RM
859
R313
V.6
no. 1
c. 1

GERSTSlUM
EDITED BY

CHARLES H. VIOL, Ph.

D.

AND
WILLIAM H. CAMERON, M.

D.

OCTOBER, 1915

VOL. VI

No. 1

CONTENTS
A Study of the Internal Therapeutics of Radium, Samuel Delano, M. D.

Reviews and Abstracts

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15

A MONTHLY JOURNAL DEVOTED TO THE CHEMISTR^
PHYSICS AND THERAPEUTICS O^ RADIUM

ANDRADIO-ACTIVE

SUBSTANCES

'\

lUM
A MONTHLY JOURNAL DEVOTED TO THE CHEMISTRY, PHYSICS AND
THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES.
Edited and Published by Charles H. Viol, Ph. D., and William H. Cameron, M. D.
with the assistance of collaborators working in the fields ofRadiochemistry, Radioactivity and Radiumtherapy.
Subscription $2.50 per year,or 25 cents per copy in the United States andCanadain all other countries $3.75 per year.

Address all communications to the Editors, Forbes and Meyran Avenues,
Pittsburgh, Pa.

VOL.

VI.

OCTOBER, 1915

No. 1

A Study in the Internal Therapeutics ofRadium*By SamuEi. Delano, M.D., Boston, Mass.
In connection with this summary of the first Boston application ofradium emanation therapeutics, it ought to be borne in mind that nothinghas been used alongside that could in anyway influence results neither
drugs, nor' in general any of those physical adjuncts such as changeof air, of scene, of regimen, or of habits, that are so often pointed toas the real efficient agents in treatment at spasi.
One important particular distinguishes this series from previous
ones, viz., the mode of exhibiting the radium (sc. radium emanation).
Radium emanation may be introduced in several ways, viz., by injection,;by inhalation, by bath, and in solution by drinking. But rarely, however, has it been given conjointly with its source, radium, because thisyoking uip has not until now been generally available.
Loewenthal in his "Grundriss" endorses this,, however, as the mostdesirable method of exhibiting emanation, viz., a radium salt in solution,
which, after sealing, has produced the emanation within its own
precincts.

In (SUch a case there is present, after a month, that amount of
emanation which is in equilibrium with the radium salt (what may
be called the maximum-equilibrium-constant) and there is also theradium salt as well. This last has an infinite capacity in emanation andmust give ofif a further amount in its passage through the body.
One microgram of radium referred to (abbreviated 1 mcgm.
1/1000 of a milligram) means a solution of enough of a radium salt
The amount of emanation
to yield that equivalent of radium element.
in equilibrium with this one microgram of element is a microcurie, themeasurement of which is 2,700 Mache units.
The cases are not in any sense selected. On the contrary, it seemedworth while to take them as they fell failures, successes, slight or=—

Medical Record, I.XXXVIII,

pp.

137_143, July 24,

1915.

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Radium2

complete. This, because of the novelty of the subject and the meager
use as yet made of radium emanation in this country.
Moreover, even if some of the cases are very thin in clinical results,
they at least shov^ that radium can be taken without untoward effects.
In this connection, too, it may be said that the earliest cases have been
observed for a period of eighteen months.

Rheumatism and Gout.

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Case I. General Debility zvith Gouty Tendency. F., xt. 54. Painin back of headgreat toe reddened and sensitive
some eczema about
foot, of long duration.
Took 2 mcgm. radium daily and 3 radium baths
a week. After about a month much improvement with disapi:)earanceof local signs in foot. Radium markedly diuretic and laxative. After
four months, repeated for tonic action only.
Then again in eightmonths with a swollen finger joint. On the third treatment writes,"There is no doubt that for me radium is a good tonic.'"'Case II. F., ast. 46. Pain in back of neck with creaky vertebrae
and knees. Had persisted good while other treatm.ent ineffective. Two
micrograms of radium, sometimes three daily 60 altogether. No creaking in knees very much improved markedly laxative effect.
Threemontha later remains in unusually good health without symptoms.
Case III. Gout. M., aet. 46. Previous history of three attacks
of gravel with two small stones large patches of eczema pruritus ani

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for a year.
Intestinal putrefaction with very loose discharges
foulbreath and tongue neuritis in shoulder for a year.
Radium at threedifferent times(60 micrograms over space of six weeks) in courseof year completely freed frompruritus and eczema; marked tonic
action better condition of bowels and sweet breath.
Had radium by
cataphoresis for shoulder; neuritis has disappeared.
Case IV. Chronic Rheumatism Four Years. M., set. 24. Motorman; pain in back, toes and wrists; interfered with work; much treatment including Mt. Clemens; 36 micrograms radium and one dozen
radium baths in three weeks' time. At expiration of this time showedmuch improvement; gain in weight; amelioration of dyspepsia. Six

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months later continued well.
Case V. Rheumatoid Arthritis. M., aet. 72. All joints, especiallyhands and knees
distortionand increase in size
unable tosit down in a chair, dress himself, or go downstairs.
First week sharp
reaction; seventh day, "first good day;" in three weeks, after 36 micrograms radium and 12 radium baths, dressing himself every morning,coming downstairs alone, getting down in chair and up, and going out.

—;

Markeddiuretic

effect,;withinterfering

sleep

;

also

excitant.

Lostsight of.

Case VI.-^F., aet. 50. Recovering from acute rheumatism.
Patient in bed but with normal temperature radium produced reaction
with temperature 100°. Patient soon up, which the physician attributes;

to radium.

—

Case VII. F., set. 82. Sciatica.. Headache, depression of spirits;
imder radium (two micrograms increased to six) in all 384 micrograms
over period of ten weeks. Nurse reports enthusiastically absence of
pain and headache much better look more energy and able to do more.
;;;

The physician reports that patient "bothers" him much less.

—Case VIII. Physician, aet. 50. Rheumatism in hip; painful andan inconvenience. Orthopedist, after exhaustive examination, called itrheumatism. After a month, patient reports many good days says radium
;

;

I

Radium3

him up; produces reactionary pains in other joints; disnow taking larger doses. Second report after taking
288 micrograms over eleven weeks thinks it has done him good because
certainly stirs

tinctly diuretic ; is;;less acute pain.

—

Case IX. F., aet. 55.
Chronic progressive rheumatism; swellingof wrist; example of postponed action.
After 36 micrograms radium
over a period of three weeks, physician thought there was not much
Four months
result, though swelling of wrist was less in a few days.
later reported very enthusiastic over radium.; "had cured her rheumatism" and sent word to Case VIII to persist.
Case X. F., aet. 50. Wife of physician; mild arthritis deformans(chronic progressive) of fingers; took 24 micrograms radium without
admitting benefit.
Case XI. F., aet. 55. School teacher over weight pain and lameness in hip, making it difficult to get about some months duration took
36 micrograms radium and one dozen radium baths three months later
writes as if benefited.
Case XII.
peculiar affection of hips characterized by adductionof the thighs. Took 24 micrograms radium and 2 radium baths. Physician reported after several months that treatment had apparently pro-

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duced an improvement.
Case XIII. F., aet. 65.

