been removed. On March 2. 

therefore, an operation was done antl a malignant testicle only aliout

28 Radium 

twice the size of a normal gland was removed together with several enlarged 

iliac glands. Microscopic examination of the testis showed embryonal 

carcinoma. Through an opening in the peritoneum could be 

felt masses of enlarged glands extending as high as the renal pedicle. 

These were not disturbed. The patient was given three X-Ray treatments 

by Dr. L. B. Morrison. In June, 1922, he was given a high voltage 

treatment at the Huntington Hospital, but collapsed while it was 

going on. Later treatments were therefore given by means of radium 

packs. In October and again in November. 1922, he was given 2100 mc. 

hours over the upper abdomen. 

In March. 1923, he had lost 6 pounds, complained of pain in the upper 

lumbar region, and on deep palpation a mass could be felt in the upper 

left quadrant. He was given 2640 mc. hours over that area. 

In May, July and October. 1923. he was given similar treatments of 

about 2700 mc. hours each. In April, 1924, he was given 1800 mc. hours 

over the left groin, where a small mass was palpable beneath the scar. 

November 23, 1924, he appeared to be well. Weight 115. Color excellent. 

Digestion good. No subjective symptoms. No masses palpable 

in abdomen. Lungs resonant. No enlargement of palpable glands. 

It can hardly be expected that kidney tumor will respond to deep 

radiation. The circulation is so free and the tumor usually so bulky 

that nephectomy should be done whenever possible. After that, X-Ray 

treatments may be given in the hope that metastases may be destroyed 

or restrained. The metastases of hypernephroma, however, are so widely 

disseminated that there is little chance of accomplishing anything important 

by radiation. 

The embryonal renal tumors of childhood should yield more satisfactory 

results. Ewing says that he has seen regression of such a tumor 

follow J4 of an erythema dose. This was attended by collapse of the 

infant, so we must be cautious in ihe employment of radiation in these 

cases. 

Tumors of the Bladder.—The proper measures to employ in these 

cases depend so much upon the type and situation of the growth that no 

sweeping recommendations can be made. Benign papillomata yield well 

to fulguration through the cystoscope, and do not tend to recur any more 

frequently after this treatment than after excision. Other growths so 

situated ihat excision may be satisfactorily performed should be removed. 

but in at least half the cancers encountered, the growth is either so situated 

or has progressed so far that resection would obviously be inadequate. 

For such cases cystotomy, removal of the fungating portion of the 

growth by means of the cautery or diathermy, followed by implantation 

of seeds or of radium needles of small potency, will usually give excellent 

results. There is of course a limit to the size of the area which can 

he so treated. If a section of bladder wall more than 4 cm. in diameter 

is involved, there is little use in trying to check the growth. The chances 

are thatit is already outside the bladder. We have had a number of very 

encouraging cases treated by the implantation of seeds. 

The case which has gone longest without recurrence-is T. D., age 43. 

November 3, 1921. On November 9th of that year cystotomy was done. 

Into a sessile growth about 2 cm. in diameter, involving the right ureteral 

orifice, 10 seeds totaling 27 inc. were implanted. A specimen removed at 

the time was reported "Carcinoma." Jan.. 1925, examination by cystoscope 

and external palpation showed no sign of growth. The patient 

had gained much weight and considered himself well.


In other cases the growth has apparently been destroyed, but the 

time elapsed since operation is too short to report them even as probable 

cures. 

Another use for radium in cancer of the bladder is in meeting local 

recurrences as they arise. I hrough the cystoscojie one or two seeds can 

be implanted in early recurrences. One seed will destroy a tumor a cm. 

in diameter. By keeping after these cases some of them can be carried 

along in comfort for a number of years. 

Cancer of the Prostate.—In my own experience these cases fall into 

one of two groups. Either they are suitable for total prostatectomy, 

usually with vesiculectomy, an operation which I have done upon 15 

cases with no operative mortality* ami with most satisfactory results, 

or they are inoperable. Contraindications for operation are; cachexia, 

definite metastases, usually demonstrable by X-Ray in spine or pelvis, 

invasion of the trigone by the growth, or extension of the growth on to 

the pelvic wall. The cases which I have ireated by total excision in certain 

clinics would have been radiated. At the Mayo Clinic, for instance. 

radium is applied from the urethral surface, the rectal surface, and by 

inserting needles bearing it into ihe gland itself. Barringer of New York 

favors the latter method. I have yet to be shown why total prostatectomy 

as originally performed by Hugh Young is not preferable to these 

slower and less certain methods. If spinal metastases occur, the pain 

which they cause can usually be controlled by X-Ray. 

For the inoperable cases, which are usually far advanced, X-Ray 

may be tried. At the Huntington Hospital we have used the high voltage 

machine on seven cases. Usually a course of treatments consists 

of four half erythema doses given on successive days. The target distance 

is usually set at about So centimeters, the Kilo voltage is 170, the 

filter is 0.5 millimeters copper and the current 3 milliamperes. Sacral 

and suprapubic regions are exposed on alternate days. 1200 electro 

static unit seconds is regarded as the standard erythema dose. 

(1) E. H. 66. X-Rays showed invasion of the rami of the pubic 

bone. 4 exposures in April, 1924. Died October 30. 1924. 

(2) G. L. 72. July 12. 1922. was given an erythema dose. y2 

anterior, f/2 posterior. August 3. Glands in groin smaller. Patient 

able to empty bladder. Went into coma and died. 

(3) R. P. 56. Mass of glands 3 inches thick inside left pelvic wall. 

Great edema left leg. Takes morphia for pain. Prostate typically malignant. 

Weight 111 pounds. January 23 and 24, 1923, erythema dose over 

sacrum and one over pubes. March 20 and 21, one-half erythema dose 

over sacrum and y> over pubes. June 6. 1923. Has been working for 

3 weeks. Weight 130 pounds. Mass in pelvis partially gone. No need 

for morphia now. June 25 and 26. Two more x/2 doses. October 31, 

1923. Recently has failed and lost 20 pounds. X-Rays show metastases 

in cervical and thoracic vertebrae. Died Jan. 15. 1924. This patient 

showed remarkable improvement for a time. 

(4) McD. Patient had total prostatectomy in May, 1922. Growth 

recurred about trigone a year later. June. 1923, had 4 half erythema 

doses. October 4, 1923. No marked change. Growth feels softer on 

rectal examination and palient empties bladder completely. December 

•One of these casts died while still in the hospital. Uiree months after operalion. 

The arowth had invaded ttm loft vehicle so extensively that I could not 

remove it. so radiated the area. The patient did well at first, about one month 

after operation he began to lose Kround and grew progressively weaker.


6, 1923. Cystoscopy: Base of bladder covered with growth. Died July, 

1924. Very little help, if any, from his radiation. 

(5) P. S. 65. September 26, 1923. Extensive carcinoma prostate 

with involvement of sacrum and inguinal glands. X-Rayed to stop pain. 

Eight half erythema doses over a period of 3 months. Glands in groin 

disappeared. Prostate felt softer. Pain was completely relieved, but 

new pains from new metastases developed. Died July, 1924. 

(6) W. M. 69. April. 1924. Cystoscopy showed invasion of trigone. 

Growth apparently limited to prostate, vesicles and trigone. April, 

1924—four V2 erythema doses. Repeated in July. Although he gained 

9 pounds in weight, his prostate in August, 1924, felt the same as before 

treatment. His doctor reports (Dec. 6) he has been more comfortable 

since his radiation, but that the disease is progressing. He has had no 

vesical or redal symptoms, but has pain apparently from spinal metastases. 

(7) T. II. 55. Laborer. May 17, 1923. Cachectic man. Symptoms 

of 1 yr. duration. 'To inner side of each Poupart's Ligament is a 

round mass size of tennis ball. Chain of glands along left iliac vessel. 

Prostate hard; induration in vesicles. Cystoscopy shows 4 oz. residium. 

Prostatic outline irregular, with nodules and masses projecting. On base 

of bladder is one discrete round tumor. 

June 20-21-23. One-half erythema dose—170 K. V. on each of three 

successive days. No ill after effects. 

No. 15, 1923. For three months patient was in bed with swelling of 

left leg. For two weeks has been at work. No bladder symptoms. Gain 

of 15 pounds. Mass in right pelvis is one-fourth the sizeit was. Even 

less inside of left Poupart. Suggestion of enlarged glands along aorta. 

Reclal: induration higher than finger can reach. Prostate is flat and 

softer than a malignant gland. Cystoscopy: No residuum. Prostatic outline 

only slightly prominent. Smooth except on upper quadrant where 

mucosa is irregular. One small nodule on trigone. Advised to have 

more X-Ray but did not come in. 

March 6, 1924. Has been working. Weight 195. a gain of 12 

pounds. Urine clear. Rectal: Prostate feels soft and not at all suggestive 

of malignancy. Above prostate bladder base feels firmer than 

usual. Cystoscopy: Prostate appears prominent, more like adenoma than 

carcinoma. Just above anterior commissure is a nodule in the bladder 

wall. Trigone—clear! Abdomen: mass inside of left ilium is barely 

palpable. No other glands felt. 

April 14-15-16-17. X-Rays. No reaction. l/A erythema dose each 

day. 

June 5. Feels well—no pain. No trouble voiding. Nocturia 1-2. 

Prostate large, elastic, movable, no suggestion of carcinoma. No 

masses in abdomen. Cystoscopy: Prostate prominent, like adenoma. No 

masses elsewhere in bladder. Sloughing area in roof has disappeared. 

November 27, 1924. Patient is feeling well and working full time. 

Only complaint is slight burning on urination. Color good. Weight 

normal. Abdominal examination shows no masses. Rectal examination: 

prostale large and elastic, not at all suggestive of malignancy. Cystoscopy: 

Urine slightly hazy. 1 oz. residuum. Prostate shows enlargement 

of the lateral lobes, the appearance being typical of a benign hypertrophy. 

There arc no sloughing areas and no tumors seen anywhere in the bladder.


The recital of this case, lo me a very remarkable one, closes the very 

short series of clinical observations on this subject. 

In estimating the value of radiation in urology 1 would agree with 

Ewing's statement that while radiation of deep lying tumors may relieve 

pain and restrain their growth, it rarely cures. As an adjuvant to surgical 

removal, deep radiation is a rational measure to employ, for it may 

restrain early metastases. 

In a large proportion of cases of carcinoma of prostate and bladder. 

especially of the former, metastasis lo the spine has already taken place 

before the diagnosis is made. We cannot ex|tect radiation of the pelvic 

to check growth in the dorsal vertebrae, nor is it possible to radiatethe 

entire body with a view to checking such metastases. We can only wait 

for them to develop, but when they do begin to cause pain, the suffering 

can be greatly relieved by appropriate radiation. 

In cases where it is inadvisable for any reason to remove the growth. 

such as early cancer of the penis or certain cancers of the bladder, ihe 

direct attack upon the tumor, using lx>th Gamma and Beta radiation to 

slough out the pathological area, is a most satisfactory procedure, and 

one which may l>e attended by cure, provided metastasis has not already 

laken place. 

In short, there is place for radiation of the deeply penetrating type 

or of Ihe locally caustic type in the majority of cases of malignant diseases 

of the genito-urinary tracl. It may also be used with a fair measure 

of success in one condition which is not due to malignancy—namely. 

fibrosis of the corpora cavernosa. As regards the efficacy of deep radiation 

in controlling metastases, we have not yet sufficient information to 

enable us to know just how much it will accomplish. That it will check 

ihe development of many growths we have already discovered; it will 

require much more extensive observation before we can estimate with 

accuracy the value of radiation in this field. 

i. 

2. 

REFERENCES 

Radium Therapy. Simpson. Frank E.—C. V. Mosby Mosbv Co.. Co., 1922. 

Radium Report of the Memorial Hospital, New York. Second 

Series, 1923. P. B. Hober. Inc. 

CLOSURE OF BRONCHIAL FISTULA OF TWELVE 

YEARS' STANDING BY USE OF RADIUM* 

By William L Harris, M. D., Providence, R. I. 

The nonsurgical treatment of a bronchial fistula has always been a 

troublesome task. Following the rupture of a pulmonary abscess into 

the pleural cavity the opening into the bronchus may close some weeki 

after the resulting empyema has been drained, but this satisfactory result 

is by no means a constant one. Usually, after months of surgical care 

have failed to bring about the closure of a bronchial fistula,the sufferer, 

on account of distressing symptoms, will submit to further surgical intervention 

with results that arc not always satisfactory, as permanent 

•Reprinted by permission from the Medical Journal and Record, CXX, 590-5S1, 

Dec. 17. 192*.

32 Radium 

closure of a divided bronchus is not always possible. Furthermore, since 

the operation is one of very considerable gravity, any other method offering 

possibilities of success may well be worth considering. 

The characteristic, extensive fibrosis which follows the application 

of radium to vascular tissue (as in the treatment of an angioma), suggested 

the use of radium in the following case of long standing bronchial 

fistula: 

Case.—Patient, male, forty-five years old, weighing 270 pounds, 

had an empyema following an attack of pneumonia. Under local anesthesia, 

a portion of a rib was resected and the pleural cavity drained. 

At the end of one year there was no improvement in patient's condition, 

and. as at the age of seventeen ( ?) he had been operated upon for suppurative 

cervical adenitis, the continuation of the discharge with the persistence 

of the bronchial fistula suggested the possibility of a tuberculous 

process. During a period of more than twelve years drainage ceased 

several times. Upon one occasion the patient seemed perfectly well for 

about eighteen months. During these years it was necessary to reopen 

the pleural cavity many times, and upon each occasion the opening into 

the bronchus was always in evidence. For the greater part of this long 

period the discharge was so profuse that dressing twice a day was necessary. 

Infection of the skin covering the chest caused much distress 

and for some years daily treatments of the entire chest wall with the 

quartz light was the only means of securing relief. Upon several occasions 

the long sinus seemed about to close, but this desideratum always 

represented a false hope, and the necessary reopening and extensive dissection 

of the fibrous pyogenic membrane running through a greatly 

thickened pleura was always followed by the whistling gurgle through the 

bronchial fistula. 

As a forlorn hope the use of radium was suggested, the idea being 

entertained that the tough fibrous membrane would disappear, and that 

deep introduction of the radium clement might produce a fibrosis,with 

subsequent contraction of the vascular pulmonary tissue in the neighborhood 

of the patulous bronchus bringing about its closure. Within a 

period of ten weeks about 4200 milligram hours of radium treatment 

were given, directed at different portions of the sinus, and within four 

months the thickened scar tissue had disappeared. The sinus, which 

measured about seven inches, gradually closed and for the past eighteen 

months the patient has been perfectly well. I cannot but feel that the 

patulous bronchus was responsible for ihe many years of drainage from 

the pleural cavity and that, following the destruction by radium of the 

endothelial cells lining innumerable capillaries in the pulmonary tissue 

surrounding the ruptured bronchus (thus transforming the capillaries 

into fibroids—which automatically contract), the opening into the bronchus 

was occluded. To have attempted its closure by surgical intervention 

in this patient weighing 270 pounds would have been most hazardous, 

and indeed it was never considered. 

I have so often seen satisfactory results following the use of radium 

in conditions where fibrous indurations, by interfering with drainage, 

were impeding recovery, that I feel in this element we have a most potent 

agent to aid us when confronted by abnormal areas of fibrous tissue.


index of articles relating to the therapeutic 

use of radium and radio-active 

substances which appeared in 1924* 

BOOKS PUBLISHED DURING I924 

Andrade, E. N. daC. The Structure of the Atom. Cloth. $6. Pp. 31 

with illustrations. Harcourt. 

Bachem, Albert. Principles of X-ray and Radium Dosage. Cloth. $8. 

Pp. 274, with 67 illustrations. Chicago: Albert Bachem. 1923. 

Blumenthal, F. Strahlcnbehandiung (Roentgen-Licht Radium) bei 

Hautkrankheiten. Cloth, 12 gold marks. Pp. 235. with 120 

illustrations. Karger. 

Cancer Research Fund, Eighth Scientific Report on the Investigations 

of the Imperial Cancer Research Fund. Under the direction 

of the Royal College of Physicians of London and the Royal 

College of Surgeons of England. Paper, 20 shillings. Pp. 142. 

with illustrations. Taylor and Francis, 1923. 

Ersettig. XJ. Radiumtherapia in Dermalologia. 30 lire. Pp. 225. with 

50 illustrations. Cappelli. 

Faurc. Jean-Louis. Cancer de 1'Uterus. Paper. 20 francs net. Pp. 229. 

with 117 illustrations. Doin. 

Memorial Hospital. New York. Radium Report of ihe Memorial Hospital. 

New York. Second Series, 1923. Cloth, $5. Pp. 293, 

with 55 illustrations. Hoeber. 

Piery and Milhaud. I-es Faux Minirales Radio-Actives. Emanotherapie 

Generalc ct Cures Hydro-Minerales. Preface de M. J. Teissier. 

Paper. 30 francs net. Pp. 456. with 74 illustrations. Doin. 

Varley. G. H. Radium, Its Therapeutic Uses in General Practice. Cloth. 

Pp. 103. Oxford. 

Journal Articles 

Abrami. P. and Widal. F.—Effectual action of radiotherapy on asthma 

in hyperthyroidism. Presse med. 32:473-476, May 31, '24. 

Alamartine and Charleux — Radium treatment of degenerated papilloma 

of bladder, J. d'urol. 16:291-294. Oct. '23. 

Alquier. A.—Radioactive mineral walers. Medccine 5:718-719, June '24. 

Apcrt, E., and Kermorgant— Offspring after gynecologic irradiation, 

Presse med. 31 :i020, Dec. 5. '23. 

Arthritis— 

—Further experiences in the treatment of arthritis with high doses of 

radium emanation, (Th. Valernahm), Medizinischc Klinik, 

18:1477-1479, Nov. 23, 1922; ab. Radium, 3. N. S.. 156-160, 

July '24. 

Asnis, E. J., Clark. W. L„ and Morgan. J. D.—Treatment of neoplastic 

diseases ,hy combined methods. Atlantic M. J.. 27:541-5^9 

May '24. 

•Thislist has beer, prepared, uslntt os the main basis the tides given In the 

Quarterly Cumulative Index lo Current Medical Literature, vol. 9. I9i1. published 

by the American Medical Association. Mosl or the articles will he found listed 

under the name of


Asthma—Complications 

—Effectual action of radiotherapy on asthma in hyperthyroidism, (F. 

Widal and P Abrami), Presse med. 32:473-476, May 31, '24; 

ab. J. A. M. A. 83:309, July 26. '24. 

Atoms— 

—Progress in research on atoms, (H. Kustner) Deutsche med. 

Wchnschr. 50:1300-1302, Sept. 19. '24; cont. 50:1337-1338, 

Sept. 26, '24 (charts); cont. 50:1380-1381. Oct. 3, '24. 

Ayres, Samuel, Jr.—Radium in ihe treatment of subungual verrucae. 

Arch. Dermat. Syphilol. 5:748-749, June, '22; ab. Radium, 

2. N. S„ 317-318. Jan. '24. 

Bachem. A.---Radium and roentgen rays as different agents in superficial 

and deep therapy. Am. J. Roentgenol. 11 :i3-i9. Jan., '24. 

Bacillus—Coli 

—Influence of radium emanation on fermentation of lactose and 

glucose induced by colon bacillus. (G. Graziadei) Riforma 

med. 40:315-317, April 7. '24 (charts). 

Bailey, Harold—Radium as prophylactic and curative agent in recurrent 

carcinoma of uterus, New York Stale J. Med. 24:985-986, 

Dec. '24. 

and Healy. W. F.— Follow-up results of 908 cases of uterine cancer 

treated by radium, Amer. J. Obstet. & Gynec. 6:402-406 and 

491-495, Oct., '23; Radium 2, N. S.. 277:284, Jan. '24. 

--Cancer of uterine cervix, treated by irradiation; methods of treatment 

and results in 1.021 cases. I. A. M. A. 83:1055-1056, 

Oct. 4. '24- 

Barringer, B. S.—Malignant growths of prostate and bladder, M. J. & 

Record, (supp.) 119:158-159. June 18, '24. 

—Radium in treatment of prostatic carcinoma. Ann. Surg. 80:881- 

S84, Dec. '24. 

—and Dean, A. L., Jr.—Epithelioma of penis. J. Urology, 11:497-5i4. 

May '24. 

Beers. N. T.- -A radium applicator for small lesions. Amer. J. Roentgenol. 

10:643-645, Aug. '23; ab. Radium 2. N. S.. 331. Jan. '24. 

Belugin, T.—Mortality in radium therapy of uterine cancer, owing to 

abscesses in small pelvis. Zentralbl. f. Gynak. 48:1970-1974, 

Sept. 6, '24. 

Bcnda. R., and Chiray. M.-—Improvement of myeloid leukemia under 

thorium X, Bull, et mem. Soc. med. d hop. de Par. 48:245-250, 

Feb. 29, '24. 

Bcrgmeister, R.—Irradiation injuries of eyes. Wien. klin. Wchnschr. 

37:1061-1063. Oct. 9. '24. 

Black. P., and Black. S. O.—Radium, X-ray and surgery, Virginia M. 

Monthly, 51:437-438. Oct. '24. 

Black, S. O., and Black. P.—Radium. X-ray and surgery. Virginia M. 

Monthly. 51:437-438. Oct. '24. 

Bladder, cancer— 

—Malignant growths of prostate and bladder, (B. S. Barringer) M. J. 

& Record (supp.) 119:158-159, June iS. '24. 

—Modern methods and results of treating malignancy of bladder. (H. 

C. Bumpus, Jr.) J. A. M. A. 83:1139-1142. Oct. n, '24. 

—Tumor: Radium treatment of degenerated papilloma of bladder, 

(Alamartine & Charleux) J. d'urol. 16:201-294. Oct. '23 (illus.) 

Bland. P. B.—Radium therapy in gynecology. M. J. & Record 120:101- 

107, Aug. 6, '24; cont. 120:156-160, Aug. 20, '24.


Block, F. B., and Clark. J. G.—Relative values of irradiation and radi 

hysterectomy for cancer of cervix. Am. J. Obstet. & Gynec. 

7:543-549- May, '24; ab. Radium, 3, N. S.( 135:140, July '24; 

Atlantic M. J. 27:696-699. Aug. '24. 

Blood, coagulation— 

—Irradiation and coagulability of blood. (P. Pagniez. A. Ravina and 

I. Solomon) Compt. rend. Soc. de biol. 90:1227-1228, May 

16, '24. 

—Reaction of: roentgen rays and hydrogen ions in blood (J. Cluzet 

and T. Kofmann) Compt. rend. Soc. de biol. 91 :946-948, Oct. 

31, '24; ab. J. A. M. A. 83:1881. Dec. 6. '24. 

Bone, marrow— 

—Effect of X-rays on bone marrow (E. H. Falconer. L. M. Morris 

and II. E. Ruggles't Am. [. Roentgenol. 11:342-351. Apr. '24 

(illus.) 

Bowie, E. R.. and Samuel, F. C.— Radiation in treatment of carcinoma 

of uterus. Am. J. Roentgenol. 12:370-372, Oct. '24. 

Bowing, H, H.—Radium and X-ray treatment of advanced carcinoma of 

breast prior to amputation. Radiology 2:143-150, March '24. 

—Microscopically proved sarcoma of humerus, S. Clinics N. America 

4:53'-542, April "24. 

Braun. G.—Action on goiler of intrauterine use of mesothorium. Zentralbl. 

f. Gynak. 48:2198-2200, Oct. 4, '24. 

Breast, cancer— 

— Case of malignant degeneration in radiodcrmatitis, successfully 

treated by electrocoagulation and skin grafting, (G. E. Pfahler 

and C. F. Nassau) Radiology 3:297-300. Oct. '24 (illus.) 

—Inflammatory carcinoma of breast, report of 28 cases from breast 

clinic of Memorial Hospital, (B. J. Lee and N. E. Tannenbaum) 

Surg. Gynec. Obst. 39-580-505. Nov. '24 (illus.) 

—Palliation in cancer of uterine cervix and cancer of the breast, (E. 

A. Ill) J. M. Soc. New Jersey. 21:243-249. Aug '24. 

—Problems in treatment of carcinoma of breast, (H. A. Kelly and 

R. E. Pricked Surg. Gynec. Obst. 38:399-402. March '24 

(illus.) 

—Radiation in treatment of carcinoma of breast. (G. E. Pfahler) 

Southern M. J. 17:203-207, March '24. 

—Radium and X-ray treatment of advanced carcinoma of breast prior 

to amputation, (H. H. Bowing) Radiology 2:143-150. March, 

'24 (illus.) 

—Treatment of primary inoperable carcinoma of breast by radiation; 

report of 54 cases from Breast Clinic. (B. J. Lee and R. E. 

Herendecn) Radiology 2:121-136. March 24 (illus.) 

Brcnzinger, M.—New device for charging electroscopes and iontoquantimeters. 

J. Radiol. 5:241-242, July '24. 

Bright, E. M„ and Redtield, A. C—Physiological action of ionizing 

radiations; evidence for ionization by beta radiation. Am. J. 

Physiol. 68:54-61. March '24. 

—Physiological action of ionizing radiations; path of alpha particle, 

Am. J. Physiol. 68:62-69, March '24. 

—Physiological action of ionizing radiations; X-rays and their secondary 

corpuscular radiation, Am. J. Physiol. 68:354-367, 

Apr. '24. m . . , 

—and Wertheimer. J.—Physiological action of ionizing radiations;

:u; 

Radium 

comparisons of beta and X-rays. Am. J. Physiol. 68:368-378, 

Apr. '24. 

Ilroeman, C. J.—Radium in medicine. Ohio State M. J. 20:226-231. 

April '24. 

Buckman. T. E.. Isaacs, R., and Minot. G. R.—Chronic myelogenous 

leukemia: age incidence, duration, and benefit derived from 

irradiation. J. A. M. A. 82:1489-1494, May 10/24; ab. Radium 

3, N. S. 217:219. Oct. '24. 

Bumpus. II. C Jr.—Radium in treatment of benign hypertrophy of prostate. 

I. Urology. 12:63-70. July '24 

—Modern methods and results of treating malignancy of bladder, 

J. A. M. A. 83:1139-1142. Oct. n. '24. 

Burnam. C. F.—Report of some observations of effects of radium therapy 

in cases of large uterine fibroids. Am. J. Obst. & Gynec. 8:411- 

415, Oct. 24. 

Burns. F. S.—Radium in treatment of non-malignant diseases of skin, 

Boston M. & S. J. 191:16-20. July 3, '24; Radium 3, N. S., 

189-195, Oct. '24. 

Butler. C.— Radium treatment of exophthalmic goiter. An. de Fac. de 

med.. Montevideo. 8:793-813. Sept. '23. 

Callfas. W F.. and Quigley, D. T.—Carcinoma of Antrum; sarcoma 

of middle ear, Nebraska M. J. 9:167-168, May '24. 

Cameron, W. H.—Points lo be considered in application of radium, 

Radiology 3:140. Aug. '24. 

Cancer, Diagnosis 

—Biologic research on serum in cases of cancer before and after 

injections of radium emanation, (R. Fischer and A. Kotzareff) 

Bull, acad. de med. Par. 90:334-336. Nov. 13, '23; ab. J.A.M.A. 

82:163, January 12. '24. 

— Metastasis, Treatment of malignant diseases in moulh. (G. W. Grier) 

Am. J. Roentgenol. 12:347-352. Oct.. '24 (illus.) 

— Radiotherapy. Cancer problem from radiological slandpoint, (H. 

Schmitz) Radiology 2:7-13, Jan. '24 (illus.) 

—Evaluation of X-ray and radium iherapy in cancer and its future 

outlook. CM. J. Sittenlield) Radiology 2:74-79, Feb., '24. 

Five year end-resulls obtained wilh carcinoma of female pelvic organs 

with special reference to radium and X-ray therapy, (H. 

Schmitz) Surg. Gynec. Obst. 39:775-7&o> Dec. '24. 

Radiation in treatment of primary malignant disease, (G. E. Pfahler) 

Atlantic M. J. 28:76-80, Nov. '24; Radium 3. N. S.. 240-244, 

Jan. '25. 

-Radiation method of cancer treatment. (B. J. M. Harrison) M. J.. 

Australia. 2:222-227. Aug. 30, '24. 

-Radium: Its uses in trealnicnl of cancer, (C. W. Hanford) Cincinnati 

J. Med. 4:391-396, Oct. "23; Radium 2, N. S. 297-302, 

Jan. '24. 

—Radium, X-ray and Surgery. (S. O. and P. Black) Virginia M. 

Monthly, 51 :437-l38. Oct. '2.1. 

—Report on lectures on radiotherapy of cancer delivered at Montreal 

and Quebec (C. Regaud) Bull. Acad, de med. Par. 92:978-980. 

Oct. 7, '34. 

- Some biological aspects of radiation iherapy of cancer. (C. Regaud) 

Am. |. Roentgenol. 12:97-101. \ug., '24. 

- -Treatment of malignant growths about the face, (S. Withers and

R a d i u m ?,- 

J. R. Ranson) Colorado Med. 21^2-97. Apr., '24 (illus )- 

Radium, 3, N. S. 181-188. Oct. '24. 

Cancer, radiotherapy— 

—Use of X-ray and radium in superficial malignancies, (A. M. Cole) 

J. Indiana M. A. 1771-76, March '24 (illus.) 

—Radium therapy in, Elective fixalionof radium emanations by embryonal 

and cancer cells. (A. Kotzarcff and L. Wevl) Presse 

med. 31 :Q25-927. Nov. 7. '23 (illus.) 

—Action of buried glass capillaries of radium emanation on plant and 

animal tissues: experimental and clinical studv. (I. Levin and 

M. Levine) J. A. M. A. 83:1645-1650, Nov. 22, '24 (illus.) 

—Basis in experimental pathology for radium therapv of malignant 

disease. (R. II. Parry) Brit. J. Radiol. 29:317. Jan. '24 (illus.) 

—Radium therapy: its present position in treatment of certain skin and 

malignant diseases. (H. Lawrence) M. J. Australia, (supp.) 

2:5'5-5iS. July 19, '24 (illus.) 

—Radium treatment in two cases of epithelioma, (Dasque and Durand- 

Dastes) J. de med. de Bordeaux, 03:03

38 RADIUM 

Chevallier, A., and Cluzet—Thorium in chronic leukemia. Bull. Acad, de 

med. Par. 01 :6i5-624. May 13. '24. 

—Treatment by inhalation of thorium. Medicine 5:681-682, June '24. 

Chiray. M., and Benda R.—Improvement of myeloid leukemia under 

thorium X, Bull, et mem. Soc. Med. de hop. de Par. 48:245- 

250. Feb. 29, '24. 

Clark. H.—Measurement of air-ionization by means of a small chamber 

made of bakelitc and ambroid for use in study of roentgen-ray 

dosage, Am. J. Roentgenol. 11:445-451, May '24. 

Clark. J. G.- Surgical and irradiation treatment of benign and malignant 

growths of uterus, Internal. Clinics 1 74-87, March '24. 

—and Block. F. B. -Relative values of irradiation and radical hystereclomy 

for cancer of cervix, Am. J. Obst. & Gynec. 7:543-549, 

May '24; also in Atlantic M. J. 27:696-699, Aug. 24; ab. 

Radium 3, N. S., 135-140, July '24. 

Clark, W. L.. Morgan. J. D., and Asnis, E. J.—Treatment of neoplastic 

diseases by combined methods. Atlantic M. J. 27:541-549, 

May '24. 

Cluzet, J., and Chevallier. Thorium in chronic leukemia. Bull. Acad, de 

med. Par. 91:6i 5-624, May 13, '24. 

-Treatment by inhalation of thorium. Medicine 5:681-682. June '24. 

Cole, A. M.—Use of X-ray and Radium in superficial malignancies, J. 

Indiana M. A. 1771-76, March '24. 

Colebrook, L.. Eidinow, A., and Hill. L.— Effect of radiation on bactericidal 

power of blood, Brit. J. Exper. Path. 5.54-64. April '24. 

Coley. B. L.—Retroperitoneal lymphocytoma causing chylous ascites and 

chylothorax. J. A. M. A. 82:2031-2032, June 21, '24; ab. 

