Untitled - Clpdigital.org

Publisher.
PRESENTED BY

R A D I U M
A MONTHLY JOI'RNAL DEVOTED TO THE CHEMIS­
TRY. PHYSICS AND THERAPHEI'TICS OF RADIUM
AND OTHER RADIO-ACTIVE SUBSTANCES
b V b
VOLUME SEVENTEEN
APRIL, 1921. TO SEPTEMBER, 1921
PITTSBURGH, PA.
1921

Uftfltftj - Mull
xirv
CONTENTS OF VOLUME XVII
NTMBKR
ONE
Madame Marie Curie's Visit to the United States 1
American Radium Society 3
Reviews and Abstracts,
Russell H. Boggs, M.D. The Lethal Dose of Radium in Malignancy
5
A. N. Clagett, M.D. The Treatment of Goiter with Radium. ... u
J. F. Gudernatsch, Ph.D., antl H. J. Bagg, Ph.D. Disturbances in
the Development of Mammalian Embryos Caused by Radium
Emanation 11
Obituary. Joseph Ransohoff, M.D [6
NUMBER TWO
William L. Clark. New Conceptions Relative to the Treatment
of Malignant Disease with Special Reference to Radium in
Needles 17
Reviews and Abstracts.
F.verett S. Lain, M.D. A Clinical Study of Epithelioma of th
Lower Lip 35
NUMBER THREE
Charles H. Viol. Ph.D. The Story of Madame Curie's Gram of
Radium 27
NUMBERS FOUR-FIVE
The Dangers in Working with Radium and X-Rays. How the
Problem Is Being Met 53
C. J. Johanneson, M.D. Report of Case of Gastric Carcinoma. . (10
Reviews and Abstracts.
J. C. Mottram, M.B., D.P.H. The Red Cell Blood Count of Thos
Handling Radium for Therapeutic Purposes 02
J. C. Mottram. M.B.. D.P.H. Histological Changes in the Bone
Marrow of Rats Exposed to the Gamma Radiations from
Radium 65
Madame Marie Curie's Visit to America: A Correction 67
The Measurement of Madame Curie's Gram of Radium 68
NUMBER SIX
A. F. Hayward Pinch. F.R.C.S. A Report of the Work Carried
Out at the Radium Institute. London, from January 1st. 1920,
to December 31st, 1920 69

A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY, PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES
Copyright 1921 by Radium Chemical Co.
Edited by Charles H. Viol. Ph. I)., 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,
Pittsburgh. Pa.
Subscription $2.50 per year, or 25 cents per copy in the United States and
In all other countries S3.75 per year.
VOL. XVII APRIL, 1921 No. 1
STATES
MME. MARIE CURIE'S VISIT TO THE UNITED
On May 7th Mme. Curie and her daughter Irene will leave France
to visit the United Stales, where she will receive as a gift of the women
of the United States a gram of that precious element r.adium which she
and her husband, Pierre Curie, discovered in 1S9S.
While in the United States. Mme. Curie will visit New York, Boston,
Washington, Pittsburgh, Chicago and she will make a trip to the
Grand Canyon of Colorado. Mme. Curie will make the trip as a result
of an invitation from Mrs. William Brown Meloney, editor of the "Delineator,"
and it was to bring about Mme. Curie's fondest wish that
Mrs. Meloney has organized the Marie Curie Radium Fund Committee,
through which funds are sought for the purchase of a gram of
radium, which will be presented to the world's most distinguished woman
scientist as a tribute from the women of the United States. Subscriptions
to this fund are solicited from all women and should be made to
the Marie Curie Radium Fund, at the Equitable Trust Company, 37 Wall
Street, New York City.
When inquiry was made as to what she particularly wished to see
while visiting the United States Mme. Curie expressed her desire to
visit Pittsburgh in order to sec where the world's greatest output of
radium is produced. She further expressed a desire to visit the Grand
Canyon of the Colorado. These wishes are to be gratified and Mme.
Curie will visit a number of the country's largest cities. She will also
be the recipient of many honorary degrees while in this country.
Mme. Curie was born in Warsaw. November 7, 1867 the daughter
of John Sklodowska, a professor of physics in the University of Warsaw.
Her mother was Swedish and her father a Jew, who was conveiled
to Catholicism shortly before the birth of his daughter.

2 R a d i u m
The story of the discovery of radio-activity of polonium and
radium is a most interesting example of how science advances. In
her classical work "Traite de Radioactivite," published in Paris in
1910, Mme. Curie tells this story in detail, and the following has been
taken from that work.
When Roentgen in 1895 discovered the x-rays, the vacuum tube,
through which he passed the current, did not have a metallic anticathode
such as is now used, and as a result the cathode stream struck
the glass of the tube rendering it fluorescent. The suggestion was made
by Poincare that possibly the production of the x-rays was in some way
connected with the observed fluorescence. Following out this idea Henri
Becquerel of Paris in 1896 began experimenting to see wnether certain
fluorescent uranium salts would affect a photographic plate through
opaque coverings. His firstresults seemed to indicate that the fluorescent
uranium salts did affect the covered photographic plate. Later
Becquerel observed that the uranium salts caused the same action on
covered photographic plates, when in the dark, and this led him to doubt
whether the fluorescence had anything to do with the result. On trying
he found that all uranium compounds, whether fluorescent or not, caused
the darkening of covered photographic plates, and he attributed this
action to what he called the uranium rays. These rays he found would
penetrate through thin metal films and cause the discharge of electrified
bodies. Mme. Curie utilized this latter property, (which Rutherford
found was due to the action of the rays in ionizing gases wherebv the
gases are rendered conductors of the electric current) to make quantitative
measurements of the intensity of the uranium rays from different
uranium compounds, a delicate electrometer being the instrument
employed. She found the activity of the uranium constant, and the
activity of the various compounds was proportional to the amount of
uranium in the substance. In 1898 Mme. Curie carried over her observations
to the other known elements, and independently discovered,
what Schmidt in Germany had just announced that the element thorium
also emitted a radiation comparable to the uranium rays.
Mme. Curie next undertook a study of many substances to see
whether there could be any other radio-active substances other than
uranium and thorium. The word radio-active used to describe the property
of these substances which emit the Becquerel rays, we owe to Mme.
Curie. In this study Mme. Curie tested many minerals and among them
found certain ones radio-active. All of these active minerals contained
uranium or thorium or both, but the significant fact was that the activities
of these minerals were all three to four times greater than could be
accounted for by the uranium or thorium content. On preparing artificial
chalcolite, a copper uranate. the artificial mineral was found to
have the normal lower activity. This led Prof, and Mme. Curie to
seek in these minerals other radio-active elements than uranium or
thorium. For this study the Curies took pitchblende, a uranium
mineral that could be easily secured in quantity. On separating this
mineral into its many constituents, Mme. Curie found by electroscopic
testing that part of the minerals' activity was separated with the bismuth.
To this radio-active substance which was associated with the
bismuth, the name polonium was given, in honor of Mme. Curie's native
land. The barium extracted from the pitchblende was found also
to be active and in December of 189S there appeared in the Comptes
rendus of the Academy of Sciences, the first report of this work by
the Curies in collaboration with G-. Bemont, which concerned the new

I^APITJM 3
radio element associated with the barium, to which the name radium w
given. The radiferous barium chloride obtained from pitchblende was
900 times as active as uranium oxide, while the polonium preparations
with bismuth were 400 times as active as uranium oxide. Careful study
by spectroscopic and chemical methods indicated that the amount of
these new elements present in the mineral was infininitcly small, and it
was only after separating many kilograms of barium sulfate from several
tons of Bohemian pitchblende residues that Mme. Curie obtained sufficient
material to effect a separation of the radium. By a tedious process
of fractional crystallization she finallysucceeded in securing very intensely
active mixtures of barium and radium which showed higher
average atomic weight than that of barium (Ba-137). First 140, then
141, 145.8, 173.8, 223, 225.3, 226.45. At 145.8 the spectrum showed new
lines and at 223, the salt had a spectrum in which only a few of the
strongest barium lines showed, and the lines of the new element, radium
predominated.
For their work in radio-activity Prof, and Mme. Curie, and Prof.
H. Becquerel of Paris were jointly awarded the Nobel Prize in Physics,
in 1903. In 1911, Mme. Curie was awarded the Nobel Prize in chemistry.
She was nominated for membership in the French Academy, to
which no woman has ever been admitted, and failed of election by only
two votes. She has a professorship at the Sorborne, a post to which she
acceeded on the death of her husband who was run over by a dray and
instantly killed in Paris April 19. 1906.
To further her scientific work Mme. Curie urgently requires a
quantity of radium. She is entirely dependent upon her very small university
salary for the support of herself and her two daughters, and she
is therefore unable to secure the radium out of her own limited means.
Mme. Curie has not benefited financially from her great discoveries, and
it is the sad truth that in the laboratory of the discoverer of radium,
there is practically no radium available for scientific work. It is to
make up this deficiency and to honor the world's most distinguished
woman scientist that the women of the United States are planning a gift
of a gram of radium for Madame Marie Curie.
AMERICAN RADIUM
SOCIETY
The following papers have been announced on the preliminary program
of the Sixth Annual Meeting of the American Radium Society to
be held in Boston Monday and Tuesday, June 6th and 7th, 1921. The
place of meeting for the scientific papers will be the Harvard Medical
school.
Monday, June 6th, 1921
"Treatment of Primary Carcinoma of the Vagina with Radium."
Leda J. Stacy, M.D., Rochester, Minn.
"Histologic Changes Occurring in Carcinoma of the Cervix following
Radiation, with Special Reference to the Factor of Distance."
Charles C. Norris, M.D., and Norman S. Rothschild, M.D., Philadelphia.

4 R a d i u m
"Radium in the Treatment of Carcinoma of the Breast as an Ad
to Surgery."
Ben R. Kirkendall, M.D., Columbus, Ohio
"Radium Combined with X-Ray Treatment in Carcinoma of the Breast."
George E. Pfahler, M.D., Philadelphia.
"Treatment of Glandular Enlargements with Radium."
Russell H. Boggs. M.D., Pittsburgh.
"A Comparison of Radiation Dosages Attainable by Use of Radium on
and Within Tumors."
Charles H. Viol, Ph.D., Pittsburgh.
"Dosage in Radium Therapy."
Gioacchino Failla, E.E., New York
"A Comparison of X-Ravs with Gamma Rays."
William Duane, Ph.D., Boston.
"Hypcrthyroidism-Classification-Basal Metabolism in Diagnosis-Rena
and Blood Findings-Treatment by Radium."
R. E. Loucks, M.D., Detroit, Mich.
"Action of Radium on the Blood and Blood-Forming Organs."
Isaac Levin, M.D., New York.
"Experiences in the Treatment of Nasopharyngeal New Growths."
Curtis F. Burnam, M.D., Baltimore.
"Treatment of Multiple Papilloma of the Larynx in Children."
Gordon B. New, M.D., Rochester, Minn.
Tuesday, June yth, 1921
"Radium in Dermatology."
Frank E. Simpson, M.D.. Chicago.
"Dosage in Superficial Lesions."
William S. Newcomet, M.D., Philadelphia
"Treatment of Carcinoma of the Rectum."
Douglas Quick, M.D., New York
"Treatment of Prostatic and Bladder Carcinoma."
Hugh H. Young, M.D., Baltimore
"Treatment of Malignant Disease of the Bladder."
Benjamin Barringcr, M.D., New York.
"Treatment of Brain Tumors by Radiation."
Henry K. Pancoast, M.D., Philadelphia.
On Monday evening the annual dinner of the society will be held
at the Hotel Brunswick, at which time the president will give his address.
On Tuesday afternoon a radium clinic will be held at the Huntington
Memorial Hospital, by invitation and under the direction of Dr. Robert
Greenough.
The officers for the Boston meeting arc: Dr. Henry Schmitz, president,
Chicago, III.; Dr. H. H. Janeway, firstvice president (deceased).
New York City; Dr. Leda June Stacy, second vice president, Rochester,

R a d i u m 5
Minn.; Dr. R. E. Loucks. treasurer. Detroit, Mich.; Dr. William S.
Newcomet, secretary, Philadelphia. Pa.
The program committee consists of Dr. H. K. Pancoast. Philadelphia.
Pa.; Dr. Ernest C. Samuel, New Orleans, La.; Dr. Gioacchino
Failla, New York City. .
The membership committee consists of Dr. R. E. Loucks, Detroit,
Mich.; Dr. James T. Case, Battle Creek, Mich.; Dr. Douglas Quick,
New York City.
The local committee of arrangements consists of Dr. Isaac Gerber,
Providence, Mass., and Dr. J. Harper Blaisdell, Boston, Mass.
REVIEWS AND ABSTRACTS
Russell H. Boggs, M.D. (Pittsburgh). The Lethal Dose of Radiu
in Malignancy. N. Y. Med. Jour, cxi, 1013-1015, June 12, 1920.
"The results of radium treatment in malignancy depend upon
whether a lethal dose is given. In giving a lethal dose the susceptibility
of the malignant tissue to the radiation must be determined as well as
its depth from the surface. Many are still confusing the erythema with
the lethal or cancer destroying dose; the erythema dose in some instances
is the lethal dose. In the past many radiotherapeutists expected
an erythema dose to cure the malignant lesion regardless of the type. It
was known almost from the beginning that basal cell epitheliomata and
lymphosarcomata were more susceptible to radiation of either radium
or the roentgen rays. Some have realized that certain types of sarcoma
and carcinoma require three or more times the erythema dose. The
metastases may be more malignant or less malignant than the original
growth, but recurrences are generally more malignant than the primary
growth. It is also true that the metastatic glands in every case do not
respond to the same amount of radiation. It requires more radiation
as the distance from the surface increases, and this loss of intensity
must be made up by crossfiring. Therefore, it can readily be seen that
radiotherapy is a difficult and complex problem, and although the subject
is difficult for many to master, most of those using radium and the
roentgen rays have not made a comprehensive study of either agent or
malignancy."
"Malignancy should be a specialty in itself, but wilh most surgeons
and with most of those applying radium it is a side issue. Inefficient
treatment so often leads to a fatal ending in favorable cases that
no one inexperienced should treat even the early cases. Eradicating
every malignant cell is difficult, no matter how thoroughly the method
employed is carried out. Most radiologists and surgeons formerly were
satisfied with the removal of the visible part of the disease. If the local
growth is removed either by surgery or by radium, leaving a cancer
growing edge, the patient will not be cured. Cutting out the center of
a malignant growth usually hastens metastases, because it removes the
natural local barriers. Anteoperative raying is being advocated by some
and may even be more valuable than postoperative. Even if a lethal dose
cannot be given, the treatment may be sufficient temporarily to check
proliferation and make the lymphatics a stronger barrier against cancer

6 R a d i u m
cells when operation is performed. In fact, it would seem that anteoperative
raying renders latent many cases of malignant growths."
"Dr. William J. Mayo, in his presidential address before the Clinical
Congress of the American College of Surgeons, October 20, 1919, advocated
ante-operative radiation in the following words:
" 'Radiotherapy has justly achieved a reputation in the postoperative
treatment of cancer. It would appear, however, to have its greatest
field of usefulness in preparing a malignant area against wound grafting
during operation and its ability at least temporarily to reduce the
vitality of the malignant cell. Radiotherapy, whether applied as radium,
x-ray, or heat, sickens malignant cells beyond the area of destruction.
During this period of cell sickness their resistance is reduced and operation
is most efficient; but operation should not be delayed after radiotherapy,
since the period of increased cell vulnerability is short and the
connective tissue development, which interferes with subsequent operation,
is rapid. By properly combining radiotherapy with surgery we can
increase operability, lower mortality, and increase percentage of cures.
Radiotherapy destroys cells for a certain distance, but cells are sterilized
at a greater distance, so that their reproduction is checked, and connective
tissue is caused to develop which acts as a barrier to the further
extension of the malignant process.'"
"In calculating the filtration and the number of ports of entry or
amounts of crossfiring necessary to give a lethal dose to metastatic lymphatic
glands, it is not only necessary to know the anatomical situation
and which chains arc most prone to metastases, but we must know- the
depth and the density of the overlying structures. It makes quite a
difference whether ihe glands arc situated half an inch or four inches
from the surface. Formerly those employing both radium and the
roentgen rays paid little attention to loss of radiation by divergence of
the rays or by absorption in the tissues. They seemed to think that
because radium would penetrate thick metals or because a roentgenogram
could be taken of thick parts, the penetrating power was all that
was needed. Therefore, a majority of those employing radiotherapy
give a surface erythema dose, and perhaps only one-eighth or less of the
dose reaches four inches below the surface of the skin. Then, if the
lethal dose is from three to four times the amount of the erythema dose,
the radiation at this distance through one port of entry is useless."
"Every one employing cither radium or the roentgen rays should
make a study of the lethal and the erythema dose, and also know at
what depth from the skin he is able to destroy certain types of malignant
tissues. The degree of malignancy is no guide to the amount of
radiation in determining its lethal dose. On account of rodent ulcer
being of a low degree of malignancy, growing slowly and responding to
small amounts of radiation, these circumstances led many to believe that
a lethal dose was determined by the degree of malignancy of a tumor.
This is erroneous. Medullary carcinoma may respond more rapidly to
radiation than the scirrhus type, but it grows more rapidly and invades
the glands earlier, so if a cure or even an inhibitor}' effect of the disease
of this type takes place, both the local tumor and metastases must be
given sufficient radiation. If results arc going to be produced in the
medullary type, the cancer cells must show effect within three or four
weeks, and fibrous tissue must be forming at the end of this time. In
the scirrhus type, the fibrous formation has already taken place by nature's
process."
"In squamous epithelioma of the lower lip an erythema dose will

R a d i u m 7
often partially heal the lesion, and it may remain stationary for some
time; but it nearly always requires three or four times this amount to
destroy all the cancer cells. Clinically much less than a lethal dose
checks the growth of a cancerous process and starts fibrosisat the end
of three or four weeks. It is always important in estimating the susceptibility
of a growth to radiation to know the histological type."
"In this connection permit me to quote the following conclusions
from the article of Wood and Prime, published in the Journal of the
American Medical Association, January 31, 1920, in their study of lethal
doses in mouse tumors:
" 'The practical conclusion which may be drawn from these observations
is that the amount of roentgen ray necessery to kill all the cells
of a rapidly growing, very cellular, and highly malignant sarcoma or
carcinoma in man is between five and seven erythema doses of filtered
roentgen ray when the tumor is on the surface of the body. Every
centimetre of tissue that covers the tumor makes an additional amount
of roentgen ray necessary.' They further conclude that, at a depth of
ten cm. from the surface, 'while many tumor cells may possibly be
slowed in their progress and mitotic forms killed at such depths,it is
doubtful whether all can be destroyed. The basal cell tumors and the
lymphosarcomata arc, as is well known, much more susceptible to radiation.
Small, superficial, metastatic carcinomata are also, in some instances,
more susceptible than in the primary tumor.'"
"It is to lie remembered that Wood and Prime arc speaking of only
the direct action of radiation on malignant tissue, but there is an indirect
effect of radiation on malignant cells by the formation of fibrosis
which starts to fonn three or four weeks afterward. Both are important,
and a lethal dose should always be given whenever possible; but
less than a lethal dose sickens malignant tissue, as Mayo expresses it,
and starts the formation of fibrous tissue which is a barrier against the
disease. At present, by burying radium needles, a lethal dose can nearly
always be given, but in the treatment of deep metastatic glands we may
be compelled to depend upon both the direct and indirect effect of radiation
on malignant cells."
"In a paper on Radium in the Treatment of Carcinoma of the Cervix
and Uterus, read before the Eastern Section of the American Roentgen
Ray Society, January, 1920, I discussed the difference between the
erythema and lethal doses of radium and the roentgen rays. An attempt
was made to show that many were treating the local growth efficiently,
but only a small number of these realized the difficulty in
treating the metastatic lymphatics in the pelvis. In all malignant lesions,
except rodent ulcer, radiation should consist of treatment of the local
growth and the adjacent lymphatics. In treating both the local growth
and the lymphatic glands, the burying of radium is a step in advance
over surface applications, as it requires so much less radium to give a
lethal dose. Hanley's investigation of the lymphatics have made metastases
more thoroughly understood. Unfortunately there is no method
of diagnosis by which we can tell whether metastases have reached a
certain chain of lymphatics or not. In some cases metastasis takes
place so early in the disease that it has been stated it was regional from
the beginning. In practice we must regard every case of cancer as one
in which glandular metastasis has taken place."
"Basal cell epithelioma or rodent ulcer is amenable to treatment by
radium, and if the ulceration is not deep or extensive, an erythema dose
may heal the lesion, but ifit is of the squamous cell variety, the lethal

8 R A D I U M
dose is usually three or more times the erythema reaction. In the early
days this difference in susceptibility of the two types of epithelioma led
many to believe that the squamous cell cancer could not be cured by
radium."
"When the lethal dose is given, radium is the most efficient method
we possess in the treatment of malignant growths of the mouth and
throat. In the early days of radiotherapy I always gave three or four
times the erythema dose, which in some cases produced local necrosis,
and after the lymphatic glands of both sides of the neck were rayed,
e'ther by x-ray or radium, the necrotic tissue was later removed by
electric coagulation or surgically. Since we have been inserting radium
needles through all parts of the malignant tissue, it is necessary to resort
to an electric coagulation or surgery in only comparatively few
cases, the submental glands, the parotids and submaxillary glands, at
least on the affected side, while the cervical glands are generally treated
by the roentgen rays."
"Epithliomatous growths on the tongue and on the floor of the
mouth under the tongue, as well as those of the tonsil, even when the
lesion was advanced and breaking down, have been clinically cured
either by surface applications of radium, followed by electrocoagulation,
or by inserting radium needles into and around the growth. Results during
the past two years have been obtained by this process which could
not have been obtained by cautery or any other method. In all these
cases the patients received intensive radiation on both sides of the neck.
In some of these advanced cases the results were of short duration,
while others were clinically cured for over two years. Sarcoma
of the tonsil, even if it fills one half or more of the throat, will
disappear under radium treatment in nearly even- case within a month,
but there is a tendency to recurrence.
"As a routine treatment for epithelioma of ihe lower lip, radium,
applied from all sides of the lip. offers more than even the most complete
excision. Since it has been stated surgically that no patient with
cervical nodes or with more than one group of lymph nodes involved
at the time of o[>eration lias remained well, it is plain to be seen that even
in lower lip cases, if the patients are operated upon, anteoperative and
postoperative treatment should be given."
"The prognosis and treatment of mammary carcinoma can be
estimated only after consideration of many factors. Hanlev considers
operation contraindicatcd when there is extensive ulceration and when
the tumor is adherent to the chest wall: when axillary nodes are fixed;
when there is supraclavicular involvement, and when there is indication
of distant metastases. When the axillary glands are palpable there
are very few cures by surgery alone without radiation, even when .".miliary
nodes are not palpable, and when the glands are found to contain
cancer cells microscopically only about twenty per cent, of the patients
are cured at the end of five years. Then, since statistics show that
operation shortens life in recurrent cases, it seems advisable to give
both anteoperative and postoperative radiation. There is a growing
tendency to remove the breast in case of chronic mastitis or suspected
carcinoma, and it seems justifiable. In suspected carcinoma many assert
that it is safer to remove the entire breast than to make a partial
excision for diagnosis. The past history of cancer of the breast with
the unfavorable prognosis, except in miniature carcinoma, has made
even1 one pessimistic in regard to the treatment. Radium and the roentgen
rays have proved valuable either as an adjunct to surgery or even

R a d i u m 9
alone in certain types of cases, but neither can be relied upon as a specific
cure."
"It is a difficult problem to give a lethal dose of cither radium or
the roentgen rays to all of the cancer cells in anything except the very
early cases, because the breast is connected with more lymphatic chaii-s
than almost any other organ in the body. The clinical and pathological
studies of cancer of the breast have shown that both surgery and radiotherapy
meet with many difficulties and uncertainties. The anatomical
types are many, the variations of the clinical course are so wide, the paths
of dissemination so diverse, and the difficulty of determining the acuial
conditions so complex, that giving a lethal dose is difficult."
"After cancer cells have reached the axillary nodes, the disease soon
becomes generalized and tissue in almost any part of the body may become
involved. If we had an x-ray microscope and it were possible to
give a lethal dose to all cancer cells, the end results would t>e different.
When it is impossible to give a lethal dose, palliation and prolongation
are obtained in nearly all cases. Less than a lethal dose will frequently
«rnn cell proiferation, produce a fibrosis of the lymphatics and obstrur'
or obliterate the lymphatic vessels, thereby checking cancer dissemination.
In fact, radiation changes the character of the disease, rendering it
more of a scirrhus form by decreasing glandular cells and increasing
the fibrous stroma. This mechanical choking clinically seems to influence
the constitutional resistance of the patient."
"During the past five or six years it has been a common occurrence
for many of the surgeons to operate on carcinoma of the breast and then
refer the patient for radiotherapy, suggesting a Coolidgc x-ray treatment
over the incision once a month for six months, omitting many
adjacent lymphatics. The radiotherapeutist may not be familiar with
metastases and the adjacent lymphatics are often left untreated. There
are about twenty lymphatic chains connected with the breast and many
treat only the axillary and supraclavicular inefficiently. It is impossible
to determine the real value of anteoperative or postoperative treatment-,
as there is no way by which metastases can be visualized at the time of
operation, and much of ihe radiation has been done in an incompetent
manner."
"I will report briefly two cases, in one of which both anteoperative
and postoperative radiation had been given, and in the other only postoperative
treatment. Both were advanced cases of carcinoma and would
be considered inoperable; in each there were a mass in the breast about
th size of an egg, retracted nipple, and axillary involvement. In one
case the patient received a complete course of ante-operative radiation.
treating the breast at different angles and crossfiring adjacent lymphatics
in every direction. Eight weeks afterward a radical operation was performed.
The axillary glands, which were greatly reduced in size at the
time of operation, had undergone fibrous degeneration. The patient had
postoperative treatment and is still clinically cured three years after
operation. In the other case, the patient, without anteoperative radiation,
was operated upon by the same surgeon. Postradiation was started
two weeks after operation. This patient had no superficial recurrence.
hut died from internal metastases within a year. I could report a number
of similar advanced cases which would favor anteoperative radiation,
and some in which only the breast was amputated, the axilla no:
being opened.
"Radium has taken an important place in the treatment of carcinoma
of the cervix and in some institutions they are treating primary cases

10 R a d i u m
without operation. Many have purchased radium and are employing it
in uterine cases without having a good technic. The method of applying
radium varies considerably and it is natural that the end results, as well
as the amount of palliation, should vary."
"'At present more favorable cases are referred since the gynecologists
are realizing what can be accomplished by radium. Until recently
hysterectomy was the only method by which a cure could be expected,
although the five-yearperiod showed a discouragingly low percentage ol"
patients alive. It has long been realized from a microscopical viewpoint
that even the boldest operator could not expect to remove all the lymphatic
tissue about the base of the bladder, in the parametrium or in the
region of the uterosacral ligaments."
"For the purpose of description, carcinoma of the cervix may be
classified as follows:
"First, early cases where the disease seems to be limited to the
cervix and does not extend into the vaginal wall. Even in these cases,
there are so many recurrences that radium should be used."
"Second, where the process is more advanced, but clinically it seems
limited to the uterus as the organ is freely movable, but the chances are
that there are metastases in the pelvic nodes. These patients will undoubtedly
derive great benefit from anteoperative treatment and the end
results should be improved."
"Third, where the carcinomatous process extends into the vaginal
wall and there is slight fixation of the uterus. These might be considered
borderline cases, and as most of them can clinically be cured by radium
alone, radium should be used with operation."
"Fourth, where there is marked fixation of the uterus and the disease
extends into one or both broad ligaments. In many of these cases
extensive glandular involvement has taken place, and in some cases
metastases may have extended into the liver. Thes patients will derive
benefit from radium. A local clinical cure may take place but usually
metastases have been so extensive that there is usually a recurrence in
from one to three or more years. When you consider that many of
these patients live as long by radium treatment as a large percentage in
even early cases, when operated upon, it means much to the patient.
Many of these patients will die from internal metastases without a local
recurrence."
"When primary cases of carcinoma start in the cervical canal there
are very few cases cured by operation. For this reason, some gynecologists
assert that these patients receive more benefit from radium than
operation. Time will tell whether radium alone is advisable. All gynecologists
have conceded that radium is the best palliative measure in inoperable
and recurrent carcinoma. Local disappearance of the disease
tkes place in some cases and marked improvement is noticed in a large
proportion of the others. After radium treatment the offensive discharge
the treatment would be justified. The deodorizing and sterilizing
effect is remarkable where there is a broken down mass of cancerous
tissue. Many of these patients show an irregular temperature from absorption
of broken down material which generally disappears after application
of radium."

R a d i u m 11
A. N. Clagett, M.D. (Chicago). The Treatment of Goiter with
Radium. 111. Med. Jour. XXXVIII, Oct. 1920, pp. 318-320.
"There are many kinds of goiter: Congenital, the goiter of adolescence,
simple, cystic, colloid, fibroid, malignant, toxic and Graves' disease.
The purpose of the present paper is to discuss the toxic and
Graves' disease forms only."
"It would seem to us that these, plus the malignant and the parenchymatous,
are the only varieties where radium would be beneficial,
though it may be that experimental work might show it applicable to
a few of the other forms."
"Of the many theories put forward to explain exophthalmic goiter
two still stand up as probable. First, that the trouble is due to a hypersecretion
of the gland, which, however, may be and probably is changed
in its character. The other, that the secretion of the gland stimulates
the sympathetic system which in turn again stimulates the gland and
thus a vicious circle is instituted. The major part of the evidence seems
to favor the first theory. This much is certain that, regardless of the
etiology, certain distinct changes take place in the thyroid gland, the
blood and some of the other organs. Many observers have noted an
almost universal proliferation of the glandular cells, an increase in the
connective tissue, certain groups of lymphoid tissue scattered through
the connective tissue and enlargement and multiplication of the blood
vessels. The colloid material is scanty and lacks the usual bright stain.
There is a lymphocytosis and decreased polymorphonuclear neutrophiles
suggestive of disturbance of the lymph system. This is further evidenced
by the presence of an enlarged thymus gland. Melchior stating
that, based on his personal experience and 151 papers, the unduly enlarged
thymus occurred in about 90 per cent, of the exophthalmic
goiters. There is enlargement of the spleen and the lymph glands."
"It is the purpose of the normal thyroid gland to formulate an iodine
compound, working over the iodine into an iodothyro globulin and
secreting a colloid material in which the iodine is stored up. Thus the
explanation why. in Graves' disease, with lessened colloid secretion
there would be so much more iodine in the blood and suggesting decidedly
that the trouble is due more to an altered secretion than a superabundance
of normal secretion. In other words, the gland secretes
a toxic substance which is thrown into the blood stream and causes the
well known phenomena.
In undertaking to treat this disease we must consider medical treatment,
surgery and ray therapy. As the etiology is unknown, we must
attack it symptomatically and with regard to what is known of the
pathology. Medical and hygienic treatment have an undoubted place,
but should not be persisted in until degenerative changes have taken
place in the heart. Crile of Cleveland expresses the opinion that "nonsurgical
treatment should always be tried. If this has been done without
avail, then surgical procedures calculated to break the force of the
disease are indicated." There has been a tendency, especially of late
years, to rather regard exophthalmic goiter as a surgical disease and
we agree with Crile in holding this to be a fallacy.
"The results of surgery have not been markedly brilliant and a
number of prominent surgeons have expressed the opinion that surgery
is unscientific, applied to this disease. The statistics of the Mayo Clinic
show a mortality rate of three to four per cent. Kocher shows likewise
a similar death rate. V. C. David states that of sixty-five patients
operated on 38 per cent, were cured, 40 per cent, benefited. Judd and

12 Radium
Pemberton report 121 cases of which 45 per cent, were cured, the rest
of them showing improvement or none at all. The average length of
time required to effect a cure by surgery was 17.9 months. We must
remember further that these were selected cases a number being refused,
the operative risk being considered too great, and that these represent
the statistics of the more skilled surgeons and undoubtedly the operative
mortality is greater broadcast throughout the country. Kocher
also made a habit of ligating vessels and extending the course of treatment
over a considerable time before operation and he goes so far as
to state that the operation for Basedow's disease is a most serious one
and should not be undertaken by any surgeon "who has not previously
operated a number of times upon simple goiter.
DaCosta states that it is the Mayos' custom to use x-rays daily for
several weeks and then to operate, and it is also his own custom to use
the rays preliminary to operation in order to decrease the vascularity
of the part, to lessen the amount and diminish the toxic quality of
the thyroid secretion.
Schwartz states that the radiotherapeutic treatment of Graves' disease
has as high a percentage of success as the surgical method and has
none of the danger and pain incident to the latter. He claims 00 per
cent, of success for radiotherapy.
In the year 1913 Abbe of New York treated a case of goiter by
burying radium tubes in the gland and reported a remarkable success.
Many other workers, among them Wicham, Degrais, Dominici, Barcat,
Aiken of Toronto. Moriarta of Saratoga Springs, have used radium
by external application and reported gratifying results.
When we consider the pathology- of the gland and the action of
radium it would seem to have a most certain place as a remedial agent.
We again bear in mind that there is a proliferation of the ghndular
cells, deposits of lymph tissue through the thyroid, an enlarged and active
thymus and lymph nodes and we see that the disease apparently is
not confined merely to the thyroid gland. If surgerv be done a diseased
portion of the gland is removed and healthy thyroid tissue also taken
away. In the portion left behind, certain of the diseased elements remain
to often cause further trouble and perhaps to again proliferate
when the strain for caring for the body is thrown upon the small remaining
amount of normal thyroid tissue, also the thvmus gland is not
operated upon. We remember that there is a hyperplasia of the arteries
which Kocher and the Mayos have endeavored to attack by ligation
but this does not distribute the blocking process evenly through the
gland.
Radium possesses the ability to kill a diseased cell or a new growth
cell when five times the same dose would be necessary to kill a normal
adult cell. Also when applied to a blood vessel there is a swelling of
the tunica intima folowed by an obitcrative endarteritis in the smaler
vessels and diminution of the caliber of the larger ones. Now whether
the toxic secretion be due to the additional blood supplv or to the activity
of the new formed cells in the gland, or to both, it will be affected
by the radium action. There is this further advantage in using radium,
that while diffuse action over the entire gland will eliminate the toxic
cells yet the normal healthy tissue will be left untouched provided the
dosage can be accurately estimated. Further the blood supply will be
reduced much more evenly throughout the gland than can be done by
ligation of some of the thyroid arteries."
"We also see that radium can be used not only on a case suitable

R a d i u m 13
for a surgeon, but on cases where the surgeon is compelled to decline to
operate and even on cases where the surgeon has operated and failed.
The thymus and lymphatic system can be, and are, rayed, which may
explain the success of radium on a case where operative removal of a
part of the thyroid has not been successful."
"So far the literature shows no death resulting from radium therapy
and there is a marked advantage over the x-ray in that the dark discoloration
of the neck following x-ray treatment has not been observed.
Radium can be used upon a nervous patient where the x-ray would be
prone to cause excitement and furthermore ihe radium can be carried
to a patient at home if necessary."
"The following is a summary of my own work. The technic as
given by me in a paper read last Fall before the Radiological Society
of North America has not been changed. I have treated to date 47
cases of exophthalmic goiter with radium—the first case being treated
in September, 1917. The patients' ages have varied from 16 to 74 years.
Two were of the ages of 16 and 19, both with pronounced exophthalmic
goiters. Of these cases six had already been operated on with recurrence
of symptoms as bad or worse than before. Seventeen cases were
declined as operable risks by some of our best surgeons. I have had to
ray eight cases the second time as the dosage was inadequate and while
the patients improved, the firstraying did not give sufficiently satisfactory
results. Last October, in a paper read before the Radiological Society
of North America, at Chicago, I stated that one patient who had
taken up Christian Science was apparently not benefited, but am pleased
to be able to report that recently this patient's sister informed me that
the patient, now living in the country, is feeling entirely well and that
she now ascribes her recovery to the radium treatment. Two cases
with very bad broken compensation of the heart have died since treatment
from acute dilatation, one three months after treatment, the other
five and one-half months, though in both these cases the pulse had
slowed an average of thirty beats and the nervous symptoms were remarkably
reduced. In one case out of five there has been no reduction
of the goiter; the circumference of the neck has diminished from %
of an inch to 3J4 inches in the others. One woman's goiter did not decrease
until thirteen months had elapsed and then suddenly went down
i$4 inches in less than two months."
"The exophthalmos has been usually the last symptom to disappear
and has remained in five of the cases. The pulse beat has been reduced
twenty to fiftybeats. Nervous symptoms and tremors have disappeared
entirely and the patients gained in weight and general well being. There
has been symptomatic cure in all of the cases treated with the exceptions
noted."
"Conclusions: I believe radium should be given a trial in exophthalmic
goiter:"
"First: There is no mortality, no scar or pain, no long hospitalization.
Three or four days suffice for the treatment."
"Second: Its advantages over the x-ray are—no discoloration of
the neck—less time consumed in the treatment—simpler to apply."
"Third: The thymus gland can be treated."
"Fourth: While surgery in removing proliferating cells leaves
others behind, and by Iigating still leaves some of the blood supply more
or less undisturbed, the selective action of the radium ray, to a much
greater degree destroys the harmful cells and also causes a much more
symmericai diminution of the blood supply."

14 R a d i u m
"Fifth: It can be used in cases where surgery fears to venture or
has failed."
"Sixth: Surgery has not been necessary after the radium treatments
in a single one of my forty-seven cases, some of them extending
back nearly three years."
J. F. Gudernatsch and H. J. Bagg. Disturbances in the Development
of Mammalian Embryos Caused by Radium Emanation. (From
the Department of Anatomy and the Memorial Hospital, Cornell University
Medical College, New York City). Reprinted from the Proceedings
of the Society for Experimental Biology and Medicine, 1920
XVII, pp. 1S3-1S7.
"As has been shown by various observers, the exposure of living
tissues to the influence of radium rays leads to a severe injury and
ultimate destruction of these tissues. In our work an attempt was made
to study this destructive influence on mammalian embryos in utero, in
the hope that a partial or complete destruction of one or more tissues
might lead to delnite abnormalities or malformations in these fetuses."
"Bagg had lately used a method of applying radium, which was described
in the Journal of Cancer Research, Vol V, 1920. Radium emanation,
carried in a very small amount of saline solution, was injected in
measured quantities into adult rats, either subcutaneously or intravenously.
This solution contained all the properties of the radium metal
itself, and, no doubt, the resulting physiological changes were due mainry
to the activity of alpha rays. Such an injection produced peculiar destructive
changes in the inner organs of the animals."
"The same method was used in our experiments. After long experimentation
we found that a dose of 5 mc. (= milli-curies, a standard
unit in radium experimentation) was about the optimal dose. Such an
amount was injected into female rats, pregnant and non-pregnant, with
the purpose of either injuring the ovarian or uterine tissues, or, in case
of pregnancy, the embryonic tissues. While the results were not those
which we expected, viz., the production of various types of monstrosities,
yet a definite influence of radium on the fetal and placcntial tissues
was noticeable. Radium-treated rats were killed at different periods of
pregnancy, so as to procure a series of fetuses of various ages."
"The most destructive results of radium emanation, injected subcutaneously,
were seen in a number of pregnant females, in which the
embryos were killed in the uterus and. instead of being aborted, remained
attached to the uterine wall and were gradually absorbed (group I).
Whether the embryos were killed primarily, or their death was due
to the destructive influence of the radium on the maternal, placental
tissues, cannot, of course, be determined. Probably the first assumption
is correct, since other findings (group II) showed, that the toxic
agent does pass the placenta and affects the embryos directly."
"A number of such partially absorbed embryos were found, the age
of which, naturally, could not be determined. Judging from the sizes
of their respective placenta:, however, development must have proceeded
to some extent before the radium was applied. The remnants of the
embryos were small, nodular bodies attached to the placenta? figures
were shown) and had lost all resemblance to properly developed fetuses."
"In one case a small, ovoid shaped sac was found, attached i>v a
thin stalk to the uterine wall (figure shown). This apparently repre-

R a d i u m 15
sented the remnants of a former embryo and placenta, although neither
one could be recognized any longer. In the sac extravascated blood and
cell detritus were found. A great many large cells of an epithelioid
nature probably belonged to the former embryonic syncytium. The wall
of this cyst was formed by fibrous connective tissue."
"In a number of other cases (group II), the fetuses were not
killed by the radium emanation, but peculiar macroscopic lesions appeared
in their skin vessels."
"When the fetuses were removed from the uteri, peculiar hemorrhagic
areas were noticeable, in some cases just along the dorsal midline,
in other cases, spreading over the entire body with the exception
of the ventral surface. These extravasations took place in the vessels
of the subcutaneous connective tissue and along the meningeal sinuses.
In all cases, one or more hemorrhage appeared in the midline, mainly
in the head and thoracic regions. It seems that the vessels in this dorsal
median zone are especially liable to injury. In one instance, there was
a large area of hemorrhage extending over the thoracic and lumbar region.
Its outline was just symmetrical to the dorsal midline (figure
shown). In other cases, a great number of such hemorrhagic areas,
some extremely small, were found over the lateral aspects of the head
and body. Probably these affected fetuses would have died, if left
longer in the uterus, and would have undergone absorption. In many
animals which we killed in the early parts of the experiments we failed
to find any fetuses, although we definitely believed that these animals
had been pregnant before. We probably waited too long after treatment,
so that the embryos were completely absorbed, when the animals
were opened."
"Not all of the fetuses of one litter are affected in the same degree.
In one case, for instance, we found among 7 fetuses 3 showing hemorrhagic
lesions. 2 beginning to macerate and 2 in the process of absorption.
This difference in resistence may be due either to the higher or
lower vitality of the embryos themselves or to the amount of radium
which passes the placenta. In another case the fetuses, although injured,
were carried to full term and among 6 young of one litter we
found two normal and four showing hemorrhagic spots on head, face
and along the dorsal midline."
"In one very remarkable instance the female had been treated 22
days previous to conception and yet the fetuses, approximately 16 days
old. showed areas of extravasation (one of considerable size shown in
figure). These lesions were much more widely distributed than in
previous cases, extending over both lateral and dorsal surfaces (figure
shown). These results cannot be explained at present. It would seem
as if the treatment of the mother previous to conception had lessened
the faculty of the later embryos to form proper endothelial walls. The
wide distribution of the lesions would seem to substantiate such a view.
This is in accordance with findings in adult animals treated with radium
in which the extravasations in the organs arc due not only to increased
blood pressure, as would seem at first,but to the actual breaking down
of the endothelial tubes. In other words, the effect of radium on endothelium
might be selective."
"When the radium was injected intravenously (group III) instead
of subcutaneously, the same lesions resulted along the vascular channels.
Females of about 19 days pregnancy were injected intravenously
and the young, born dead 24 hours later, showed the hemorrhagic lesions
along the dorsal midline (figures shown). In one case we found a

16 ' R a d i u m
striking difference in the size of the placenta; of different fetuses. One
fetus, for instance, had a markedly enlarged placenta completely filled
with blood, so that it had the appearance of a large hemorrhagic sac.
This fetus did not show any hemorrhagic lesions, while their placenta?
were of normal size and moderately tilled with blood. It would seem as
if in the firstcase the placenta functioned as an effective "shock-absorber,"
while in the other cases the radium emanation passed through
the placenta; to the fetuses."
"Lately Bagg exposed pregnant females, near full term, directly to
the action of beta rays (group IV). This radiation of the fetuses in
utero, through the abdominal walls produced hemorrhagic lesions of
the same nature as described above. However, the lesions did not appear
until about 10 days after exposure. The young were born 2 days
after treatment and appeared normal. After about a week they began
to fail considerably, hemorrhagic areas appeared along the mid-dorsal
line, especially in the head region and death followed. The homorrhages
in these animals were mainly along the meningeal sinuses (figures
shown), in some cases frontal and occipital hemorrhages were just beginning,
in others they extended considerably over the cerebral hemispheres.
Additional lesions on the dorsal side of the thorax were
found."
"The interval of 10 days after treatment strictly corresponds to the
time at which a primary skin erythema develops in radium treated patients.
Again it seems as if the endothelial walls had been injured at
the time of exposure and gradually gave way to the blood pressure."
"In the course of the experiments, we also found numerous hemorrhagic
areas in the uteri and especially in the ovaries (figures shown).
Congestion of the uterine vessels always was pronounced."
"While in experiments on adult animals reported by Bagg before.
the injection of radium emanation led to considerable injuries in the
internal organs, in our experiments the weaker doses did not produce
any macroscopically visible effects on the maternal tissues. However,
the embryonic differentiating tissues were easily affected. This fact
might be of some biological significance, when one remembers that
radium rays have a decided effect on fast growing tumor and cancer
tissues."
OBITUARY
DOCTOR JOSEPH RANSOHOFF
Dr. Joseph Ransohoff, professor at the University of Cincinnati died
at his home in Cincinnati March 10th, 1921, following a prolonged
illness which had confined him to his home since last fall. Dr. Ransohoff
was born in Cincinnati May 26th, 1853. and received the degree of M.
D. from the Medical College of Ohio in 1874. Since 1S77 at which time
Dr. Ransohoff was made a member of the Royal College of Surgeons in
London, Dr. Ransohoff specialized in surgery. Since 1905 he has been
Professor of Surgery in the University of Cincinnati and at his death
was a member of the staffs of the General. Good Samaritan and Jewish
Hospitals. He was an extensive contributor to current surgical literature
and with his son. Dr. J. Louis Ransohoff. also a surgeon, has contributed
a number of articles on the applications of radium in combination
with surgery.