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Chronic progressive rheumatoid arthritis.
All joints afifected: enlarged even to twice normal; one and a half years
duration has been lifted out of bed in morning and placed in chair
where she isat until put back at night fed for six months. Complete
atrophy of muscles contraction of ham strings parchment conditionof skin; pronounced an "impossible case" by an experienced clinician.
Radium by intravenous injection; four of 50 micrograms over a periodof four months.
Immediate improvement showed itself; able to feed
herself using both hands on tenth day.
Improvement continued fairly
steadily with some interruption; in three months got out of bed alone;
seven months from date of first injection having had no radium forthree months, the hands and feet are free, with much more movement
in shoulder and knees. There is an absence of pain in joints, but patientis troubled by a stitch-like pain in back, which intereferes with her
rising or sitting up as much as would be otherwise possible. Remarkable
improvement! has occurred in general condition color nutrition of skinand hair; appearance again of perspiration in feet; gain in weightwith a stimulated appetite from the outset. She is able to use a needle
the very latest developments have been (8 months after the first radium)appearance of perspiration of feet and cracking of shoulder joints.
Much freer mobiHty of knees without resistance of hamstring; absenceof pain comiplete; feet natural; as far as joints are concerned, could
walk, but very little muscle development yet; greater degree in arms.
This a hospital case, observed by five physicians.
Case XIV. F., aet. 60. Chronic rheumatism with much pain took
24 micrograms radium distributed over three weeks well-marked improvement and relief of pain. One month later her physician reports
her as marveling "that so much benefit could have followed us,e of what
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seemed merely water ;" diuresis in this case.
Case XV. F., set. 54. Rheumatoid arthritis. Took 72 micrograms
radium distributed over three weeks patient had no faith and was—;

reluctant to take.
Was not observed very much but the physician said
that two months later he could not get patient to admit more than an
early and passing improvement.
Four months after radium treatment

;;Radiumpatient had uterine hemorrhage polyp was removed on further hemorrhage, scrapings were reported on adversely, and to give benefit offioiibt, an hysterectomy was done and a virgin uterus removed.
;;—

Case XVI. M., physician, set. 57.
Weight 225 inherits rheumatism; his own form is of chronic progressive type; shoulder and hips.
Took 48 micrograms radium by mouth over space of six weeks. Felt
that it stirred him up was markedly diuretic had many ups and downs
as to pain. At end of four weeks better than for long time where hecould not get leg across to put on slipper can now almost shoulder thelimb; marked improvement in digestion in respect to flatulency which
had been very marked and annoying an enormous appetite which hehas to restrain. Verdict six weeks after, was that he was better thanhe had averaged and that radium had done him good.
[Note: The
amount of radium seemed by no means proportioned to the case or theman; it may have been just enough to keep condition stirred up well
;

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without proportionate curative

effects.]—

Case XVII. F., set. 48. Heavy person sciatica and pain in hip
under care of osteopath. Took 24 micrograms radium and one dozen
radium baths over space of about two months with intermission. The
physician's conclusions were that the treatment had a favorable effect.
The stimulant action was noticeable and care had to be taken as to;overmuch excitation.
Case XVIII.—The patient middle-aged club man accustomed toliquor; full of fugitive pains; was well relieved by radium (36 microgramma in three weeks), which in a way took the place of liquor; six;months later he wanted the physician to order radium for his wife.

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Case XIX. Physician's wife, get. 40.
Painful knee; not incapacitated; was decidedly relieved by 24 micrograms over three weeks;well marked laxative action, missed by patient after leaving off.

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Case XX. ^F., aet. 70. Took 48 micrograms radium over six weeks
nurse reported very enthusiastically over results. The patient reported
she had no "catarrh" while taking (previously constantly complained of)influenced 'by results in this case, another person in the house resorted
to radium.
;—

Case XXI. F., set. 40.
Pains in fingers; took 60 micrograms
radium over space of three weeks reported much relief, though physician remarked that he did not think much was the matter.
;—

Case XXII. -M., set. 28. Chronic progressive rheumatism. Fingers
and ankles swollen had had vaccine when seen, dilated heart, excitedaction souffle well-marked cyanosis of nails and prolabia.
Took 36
micrograms radium over space of four weeks in ten days marked improvement.
Heart down to normal dimensions, steady at 70; verymuch improved color. On a slight relapse became discouraged andhis physician had him go to a hospital and have tonsils removed as theprimary source. But, two months after leaving hospital, he again wanted
radium for its tonic effect and took some. After four months is about
free and in improved condition but says he will have radium intravenously
in case of recurrence.
In this case it is certainly open to doubt whether
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the cure may not be placed to radium.

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Case XXIII. M., set. 32.
An acute exacerbation of gonorrheal
rheumatism affecting especially wrists 36 micrograms radium irregularly
over four weeks. A very undependable patient, but the verdict of his
physician was that it had been of benefit.
;;Radium
—Ball-player; arm crippled with pain;
Case XXIV. M., aet. 30.
took 12 micrograms radium was immediately better and both his physician and himself ascribed the cure to radium.
Case XXV. M., set. 25. Gonorrheal rheumatu'm of three or four
This attack of six months' duration;
years' duration, with remissions.
quite crippled, swollen tarsus and toes and tendo Achillis; painful hips
and shoulders marked anemia and loss of weight not worked" for fourmonths vaccines and other treatment. Fifty micrograms intravenously
;

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two weeks so much
.SO micrograms given
quite pronounced reaction again
at twenty days' interval from first
but in six weeks very great improvement with no swelling of foot andalmost no lameness, but swelling and tenderness of clavicular joints. At
this time a rheumatic iritis developed; was given 15 micrograms radium
and at date of writing has been at eye hospital; improvement in joints
continues on leaving hospital reported improvement.
Case XXVI. M., set. 25. Very severe gonorrheal rheumatism of
six months' duration; not worked for four months; thickening of one
knee; swelling of tendo Achillis and of tarsus, pain in instep making it
treatment by specialist including much vaccine.
impossible to standFifty micrograms intravenously; thought a little improved and wanted
At sixAnother.
Fifty micrograms given at three weeks' interval.
\:eeks the physician and himself found difficulty in seeing improvement;
no change in weight but laces his shoe tighter and knee, perhaps, a little
loss swollen but cannot stand therefore cannot resume work.
Case XXVII. Elderly woman with rheumatic arthritis', especiallyaffecting neck which was, painful and offered difficulty in moving.
Twenty- four micrograms radium over three weeks and radioactive earth
effected much improvement according to both patient and doctor.
Case XXVIII. F., set. 35. Infectious rheumatism after birth ofafter reaction, first improvement in a week; inAnotherbenefit that patient "crazy for another,"
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Chronic progress leading to ankyloses;
seven years duration.
knees bent to almost right angle (these have been operated on at Johns
Hopkins Hospital). Right arm has very little motion (from shoulder)so that she can just get it to mouth with left, this is impossible. Fingers
One hundred and fifty microdistorted; some flexed, some extended.
grams radium; three injections over space of three months. Improved
after first with mitigation of pain and better nights; wanted another.
Three months after beginning of treatment there is a little improvement. Is having 10 micrograms injected about left elbow. One cannot
speak of much result in this case after a longer observation.
child;;—

Wife of physician; had been much
Case XXIX. F., set. 40.
Thetroubled with pain in joints; no other (objective) symptoms.
physician had tried many things but said she had improved much underradium; 36 micrograms over four weeks; it was markedly diuretic.

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Case XXX. Patient an old lady with rheumatic arthritis anddouble senile cataract. The case may be related in the doctor's own"There was in this casewords. Five weeks from inception he writes
a marked reaction in the joints and muscles lasting four or five days,
severe enough to keep her awake nights, attended with a slight fever
and marked anorexia. This reaction was followed by a rapid and very
decided improvement in all the joints so that she was soon walking about
and down to the dining room (by elevator). However, coincidently
with the arthritic improvement she developed a state of most intense
nervousness and irritability which was most trying. From being mostconsiderate, sweet, and patient she became utterly unreasonable, wakeful,:Radium
extremely nervous, and 'touchy.' This change of disposition was quitepersistent so that I finally omitted the radium after having reduced it to

2 micrograms a day. The nervous excitation gradually isubsided, sothat lately she has been in that respect about as usual.
After leaving
oflf the radium, however, her joint symptoms became worse again andafter a few days I resumed itsi use, giving 2 micrograms a day. Abouta week ago we were out of the radium for two days.
To make up
for that I gave her 4 micrograms a day for two days when starting it
again.
That has been followed by a moderate joint reaction, but without so far any reaction on the part of the nervous system and I have
reduced the dose again to 2 micrograms daily." One week later the
doctor writes"My patient continues to gain now without further:

Two months later:

reaction, sloAvly to be sure but gratify ingly.""She

has improved immensely; from being practically helpless, goes out for
short walks every few days, dresses herself all but her hair and except
for more or less aches at night, feels fine."
Case XXXI. F.. set. 70.
Physician's mother; general arthritic
pains; no objective signs; chronic; accustomed to daily dose of deodorized tincture of opium, as high as 90 minims. Ten micrograms radium
given twice suibcutaneously at weekly intervals.
Six weeks after the
doctor reports the patient had experienced relief.
Case XXXII. M., set. 50.
Gout; right great toe swollen andtender; leg swollen; confined to bed; two previous attacks; one lasting
six weeks.
There is already some improvement under other treatment.
Intravenously 25 micrograms radium; 12 micrograms by mouth; infour days resumed work and improvement was continuous and lasting.
Twenty-five micrograms intravenously repeated in ten days reported
well on sixth week.
Complaint of palpitation at night.