Radium 3, N. S. 260-263, Ian. '25. 

Coley. W. B.—Prognosis in giant-cell sarcoma of long bones. Ann. Surg. 

79:321-357. March '24; cont. 79:.S*>i-595. April '24, 

Conjunctiva, cancer—- 

—Treatment of carcinoma of conjunctiva with radium, (F. M. Johnson) 

Am. J. Ophth. 7:589-505, Aug. '24; Radium 3. N. S., 232- 

240. Jan. '25. 

Conjunctivitis, vernal— 

—Concerning vernal conjunctivitis; some phases connected with its 

clinical features, duration, prognosis and treatment, (W. C- 

Posey) Atlantic M. J. 27:215-210. Jan. '24; Radium 3. N. S. 

35'43- April '24. 

Corbett, J. J.—Radium clinic for treatment of eye. ear, nose and throat 

condilions. Boston M. & S. J., 100:1082-1084, June 19, '24; 

Radium, 3, N. S.. 199-202, Oct. '24. 

—Effect of radium on glaucoma, Boston M. & S. J., 190:1124-1126. 

June 26. '24; Radium 3. N. S.. 202-207, Oct. '24. 

Crain, R. C. and Woolston. W. I.—Protective method of applying 

radium in cervix. J. A. M. A. 83:1429. Nov. 1, '24. 

Crile, G. W.—Surgery vs. X-tav and radium therapy in treatment of 

tumors of the uterus. Illinois M. J. 45:177-179. March '24. 

—Carcinoma of the uterus, Am. J. Ohst. & Gynec. 7:528-535, May 

'24; ab. Radium 3. N. S., 141-146. July '24. 

Culver, G. D.--Technique of radium trcalmcnt for lupus erythematosus, 

Radium 3. N. S. 65-66. April '24, 

—and Montgomery. D. W.—Verruca of nail fold, Arch. Dermat. & 

Syph. 10:425-428, Ot. '24.

R a d i u m :;:» 

—Epithelioma of lip treated with radium, California and West med 

22:628-631, Dec. '2|. 

Cunningham, J. H.-General principles involved in prostatic problem. 

Boston M. & S. J. 190:6-12. Jan. 3, '24. 

Curtis, A. H.—The pathology and treatment of chronic leucorrhea. Surg. 

Gynec. Obst. 37:657-66o. Nov. '23; ab. Radium, 2. N. S., 118- 

321. Jan. '24. 

Czepa, A.—Irradiation of malignant tumors, Wicn. Klin. Wchnschr. 

37:898-901. Sept. 11, '24. 

—and Hogler. F;—Pathogenesis of acute roentgen and radium intoxication. 

Klin. Wchnschr. 22341-2344, Dec. 24. '23. 

Dacls. F., and De Backer. P.—New techniques of "Curie" therapy of 

cancer of cervix uteri, Brit. J. Radiol. 29:315-318. Sept. '24. 

Danne. G., and Mallet, I..—Research on gamma rays by means of an 

ionomicromeler. J. Radiol, ct d'electrol. 8:248-255, June '24. 

Dasque and Durand-Dastes- Radium treatment in two cases of epithelioma. 

I. de med. de Bordeaux 95:939-940, Nov. 25, '23. 

Davis. K. S.—History of radium. Radiology 2:334-342, May '24. 

Dean, A. L., Jr.—Four cases of epithelioma of penis treated by radium. 

M. J. & Rec. (supp.) 119:155-156, June iS. '24. 

—and Barringer. B. S.—Epithelioma of the penis. [. Urology, 11:497- 

514. May '24. 

DcCourcy, J. L.—Cancer of thyroid. Ann. Surg. 80:551-554. Oct. "24; 

ab. Radium 3. N. S.. 263-264. Jan. '25. 

Dennis, C. E.—Notes and experiences in radium therapeutics, M. J. Australia, 

1:607-610, June 2i, '24. 

Derby, G. S.—X-ray and radium in non-malignant diseases of eye. Boston 

M. & S. J. 101:2o-2i. July 3. '24. 

Desjardins, A. U.. and Ford, F. A. -Hodgkin's disease and lymphosarcoma. 

A clinical and statistical study. J. A. M. A. 80:925-927. 

Sept. 15, '231 ab. Radium 3. N. S.. 214-217, Oct. '24. 

Dobrovolskaia-Zavadskaia. N.—Effect of intramuscular radioactive foci. 

J. de radiol. et delectrol. S:j9-6i, Feb. '24. 

—Action of radium rays on blood vessels. Lyon chir. 21 :397-427, Julv- 

Augusl '24. 

Dodds, E. G. and Webster. J. H. D.—Metabolic changes associated with 

X-ray and radium treatment, Lancet 1:533-536. March 15, '24; 

also in Brit. J. Radiol. 29:1.10-140. April '24. 

Donaldson, C. O.. and Knappenberger. G. E.—Radium treatment of cancer 

of cervix. J. Oklahoma M. A. 17:198-201, Aug. '24. 

Du Casse. R. R.—Sycosis vulgaris and radium. Ohio State M. J. 20:357- 

358. June '24. 

Durand-Dastes and Dasque—-Radium treatment in two cases of epithelioma, 

J. de med. de Bordeaux. 95:939-040, Nov. 25. '23. 

Ear, tumor— 

—Carcinoma of antrum; sarcoma of middle ear.


Endocrine Glands, disorders— 

—Radiotherapy in endocrine disturbances of sex apparatus, (S. Recascns) 

Med. Klinik. 20:810-812, June 15. '24. 

Enfield, C. D,—Radium and X-rav therapv, Am. |. Surg. 38:302-306, 

Dec. '24. 

Esophagus, cancer— 

—Radium in cancer of mediastinal esophagus, (F. O. Lewis) S. 

Clinics X. America 4:101-103, Feb. '24. 

—Radium treatment for cancer of upper end of esophagus, (C. D. 

Harrington) Journal Lancet 44:333-334. June 15, '24 (illus.) 

—Some considerations in treatment of carcinoma of esophagus, (D. 

Quick) Am. J. Roentgenol. 11:383-391. May '24 (illus.) 

—The technique of radiation therapy of esophageal carcinoma, (J. T. 

Case) Am. J. Roentgenol. 10:859-866. Nov. '23; Radium 3. 

N. S„ 24-35. April '24. 

—Treatment of carcinoma of esophagus by radiation. (D. G Greene) 

Am. J. Roentgenol. 12:471-474. Nov. '24. 

—Treatment of carcinoma of esophagus vvith radium. (T. E. Carmody) 

Laryngoscope 54:101-106, Feb. \*i. 

Eye. radiotherapy— 

—X-ray and radium in non-malignant diseases of eye, (G. S. Derby) 

Boston M. & S. J. 191:2o-2i. July 3, '24. 

Radium in Ophthalmology, with special reference to its use in benign 

affections. (L. A. Lane) J. A. M. A. 83:1838-1845, Dec. 

6, '24. 

—Tumor, melanotic epibulbar tumor dispelled bv use of radium, (W. 

H. Wilder) Arch. Ophth. 53355-361. July '24 (illus.) 

Fabry, C— Radiations, J. de Radiol, et d'electrol. 8:147-154. April '24. 

Failla, G.- -Some important factors in biological action of radiation. Am. 

J. Roentgenol. 12:454-464. Nov. '24. 

Fallopian lube, disease-— 

- Untoward results in radiation therapy of uterine cancer when complicated 

with latent gonococcic salpingitis. (B. F. Schrciner and 

L. C. Kress) Am. I. Roentgenol. 12:51-53. July '24. 

Figi, F A., and New. G. B- Treatment of fibromas of nasopharynx. 

Am. J. Roentgenol. 12:340-343. Oct. '24; ab. Radium 3, N. S-, 

275-277. Jan. '25. 

Fischel. E.—Radium in internal medicine, Ann. Clin. Med. 3:245-248. 

Sept. '24. 

Fischer. \i.. and Kotzarcf. A.—Biologic research on serum in cases of 

cancer before and after injections of radium emanation. Bull. 

Acad, de med.. Par. 90:334-336, Nov. 13, '23. 

Plateau, W. S. — Results of radiotherapy of cancer of the uterus, Zentral. 

f. Gynak. Nov. 19. '23; also ab. J. A. M. A. Sept. 1, '23. p. 790; 

ab. Radium 3. N. S., 213-214. Oct. '24. 

Flecker, H.— Radium emanation. M. J. Australia. 1:6io-6u. June 21, '24. 

Flocculation, mcchanism- 

•Influence of wave length on flocculationof colloidal solution by 

roentgen rays. (A. Dognonl Compt. rend. Soc. dc biol. 91 :i97- 

199, June 27. '24. 

Foerslcr. O. H.—Radium in dermatology. Arch. Dermat. & Syph. 9:38- 

50. Jan. '24. 

Ford. F. A., and Desjardins. A. U.—Hodgkin's disease and lymphosarcoma. 

A clinical and statistical study, I. A. M. A. 80:925-927, 

Sept. 15, '23; ab. Radium 3. N. S. 214-217, Oct. '24.

R a d i u m 

4I 

Forsdike. S.-Cancer of cervix. Brit. M. J. 2:94.9s. July 19, '24. 

rorssell. o.- Experiences m immanency of radiological cure in cancer 

Am. J. Roentgenol. 12:301-311. Oct. '24; ab. Radium 3, N. S. 

25.V258. Jan. '25. 

Frazier, C. N.—Radium; A resume ui its phvsical and therapeutic properties. 

China M. I., 58:341-349. Mav 'j|. 

I-ncke. RE., and Kelly. H. A.-Problems in treatment of carcinoma 

1 f»aSt* Su'*S'

42 Radium 

Guy, W. H., and Jacob, I**. M.—Erythema close of radium. Arch. Dermat. 

& Syph. 9:73-81, Jan. '24: Radium 3, N. S., 225-231, Jan. '25. 

Gynecology, radiation in — 

—Radium therapy in gynecology, (P. B. Bland) M. J. & Record, 

120:101-107. Aug. 6/24 (illus.); cont. 120:156-160, Aug. 20, '24. 

Hagans,I-'. N.—Radium iherapy of thyroid, Endocrinology, 8:404-408, 

May -24. 

—Radium treatment of malignancy. Illinois M. J. 46:336-339, Nov.'24. 

Hair, removal of— 

Radium depilation in hypertrichosis in women (V. Palumbo) Gior. 

Ital. (I. mal. ven. 05:721-731. April '24 (illus,) 

Halbcrslaedler. L.— Intratumoral injections of thorium X, Deutsche 

med. Wchnschr. 49:1295-1296, Oct. 12. '23. 

Halter, G.-—Intrauterine radiotherapy in gynecologic hemorrhage, Zentrl. 

f. Gynak. 48:2000-2007. Sept. 13, '24. 

Han ford, C. \\'.— Cancer of tongue under influence of radium, electrocoagulation 

and X-ray, J. Radiol. 5:55-57. Feb. '24. 

—Radium: Its uses in the treatment of cancer, Cincinnati J. Med. 

4:391-396, Oct. '23; Radium 2. N. S., 297-302, Jan. '24. 

Harrington, C. D.—Radium treatment for cancer of upper end of esophagus. 

Journal-Lancet, 44:333-334 June 15. '24. 

Harris, W. L.—Closure of bronchial fistulaof 12 years' standing by use 

of radium, M. J. & Rec. 120:590-591, Dec. 17, '24; Radium 4. 

N. S., April '25. 

Harrison. B. J. M.--Radiation method of cancer treatment, M. J. Australia 

2\222-22y, Aug. 30, '24. 

Hartley. I'.—Effect of radiation on production of specific antibodies, 

Brit. J. Exper. Path. 5:306-313. Dec. '24. 

Mealy, W. P.. and Bailey. H.—Cancer of uterine cervix, treated by irradiation: 

methods of treatment and results in 1.024 cases, J. A. 

M. A. 83:1055-1056, Oct. 4. '24. 

—Follow-up results of 90S cases of uterine cancer treated by radium, 

Am. J. Obst. Gynec. 6:402-406. and 491-495. Oct. '23; Radium 

2. N. S., 277-285. Jan. '24. 

Hcrly, L.—Adenomvoma of rectovaginal septum; association with pregnancy; 

radium treatment; apparent recurrence, adcnomyoma 

of uterus; relation lo malignancy, Surg. Gvnec. Obst. 39:626- 

635. Nov. '2\. 

Hess, V 

F.—Use of audion amplifiers in measurements of beta and 

gamma ray intensities, Radiology 2:100-103. Feb. '24. 

Heuser. C.—Stenosis of esophagus and radium treatment, Semana med. 

2:333-339. Aug. 7.'24. 

Heyman, II. V. J. —Technique and results in treatment of carcinoma of 

uterine cervix at "Radiumhemmet," Stockholm. J. Obst. & 

Gynec. Brit. Emp. 31:1-19. '24; ab. Radium 3. N. .$., 258-260, 

Jan. '25- 

Hill. E. C. and Macht. D. I.—Effect of ultraviolet, X-ray. and radium 

radiations on toxicity of normal blood, J. General Physiol. 6: 

671-676. July '24. 

Hill, W. C, and Thomas, G. F.—Treatment of non-malignant uterine 

conditions. Am. J. Roentgenol. 12:337-361. Oct. '24. 

Hospitals, Roentgen ray service in— 

—New department of radiology of St. Louis City Hospital, (L. R. 

Sante) Radiology 3:402-407, Nov. '24 (illus.)


Hot Springs, Arkansas- Physiological action of natural radioactive wat 

of Hot Springs. Ark., (M. F Lautman) Southwestern Med. 

8:435-437. Sept. '24. 

Hygroma cystica treated with radium. (G. B. New) S. Clinics N. America, 

4:527-52S. April '24 (illus.) 

Ill, E. A.—Palliation in cancer of uterine cervix and cancer of breast. 

J. M. Soc., New Jersey, 21:243-249. Aug. '24. 

Intestines, tumor— 

—Lymphosarcoma of small intestine, (T. H. Kelley) J. A. M. A. 

827S5-787. March S, '24 (illus.); ab. Radium 3, N. S-, 260, 

Jan. '25. 

Ionization, treatment— 

—Comparative study of different materials of walls for ionization 

apparatus for rays of different wave lengths, (A. Dognon) J. 

de radiol. et d'electrol. 8:198-200. May '24. 

—Therapeutic irradiation and inhalation. (H. Picard) KHn. Wchnschr. 

2:2066-2070. Nov. 5. '23 (illus.) 

Isaacs, R., and Minot. G. B.—Lymphatic leukemia; age incidence, duration, 

and benefit derived from irradiation. Boston M. & S. J. 

19' -'-9> Ju^ 3. '24- 

—and Minot, G. R., and Buckman. T. E.—Chronic myelogenous leukemia; 

age incidence, duralion, and benefit derived from irradiation. 

J. A. M. A. 82:1489-1494. May 10. '24; ab. Radium 3. 

N. S., 217:219. Oct. '24. 

Jacob. F. M., and Guy. W. H.— Eryjhema dose of radium. Arch. Dcrmat. 

& Syph. 9:73-81. Jan. '24; Radium 3, N. S.. 225-231. Jan. '25. 

Jacobs, A. W., and Goldmark. C.—Purpura hemorrhagica (postpartum) 

treated with radium ami roentgen ray. Am. J. Obst. & Gynec. 

8:208-210, Aug. '24. 

Johnson, F. M.— Radium treatment of carcinoma of antrum, Surg. 

Gynec. Obst. 38:819-822, June '24; Radium 3. N. S.. 174-180, 

Oct. "24. 

—Treatment of carcinoma of conjunctiva with radium. Am. J. Ophth. 

7:589-595, Aug. "24: Radium 3. N. S.. 232-239, Jan. '25. 

—and Steedly. B. B.— Some problems in radium therapy. J. S. Carolina 

M. A. 20:222-226. Sept. '24. 

Jones, A. P.—How does radium produce its results? Virginia M. 

Monthly 50:768-769, Feb. '24. 

Jones, T. E.—Role of radium in benign and malignant tumors of uterus 

Wisconsin M. 1. 22:466-460, March '24; also in Illinois M. J. 

45:255-258, April '24. 

—Role of radium in treatment of carcinoma of uterus, Am. J. Obst. & 

Gvnec. 7:541-542, May '24; ab. Radium 3. N. S.. 146-147. 

Tulv '24- 

lones-Phillipson. C. E.. and Moffat. H. A.—Nasopharyngeal hbroma 

treated with radium and surgical diathermy. J. Laryngol. & 

Otol. 39:571-573. °ct- '24. 

Josselyn. R. B.—Angioma cavernosum treated with radium. J. Maine 

M. A. 14:211-212. May '24. 

Julliard, G, and Gilbert, R.—Sarcoma treated by beta rays. Schweiz. 

med. Wchnschr. 54 :So3-805< Aug. '28. '24. 

Karsis, M.—Exophthalmic goiter cured after radium treatment of uterine 

fibroma.Gynec. et Obst. 10:102-104. Aug. "24. 

Keene. F. E.~Contraindications to radium in treatment of diseases of 

female pelvis, Am. T. Obst. & Gynec. 8:201-204. Aug. '24.

44 Radium 

Keith. I. P., and Keith. D. Y.—Radiation in benign affections of uteru 

Kentucky M. J. 22.264-271, July '24. 

Kelley. T. H.—Lymphosarcoma of small intestine. J. A. M. A. 82:785- 

7S7. March 8, '24; ab. Radium 3, N. S., 260. Jan. '25. 

Kennedy, W. H.— Superiority of radium over surgery in cancer of 

uterus, M. J. &- Record (supp.) 120:148-149, Nov. 19, '24. 

Kingsbury. A. N.. and Mottram, J. G— Action of radium and X-rays 

correlating production of intestinal changes, thrombopoenia, 

and bacterial invasion. Brit. J. Exper. Path. 5:220-226, Aug. '24. 

Knappenberger. G. E.. and Donaldson. C. O.—Radium treatment of cancer 

of cervix. J. Oklahoma M. A. 17:198-201, Aug. '24. 

Kotzareff, A., and Fischer. R.—Biological research on serum in cases of 

cancer before and after injections of radium emanation. Bull. 

Acad, de med., Par. 90:334-336. Xov. 13. '23. 

—and Weyl, L.--Elective fixationof radium emanation by embryonal 

and cancer cells, Presse med. 31 \cy25-cj27, Nov. 7, '23. 

Kress, L. G. and Schreiner, B. F.—Contribution to treatment of cancer 

of lip by irradiation. J. Cancer Research 8:221-233, July '24. 

—Untoward results in radiation therapy of uterine cancer when complicated 

vvith latent gonococcic salpingitis, Am. J. Roentgenol. 

12:51-53. J»'y '24- 

—Clinical results after irradiation of cancer of cervix uteri, New York 

State J. Med. 24:981-984. Dec. '24. 

Laborde, S.—Conception of radiosensibility of tissues, J. de radiol. et 

d'electrol. 8:289-306, July '24. 

Lacassagne, A., and Lattes, J.—Distribution of polonium after subcutaneous 

injection in cancer rats, Compt. rend Soc. de biol. 00:352- 

353. Feb. Uv '24- 

—Localization of polonium in organs. Compt. rend Soc. de biol. 90: 

485-489, Feb. 29. '24. 

Lane. L. A.—Radium in benign conditions of nose and throat, Minnesota 

Med. 7:57^-5^3. Sept. "24. 

—Radium in ophthalmology, J. A. M. A. 83:1838-1845. Dec. 6, '24. 

Larkin, A. I.—Radium needles in malignant growths of the tongue; the 

time factor. Amer. J. Roentgenol. 10:734-735, Sept. '23; ab. 

Radium 2, X. S.. 322 323. Jan. '24. 

Larynx, cancer — 

—Radiation treatment of carcinoma of the larynx, (H. K. Pancoast) 

Amer. J. Roentgenol. 12:217-210. Sept. '24. 

-Radium in cancer of larynx, (W. S. Newcomet) S. Clinics N. America 

4:97-100. Feb. '24. 

Lattes. J., and Lacassagne, A.--Distribution of polonium after subcutaneous 

injection in cancer rats, Compt. rend. Soc. de biol. 

9:352-353. Feb. 15, '24. 

—Localization of polonium in organs, Compt. rend. Soc. de biol. 

90:485-489. Feb. 29, '24. 

Lautman. M. F.—Physiological action of natural radioactive water of 

Hot Springs. Ark., Southwestern Med. 8:435-437, Sept. '24. 

Lawrence. H.— Radium therapy: its present position in treatment of 

certain skin and malignant diseases, M. J. Australia (supp.) 

2:5i5-5'8- J"ly '9. '24- 

Lawrence. W. S.—On ihe reasons for choice—radium or X-ray. when 

radiotherapy is indicated, Urol. & Cutaneous Rev. 28:294-296, 

May '24; ab. Radium 3, N. S., 147-151. July '24.


Lee. B. J., and Herendeen. R. E.—Treatment of primary inoperable carcinoma 

of breast by radiation. Radiology 2:121-136, March '24. 

Leland, G. A., Jr.—Massive dose radium treatment in carcinoma of cervix 

uteri. Am. J. Roentgenol. 12:373-378, Oct. '24. 

Lepape. A.—Mineral Springs of Bagneres de Luchon; radioactivity and 

sulphur content, Paris Med. 1:36g-373, April 19, '24. 

Leukemia, lymphatic—- 

—Lymphatic leukemia; age incidence, duration, and benefit derived 

from irradiation. (G. B. Minot and R. Isaacs) Boston M. & S. J. 

191:1-9, July 3. '24 (charts). 

—Myelogenous--Chronic myelogenous leukemia; age incidence, duration 

and benefit derived from irradiation. (G. R. Minot. T. E. 

Buckman and R. Isaacs) J. A. M. A. 82:1489-1494. May 10. '24 

(charts); ab. Radium 3, N. S., 217-210. Oct. '24. 

—Improvement of myeloid leukemia under thorium X, (Chiray and 

R. Benda) Bull, et mem. Soc. med. de hop. de Par. 48:245-250, 

Feb. 29, '24. 

—Studies in blood cell morphology and function; morphologic changes 

of blood in myelogenous leukemia under radium treatment, 

(M. M. Strumi'a) J. Lab. & Clin. Med. 10:106-122, Nov. '24 

(charts). 

•—Successful treatment of myelogenous leukemia with thorium X, (E. 

J. Feilchenfeld and A. Peters) Klin. Wchnschr. 3:1449-1450, 

Aug. 5. '24 (chart). « 

Treatment- Radiation therapy in treatment of leukemia summarized 

from a series of 25 cases. (B. F Schreiner and W. L. Mattick) 

Am. J. Roentgenol. 12:126-133, Aug. '24 (charts). 

Leukocytes, count— 

—Studies in blood cell morphology and function; morphologic changes 

of blood in myelogenous leukemia under radium treatment, I M. 

M. Strnmia) J. Lab. & Clin. Med. 10:106-122. Nov. '24 

(charts). 

Leukorrhea, treatment— 

—Pathology and treatment of chronic leukorrhea. A further clinical 

and laboratory study of the subject, (A. II. Curtis) Surg. Gynec. 

& Obst. 37:657-660, Nov. '23; a"- Radium 2, N, S., 318-322. 

Jan. '24. 

Levin, I.—Intraperitoneal insertion of buried capillary glass tubes of 

radium emanation in carcinoma of cervix uteri. Amer. J. Roentgenol. 

12:352-357, Oct. '24; ab. Radium 3. N. S., 265-268, 

Jan. '25. 

—and Levine, M.—Action of buried glass capillaries of radium emanation 

on plant and animal tissues. J.A.M.A. 83:1645-1650. Nov. 

22, '24. 

Levine, M.. and Levin, I.—Action of buried glass capillaries of radium 

emanation on plant and animal tissues, J.A.M.A. 83:1645-1650. 

Nov. 22, '24. 

Lewis, F. O.—Radium in cancer of mediastinal esophagus. S. Clinics N. 

America, 4:101-103. Feb. '24. 

Lip, cancer— _ . . 

—Contribution to treatment of cancer of lip by irradiation: report on 

136 cases, (B. F. Schreiner and L. G Kress) J. Cancer Research 

8:221-233, July '24 (illus.)


—Epithelioma of lip treated vvith radium. (D. W. Montgomery and 

G. D. Culver) California and West. Med. 22:628-631, Dec. '24 

(illus.) 

—Treatment of cancer of lower lip, (O. L. Norsworthy) Texas State 

J. Med. 20:184-188. July '24 (illus.) 

Loucks. R. E.—Radium treatment of toxic goiier with metabolic deductions. 

Amer. J. Roentgenol. 10:767-776. Oct. '23; ab. Radium 

3. N. S., 151-156. July '24. 

Lupus, erythematosus— 

—Technique of radium treatment for lupus erythematosus, (G. D. 

Culver) Radium. 3, N. S.. 65-66, April '24. 

Lymphogranuloma 

—Hodgkin's disease and lymphosarcoma. A clinical and statistical 

study, (A. U. Desjardins and F. A. Ford) J. A. M. A. 80:925- 

927. Sept. 15, '23; ab. Radium 3, N. S., 214-217, Oct. '24. 

—Treatment— 

—Radiation therapy in 46 cases of lymphogranuloma. (Hodgkin's disease), 

(W. F. Mattick and B. F. Schreiner) Am. J. Roentgenol. 

"2:133-137. Aug. '24. 

Macht, D. I., and Hill. E. G—Effect of ultraviolet X-ray and radium radiation 

on toxicity of normal blood. J. General Physiol. 6:671- 

676, July '24. 

MacKay, H.—Naevi and their treatment by radium, Canad. M. A. J. 

14:39-4-3Q7. Mav 24; also in J. Radiology 5:305-307, Sept. '24. 

McKee, A. B.. and Swett. W. F.—l.Tse of radium in cataract, Amer. J. 

Ophth. 7:58/-s88. Aug. '24. 

Maliniak. J.--Radium applicator for upper air and digestive passages. 

Laryngoscope, 3472573'. Sept. '24. 

Mallet. I... and Danne.


Mineral Waters, examination— 

-Mineral springs at Bagneres de Luchon; radioactivity and sulphur 

content. (A. Lepape) Paris Med. 1:369-373. April i

48 RADIUM 

Nassau. G F.. and Pfahler, G. E.—Malignant degeneration in radiodermatitis, 

successfully treated by electrocoagulation and skingrafting, 

Radiology 3:297-300, Oct. '24. 

Neil. W., Jr.—Our present attitude towards fibroidtumors. Am. J. Obst. 

& Gynec. 8:205-207, Aug. '24. 

New. G. B.. and Figi, F. A.—Actinomycosis of the head and neck, a 

report of 107 cases. Surg. Gynec. Obst. 37:617-625, Nov. '23; 

Radium 2, N. S., 257-271, Jan. '24. 

- Treatment of fibromasof nasopharynx. Am. J. Roentgenol. 12:340- 

343- Oct. '24; ab. Radium 3. N. S., 275-277, Jan. "25. 

Ncwcomet, W. S.—Radium in cancer of larynx, S. Clinics N. America 

4:97-100. Feb. '24. 

Newell, E. D.- Conclusions after six years' use of radium. Southern 

M. J. 16706-708. Sept. '23; Radium 2. N. S., 302-305, Jan. '24. 

Norris. G G. and Vogt, M.—Carcinoma of body of uterus. Am. J. Obst. 

& Gynec. 7:550-566, May '24; Radium 3, N. S., 97-112, July 

•24. 

Norsworthy, O. L.—Treatment of cancer of lower lip, Texas State J. 

Med., 20:184-188, July '24. 

Nose, polyps— 

—Use of radium for nasal polyps. (G. Sluder) Laryngoscope 34:124- 

125. Feb. '24. 

Ochsner, A. J.—Use of X-ray and radium from standpoint of clinical 

surgeon, Intemat. Clinics 4:104-108, Dec. '24., 

Otorhinolaryngology. radium clinic for— 

- Treatment of eye, ear, nose and throat conditions. (J. J. Corbett) 

Boston M. & S. J. 190:1082-1084, June 19. '24; Radium 3. 

N. S., 199-202, Oct. '24. 

Ovary, cancer— 

—Treatment of ovarian cancers vvith combined surgical and radiological 

methods, (H. Schmitz) Wisconsin M. J. 23:125-128, 

Aug. '24. 

- Radiation of. Effects of radium rays upon ovary; experimental, 

pathological and clinical study. (H. B. Matthews) Surg. Gynec. 

Obst. 38:383-393- March '24 (illus.); ab. Radium 2. N. S., 

323-.V9. Jan. '24. from Am. J. Obst. & Gvnec. 6:61 (-6i8, Nov. 

'23. 

Pal umbo. V.- Radium depilation in hypertrichosis in women, Gior. ital. 

d. mal. ven. 65721-731. April '24. 

—Methods used in the Phototherapy Institute at Florence. Gior. ital. d. 

mal. ven. 65:818-839, June '24. 

—Radio-active treatment of epithelioma in the mouth. Gior. ital. d. mal. 

ven. 65:898-919. June '24. 

Pancoast, H. K.—Radiation treatment of carcinoma of the larynx. Am. 


Parry, R. H.—Basis in experimental pathology for radium therapy of 

malignant disease, Brit. J. Radiol. 29:3-17. Jan. '24. 

Peighial. T. G, and Taylor, H. G—bind results of 201 cases of carcinoma 

of cervix. Am. J. Obst. & Gynec. 8:288-297. Sept. '24; Radium 

3. N. S.. 245-253. Jan. '25. 

Pelvis, cancer— 

—Five year end-results obtained in carcinoma of female pelvis organs, 

with special reference to radium and X-ray therapy, (H. 

Schmitz) Surg. Gynec. Obst. 39775-780, Dec. '24.


—Treatment of inoperable cancer of pelvis by radium (A. Soiland 

Am. J. Roentgenol. 12:378-379, Oct. '24. 

Pemberton, F. A.—Chi Id bearing after radium and X-ray treatment, Surg. 

Gynec. Obst. 39:207-209, Aug. '24; Radium 3, N. S., 196-199. 

Oct. '24. 

Penis, cancer— 

—Epithelioma of penis. (Ii. S. Barringer & A. L. Dean, Jr.) J. Urol. 

" :497-5'4- May '24 (illus.) 

—Four cases of epithelioma of penis treated by radium. (A. L. Dean, 

Jr.) Am. J. Rec. (supp.) 119:155-156. June 18. '24. 

Perrola. A.—Inoperable cancer of uterine cervix. Rev. Franc, de Gynec. 

et d'obst. 18:321. May 25. '23; ab. J. A. M. A. 1056. Sept. 22. 

'23; ab. Radium 2, N. S., 332, Jan. '24. 

Pfahler, G. E.—Diagnosis of enlarged thymus by X-ray, and treatment 

by X-ray or radium. Arch. I'ediat. 41 :39"46, Jan. "24. 

—Radiation in treatment of carcinoma of breast. Southern M. J.. 17: 

203-207, March '-'4. 

—Radiation in treatment of primary malignant disease. Atlantic M. J. 

2S76-S0, Nov. '24; Radium 3. N. S.. 240-244, Jan. '25. 

Picard, H.—•'Therapeutic irradiation and inhalation, Klin. Wchnschr. 

2:2o66-2070, Nov. 5, '23. 

Piersall, C. E.—Prcscnt-day X-ray and radium therapy. California State 

J. Med. 22:9-10. Jan. '24. 

Pinch, A. E. H.—Therapeutic uses of radium. Bristol Med.-Chir. J. 41: 

97-112, July '24. ^ 

—Report of work carried out at the Radium Inslitute, I.ondon, from 

Jan. 1, '23, to Dec. 31, '23; Radium 3, N. S., 1-24. April '24. 

Polak. J. O. -Fibroid tumors: their development and how they produce 

symptoms; their effect on pregnancy and labor; treatment, Virginia 

M. Monthly 51:461-46.1, Nov. '24. 

Polonium— 

—Localization of polonium in organs, (A. Lacassagne and J. Lattes) 

Compt. rend. Soc. de biol. 90:485-489, Feb. 29, '24. 