A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY. PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES
Copyright 1921 by Radium Chemical Co.
Edited by Charles H. Viol. Ph. D.. and William H. Cameron. M. D with the assistanc
collaborators working In the fieldsol Radlochemistry, Radioactivity and Radium therapy.
Address all communications to the Editors, Forbes and Meyran Avenues,
Pittsburgh. Pa.
Subscription $2.50 per year, or 25 cents per copy In the United States and Canada
In all other countries $3.75 per year.
VOL. XVII MAY, 1921 No. 2
NEW CONCEPTIONS RELATIVE TO THE
OF MALIGNANT DISEASE WITH SPECIAL REFER­
ENCE TO RADIUM IN NEEDLES*
TREATMENT
Twenty-four IIlustrationsf
WILLIAM L. CLARK. M.D.. PHILADELPHIA
Those of us who are engaged in studying and treating malignant
disease realize that much is yet to be learned before the problems of
malignancy are entirely solved; yet realizing our definite limitations,
we know that much more can be accomplished by combined methods
of attack than could be accomplished in the past when operative surgery
alone was relied upon. When the etiology of cancer is finally determined,
perhaps some specific, analogous to anti-toxin in diptheria or quinine in
malaria, may be found, but from present knowledge local attack is most
fruitful of positive results. Operative surgery, electrothermic methods
(desiccation, coagulation, cautery), radium and x-rays, alone or in
combinations, are the most important methods to be considered, and they
have been found to be of the greatest practical value in combating malignant
disease in its various manifestations. Since it is almost impossible
•Reprinted by permission from ihe Penna. Med. Jour. XXIV. 211-221. Jan.
1921. Read before the General Meeting of ihe Me-lical Society of the State of
Pennsylvania, Pittsburgh Session. October 5. 1920.
fit is the impression of the author that visualization of results favorable and
unfavorable will give a clearer idea of the merits of the respective methods under
consideration than the citation of full case histories, which would require more
space than is available: hence it is hoped that brief legends accompanying the
photographs will in a measure serve the purpose intended.

iS
R a d i u m
for one man to be proficient in
all these methods, co-operation among
a group of men, each expert in his
own specialty, is desirable. To accomplish,
however, the maximum of
success, with these available weapons,
it is necessary to revise some fallacious
ideas which are still considered
orthodox by many, perhaps by a majority
of the medical profession. The
use of combined methods in the
treatment of cancer has been shown
from clinical experience to be sound
practice. The physician who employs
only one to the exclusion of all others,
while he may have limited success
with certain types of cancer, can not
obtain so brilliant results in a wide
range of cases as he who uses various Fig. 1. — Exemplifying rccurri.-ni-e
methods judiciously combined.
after surgical excision of an epithelioma
r-f the lower lip and dissection
The problem of basal cell epitheliomata
or rodent ulcers involving Of metastatic cervical glands without
preliminary preparation wilh
cutaneous surfaces, especially about
the face, eyelids, etc., growths which
radium or x-rays. The migratory
seldom metastasize even though advanc cells in Ihe lymphatic ducts drained
cation of the lesion bv anv method will
into the tissues of the neck and diffuse
recurrence soon took place.
ed. has been solved. Total eradiresult
in clinical cure. Epithelio-
Fig. 2.—A, mixed angio- and osleos.ircoma. Referred by lir J W Croft Waynesboro.
Pennsylvania. Ii. note retrogression after first radium needle treatim-nt
Two later nidlum treatments from the outside resulted in still further reduction
in the sls>e of the lesion. An absolute cure is not expected In this case because
of very deep involvement, but the patient's life has undoubtedly been prolonged

Radium: 19
Pig. 3.—A, B. C, small round cell sarcoma, shown from different angles, involving
frontal region, bone, frontal sinus, eyelids and nose. Recurrence after surgical
operation, when growth in the sinus was curetted through opening In frontal
bone. Case referred by Drs. Homer I. Silvers and W. Price Davis. Atlantic City.
N. J. D. result of radium needle treatment. Xote total retrogression without
destruction of tissue, and conservation of eyelids. No recurrence In two years.
mata involving the skin of the extremities are treated less successfully
because of the greater tendency of such growths to metastasis. The
method, or methods, to use in these cases is a matter of personal preference.
An operator who is a master of his own method will succeed
where others using the same method will fail because of imperfect
technic.
The squamous cell and glandular types of cancer are the most difficult
of management, because they usually progress rapidly, metastasize
early, and because the migratory cells in the ducts cannot be reached by

20 Radium
surgical treatment. Malignant disease of the lip. buccal surface, tongue.
floor of the mouth, alveolus, antrum, tonsils, soft palate, pharynx, epi-
• A
*
i - 3 k
' \
A
B
Fig. 1.—A. mixed cell sarcoma, recurrence after two surgical operations. B. result
Of combim-d dCSlCCatlOn and radium needle treatment. No recurrence In 7 months,
glottis, larynx, esophagus, stomach, breast, uterus, rectum, etc., taxes
the skill of the surgeon; but frequently brilliant results are obtained even
in ihese cases by the use of combined methods, results that were impossible
of accomplishment in the past before the newer methods were
availabl. This is true also of the various types of sarcoma.
Fig. 5.—A extensive sarcoma involving the deltoid and shoulder, attached to .s.
bon.-. extending to the subclavian and axillary regions. I^f.tml 1 v r Joh, ?-h ,.e
mers l.a Costa. Philadelphia. B. result of one radium needir^aiment Thenw «
total retrogression of the disease in this case with no recurrent in ten EomiX

R a d i u m 21
Excision or other treatment of primary malignant lesions of the
types which metastasize, together with block dissection of apparently
uninvolved glands, for prophylaxis, or of palpable metastatic glands for
the purpose of total eradication of the disease, no matter how thoroughly
executed, is certainly not sufficient. The migratory cells in the lymphatic
ducts must also be taken into consideration and rendered innocuous by
appropriate measures to be discussed later, else they will drain into the
tissues after the glands, nature's safeguards, have been removed, and
early recurrence and rapid progress of the disease will usually result.
Operative surgery, without preliminary preparation., is unsafe in these
cases, and the patient, if denied the benefits of preliminary treatment.
will usually live longer and in greater comfort if the disease is left to
inn iis course without interference. That migratory, malignant cells do
exist is not a mere hypothesis, but a reality recognized by pathologists,
and measures must be adopted to destroy the microscopic cells in situ
before attempting surgical or any other treatment of the perfectly apparent
lesions.
The lethal action of radium, and in a lesser degree of ihe x-rays,
upan malignsnt cells of all types—some types resisting more than others
— hrs been proved both in the laboratory and in practice. The following
quotation from a paper by Sonnenschein, "The L'se and Possible
1
•
f ' hi
~*r
A
B
Fig, 6,—An inoperable adenocarcinoma of the breast and axilla. Referred by Dr.
Wii Kenham Snow, New York City, and Or. F, A. Jewett. Brooklyn. Diagnosis
m?de by Professor John Chalmers l>a Costa. Philadelphia. B. result of radium
needle and x-ray treatment. There was total retrogression of the disease in six
weel^s. When treatment was begun the patient was toxic, cachetic and anaemic.
had lost much weigh), and dealh seemed Imminent. After treatment she regained
Abuse normal of weight, Radium and in has the been Treatment free from of apparent Malignant disease Tumors for eight of months. the Nose
and Throat," published in the Journal of the American Medical Asso-

2Z
R a d i u m
ciation, September 25, 1920, embodies present knowledge regarding the
action of radium upon malignant cells from the laboratorv standpoint:
'Wood and Prime showed that exposure to beta and gamma rays for a
Fig. 7.—A, basal cell epithelioma involving the ear and mastoid region. Referred
by Ur. F. c. Tlce, Roanoke. Va. B, retrogression of growth after radium needle
treatment, with conservation of ear. Patient In good condition after 15 months.
Fig. S.—A. basal cell epithelioma of the dorsal surface of hand Involving i*nrt«.nS
and
and
bloodvessels
bloodvessels
and
and
adhereni
adherent
to
to
t:one.
tone.
Patient
Patient
aged
agfd":«"
76
"RpTorV^rhv"n.."Vi*'"if
rSmmtISi hi rvJV i «
Baxter.
Baxter.
Philadelphia.
Philadelphia.
B.
B.
retrogression
retrogression without
with.
gr^.timp.irmem
/. «^Fi£
of
_V J?_r:,"'
lllSi «f
fi
the hand after radium needle treatment. This dl/KlSRKSK-S S F S U &
amputation was done to guard against metastasis upon the advice of th"uteri'ling
surgeon.
time just loo short to kill the tumor cells caused a marked slowing in
the growth of the cells. They cannot explain the variability in lethal
action of the rays except to say 'that it is exhibited ontv in'groups of
young cells undergoing, or which have recently undergone mitosis, and
that older cells escape to grow in the tissues of the host and produce

R a d i u m 23
tumors They found that 80 to 100 mg. of radium element would kill
cancer cells in seven hours. To get lethal action in the depths of the
A
Fig. 9.—A. glioma of the retina, recurrence after enucleation. Referred by Dr.
Paul Pontiu'. PMIadelphia. Pathological examination by Dr. Nelson M. Brinkerhoff.
Philadelphia. B. entire retrogression and disappearance after radium needle
trealmeni, 1- ree froi.i recurrence six months, when the other eye became involved
with disease. An opportunity to give further treatment was denied and patient
died from extension of the disease.
Fig. 10.—A, glioma of the retina In child 9 years old. Referred bv Dr. G. Oram
Ring, Philadelrhia. Patr.cloglcal examination by Dr. C. Y. White. Philadelphia.
Recunence after enucleation of eye. This glioma grew so rapidly that in five
weeks it treisired twenty inches in circumference. B. result two months after
electrocoagulation operation. The condition later healed very much more. Child
died nine months later during the late epidemic of infantile paralysis. Whether
tissue death was caused by spiral metastasis or infantile paralysis has been impossible
to determine the gamma since rays ;-uti.]>sy are essential. was refused.
That There immature was no cells local or recurrence.
those in a
state of subdivision arc more sensitive to radiation than those which
have already acquired adult morphological and physiological characters

24 R a d i u m
is the law propounded bv Bergonie and Tribondeau. and quoted by
Knox. Radium acts on normal tissues by stimulating in small doses, with
larger amounts producing earlv congestion and later hbrosis. II tne
exposures are prolonged and the filtrationis insufficient, the action ot
the ravs mav become caustic, or the process may go on to necrosis or
sloughing. With proper exposure there will be inflammatory reaction,
which slowlv subsides, fibrous tissue forms, cutting off the blood supply,
with necrosis if the action is rapid, or atrophy if it i> slower. Radiation
effects depend on quantitv of radium, filtration, distance of application
A i.
Fig. II.—A. basal cell epithelioma in which the eyeball and the bones of the
orbit were involved. Referred by Dr. E. Kapeghian, Philadelphia. B, result Of
one electrocoagulation treatment. Complete exenteration of the orbit was accomplished
without hemorrhage immediately afterwards. No recurrence In three
years. Note slight contracture and regeneration of tissue.
and length of exposure. Ionization of the nuclei, alteration in type of
the cells to a more benign form, the production of antibodies, etc., are
some of the theories advanced by Pawing, Lazarus-Barlow. Wood and
others to explain the action of radium on the tissue cells."
It is recommended, after observing the good results in practice, that
at least one maximum radium treatment with proper technic be given
.1
Fig. IS.—A. sarcoma Involving the globe and orbit. Referred by Tr. Don M.
Campbell. Detroit, Michigan. B. result -1 enucleation and radium needle treatment.
Note .In addition to the retrogression of the growth, the gain In weight
and improved appearance of the patient. No recurrence in seven month*,

R a d i u m 25
preparatory to any other procedure, especially before a surgical operation,
for the purpose of first inhibiting and finally rendering benign the
migratory cells in the ducts, and producing glandular fibrosis. It has
A
R
Fig. 13.—A, sarcoma involving the sclera and cornea. Referred by Dr. Burton
Chance. Philadelphia. Pathological examination by Dr. Nelson Si. Brinkerhoff,
Philadelphia. Bxcislon was practiced twice with recurrence each time.
B, result of one desiccation treatment under local anesthesia. Free from recurrence
four years.
been ihe author's custom to allow a week or more to elapse between the
radium treatment and whatever operative work is undertaken; but. if it
does not seem prudent lo temporize with a rapidly growing lesion this
may be modified. At least three cross-fire radium treatments, averaging
six weeks apart should also follow any operative or other procedure
for further inhibitory and lethal action upon any malignant cells that
may still remain. The x-rays, though less potent, may sometimes be
used to supplement this treatment, cross-firing through other skin areas,
thus adding to the potency of radium.* Hard x-ravs from a Coolidge
or other suitable tube may be used advantageously to reach deep structures,
if a large quantity of radium is not available. Most physicists
and most radiumologists believe that there is little choice between the
activity of radium element and the emanation, milligram for millicurie.
The emanation, however, decays and loses its potency from day to day
unless renewed, while the element is permanent in its activity. The folly
of depending upon any one method alone in cancer with metastasis and
the wisdom of pre- and post-operative treatment have been amply demonstrated
by various workers in this field throughout the country.
If the invaded glands have not broken down, they will usually disappear
under judicious cross-fire radium treatment. If the glands are
small, treatment may be given externally; if large, radium needles
should be inserted directly into the glands. It is often difficult and
may be impossible accurately to determine whether the glands are simply
inflammatory or whether true metastasis has taken place; but the indi-
Mmportant experimental work is under way in Kuropean and American
laboratories to improve the efficiency of the x-rays by increasing the current
frequency and shortening the wave lengths, thus making possible homogenous
penetrating rays, no that the action of these improved x-rays may approximate
ihe action of the gamma rays of radium. Very powerful x-ray machines with
tubes to back up an eighteen to twenty inch spark gap have been constructed.
From preliminary reports it would appear that this object may in time be accomplished.

2 Radium
'
,tf
«
%
* '
1

R a d i u m 27
\.-lK j6

R a d i u m 29
A
It
Fig. IS.—A, advanced basal cell epithelioma involving the cheek, parotid gland
arm osseuu. Structures. Keierreu by Dr. Win. H.n.illfi.i, 1' uu

30 Radium
Fig. 19.—A, result of electrocoagulation operation for extensive carcinoma involving
the upper alveolus and Inner surface of the Up. also the antrum on both
sides. Case referred by Dr. John B. Deaver. Philadelphia. B. deformity without
dental plates. C. dental plates showing posterior views made by R. Douglas
Scott. D.D.S.. Philadelphia. D. appearance of patient with plates in place. She
Is able to articulate distinctly and deformity is corrected. No recurrence in
three years.
A preliminary gastroenterostomy was performed in both cases by Dr.
Frank White of Philadelphia at the American Stomach Hospital, Philadelphia.
The malignant pylorus was then stitched to the abdominal wall.
after which five radium needles attached to braided silk thread were inserted
extraperitoneal!)* into the growth parallel to the serous membrane,
and allowed to remain in place for twenty-four hours. After withdrawing
the needles the abdominal incision was closed by through and through
sutures, which had been inserted without tying at the time of the operation.
The wound in both cases healed by firs: intention and the patient
made rapid recovery. One patient gained much in weight, suffers no
discomfort, and is now in good health after one year. The other case
died nine months after the treatment, perhaps from recurrence of the
disease, but the temporary improvement in health and relief from pain
were remarkable. This may have been due perhaps in a measure to the
gastroenterostomy.
After experimentation with various metallic elements, including
gold-plated steel, platinum, iridoplatinum. monel metal, stellite. and an
alloy of steel and nickel known as "non-corrosive steel," the last named
has been adopted as most durabe and possessing the proper filtration
qualities for the purpose of radium application. These needles have
been made to order in lengths varying from 20 to 30 milimeters. Some
are round with tapering points, others have cutting, trocar points; and
yet others are compressed until they are slightly flattened though still

R a d i u m 3'
maintaining the hollow center, so
that they may be inserted, for example,
through an endoscope into
the larynx between the cartilage and
the membrane with a minimum
amount of trauma to the tissues. The
eye end of the needle is tapering so
that it may be withdrawn easily by
means of a braided silk thread after
insertion below the surface. The
shorter 20 mm. needles are used in
delicate structures such as the eyelids,
canthi, larynx, etc., and the
longer 30 mm, needles in less delicate
structures more extensively
diseased. The wall thickness is invariably
0.3 mm., as this seems to
give the desired filtration. The dia-
Fig. 20.—a. showing sequestrum of meter at the widest point of the
exostosis of the hard palate following .l,-1, _,„ji„ • " „„.
devitalization of bone by the desicca- author S IieedlCS IS 2 mm. Or 15
tion method. There is less danger or gauge measured by a Stubs English
entering th© antrum by this method. ». ** f
with careful technic. than if the chisel wire gauge. I he hollow needles are
or other bone instruments were used "nnctrii*-toil tl»ii ihf\- iei» Hivirlod
alone, b. sequestrum of alveolus foi- sp constructed that the> are divided
lowing electrocoagulation treatment of about I mm. below the CVC. After
carcinoma. jhe nee(||cs are fi„e

32 Radium
It is still the opinion of some physicists and radiumologists that
radium needles are of little practical utility, since it is thought that the
secondary radiations from the metal in contact with the tissues cause
great irritation and objectionable
sloughs even
with short exposures, and
that sloughing near vital
structures may jeopardize
the life of the patient.
Clinical experience has
demonstrated the fallacy
of this idea, if exposure
is not too long. It is true
that, when a metal applicator
containing radium
is applied to the dry skin
for a sufficient period of
time, a severe burn of the
third degree and sloughing
of tissue will result;
but when radium needles,
each containing 5 to 10
milligrams, or even more,
of radium clement, are
inserted into moist tissues
such as constitute
malignant growths, the
film of moisture surrounding
the needles may
perhaps be sufficient to
absorb the secondary rays
Fig. 21.—Applicators, trocar, forceps, containers,
and the destructive beta
etc The needles may he used singly, grouped together
in round brass capsoles, or placed side by
rays. The needles may
remain in place in some
side in ilat brass containers as shown.
tissues as long as 24 hours, causing retrogression and disappearance of
malignant growths but no destruction by sloughing. Tissues of low
vitality, or truciures such as the uvula, or soft tissues which are partly
broken down or devitalized will slough unless the radium dosage is
accurately estimated: hence the time of exposure must depend upon the
density and vitality of the tissues and the proximity to vital structures,
although blood vessels such as the carotid artery are surprisingly resistant
and no damage has ever been noted, even though the needles were
close to the artery as long as 24 hours. In some cases of very advanced
cancer of the cervix the needles have been allowed to remain in place
4S hours without great sloughing and with excellent results. Radium
needles are applicable in cases of malignancy where tissue is to be conserved
for vital or cosmetic reasons, and their great value has been
proved in many cases.
Radium needle treatment should be administered in a hospital under
strictly sterile conditions with a trained nurse in attendance. Every
case is a rule unto itself and no absolutely definite guide can be given
as to the duration of the application or the amount of radium to be
used. Generally speaking, the needles placed in sarcomatous tissue 20
millimeters apart should be withdrawn in 12 hours. In the case of carcinoma
the needles placed 25 millimeters apart should be withdrawn in

33
Fig. 22.—A. showing sequestrum of lower Jaw after
electrocoagulation treatment of extensive carcinoma
of the alveolus with the view of conserving a shell of
bone in the inferior position, thus avoiding the necessity
of complete resection. B, showing fracture of
the Jaw after sequestrum was removed. This united
quickly and deformity was avoided,
from 18 to 24 hours. The treatment is repeated in six weeks, if necessary,
although one needle treatment is usually all that is required. The
subsequent treatments may be given by capsule from the outside.
It is felt that radium' in needles has been employed for too brief a
period to attempt analytical and statistical study of results in regard to
permanency, hence this paper may be regarded more as a preliminary
report than as a final analysis. Encouraging results have been accomplished
during the past two years since radium needles have been shown
to be of practical utility in the treatment of malignant lesions, even with
almost no guide as to filtration, time of exposure to the rays, and technic
generally; yet it is the author's conviction that this method of treatment
is only in its infancy and that the future will show radium, with better
technic and greater knowledge concerning it, to be of far greater potency
than is realized at the present time. It is not to be understood that
all cases of malignant disease uniformly react favorably to radium, for
it has been observed that some cases respond better than others. The
impression from present experience is that, if a malignant lesion does
not respond to three or at most four full radium treatments, then the

34 R a d i u m
Fig. 23.—Radium needles The tnree sets of needles above are
25 millimeters long, contain 10 milligrams of radium each,
and are attached to braided silk thread. The single set below
are 20 millimeters long and contain live milligrams of radium.
lesion cannot be favorably influenced by further treatments. One must
guard against overexposing patients to radium. If a malignant lesion is
overexposed, great devitalization and sloughing of the normal tissue beyond
the malignant growth is likely to result. The ulcer shows little
tendency to heal, and this condition may be so serious as to be almost as
undesirable as the malignant lesion itself. Beginners in the use of
radium are therefore warned to underexpose patients rather than overexpose
them to the powerful radium rays, until an exact technic of application
has been acquired. It seems appropriate at this time to sound
a note of warning to physicians and attendants to guard themselves
against handling radium carelessly. Familiarity breeds contempt and
it is advised that eternal vigilance be practiced, else distressing permanent,
third degree bums, keratoses, and even cancer of the cxposd parts
may rsult from the constant irritation of radium rays. Distance is the
best safeguard and it should be the invariable
practice to handle radium applicators
of any description with forceps
at least four to six inches in
length.
notwithstanding the potency of radium,
it is better not to temporize unnecessarily
with cancer. If the lesion
is localized and can be conveniently
immediately and entirely destroyed by
Fig. 21.—Five needles, each containing
10 mg. of radium, were tion or coagulation, it is recommended
some method, such as electrodesicca-
placed upon an envelope containing that it be employed in preference to
a sensitized photographic plate for radium or operative surgery as the
two minutes. Note concentric radiations
from needle to needle. chance of eliminating the disease at
primary agent; provided there is a
Radium rays are projected In the one operation; otherwise the growth
tissues In the same manner.

R a d i u m 35
will be stimulated. The author's personal preference is electrodesiccation
or coagulation, since the destructive action may be accurately confined
and the blood and lymph channels sealed, rendering local recurrence
less likely. This may be followed by radium applied to the sue
of the operation as an additional safeguard, if this appears necessary.
Operative surgery is of the greatest importance in cancer involving
inaccessible anatomical structures to ligate blood vessels, if necessary,
and when there is extensive bone involvement; but the use of electrothermic
methods, radium, r-rays, or perhaps all in combination, directly
applied immediately after operation, will reach malignant cells inaccessible
to the scalpel with results that cannot possibly be obtained by surgery
alone. It is therefore concluded in the light of experience that
the greatest success in the treatment of malignant disease in its various
manifestations lies in the complimentary action of surgery, electrothermic
methods, radium and x-rays, judiciously selected or combined to
meet the particular requirements of the individual case.
REVIEWS AND ABSTRACTS
Everett S. Lain, M.D. (Oklahoma City). A Clinical Study of
Epithelioma of the Lower Lip. Jour. A. M. A. Ixxv, 1052-1055, Oct.
16, 1920.
"During the last few months I have been impressed by the increasing
number of cases of epithelioma of the lower lip which I have had
occasion to see. After observing a few metastases in unusual regions,
I was led to make a partial review of medical literature for reports on
malignancy in this particular region of the body, and to correlate and
summarize my own private cases which have occurred during the last
ten years. In reviewing some of the literature. I was rather disappointed
to find that although cancer of the lower lip constitutes more than 2
per cent, of all deaths from cancer. American physicians have not in
their writings dealt very frequently with this subject."
"In the private practice of Dr. M. M. Roland, my associate, and
myself during the last ten years we have seen 122 cases in which the
diagnosis of epithelioma of the lower lip was made."
"For purposes of prognosis and routine treatment we have foundit
convenient to classify epithelioma of the lower lip in three groups."
"Class 1. Epitheliomas which may begin as a seborrheic-like crust,
a small recurrent vesicle or fissure,at firstsuperficial, later becoming
infiltrated and indurated, etc., and situated entirely or almost entirely
on the cutaneous surface of the lower lip. These lesions are generally
of slow growth and late to metastasize. If metastasis does eventually
take place, it is usually in the smaller and more superficial of the submental,
supracricoid or anterior submaxillar}* glands, which are easily
palpable and freely accessible to treatment by any method."
"Class 2. Those which are so located that one-third or more of the
lesion overlaps the mucocutaneous border of the lip, though no glandular
enlargement is easily palpated. However, if a more careful examination
is made in each of these cases, perhaps after only a few weeks'
duration, there probably can be felt, in the suprathyroid of the deep
submaxillary regions, glandular enlargement due to an already begin-

36 R a d i u m
ning infiltration with malignant or other inflammatory products. ^ne*e
are the cases which have in the past so frequently deceived both the
surgeon and radiotherapist by the rapid metastatic development within
a few weeks or months after the primary growth had apparently been
successfully treated or removed. We are convincel that routine attention
to the' lymph drainage of this class of epitheliomas, however early
or localized they may at first appear, whether the treatment be surgery
or radiotherapy] will result in quite a perceptible increase in the percentage
of cures."
"Class 3. All cases in which more than half of the malignant
growth is situated on the mucous surface of the lip of many weeks' or
months' duration, and cases which owing to neglect or incomplete treatment,
have had a marked recurrence. In this class of cases there has
frequently already begun in the submental, submaxillary and perhaps
the upper group of the deep cervical glands, metastases which are extremely
difficult 10 discover and remove. In this class of cases the
prognosis by any known method of treatment is always unfavorable."
"In our series of 122 consecutive cases of epithelioma of the lower
lip, 117 were men and 5 were women, the ages ranging from 23 to 86
years, affecting mostly farmers and outdoor laborers. Treatment with
the roentgen ray or radium, singly or combined, was given to 107 patients.
Of seventy-two patients treated and belonging in Class 1. 95.8 per cent.
are living today or have lived for more than three years. Of twentyseven
patients belonging in Class 2, 70.3 per cent, lived from one to nine
years. In Class 3. nineteen patients were examined, of whom four were
treated. Three of these died within one year."
"Treatment. All agree that radical removal of all possible pathologic
ceils is the single aim of any successful method of treatment, and
that complete surgical extirpation of the primary growth, with careful
dissection of all metastasizing glands has cured a high percentage of
cases of epithelioma of the lower lip. However, no well informed, unbiased
physician longer doubts that just as successful work with either
roentgen ray or radium, or with their combined application, may be
accomplished in a certain class of cases in the hands of ex[>ert radiotherapists."
"When we consider the complete function of the lymph glands, is
it not reasonable to suggest that a certain degree of stimulation instead
of extirpation is the more scientific method of eliminating or preventing
metastases in a certain class of epitheliomas, as well as in ordinarv inflammatory
products which they collect?"
"Conclusions. 1. Considering the gravity of epithelioma of the
lower lip and its frequency in adult males, we believe the subject has
not been given the study and attention it deserves by American physicians."
"2. As noted by others, our reports also show epithelioma of the
lower lip to be far more common in outdoor workers, and most frequently
seen on the side of the mouth where a cigar or pipe is held.
"3. Early diagnosis and treatment of the lymph drainage of the
lips will materially raise the percentage of cures."
"4. Neither surgery, radiotherapy nor any other one successful
method of treatment should be used in all cases alike."
"5. Radium and the roentgen ray, singly or combined, give the
most satisfactory results in a selected class of epithelioma of the lower
lip."

A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY. PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES
Copyright 11)21 by Kadium Chemical Co.
Edited by Charles H. Viol. Ph. D., and William H. Cameron. M t) with the assista
collaborators working In the fieldso' Radiochemistry. Radioactivity and Radlumtherapy.
Address all communications to the Editors. Forbes and Meyran Avenues.
Pittsburgh. Pa.
Subscription $2.50 per year, or 25 cents pet copy In the United Stales and Canad
In all other countries $3.75 per year.
VOL. XVII JUNE, 1921 No. 3
THE STORY OF MME. CURIE'S GRAM OF RADIUM
Charles II. Viol. Ph. D.
- PITTSBURGH, PA.
In May. 10,11, Joseph M. Flannery .of Pittsburgh founded the
Standard Chemical Company, and undertook to produce in the United
States, from carnotite. a Colorado uranium ore. radium, that precious
substance which until then had only been produced on a small scale in
Europe. Mr. Flannery was not only a man of vision, but also given to
carrying through his plans, and so after two years of the hardest toil,
the first radium to be produced on a commercial scale in the I'nited
States was refined in the Radium Research Laboratory of the Standard
Chemical Company in Pittsburgh. This pioneer achievement of Mr.
Flannery meant more than the building up of a technical staff to duplicate
the refining operations as practiced in the radium refineries of
Kuroi*. for the Colorado carnotite ore presented many new problems
which had to be met and solved. L'nlike pitchblende, carnotite ore
occurs rather plentifully, but in the form of a very low grade sandstone
ore, the carnotite material forming part of the cementing substance between
the sandgrains. The first problem which Mr. Flannery solved
was that of concentrating this low grade ore so as to make a concentrate
that could be transported more readily from the mines over the many
miles of poor roads to the nearest railway and so as to make the production
of radium |>ossible by the use of a reasonable tonnage of chemicals
necessary for its extraction. Then came the radium itself and
later the other values in the ore, vanadium and uranium, and at the
time of his death, in February. 1920. Mr. Flannery had seen success
assured to his efforts.

38 R a d i u m
JiiSKJ'H M LANNKKY
Whose vision, initiative and untirini; energy gave new
Industrie* lo ihe world, and made It a better place
In which to live.
1887—1980
The production record of the Standard Chemical Company has
been a remarkable one, over half of the world's stock of refined radium
having come through the work in its mines, mills and laboratories. Since
the discovery of radium in 1S0S by Professor and Madame Curie in
Paris, it is estimated conservatively that the world's total radium output
•has not exceeded one hundred forty grams of radium element, and
figures based on reasonable assumptions make the total not more than
one hundred twenty grams. Of this total approximately one hundred
grams have been refined in the United States and seventy-four grams
of this total represent the output of the Standard Chemical Company
to June, 1921.
While visiting in Paris Mrs. William Brown Meloney of New York,
F.ditor of the Delineator, made the acquaintance of Mine. Curie, and
conceived the idea of having Mme. Curie visit the Tinted States. Her

R a d i u m x>
JAMBS C. (JRAV. L.L. D.
President of the- Standard Chemical Company. Mr. Gray
was associated with Mr. Flannery for many years,
and was a Director of the Siandard Chemical
Company al It* organization and
General Counsel
pressing invitation was finally accepted and on Mrs. Meloney's return
to Ihe United States, she founded the Marie Curie Radium Fund Committee
with the purpose to have this committee secure by subscription
from the women of the United States a fund sufficient to purchase a
gram of radium which could be presented to Mme. Curie when she
came on her visit.
The committee was successful in its work, and when Mrs. Meloney
sailed for France early in May to escort Mme. Curie to this country,
she knew that her splendid idea had worked out successfully, and that
the distinguished co-discoverer of radium would soon be the possessor
of an adequate amount of radium of her own to carry on researches,
which had been held up by the lack of this precious material.
When asked what she would particularly like to see while in the
United States Mme. Curie expressed a desire to visit Pittsburgh, so

40 R A D I U M
that she might see the radium refining operations as conducted there on
the largest scale by the Standard Chemical Company and to visit the
Grand Canyon of the Colorado.
As was to be expected, it was the Standard Chemical Company
of Pittsburgh that supplied the gram of radium which the women of
America presented to Mme. Curie and this has been written to give a
better idea of what a gram of radium means, for many cannot conceive
that a tiny pinch of material, a twenty-eighth of an ounce, can have an
intrinsic value of one hundred and twenty thousand dollars.
Carotite ore occurs in an area of many hundreds of square miles
throughout the southwestern corner of Colorado and in southeastern
Utah. It is found in larger or smaller pockets or scams, in a particular
geological horizon, and as this level is not far from the surface of
the plateau-like country, the earlier prospectors worked by observing
the bright sulphur yellow carnotite debris which occurred on the canyon
or valley sides, and by following this back, located the pocket or seam
near the "rim rocks" which gave rise to the debris. Systematic drilling
wilh a diamond core drill, as carried out by the Standard Chemical
Company on the Hats back from the canyon and valley walls, has brought
to light much ore that would otherwise not have been found, and a conservative
estimate of the radium recoverable from the properties of the
Standard Chemical Company places the figure at upwards of a thousand
grams.
The carnotite seams are narrow and so :he securing of milling ore
involves taking out a great deal of worthless rock, one ton of average
milling ore requiring the mining of about five tons of rock and ore. FYom
this mined material, ihe milling ore is taken by hand sorting, the sorted
ore being sacked and hauled down the hillside trails :o the roads by
burros. Picked up by trucks or wagons, the milling ore is hauled ten
to fort)- miles to the concentration mill of the Standard Chemical Company
located on the San Miguel river, about sixty-five miles from
Placerville. Colorado. To secure one gram of radium in the finished
product an average of 500 tons of the milling ore must be used.
When received at Canonsluirg. Pennsylvania, twenty miles southwest
of Pittsburgh, the carnotite is carefully washed and then treated
drastically with chemicals to remove all [nissible barium and radium
salt. The ore concentrate contains about ten parts per billion of radium
and abou: one-half per cent, of barium salt. The chemical similarity of
the barium and radium permits the extraction of the radium by the removal
of the greater quantity of barium salt. The solution of radium
and barium is treated with sulfates to precipitate an insoluble "raw sulfate"
of radium, one gram of radium being contained in about a ton of
such crude sulfate. This sulfate is carefully purified and treated to
yield nearly pure barium-radium chloride, about a thousand pounds of
this material containing the gram of radium. To secure this quantity
of radium barium chloride requires the chemical treatment of carnotite
concentrate from 500 tons of milling ore and the use of 500 tons of
various chemicals, acids and alkalies, the power from 1000 tons of
coal, the use of upwards 10.000 tons of purified and distilled water.
and the labor of 150 men for a month.
The further refining of the radium barium chloride is cssentiallv a
process of fractional crystallization, as first devised by Mine. Curie.
since no single chemical oi>cration is capable of removing the tiny
quantity of radium from the huge amount of accompanying barium

•
R a d i u m
•1'
Headquarters of Ihe Standard Chemical Company at the head of Paradox Valley.
in Colorado, fifty miles from the railroad at I'lacervtlle. Colo.
Carnotite mine in southwestern Colorado, These workings In .1 s indstone formation
follow the carnotite seam, and are often several hundred feet Ion*.

42 radium
Preparing lo bias! oui carnotite and rock with dynamite.
Gathering up the ore and rock after the blast.

R a d i u m 43
Sorting milling carnotite ore by hand from the mixture of ore and rock.
milling ore represents an average of about one-fifth of the
mined material.
The
Sacking the milling ore preparatory to hauling it on burros and by wagon to
the concentration mill.

44 R A D I U M
5
-i
• .c
Ii
'- =
>
m —

R a d i u m 45

46 R a d i u m
Mine. Curie Inspecting ihe plant of the Standard (Tiemical Company at Canonsburg,
Pa., escorted by President Gray and Mr, L. P. Vogt. Works Manager,
It was here that the radium was extracted, which the
women of America presumed to Mme. Curie.
salt. The purified radium barium chloride, after a preliminary crystallization
on a large scale at Canonsburg, is then shipped to the Radium
Research laboratory of the Standard Chemical Company at Pittsburgh,
and here the final delicate oj>erations of fractional crystallization, first
as chloride, and then as bromide, are performed, the final product obtained
after five weeks oj>erations being a tiny pinch of nearlv pure
radium bromide, which when freshly evaporated from solution, exactly
resembles |>owdered sugar. On standing in a sealed tube the salt acquires
a brownish color, and loses some of the bluish phosphorescent glow
which at firstis quite marked when the salt is observed in the dark.
For most medical uses the insoluble sulfate of radium is usually
supplied, the salt being hermetically sealed in suitable small glass tubes,
in metal needles, or fused in the surface of a glaze on a metal plaque.
The medical use of radium consists in the exposure of the diseased parts
to a suitable amount of radium, whose radiations, like the x-rays penetrate
and influence the diseased tissues. Used in this wav, the' radium

R a d i u m 47
Radium Research Laboratory and General Offices of the Standard Chemical Company,
and the Radium Chemical Company. Distributors, at Forbes Street
and Meyran Avenue. Pittsburgh. Pa. In this laboratory ihe first
commercial production of radium tn America was made In 1913,
,md to date over 71 grams of radium have been refined
here, this output representing well over half the
world's entire radium production.
is not exhausted, and its natural decay, inherent to radioactive substances,
is such that only in 25 years is one per cent, of its substance transmuted,
and at. this rate it requires 1700 years for the decay of half of any
quantity of radium.
Six months are consumed in the production of radium, from the
mining of the ore to the tubing of the finished salt, and after this the
material must "age" or mature for thirty days to attain its maximum
activity, when it is shipped to the United States Uureau of Standards
at Washington. D. C. to have its activity certified.

4S
R a d i u m
Chemical preparation of sample* for determination of radium content by the
"Emanation" method. Two hundred-millionths of a gram of radium constitute
the amount desirable In an analytical sample. Radium extraction
and retlnins are controlled by these mensure-nents mad*
Iti the Kadium Research Laboratory of the Standard
Chemical Company at Pltt*bursii.
Electroscouic determination of radium in a mill process sample bv the "Fin un
tlon" method. Over twenty-five thousand such measurements have been
made on different samples, by the Radium Research Laboratory
of the Standard Chemical Company.

R a d i u m 49
Early stage In the fractional crystallization of radium barium chloride. In
the Radium Research Laboratory of the Standard Chemical Company.
in Pittsburgh, P».
Final stage In the crystallization of Mme. Curie's gram of radium in the Radium
Research Laboratory "i the s'tandard Chemical Company at Pittsburgh,
Pa. The silica dish shown contains over two grams of radium, in
form of radium barium bromide. This represents all the
radium from a thousand tons of milling carnotite ore.

Tubing Mme. Curie's gram of radium. Protected by thick lead plates, the
powdery white bromide of radium was carefully transferred from a tiny
dish to the thin walled glass capsules shown In the next
illustration.
To produce a gram of radium per month requires the work of 200
miners antl mill men in Colorado, 150 men in the Chemical Works at
Canonshurg. and 15 technical men in the Radium Research Laboratory
at Pittsburgh, without making allowance for the auditing, sales and
executive departments; the mining and milling of 500 tons of ore. and
the chemical treatment of ore concentrate involving the use of 500 tons
of chemicals. 1000 tons of coal. 10.000 tons of water, and work extending
over six months. Truly a vast labor and expense to yield half a
thimbleful of radium salt, and at such a cost of production radium
sells cheaply at the price of $120,000 per gram.
Such is the story of the production of the gram of radium which
was presented by President Harding, on behalf of the women of the
United States of America, to Mme. Marie Curie, at the White House.
on the afternoon of May 20th. 1021. in the presence of a distinguished
assemblage of over five hundred who represented womens' organizations,
the Cabinet, the Diplomatic Corps. Congress, and distinguished
leaders in medical, chemical, physical and other scientific fields.
Mine. Curie's desire to visit Pittsburgh has been gratified and on
the afternoon of May 26th, ihe writer had the honor of conducting the
distinguished guest through the various departments of the Radium Research
Laboratory of the Standard Chemical Companv in Pittsburgh.
( 'n the following day Mme. Curie and her party visited the Chemical
Reduction Works of the Standard Chemical Companv at Canonshurg,
Pennsylvania, and for several hours she manifested the greatest interest
as she viewed the various operations in the chemical treatment of carnotite
under the escort of President J. C. Gray and Works Manager
L. F. Vogt.

R a d i u m 5'

5- R a d i u m
Gold key to the case holding Mme. Carle's groin of radium. Engraved The
Women of America to Marie Curie.'" and on the reverse, "The While House.
May 20, I SSI." The key with the engrossed deed of sift was presented
to Mme. Curie !>> i Harding.
IO PRESENTED BY THE PRESIDENT OF THE
UNITED STATESDF AMERICA QNEEII.
Or THE WOMEN OFAMLRlCA
TO
MADAME MAtflF.SKLDDnWSKA CURIE".
(N RECnfiNmnN IIFHEft TRANSCENDENT
St'RVlfl III SCIINCE ANU TO HUMANITY
IN THt DISCOVERY OF K\i
THE WHITE HOUSE. WASHINGTON VLC.
'•TwrfcjTIEmNINETfEN
TWENTY
Inscription on gold, plata affixed to the ton cf Hie mahogany case which held
Mme. Cun.'s radium.
Al the lime this is written. Mme. Curie is on her way to visit the
Grand Canyon of the Colorado, and alter more honors and degrees have
been bestowed u|»on her at Chicago. Boston and New Haven, she will
set sail for France on June 2$, with the cordial best wishes of her many
admirers for a safe journey horn?, and :he hope that the inspiration
from her visit to America, and the gift of the women of America will
enable her to add even greater works to her alreadv transcendent
achievements.

A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY. PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES
Copyright 1921 by Radium Chemical Co.
Edited by Charles H. Viol. Ph. D.. and William H. Cameron. M. D with Ihe assis
collaborators working In Ihe fields of Kadlochemis.trv. Radioactivity and Radlumtherapy.
Address all communications to the Editors. Forbes and Meyran Avenues,
Pittsburgh. Pa.
Subscription $2.50 per year, or 25 cents per copy In the United States and Ca
In all other countries $3.75 per year.
VOL. XVII JULY, AUGUST, 1921 Nos. 4-5
THE DANGERS IN WORKING WITH RADIUM AND
X-RAYS. HOW THE PROBLEM IS BEING MET.
During the past seven months many references have been made in
the medical literature to the dangers encounlt red by those who work
more or less constantly with radium and with ihe high intensity penetrating
x-rays such as are now used in the massive dose treatment work.
A knowledge of these dangers and of the means of avoiding serious
effects is of the greatest importance lo all who arc using radium and
x-rayS, and in the following excerpts from the literature the recognized
dangers and suggestions of means for avoiding them are given.
The London correspondent of the Journal of ihe American Medical
Association, J.A.M.A. vol. 76, p. 14'2. May 21, 1921, says:
"Recently I reported the deaths of three workers at the Radium
Institute which were attributed to aplastic anemia due to their occupation.
The matter was firstpublished here through a circuitous channel,
being derived from a French report. An official report has now fteen
made by the medical superintendent of the institute, Mr. Hay ward
Pinch, which considerably modifies the previous one. The first death
occurred in December, 1916. in a worker who was seen by several eminent
specialists and whose death was ascribed by them to pernicious
anemia. The second death occurred in January, 1920, in a nurse, and
was due to infective endocarditis; but it is admitted that the radium had
unquestionably affected her, though it was not from this alone that she
died. The third death occurred in February, 1921, in a man, aged 47.
and was due to acute pneumonia. Each case is claimed to have been due
to a definite disease apart from the effects of radium, but the institute
committee considered it highly probable that the work of these persons

54 R a d i u m
weakened the powers of resistance lo the diseases from which they suffered.
Dr. J. C. Mottram was appointed to make a special investigation
of the effects of radium on the staff of the institute. For a year he
made examinations of the blood of every worker, from the superintendent
down to the hall porters. He found definite changes in the red and
white corpuscles due to exposure to radium. He showed that radium
workers are subject to widely different amounts of irradiation varying
as they work near to or distant from radium and according to the period
of exposure. Laboratory workers who prepare and measure applicators
containing emanation and radium, and clinical workers who attach
screens to the radium applicators and subsequently apply them to patients
are especially exposed. Other workers, down to the servants of the
institution, are subject to only small quantities of Ihe gamma radiation,
which pervades the whole building. The polymorphonuclear, leukocytic.
and lymphocytic blood count of radium workers was found decidedly
lower than that of normal persons. Even among the less irradiated
workers there was no evidence of leukocytosis. This contrasts with
the fact that in small animals alternate periods of irradiation and freedom
from irradiation will under certain conditions produce profound
leukocytosis, and that the leukopenia following a single dose of roentgen
rays is often followed by leukocytosis. The leukopenia of radium
workers is manifest after a few weeks' exposure. No association was
found between the leukopenia and any ill health. An extremely thorough
protective system has been elaborated and has been copied by other
institutes. Dr. Motram has recently reported, after a year's blood
examinations of the workers, that their blood condition is slowlv returning
to normal."
In ihe same issue (J.A.M.A. p. 1413), the Paris correspondent
says:
"In providing for the protection of operators against ihe possible
damaging effects of scattering roentgen rays, thus far consideration has
been given exclusively to lateral protection by surrounding ihe roentgenray
apparatus with double lead screens from 5 to 6 mm. thick. But
against the vertical radiations no protection has been provided. The fact
remains that persons who occupy the floors above and below ihe apparatus
are exposed to inlense applications of roentgen rays. Deep roenigen-ray
therapy requires for the treatment of cancer a high intensity of
the rays, in France a spark gap of 25 cm. and one sitting of from twelve
to fifteen hours, and in Germany a spark gap of 12 cm. and one sitting
of five hours being employed. The irradiation produced by such intensity
possesses an immense power of penetration. Monsieur Contremoulins,
who lately called the attention of ihe Academy of Science to these
facts, thinks that such high-powered apparatus cannot be installed in
densely populated urban centers without exposing "the inhabitants to
grave dangers. Special measures of protection must therefore be provided."
Dr. Mottram, director of the Research Department of the London
Radium Institule. makes the following report in the annual report of
that institution (for the year of 1920) which has recently been published.
"Since the last report a second paper dealing with the blood of the
workers at the institute has been published (Archives of Radiology and
Electrotherapy, December. 1920), and read before the Pathological
Society of Great Britain and Ireland, August. 1920. In this communi-

Raditjm 55
cation Ihe red cell content was dealt with. In several cases a mild
anaemia* was found, down to 4,150.000 per cubic millimetre for males
and 3,300,000 for females. In all these cases the color index was above
the normal."
"The pajier also describes three cases of death amongst radium
workers, two in this country and one in France. In two of these cases
death was ascribed to aplasic pernicious anaemia, in the third case the
blood condition was similar but the case was complicaled by signs of
infective endocarditis. From these two sets of facts—the mild anaemia
of the pernicious type found among the workers, and the three deaths
accompanied by profound aplasic pernicious anaemia, it was concluded
that exposure to radium was the important aetiological factor."
"The association of this condition of anaemia wilh a polynuclear
leucopenia, previously reported, indicaled that the case is a direct action
of the radium (gamma radiation) upon the bone marrow."
"In order to lest this assumption a series of rats have been exposed
to varying amounts of gamma radiation. The bone marrows were then
removed, and compared with those of normal animals. A decrease in
the number of mitoses in the radiated sj>ecimens was observed, indicating
a decreased output of blood cells."
"Details of these experiments are given in the Archives of Radiology
and Electrotherapy, December. 1920—"Histological changes in the bone
marrow of rats exposed to the gamma radiation of radium." The results
confirm the view that the effects found among the radium workers
are.due to gamma ray exposure."
"During 1920 increased protection from radium for the workers
was instituted (sec last report), and as a result the blood condition of
the workers is already (February, 1921) returning to the normal. Details
of this return to the normal will be given in the next report."
Referring to recenl papers by Drs. Regaud and Tuffier, the Paris
correspondent of the Journal of the American Medical Society (J. A.
M, A. vol. 77, p. 29S, July 23, 1921). gives the following:
"At recent sessions of the Academy of Medicine, considerable attention
was given to the dangers of radium. Dr. C. Regaud (Bui. de
I'Acad. de Med. v. 85, p. 608, May 21, 1921). director of the biologic
laboratory and the therapeutic service of the Radium Institute of the
University of Paris, presented an interesting communication on ihe
subject, from which I take the following excerpts: The accidental absorption,
by inhalation, of radium emanations is no! dangerous except
in a confined space. The rays of radioactive substances present for
the skin and deep-seated organs (and especially for the hematopoietic
system) dangers similar to those connected with roentgen rays. Operators
and attendants can protect themselves by forming the habit of:
(1) taking judicious advantage of the law of distance (especially
through the use of special tongs in performing manipulations), and (2)
interposing between the operator's body and any source of radiation
leaden screens several centimeters thick and impervious to penetrating
rays. The few accidents that have happened up to the present time have
been the result of ignorance of the danger and lack of precautions.
Regaud believes that in a well organized establishment with an instructed
and well trained personnel, the nurses and others near Ihe
patients under treatment will not run any risk through the action of
radioactive bodies. Dr. Tuffier (Bui. de I'Acad. de Med. v. 85, p. 617,

56 RAPITTM
May 31, 1921), professor at the school of medicine of the University of
Paris, was anxious to obtain documentary information on the dangers
of radium from the important American centers where radium has been
in use for a long time and in large quantities, since there entire hospitals
are devoted to the study of radioactive action. He has received
replies from the cancer commission of Harvard University, ihe Howard
A. Kelly Hospital in Baltimore and Ihe Mayo Clinic. At the Mayo
Clinic no menstruation troubles of any kind have been observed among
the nurses handling radium applicators. There have been only accidents
of a local nature, such as cutaneous lesions, not at all serious.
To prevent accidents happening the personnel is changed very often.
However. Ihe cancer commission of Harvard University, and the Kelly
Hospital gave him the following information: Soon after ihe study of
radium therapy was begun, several cases of menstrual and general disturbances
were noted among the nurses in charge of radium applicators.
These disturbances occurred when the nurses were in contact with
radium for two or ihree months in succession. They disappeared when
Ihe nurses left this service. Five cases have been noticed during recent
months, and since thai lime a rotatory schedule has been established to
prevent these accidents, so thai now no nurse remains longer lhan two
months in the service, and they are taught not to handle radium lubes
without using tongs, and to keep them in a box specially constructed to
prevent radiation. At Harvard University manifestations of azoospermia
were also noied, but these disappeared after a few months when
the operators were protected against radiation. At the Kelly Hospital,
where the operators have had a great deal of experience in handling
radium, a careful study has been made concerning accidents due to
radiation. A reduction of polymorphonuclear elements and an increase
of lymphocytes in the blood were noted, sometimes also a slight lcuko-
|>enia. The disturbances thai were noted at the beginning disappeared.
thanks to precautions taken by the nurses. Time is the most important
factor in ihe case, for since the nurses have been changed every month
no disturbances have been noted either in menstruation or in ihe blood.
The results of this inquiry show that accidents occurring through the
handling of radium can be prevented by laking into account ihe duration
of service and the faclor of distance in ihe application of radium."
In discussing Ihe dangers of radium. Bui. de I'Acad. de Med. vol.
S5. p. 660. June 7, 1921, quoted in abstract (J.A.M.A. p. 323, July 23,
1921):
"Broca presents the report of the committee appointed to study this
subject. It states "The dangers are real, but they are easily avoidable.
with proper precautions, for all except the manipulators of the emanation
and during radioscopy. But society has lo have these regardless of the
danger, jusl as physicians have to expose themselves daily to contagious
diseases. The probability of injury- is aboul the same in both these fields,
but the dangers arc faced by men who accept them in view of the importance
of the task, and who know the precautions to be taken." .
'If some of them suffer in consequence of iheir devotion, notwiihstanding
the known precautions, the instances will be rare, and thev will be
accompanied by our respect and our gratitude.' "
In England a committee was appointed to consider x-ray and radium
proteclion and in the June 25th issue of the British Medical Journal.
pp. 936-7 there is given a preliminary report of this committee, which
is herewith reproduced.