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Neuritis and Neuralgia.

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Case XXXIII. M. Neuritis of arm of some duration and sometime under treatment. Took 12 micrograms radium; 1 microgram daily;
physician said patient reported entirely cured.
Case XXXIV. F. Neuritis of arm three weeks duration with

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and paresthesia; 24 micrograms internally; also locallythree different injections of 10 micrograms each at expiration of ten
days patient so much better she did not want the third injection. A
month after, no recurrence and the doctor prescribes radium for anotherpain, tenderness,;patient.

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Case XXXV.. M., set. 35. Neuritis; previous attack of neuritis
eight years ago, when in bed four months present attack seven months'
duration. Severe pain in left arm requiring anodyne and making nights
entirely immobile atsleepless arm markedly swollen hanging at side
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(has been advised by surgeon to have operation on bursa
and joint); fingers glazed and tense; jaundice six weeks ago; sugar
reaction in urine (also for four years). Two micrograms radium daily
with radium compress; after four days swelling decidedly reduced;
fingers wrinkled bones of elbow showing arm can be moved from side
After this,, continued
sufficiently to cleanse axilla (before impossible).
use of radium internally, of compress, and in addition three diflferent
Steadyinjections about shoulder of ten micrograms of radium each.
improvement with rapid subsidence of pain out in eight days backin a month
to business in twelve days (away from business six weeks)rarely pain; arm now discloses atrophy of muscle from disuse; can now
shoulder;

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ItADIXJM'

7

button shirt and tie scarf marked improvement in sleep, looks, digestion,
tongue, and breath (odor).
In six weeks joint quite movable.
Hastaken 144 micrograms radium with 30 injected.
In two months continued increased motion; pain absent. Six months later the patient hasremained well. The arm has free though not perfect motion at theshoulder.
;—Case XXXVI. Neuralgia; with postoperative conditions after excision of glands.
Patient had local process in cheek; ulcerated plaquescauterized several times.
Finally submaxillary gland removed by incision; histological report malignant.
Injection of alcohol for facial
neuralgia produced paralysis of fifth nerve.
This patient had freshscar of recent operation (two lymphatics), facial paralysis, and neuralgia.
Had radium pad of 50 micrograms; scar retracted and organized unusually promptly; developed another enlarged gland; had improvementin neuralgia for three weeks with some relapse in fourth recovered use
of facial muscles; three weeks later recurrence of pain;. ten weeks after
commencement of treatment had taken 240 micrograms radium. In
fourth month the case looks like recurrent malignant disease of jaw.
;—

Case XXXVII. M., set. 55. Bpigastralgia and chronic neuralgia
radiating to arm; angina; brother of physician; number of years duration; last six weeks very severe in morning; interferes with exertion;
has to stop; much belching of gas which relieves pain. Diagnosis, calcification of coronaries and angina (with bad prognosis, by prominent
consultant). Heart is small, at apex second sound accented; no impulse
felt by handnothing" about aorta no general atheroma ; blood pressure
120; chronic scaling eczema of face. After four weeks (96 micrograms
radium) apparent improvement; has' days of entire freedom; eczema
much less evident. Heart has enlarged, there is some impulse and firstsound has some booming character and carries the accent. Pressure inPain recurring,creased as high as 220; artery much fuller to touch.
patient left ofif radium. After six weeks of increased suffering, sudden;

death supervened.

;—

Case XXXVIII. F., set. 35. Neuritis, arm has had several attacks
and they last several weeks. This attack quite similar to the others andThen radium was substituted.
for a few days used other remedies.
Took 24 micrograms radium and used radioactive earth locally. Bothdoctor and patient were of the opinion that the case was controlled byradium; both because of relief and short duration.
Case XXXIX. F. Facial neuralgia. Took 24 micrograms radium
and used radium compress without relief. X-ray showed unerupted wisdom tooth which seemed an efficient cause for the neuralgia.
;—

Nephritis and Metabolism Cases.
Case XL. Interstitial nephritis marked arteriosclerosis. F., set. 70.
Chronic invalid for some years; confined to room; increasing edema

Underdecreased amount of urine very marked anemia.
of ankles
radium continuously for three months, about 190 micrograms being taken.
There was the most remarkable improvement edema disappeared urine
increased from 15 to 45 ounces and maintained itself; great improvement
Urea also was measured and showed
in appetite, color, and spirits.
The patient got enough better to go out riding. The radiumincrease.
was omitted for a couple of months. Patient had suddenly uremic convulsions with pulse of 150 of great irregularity, and complete suppresRadium was resumed cautiously and.sion; she seemed about to die.
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Radium:

her condition rapidly improved.
greatest tribute to the treatment.

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The doctor andthe family paid theA

Case XLI. M., get. 68. Catheter-life case.
year previously thequestion of prostatectomy had been raised but decided negatively on
the ground of poor work by kidneys. There was an analysis made immediately previously to taking radium.
Two micrograms daily was
given for a week at the end of that time the urea and uric acid showed
an increase of 50 per cent. For some reason the radium was omitted
but the physician inquired some time later if the radium was cumulative
inasmuch as the urea and uric acid and amount had continued to increase and the showing became quite satisfactory.
The patient, however, was seized by an obstinate singultus to which he later suc;

cumbed.

—Case XLII. ^M., get. 12.
Essential diabetes with accompanying
parenchymatous inflammation of the kidneys. The patient was lethargic,
moped, and it was for this that the radium was prescribed in the hopeof getting a stimulant effect; it was an unqualified success so that it
was kept up for a couple of months. The effect on the sugar excretion
was also appreciable; a quantitative analysis was not made, but the
somewhat increased amount of urine was reduced to normal and thequalitative test was less marked. The patient was lost sight of.
The story of these cases recounts not much more than the simple,
familiar, clinical facts of everyday practise.
To some, the glamour of—laboratory tests being wanting, they may appear not complete perhaps
not scientifically precise. But there is still a large place for empiricism
in medicine.
Radium can reduce blood pressure, but there was no opportunity
for such specific applications of it.
So likewise radium has marked
effects on the blood picture, but no cases of pernicious anemia or leucemia offered themselves. For the cases in general, then, observations
along these Hnes would not be likely to add much of value.
So ourcases are clinical pure and simple.
No doubt many will scent a strong"psychical" odor in them. In quite a proportion of the cases, however,there were decided features of an objective character, whose disappearance coincided with the general relief.

In our quest for greater socalled scientific precision in the shapeof objective laboratory findings we are in danger of making "subjective"
tantamount to "psychical." No doubt it is much to be desired that thehighly complex phenomena of radium's action be co-ordinated. But thisconsummation, though devoutly to be wished, appears to be a long way
off.
But many disturbances of the economy of sufficient proportions
to constitute a morbid state and 'to make a patient of a person, are purely
The disappearance
subjective, i.e. divorced from objective phenomena.
of these states is no less an ostensible cure, without quibbling as to its
demonstration, or classifying it as psychipal.

And yet it may be that in the case of radium emanation we areface to face with a greater consonance of behavior, outside and inside
For radium isthe body than in all drug therapeutics put together.
unique in being a force and in expressing itself by liberating energy,
which in turn is capable of measurement. This idea of introducing
a force into the body and more particularly in the form of a solution,is more or less' puzzling because unfamiliar; but the "idee mere" ofradium internally isi to make the blood radioactive through the presenceof radium emanation a radioelement characterized, as all radioelements
are, by its instability and its certainty of passing over, according to its—

I

ItADITJM
own law, into the next radioelements in the scaledecay, orenergy.

resolution,

tobeattended bythe—this transmutation,liberation

of

rays

and

This idea of a force, once seized upon, not only makes the effectsof radium seem consistent, but it puts radium therapeutics into thecategory of natural and physical means, as contradistinguished fromdrugs nay more, it even links up the use of emanation internally withthe use of radium for irradiation, .since they both have the common purpose to produce a biological recoil on the part of the tissues.