—Distribution of polonium after subcutaneous injection in cancer 

rats, (A. Lacassagne & J. lattes) Compt. rend, de Biol. 90: 

352-353. Feb. 15, '24. 

Pomeroy, L. A., and Strauss, A.—Carcinoma of cervix uteri; review of 

100 cases, with es|«cial reference to predominating type of cell, 

J. A. M. A. 83:1060-1062, Oct. 4. '24. 

Posey, W. G—Vernal conjunctivitis, Atlantic M. J. 27:215-219, Jan. '24; 

Radium 3, N. S.. 35-42, April '24. 

Pouey, E.—Radium treatment in North America, An. de Fac. de med., 

Montevideo 9:402-438, May '24. 

Prostate, cancer— 

—Blocking lymphatics in control of carcinoma of prostate gland, (R. 

H. Herbst) J. A. M. A. 82:1590-1592, May 17, '24 (illus.); 

Radium 3, N. S., 113-119, July '24. 

—Malignant growths of proslate and bladder, (B.. S. Barringer) M. J. 

& Record (supp.) 119:158-159. June 18. '24. 

—Radium in treatment of prostatic carcinoma. (B. S. Barringer) Ann. 

Surg. 80:881-884, Dec. '24 (illus.) 

—Technique for application of radium (emanation) in carcinoma of 

prostate. (E. M. Watson) Rnllelin of the Buffalo General 

Hospital, January '24; Radium 3, N. S., 119-124. July '24.


—Radium in treatment of benign hypertrophy of prostate. (H. C. 

Bumpus, Jr.) J. L'rology 12:63-70, July '24. 

Quick, D.—Some considerations in treatment of carcinoma of esophagus. 

Am. J. Roentgenol. 11 1383-391, May '24. 

Quigley, D. T., and Callfas. W. F.—Carcinoma of antrum; sarcoma of 

middle ear. Nebraska M. J. 9:167-168, May '24. 

Radiations— 

—Radiations, (G Fabry) J. de Radiol, et d'electrol. 8:147-154. 

Apr. '24. 

—Effects of: Acquired radio immunization in cancer tissues, (C. 

Regaud) Bull. acad. de med.. Par. 91:604-607. May 13, '24; 

ab. J. A. M. A. 83: 308, July 26. '24. 

—Action of ionizing radiations; evidence for ionization by beta radiation. 

(A. G Redfield & E. M. Bright) Am. J. Physiol. 68:54- 

61, March '24 (charts). 

—Blood findings in personnel of roentgen and radium institutes. (E. 

Rud) Ugesk. f. Laeger 86:438-442, May 29. '24; ab. J. A. M. A. 

83:230. July 19. '24. 

—Cellular reactions following X-ray and radium therapy, (H. R. 

Wahl) J. Missouri M. A. 21 :i/3-i77, June '24 (illus.) 

—Conception of radiosensibility of tissues, (S. Laborde) J. de Radilo. 

et d'electrol. 8:289-306, July '24. 

—Effect of ultra-violet. X-ray and radium radiation on toxicity of 

normal blood, (D. I. Macht. & E. C. Hill) J. General Physiol. 

6:671-676. July '24. 

—Effect of X-ray and radium upon malarial parasite in vitro. (L. 

J. Menville) Radiology 3:399-401. Nov. '24. 

—Important factors in biological action of radiation. (G. Failla) 

Am. J. Roentgenol. 12:454-464, Nov. '24 (charts). 

•—Physiological action of ionizing radiations; comparison of beta and 

* X-rays. (A. C. Redfield. E. M. Bright and J. Wertheimer) Am. 

J. Physiol. 68:368-378. April '24 (illus.) 

•—Physiological action of ionizing radiations; path of alpha particle, 

(A. G Redfield. and E. M. Bright) Am. J. Physiol. 68:62-69. 

March '24 (chart). 

—Physiological action of ionizing radiations;X-rays and their secondary 

corpuscular radiation, (A. G Redfield & E. M. Bright) 

Am. j. Physiol. 68:354-367, April '24 (illus.) 

—Some researches into action of radium and X-rays correlating production 

of intestinal changes, thrombopocnia. and bacterial invasion. 

(J. G Mottram & A. M. Kingsbury) Brit. J. Exper. 

Path. 5:220-226. Aug. '24. 

—Physics: Roentgen rays and radium. (A. Rosselet) Schweiz. med. 

Wchnschr. 54:526-530, June 5, '24 (illus.); ab. J. A. M. A. 

83:227. July 19, '24. 

—Toxic effects: Pathogenis of acute roentgen and radium intoxication, 

(A. Czepa and F. Hoegler) Klin. Wchnschr. 2:2341-2^44. 

Dec. 24. '23. 

-Case of malignant degeneration in radiodermalitis. successfully 

treated by electrocoagulation and skin grafting, (G. E. Pfahler 

& C. F. Nassau) Radiology 3:297-300, Oct. '24 (illus.) 

—Childbearing after radium and X-ray treatment, (F. A. Pemberton) 

Surg. Gynec. Obst. 39:207-209. Aug. '24; Radium 3, N. S., 

196-199. Jan. '24.


- Metabolic changes associated with X-ray and radium treatment, (E. 

G Dodds & J. H. D. Webster) Lancet 1 :533-536. March 15, 

'24 (charts); also in Brit. J. Radiol. 29:140-149, April '24 

(charts). 

—Occupational hazards of radiologists, with special reference to 

changes in blood, (R. D. Carman & A. Miller) Radiology 3: 

408-419, Nov. '24. 

—Radiodermatitis and its treatment, (A. U. Desjardins & F. L. Smith) 

S. Clinics N. America 4 :479"493- April '24 (illus.); also in New 

Orleans M. & S. J. 77-J77'&3- Nov. '24 (illus.) 

Radioactivity— 

—Radioactive subslances in therapeutics, (P. Castro Escalada) Semana 

med. 2:653-674. Sept. 18, '24. 

Radiologist—- 

—Blood of workers in radiologic institutes, (E. Rud) Compt. rend. 

Soc. de Biol. 91 775-776, Aug. 12, '24; ab. J. A. M. A. 83:1037, 

Sept. 27, '24. 

Radiology, in hospitals— 

—New department of Radiology of St. Louis City Hospital, (L. R. 

Sante) Radiology 3:402-407. Nov. '24 (illus.) 

Radiotherapy, dosage— 

—Dosage with radioactivesubslances, (P. Castro Escalada) Senama 

med. 1750-763. April 24. "24 (charts). 

—Progress of: Present day X-ray and radium therapy, (G E. Piersail) 

California State J. Med. 22:9-10, Jan. '24. 

Roentgen and radium treatment in Germany and France. (J. Friihauf) 

Cas. lek. Cesk. 63:245-253. Feb. 2, '24 (illus.) 

—Our success in the treatment of carcinoma of uterus by radiotherapy. 

(G. S. [. Schollen) Munich, med. Wchnschr. 70:300-301, March 

9, '23; ab. Radium 2, N. S., 320-330, Jan. '24. 

- Technic: Radium and roentgen rays as different agents in superficial 

and deep therapv, (A. Bachem) Am. J. Roentgenol. 11: 

13-19. Jan. '24 (charts). 

—Methods used in Phototherapy Institute at Florence, (V. Palumbo) 

Gior. ital. d. mal. ven. 65:818-839; June '24 (illus.) 

—Radiotherapy technic, radium and X-ray therapy. (C. D. Enfield) 

Am. J. Surg. 38:502-306, Dec. '24. 

—Roentgen rays and radium. (A. Rosselet) Schweiz. med. Wchnschr. 

54:526-530. June 5, '24 (illus.); ab. J. A. M. A. 83:227. July 

19. '24. 

—Value of: Therapeutic uses of electricity. X-ray. ultra-violet ray and 

radium methods and results. (S. Touscy) New York State J. 

Med. 24:191-197, Feb. 22, '24. 

—Iherapy with radioactive substances. (P. Castro Escalada) Semana 

med. 1:1273-1300. June 26, '24. 

—Use of X-ray and radium from standpoint of clinical surgeon, (A. 

J. Ochsner) Internal. Clinics 4:104-108. Dec. '24. 

—Value of radiation therapy in ophthalmology. (S. Withers) Am. J. 

Ophth. 7:5I4-521- Jul.v '2I- 

Radium, applicators— 

—Radium applicator for small lesions. (N. T. Beers) Am. J. Roentgenol. 

10:643-645. Aug. '23; ab. Radium 2, N. S., 33»"332. 

Jan. '24.


—Clinic: Radium clinic for treatment of eye. ear, nose and throat conditions. 

(J. J. Corbett) Boston M. & S. J. 190:1082-1084, June 

19, '24: Radium 3. N. S., 199-202, Oct. '24. 

—Dosage: Erythema dose of radium. (W. H. Guy & F. M. Jacob) 

Arch. Dermal. & Syph. 9:73-81, Jan. '24 (illus.); Radium 3, 

X. S.. 225-231. Jan. '25. 

—Effects: Effects of radium rays upon ovary; experimental, pathological, 

and clinical study, (H. II. Matthews) Surg. Gynec. 

Obst. 38:383-393. March'24 (illus.) 

—Action of radium ray> on blood vessels. (X. Dobrovolskaia-Zavadskaia) 

Lvon chir 21:397-427, July-Aug. '24 (illus); ab. J. A. 

M. A. 83:1279. Oct. 18, '24. 

—Exophthalmic goiter cured after radium treatment of uterine fibroma, 

(M. Karsis) Gynec. et Obst. 10:102-104, Aug. '24; ab. J.A.M.A. 

83:1205. Oct. 11, '24. 

—How does radium produce its results? (A. P. Jones) Virginia M. 

Monthly, 50:768-769. Feb. '24. 

—Meniere's syndrome following use of radium, (E. I. Thompson) I. 

A. M. A. 82:38s. Feb. 2. '24. 

—Preliminary note on observations made on physical condition of 

persons engaged in measuring radium preparations, {R. G Williams) 

Public Health Reports. 38: No. 51. 3007-3028, Dec. 21, 

'23; Radium 3, N. S.. 43-64. April '24. 

—Skin reactions to radium exposure and their avoidance in therapy; 

experimental investigation. (J. G Mottram) Brit. J. Radiol. 

29:174-180. May "24. 

•—Study of effects of radium on metabolism, (J. Rosenbloom) J. Metabolic 

Research 4:75-88, July-Aug. '23. 

—Emanation: Advantages of "loading slot" in radium emanation implantation, 

(J. Muir) J. Urology 11:319-325. March '24 (illus.) 

—Action of buried glass capillaries of radium emanation on plant and 

animal tissues; experimental and clinical study, (I. Levin & M. 

Levine* J. A. M. A. 83:1645-1650, Nov. 22, '24 (illus.) 

—Apparatus for purification of radium emanation, (J. E. Gendreau) 

J. de radiol. et d'electrol. 870-72. Feb. '24 (illus.) 

—Effects of intramuscular radioactive foci. (N. Dobrovolskaia-Zavadskaia) 

I. de radiol. et d'electrol. 8:49-61, Feb. '24 (illus.) ; ab. 

J. A. M. A. 82:1482. May 3. '24. 

—Elective fixationof radium emanation by embryonal and cancer 

cells. (A. Kotzareff & L. Weyl) Presse med. 31:925-927, Nov. 

7. '23 0»"S.) 

—Further experiences m the treatment of arthritis with high doses of 

radium emanation (Th. Vaternahm) Med. Klinik. 18:1477-1479, 

Nov. 23, '22; ab. Radium 3, N. S., 156-160. July '24. 

—Influence of radium emanation on fermentation of lactose and glucose 

indued by colon bacillus, (G. Graziadei) Riforma med. 

4o:3i5'3'7. April 7. '24 (chart.) 

—Intravesical (cystoscopic) treatment of carcinoma of bladder by implantation 

of radium emanation tubes, (A. Hyman) Surg. 

Gynec. Obst. 39:827-831. Dec. '24 (illus.) 

—New cystoscopic forceps especially adapted for implantation of 

radium emanation "seeds." (R. L. Dounnashkin) J. Urologv 

12:89-91. July '24 (illus.)

R a d i u m 

58 

Radium, emanation— 

—Radium emanation. (II. Flecker) M. J. Australia 1:610-611. June 

21, '24. 

—Radium emanation in therapeutics, (J. Strasburger) Deutsche med. 

Wchnschr. 40:1459-1463, Nov. 30. '23 (charts) ; ab. J. A. M. A. 

S2 =343. Jan. 26, '24. 

Radium emanation in treatment. (E. |. Jonquieres) Semana med. 2: 

23-29. July 3. '24 (illus.) 

—Technique for the application of radium (emanation) in carcinoma 

of prostate, (E. M. Watson) Bulletin of the Buffalo General 

Hospital, Jan. '24; Radium 3, N. S., 119-124, July '24. 

—History of radium. (K. S. Davis) Radiology 2:334-342. May '24. 

—Injury: Six day anuria consecutive to radium treatment. (A. Matusovszky) 

Monatschr. f. Geburtsh. u. Gynak. 65:299-306 Feb 

'24; ab. J. A. M. A. 82:1486, May 3. '24. 

—Protection: X-ray and radium protection committee, Brit. J. Radiol. 

29:19-26, Jan. '24. 

—Therapy: Radium therapy, (B. B. Steedly Sc F. M. Johnson) J. S. 

Carolina M. A. 20:222-226, Sept. '24. 

—Radium iherapy. (R. R. Wettenhall) M. J. Australia 1:612-613. 

June 21, '24. 

—-Actual status of radium therapy in gynecology, Ri forma, med. 40: 

659-660, July 14, '24. . 

—Contraindications for radium iherapy, (P. Castro Escalada) Semana 

med. 1 :823-827, May 1. '24. 

—Contraindications to radium in treatment of diseases of female pelvis. 

(F. E. Keene) Am. J. Obst. & Gynec. 8:201-204, Aug. '24. 

—Contribution to radium therapy. (G. Mazercs) J. de radiol. et 

d'electrol. 8:102-106. March '24 (charts). 

—Follow-up results of 00S cases of uterine cancer treated by radium. 

(H. Bailey & W. F. HealvA Am. J. Obst. & Gynec. 6:402-406 

and 49>-495. Oct. '23; Radium 2, N. S„ 277-284, Jan. '24. 

—Methods of improving external application of radium for deep 

therapy, (W. Stenstrom) Am. J. Roentgenol. 11:176-186. Feb. 

'24 (illus.) 

—New terms used in radium therapy. (P. Castro Escalada) Semana 

med. 1 :664-665, April 10. '24. 

—Notes and experiences in radium therapeutics, (G E. Dennis) M. J. 

Australia 1:6o7-6io, June 21, '24. 

—On the reasons for choice—radium or X-ray, when radiotherapy is 

indicated, (W. S. Lawrence) Urol. & Cut. Rev. 28:294-296. 

May '24; ab. Radium 3. N. S.. 147-151, July '24. 

—Pharyngeal application of radium. (L. Capelli) Policlinics (sez. prat.) 

31:647-649. May *9- *24 (ill«s.) 

—Points to be considered in application of radium, (W. H. Cameron) 

Radiology 3:140. Aug. '24 (illus.) 

—Progress in radium therapy, (P. G Escalada) Semana med. 1:306- 

308, Feb. 14. '24. 

—Protective method of applying radium in cervix. (W. J. Woolston 

& R. G Crain) J. A. M. A. 83:1429, Nov. 1, '24. 

—Radium; a resume of its physical and therapeutic properties, (G N. 

Frazier) China M. J. 38:341-349, May '24.


— Radium and internal medicine, (E. Fischel) Ann. Clin. Med. 3:245- 

248, Sept. '24. 

—Radium applicator for upper air and digestive passages, (J. Maliniak) 

Laryngoscope 34725-731, Sept. '24 (illus.) 

—Radium for non-malignant gynecologic diseases, (T. J. Watkins) 

Wisconsin M. J. 23:123-124, Aug. '24. 

—Radium in benign conditions of nose and throat, (L. A. Lane) Minnesota 

Med. 7:578-583. Sept. '24. 

— Radium in dermatology, (O. H. Foerster) Arch. Dermat. & Syph. 

9:38-50. Jan. "24. 

—Radium in medicine. (G J. Broeman) Ohio State M. J. 20:226-231. 

Apr. '24 (illus.) 

—Radium in ophthalmology with special reference to its use in benign 

affections. (L. A. Lane) J. A. M. A. 83:1838-1845, Dec. 6/24. 

—Radium in treatment of non-malignant diseases of skin, (F. S. 

Burns) Boston M. & S. J. 191:16-20. July 3, '24; Radium 3. 

N. S-. 1S9-195, Oct. '24. 

—Radium: its uses in the treatment of cancer, (G W. Han ford) Cincinnati 

J. Med. 4:391-396, Oct. '23; Radium 2, N. S.. 297-302, 

Jan. '24. 

Radium therapy in otorhinolaryngology. (A. Tarasido) Rev. Asoc. 

Med. argent. (Special Congress Number) 5:433-460, '24. 

— Radium therapy: iis present position in treatment of certain skin 

and malignant diseases, (H. Lawrence) M. J. Australia (supp.) 

2:515-518. July 19, '24 (illus.) 

—Radium in the treatment of subungual verrucae. (S. Ay res. Jr.) 

Arch. Dermal. Syph. 574S-749. June '22; ab. Radium 2. N. S-, 

317-318. Ian. '24. 

—Radium treatment in North America, (E. Pouey) An. de Fac. de 

med.. Montevideo 9:402-438. Mav '24 (illus.); ab. J. A. M. A. 

83:879. Sept. 13, '24. 

—Radium treatment in otorhinolaryngology. (L. Samcngo) Semana 

med. 2:1320-1338, Dec. 20, '23 (illus.); ab. J. A. M. A. 82: 

504. Feb. 9, '24. 

— Radium treatment of loxic goiter with metabolic deductions, (R. E. 

Loucks) Am. J. Roentgenol. 10767-776, Oct. '23; ab. Radium 

3. N. S.. 151-156. July '24. 

—Radium treatment with observations upon its action in selected cases. 

(G. C. Wilkins) Boston M. k S. J. 191 :ioi4-ioi8. Nov. 27, '24. 

—Skin reactions to radium exposure and their avoidance in therapy; 

experimental investigation. (J. G Mottram) Brit. J. Radiol. 

29:174-180. May '24. 

—Therapeutic uses of radium, (A. E. H. Pinch) Bristol Med. Chir. J. 

41:97-112. July '24 (illus.) 

—Treatment with radium. (S. Touscv) Internal. Clinics 2:71-84. June 

'24 (illus.) 

—Use of audion amplifiers in measurements of beta and gamma ray 

intensities, (V. F. Hess) Radiology 2:100-103, Fe"- '24 (illus.) 

Ranson, J. R.. and Withers, S.--Treatment of malignant growths about 

the face. Colorado Med. 21:92-97. April '24; Radium 3. N. S., 

181-1S8. Oct. '24. 

Redfield, A. G. and Bright, E. M.—Physiological action of ionizing 

radiations; evidence for ionization by beta radiation, Am. J. 

Physiol. 68:54-61, March '24.

R a d i u m .>.) 

—Physiological action of ionizing radiations; path of alpha particle. 

Am. J. Physiol. 68:62-69, March '24. 

—Physiological action of ionizing radiations; X-rays and their secondary 

corpuscular radiation, Am. J. Physiol. 68:354-367. 

April '24. 

—and Wertheimer, J.— Physiological action of ionizing radiations; 

comparison of beta and X-rays, Am. J. Physiol. 68:368-378, 

Apil '24. 

Regaud, C.—Radio-immunization of cancer tissues. Bull. acad. de med., 

Par. 91 :6o4-6o7. May 13. '24. 

—Some biological aspects of radiation therapy of cancer. Am. J. 

Roentgenol. 12:97-101. Aug. '24. 

—Report on lectures on radiotherapy of cancer. Bull. acad. de med.. 

Par. 92:978-980. Oct. 7. '24. ' 

—and others. Radiotherapy of sarcoma. Paris med. 1:119-125. Feb. 

2, '24. 

Richards, A. N.. Mendenhall, W L.. and Taylor, E. M.—Action of 

minute amounts ot barium chloride upon kidney, Am. J. Physiol. 

71:174-177. Dec. '24. 

Roentgen Ray, burns and injuries— 

—Action of roentgen rays on embryos. (P. Ancel and P. Vintemberger), 

Compt. rend. soc. de Biol. 91:606-609. July 25, '24; 

ab. J. A. M. A. 83:877. Sept. 13, '24. 

—Acute suprarenal insufficiency from roentgen-ray exposures. (F. G 

Arrillaga and R. A. Izzo) Semana med. 1:327-331. Feb. 21, 

'24 (illus.); ab. J. A. M. A. 82:1307. April 19. '24- 

—Case of deep roentgenotherapy of lower part of back, complicated 

by intractable vomiting and grave hematemesis during six weeks. 

cured by epinephrin injection, (Tuffier) Bull. Acad, de Med., 

Par. 91763-766. June 17. '24; ab. J. A. M. A. 83:477. Aug. 

9- '24- 

•—Effect on offspring of roentgen ray treatment of mother, (L. F. 

Driessen Nederl. Maandschr. v. Geneesk. 12:239-247. '24; ab. 

J. A. M. A. 83:161. July 12, '24. 

—Extensive oedema following intensive X-ray treatment; a word of 

warning, (G G Anderson) Arch. Radiol. & Electro. 28:217- 

2i8. Dec. '23. 

—Hereditary structural defects in descendants of mice exposed to 

roentgen ray irradiation, (H. J. Bagg and C. G Little) Am. 

J. Anat. 33:119-145. March '24 (illus.) 

—Injury to larynx induced by X-ray treatment, (O. Strandherg) J. 

Laryngol. & Olol. 39:437"440. Aug. '24. 

—Irradiation injuries of eyes. (R. Bergmcister) Wien. Khn.Wchnschr. 

37:1061-1063. Oci.o. '24; ab. J.A.M.A. 83:1723. Nov. 22. '24. 

—Late roentgen-ray injuries. (F. Heimann) Klin. Wchnschr. 2:2034- 

2036, Oct. 29, '23. 

—Occurrence of hepatic lesions in patients treated by intensive deep 

roentgen irradiation. (J. T. Case and A. S. Warthin) Am. J. 

Roentgenol. 12:27-46, July '24 (illus.) 

—Prophylaxis of roentgen ray overdosage, (R. H. Rullison) J. A. 

M. A. 83:1505-1506, Nov. 8, '24. 

—Roentgen exposures and the offspring. (W. Schmitt) Kim. 

Wchnschr. 3:1358-1360. July 22. '24; ab. J. A. M. A. 83723. 

Aug. 30. '24.


—Roentgen-ray cachexia, (G L. Martin & F. T. Rogers) Am. J. 

Roentgenol. 11:280-286. March '24 (illus.) 

—Roentgen-ray sickness and chloride retention. (A. T. Cameron & 

J. G McMillan) Canad. M. A. J. 14:679-683, Aug. '24. 

—Roentgen ulcer therapy, (H. Muchow) Dermat. Wchnschr. 78:509- 

510. May 3. '24. 

—Surgical treatment of X-ray burns. (E. G Blair) J. Radiol. 5:149- 

152, May '24 (illusA 

—Tardy ulceration after radiotherapy, (H. Rahm) Beiir. z. Klin. 

Chir. 131 :456-46o. '24; ab. J. A. M. A. 82:1739. May 24, '24. 

—Wire's method of cauterization of teleangiectasis occurring after 

roentgen treatment, (H. Kriser) Wien. Klin. Wchnschr. 37: 

1068-1069. Oct. 9. '24; ab. J. A. M. A. 83, 1723. Nov. 22, '24. 

—Cancer— 

—Malignant roentgen ulcers and their treatment, (G. Tillmann) 

Munchen med. Wchnschr. 71:516-517. April 18. '24 (illus.); 

ab. J. A. M. A. 82:1903, June 7, '24. 

—Myoma of uterus combined vvith roentgen cancer. (K. Nakamoto) 

Gann. 17:66, 1923 (In German). 

—Effects: Action of roentgen rays in accelerating coagulation of blood. 

(P. Pagnicz. A. Ravina and I. Solomon) Presse med. 32:545- 

548, June 25, '24; ab. J. A. M. A. 83:478, Aug. 9, '24. 

—Action of roentgen rays on blood and agglutinin formation, (G 

Frei and A. Alder) Schweiz. med. Wchnschr. 54:670-675. July 

24. '24 (charts); ab. J. A. M. A. 83721, Aug. 30, '24. 

—Action of roentgen rays on metabolism, (H. Bernhardt) Ztschr. f. 

Klin. Med. 98:50-57. '24 (charts); ab. J. A. M. A. 82:757, 

March 1. '24. 

—Antagonistic action of various roentgen rays on flocculationof colloidal 

suspension, (A. Dognon) Compt. rend. Soc. de Biol. 90: 

778-780. March 28, '24 (illus.); ab. J. A. M. A. 82:1653. May 

17. '24. 

—Artificial radiosensitizalion of tissues. (N. Samssonow) Paris Med. 

1 :io8-!ISi Feb. 2. '24; ab. J. A. M. A. 82:1005. March 22, '24. 

—Biological action of X-rays, (E. W. Rowe) Nebraska M. J. 9:303- 

306, Aug. '24. 

—Blood count under experimental irradiation. (A. Lacassnage and 

J. Lavedan) Medicine 5:683-688, June '24. 

—Effect of ligature on radiosensibility, (J. Jolly) Compt. rend. Soc. 

de Biol. 91:532-534. July 25. '24; ab. J. A. M. A. 83:877, Sept. 

13. '24- 

—Effect of radiation on bactericidal power of blood, (Hill, L., Colebrook, 

L., and F.idinow. A.) Brit. J. Exper. Path. 5:54-64. 

April '24. 

—Effect of roentgen rays on adrenal glands, (G L. Martin. T. F. 

Rogers, and N. F. Fischer) Am. J. Roentgenol. 12:466-471. 

Nov. '24. 

—Effect of X-ray exposure on metabolism, (A. L. V Barreto) J. 

Metabolic Research 3737-747. May-June '23 (illus.) 

—Effect on blood of irradiation, especially short wave length roentgen-ray 

therapy. |G. R. Minot & R. G. Spurling) Am. J. M. Sc. 

168:215-241. Aug. '24 (charts) ; ab. Radium 3. N. S„ 268-275. 

Jan. '25.

R a d i u m 

57 

—Experimental research on biologic action of roentgen rays on canccrs. 

(C. Asami) Gann. 17:1-6. '23 (In German). 

—Muctuations in radiosensitiviiv of cells, (G. Schwarz) Wicn klin 

Wchnschr. 36:887-888. Dec. 13. '23. 

—Influence of wave length on fiocculaiionof a colloidal solution by 

roentgen rays, (A. Dognon) Compt. rend. Soc. de biol. 91:197- 

l9. June 27. '24. 

—Radiation iherapy in 46 cases of lymphogranuloma, (Hodgkin's 

disease) Amer. J. Roentgenol. 12:133-137. Aug. '24 (illus.) 

—Radiation therapy in treatment of leukemia summarized from a series 

of 25 cases. YY. L. Mattick & B. F. Schreiner) Amer. J. Roentgenol. 

12:126-133. Aug. '24. 

—Roentgen rays and hydrogen ions in blood. (J. Cluzet & T. Kofmann) 

Compt. rend. Soc. de biol. 91:946-048, Oct. 11. '24; ab 

J. A. M. A. 83. 1881. Dec. 6, '24. 

—Some phenomena of radio-biology in their relation to therapeutic 

methods. (G. Schwarz) Wicn. klin Wchnschr. 36:906-907, Dec. 

20, '23; ab. J. A. M. A. 82:429, Feb. 2. '24. 

—Studies on effect of roentgen rays on glandular activity; effect of 

exposure of abdominal and theracic areas to roentgen rays on 

gastric secretion; roenlgcn cachexia. (A. C. Ivy, J. E. McCarthy 

& B. H. Orndoff) J.A.M.A. 83:1977-1984. Dec. 20, '24 (illus.) 

—Theoretical study of biophysical action of X-rays in treatment of 

malignant neoplasms, (D. C. A. Butts) J. Radiol. 5:313-315, 

Sept. '24. 

—Protection against: X-ray and radium protection committee. Brit. 

J. Radiol. 29:19-26, Jan. '24; Radium 3. N. S., 207-213. 

Oct. '24. 

Rosenbloom. J.—Effects of radium on metabolism, J. Metabolic Research 

475-88, July-Aug. '23. 

Rosselet. A.—Roentgen rays and radium. Schweiz. med. Wchnschr. 54: 

S26-530, June 5. '24. 

Rud, E.—Blood .findings in personnel of roentgen and radium institutes, 

Ugesk. f. Lacger 86:438-442, May 29, '24. 

Rulison, R. H.—Prophylaxis of roentgen-ray overdosage. J. A. M. A. 

83:1505-1506, Nov. 8. '24. 

Russ. S.—Animal tumour cells made resislant to X-rays by X-rays. 

Lancet, 1:592-593. March 22. '24. 

—Experimental studies upon letlnl doses of X-rays and radium for 

human and ofher tumors. Brit. J. Radiol. 29:275-292. Aug.'24. 

Sainz de Aja—Mixed surgical and radium treatment of prominent keloids. 

Siglo med. 72:1185-1187. Dec. 8. '23. 

Samengo. L.--Radium treatment in otorhinolaryngolcgy, Semana med. 

2:1329-1338. Dec. 20. '23. 

Samuel. E. G, and Bowie. E. R.— Radiation in treatment of carcinoma 

of uterus. Am. J. Roentgenol. 12:370-372. Oct. '24. 

Sante. L. R.—New department of radiology of St. Louis City Hospilal. 

Radiology 3*402-407. Nov. '24. 

Sarcoma, radiotherapy— 

—Case of sarcoma of forehead treated with deep beta therapy. (Julliard 

& R. Gilbert) Schweiz. med. Wchnschr. 54:803-805. Aug. 

28. '24 (illus.) 

Schmidt. W. II.—Indications for radium and other methods of treatment 

in cancer, Am. J. Roentgenol. 12:219-230. Sept. '24.

58 Radium 

Schmitz, H.—Treatment of primary and latent injuries of skin from 

radium and X-rays. Radiology 1:34-38; Sept. '23; Radium 2, 

N. S., 271-277, Jan. '24. 

—Cancer problem from radiological standpoint, Radiology 2:7-13, 

Jan. '24. 

—Treatment of ovarian cancers with combined surgical and radiological 

methods, Wisconsin M. J. 23:125-128, Aug. '24. 

—Five year end-results obtained in carcinoma of female pelvic organs 

with special reference to radium and X-ray therapy, Surg. 

Gynec. Obst. 39775-780, Dec. '24. 

Schollen, G. G J.—Our success in treatment of carcinoma of uterus by 

radiotherapy, Miiench. med. Wchnschr. 70:300-301, March 9, 

'23; ab. Radium 2, N. S., 329-330. Jan. '24. 

Schreiner, B. F. — Summary of clinical results after irradiation of cancer 

of cervix uteri. Am. J. Roentgenol. 12:367-370. Oct. '24. 

•—and Kress. L. G—Contribution to treatment of cancer of lip by irradiation. 

J. Cancer Research 8:221-233. July '24. 

—Untoward results in irradiation therapy of uterine cancer when 

complicated with latent gonococcic salpingitis. Am. J. Roentgenol. 

12:51-53. July '24. 

—Clinical results after irradiation of cancer of cervix uteri, N. Y. 

State J. Med. 24:981-984. Dec. '24. 

Schugt. P.—Hematuria after roentgen and radium exposures, Zentralbl. 

f. Gynak. 47:1862-1868, Dec. 15, '23. 

Sellers. T. B.—Use of radium in treatment of benign and malignant conditions 

of uterus. New Orleans M. & S. J. 77:217-222, Dec. '24. 

Sherwood, M. W.—Uterine malignancies treated by cautery, radium and 

X-ray, Texas State J. Med. 20:352-355, Oct. '24. 

Shurly. B. R.—Removal of tonsils with special reference to methods 

other than complete enucleation, J. A. M. A. 81:8oo-8o2, Sept. 

8, '23; ab. Radium 3, N. S., 219-221. Oct. '24. 