R a d i u m 57
"The x-ray and radium protection committee, representing the
various radiological and other scientific bodies with their headquarters
in the metropolis, after deliberating for some weeks, has issued its preliminary
report, which is admittedly tentative in some of its recommendations.
This report, which is a carefully thought out statement of
present knowledge in regard to equipment, ventilation, and working
conditions of x-ray and radium departments, was a matter of considerable
urgency owing to the constant demand for guidance from individuals
and institutions;it is printed in full below. After the completion
of this, ihe preliminary part of its work, the committee intends to
proceed with its more extensive objects which may entail considerable
research."
"The chairman of the commiltee is Sir Humphrv Rolleslon, K.C.B.
The other members are: Sir Archibald Reid. K.B.E., C.M.G. (St.
Thomas's Hospital), Dr. Robert Knox (King's College Hospilal), Dr.
G. Harrison Orton (St. Mary's Hospital), Dr. S. Gilbert Scott (London
Hospital), Dr. J. C. Mottram (Pathologist, Radium Institute), Dr. G.
W. C. Kaye. O.B.E. (National Physical Laboratory), and Mr. Culhbert
Andrews. The honorary secretaries are Dr. Stanley Melville (St.
George's Hospital) and Professor S. Russ (the Middlesex Hospital)."
"Suggestions and offers of personal or other assislancc are invited,
and should be sent to the honorary secretaries of the committee, care of
Royal Society of Medicine, i Wimpole Street, W.I. Copies of the
preliminary report may be had on application to the honorary secretaries."
"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: (i) Visible injuries to Ihe superficial tissues which may
result in permanent damage. (2) Derangements of internal organs and
changes in the blood. These are especially important, as their early
manifestation is often unrecognized."
"General Recommendations. It is the duty of those in charge of
x-rav and radium departments to ensure efficient protection and suitable
working conditions for the personnel.
The following precautions are recommended:
1. 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 month, 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
sen'ice.
"Protective Measures. It cannol be insisted upon too strongly that
a primary precaution in all x-ray work is to surround the x-ray bulb
itself as completely as possible with adequate protective material, except
for an a|>erture as small as possible for Ihe 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 therapy,
III. X rays for deep therapy.
IV. X rays for industrial and research purposes.

5s
R a d i u m
V. Electrical precautions in x-ray departments.
VI. Ventilation of x-ray departments.
VII. Radium therapy.
It must be clearly understood that the protective measures recommended
for these various purposes are not necessarily interchangeable:
for instance. 10 use for deep therapy the measures intended for superficial
therapy would probably subject the worker to serious injury.
I.—X-Rays for Diagnostic Purposes
"(i) Screen Examinations. The x-ray bulb to be enclosed
as completelv as possible with protective material equivalent lo not less
than 2 mm. of lead. The material of the diaphragm to be equivalent
to not less than 2 mm. of lead."
"(b) The fluorescent screen to be fitted with lead-glass equivalent
to not less than 1 mm. of lead, and to be large enough to cover the
area irradiated when ihe diaphragm is opened to its widest. (Practical
difficulties militate at present against ihe recommendation of a greater
degree of protection.)"
"(c) A traveling protective screen, of material equivalent to not
less than 2 mm. of lead, should be employed between the operator and
the x-ray box."
"(d) Protective gloves to be of lead-rubber (or the like) equivalent
lo not less than one-half mm. of lead and to be lined with leather
or other suitable material. (As practical difficulties militate at prcsen.
against the recommendation of a greater degree of protection, all manipulations
during screen examination should be reduced to a minimum).
"(e) 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 to be as expeditious as possible."
"(2) Radiographic Examinations ['Overhead' Equipment). (?)
The x-ray bulb to be enclosed as completely as possible with protective
material equivalent to not less than 2 mm. of lead."
"(b) The operator lo stand behind a protective screen of material
equivalent to not le~s than 2 mm. of lead."
II.—X-R.ws for Superficial Therapy.
"It is difficult to definite the line of demarcation between superficial
and deep therapy. For this reason it is recommended lhat. in the
reorganization of existing, or ihe equipment of new, x-ray departments
small cubicles should not be adopted, but that the precautionary measures
suggested for deep therapy should be followed. The definition of superficial
therapy is considered to cover sets of apparatus giving a maximum
of 100.000 volts (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, preftrablv
provided with an exhaust electric fan in an outside wall or ventilation
shaft. The controls of the x-ray apparatus to be outside the cubicle.
"_\ The walls of the cubicle lo be of material equivalent to not
less than 2 mm. of lead. Windows to be of lead-glass of equivalent
thickness."
"3. The x-ray bulb to be enclosed as completely as possible with
protective material equivalent to not less than 2 mm! of lead."

III.—X-Rays for Deep Therapy,
R a d i u m 59
"This section refers lo sets of apparatus giving voltages above
100.000.
"1. Small cubicles are not recommended."
"2. A large, loftv, well ventilated and lighted room to be provided."
"3. The x-ray bulb to be enclosed as completely as possible with
protective material equivalent to not less than 3 mm. of lead."
"4. A separate enclosure to be provided for the operator, situated
as far as possible from ihe x-ray bulb. All controls to be within this
enclosure, the walls and windows of which lo be of materia! equivalent
lo not less than 3 mm. of lead."
IV.—X-Rays for Industrial and Research Purposfs.
"The preceding recommendations for voltages above and below
100.000 will probably apply to the majority of conditions under which
x-rays are used for industrial and research purposes."
V—Electrical Precautions in X-Ray Departments.
"The following recommendations are made:
"1. Wooden, cork, or rubber floors should be provided; existing
concrete floors should be covered with one of the above materials."
"2. Stout melal tubes or rods should, wherever possible, be used
instead of wires for conductors. Thickly insulated wire is preferab'e
to bare wire. Slack or looped wires arc to be avoided."
"3. All metal parts of the apparatus and room to be efficientlv
earthed."
"4. All main and supply switches should be very distinctly indicated.
Wherever possible double-pole switches should be used in preference
to single-pole. Fuses no heavier than necessary for Ihe purpose
in hand should be used. Unemployed leads to the high-tension gen*r?-
tor should not be |>ermitted."
VI.—VENTILATION of X-Ray Departments.
"1. It is strongly recommended that the x-ray department should
not be below the ground level."
"2. The importance of adequate ventilation in bolh 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, bolh of which are
prejudicial to the operator. Dark rooms should be capable of being
readily opened up to sunshine and fresh air when not in use. The walls
and ceilings of dark rooms are best painted some more cheerful hue than
black."
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 fingersthe radium, whether in
the form of applicators of radium salt or of emanation tubes, should
always be manipulated with forceps or similar instruments, and it should
be carried from place lo place in long-handled boxes lined on all sides
with 1 cm. of lead."
"2. In order to avoid the penetrating rays of radium all manipulations
should lie carried out as rapidly as possible, and the operator

.., R A D I U M
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 wall
thickness of which should be equivalent lo not less than S cm. of lead."
"3. In the handling of emanation all manipulations should, as far
as possible, be carried oul during its relatively inactive stale. In manipulations
where emanation is likelv lo come into direct contact with ihe
fingers thin rubber gloves should be worn. The escape of emanation
should be very carefully guarded againsl, and the room in which it is
prepared should be provided with an exhaust electric fan."
"Existing Facilities for Ensuring Safety of Operators The governing
bodies of many institutions where radiological work is carneo
on may wish to have further guaranlees of the general safely of the
conditions under which their personnel work."
"1. Although the commiuee 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-operaiion of the personnel in following ihe precautionary measures
outlined for their benefit."
"2. The committee would also point out that ihe National Physical
Laboratory. Teddington, is prepared 10 earn- oul exact measurements
upon x-ray protective materials and lo arrange for periodic inspection
of existing installations on the lines of the present recommendations."
"3. Further, in view of the varying susceptibilities of workers to
radiation, ihe committee recommend thai wherever possible, periodic
tests—for example, 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 ii is difficult to decide
when small variations from the normal blood count become significant."
In the United Stales over 50 grams of radium element is now in
use for thera|>eutic application and all are aware of the more
extended use made of the x-rays following the development of the
Coolidge tube. The dangers from these agents on those who work with
them arc great, and as in England, so here there should be a committee
which would give such matters careful study. An active joint committee
representing the American Radium Society, ihe American Roentgen
Ray Society and ihe Radiological Society of North America could make
a good start in this work and suggest necessary precautions, as well as
lines for study.
REPORT OF CASE OF GASTRIC
CARCINOMA
By C. J. Johannesos. M.D.. St. Mary's X-Ray Laboratory.
Walla, Walla, Wash.
Paiient. male, 42 years old, white, was admitted to ihe Hospital of
Hoi Lake Sanatorium. Oregon, in a very emaciated condition. For
several months had been unable to take any other nourishment but fluid.
and for the last few days before arriving at the hospital, he had to
vomit up practically all he took per mouth; and was unable lo walk, etc.

R a d i u m 61
The history revealed evidence of gastric or duodenal ulcer a few
years ago. At time of admission the patient complained of a general
"aching" throughout Ihe abdomen, but no distinct "pain point,"—no
palpable tumor-mass could be located definitely.
A complete gastro-iniestinal radiographic examination was performed
which showed a very large stomach, atonic, wilh persistent
''filling defeel" of pars pylorica and complete closure of pylorus. A scries
of plates was taken of the stomach and in 24 hours after the bariummeal
was given, nothing had gone through the pylorus. The "fillingdefect"
was typical of carcinoma. A barium-enema showed the entire
colon and caecum negative to pathological findings.
The patient was operated two days after admission by Dr. W. T.
Phy, of Hot Lake Sanatorium (Nov. 8, 1920). Dr. Phy found a very
large, hard, but friable carcinoma-mass involving the entire pars pylorica
and pylorus. Duodenam was apparently negative. Complete closure of
pylorus. The mass was so friable lhat, when Dr. Phy attempted to pick
tip the stomach, his finger went through ihe tumor-mass. A posterior
gastrojejunostomy was performed; meanwhile we decided to apply
radium, though we had little or no hope for the patient.
Considering the seriousness and extensive involvment. I decided to
apply the radium as follows: 25 milligrams, unscreened tube applied
within the hole Dr. Phy had accidently made with his fingerin the lumor
mass, and two needles "of 12.5 milligrams, unscreened, each applied (or
buried) in the stomach wall near pylorus involved by carcinoma. The
tubes and needles were properly anchored.
After this the abdomen was closed and patient removed to a private
room, wilh no expectations of recovery.
After 12 hours exposure to radium the tube and needles were removed,
without opening the abdomen.
After a couple of days the patient began to give hoj>e for recovery
and showed progre-s as time went on. Two weeks after the operation
I gave the patient a series of x-ray applications covering the entire abdomen
and dorso-lumbar region (cross-fire method).
Four weeks after the operation the patient had been walking around
in the institution and was allowed lo go home. He was able to digest
his food, which, of course, was a restricted and outlined diet. He was
fast gaining strength and weight. He was told to rei»ort back in a month
from this discharge.
First pari of January, 1921. the patient returned and submitted
himself lo an exploratory laparotomy, as we were anxious lo learn about
the result. He had meanwhile gained 24 pounds in weight, could eat
anything and everything he wished. Ihe digestion was perfect, and the
patient looked like an entirely different person than when he was admitted
in November, 1920.
The operation showed that the carcinoma-mass had almost entirely
disappeared; only a slight induration about t^.e pars pylorica near the
pylorus still showed evidence of malignancy; Dr. Phy decided not lo
interfere surgically, therefore we again applied radium as follows:
Two needles of 125 milligrams, each unscreened, buried in the indurated
tissue of pars pylorica on either side of the stomach and the
tube containing 25 milligrams, screened with brass capsule, applied in
close contact with a small hard mass at duodenum. After this the abdomen
was immediately closed up.

62 R a d i u m
After 14 hours exposure to Ihe radium the needles and tube were
removed.
The patient left the hospital three weeks after the second operation.
though before leaving he was given a series of x-ray applications, same
technique and method as after the firstoperation.
The patient was advised to return in from four 10 six weeks for
x-ray treatments, but did not come until eight weeks from the second
operation, when he received a series of x-ray exposures covering ihe
abdomen and back. He was improving rapidly, slill gaining weight and
said he felt fine now and had no more "stomach trouble."
The patient called al my present office a few days ago (May. 1921 I,
inquiring if I though! it would be necessary to have more x-ray treatments;
his present weight is 16S pounds (againsi 117 when he was admilted
in November 1920) ; said he had not been feeling so well in years;
his stomach was working fine; he had been doing all his work on his
ranch for the last four or five weeks.
Examining the abdomen we could find no tenderness nor palpabL
mass. I advised another series of x-ray applications for prophylaxis.
Though I have been working with radium for some years, and in
practically all. gynecological work, uterine cancers and fibromas, etc.. f
have obtained excellent results; this is the firstgaslric carcinoma in
which I have personally seen such an amazing result, and I feel sure
the radium application in such cases should be used to much greater
extent than il is at ihe present time, especially in this part of Ihe country.
I could hardly have believed the successful result obtained in such a short
lime in this case, if I had nol seen il myself.
The success in this case is to a great extern due to the splendid surgical
procedures by Dr. W. T. Phy and his many good advices in the
application of radium.
REVIEWS AND
ABSTRACTS
J. C. Mottram, M.B., D.P.H. The Red Cell Blood Content of
Handling Radium for Therapeutic Purposes. Archives of Radiology
and Electrotherapy, xxv. 194-197. Dec. 1920. From ihe Research Department
of the Radium Institute. London, presented before the Pathological
Society of Great Britain and Ireland. Aug. 3, 1920.
"A paper dealing with the leucocytic blood content of individuals
working with radium has already appeared (1920). A leucopenia was
found affecting both the polynuclears and the lymphocytes, reduction to
one half being of common occurrence. The red cell content has been
similarly investigated, except thai material gathered from outside the
Institute has been included. In many cases a diminution in the number
of red cells, with a high color index, was observed. In three cases
a profound aua*mia was found, and was followed by death after an illness
of a few months. These cases will be dealt with separately.

R a d i u m 63
"Ihe.red cell counts of the other workers is shown in diagram in
Fig. 1, where a comparison is made with the blood of normal individuals.
The workers are divided inio males and females, laboratory and clinical
workers (L. and C. in diagram). The remaining individuals are made
up ot porters, clerks, etc., who are not directly eximsed lo radium | N.
m diagram), but work in the same building: they serve as a second control."
"Alf$
'C^Atrs
§.9
49
*0
F10. 1.
C. = Clinical Worker. L = Laboratory Worker.
N. = Unexposed) Worker. Numbers below sleps = Color Index.
"Il is seen thai the clinical and laboratory workers present, on the
whole, a diminution in the number of red cells as compared with the
unexposed workers. However, they fall within normal limits with iive
exceptions, three male and two female clinical workers. The three males
(415, 4-2 and 43 millions per c.mm.) are a little below the lowest male
found by Bing '(4-4 millions). The two females (33 and 34) arc. however,
very much below Bing's lowest female (4 millions). The haemoglobin
content of these cases shows much less deviation from the normal,
so that the color index is high. Referring to the diagram,it is seen that
all the unexposed individuals have a color index of close upon ro,
whereas the color index of the clinical workers is usually in the region
of 1 2. The male clinical worker with a lox index and a red cell count
of 54 millions was away from ihe Institute during the war for two and
a half years. Apart from slight anisocytosis being sometimes present.
neither signs of degeneration nor of regeneration were observed."
"These findings would be perhaps of only academic interest were
they considered apart from the three fatal cases accompanied by anaemia
which have occurred among radium workers. Of these, one was a

64 R a d i u m
female nurse, another a male laboratory worker, and the third a male
clinical and 'laboratory worker. For convenience they will be called
Cases A. B and C."
"Case A, aet 36., had been a radium worker for eight years. She
had excellent health during this period. She was first noted to be pale
on returning from a holiday of two months. Her red cell count was then
found to be 22 millions per c.mm.. and hxmoglobin 50 per cent., color
index 1 14. There was considerable anisocytosis."
"The following blood counts were subsequently taken;—
16U1 day of illness. 19 millions; color index. 105
»6ih day of illness. 1^ millions; color index. 109
33rd day of illness. 1-2 millions; color index. 91
53rd day of illness. 11 millions; color index. -68
"During the period between ihe lasi two counts three transfusions
of blood were given. She died seventy-three days after being firstobserved
to be anaemic. There was also considerable leucopenia, as is
constantly the case in radium workers. The polynuclears numbered between
5-600 per c.mm.. and the lymphocytes were usually as numerous.
It cannot be said with certainty that death was primarily due to ihe blood
condition, as certain conditions and signs of infective endocarditis were
present. No post-mortem examination was obtained."
"Case B. at 33, had been working with radium for three years. As
in the case of A, he was laken ill shortly after returning from a month's
holiday. He died three months later. No post-mortem examination
was made. Two blood examinations were made:—
241I1 day of illness. 1-3 millions; color index. 12; leucocytes 960
36th day of illness. 8 millions; color index. 13; leucocytes 1,520
"The polynuclears were 960 and 730. the lymphocytes 492 and 790.
Anisocytosis was obserbed. The case was diagnosed aplastic pernicious
anaemia.
"Case C, act. about fifty years, had worked with radium for ten
years. Previous to this his blood presented some anomalies, notably a
mast-cell leucocylosis. His illness was of short duration, and was diagnoed
as aplastic pernicious anaemia. No post-mortem examination was
made.
"The following Wood count was made 20 days before his death:—
Hemoglobin Gowers Sahli. 125
Tallquist, •« 20 »• 10
Globules rouges. 527.500 per mm.s Globules blanc, 850 per mm.8
Valeur globulaire, 0.884
Pourcentage leucocytaire. polynucleaires neutrophils. 135
Petit myelocyte neutrophile type de metamyelocyte. 1
Polynucleaires neutrophile avec degeneresence. 1
Polynucleaires eosinophils, 12
Grands mononucleates, 10
Movens mononucleates, 8
Lymphocytes, 405
Petits cellules plasmatiques. 24S
Hemalies nuclees environ 4 pour 100 leucocytes, legere poikilocvtose,
anisocylosc ires marquee, notable polvchromatophilic."
"Reviewing these three cases, and taking into account the greai
rarity of aplastic pernicious anaemia, ii might reasonably be concluded

R a d i u m 65
that exposure to radium was the important aetiological faclor. When,
however, Ihe blood examination of the other workers is also taken into
account, the above conclusion becomes hardly open to doubt. The
anaemia found was of exactly the same type, only less profound. Add
lo these facts the constant occurrence of a marked polynuclear leucopenia,
and a complete absence of signs of regeneration, it is clear that
the hematopoietic system of these workers is seriously damaged. In
keeping with this view is the fact that recovery from the leucopenia
is very slow. The effect of being away from radium exposure for several
months is seen in the following figures obtained from two female
clinical workers:—
19/12 2/1 29/1 23/2 24/3
Polynuclears .. . 1382 2419 2254 3835 3484 Holiday
Lymphocytes 778 1210 1824 2665 1662 Dec. 5-Feb. 13
Polynuclears . .. . 19S0 2364 2S05 2419 1S72 Holiday
Lymphocytes ....1320 1576 2193 1599 1833 Dec. 5-Feb. 9
(Note the return of the leucopenia on reluming lo work.)
"The aplastic pernicious anaemia found differs from the rare disease
of young women in being accompanied by a leucopenia instead of a leucocytosis.
In this respect it is similar to certain anaemias produced by
poisons, as, for instance, trinitrotoluol. In these a polynuclear leucopenia
is often present, but in contrast to the present type a lymphocytosis
occurs instead of a lymphopenia. (Minst).
"The experimental data dealing with the action of x-rays and radium
radiations on ihe blood, spleen, and hematopoietic system are very extensive
(Colwell and Russ). There is agreement in respect of the destruction
of lymphocytes and of destructive changes in the tissues of
the spleen. As regards the bone marrow under certain conditions of
x-radiation, hyperactivity was observed, but whether this was due to the
direct action of the radiation, or to a reaction to the destruction of circulating
blood cells, was not decided. Destructive changes in bone marrow
have also been described. It would seem probable that the very
penetrating gamma rays of radium may have a destructive action on
bone marrow, which relatively soft beta rays may not possess."
"In conclusion,it may be said that even those who are not entirely
convinced that these deaths were directly due lo this occupation will
admit that the workers are suffering very serious damage, and that,
therefore, they should be given every practicable and reasonable protection.
D.elails of the various protective appliances in use at the Radium
Institute are to be found in the annua! report for I9I9-"
"I am indebted for the results of some of the blood examinations
to Dr. Rubens Duval, Hospital St. Michel, Paris, and to Dr. J. W. H.
Evrc, Guy's Hospital, London."
J. C. Mottram, M.B., D.P.H. Histological Changes in the Bone Marrow
of Rats Exposed to the Gamma Radiations from Radium. Arlhives
of Radiology and Electrotherapy, xxv, 197-199, Dec. 1920. From the
Research Department of the Radium Institute, London.
"Twenty-three rats were taken. Of these eight were set aside for

66 R a d i u m
controls, and fifteen for exposure. This was made a fair division as
regards the sex. age and weight of Ihe animals. The exposures varied
from twelve hours to 460 hours, as shown in the table. Exposures above
forty-eight hours were not continuous; ihe animals were irradiated for
twelve hours during the night; during the day ihe radialion was discontinued.
The animals were confined in a box 15 in. long and 9.5 in.
wide. Varnished radium applicalors (4 by 4 cm.), containing each 80
mgr. of radium bromide (RaBr-2H.O), were placed at either end of Ihe
box. 95 in. from ihe center. The end of the box. which was made of
deal 06 in. thick, and 225 mm. of lead, intervened between the animals
and the applicator. The animals were killed when Ihe exposure was
complete, except in the case of some of the short exposures, when intervals
of time up to three days were allowed to elapse."
"The bone marrow of Ihe femur was fixed in Helly's mixture, and
stained wilh eosin methylene blue, and with iron hematoxylin."
"Histological Findings. Two decided differences between control
and experiment were noted in cases of exposures above forty-eight
hours. The control specimens, mounted on the same slide as the experimental,
stained much more deeply with iron hematoxylin, and a decidedly
more intense blue with eosin methylene blue. Detailed examination
showed this to be due to a diminution in numbers, in the radiated
specimens, of young recently divided and darkly staining nuclei, and of
nuclei in Ihe anaphase. The more differentiated and granule containing
cells presented no difference."
"The other observed difference was a decrease in the number of
mitoses in Ihe radiated specimens. To tesi this observation the mitoses
were counted with a 1/12 in. objective, using a square diaphragm in
the eye-piece to restrict Ihe field. The sections were cui 3 microms
thick, and only the central portion of a cross section of the bone marrow
was used. Forty fields were counted in each case without knowledge
of the specimen."
"The following figures were obtained:—
Eight controls
1
2
3
4
5
6
7
8
Mitoses
61
74
82
S5
$7
89
93
104
Fifteen experimenlals
Exposures in
hours
1
12
2
12
3
24
4
24
5
24
6
24
7
4«
S
93
9
10S
10
139
u
280
12
432
>3
432
U
432
'5 460
Mitoses
109
S7
no
67
122
46
65
40
49
36
43
57
57
47
4i
"Discussion. These results are in keeping with and will explain the
blood changes found in radium workers. The low polymorph blo.xl

R a d i u m °7
content commonly found, and the anaemia of an aplastic type affecting
the much exposed workers, pointed to an interference wilh 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 has been noted in a few
cases."
"Experiments on animals show that the bone marrow is less affected
by x-rays than are lymphoid tissues. Warthin found an inhibition of
white cell production and a preponderance of senile over young forms.
Il would seem that the penetrating gamma rays arc able to reach the
bone marrow, whereas the relatively soft x-rays used clinically faii in
this respect. In view of the fact that a harder type of x-radiation is
every day being more largely used, perhaps effects on bone marrow will
in the future be observed and require lo be guarded against"
MADAME MARIE CURIE'S VISIT TO THE UNITED
STATES. A CORRECTION.
The editors are in receipt of a letter from the director of the Polis
Bureau of Information, 40 W. 40th Street, New York City, and herewith
reproduce the letler as a means of correcting a misstatement made
in an earlier issue of this Journal,
New York, N. Y.,
June 22, 1921.
Dear Sirs:—
My attention has been called lo a statement about Madame Curie's
parentage in Radium, volume 17, No. 1, April 1921. The statement
is said lo be that Madame Curie's father, John Sklodowska (sic), was
a Jew, while her mother was Swedish. This story was probably taken
from a report in ihe New York Times, published last February, antl
corrected by Madame Curie's niece, Miss Dluska, in the New York Times
of February 23rd. Apparently, the correction escaped your contributor's
attention.
A few days ago the Chicago Daily News had an English translation
of a Polish letter written by Madame Sklowdowska Curie while she was
in Chicago to Mr. Czarnecki, of the editorial staff of the Chicago Daily
News. Madame Curie states emphatically that she was born in Poland
of Polish Roman Catholic parents of purely Polish extraction.
Hoping that you may see your way to correct this misstatement,
I am,
Yours very truly,
(Signed) Ludwik Ehrlich, Director.

frS
R a d i u m
«u.»«iio *ca£E* coy AmcttJif-\
Oi-|i.itInii'iiti'l" ifommcrcr
Bnrraii* •landsn-.s-4UI. *trjit?!i Dinctor
Z & g * * * * * ?
*•*
«AD3f®A(CC?UE nijtCEST&iC
fer*
.".< -*.-..n
THE PRESTECNT CP Tni-'-NT!^ S7-TES (* AMOK*
cn pmwLr cr the v*omd> w amsuck
t-
Madaroe AWie Sfclodowska Car»te.
•>' •
OTtf -tf-fg .P-J .-.'.'•-.j'.yWU.'-',l-"».jWiViw +*?&**&*+Mr (B»jni'
'•-.- .--.- .•••. fc*!(*~j -..-V. • »,w:.»7«Wfl«r^ V-'.'.-!«
•-- : -
Ml 1
-
441*
*.- N
-
.* •
I —
1 1
•
.
.
.
S-YTSxa
!*-
THE MEASUREMENT OF MADAME CURIES CRAM
OF RADIUM
Above is reproduced the specially engrossed certificate issued by
the National Bureau of Standards in certifying ihe measurement of
the gram of radium which was the gift of the women of ihe L'nited
Stales lo Madame Curie. The total radium clement content of the
ten tubes is ioio.i milligrams.

A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY. PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES
Copyright 1921 by Radium Chemical Co.
Edited by Charles H. Viol. Ph. D.. and V/lllbm H. Cameron. M. D wilh the assistance
collaborators working in the fieldsol Radlochemtstry, Radioactivity and Radlumtherapy.
Address all communications to the Editors, Forbes and Meyran Avenues,
Pittsburgh, Pa.
Subscription $2.50 per year, or 25 cents per copy In the United Slates and Canada
In all other countries $3.75 per year.
VOL. XVII SEPTEMBER, 1921 No. 6
A REPORT OF THE WORK CARRIED OUT AT THE
RADIUM INSTITUTE, LONDON, FROM JAN. 1st,
1920, to DEC. 31st, 1920.
A. E. Hayward Pinch, F.R.C.S., Medical Superintendent
The character of the Report of the Radium Institute for the year
1920 varies widely from that of any previously published. In it, an
attempt is made to present radium therapy on a rational scientific basis,
and thus to free it from the reproach of empiricism which is sometimes
leveled against it. This has been done by a consideration of certain
physical and physiological principles, and a review of the histological,
pathological and clinical data derived from the administration and results
of eighty thousand treatments, supplemented by the information
obtained from a perusal of much recent literature dealing with the
physics and therapeutics of radium.
No cases are described in detail, as previous reports have been
largely composed of. clinical histories, but the general laws which should
govern the treatment of the various classes of disease are formulated,
and some indications as to the special conditions calling for a departure
from routine methods are given.
The lines of treatment set forth are based principally upon the
procedures employed at the institute during the past ten years, but full
Editors' Note—With the kind permission of Mr. Pinch the latest Report of
the London Radium Institute Is herewith reproduced, save that the brief clvapters
dealing with apparatus and screening have been omitted. These topics together
with Uic subjects of technique, reaction, sequel lac, the effects of radium radiations
on radium workers and the protection of radium workers were covered in
the last Report, which was reprinted in the August, 1920 issue of this Journal.

70 R a d i u m
consideration is also paid to the methods which have been introduced by
other workers, and of which the value has been clearly proved. The
table of cases refers only to those patients who were seen for the first
lime between ist January, 1920, and 31st December, 1920, and do not
include any cases examined prior to those dates, though many such have
received treatment during 1920. (For table see pages 76-77)..
The policy of declining lo 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 Ihe only ones
refused were ihose 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 lo 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 firsttime 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
trace of the original lesion or lesions has disappeared, in which there
is no sign of any recurrence, and in which the palient is. so far as can
be determined by a thorough and careful examination, free from any
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, either in the direction of retardalion of ihe progrss of
the disease, diminution in the size of a growth, healing of ulceration and
arrest of haemorrhage and discharge, or of relief to such subjective
symptoms as itching, tenderness, pain, dyspnoea and dysphagia.
The strength of all the apparatus used in the treatment of cases is
expressed in terms of hydrated radium bromide, a salt the radium element
content of which is 53.6 per cent. *
8,134 treatments were administered during the year, of which 4.598
were given free of all charge to necessitous patients.
765 emanation applicators were prepared during the year, and distributed
to hospitals and medical practitioners throughout the United
Kingdom for the treatment of patients.
THE RAYS OF RADIUM
Radium may be used for Ihe treatment of disease cither in the form
of radium salts or radium emanation, the therapeutic effects being
identical.
Both radium salts and radium emanation emit three kinds of rays
—alpha, beta and gamma—Iheir respective proportions being approximately
10,000:100:1.
THE Alpha Rays are particulate. They consist of a stream of particles
carrying a positive electrical charge projected with a velocity of
about one-fifteenih ihe velocity of light. They can be deflected by intense
magnetic or electric fields, and are readily absorbed by thin metal,
glass, paper, rubber, or a few centimetres of air.
Their therapeutic power is negligible, as they are unable to pass
through the glass or melal walls of emanation containers, and in var-
•Very important to bear in mind, since dosage in the U, S. is exnr«.*«Pd in
terms multiply of milligrams the given figures of radium by 0.536.—Ed.
clement. To so express results 8 given * In in """ this r^r, report

R a d i u m 71
nished or vulcanite radium sail applicators only a few rays can escape
through minute cracks.
The Beta Rays are far more penetrating than the alpha, and consist
of negative electrons projected with velocities of the same order as
the velocity of light. They are far more easily deflected than the alpha
rays, and are in type identical with the cathode rays developed in a
vacuum tube.
They vary considerably in their velocities and power of penelration,
and for this reason have been divided into "soft," "medium," and "hard"
beta rays.
The transition from one group to another is very gradual, and no
abrupt lines of demarcation can be established by physical measurements.
For clinical purposes, however, it is convenient to regard as:—
"Soft." Those which cannot pass through o,2 mm. aluminum.
"Medium." Those which can pass through 0.2 mm. aluminum, but
cannot pass through 0.2 mm. silver.
"Hard." Those which can pass through 0.2 mm. silver.
The Gamma Rays are very penetrating, and cannol be deviated by
a magnetic or electric field. Their true nature is still undetermined,
but they are analogous in many respects to very penetrating Roentgen
rays.
The Secondary Rays. The passage of gamma rays through
screens of the heavy metals gives rise to the production of secondary
rays—"reflected" and "emergent."
The "emergen!" secondary rays exert a distinctly irritating effect
upon the tissues, and their elimination is therefore a matter of considerable
clinical importance.
Very few and non-irritanl secondary rays are excited by the passage
of gamma rays through aluminum, and this substance will absorb
the irritant secondary rays produced by the passage of gamma rays
through the heavier metals. For this reason the leaden screens, 2 millimetres
in thickness, which are generally used when the therapeulic employment
of the gamma rays only is desired, are covered with sheet
aluminum 0.2 millimetre in thickness.
If. however, aluminum screening is not available, the same result
may be obtained by the interposition of several layers of black paper,
lint, or rubber between the leaden screen and the tissues.
The Action of the Radium Rays. Radium rays falling upon the
cells of living tissues act as a slimulus lo them, but the degree of stimulation
varies wilh the character of the rays, the extent of their absorption,
and the length of time during which they are permitted to act.
Clinical experience has shown that cells of a pathological character
are more susceptible than normal cells to radium rays, and experimenial
research bearing upon these points has been carried out by many observers^
who have found that, other factors being constant, different
varieties of cells behave differently to radiation of a given wave length,
and that the use of the term "selective action" is thus, to a certain
extent, justified.
Il has further been shown that cells are most susceptible lo radium
irradiations when in a slate of active nuclear division. The lethal dose
of radium irradiation has been determined with respect to mouse carcinoma,
rat sarcoma and spheroidal-celled breast carcinoma by Russ and
his co-workers—Wedd, Chambers and Mottram.
Considerable variations have been noted in the response of cells of
a different pathological character — squamous epithelioma, columnar

72 R a d i u m
carcinoma, spheroidal carcinoma, and sarcoma—those of mesobla
origin being ihe most susceptible.
Hvpoblastic and epiblaslic growths also exhibit some difference in
their behavior, the former being more readily influenced by relatively
short exposures with large quantities of radium salts, the latter by longer
exposures with smaller amounts.
The Absorption of the Radix-m Rays by the Body Tissues.
When alpha and beta rays pass through matter their speed is gradually
reduced, and their power of ionization weakened, until it finallydisappears
; they are then said lo be completely absorbed.
In the case of alpha rays this absorption occurs very quickly, and
is complete at a depth of o.oi millimetre from ihe surface of the skin.
The bela rays, however, van- widely in the degree of their absorption,
the "soft" weakly penelrating rays rapidly losing their ionizing
power. The "hard" beta rays are reduced lo about 6 per cent, of their
initial value in their passage through i cenlimetre of body tissues.
For this reason, therefore, the therapeutical powers of the beta rays
are most effective when dealing wilh lesions or growths not exceeding i
centimetre in depth or thickness.
The penetrating power of ihe gamma rays is very great, and complete
absorption of the hardest gamma rays by the body tissues never
orcurs.
A series of measurements made by Giraud showed that it required
a thickness of 14.4 ceniimetres of blood, or 7.6 centimetres of muscle
tissue, lo reduce them to 50 per cent. *
The Action of Beta and Gamma Rays on Normal Tissues.
The Bela Rays.—The physiological changes produced in normal tissues
by absorption of the bela rays arc comparable to those attendant on
direct cauterization, and burns from the firstto the fourth degree—
their intensity depending upon the duration and strength of the radiation—may
be readily induced.
Two points of difference, however, are to be-noted:—
(1) The changes in the radiated area occur very slowly, ihe four
degrees appearing in orderly sequence; the finalulcerative stage not
being manifest for from fourteen to twenty days, or even longer.
(2) The associated gamma radiation causes great increase of
growth of fibroblasts, and so favorably influences the process of repair.
Healing takes place very gradually, bui the resultant scar is smooth
and supple. If ihe ulceration has been prolonged, telangiectatic changes
may ultimately appear in the scar.
The gamma radiation is isolated by the employment of leaden
screens, not less than 1 millimetre in thickness (or the equivalent in
some other heavy metal), as such screening cuts out 99 per cent, of the
beta rays.
The action of radium rays on the various tissues and organs of the
body has been carefully sludied by many observers, and a brief sum-
2—T^jgfift^ £ £&•&&& HKT£
specific gravities of these two materials. Kroenigand FriJilrt!^ .J^L «"1 'I'
Fhys.kalische und biologische Grundlagen der s^rahtmherS £ *SS b£&
''•",ii''l'«-ali»B thai water ha- aboul the -,,„• .,>.,..££2' ;,„ .V J T m H
tissue for all types of x-rays as well as gamma ravs and thi.i,« JVK t
measurements indicate that 3.5 cm. ot muscle tissue absorb.is 7- of h, «1
absorbing for rays from mesnihonum of radium Tin- mesothorium thickness gamma Kroenig gamma rays of while aluminum and of rays. mesothorium 5 Friedriehs cm. of of 18 muscle mm. figures are slightly for tissue W radium absorb clt. more gamma p.P^) m,,,,.!,.,,... 22.7ft. *-»•*. ravs indicat and «im ,*,.„ {."a v> gamma a. -v.-« hair £ mm.

R a d i u m
mary of the more important results obtained is now given.
The Skin. The changes induced in an area subjected to radium
irradiation are:—
(i) Epidermal proliferation followed 4>y desquamation, which
may even lay ihe cutis bare. Regeneration of ihe epidermis occurs at
a slow rate, but the normal condition is gradually restored.
(2) Congestion of the dermis with destruction of hair follicles
and sebaceous glands. Numerous fusiform branching connective tissue
cells appear (fibroblasts). The cell processes anastomose, forming a
close plexus, which almost obliterates the normal fibrous and elastic
tissue of the cutis.
The blood vessels become dilated and branched, and the cells of
their endothelial lining proliferate, and become plasmodial in character
—this is "ihe stage of embryonic regression."
(3) Fibrosis. The fibroblasts gradually become transformed into
a dense fibrous tissue, which is characterized by the extreme regularity
of its structure, the bunches being arranged in parallel layers, and containing
a relatively large number of elastic fibres. It is to these factors
that the soft and supple nature of radium scars is due. This is "the
stage of fibrosis."
(4) Regeneration of the hair follicles and sebaceous glands. This
occurs at a later date, usually from vestiges of the original structures.
In some instances, actual new formation is seen from down-growths of
epithelial columns from the scar area. This is "the stage of regeneration."
The Blood Vessels. Prolonged intense radiation of blood vessel?
with radium rays is productive of proliferation, vacuolalion, and degeneration
of the endothelial cells, with leucocytic infillration of ihe
walls, and subsequent dislortion of iheir calibre.
If, however, the radiation be of mild degree, acting for but a short
time al prolonged intervals, multiplication of the endothelial cells with
increased fibrosis of the vessel walls occur. These changes result in a
definite narrowing, perhaps even obliteration of the lumen of the smaller
vessels, and it is in this fashion lhat ihe cure of angiomata is induced.
The Blood. Some information as to the action of radium irradiations
upon the red and white blood cells has been obtained from experimental
researches on animals, solutions of radium salts being injected
into the blood stream. The chief effects noted were a rapid increase in
the number of the red blood corpuscles which persisted for some time.*
With this was associated a leucocytosis of comparatively short duration,
followed by a well marked leucopenia. Very prolonged exposures
to either radium salt or radium emanation solutions, both of which emit
alpha rays, resulted in haemolysis of the red and disintegration of the
while blood corpuscles.
The opsonic properties of Ihe blood serum were also destroyed.
Much more valuable knowledge, however, has resulted from analysis
of the periodic examination of the blood of the nurses and laboratory
workers which has been carried out at the Radium Institute.
In these instances, ihe changes in ihe blood cells have been conditioned
by repeated short exposures with the gamma radiation to which
workers in radium have, by the reason of their special duties, been subjected,
and which must be regarded as due to a slow, but steady, cumulative
action of the gamma rays.
leucopenia is an invariable symptom, the white cells frequently

74 R a d i u m
being reduced to 50 per cent, below normal. Ihe reduction falling principally
upon the polynuclear leucocytes and ihe lymphocytes. The effect
goes on slowly, but "when once established is very peisisteni. and a prolonged
absence from all contact with radium is necessary to restore the
leucocvtic count to the normal. The lymphocytes in particular are very
definitely affected, and many monlhs may elapse before the njrmal percentage
returns.
Willi Ihe red blood cells, there is at first a decrease in the total
number of the red corpuscles, but Ihis is compensated for by an increase
in the color index. This increase is. however, transitory, and if the
exposure lo the radium be continued, gradual decrease in the total number
of corpuscles and in the haemoglobin percentage ensues, both falling
to some 50 per cent, of normal, or even lower.
Researches which have been carried out on rats appear lo indicate
that the gamma radiation seriously affects Ihe haemapoietic tissues, more
especially the bone marrow and the spleen, leading to Irue aplasic
anaemia. It is for this reason that all those who habitually work with
radium should be as far as practicable guarded against ihe possibility
of radium rays impinging upon the abdominal and thoracic cavities.
The Spleen. Radium rays exert a rapid and profound effect upon
this organ, increasing the amount of connective tissue, diminishing, ihe
cellular elements, and causing an almost complete disappearance of
lymphocytes.
Concomitant changes are also noticed in the blood, lymphatic glands
and bone marrow. Leucopenia occurs, the percentage proportion of
polynuclears and large mononuclears is greatly decreased, and there is
a definite accumulation of red corpuscles in Ihe bone marrow, and mamsmall
haemorrhages in its substance.
The Thyroid 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 funclions.
Tt is probable, however, that frequently repealed prolonged screened
radiations would, by inducing fibrosis,ultimately cause atrophy of its
cellular elements, and arrest of its secretory function, as this phenomenon
has been recorded as occurring afler numerous x-ray trealments.
The Testes and Ovaries. The amount of experimental research
that has hitherto been carried out in respect to the action of radium
rays on ihese organs is not great, but it has served lo establish the fact
that the seminiferous tubules and Graafian follicles are extremely susceptible
to such radiation, and their degeneration is rapidlv produced.
Additional support is afforded bv the clinical evidence which, is available
lo show that sterility specially occurs in x-rav workers, unless precautions
are taken to protect them from ihe hard x-ravs, which are
analogous to the gamma rays of radium.
The occurrence of amenorrhcea of many months' duration in female
workers with radium is sometimes noted, and is to be ascribed to the
cumulative aclion upon the ovaries of frequent small doses of gamma
radiation, received in the course of their occupation, as the amenorrhea
disappears if the patient be removed from all coniact with radium for
three or four months.
RADIUM THERAPY
Before proceeding with the consideration of ihe specific treatment
called for in dealing with the various classes of disease—malignant and

R a d i u m 75
non-malignant—it is essential that certain fundamental principles be
enunciated.
The effect of radium irradiation upon any living cell, if of sufficient
intensity, and permitted to acl for a sufficient length of time, shows
three clearly established phases:—
(1) Increase of cell activity, with possible associated proliferation.
(2) Arrest of cell activity.
(3) Degeneration and destruction of the cell.
No hard and fast line can be drawn between these three phases,
the transition from stimulation lo destructive irradiation being simply
one of degree, depending entirely upon the intensity of the stimulus.
All cells are more vulnerable to irradiation when in a slate of active
nuclear division.
A pathological cell is much more susceptible to irradiation than is
the normal one, so that a stimulus which would act only beneficently on
a normal cell, could quite well prove destructive to an abnormal one.
It is upon the correct appreciation of this fact that successful
radium therapy is largely dependent. If the dose be incorrectly calculated,
and be excessive, destruction not only of the pathological but
also of the normal cells occurs, resulting in great loss of tissue with the
formation of an inlraclable ulcer or fistula. On the other hand, if the
dose be loo weak, the pathological cells may be stimulated to activity,
with consequent rapid increase in the size of the growth.
MALIGNANT DISEASE—THE TREATMENT OF
CARCINOMATA
Squamous-Celled Carcinomata. (Epitheliomata). These growths
may be divided clinically into three main classes:—
(1) Fungating Epitheliomata. These tumors are most frequently
met with at the sites where mucous membrane and skin meet, e.g., the
lips, anus, and occasionally vagina. In their early stages they are exuberant
rather lhan invasive, standing prominently above the level of the
surrounding skin. For this reason they lend themselves lo treatmcnl
by the beta rays, which whenever possible should be resorted to, and a
destructive reaction produced. Powerful unscreened applicators should
be applied to the surface of the growth, and their action may be supplemented
by Ihe actual burying in the mass of tiny emanation tubes,
either unscreened, or screened with 0.3 mm. of platinum. The reaction
produced by these means is usually inlense, and is accompanied by considerable
circumjacent inflammation, but with its subsidence, if the
dose has been correctly calculated, the growth" rapidly disappears, leaving
a smooth and supple scar.
In view, however, of the rapid dissemination of these growths by
permeation through the lymphatics, it is advisable to subject the surrounding
areas for some little distance from the main growth to prolonged
exposures with screened apparatus emitting gamma radiation, as
this procedure is of service in bringing about the degeneration or encapsulation
of possible outlying foci of disease.
(2) Pavement Epitheliomata. This class of growth is probably
the most malignant of all epitheliomata. It is accompanied by very
definile "cell-nest" formation, the basement membrane of the epidermis
is ruptured at a very early stage, and downgrowths of the epithelium
into the dermis occur.
Clinical observation shows that these lesions are particularly susceptible
to the action of the middle and hard beta rays, and the best results

76 R A D I U M
TABLE I.
Classification of Cases.
>.
OB 5b
?-
Disease
Carcinoma, Squamous-eel led:
Glabrous skin
Buccal, oral, lingual, and
pharyngeal mucous membrane
CEsophagus
Larynx
Vulva
Vagina
Uterus
L'rethra
Bladder
Anus
Carcinoma, Spheroidal-celled:
Breast
Thyroid
Liver
Gall bladder
Pancreas
Carcinoma, Columnar-celled:
Large intestine
Rectum
Stomach
,Ovary
Testis
Prostale
Kidney
Rodeni L'lcer
Sarcomata
Melanoma
Endothelioma
Tumour of parotid
Malignant glands
Malignant sebaceous adenoma
Mediastinal tumour
Villous tumour of bladder
Papilloma of vagina
Adenoma (thyroid, etc.)
Hypernephroma
Grauloma
Lipoma
., g a eaie«
]1 _o I |i|Blf?
-
2
'3
'7
i-l 17 3
i| 95
5
3
i
5
»7
i
2
37
i
3
40
2
26
2
37
10
1
6
2
2
2
12
I
3
2
16
i
il —
11
4
iS
16
74
3
4
6
5
90
1
6
1
102
4
2
I
I
6
38
1
5
1
2
1
145
47
5
22
7
11
1
8
3
1
5
1
5
1

R a d i u m 77
Lymphadenoma
I>is«-i(S
O
k
a
£
—>
o
I*
11
11
Fiborid disease of uterus... .
*5
Fibromata
3
Leucoplakia
5
Naevi:
Capillary
Caverous
19
15
27
21
Moles, warts and papillomata
27
36
Tuberculosis:
Skin
Glands
Sclera
Sinus
13
7
1
1
21
'7
1
Spring catarrh
Chronic mastitis
Chronic metritis
Keloids, etc
Lupus erythematosus
Psoriasis
Pruritus
Chronic eczema
Lichenification
Xanthelasma
X-ray dermatitis
Lymphatic leucocythaemia ..
Exophthalmic goitre ........
Neuritis
Myositis
Arthritis deformans
Various
Totals
3
*3
4
4
5
1
1
1
1
1
2
1
1
11
78 114 38 133 28 I !
3361 74l
2
3
9
23
6
4
5
3
3
1
2
2'/
12
62 33I806

78 R a d i u m
are usually obtained by the use of large flat applicators of quarter or
half strength—Ihe former preferred—screened with one-tenth of a millimetre
of lead, and applied lo ihe surface of the lesion for a period of
from eighteen to twelve hours in all. best administered in three or two
exposures, each of six hours' duration, on successive days.
This treatment produces a steady progressive exfoliation of the
diseased tissue, while at the same time the stimulant effect of the hard
beta and gamma rays on the fibroblasts of the cutis leads to the formation
of a defensive and protective fibrosis, which prevents ihe spread
of the disease into ihe deeper tissues.
The additional precaution of radiating a wide surrounding area
wilh gamma radiation should also be taken, as in ihe case of the preceding
group.
(3) Tubular EpW>eliomata. This class of lesion is characterized
by ihe presence of long finger-like columns of epitheliomatmis cells running
at right angles to ihe skin surfaces, ami permeating deeply into ihe
sub-cutaneous tissues. These lesions arc not so malignant as either class
1 or class 2, and in many instances microscopical examination snows
the basement epidermal membrane to be still intact, and the cell nests
to be but few in number or wholly absent.
Gamma radiation is to be resorted lo almost entirely in the treatment
of this class of case, as 94 per cent, of the bela radiation is absorbed
by 1 centimetre of tissue, and these growths often extend to a
depth greatly exceeding lhat.
Cross-fire irradiation—the apparatus being so applied that the focus
of their combined radiation corresponds with the cenier of the growth
—should he adopted, and ihe exposure should be prolonged, twenlv-four
to thirty hours' irradiation, the series being repeated at intervals of not
less than four weeks. Screening of 2 mm. of lead should be used, in
order lo prevent destruction of the normal skin by the action of beta
adopted.
The retrogression of cpithcliomatous growths usually occurs at a
very much slower rale than in the case of sarcomatous masses, and ihe
reason for this probably lies in the comparative avascularity of these
lesions, the degenerated cells having either to be thrown off bv exfoliation,
removed by the lymphatics, or encapsulated by the fibroblasts.
Spheroidal-Celled Carcinomata. These growths, the most typical
and common of which are met with as cancer of ihe breast, are
often favorably influenced by radium, more especially when the disease
has occurred in women who have passed the menopause, anil who are
of a comparatively spare habit of body.
Treatment is carried out with the object of re-inforcing nature's
attempt at the arrest of Ihe disease. Microscopical section of a carcinoma
in the early stages, from a patient who possesses a fair inherent
power of resistance, will show all transitions from a dense central
schirrotic focus to a comparatively medullary condition at the periphery.
In ihe former situation there are but few cells and many connective
tissue fibres: in the latter, fibres are scanty, and malignant cells
predominant.
The effect of prolonged gamma radiation is two-fold, h arrests the
vitality and proliferation of the cells in the scattered alveoli bringing
about their gradual degeneration. It at the same time stimulates ihe
multiplication of fibroblasts,thai organize and form bands of fibrous
tissue, which surround the encapsulated cells and prevent their ranid
dissemination.