—

Radium emanation we ought to challenge with three distinct interpellations

:

in

its

use there are three

distinctpropositions

involved,

Does it do anything, what can it do: and can it do harm?
Those who have assumed to think of radium-emanation-therapeutics
as a myth, a mere piece of emptiness, are entitled to another guess.
Radiam internally is a real remedy
It is not inert
It has potentialities
that make it both useful and beneficent, though its action may at times
viz.,

!

!

be mystifying, indeed, a bit uncanny.
It is to be emphasized, however, that we have in mind a soluitionof a radium salt, which alone gives an assurance of permanence anddependability.
Much of the disappointment and contradiction of thepast hinges on the unreliability of emanation as divorced from its parent
and source, viz., radium.
What can radium emanation do as revealed in this series?

It is diuretic.
This is, perhaps, the most consistent single effect1.
of radium.
The ratio is, perhaps, in seven out of ten cases. Thisfeature may be rather rapidly produced or show in any pronounced
way only after three or four weeks. It would not seem to be ascribableto direct action on the kidney because radium is not excreted to any
extent by the kidney.
Some investigators have altogether denied thepossibility of radioactivity in the urine.
recent very reliable estimation gives (after intravenous injection of a solulble salt) a recoveryof 1.88 per cent, only, after three days: most of which is on the firstday. If diuresis is not to be ascribed to local action, it can be referable
only to general influences, such as systemic effects or changes) in theAconstitution of the urine.

—2.
It is laxatiz'e
not so often as it is diuretic, but in a good
percentage of cases. This does not mean that it procures loose motions
recent inbut only what seems ascribable to quickened peristalsis.
vestigation of great accuracy shows that after intravenous injection ofa soluble salt there was recoverable in the feces on the first day 17.9
per cent, and in four days 43 per cent. This item of excretion by theintestine has a somewhat important bearing because of the possibility of(the radioelement of
irritation.
The same holds true of thorium
This has been accused
the thorium series, which is used internally).
of doing much damage by producing congestion, hemorrhage, andgangrene with, it is alleged, resulting death in some cases.
Nothing of the sort has been observed by us. One case, however,pointed in this direction:
Case XLIII. F., set. 70. In the last years much pain of a rheumatic nature; enormous varicosity of abdominal veins; in last twomonths two outbreaks of purpura, legs and abdomen, spots size of silver
dollar, now fading; took only 18 micrograms radium over space of two
weeks, when an ounce of bright blood escaped spontaneously from[Of course there is therectum; never had had any hemorrhage.

A

X

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:

T?ADIUM10
possibility ofconnecting this with the purpura, whicli however, was

not active.]

Cases XIII and XXVIII, in which the largest amounts of radium
were used, and that intravenously, both had, about six to eight weeks
after the first injection, almost a week of colicky diarrhea they wereboth in bed at the time. This phenomenon was very suggestive of the;elimination of radium.
3.

It is tonic

tency oneand stimulant.

Remarkable is it with what consis-

may predict that radium will make a patient look and act

As a direct hematinic it is indisputable that radium will stimua pronounced increase of red cells and hemoglobin, so that casesof pernicious anemia rapidly lose their perniciousness (if we may not
speak of cure). This direct effect on the blood would not, however,seem to be the whole story, inasmuch as there appears to be an indeSome patients have spoken of a heating
pendent stimulant action.
influence, and in Case XLVIII, even after a long period of use, thedosie had to be reduced on that account.
Physicianvery nervous
had some
Case XLIV. M., a^t. 60.
pains and got an idea of trying radium; took 36 micrograms radiumin a month's time; it was during extremely hot weather which wasparticularly trying to him the verdict was that the immediate effect of
the radium wasi to increase nervousness.
for a remarkable observation along the lines
See also Caseof ultrastimulant effect. Even more striking is the following:
Case XLV. M., set. 85. Senile with marked atheroma; the senility
was of the harmlesis variety and the patient went about the house andto meals. Radium was ordered and four micrograms given in two days
the patient became violently excited, singing and shouting; a nurse had
to be retained and the patient restrained.
There had never been any
manifestation of this sort before and the condition passed promptly on
suspending the radium.
This tonic and stimulant effect, while not to be regarded as reflecting the most essential physiological activity of radium, is, nevertheless,a very important and satisfying exhibition.
It seems to distinguishradium from drugsi, where the by-play is to speak broadly, depressantand harmful. Thus, to take that chief of alterants potassium iodide(this being in a measure analogous to radium) in securing our effects
from the iodine we have to submit with patience to the deleterous influence of the potassium.
The effect of radium in the matter of increasing sexual vigor (apart of its reputation that is historical and on which von Noorden lays
stress) has not been observed, though not specifically inquired into.
One case was treated with this attainment in view
Case XLVI. M., set. 40. Complete sexual incapacity for a matterof fifteen years, during which he had been under observation by aspecialist
from 48 micrograms of radium over a month's period hebetter.
late

—

;

;

;

XXX

—

—

;

had no change to report.
4.
Metabolism and nutrition.

Here we are approaching the copestone of the arch of radium's psysiological action.
While it is truethat the physiological action of radium may not have been so thoroughly
studied as perhaps it some time will be. there is not much displite as
to its increasing the nitrogenous metabolism.
Outside of the body it ismarvelous in catalysis and autolysis and in the intensifying of fermentative and digestive processes.
What it does on the laboratory table itwould seem likely to repeat inside the body (which so often is not theRadiumcase), because itis11present in the system in the same unchanged form.

Radium from this standpoint may be looked upon as stimulating to
the innumerable ferments of the body as supplying a goad, so to speak,to the vital processes.
corollary to this would be that it ought to bean equalizer, tending to restore the balance of forces. \''ery interesting:A

connection are the observations on the heart in Cases XXII and
If these observations are correct (the reporter is responsible
for them) then, while taking radium, one heart very obviously increased
its dimensions while the other decreased
with a correspondence ofcollateral signs that was strongly corroborative.
Granting that thefundamental effects of emanation are on metabolism, this would give it
a very wide range of applicability with which it seems proper to credit
especially, it may be repeated, as it does not have the disturbing
itby-play of drugs.
Its action on rheumatism and neuritis is. probably through its attacking the inflammatory conditions and promoting absorption and excretion.
Bactericidal action within the body, though demonstrable to a good
degree outside, is probably not to be reckoned wath.
It would not be
surprising if in the future some relationship of radium to the ductlessglands were to be made out, as for example, to the adrenals.
in thisXXXVII.

—;The effects of radium on nutrition of the skin seem to me very
happy. Old skin brightens up and looks younger. In Case XIII (underobservation ten months) this feature was very pronounced.
At theoutS(et, the patient could have been pronounced a mummy
the skin was
atrophic and parchment-like; it is now so'ft like a child's.
The nails;commenced

togrow andrequire attention

and thefeettoperspire.

One observer using radium for rheumatism found an acne rosacea improve; andin

an old lady (where the tonic

effects

were pronounced)

brown spots on the face cleared up.
Case XLVII. 'M., aet. 55. Apothecary; General eczema (called
psoriasis .because so scaly) two months previous, treatment with arsenic;—;

on 36 micrograms radium cleared up absolutely in three weeks.
A case of psoriasis of
See Case III for eczema and pruritus.
17 years' standing, now being observed by a specialist and under treatment by intravenous injection ('95 micrograms radium thus far) has
shown a remarkable and immediate imiprovement.
In our series of neuritis and rheumatism cases the results havebeen such as to point to a considerable degree of control by radium
over the conditions. As in so much of the task offered to radium (andof the radiation of neoplasms) nothing is
this is even more true
bequeathed to radium until it is wellnigh hopeless. Many of the cases
Perhapshave been rheumatoid with much change in the anatomy.
the time will come when radium will be offered something easier. Falta
uses emanation in acute rheumatism and prefers it to the salicylates.
In general it may be said that the nearer the joint is to a "juicy"—

periarticular or intraarticular edema or effusion, the more pleasingstage
the prospect.
was really
The neuritis cases have all done well. Case
The more of an inflammatory element the better.
brilliant.
As a pain killer radium has great power, but in the case of nuerotic
neuralgia in highly nervous individuals the outlook is not so good.