Simmons, G G—Carcinoma of buccal mucous membrane, Boston M. & 

S. J. 19:1018-1022. Nov. 27. '24. 

Simpson, F. E.— Radium in treatment of vascular naevi. Surg. Gynec. 

Obst. 38:407-411, March '24. 

Sittenfield. M. J.—Evaluation of X-ray and radium therapy in cancer, 

and its future outlook. Radiology 2:74-79, Feb. '24. 

Skin, injuries— 

—Treatment of primary and latent injuries of skin from radium and 

X-rays. (H. Schmitz) Radiology 1:34-38. Sept. '23; Radium 

2, N. S., 271-277. Jan. '24 (illus.) 

Sludcr. G.—Use of radium for nasal polyps. Laryngoscope 34:124-125, 

Feb. '24. 

Smith, F. L., and Desjardins. A. U.—Radiodermatitis and its treatment, 

S. Clinics N. America 4:479-493. April '24; also New Orleans 

M. & S. J. 77:t77-'83. Nov. '24. 

Smith, Leon H.—Epithelioma of tonsil. New York State J. Med. 24:289- 

292, March 7, '24; ab. Radium 3. N. S.. 264-265, Jan. '25. 

Soiland. A.—Comments on use of radium for intra-oral cancer, J. A. 

M. A. 83:410-412. Aug. 9, '24. 

—Treatment of inoperable cancer of pelvis by radium. Am. J. Roentgenol. 

12:378-379. Oct. '24. 

Sokoloff, B., and Weckowski, C.--Radium treatment of tumors, Comp. 

rend. Soc. de biol. 90:60-61. Jan 25, '24.

R a d i u m 

59 

Spleen, physiology— 

—Some probable functions of spleen as demonstrable by effects of 

radio-activity upon that organ, (A. Henriques) New Orleans 

M. & S. J. 76:534-537. June '24. 

Spurting, R. G.. Stewart. F. W.. and Minot. G. R.—Effect on blood 

of irradiation, especially short wave length roentgen-ray therapy, 

Am. J. M. Sc. 168:215-241, Aug. '24; ab. Radium rN.S., 

268-275, Jan. '25. 

Stecdly, B. B., and Johnson. F. M.- -Problems in radium therapy. J. S. 

Carolina M. A. 20:222-226, Sept. '24. 

Stcnstrom. W.—Methods of improving external application of radium 

for deep therapy, Am. J. Roentgenol. 11 :i76-i86, Feb. '24. 

Stevens. J. T.—Statistics and technique in treatment of superficial malignancy 

with radium, roentgen rays and electrothcrmic coagulation. 

Am. J. Roentgenol, ti :24i-246, March '24. 

Stevens. R. H.—Malignant growths of paranasal sinuses treated by irradiation, 

electrocoagulation and other methods. Am. J. Roentgenol. 

11:532-536. June '24. 

Stomach, radium therapy— 

—Intragastric radium application, preliminary report. (T. O. Mcnees) 

Am. J. Roentgenol. 11:561-562, June '24 (illus.) 

Strasburger. J.—Radium emanation and therapeutics, Deutsch. med. 

Wchnschr. 49:i459-i463,_Nov. 30, '23. 

Strumia, M. M.—Blood cell morphology and function; morphologic 

changes of blood in myelogenous leuccmia under radium treatment, 

J. Lab. & Clin. Med. 10:106-122, Nov. '24. 

Sugiura, K.- Influence of radiations from radium emanation upon tumor 

susceptibility in albino rats, J. Cancer Research 8:576-^84, 

Oct. '24. 

Swett, W. F.. and McKee. A. B.—Use of radium in cataract. Am. J. 

Ophth. 7:587-588. Aug. '24. 

Tarasido, A.—Radium therapy in otorhinolaryngology. Rev. Asoc. med. 

argent. (Special Congress Number) 5:433-460, '24. 

Taylor, E. M., Richards, A. N., and Mendenhall. W. L.—Action of 

minute amounts of barium chloride upon the kidney. Am. J. 

Physiol. 71:174-177. Dec. '24. 

Taylor, H. G. and Peightal. T. G- -End results of 201 cases of carcinoma 

of cervix. Am. J. Obst. & Gynec. 8:288-297, Sept. '24; 

Radium 3. N. S., 245-253, Jan. '25. 

Thomas, G. F., and Hill. W. G- --Treatment of nonmalignant uterine 

conditions, Am. J. Roentgenol. 12:357-361, Oct. '24. 

Thorium X— 

—Immunization with thorium X, (M. Yamauchi) Ztschr. f. Krebsforsch. 

21:230-240, Mav '24 (illus.); ab. J. A. M. A. 83:77, 

July 5. '24. 

—Therapy—Treatment bv inhalation of thorium, (J. Cluzet and A. 

Chevallier) Medicine 5:681-682. June '24; ab. J. A. M. A. 83: 

391, Aug. 2, '24. 

Throat, radium treatment— 

•—Radium treatment of otorhinolaryngology, (L. Samengo) Semana 

med. 2:1329-1338, Dec. 20, '23; (illus.); ab. J. A. M. A. 82: 

504, Feb. 9. '24.


Thymus, enlarged— 

—Diagnosis of enlarged thymus by X-ray. and treatment by X-ray or 

radium, (G. E. Pfahler) Arch. Pediat. 41:39-46, Jan. '24. 

Thyroid, cancer— 

—Diagnosis of thyroid, (J. L. DeCourcy) Ann. Surg. 80:551-554. 

Oct. '24 (illus.); ab. Radium 3. N- S., 263-264. Jan. '25. 

—Radiotherapy of: Radium therapy of thyroid, (F. M. Hagans) 

Endocrinology 8:40.4-408. May '24. 

—Tumors: Malignant tumors of thyroid. (W. P. Herbst. Jr.) Ann. 

Surg. 79:488-494, April '21. 

Tomanek. F.—Radium treatment of pernicious anaemia, Cas. lek. Cesk. 

63:549-552. Aprl. 5, "24. 

Tongue, cancer— 

—Cancer of longue under influence of radium, electrocoagulation and 

X-ray. (C W. Han ford) J. Radiol. 5:55-57, Feb. '24 (illus.) 

—Radium needles in malignant growths of the tongue: the time factor. 

(A. J. Larki^ Am. J. Roentgenol. 10734-735. Sept. '23; ab. 

Radium 2, N. S.. 322-323, Jan. '24. 

Tonsil, cancer— 

—Epithelioma of tonsil, (L. H. Smith) New York State J. Med. 24: 

289-292. March 7, '24; ab. Radium 3. N. S.. 264-265, Jan. '25. 

—Deep roentgen and radium therapy in carcinoma of tonsil. (G. W. 

Grier) Am. J. Roentgenol. 11 :537*544. June '24. 

- Radiological treatment: Pathologic basis for roentgen-ray treatment 

of tonsil disease. (W. W. Watkins) J. A. M. A. 83:1305-1308. 

Oct. 25. '24; ab. Radium 3. N. S., 277-282, Jan. '25. 

—Removal of tonsils with special reference to methods other than 

complete enucleation. (B. R. Shurly) J. A. M. A. 81:800-802. 

Sept. 8. '23; ab. Radium 3, N. S., 219-221. Oct. '24. 

—Use of radium radiations in treatment of tonsils; a further report. 

(F. H. Williams) Am. I. M. Sc. 168:18-34. July '24 (illus.) 

—Radium treatment of tonsils. (C. A. Simpson) Am. J. Roentgenol. 

Dec. '24. 

Tousey. S.—Therapeutic uses of electricity, X-ray. ultra-violet ray and 

radium methods and results. (New York State J. Med. 24:191- 

197, Feb. 22, '24. 

—Treatment wilh radium. Intermit. Clinics 271-84, June '24. 

Trachoma.— 

—The effect of radium on glaucoma. (J. J. Corbett) Boston M. & S. J. 

190:1124-1126, June 26. '24 ; Radium 3, N. S.. 202-207, Oct. '24. 

Tumor, angioma— 

—Naevi and their treatment by radium, (H. MacKay) Canad. M. A. J. 

i4:304-397- May '24 (illus.); also by Radiol. 5:305-307. Sept. 

'24 (illus.) 

—Radium treatment in vascular naevi. (F. E. Simpson) Surg. Gvnec. 

Obst. 38:407-411. March '24 (illus.) 

—Radium treatment of angiomas. (L. Mazzoni) Gior. ital. d. mal. ven. 

65:920-936, June '21 (illus.) 

—Fibroma: Treatment of fibromasof nasopharynx ; report of 32 cases, 

(G. B. New & F. A. Figi) Am. J. Roentgenol. 12:340-343; Oct. 

'24; ab. Radium 3. N. S„ 275-277. Jan. '25. 

—Radiotherapy: Radium treatment of tumors, (B. Sokoloff & G 

Weckowski) Compt. rend. Soc. de Biol. 90:60-61 Jan 25 '24- 

ab. J. A. M. A. 82:926, March 15. '24.

R a d i u m 

6l 

—Animal tumor cells made resistant to X-rays by X-rays, (S. Russ) 

Lancet i 092-593. March 22. '24. 

—Influence of radiations from radium emanation upon tumor susceptibility 

in albino rats, (K. Sugiura) J. Cancer Research 8:376- 

384, Oct. '24. 

—Lethal doses of X-rays and radium for human ami other tumours, 

(S. Russ) Brit. J. Radiol. 29:275-292, Aug. '24 (illus.) 

—Treatment: Intratumoral injections of thorium X. (L. Halberstaedter) 

Deutsche, med. Wchnschr. 49:1295-1296. Oct. 12, '23. 

Ulcers, rodent— 

—Radium in treatment of rodent ulcers at Sydney Hospital. (L. Johnston) 

M. J. Australia 2:467-471, Nov. 1, "24 (illus.) 

Uterus, cancer— 

—Action of radium upon cancer of cervix. (T. Zbinden) Ohio State 

M. J. 20:14-16, Jan. '24 (illus.) 

—Cancer of cervix. (S. Forsdike) Brit. M. J. 2:94-98. July 19. '24 

(illus.) 

—Cancer of uterine cervix, treated by irradiation; methods of treatment 

and results in 1,024 cases, (H. Bailey & W. P. Healy) 

J. A. M. A. 83:1055-1056, Oct. 4. '24. 

—Carcinoma of body of uterus, with report of 115 cases, (G G 

Norris & M. E. Vogt) Am. J. Obst. & Gynec. 7:550-566. May 

'24; Radium 3, N. S.. 97-112, July '24. 

—Carcinoma of uterus. (G. W. Crile) Am. J. Obst. & Gynec. 7:528- 

535. May '24; ab. Radium 3. N. S.. 141-146. July '24. 

—Clinical results after irradiation of cancer of cervix uteri. (B. F. 

Schreiner and L. G Kress) New York State J. Med. 24:981- 

984, Dec. '24 (illus.) 

—End results of 201 cases of carcinoma of cervix, (H. G Taylor and 

T. G Peightal) Am. J. Obst. & Gynec. 8:288-297, Sept. '24; 

Radium 3, N. S., 245-253, Jan. '25. 

—Follow-up results of 908 cases of uterine cancer treated by radium. 

(H. Bailey and W. P. Healy) Am. J. Obst. & Gynec. 6:402- 

406 and 491-495. Oct. '23; Radium 2, N. S., 277-284, Jan. "24. 

—Hysterectomy versus radium for uterine cancer. (J. L. Faure) Bull. 

acad. de med., Par.. 92:1040-1043. Oct. 21. '24; ab. J. A. M. A. 

83:1800, Nov. 29. '24. 

—Inoperable cancer of uterine cervix, (A. Perrola) Rev. franc de 

Gynec. et d'obst. 28:321, May 25. '23; ab. J. A. M. A. 1056, 

Sept. 22, '23; ab. Radium 2, N. S.. 332, Jan. '24. 

—Intraperitoneal insertion of buried capillary glass tubes of radium 

emanation in carcinoma of cervix uteri, (I. Levin) Am. J. 

Roentgenol. 12:352-357. Oct. '24. 

—Massive dose radium treatment in carcinoma of cervix uteri, (G. A. 

Leland, Jr.) Am. J. Roentgenol. 12:373-378, Oct. '24. 

—Mortality in radium therapv of uterine cancer, owing to abscesses in 

small pelvis. (I. Belugin) Zentral. f. Gynak. 48:1970-1974. Sept. 

6. '24; ab. J. A. M. A. 83:1210. Oct. 11, '24. 

—New techniques of "Curie" therapy of cancer of cervix uteri. (F. 

Daels & P. DeBacker) Brit. I. Radiol. 29:315-318, Sept. '24 

(illus.)


—Our success in treatment of carcinoma of uterus by radiotherapy, 

(G. C..J. Schollen) Miinch. med. Wchnschr. 70:300-301, March 

9, '23; ab. Radium 2, N. S., 329-33°- Jan- '24- 

—Protective method of applying radium in the cervix, W. J. Woolston 

and R. G Crain) J. A. M. A. 83:1429, Nov. 1, '24. 

—Radiation in treatment of carcinoma of uterus, (E. G Samuel and 

E. P. Bowie) Am. J. Roentgenol. 12:370-372, Oct. '24. 

—Radium as prophylactic and curative agent in recurrent carcinoma 

of uterus, (H. Bailey) New York State J. Med. 24:985-986- 

Dec. '24. 

—Radium therapy in gynecology, (P. B. Bland) M. J. & Rec. 120: 

101-107, Aug. 6, '24 (illus.) 

—Radium treatment of cancer of cervix. (G O. Donaldson & G. E. 

Knappenberger) J. Oklahoma M. A. 17:198-201, Aug. '24. 

—Relative values of irradiation and radical hysterectomy for cancer 

of cervix. (J. G. Clark and F. B. Block) Am. J. Obst. & Gynec. 

7:543-540. May "24; also in Atlantic M. J. 27:696-699, Aug. 

"24; ab. Radium 3, N. S., 135-140, July '24. 

—Results of radium or roentgen treatment of uterine cancer; 158 

cases. (C. P. van Raamsdonk) Ncdcrl. Maandschr. v. Geneesk. 

12:45-60. '23 (illus.) 

—Role of radium in treatment of carcinoma of uterus, (T. E. Jones) 

Am. J. Obst. & Gynec. 7:541-542, May '24; ab. Radium 3, 

N. S., 146-147. July '24. 

—Superiority of radium over surgery in cancer of uterus, (W. H. 

Kennedy) M. J. & Rec. (supp.) 120:148-149. Nov. 19, '24. 

—Technique and results in treatment of carcinoma of uterine cervix at 

"Radiumhemmett." Stockholm, (H. V. J. Heyman) J. Obst. & 

Gynec. Brit. Emp. 31:1-19. '24 (illus.); ab. Radium 3, N. S., 

258-260, Jan. '25. 

—Treatment of malignant diseases with radium and X-ray; cancer of 

cervix. (R. B. Greenough) Surg. Gynec. & Obst. 39:18-26, July 

'24; Radium 3. N. S„ 161-174, Oct. '24. 

—Untoward results in radiation therapy uterine cancer when complicated 

with latent gonococcic salpingitis. (B. F. Schreiner & L. 

G Kress) Am. J. Roentgenol. 12:51-53, July '24. 

—Uterine malignancies treated by cautery, radium and X-ray. (M. W. 

Sherwood) Texas State J. Med. 20:352-355, Oct. '24. 

—Fibroma: Effects of radium therapy in cases of large uterine fibroids, 

(G F. Burnam) Am. J. Obst. & Gynec. 8:411-415. Oct. '24. 

—Exophthalmic goiter cured after radium treatment of uterine fibroma, 

(M. Karsis) Gynec. et Obst. 10:102-104. Aug. '24; ab. J. A. M. 

A. 83:1205. Oct. 11. '24. 

—Operation versus irradiation for uteripc fibromas, (H. Hartmann) 

Gynec. et Obst. 10:203-205. Sept. '24. 

—Radium treatment of fibroidtumors of uterus. (G. S. Willis) M. 

J. & Rec. (supp.) 120:146-147, Nov. 19. '24. 

—Hemorrhage: Intrauterine radiotherapy in gynecologic hemorrhage. 

(G. Halter) Zentral f. Gynak. 48:2000-2007. Sept. 13, '24; ab 

J. A. M. A. 83:1284, Oct. 18. '24. 

—Radium therapy in uterine hemorrhage. (J. M. Emmett) Virginia 

M. Monthly 51:562-566. Dec. '24.

R a d i u m 

es 

—Treatment of uterine bleeding in young women, (L. S. Coin) 

Radium 2, N. S., 305-307, Jan. '24. 

—Radiotherapy: Results of radiotherapy of cancer of uterus, (W. S. 

Flatau) Zentral. f. Gynak.. Nov. 19. '23; do., May 12, '23; ab. 

J. A. M. A., Sept. 1, '23. 790; ab. Radium 3. N. S., 213-214. 

Oct. '24. 

—Use of radium in treatment of benign and malignant conditions of 

uterus, (with report of cases). (T. B. Sellers) New Orleans 

M. & S. J. 77:217-222, Dec. '24. 

—X-ray and radium in treatment of non-malignant diseases of uterus. 

(L. B. Morrison) Boston M. & S. J. 191:13-15. July 3, '24. 

—Tumors— 

—Contraindications to radium in treatment of diseases of female pelvis. 

(F. E. Keene) Am. J. Obst. & Gynec. 8:201-204. Aug. '24. 

—Role of radium in benign and malignant tumors of uterus, (T. E. 

Jones) Wisconsin M. J. 22:466-469, March '24 (illus.) ; also in 

Illinois M. J. 45:255-258. April '24. 

—Surgery vs. X-ray and radium therapy in treatment of tumors of 

uterus, (G. N. Crile) Illinois M. J. 45:177-179, Mar. '24. 

—Surgical and irradiation treatment of benign and malignant growths 

of uterus. (J. G. Clark) Internatl. Clinics 1 74-87, March '24 

(illus.) 

van Raamsdonk, G P.—Results of radium or roentgen treatment of 

uterine cancer, Nederl. Maandschr. v. Geneesk. 12:45-60, '23. 

Vaternahm. Th.—Further experiences in the treatment of arthritis with 

high doses of radium emanation. Med. Kiinik. 28:1477-1479, 

Nov. 23, '22; ab. Radium 3, N. S.. 156-160, July '24. 

Verruca— 

—Verruca of nail fold, (D. W. Montgomery and G. D. Culver) Arch. 

Dermat. & Syph. 10:425-428, Oct. '24 (illus.) 

—Treatment: Radium in treatment of subungual verrucae, (S. Ayres. 

Jr.) Arch. Dermat. & Syph. 5:748-749. June '22; ab. Radium 

2, N. S., 317-318. J*"1- '2*4- 

Villano, M.—Radium treatment of xeroderma pigmentosum. Ri forma. 

med. 40:172-174, Feb. 25, '24. 

Vogt, M. E., and Norris, G G—Carcinoma of body of uterus, Am. J. 

Obst. & Gynec. 7:550-566, May '24; Radium 3. N. S.( 97-112, 

July '24. 

Wah). H. R.—Cellular reactions following X-ray and radium therapy. 

J. Missouri M. A. 21:173-177, June '24. 

Watkins, T. J.—Radium for non-malignant gynecologic diseases. Wisconsin 

M. J. 23:123-124, Aug. '24. 

Watkins, W. W.—Pathologic basis for roentgen ray treatment of tonsil 

disease. J. A. M. A. 83:1305-1308, Oct. 25. '24; ab. Radium 

3. N. S., 277-2S2. Jan. '25. 

Watson. E. M.—Technique for the application of radium (emanation) 

in carcinoma of prostate, Bulletin of the Buffalo General Hospital. 

Jan. '24; Radium 3. N. S., 119-124, J»'y '24. 

Webster, J. II. D.. and Dodds. E. C—Metabolic changes associated with 

X-ray and radium treatment. Lancet 1:533"536, March 15, '24; 

also in Brit.J". Radiol. 29:140-149. April '24. 

Weckowski, G, and Sokoloff. B.—Radium treatment of tumors. Compt. 

rend. Soc. de Biol. 90:60-61, Jan. 25. '24.


Wertheimer. J.. Redfield, A. G, and Bright. E. M.—Physiological action 

of ionizing radiations, comparison of beta and X-rays, Am. J. 

Physiol. 68:368-378. April '24. 

Wettenhall.'R. R.—Radium therapv. M. J. Australia 1:612-613. June 

21, '24. 

Weyl. I... and Kolzareff. A. -Elective fixationof radium emanation by 

embryonal and cancer cells. Presse mid. 31:925-927, Nov. 

7- '23- 

Wharrv. H. M. Extensive lupus of upper air passages treated by radium, 

Proc. Roy. soc. Med. (Sect. Laryngol.) 17:56-57, June '24. 

Widmann, B. P... and Pfahler. G. E.—Relation of blood groups to malignant 

disease and influence of radiotherapy. Am. J. Roentgenol. 

12:47-50, July '24. 

Williams. F. H.—Use of radium radiations in treatment of tonsils, Am. 

J. M. Sc. 168:18-34. July '24. 

Williams, R. G—Preliminary note on observations made on physical 

condition of ]>ersons engaged in measuring radium preparations. 

Public Health Reports 38: No. 51, 3007-3028. Dec. 21. '23; 

Radium 3, N. S.. 43-64, April '24. 

Willis, G. S.—Radium treatment of fibroidtumors of uterus. M. J. & 

Rec. (supp.) 120:146-147, Nov. 19. '24. 

Withers, S.--Value of radiationtherapy in ophthalmology. Am. J. Ophth. 

7:5'4-52i. July '24. 

— and Ranson. J. R.- Treatment of malignant growths about the face, 

Colorado Med. 21:02-97. April '24; Radium 3. N. S., 181-1S8. 

Oct. "24. 

Wood. F. G- -Limitations in radiotherapy of cancer, J. Cancer, 156-165. 

July '24. 

Woolston. W. J., and Gain. R. G— Protective method of applying 

radium in cervix, J. A. M. A. 83:1429. Nov. 1. '24. 

Xeroderma, pigmentosum— 

—Radium treatment of xeroderma pigmentosum. (M. Villano) Riforma 

med. 40:172-171. Feb. 25. '24 (illus.) 

Yamauchi. M.—Immunization of thorium X. Ztschr. f. Krebsforsch. 

21:230-240. May '24. 

Zbinden, T.—Action of radium upon cancer of cervix. Ohio State M. J. 

20:14-16. Jan. '24. 

Zwaardcmaker. H.—Bioradioactivity and entropy. Compt. rend. Soc. de 

Biol. 90:68-70, Ian. 25. '24. 

NEW JOURNALS 

The Editors are in receipt of issues of two new publications devoted 

to radio therapy. Le Cancer, the Belgian journal of cancer studies, published 

in Brussels, under ihe editorship of Professor A. Bayet. appears 

quarterly. The three issues of Volume I received are splendidly printed 

and illustrated, amiit is to be hoped that this Belgian contribution to the 

study of cancer will receive the hearty support not only of the Belgian 

research workers and practitioners, but also from those all over the world. 

A less pretentions, hut more practical, publication is the Radiological 

Review, published bimonthly by the Radiological Review Publishing 

Company of Quincy, Illinois, under the editorship of Harold Swanberg. 

M. D. This journal is devoted to the progress of x-ray and radium as 

these relate to the practicing physician and dentist.

PUBLISHED SEMI-ANNUALLY AND DEVOTED TO THE THERAPEUTICS 

OF RADIUM AND RADIOACTIVE SUBSTANCES. 


Edited by Charles H. Viol, Ph. D., and William H. Cameron, M. D., with the as 

collaborators working In the fields of Radiochemistry. Radioactivity and Radiumtherapy. 

Address all communications to the Editors. Forbes and Meyran Avenues, 



THIRD SERIES OCTOBER, 1925 No. 2 

MR. ALBERT R. RAYMER, PRESIDENT 

STANDARD CHEMICAL COMPANY, PITTSBURGH, PA. 

At the May meeting of the Board of Directors of the Standard 

Chemical Company of Pittsburgh Pennsylvania, Mr. Albert R. Raymer, 

who has been a Director of the company since 1913 and Vice-President 

since 1917. was elected President, filling the vacancy caused by ihe death. 

on May 1st, 1925, of Mr. James C. Gray. Mr. Thomas J. Gearing was 

elected Vice-President. Mr. H. A. Neeb. Treasurer, and Dr. Charles H. 

Viol, Secretary; the officers, with Messrs. W. S. VanDyke. Joseph A. 

Kelly, C. B. Aylesworth, J. M. Schoonmaker. Jr., and H. C. Sherrard. 

air of Pittsburgh, constituting the Board of Directors of the company. 

Mr. Raymer was born in 1862 and was graduated in 1S84 from the 

University of Toronto with the degree of Civil Engineer. Since graduation 

he has been continuously engaged in railroad work. In 1891 Mr. 

Raymer became associated with the New Central Lines, and in 1896 

he was made Assistant Chief Engineer, and in 1920 Chief Engineer of 

the Pittsburgh and I.ake Erie Railroad. Mr. Raymer is a past President 

of the Engineers Society of Western Pennsylvania; a Director of the 

American Society of Civil Engineers; a member of the American Railway 

Engineering Association and of the Duquesne Club, Pittsburgh.


MR. ALBERT R. RAYMER 

President 

Standard Chemical Company, Pittsburgh, Pa.

R a d i u m e? 

CONTRAINDICATIONS TO THE USE OF RADIUM IN 

GYNECOLOGY* 

By William P. Graves. M. D.. Boston, Mass. 

In the enthusiasm that follows the advent of so brilliant a remedy 

as radium there is danger of overestimating its field of usefulness 

and of regarding too little its possibilities of doing harm. 

The purpose of this paper is to emphasize certain dangers with 

which the use of radium is attended in gynecological practice and to 

discuss its indications and contraindications in various conditions in 

regard to which there is at present a division of opinion. 

The particular dangers of radium in gynecologic cases, are only 

loo familiar lo those experienced in its use. These dangers have been 

lo some extent brought to the attention of the general profession, but 

are almost unknown to the laity who, deriving their information from 

unreliable sources, see in radium only a miraculous and harmless remedial 

agent. 

A clear realization of the dangers of radium is of greatest importance 

to those who arc employing it as beginners, of whom there is 

at present a large and rapidly increasing class. Where radium is owned 

by hospitals it has been, as a rule, assigned to selected members of the 

staff, many of whom have wisely taken a preliminary course of instruction 

in its use. Under such conditions comparatively little harm has 

been done, treatment having been given by men who possess a competent 

clinical knowledge of the diseases with which they are dealing. 

In view, however, of the great increase in private ownership of radium. 

and of the institution of distributing centers from which radium emanations 

may be secured., there is cause for fear that its use may become 

too indiscriminate and productive of harm. 

It is not in any sense the desire of the writer to discourage the 

wide distribution of a remedy so beneficial to mankind as radium, but 

merely to aid in calling attention to both physician and patient that 

radium is a powerful agent with destructive properties that are capable 

of serious or even fatal results. 

The misuse of radium has not so far as I know led to any definite 

legal regulations, hut such an event is certainly within the range of possibility. 

In order to avoid restrictions that might be undesirable it is 

necessary that those who are employing radium should exercise the 

greatest caution in its application and should be frank in reporting evil 

as well as good results. 

The practitioner who is contemplating the treatment of patients with 

radium should thoroughly realize at the start that the most complete 

knowledge of the physical properties of radium and the most elaborate 

equipment do not justify him"in treating diseases with which he is not 

clinically perfectly familiar. He should realize, for example, that cancer 

is not a distinct* disease by itself which is subject to standaradized 

methods of treatment; but that it is merely a generic term to define 

malignant changes that take place in many different tissues. Cancer 

•Reorinted by permission from The American Journal of Obstetrics and Gynecology 

i>c. 445-452; 561-56G; April, 19Z5. Read (by invitation) at a meeting of the 

Obstetrical Society of Philadelphia. May 1. 1024.


is merely a collective expression that includes as many distinct clinical 

diseases as there are organs which it attacks. Each of these diseases 

is a particular entity, differing from the others in its tissue reactions. 

its methods of metastasis, its anatomic relationships, its amenability 

to radium or surgery, and in many other ways. Moreover, cancer appears 

in manifold types, each of which exhibits specific variations in 

the organ in which it is located. An adequate knowledge, therefore, 

of all the organ-cancers in the body is requisite for the universal radiologist 

who is setting out to treat cancer in general. 

Furthermore, in undertaking so important a vocation he should be 

familiar with the treatment of organ-cancers by other means than radium. 

Until the advent of radium, cancer had been preeminently a surgical 

disease. Although radium has done wonderful things, and in some 

cases accomplishes what surgery cannot, nevertheless it has not supplanted 

surgery by any means, nor at present indications is it likely to, 

desirable as such an outcome might be. There are occasions, even in 

treating those lesions in which radium is most efficient when operation 

is the procedure of choice, and there are many other conditions in which 

radium is imperatively contradindicatcd, in favor of surgery. 

It would seem, therefore, that the radiologist should possess not 

only a thorough knowledge of ihe pathology of the organ-disease which 

he is treating but also the ability to treat it surgically if need be. 

Of no small importance is the technical expertness necessary for 

making applications of radium in the various cavities of the body ihat 

give access to specific organ-cancers. It is a grave mistake to suppose 

as some do that the technical use of radium is a simple matter and one 

easily learned. On the contrary, the skill necessary for properly applying 

radium to some organs is quite comparable to that required for 

surgery of the organ. When one hears of an inexperienced operator 

undertaking to treat cancerous disease in general with irradiation, one 

wonders what work will !>e made of those instruments used in manipulations 

of the bladder, vagina, nose, ihroat. etc.. skill in which it has 

required Ihe specialist years to acquire. It is not uncommon even to 

see mistakes of omission or commission made because an operator has 

had insufficient skill to remove tissue for microscopic examination. It 

is as blameworthy to apply radium to a normal organ on an unfounded 

suspicion of cancer, as it is to perform a radical operation on similar 

grounds. 

It must be admitted, therefore, that radium should be entrusted 

only to those who have a competent surgical knowledge of the organs 

which they are to treat. This does not necessarily exclude the general 

radiologist but it does impose upon him the duty of making a very complete 

clinical preparation for his work. 

Having called attention to the possibilities of harm from the indiscriminate 

use of radium, we shall now direct our criticism to those who. 

like the reader, have employed radium as specialists. 

Of the various gynecologic conditions which react dangerously to 

the influence of radium, ihat of pelvic inflammation is of supreme importance. 

Everyone who treats gynecologic cases is familiar with the 

serious damage that may be done in the presence of pelvic inflammation 

by such intrauterine instrumentation as curettage, the wearing of 

stem-pessaries, artificial insemination, insufflation of the tubes, etc. This 

same danger of lighting up an old inflammation exists and is greatly 

intensified after the insertion of radium lubes in the uterine cavity; for


in addition to the injurious effect resulting from the presence of a foreign 

body in the uterus, there is added the devitalizing influence of the 

radium on the surrounding tissues and the consequent reduction of their 

resistance to infection. The application of radium, like the other forms 

of intrauterine manipulation, docs not stir up a reaction in every case 

of chronic pelvic inflammation, but it has the possibility always of doing 

so, and when such an event does take place ihe extent of destruction 

exceeds that of any infection ordinarily encountered in the pelvis from 

other causes. 

The evil results from the effect of radium or pelvic inflammation 

are especially menacing because they are most apt to occur after applications 

to control nonmalignant uterine bleeding. This particular use 

of radium at the present time is one of the most valuable of the gynecologist's 

resources. Myopathic conditions which formerly resisted medical 

or palliative measures and often required radical operation, are now 

successfully overcome by a single treatment of radium. The mere application 

of radium to a myopathic uterus requires little technical skill 

and can be performed by the veriest tyro. On account, however, of 

the danger of lighting up an old inflammatory process it does require 

an expert preliminary pelvic examination. The detection of latent or 

potential infections of the adnexa is often difficult for the most experienced 

gynecologist, and such a condition is not infrequently overlooked 

even after the greatest care has been taken in making the diagnosis. 

It is a grave mistake therefore to assure the patient, as many 

do, that the use of radium inside the uterus is unattended with risk, for 

such is not the case. 