R a d i u m 79
Again, the warning should be raised, that it is not sufficient lo
radiate the primary growth only; equal attention must be paid to the surrounding
lymphatic areas, in order, so far as poss'ble, to bring about the
destruction of any unseen and unsuspected foci.
Columnar-Celled Carcinomata. The treatment of these malignant
growths is fraught with much difficulty. The most common site
for the development of columnar-celled carcinomata is some portion of
the intestinal canal, calling oflen for very special technique.
Cells of hypoblastic origin exhibit some difference in their response
lo radium rays when compared with cells of cpiblastic nature, and it is
found they arc more definitely affected by a relatively short exposure
with a large dose of radium, than by a long exposure with a small dose,
though the total in milligramme-hours may be the same.
There is further the faci that these tumors originate on a mucous
membrane which overlies a submucosa abundantly provided with lymphatics
and blood vessels, and infiltration rapidly occurs.
In addition lo this, with the exception of the rectum proper, almost
the whole of the alimentary canal, from the cardiac orifice of the stomach
to the rccto-sigmoid junction, is constantly moving, a fact which contributes
very greatly to Ihe dissemination of Ihe disease.
When dealing with diseases affecting the stomach, small intestines,
and colon, it is but rarely possible to do anything more than utilize
gamma radiation obtained from screened applicators placed externally.
But little real benefit seldom occurs, though in many cases a distinct
retardation of the progress of the disease is recorded, with occasional
amelioration of pain, if such be present.
With disease of the rectum, however, Ihe use of the proctoscope
inakes the direct application of radium to the growth feasible.
When the tumor is small, circumscribed, and of an exuberant type.
projecting from Ihe rectal wall, the actual insertion of a screened
emanation tube into the substance of ihe growth will often bring about
a definite diminution in its size, and in some cases retard the disease
for a considerable time.
If the growth be annular, and all the walls infiltrated, the introduction
within ihe lumen of a powerful tube of 150 or 200 mgrs..
screened with 2 mm. of lead, for a period of about eighteen hours, not
infrequently arrests the rate of growth, heals the ulceration, lessens the
existing circumjacent infiltration, and renders the condition operable.
Sarcomata. These growths arc of mesoblastic origin. They are
characterized by their vascularity, and the great preponderance of c-ells
over connective tissue fibres. The individual cells arc of embryonal
type, and they display a greater tendency to rapid cellular proliferation
than to the production of connective tissue fibres. Sarcomata vary
very widely in their histological appearances. In some, their structure
very closely resembles that of a simple fibroma, and it is often difficult,
if not impossible, clearly to distinguish between them. In others, t!»e
tumors are composed of a mass of small round cells, with conspicuous
nuclei, and between these two all types from the highly cellular to the
definitely fibrous growth may be met wilh.
The growths are malignant, but the degree of their malignancy
varies greatly, and speaking in general terms, is directly proportionate
to the preponderance of the cellular over the fibrous clement. They all
tend to grow at a rapid rate, and form distant metastases.

so
R a d i u m
Prognosis is worse in the case of ihe small round-celled, and best
in respect of the small spindle-celled sarcoma, ihe latter type of tumor
often approximating very closely to a irue fibroma.
The variety of tumor formerly termed "melanotic sarcoma" is not
now regarded as a true sarcoma, and is classified as a "melanoma."
The treatment of all forms of sarcomata is best carried out by the
use of ihe gamma radiation, as il is often of the highest importance to
avoid any extensive breach of continuity of the investing skin, since if
this should occur, the risks of haemorrhage, and possibly of septic infection,
are very great.
Treatment must be vigorous, and a large quantity of radium should
be used, the applicators being disposed in such fashion as lo procure «n
equal intensity of radiation in all parts of the growth, and this is often
best accomplished by the actual burial of one or more radium tubes.
screened with 1 mm. of silver, in the cenier of the mass, powerful applicators,
screened with 2 mm. of lead, being applied over and around
its circumference.
If ihe dose be correctly estimated, the rapid diminution in the size
of ihe growth, more especially in cases of lympho-sarcomata and small
round-celled sarcomata, is often amazing. The gamma radiation acts
first by inhibiting nuclear activity, and arresting cell proliferation. With
the continuation of the stimulus the cells degenerate, and are engulfed
by the phagocytes, or broken-down and absorbed by ihe body fluids, this
latter resull being much expedited by the presence of numerous small
thin-walled blood vessels which traverse all parts of the growth.
The absorption of the substance derived from the broken-down
cells into the blood stream invariably produces a toxaemia, which is
directly proportionate to the size of the growth affected. This phenomenon
is best seen when treating lympho-sarcomaia. These growths will
often commence to shrink within three days of the irradiation, and disappear
completely by the end of a fortnight, and during this lime patients
experience a very definite vomiting, headache, and a rise of temperature
to 1010 or 1020. In the case of lympho-sarcomata and the round-celled
sarcomata too greal an im(tortance should nol be attached to the rapid
disappearance of the primary growth, and the patient should be very
carefully watched for some considerable lime to come, so that the
appearance of any metastasis may be promptly dealt with.
The spindle-eel led sarcomata, on the other hand, do not exhibit
so great a tendency to recurrence, or to metastatic deposits, and when
once growths of this character have been apparently cured bv radium,
they tend to remain well for an indefinite period.
It is highly probable thai this is to some extent explained by Ihe
fact Ihat the spindle-celled growths approach very nearly in their structure
and characteristics to the connective tissue cells of a fibroma, and
that the effeel of the radium stimulation is to check iheir tendency 10
cellular proliferation, and lo divert them rather to ihe formation of connective
tissue fibres, thus transforming a malignant into a non-mal'gnant
neoplasm.
Beta radiation is rarely of use in the treatment of sarcomata as thev
tend lo develop beneath the dermis, in connection with muscles, serous
membranes, fasciae, and the connective tissue planes generally'.
An exception may perhaps he made in the case of the formerly *ocalled
"melanotic sarcomata." as these tumors probably develop from
pigmenl cells of Ihe corium, and are therefore of epiblastic rather than
mcsoblastic origin.

R a d i u m
si
The primary lesion in melanoma, if of comparatively small size,
may therefore be treated with unscreened apparatus, the beta rays being
employed to produce an intensely destructive reaction. The lymph
channels leading from the primary focus should, at the same time, reieivc
a prolonged gamma radiation, in order to destroy any isolated foci
whirh may be present in these regions.
By Ihe adoption of these measures, temporary arrest of the progress
of the disease is often obtained.
Rodent Ulcer. It is in the treatment of this class of lesion thai
the most striking, remarkable and permanent results of radium therapy
are obtained.
A section of a typical rodent ulcer, when subjected to careful
microscopical examination, reveals malignant invasive proliferation of
Ihe deeper layers of the epidermis, down growths of cylindrical type
passing deeply into the corium, interlacing and forming alveoli and
acini.
The cells of these processes are smaller than those of a true
epithelioma; there is always a definite basal layer of cubical or cylindrical
cells, and cell nesls are of extremely infrequent occurrence. Vacuolation
is often observed in many of the acini, forming the so-called
"cystic" type of rodent ulcer. At the edge of the ulcer there is an inflammatory
cellular infiltration consisting of leococyles, plasma and
mast cells, with some increase of the adjacent fibrous tissue. This forms
the "rolled edge" which is so typical a characteristic of the disease.
These growths, though classified as malignant, vary from the
ordinary carcinomata, in that they grow only by direct extension, and
metastases rarely, if ever, occur. From a clinical standpoint they may
be divided into two main classes:—
(i) Lesions of a hypertrophic and exuberant type, with slight
superficial ulceration, and often limited by a distinct rolled edge. The
piesence of a definite rolled edge, and the protrusion of the growth
above the skin level may be regarded as an indication of the facl thai
;he patient possesses a strong inherent power of resistance to the disease,
the rolled edge being due to nature's attempt to set up a barrier against
the invading acini. A section through a lesion of this type shows thai
the rolled edge is continuous beneath the base of the ulcer, forming
really an indurated saucer in which the malignant structures lie.
(2) Growths of excavating type with thin over-hanging edges and
a soft gelatinous base—no rolled edge being present. In this latter clasof
case the defensive powers of the organism are deficient, the absence
of the rolld edge showing that no protective reaction is occurring.
(1) Ulcers of the first group usually do exceedingly well, an«i it
is quite safe in these cases to give a prolonged exposure with unscreened
apparatus emitting beta rays, the length of ex|>osure varying from one
10 three hours, according to the thickness of the lesion.
The reaction produces degenerative necrosis, and removal by ulceration
of all the malignant '.issue, and possibly of a small layer of the normal
tissue. The stimulant action of the gamma rays acling with ihe
beta induces a rapid multiplication of the number of the fibroblasts, and
an increase in the elastic tissue of the underlying corium. Repair occurs
at a relatively slow rate, but the resultant scar is smooth, soft and
supple.
(2) In this class the results are not nearly so uniform or good,
and it is of the utmost importance always to irradiate some consider-

82 R a d i u m
able distance beyond the visible margin of the lesion, in order to deal
with the outlying invasion columns of cells which undoubtedly are
present in these situations. It is not wise, however, to give so severe a
dose as when dealing with the previous group, as repair is always extremely
slow, and often imperfect, and if loo large a dose has been
given, a painful, intractable, though benign ulcer may result. These
cases exhibit a strong tendency lo recurrence, and on that account should
he subject to inspection at fairly frequent intervals, even if an apparent
"cure" has been produced.
In cases of very long standing, accompanied by great destruction
of tissue, and invasion of ihe mucous, cartilaginous or bony tissues.
radiation with beta rays should not be employed. Radium irradiation
of any kind is powerless to cure rodent ulceration of bony lissues, and
the same is almost equally true with respect to cartilage. For these
reasons affected portions of these tissues should be removed as far as
possible before radium treatment is commenced.
A gamma radiation applied lo the borders of the growih, and its
deeper processes, will often serve to arrest the progress of the disease,
diminish the pain and induce some slight degree of repair, but it will
not and cannot do more than this.
Endothki.iomata. From a clinical standpoint these growths
occupy a position mid-way between carcinomata and sarcomata. They
grow slowly, form lobulated masses in which mucoid degeneration frequently
occurs, do not tend to infiltrate the surrounding skin, and
rarely, if ever, give rise to metastases.
They are most commonly met with in conneclion wilh the parotid
gland, and less frequently in the sub-maxillary gland and carotid body.
Their microscopical appearances exhibit very great diversity, often rendering
ihe exact diagnosis difficult or impossible.
In a typical section the main characteristics are numerous and
closely-set flattened spaces, containing irregular groups of polygonal or
cuboidal epithelium. There is no attempt at the formation of acini.
giant cells are present in varying numbers, and there is oflen definite
mucoid degeneration apparent.
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 ihe fact that'the growih
spreads only by direct extension, and does not form metastases, enables
the irradiation lo be concentrated over a comparatively limited
area, and thus powerfully to affect any isolated extensions of growth
which the surgeon may have failed to eradicate.
( If the growih be inoperable, ii should be treated both by "crossfire
' irradiation with heavily screened external applicators.'emitting
gamma rays only, supplemented by ihe actual insertion of a radium tube
screened with i millimetre of silver into its centre, an exposure of from
twenty to thirty hours' duration being given. Rv this method arrest of
cell growth followed by degeneration is induced, and with this there is
an associated increased development of ihe fibroblasts, which when
fully organized into fibrous tissue, contract and greatly reduce the size
of the mass, and bring about its encapsulation.
When these tumors occur in connection with the parotid or submaxillary
glands, the burying of an emanation tube in their interior
shouid not be lightly undertaken, as if the track of the tube be in contact
with any normal secreting gland tissue, a fistula is quile likely to

R a d i u m 83
form shortly after the operation, which defies all efforts to obliterate
it. and forms the starting point of a progressive intractable ulcera'ion.
NON-MALIGNANT DISEASE
Fihro-Myomata of the Uterus. These tumors vary very greatly
in their size, number, distribution and density. They are almost invariably
multiple, and arc classified in three main groups, according lo
their position:—
(i) Sub-serous.
(2) Interstitial.
(3) Sub-mucous.
Microscopically, they are found to be composed of masses usually
roughly spherical in shape and made up of smooth muscle fibres and
connective tissue, the latter element usually being the predominant one,
the bundles of fibrous tissue displaying a concentric arrangement atound
numerous secondary centres. Each tumor is surrounded by a loose capsule
of fibrous tissue, which is very vascular, and contains many enlarged
vessels, resembling those of a pregnant uterus.
Few blood vessels actually penetrate into the substar.ee of ihe
growths, their nutrition being maintained by exudation from the vessels
of the capsule. When cont|>osed principally of muscle tissue they ire
moderately soft, but if almost wholly fibrous their density approaches
very nearly to that of cartilage. Cystic degeneration is some* hues noted,
and calcification of Ihe growth is not infrequently met with.
Patients suffering from fibro-myomata usually complain either of:—
(a) Excessive haemorrhage, worst at the menstrual periods, or
(b) • Pressure symptoms:
Ha'morrhage occurs only when the growth affects the endometrium.
Pressure symptoms arc especially apt to occur when the fibro-myomata
are of the sub-serous or interstitial type.
Surgical treatment should be resorted to whenever practicable; in
some cases myomectomy suffices, in others a sub-total hyslerect >my is
necessary. Many patients, however, are strongly averse to operative
interference, and radium treatment may then quite justifiably be resorted
to.
When uterine haemorrhage is the principal symptom considerable
relief may confidently be anticipated.
Treatment is best effected by the introduction of a 100-mgr. tube.
screened with 2 mm. of lead and rubber, into the uterine cavity, and
this may well be supplemented with a plate of equal strength, screened
in similar fashion and applied externally over the fundus. An exposure
of twenty-four hours' duration should be given, and may, if necessary,
be repeated after an interval of about three months.
The effect of this treatment is twofold. It causes an exfoliation
of the hyperlrophied and congested uterine mucous membrane, which
is afterwards replaced by healthy cells. In addition to this, a perivascular
fibrosis and proliferation of the endothelial cells of the enlarged
uterine blood vessels is set up, which progresses to a condition of endarteritis
obliterans.
In some cases the congestion attendant upon the application of the
radium causes an even greater increase in the menstrual flow at the
immediately following period, but the successive periods show a progressive
diminution in the amount lost, until the flow returns to normal,
or amenorrhea occurs. When the patient is, however, troubled
principally by pressure symptoms, due to the size or position of the

84 R a d i u m
growth, the prognosis is not so good, and if the tumor be chiefly fibromatous,
as opposed 10 myomatous in character, but little actual reduction
in ihe size of Ihe mass may be anticipated.
With the soft myomatous* vascular type, however, definite shrinking
is frequently observed, a result which is to be attribuled largely to
the increased multiplication of fibroblasts, and the fibrous contraction
which follows upon their compleie organization.
When patients are past the child-bearing age, and are nearing their
climacteric, il is often quite justifiable, wilh the patient's knowledge and
consent, lo attempt lo produce a premature induction of the menopause,
as il is well known lhat fibroid tumors rarely, if ever, increase in size
after ihe menopause has been established.
In such cases, therefore, Ihe internal irradiation of the uterine
cavity may advantageously be supplemented by prolonged irradiation
of both ovaries with powerful screened applicators. This treatment
brings about a degeneration of the Graafian follicles, thus arresting the
ovarian functions, and leading to the establishment of the menopause.
Leucocytiiakmia. (i) Spleno-medullary leucocythaetma. — A
disease characterized by great enlargement of the spleen, wilh associated
changes in the bone marrow and blood, followed in the later stages by
multiple haemorrhages and a progressive anaemia. Microscopical examination
of sections cut from ihe affected spleen show ihe splenic pulp
lo be closely packed with leucocyies, but there are in addilion many
marrow cells—"myelocytes"—both neutrophilic and eosinophilic.
In aculc cases, or in Ihe early stage of the disease, Ihe organ is
soft, but as the condition becomes chronic a fibrosis and thickening of
the reticulum of the pulp occurs. Examination of the blood reveals a
greatly increased total white cell count, ranging from 200,000 to 1,000,-
000 (or even higher) per cubic millimetre, ihe myelocytes forming from
forty lo fifty per cent, and the lymphocytes being reduced to five per
cent, or even less.
The changes in the red blood cells are not so evident al first,but
ultimately a progressive anaemia, with a diminuiion of the red cells to
two million or less per cubic millimetre, with an associated deficient
color index, is noted.
Nucleated red blood cells and poikilocytes also occur in varying
numbers.
In the early stages of this disease, while the spleen is still soft, and
anaemia non-exislcnt, radiation with the gamma rays is of very great
benefit. Exposures of from twenty lo thirty hours' duration should be
given with flat applicators screened with 2 mm. of lead, and containing
from 200 to 500 or more milligrammes, according to the size of the
spleen. The effect of ihis treaimenl is usually very striking, as evidenced
by Ihe changes in ihe while blood cell count, the total of which is often
reduced by fiftyper cent, or more within three days of the exposure, and
by the decrease in the size of the spleen, the organ rapidly shrinking
almost to normal dimensions, and thus rendering the operation of splenectomy
much more easy of accomplishment.
If ihe condition has existed for some lime, and Ihe spleen has
previously been subjected to much treatment with x-rays, bul little
actual decrease in its size is likely lo be effected by radium" as extensive
fibrosis of the splenic interstitial lissue will have taken place, but the
changes in the while blood cell count, and in the relative percentage
proportions of these cells, will still be produced, with consequent benefit
to the patienl.

IUM 85
If the spleen be radiated at intervals of two or three months it is
often possible greatly to retard the appearance of anaemia, and its accompanying
haemorrhages, and so to prolong the life of the patient in comparative
comfort for a very considerable time.
(2) Lymphatic leucocythaemia.—This form of leucocythaemia is
rare, but differs from the preceding chiefly in ihe histological characters
of the blood. The increase in the total number of leucocytes is never so
great, rarely if ever exceeding 500,000 per cubic millimetre, no myelocytes
are present, and over ninety per cent, of all the white blood corpuscles
are of the small mononuclear type. Some associated slight enlargement
of ihe spleen is occasionally noted, but this feature is not constant.
The superficial groups of lymphatic glands are those most usually
affected, and the enlargement is not so great, and the confluent masses
not of such size, as are met with in Hodgkin's disease.
The condition is of a more chronic type than ihe splenomedullary.
and the late ana'tnia is not so profound. The disease is a comparatively
rare one, but in the few cases which have been treated, temporary
benefit has been noted. The radiation of the affected glands with gamma
rays for periods of from twenty to thirty hours is usually followed a
few days later by a very definite decrease in ihe total number and percentage
proportion of the lymphocytes, and the effect persists for two
months or possibly longer, Ihe condition of the blood then slowly reverting
to its previous stale, when the exposures should be repeated. The
ultimate prognosis is bad. though by ihe means indicated, the date at
which death occurs may be postponed for two or three years, or possibly
longer.
Exophthalmic Goitre. Experimental researches on mammals
have shown that radium irradiation has but little effect on the normal
thyroid gland, and for this reason the treatment of parenchymatous,
fibrous, or adenomatous goitre with radium is usually very ineffective.
With exophthalmic goitre on the other hand, distinct benefit is
often observed.
Microscopical examination of the thyroid gland of a patient suffering
from exophthalmic goitre shows a very definite and characteristic
picture. The vesicles are not distended, and not clearly defined.
colloid is greatly reduced in quantity or wholly absent. In the place of
single layer of cubical epithelium lining the vesie'es, they are seen [o
be almost choked with an irregular mass of proliferated, rounded, or
sometimes columnar cells.
If the condition has existed for a long time some degree of increased
fibrosis is occasionally met with, but its appearance is not common.
Numerous theories have been advanced by various observers as to
ihe exact cause of the symptoms of Graves' disease, some contending
that they are entirely nervous in origin, and due to disturbance of the
sympathetic; but there is. on the other hand, abundant and well-reasoned
evidence to show lhat an increase of the thyroid secretion plays
a very important part, and this theory is justified by the microscopical
appearances above alluded to, which suggest thai the gland is in a condition
of exalted cellular activity.
Prolonged irradiation with the gamma rays will often prove of greal
use when routine medical treatment has failed. Exposures with quantities
of aboul 200 mgrs. of radium screened with 2 mm. of lead for a

86 R A D I U M
total period of twenty-four to thirty hours should be given. This treatment
is sometimes followed by a definite exacerbation of all the symptoms,
and it seems fair to atlribute this to 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 ihe action ol the
rays bringing about an arrest of ihe vitality and retardation in the development
of the actively proliferating cells, thus restoring the output
of the cellular secretion more nearly to normal limits.
With this ihere is also associated a fibrosisof the connective tissue
of the gland, causing the organ to become firmer and smaller.
Microscopical testimony as to the validity of this inference remains
lo be established, but there are excellent clinical grounds for the theories
advanced.
Tuberculosis. Tuberculosis cutis, lupus vulgaris.—The primary
nodule of this disease originates in the deeper layers of the corium, and
implication of the epidermis is always a secondary phenomenon, ihe
cellular infiltration and inflammatory slasis in the neighborhood of ihe
nodule leading lo degeneration of the covering skin, resulting in ulceration
which may extend deeply, leaving when healing is complete, ugly
scars and cicatricial contractions.
In some few instances ulceration of the epidermis does not take
place, the patch slowly undergoing involution, and leaving a central
smooth, firm, white scar—this is the "lupus non exedens."
Microscopical examination of a lupus nodule shows it lo consist of
a central large multi-nucleated giant cell, surrounded by an inner layer
of endothelial cells, and an outer layer of lymphocytes, or the small
round cells of inflammatory infiltration. No blood vessels traverse the
nodule.
In rapidly growing cases it is sometimes possible to demonstrate
ihe presence of tubercle bacilli within the gianl cells, but failure more
often than success attends the efforts to do so.
Numerous experiments have been made with regard to ihe action
of radium rays on cultures of tubercle bacilli, and it is found thai an
exposure of al leasl one hundred hours' duration, with full strength
apparatus unscreened, is necessary to obtain a lethal effect. Exposures
of this duration are outside the range of practical therapy, and on this
account radium radiation cannot be used for the distinct purpose of
killing tubercle bacilli.
It has. however, been noted that cultures of tubercle bacilli which
receive a relatively short irradiation have their vitality greatly inhibited.
anil sub-cultures made from them grow much more slowly ihan controls.
and exhibit numerous involution forms. Il is probable, therefore, that
the radiation of a lupus patch for a moderate length of time weakens
the vitality of the tubercle bacilli, and so enables their ingestion bv the
phagocytes lo be more easily and completely accomplished.
When treating lupus vulgaris the exposure and screening to be
adopted must be governed by the characters of the lesion. If ulcerated.
superficial, and wilh but little accompanying induration, an unscreened
exposure of an hour to an hour and a half's duration, utilizing praclically
all the beta rays, suffices to produce a destructive reaction of
moderate degree, which is followed bv the formation of a smooth and
supple scar.

R A D I U M 87
If, on Ihe other hand, ulceration has not occurred, but definite
infiltration and induration are apparent to the touch, screening of onetenth
of a millimetre of lead should be used, an exposure of two to
three hours' duration given, and repeated at intervals of aboul six weeks.
By this method no breach of the skin is produced, the congestion
and induration are much lessened, and with repeated exposures the skin
becomes apparently normal in character.
In cases of lupus of long standing, with extensive ulceration and
destruction of the hypoderm and cartilage, it is wiser to resort entirely
to the employment of the gamma rays, using a screening of 2 mm. of
lead, and giving a total exposure of tw-enty to thirty hours' duration.
Very great and permanent improvement is often obtained by these means.
Tuberculous Adenitis.—The primary lesion in these cases is identical
in character with lhat met with in tuberculosis of the skin, but it
occurs in the substance of a lymphatic gland. If treated with radium
at an early stage, before caseation has occurred, and fluctuation of the
gland or implication of the covering skin is appreciable, fibrosis of the
gland, with encapsulation of the containing pathogenic material, may
frequently be obtained, and Ihe necessity for surgical interference obviated.
It is advisable, where praclicable, to employ the method of "crossfire"
irradiation, using screening either of 1 mm. of silver, or 2 mm. of
lead, and giving exposures in the one case of eighteen, and the olher of
twenty-four hours' total duration.
The exposure may have to be repeated at intervals of about six
weeks or two months.
If caseation of the affected glands is apparent; radium treatment
is useless, and operative measures should be adopted.
In favorable cases the glands arc often reduced to almost normal
size, and become scarcely palpable.
Naevi. Capillary Naevi.—These lesions, which are of congenital
origin, are due lo an increase in the number or size of the blood vessels
in the skin. When only the capillaries and arterioles are concerned the
patches are of a bright red color, and frequently of a stellate character,
"Spider naevi." When the veins of the corium are also implicated
the lesion is of a dark purple, antl of a more uniform character, forming
the so-called "Port-wine stain." As in this class of lesion only the
tissues of the corium are affected; the bela rays are largely used in their
treatment.
Much depends upon the density of the patch; if diascopy with light
pressure effects complete blanching, then it is advisable lo utilize the
softer beta rays, and by using an unscreened applicator to obtain a reaction
which just causes definite vesication.
This will serve practically to obliterate the distended arterioles and
capillaries, and the resultant scar will be barely distinguishable from the
surrounding skin.
When treating a "port-wine mark" it will often be found thai even
firm diascopy fails completely to blanch the tissue, and when this is the
case it is advisable to use a screening of one-tenth of a millimetre of
lead. This cuts out the majorily of the soft and middle beta rays, and
the remainder of Ihe middle, with the hard beta rays, should be utilized
to produce proliferation of the endothelial lining of the vessels, and
their slow construction by the gradual development of fibrous tissue
from newlv- formed fibroblasts.

88 R A D I U M
Care musi be taken not to give too large a dose. The best results
are usually obtained by exposures given on each of three successive
days of from thirty to sixty minutes' duration, the series being repeated
ai intervals of two months'. The process is tedious, but the results are
usually fairly satisfactory-
Cavernous Naevi—These are due either to the dilatation of the
vessels of, or the development of numerous dilated spaces lined with
endothelial cells in ihe connective tissue. Between these spaces are bands
of fibrous tissue forming the supporting framework of the vessels.
In the majority of instances the investing skin is not discolored, ihe
vessels of the corium and epidermis being unaffected, although all combinations
of capillar}- and cavernous naevi are met with from time lo
lime.
These growths are most successfully treaied by radium therapy, and
the procedure which should be adopted is that indicated above in dealing
wilh the "port-wine marks," the only point of difference to be noied
lying in Ihe fact that as these growths frequently form definite prominent
tumors, they lend themselves particularly well 10 cross-fire irradiation.
The treatment of these growths with radium should be undertaken
at ihe earliest age. as infants prove much more susceptible to irradialion
than children approaching their leens. and if Ihe necessary caution be
observed, no untoward result can possibly occur.
Keloids. Microscopical examination of these growths shows them
to be composed of interlacing bundles of collagen, which frequently
exhibit an almost hyaline structure. They are further characterized by
an increase in ihe cellular and vascular elements: true fibroblasts are
but few in number.
These growths appear to extend along the course of ihe neighboring
blood vessels by a process of peri-vascular fibrosis. As they frequently
occur on exposed portions of the skin, chest, face and neck
they are apt lo be particularly disfiguring, and in the female sex, their
removal becomes a matter of considerable importance.
Surgical interference is useless, as the growth speedily recurs in
the scar.
If taken at an early stage, and be fere the collagen bundles have developed
into fully organized connective tissue, radium irealment is often
of the greatest possible value.
The lesions are usually both irritable and tender, and for ihis leason
it is expedient to avoid a surface reaction. Half strength applicators,
screened with i mm. of silver, should be employed. This screening
cuts out all but 1.2 per cent, of ihe bela rays, and allows 95.5 per
cent, of the gamma to pass.
It is advisable to give three exposures, each varying from four to
six hours' duration, on each of three successive days, an Interval of
some eighteen hours being permitted lo elapse between the successive
exposures, and the series of exposures should be repeated ai periods of
about iwo months.
This Irealment is followed by absorption of the keloidal mass, with
a gradual restoration of the color to normal, and although it is difficult
to speak of the exact changes which produce this result, owing 10 the
difficulty of oblaining material for microscopical research, it seems fair
to infer thai the character of the radiation employed serves to increase
very greatly the number of fibroblasts, which form a dense and regular

R a d i u m 89
fibrous tissue that supplants the hyaline collagen. At the same time
gradual obliteration of the superfluous vessels occurs, thus restoring
the skin tint to normal.
Lupus Erythematosus. The characteristic lesions of this disease
are essentially inflammatory in type. The process begins in the blood
vessels supplying the superficial layers of Ihe cutis and the papillae,
which become congested and distended. The associated diapedesis of
cells from the blood vessels, and their accumulation around the hair
follicles and sebaceous glands, induce excessive action of these structures,
with the formation of sebaceous plugs, which protrude from the
orifice of the glands and expand into small adherent scales of sebum.
This latter feature is particularly conspicuous when the disease
affecls the face or other areas where the sebaceous glands are numerous
and large. In the hands and fingers these seborrhceic appearances are
lacking.
Later, the cellular elements undergo fatty degeneration and disintegration,
leaving an atrophied epidermic layer covering a corium destitute
of hair follicles and sebaceous glands.
The changes are, however, always very superficial in character, the
deeper layers of the corium are not implicated, ulceration does not
occur, and there is no cicatricial contraction.
The etiology of this condition is obscure, and has excited much controversy,
though the majority of observers are agreed in regarding the
skin lesions as a local manifestation of a constitutional disorder. For
this reason it is unwise to speak of ihe "cure" of lupus erythematosus by
radium treatment, though its adoption will often bring about the rapid
disappearance of the affected patch.
As the disease is extremely superficial in its character it responds
well to treatment with the bela rays. Unscreened applicators, or
screened with one-hundredth of a millimetre of aluminum, should be
used, and an exposure varying from thirty minutes to one hour's duralion
given. This produces a temporary but very definite increase in the
congestive character of the lesion, with some superficial ulceration. This,
however, speedily subsides, leaving an area of skin which differs in
character but little from the immediately surrounding parts.
Leucoplakia. This condition is most generally met with on the
tongue and buccal mucous membrane, or on the vulva. In the former
situation ii is generally associated with a definite specific history-, and
may be regarded as a pre-cancerous condition. When occurring on ihe
vulva it is almost invariably accompanied by intense pruritus, and it is
for this symptom, rather than for the disease itself, that the patient
seeks relief.
Three definite degrees of leucoplakia are met wilh. The first slage
is characterized by slight congestion, with swelling of the epithelium.
and the formation of glistening, translucent patches. In the second
stage these patches become thickened, opaque, and pearly white in color,
often forming distinct raised plaques with everted and over-hanging
edges. In the third stage the patches become still thicker, and cracked
or deeply fissured. At the bottom of these fissures ulceration occurs,
and often forms the starting point of epithelioma.
The microscopical pathology of this condition reveals a primary increased
vascularity of the sub-epithelial tissues, with swelling of the
epithelial cells, and desquamation. This is followed by hypertrophy of
the papillae, with thickening and cornification of Ihe epidermis.

90 R a d i u m
Associated with this is a lymphocytic infiltration of the corium, with
an increase in the number of mast cells, disappearance of the elastic
tissue, and an increase of the connective tissue fibres.
In the vulvar region these changes at a late stage often produce
atrophy and sclerosis of the parts.
The treatment of leucoplakia by radium must be related to the
stage of the disease. In cases of the first degree exposures of fifteen
to twenty minutes' duration wilh a half strength applicator, screened
with one-hundredth of a millimetre of aluminum, will often speedily
clear up the lesion. The inflammation is at first increased, congestion
ihen disappears, and the skin or mucous membrane resumes its normal
appearance.
In the second slage, when ihickenet' and hypertrophic plaques are
present, the employment of the middle and hard bela rays is to be advocated,
full strength applicators, screened with one tenth of a millimetre
of lead, being applied for one hour on two or three successive days, the
shorter exposure being given when the disease affects the tongue or buccal
mucous membrane, the latter when the vulvar epidermis is affected.
In the third stage, when well-marked Assuring and ulceration are
apparent, ihe condition should be regarded as pre-cancerous, and surgical
measures should be resorted to—local excision of the affected
patch usually proving sufficient—and ihis procedure should always be
adopted in longue cases, as patients are unable lo tolerate an exposure
in the moulh of a duration and intensity sufficient to produce healing
of the affected area.
In the vulva, if Ihe patient refuses operative measures, prolonged
radiation with gamma rays will not infrequently effect very great improvement
in the condition, and will almost certainly free the patient
from the accompanying intense irritation and pruritus. Such improvement
is, howeper, likely lo prove but temporary, as the condition lends
to recur in a few months' time, and on this accouni the patient should
be kept under close observation.
Warts, Keratomata, Papillomata. These growths are all of a
proliferative rather than an invasive character, and ihere is little or no
subjacent infiltration of the skin. Microscopical section of a war! or
papilloma shows it to be composed of numerous finger-like projections
from ihe corium, these projections being covered with a large thickened
epidermal layer in which the prickle cells are conspicuous and prominent.
The central core of each papilla or projection is composed of loose
connective tissue, earning a group of tiny blood vessels.
These growths should be treated by the employment chiefly of the
beta rays. Unscreened applicators arc used, and an exposure averaging
an hour in duration is given. A treatment of this strength and intensity,
the applicator being carefully adjusted to the size of the growth.
and the surrounding healthy skin shielded from Ihe action of the ravs!
usually suffices to bring about a slow degeneration of the proliferated
epidermal cells. logelher with contraction and obliteration of the blood
vessels supplying each individual papilla; and if the exposure has been
correctly estimated, the wart or papilloma rapidly shrinks, or some?tines
drops off (especially if of a pedunculated type), at the end of three to
four weeks, leaving smooth, healthy skin.
The same holds good for senile keratomata, but as in this class of
lesion the papillated characters are not so evident, and the growth is
usually attached in flakes,the exfoliation occurs very gradually, usually
being complete in four or five weeks' time.

superficial skin lesions.
R a d i u m 91
Chronic Eczema, Psoriasis, Lichenification, Pruritus. The
majority of these affections may be speedily cleared up with radium,
though some of Ihcm recur after an interval of Ihrec or four months.
They all call for treatment by short exposures with the sott and
middle beta rays, and Ihe apparatus should therefore be used unscreened,
or screened with one-hundredth of a millimetre of aluminum.
When there is definite ulceration or parakeratosis of the epithelium
(e.g.,. eczema or psoriasis), no screening is necessary as the action of
the very soft beta rays serves to accelerate the exfoliation of the diseased
epidermal cells.
In lichenificalion, on the other hand, when the surface of the skin
is smooth, or in pruritus, when no actual skin lesion is visible, Ihe employment
of screening of one-hundredth of a millimetre of aluminum
serves to prevent undue action on the superficial layers of the epithelium.
The exposures should vary in length from five to twenty or even thirty
minutes, according lo the extent and character of the area treated, and
tt is found as a matter of clinical experience that the best results are obtained
when such exposures are given in three periods of equal duration
on three successive days, e.g., an exposure of fifteen minutes—three
days, five minutes each day.
I desire to express my indebtedness to my colleagues, Dr. J. E. A.
Lynham, assistant medical superintendent; Dr. J. C. Mottrom, director of
the Pathological Research Laboratory; Mr. W. L. S. Alton. F.I.C., director
of the Chemico-Physical Laboratory, for much generous help
and most valuable criticism in the preparation of this report, which may,
therefore, be regarded as expressing the views of the staff of the Radium
Institute.
The report necessarily contains some amount of theory, but contentious
matters have been, so far as possible, avoided; it is written in
the hope that it may serve to stimulate inquiry into these problems of
radium therapy upon which further illumination is needed.
REPORT OF THE RESEARCH DEPARTMENT*
By J. C. Mottram, M.B., D.P.H., etc.. Director.
REPORT OF THE CHEMICO-PHYSICAL LABORATORY
By W. L. S. ALTON, F.LC, Director.
The work of the laboratory for 1920 is summarized in a table giving
the figures for 191, and 1920:—
1920 1919
Number of bollles of radium emanation solution distributed
4,800 5,000
Total output in litres 1,200 1,250
Number of emanation tubes and applicators prepared 765 771
Activity of above in terms of radium bromide **65-235 **66.04
Number of radium applicators prepared 5 33
Number of measurements of radio-activity 31 24
The number of emanation applicators prepared was substantially
thc same, and as the demand was increasing, more radium bromide (approximately
0.5 gramme) was purchased and added to the apparatus
for the production of emanation.
•Dr. Mottram's report was reprinted in the last issue of this Journal, page-
5t. in a discussion of the dangers of workinn with radium and x-rays.—Ed.
"Grammes,

92 R a d i u m
The advice of the institute is ofien asked by hospitals and by medical
men with regard to ihe relative efficiency in the use of emanation
applicators or radium applicators; from a therapeutic point of view
their respertive efficiency is nearly identical, bul while ihe activity of
emanation applicators is of comparatively short duralion. that of radium
applicators is permanent.
In general, the advice given depends on the amount of radium salt
available, and il is nol considered advisable to set up an apparatus for
the production of radium emanation unless at least one gramme of
radium bromide, or its radium equivalent, is available. Smaller quantities
than this are belier put into platinum needles and surface and surface
applicators capable of being used at all limes, leaving the special
advantages of emanation applicators to those whose resources enable
them lo deal with the production of this particular type.
The tendency abroad, especially in ihe United Siaies, appears to
show thai ihe use of radium salts for the production of emanation applicators
is becoming the general method employed, and an account of
the method in use at this institute may be of interest.
The separation of radium emanation in a condensed form for therapeutic
uses may be classified under two headings:—
. (i) A purely chemical method.
(2) A method involving chemical and physical separation.
The first method involves the use of various chemicals as absorbents
to eliminate the mixed gases (oxygen, hydrogen, carbon dioxide, and
Iraces of ozone, chlorine and bromine), leaving as a residue a high concentralion
of emanation which is then introduced inlo capillary tubes
or flat applicators by suitable means.
The Duane apparatus extensively used in the United Stales appears
to fulfill this purpose admirably, though repairs to this apparatus, when
necessary, must be difficult 10 execute. A chemical method has been
studied in ihis laboratory which seems lo be worthy of further inquiry.
preliminary experiments having shown ihe method lo be sound in principle,
ihough nol yet perfect in detail. The difficulty in all methods
of chemical absorption is that there is no chemical that can be used to
absorb nitrogen from the accidental introduction of even a minute bubble
of air. and this contamination is very difficult to guard against.
This objection cannot be urged against (he second method in which
some of the impurities are eliminated chemically, and liquid air used
finally to separate the emanation in a concentrated form: this method is
the one preferred at this institute, and has been modified considerably
during ten years of practice until it gives complete satisfaction.
There is then given a detailed descriplion with figures illustrating
the meihods employed at the London Radium Institute in separating
the radium emanation from the solution of a radium salt, its purification
and tubing, etc.. and Ihe method of dissolving radium emanation in
water for the preparation of emanation drinking water.

A MONTHLY JOURNAL DEVOTED TO THE CHEMIS­
TRY. PHYSICS AND THERAPHEUTICS OF RADIUM
AND OTHER RADIO-ACTIVE SUBSTANCES
VOLUME EIGHTEEN
OCTOBER, 1921, TO MARCH, 1922
PITTSBURGH, PA.
1922

CONTENTS OF VOLUME XVIII
NUMBER
ONE
Measurement of Absorption and Dosage of Gamma and X-Rays
by Ionometric Methods. A Review of Recent Work
I
Reviews and Abstracts.
Acta Radiologica. A New Journal Devoted to Radiology 12
The Dangers of Radiation and Radiology in Cancer 14
Frederick Soddy. The Interpretation of Radium and ihe Structure
of the Atom
i
NUMBER TWO
Radiumtherapy—Fro and Con 17
Reviews and Abstracts.
Arthur Burrows. M.D. The Treatment of Advanced Carcinoma
of the Cervix of the Uterus by Radium -9
NUMBER THREE
Reviews and Abstracts.
Russell H. Boggs, M.D. The Treatment of Carcinoma of the
Breast by Imbedding Radium Supplemented by X-Ray 33
Russell H. Boggs. M.D. The Treatment of Tuberculous Adenitis
by Roentgen Rays and Radium 36
C. Augustus Simpson. M.D. Atrophy of Lymphatic and Tonsilar
Tissue by Radium and X-Ray y.
Waller A. Wells. M.D. On the Practicability of Effecting a
Complete Atrophy of the Tonsils by ihe Use of Radium 41
D. Bryson Delavan. M.D. Results of the Treatment bv X-Ray of
Diseased Tonsils and Adenoids , >
R. H. Lyons, M.D. The Use of Radium in the Treatment of
Myxomatous Nasal Polyps ,?

J. C. Mottram, M.D. Effect of Increased Protection from Radiation
Upon the Blood Condition of Radium Workers 44
Robert Knox. M.D. Treatment by X-Ray and Radium, with
Special Reference to the Value of these Agents 46
NUMBER FOUR-FIVE
Radium and Deep Therapy in the Treatment of Malignancy.
Russell H. Boggs, M.D 49
Reviews and Abstracts.
Arnold Schwyzer, M.D. Radium: Its Thera|>eiitic Uses in
Surgery 63
S. A. Heyerdahl, M.D. Radium Treatment of Changes in the
Thyroid Gland 68
John Albert Marshall, D.D.S., Ph.D. A Laboratory and Clinical
Study of the Bactericidal Action of Solutions of Radium
Emanation 7'
NUMBER SIX
A Report of the Work of the Radium Department of the University
of California Hospital, Between April. 1920. and April, 1921.
Laurence R. Taussig. M.D 73
Reviews and Abstracts.
Francis Carter Wood. M.D. Biological Determination af Radiation
Dosage 75
Francis H. Williams, M.D. Treatment of Hypertrophied Tonsils
and Adenoids bv Radium, A Preliminary Statement
Si
•
Frank C. Benson. Jr.. M.D. and Joseph V. F Clay, M.D., F.A.C.S.
A Case of Parinaud's Conjunctivitis Treated with Radium. 82
1 itle-page and Index to Volume XV III.

A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY, PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES
Copyright 1921 by Radium Chemical Co.
Edited by Charles H. Viol, Ph. 1).. and William H. Cameron, M. D with the assista
collaborators working In the fieldsof Radiochemisb-y, Radioactivity and Radlumtherapy.
Address all communications to the Editors, Forbes and Meyran Avenues,
Pittsburgh, Pa.
Subscription $2.50 per year, or 25 cents per copy In the United States and Canada
In all other countries $3.75 per year.
VOL. XVIII OCTOBER, 1921 No. 1
MEASURMENT OF ABSORPTION AND DOSAGE OF
GAMMA AND X-RAYS BY IONOMETRIC METHODS
- A REVIEW OF RECENT WORK
The general adoption of the gamma ray method of standardizing
radium preparations, and the setting up of the International Radium
Standard constitute very important steps in the advance which radium
therapy has made in the last decade, making it possible for radium
workers lo handle definitely known amounts of radium and to describe
radium treatment in terms of a common unit of quantity—the milligram
of radium element,* or its equivalent, the millicurie of radium
emanation.
In the fieldof roentgenology, the development of the Coolidge tube
undoubtedly has marked the greatest advance, making possible as il
does, the standardizing of x-ray oulput, and simplifying technic, particularly
where large doses of the x-ray are used, as in therapy. In the
case of radium there is a definite output of beta and gamma ray energy
per unit of mass of radium, while in the case of the x-ray lube, both the
quantity and quality of rays may be varied widely, and with the older
forms of gas tubes, these variations were not definitely controlled. However,
the advent of the Coolidge lube has brought this desirable control.
"Some still adhere lo the earlier used unil. the milligram of pure crystalline
radium bromide, ItaBr* ZWO. The radium element content of this salt is 53.6%.
and so data given in terms of this unit is approximately and readily transformed
to the radium element basis by dividing the given figureby two. The data from
the London Radium Institute are always given In the bromide unit. The earlier
French activity units were based on the assumption that the total ionizing activity
of pure crystalline radium bromide was 2.000.000 times that of pure uranium.
Thus, on this basis. 50% pure radium bromide was said to be of 1.000 000
activity, etc. The gamma ray method of standardizing radium has entirely 'displaced
the activity unit.

R a d i u m
The measurements of gamma ray intensities have always been carried
oul by use of the electrometers (electroscopes) making use of
the ionization which these rays produce in air and other gases. It was
possible to estimate the absorption of these rays in matter, and absorption
coefficients were determined for the gamma rays of different penetrating
powers, in various substances by measuring the residual amount
of radiation after the beam had passed through known thicknesses of
the substances.
In ihe case of x-rays, the dosimetric methods employed by the roentgenologists
have in the main been photochemical, in that the intensity
of the rays was determined by observing their aciion in such reactions
as ihe darkening of a photographic plate (Kienbock sirips, effect on silver
salts) barium plalino cyanide crystals (Sabouraud-Noirc pastille)
and selenium (Fuerstenau intensimeter).
As long as the unscreened x-rays were used these more or less inadequate
methods were comparatively useful, and certainly far better
than nothing. The use of filtered x-rays in massive dose treatment soon
showed thai the indications of these pholochemical reaclions were entirely
different for the filtered rays and the unfiltered. and varied according
to the quality of the rayi used.
csrni
tsartl)
Figure 1. Schematic diagram of apparatus used by Friedrich and Kroenig,
fc. is the MlilarWulf electrometer, the fall in potential of the threads being observed
through a reading microscope. This electrometer is equipped with *i charging
device I, connected to the battery, and an additional capacity C. which can be
connected with the thread system through S. The electrode in the tiny ionization
chamber J. (graphite coated horn), is connected to th« electrometer by the
metal sheathed rubber cable Z.
The most comprehensive comparative study of x-ray dosimetric
methods is thai given in Friedrich and Kroenig's book, Physikalische and
Biolologische Grundlagcn der Strahlentherapie* (Berlin, 1918), which
Dr. Henry Schmitz has translated into English.**
•See brief review of this book by Iser Solomon translated from French In
Jour, de Radiol, et Klecirol. IV. 35S-361. 1920. in the December 1920 issue ol
Radium. Important daia from this book are also given in the paper by Dr H
Schmitz. on the Newer Methods of Measuring and Applying the Roentgen Dose
in the January 1321 Issue of the Journal of Radiology.
"Dr. Schmitz advises that Rebman and Companv of New York will shortly
issue this book. A supplemental chapter will give int.-resting data obtained by
Dr. Schmlta during the past summer, working in Friedrich's laboraiorv giving
Isodose measurements on the smaller sized American radium preparations'.