XXXV

—

Case XLVIII. Fractured hip in an old withered limb; patient up
and about in spite of it, but suffered much pain at night; was muchrelieved Iby radium and took it for six weeks or more; it was quite
excitant.

—

—

;

Radium12:

External and topical. Even a weak solution (2 micrograms' tois anodyne.
We can testify from personal experience to its
instant relief of toothache; this a dentist has confirmed in several
instances.
Held in the mouth for a few minutes a small quantityof the same si5Iution will produce, not immediately, but after somehours, stiffening of the mucous membrane, swelling and blanching of
the lip, viscidity of the pharyngeal mucus, and it almost seemed, a little
clumsiness in speech.
5.

2 ounces)

Saliva diluted with water will be very foul in forty-eight hours
diluted with radium solution (amount of radium 1/15,000 mgm.) itremain unchanged a week.
Case XLIX. F., set. 10. After incising a fat boil on the lip (sizeof the tip of the little finger) I applied solution of radium (2 micrograms to 2 ounces) as a moist dressing. The boil was entirely dry,
scabbed, and insensitive in eighteen hours. The patient later volunteered
will—

the information that "the scab was white."
Case L. Ivy poisoning; the rash failed to mature and the itching
was much relieved; in this case also; there was a dry white skin at
the point of greatest intensity.
Case LI. Pyorrhea alveolaris; a tooth inflamed to extreme tenderness, very loose with gum beefy and with an alveolar absess.. which
two dentists said would be lost, is now relatively firm and entirely
serviceable. In this case a solution of radium (25 micrograms to 2 c.c.)
was packed beneath the gums and this same solution was used in thenerve cavity after excavating. Solution of radium (2 micrograms to 2
ounces) was used to rinse the mouth.
In a metropolitan surgical clinic all pus cases have been treated withsolution of radium (2 micrograms to 2 ounces) and the control ofradium over the process has been surprising.
Chronic empyema of the accessory sinuses (cures of which byradium internally have been reported) have been treated in two instances.
Case LII. Purulent catarrh of the antrum and ethmoid; a year's
duration; operation advised by several observers, but refused; treated
for a number of months by injection without improvement; put on
radium solution internally with injection of the same (2 micrograms to
2 ounces) ; after four weeks the doctor reported the amount of pus
in the wash water as reduced one half with the advent of what was
For some
apparently cholesterin
the patient said she felt better.

—

—

;

reason in spite of this improvement (which was confirmed by nurse
assistant) treatment was not persisted in.
Case LII. M., aet. 45. Empyema of antrum causing vertigo. The
patient, a physician, was obliged to relinquish work; absess drained
and washed out with solution of radium (2 micrograms to 2 ounces).
The attendant says the case did extremely well. The vertigo promptly
disappeared and the patient has no symptoms. After two months there
is a very slight discharge in the washings.
Dosage. In making a radium salt form the basis of dosage, it
must be borne in mind that the amount of emanation present is subject
to a definite law
it cannot be more than the equilibrium quantity, which
is a fixed constant.
Quite otherwise is it with emanation per se theamount of which present can be increased ad infinitum. The basisof comparison between a solution of a radium salt and a merely radioactive water (emanation) is quite unequal.
For, the moment theemanation of the radium salt solution is separated or transmuted

—

—

—

—

I?ADIXJM

13

more will be furnished to take its place.

Thus a solution of a radium
has potentially a reserve supply of emanation which for the time
being yields no units of electrical measurement.
salt

In the preparations used in this series the maximum of emanation
had already collected and thus in association with 1 microgram' ofradium we have one microcurie of emanation or 2,700 Alache units
by measurement.
Some of the radioactive springs of Europe have an almost ridiculously small emanation strength (a few Mache units to the liter).
Results have been claimed from them nevertheless.
When now weturn to such doses as 1,000,000 to 1,500,000 Mache units of the London
Radium Institute, no wonder that the older observers are inclined toapply the term "psychical" to their early results.
From this wide range of extremes it might seem as though there
was nothing fixed about the dosage of radium. No doubt the doseis more or less flexible.
The very high doses came about through the
influence of thorium X, the cheapness of which gave the desired opportunity for forcing the pace.
But the experience was a thorny one.
Injury and death were confessed to and warned against by the very
users.
Since then the tendency has been towards lower dosage justas in the use of radium salts for irradiation.
Moreover, the men of
longest and largest experience are saying that they obtained equally
good results! with the small as with the larger quantitiesi.
Our own experience in the above cases has shown that the adjustment of quantity to the case is a matter of nicety and calls for judgment.
Of the very large doses it may be said that, if radium is selective
a really superfluous and unutilizable quantity may have been introducedwith the bare result of a mere Avaste of ammunition. One has to beon the look-out, no doubt, for something corresponding to the actionof radium in irradiation, viz., in one case stimulation, or absorption, anddisappearance of moi^bid processes in another.
One puzzling part of the application of dosage is the productionof reaction either to an undesirable degree or prolonged.
It then becomes a nice question whether to leave off or to increase the dose.
The cases related had many of them this essential drawback, thatthe treatment could not be prolonged or the dosage pushed at will on
account of the expense. So that in many of them, we may say
there was no proper try-out and that results are merely fragmentary.
The duration of a radium cure, if for well-established and intrenchedMoreover, theconditions, ought to be from two to three months.
maximum effect does not always coincide with treatment and there may
be even a delayed improvement setting in only after cessation.
Without any question we have seen some such exhibitions. Thisis, perhaps, more likely to occur where a radium salt is taken, because
None can be predicted asof the greater possibility of accumulation.
possible with emanation simlply, but only the retention of some of thelater radioelements in the scale.
Proescher and Viol have shown that, following injection of aradium salt, radioactivity may be demonstrated in the organism afterat least three months, and that by far the largest amount of radium
may be recovered from the bone and bone-marrow, where it has been
deposited in the form of an insoluble salt.
The average dose with which we have tried to work has been
about 4 microcuries daily, viz., about 11,000 mache units. (In Kreuznach,14

Radiumwhere radium treatment has been most systematic, the daily dose isfrom 5,000 to 15,000). A smaller dose and for a shorter period has
seemed to render service in some mild conditions. It is quite clear thatthe attempt to crowd the dose, in a certain proportion of cases at least,
may throw the patient into a decidedly upset state. There may belassitude and a decided lack' of energy or a mere state of nervousness.
The experience with these cases has seemed to teach the lesson of
approaching the maximum dose very gradually.

But nothing is to be expected from a low dose and short period ofadministering in serious chronic conditions. Thus there had been fourcases of paralysis agitans which it did not seem w^orth while to include
because there was no really serious or consistent employment of thetreatment.
It is to be said, however, that in two of them a stimulant
action could be noted and a rally from the extreme depression.
I haveseen one case under much longer radium treatment in which the patient
so far improved as to be able to feed himself and to go about, neitherof which things was possible at the commencement.

The object being to introduce the emanation into the blood, lodging
there by the immediate route of the vein is, of course, the method par
excellence, hypodermic or deep injections would come next and givingby the mouth last. Here, owing to the extreme difit'usibility of theemanation, there is a considerable portion of it lost without passing into
the systemic capillaries.
Subcutaneous or deep injection gives someshare to local action, although it has been shown that a soluble salt does
not linger long.
Can radium internally do any harm?
have not been able todetect any traces of damage.
Under the skin and intravenously there
is nothing in the way of local reaction and it is certain that we canintroduce into the blood good large quantities without particular reaction.
Pains may be touched up, but of constitutional disturbances there is noevidence. Cameron and Proescher have given 1,800 injections of radiumsalts over a Stpace of two years and in quantities up to a milligram
without observing the slightest injurious effects.
Administering per os has perhaps one advantage, viz., its local
action on stomach and digestive tract. The influence here is undoubtedly
considerable and favorable.
In conclusion it may be said that this experience has served toteach that radium emanation (and the same thing is true of irradiation)
calls for one requisite that makes it in a way ill-adapted to the American
temperament, viz., patience. That one should attempt to disturb a profound, well-in-trenched chronic state, with a week's use of radium isah puerile as to set oft" firecrackers and assume to call it an assault
on the citadel.
The impression which it is desirable to make, whether we are using
radium externally or internally, is essentially biological, i.e. morbidity
is to be made to reform itself by a process originating in its own bailiwick.
Here the initial performance would undoubtedly be to set inmotion just those processes that could acquire momentum and propagate themselves, viz., a cellular recoil. In either case, within or without,radium is to be looked at as just the goad or stimulus to the self-regenerating apparatus.
At all events, the radium question is here and it will be settled andsettled right.
That will take time and a heap of patience. To thisend open mindness is a great desideratum. Above all, systematic useof it after every fashion on an ample scale is to be hoped for. To beit

WeRadiumthis, in:t5

respect to emanation, the above series could, of course, scarcely

make claim, but as an initial try out it may prove of interest and we
iiope a little importance.