In this same connection, a special danger lies in the fact that salpingitis, 

particularly in the subacute stage is often associated with abnormal 

uterine bleeding, sometimes of an alarming nature. Such cases 

are apt to be subjected to radium treatment just as formerly they were 

to curettement. The destructive effect on the pelvic organs may be 

calamitous in the extreme, as we have had the misfortune to note both 

in our own experience and in that of others. In treating myopathies 

of the uterus, therefore, with a suspicion of pelvic inflammation present. 

it is safer to refrain from radium ami to resort to operative measures, 

for in such cases the dangers of radium greatly exceed those of surgery. 

Other contraindications to the intrauterine use of radium have not 

all been told, and will be sooner or later learned by experience. It will 

suffice to mention several of these that have appeared in the practice 

of the writer. 

Radium should not be given if there exists a retention follicular 

cyst of the ovary. Cysts of this kind may pass through periods of enlargement 

and recession. During the latter stage they may readily be 

overlooked by the examiner. The effect of radium on these cysts is 

to cause an immediate and painful enlargement which may become permanent. 

In the case treated by the writer, a subsequent removal of the 

pelvic organs became necessary. 

The futility of the radium treatment of submucous polypoid myomas 

and pedunculated subserous myomas of the uterus has been frequently 

mentioned in the literature and needs no special comment, excepting 

that the writer's experience accords with that of others. 

The inadvisability of treating sloughing fibroids with irradiation is 

obvious and yet we have heard of its being done.


One of the writer's personal mistakes was to treat with radium a 

patient with chocolate cysts. The patient, a woman of fifty, was given 

a full dose of radium, intrauterine, for severe hemorrhagia, the diagnosis 

being that of uncomplicated fibroids. After about a year of 

amenorrhea, the menorrhagia returned with great severity, necessitating 

a radical operation. The fibroids were found reduced in size but 

the entire pelvis was filledwith endometrial adhesions and implants, including 

two large chocolate cysts of the ovaries. The natural difficulties 

of the operation were greatly intensified by the dense sclerosis resulting 

from the radium treatment. It is interesting to note that in this 

case the action of the radium did not have the destructive effect on the 

adnexa that is seen in cases of adhesions, resulting from true infection. 

A most important contraindication to the use of radium is in the 

treatment of carcinoma of the body of the uterus. Radium is at present 

little used for this purpose, nevertheless there are some who are thus 

employing it and the writer is himself one who has made the error of 

trying it out. The reason usuallv given for not radiationg cancer of 

the uterine body is that the operative results are so good that it seems 

inadvisable to trust to any other treatment. We are now in a position 

to give positive reasons against its use in this disease. We have shown 

in a very small series of cases and the smallness of the scries makes it 

more convincing that an eailv cancer of the fundus that is entirely 

curable by operation is liable to reoccur when treated by radium alone. 

The uncertain curability of the disease at its primary focus by 

radium is alone sufficient to condemn its use. but there is still another 

reason which should convince ihe most enthusiastic of radiologists. It 

has long been a matter of observation that cancer of the body of the 

uterus metastasizes first in the ovaries. The mode of transmission of 

the disease from the endometrium to the inner tissues of the ovary was 

a scientific mystery until the epochal work of Sampson taught us the 

frequency with which endometrial elements may become transplanted 

in the ovarian substance. Thai the intrauterine application of radium 

will not destroy endometrial elements in the ovaries is attested by two 

of our cases, one where the patient died of probable ovarian cancer after 

radium treaiment for cancer of the fundus; and one where active chocolate 

cysts were removed a year after a radium treatment for nonmalignant 

bleeding. We must conclude from the foregoing that the treatment 

of cancer of the fundus of the uterus should be treated by a radical 

operation that includes both ovaries. 

It should also be added that inasmuch as cancer, of the body is a 

frequent associate of myomala. the ovaries should never be left in situ 

after the removal of a fibroid uterus without a careful inspection of the 

uterine canal of the removed specimen. 

In the treatment of uterine myomata there is little disagreement 

among operators. Our own conclusions tally in general with those of 

Clark. Keane, Heaney, and others. In the case of smaller nonpedunculated 

fibroids in patients with menorrhagia. near the menopause, radium 

has a most useful tietd, provided there are no pelvic complications. The 

final results, however, are not as definite as in myopathic cases with 

simple uterine insufficiency. In the treatment of larger fibroids wc 

employ radium vvith extreme conservatism, and then chiefly as a palliative 

when there is grave secondary anemia or some dangerous constitutional 

affection. It should be remembered that in the majority of the 

larger fibroid tumors there is some associated complication. Of these

Radium 71 

the most common, in the order named, are peritoneal adhesions with 

greater or less inflammatory reaction, adenocarcinoma of the endometrium, 

and sarcomatous degeneration, all conditions which definitely 

contraindicate the use of radium. 

The operation of supravaginal hysterectomy has become so well 

standardized, and can be so rapidly and bloodlessly done that it must 

be regarded in most cases as the procedure of choice in the larger 

fibroids attended as it is with less danger than radium to the life and 

health of the patient. The borderline of choice between radium and 

operation must be decided by the experience of the surgeon who should 

take into account not alone the size of the tumor but its location, its 

behavior, and the possibility of complications. During the active childbearing 

period radium should be used to treat fibroids with the greatest 

reluctance. In order to effect a permanent diminution of a uterine 

fibroid it is necessary to give a sufficient dose of radium to destroy the 

menstrual and reproductive function of the organs, for if the catamenia 

does return, even after a considerable period of amenorrhea, the tumor 

will also recur to its former size and activity. 

We take this occasion to emphasize the value of myomectomy during 

the childbearing period. It is encouraging to see that this operation, 

at one time somewhat inill repute, is being revived in many clinics. 

It is surprising what hope I ess-looking tumors may be removed with 

complete resloration of the uterus to its normal contour and function. 

The operation requires ingenuity and practice, but when mastered it is 

one of the most interesting as well as satisfactory procedures in gynecologic 

surgery. 

One of the newer problems that confronts the gynecologist is the 

production of amenorrhea or sterility for other reasons than those of 

local uterine disease. Of these the most important are the intractable 

dysmenorrheas and the intolerable headaches or other nervous manifestations 

that are dependent for their existence on the menstrual rhythm. 

In selected cases of this kind radium has proved of much value. 

With the spread of lay knowledge of radium and its effects, patients 

of other types are applying for treatment, namely, those who 

desire sterility on the grounds of expediency. The problem of treating 

these patients is an ethical one. In the case of married women 

who wish sterilization the procedure, in our opinion, should be the 

same as that in the matter of inducing abortions. There should be two 

other consultants and the decision should be made on the basis of the 

patient's physical health and not on that of her personal wishes or domestic 

exigencies. 

When sterilization is desired for immoral purposes, treatment is 

obviously unethical and borders on criminal practice. 

Perhaps the most important field of work in gynecology today is 

the treatment of cancer of the uterine cervix. Before the advent of 

radium the extended Wertheim operation had reached the limit of its 

possibilities and progress depended solely on the improvement in skill 

of the individual operator. Radium has given us new hope in treating 

this dreadful and rapidly increasing disease. In its use as a palliative, 

there is almost no case so far advanced in which the distressing discharges 

and often the pain may not be alleviated by irradiation. 

In less advanced but still incurable cases the disease may with few 

exceptions be checked by a single treatment, so that the patient may 

live from one to three or even four years in perfect health. Reoccur-


rence when it doe- take place is apt to be internal and unassociated with 

the offensive discharges and fistulaethat were formerly universal in the 

final stages. 

It is in ihe so-called operable case that the question of the indication 

or contraindication of radium arises. Though not a few surgeons 

have discarded operation altogether in favor of radium, we have not 

yet personally come to a final conclusion. At first convinced that it was 

the duty of the surgeon to operate on every operable case instead of 

taking the more comfortable path of irradiation we have nevertheless 

made certain concessions to the radiologist. We have, for example, 

greatly modified our classification of cases. We have changed the term 

"operability" to "curability by operation," which has quite a different 

significance. Whereas we formerly over a period of many years operated 

on about 60 per cent of all cases, we now subject to operation only 

about 20 per cent. During the last five or six years we have carried on 

parallel scries of operated and radiated cases, in which the disease IS 

limited io the cervix and frankly curable by either operation or radium. 

Such patients have been chosen for irradiation as. on account of obesity 

or constitutional weaknesses, incurred a special risk in operation. Sufficient 

time has not elapsed to draw authoritative conclusions from this 

series, especially as the operated cases greatly exceed the others in 

number. 

Nevertheless a recent comparison of the two types of cases of less 

than five years' duration shows a similarity of results that, it must be 

confessed, has been somewhat surprising to the writer and encouragingly 

favorable to the use of radium. 

198 Commonwealth Avenue. 

DISCUSSION 

Dr. John G. Clark.—Dr. Graves has pointed out salient contraindications 

to the employment of irradiation in the wrong class of cases. 

In all novel procedures there is a great tendency, and I believe this applies 

with particular force to our American colleagues, for the ill-advised 

use of all new therapeutic remedies. Pioneer workers may point out the 

dangers of a remedy which has been based upon carefully noted objections 

and yet all too often the novice who could so easily avoid these 

obstacles will steer head on into them, although these hazards have been 

charted accurately. As Dr. William Mayo has said, there are innumerable 

physicians and surgeons buying a nickel's worth of radium and 

doing a million dollars worth of harm with it. Possibly the lure of dividends 

from a new investment may at times becloud therapeutic judgment. 

Because I am so constantly licing consulted bv those who have 

been badly advised in the use of radium and arc seeing the disasters of 

a good remedy injudiciously used. I particularly favor therefore all articles 

which point out the dangers of this remedv. Keene and I have 

dwcalt at length upon these points on several occasions when this issue 

has been up for discussion. Given a radiologist who is not a surgeon, 

or a surgeon who is not a radiologist, these patients will certainly not 

get a square deal with either, but I frankly believe that less harm will 

be done by such a surgeon than by the radiologist. As all of these tumors 

should primarily be passed upon by the gynecologist, likewise their treatment 

by irradiation should be controlled by him. 

A history of present or past inflammatory involvement of the ad-

R a d i u m ?:; 

nexae is a positive contraindication to irradiation, and if the question 

of childbearing is an issue, only under unusual precaution should this 

remedy be employed. In very young women who suffer with menorrhagia 

of ovarian origin, radium may be used with due care and the 

menses restored to normal without prejudice to the childbearing future, 

but in our experience this does not apply in cases of myoma in married 

women, which are causing menorrhagia. Here surgery has prior preference, 

first111 the hope of performing a myomectomy, and second, of 

preserving the ovarian influence should a myomectomy not be feasible. 

Thus we find that age constitutes a zonal line; below forty, surgery is 

the elective means of ireatment; above this, irradiation. In general, 1 

am in full accord with Dr. Graves' limitations and strictures in the employment 

of radium. Dr. Graves has spoken of that unique and brilliant 

discovery of Sampson, ihe chocolate cysts of the ovaries. Sampson 

attributes their origin lo the retrograde transportation of uterine 

mucosa from ihe uterine cavity out through the tubes to the ovaries and 

into Douglas' culdesac. where these transplants may develop perforating 

cysls of the ovary, and actually may find pathologic lodgment on other 

pelvic sites. He warns of the possible dangers in cancer of the fundus 

of stirring up and causing these transplants through curettage. We have 

had one case in a young woman only twenty-four years of age in whom 

a curettage was performed and a pathologic examination revealed a 

carcinoma of the fundus. Radium was applied at the same sitting. 

When the diagnosis had been fully corroborated by a second curettage 

six weeks later, a hysterectomy was performed. In addition to an 

early carcinoma of the fundus, a small mushroom-like excrescence was 

found on the ovary which proved also lo be carcinoma. Was it a transplant 

from the uterine which had been loosened during the curettage? 

Such an incident appears plausible in the light of Sampson's warning. 

I am especially interested in Dr. Graves' statement that through 

his employment of radium he has dropped his operative selection of 

carcinoma of the cervix from sixty to twenty per cent. In my discussion 

of the use of irradiation versus the radical operation. I have thus 

far maintained that in the hands of an expert I would not decry radical 

surgery, but since the experts are "few and far between." I really believe 

the greatest good for the greatest number of those victims will follow 

from car fully administered irradiation rather than from these very dangerous 

operations which carry besides a high mortality, a considerable 

morbidity percentage. 

In my Clinic at the University Hospital we have practically reached 

the parting of the ways and now tread the radium path. The best fiveyear 

salvage we ever obtained from the radical operation was 33 per cent 

of five-year cures. With radium, we have a 2?}4 per cent salvage of 

operable cases and "l/i per cent salvage in borderline and inoperable 

cases. Thus our ratio of cases is almost equal with the preference slightly 

in favor of radium. The difference on the other hand in favor of a 

short detention in the hospital, an immediate return to preradiation efficiency, 

with practically no mortality, far outweighs the surgical side 

of this question. As will appear later in a carefully supervised study 

of this novel therapeutic remedy by Dr. Grcenough, Chairman of ihe 

Cancer Committee of the American College of Surgeons, the radical 

operation alone and irradiation alone are about equal in ultimate results. 

whereas the preliminary use of some palliative operation, such as cau-

74 Radium 

terization, amputation of the cervix plus irradiation, etc.. supersedes 

them both in three-year curative possibilities. 

Dr. Brooke M. Ansi-acii.—Dr. Graves has pointed out. very properly, 

some of the dangers attending the use of radium. The indications 

for its use in gynecologic practice are today clear-cut and well-defined 

and in the overwhelming majority of instances, attended with no complications 

or unfortunate sequelae. Indeed, when properly applied, it 

lias come lo be regarded as a very efficient but withal a harmless remedy. 

Nevertheless, there are certain contraindications to its use. or rather 

certain conditions in which radiation is not the best plan of treatment 

and may be dangerous. I wish to report several cases that occurred 

in my own practice in which it would have been better had radium not 

been used. In the first one. a myoma, ihe size of a billiard ball, which 

I thought was uncomplicated, the patient was very stout; the usual 

application of radium was made; fever and lower abdominal pain immediately 

followed: under the customary treatment for pelvic peritonitis, 

ihe symtoms increased and a pelvic tumor developed, rising above the 

pelvic brim. At operation I found a thin-walled cyst of the ovary, filled 

with chocolate colored fluid; evidently there had been a cyst of the 

ovary of small size which was not recognized even under anesthesia on 

account of the very fa' abdomen. She certainly did not have a tumor 

of any size at the lime of the application, but inside of three weeks she 

had an ovarian cyst as large as a good-sized grapefruit, vvith persistent 

elevation of temperature. In another case of myoma, in which old inflammatory 

lesions were not recognized, a pelvic abscess developed which 

required evacuation by a vaginal incision. 

I also wish t

R a d i u m 

76 

essential to successful irradiation. First, a skilled diagnostician, one 

who is not only skilled along the lines of diagnosis, but also is in a position 

to appreciate the relative merits of operation or irradiation in the 

treatment of a given condition. Secondly, a competent gyneclogic pathologist 

and third, a consulting radiologist who fully appreciates the limitations 

of x-ray or radium treatment. Unfortunately the day is past 

when radium is available only in Ihe larger institutions where these 

requisites can be met and l^cause of ibis many cases will be treated 

unwisely and not only will* radium therapy be discredited thereby, but 

what is more important, actual harm will be done to many patients. Since 

we began to use radium in Dr. Clark's Clinic in 19IJ. our cases have 

been followed very carefully from year to year and from this experience 

we have formulated very definite conclusions as to the indications 

and contraindications to radium therapy. In addition to the contraindications 

which Dr. Graves has mentioned, namely, the large tumor. 

the pedunculated, hard, subperitoneal tumor, the necrotic tumor, or 

tumors in young women, in all of which wc agree, it seems to me. there 

are a few others which might be mentioned which are equally important. 

We look upon pain in association with myoma as one of the chief 

contraindications to irradiation. Speaking generally, pain means one 

of three conditions, namely, an associated adnexal inflamamtory disease. 

degeneration of the tumor, or adenomyoma. Dr. Graves has enlarged 

on the ill results following upon irradiation in the presence of infection. 

It is self-evident that a necrotic tumor or a tumor presenting extensive 

degeneration should never be^ irradiated. We arc still in doubt as 

to the effect of irradiation \\\x>n adenomyomata but our belief thus far 

is that the results are usually unsatisfactory. Therefore, it can be said 

that any tumor associated with pain is better treated by operation than 

irradiation. We believe that radium should not be used in the presence 

of pressure symptoms irrespective of the size of the tumor. While it 

is undoubtedly true that tumors are reduced in size following upon irradiation, 

this reduction requires a matter of months and operative removal 

is better than trusting to this long delay. Again, a rapidly growing 

tumor contraindicates radium, suggesting sarcoma or some type of 

rapidly forming benign degenerative process. Lastly. I would emphasize 

the inadvisability of using radium in treating women of highly nervous 

temperament. The severity of menopausal symptoms can never be 

prophesied even in the normal -.voman; in the highly nervous individual. 

these symptoms are often very marked. Our experience has taught us 

that the symptoms of a premalure menopause brought about in highly 

nervous women arc often extremely severe, and for this reason we feel 

that operation is preferable lo irradiation. 

In closing, I would say a word as lo the use of radium in the treatment 

of carcinoma of the cervix. It is undoubtedly true that when intelligently 

applied, radium offers more in Ihe way of relief to inoperable 

cases than anv other means at our disposal, bringing about, as it does, 

a cessation of' the bleeding and foul discharge and often relieving pain 

at least temporarily. While formerly every case of advanced malignancy 

that presented itself to our clinic was treated, we now feel that 

such a course is a mistake, so that wc no longer apply radium to those 

cases in which there is wide extension to the bladder or rectum because 

the effects of radium can very readily bring about a condition which 

makes the patient's suffering even more deplorable than before the radium 

was applied.

7G 

R a d i u m 

Dr. Graves, (closing).—Our experience in using radium for cancer 

corresponds very closely to the conclusions Dr. Clark spoke of, as 

being found by Dr. Greenough. who is getting up statistics for The 

American College of Surgeons. For example, we find postoperative 

use of radium in cases where we had done perfectly satisfactory operation 

did not seem to do much good. There was more danger of fistula 

and we gave that up entirely in cases we felt satisfactorily operated 

upon. We have long ago given up preoperative use of radium. I can't 

see the slightest sense in it or imagine why it is done. We also discovered 

surprisingly good results in partial operations, and I would ask 

Dr. Clark if this has been his experience? 

Dr. John G. Clark.—Occasionally, not many. 

Dr. Gravis—In what seemed partial operations where we felt 

pretty sure we had left in some cancer in the cervix. In several cases 

where we had packed out in hysterectomy and left cancer there and 

ihen gave radium, we obtained surprisingly good results. Recently 

1 have had no cases where I have deliberately done supravaginal hysterectomy. 

In some cases after taking out glands the patient has been 

cured and then given radium later. 

GYNECOLOGICAL CONDITIONS TREATED WITH 

RADIUM ALONE OR COMBINED WITH SURGERY* 

Report of One Hi-noreo Fifty-six Cases 

Bv William Sidney Smith. M. D.. I\ A. C. S.. Brooklyn, Xew York 

From the Department of Gynecology and Obstetrics of ihe Brooklyn Hospital 

We have been using radium for the treatment of some gynecological 

conditions at ihe Brooklyn Hospital since January I. 1921, a period 

of nearly 4 years, hi that time. 156 cases have been treated, of which 

there have been 66 cases of chronic metritis at the menopause. 21 cases 

of fibroids.41 cases of carcinoma of the cervix. 17 cases of carcinoma 

of the fundus, and 11 miscellaneous cases. 

In all of these, the radium salt was used, contained in two 50 milligram 

tubes. The screens were a glass capsule containing the radium. 

a second capsule of platinum 1 millimeter in thickness and a rubber tube 

2 millimeters in thickness. One half millimeter of platinum is supposed 

to absorb all the primary 'i-rays. and the emergent secondary J-rays are 

absorbed by Ihe 2 millimeters rubber screen, so that our cases have received 

only v-rays. 

As you know, there are various materials used for screening purines. 

In the absorbing power of ;S-rays. platinum has exactly twice 

that of silver or lead and nearly two and three-quarter times that of 

brass, according lo the Radium Company of Pittsburgh. We are indebted 

to Dr. Harold Bailey, of Xew York, for the suggestion that we 

use 1 millimeter of platinum as a screen and that by so doing we would 

probably avoid some serious injuries. 

,« '^SK^'S! b7 !*lwlon from S«r«ery. Gynecology and Obstetrics, Kl, 6fl-«04. 

May. 1925. Road at the October meeting of the Brooklyn Gynecological Society.


Our technique is to tie a strong silk thread into the eye of each 

platinum capsule. The capsules arc then placed in a 20 per cent carbolic 

and alcohol solution for 20 minutes. The rubber tubing is boiled: a 

sterile nurse then inserts ihe radium capsules into the rubber tube, ties 

off both ends of the tube vvith silk, leaving a long thread attached to one 

end. By this measn, we have a silk thread attached to the rubber tube 

and to each radium capsule. The screened radium is now ready for 

use. Later, the three silk threads are attached to the patient's thigh 

by adhesive plaster. 

CHRONIC METRITIS 

You will see that over half of our patients were suffering from 

chronic metritis or small fibroids. 

The metritis cases were all at about the menopause age and gave 

no history nor physical findings of previous inflammatory trouble. The 

principal symptom was uterine bleeding. They were all subjected to a 

careful examination under anaesthesia, and uterine curetting. The curettings 

were later examined by the pathologist. If the diagnosis of chronic 

metritis was sustained by clinical findingsat ihe time of operation, these 

patients received 1200 milligram hours of radium at one dose in two 

50 milligram tubes in tandem, screened with 1 millimeter of platinum 

and 2 millimeters of rubber. Radium was carried well up to the fundus 

of the uterus, and kept there by a narrow strip of gauze packed into 

the cervical canal and the vagina was packed full of dry gauze. Patients 

have not had any difficulty in voiding, and we have not used a 

self retaining catheter, as is the custom in some institutions. Gauze and 

radium were removed 12 hours later, without difficulty or pain to the 

patients. Our rule is bed for 6 days. 

The results have been very satisfactory. Uterine bleeding stopped 

in 5 or 6 weeks, and the uterus gradually became smaller in all but three 

cases. Two cases had a second radium treatment. 6 months to a year 

later, of 1200 milligram hours, which cured them, and the third case 

came to subsequent operation vvith a very interesting pelvic condition. 

A fourth case came to operation t year later for appendicitis, and as 

the uterus was large and soft, even though there had been no vaginal 

bleeding, the surgeon performed a supravaginal hysterectomy. 

Of these 66 cases of chronic metritis. 11 had the combined treatment 

of radium and surgery at the same sitting. Ihe operative procedures 

were trachelorrhaphy, amputation, or repair of the anterior or 

posterior vaginal walls. In many of these cases, the radium was placed 

in the uterine canal and ihe rubber tube, used as a screen, stitched to 

the anterior and posterior lips of the cervix with a chromic gut stitch. 

This suture was tied with a half bow knot, leaving a long end which was 

carried out of the vagina and attached to the patient's thigh. When 

radium is thus fastened within the cervix and uterus, the vagina is not 

packed with gauze. We have had no bad results from not using the gauze 

packing and the repair operations have healed nicely. 

FIBROIDS 

In this group of 11 cases there is only one which had a Byrne cautery 

amputation of the cervix, and I will report it in more detail. 

Mrs. S. W.. age 33, Russian, was admitted to the hospital with a 

history of spotting between periods for 2 months. On examination, the


uterus was found enlarged and hard with a cervix lacerated and eroded. 

The clinical diagnosis was a very early carcinoma of cervix or a chronic 

metritis with cervical erosions and lacerations. A circular amputation 

of the cervix was performed with the Byrne cautery knife, leaving 2^ 

inches of uterine canal. Two thousand four hundred milligram hours 

of radium were given within the uterus. The pathological report stated 

ihat the cervix was not malignant. Convalescence was stormy because 

of secondarv haemorrhage from the cervix. The patient left the hospital 

in 3 weeks with the cervix healed and in good condition. 

Two years laler this patient complained of abdominal pain once a 

month. There was never any flow and no fever. She looked well. Six 

months later the pain each month had increased and a presumptive diagnosis 

of haemalomctra was made, and a laparotomy was performed. The 

pelvic organs were very adherent, and there was a double haematosalpinx 

of considerable size, and the uterus was distended with old menstrual 

blood. A supravaginal hysterectomy with a double salpingo-oophorectomy 

was done. The stump of the cervix was split for drainage and the 

patient made a slow but satisfactory recovery. 

Here is a case in which 2400 milligram hours of radium within the 

uterus failed to stop ihe menstrual periods for more than iy2 years. The 

menstrual function then slowly returned, but. as there was a stenosis of 

ihe cervical canal, due lo the cautery amputation, there was no drainage 

and the blood backed up into the uterus and tubes. 

The fibroid cases treated with radium were 21 in number. For the 

most part they were small fibroid tumors in the wall of the uterus, or 

'inall myomata. In only 3 cases have tumors larger than a fetal head 

been treated, and we have been careful to exclude submucous or pedunculated 

tumors, and Ihose causing pelvic pain. With one exception. 

the patients' ages have been between 40 and 50 years. These patients 

were all subjected to a careful bimanual examination under anaesthesia 

and an intra-uterine invesligation with a curette before the radium was 

introduced into the uterus. The usual radium dose was 1200 milligram 

hours. One patient received 1500 milligram hours and two received 

2400 milligram hours at one session. The results have been excellent. 

Patient, aged 26. with a fibroid tumor extending 3 inches above the 

-ymphysis, was flowing heavily, and refused surgical measures. Radium 

was used after its effect had been fully explained to her. The result 

of one 1200 milligram hour dose was all that could be desired. The 

flow ceased, and the tumor slowly became reduced in size. 

I know of only two cases where ihe bleeding did not stop with the 

single 1200 milligram hour dose. In both of these cases the periods 

have been reduced to normal in frequency and amount, the uterus remaining 

about stationary in :.ize. 

In one case surgery was combined with radium treatment. A 

myoma fillingthe pelvis was treated with a 1500 milligram hour dose. 

the tubes being sutured in place, and an cxtensiveôperation for lacerated 

perineum and rectoccle was carried out with excellent result from both 

radium and surgery. 

Two patients, with large fibroids, heavy flow, and very low haemoglobin 

have had a 2400 milligram hour radium treatment, each as a 

preliminary to a later supravaginal hysterectomy. In each case the flow 

ceased, the haemoglobin increased, and the patient became a good operative 

risk with eventual recovery after hvstcreciomv.

carcinoma of the CERVIX 


We have had 41 cases of carcinoma of the cervix, of which 3 were 

of the epidermoid variety and 38 were of the squamous cell type. Grouping 

these 41 cases in another manner, there were 34 which were inoperable; 

that is, ihere was induration in the broad ligaments and some degree 

of involvement of cervix and vagina; and there were seven cases 

which did not show extension into ihe broad ligament, as far as could 

be ascertained. 

Making still another giouping of these 41 cases: One received 

radium treatment, and in 1 month ihe disease had spread very rapidly. 

One received radium treatment and 2 months later was subjected to a 

total abdominal hysterectomy. 

Eight received a Byrne caulery operation ami radium at the same 

session with or without later X-ray treatment, and 31 cases received 

radium alone or with X-ray as a palliative remedy. 

The case with such a rapid advance of the disease was a widow of 

39 years with a history of spotting between periods for 6 months. The 

cervix was eroded, only, and the uterus mobile. She received a 2400 

milligram hour dose within the cervical canal. Cancer of the cervix 

was suspected, and the report from the pathologist confirmed it. One 

month later the cervix was entirely involved. She received heavy radium 

dosage in another hospital, and died 4 months after the firsttreatment. 

1 do not know whether the treatment had anything to do with the rapidity 

of the course of the disease. 

'The patient who was subjected to radium and total abdominal 

hysterectomy was a married woman of 40 years. In 1919 her cervix 

and perineum were repaired. At that time, the pathologist reported that 

malignancy was suspee'ed in the cervix.. She was not seen again until 

1923. when she complained of flowing and spotting a little between 

periods. On examination, the cervix bled a little to touch, and carcinoma 

was suspected. The uterus was small, hard, movable and therewas 

no induration in the broad ligaments. She received a tlose of 2400 

milligram hours of radium within the cervical canal. A section of the 

cervix was reported by the pathologist to be epithelioma. Bleeding subsided 

after treatment. Three months later the patient was subjected 

to a total abdominal hysterectomy. Convalescence was uneventful. Seven 

months later she again came under observation with a small, hard nodule 

in the scar in ihe vaginal vault; the pathologist's report was squamous 

cell carcinoma. A second 1200 milligram hour radium treatment was 

given, flic tubes being placed in parallel against the scar. Nine months 

have now elapsed, and ihe patient has gained 20 pounds in weight, and 

her general health is excellent. The vaginal vault is free and soft, and 

there are no nodules or granulations. 

Of the 31 advanced cases which received radium as a palliative 

remedy, there were 3 which had received a supravaginal hysterectomy 

for fibroids from 6 to 14 years previously. These 31 cases have had 

their radium within the cervical canals with the tubes in parallel or in 

J. fashion. They have nearly all had second doses of 2400 milligram 

hours after an interval of 4 to 6 months and many have been given X-ray 

treatment across the abdomen. 

Of this entire group of advanced cases, some are dead, and some 

are living. Those that are living will eventually die from carcinoma. 

but I am of the firm opinion that radium treatment, either alone or vvith

so 

R a d i u m 

X-ray, is the best palliative remedy at our command. Life is prolonged. 

the foul discharge and the bleeding are very much decreased. Pain may 

or may not be less than without treatment. The patients gain in weight, 

they are able to carry on their daily duties, and they really feel as though 

something had been done for them. If this much can be accomplished 

for these poor unfortunates. I think that you will agree that this form 

of treatment is worth while. 

Right cases received the Byrne operation and radium. In this 

group, 2 cases had the cautery operation first, radium treatment following 

in 9 weeks, and n months respectively. The other six cases had the 

Byrne operation and radium at the same session. Five of this group 

of 8 patients have only been under observation for il/2 years or less. 

so it is too soon to speak of them, except to say that 4 are doing nicely, 

and that one is having a slow extension of the disease. This last case 

had sonic growth on the anterior vaginal wall which could not be entirely 

eradicated at the time of the operation, so the extension of the 

disease is not unexpected. 

The other three cases are of interest. 

One case came under observation on July iS. 1921. 3 years ago. 

She was 43, pale, thin and bleeding profusely. Examination of the 

cervix revealed a large cauliflower growth on the posterior lip. The 

utenis was mobile. It was possible to pull down the cervix and to get 

around it with the cauterv knife. She received a Byrne operation, leaving 

\Yi inches of the uterine canal. One tube of radium was placed 

in the canal and one tube was placed crosswise in the crater. The 

pathologist reported squamous cell carcinoma. Convalescence was 

stormy due to a secondary haemorrhage. Two weeks after discharge. 

the patient was re-admitted to the hospital, suffering from another haemorrhage. 

On discharge she went to the Home for Incurables and, after 

about 3 months she began to gain in weight and color. Six months later 

she was discharged from the Institution because the authorities there 

considered her too healthy to be retained as an inmate. This patient 

will not come for examination, but our social worker reports that she 

is alive and working at her household duties at ihe present time. 3 years 

after treatment. 

The second of these cases was a married woman of 37 who came 

for observation on June 15. 1921, with an epidermoid carcinoma of the 

cervix. Her history was: menorrhagia for 4 months, spotting between 

periods, and some loss of weight, though she was not cachectic. The 

cervix was lacerated, eroded, bled easily to touch and the uterus was 

large and movable. The Byrne cautery operation was performed and 

2400 milligram hours of radium were given at the same session. One 

tube was placed in the canal, and one crosswise in the crater. Convalescence 

was stormy, due to two secondary haemorrhages. The patient 

finallyleft the hospital in good condition. Four months later she 

was re-admitted with a spotting history. She looked very well. The 

uterus was freely movable, and felt like a round ball in the pelvis. The 

uterine canal was easily dilated, and two radium tubes were inserted 

in ihe canal in tandem. Total dose 600 milligram hours. Since that time. 

this patient has had no spotting or discharge. The utenis is freely movable, 

and the patient feels well and attends to her household duties. It 

is nowr 3 vears since her last treatment. 