R a d i u m 3
Their observations of the action of unfiltered and variously filtered
x-rays on the commonly used x-ray dosimeters brought out clearly that
the same amount of x-ray energy in Ihe form of penetrating filtered
x-rays did not produce the same effect on the dosimeter as the softer
unfiltered x-rays. Their work did show that the ionization in air was
practically proportional to the intensity of the x-rays, irrespective of
their hardness, and this led to iheir choice of the ionometric method
for determining x-ray absorption and dosage. Since the absorption of
gamma rays and x-rays is largely an electronic rather than an atomic
or molecular function of matter, and since the absorbing power of
atoms of substantially the same atomic weight (i.e. same electronic
structure) is about equal,it is not surprising that Friedrich and Kroenig
found that water has practically the same absorbing power as an
equal thicknesses of muscle tissue.
By use of a small ionization chamber of graphited horn,* o.S mm.
thick, the chamber having a volume of i ccm. and being connected by
a long flexiblecable to an eleclrometer, they were able to measure the
actual ionizing intensity of radiation, which penetrated through the
skin surface to hollow organs of the body into which the tiny ionization
chamber was inserted.
/
0 U
G3 Arri-er • A«#»i Q Brass
Figure 2. Section through the graphited horn ionization chamber of Kroenig
and Frledrlcn'a apparatus, showing the construction and manner of connecting the
insulated graphite rod K with the charged filarsystem of the Wulf Klectrometer.
bv tin- brass part M and the insulated copper wire K. The diameter of the ionization
chamber was 10 mm. and its length,2v> mm. The graphite electrode was
2 mm. in diameter and 15 mm. long.
To study the intensity of the ionizing rays at various depths
in tissue, the authors used a large vessel full of water as a
"phantom," immersing Ihe small ionization chamber to various depths
below the water surface. Such measurements using x-rays filtered
through io mm. of aluminum brought out Ihe rather astonishing fact
thai ihe scattered x-rays acting on a point at io cm. below the water
surface greatly increased the intensity of ionizing rays, the measured
dose being 31 per cent .of the water surface dose, whereas at this depth.
if only the absorption and dispersion of the rays arc taken into account,
the calculated io cm. depth dose is 8.4 per cent, of the surface dose.
The authors found that Ihe magnitude of this effect of the scattered
x-rays and secondary rays was mainly influenced by the size of the portal
of entry, the effect being greater for the larger portals.
Friedrich and Glasser (Strahlentherapie XI, p. 20, 1920) have indicated
the same general phenomenon for the gamma rays in that the
actually measured dose at 10 cm. below the skin surface is 130 per
•It Is very important that the walls of the ionization chamber be construct
of material having an average low atomic weight, approximating as far as possible
the composition of tissue. Kroenig and Friedrich first employed aluminum (at.
wt. 27) but found that the graphited horn gave better results. In most of the
older work this important point has been neglected, and therefore the older data
arc not directly comparable with Friedrich and Kroenig's.

R a d i u m
Figure 3. Photograph of Kroenig and Friedrieh's apparatus for measuring
gamma and x-ray Intensity at a point.
r
R
i
i
- xsr:::::::l
- — ft-
L$-
U
4 pTDESEEBEffi * Tletiromtfer
r
at
Figure 4. Schematic diagram of the water "phantom" used by Kroenig and
Friedrich. to measure the intensity of ionization at various depths in water, this
corresponding closely to the intensity of ionization produced jn body tissues at
corresponding depths. The gamma or x_ray beam played down vertically on- the
surface of the water contained in the cylindrical zinc vessel. 35 cm. in diameter
and 25 cm. high. Water filledthe vessel to a depth of 20 cm. K Is micro-ionization
chamber with connecting cable to the electrometer.
cent, greater than the dose based on calculations which only take into
account the absorption of the rays and their, divergence. R. M. Sievert,
in an article on the Distribution of Intensity of Ihe Primary Gamma
Rays from Radium Applicators Used in Therapy, (Acta Radiologica
(Stockholm) Vol. I, pp. 89-119, July 25, 1921), making the same general
sort of measurement, with the exception that the tiny aluminum
ionization chamber was placed in the axis of a glass test lube of about
1 mm. wall thickness, Ihe test tube being immersed in water, found that
the measured gamma ray dose corresponded within less than 2 per cent.
with the calculated dose, calculations taking into account only absorption
and divergence with dislance from the source. At the same depth
in water (1.5 cm.) ihe figures given by Friedrich and Glasser indicate
a difference of over 20 per cent, between the measured and calculated

R a d i u m
w,'
Figure .. Schematic diagram showing the apparatus used by Sievert to measure
gamma ray ionization at a point. M W
is the mlcro-ionlzation chamber, with
wall of thin aluminum the chamber being 9 mm. in diameter and " mm. long.
E is the tiny brass electrode which connects Uirough an insulated wire with the
"Balkenelectrometer" E to which is connected the condenser C. A 5 cm. thick
lead plate BB screened the electrometer and condenser from direct action of the
gamma rays. The discharging effect of the gamma rays acting on the microionization
chamber was compensated by increasing the charge on the condenser
C by means of the battery A' and resistance W and W'l. the precision voltmeter
V showing the difference of potential between the condenser and eartn.
The measure of ray intensity was the time required for the change of potential
of the condenser from one constant value to another, the electrometer reading
being held meanwhile at the null or zero point. The distance between the r.dium
preparation and the electrometer was 5(> cm. and over the electrometer was a
3.5 cm. lead housing.
doses. Part of the difference between his results and Friedrich and Glasser's,
Sievert accounts for by their use of a different gamma ray absorption
factor, Ihe use of Sieverl's figure, in the calculated value for gamma
ray intensity at io cm. below ihe water surface, giving a figure only 70
per cent, different from the value measured by Friedrich and Glasser,
whereas their calculated value differed by 130 per cent, from the measured
value. The only other notable difference lay in the use of a glass
tube by Sievert, and this would account for his getling lower value for
the gamma ray intensity, since the glass would screen out soft secondary
rays of the beta ray type. Sievert's method therefore would more
accurately measure gamma ray intensity, while Friedrich and Glasser's
method would more nearly determine the total ionizing energy.
Interesting figures given by Friedrich and Kroenig in their book
are those which they found for the absorption of unscreened and of
variously filtered x-rays and gamma rays in water and aluminum. They
used a Coolidge tube, with a transformer and gas interrupter, with a
parallel spark gap between plate and point of 30 cm. for the unfiltered
and 3 mm. filtered x-rays, and spark gaps of 35 and -|0 cm. respectively
for the 10 mm. Al and 1 mm. of Cu filtered x-rays.
Measurements were made using Ihe small ionization chamber on the
absorption in water up to 10 cm. and in aluminum up to 10 mm. of the

6 RAPITJM
unfiltered x-rays. X-rays filtered through 3 mm. and 10 mm. of aluminum,
x-rays filteredthrough 1 mm. of copper and gamma rays of dmm
and mesothorium screened wilh 1.5 mm. of brass and 5 mm. of celluloid.
The thicknesses of aluminum (mm.) and water (cm.) respectively
which absorb the first 50 per cent, of ihese various types of rays are
given in the following table from ihe data of Friedrich and Kroenig:
Thickness of water
Thickness of Al. (apprax. same for
which absorbs 50r< muscle tissue) which
of the rays absorbs 5J"i of rays
Unfiltered x-ravs 2.15 mm. 1.8 cm.
3 mm. Al. filteredx-rays 4-25 mm- M cm-
10 mm. Al. filteredx-rays 6.9 mm. 3-25 cm
1 mm. Cu. filteredx-rays 10.5 mm. 3-7 cm.
/•* f n .i_ 1 . - «.«. 3.5 cm. water at>sor»
Gamma ravs of Ra. through 1.5 mm.
i65*-c of the gamma
brass and 5 mm. celluloid 48.0 mm. -ff 11% A J W *
Gamma ravs of mesothorium screened
a half absorption
„ f„_ d- -^ «„. value of about 13.5
as for Ka j2. mm. cm may ^ calc
From these data il is clear how much greater the penetrating power
of the hard gamma rays is than even ihe portion of hardest x-rays
available after tillering the x-rays through 10 mm. of aluminum or 1 mm.
of copper.
Figure 6. Photographic view of Steven's apparatus, showing the lead-covered
electrometer :md condenser at upper left side, lead plate in center and insulated
shaft leading ft-onilead plate at right to micro.ionization chamber at end or
shaft. In Sievert's paper cited above, he developes complex mathematical
formulae which permit the calculation of the intensity of the primary
gamma rays about radium preparations, such as are used in therapy,
such for example as for tubes, singly and in groups, and for plaoues.
The data obtained by use of these formulae were checked by experimental
measurements and these results agreed closely with the computed
values.
Sievert calls attention to the fact that the gamma rays of radium
are not homogeneous and cites Kohlrausch's work which indicates three

R A D I U M
Figure ". Arrangement used by Sievert to measure intensity of rays In
water. A thin walled glass test tube G passing through the stopper of the llask.
permits insertion of the shaft bearing the microjonizatlon chamber, the gamma
rays playing on this through what would ordinarily be the bottom of the llask.
groups of gamma rays from Ra B and C, the hardest group having a
relative intensity of 8, the next softer, 6, and the softest, I. In other
words the hardest rays make up 8/15, ihe intermediate 6/15, and the
soft 1/15 of the gamma rays from radium. Each of these types of
gamma ray will be absorbed in a different measure in various materials.
This point is also brought out clearly by the figures given in Failla's
(Radium Research Laboratory, Memorial Hospital, Newr York) paper
on ihe Absorption of Radium Radiations in Tissues—Am. Journal of
Roentgenology, VIII, P15-232, May* 1921. We quote the summary
given by Failla of his work.
"1. The apparatus used, consisting of a gold leaf electroscope and
conical ionization chamber, and the experimental procedures are described
in detail.
"2. The most imi>ortant limitations imposed by the experiment.-d
method adopted are discussed. They are due to:
(a) Use of a metal ionization chamber.
(b) Use of a gas as Ihe absorbing medium in the ionization
chamber.
(c) Exclusion of scattered and secondary radiation produced in
tissue.
(d) Inability Io reproduce in the physical laboratory physiological
conditions.
"3. The absorption curves for aluminum, brass, and lead are given.
Prom these'we see that:
(a) As ihe fillerincreases the transition from sofi to hard radiation
is quite sharp.
(b) Beyond a thickness of filter of a few millimeters in the case
of aluminum and brass the absorption is exponential (1= I°e"ud). In
the case of lead it is not ex|K>nential in the range of thickness used.
(c) This shows lhat the filtration by a small thickness of metal
is sufficient to give a radiation which is absorbed exponentially by metals
of medium or low atomic weight. The radiation, however, is not strictly
homogeneous, as indicated by ihe lead absorption curve.
"4. The criterion for the quality of radiation to be used m deep
therapy being the expoential absorption of the radiation by tissue, irom
Figures 3 and 4 we see lhat:
(a) A metal should be used as the primary filter.
(b) A secondary filter, composed of light elements like tissue.
should be used to remove the soft, secondary radiation of the metal.

RAPIXJM
(c) There are different combinations of primary and secondary
filters suitable for deep therapy.
(d) Beyond a certain point additional filtration, while increasing
the penetrating power of the radialion slightly, decreases the intensity
of the radiation considerably.
lot nation
Chan be
4p
p -
Elecfrosccpe
ttot
Electros

R a d i u m »
count had lo be taken, however, of the 'natural leak' of the Instrument, thai >#.
of the slow discharge of the electroscope leaf when the source of radiation which
we wished to investigate was nol present. This correction is made by sub*
trading the rate of fall of the leaf due to the natural leak atone from Ihe rn*»
of fall due to the combined effect of the radiation Which enters tiie ionization
chamber, and the natural leak.
"It Is important to bear in mind Just what we are measuring with an apparatus
of this sort, because on that depend the conclusions which we may draw
from the experimental results. The cone of rays which enters the ionization
chamber ionizes the air In it. The formation of Ions implies that energy is being
used up in the process, since work must be done lo separate negative from
positive electricity on account of the force of attraction be twee ntiie iwo. This
energy is supplied by the radiation. The difference of potential between the wire
ami the walls of the ionization chamber is sufficient to cause the positive and
negative Ions lo be separated from eacn Other as soon as they are lormed. th-is
preventing their recombination, I'nder these conditions the electric current thus
produced Is proportional to the number of ions produced per second, which Is a
measure of the energy absorbed by the air in the chamber. The electroscope,
used in conjunction with a stopwatch, measures this ionization current. Consequently
Ihe readings which we obtain in this manner are proportional 10 the
energy absorbed."
"5. In deep therapy the limiting factor is the effect on the skin.
Therefore it is important to know what fraction of Ihe skin radiation
reaches a given depth of tissue. The value of this fraction can be
varied within limits by varying the distance of the applicator from the
skin, or the filtration.
(a) An example is worked out u> show that in the case of gamma
rays il is more economical to increase the percentage of the skm radiation
which reaches a deep tumor by increasing the distance of ihe applicator
than by increasing the filtration.
(b) A second example shows that, using two sources of radiation
of distinctly different penetrating power, we can get the same percentage
of a skin dose at a certain depth of tissue in either case by choosing
the distance of application properly.
(c) Table I shows that when ihe distance of the applicator is
large in comparison to the tumor depth, the penetrating power of the
radiation has the greater influence on the tumor dose. (This is the
case of x-rays). On the other hand, when the distance of application is
about the same as the tumor depth, and the radiation is very penetrating,
the distance has the greater influence on ihe tumor dose. (This is the
case of radium therapy).
(d) The table shows also that when the distances are adjusted so
as to get the same skin dose and the same dose at a depth of three centimeters,
using radiation of different degrees of hardness, the doses are
not the same at any oilier tissue depth, and especially at greater depths
than the one for which the doses are ths same.
"6. The coefficient of absorption is the important factor which
identifies radiation. The numerical value depends on the quality of
the radiation and on the nature of the absorber. From Table II we see
that:
(a) When the same tissue is used as an absorber and the filtration
of radium rays is varied in steps from 0.48 mm. of brass to 3 mm.
of lead, the coefficient of absorption gradually decreases from 0.0765
to 0.0709. But while the penetrating power of the radiation is increased
7.3 per cent, by the additional filtration, the available radiation
is decreased 65 per cent.
(b) The same radiation (1.92 mm. brass filter) is absorbed io a
different extent by different tissues. For soft tissues ihe coefficient of
absorption is proportional to the density of Ihe tissue.

10 ffAPITJJM
(c) The absorption by tissue from different organs (except lung
tissue, fat and solid bone) is nearly the same. Therefore if we take
0.075 fl>r 'he value of the coefficient of absorption of gamma radiation
filtered through 1.92 mm., of brass, we are sure io be on ihe safe side
in any calculation we may make for practical use. Corresponding to
this value of the absorption coefficient, the thickness of tissue necessary
to absorb one-half of the radiation is 9% centimeters. As a round
figure, easy to remember, we may take ihe half value thickness of
human muscle lissue for gamma rays lo be ten centimeters.
(d) The presence of bone in Ihe path of the radiation is of no
great consequence in regard to the amount of gamma radiation which
reaches the luinor beyond it. The only pan of ihe bone which absorbs
considerably more than muscle is the solid part. But in any practical
case this makes up a small fraction of the total thickness traversed by
the radiation. In the case of x-rays bone plays a more important part.
"7. The resulls obtained from the experiments described in this
pajier can be used for ihe solution of problems in radium therapy, subject
to ihe following limitations:
(a) The calculated amount of radiation reaching any given tissue
depth is always the minimum amount which will reach this depth under
the conditions of application.
(b) Skin doses of bela and gamma radiation are not to be compared
according to the ionization values given in Figures 3 and 4. They
must be determined independently by physiological experiments."
A paper by Fdith H. Quimby (Radium Research Laboratory-
Memorial Hospital, New York), on the Kffect of Different Filters on
Radium Radiations (Am. Jour. Rocnt. VII, 492-501, Oct. 1920), gives
experimental results of ihe ionometric measurement of the absorption
of radium rays (beta and gamma) by metals, antl also showing the
intensity of ionization by rays filtered through metal plus tissue. Mrs.
Quimby used the same apparatus in her work that Dr. Failla used.
Mrs. Quimby's conclusions are quoted:
"Kquivalent filtersof different melals have been determined, which
give Ihe same intensity of ionization in the apparatus described.
"When the radiation filtered through these 'equivalent' thicknesses
is transmitted through tissue, Ihe ionization produced is not the same.
"For thin filters, up to half a millimeter of brass or its equivalent,
Ihe radiation transmitted by lead is more penetrating than that transmitled
by brass, which in turn is more penetrating than that from
aluminum. When the absorption by the tissue becomes great in comparison
to that by the filter,this effect is obscured.
"For thick filters,equivalent to one millimeier of brass or more
this effect is reversed, the radiation transmitted by lead having a larger
percentage of soft radiation than thai transmitted by brass or aluminum.
"To obtain the necessary penetrating radiation for deep therapy.
in general a combination of filters is necessary. When substances of
high atomic weight are used as filters, a considerable part of the emergent
radiation is easily absorbed in tissue. Hence ihe necessity of a
secondary filter of low atomic weight to remove this soft radiation.
The analysis by tissue of the transmitted radiation enables us to determine
what additional filtrationis necessary when any metal is used
as the primary filter.
"For practical reasons brass is a good substance Io use as a primary
filter. Its secondary radiation is not very intense and can be removed

R A D I U M 11
to a sufficient extent by a few millimeters of rubber, which have the
same effect as an equal thickness of tissue. A thickness of 2 millimeters
of brass is sufficient for deep therapy.
"The results obtained in these experiments are directly applicable
to the treatment of patients, since ihe absorption by the tissue used is
the same, within the limits of experimental error, as thai by living
tissue."
This paper also contains an interesting paragraph on a much
mooted question of what is the best metal filter for radium :
'The best filterfor deep therapy is one that will give a penetrating
beam with as little secondary radiation as possible. Brass gives less
secondary radiation than lead, therefore in this respect it is a better
filter. Brass is also one of the easiest metals to machine; it does not
rust; it is hard, so that Ihe applicators keep their shape; it is inexpensive
and easily procured. Furthermore, 2 millimeters of brass is a sufficient
thickness to remove the soft radiation. Since the curves for 1.96
and 3.04 millimeters of brass are practically parallel, the extra millimeter
of brass has not increased the relative penetration appreciably, but it
has absorbed 4 per cent, more of the original penetrating radiation, thus
decreasing the efficiency. This argument applies more strongly when
2 millimeters of lead are used as a filter,for in this case about 10 per
cent, of the penetrating radiation is absorbed."
For practical reasons it is desirable Io have glass radium capsules
enclosed in a protective metal screen, however, it is also frequently desirable
to assemble a number of radium lubes in a single metal screen.
It is to avoid ihe handling of the bare glass tubes that has led to the
supplying of a silver protective capsule, (wall thickness of 0.5 mm. and
with a screening power approximately equal to 1 mm. of brass) with
a brass screen (1.0 mm . wall thickness) lo cover the silver tube. This
combination gives practically the same result then as is obtained by the
use of 2 mm. of brass, and where several silver tubes are enclosed in a
single brass screen, there is no extra waste of gamma rays.
Kroenig and Friedrich show in their book that if ihe same amount
of x-ray energy is absorbed in the same amount of tissue, dosage being
measured with the graphite coaled horn ionization chamber, the physiological
reaction is the same, no matter what the quality of the radiation,
i. c. the same reaction for equal energy quanta of radiation absorbed
whether it be unscreened or screened x-rays or gamma rays.
With this important point settled, it then becomes possible lo measure
gamma ray and x-ray dosage in the same units, if the absorption
coefficients of the rays in the tissues are known, and this can be determined
by the measurement of the ray intensity at two points, first
before the beam enters a tissue, and second as il leaves. This makes
possible then the long desired interrelation of gamma ray and x-ray
dosages. It must be strongly emphasized thai the ionometric measurements
are not so simple to make, and really are only to be relied on
where performed by a competent operator, and Kroenig and Friedrich's
work shows how important it is that the ionibation chamber be made of
some low atomic weight material, since their results using an aluminum
ionization chamber show very wide deviations from the results obtained
wilh the graphite coated horn chamber.
Summarizing, we may say that the recent work on the ionometric
measurement of gamma and x-ray absorption and dosage is of the highest
importance, since it gives the prospect of a scientifically accurate
method for determining dosage which applies ot both gamma and x-rays.

12 R a d i u m
reviews and abstracts
Acta Radiologica. A Xew Journal Devoted to Radiology.
The first issue of Acta Radiologica appeared July 25, 1921, this
journal being published by the Radiological Societies of Denmark, Finland,
Norway and Sweden, wilh Professor G. Forssell of Stockholm,
Sweden, as Editor. We quote the following from the editorial in the
first issue:
"This journal which is now making its appearance before the world
of science is ihe fruit of ihe collaboration between the associations of
medical radiology in Denmark. Finland. Norway and Sweden. United
as they are by a common culture and similar medical training, the
radiologists of Scandinavia and Finland have decided to present the
results of radiological research in their respective countries through the
medium of their own journal."
"Medical roentgenology as well as radiotherapy and heliotherapy
stand on a high level in these couniries which have associated themselves
wilh Acta Radialogica. and scientific reseorch in these subjects
is here in a promising stale of development."
"We jxjssess well-equipped roentgenological departments at all our
university clinics and at ihe big municipal hospitals, and ihese departments
have iheir own chiefs who devote themselves entirely to radiology.
New independent roentgenological departments are springing up year
after year, anil these are under the guidance of specialists. All hospitals
have iheir own roentgenological laboratories."
"Denmark is known all over the world as ihe cradle of heliotherapy
and as being that country in which this science has attained the highest
pitch of development through Finsen's work antl that of his followers.
Sweden possesses a special hospital for Ihe radiological treatment of
cancer, in ihe shape of the Radium Home in Stockholm, and Lund University
has also a special clinic for radiological therapy. The University
Hospital "Rikshospitalei" in Norway has likewise a clinic for radiotherapy
and heliotherapy, antl a special hospital for the radiological
treatment of cancer disease is being planned. In Copenhagen also a
fully modern clinic for radiotherapy is under organization, equipped bv
means of funds which have been supplied by public contribution and
national grants. There is systematic instruciion in medical radiology
at most of our medical colleges."
"But hitherto, however, an independent and special medium for the
publication of our articles within the branch of medical radiology has
been lacking. Our contributions have either been scattered in the special
periodicals of other countries or else published in our home medical
journals in which, in the majority of cases, they have been inaccessible
to researchers from the foremost civilized countries on account of the
difficulties encountered with regard to the comprehension of the Scandinavian
languages."
"Ray-therapy is still in its infancy, but this branch of the art of
healing has. by exact methods of research, entered the field of science
and il has already attained very auspicious results in several Conns 01
disease. It employs physical forces which deeply interfere with the
normal and pathological functions of the organism." and it therefore demands
not only a sufficient knowledge of radiophvsics. but also scien-

R a d i u m 13
tific apprenticeship in physiology and pathology, and a thorough knowledge
of the research methods of internal medicine in those branches
which come into touch with radiotherapy. In order to further develop
his science, Ihe radiotherapeutisl must possess clinical training and have
the opportunity of developing his science in his own clinic. At the same
time, radiophysics is developing to a comprehensive science which it is
impossible for a physician to master in a proper, scientific manner.
Physicists have, therefore, been called ever more and more into the service
of medical radiology and in all leading civilized countries there
exist at certain radiological clinics scientific physical institutes."
"Whilst ray-therapy as well as x-ray diagnostics are increasingly
developing towards specialization, yet, on the other hand, these special
branches of medicine daily attain ever greater importance as auxiliary
sciences to most of the other branches of medical science. A large hospital
already needs access to x-ray diagnostics as well as to radio therapy
for most of its departments, and hospital doctors must have a corresponding
opportunity of receiving an adequate training in these subjects
and the possibility of following their development, in order to be enabled
to rightly judge of the possibilities and limitations of the new science."
"Radiotherapy, however, will scarcely become the general practitioner's
property within a reasonably near future. But with the simplification
which the technique of x-ray diagnostics has gradually arrived
at, above all through the triumphal progress through the world of the
Coolidge tube, the time should not be far distant when an x-ray equipment
for less complicated examinations should be part and parcel of Ihe
equipment of a vast majority of medical practitioners. Before long the
cost of providing a simple x-ray instrumentarium will nol much exceed
the cost of a first-class microscope and as far as practical importance
for a doctor's diagnostical proficiency goes, be comparable with a microscope.
It will then, of course become necessary for those doctors who
make use of the x-ray apparatus in their practice to carefully follow the
development of x-ray diagnostics."
"Acta Radiologica w-ill be published in volumes of about 500 pages,
divided into four occasional numbers. Short articles are accepted tor
the journal itself, as a rule not exceeding 32 printed pages. More comprehensive
contributions will be published as supplementary volume?* to
Acta and will be issued as detached works."
"We have decided to publish the articles in Acta in the English,
French or German languages, according to the choice of the author. We
shall thereby reach not only the Scandinavian doctors who, as a rule,
can read these languages quite freely, but also have the opportunity of
introducing our work to the whole of the medical world."
The first number contains ten articles, two of interest to Ihe radium
therapist. Lars Edling contributes a pa|>er (in English) on Plastic
Means of Application and their Use in Radium Therapy and R. M.
Sievert a very interesting paper (in German) on the Distribution of
the Primary Gamma Rays About Radium Applicators as Used in
Therapy.

14 Radium
The Dangers of Radiation and Radiology in Cancer British Medical
Journal, p. 290, Aug. 20 ,1921, and p. 331, Aug. 27, 1921. In the
first mentioned issue of the British Medical Journal the leading editorial
is devoted to the topic of the Dangers of Radiation.
"The two matters which have recently most occupied the minds of
ladiologists were both discussed in ihe section of radiology and electrotherapeutics
at the annual meeting of the British Medical Association ai
Newcastle: the one is the method of x-ray therapy brought prominenlly
10 notice by the claims made by the Erlangen school; the other the
hitherto not fully recognized dangers to radium and x-ray workers. Possibly
the former has in some measure been responsible for ihe full
realization of ihe latter."
"For a few years past a certain school of raliographers has been
calling for more powerful apparatus, for the production of the highly
penetrating type of x-rays in larger quantities, and for the use of massive
doses in the treatment of various diseases; the culminating point
of all Ihis is for the present the German technique. A machine capable
of yielding 200,000 volts and a tube which will pass for hours a current
backing up a 16-in. spark gap al 2 to 2.5 milliamperes are asked for.
Drs. Seitz and Wintz claim that they have worked out with such an
apparatus Ihe definite dose of x-rays which should be administered at
a single sitting in cases of malignant disease, and which so administere
tl will "kill" the malignant cell. This contention, if true—and at
ihe present time this "if" is all-important—would mark a very long
step forward in scientific treatment from the hitherto more or less
happv-go-lucky dosage which has been administered in an empirical
manner. Whether these German workers will or will not eventually be
proved to have established their points as to ihe definite dose and ihe
single silting, they al any rale have pursued their investigations upon
thoroughly sound and scientific principles."
"At the recent meeting at Newcastle Dr. Knox, the President of ihe
Section, in discussing the intensive treatment of cancer, spoke of the
need for the careful study of the effect on the blood, not only as regards
variation in ihe proportion of the different corpuscles, but also as
to any effects on the corpuscles themselves and on the serum; the decision
of questions as to the protection of workers is, as he pointed out,
intimately associated with what is already known about these blood
changes."
Mention is made of the work of Russ, Mottram, Lazarus-Barlow
and Gulland on the action of the rays on the blood.
"In relation to the modem trend in favor of intensive x-ray treatment
it is to be noted lhat it was asserted during the discussion that
ihe dosage must be massive, as powerful indeed as the superficial tissues
will stand, that it must be given at long intervals, and that frequent and
small doses only stimulate Ihe abnormal condition. These statements
are open to question. In the past it has frequently been noticed that
the blood count quickly improves and even becomes normal under small
and frequently repealed fractional doses, with very small currents passing
through the tube. This method avoids all the unpleasant effects so
often produced upon patients by massive doses, and is not light 1v to be
set aside. The statement that these small doses stimulate the lesion has
not been proved: we know, indeed, of no evidence in ils favor."

R a d i u m 15
The necessity for adequate protective measures for those who work
with radium and x-rays is emphasized.
"As the effects of the high penetrating x-rays and the gamma rays
of radium are identical, it follows that protection for radium workers
is equally important, and generally speaking the principles upon which
it is to be carried out will be ihe same, modifications being made to
suit the special requirements of radium."
"There are many other practical details which still require consideration
in order that workers may be thoroughly protected; among
these are the suitability of rooms as regards size, ventilation, and the
access of fresh air, the hours of work, sufficient holidays, and so on;
but granted all the dangers and all the difficulties, there appears to be
no reason why x-ray work at any rate, should not with care be made
perfectly safe for both operators and patients."
In the August 27th issue of the British Medical Journal the following
editorial comment is made on the subject of "Radiology in Cancer
:"
'In view of the publicity that has been given to radiotherapy in
the treatment of cancer by Ihe publication of laudatory articles in the
medical and lay press, and the extraordinary claims that have been put
forward by the authorities of the West London Hospital, the British
Association for the Advancement of Radiology and Physiotherapy,
which includes the majority of radiologists in the country, has deemed
it advisable to issue to the lay press a considered statement on the use
of these agents. The claim put forward by the Erlangen school is that
it is possible by a special method to administer a dose of x-rays which
will cure cancer in one application. The statement points out that the
treatment, which has not yet been thoroughly tested, possesses great
potential dangers, and may not prove as efficacious as the claims now
matle would suggest. In the nature of the rase, however, no certainty
can be arrived at for some years. The unwarranted laudation of this
change in technique will, it is thought, probably lead to a reaction, and
bring discredit upon x-ray treatment in general. The subject has so
recently been discussed by Dr. Knox in his address to the Section of
Radiology at the annhal meeting of the British Medical Association, and
in a leading article published last week (pp. 267 and 290) that we need
not reproduce the statement in full. It will suffice to say that the
experts by whom it is issued state that the lime has not yet come when
radiotherapy may be regarded as the first choice in the treatment of
the majority of cases of cancer; they believe that, of any single method.
surgery still offers the besl prospect of cure in nearly all cases of cancer,
and that until much more convincing proof of the efficacy of x-rays
or other form of radiation is forthcoming the possibility of successful
surgical intervention ought to be, in each particular case, fully discussed.
They go on, however, to express the opinion that a closer co-operation
between the surgeon and the radiologist would lead to a clearer appreciation
of the value of radiation in treatment, and that in all cases both
surgery and radiation therapy should be fully considered, with a view
to making the fullest use of both. Combined treatment ,it is thoughl.
offers the greatest hope of success. Radiologists in this country, the
statement continues, have, during the past few years, so far perfected
their technique that the risk of any injury to the patienl is now small.
provided that the treatment is under the direction of a medical man of

16 Radium
wide experience in this class of work. If the prospects held oul by the
more drastic procedure prove to be better lhan those offered by existing
methods full advantage will be taken of it in this country-; the real contributions
to progress of the Erlangen school are held to be lhat it has
employed in suitable quantities x-rays of a higher ]>enetration than that
hitherto used, and has carefully systematized already known methods
of measuring dosage. Il is unnecessary io import the apparatus from
Germany; several firms in this country are now making the requisite
equipment, so that difficulty of obtaining plant will not be a bar to research.
The statement concludes by pointing out that x-rays have already
relieved suffering and prolonged active life in thousands of cases.
anil have even effected a few apparent cures, while their value in helping
Io prevent return after operation is now generally recognized. Il would
therefore be neither more nor less than a calamity if public disappointment
resulting from unfulfilled promises were to bring discredit on
radiation therapy, which is in reality a powerful agent in the warfare
against disease."
Frederick Soddy. The Interpretation of Radium and the Structure
of the Atom.
In 1920 there was issued the fourth edition* of Prof. Soddy's
book on the Inierprelation of Radium and the Structure of the Atom.
For -ome years the third edition primed in 1912 has been exhausted,
and the welcome new edition, revised to date, maintains its place as the
most interesting non-mathematical presentation of the subject. In the
preface of the original 1908 edition Prof. Soddy says:
"The book contains the main subsiance of six popular experimental
lectures delivered in the University of Glasgow at ihe beginning of the
year, but being relieved from the necessity, always present in lecturing,
of co-ordinating Ihe experimental and descriptive sides, I have, while
adhering to the lectuse form of address, entirely rearranged and very
largely rewritten the subject matter in order to secure the greatest possible
degree of continuity of treatment.
In the preface to the fourth edition the author adds:
"In again revising Ihis book I have conformed to the earlier plan
of writing whai I should have said if Ihe lectures had been delivered in
1920 instead of 1908. The original statement has been amplified rather
than modified. It has losl. long since, ihe appearance of challenge to
existing theories which at first it may have presented.
The book is illustrated with forty-four photographic reproductions
and diagrams and contains sixteen chapters under the following topics:
The Discover)- of Radioactivity; Radium: The Rays of Radioactive
Substances (2 chapters)): The Radium Emanation; Helium and
Radium : Theory of Atomic Disintegration; The Origin of Radium ; The
Successive Changes of Radium; Radioactivity and the Nature of Matter;
Radioactivity and the Evolution of ihe World; The Thorium and
Actinium Disintegration Series: The Ultimate Structure of Matter;
The Nuclear Atom; Isotopes; The X-rays and Concluding Evidence.
This is a book which every radium therapist should own and read.
•O. P. Pu'nnm's S""* X*-w York. SS.75

A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY. PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES
Copyright 1921 by Radium Chemical Co.
Edited by Charles H. Viol, Ph. D., and William H. Cameron, M. D with the assistanc
collaborators working In the fieldsof Radlochcmlstry. Radioactivity and Radlumtherapy.
Address all communications to Ihe Editors, Forbes and Meyran Avenues,
Pittsburgh, Pa.
Subscription $2.50 per year, or 25 cents per copy In the United States and Canada
In all other countries S3.75 per year.
VOL. XVIII NOVEMBER, 1921 No. 2
RADIUMTHERAPY-PRO AND
CON
The curative value of radium in the treatment of malignant disease
was sharply questioned by Dr. John B. Deaver in his Presidential address
before the American College of Surgeons, meeting in Philadelphia
during the week of October 24th. His remarks brought forth a great
volume of comment from all over the world, a small number upholding
his view, a few admitting their inability to judge the matter, and the
greatest number standing strongly against Dr. Deaver .
On Wednesday morning, October 26th, Dr. Henry K. Pancoast,
Professor of Roentgenology at ihe University of Pennsylvania Medical
School, read a paper on "The Modern Treatment of Epithelioma of the
Lip and Buccal Cavity," which was discussed by Drs. G. E. Pfahlcr,
Wm. L. Clark, Wm. S. Newcomet, D. R. Bowen and A. G. Miller of
Philadelphia, Dr. Douglas Quick, of New York, and Dr. Russell H.
Boggs of Pittsburgh, Dr. Pancoast and all those discussing his paper
speaking very favorably of the use of radium and x-ray and taking
exception to Dr. Deaver's statement.
The controversy is one which might better have been waged in the
medical journals rather than in the newspapers; however, time will alone
demonstrate the truth or the fallacy of Dr. Deaver's remarks. Certainly,
on the evidence presented, Dr. Deaver's position seems to beill
advisedif his assertion is to lead to the complete abandonment of radium
as an agent in the treatment of malignant disease.

is
R a d i u m
The following are excerpls from the newspapers bearing on the
question raised by Dr. Deaver:
From Philadelphia Public Ledger, October 25, 1921.
"Dr. John B. Deaver, newly inducted president of ihe American
College of Surgeons, expressed the fear last night that radium must be
abandoned as a cure in the treatment of cancer.
" 'At times when its use could have been most valuable radium
failed ultcrly in the treatment of cancer,' Dr. Deaver declared. "I almost
hesitate to express the fear which I have lhal nothing can be looked for
from radium in the future to be of advantage in the treatment of cancer.'
"Dr. Deaver made lhal staietneni in the course of an address on
'Old Methods Versus Xew in Surgical Diagnosis' at the formal opening
of the sessions of the eleventh annual Clinical Congress of the American
College of Surgeons in the Bellevue-Stratford.
"His remarks were followed by an almost death-like hush that came
over the audience of nearly 2,000 surgeons gathered from all parts of
the count ry and Europe and who were sealed in ihe room. Almost
apologetically Dr. Deaver recited ihe instances where radium had been
used when it was most sorely needed. Its benefit, he declared, had been
practically negligible, and, in many cases, was found to work greater
harm than good."
From the Philadelphia Evening Bulletin, October 25, 1921.
"The American College of Surgeons will select a noted committee
to investigate the effect of radium for treatment of cancer.
"This aclion has been decided on by members of the college attending
sessions in this city, as a result of the statement made by Dr.
John B. Deaver that little can be expected from radium as a cancer cure.
"Dr. Deaver. newly inducted president of the college, in his address
at the opening session Monday night, said radium had failed utterly in
the treatment of cancer and in many casesit was found to have worked
more harm than good.
"Sir Harold Stiles, K.B.E., rcgius professor of clinical surgery in
the University of Edinburgh will address the college Friday night, and
al that time he will urge that the efficacy of radium be thoroughly investigated.
"The broadside upon radium coming from a surgeon of Dr. Deaver's
standing has aroused Ihe keenest interest among surgeons and specialists
attending the college sessions here.
"Dr. D. Bryson Delavan. director of the American Society for Control
of Cancer, said that Dr. Deaver's remarks were 'very discouraging.'
* 'Dr. Deaver's statement as reported.' he said, 'is very broad and
general, and it should be so accepted by those who at first might interpret
them as giving no hope for olher than surgical care for cancer.
Apparently he is speaking from the point of view of the surgeon. Before
my opinion can be expressed, it must be known what Dr. Deaver's
definition of cancer is. The term cancer has been applied to a great
many varieties of growths, some external and some internal and malienan.t.
" 'Just how far radium can be used for cancer depends upon future
discoveries of its properties. It is a comparalively new element and its
properties at present are by no means fully understood. Thus far. however,
radium and the x-ray have shown curative values in the treatment
of new growths, in the external and less malignant types of cancer In
these limited fields radium by no means has been a failure and in many
cases its use has been most gratifying.'

I^ADITJM 19
"Dr. C. Lincoln Furbush, director of the Department of Public
Health, defends the purchase by the city recently of two grams of radium
for $230,000 to be used in treatment of cancer.
'"It was one of the most progressive steps ever taken by a municipality,'
he said.
" 'My attitude is the same today as it was when I spoke before the
Council Committee on Public Health. I said radium was not a cure-all,
but that it had a most positive place in progressive medicine. The city
of New York purchased two grams of radium some time ago and is now
buying two grams more.'
"Dr. Frank Edward Simpson, Chicago, recognized as that city's
leading exponent of therapy, however, takes issue with Dr. Deaver's
statement.
" 'Such a statement is little short of criminal,' he said. 'There are
hundreds of cases on record where radium has effected a permanent
cure. Dr. Deaver should come West for a few days and then he would
issue a retraction.' "
From the Philadelphia Public Ledger, October 25. 1921.
"New York, Oct. 25. New York physicians and cancer experts.
interviewed today concerning the doubt expressed by Dr. John B. Deaver
at the meeting of the American College of Surgeons in Philadelphia
concerning the efficacy of radium in the treatment of cancer, were generally
of the opinion that radium had proved its efficacy. They said.
however, that it was still on trial and thatit had by no means displaced
surgery.
"Dr. Deaver's statement that 'nothing can be looked for from radium
in the treatment of cancer.' was characterized, in most instances, as too
sweeping a generalization.
"Several physicians maintained that the subject w-as so complex
as to make any general statement valueless, and that such statements
only served to confuse and mislead the public. Optimism was expressed
by the majority, however, who look forward to a time when the cure
of cancer by radium shall be an established fact. At present it is impossible
to make definite assertions on either side of the question,it is
held, but there is a dominant conviction that Dr. Deaver has erred on
the side of conservatism as widely as other recent opinions have erred
on the side of extravagant claims.
"One of the leading physicians of New York, a member of the
American Surgical Association and a director of Bellevuc Hospital,
summed up the situation as, he said, it appeared to the greater number
of men here:
"'The type of publicity which has been given to the speech made
by Dr. Deaver to a body of medical men is unfortunate and may do great
harm,' said the surgeon. 'The public is not in a situation to understand
a problem of such technicality and complexity.
" 'Radium and the x-ray have proved themselves to be of benefit in
the treatment of superficial lesions of varying malignancy. In some
instances undoubted cures have been obtained by these means. In more
instances, however, these less malignant lesions failed to respond to the
x-ray or radium treatment. In deep malignant conditions there can be
no doubt that the x-ray and radium hold a valuable place as therapeutic
agencies. They cannot, however, be designated as in any sense cures
for these conditions. It is quite correct to believe that they are constantly
proving themselves of more value as an aid to surgical treat-

20 R a d i u m
ment as our knowledge of their appliance becomes more extensive and
active. The facts at the disposal of investigators at present would not
seem lo justify a stronger position pro or con.'
"Dr. William C. Bainbridge, who was for a while attached to the
New York Skin and Cancer Hospital in the treatment of cancer, said
thai radium was coming more and more to be recognized as an effective
aid in the treatment of cancer.
" 'Already,' said Dr. Bainbridge, "the advocates of radium are being
divided into camps, each one making various claims denied by the other.
The middle point of view is the only one which we can logically adopt
now.
" 'We must remember that radium may do harm as well as good. Do
not forget that surgery is our mainstay. Doubtless the use of radium,
as has been said by many, will aid the surgeon, but it is not a solution
of the cancer problem.'
"At the Memorial Hospital, which has used radium in the treatment
of car.cer some time,it was said lhat there could be no question of its
usefulness.
" 'Radium is a definite agent in the treatment of cancer,' said Dr.
George F. Holmes, a member of the staff of the Memorial Hospital. 'No
one claims that it is a cure, but withoul a doubt it has been proved here
and elsewhere that radium is a very valuable aid.'
"At the offices of the Rockefeller Institute it was reported that
radium had not been used there in the treatment of cancer in the last
three or four years.
"Pittsburgh, October 25. Radium specialists in Pittsburgh today
took exception to statements credited to Dr. Deaver, showing a doubt
of radium as a cure for cancer.
" 'Xo claim is made that radium is a cure-all; its use in the medical
profession is still in its infancy; but there is no question that many
cases are being benefited by its use,' said Dr. Clyde O. Anderson, one
of ihe leading radium specialists of this city. 'There is no question about
radium having a wonderful fieldin the medical profession.
" 'Not all cases treated by radium arc cured nor are all cases ireated
by operation cured, but we are not ready to condemn the operation as a
method of treating human ills.
" 'The fact should not be overlooked that generally there is little
comparison between the cancer eases treated by radium and those treated
by operation. The latter generally are mild cases, while ihose treated
with radium are more often advanced cases and, consequently, much
more difficult of treatment.
" 'There is as yet no known cure for anything. There is no cure
for pneumonia; there is no cure for diphtheria, and there is no cure for
cancer; but there are specifics which are effective in the majority of
cases. A great many cases of diphtheria are cured bv ihe antitoxin
treatment and a great many cancer cases are cured by radium treatment.
But no certain cure has ever been found for any single ailment.
" 'From 9 o to 95 per cent, of the cases of skin cancer now being
treated by radium are being cured and cases of an advanced sort are
being greatly improved in its use. In the case of cancer in an advanced
stage, the radium treatment had proved effective in stopping the growth
of cancer, after which an operalion can be performed with a greater
measure of success.'
"Boston, Mass., October 25, Dr. Robert B. Greenough, director
of the Cancer Commission of Harvard University, when asked last

R a d i u m 21
evening for a comment upon Dr. Deaver's statement, declared that he
'could not believe Dr. Deaver had actually asserted lhat radium has
proved a failure as a cancer cure.'"
From the Philadelphia Public Ledger, October 26, 1921.
"Kane, Pa., October 26.—Dr. Evan O'Neil of this city, a Fellow
of the American College of Surgeons, today issued a statement challenging
the attitude of Dr. Deaver on the use of radium in treating cancer.
The statement follows:
" 'In the issue of yesterday the Public Ledger quotes Dr. Deaver
as telling our College of Surgeons he fears radium no cure for cancer.
This astounding statement from so eminent a surgeon should not go unchallenged.
"T might as well reply thai I fear lhat the knife is no cure for
cancer. Where radium fails the knife is worse than useless. The knife
breaks down Nature's barriers of resistance allowing cancer germs to
be carried through the entire body. Radium walls off the growth. The
knife causes ghastly deformity. Radium docs not. Radium makes
many marvelous cures. A knife often hastens death, thus discrediting
surgery and driving ihe sufferers into the hands of quacks.'"
From the New York World, October 26, 1921.
"Dr. Francis Carter Wood, eminent pathologist, director of the
Institute of Cancer Research at Columbia University, strongly disagrees
with Dr. John B. Deaver as to the present and possible future value of
radium in the treatment of cancer.
"Radium is a failure as a cure for cancer, according to Dr. Deaver,
a distinguished surgeon of Philadelphia, who took office as President
of the American College of Surgeons there on Monday night.
" 'At times when its use could have been most valuable, radium
failed utterly in the treatment of cancer,' Dr. Deaver told 2.000 surgeons
assembled in convention from all over the United States. T almost
hesitate to express the fear I have that nothing can be looked for from
radium in the future of advantage in ihe treatment of cancer.'
"Dr. Deaver told of cases where radium had been used when good
effects from it were most sorely needed. But its benefit had been practically
negligible; indeed, in many cases it worked more harm than good.
* 'Dr. John B. Deaver. in discussing the failure of radium to cure
cancer, speaks as a general surgeon and not as a specialist.' said Dr.
Wood yesterday. 'He believes, as does the medical profession in general,
that at ihe present time radium will not cure internal malignant
tumors, such as those of the stomach and intestines, even though it may
greatly relieve them or retard their growth. What radium will do in
the future it is impossible to say; but there is no reason to believe that
it will cure all kinds of cancer. Indeed, some types are so very resistant
to this interesting physical agent that the destruction of the cancer
cells requires such large doses that the surrounding healthy tissue is
more damaged than are the diseased structures.
" 'On Ihe other hand, it is well known lhat radium is extremely effective
in curing the small cancers of the face, which are. fortunately, much
less malignant than those in other parts of the body, and it is quite justifiable,
contrary to Dr. Deaver's statement, to use radium on such
tumors if their exact nature is known.
" 'There are many instances of cures of such face cancers, the
patient having remained well for ten to fifteenyears after the treatment,
" 'In cancer of the womb, also, radium has been most valuable.
Whether it will be found to cure permanently cancer of this region, we

22 R a d i u m
are not yet prepared to say, but that the palliative results are often ext
ordinary is generally acknowledged. Women are not infrequently restored
io full health, even for a year or iwo, and entirely relieved of pain
and discomfort and are able lo go back to their regular household duties.
While such improvement is often only temporary, wider experience and
the use of large quantilies of radium may ultimately make possible the
attainment of a certain number of permanent cures in patients whose
cancer is so extensive thai they cannot be operated upon. When cancer
of the womb is very small and localize surgery is to be preferre. but
when the results of'surgery are doubtful owing to the wide extension
of the growth, radium is the better.
" 'Dr. Deaver's statement lhat he hesitates to express the fear he
has that nolhing can be looked for from radium in Ihe future, is a very
unsafe generalization. In ihe last three years we have learned more
about the use of radium and x-rays than we learned in ten or fifteen
years before. There is no question that in a few instances most extraordinary
results have been obtained. To say there is going to be no
progress in the future is Io be far more venturesome than I am willing
to be. No one can say what ihe future will bring forth.'
"The Institute of Cancer Research was founded by George Crocker
of the wealthy California family, who died of cancer, as did his wife.
Mr. Crocker left money to Columbia University for the establishment
of a laboratory for the study of the cause and cure of cancer. The laboratory
was opened in December, 1913, under Dr. Wood's dircclion.
"The discussion between those who favor the knife and those who
prefer radium in ihe treatment of cancer is the more interesting and
valuable at the moment because "National Cancer Week" will be held
all over the country by the American Society for the Control of Cancer
from October 30 to November 5 next. Then the lesson will be taught:
" 'Above all things early diagnosis and prompt treatment are needed
to cure cancer, for most cases can be cured in the incipient stages.' "
From the New York World, October 27, 1921.
" 'Such an utterance smacks of the surgical knowledge of Ihe middle
ages!"
"This was Dr. Harvey Russell Gaylord's biting criticism of the
declaration by Dr. John B. Deaver, lhat, in his experience and belief,
radium has failed in the treatment of cancer. As Ihe 'World' has told.
Dr. Deaver. an eminenl surgeon, made Ihe assertion in his address when
inducted as President of the American College of Surgeons at its eleventh
annual convention in Philadelphia Monday.
"Dr. Gaylord is equally distinguished in his profession. Like Dr.
Deaver, he is a graduate in medicine from the University of Gocttingen
for ihree years; for. before the great war, many American students
flocked 10 the German centers of medical knowledge. Dr. Gavlord has
been for twenly-two years director of ihe New York State Institute for
the Study of Malignant Disease ai Buffalo. He has been president of
the American Association for Cancer Research, and is associated with
the American Society for the Control of Cancer, which has planned a
"National Cancer Week" from October 30 to November^. Durin" that
week facts regarding the disease, and Ihe absolute necessity for its
early diagnosis and treatment will be disseminated bv lectures and
treatises by specialists.
"A special dispatch 10 'The World" states Dr. Gaylord deeply implores
the controversy which, he believes, is inevitable as a result of Dr.
Deaver's statement.