39 NEWBURY STREET.

Reviews and Abstracts.
John G. Clark, M.D. (Philadelphia). What Do the Newer Methodsof Treatment Offer the Patient With Malignant Disease of the Uterus?
N. Y. Med. Journ., Sept. 4, 1915, pp. 485-487. "From time to time
new remedies or 'cancer cures' have appeared on the medical horizon,
engendering hope as to their therapeutic possibilities, dazzling us forthe moment with their cometlike splendor, only to sink into oblivion,never to reappear during our generation.""In the continental literature of three years ago surgery was the
only method of treatment considered; suddenly, however, a wave ofenthusiasm swept over France, Germany, and, to a lesser degree, conservative England, and radium became the subject for extended discussion in the literature.
From the pinnacle of surgical exaltation thescene shifted, and some of the strongest advocates of radical treatment
turned abruptly from the enthusiastic laudation of surgical measures
to the advocacy of mesothorium and radium.
Thus in the space of
two years we find Kroenig, of 'twilight sleep' fame, who, in the last
review of his ultimate results in the clinic at Halle, held that, insteadof limiting the extent of operative indication, they should be broadened
so as to .encompass- a larger number of cases hitherto considered inoperable, veering away from surgery, and acclaiming mesothorium andradium as the great panaceas.
Such enthusiasm must be counterbalanced by the conservative physician, for undoubtedly there is avast deal of good in both rrieasures. Startling assertions in favor of thepotency of mesothorium and radium were made, and, what was moreastounding, these assertions were apparently sustained by the reportTheof a long series of cases studied accurately from every side.
clinician pronounced the disease a carcinoma of inoperable extent; theand radium was then applied,
microscopist confirmed the diagnosis
and soon a remarkable transformation was observed; usually thehemorrhage and offensive discharge ceased, and the local areas of ulcerThe cancerous tissue either disappeared
ation underwent cicatrization.
or showed evident signs of degeneration, and microscopists confirmed
lliese retrogressive changes in the malignant cell and observed a regrowthWith it all, however, even the most enthusiasticof healthy tissue.
followers of the new method cautioned against the abandonment ofsurgical procedures in favor of this hewer agent, and this is precisely
the position we occupy today, even after three years of active use, upon
the continent, of the radioactive substances in the treatment of malig;nant growths.""Schauta, of Vienna, who has made a careful but conservative studyof these cases, gives an excellent summary of the effects of radium, andIn his discription of reof what may ultimately be expected from it.
:"
sults he says
"The nodular masses covering the cervix disappear; one may also
The rigid, resistant.
say that they melt away, as ice before the sun.

Radium

16

easily bleeding walls become soft and smooth ; in many cases the formerly
unrecognizable portio vaginalis assumes again its original contour.

A

these changes; in no instance was the vagina in any way inflamed there w^as no necrosis produced, not even a reddening or desquamation of the epithelium could
At the end of the treatment the line of transition frombe noticed.
carcinomatous tissue to healthy vaginal wall is generally marked by adistinctive elective action

isnoticeable inall;circular wall of connective tissue in which no carcinoma is to be found,a more or less well marked crater indicating the site of the former
Microscopic examination of the excised bits ofcancerous growth.
tissue showed, often after the first or second application, at the latest
after the third, no unaltered carcinoma, but only swollen, degenerated

carcinomacells,or none atall.""In addition to these local effects, however, again to quote Schauta,
he encountered quite marked general reactions, such as headache, lossof appetite, gastralgia, enteralgia, alternating constipation and diarrhea,
Except in apain in the bladder region, and temperature elevation.
very few cachectic and seriously ill patients, these symptoms always
disappeared within twenty-four hours after the radium tube was removed, and no permanent injury from its use could be demonstrated,in a few instances quite severe hemorrhages occured, probably the
result of destruction of tissue by the action of the radium.""In one case a vesicovaginal fistula, and in another a rectovaginal
These were probably due, not to any destruction ofhealthy tissue by the radium, but to the fact that the respective septa
in question were completely infiltrated with carcinoma, and as thesewere destroyed by the radium, a fistula naturally resulted.""As regards the indication for the employment of this agent, Schauta
considers every case of carcinoma a suitable one for radiotherapy;" forthe present, however, he declares that he will continue to employ surgical measures on all operable cases, as permanency of the apparent
radium cures has: not as yet been established after all operations, however, he will apply moderate doses of radium as a routine to ward off
fistula resulted.

;

possible recurrences."

who"Another report that runs along similar lines is that of Exner,
for ten years has used radium in the treatment of malignant

growths, getting splendid results in the case of superficial, but very
Of forty
unsatisfactory ones in the more extensively involved cases.
cases so treated, two which were apparently cured remained so forfrom seven to nine years, when recurrences developed and they ended
fatally.
He beUeves, however, that the lives of all the patients wereprolonged, and the majority rendered more comfortable, but he does
not aver that a cure was effected in a single case.""Wertheim, one of the sponsors for the radical method of operaNone
tion, has employed radium in nineteen cases of uterine carcinoma.
of these was in the operable stage, one was a borderline case, andIn seven of the operable cases
nine cases were absolutely inoperable.
a hysterectomy was performed after the application of radium had beenmade. Specimens removed showed that decided destructive effects hadtaken place in the carcinomatous cells, iDut he asserts that a complete
disappearance of the tumor was not observed except where the growths
This observer believes that similar effects may
Iiad been superficial.
be accomplished as the result of cauterization or of amputation of thecervix.
Speaking from his personal experience, he does not believe

Radiumthat there

is

"At

the

evidence to warrant the assumption
to be disiplaced by radium therapy."

sufficientradical operation

summer of\risInternational

Medical Congress held

in

that

London

in

the
the

two French observers, Cheron and Duval, reported
the results of 150 cases of uterine and vaginal carcinomata treated withradium during the past five years.
These writers believe that theunfavorable results reported in the literature were due to a faulty technic
in the administration of the radium.
They laid particular stress upon
efficiency of massive doses well filtered.
In their opinion radium given
in small doses ranging from ten to twenty mg.
is worse than useless,in that the remedy may actually stimulate the growth of the tumor cells.
Similar reports have emanated from the London Radium Institute.""From the literature here reviewed we must inevitably draw theconclusion that radium offers excellent possibilities in the treatment ofsuperficial growths and is useful for the relief of hemorrhage andto lessen the offensive discharge in extensive cases, but that no- extreme
degree of optimism can be gathered from these reports, since they all
point to one fact, namely, that the deeper metastases are not reachedby the radium, and that, therefore, the fate of the patient hangs uponthis one point.
This is a somewhat interesting observation, since it
1914,

—

talliesso completely with ourown surgical observations in the treat-ment of carcinoma of the uterus. We have long since abandoned theextensive dissection of lymph glands, and, from my personal observation of cases coming under my care, I reached the conclusion, five
years ago, that when the deeper iliac glands are the seat of metastases,
we are merely fighting wind mills, so to speak, in the attempt to curethese patients. Since that time it has been my controlling policy merely
to remove one or two glands for microscopic examination.
When aradical operation has been performed and these glands are demonstrated
Conto be free from cancer, the prognosis is guardedly favorable.
versely, if metastases are found, no hope for ultimate cure can be held
out."