The third case in this group of three is a married woman of 39 who 

came under observation May 21, 1920, nearly 4'/2 years ago. She had


a bleeding, cauliflower mass on the cervix, and a uterus which was not 

entirely mobile. The report from the pathologist was squamous cell 

carcinoma. A Byrne cautery operation was performed, leaving a uterine 

canal 2 inches in lenglh. She did not have radium treatment at that 

time because we did not have any in our possession. Convalescence 

was easy. Prognosis was had. and her family were told that she might 

live 6 months or a year. Two months later she suffered severe pain 

at her periods, due lo stenosis of the uterine canal. One dilatation of 

the canal cured the trouble. The patient gained weight and felt well 

for i year, then she noticed spotting between her periods. Examination 

showed a hard nodule in the scar of the Byrne operation. Section of 

the nodule was reported as squamous cell carcinoma. The uterine canal 

was dilated and one tulie of radium was placed within the uterus, and 

one tube crosswise against the nodule in the vault of the vagina. Dose 

2200 milligram hours. Her periods and all staining ceased. The patient 

had no complaints for 2]A years. She then became ill with severe abdominal 

cramps and some hours later a heavy flow appeared, lasting 4 

days and resembling menstruation. Examination elicited no signs of 

extension of the disease. Six months later a similar attack occurred. 

She was re-admitted to the hospital, and examined under anaesthesia. 

The uterus was fully movable, and the pelvis was free and clear except 

for scar tissue due to the original cautery operation. The uterine canal 

was identified with difficulty, and dilated. A small amount of thin. 

serous fluid escaped from the uterus. Exploration of the uterine cavity 

with a curette produced little or no material. Two 50 milligram tubes 

of radium in tandem were placed within the uterus. Dose was 2400 

milligram hours. Since thai time, 8 months ago. the patient has been 

in excellent condition. There have been no more attacks of bleeding 

and no discharge. There has been no change in vagina and uterus on 

palpation. On inspection there is a small, red area at the entrance of 

the uterine canal. This area does not bleed on sponging and it is soft 

to touch. 

I think the last two attacks of bleeding were a beginning return of 

ovarian function, and the pain was undoubtedly due to a stenosis of the 

opening of the uterine canal. I doubt very much whether radium had 

anything to do with the secondary haemorrhages reported in these cases. 

I rather think thai they are due to the high Byrne cautery operation 

which may have been done too rapidly or with too great a degree of 

heat. 

For these haemorrhages, our treatment has been a free use of morphine 

and raising the foot of the bed. 

ADENOCARCINOMA OK THE CORPUS UTERI 

Of the 17 cases of adenocarcinoma of the corpus. 7 were advanced. 

and 10 were fairly early cases, that is, the fundus was movable, and 

there was no demonstrable induration in the broad ligament. All these 

patients were between 38 and 60 years of age. 

The advanced cases were given 2400 milligram hours of radium 

within the uterine canal. Four of these cases had abdominal X-ray 

treatment and three did not have it. None of this group was operated 

•on. Three patients had a second 2400 milligram hour radium treatment 

6 months after the first, and one patient has had three such treatments. 

Of these seven advanced cases, four have died, two have disappeared. 

and one is living, i'/2 years after the firsttreatment.


This is the patient who has had 7200 milligram hours of radium 

within the uterus, in addition to X-ray. She has no bleeding, and no 

watery discharge, but her pelvis is filled with a hard, immovable mass. 

and there is extension inlo ihe cervix. She will eventually die of cancer. 

1 feel quite certain, however, that radium has relieved this group 

of women of considerable bleeding, much foul discharge, and prolonged 

their lives. 

The ten cases with movable uterus, and no demonstrable broad 

ligament induration, received a 2400 milligram hour dose of radium 

within the uterus. Two of Ihe cases were subjected to a complete abdominal 

hysterectomy 10 days after their radium treatment, and the 

remaining S had their hysterectomy 6 weeks after their radium. 

Eight of these patients are alive, and doing nicely, 1 to 3 years 

after operation. Of the remaining 2 cases, one died of general peritonitis 

a few days after the hysterectomy, and the other is having an extension 

of the disease in the vault of the vagina 2 years after operation. This 

patient, however, had an extension of her trouble in one tube at the 

time of her hysterectomy, so the outcome is not entirely unexpected. 

Curiously, these two are the only patients who had early hysterectomies. 

In this group of ten cases of which I have l>een s|>eaking. there 

is one which 1 will re|x>rt in detail, because her abdomen had been 

opened, and her uterus and ovaries inspected 2 weeks before her radium 

treatment. She was then subjected to a total abdominal hysterectomy 

6. weeks after her radium treatment, and her pelvic organs were again 

inspected and sent to the laboratory for section. 

Miss Y., age 38, school teacher, was admitted to the surgical service 

with the symptoms of chronic appendicitis, and the history that her 

periods had been profuse for several years, and that she had been spotting 

between periods for 3 months. She was curetted, and a laparotomy 

was performed for chronic appendicitis and retroversion. When 

the abdomen was opened the uterus was a bit large, congested; the broad 

ligaments soft. The curettings. which had not excited suspicion on 

gross inspection, were reported as adenocarcinoma by the pathologist 

Two weeks after the laparotomy, she was given 2400 milligram hours 

of radium within the uterus as a preliminary to total abdominal hysterectomy 

performed 6 weeks later. At this last operation the ovaries on 

gross inspection, were small and atrophied. On opening the uterus it 

was possible to see where the radium capsules had been placed, and no 

carcinoma could be seen in gross. She is apparently well at present. 

The pathologist's report is as follows: Specimen consists of uterus. 

ovaries, and tubes. Pathological diagnosis: carcinoma of uterus; localized 

acute and subacute endometritis (Radium). 

The fundus consists of firm, whitish tissue, the fibers arranged in 

whorls. This area is indistinctly demarcated from the surroundings; 

it appears to be carcinomatous. There is a patch 1 centimeter in diameter, 

on the endometrium of the lower part of the body of the uterus. 

consisting of soft yellowish fibrin; it is surrounded by a zone of congestion. 

The tubes and ovaries apjiear normal, though ovaries arc small 

and atrophied. 

Microscopic examination. Ovary: No follicles are present. Manv 

small arteries show obliteration of the lumen by a process of finely granular 

degeneration affecting the vessel and giving it a slaty blue stain. 

Similar areas of large size, possibly follicles, are seen. No other pathological 

changes are evident.

R a d i u m 

HS 

Fibrinous patch on endometrium consists of fibrin containing many 

polymorphonuclear cells; beneath it is a zone containing young fibroblasts 

and polymorphonuclear cells. Under one end of the patch is a 

dilated gland, with bizarre epithelium; it appears to be altered in the inflammatory 

process rather than malignant. In places the leucocytes are 

fragmented and necrotic. No mucosa is present. In some places beneath 

the fibrin and extending into the muscular wall are nodular accumulations 

of round ceils about groups of giant cells, the whole suggesting 

a tubercle. The blood vessels beneath this inflammatory zone are thickwalled, 

the intinia being chiefly involved. The lumina of some are entirely 

obliterated; in others the lumen is tilled with organizing thrombus 

or contains large pale cells, evidently fat-containing cells. The process 

in this region appears to involve essentially a destruction of the mucosa. 

and the underlying tissue, including the blood vessels of all sizes with an 

inflammatory cellular reaction determined by the products of this destruction. 

No carcinoma is evident either in the muscular wall or the atrophic 

mucosa of the central portion of the fundus. In one small area of a 

block cut just to the left of this region, the mucosa is covered by a 

straggling network of epithelial cells which approach squamous cells in 

type and in a few cases show distinct cell-bridges. There is an abundant 

infiltration of small round cells, which obscures the stroma. The 

mucosa and wall do not appear invaded. 

Review of the curettings removed earlier confirms the diagnosis of 

adenocarcinoma. There is no evident relation in type between these 

tumor glands and the growth above described. It is possible that a metaplasia 

has been the result of radium. 

If radium has any effect at all on the parametrium, and you will 

probably agree that it'has. then I think, it is logical to use radium as 

a preliminary to total abdominal hysterectomy in the treatment of early 

fundal carcinoma. 

MISCELLANEOUS CASES 

Of the ii miscellaneous cases. 3 were in young women vvith chronic 

discharges from the cervix following old gonorrhoea! infections. They 

received 400 to 600 milligram hour treatments at one session. Radium 

was sutured within the cervix. One case is too recent to speak of in 

regard to results. T he other two patients each missed one period and 

their discharges have been very much lessened. They are not entirely 

cured. 

There have been three cases of hyperovarian function in young 

women. Radium was used within the uterus after an exploration of 

the uterine cavity with a curette. Dosage 400 to 600 milligram hours. 

All these patients have been greatly benefited and there has been no 

lasting damage lo the menstrual periods. 

Five cases were suffering from chronic trachelitis, and erosions 

of the cervix. These patients were all about the menopause age. They 

were poor operative risks from general causes, and they received 1200 

to 2400 milligram hours of radium against the cervix or in the cervical 

canal. None of these cases was considered malignant by the pathologist. 

The results have been that the cervices have all been reduced in size 

and the erosions have healed.


REACTIONS 

Practically every patient who has had radium inserted within the 

uterus has suffered from nausea and vomiting while the radium tubes 

remained in place. The symptoms subside as soon as the tubes are removed. 

We are of the opinion that the nausea is caused by the foreign 

body within ihe uterus and that it is not necessarily due to radium. 

Patients have reported very little troublesome leucorrhcea. 

There have been only two patients who have complained of bladder 

symptoms following radium treatment. One had an advanced carcinoma 

of the cervix and anterior vaginal wall, and the radium was placed directly 

against the parts affected; the other case was one on whom a 

Byrne cauicry operation was performed. She had some extension on 

the anterior vaginal wall al ihe time of the operation. She has now a 

vesicovaginal fistula, which may be due to the disease, the cautery, the 

radium or to all three. There have been no cases of stenosis of the 

cervix or adhesive vaginitis due to radium in the entire group. There 

has been only one patient who has complained of rectal symptoms. She 

was treated with a Byrne operation and radium within the uterus. A 

troublesome proctitis continued for some time. We wonder whether 

the radium did not slip out of the uterus into the vagina. Only four 

temperature reactions have been noted in this entire group. 

One case had a 600 milligram hour dose within the cervix for 

chronic leucorrhcea following gonorrhoea! infection 2 years before. 

Smears had been negative for 6 months. Examination showed a small. 

movable uterus, and no adncxal masses. There was no curetting. The 

cervix was dilated, and the radium was sutured in place for 6 hours. 

Seventy-two hours later ihe patient had a chill, a fever of 102. sharp 

pain over lower abdomen, and she began to flow. Leucocyte count was 

18,400 with So per cent polynuclears. The fever continued for 24 hours, 

and gradually subsided, as did the leucocytosis, pain and flow. The 

pelvis remained clear of adncxal masses, but the cervix was very tender 

on motion. 

The second case with a serious reaction was a woman of 45 with 

a diagnosis of chronic metritis. There was no history of pelvic inflammation 

and no adnexal masses were palpated. She was curetted and 

given a dose of 1200 milligram hours within the uterus. Her convalescence 

was uneventful until the fifth day. when she suddenly developed 

severe nausea, vomiting, diarrhoea, and a fever of 103. The leucocytes 

increased to 27.000 with 85 per cent polymorphonuclears. The gastrointestinal 

symptoms slowly subsided, there never were any pelvic symptoms, 

subjective or objective. Blood cultures were sterile on several 

occasions. She finallydeveloped fluid in the pleural cavity which showed 

no organism on culture, or after injection into a guinea pig. Finally 

pus developed in her left forearm, which was opened and drained. After 

remaining in the hospital for 2 months she was discharged and has remained 

in good health ever since. 

The third case with .1 fever was a case of advanced carcinoma of 

the cervix with extension into the posterior wall of the vagina. Radium 

tubes were thought to have been placed in the uterine canal. Owing 

to the friability of the diseased cervical mass, the identification of the 

canal was very difficult. The dose was 2400 milligram hours. Convalescence 

was easy until the fifth day, when a fever of 102 occurred" 

with lower abdominal pain. Fever continued, gradually reaching nor-

R a d i u m 

sr, 

mal 7 days later. Abdominal examination elicited that the pelvis and 

lower abdomen were filled with a hard exudate, which continued for a 

period of 3 months, slowly subsiding without further symptoms. At the 

present time this patient is in excellent general health, free from pain. 

foul or bloody discharge. The disease, however, is slowly extending 

along the posterior vaginal wall. 

The fourth case with a disastrous reaction, was due to streptococcus 

haemolyticus. The patient was a Russian of 42 years. She gave a false 

history. Our clinical diagnosis was chronic metritis, and she was subjected 

to a curettage and 1200 milligram hours of radium. The true 

history was that she had an induced abortion a few weeks previous to 

admission. Her convalescence was uneventful for 5 days, then her temperature 

rose to 104, with a pulse of 120, and she complained of painful 

areas over the veins of her legs, and painful wrisls. She appeared very 

ill. Leucocyte count was 5:00. .villi 83 per cent polymorphonuclears. 

Blood culture showed streptococcus haemolyticus. Death occurred 6 

days after the onset of the fever. 

SUMMARY 

My impressions are that— 

1. Radium, heavily screened with one millimeter of platinum and 

2 millimeters of rubber and used within the uterus in 1200 to 2400 milligram 

hour doses, even with repeated administrations, causes no unto 

ward effect on bladder and rectum and produces very little troublesome 

leucorrhcea. If the radium is used within the vagina without careful 

proteclion of bladder and rectum, it will cause a reaction; but not nearly 

so disastrous as would be Ihe case if ji-rays were used. 

2. The temperature reactions occasionally seen are more likely to 

be due to a fresh invasion by organism started by the curetting and 

blocked drainage than to radium. 

3. Radium alone is an excellent treatment for chronic metritis and 

small fibroids at the menopause age, curing most of the cases with one 

1200 milligram hour dose, but even a 2400 milligram hour dose will not 

always control the bleeding indefinitely in all patients. 

4. Plastic operations on cervix and perineum may be performed 

with excellent results at the same time that radium is applied to the 

interior of the uterus. 

5. For advanced cases of cancer of the cervix and corpus, radium. 

as a palliative measure, gives more relief than any other treatment at 

our command. 

6. In early cervical cancers, the Byrne cautery operation, and 

radium at ihe same session, with or without X-ray treatment later, give 

results which are so valuable ihat it should be thoughtfully considered as 

a possible standard method of treatment. 

7. It it is impossible lo forecast how much or how little radium 

treatment will accomplish for any particular patient suffering from carcinoma. 

I am Indebted to all the members of ou. staff for the privilege of reportinc on 

their cases which have been treated with radium.


TREATMENT OF CANCER OF THE CERVIX. SHALL 

IT BE RADIUM OR OPERATION? 

A Collective Review of the Recent Literature 

By John Osborn Polak, M.D., and George W. Piielan, M.D., 

Brooklyn 

The treatment of cancer of the cervix presents one of the problems 

of ihe day, and is not only of interest to the profession, but to the laity. 

Shall it be treated by radical operation, or by radium, or by a combination 

of radium, operation and postoperative radiation, is the question 

that is confronting the surgeon. 

That Ihe incidence of cancer is actually on the increase, there seems 

to be no room for doubt. That a certain proportion of the public have 

cancerphobia is also an evident fact to clinicians in every large community; 

while doubt as to its curability is "back in the mind" of both 

medical man and patient. Though wc have no definite knowledge as 

to the cause of cancer, we do know that it begins as a local lesion, which 

ot one time in its clinical course i: amenable to radical removal, or complete 

destruction. Furthermore, wc know that cervical lacerations and 

chronic infections of the cervix, which subject the cervical tissues to 

chronic irritation, are precancerous factors. 

Unfortunately, early epithelioma or carcinoma of the cervix is a 

rare clinical finding; for the majority of the patients do not present 

themselves to the surgeon until the disease is far advanced. Hence, our 

efforts must lean toward prophylaxis in the cure of precancerous lesions. 

such as infections and traumatisms of the cervical tissues until cervical 

cancer can be recognized in the incipient stage. When first seen by the 

physician the lesion has already passed beyond the incipient stage, for 

bleeding, which is usually said to be the first symptom of cancer of the 

portio, cannot occur until the new tissue begins to break down and superficial 

necrosis takes place: in other words, until there has been active 

cell proliferation. These same conditions for many years prevailed in 

tuberculosis; but by organized propaganda and proper education of both 

the public and the profession, it has been demonstrated that tuberculosis 

is amenable to treatment and cure. So. also, is cancer, if the initial stage 

can be discovered at the time when it is a localized simple growth. 

Whether this initial growth shall be removed by radical extirpation or 

destroyed by radium is the question under discussion in this review. 

Experimental study of the behavior of implantation cancer allows 

us to draw an analogy between its behavior in animals and when similarly 

located in man. These experiments have shown that where cancer 

is implanted in the heallhy animal, and the animal is properly nourished. 

the graft takes, but the growth usually remains localized and fails to 

metastasize—in other words, the animal establishes an immunity against 

the cancer's further growth, and the implant may remain localized for 

months or years, or as long as the animal remains in good health. On 

the other hand, if this animal is subjected to repeated or continuous 

blood loss, the growth, which up to this time has been quiescent, rap- 

• Reprinted by permission from The American Journal of Obstetrics and Gynecology, 

X, 140-144. July. 1325.

R a d i u m 

ST 

idly develops and metastasizes, or if the tissues immediately surrounding 

the graft are traumatized, the implant grows with rapidity; or again, 

if the animal is subjected to prolonged ether or chloroform anesthesia, 

extension of the growth into the surrounding tissues is stimulated. 

These three conditions, i. e.. blood loss, trauma, and prolonged anesthesia, 

obtain in every radical operation for the removal of a malignant 

growth. Therefore, it may be presumed that in the woman suffering 

from cancer upon whom the radical operation is done, the Immunity 

which she has developed againsl (he growth, for the tunc being at least. 

is broken down—and if metastasis has already occurred, or if the operation 

has not completely removed every vestige of the tumor, rapid recurrence 

may be expected; for her tissue reaction has been reducd by these 

three factors. 

The radical operation has a primary operative mortality of from 

8 per cent to 20 per cent which must be taken into consideration in 

evaluating the resulis of surgery versus radium. Radium and x-ray. 

on the other hand, may be used without increasing either the blood loss. 

or traumatizing the surrounding healthy tissues, and may be applied in 

many instances without a general anesthetic. Hence, irradiation has an 

advantage over operative procedure, in that group of cases in which the 

radium can be placed in direct contact with the tumor mass. 

Furthermore, irradiation of the parametria with the x-ray eslablishes 

a connective tissue barrier which limits the lymphatic extension." 

This is especially valuable in cervix cancer, for in this tvpe of growth 

extension and recurrence is confined to the pelvis and is. therefore, more 

readily attacked. 

Operability is a variable personal equation that cannot be sharply 

defined, hence it is of greater clinical value in this discussion for us 

to accept the morphologic grouping of the cases of cervix cancer as 

they present themselves to the surgeon. 

According to H. Schmitz.1'* the cases that present themselves for 

surgical or radium treatment fall into one of four general groups: 

1. The clearly localized simple growth, the primary ulcer or nodule, 

with no extension or infiltration into the surrounding cervical tissues— 

the case in which the diagnosis can only be made by biopsy specimen. 

2. The nodule or ulcer with beginning infiltration of the surrounding 

cervical tissues but which has not extended beyond the confines of 

the cervix. 

3. Multiple growths with infiltration of the parametria, this infiltration 

mav be recognized by rectoahdominal examination. 

4. Cancer of the cervix with extensive ulceration and necrosis, infiltrating 

the surrounding tissues producing sepsis, hemorrhage and 

cachexia. 

It is conceded ihat the treatment of carcinoma, whether it be by 

radium or operation, to be of any avail, must be carried out in the early 

stage. It is, therefore, of the utmost importance that the disease should 

be recognized at the earliest possible moment; for if an epithelioma 

or carcinoma has overspread the limits of the cervix, the case is usually 

hopeless as to permanent cure. Therefore, in the treatment of patients 

with cervical cancer, falling within Group 1, namely, where the lesion 

is a clearly localized simple growth, radium alone or combined with 

deep x-ray therapy and the radical operation come into competition. 

fn America, few surgeons except Kelly. Schmitz.''2 Clark.3 Crile,


Bailey and llcaly.1 elect radium in preference to radical extirpation. 

However, a careuil review of their statistics and end-result seems to 

prove their case in favor of radium and intensive x-ray radiation of 

the parametria. 

Operative treatment: In considering the operative treatment, we 

must first take into consideration the question of operability. In Europe. 

where both the laity and the profession are belter educated in the subject 

of cancer of the cervix, the operability ranges from 60 per cent 

(Wertheim) to 90 per cent, as claimed by Bumm.4 In New York 20 

per cent may be taken as a good average. 

Primary mortality: The radical oi>eration for cervical cancer is the 

most serious procedure that the gynecologist is called upon to do; for 

the extensive dissection which is necessaiy imperils the integrity of the 

ureters, bladder and rectum—and aside from ihe danger of trauma to 

these structures, the wide exposure of cellular tissues opens up avenues 

for streptococcic infection and fatal peritonitis; for it is well known 

that these proliferating carcinomatous growths are frequently the abode 

of the streptococcus. Furthermore, pieces of carcinomatous tissue may 

be implanted in the operative area. Hence, it will be seen that the blood 

loss, traumatism, prolonged anesthesia and infection all contribute their 

share to the primary mortality. Hemorrhage, shock and peritonitis are 

the usual causes of death. 

In this country, ihe primary operation mortality ranges from 8 per 

cent to 20 per cent; in Europe from 5 per cent to 11 per cent. It may. 

therefore, be conservatively stated that even in the hands of the most 

competent surgeons, 10 per cent mortality is a fair average. Thirty per 

cent of cures after the five year period is about all that can be claimed 

for the radical operation by even the best American operators. 

Hence, in studying the finalstatistics, it is unfair to compare operative 

results, which in reality, only record those women who have survived 

the operation with those obtained by radium and deep x-ray therapy 

which include "all comers." 

For example: Of 100 cases of cancer of the cervix applying for 

operative treatment, at most only fifty can be accepted as operable, and 

of these five will die from the operation; so that of the forty-five surviving 

the operation, but fourteen or 30 per cent can he expected to survive 

the five year period. Consequently, of the 100 cases, only fourteen 

are alive at the end of five years. 

With radium, on the other hand, al! of the 100 will be accepted for 

treatment, and of this number, we can expect at least 15 to 25 per 

cen(ioindi?j l0 ije a]jve at Ine €n(j 0f £ve years w;tn practically no primary 

mortality. 

Ward,11* before the American Medical Association, 1925, reporting 

upon all cases of cancer, in all stages, which received radium, treated 

at Woman's Hospital, including both the operable and inoperable cases, 

shows 25.9 per cent to be alive at the end of five years, while in the 

operable group 52 per cent are living after five years. 

Therefore, we must admit that radium alone or in conjunction with 

deep x-ray therapy is a measure which is now accepted for the complete 

and permanent cure of cervix cancer; for there is sufficient accumulated 

evidence to show that this treatment has been entirely satisfactory. 

Certain clinical facts have been observed: 

theliomata. 1. Radiation has had its best success in the several forms of epi


2. Cervical cancer of the adenomatous type is less susceptible to successful 

radium treatment than is that of the squamous cell variety. 

3. Destruction of the cells acted upon by the gamma rays is shown 

by swelling and vacuolization of the protoplasm and shrinking of the 

nuclei; this is followed by phagocytosis and absorption, and the space 

occupied by the destroyed calls is replaced by a homogeneous connective 

tissue network. 

4. As squamous cell epitheliomata originate from the epithelium 

of the vaginal portion of ihe cervix and tend to grow outward into the 

vagina, the application of radium in this type of growth produces the 

most astonishing results. 

According to Frank, Healy and Bailey,0' the parametrial cellular 

reaction plays a large part in the temporary curative effects produced 

by radium; for under the influence of the rays, this connective tissue 

proliferates, contracts and hardens, and by the production of dense 

scar tissue blocks the lymphatics and the smaller blood vessels and 

starves the growth, having a similar effect to that obtained by ligation 

of the internal iliac arteries. 

We have previously stated. "It is conceded that the treatment of 

carcinoma, whether it be radium or operation, to be of any avail, must 

be carried out in the early stage." and by ihat we mean those cases which 

fall under the morphologic classification known as Group i. 

That this broad statement is true concerning operation, there can 

be no doubt, but with accumulated statistics concerning the so-called 

"five-year period cures." radium presents a little brighter picture, for 

even in the borderline class radium can claim over 30 per cent of cures. 

E. MuhlmannB states that, comparing the observations of Doderlein, 

Scitz, Wintz and Flatau. 10 to 20 per cent of permanent recoveries 

may be assumed for inoperable carcinoma; while II. Hcyman7 claims 

thai 16.6 per cent of the inoperable cases were free after the five year 

period. 

Numerous other statistics could be quoted, but the above are sufficient 

to show that to even the hopeless case some hope can be given. 

Another point well worth remembering in the use of radium and 

x-ray is the considerable delay in mortality. Grcenough." in the report 

of the Committee on Treatment of Malignant Disease with Radium and 

X-ray (American College of Surgeons), says the duration of life in 

the unsuccessful case is greater with radium than with operation; while 

it may be further staled that in the unsuccessful cases there is a marked 

amelioration of the symptoms complained of, the pain is less, the bleeding 

negligible and sepsis is absent. 

In a review" published five years ago in this journal, on the same 

topic, the final conclusion was as follows: "The results with radium 

in operable cases alone are still inferior to operation, amounting to 31.5 

per cent (131 out of 415) as compared to 45 to 50 per cent by operation; 

but closer analysis will show that while the percentage of operative 

cures is greater in the early operable group, the percentage of radium 

cures is greater in the early operable group, the percentage of radium 

cures is greater in the borderline case." We can still subscribe to the 

latter part of the above conclusions, but feel ihat the percentage of cures 

by radium in the first group now leads that of any other method. In 

Schmitz"s article forty-three cases (Group 1) are reported from five 

different clinics with a 51.56 per cent of "five year cures."


In conclusion, we must all agree that it needs but one reliable report 

covering a sufficient number of cases falling in Group i to prove the 

value of radium as against surgery, and that we believe has now been 

presented in the 191& to 1925 report of the work at the Memorial Hospital 

by Healy and Bailey0'--0 with its 50 per cent of cures after the 

five year period. 

Where surgery is done, the parametria should always have postoperative 

irradiation and finallythe great success of radium in borderline 

cases of the epitheliomatous type justifies its acceptance as a curative 

measure, without recourse to subsequent surgery. 

REFERENCES 

1. Schmitz: Surg, Gynec. and Obst., 1924, xxxix, 775 and 839. 

2. Schmitz: Jour. Am. Med. Assn., Jan. 10. 1925. Ixxxiv, 81-84. 

3. Clark, J. G.: Ann. Surg., 1924, Ixxx, 138. 

4. Bumm: Archiv., 1923. 

5. Bailey, H.. and Healy. W. P.: jour. Am. Med. Assn., Oct. 4. 1924. 

lxxxiii, 1055. 

6a. Healy: Phila. Obstetric Society. April. 1925. 

6. Muhlmann. E.: Strahlentherapie, Berl. u. Wien. 1923. xvi, 137. 

No. 1. 

7. Hcyman. H. V. J.: Obst. and Gynec. Brit. Emp., Manchester, 1924, 

xxxi, 1, No. 1. 

8. Greenough, R. B.: Surg.. Gynec. and Obst., July, 1924, xxxix. 18. 

9. Taussig: Am. Jour. Obst. and Gynec. i, 314. 

10. Radium Report of the Memorial Hospital. 1923. 

11. Clark, J. C. and lilock, F. B.: Am. Jour. Obst. and Gynec, Mav. 

1924, vii, 543. 

12a. Ward, G. G.: Jour. Am. Med. Assn., Sect, of Obst. and Gynec. 

May, 1925. 

12. Jones, T. E. : Am. Jour. Obst. and Gynec. May, 1924, vii, 541. 

13. Regaud, C.: Jour, de radiol. et d'clectrical. Paris, November. 1923. 

vii, 510. 

14. Van Raamsdonk. C. P.: Nederlaudsch, Tijdschr. v. Geneesk. 

Leiden, 1923, \ii. 45. No. 2. 

15. Ostreil, T.: Prakticky lek. Prague. No. 1, 1923, iii, 251. 

16. Gagey. Jean: Bull. Soc d'obst. et de gynec de Paris, 1924. xiii, 22, 

No. 1. 

17. Daels and DeBacker: Brit. Jour. Radiol.


irradiation treatment of myopathic 

haemorrhage* 

By John G. Clark. M. D.. Philadelphia 

When men of equal standing and ability become ardent disputants 

on any subject in medicine a final decision frequently favors an intermediary 

policy. In the earlier history of the surgical treatment of 

myoma uteri, the mortality attending all operations was appallingly high 

when compared vvith modern evolutionized operations. Three decades 

ago. the electric treatment of these growths largely fostered by French 

specialists, appeared for the moment, because of its small risks, to challenge 

the right of surgeons 10 pursue an operative policy. Experience. 

however, gradually eliminated electricity as a reliable therapeutic agent 

because the development of hysteromyomectomy and myomectomy followed 

such secure lines that both morbidity and mortality sank to an 

exceedingly low point and through the beneficent effects of these operalions 

the patient was assured of health and the fear of a recurrence was 

practically eliminated. Therefore, the skilled chirurgical craftsman of 

recent years has approached these problems with the greatest assurance 

of a successful issue. Myomectomy in young women yields excellent 

results, and when this is not feasible the removal of the uterus with 

conservation of the ovaries reduces climactic morbidity to a minimum. 

With the attainment of such an exceedingly favorable trial balance. 

how could the results be bettered? To the positive mind of strict surgical 

trend there could be but one answer, consequently the discussion 

before such men of the merits of any form of irradiation in preference 

to an operation kindled as glowing a response as thai of an oxvhydrogen 

blowpipe to a fading ember. 

In testing therapeutic remedies of former days, decades or a generation 

might pass before the truth of an issue became clarified. Today, 

however, the well-ordered American clinics, with their follow-up systems, 

and the great medical societies of this country, which serve as 

progressive forums of debate, make it possible to arrive at a much more 

expeditious judgment. These institutions, therefore, function as great 

medical clearing houses in estimaling the value of novel operations and 

therapeutic procedures. Thus within a decade one may witli great 

confidence evaluate the results of irradiation in the treatment of myomatous 

and myopathic transformations in the uterus. From this survey. 

one may assert that such a controversial phrase as "surgery versus irradiation" 

should be eliminated from current medical literature. Were 

such the issue the conclusion would be incontrovertibly in favor of 

surgery. As to a choice between these methods of treatment, surgical 

intervention would decidedly hold the vantage point, for its merits have 

been established beyond cavil. Irradiation in the light of our present 

knowledge must without question be subordinated to operative measures. 

and the judge as to its invocation should be the surgeon. Because of 

the dovetailing of these two therapeutic agents every gynecological and 

surgical clinic should have radium as a part of its armamentarium. 

The application of this remedy should be made by the surgeons 

because its employment is attended by definite surgical risks. On Ihe 

•An Editorial, reprinted by permission from Surgery. Gynecology and Ohatetrlcs. 

Ml, 878-880, June, 1925.


other hand, roentgen-ray treatment should be supervised directly by the 

roentgenologist, for its dangers can be estimated and avoided only by 

the specialist trained in this novel branch of physics. Neither remedy 

should be in the hands of the novice, for each is attended by great 

hazards if injudiciously employed. 