R a d i u m 23
" 'This is no time,' said Dr. Gaylord, striding up and down his office
in the oldest institution for the study of cancer in the world, 'to raise
the question whether or not radium is more efficacious than surgery in
the treatment of cancer. Radium has cured cases of cancer which the
surgeons could not help. In other cases, far advanced, radiation has
lengthened life, relieved suffering and helped where the patient has been
beyond assistance from surgery.'
" 'If Dr. Deaver findsit possible, to dispose of the radium treatment
of cancer by saying it is doomed, I should like to ask him, in the name
of humanity, what he would put in its place. What is he going to do
for those suffering from cancer whom surgeons cannot help?'
"In the office with Dr. Gaylord was Dr. B. F. Schreiner, his chief
assistant, and Dr. Hans Holfelder, in charge of the clinic for the treatment
of cancer by radium in the University of Frankfort. Dr. Holfelder
is probably the best known radium expert in Germany. At Dr. Gaylord's
suggestion, and to emphasize his argument in favor of radium, Dr.
Schreiner gave the results obtained at the institute from the radium
treatment of cancer.
"Number of patients under treatment, 700. This includes all persons
treated since the institution was founded, as a name is never taken
from the book while the patient lives.
"Ninety-seven per cent, of all cases of cancer of the skin treated
have not yet shown a relapse, and some still under observation arc five
years old. No surgical operations for skin cancer are performed now at
the institute.
"No operation has ben performed for cancer of the womb for
three years. The records show that 34 per cent, of such cases are, apparently,
jiermanently cured, although it is impossible to state that
definitely, as the disease may recur, in such cases, in three, five,ten or
even twenty years. Seventeen per cent, of these cases were reported
favorably at the lime of beginning treatment; that is, as likely to be
benefited by radiation. And 17 per cent, were cases for which no surgeon
could offer relief by operating.
"Fifty per cent, of those who apply for treatment at the institution
arc beyond cure. But the radium treatment has given many of them
a longer lease of life, in some cases as much as five years. Most of
these hopeless cases, Dr. Gaylord said, had been given up by surgeons
afier operating upon them.
"It is possible to cure 75 per cent, of cancer of the lip by radiation.
Dr. Schreiner insisted.
"Both Dr. Gaylord and Dr. Schreiner made it plain they did not
use the word 'cure' in the ordinary sense—in the lay cases—but to mean
that ihe radium treatment had resulted in healing the cancer, and that
the visible signs of cancer had disappeared. How soon, how long, before
the outward evidence of cancer would reappear, if at all, in any one case
they could not say; no one can say. But the patient regarded as cured
is, as far as outward appearances go and medical skill can determine, in
good health."
From PJiilade/phia Public Ledger, October 27, 1921.
"The use of radium in the treatment of cancer found a staunch advocate
yesterday in Dr. J. Chalmers Da Cosla. professor of surgery in
the Jefferson Medical College and a widely known text-book writer. Dr.
Da Costa made his plea for the use of radium in the course of his weekly
clinic in Jefferson Hospital.
"More than 1,000 men, students and visiting surgeons heard ihe

24 R a d i u m
surgeon's remarks, and Dr. Da Co;la was applauded. The question of
using radium was raised Monday by Dr. John B. Deaver in an address
before ihe American College of Surgeons, when Dr. Deaver said thai
little could be looked for from radium in ihe treatment of cancer.
"Dr. Da Costa was describing an operation for cancer of ihe lower
end of the upper arm by the use of radium needles. The surgeon said
he 'did not agree with certain statements recently made* as to the value
of radium.
"His own experience, he said, was lhat radium relieved pain and
that in certain cases where the growth seemed hopeless did give hope
and the cancers growth seemed to disappear rapidly.
"He expressed ihe belief that radium, used with the knife, together
with sound clinical judgment, could be recommended as a valuable adjunct,
but that any one who uses radium for all cases was as much a
menace to the public as the doctor who uses strychnine or the x-rays for
everything, no mailer what the condilion.
"In conclusion, Dr. Da Cosla declared he would continue lo use
radium.
"Dr. Deaver's statement continued to be one of the chief topics of
discussion yesterday among Ihe delegates to the American College of
Surgeons.
''The most interesting was the exhibition of six living specimens
and Ihe presentation of lantern slides io refute the contention lhat radium
is of little use in treating cancer."
From Public Ledger, Philadelphia, October 27. 1921. Special Cable
Dispatch from Paris, France. (Copyright, 1921. by the Public Ledger
Company.)
"Dr. Albert Robin, of the French Academy of Medicine, considered
the most eminenl cancer specialist in Europe, said today in connection
with the discussion of the American College of Surgeons on ihe subject
of cures by radium:
" T believe the use of radium indispensable in the treatment of cancer.'
"Dr. Robin pointed to a heap of manuscripts, the reports of experiments
and treatments covering thousands of cases which he has been
collecting specially for twelve years, ihe results of which will appear in
a volume to be complete next month. He said;
" 'There are many scientists who have labored in the interests of a
cancer remedy, but never were there so many as today.
" 'The medical profession has registered a great impetus in researches
in medical and surgical fields,but in all and especially in the
use of radium the question is not yet ripe. Though we need not be
alarmed we must realize that cancer is increasing in all countries of
the world, and the number of deaths from cancer in France is augmenting.
" 'As for radium there are partisans both for and against it in
France the same as in America, but here the researches will require
years before all the benefit from its use can be determined.
"Both Madame Curie and Dr. Regaud of the Radium Institute.
are doing experimental work that can only develop the best results after
a long time, but I believe—although no scientist can say T am right'
I believe the use of radium in the treatment of cancer is not only indispensable
now. but the value has been revealed onlv in small proportion
to whal will be discovered in the future. The three principal methods
are operation, radium and treatment from a chemical viewpoint."

R a d i u m 25
"Dr. Robin declared lhat he had made the greatest success, not
with operations or through the use of radium, but in attacking the consequences
of cancer on the system. He explained ihis yesterday before
the members of ihe academy and gave your correspondent the following
resume:
"'I found that cancer patients were all more or less anemic. The
results of our analysis of anemia showed il was caused by a ferruginous
demoralization of blood and especially of the iron reserve in the tissues.
Disintegrated iron was found in the urin and in double the normal
proportion. Anemia is due to an insufficiency of globular cells, which
arc a fundamental element in reconstitution. Thus the loss of iron
justifies the use of protocarbonate of iron in cases where cancers are
not bleeding and perchlorate of iron in cases of hemorrhageous cancers,
not as a treatment for cancer itself but for anemia which is a consequence
of cancer and which, in several cases, has been ameliorated temporarily
by this medication.'
"Dr. Robin is not optimistic about an absolute cure for cancer, but
said Ihe world looked at present to radium."
From Toronto Star, October 31. 1921.
"The Statement of Dr. J. B. Deaver, president-elect of the American
College of Surgeons, to the effect that radium had failed as a cure for
cancer was today challenged by Dr. W. H. B. Aikins, noted authority
on the use of radium, and one of the best known surgeons in Toronto.
"Dr. Aikins has just returned from the congress of the American
College of Surgeons, held at Philadelphia, and was present when Professor
Deaver made the statement referred to.
" 'What is your feeling regarding radium treatment for cancer,
after the discussion at Ihe congress?' Dr. Aiken was asked by 'The Star.'
" 'The fact that I acquired additional radium for the Radium Instilute
is sufficient evidence of my confidence in this agent as an effective
help in the treatment of cancer." he replied.
" 'Have you, in your own practice, evidence of the value of radium
in the treatmenl of cancer?'
" T have several hundred living reasons on which my faith is founded
and they are walking about on two legs.'
"Dr. Aikins not only emphatically expressed his own faith in '.he
efficacy of radium treatment for cancer, but he produced some of his
private records to show what he has succeeded in doing with radium.
"These records consisted of actual photographs of patients suffering
from the dread malady, before and after treatment. Portions of the
faces of some patients had become positively ugly and hideous from the
inroads of the cancerous growth, yet later photographs revealed .he
same faces after persistent Irealment restored Io their natural contour.
It was like the revelation of actual miracles. One looked first at ihe
awful spectacle of certain cases as they appeared before having the
growth subjected to radium, and one naturally concluded, 'He's a
goner.' Yet, later history of the case as depicted by the camera, which
is no respecter of persons, showed substitution of healthy flesh where
previously had appeared the ravages of the greatest scourge of the race.
" 'Then why isit that there is the almost general belief that cancer
is absolutely incurable ?' the doctor was asked.
" 'Because the public is misinformed,' he shot back. 'There is no
secret about the thing. We know it is not the exception, but the rule,
to have successful results in the treatment of cancer with radium.'
"In the early stages of cancer, Dr Aikins averred, operation is not

26 R a d i u m
necessary io positively eradicate Ihe growth. Application of radium
will do this, he said.
" 'There are surgeons who decry withoul reserve the use of radium
in the treatment of cancer, and ihere are also radium experts who see
little future for surgery',' said Dr. King. 'Both views arc extreme.
Cases in which surgery has failed have been much benefited by radium,
and in many instances, where radium could not be of benefit, surgery*
has been of marvelous value. A judicious use of radium in combination
with surgery, will, in many cases, give the most favorable results."
" 'Had the statement of Dr. Deaver been made fifteen years ago,
when the therapeutic use of radium was in iis infancy, il might certainlyhave
been justified. But to make such a sweeping assertion in the face
of facts established after long years of experience is decidedly unwarl
ranted. Throughout the continent of America there are numbers of
radium experts who can show cures of five lo ten years' standing. This
lenglh of time means a 'cure' in surgery. Why not with radium?'"
From the New York Times, October 31, 1921.
"To the Editor of The New York Times:
"We are writing you in reference to alarming and disconcerting
statements recently made in a public address by an eminent surgeon, to
the effect that the treatment of cancer by radium was a failure, and that
the old remedy of cutting operations by the knife was still the only
method of irealment giving hope of relief or cure in this" disease. We
have not had the opportunity of reading the full address referred to and
have seen only the press reports published in ihe last few days.
"As directors of a large cancer hospital which uses radium exiensively,
we feel called upon lo dissent from this conclusion.
"The particular point at which any unwarranted condemnation of
ihe use of radium in the treatment of cancer affects us and the public
is found in the daily conduct of a cancer hospital and in our dealings
with the sick who apply to us for aid. At the Memorial Hospital we
have under irealment several thousand sufferers from cancer, many of
whom are being trealed with radium. These people read the papers,
and when doubt is cast upon the efficacy of the method with which
they are being ireated they are apt lo suffer grave mental disturbance.
Iheir proper irealment may be interfered wilh or even interrupted, and
the best efforts of our physicians and surgeons are hampered. The
attending staff of the Memorial Hospital, drawn from the Faculty of
Cornell University Medical College, unanimously disagree with ihe
conclusions of the above-mentioned surgeon.
"The Memorial Hospital for the Treatment of Cancer and Allied
Diseases, an institution .supported by private contributions, treats thousands
of patients yearly. For the past four months our records show
treatments in the hospital as follows:
June July Aug. Sept.
Room patients 63 49 54 43
Ward patients 123 92 121 125
Free palients 50 57 47 75
Total admitted to hospital 236 197 222 243
Observation department:
Visits for examination and advice. . .163S 1641 1359 1632
Radium treatments given to ambulalory
palients 135 176 135 1S2

R A D I U M
27
X-ray department:
Visits for examination and advice
(not treated) 127
Patients radiographed i/4
X-ray treatments given 507
188
*45
406
189
116
342
930
201
3«*
"The hospital has in its charge $400,000 worth of radium—the
largest quantity of radium, we understand, in any public hospital in the
world—and the entire emanation from this is used every day in the
year. We need double the quantity of radium now on hand. Our research
laboratory is in the hands of eminent scientists who not only
study Ihe causes of cancer and investigate methods for its prevention
and cure, but devise and constantly study means for the application of
radium Io cancerous growths. Mme. Curie recently spent an entire
afternoon in this laboratory, and we have sent drawings showing Ihe
installation of our radium apparatus at the hospital to Mme. Curie in
Paris, for her use in the installation of radium in her laboratory-
"The Memorial Hospital treats cases of cancer in several ways—
either by surgery only; by surgery and the application of radium or
x-ray or both; by the application of radium or x-ray alone; or by the
application of both radium and x-ray.
"We arc finding treatment by radium most effective in hundreds
of cases, and while our medical staff cannot announce any cures until
more time has elapsed it is significant that great numbers of cases,
after several years, show no recurrence of Ihe disease.
"Our staff holds that each cancer case should be treated as a
separate problem, separately studied no! only by the physicist but by
the surgeon. In many cases, whether early or lale, surgery seems to
offer the only remedy; in other cases, other methods seem certainly
more effective.
"As representing an institution using in its treatment of cancer
more radium than any other public institution in the world we deprecate
broad, general statements that from lime to time api>ear in the
public press to the effect that the use of radium is either unprofessional,
improper, wholly ineffective, unwise or dangerous as a therapeutic agent.
"The claim of our hospital is that in many cases radium offers the
best probable relief in cancer; that in other cases its use is either ineffective
or unwise; that by the proper use of radium under highly
trained and expert medical advice only, either separately or in conjunction
with other methods, the fieldfor the relief for cancer sufferers is
broadened and the outlook for the final onquest of the disease is
brighter.
"It is most unfortunate and ill-advised to state that "nothing can
be looked for from radium in the future to be of any advan'age in the
treatment of cancer." The facts show too much already accomplished
to warrant any such statement.
"Radium in the hands of the untrained is one of the most dangerous
forces in the world. It should be administered or handled only
by experts especially trained in its use. That this subtle element, with
its all potent strength and force and inexhaustible energies, may be
finally conlrolled and used most effectively by scientists in the cure of
cancer is the aim and hope of our hospital.
"Sweeping and general denunciations, based on data nol thoroughly
investigated, are misleading to the public and serve no good purpose.

28 R a d i u m
Memorial Hospital for the Treatment of Cancer and AUied Diseases.
New York. Oct. 29, 1921."
By Herbert Parsons, President
Archibald Douglas, Secretary.
From the New York Herald, November 2, 1921.
"Dr. Howard A. Kelly of Johns Hopkins Hospital, Baltimore, whom
hosts of physicians esteem as the highest living authority on radium and
radiotherapy, replied last night 10 the strictures recently pronounced by
Dr. John B. Deaver of Philadelphia on the curative results of radium
in application to cancer.
"Dr. Kelly's address was delivered to an audience which filledthe
large auditorium of the First Congregational Church in Montclair,
N. J. It was a feature of the observation of "Cancer Week" and ihe
speaker was introduced by Dr. James M. Brown, chief surgeon of the
Montclair Hospital and chairman of the Montclair section of the American
Society for Ihe Control of Cancer.
" 'I am particularly glad to come here and talk of both surgery and
radium in their control and treatment of cancer,' said Dr. Kelly, 'because
Ihe use of radium recently has been severly attacked by one of
my very dear friends. I can readily forgive Dr. Deaver, for, after
having been elected president of ihe American College of Surgeons, one
would naturally attain such a slate of exaltation thai he might well be
pardoned for saying anything.'
"In certain types of cancerous growth. Dr. Kelly contended, radium
has accomplished marvellous cures in cases where surgery would have
been impossible, or at least would have been attended with great hazard.
The speaker gave ocular demonstration of this by displaying with lantern
slides upon a screen photographs of scores of cases where cancerous
growths had made frightful inroads upon the face, neck or thyroid
gland. Each of these was shown in pairs, the second photograph
showing ihe patienl completely cured and in most cases wilh all disfigurement
practically removed and bolh health and appearance restored to
normal.
" 'Do not misunderstand my strictures,' cautioned Dr. Kelly. 'The
skilled surgeon who sees a case knows well what he can and what he
cannot do, and he should be depended upon to advise the patient accordingly.
Radium is far from being a solution of the cancer question.
Il will not cure all cases, even in iheir early stages. While it covers pan
of Ihe fieldoccupied by surgery, it by no means derogates from surgery
its whole function. Radium will not cure cancer of ihe stomach, which
is so common.
"'But radium's greatest achievement is that marvelous results are
sometimes attained in dissipating all the accessible disease in cases
which are so far advanced as to be utterly inoperable. Radium also
will often take care of recurrences, even advanced ones, where surg-rv
is helpless.
s" '
" 'Radium is pre-eminent in cancer of the face. We can cure:
and I use the word 'cure' unhesitatingly after thirteen fears of experience—95
per cent, of cases of cancer of the skin and face if the disease
has not progressed loo far. Not infrequently we have cured very considerable
lesions of Ihe fact with a single application of radium and
the evidences of cancer disappear in a few weeks.'
" 'Almost too wonderful to relate,' went on the speaker, 'we have
also cured many cases of that terrible affliction known as Hodgkin's

R a d i u m 29
disease, which is characterized by a swelling of the glands all over the
body. Several patients who have had this disease of a year's standing
arc now going about perfectly well. By taking them when Ihey are
not too far advanced we have also cured some cases of gland tuberculosis.
Observe that I say 'some cases.' We cannot cure them all.
" 'But the most beneficient field for radiotherapy lies in those cancers
of the skin common about the face. Here the surgeon is hampered
by the contiguity of the growth to important features.'"
From Netv York Evening Post, October 31, 1921. Special Cable
Dispatch. (Copyright, 1921, by the Public Ledger Co.)
"Paris, October 31.—A distinctive change in the attitude of officials
of the Radium Institute towards making public statements on the use
of radium in the treatment of cancer has taken place since Madame
Curie requested such a statement last week. When your correspondent
informed the discoverer of radium that in a statement in Philadelphia
Dr. John B. Deaver had expressed doubl as lo the value of radium
in the treatment of cancer, Mme. Curie said she must have a precise
statement from a doctor of the Radium Institute, though she was confident
herself of the help radium had given medical science. Mile.
Irene Curie, daughter of the scientist, has since made public the following
statement:
" 'Mme. Curie, not being a doctor herself, does not desire lo take
part in a public discussion on the radium theory. She, therefore, communicates
the following opinion of Dr. Regaud, director of the Laboratory
of Biology and of the therapeutic service of the Radium Institute:
"'(1) One cannot express an exact opinion on declarations communicated
by the press without having in hand the full and authentic
text of the subject.
"'(2) In a general wayit is hurtful that a discussion of the value
of any therapeutic agent, notably that of radium, be brought before the
public in the form of a newspaper interview. The main objection is
that it often creates among those who suffer unjustified hope or disappointment.
Popular articles on the progress of medicine should only
be written for Ihe instruction of the public afler having been carefully
studied and signed by competent authors.'
"The Radium Institute under Dr. Regaud is the highest authority
in Europe if not in the world, on the therapeutics of radium. It consists
of two small brick buildings, in one of which Madame Curie and
her staff work on radium experiments and in the other of which Dr.
Regaud conducts biological tests on animals and in connection with the
hospital of the institute, where the most important research is the study
of cancer."
REVIEWS AND ABSTRACTS
Arthur Burrows, M.D. The Treatment of Advanced Carcinoma
of the Cervix of the Uterus by Radium. British Med. Jour. Oct. 1,
1921, pp. 524-5. (From Ihe Manchester and District Radium Institute.
Royal Infirmary, Manchester, Eng.)
"This paper deals with the treatment of advanced uterine carcinom?.
by radium, and I will not discuss the treatment of early carcinoma of
the cervix of the uterus. Until within the last two years all cases which
I have treated have been beyond operation, consequently any figuresthat

30 Radium
I mav give cannot fairly be compared with statistics showing the success
or otherwise of Wertheim's hysterectomy. Every single case ol appaientlv
hopeless malignant disease saved or rendered operable by radium
is a subject of rejoicing and hope, and much solid satisfaction can be
obtained by contemplating the large number whose symptoms are made
negligible for months or even years. Radium has not, so far, solved the
problem of dealing effectually with the secondary deposits, although
recent research shows possibilities in that direction, but of its great
value in the treatment of carcinoma of the cervix of the uterus there is
no doubt."
"In the early days of radium treatment Wickham and 'hose associated
with him firsttreated cancer of ihe cervix by placing, for varying
times, heavily screened radium applicators against the growth. They
reported considerable success, but later the insertion of a strong radium
tube into the cervical canal proved more beneficial. Still more recently
the practice of burying a number of radium or radium emanation tubes
in the cervical growth and those tissues round aboul it. which are actually
invaded or liable lo be so, has improved results still further."
"At the prescni time I adopt one of two methods, and even after
more lhan a year of comparison have not been able to make up my
mind which is Ihe better. There is no necessity for ihe heavy metal
screening which has been employed by radiologists, but still Ihe chece
lies between a screened and an unscreened method of treatment. In no
case need a screen thicker than i mm. of silver be employed, unless the
huge doses (not available to most of us) used at Baltimore can be considered."
"In the screened melhod al Manchester about seven tubes are inserted
under an anaestheiic. A large one of aboul 50 millicuries of
emanation (that is, 50 mg. of radium element) screened by 1 mm. of
silver is introduced well up the cervical canal. Six other smaller lubes
screened by 0.3 mm. of brass (previously platinum) are pushed into
or about the cervical growth, care being taken to introduce two or ihree
into the broad ligaments. The strength of e~ch of these smaller tubes
is about 15 millicuries. If consistently good results are to be obtained,
a dose of never less than 120 millicuries for twenty-four hours must be
given."
"In employing the unscreened method I still use the large central
tube mentioned above, bul insert in the surrounding tissues small unscreened
capillary glass tubes, each containing radium e*-ianation of a
strength of 2 to 5 and even occasionally 7 millicuries. Thev are inserted
to the number of two to eight by means of an exploring syringe
needle and stilette. No effort is made to withdraw* the small tubes, but
the large one is removed after twenty-four hours."
"So far I think I may say that with practice and strict cleanliness
there is no immediate danger in either method. In each case Ihe vagiua
is packed with gauze after the insertion in order to maintain the tubes
in position. Occasionally Ihis packing produces retention of urine, and
catheterization is necessary."
"Douching should be performed daily after the operation—first
and most important, to keep as clean as possible the reacting growth;
and secondly, though not now so important since tubes have been buried
and not merely placed in the vagina, to prevent the formation of vacinal
adhesions.
"There still appears to be considerable possible variation in ihe
quantity of radium employed, its time of application, and the screening

R a d i u m 31
used—so much so thai reports of successful cases, now coming from all
over the world, often make one pause and think."
"Cases for Treatment and Prospects.. .In the treatment of inoperable
malignant disease there is, of course, not a great deal of choic? in
the cases. The vast majority of those who come as hospital cases for
examination with a view to radium Irealment are put down for radium.
But even for radium a few cases are worse than hopeless; they come
with large' secondary masses in the liver and abdomen; paralyzed legs
from deposits in the spine and the pressure of glands; while, locally.
the large cloacal fistulous openings sometimes seen only remind one that
all the troubles of patients dying from malignant disease should nol be
put down to radium. Such extremely advanced cases should be left
alone, but they do nol form more than 5 per cent, of ihose seen."
"When cases are not so bad the outlook is not good. (1) When ihe
growth is very large and hard. With adequate treatment it lends to
slough, with inadequate treatment nothing happens to the patient's advantage.
Large fungating growths do not matter—curettage may spare
somewhat the small quantities of radium at our disposal, but I have
not otherwise found it necessary. (2) Cases with very extensive infiltration
of the vaginal wall rarely give a good result, even from the
point of view of palliation. (3) I have yet to be convinced that the
cxacl histology of ihe carcinoma is much help :n the prognosis of cases,
but of course those tumors which form metastases rapicly give the
worst results, and it is probably for that reason that the outlook in
women under 40 is bad whatever the stage of the disease-, wh''e the
prognosis improves as the menopause is approached or pa.-sed."
"For the besl results cases jusl beyond opera! ility, as might be
expected, are Ihe best, but the presence of some slight mobility of the
uterus, a good blood supply to the tumor, and the slow formation of
secondary growths, arc all factors of good omen."
"The more firmly the growth is adherent to the bladder and the
greater the infillration of the bladder wall and urethra, the more chance
is there of a fistularesulting from the treatment; but the percentage is
low (in fact, very little above that of untreated cases), and adhesion to
the bladder by no means renders Ihe case hopeless. I find that a rectovaginal
fistula is quite uncommon."
"In estimating the immediate results of radium treatment, with an
eye to the future progress of a case, a very high standard must be set.
The patient in a so-called "symptomatic cure" should profess to fee!
perfectly well and to be absolutely free from pain or discharge. Examination
should show the uterus to be quite mobile, while the cervix should
be small, smooth, and any scar tissue soft and supple. Vague pain in
the abdomen, hack, or limbs, slight induration in the vault of the vagina,
enlargement and hardness of the cervix, are all factors which promise
recurrence."
"It is interesting, however, to note that sometimes recurrence may
not be manifest until so long a period as two years has elapsed."
"Pathological Notes. During the last two or three years, owing to
the interest and help of the Manchester gynaecologists, I have been able
to obtain microscopical examinations of a number of cases of carcinoma
of the cervix which have been treated first by radium, the uterus being
removed six to twelve weeks later. It is interesting to note that in most
of the cases the growth in the cervix has completely disappeared and
been replaced by the characteristic dense radiation connective tissue.
Occasionally a few degenerate malignant cells are seen. One of my

32 R a d i u m
cases, who was killed in an accident six months after treatment, showed
no sign at all of growth at the post-mortem examination. From this
it would seem lhat. at least locally, radium can be and often is effective
in its destruction of a cancer."
"Statistics. I propose to deal only with some figures from my
own cases. All ihe cases dealt with in detail here were inoperable, and
presumably surgical interference would have been useless. For further
figures on ihe subject as a whole I must refer you to Dr. Janeway's
valuable paper published in Surgery, Gynecology and Obstetrics. September.
1919."
"In 1915 I found lhat 10 per cent, of my cases of cancer of the
cervix of the uterus showed no sign of disease at the end of the year.
This figure has gradually improved with betier technique, and, in spite
of increasing number, has risen to nearly 30 per ceni. *
"I have analyzed in more detail the 100 cases I treated between
April, 1916, and July, 191S. I have not gone earlier because I was
then only using a single tube, but in 1916 I began increasing the dosage
and the number of tubes employed. The figures, therefore, are taken
as far back as possible in the early stages of more adequate dosage.
The cases were treated between three and five years ago. Prior to that
period I have been able to trace two cases which have been alive and
well for over five years."
"The hundred cases are divided as follows, and those who have
tried to trace patients in numbers will bear with me in the deficiencies
of the list:
6 are definitely well today and have been well from ihree to four
and a half years (1 Ihree, 2 ihree and a half, 1 four, and 2
four and a half years).
5 were well twelve months after ireatment. bul I have failed 10
trace them since.
7 were well three to six months after treatment, but have not since
returned.
6 were rendered operable and operation performed.
32 were made quile comfortable and able to work from six months
to two years. Some of these have died subsequently.
26 were not improved or died quickly.
16 cases I could get no information aboul at all.
2 were given prophylactic irradiation."
"This gives 6 per cent, who have definitely lived up to the present
time and been well for a period of three to four and a half vears. During
the period analyzed the number of cases traced to "be apparently
well ai the end of ihe year was aboul 15 per cent. It is now nearly 30
per cent., so it seems at least probable that 12 per cent, of the inoperable
cases of carcinoma of the cervix treated by radium at ihe present time
will be alive and well in three lo four and a half years' time. When to
this 12 per ceni. are added ihose cases which become operable and ihose
which remain well for a considerable time and disappear, the record is
considering the present stale of ihe therapeutics of cancer, a hopeful
one."
"But, apart from all the above facts, ihe radium Irealment of cancer
of the cervix is well worth while for its wonderful powers of palliation
alone." *^

A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY, PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIOACTIVE SUBSTANCES
Copyright 1921 by Radium Chemical Co.
Edited by Charles H. Viol, Ph. D.. and William H. Cameron, M. D with the assist
collaborators working in the fields of Radiochemistry, Radioactivity and Radlumtherapy.
Address all communications lo Ihe Editors, Forbes and Meyran Avenues,
Pittsburgh, Pa.
Subscription $2.50 per year, or 25 cents per copy In the United States and Cana
In all other countries $3.75 per year.
VOL. XVIII DECEMBER, 1921 No. 3
REVIEWS AND
ABSTRACTS
Russell H. Boggs, M.D., (Pittsburgh, Pa.) The Treatment of Carcinoma
of the Breast by Imbedding Radium Supplemented by X-Ray.
American Journal of Roentgenology, viii, pp. 20-24, January, 1921.
"In all ihe progress made in recent years in radiotherapy, nothing
has been evolved of such significant import in the treatment of carcinoma
of the breast, as the advanced method of imbedding radium, with
its manifold and varied advantages and possibilities in deep therapy. By
imbedding radium throughout the entire breast, in the axilla, into ihe
glands leading from the breast to the axilla and info Ihe glands below
the clavicle, it is now- possible to make radiation for carcinoma of the
breast as thorough as a radical dissection without opening the lymph
channels. Supplementing Coolidge x-ray treatment lo the twenty or
more lymphatic chains draining the breast, using 10 mm. ot aluminum
and cross-firing as much as possible, there is completed the most advanced
and most effective irealment, which is in marked contrast lo the
treatment given fifteen or twenty years ago with a comparatively low
penetrating gas tube, using no fillration or meters for giving exact dosage,
and thus administering only superficial radiation when deep treatment
was necessary."
"Radiation for the treatment of carcinoma of the breast has been
so changed by imbedding radium that where only superficial skin effects
were formerly produced, now cancerous tissue deeper than that which
can be removed by the knife can be destroyed without opening ihe
lymphatic chains. Before imbedding radium I always give surface applications
in the axilla and over the glands below the clavicle, and I
give a complete course of heavy filtered x-ray treatment to the ' reast

34 R A D I U M
and all the glands draining it. This checks cell proliferation and lessens
the danger of metastases when the breast and adjacent lymphatics are
speared and radium inserted. Il is generally agreed that it requires
from Iwo to four weeks to check cell proliferation. It has been shown
that the lymphatics begin to undergo a fibrosisat the end of the fourth
week and thai the caliber of the lymphatic vessels is smaller than before
treatment was given. It seems jusi as advisable to give surface
treatment before imbedding radium as before operation. Some few
surgeons are now advising ante-operative irealment. and if they would
include imbedding radium and remove less tissue, thereby leaving the
sclerosed lymphatic tissue as a barrier against cancer cells, I feel sure
that ihe end results would be better, at least in borderline cases; thai
is, there would be fewer recurrences, and if a recurrence did take place
it would be considerably later than when the operation precedes radiation."
"Imbedding radium in the Irealment of carcinoma of the breast is
a step in advance, but the number of cases Ircaled by this method are
not sufficient and its use is of too short duration to speak aboul anything
but temporary results. Even in some of ihe advanced cases the
disease in the breast and ihe glands appears lo have retrogressed, clinically.
Of course in some cases there is still thickening due lo ihe
fibrosis from the radiation. Xot enough cases have been operated ujton
to give definite histological changes. In the inoperable cases we were
inclined to leave well enough alone, and in the early cases each one has
refused operation. My advice has been, even in the advanced cases,
where the disease has clinically receded, to have ihe breast removed without
opening the axilla; but to my extreme disappointment, in almost
every advanced case that I turned over to the surgeon he opened ihe
axilla, and when the patient returned, almost without exception she had
a swollen arm and was in much worse condition than before operation.
I feel sure, however, that if we could have the surgeon remove only ihe
breast, thereby taking away ihe unhealthy mammary* gland, the patient
would be greatly benefited. I am speaking of ihe advanced or inoperable
cases which have had thorough radiation, and not the early casts
which we are advising to have ante-operative radiation. Imbedding
radium as described lakes ihe place of operation in advanced cases, and
as before staled, the removal of the breast is all thai is advised."
"Il is imperative that even* iherappeulist should make a comprehensive
study of the lymphatics draining the breast before he attempts
to treal mammary carcinoma. The lymphatic supply to the breast is
greater than to almost any other organ of ihe body. A studv of ihe
lymphatic and bone metastases will show that although the case is
operated on early, ihe raying of the line of incision, axilla and supraclavicular
region is very- incomplete."
"The clinical and pathological studies of cancer of the breast have
shown lhat both surgery and radiotherapy meet with manv difficulties
and unceriainiies. The anatomical types are so manv. ihe variations of
ihe clinical course are so wide, the paths of dissemination so diverse and
the difficulty of determining the actual condition so complex, that giving
a lethal dosage is difficult. Since Deaver and Bloodgood both claim
thai an incomplete operation hastens death, there is good reason for
advocating ihe imbedding of radium into ihe breast and into the adjacent
lymphatics wherever possible. A study of autopsies shows that
almost any organ of the body may metastasize from cancer of the breast

R a d i u m 35
and however closely confined to the superficial tissues the growih seems
to be, no one can tell where the cancer-growing edge may extend; although
unappreciable by ordinary methods of examination, ii is just
as definite as ringworm. This shows us thai even in the early cases
no lymphatic chain should be omitted when raying the lymphatics with
a Coolidge x-ray lube, and as much cross-firing should be used as possible.
In an article which I read before this society in 1917, I described
the glandular distribution of Ihe breast and the method of raying with
a Coolidge x-ray tube. Since then I have been using 10 mm. of aluminum,
giving from fifteen to twenty minutes' exposure. At tha* time I
made Ihe statement that "we are all looking for some means by which
the skin will tolerate larger doses." This has Io a certain degree been
accomplished by imbedding radium and using heavier filteredx-rays."
"In calculating the filtration and the number of ports of entry or
the amount of cross-firing necessary Io give a lethal dose Io metastatic
lymphatic glands, it is necessary not only lo know the anatomical situation,
but we must know the depth and density of the overlying structures.
It makes quite a difference whether the glands are situated one-half inch
or four inches from the surface. The erythema dose in carcinoma of
the breasl is very seldom the lethal dose. The lethal dose is from three
to six times Ihe amount of Ihe erythema dose. Therefore, if a surface
erythema dose is given and the disease is four inches below the surface
of the skin, ihe loss of radiant energy by divergence of the rays and
absorpiion of ihe tissues with an x-ray tube placed eight inches from
the surface with Ihe equation used, is about one-ninth; or in other
words, only about one-ninth of the surface radialion reaches four
inches below the surface of Ihe skin. Then if the lethal dose is from
three to six times the erythema dose, it can be readily seen that when
only one port of entry is used the treatment would be useless. Formerly,
too many were'satisfied with the removal of the visible part of
the disease. The degree of malignancy is no guide to the amount of
radiation determining its lethal dose. On account of rodent ulcer growing
slowly and responding to small amounts of radiation, these circumstances
led many lo believe that a lethal dose was determined by ihe
degree of malignancy of a tumor. Medullary carcinoma may respond
more readily to radiation than ihe scirrhus type, but it grows more
rapidly and invades the glands early, so if a cure or even an inhibitory
effect of the disease of this type takes place, both the local tumor and
metastases must be given sufficient radiation. If results are going to be
produced in ihe medullar*.* type, Ihe cancer cells must show effect within
three or four weeks, and fibrous tissue must be forming al the end of
this time. In the scirrhus type, the fibroid formation has already taken
place by nature's process."
"When we speak of the lethal dose of radiation, we refer to direct
action on malignant tissue; but there is an indirect effect of radiation
on malignant cells by the formation of fibrosis which starts Io form
three or four weeks later. Both are important, and a lethal dose should
be given whenever possible, but less than a lethal dose sickens the
malignant tissue, as Mayo crprcsses it, and starts the formation of
fibrous tissue which is a barrier against the disease. In locations where
radium can be buried a lethal dose can nearly always be given, but in
the treatment of deep metastatic glands we may be compelled to depend
upon both the direct and .indirect effect of radiation on malignant cells.
Therefore, when carcinoma of the breasl is so far advanced lhal a cure

36 R a d i u m
cannot be expected, the patient should have all the palliation possible
from bolh the direct and indirect effects of radium and x-ray."
"In a tumor thai does not respond readily to radiation there is more
necrosis and less absorption when a lethal dose is given. In two cases
in which ihe mass in ihe breast was hard and of long duration, the
growth was walled off, and when Ihe breast was speared, broken-down
non-offensive material came out through the trocar. This was due lo
heavy surface applications of radium. In each of these cases a clinical
cure was obtained after imbedding radium, and Ihe normal tissue
was not injured in eilhcr case.''
"The ability to classify cases requires clinical experience and forms
an important part of ihe training of the radiologist. The question of
large dosage altering normal lissue after the reaction has disappeared
is an important factor, and this alteration of tissues will not permit the
normal tissue to bear so well a second, ihird or fourth exposure. The
normal tissues are usually injured by a frequent repetition of the radiation,
while the cancerous tissue, if any remains, may not retrogress in
a proportional degree. In fact, the cancer cell and normal tissue may
react in about Ihe same degree, or there may be a reversal of the primary
susceptibility. This shows the advantage of imbedding radium wherever
possible after a maximum surface dosage has been given."
"The method I have adopted is to give a thorough course of Coolidge
x-ray treatment to all the glands draining the breast, using ihe following
equation: io mm. aluminum, S inch tube distance, five milliamperes of
current, nine inch spark-gap and from fifteen fo twenty minutes' exposure.
A constant voltage is difficult to obtain. The pastille erythema
dose is very- unreliable and is not as accurate as the milliampere dose,
using the different types of transformers with a fluctuatingvoltage. Calculations
based upon false assumptions have been very misleading, and
in giving a lethal dose exact standards must be employed. In many of
Ihe cases the breast and axilla receive a maximum dose from radium
packs before imbedding radium."
"Two or four weeks after surface applications I have been imbedding
io mg. radium needles, placing ihem I cm. apart, and giving
from five to eight hours' exposure. In some cases this produced a slight
inflammatory reaction, but in no case has necrosis taken place. I may
say that I started over three years ago—most reluctantly—to imbed
radium in more superficial lesions; I can now indorse this technique
as presenting many points of advantage over surface application in the
treatment of many forms of malignant lesions, but it will not take the
place of the Coolidge x-ray tube in the treatment of dislant and deep
mctaslases."
Russell H. Boggs, M.D., (Pittsburgh, Pa.) The Treatment of
Tuberculous Adenitis by Roentgen Rays and Radium. American Journal
of the Medical Sciences, clxii, pp. 90-95, July, 1921.
"Formerly radiotherapy was used in ihe treatment of tuberculous
adenitis to avoid deformity and unsightly scars; today this treatment
is advised because more permanent cures are obtained lhan bv any
other method. At present surgeons of experience are nol operating
primarily for tuberculous adenitis. If they operate it is only to remove

R a d i u m 37
fibrous nodes after the tuberculous foci have been destroyed by roentgen
rays or radium. Then a dissection of the cervical glands is always conira-indicaled.
Radiotherapy alone will cure over 90 per cent, of the
cases."
"Experience has proved that tuberculous adenitis is not primarily
a surgical disease. The reason that it took years to prove that cervical
adenitis was belter treated by radiolherapy was really our fault in being
too slow in reporting the cases, and a surgeon would see only a few
cases, in the most of which the treatment was inefficient and incomplete.
As before stated, in only a small ->ercentage of cases, 5 to 10 per
cent., is it advisable to remove fibrous nodules after radiation. If such
nodules are removed and examined, little or no tuberculous material
would be found, the fibrous stroma of Ihe glands remaining."
"In the treatment of tuberculous adenitis the first and most important
consideration is that it is a local manifestation of a constitutional
disease."
"Most of the laryngologists are referring tuberculous adenitis for
radiation as a routine procedure, and many will not remove diseased
tonsils if the cervical glands are enlarged until Ihe glands have been
given a thorough course of treatment, either by roentgen rays or radium.
Radiation of the enlarged cervical glands is important before removing
Ihe tonsils of children under fifteen years of age, and particularly so if
under the age of five or six, as the lymphatic vessels are wide open, and
in the removal of the lonsils before radiation there is danger of producing
a general infection if tuberculosis is present."
"Injudicious surgery has been very detrimental. Inefficient surgical
treatment is followed by recurrence in the adjacent glands so frequently
that when there is an operation performed it is looked upon as
the beginning of a series of operations. The contra-indications of treatment
by surgery are: (1) Children get well without it; (2) we have no
certain method of diagnosis in early cases; (3) all the affected glands
cannot be removed; (4) scars; (5) recurrences. Since the disease can
be removed more successfully by roentgen rays or radium, with no
danger of spreading the disease without scarring and without sacrificing
tissue, complete extirpation of the tuberculous glands should never be
performed until the disease is well localized. Past experience and present
results should make everyone advise radiotherapy, for at least the
localized effect."
"In many clinics more than a thousand cases have been treated by
radiotherapy, and operation was required in less than 10 per cent, of
the cases, even for the removal of fibrous nodules. Over 90 per cent.
were cured by radiation alone."
"Different authorities call attention to the fact thai when the older
methods are employed a certain percentage of the patients acquire pulmonary
tuberculosis. This possibility never occurs when radiation is
given before any lung involvement takes place. For this reason the
medical treatment should not be persisted in too long without radiotherapy."
"I am sure that the susceptibility to the development of tuberculosis
is always greatly lessened after a few radiations, and that the patient,
at least in some cases, is rendered immune."
"There is no longer any doubt that the lymphatic glands form the
first line of defense against tuberculosis. Nowhere is this so well demonstrated
as when the glands of the neck are invaded, because almost

3S
R A D I U M
invariably ihe virulence of ihe bacillus is greatly lessened after its entrance
into the glands. In many cases the disease does not become general,
so lhat many palients recover in a way that shows truly this infection
is arrested. These tumors may spontaneously subside without suppuration,
while in other patients the disease progresses until fluctuation
shows lhat suppuration has taken place in the glands. Constitutional
infection is not uncommon when tuberculous glands are neglected.
Therefore a patient with chronic enlarged glands in the neck should
have treatment before ihe constitutional symptoms develop. In the
past this did nol receive sufficient attention. We see too many cases
coming too late where Ihe glands have been enlarging a year or more.
Such neglect often necessitates longer treatment and may even endanger
th life of ihe patient."
"By raying the local infection in the glands its hypersusceplibility
is reduced, which prevents the spreading of ihe disease. Tuberculin has
been given for ihis purpose, but experience has shown thai unless we
are able to give the proper dosage, with the proper intervals, it may
even increase the hypersusceptibility of the patient."
"We must remember the responsibility of checking ihe disease in
the primary stage and treat ihe glands by radiotherapy as soon as discovered.
Ii should be apparent to everyone that the removal by radical
operation is contra-indicated, and when a recurrence takes place, not
on account of the lack of surgical skill but because of ihe presence of
ihe tubercle bacilli which are beyond ihe reach of ihe knife, the organism
is rendered more susceptible, giving the disease a greater chance to
spread than before the operation. The hypersusceplibilily to suberculosis
is greatly increased by anything which tends to lower ihe vitality
of the patient."
"Tuberculous glands have teen classified with regard lo the pathologic
involvement. Closed glands are found in two varieties, the hyperplastic
and the fibrous. In the hyperplastic type the glandular substance
increases, together with ihe stroma. If this variety is left untreated
ihe glands soon liquefy and form an abscess known as soft
glands. These may remain a long time, but if left untreated a tryptic
ferment will digest the capsules, finally reaching the surface and producing
unsightly scars. Fibrous glands occur in those who have a
greater resistance, the tuberculous process is slower and the glandular
material is not increased in ihe same ratio as the fibrous tissue. In the
fibrous variety nature is almost curing ihe patient. If ihe fibrous tissues
doe- noi entirely absorb it will frequently leave a hard nodule, the size
of which is determined by the number of glands."
"Cicatrized glands are enlarged glands in which the tuberculous
process has been healed by the formation of scar tissue. If the glands
have attained great size before radiotherapy has been employed a palpable
nodule will usually be left. The patient may ihen think there is
still a tuberculous process, and even the physician may noi realize thai
a fibrous healing lakes place in the cervical glands the same as il does
in the lungs. Particular attention should be directed to this end. and
the rays canno! be expected to absorb alt the scar tissue which has been
formed by the tuberculous process, when the glands have attained greal
size or when large amounts of fibrous tissue have been formed by
nature's cure before radiotherapy has been emploved."
"Then when operations are performed for "such cicatrized glands
radical procedures are never necessary and large, unsightly scars are
avoided because the operation is performed for a different purpose. The

R a d i u m 39
healed nodules can be removed through a small incision and closed by
sutures so lhat no deformity is left."
"Open glands are those lhal have suppurated and opened to ihe
surface. There are two varieties; those lhat break down as a result
of tryptic ferment, the discharge of which is sterile, and those which
break down, due to a mixed infection."
"Recurrent glands, after a radical operation consisting mainly of
mixed infections, arc ihose recurrent immediately after the operation
and those coming on slowly and some lime after Ihe operation, which
are usually of a purely tuberculous character. The increased hyper
susceptibility- of the patient after ihe operation is often a factor in the
recurrence. Glandular enlargements on the opposite side of the neck
or in any part of the body shows the increase of susceptibility after a
radical operation. In these cases it is important to begin radiotherapy
at once and not attempt a second operation, as has been ihe custom in
Ihe past."
"Radiotherapy in its development to date offers a number of problems,
a solution of which means a great advancement in the treatment
of diseases described as multiple glandular tumors. There is no other
treatment which adds so much Io the comfort of the patient and prolongs
life to the same extent in lymphatic leukemia, Hodgkin's disease
and lymphosarcoma."
"Conclusions, i. Radium and roentgen rays will cure more
cases of tuberculous adenitis than any olher method. Radiotherapy
alone will cure over 90 per cent, of these cases."
"2. Surgical treatment is always contra-indicated primarily in
every case of tuberculous adenitis."
"3. Those who still hold to radical operation will find the responsibility
harder 10 shoulder with the ever-increasing recognition of the
fact that tuberculous adenitis can be cured without it."
"4. Hard, fibrous nodules following radiotherapy seldom ever contain
any tuberculous foci, but it may be advisable to remove these nodules
through a small incision the same as a foreign bod v."
"5. It is to be remembered that large cervical glands may he due
to sarcoma, Hodgkin's disease, leukemia, etc., and thai radiotherapy is
still the best form of treatment for multiple glandular tumors, but the
end-results arc not the -ame as when the enlargement is due to tuberculosis."
"6. In the treatment of tuberculous adenitis in the future, when
a more systematic raying is employed and when ihe cases are referred
earlier, this method of treatment will be universally accepted."
C. Augustus Simpson, M.D., (Washington, D. C.) Atrophy of Lymphatic
and Tonsilar Tissue by Radium and X-Ray. Journal of Radiology.
II, No. 8, pp. 35-38, September, 1921.
"From the Rockefeller Institute and Journal A. M. A., January
22, 1921, a report has recently been made that will prove a land mark
in the treatment of hypertrophied tonsils. This article, coming from
such an ultra-scientific and ethical institution and men, is not lo be
questioned or doubted. Briefly, il told of the treatment of forty-six
patients ranging in age from $)/• to 45 years by exposing the area of the
tonsils lo a massive dose of x-ray. Two weeks later distinct shrinkage

40 R a d i u m
of the hypertrophied lonsil was noted. This continued from one io two
months, at which time the tonsillar crypts had opened and drained, and
in all bul a few ihe exudate had disappeared from ihe throat, leaving
the tonsil smooth, pale and of a healthy appearance."
"Cultures were made from ihe crypts in forty of the forty-six
patients before and at intervals afler the trealmeni began. The common
organisms of the throai were not affected. Thirty-six of die fortypatients
showed hemolytic slreplococci, and of this number the tonsil
of thirty were free of this organism four weeks after treatment began."
"As the atrophy of the tonsil progressed the crypts became moie
shallow and drained'belter, the streptococci disappeared and the lymphatic
tissue became displaced by connective tissue. The hypertrophied
tonsils had undergone a shrinkage comparable to the ?trophy of old age
when the gland is composed of little more than a small collcciion of
fibrous tissue."
"Viewing the treatment from Ihe point of a roentgen therapeutist
the entire technique is most simple and easily accomplished in one or
two treatments."
"The measured amount of ray over ihe tonsillar area is less than
that given for a skin cancer and averages the quantity used in the treatment
of ring-worm of the scalp, or in other words, a perfectly safe
amount of x-ray."
"The one ihing, and to my mind the only pari of the technique lhat
detracts from the treatment is the fact that the target or tonsil being at
least an inch or more below ihe surface of Ihe skin, especially in
adulls, and not in a very accessible or exposed location may not receive
Ihe full amount of ray intended for it. This would entail more visits,
treatments, expense, and Ihe loss of time of at least one month or morj.
as such large doses of x-ray cannot be safely repeated under four
weeks."
"In order to overcome this difficulty and to be able to concentrate
the rays accurately and directly on the tonsil, obviating the use of large
doses of x-rays over the structures of ihe neck, to save time and to
make doubly sure of the results, I am using a flat dermatotogical 30
mg. double strength radium applicalor. covered only with a single laver
of sterile rubber tissue. Swabbing the ihroat and tonsil with a two
per cent, novocain solution will usually eliminate any gagging."
"A convenient handle is supplied with the applicator which enables
Ihe patient lo hold the unscreened radium directly on Ihe tonsil for an
hour. With this original technique it is perfectly remarkable how
quickly the tonsil begins lo shrink and show olher atrophic changes.
A mild reaction which turns white is lo be seen where the radium has
been held. This slight irritation of the tonsil disappears in two or
three days."
"In one patient with a temperature of a hundred and one degrees.
exudate in the crypts of the enlarged protruding and inflamed tonsils,
cervical glands of the neck the size of half an orange associated with
malaise loss of appetite the picture was changed in one week and after
a single treatment. After two weeks the tonsil was ihe only pari of
the entire naso-pharyngeal field that did not share in the verv acule
red. inflamed condition that involved every other part of the posteriornares
and pharynx. The enlarged glands had disappeared in three
weeks, and only a small part of the tonsil was to be seen when the
anterior pillar was pulled lo one side. On the opposite side, not com-

R a d i u m 41
plicated by enlarged cervical glands, the enlarged protruding tonsil had
entirely disappeared after a single exposure of x-ray and radium."
"By using the unscreened radium applicator on Ihe surface of the
tonsil combined with three points Hampson x-ray through three mm.
aluminum pastile on -kin and covered with two layers of chamois skin
exlcrnallv, I gel a cross-fire of radium and x-rays which is concentrated
and centered on the tonsil itself."
"This technique to me seems a much more scientific and accurate,
a sure and quicker way of reaching and atrophying the tonsil."
"The dermatological flat radium applicator without fillers is not
only ihe practical applicator to use, but its advantages are apparent
with the mosl superficial knowledge of radio-therapy. The radium is
on ihe surface of the metal capsule, having no aluminum 1o cover it and
filter out the valuable beta ray and being of double strength, the strongest
made, the effects are immediate and both superficial and deep. All of
the more valuable beta rays are available, which is impossible when
using, say the popular metal capsules or needles such as are employed
in uterine and deep cancer work. This metal capsule employed bv
gynecologists and surgeons is most frequently made of one-half to one
mm. of silver, which equals in density and filtration power two to four
mm. of aluminum. Such a filtereliminates and absorbs from fifty to
ninety per cent, of the very type of rays that one seeks to employ in
this work. Not only does it waste from half lo ninety per cent, of the
beta ray that is useful and needed, but it prolongs and multiplies the
duration of treatment from four to eight times."
Walter A. Wells, M.D., F.C.S. (Washington, D. C) On the
Practicability of Effecting a Complete Atrophy of the Tonsils by the
Use of Radium. Southern Med. Jour, xiv, 907-909. Nov. 1921.
"It seemed to the writer that radium might possess a decided advantage
over the roentgen ray in that it could be brought directly to the
seat of trouble instead of being obliged to pass through a mass of healthy
tissue, which lessens Ihe activity of the rays and which incidentally
might be unfavorably influenced by them."
"In my cases Ihe radium enclosed in the hollow of a specially adapted
needle is imbedded in the center of the substance of the tonsil for a
length of time which varies according to circumstances. The rays pass
through a screen 0.15 mm. in thickness, consisting chiefly of an alloy of
platinum and iridium (30 per cent)."
"The users of x-ray have pointed to the fact thai after exposure
they have noted a disappearance of the small disseminated deposits of
lymphoid tissue often seen in the pharynx, and have claimed this as an
advantage. But this view has no support in laryngological experience,
for these little lymphoid deposits are never the seat of pathologic exudate,
and iheir removal has never been found necessary to eliminate infection.
If sometimes they aer seen to appear or become larger after
radical tonsillectomies, it is a question if this is not to be regarded as
compensatory and protective rather than a pathologic reaction."
"In our opinion, therefore, the shot-gun aclion of the x-ray charge
is a real obieclion rather than an advantage, and the stray shots which
go wide of the real mark not only do no good, but may do harm 10
perfectly innocent by-standers."