"The X-ray in Carcinoma of the; Uterus. Because of the great
expense of the radium treatment, attempts are being made in all countries
to achieve good results with the X-ray as could be secured from themore expensive form of therapy. Perhaps the most thorough reporton this subject comes from Professor Bumm, of Berlin, who has endeavored to perfect a method of treatment by the use of the X-ray.
He believes, that, eventually, the Roentgen ray will prove a very effective
substitute; indeed, he is inclined to predict that this latter agent will
In hissupercede radium in the treatment of uterine carcinomata.
opinion a technic will be evolved to permit of satisfactory treatment
with the X-ray, without resulting serious burns of normal tissue. He
even makes the startling assertion that, with the use of the newer tubes,
it may be possible ultimately to reach these cases without the necessity
for employing vaginal treatment. In order to prove his theory, Bumm
subjected six women suffering from advanced carcinoma of the cervix,
in all of whom large, fungoid, freely bleeding masses completely filledIn
the vaginal vault, solely to radiation from the abdomen or back.
all these cases the tumor disappeared completely within a few weeks.
Si>ecimens of tissue excised for microscopic examination showed almost
complete destruction of the carcinoma cells, only a few scattered, degenerating remains being found, and these surrounded by dense mlassesof fibrous tissue. In one instance, no cancer cells were demonstrated."
believes that many deeply seated"From these experiments

Bumm

:

Radium18:

growths hitherto regarded as of unfavorable prognosis may be offereda hope of cure by the use of the X-ray.
The technic must be very
carefully carried out, however; moreover, the method requires time andis costly, facts that must be recognized by physician and patient.
Thisobserver draws attention to the fact that in many instances considerable
irritation of the skin is bound to result, and this may even go on to
the formation of blisters. This dermal condition, he states, will rapidly
disappear under local treatment, and, in his opinion, is a very slight
objection when compared with the ultimate cure of an otherwise hopeless malignant growth.""Out of this mass of literature reviewed by us, we arrive at theinevitaible conclusion that the X-ray in these large doses must possess
harmful effects upon normal tissues, and prove an actual danger fromdeeply seated burns.
Kroenig, one of the most enthusiastic exponentsof the use of mesothorium and radium, does not, as previously stated,aver that a single cure of cancer in which there were deeply seatedmetastases has been effected. Basing our statements upon the literatureand upon our own limited experience in the use of radium, we should

down as definite postulates the following conclusions

set
,

1.

"Up to the present there is not sufficient evidence in favor ofradium to justify one in using it as a substitute for surgical measuresin operable cases.""As a forerunner to and a follower up of an operation, it is2.
unquestionably advisable.""In inoperable cases it should invaribly be tried, for apparent
3.
cures have occured in some markedly advanced cases, and in thosecases that are not ultimately cured there is, nevertheless, a decided
amelioration of symptoms in many instances, the offensive discharge
and hemorrhage completely disappear."4.
"A serious disadvantage in the use of radium is that it occasionally produces a widespread necrosis, leaving vesical and rectal
This, however, usuallyfistulae in tlhe wake of its destructive action.
occurs only in advanced cases of carcinoma, and need not, therefore,
deter us from the use of the remedy.""Che;mothii;rapy. From time to time chemical means for the cureThus far, however, no measure hasof cancer have been advocated.
proved of sufficient value to be accorded more than a temporary placein the literature, and, therefore, this subject may be dismissed without
further discussion.""The treatment of carcinoma by cancer extracts and various serums
has also proved to be worse than valueless.""The Treatment of Inoperable Carcinoma by Heat. In thiscountry a very ardent advocate of dessication heat for the cure of carcinoma is Percy, of Galesburg, Illinois. This investigator is of theopinion that experimental work has proved that cancer cells may bedestroyed when the temperature of the affected part is raised to between
50° and 55° C.
For the purpose of applying heat to inoperable carcinoma masses he uses a 'cold cautery' at a comparatively low degreeof heat for a sufficient length of time to destroy not only the superHe has not as yet publishedficial, but also the deeply seated growths.
a report of a definite series of cases treated by this method, and thus
far his experiments have been conducted largely upon a theoreticalbasis.
He maintains that he has had most remarkable results in individual cases, but as these are but isolated examples, it seems that ncv
proper estimate of this plan of treatment can be made until a careful

—

'

'

Radium19

detailed study of the cases is presented.
In justice to Percy, however,must be said that the majority of surgeons in the United States whoitare attempting to use his method, have started in on the assumptionthat he employs cauterizing heat.
He protests very strongly against
this use of his cautery, and prefers to speak of it as a 'cold cautery^
Much credit is due him for having elaborated this method, and where'—radium is not available, I consider it the duty of every surgeon to equip
himself with this apparatus.""From my own experience, however, with the use of radium, I feelthat this agent affords better, at least equally good chances for curewithout the attending dangers of mortality incident to the operation
proposed by Percy."

Russell H. Boggs, M.D. (Pittsburgh).
Radium and Mesothorium
Conjunction with Roentgen Therapy.
The American Journal of
Roentgenology, April, 1915, pp. 831-736. "All Roentgenologists realize
the value of radium, but there is much difference of opinion in regard
to its exact uses and limitations.
Some will say they are unable to see
any difference between radium and Roentgen ray reaction, while others
will say that there are certain things that can be done with radium thatcannot be done or at least duplicated, with Roentgen ray. Nearly all
agree that certain lesions can be treated just as well with one agent
as with another. There is no question among the physicists that radium
and the Roentgen rays have certain differences, but bhat each contains
certain rays which are analogous.""It is not my purpose to attempt to describe the physical properties of radium, mesothorium or the X-ray, because my paper pertains
inof the subject."generally- admitted that the action of radium and mesothorium are the same. Most authorities who have worked with iboth
claim that they observed practically no difference in the results accomto the clinical side

"It

is

They all agree that the radio-active substances should be as
highly concentrated and used in as small containers as possible as thepenetration is deeper.""From a clinical standpoint, I believe the penetration, method of
fdtration and accessibility of application, more than the agent employed,
determine the results in nearly all diseases which have been treated by
Of course, radium or mesothorium
the Roentgen rays and radium.
are supposed to have .about ten times greater penetration than thepresent Coolidge tube. There are only a few lesions where such highpenetration is needed or used because, even when treating with radium,most lesions are so situated that authorities advise using filters, whichallow lower rays to pass, which predominates, and then the reaction isplished.

;produced by this radiation.""From the results produced by radium on angiomas and conditions
closely allied to these tumors, such as flat naevi or port wine stains,
it would appear that the endothelium of the blood vessels is more sensiAlthough Pusey states that hetive to radium than the Roentgen ray.
can even duplicate the results of those which even obtained in thetreatment of vascular naevi by the Roentgen rays.""An advantage of radium frequently mentioned is that a dermatitisof the same degree heals up much more quickly, when produced byradium than by the Roentgen rays. In one or two cases in which I
applied mesothorium, a dermatitis with a marked vesiculation occurred,

tADIUMI

20

and I was greatly surprised how promptly each healed without leaving
a scar. I was rather inclined to think that it might be due to the small
area involved, instead of the different quality of radiation.
This is apoint I cannot decide at the present time, for you all know that wehave produced dermatitis of a marked degree with the X-ray, and were
surprised at how promptly it healed.
It has been pointed out thatwhen the gamma rays (filtered through two millimeters of platinum)produced a marked reaction, less fibrous tissue seems to be subsequently
formed, than when a reaction of the same degree is produced by rays
filtered through one-half millimeter of platinum.
I believe for thelast few years the most of us have been treating keloids with as higha penetrating X-ray as possible, because results can be produced quicker
with less amount of radiation. Then would this indicate that the highpenetrating rays have a more marked effect on fibrous tissue than the
low penetrating rays?""The therapeutic value of radium cannot be rightly appreciated if
it has not been studied with a sufficiently complete and varied rangeof filtration. It is very necessary to study secondary radiation producedby the various filters and the best methods of avoiding the deleterious
effects of these rays."*Tn treating a case either by radium, mesothorium or the X-ray
Given a case with a certain lesion,