While the value of irradiation has been established, it yields its best 

therapeutic results only to the careful diagnostician who takes into account 

the size and character of the tumor, its symptomatology, the age 

and nervous stability of the patient, and the associated or coincident 

pathological lesions. In the gynecologic clinic of the University of Pennsylvania 

we have for some time rested our decision as to the irradiation 

of these tumors upon one chief point, and that is hemorrhage. Furthermore, 

experience has confirmed another rule, and that is to submit all 

tumors over the size of a four months pregnant uterus to operation unless 

there are such grave contraindications as to render surgical intervention 

a too hazardous policy. Tumors which have as their chief 

symptomatic manifestation pressure effects, should fall within ihe surgical 

domain, whereas in those uncomplicated tumors of a size under ihat 

of a four months pregnant uterus, whose sole symptom is excessive 

bleeding, irradiation is the method of treatment par excellence provided 

the patient is beyond her fourth decade, and that the tumor is not of the 

large submucous type. Myomata in young women fall, as a rule, within 

the surgical domain, as a myomectomy or partical hysterectomy, with 

preservation of the ovarian function, is decidedly preferable to irradiation. 

A point relative to the irradiation menopause: At one time we 

held as a blanket rule that ihe nearer the meridian of life the menopause 

was induced by any artificial means, ihe less the climacteric disturbances. 

As a result of comparative reviews of a series of myomata 

and pelvic inflammatory cases passing through the Gynecologic Service 

of the University Hospital, in which a surgical or an irradiation climacterium 

has been induced, it has been found that in general the age factor 

is still of capital importance in estimating the severity of this precipitate 

issue. However, another weighty factor, and one always to be 

estimated most carefully, is the nervous stability of the patient. A 

woman of equitable temperament at thirty years of age may be shaken 

relatively little by the abrogation of the ovarian function, whereas a 

nervous, apprehensive, neurotic woman in the fourth decade, will pass 

through a veritable climacteric upheaval if nature is forestalled in this 

event, just as she may when its natural termination arrives. In a nervous 

woman, therefore, the extirpation of the tumor with the conservation 

of ovarian tissue even in the menopausal years must take precedence 

over irradiation. The fear of malignant transformation in myoma uteri 

has been greatly overstressed in the past as is shown by a critical pathological 

analysis of 816 myomatous tumors, which have passed through 

the Gynecologic Laboratory of the Hospital of the University of Pennsylvania. 

In this large number of cases only 25 sarcomata were discovered, 

and of these 12 could in no sense be considered as malignant 

transformations, but were sarcomata from the start and were so diagnosed 

clinically. In more than 1.300 hysterectomies, sarcoma subsequently 

developed in the cervical stump in only one case and this sequel 

was cured by two applications of radium. The infrequency of this type 

of malignant change and its dangers is therefore of negligible import 

as an urgent indication for surgical intervention. 

Since cancer of the fundus can practically always be determined

R a d i u m 

93 

by a study of curettage debris, there is again very little possibility of 

error if the diagnosis rests upon skilled microscopic judgment. If Well 

established rules arc followed in selecting the tvpc of case to be submitted 

to surgery and to irradiation the two methods of treatment will 

work in perfect harmony, and are in no sense antagonistic to each other. 

SIGNIFICANT CELLULAR CHANGES OBSERVED IN 

IRRADIATED TISSUE, ESPECIALLY OF CANCER 

OF THE RECTUM* 

By Harry II. Bowing, M.D. 

Section on Radium and X-ray Therapy. Mayo Clinic, Rochester, Mi 

From June. 1919, to June. 1924. forty-three cases of cancer of the 

rectum were resected at the Mayo Clinic, in which radium alone or in 

combination with roentgen rays was applied prior to operation. Thirtyfour 

cases were treated as a pre-operative procedure, following a short 

interval after permanent colostomy. Nine cases were treated elsewhere. 

and in only one of these was a colostomy made prior to the irradiation. 

This small group of cases was studied for the special purpose of 

observing, if possible, those changes resulting from the application of 

ihe therapeutic rays of radium, and the X-ray. A similar study of cancer 

of the breast was made (2). which proved to be a substantiation of 

the work of Alter on irradiated cancer. MacCarty and Brodcrs have 

reported dala on cases of unirradiated cancer. It seems evident that 

cellular changes can be abundantly produced in malignant tissue, which 

reduce or inhibit the malignant process. 

Microscopically, the cellular changes in irradiated tissues seem to 

be identical to those which the body naturally produces in its effort to 

rid itself of malignant disease, and would indicate that the mechanism 

was similar. A betlcr understanding of this mechanism should afford 

means for improving technic. and methods of dealing with the disease. 

It is not uncommon for radiotherapists to find thai cancer of the 

rectum has been favorably modified, and occasionally that the visual and 

palpable manifestations of the disease have entirely disappeared. There 

are cases in which careful microscopic section of the tissue removed 

does not reveal any active cancer cells. Not only is there local improvement, 

but a gradual, steady, systemic improvement. Various factors 

mav account for such improvement, but only the probable mechanism 

underlying the reduction i;; malignant tendencies in tumor tissue, with 

and without irradiation treatment, will be discussed here. 

Brodcrs, as a result of summing up or averaging observations on 

unirradiated tumor tissue, has graded tumors so as to furnish a valuable 

index to the degree of malignancy. The surgical staff of the Clinic. 

in view of the practical aspects of such graduation, now use it as a 

guide to effective surgical procedures. In order to treat neoplasms 

scientifically it is essentia! ihat these important tissue changes should 

be recognized. Since these factors normally occur in untreated cancer 

•Reprinted by permission from Radiology. Iv, 378-383, May, 1925. Read before 

the Radiological Society of North America. Chicago. June. 1921.


tissue, although at a comparatively slow rate, and in varying degrees, a 

study of irradiated tissue in which this natural process had been produced 

at a comparatively rapid rate seemed pertinent. This phase of 

the study, as has been mentioned, cannot he overemphasized. 

A. few years ago the physicist was in much the same position as 

that of the pathologist today. It was not until the physicist's knowledge 

became practical that the art of radiotherapy advanced; the perfection 

to which the mechanical phase of radium and roentgen-ray treatment 

has reached can be attributed in great measure to his efforts. The 

physician who employs these agent? must have a liberal knowledge of 

the fundamental physical phenomena controlling them. 

Information now received from the pathologist concerning his diagnosis 

of malignancy is incomplete; he must furnish more definite information 

concerning the degree of malignancy found in a given case; 

both factors are equally important. 'Thus his specialty has come to occupy 

a definite place in ihe therapeutic management of a case. Physicians 

treating malignant disease must have a working knowledge of 

this phase of the work, and the art of radiotherapy will be greatly improved 

and further advances assured when these factors are taken into 

account at the time treatment is outlined and applied. It is not within 

the scope of this study to discuss details concerning the factors which 

form the basis for this grading, but rather to record the data in the 

forty-three cases observed, and compare them with Broders' and Mac* 

Carty's dala on cases of malignancy in which prc-opcrative treatment 

by radium was nol given. 

Grossly, the tumors removed at operation in this series of cases 

were large and bulky. Very few. if any, could be designated early 

operable lesions. The tumor was divided longitudinally, and a section 

for microscopic examination was taken from the margin and the center 

of the malignant tissue. This procedure furnished material fairly representative 

of the bulk of the tumor. 

Taole I 

types ok ti.'moks 

(brodfb's classification) 

Cases Per cent 

Adenocarcinoma 37 86.04 

Colloid carcinoma 4 9-30 

Squamous-cell carcinoma 1 2.32 

Not determined 1 2.32 

Total 43 

From the standpoint of a radiotherapist, it is gratifying to knowthat 

so large a percentage (86.04.) of tumors are of the adenocarcinomatous 

type, for as a rule a response to treatment can be expected. 

Squamous-cell cancer in the rectum metastasizes rapidlv to the inguinal 

glands, and the result is usually that of disseminated cancer. The primary 

tumor can be modified and made less malignant, but the multiple 

and widely distributed secondary growths are fatal. Colloid cancer 

by producing colloid material, seems to bring about atrophic change 

in the cell, possibly as a result of pressure, and death of the malignant

R a d i u m 

96 

parenchyma eventually ensues. Whether or not this function can be 

accelerated is highly problematic. 

Owing to the previous exposure to the therapeutic rays the true 

malignant character of the tumor was masked, and therefore the possibility 

of error must be considered in the grades recorded. The grades 

as a whole check satisfactorily with Broders' findings, so that it is reasonable 

to assume that this error is not large. 

The cases studied by Broders were selected from various locations 

such as the genito-urinary tract, the lip and skin (Table II). Allowance 

for variations, due to anatomic location of Ihe malignant growths. 

should of course he made in considering the data, but it is clear that the 

grade of malignancy has a direct bearing on results, regardless of the 

location; in this point, particularly, radiotherapists are interested 

As will be seen in Table II 'Broders' series), the results of operation 

without preoperative treatment were good in 92.2 per cent of the 

untreated Grade 1 tumors, whereas the results were poor in 89.2 per 

cent of the untreated Grade 4 tumors. This high percentage of poor 

results in Grade 4 tumors shows why many surgeons regard this degree 

of malignancy as inoperable. However, in the series of tumors of Grades 

3 and 4. which were irradiated pre-operatively, the results were poor 

in only 57.89 per cent. Although the series is probably too small a one 

on which to base an accurate opinion, ihis improvement of 32 per cent 

certainly indicates that the effects of pre-operative radium treatment 

are noteworthy in cases of highly malignant tumors (Grades 3 and 4). 

Moreover, the cells of highly malignant tumors divide rapidly, and at 

ihis stage are most vulnerable to. the therapeutic rays. It mav he remarked 

that whereas the results for tumors of Grades 3 and .1 were 

decidedly improved by pro-operative irradiation, they were comparatively 

unfavorable when similar therapeutic measures were employed for 

tumors of Grades 1 and 2. since good results were obtained in onlv 60.2 

per cent as compared with Broders' 92.2 per cent. This may be "owing 

to ihe large size of all the tumors in the present series, and possibly to 

the anatomic position. It may indicate that tumors of Grades 1 and 

2 are best treated by surgery alone. 

In 1922. MacCarty studied the factors which influence longevity in 

cancer. Included in his cases were 102 of cancer of the rectum. The 

specimens were studied to determine the frequency and possible influence 

of lymphocytic infiltration, fibrosis, hyalinization. and cellular 

differentiation 011 post-operative longevity. Since he does not classify 

ihe tumors according to Broders' grading, the results in this series cannot 

be compared on that basis. However, in Table III are compared 

the factors of longevity and of lymphocytic infiltration, fibrosis, hyalinization, 

and cellular differentiation. Although the present series of cases 

is smaller than MacCarty's. there is a certain significance in the comparison, 

and it is hoped that it will stimulate others to add to the data 

relative to pre-operative irradiation in cases of cancer of the rectum. 

The factors of differentiation in the parenchymal cells of the tumor, 

and in the lymaphocytic. fibrotic and hyaline changes in the stroma or 

supporting matrix, are 110 doubt intimately combined, and represent or 

afford visualization of the tissue effects of the intrinsic cancer-resistant 

mechanism at work. When present, they are the markers which indicate 

that the patient is putting up a fight against the invading malignant cell. 

The findings in the irradiated group compare favorably with MacCarty's. 

The tissue changes brought about by the treatment are definitely shown


Table II 

UNTREATED CASES (ftRODEKS) 

Post-operative results 

Cancer of the genito-urinary tract 

Cancer of the lip 

Cancer of the skin 

Total 

Good 

43 

13 

Gfi 

Grade 1 

Grade 4 

Pair ' Poor Good Fair Poor 

1 1 10 

72 

2 

4 

1 

7 

4 1 10 

S3 

(92.9% > 

(10.8%) (89.2%) 

TREATED CASES 

fBOWING) 

Post-operative results 

Cancer of the rectum 

Grade3 1 and 2 Grades 3 and 4 

Good 1 Fair ! Poor J Good Fair 

li -1 11 | 4 

(69.2%)' (30.8'r) (57.89%) 

Poor 

4 

Cases 

Table HI 

CANCER OF THE RECTUM 

Average length of post-operative life 

Frequency of differentiation 

Frequency of lymphocytic infiltration 

Frequency of fibrosis 

Frequency of hyalinization 

Frequency of differentiation and lymphocytic infiltration 

Frequency of differentiation and fibrossi 

Frequency of differentiation and hyalinization 

Frequency of lymphocytic infiltration and fibrosis 

Frequency Average length of lymphocytic of post-operative infiltration life and hyalinization 

Frequency 

With differentiation 

of fibrosis and hyalinization 

Without differentiation 

With lymphocytic infiltration 

Without lymphocytic infiltration 

With fibrosis 

Without fibrosis 

With hyalinization 

Without hyalinization 

With differentiation and lymphocytic infiltration 

Without differentiation and lymphocytic infiltration 

With differentiation and fibrosis 

Without differentiation and fibrosis 

With lymphocytic infiltration and fibrosis 

UnircnU-d 

(MacCarty) 

1 Per 

Yra rs 

1,17 

1.54 

1.08 

1.57 

1.31 

1.53 

1.29 

2.33 

1.44 

1.59 

0.71 

1.58 

1.15 

1.65 

1.17 

Treated 

(Bowine) 

by Without the increase Ivmnbocvtio in the infiltration post-operative nnd fibrosis years. The frequency of differentiation, 

lymphocytic infiltration, fibrosis, and hyalinization are all greatest 

in the treated patient. 

The average length of life in MacCarty's series of cases was 1.47 

years; in the present series. 1.76 years. The highest percentage (85) 

in MacCarty's series was related to the factor of differentiation, and 

cent 

85 

57 

7b 2 

Mi 

70 

2 

17 1 

2 

Year* (Percent 

1.76 

100 

100 

100 

7.69 

100 

100 

7.69 

100 

7.69 

7.69 

1.76 

1.76 

1.76 

0.59 

1.88 

1.76 

1.76 

1.76


ihe lowest (2) was that of hyalinization. Percentages in the present 

series are persistently increased in every combination. This no doubt 

indicates that ihe natural defense mechanism was brought into action. 

When the percentages are studied as a whole, they demonstrate clearly 

that the factors influencing longevity in patients with cancer of the rectum 

can be enhanced or accelerated by ihe application of radium (Table III). 

Of the thirty-three patients (94.28 per eenO who were traced after 

leaving the hospital, eighteen (51.54 per cent) are living, and fifteen 

(45-4° per cent) are dead. Ten (55.55 I*-" cent) of the eighteen patients 

are living three years after ihe first application of radium, two 

(11.12 per cent) less than one year, and six (3333 per cent) less than 

between two and three years. 

The surgical mortality (18/) per cent) was loo great in the treated 

scries: this may be attributed to posl-influenral infections, especially 

prevalent in 1019. and 10 nperati |K-rformed too early, when the effects 

of treatment 0:1 the lis>ues were mo*t severe Most patients were 

operated on less than two weeks after the first application of radium. 

two or three treatments having been given. The reaction was, therefore. 

at its height. A longer interval is now allowed. 

TECHNIC OF ADMINISTERING RADIl/M 

No distinction was made between the applicator containing the 

radium sulphate and ihe radium emanation (rationK provided the measurements 

of energy content weie relatively equal. When the radon was 

employed, the brass filterused was equal to a filter of 0.5 mm. silver. 

The Universal silver tulie applicator with walls 0.5 mm. thick, and containing 

50 mg. of radium element fsulphatet. was the applicator of 

choice. This was usually placed in a thin brass shell with a wall about 

0.3 mm. thick, one end of which was closed and soldered lo a lead stem 

which made it possible to direct, as well as to fix. the applicator into 

position. The lead stem was about 20 cm. long and could easily be ben* 

to suit the contour of the buttock or sacral area:it was held in place with 

adhesive plaster. Ordinary motions in bed will not displace this applicator. 

Over the brass shell was placed a para rubber tube wall 1.5 mm. 

thick and about 2.5 cm. long, allowing the end to protrude beyond its 

end about 2 or 3 mm. The contracture in the rubber tube insured the 

fixation of the Universal radium tube in the shell; it also furnished a 

soft lip. for minimizing trauma in placing the applicator. 

The dose was planned lo be given in two or three applications of 

from twelve to fourteen hours each, and repeated in two or three days. 

The lotal dose was arranged so that the posterior resection would follow 

from ten to fourteen days after the firstapplication. Five patients 

were given the average tolal treatment of 750.4 mg. hours; twenty-two 

were given the average total treatment of 1,614.0 mg. hours, and nine 

were given the average total treatment of 2.499.77 mg. hours. 

The interval between the first application and the oi>eration was 

less than two weeks for fifteen patients; more than two weeks and nol 

greater than four weeks for sin; the interval was not less than six 

weeks and not greater than seven weeks for three antl much longer, varying 

from fifteen to siNty-seven weeks for nine. The chief reason for 

this long interval was the patient's poor general condition, which added 

greatly lo the risk of the operation Following ihis interval, patients 

regained much of their strength, and thus the poterior resection was


warranted. In eleven cases (25.58 per cent) the gross effects of the 

tissue changes noted at operation were recorded as "edema," "oozing," 

"fibrosis." or "fixation." in four surgical records (9.3 per cent) it was 

noted that the operation was made more difficult by the effects of the 

treatment. 

All of the tumors were large and ulcerated and many were bulky 

and fixed before treatment was begun, so that some of the complications 

may have been due to ihe character of the disease, although since most 

of the patients were operated on within the two-week interval, it is reasonable 

lo conclude that the altered tissue added to the surgical difficulties. 

It is difficult to determine the most satisfactory treatment interval 

since much depends on the dose and the individual response. All of the 

effects of the treatment should have disappeared and the secondary infection 

and ulceration be reduced to a minimum before surgical intervention 

is undertaken. It can be assumed that at the end of six or eight 

weeks the patient should be re-examined, at which time operation, or 

a longer treatment interval, should be decided on. 

discission 

From the foregoing it would seem that the healing process following 

radiotherapy, in cases of cancer, may be divided into two phases: 

ihe changes in ihe parenchyma cell, and the changes in the stroma or 

supporting matrix. In the first of these, provided the exposure is destructive, 

necrosis is the characteristic feature; if the exposure is nondestructive, 

differentiation occurs in the parenchymal cells, and the 

range of difterentialion is evidently an inherited distinctive feature. 

related to cither form or function. The character and amount of reaction 

noted in the matrix are no doubt dependent on the intensities employed, 

as well as on the susceptibility of the individual, and are characterized 

by a combination of ordinary sequences: (1) invasion of a 

leukocytic infiltration: (2) fibroblastic changes resulting in the formation 

of a very cellular fibrous tissue, and later, of a very dense noncellular 

tissue, and (3) formation of iiyalin. Eventually, a definite degenerative 

change is indicated by the deposits of calcium; this demonstrates 

thai, when ihe purpose of the reaction in the supporting matrix 

is accomplished, degeneration occurs, and that it is no longer of value 

in ihe restorative process. 

As yet. very little has been done to determine the quantity and 

quality of therapeutic rays necessary to bring about this satisfactory 

result in arresting neoplastic disease through differentiation rather than 

through destruction, by imitating or stimulating the natural defense processes 

observed in untreated neoplastic tissue. 

The science and art of radiotherapy will be greatly advanced by 

the determination 01 these as yet unknown factors. In the meantime, 

we should be studious and observant, and endeavor in every case to rive 

individual treatment. 

CONCLUSIONS 

1. This study is intended, primarily, to record the tissue changes 

in cases of cancer, and, if possible, to correlate observations. 

2. The natural defense mechanism or the factors influencing the 

longevity of patients with cancer can be greatly enhanced or accelerated 

by the application of the therapeutic rays of radium.


3. The treatment interval between the first application and the 

operative procedure should be sufficiently long to permit the maximum 

of tissue repair, thus reducing to a minimum the surgical difficulties, the 

great chance of secondary infection in the operative field, and the malignant 

characteristics of the tumor. 

4. The pathologist can be of great service in the therapeutic management 

since his opinion furnishes an extrcmelv valuable index to 

govern ihe best method of procedure. A careful biopsy can be 'lone 

just before the application of the first radium treatment vvith very little. 

if any. risk. 

5. It is hazardous to set up a thcra|ieutic framework in the management 

of patients with cancer by a combination of radium therapy 

and radical surgical measures. The best results are possible only by 

individual treatment with a sufficient time interval between the first 

radium application and the operation for all ihe important effects on 

the tissue to have occurred and subsided. Such lime is estimated in 

weeks rather than days. 

BIBLIOGRAPHY 

1. Alter. X. M.: Ouoted by Bowing. 

2, Bowing, II. H.: Radium and X-ray treatment of advanced carcinoma 

of the breast prior to amputation. Radiology. 1924. ii. 

I43-150- 

3. Bowing. O. H.. and Anderson, F. \V.: 'Ihe treatment by radiation 

of carcinoma of the rectum. Am. .lour. Roentgenol.. 1923. n. 

230-239. 

|. Broders, A. C: Squamous-cell epithelioma of the lip. Jour. Am. 

Med. Assn., 1920. Ixxiv. 656-664. 

5, Broders, A. C.: Squamous-cell epithelioma of the skin. A study 

of 256 cases. Ann. Surg.. 192'. Ixxiii. 141-160. 

6. Broders. A. C.: Epithelioma of genito-urinary organs. Ann. Surg.. 

1922. Inxv. 574-604. 

7. MacCartv. \V. C.: Factors which influence longevity in cancer. A 

study of 293 cases. \nn. Surg.. i')22, lxxvi. 9-12. 

RADIUM REMOVAL OF CARCINOMA OF 

BLADDER* 

THE 

By B. S. Barrikckb, M. D.. Memorial Hospital. Xew York 

Today, most urologists, no matter how specialized their operative 

technique, will concede to radium some value in the control of bladder 

cancers. For instance, certain papillomata, apparently benign, and certainly 

benign on pathological examination of small excited portions. 

refuse to be destroyed by fulguration. or if destroyed, rapidly return in 

situ. If radium be held against such tumors, they entirely change their 

reaction to fulguration, and disappear with the greatest ease. 

If the bladder tumor, instead of being soft and papillary, looks 

•Reprinted by permItftOfl from The Journal of I'rology. xlfl. 131-117. February, 

1925. Read at the annual iiirellnK ot the Amer Iran I'rologlcal Association, Atlantic 

City, New Jersey, Juno. 19?*.

100 RAPIU M 

FIs- L 

Multiple Papillary Carcinoma of Bladder 

Fig. J. Solid Type Papillary Carcinoma; Bladder Trabeculated: 

Knlarged Proatatt at Left

R a d i u m 101 

harder and shows on pathological examination atypical cells in atypical 

arrangement, such a tumor is more malignant and urologists arc some 

divided as to whether such a tumor is better dealt with by radical operalion 

or by radium. 

If a tumor is from the -tail fiankiv infiltrating, fiat and ulcerating. 

and has no papillary characteristics, then radium is. in the opinion of 

many, useless. Yet, in the past ten years we have destroyed not a few 

such tumors with radium alone, and I believe we have statistics at hand 

lo prove that the most brilliant results arc in the small infiltrating bladder 

carcinoma, many of which can be thoroughly and easily irradiated 

through the cystoscope, so dispensing with any operation. If this is so. 

we can immediately place in the ledger, on the credit side of radium. 

Ihe operative mortality (5 to 20 ]>er cent) to which the patient would 

have been subjected had there been an attempt to remove the tumor by 

operation alone. 

For the sake of presenting as definite statistics as possible, wc have 

reclassified all our cases at the Memorial Hospital, making two broad 

classifications of bladder carcinoma: (1) papillary carcinoma; (2) infiltrating 

carcinoma. 

In the first group are put all cases which are frankly carcinomatous, 

and so proved by the appearance of slough (the large majority 

were sloughy in whole or part) by the pathological examination, or by 

the failure to react to fulguration. 

In the second group are placed those cases showing induration by 

palpation or infiltration by pathological examination of some portion 

of the tumor and the adjacent bladder wall. 

No pure papillomata are included in these groups. We have included 

all cases of large or small carcinomas which have been removed 

intravesically and all cases in which, because of the size of the tumor. 

we have implanted radium through a suprapubic opening. These last 

cases date from June. 1919. when we first used this method. 

PAPILLARY CARCINOMA OF THE BLADDKR 

Twenty-three cases, including all types, not proved by pathological 

examination or palpation, to be infiltrating. 

Results 

Xumber of cases 

Well *§ 

Result not yet determined 

Dead or dying 2 

Dead or dying 2 

Papillary carcinoma of the bladder, analyses of well cases 

Pvthology 

Xumber of case; 

Positive for carcinoma 

s 

Positive for papillomata -1 

No section 3 

In these last t, cases the diagnosis of carcinoma was made because 

of sloughv solid tumors seen on cystoscopy, or suprapub.cally. In one 

case the tumor was in addition resistant to fulguration.

102 R a d i u m 

Pig". 3. Papillary Carcinoma Show i nit Slough at Lower 

Pact of Tumor 

Fig. 1. Infiltrating Carcinoma Show inn cat lilsht i Submucous 

Extension of Tumor

a d i u m 103 

Sloughy 

Not sloughy .... 

Sloughy tumors 

Number of cases 

'3 

She (Xoc of tumors, but of bases of tumors) 


4 sq. cm _i 

6 sq. cm 2 

7 sq. cm 2 

9 sq. cm i 

12 sq. cm 2 

Extensive 2 

Not determined 2 

Location 


Bladder neck 8 

Base, trigone 5 

Later walls 1 

Base, not on trigone 1 

Apex 

O 

The difficulty of operative removal of these tumors is seen from the 

above table. 13 of the cases involving the trigone or bladder neck. 

Multiple 

Single . 

40 to 50 

50 to 60 

60 to 70 

70 to 80 . 

Form of tumor 

Age 


5 

10 


1 

5 

.... 5 

4 

The fact ihat most of these cases have occurred in patients past sixty 

years emphasizes the malignancy of the tumors. 

Intravesical!)' 

Suprapubicaliv 

To 1 year 

1 to 2 years . 


3 to 4 years 


6 to 7 years 

Method of removal 

Time well 


12 

3 


.... 3 

3 

6 

1 

1 

1

104 Radium 

FIk. 5. Implantlmc Bare Tubes of Itadium Through 

Cystosi ope. Needle is shown pointing nt tumor base 

Fig. 6 Implanting Bare Tubes of Radium Through 

Cystoscope. Needle is thrust into base of tumor 

and seed Implanted

R a d i u m 

105 

But 2 of 15 cases have gone over ihe fiveyear period. 

No patient should be considered cured until he has passed the five 

year period. We have had one case which was well for four years, and 

then developed a seondary tumor, in his prostate, probably from some 

residiuum of his bladder carcinoma. 

Proof of removal 

Number of case- 

Proved by cystoscopy 10 

Proved by operation 2 

Not proved .. 3 

It is our routine to cvstoscope all cases every six months up to five 

years, unless there be suspicion of carcinoma, hematuria, etc., between 

these times. 

Mortality of suprapubic removal 

Of 9 cases in which this was done. 1 case died of carcinoma one 

year and nine months after operation, so there was no dircet operative 

mortality. 

Papillary carcinoma of the bladder, analysis of the 2 dead or dying cases 

1. Extensive carcinoma, all over the bladder, died two years after 

radium implantation, from metastases to urethra and inguinal glands. 

2. Multiple carcinoma of the bladder neck, removed intravesical!)'. 

Two years later had swollen legs from metastases to glands around iliac 

veins. 

INFM.TRATINC. CARCINOMA OF TUT- RLAOOKR 

Sixty-one cases, including only those which pathological section or 

palpation or cystoscopy have shown infiltration of Ihe bladder wall. 

Results 


Well -8 

Result not yet determined 13 

Dead or dying 3° 

These results, as compared vvith the results in papillary carcinoma. 

indicate how much more serious is the infiltrating type. 

Infiltrating carcinoma of the bladder, analysis of zvell eases 

Pathology Number of cases 

Infiltrating carcinoma 5 

Carcinoma * 

Papilloma 

No section - 

In many of these cases the pathological examination was made from 

a very small portion excised with a cystoscopic forceps. It is not always 

possible although it is always attempted, to get a piece of the edge of 

the tumor where it infiltrales ihe hladder wall.

106 Radium 

Fir 

Tumor Near 1'reihra. Therefore Radium Implanted 

ThroiiKh Urethroscope 

Fig. 8. Large InlUtrathig Carcinoma; Itadlum to be 

Implanted In Rase Through Suprapubic Opening

R a d i u m 107 

Sice (not of tumor, but of base of tumor) 


-: sq. em 2 

4 sq. cm , 

6 sq. cm 5 

12 sq. cm , 

16 sq. cm . 

30 sq. cm 2 

60 sq. cm ( 

Location 


Bladder neck 

^ 

Base, trigone 

y 

I-ateral walls 6 

Base, not 011 trigone 1 

Apex 

o 

As in papillary carcinoma 01 the bladder, the majority of cases. 

11 out of iS. involved the trigone, or bladder neck. 

Form of tumor 


Multiple 4 

Single 14 

In all of the above cases, vvith no exception, the tumor was confined 

to the bladder. In this exception, the tumor, as large as a hen's 

egg. had grown through the anterior bladder wall, and was adherent 

lo the pelvis. 

years 

Age 


30 to .10 years 1 

40 to 50 years 3 




Youngest 33 

Oldest 77 

Method of removal 


Intravesicallv 6 

Suprapubically - - 

This almost exactly reverses the statistics of papillary carcinoma 

of the bladder, the reason for this being the large size of most infiltrating 

bladder carcinomas, when they reach us.

108 Radium 

Fig. 9. Getting Specimen of Tumor for Examination. 

Prior to Operation 

Fig. 10. Same Tumor as Fig. 9. Top snared oft and base 

exposed ready for radium implantation

IUM 109 

Time well 


i to 2 years 

2 to 3 years > 

3 to 4 years . ... ?* 


5 to 6 years _,* 


7 to 8 years l 

•One patient died with the bladder free of carcinoma, from apoplexy. 

So as yet only 4 of the 18 cases have gone over ihe five year period. 

Proof of removal 


By cystoscopy 13 

By operation , 

Not proved 4 

In these 4 cases the patients were entirely well, but refused cystoscopy. 

Mortality of suprapubic implantation of radium 


Infiltrating carcinoma suprapubic implantation 53 

Dead 22 

7 twe living, post-operation 


1 month post- operation 1 

2 months post-operation 2 



5 months post operation o 


6 to 12 months post-operation 4 



18 lo 24 months jiost-operation 2 


36 to 48 months post-operation I 

The operative mortality was. therefore, less than 2 per cent. The 

1 patient that died in the first month from the operation, died uremic. 

He had an extensive, sloughy carcinoma of the base and lateral wall, 

with a base 36 sq. cm. His urea nitrogen before operation was 42 mgm. 

per 100 cc. This rose steadily to 120. and he died uremic three weeks 

after operation. Of the 2 patients that died in ihe second month one had 

metastases to the lung before operation, and the operation was done 

because of misinterpretation of the picture. The other died of what 

was apparently an entirely separate disease, lymphatic leukemia.

110 Radium 

Fig. II. Same Tumor as Fig. 9. Base implanted with 

radium seeds 

Sise of carcinoma in the 30 cases, dead or dying (Infiltrating carcin 

5 sq. cm 2 

10 sq. cm 5 

15 sq. cm 4 

20 sq. cm 5 

30 sq. cm 5 

40 sq. cm 2 

50 sq. cm 1 

60 sq. cm 1 

70 sq. cm 1 

100 sq. cm 1 

Kntire vault and later walls originating in prostate ("').. I 

Diffuse all ocvr bladder 2 

// is only fair to our operotwe statistics to say that we have opened 

up all cases in which we believed the carcinoma was confined to the 

bladder, and no matter how large the carcinoma was, we have implanted 

radium, knowing that in many cases We could do but little. In I case 

the entire half of the bladder was filledwith an infiltrating carcinoma. 

The patient was seventy-two years of age, and today, three years after 

operation, he is entirely well, sleeping Ihe night through without urinating. 

Another patient had a tumor of the anterior bladder wall, as 

large as a hen's egg. growing through the bladder, and adherent to the 

pelvis. This patient has no bladder tumor four years after cystotomy. 