42 r a d i u m
"Using radium by the method which we advocaie, one secures a
concentration of radio-activity upon the diseased tonsil which is fell
wilh greatest intensity in ihe very- center, and wilh gradually diminishing
intensity as the rays reach Ihe periphery of the organ."
"Willi regard to the effect, we have now- observed more than sufficient
cases lo speak posiiively as to certain points."
"First, there can be no doubt thai with proper usage we can obtain
within a few weeks a marked reduction in size."
"For purpose of comparison it has been my habit lo begin always
with ihe larger of two tonsils, and the effect is always impressive when
at the next sitting we observe thai the proportion is reversed and lhat
the previously larger tonsil has now become the smaller one. In addition
to mere reduction of size, a decided difference is remarked in the
appearance of the organ. A tonsil lhat previously presented an irregular
nodulated surface or perhaps has been of ihe so-called ragged or
spongy type, now appears smooth, firm and pale. Very important proof
that the alrophic process has successfully attacked the diseased lymphoid
structure is found in the progressive lessening of colonies of bacteria,
and especially the fact thai we can no longer obtain pathologic exudale
from the crypts on pressure."
"The author has histological proof of the effect of ihe radiation in
bringing about a cellular atrophy. I have had sectioned and examined
microscopically tonsils that have been radiated and then removed surgically
al varying iniervals of lime afterwards, but ihese studies must
be made the subject of a later communication."
"After each radiation there occurs wilh remarkable constancy and
regularity a certain degree of reaction, subjectively expressed by a soreness
of the Ihroat, and objectively by the presence of slreaks or larger
whilish plaques upon the surface of ihe tonsil. This will take place from
seven to fourteen days after treatment, depending upon the number of
milligram hours employed, occurring earlier in the large dosages, but
longer delayed when the dose has been small."
"In Ihe course of lime and with sufficient dosage (repealed if
necessary) it is certain that we can obtain an atrophy of Ihe tonsil,
which we may liken to the normal physiological airophv. and lhal all
physical evidences of disease are made to disappear."
"We need one further evidence of the value of this meihod of
attacking the diseased tonsil in order that it may be fairly compared with
surgical removal, viz., the disappearance of systemic infections of
varying character, that are known to have had their origin in ihe tonsillar
disease. This appears from limited observation to be true, hut
more experience wilh longer elapse of time is necessary before one may
speak of this phase of the subject with a proper feeling of conviction
and authority."
D. Bryson Delavan. M.D. (New York). Results of the Treatment
by X-Ray and Radium of Diseased Tonsils and Adenoids. From
the Report of the 43rd Annual Congress of the American I-ar\ngological
Associalion, Medical Record, pp. 738-9, Oct. 22, 1921.
Dr. D. Bryson Delavan of New York presented this communication,
in which he said that very small amounts of x-rav were sufficient
for the reduction of lymphoid tissue, doses so small thai no injury, it

adium 43
was claimed, resulted to other parts from its application. The current
used was too weak lo affect even the external integument, but sufficiently
strong nevertheless to destroy the lymphoid tissue, and no scar tissue
was left behind. The rays themselves did not destroy bacteria, hence
they did not affect concealed abscesses of the tissue. They acted by so
modifying the crypts lhat free drainage from them was secured, and
ihus ihe crypts continued to empty themselves of all offending contents.
As the tonsil atrophied the infection disappeared from the opening up
and drainage of the crypts. Dr. Murphy maintained that little atrophy
would result in the case of fibrous tonsils, since the rays had no effect
upon fibrous tissue. This being true such cases must continue to be
treated surgically, as heretofore. Moreover, since radiation did not
affect bacteria, its application in cases of concealed chronic abscesses
of the tonsil would be ineffective, an unfortunate circumstance in view
of the prevalence of this condition. Thai the method of treatment by
radiation would quickly come into general use was improbable. The
region of the neck was one containing numerous important anatomical
structures which must be carefully guarded against injury. Inasmuch
as a knowledge of the safe and effective use of bolh x-ray and radium
was acquired only through highly intelligent study and much experience,
it was far better that experiments be carried out by those qualified for
the work than that the success of a method of such good promise should
be compromised and perhaps discredited through errors due lo incomplete
understanding of the medium or to faulty technique in ils application.
Knowledge of this subjeel was in its infancy, and far more study
and observation was needed lo prove the value of the theories already
suggested. What had been done had developed questions of the greaiest
interest, not to be settled by theoretical discussion but by painstaking
experimentation and accurate scientific observation.
H. R. Lyons, M.D., (Rochester, Minnesota.) The Use of Radium
in ihe Treatment of Myoxmatous Nasal Polyps. American Journal of
Roentgenology, viii, pp. 407-8, July, 1921.
"My regret to find that the rapidly recurring ty|»e of myxomatous
nasal polyp does not always respond to medical treatment or surgical
measures, led me about two years ago Io use radium postoperatively."
"It is well known that radium stimulates the production of fibrous
tissue, and this action is utilized in Ihe treatment of myxomatous
polyps. After one, two or three treatments by radium, ihe primary
myxoma recurs as a fibromyxoma or a fibro-adenomyxoma. This type
of polyp is very much more satisfactory to deal with than is the myxomatous
type."
"It must be emphasized, first,that radium inserted, for example,
into a large solitary nasal myxoma will not cause such a tumor to disappear,
nor will it change Ihe type of the tumor; second, radium postoperatively
does nol prevent ihe recurrence of a polyp; and third, the
use of radium in treating myxomatous polyps associated with a loo/
suppurative process does not cure the latter."
"A hypothetic case illustrating the treatment by and action of
radium on myxomatous nasal polyps is as follows: A patient presents
himself because of constant nasal obstruction. He gives a history of

44 R a d i u m
having consulted a rhinologist four years before, who operated on his
nose, removing large masses of jelly-like polyps. He was greatly relieved
for a short time, but the obstruction returned and operation for
large masses of polyps was again necessary six months after the diagnosis
was first made. He has had a total of seven operations for nasal
polyps."
"Examination reveals a large mass of multiple polyps in the right
middle meatus. The polyps are jelly-like and very- sofl; they appear
"water-logged." A specimen is sent to the pathologist, who reports
myxomatous polyp tissue. The patient is advised that one or more
operations are necessary, and that radium treatments will be used."
"A radical operation for the removal of the polyps is performed and
all the polyp; are removed with a considerable amount of the adjacent
tissue which is not frankly myxomatous, but which, as experience has
taught, rapidly recurs as such. As soon as the reaction diminishes.
from three to six days postoperatively, radium treatment is given and
the patient is kept under observation. Soon some very pale tissue in
the middle meatus, not quite healthy in appearance, is noted. Within
the next week or two this tissue becomes frankly polypous. Local
treatment is continued. In case of recurrence in the remaining tissue
a section is senl to the pathologist who reports fibromyxomatous tissue.
A second operation, not so extensive as ihe first,is performed. The
fibromyxomatous tumor which resembles a fibroma malic is removed
surgically much more satisfactorily than the primary tumor. If Ihe
recurrence is extensive the second operation is followed in from three
to six days by a second radium treatment; a third treatment is rarely
found to be necessary."
"In my early cases I used a 25 mg. tube of radium, screened with
a silver tube covered by a sterile rubber finger cot for one hour. Experience
gradually eliminated my fear of a burn and indicated that
larger doses were necessary-. I now use a 50 mg. tube for two hours.
Subsequent treatments are given wilh an interval of one week. The
radium tube is put in the region of ihe myxomatous tissue and made
secure by packing with sterile vaseline gauze. The string tied Io the
radium tube is attached lo the cheek by a piece of adhesive tape. After
two hours tne pack and radium are removed. The reaction resulting
from this irealment is not apparent for forty-eight hours or more. In
fourteen cases treated with 25 mg. or 50 mg. for two hours no burns
occurred."
"Conclusions regarding postoperative radium treatment await ihe
test of more time and more experience. I believe, however, that in 'he
stubborn cases of myxomatous nasal polyps, especially those recurring
after operative measures, the treatment will result in'a change from a
myxomatous type lo a fibromyxomatous type in which operation mav
be more successfully performed. Also the polyps recur less rapidlv
with radium treatment and thus the interval of relief is lengthened."
"The detailed report of fourteen cases treated postoperatively since
Xovemher 1. 1918. will be submitted later."
J. C. Mottram. M.D.. (Research Department, Radium Institute,
London). The Effect of Increased Protection from Radiaiion upon the
Blood Condition of Radium Workers. Archives of Radiology and
Electrotherapy. No. 250, pp. 36S-372. May, 1921.

R a d i u m 45
"The corpuscular content of the blood of ihe workers at this institute
has already been described. A profound leucopamia was found
affecting both the polynuclears and the lymphocytes, and also a mild
anaemia, accompanied by a high color index."
"Since these observations were made, in the summer of 1919, increased
protection from radiation has been instituted, and has now
been in operation for six months. As will be seen this has resulted,
with few exceptions, in a return of the blood conditions to the normal."
"A table gives the actual counts. The left hand figures are the
original counts, and the right the recent counts. At the bottom of the
table are the figures obtained by adding all the counts. Note the substantial
rises in the case of red cells and polynuclears, and the almost
unchanged lymphocyte total."
"It may be concluded that the protective devices which have been
instituted are effective in protecting the worker against these blood
changes; at any rate in the case of the red cells and polymorphs. Such
being the case, it has been thought desirable to give a short description
of the protective devices which have been employed."
Males
Polymorphs
Lymphocytes
Red Cells
Millions
1
2
3
4
5
4927—2902
6860—6186
3598—3377
2220—3760
1S64—4704
1620—1591
2597—2006
1980—1822
2139—2424
1535—16S0
5-3—4.7
5-4—5-0
4-2—5.7
4-i—5-i
4-3—4-5
Females
1
2
3
4
5
3267—4672
1035—3240
2008—2416
522—3240
4441—377S
2236—1710
706—1215
>935—25i6
885—1566
2133—1660
4-2—5-3
3-4—4-9
4-3—5-0
3-7-4-8
4-3—4-9
30744—38275
17766—1S190
43-2—49-9
"Protective Devices, i. Against emanation."
"The workers are not subjected to an atmosphere contaminated
with radium emanation, except for the occasional accidental escape of
emanation during its manipulation. Those who handle the varnished
radium sulphate applicators are free from this danger, as observations
have shown a normal elcctroscopic leak in rooms from which large
quantities of radium in this form had been removed a few minutes previously.
Nevertheless, ihe precaution of well ventilated rooms is provided,
and when there is a possibility of the escape of emanation, an
electric fan is fittedfor rapidly changing the air."
"2. Against beta radiation."
"The hands of the workers are especially subject to this radiation

46 R a d i u m
during ihe making and handling of emanation apparatus, and during the
screening and applying to patients of radium applicators. As far as
possible the handling of emanation is carried out before it has become
fully active, a period of three hours after it is pumped off the radium
solution."
"Three protective meihods are employed:—
"(a) Long-handled wooden forceps are, as far as possible, used
whenever radium has to be moved, in order to keep it as far distant as
possible from the fingers. For the same reason it is carried from place
to place in leaden-lined boxes, having long (16-inch) slings. Aud
further, when it is being applied to patients il is, whenever possible,
picked up by pressing ihe cenier of a long piece of adhesive strapping
on to the back of the applicator; the strapping is then used for fixing
the applicator to the patient.
"(b) The hands are protected by lead rubber gloves, preferably
lined with thin leather, or by thin non-lead rubber gloves when the
manipulations cannot be carried out with the thick gloves.
"(c) The screening of the applicators, which is the manipulation
causing the largest amount of exposure, is carried out by a team of
temporary workers, which is changed every three months. The skilled
work, which cannot be done by temporary workers, is distributed as
evenly as possible over the permanent staff."
"3. Against gamma radiation. '
"In this case it is the whole body of the worker that needs protection,
and not especially the hands, as is the case with beta radiation.
Temporary workers are employed as far as possble. Lead screens 5 cm.
thick are used, from behind and round which the radium is manipulated.
The work tables are also covered with lead 5 cm. thick, so that the legs
of ihe workers are screened.. The workers do not remain in rooms containing
radium for longer than is necessary, and the radium is carried
from room to room, close to the ground, in lead-lined boxes having long
leather slings."
"It is, however, not enough to provide protections, the workers
must know how to take advantage of them. One has heard of a case of
a nurse who was accustomed to carry radium each morning from one
room to another. She suddenly developed a bad radium burn of the
hand, which was accounted for by discovering that some days previously
she had had a long conversation with a friend in the passage between
the Iwo rooms."
Robert Knox, M.D., (London. England.) Treatment by X-Ray and
Radium, with Special Reference to the Value of these Agents. Archives
of Radiology and Electrotherapy, Nos. 252 and 253, July, August, 1921,
pp. 57-66 and S6-98.
"The correct appreciation of the value of a remedial agent is always
difficult This is particularly the case in internal medication where
the action of, for example, a drug is in question, and it is often only
possible to arrive at the true value after numerous experiments and the
lapse it may be of years."
"When an agent which appears to act upon all structures with
which it conies into contact is employed, the difficulties increase pro-

R a d i u m 47
portionately wilh its effects upon their structures, and the greatest care
must be exercised in all attempts to estimate its value. The radioactive
bodies are agents of this class, and it is very difficult even approximately
to estimate their value. The range of therapeutic activity
of radiations is an exceedingly wide one, extending from ihe very lowultra-violet
to the penetrating gamma ray of radium. The fundamental
principle of radiation therapeutics is easily unlerstool, if il is realized
that the wave-length of the raliation is the determining factor. When
the correct wave-length for a particular depth has been estimated, it
is then merely a matter of time, i.e., duration of the exposure, to produce
a particular effect upon the tissues. The effect of the radiation
is dependent upon the power of absorption the tissues possess for these
particular wave-lengths, and the absorption of ihe radiations causes
changes in the cells, which may vary in their degree; chemical changes
may result which have a far-reaching effect upon the organism. In
order Io obtain effects over a wide range of morbid processes, it is necessary
to have at our disposal radiations of all wave-lengths so lhal any
condition may be trealed. In x-rays anil radium rays we possess the
particular values required. Large quantities of radium may be used
with advantage, ar, for example, at ihe Middlesex Hospital, where $*/:
grammes have been used for varying times in the treatment of malignant
disease. Many valuable observations have been made on the effects
of such large doses of the gamma rays. '
"The physical data in radiation therapeutics arc readily arrived at.
The great difficulty is that we have so far not been able to gauge with
accuracy the biological response lo the radiations on Ihe part of the
tissues acted upon. Thai always has been, and will always be, ihe chief
difficulty."
"The estimation of the value of radiations in the treatment of
disease is consequently very difficult, and calls for much accuracy and
impartiality on the part of the observer."
"Relative Value of X-Rays and Radium. A grcal deal of unnecessary
discussion has taken place on Ihe relative values of x-rays and
radium rays, the assumption being that these agents act differently upon
the tissues. The matter will be more clearly understood if we assume
that we are dealing with radiations which have a very wide range of
wave-length, the gamma ray from radium representing the extreme
limit of penetrative power. Given an equal wave-length from either
agent the effect will be the same. The x-ray value has been up to the
present limited by the inability of the apparatus to generate the high
voltage necessary lo produce from the x-ray tube a short wave-length
which will equal that of the very penetrating gamma ray. So far it
has only been possible to use voltages of from 200,000 to 250,000; the
voltage required to produce x-rays equal to the gamma ray is approximately
betweenone and two millions. Nevertheless, ihe-voltages of
250,000 give us a very useful radiation, which, if applied in sufficient
intensity, may give very good therapeutic results. For example, cancer
of the cervix uteri may be influenced by massive doses of x-rays administered
through several ports of entry. The dose may have to be
very prolonged, from five to eight hours at a single treatment. Good
effects are claimed for ihis particular technique. Radium is more applicable
in these cases, because it can be applied directly to the growth,
and gives in this very brilliant results; these are, however, purely local,
and are not permanent. The use of both agents would appear to be a

4S
I N D I U M
rational procedure. By this method of attack it is possible to obtain
the maximum effect from both agents, ihe radium acting from a local
focus and spreading outwards to the periphery, while the x-rays are
used from the periphery to a centra! focus point. The tissues are thoroughly
saturated and simultaneously attacked from all points. It is
possible that in this way peripheral extension of ihe new growth may
be checked."
"It is a common experience to find thai in superficial lesions of the
skin, ultra-violet, x-rays and radium rays can all be employed with
success."
"It is impossible to deal in delail wilh all the diseases which may
be treated by radiations. For the purpose of this paper it will be sufficient
to group the diseases and discuss ihe value of the treatmeni in
relation to particular diseases in each group."
"Superficial lesions arc the most favorable for treatment, in so
far as Ihey can be Jcept continually under observation and progress
noted; occasionally, it is possible to remove a piece of tissue for examination,
when changes in tissue due to the treatmeni may be noted, and
the exact character of the condition ascertained."
"Exactly the same sequence is noted in the so-called deep therapy.
The effects are, however, much more difficult to obtain on account of
the greater difficulty in administering the correct dosage; more penetrating
radiations are required in order to reach the depth of the lesion,
while the intervening tissues absorb in a diminishing ratio, according
to their deplh from the surface, the radiations which have to pass
through ihcm to reach the tumor."
"When these difficulties are allowed for it will be seen that the
order of response is almost identical with that of the more superficial
lesions."
"The malignant cases give the least favorable results. The earlier
a case can be treated the greater is the chance of a successful result.
Surgery offers in nearly all cases a better prospect than radiation treatment,
so it should be given the firstplace, and radiation should be used
after operation in Ihe hope that recurrence may be delayed or prevented.
Combined treatmnt should be more successful than either alone."
"There are conditions of malignant disease in which surgery may
not offer any belter prospect than radiation, and in these it should be
our aim to give the very best treatment in ihe hope of helping the
patient. Radiations must be very thoroughly administered. In malignant
disease of Ihe thyroid, for example, it may be possible to do as
much wilh radiation as by surgical operation. 1-arge tumors of a lowdegree
of malignancy may be diminished in size and their progress
delayed."
The author ihen discusses the Irealment of rodent ulcer. lupus
vulgaris, hyperidrosis, Ihe leucaemias, Banti's disease, exophthalmic
goitre, benign and malignant diseases of the lymphatic system, uterine
hemorrhage and fibromyoma. carcinoma of the breast and uterus, and ante
and post operative radiation. The discussion in the main relates to the
use of x-ray, the author referring to Ihe results of others obtained by
use of radium in the treatment of some of the conditions.

A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY, PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES
Cupilllgllt 10£fi
x£m&ktf8kb*Rad,um Chcm'cai Co
Edited by Charles H. Viol, Ph.' D., and William H. Cameron, M. D. with the assist
collaborators working In the fieldsof Radlochemlstry, Radioactivity and Radlumtherapy.
Address all communications to the Editors, Forbes and Meyran Avenue*,
Pittsburgh, Pa.
Subscription $2.50 per year, or 25 cents per copy In the United States and Canada
In all other countries S3.75 per year.
VOL. XVIII JANUARY-FEBRUARY. 1922 Nos. 4-5
RADIUM AND DEEP THERAPY IN THE TREATMENT
OF
MALIGNANCY*
By Russell H. Boggs, M.D,, Pittsburgh, Pa.
A review of radiotherapy, including both radium and x-ray treatment
during the past twenty years shows it has passed through at least
four or five different stages in attaining the position it occupies today.
When we firststarted to treat with the x-ray, extravagant claims were
made, which were unjustifiable and, on account of the inefficient equipment
and lack of technic, only superficial instead of deep treatment was
given. All obtained results in the treatment of basal cell epithelioma,
but the percentage of cures was much lower than we obtain today, while
squamous cell epitheliomas, on account of the inefficient technic, seldom
responded. Today we are curing nearly all rodent ulcers or basa! cell
epitheliomas and a large percentage of squamous epitheliomas. In the
early days no filtration and little or no cross-firing was used. Later,
a millimeter of aluminum or a piece of sole leather was employed for
filtration. Such greai improvement in treating cases of carcinoma followed
this technic that it was only a short time until three and finally
ten millimeters of aluminum were employed in the treatment of all deepseated
lesions.
At present there are new transformers on the market in which high
voltage (twenty inches spark-gap) is employed to excite the x-ray tube.
•Read before the Roentgen Hay Society of Central Pennsylvania, at Altoona.
October 89, 1921.

5° R a d i u m
Figure 1. ShowiRK th

R a d i u m
Figure 2. Miss J. Advanced inoperable carcinoma of the breast
Inserted lor rive hours. Patient greatly improved.
•.-. nee lie*
at aboul twenty times the expense of the apparatus which we employed
fifteen years ago. Therefore, many will never install such an apparatus
where the work is largely diagnostic. These therapeutic machines will
not be as efficient for diagnosis as the shorter spark transformers.
Radium therapy has undergone the same rapid advancement in regard
to filtration,quantity employed, etc. A few years ago an attempt
was made to treat cancer with small quantities of radium with inefficient
technic. which was usually unsuccessful, whereas today similar cases
arc being treated with small and large quantities of radium, prescribed
according to size or depth of the lesion, just the same as any drug is
prescribed in the treatment of a disease, with decidedly better and more
uniform results. .Many malignant cases are now treated by imbedding
radium into and underneath the cancerous growth.
Radium and ihe x-ray have superseded surgery in the treatment of
some types of malignancy. The surgeons have tried conscientiously, but
unsuccessfully, to avoid the possibility of leaving any cancer cells behind
by the removal of all lymphatics draining the cancer area, thus sacrificing
many important structures. In the end they found that the dissection
left cancer cells behind and very few cases were cured by operation
alone in which there were palpable glands adjacent to a malignant
growth or when more than one chain of lymphatics was involved microscopically.
This was the means of influencing a few of the broaderminded
surgeons to advise anlc- and post-operative radiation.
When radium or x-ray is employed, il is imperative that a lethal
dose be given to all deep carcinomatous tissues. It usually requires

5-'
R a d i u m
Figure 3. Snowing the manner In which the radium needles were distributed
for carcinoma of the breaM- The 10 micm. radium needles were Implanted lithe
i-rowth for 8 hours. A total of 35 needles was employed.
from seven to ten skin erythema doses to give a lethal dose four inches
below the surface of the skin. This amount of cross-firing has been
used by very few radiologists during the past five years. It remains to
be seen whether one or two large ports of entry, as used by the Ger-

R a d i u m 53
Figure 4. Mrs. S. - Advanced carcinoma of left breasl. If 10 nis hrs. of
radium used directly over breasl. supplemented by x-ray over all other areas.
lAt right) six months later.
mans, will produce better results than smaller ports of entry with more
cross-firing. Regardless of the method employed a lethal dose must \*e
given.
Radium is not only the most efficient method we have in treating
epithelioma, but il is the most efficient method we possess in ihe irealment
of malignant growths of the mouth and throat. Les:onS in the
mouth and throat are more malignant and metastasize early; therefore.
a lethal dose must be given to the local lesion and the adjacent lymphatic
glands. The glands on both side* of the neck are closely connected, and
when the cancer cells have reached one chain, it is only a short time until
the other chains metastasize.
F.pithcliomatous growths of the tongue and floor of the mouth, as
well as those of the tonsil, even when the lesions arc advanced and
breaking down, have been clinically cured by surface applications of
radium, followed by inserting radium into and around the growth or
bv electric coagulation. Since we have been imbedding radium, better
results have been obtained than by cautery or any other method.
Epithelioma or cancer of ihe mouth and throat shows itself by its
progressive extension of the primary growih, and there is almost always
an earlv invasion of the lymphatics of the neck, while secondary involvement
of distant organs or tissue rarely occurs. Formerly it was said
that there was a collar around the neck through which cancer cells
rarely penetrated. This is not true, because by the older methods of
treatment, death occur ret 1 from the local or regional disease before

54
Figure 5, Mr. I. >'.irclnoma of the submaxillary elands. Eighteen 10 m;
needle* inserted for three hour;.
Figure 6. Air. F. Lympho-sarcoma of upper right cervical glands. Seventeen
10 mg. needles inserted for four hours. Two months later. fourteen lo mi.
needles inserted for 24 hours. t.\i right t Result seven months later.
there was sufficient time for secondary deposits to become active. A
review of any recent system of surgery shows thai even most of the
early cancerous lesions exhibit only the visible part of the disease, but

R a d i u m 55
Figure 7. Showing distribution cf needles : n ciKinoma of the tonsils. 15
needles each containing 10 mgm. inserted for 3 hours. Patient clinically cured
nearly 1 year.
there usually is a cancerous dissemination in the lymphatic spaces and
the glands are invaded at a considerable distance from the primary
focus, even at an early stage of the disease. It is true that the cancergrowing
edge, although not recognized by ordinary methods of examination,
is definite. When more than one lymphatic chain in the neck has
been found microscopically Io contain cancer cells and when the deep
cervicals are involved, the cases are noi cured surgically. Il is important
for the radiologist to know what glands drain each area of the mouth
antl throat as well as the anastomosis of the lymphatic system.
Carcinoma of the tongue is one of the most difficult of the mouth
lesions to Ircat and the most difficult to obtain complete retrogression,
because even in the early cases the glands have metastasized, minute
processes often have invaded muscle substance for a considerable depth
and if the growth is situated in the posterior pari of the tongue there
is an early invasion of the tissue towards the tonsil. Therefore, the
groove between the tongue and tonsil should always receive radiation.
The method that should give the best results is extensive surface radia-

56 R a d i u m
Figure 8. Showing dislrlbutlon of needles In carcinoma of the tongue.
Needles of 10 mgm. content inserted 5 hours. Patient clinically cured.
(ion, together with intensive radiation of ihe lymphatics, burying radium
needles two to four weeks later in the -tosterior ha'f of ihe tongue and
in the tissue in front of the tonsil and in the tonsil on the affected side.
This should be followed in some caies by electric-coagulation.
In ihe treatment ot" ihe lymphatics rcdiat'on should be as thorough
as possible, and even then, like a thorough d'sscction. ii often is not
radical enough. If an operation is per forme !ii should be preceded by
radiation because raying should destroy ihe small deposits in the glands
which are not palpable or at leasi check proliferating cancer cells. By
waiting five or --i\ weeks after raying the primary growth the cancer
cells are far on toward retrogression. Besides, there is not the same
danger of spreading cancer cells. Il is claimed that the lymph nodes do
for a time check cancer cells. \\ hile radium h.^s manv shortc-mings in
the treatment of cancer of ihe tongue, n >s a step in advance, and with
improved technic more should be accomplished in ihe future.
Primarily all epithelioma or cancer of ihe lower lip should be treated
by radium and surgery should be reserved for correcting the deformity
in cases in which ihe disease has caused loss ,,,* (issue before

R a d i u m 57
Figure 9. Mr. C. Carcinoma of the stomach given 15.000 mg. hr». of radium.
Patient improved temporarily, l.nnrt mgm radium used on paci* ir>xl5 cm. at
1 cm. from the skin surface.
radiation was begun and for the removal of vestiges of the disease which
remain in the muscle tissue after advanced cases have been radiated.
The lymphatic glands in bolh sides of the neck should receive thorough
radiation and. if any glandular involvement is present, radium should be

5« Radium
Figure l" Mrs. s. Carcinoma of the vulva. Twenty lo mg. needles inserted
for three hours. Patient greatly improved.
imbedded into ihe palpable cancer enlargements. If epithelioma of ilie
lip is removed surgically the routine bilateral block dissection has been
followed as the orthodox procedure. Then why omit radiating these
glands in both early and laic cases?
The following are some of ihe reasons why lower lip cancer should
be treated by radium:
First, more cases can be cured.
Second, the disease can be successfully removed in a large per-
centage of the cases without opening the lymphatics.
Third, no deformity is caused by the treatment.
Fourth, ihe deformity in removing a primary growih from the lip
by the Y-shapc incision is an uncomfortable deformity, especially if a
thorough operation is performed. Because of the great sacrifice of
tissue, there is always a hesitancy on the part of the .surgeon to remove
sufficient tissue, and afterwards the contraction is often sufficient to
irritate the scar, which may be the exciting cause of a prompt recurrence.
Fifth, patients will submit to radiation and will come earlier when
they realize that they can be treated successfully with radiation without
operation.
For these reasons the treatment of cancer of the lip with radium
deserves the foremost place.
Sarcoma of the tonsil and throat can nearly always be cured clinically
by radiation wilhin a comparatively short time, but within a year
or two a recurrence takes place in nearly all cases. Formerly we did
not seem to realize the extreme malignancy of sarcoma and" did not

6o
R a d i u m
Figure 11. Radium treatment of Inoperable carcinoma of the cervix uteri.
Had previously received radium treatment elsewhere. Present treatment consists
in insertion of ten 10 mgm. needles for S hours with massive doses of heavily
screened x-rays from without. Advance of growth had obliterated cervical canal
making necessary implantation of needles. Further radium treatment may be
necessary.
late cases the method just described is at least superior to any form of
operation primarily and in these cases, if ihe breast is removed, al least
the axilla should seldom be opened following radiation. Finally, probably
the safest method in all early cases is to give surface application of
radium or the x-ray, two or four weeks later imbed radium, and Ihen
from four to eight weeks later remove the breast and as much of the
adjacent tissue as is deemed necessary; and to depend upon radium and
the x-ray in advanced cases and in some of these late cases to remove
the breast without opening the axilla.
As a primary procedure gynecologists were the first surgeons to
advise primary treatment of carcinoma of the cervix and uterus by
radium. The results obtained in far advanced and border-line cases
and a number of recurrences following early operations, raised the question
as Io whether radium treatmeni or surgical removal offered the
most in primary cases Today nearly all gynecologists consider cancer
of ihe cervix and uterus a surgical condition, but they are dissatisfied
with the end results Many gynecologists and surgeons*are using inefficient
quantities of radium with poor technic and are omitting the irealment
of adjacent glands by deep roentgen therapy. During the past

R a d i u m 61
Figure 12. Inoperable cancer of rectum treated with 150 mgm. of radium
applied in 5 tubes for 5 hours. The radium capsules were embedded in heavy
soft gum rubber shaft outline of which shows in illustration.
twenty years the gynecologists have improved their surgical technic from
time to time removing more tissue until extremely radical operations
have been performed. However, surgically there are not many more
cases cured than there were fifteen or twenty years ago at a certain
stage of Ihe disease, except by the Wertheim operation, which is considered
too radical by most authorities. The improvement in surgical
technic reduced the mortality from an operative standpoint more than
it increased Ihe number of patients cured al the end of five years. It has
been shown in the different surgical clinics that only about seven or
eight percent, of the patients coming for treatment are free from carcinoma
of the cervix at the end of five years. Therefore, it is imperative
that at least ninety percent, of the cases of carcinoma of the cervix
should have the benefit of radium.
Cancer of the cervix is being treated in a number of different ways:
First—Those using radium locally.
Second—Those who use radium locally, giving rather large doses
intro-uterine and also by packing radium around the cervix or carcinomatous
mass in the vagina and treating with large packs of radium from
the outside.
Third—Those who use rather large doses of radium or all the tissues
will stand locally, and deep roentgen therapy from the outside.

62 R a d i u m
Fourth—Those who are depending entirely on very high penetrating
x-ray without using any radium locally.
•
It seems that those who have made an extensive study of this subject
are familiar with ihe results produced by giving as much radium
locally as the tissues will stand antl as much radiation externally as
the skin will tolerate are producing the best results. The most plausible
reason why this method has not been universally adopted is that many
of those treating carcinoma of ihe cervix and uterus have radium only
in small quantities and are not familiar with deep roentgen lechnic;
others do not have radium and have been carried somewhat too far by
the reports from the German clinics. It certainly seems unwise to
attempt to destroy cancer cells in the pelvis through the skin if it can
be treated locally by radium, and it is certainly just as unwise to expect
to kill cancer cells in the adjacent glands at any great distance by the
use of radium applied locally.
I'nforiunately a large percentage of the cases are not being treated
intelligently. The treatmeni of cancer by radiation is a specialty and
unless ihe gynecologist makes a comprehensive study of this subject he
is bound to do more harm than good. On the other hand, unless the
radiologisl is able to diagnose and differentiate the different stages and
types of the disease, he is treating his cases jusi in ihe same manner as
the gynecologist who knows practically nothing about radiation. It is
neither the occasional brilliant result nor ihe failure lhal counts in ihis
kind of work, but it is the correct analysis of all cases with full histories
and careful follow-up records thai will give us the real value of this
procedure.
Before an operation is performed radium should always be considered,
because the end results even by the combination of surgery and
radiotherapy are still far from being satisfactory. Time would not permit
to go into detail to classify the different groups clinically, nor to
describe results which have been achieved by radium alone, or with
radium in conjunction with surgery, but it will be sufficient lo say that
radium is a specific palliative in inoperable cancer of the cervix and
uterus. It will clinically cure about one-third of the inoperable cases
and subjective improvement is noticed in nearly all others. However,
in these far advanced cases there is usually so much adjacent glandular
involvement that Ihe disease is only checked for a time (from six months
to three years). During this lime the patient regains normal health and
can lead a useful life. In these hopeless cases, the offensive discharge
disappears within from two to four weeks after the treatment has been
given. The deodorizing and sterilizing effect of radium is very remarkable
in the inoperable and recurrent cases where there is broken down
cancerous tissue. The early cases can be clinically curd by radium, but
whether the end results will be superior or equal io surgical removal no
one can tell at Ihe present time, but in the border-line and advanced
cases better results are obtained by radium and deep roentgen therapy.

R a d i u m 63
reviews and abstracts
Arnold Schwyzer, M.D. (St. Paul, Minn.) Radium; Its Therapeutic
Uses in Surgery. Minnesota Medicine, Sept. 19^1.
"The uterus is a favorable area for Ihe treatment of its tumors, and
here indeed did we see the firststriking results. I have observed cessation
of profuse menorrhagia in uterine fibroid and an almost complete
disappearance of the fibroiditself which was the size of a three months'
pregnancy, after one 24 hours application of 50 milligrammes of radium
element. And the radium was only applied vaginally. 1 have not used
the radium in fibroidslarger than a uterus 4 months pregnant. The generally
accepted technic is the intra-uterine application of radium in these
cases. I have persisted in the simple vaginal introduction combined with
external application over the lower abdomen. Unless there are complications
like inflammatory changes of the adnexa or similar special
reasons, we prefer radium lo operations in the moderate sized fibroids."
"In simple uterine bleeding, meno- or mctrorrhagic a diagnostic
curettage should be made in all cases. Intra-uterine application of
radium can be combined at once, or the radium may be introduced
vaginally. In intra-uterine application nausea may Ikt severe, a watery
discharge may follow the treatmeni al limes for even months, and if
even very slight and quite, old inflammatory residues exist in the adnexa,
intra-uterine radium treatment is a mistake which revenges itself most
unpleasantly. It is necessary to tell the patients beforehand of Ihe possible
sequela?, especially of nervous symptoms in case a suppression of
the menses is strived at, otherwise a sense of disappointment multiplies
the regular menopause molimina, and the produce is charged to your
medication."
"The most glorious results of radium therapy are seen in inoperable
carcinoma of the uterus. Even badly advanced cervix carcinomas
with involvement of ihe vagina forming foul ulcerated cralers quite
commonly improve so much lhat those practitioners and surgeons who
have not seen this improvement before, are often not only elated but
perplexed. Right here a word of warning is apropos. First of all the
observations arc not yet of many years' standing, though Heyman of
Stockholm had in 66 cases 2S.8 per cent, cures after 5 years. If a return
of the growih occurs, and some very experienced men do not dare hope
for a permanent cure in these cases, there comes a time when radium
has no further staying effect; the growth then runs wild. The primary
results van- greatly. Some patients stand the treatment with the greatest
impunity, others not, especially when the rectum is involved. A moderate
encroachment of the bladder is already less disastrous in our
experience, as these forms of carcinomata remain local growths for a
longer time. Carcinoma of the body of the uterus has such good surgical
prognosis that its treatment is operative. One case where operation
was ruled out, is well so far, but only of recent date. Particularly favorabel
cases for radium treatment are post-operative recurrences in the
vagina. They may remain well. Even in other parts of the body these
local implantations often seem to yield readily to radium, as after breast
operations. One case of carcinoma of the alveolar process in which I
made a resection of the upper jaw, had a recurrence in the wound of ihe

°4 R a d i u m
incision of the cheek. It is now five and a half years since ihe operation
and the patient, whom I met a short time ago, smoking a big cigar, is
in splendid health."
"Speaking of carcinoma of the upper jaw I have two cases which
have been operated upon elsewhere, and came to me as inoperable, three
and three and a half years ago respectively. As we have done for more
than ten years, we first resected atypically extensively and then applied
the hoi soldering iron to the limit of permissibility. This was also done
in the two cases called inoperable, and 5000 milligramme-hours of radium
were given starting a week or so after Ihe operation and giving the who!e
dose within a week if possible. Both cases arc still well and very happy."
"Carcinoma of the tongue, palate, pharynx and mouth. While writing
this paper I have two patients in the hospital, who were bolh operated
upon for carcinoma of the tongue. One had his operation a year
ago. It was a carcinoma of the base of the tongue which wc removed
by a lateral submandibular incision. The tumor reached very close to
the epiglottis. We removed the base of ihe tongue, going well beyond
the midline and backward to the epiglottis removing even part of the
mucosa covering the anterior surface of ihe epiglottis itself. Radium
was placed into the bottom of the remainder of the tongue.—50 mgr.
were left in place for 48 hours. This was a large dose, half of ihe
amount used in full Irealment of carcinoma of the uterus. We watched
closely and with apprehension for possible sudden edema of the larynx.
though the radium was placed as far from ihe epiglottis as feasible. No
signs of choking occurred, but later on ihe wound gradually opened
somewhat and now at the end of a year we put a pedunculated flap over
the opening which was the size of an impeded almond, in the midst of
which you could readily see the epiglottis and the scarry neighborhood
of the base of the tongue."
"The other mentioned case of carcinoma of the tongue, where we
removed over half of the base together with the tonsil and its two pillars
and ihe adjoining portion of the pharynx after splitting the lower
jaw in the midline, had too extensive an operation to make it advisable
to add possible shock of radium immediately. An operation for strangulated
femoral hernia—due to the coughing—three days afler Ihe tongue
operation made us wait two weeks with the insertion of ihe radium.
This case ought to be a ralher favorable one, as the forms of tongue
carcinoma, where wc do not have large fungating ulcerating surfaces but
rather moderately ulcerated hard nodes, are much more favorable, especially
if ihe microscopic picture docs not prove it to be of squamous
cell type with horny pearls. In these latter forms the radium is rather
powerless. Carcinoma of ihe tongue and the floor of the mouth is one
of the saddest chapters in surgery, and if radium should prove lo be of
benefit as it seems to be, it is a real blessing."
"Endotheliomata and mixed tumors of the parotid gland are favorably
influenced. Two of my cases are under complete control for 4 and
5 years, one of them after operative recurrence."
"Carcinoma of the pharynx and naso-pharynx are as a rule favorably
influenced. One case came lo us in June, 1919 with great dyspnea.
A tumor of the size of a tangerine filled the back part of the mouth and
pharynx. The patient was snorting with the mouth wide open. The
first thing to do was a tracheolomy. Then plugging the entrance to the
larynx we bluntly removed quickly the large mass from the posterior
wall of the pharynx, inserted 50 mgr. of radium and packed tightly.