So occasionally very large tumors can be controlled. Of the two small 

carcinomas each 5 sq. cm. in area, which have died, one probably originated 

in the seminal vesicles, but was not so diagnosed. The other

R a d i u m 111 

died of a secondary growth in the urethra, with metastases to the inguinal 

glands. 

Radium dose, infiltrating carcinoma 

Cases well -g 

Bare tubes alone g* 

Screened radium alone 

4V 

Bare tubes and screened radium 4 

Unscreened radium held against tumor and screened 

radium 

ij 

Bare tubes and unscreened radium 1 

*One case multiple treatment through cystoscope. 

IGne case 2 treatments: one case 3 treatments. 

(Three treatments. 

There were 8 cases in which bare tubes alone were used. In these 

8 cases the strength of the bare tubes varied between 0.2 and 3.0 millicuries. 

and 1 to 2 tubes to each cubic centimeter were used. In 5 of 

the 8 cases bare tube treatment alone succeeded in removing the carcinoma. 

In 3 cases, subsequent treatments were necessary to destroy 

the growth. 

SQUAMOUS CARCINOMA 

In 61 cases of infiltrating carcinoma there were 3 cases of squamous 

carcinoma. As far as I could *ce there was no way in which the 

diagnosis could be made prior to sectioning. They resembled any other 

flat infiltrating carcinoma. I believe they are more malignant than most 

carcinomas, and are somewhat more resistant to radium treatment. Of 

these 3 cases. 1 is well, and 2 are dead or dying. 

REASONS FOR FAILURE OF RADIUM IN* SOME CASKS 

In 2 cases we tried to implant radium in the base of the tumor without 

firstsnaring the tumor off. Boih of ihese cases were pretty extensive, 

and one especially very malignant. I am convinced we would have 

done better in these cases had we snared the tops of the tumors off, 

because wc should have been able to more accurately implant the base 

with radium, and the good results we have had are due to this very accurate 

implantation. All cases that have had a definite submucous extension 

is covered with normal mucous membrane. It is, as a rule, difficult 

to see. but can easily be felt. Notwithstanding we have had several 

cases in which the tumors have been removed by implanting bare tubes 

of the strength of 0.2 millicuries. such cases are rare, and the strength 

most useful is 0.6 to 0.7. There have been several cases in which it has 

seemed that we ought to have removed the tumor, and the reason that 

we have not done so was that we did not reinforce the bare tubes by 

the addition of screened radium to the surface of the tumor base. 

PRESENT ESTIMATE OK PROPER RADIATION 

Dr. Adair has suggested that various parts of the body be dividec' 

into sensitive and insensitive areas, and the method of radiation be 

varied according to the relative sensitiveness of the parts treated. This 

condition applies very well to the bladder, all parts of which are fairly

112 R a d i u m 

insensitive to the pain caused by the implanting of bare tubes, except 

the trigone and bladder neck. Tumors which deeply infiltrate these 

regions are at best very difficult to cope with, and while we have destroyed 

a number of such, the pain caused by the bare tubes has been 

great. It is possible that such tumors, if they have grown beneath the 

trigone and into the prostate, will be better treated by radium needles. 

which can be withdrawn. Each cubic centimeter will probably require 

a dosage of about 100 millicurie hours. 

INFECTION OF BLADDER TUMORS 

It has been demonstrated that streptococcic infection of a tumor 

inhibits the effect of radium or X-ray. Cancer of the glands of the 

neck, the inguinal glands, fascial sarcomata and many others have shown 

this fact. It is probable that if a bladder cancer becomes infected by 

streptoccocci, a like hopeless condition exists. We are at the present 

time attempting a study of the bacteriology of bladder tumors. If we 

find streptococcic infection, it is possible that this will have to be eliminated 

before any radium treatment is effective. 

ACTION OF RADIUM IN PATIFNTS WITH LOW HEMOGLOBIN 

Dr. Dean has made the interesting observation that in patients with 

reduced hemoglobin ihe action of radium is much delayed. He has 

used a long series of skin tests to demonstrate this. I have had i case 

to which I gave radium twice, and whose hemoglobin varied between 

10 and 50. He had a very extensive infiltrating carcinoma of the bladder 

and had several transfusions. While he ultimately succumbed to his 

disease, his bladder was virtually carcinoma free at the time of his death. 

This one case might seem to be some evidence against Dr. Dean's conclusions. 

However, it is well to keep them in mind, and certainly a patient 

wilh low hemoglobing should be transfused before any suprapubic 

implantation of radium. 

SUMMARY 

All cases of carcinoma of the bladder have l>ecn re-classified into 

2 groups: papillary carcinoma, and infiltrating carcinoma. In these 

groups have been included all cases removed intravesical!)' up to June. 

1919. when wc first began suprapubic implantation. Since June. 1919, 

all intravesical and suprapubic cases are included. 

Of 23 cases of papillary carcinoma of the bladder, in 15 the carcinoma 

has been removed, in 6 the result has not yet been determined. 

2 arc dead or dying 

Of 61 cases of infiltrating carcinoma of the bladder. 18 are well, 

result not yet determined 13 cases, dead or dying. 30 cases. 

A large majority of both papillary carcinoma and infiltrating carcinoma 

have involved the bladder trigone and bladder neck. 

Of 15 cases of papillary carcinoma the tumor has been removed 

intravcsically in 12 cases, and suprapubicallv in 3 cases. 

In iS cases of infiltrating carcinoma the tumor was removed intravesically 

in 6 cases, and suprapubicallv in 12 cases. 

The operative mortality of suprapubic implantation of radium in 

infiltrating carcinoma is less than 2 per cent.

R a d i u m 113 

epithelioma of the lip* 

Observations on One Hundred and Fifty Cases 

By William H. Kennedy, M. D.. Indianapolis, Indiana 

hpithelioma of the lip comprises, on the whole, about 2 per cent 

of all repotted cases of malignancy, and—in conjunction with neoplastic 

growths in other parts of the body- -its incidence is undoubtedly becoming 

more common, the frequency of its occurrence being out of proportion 

to the relative increase in population. As an increasing numlier of 

cases of epithelioma of Ihe lip continually present themselves for treatment, 

the necessity for better technic and more competent handling of 

the condition becomes particularly evident. Hampered as we still are 

by the lack of definite knowledge, regarding ihe etiology of these lesions. 

and. until recently, having no means of treatment which might be regarded 

as even reasonably reliable or satisfactory, progress has necessarily 

been slow. Those who have been most familiar with all phases 

of the condition, and who. therefore, were in a position to speak with 

greatest authority, have felt the need of caution in advancing along newlines, 

and. despite the most brilliant results in individual cases, these 

men have remained conservative in their attitude toward new methods. 

The wisdom of such a stand should meet with general approval. 

for the fact that they who had reason to believe lhey had "cured" a previously 

"incurable" disease were slow to blazon their success from the 

housetops, bespeaks the scientific spirit under which the investigations 

and experiments were undertaken, and. by the same token, enhances 

the value of the results obtained. 

The use of radium in the treatment of malignancy is now long past 

the experimental stage. Of 'hi? fact there can be no question. We no 

longer ask ourselves whether radium shall be employed, but rather howit 

shall be used, how much radium, how often, and especially whether 

it should be used alone or in conjunction vvith other curative measures. 

From the very outset radium has seemed peculiarly applicable to 

all malignant conditions of the lip. Even those who have remained 

skeptical as to its efficacy in all forms and stages of cancerous disease 

have admitted that radium is undoubtedly useful in the early stages of 

growth: antl as a malignant condition of the lip is usually one of the 

earliest lo be brought to the physician's attention this faci may, to a 

certain extent, account for the marked success within this special area. 

The reason for reporting ihis condition at an earlier stage than is 

frequent with most malignancies can readily be understood. Any abnormality 

about the mouth i* conspicuous and disfiguring, and moreover 

it constantly interferes with regular and important habits, such as eating 

and talking, in consequence of which Ihe person so afflicted will 

hasten in search of relief. If the case falls into the hands of a competent 

physician who is able to make a diagnosis, or. failing to do so. one 

who is willing to refer the patient to one who is qualified, the chances 

for ultimate relief are good. 

The mortality rale from epithelioma of the lip is still much higher 

than it should be. considering the accessibility of the lesion and the opportunity 

usually afforded for early treatment. However, as radium ther- 

•Reprinted hy permission from Radiology.i\*. 319-324. April. 1925.

Ill 

Radium 

apy has become more general, the published tabulated reports have coincidentally 

grown more encouraging, indicating that a larger number 

of cases of epithelioma of the lip are receiving earlier and more adequate 

treatment. Unfortunately, our statistics are still incomplete and proportionately 

misleading; but each year sees a larger number of cases reported 

and an ever-increasing percentage of "cures lo date." Even the 

most conservative operators now admit that a person who has remained 

Fig. 2 

(Cas,- I). C. M. S.. age »9. Duration of lesion on lower 

It cular p. nriR lesion year. on Al right- time aide »f of examination lower lip. slightly there was elevated a cir 

and about 1 im. In dlam-ter. 

in good health with no sign of recurrence for a period of five vears or 

longer can rightly be considered cured. 

Epithelioma of the lip is essentially a disease of middle life, although 

it occasionally occurs in the aged and. very exceptionally, in young 

people. Il is frequent in both sexes, priority being claimed for males 

Drawer (i) in a series of 9S1 cases at the Presbyterian, Roosevelt antl 

General Memorial Hospitals reports 95 per cent occurring in males.

R a d i u m 115 

This writer also found cancer of the lower lip lo be twelve times as frequent 

as cancer of the upper lip. 

The etiological factors in ihe production of this condition are still 

causing considerable discussion in all quarters. Although the use of 

tobacco--pipe-smoking especially-has long been regarded as being 

chiefly responsible for the appearance of the lesion in this particular 

locality, a sufficient number of cases have occurred in persons who never 

Fig. :: 

Fig. t 

(Case 2). N. F., age 51. Initial lesion appeared about 

one »>r in-fore examination. on mucocutaneous margin 

of lower lip, followed In three months hy ulceration. 

use tobacco to disprove this theory. And whereas smokers' burn has 

been given a prominent place in the etiology of cancer of the lip—benign 

:n ihe beginning but later developing inio a malignancy - ihe writer's 

personal experience leads him to conclude that the imi>ortance of tobacco 

in the causation of this condition has been overemphasized. In 

examining the histories of the 150 cases on which this article is based. 

it has, therefore, been concluded that the predisposing causes are undoubtedly 

of a complex nature and that no single agent can be held ex-

116 R A D I U M 

clusively responsible for this malignant state of the lip nor of the cancerous 

condition elsewhere in the human organism. 

Inasmuch as irritation or trauma may serve to aggravate an existing 

condition, leading, finally,to the cancerous state, a vital problem— 

if this theory is correct—-would be the determination, if it were possible. 

of the pathological condition of the precancerous state and of its origin, 

before the advent of this contributing factor. 

Fig. 5 

Fig. 6 

(Case 3). A. H. D.. age C2. Initial lesion keratosis. 

followed hy ulceration, and at the time of examination 

there was a roughly circular lesion in the middle of the 

lower lip with considerable destruction of tissue. 

Among the many theories presented on the subject is the inheritability 

of the tendency to spontaneous cancer in man. In a recent noteworthy 

article, Maud Slye (2) has recorded at great length a series of 

experiments and studies on mice, demonstrating this theory conclusively, 

according to this writer. Coincidental!)* the fact is pointed out that this 

premise must necessarily serve as strong evidence against the validity 

of the theory of cancer as a specific germ in the causation of this disease,

R a d i u m 117 

as held by many writers. On the other hand. Ewing in his book on 

Neoplastic Diseases contends that a demonstration of the inheritability 

of cancer in mice—a fact quite generally conceded—seems lo him to have 

no bearing upon the question of the inheritability of cancer in man, thus 

*Flg. 7 

Fig. 8 

(Case 4). I." C. age IS. Initial lesion a scaling patch 

which eventually ulcerated, located on the left side of 

lower lip. later extending across the entire lip. 

presenting, once again, both sides of the question, ably contested, for our 

choosing. 

With many other observers. Ochsner (3) believes in the infectiousness 

of cancer. In this view he claims to be substantiated bv "the studies

118 R a d i u m 

of Professor Smith, who has proved to ihe satisfaction of those competent 

to judge. Ihat cancer in plants is due to a micro-organism which 

he has been able to isolate and cultivate, and which produces cancer when 

inoculated upon healthy plants." Ochsner urges that further studies 

in human cancer be made on this basis, thereby furthering the work 

already done bv Roppin, Schill, Franckc, I.ampiasi. Scheuerlen. Konbassoff. 

Doyen, Wickham. Thoma. Sjobring, and numerous other observers. 

Here, once again, the question is raised as to whether results 

obtained in connection with cancer produced experimentally may be 

Fig. 

Fig. lit 

(Case J). A. A. I... age 44. Lcvlun appeared on mucocutaneous 

margin. left side or lower lip. al>nul nine months 

previous to examination. 

considered as conclusive evidence in a consideration of cancer in the 

human body. Is there not some influencing element or elements in the 

human organism which are lacking in ihe make-up of the lower animals 

and Ihe vegetable kingdom? 

The theoiy that cancer is a systemic or constitutional disease is also 

rather largely subscribed to. Kulkley (a) likens Ihe condition to tuberculosis, 

in that it is a product of civilization,it being the result of debased 

nutrition, with loo much food, or the wrong food, combined with underwork 

or indolence. He holds that the newer methods of transportation

R a d i u m 119 

of foods, particularly in connection with cold storage, over-indulgence 

in animal foods, the refining of Hour—by which the valuable potash salts 

and protein found in the germ and the husk are eliminated-—hasty eating, 

improper mastication and poor insalivalion. inattention to the bowel 

and kidney action, and the like, are additional contributory factors in 

ihe production of the faulty blood current leading up to cancer. 

Fig. 11 

Fig. 12 

(Case 6). S. K. Initial lesion appeared on mucocutaneous 

margin of the lower lip. near the right angle 

of the mouth. It consisted of a small warty growth, which 

gradually increased In size and eventually ulcerated. Locally 

a large ulcerating, fungating growth was present 

which occupied the entire right half of the lower lip. extending 

on the cutaneous surface practically to tin* margin 

of the chin. 

By way of citing another of the numerous views on the etiology 

of the cancerous condition, reference to a recent article by Bauer (5) 

may be of interest. This writer ascribes the immediate cause of the 

malignant state to a lowering of the surface tension of the tissue fluid, 

contending that it is the tissue rluid, and not the cells, which are responsible. 

His experiments demonstrate the fact that this isolates the cells 

and increases their tendency to divide. Bauer has found the average

120 R A D I U M 

surface tension of serum from patients suffering from cancer to be lower 

than in normal subjects. 

These scattered references will serve to suggest the trend of opinion 

which exists at the present time, indicating, above all. that, although a 

tremendous amount of earnest work is being done, no theory yet presented 

has been universally approved. How long we shall have to wait 

until the advocate of the cellular theory, the theory of infectiousness. 

or one of the numerous others already presented or still to be presented. 

shall prove conclusively that his stand is is tenable, is one of the most 

impelling questions of the age. 

In connection with the question of treatment of epithelioma of the 

lip, it is a fact that, until six or seven years ago. surgery was practically 

the only acknowledged means of relief in the treatment of this form 

of carcinoma. Notwithstanding this fact, however, the mortality rate 

remained high and recurrences were distressingly frequent. Previous 

to this time—in fact, as early as 1008—-Pusey and others had reported 

success in combating epithelioma of Ihe lip by means of X-rays, but results, 

on the whole, were discouraging. Surgery supplemented by X-rays 

apparently gave better results than either means employed alone. In 

this connection Pusey is reported to have stated that although, in an 

experience covering several hundred cases, he had treated many rather 

deep nodular cases of carcinoma of the lip with X-rays, In his judgment 

these cases required some other form of preliminary treatment. 

some means of radical destruction, as far as possible. "Whether this 

be done by electrocoagulation, surgery, or some other method of destruction 

is a moot point" (6). In Dr. Pusey's opinion, however, the claims of 

surgery arc stronger than those of electrocoagulation. 

Electrocoagulation, which consists in the coagulation of the diseased 

areas by means of heat produced by the high frequency current. 

in the hands of Dr. Pfahler has given satisfactory results in selected 

cases, the Oudin current (unipolar) being employed for small lesions 

and the d'Arsonval current for larger ones. The heat is generated in 

the tissues, and the penetrating value of this form of heat is greater 

than that obtained by thermocautery, which destroys only by transmitted 

heat. Pfahler believes that in properly selected cases the destruction 

following electrocoagulation combined with the gamma rays of radium 

or the high voltage X-rays over the adjacent tissues and the associated 

lymphatic areas will be more pv.mpl and satisfactory than can be obtained 

by radiation alone (7^. From the viewpoint of our own experience 

we have found radium most efficient in practically all cases of 

epithelioma of the lip; consequently we have had to resort to the use 

of electrocoagulation but seldom, although, in these few cases, with satisfactory 

results. 

Even those who still regard surgical intervention as offering the 

best means of cure in epithelioma of the lip. are more and more inclined 

to make use of other therapeutic agents in conjunction with it. In an 

experience covering ihe treatment of more than two thousand cases of 

malignancy, the writer has reached the conclusion that epithelioma of 

the lip can be treated most successfully hy the use of radium exclusively; 

and in the handling of the 150 cases which formed the incentive for this 

article, radium was the sole therapeutic agent employed. 

In January, 10,18. it was decided to use radium, to the exclusion of 

all other therapeutic measures, in the treatment of all forms of cancer. 

and this was done with the definite idea of thus determining the agent

R a d i u m 121 

which, in the last analysis, would be productive of a successful outcome. 

Working along these lines wc have been able to determine those types 

of malignancy which, we believe, must of necessity have the liencfit of 

other curative agents before we can hope to equal the satisfactory results 

which radium—unsupplemented—has given us in cases of epithelioma 

of the lip. The technic which we have employed has undergone many 

changes and modifications, since we have availed ourselves of the knowledge 

which other works have placed at our disposal. Healthy tissue in 

different subjects reacts in various ways to the radium rays; and. similarly, 

the effect of the latter upon different lypes of malignant tissue may 

be expected to vary in different subjects. We have seen lesions which 

disappeared after a very small dosage; in other cases, a maximum radiation 

wholly failed to destroy them. It is a common experience that a 

growth which shows rapid development often yields more readily to 

radium treatment than will an innocent-looking lesion of small proportions. 

In fact, it is not unlikely that certain apparently trivial growths 

may actually be stimulated by insufficient radium application. 

When, as is often the case, these patients are sent to the radiologist 

as the last resort, every other curative meaans having proven of no avail, 

brilliant results cannot, naturally, be anticipated. If we could always 

select our cases carefully, it would he a simple matter to be able to attain 

success in every case; but even in unselected cases results have been 

excellent, and the percentage of cures is extremely gratifying. It has 

been our experience that for the special form of malignancy under consideration 

in Ihis article, the surface application has decided advantages. 

Some radiologists have employed needles in administering radium, but 

the latter method has seemed to us to cause avoidable destruction of the 

surrounding normal area. In this group, surface applications of 50 mgs. 

of radium element were made, vvith filterof one-half millimeter of silver. 

one millemeter of brass, one millimeter of lead, and two millimeters of 

soft rubber, applying same two hours each day for fiveconsecutive days. 

which is our routine technic for such cases as 1. 2. 3. and 4. In Case 5 

the same technic was followed on both sides of lip. In Case 6 a like 

amount of radium with same screening was used but necessitated raying 

three areas due to the extensive involvement. Our experience has 

taught us that the above technic can be used in practically all cases with 

the assurance of a favorable prognosis. 

A brief summary of each case accompanies the figures. 

REFl-.RF.NCES 

1. Brewer, George Emerson: Carcinoma of the Lip ami Cheek. Surg.. 

Gynec. and Obst., Feb.. 1923. p. 169. 

2. Slye. Maud: Biological Evidence for the Inheriiability of Cancer 

in Man. Studies on the Incidence and Inheriiability of Spontaneous 

Tumors in Mice. lour. Cancer Res.. July, 1922. p. 107. 

3. Ochsner, Albert J.: Cancer Infection. Ann. Surg.. March. 1921. 

p. 294. 

4. Bulklev. L. Morton: Factors Contributing to the Increase of Cancer 

Mortality. Amer. Med.. Oct.. 1922. p. 558. 

5. Bauer, E.: Formation of Cancer. Ztschr. f. Krebsforsch. 1923. 

XX. 358. 

6. Pusev, William Allen: In discussion of article by George E. Pfahler. 

Jour. Radiol.. June, 1022. p. 216. 

7. Pfahler, George E.: Malignant Disease and Its Treatment by the 

X-ravs, Radium and Electrocoagulation. Northwest Med., Dec.

122 R a d i u m 

-923. P- 432; also Cancer of the Lip Treated by Radiation or 

Combined with Electrocoagulation and Surgical Procedures. 

Jour. Radiol.. June. 1922. p. 212. 

REVIEWS AND ABSTRACTS 

G. E. Pfahler. M. D. (Philadelphia). Radiation Therapy in Deep 

Seated Malignant Disease. Surg.. Gvnec. and Obst. xli, 443-448, October, 

1925. 

"Radiation therapy in malignant disease was at first used only on 

the recurrent and the hopelessly inoperable cases. In some of these. 

striking effects were obtained. Gradually more and more of the primary. 

superficial cases were referred for treatment, until now radiation is the 

method of choice in the treatment of the superficial and non-infiltrating 

carcinoma." 

"Likewise, in deep sealed malignant disease, only the recurrent, 

metastatic or hopelessly inoperable, cases were originally referred for 

treatment. Many of these have shown striking results, and some have 

shown permanent recovery. This has established confidence and gradually 

the entire profession is recognizing the value of radiation. More 

and more primary deep seated malignant disease is being subjected to 

radiation early." 

"The recognition of radiotherapy is national and international, as 

is indicated by the fact ihat no hospital is today considered fully equipped 

unless the radiological department is prepared for both superficial and 

deep radiotherapy. The American College of Surgeons, in its last 

report states: 'Superficial and deep therapy is advisable when possible 

and practical. Supervision through a medical roentgenologist is essential.' 

Ewing very pro|»erly says: 'The rapid adoption of radiotherapy 

must stand as evidence of the intellectual honesty of the medical profession. 

Yet there is still an undercurrent of antagonism which reaches 

the public with much force, greatly inqicdes progress, interferes with 

the spread of knowledge, retards the acquisition of equipment and prevents 

many from receiving the benefits now available.' " 

"The fact that so much progress has been made in the short period 

of 25 years indicates that the value is inherent in the radiation," 

"In superficial lesions, the problem is relatively simple. In deep 

lesions, however, it is much more difficult for one must always aim to 

preserve the normal tissues and the function of essential organs through 

which the radiation passes. Otherwise the problem would be merely a 

physical one. to be solved chiefly by the physicist. In fact, it has been 

the impression among man)-, within recent years, during which time 

one has heard much of the so-called 'deep therapy.' that a physicist, or 

a few hours' instruction bv a physicist, was the most essential requirement." 

"A good radiotherapist must have a knowledge of general medicine 

(the more the better), and of general pathology and special pathology. 

He must be well informed in physics, electricity, and mechanics, and 

he must have an imagination that will enable him to picture in his mind 

the anatomy, the distribution of the disease and the distribution of the 

rays, as each beam is directed into the body, so that he can make the 

rays produce the greatest i>ossib1e effect on the disease and the least 

upon normal tissue and organs. Therefore, the greater the knowledge 

and skill of the radiologist, the belter will be the results."

R a d i u m 123 

"It has long been recogni/.ed that tumors vary to a considerable 

degree in their susceptibility to radiation. E'en tumors of ihe same 

type vary considerably. Ewing says: 'In general, tumors derived from 

embryonal cells and retaining embryonal characters, even when growing 

rapidly, arc. as a rule, particularly susceptible to radiation, and in this 

group some of the most remarkable and paradoxical of the radium cures 

have been recorded.' Mni| of you. and all of us radiologists, have seen 

patients with most extensive disease apparently hopeless cases—respond 

beautifully and go on to recovery, while others with comparatively 

little disease show no response." 

"Ewing classifies tumors according to their radiosensibility. as follows 

: 

"i. Lymphoma: lymphocytoma, lymphosarcoma, myeloma. 

2. Embryonal tumors- carcinoma of the testes and ovary; basal 

cell carcinoma. 

3. Cellular anaplastic adult tumor-:; "round-cell" carcinoma, diffuse 

carcinoma. 

4. Dcsmoplastic tumors: carcinoma simplex, fibrocarcinoma, squamous 

carcinoma. 

5. Adenocarcinoma: adenoma of the uterus, intestine, breast, etc 

6. Fibroblastic carcinoma: osteosarcoma, neurosarcoma.'" 

' 'The microscopical changes in the cells under the influence of 

radiation consist of swelling, hy perch romati sm. vacuolar degeneration 

and solution or fragmentation of nuclei, hydropic swelling, vacuolation 

and solution of the cytoplasm. Mitotic nuclei are particularly vulnerable, 

ihe chromosomes splitting, -the spindle threads disintegrating, and 

ihe whole cell undergoing relatively speedy solution. The surrounding 

stroma exhibits hvpera-mia. slight serous exudation, outwandering of 

leucocytes, and growth of new capillaries, which in many instances probably 

plays a prominent part in (he removal of tumor cells.' " 

"Radium is probably more selective in its action on tumor cells than 

the X-rays. By h>s experiments on the larva of frogs. Friedrich has 

found that the radiation from radium in like quantity has about three 

times the biological effect ;is compared with that from the roentgen-rays. 

My clinical experience will confirm ihis observation. Therefore, when 

one can choose, it is advisable to use radium for the destruction of malignant 

disease whenever it can be brought in direct contact with the disease. 

The X-rays, however, are preferable when the radiation musl be 

carried to some depth, through other tissues in order to reach the tumor. 

or when the disease must l»c destroyed at a depth of more than 3 centimeters. 

(1) because ihe direction of the radiation from radium is most 

difficult to control, while a beam of X-rays can be directed almost like 

a bullet or a knife; u I because the radiation from radium, like thai 

of the X-rays, diminishes with ihe square of the distance, which makes 

treatment with radium at a distance entirely impractical. The distance 

in the application of radium is measured in millimeters, while most commonly 

the X-rays are used at a distance of from 20 to 50 centimeters 

or even 100 centimeters. This is more than 100 times as great a distance, 

which increases the relative depth value. Therefore, we use 

radium in deep scaled malignant disease, only when it can be inserted 

into the diseased area, such as in carcinoma of the uterus or when located 

in some of the cavities or when radium needles containing the 

radium emanation or radium element can be distributed evenly throughout 

the malignant tissue. We use the high voltage X-rays when tumor

124 R A D I U M 

cells must be destroyed at a depth of more than 2 or 3 centimeters and 

when crossfiring is an important factor." 

'"Most work has been done in malignant disease of the uterus. The 

results accomplished by the radiologists in the treatment of inoperable 

and hopeless cases of carcinoma of the uterus have gradually convinced 

the gynecologists of the value of radiation treatment, and gradually one 

clinic after another has taken up the radiation treatment and applied it 

in the borderline and operable cases, until now radiation is the method 

of choice in the treatment of all cases of carcinoma of the uterus, except 

possibly in carcinoma of the fundus. Radiation is the method of choice 

in operable cases only, however, if the proper facilities are at hand, and 

if sufficient skill and technical knowledge has been developed to give the 

treatment properly." 

'"Ihe next great group of cases of deep seated malignant disease 

is carcinoma of the breast. In this group we have very few statistics. 

Statistics in carcinoma of the breast are most difficult to prepare, because 

very few early cases of carcinoma of the breast have been referred 

for treatment. Nearly all cases have been vi^ry advanced and hopelessly 

inoperable primary cases with recurrences or with metastasis. The 

other breast cases have been referred for preoperative or postoperative 

treatment. 1 have written in detail upon these subjects and will discuss 

them only briefly here." 

"Pre-operaiive radiation is indicated because, as has been shown 

experimentally. (1) it devitalizes the malignant cells so that they are not 

easily transplanted, and because tissue that has been irradiated does not 

easily 'take' cancer when implanted, and in fact it has a destructive effect 

upon cancer cells when implanted, as shown at the Rockefeller Institute." 

"Postoperative radiation has been used over a longer period of time, 

and some statistics are appearing as a result." 

"The value of postoperative irradiation is almost universally recognized. 

Almost every one has seen the remarkable disappearance of recurrent 

carcinoma, and since all rccurrenres develop from retained carcinoma 

cells, it is logical to assume that the treatment which will make 

macroscopic lesions disappear should also make microscopical lesions 

disappear. Therefore, the postoperative radiation should be applied as 

soon as practical after operation." 

"The following conclusions may be drawn: 

"1. Patients should be taught to apply early for treatment. Any 

lump or abnormal bleeding may be due to cancer. 

"2. Physicians should learn lo recognize cancer in its early stages. 

"3. Pre-operative irradiation will devitalize the cancer cell and 

prevent its transplantation or dissemination. 

"4. Postoperative irradiation should destroy remaining carcinoma 

cells. 

"5. Thorough and skillful treatment by radiation offers most in 

all stages of carcinoma of the cervix. Sixty to So per cent mav be expected 

to recover if treated in the earliest stages, while less than 1 per 

cent will recover in the late stages. 

"6. Radiation will not cure generally disseminated cancer. The 

more extensive the disease, the less the chance of recovery. Radiation 

is a local method of treatment. 

"7. Skill is required in deep radiotherapy in the same sense and 

degree that is required for successful surgery. Surgical instruments 

are to the surgeon what radium and the X-rays are to the radiologist."

R a d i u m 125 

OBITUARY 

JAMES C. GRAY 

On May ist. 1925. James Callam Gray. President of the Standard 

Chemical Co. of Pittsburgh, died at his home, following a protracted 

1860-1925 

JAMES C. GRAY, M. A.. LL.D. 

illness. Mr. Gray was born in i860 in Dundee, Scotland, and cam 

tlie United States vvith his parents when he was twelve ve.irs

126 Radium 

of the Pennsylvania railroad. He attended the Ohio State University, 

and later came to Pittsburgh, where he was connected with the legal 

department of the Pennsylvania railroad. Later Mr. Gray entered the 

general practice of law in Pittsburgh. He was first associated with the 

law firm of Scott and Gordon, and left to become first assistant city 

solicitor. Later he associated with the late Clarence Burleigh under 

the firm name of Burleigh and Gray. Afterwards he founded the firm 

of Gray, Thompson and Rose, of which firm he was the senior member 

until his death. 

Mr. Gray helped organize the Pittsburgh Law School, which was 

later affiliated with the University of Pittsburgh. The university honored 

him with the degrees of M. A. and LL. D. 

In 1906 Mr. Gray became associated with the late James J. and 

Joseph M. Flannery. as general counsel for the Flannery Bolt Co. 

and the American Vanadium Co. In 1911 he was one of the organizers 

of the Standard Chemical Co. which was founded by the late Joseph 

M. Flannery to undertake the extraction of radium from the Colorado 

carnotite ore. On the death of Mr. Flannery, in 1920. Mr. Gray was 

elected president of the Standard Chemical Co. and held this office until 

his death. 

During his life Mr. Gray was active in church and educational 

work, being an elder in the Point Breeze Presbyterian Church and a 

member of the Board of Trustees of the Pennsylvania College for 

Women. 

The following memorial resolution was passed by the Board of 

Directors of the Standard Chemical Co.: 

"WHEREAS. God. in His Infinite Wisdom, has taken from us our 

fellow director and President; be it 

"Resolved. That on ihis solemn occasion, we liear witness to the 

many sterling qualities for which we have held him in great esteem. 

his sincere Christian spirit, his unswerving integrity and goodness, his 

self-sacrificing devotion to duties, his high ideals in business and his 

wise and upright counsel. We mourn that his death takes from his 

family a devoted husband and father, that his Church loses a staunch 

and faithful supporter, and that we are deprived of a fearless and unselfish 

leader and a 'rue friend. Be it further 

"Resolved. That this resolution be inscribed in the minutes of ihe 

Standard Chemical Company, and that a suitably engrossed copy thereof 

be sent to his bereaved family, as a token of our sorrow and an expression 

of our sympathy."

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