R a d i u m

66 R A D I U M
a piece of meal from his neighboring patient at the hospital, after which
he was allowed to try all kinds of food."
"Within three weeks he gained twenty-six pounds. In order to do
as much as possible beyond a simple palliative measure, and to give
ihe patient all possible chances and at least some reasonable hope, we
started to use radium. A glass tube containing a few milligrams of
radium bromide was sewed into a piece of linen, antl ihe whole was
fastened to a silk thread It was attached to ihe end of a sound and
inserted into the crater without any screening It was allowed to remain
there up to thirty minutes ai a time, in all about six times After a
few months (in May, 1905) ihe patient was better in appearance, weight,
strength, mental condition. Not even Ihen. however, could I insert a
tube or probe withoul the use of the esophagoscope. I imagine ii did
not find the hard rigid area, but got caught against a portion outside of
this hard ring. This patient then felt so well for a long time that he
thought he was cured, and notwithstanding my urging him to come al
intervals to see me he did not show any more. His difficulty re-appeared
later, and he died about a year afler his first visit to me. While ihe
decided temporary result was apparently due to ihe mechanical dilatation,
I cite this case as it occurred one year before Bircher published his
claim of being the firstto use radium in esophagus cancer by esophagoscopy."
"The malignant lumors of the mediastinum are a most important
ficid for the use of radium. They are moslly sarcomata and lymphosarcomata.
For the present our only hope in nearly all of these cases lies
in the roentgen rays and more especially in radium. Very large doses of
radium with sufficient filteringlo remove all but ihe hardest gamma rays
seem necessary, according to Burnam of John Hopkins University who
reports most remarkable results. He used only those radium rays
which were left after filteringwith 3 mm. of lead. If the radium can
be introduced into the tumor mass, smaller quantities may be sufficient."
"Permit me to report a case in this connection: On February 21,

R a d i u m 67
than at the first incision. This lime, and one week later, and again after
another two weeks the radium was placed into the wound, each time
for about 4S hours. In all the patient had 8600 milligram-hours. If we
consider that this dose was given in the tumor, it is a very respectable
dose and more than is usually given for instance in a carcinoma of ihe
uterus. In addition we gave during that time (including two preoperative
treatments) five x-ray exposures (10 to 15 minutes, h.-rd tube,
with 3 mm. aluminum filter). Pain in the left shoulder was complained
of for a while, but the general condition was greatly improved. The
patient could sleep in his bed, up to eight hours in the night. He went
to the theater, traveled to his home and came bark during the eight
weeks he was under our care, and was most enthusiastic. Three
months later I was informed that he succumbed to what was declared
a pneumonia."
"Carcinoma of the breast. We are of the impression that x-ray and
radium have very materially improved ihe prognosis of our cases. We
give pre-operative x-ray treatment for two days in order lo stun Ihe
cells enough to make implantation less likely. Fat young women with
soft fast growing carcinoma give a very bad prognosis, radium or no
radium. The atrophic forms, which so often come lale upon the operating
table, and for this reason have greatly hurt or almost spoiled their
operative chances, arc definitely benefited by radium and x-ray. The
treatment is not to necrose all carcinoma, but to increase the fibrotic
strangling of the carcinoma nests. Even when the skin is perforated,
healing may occur by patient use of moderate doses."
"Carcinoma of the bladder, prostate and rectum may be greatly
benefited by radium. The female bladder is more accessible of course.
But by suprapubic incision we can use the hot iron and then put the
radium into place In malignant papilloma this has worked quite well
in our hands. In carcinoma of the prostate we have laid bare this organ
as for a perineal prostatectomy and then either applied or inserted the
radium under bulky walling off of Ihe rectum. The rectum, especially
the lower portion, does not stand radium well, and the patient complains
bitterly of pain and tenesmus. Our procedure seemed therefore an improvement
over the method of treatment, as advocated in Ihe literature;
but our experience in this fieldis quite limited."
"Carcinoma of the rectum is more of a surgical possibility than
that of bladder and prostate. The inoperable forms and the post-operative
recurrences are relegated to the radium treatmeni. The circular
carcinomata of the upper rectum are the most favorable for radium or
any treatment, because they remain comparatively long rather localized.
Carcinoma of the low-er portion of the ampulla involving the sphinctei
area is the most dreaded by the surgeon. And just here I have a result
which is worth mentioning. In November 1919 a lady 65 years old,
was brought to Ihe office in a pitiable condition of pain, weakness and
corrosion around the anus. A carcinoma in ihe lowest part of the ampulla
recti involving the anal ring, had a diameter of about 6 cm. It
was situated on the left and posterior wall, was ulcerated and ihe neighborhood
was somewhat infiltrated. The lower border was protruding
from Ihe anus. The local and the general condition did not seem to
warrant surgical measures. Radium was given in a—for this region—
almost ruthless dose. She received at once 2400 milligram hours November
10, 1919. In February 1920 we gave another 2200 milligram
hours. The patient improved splendidly. In November 1919, when

68 R a d i u m
first seen she only weighed 75 pounds. In February 1921 her weight
was 115 pounds, a gain of about 40 pounds. Her only trouble now is
a prolapsus of the rectum. The sphincter does not act; we had produced
an extensive sloughing by the radium; but apart from a slight
thickening in one place, all was healed and the patient is very happy
over the result."
"This is an unusual case, as in other instances (especially when
ihe growih was fixed solidly to the sacrum) the patients pay almosl too
dearly with pain for the small benefit which is principally psychic."
S. A. Heyerdahl, M.D. (Christiania). Radium Treatment of
Changes in the Thyroid Gland. Acta Radiologica. vol. i, fasc. 2, 207-
218, Sept. 20, 1921.
"During my practice little opportunity has hitherto been given me
to try to apply radium on the thyroid gland when subject to changes.
One of ihe chief reasons why this has nol been done is because preference
has been given io the roentgen rays, and this is again chiefly due
10 the fact that the roentgen apparatuses have been established almost
all over ihe country."
"While the radium, therapeutically applied, is concentrated in our
country, so to say. in some very few institutes and infirmaries, the roentgen
apparatuses, on ihe other hand, are installed in almost every infirmary
in ihe country and also in numerous special institutes."
"Thus ihe roentgen rays have go! a good lead and the favorable
results that these rays can show in the case of the toxic goiter is the
reason why the radiologists as a rule get patients suffering from this
illness expressly for treatment with the roentgen rays and not with the
radium ones."
"Altogether, radium is less known in our country as a remedy for
struma and toxic goiter."
"When I. in spile of comparatively little experience as to the effects
of radium by changes of the thyroid gland, have undertaken to read an
introductory paper on this subject at the congress, then it is due to the
fact that radium, according to my opinion, also ought to have a place
in the sun next to his brother roentgen that lately seems earnestly to
mean to knock him out from most of the domains of the therapeutic
rays."
"In ihe year 1905 Abbe of New \ ork ireated a case of goiter by
burying a radium lube in the gland and reported a remarkable success.
"Later on other workers, among them Wickham. Degrais, Dominici.
Barcat, Aikins. Clagelt. have used radium by external application and
reported gratifying results."
"Il is specially American physicians (and radiologists) who have
launched radium as a treatment for goiier preferable not only to surgery
but also lo x-rays."
"One of the most experienced physicians in this domain. Dr Aikins
(Toronto. Canada V has treated about 100 cases of this disease in the
last twelve years."
"In acme cases he has found that treatmeni by radiation must be
supplemented by fa) rest in bed. (hi dietetic treatment, and (c) irealment
by drugs The combined treatment is always mure efficacious
than either alone."

R a d i u m
"In applying radium over the thyroid gland the radium is so
screened as lo prevent the action of the short but powerful beta rays
and to obtain the benefit of ihe more penetrating gamma rays."
"Dr. Aikins prefers the flat applications (he uses most frequently
4 cm. x 4 cm. containing io mg. radium element). The plaques are
screened with two thin aluminum screens or one fairly thick brass one
(about 0.8 mm.), wilh a layer of felt."
"As a rule he makes applications of three hours duration, giving
a firsttreatment of from 150 to 360 mg. hrs. He finds it preferable to
give smaller doses rather frequently than concentrated heavy dosage.
The first treatment is usually completed in three days and then he
leaves an interval of about 6 weeks between applications."
"If the case is very advanced, the patient is treated in a hospital;
less severe cases are treated in the Roentgen Institute for shorter
periods."
"As compared with x-rays in the treatment of toxic goiter radium
has the following advantages: (a) absolutely constant emission of rays,
and therefore exact dosage possible; (b) far greater penetration of its
rays, so that the deeper parts of the gland are reached; (c) no noisy
exciting apparatus, so that the treatment can be applied at Ihe bedside
without in any way disturbing the patient."
"Dr. A. N. Clagett (Chicago) also prefers radium in the treatment
of goiter. He has treated 47 cases of exophthalmic goiter with radium;
the firstcase being treated in September, 1917. Of these cases six had
already been operated on with recurrence of symptoms as bad or worse
than before. Seventeen cases were declined as operable risks by some
of the best surgeons."
"Two cases with very bad broken compensation of the heart have
died since treatment from acute dilatation, one three months after treatment,
the other five and a half months after."
"There have been good results in all the other cases and surgery
has not been necessary after the radium treatment in a single one of
the forty-seven cases."
"Conclusions—Dr. Clagelt believes radium should be given a trial
in exophthalmic goiler."
"First: There is no mortality, no scar, or pain, no long hospitalization.
Three or four days suffice for ihe treatment."
"Second: Its advantage over the x-rays are no discoloration of
the neck—less time consumed in the treatment—simpler to apply."
"Third: The thymus gland can be treated."
"Fourth: While surgery in removing proliferating cells leaves
others behind and by ligating still leaves some of Ihe blood supply more
or less undisturbed, the selective action of Ihe radium rays to a much
greater degree destroys the harmful cells and also causes a much more
symmerical diminution of the blood supply."
"Fifth: It can be used in cases where surgerv fears to venture or
has failed."
"Sixth: Surgery has not been necessary after the radium irealment
in one of the forty-seven cases."
"In the radium institute of the Rikshospital 16 cases of goiter,
whereof 8 of pronounced toxic goiter and S of plain goiter without
toxic symptoms or with milder nervous symptoms have been treated
with radium since 1913."
"Added to this 8 cases of inoperable struma malignum, most of
them of cancerous matter, have been treated with radium it being not

70 R a d i u m
quite oul of the question lhal they could obtain temporary rebel" from
their sufferings. Five of these patients have been temporarily improved."
"The S cases of plain goiter have been partly serious cases which
have been subject to ray treatment, the goiier being either considered as
inoperable or because it was thought connected with too great a risk to
resort to o*>eration or because it was thought connected with too great
a risk to resort to operation or because the patient objected to operation."
"In all S cases ihe goiier has diminished through the radium treatment.
In 2 cases almost complete cure was achieved; in 6 cases a
change for the better."
"With the patients that suffered from nervous symptoms, these disappeared
during the irealment."
"A few patients with big goiters and pronounced dyspnoea were
quite relieved of this and the goiier was considerably reduced. An inconvenience
by the radium treatment of plain goiter is the comparatively
long time it takes before a nolable improvement can be recorded and
that in but few cases will ihe goiter disappear altogether."
"Another inconvenience which wc also in some cases ha\e experienced
at ihe radium institute is the appearance of telangiectasis and
atrophy of the skin, and especially in those cases where the radium treatment
has been protracted and where during ihe whole time lead-filters
of i mm. and 20 hours irradiation have been applied."
"As the skin of the throat is very sensitive lo ihe radium irradiation,
comparatively thick lead-filters must be applied, and the thickness
of the filterswill have to be increased gradually."
"In cases of plain goiter I do not believe the radium treatment will
attain any general application, at any rate not by external irradiation."
"For treatment by radium (eventually roentgen rays) those cases
will be appropriale where, for some reason or other, operation cannot
be undertaken or where operation is combined with great risk."
"Most of the cases at ihe institute which were treated by radium
irradiation were just such ones where operation for said reasons could
not be undertaken."
"As a rule So to 160 mgm. of radium bromide in tubes with \y2 to
3 mm. lead-filters distributed over ihe goiter have been used. Time
of treatment—20 hours. The sittings have been repeated everv six
weeks or every month; up to ten sittings in all. The thickness of the
lead-fillers has been increased little bv little up lo a maximum of ^ mm.
of lead."
"( >i toxic goiter 8 cases have been treated with radium: whereof 1
case almost cured. 5 improved and 2 not cured. These patients have
been under observation from 2 to 5 years. The treatment has continued
for a period of from 3 months to 1 year."
"The radium treatment had an absolutely favorable influence on
the general state of health and on the nervous symptoms. The sleep
and appetite improved, the weight increased and the state of mind became
more composed. The pulse calmed and the size of the goiter
diminished. Least influence had the radium treatment on the exopthalmia."
"On a woman 30 years old (who got 2 sittings) with strongly
developed exophthalmia and Moebius-}-, but without apparent enlargement
of the thyroid gland ihe radium treatment had no curative effect

R a d i u m ?>
The patient disappeared after the treatment in 2 sittings and she has not
been heard of since."
"Another patient, a man 47 years old, was operated upon 5 months
after the beginning of the radium cure. While treated by radium his
state of health improved."
John Albeit Marshall. D.D.S., Ph.D. (San Francisco). A Laboratory
and Clinical Study of the Bactericidal Action of Solutions of
Radium Emanation. Cal. State Jour, of Med., 8-9, Jan. 1922.
"Recent observations upon the use of radium emanation indicate
that there is a possibility of employing this substance in the treatmeni
of chronic dental abscesses. Unlil further laboratory data can be obtained,
it appears advisable to mention briefly the results thus far recorded,
with the hope that other workers in this field may be sufficiently
interested to verify some of the conclusions."
"The bactericidal action of radium has been studied particularly
by Lequeux and Chrome, and Iridell and Minett. In their experiments
they exposed different organisms to radium emanation for varying
periods of lime wilh a noticeable inhibitory effect upon the growih of
cultures of streptococcus. Although the author has not repeated the
experiments referred to above, his clinical findings are in apparent
accord with ihe deductions offered. Bacteriological examinations of
the treated canals indicated sterility in 85 per cent, of the cases. In
fact, the summary presented points to the possibility of a new application
of radium in the treatment of certain diseased conditions."
"The apparent success which has attended ihe radium therapy of
skin lesions suggested the advisability of developing a modification of
the present method of application which would make possible the study
of the effects produced by this agent on chronic dental apical abscesses.
A summary of nearly a year's observation of clinical cases shows that
lesions of Ihis type yield readily to the new therapy, antl that up to the
present time no untoward effects of the radium treatment have been
observed."
"Through the courtesy of Dr. Howard Morrow, Dr. Laurence Taussig
and Mr. L. B. Clark, it has been possible for the author to secure
capillary tubes containing radium emanation. These lubes had been
used in the skin clinic and eye clinic for various purposes until the
"de-emanaiiou" had proceeded to such an extent lhat further application
for this work was purposeless. Although the degree of radiation
is recorded in the tables in terms of millicuries. the measurement of the
beta radiation from radium D and E has not been made."
"Radium emanation or niton is a gas. the disintegration products
of which are solids. It is a solution of the solids which is being employed.
That this solution contains alpha, beta and gamma rays is
known, but the effect upon diseased tissue is perhaps due to the predominance
of the beta radiation coming from radium D and E. It may
be recalled that Tarnowsky quotes Hektoen to the effect that radium
"emanation" inhibits phagocytosis and, hence, lowers the natural resistance
of the affected part; but in these experiments I have employed,
as already stated, a preponderance of the soft beta rays."
"A small amount of Ringer's solution may be rendered radio-active
by crushing in it a capillary tube containing a known quantity of radium
emanation. This operation is conveniently accomplished by placing
the tubes in a sterilized mortar of about 20 cc capacity, covering the

72 R a d i u m
lubes with Ringer's solution and then crushing them. The preparation
is transferred to a suitable container and carried to the operating-room.
On account of Ihe rapidity with which ihe radio-activity of this solution
diminishes, ii was found advisable in this research to crush the tubes
at the exact time at which ihe experiment was performed, but no more
than an hour was permitted to elapse between the preparation of the
solution and its application in the clinic or laboratory."
"The radio-active liquid was carried to ihe root canals of the tooth
by means of J. & J. sterilized cotlqn points. These were sealed in the
canals for a period of from one to four days. Subsequently the treatment
was removed, ihe pulp canals tested for sterility, and finally filled.
With one possible exception, there has been no evidence of succeeding
soreness or pain. The exception referred to is one in which the pericementitis
resulted more probably from mechanical irauma incident to ihe
previous curetting of the canal than to Ihe action of the radium itself.
The amount of solution carried to the tooth averaged 0.0= cc.: in this
there was approximated 0.0630 millicuries of radium emanation. The
variation in the dosage is noled in the appended table:
Table I
MILLICURIES
OF
TUBES*
6.0
7-9
5-5
4-6
9.1
7-5
6-3
5-3
is 8
MlI.I .ICURIES
PER CC.
1 -
1.20
1.58
I.IO
0.02
1.82
1.50
1.20
1.0b
2.70
Sutntnry
CLINICAL CONDITION
per
-ter
per
per
per
per
per
per
per
CC.
CC.
cc.
cc.
cc.
cc.
cc.
cc.
cc.
Table II
of T Went v seven ( ases
TREATMENT
AMOUNT PLACED
IN
TOOTH
.060 millicuries
079 millicuries
t>5S millicuries
.o;6 inillicurics
091 millicuries
075 millicuries
0.63 millicuries
-053 millicuries
..38 millicuries
RESULTS
Chronic apical abscess. Radium applied four Canals filled. Xo undays.
favorable symptoms
after ten months.
Infected pulp with
acute pericementitis.
Chronic apical abscess
of long standing.
Acute abscess,
Chronic apical abscess.
Radium applied seven
days.
Radium applied seven
days, removed. Second
irealment given.
Two treatments of
radium of three days
each.
Two treatments of
radium of three days
each.
Pericementitis very severe.
T o o I h extracted.
Canals filled. Xo unfavorable
symptoms
after ten months.
Canals filled. ' Xo unfavorable
symptoms
after ten months.
Canals filled. Xo unfavorable
symptoms
after ten months.

A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY, PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES
Copyright 1922 by Radium Chemical Co.
Edited by Charles H. Viol, Ph. D.. and William H. Cameron. M. P. with the assi
collaborators working in the fieldsol Radiochemistry. Radioactivity and Radiumtherapy.
Address all communications to the Editors, Forbes and Meyran Avenues,
Pittsburgh. Pa.
Subscription $2.50 per year, or 25 cents per copy In the United States and Can
In all other countries S3.75 per year.
VOL. XVIII MARCH, 1922 No. 6
A REPORT OF THE WORK OF THE RADIUM DEPART­
MENT OF THE UNIVERSITY OF CALIFORNIA
HOSPITAL, BETWEEN APRIL, 1920,
AND APRIL, 1921*
By Laurence R. Taussig, M. D., San Francisco, Director of the
Laboratory of the University of California.
The purpose of this report is to place before the members of the
medical profession a brief account of the policies and activities of the
radium department during the year following the installation of a radium
emanation plant at the University of California Hospital. In the early
part of 1920 an order was placed by the University for an amount of
radium sufficient to bring the total supply up to about 650 milligrams.
At the same time a plant for Ihe purification and tubing of the emanation
was ordered. This plant was put in operation with a little over 000
milligrams of radium element in solution early in April and has been
operating steadily ever since except for a few shutdowns to remedy
minor breakages.
When the emanation plant was installed it was thought by a number
of medical men thai the supply of emanation would be practically unlimited
and that it would make radioactive applicators available to anyone
desiring them. This, of course, is no! true. The amount of emanation
on hand at any one time cannot exceed in activity the amount of radium
in solution, and for a number of reasons, this maximum is never
reached. It would be unwise to diminish the total amount available by
the outright sale of any of the lubes. The radium committee decided
•Repriniod by permission from the California State Journal of Medicine.
XX. 50-51. February, 1922.

74 R a d i u m
that it should be applied only under the supervision of a member of
the radium staff, in order, insofar as possible to insure the best results.
Clinic and ward patients, treated at hospitals affiliated with the university,
are charged according io their circumstances. This charge is set
by the social service department after appropriate investigation. Many
of these patients receive treatment gratis. Private patients, either in the
university hospitals, or in other hospitals, arc treated only in consultation
with a member of the radium staff and are charged a definite fee according
to the amount of emanation used. Private cases which are sent
from medical men out of town are treated according to the indications
as determined by any further examination deemed advisable and are
referred back to the physicians sending them with suggestions for the
after treatment as well as an account of ihe findings and methods of
treatment employed. It is ihe policy of the department to answer inquiries
from members of the profession as lo the suitability of specific
cases for radium therapy as definitely as possible. It is hoped that physicians,
whether they possess radium of their own or not, will not hesilale
to inquire about points in technique. Furthermore, visitors are always
welcome to inspect any part of the work which interests them.
It is not the purpose of this report to go into the technique of the
application of radium. In the future, as data accumulates and definite
conclusions can be reached in the light of carefully kept records, papers
will be published, detailing technique and results in specific groups of
cases. At present the number of cases treated during the year will be
given, with a general statement of the results obtained in each group.
Insufficient time has elapsed to attempt to classify the end results because
ihe majority of these cases are of malignancy.
Basal Celled Epithelioma—91 cases. The results in this type of
malignancy continue to be eminently satisfactory. Radium therapy is especially
satisfactory in the more difficult cases, particularly in those located
at the canthi or on the lids of the eyes. The very extensive and
long standing cases of this variety of epithelioma can also usually be
improved if not cured.
Squamous Celled Epithelioma (of the glabrous skin)—20 cases. The
primary lesion can usually he healed at least temporarily if not too extensive
or if it has not been previously treated. Metastases in these cases
are frequent and the end result in a given case is therefore in doubt
for some time after finishing radium treatment.
Carcinoma of the Lip—15 cases. These cases have only recently
been submitted to radium therapy. So far the results have been very
encouraging. Radium should be combined with surgery and x-ray in
manv of them in preventing and in treating cervical metastases.
Carcinoma of the Mouth (exclusive of carcinoma of the tongue)—
25 cases. When the lesion is not too extensive, a marked improvement
can be obtained in some of these cases. The technique of treating mouth
cases is changing and with the availability of the emanation the results
have been improved.
Carcinoma of the Tongue—17 cases. Most of ihese were advanced
cases. In the earlier cases the healing of the tongue lesion is the rule and
even in late cases judicious therapy often effected considerable palliation.
The main problem is the handling of metastases.
Carcinoma of the Oesophagus—5 cases. Improvement can be obtained
in nearly all of these cases by the combination of the x-ray and

R a d i u m 75
radium
therapy. This improvement consists in temporary relief of
dysphagia, pain and cough with gain in wrcight and strength.
Carcinoma of the Cervix—38 cases. Radium is of benefit in all but
very extensive cases and recurrences. Post-operative radium therapy
has been abandoned.
Lymphosarcoma—7 cases. Radium in these cases is superior to x-
ray only when the tonsils are involved or the growth is of limited extent
Temporary relief is usual, though recurrences generally occur.
Sarcoma—16 cases. Rapidly growing sarcomata react quickly to
radium therapy, but recurrence follows a brief period of quiescence in
most of them.
Keloid—4 cases. All but long standing cases can be greatly benefited.
Keratosis of the Lip—8 cases. These are potential carcinomata and
should be treated as very superficial malignancy. Radium has proven
very satisfactory. '
Lupus Erythematosus—10 cases. In the chronic discoid type of this
disease radium is often of considerable benefit.
Lupus Vulgaris—5 cases. No other form of therapy surpasses radium
in treating even extensive and long standing cases of this disease.
Vascular Nevus—19 cases. In the raised type a good cosmetic result
is the rule, but in the flat port wine stain type a slight paling is all
that can be hoped for.
I'errucae—5 cases. In certain regions radium is the treatment of
choice. This applies particularly to those near the finger nail and to
verruca plantaris between the toes.
Grave's Disease—11 cases. The result is earlier and more marked
than in any other form of therapy. Whether the effect is permanent or
not cannot yet be stated. Radium is no! suitable in treating loxic adenomas.
Incipient Cataracts—60 cases. A large percentage of these have been
given improved vision. Radium is useless in mature cataracts.
Miscellaneous—56 cases. This includes the cases which do not fall
into any of the above groups, and in which the treatment with radium
has been more or less experimental.
Thus 420 cases of various types have been treated during the year
and though many of them are of the most hopeless in the realm of medicine,
the results have been encouraging. New fields are being opened
to radiotherapy by changing methods and improvements in technique
are leading to better resulls. The use of the emanation instead of radium
element has proven eminently satisfactory. The advantages far
outweight the few disadvantages and make the use of emanation preferable.
REVIEWS AND
ABSTRACTS
Francis Carter Wood, M. D. (New York.) Biological Determination
of Radiation Dosage. The Journal of Radiology, iii, 37-39, Fcbru-

76 JujADTUM
ary. 1922. Read at ihe Annual Meeting of ihe Radiological Society of
Xorih America. Chicago, December 7, 1921.
"The attempt io treat deep-seated neoplasm with highly tillered rays
has led to a realization of ihe fact that in order to obtain any i>ermanent
results, doses much larger than have previously been used must be given.
Owing to the necessary limitation of the number of portals through
which the exposures can be made, the dose which the skin receives must
be terminated just ai the point at which a slight erythema appears, or,
according to some workers, in such excess of erythema as is possible
without producing irreparable damage to the skin. If this latter dose
is in any way exceeded, very severe and even permanent injury to the
skin may result. These statements are true, whatever ty]»e of machine
is employed and are also true of any voltage which may be employed."
"There is no evidence to show that the burns produced without a filler
or with low degrees of filtration are any more severe than those produced
by ihe use oi thick copper filters and ihe highes; voltages now
obtainable."
"The only point is that in the first instance il is easily possible to
give lour or hve erythema doses in a few minutes, while with the highei
tillers and voltages, hours are required instead of minutes to exceed the
proper limits of skin exposure. This, however, is true that with long
skin distance and high filtrationthe high percentage deplh dose which
is possible under these condilions, may result in deeper sloughs. In
any case ii is evident that the possible skin se is ihe limit to ihe exposure
for a given area."
"The determination of such dose becomes, therefore, a mailer of
primary imiiortance before deep therapy can be properly administered as
insufficient raying stimulates tumors instead of retarding their growth."
"With heavy filtersof any of the metals employed the methods previously
used to determine dosage are extremely unreliable. The stimulation
of the characteristic radiation of silver at about twenty-five K. V.
renders photographic methods misleading. A similar error attends the
use of pastilles containing barium and platinum, in addition 10 the fact
that such pastilles are insensitive to short wave lengths."
"Simple and accurate ionization chambers are not at present available.
The use of types such as may be found in any physical laboratory
implies the employment of electoscopes or highly sensitive galvanometers.
In addition, their readings arc by no means necessarily indicative
of the biological dosage. With the advent of more powerful x-
ray apparatus yielding voltages of two hundred thousand and over and
a vastly larger output of x-rays through thick filters,ihe development
of a convenient method of determining not only the skin dose, but also
the amount reaching the tissues at a considerable depth, is imperative."
"I'nlcss the deplh dose is known, it is perfectly possible by using
four or five portals to adminster sufficiently large amounts of x-rays so
as to cause serious injury to internal organs or even to induce sloughing
of the walls of the hollow viscera with fatal results. Fortunately, some
types of cancer, though not all. are more susceptible to ravs than normal
tissues, a point about which develops all possibility of effective radiation
treatment. But often the border line is a very narrow one; hence
dosage must be accurate."
"At [»resent the only way for the x-ray therapeutist to estimate the
proper dose is to determine the skin erythema with given sphere gap
voltage, milliamperage. skin target distance and filtration. This is time

RADITJM 77
consuming, and if the limit is accidentally exceeded annoying results may
eventuate. After this, recourse must be had to tables of dosage such
as are published in current journals or in pamphlet form by Voltz and
Others. Measurement of the patient an destination of the depth from
the surface ami thickness of the tumor give the other necessary data.
The limits of error are evidently considerable and how much simpler
the matter would be if a direct reading of all these factors could be
obtained by an ionization chamber of such dimensions that it could, if
necessary, be placed in contact with the tumor, if cervical, rectal, or
prostatic, or under the patient if abdominal or thoracic, and direct
readings in biological, not physical, units obtained."
"With the scientific knowledge already available in this country
such an apparatus could be designed and calibrated with a standard biological
material and if a sufficient demand existed a number of firms
in this country have the technical force available for their construction.
I should like to sec such an apparatus regarded as the essential part of
ihe equipment of every one attempting deep therapy. Without such
equipment comparable results are not obtainable and the successful therapy
of those types of deep cancer amendable to x-ray delayed for another
generation."
"What are the scientific data necessary for the production of such
a standard apparatus?"
"It has been often stated thai the radiation effect on the cell is in
direct proportions lo the amount of energy absorbed by the cell. The
amount of this energy for different wave lengths cannot as yet be accurately
determined by physical means, but using an ionizing chamber of
aluminum, experiments conducted in the Crocker Laboratory have
shown that equal ionization closes of unfiltered and of variously fillered
rays do not have equivalent lethal effects on animal tumor cells. This
has been confirmed by Kronig and Friedrich. who, however, demonstrated
that with a chamber made wholly of horn and graphite, equivalent
ionization doses had the same effect on tadpoles, on germinating
seeds, the ovary and on the human skin, but they did not try animal
tumors. It cannot as yet be considered absolutely settled that equal
ionization doses are equally effective, no matter what the wave length
of the x-ray. While it is probable that Kronig and Friedrich are correct,
there arc many who still believe otherwise."
"Our nearest approximation Io a biological standard now in use is
the skin erythema dose. This, however, varies in individuals and over
different portions of the body, as is well known, but as it furnishes ihe
limit of all deep therapy it is still our only practical unit. ' »nce obtained
it is easily reproducible with ihe same x-ray apparatus under exactly the
same conditions of working. It cannot, however, be necessarily transferred
to any other make of apparatus, by any process of arithmetic. The
yield of the tube depends upon many factors; the wave form which in
turn depends upon the construction and adjustment of ihe rectifying
switch, the transformer characteristics, and many other variables. Each
machine must, therefore, be checked upon a human being, as has been
said, which is time consuming, and if ihe limit is exceeded may produce
permanent injury. If. however, some constant biological material
was available which required a given x-ray or radium dosage for its
destruction, it would be easy to calibrate an x-ray machine or an ionization
apparatus which would in turn exact control over the workings of
the machine."

78 Radium
"Such a lest object is available in one type of the transplantable
tumors of animals. Those suitable for this purjwse are transplantable
in a high percentage in all breeds of while mice, and practically do nol
regress, excepl in rare instances. The animals are cheap and easily
kept. They can be inoculated with the tumor and when this has reached
a convenient side, it may be exposed to a dose some multiple of the assumed
erythema. The strain uj»on which the largest number of observation
have been made is Crocker Fund 180 and with it this factor is five.
•After the exposure, the tumor is excised and bits are grafted on a
series of animals. If the dose is correct no tumors will appear. If too
iow, some will come up after a few weeks, or months, greatly slowed in
their growth rale. Another tumor can again be exposed for a slightly
longer time, and thus by a few irials the mouse tumor dose determined."
"Such a test is more time consuming, however, than the determination
of the erythema dose and obviously cannot be generally used. It
would be far better if ihe x-ray apparatus could be biologically calibrated
by the maker before it left the factory."
"This lethal tumor dose has been determined on No. 1S0 for lour
successive years, using the same machine, which has not been altered in
its adjustment, and checked with the same ionization chamber and has
not varied. The deflections of the galvanometer have been within a
couple of millimeters of the same ]>oint each time the machine has been
run. It is made of aluminum after the design of Professor \\ m. Duane.
Recently a new set of machines of much higher power were installed under
my supervision in another institution. L'sing the same voltage, distance
and filters, and adjusting the current to give the same ionization
deflection, the tumor was killed in Ihe same time, as with the older apparatus,
and the erythema dose on human skin was also found to be
the same. With these factors available, the erythema dose for varying
distances, voltages and filters was quickly oblained and in a few weeks
the plant was treating effectively a large group of patients, with heavy
dosage, yet without skin burns. For example—the lethal tumor dose
at tCf'o K. V*. 5 M. A. 40 cm. distance. 0.5 mm zinc and 1 mm. aluminum
was found to be 1S0 minutes. The erythema was posted as a safe limit
for ihe staff as not to exceed one-sixth of this, or thirty minutes lo start
with. Careful checks on patients have shown that under these conditions
and true erythema is between thirty-five and forty minutes, depending
upon the region treated."
"The erythema dose which we use is a faint reddening produced on
the skin of the chest or abdomen after seven to ten days, followed by
slight desquamation and ultimate browning. It is apparently the same
as that of Seitz and Wintz. but not more than half of that used by Warnekros.
who defines an erythema dose as such an amount as will not
cause irreparable damage to the skin. The Warnekros dose, of course.
causes skin atrophy and telangiectasis and should not be used in exposed
portions of the body, and is so near the limit of permanent damage that
it cannot be repeated on a sensitive skin."
"The mouse tumor dose, however, is a fixed quantity and not variable
like the erythema. It is determined by one fact only, the death of
all the tumor cells. If any survive, a tumor will grow from the transplant."
•The details of these experiments have l.een published in the Jour. A. M A
i$;0, LX. They have been repealed in Germany Kysser Hnd others, who are"
apparently, unaware of our work. The lethal dose with radium for this tumor
was also published in the AnnuN of Sursrry. 1915.

% D I U M 79
"Can the fact that a highly malignant mouse tumor requires five
erythema doses to kill all the cells at one treatmeni, be used as a guide to
ihe therapy of tumors in man? I believe that il can. and should. The
resistance of this tumor is comparable to that of the more malignant
types seen in man, such as the tumors of the intestinal tract, the squamous
celled epitheliomata, but it is less than that of the melanomata and
many of the bone and periosteal sarcomata in man, which often resist
extraordinarily large doses. A slow growing fibrosarcoma of the white
rat (Crocker Fund 37) for example, requires some eight erythema doses
to kill it. Other animal tumors, however, may be killed with two or
two and one-half doses, and corres*>ond to the more susceptible growths
seen in man."
"It is very dangerous lo assume that ihe proper carcinoma dose for
human therapy is that which results in the destruction of a subcutaneous
metastatic nobulc from a carcinoma of the breast, as Kronig and Friedrich
are careful to poinl out. They say that such disappearance may be
only temporary after their "carcinoma dose" and recurrence take place
later. This statement seems to have been overlooked by many writers
who have assumed that the "carcinoma dose" necessarily means a curative
dose. The conditions are entirely different from the primary tumor.
The metastatic nodule, as shown by animal experiments, is certainly at
least twice as susceptible and this susceptibility is probably due to the
surroundings, imperfect vascularity, etc., of Ihe embolic particle. When
freshly deposited it will often disappear after the erythema dose, but
if it does not every x-ray worker knows that at least a burning dose, say
one and five-tenths skin erythema doses, is necessary, and when invasion
of nearby bone or cartilage has taken place a still higher dose is
necessary. Even a basal-cell carcinoma, the most benign type we know,
is more difficult to handle after it invades bone or cartilage. It is often
loosely assumed that the cells have become "immune"—an utterly illogical
assumption."
"The fact that mouse tumors which have been exposed to nearly
lethal doses in the animal's body, and then allowed to remain for ten days
before inoculation, show a much lower percentage of takes than when
they are immediately transplanted, has been cited as showing, but does
not prove, that the tumor cells have been killed by any tissue, or immunity,
reaction. It merely shows that when the transplantation is done
immediately the cells are still in a healthy condition, and, therefore, the
few which are going to survive are able to get started before the radiation
changes begin, for it only takes about four clays for a graft to organize
its blood supply. If, on the other hand, the tumor is transplanted
after eight or ten days, when the cells are all seriously injured by the
development of the full x-ray or radium effect, the graft is in no condition
to withstand the trauma and partial necrosis which such grafts
always undergo when transplanted into a fresh soil before the capillary
supply is organized."
"Cancer cells do not become immune to repeated radiations, for if
a mouse tumor is rayed with a sublethal dose and inoculated and again
rayed and inoculated, and this process repeated a number of times, it
still may be killed at the end of the series with exactly the same dose
as at the beginning. The fact is rather that the cells of Ihe resistant
tumor are just the same as before, but that it is now impossible to attack
the tumor through its blood vessels, which is all wc do in many instances
The cells lie diffused through an avascular connective tissue,

so
R a d i u m
and while some may be killed, others remain to grow again at a much
later period."
"This is the condition so often noted when a tumor has previously
been treated with radiation or caustics, a notoriously unfavorable condition,
i here is no evidence thai the tumor cells have changed or become
more resistant."
"ihe carcinoma and sarcoma doses of Seitz and Winlz, or Kronig
and Friedrich, are, therefore, not generally applicable lo al! tumors, oniy
the lymphosarcomata, and the basal cell carcinomata arc permanently
curable with an approximate eryihema dose, and even these lumors
occasionally show lull resistance. Many, though not all of the carcinomata
of the cervix, however, seem lo be much more susceptible io radiation
than tumors of similar morphology in other parts of the body. While
an occasional lymphosarcoma will be permanently cured, it is too often
multiple and inaccessible to offer anything bul an accidental cure. The
skin and cervix tumors are al present the great fieldfor radiation, though
if easily operable, both should be removed, to be followed by prophylactic
raying. How difficult judgment is in these matters, and how im*>erfect
as yet our knowledge of biological dosage and preferable technique
is illuslraled in the somewhat active discussion now going on in tiermany
concerning the value of what has been generally assumed was one
of ihe best established fields for the x-ray, that is, post-operative raying
after carcinoma of the breast."
"Coxclusioxs—I. Il is extremely difficult to properly calibrate
an x-ray machine for deep therapy as the difference between a
stimulating and inhibiting dose for lumor cells is not very great, while
the difference between the dose necessary to inhibit or kill may cause serious
injury or even death of the patienl is also unfortunately very small."
"II. Fxact surface and deplh dosage is. therefore, a necessary
preliminary to deep therapy. This is rendered difficult at present by
ihe lack of suitable instruments calibrated in biological dosage such a- a
standard skin erythema."
"HI. The best way to calibrate such an instrument when constructed
is by the use of a mouse tumor of constant and tested biological qualities.
Such a tumor is the Crocker Fund No. 1S0. In five years of study,
it has shown no varialion in its x-ray lethal dose and this tumor takes in
practically one hundred per cent, grows rapidly antl regresses in only
a fraction of a percent in mice of any available markel stock."
"IV The lethal dose for this tumor for x-ray of any voltage and
any tiliration is approximately six erythema doses as measured by a faint
redness after ten days on the most sensitive skin areas. About five doses
for heavily pigmented skin of the back and about two and one-half lo
three severe erythemas of the Warnekros standard."
"V In comparison to human tumors, it shows about the same resi
stance to x-ray as the highly malignant neoplasms of the intestinal tract
which as yet evade successful radiotherapy."
"VI. The lethal dose for radium for this tumor being also known.
it furnishes the means for a biological comparison between the action of
x-rav and radium and permits the estimation of equivalent dosage."

R a d i u m 81
Francis H. William-, M. D. (Boston). Treatment of Hypertrophied
Tonsils and Adenoids by Radium, a Preliminary Statement. Boston
Medical and Surgical Journal, clxxxiv, 25O-J57, March 10, 1921.
"The excellent paper recently published by Drs. Murphy, Witherbee,
Craig and Hussey, entitled, "Induced Atrophy of Hypertrophied
Tonsils by Roentgen Kay," is interesting and instructive, but treating the
tonsils from "untler the angle of the jaw" and the adenoids "through the
back of the neck" is open io the criticism of exposing lo the rays other
parts than ihose it is desired to reach. The rays from radium also act
on the lymphoid tissues, of which ihe tonsils and adenoids arc made up
to a large extent, and can be applied directly lo the tonsils and adenoids,
the neighboring parts being protected by lead, that is to say, the radium
container is covered with lead except on the side through which it is
desired thai the rays should issue. When as above, roentgen rays were
used, the maximum amount reached other tissues than ihe tonsils and
adenoids; when radium is employed, ihe maximum radiation reaches the
tonsils and adenoids, and ihe minimum other parts. Another advantage
of radium is that the output is constant, and the dosage can be exact."
"1 have used 50 milligrams of bromide of radium* m a fiat container,
with the rays filtered by 0.S3 millimetre of aluminum, held directly
against or near the tonsil. The radium should be withdrawn every
few minutes, or as often as is comfortable for the patient, until ihe
total exposure of fifteen minutes, more or less as required, has been
reached. Improvement follows promptly, but the ultimate results may
be cx*>ecied only after some weeks. Guided by more than seventeen
years' experience in the use of radium, it seems to me better not to attempt
complete healing by one treatment, for the present at least, but
rather to give two or perhaps three treatments at intervals, as palients
and conditions differ."
"It may prove more convenient to use a container by means of which
both tonsils may be treated at the same lime. I have devised one to be
held midway between the tonsils, which consists, in general, of a disk of
lead (not more than 2 cm. in diameter and about 1 cm. thick, more so in
the middle) with a hole bored through its center, somewhat flared at
each end. for the exit of the rays, and another bored from the outer
edge radially to a little beyond the center. The tube containing the
radium may be slipped into this and the opening afterwards closed by
screwing a metal handle part way into it. The uvula, the back of the
throat and the parts behind it are thus protected by about 1 cm. of lead.
When treating one tonsil only, the opening towards the other may be
closed with a plug of lead. Appropriate filtersshould be used."
"Before applying the radium, the throat should be moistened with
a suitable solution of cocaine to prevent gagging from the insertion of
the container. All instruments should be covered with two thicknesses of
rubber, and for this purpose two rubber finger cots are stretched over
them and far down on the handle, where they may be secured by a
strip of plaster. Of course, fresh cots should be used for each patient."
"In using this method I have thus far treated the tonsil only, as
ihe results there may he more easily observed than in adenoids. These
may be reached through the nose by a small instrument, carrying radium,
from the end of which the ravs issue upwards."
"Adenoids can also be reached by directing the roentgen rays upon
them through the nose instead of through the back of the neck as de-
•Fquivalent tc 53.6 msn>. of radium element.—Ed.

82 Radium
scribed in the article referred lo above. This irealment might be carried
oul, for example, by distending the nostrils with a special bivalve
speculum, one blade inserted horizontally in each nostril, and by protecting
the skin inside the speculum wilh oxide of zinc plaster and that
outside by sheet lead. In this case the length of exposure would be
shorter, for children only about one minute, then when ihe rays are obliged
to traverse a large amount of dense tissue, and the risk of burns
would be far less."
"The disadvantages of operation are obvious. The roentgen rays
should be employed only by physicians who have had experience in their
use."
"It is, of course, too early to make a definite statement concerning
ihe comparative value of operation, roentgen rays, and radium. For
adenoids the roentgen rays and radium—irealment by l>oth of which
is painless — may each be of service in a special group of patients. F.»r
the tonsils, radium, if properly used. I consider Ihe safesi and lhar it
will probablv prove to be the best treatment for many patients."
"While not coming within the title of this paper, it is notewortny
that after treatment by radium. I have observed striking improvemen; ,n
acute and sub-acute tonsillitis."
Frank C. Benson, Jr., M.D. and Joseph V. F. Clay, M.D., F.A.C.S.
(Philadelphia). A Case of Parinaud's Conjunctivitis Treated With
Radium. Journ. Ophth. Otol. and Laryngol.. May, 1921.
"The case we wish to report is one offering much of interest from
a diagnostic standpoint, and also most interesting evidence of the beneficial
therapeutic effects of radium. The local medicinal management
of the condition was one series of discouraging events and it remained
for radium to perform one of its many triumphs in a most distressing
and stubborn ocular lesion."
"The patient, a female, aged 72 years, had had an attack of follicular
conjunctivitis in August, 1915. In this attack she was treated by
the late Dr. G. W. H. Conrad, whose record of the case we have had
the privilege of reviewing. From Dr. Conrad's description of the condition
we must concur in the diagnosis. This attack followed surf
bathing and yielded promptly to treatment. In May, 1917. she had a
mild attack similar to the first. In September, 191S, she consulted us
because of photophobia, lachrymaiion, and discharge from both eyes.
At this time the palpebral conjunctiva, especially of the lower lid. presented
a marked smooth, velvety, thickening. This yielded to boric
acid powder massage. Ten months later, August, 1919, there was a
return of symptoms in a sub-acute form, in the right eye only, the palpebral
conjunctiva presenting a marked ihickening. with small polypoid
elevations on the bulbar portion. This attack resisted all local treatment,
and in October the cornea presented a pannus. The conjunctiva
about the semilunar fold became hypertrophied and thrown into folds.
In January, 1920. there occurred an apparent acute exacerbation, there
being a market! increase in the lachrymation, photophobia and discharge,
of a mucoid character, and in addition severe aching pain through the

RADIUM 83
right eye and right side of the head. Associated with these local symptoms
were marked prostration, fever and enlargement of ihe pre-auncular
and posterior cervical lymphatics. The conjunctiva was now engorged
and thickened to such an extent that the patient was unable to
raise the upper lid. Eversion of the upper lid was exceedingly difficult
owing to the tremendous thickening of the conjunctiva, which presented
cobbled-likc elevations, varying in size, and of a yellowish red color.
The bulbar conjunctiva was equally involved, and at the semilunar fold
a polypus-like mass presented. The cornea, while clear, appeared buried
in a velvet-like cushion of conjunctiva. The iris was normal, the pupil
reacting readily. A spicule lenlicular opacity was noted, otherwise the
ophthalmoscopic findings were negative."
"Local applications seemed to have no influence upon the condition,
or in relieving the distressing subjective symptoms. During this time
the left eye remained absolutely free."
"A 'Section of the hypertrophied conjunctiva was removed from the
lower lid near the globe and submitted to Dr. S. W. Sappington for microscopical
study. Four sections were made, and the report states that
each section showed identical conditions, purely lymphoid tissue. The
tissue was of the same form as ordinary lymph follicles, with peripheral
concentration of small lymphocytes and central paler germ centers, but
the greater part of the sections showed a diffuse monotonous spread
of lymphocytes of the germ-center type, without any special arrangement.
Capillaries with very thin walls were seen here and there among
the cells and immediately beneath the surface: the capillaries were so
numerous as to constitute a small network. No giant cells were seen.
Necrosis and caseation were absent and there was no evidence of tuberculosis
or anything to suggest tumor growth."
"The differential diagnosis of the various conditions suggested by
clinical manifestations and the histological study of Ihis case is interesting
and not without difficulties. Tuberculosis and trachoma are the
diseases most closely suggested and the ones usually confused with
Parinaud's disease. There is perhaps much to be desired in the way of
evidence favoring the diagnosis of the latter condition in this case, and
yet it seems to lend itself more strongly to Parinaud's than to tuberculosis
or trachoma."
"According Io Morax the infective organism of Parinaud's disease
has not been discovered, and clinical features alone are not always sufficient
to make a differential diagnosis. Histological examination must
determine whether the conjunctival condition is one of the lymphatic
glands. The diagnosis of Parinaud's disease should be reserved for
those cases in which the absence of giant cells and negative results of
inoculation and culture justify the elimination of tuberculosis or sporotrichosis.
If the histological examination shows giant cells, it is either
tuberculosis or sporotrichosis. Inoculation will differentiate tuberculosis.
Culture on usual media will show the typical cultural characteristics
of the S. P.eurmanni. If no giant cells arc found the condition must
be differentiated from syphilis."
"Trachoma usually attack* bolh both eyes, while tuberculosis and anu Parinaud's
disease are more i frequently observed in one eye. Bulbar follicles
r*ui—
are uncommon in trach homa; in Parinaud's disease they are common.
Trachoma is observed at any anv age as is also Parinaud's disease, while
tuberculosis favors vouth. Trachoma results in scarring; Fannaud s
disease does not produce scars."

84 Radium
"As regards subjective symptoms, our case was unlike any ot these
diseases. In tuberculosis, unless it be ulcerating, there is little or no
distress. Likewise in trachoma, there is little distress aside from ihe
visual disturbance. Parinaud's disease usually presents few or no subjective
symptoms. Our case was acutely disturbed by the subjective
symptoms, and at no time did we observe irritation of ihe uveal tract
until after the second application of the radium."
"As regards the course of the condition. Parinaud s disease, it is
claimed, tends to a spontaneous recovery within a few months. Tuberculosis
is a very chronic disease lasting over a period of years. Trachoma
is also chronic in its course, with at times intermissions and exacerbations
until complete cicatrization occurs."'
"After a careful study of the clinical features, together with a
consideration of ihe histological findings, as reported by Dr. Sappington,
we concluded to apply radium, for the same action as procured in nonmalignant
papilloma of the urinary bladder."
"Fifty mgm. of radium element, screened wilh 0.05 mm. of silver.
were used on alternating days for exposures of one hour each (two
exposures of too mg. hrs.) until ihe inflammatory reaction appeared.
\\ hile much larger amounts of radium and longer exposures arc made
use of in the treatment of new growth-formation, greater screenage is
always used and it must be remembered that with even relatively small
quantities, inadequately screened, serious destruction of tissue may follow
even short exposures. Such inadequate screenage allows not only
ihe escape of ihe alpha and beta rays, but also of the secondary (Sagnac)
rays; all of which may be prevented by the use of sufficient tillering
media. From ihe foregoing ii may be seen that it was our desire
to set up a change in the afferent blood-supply of this condition, at the
same time stopping short of a reaction which would result in destruction
of tissue sufficient to cause scar-formation."
"After the second application of radium Ihe eye became markedly
injected and cheinolic, the nodules appeared flattened, the cornea hazy,
the iris discolored, the pupil contracted and inactive. Atropin 1 per
cent, was instilled for two days with the application of cold compresses.
At the end of iwo weeks all subjective symptoms had entirely disappeared.
At the end of four weeks ihe pannus had cleared and the
hypertrophied follicles were gradually disappearing from the bulbar
conjunctiva, receding from the limbus in a circular manner as if they
were melting away."
"The patient has reported to us at intervals of a month since ihe
application of ihe radium, and each visit a progressive lessening of ihe
thickened tissue has been noted. At this writing, January, IQ2I, the
patienl is perfectly comfortable; there has never been the slightest
tendency to recurrence of symptoms. The lid action is now normal.
The palpebral conjunctiva is still thickened but smooth and without
scar. There is a small area of thickened conjunctiva upon the bulbar
area to the lower temporal side. The cornea is perfectly clear and of
interest in passing—the lenticular spicule is not discoverable at this
time. If the change in the lenticular spicule was the result of the action
of the radium used, it must have lieen due to the gamma ray selective
alterative action."
"Since the application of the radium a simple boric acid lotion has
been used morning and evening."
Dr. Benson reports the patient still well January 26, 1922.