we always face a series of problems.
its

position,

its

extent,its

susceptibility to the influence to this or thatand then we must determine the agent or agents to use.
The duration and method of application can be varied almost to infinity.
This enables us to realize how rich radio-therapy should be in its results
when properly selected and employed.""There have been so many ridiculous statements made by men ofhigh standing about radium, for and against it, that the general medical
profession has no clear conception of its real value.""It means nothing when some enthusiastic advocate of either
radium or the X-ray states there is no doubt that one agent has destroyedcancer whereas the other completely failed. Most likely the one applyradiation,

ing the agent failed to recognize the limitations of his therapeutic agent.
No one should expect to obtain the same results in cavities with X-ray
alone as with radium or mesothorium, either alone or in conjunction
with the X-ray.""I have seen cases made worse by destructive doses of radium,
which probably would have been avoided if the after treatment had been
just as radical as the first. Many advanced cases often warrant massive
Hereradiation but the after treatment must be carefully carried out.
isa case to illustrate:"Mr. C, was referred after having consulted three of the best
surgeons in the country. He had an epithelioma situated back of theear about the size of a half dollar, with some glandular involvement.
He had been told by the surgeons, whom he had seen that on accountof his age (but in reality on account of the advanced condition of thedisease) they would advise either X-ray or radium. Before he returned
home he was given a massive dose of radium over the lesion. In three
weeks there was a violent reaction which later became necrotic. I gave
him X-ray treatment over the adjacent metastatic glands, covering the
As soon as the lesion
lesjon with tin foil, which reduced them rapidly.
became necrotic I strongly advised the removal of the necrotic area
as the man was still in excellent health.
But the surgeon objected toany such procedure, and said that the radium had only made it worse,

J

RADIUM21

and that, as the X-rays had some effect on the glands, wanted theoriginal lesion treated with X-ray.
This I did not do as it would only
have been like giving more radium. If the necrotic area and the unhealthy surrounding tissue had been removed and a flap turned in,, theman's life should have been made comfortable at least.""In consultation, I saw two similar cases in which X-ray treatment had produced the same result, one, in which the necrotic anddegenerative area was removed and a flap turned in, and the otherfrozen with carbon dioxide.
Both are apparently well at the present
time.
We must be able to differentiate between an epithelioma anddegenerated X-ray tissue. I have frequently been called in consultation to see why the X-ray was not effective in the treatment whenperhaps the physician was treating degenerated X-ray tissue, while theremoval of all this tissue and the turning in of a flap often effected acure.
Experienced Roentgenologists today are not producing such conditions but are seeing the condition after it is produced.""Hearing Charles Allen Porter's talk before the American Roentgen Ray Society in New York made me realize that, often the failureof an epithelioma to heal up was due to treating X-ray degeneration
instead of an epithelioma.
This fact has been very valuable to me
in advanced cases of epithelioma.
What has been said in regard to
X-ray degeneration, I am sure, from what I have seen will apply to
radium. However, I do not believe that we will have so much radium
degeneration as there are not as many radium or mesothorium tubes
scattered around as there are X-ray machines.""All types of epithelioma of the skin, I believe, can be treated justas well with the X-ray as radium.
Certainly superficial epithelioma is
in most instances promptly relieved by both forms of radiation.
Those
vvho have had the most experience with radium think most of it andthe same holds true with the X-ray.
It is only necessary for theoperator to be familiar with his agent.""But where the epithelioma is situated on mucous membranes insame does not hold true on account of the inaccessibilityof the X-ray and the ease with which the radium can be applied. Pinch
states that 'epithelioma of the bucal, lingual and pharyngeal mucous
memjbranes still prove both refractory and disappointing in their response to radium, but a new method of treatment has recently beendevised, which in instances of cancer of the tongue has given distinctly
cavities, theencouraging results; it consists in the burying within the carcinomatous
nodule of a very small but intensely powerful radium tube. 'A fairly
severe reaction follows,' he says, 'and in some cases the nodules cease"
to grow and become replaced by dense fibrous tissue.'"I have seen Abbe carry out this method but I do not believe wecan expect much from it. An advanced case of cancer of the tongue
is not a local disease, and what we need is a homogenous ray to checkand obliterate the disease in the glands. In the advanced cases I havebeen able to check the progress and make the patient comfortable but
have only one case which has been apparently cured for any lengthof time. On account of his remaining apparently cured I question the
However, I believe he has not taken any treatment of any
diagnosis.
kind for over three years. If epithelioma of the tongue is seen early
when the diagnosis is hard to make, there is a number of methods which
will effect a cure, particularly so if the adjacent glands are treated bysomeeffective

form ofradiation.

But when the patient comeslate.

Radium22

it is probably the most hopelessform of carcinoma and the one forwhich we can do the least.""Leukoplakia is usually a forerunner of epithelioma and responds
more readily to radium than to any other method I have tried or seen,
I have one case of tuberculosis of the palate under treatment that
lesponded to radium promptly. The X-ray, on account of its inaccessibility, would not have tbeen effective.
I treated the external glands
with X-ray, a procedure which I have adopted since I have been using
mesothorium in diseases of the mouth and the throat. This is just as
important as the removal of the glands and raying after operation for
carcinoma of the breast.""Carcinoma of the breast is one of the most common forms seenby the radio-therapeutist, and one over which there has been morediscussion, for and against, than any other form of cancer treated.
When patients of carcinoma of the breast are told the truth (so toomuch is not expected), I believe that this is the most grateful classof patients we have treated by radio-therapy, because so much can bedone and in the hopeless cases so much relief is afforded.""Pinch's report of the radium institute shows that 128 cases ofmammary carcinoma applied for treatment in 1913, which far exceededthat of any other malignant condition. His policy is still rigidly adhered
to in declining to treat operable cases just the same as the Roentgenologist.
In speaking of carcinoma of the breast he states that, 'many
patients exhibit a great susceptibility to radiumthe primary growth
becomes smaller, infected glands and subcutaneous nodules lessenedor perhaps even disappeared and that little or no effect appears to ibe
exerted in prevention of metastatic deposits, though the treatment has
not, at any rate, hastened their dissemination.'
This is one place I
believe where the Roentgen rays are superior to radium, and I am surethat the X-ray does check metastases while Pinch in the above quotation claims radium does not.
Even if radium had a greater therapeutic
effect than, the X-ray, the latter is preferred in any form of carcinomaof the breast on account of the great mass of rays that can be poured;

into the body, giving large doses tothisstatement

more distant parts.

In the future,

may have to be modified, providing radium is available

On account of the lymphatic supply being so
great and so widely distributed, it is necessary to radiate the wholechest and mediastinum with high penetrating rays, using the cross fire
method; that is, applying the rays from the front, back and side atdifferent angles."in sufficient quantities.

"Radium or mesothorium is a very useful and at times necessary
adjunct to Roentgen therapy, in treating carcinoma of the breast, asa radium tube can be placed in the axilla, where X-ray is difficult or
impossible to apply in many cases, particularly after operation. During
the past eight months I have adopted this method whenever possible,
and, without going into detail, it acted like a massive dose of the
Roentgen rays. In some cases I have applied a tube of mesothorium
over the supra clavicular glands because it is often difficult to keep a
nervous patient still in the proper position while giving Roentgentherapy. This was before I had been using the Coolidge tube.""The treatment of fibroid of the uterus and cancer of the uterus
and rectum by radium and the Roentgen ray is large and very important
subject, and my experience is so limited compared to some of ourmembers' and to many European authorities' that I shall only mention
Everythis subject here in order that fuller discussion may follow.

ItADIXJM

23

one here is familiar, at least to a certain extent, with the work done in
the clinics of Kroenig and Gauss, Albers Schoenberg, Bumm, Doderlein
and others. The symposium of Pfahler and Kelly at the last meeting of
the American Medical Association in Atlantic City will do much toward
enlightening not only the general medical profession, but many of the
Roentgenologists who have neglected this very important sulDJect.""In the treatment of fibroids of the uterus, I have used Roentgenrays alone up to the present time, while in carcinoma of the uterus, asa prophylactic measure, and in inoperable carcinoma of the rectum, I
have been using mesothorium locally and the Roentgen rays by thecrossfire method externally.
The general opinion of rectal carcinoma
is that the disease displays great variation to ray therapy;
often aproctitis occurs, which is usually transient, but sometimes persists andadds greatly to the discomfort of the patient. In one case in which
this occurred, the symptoms were relieved by a suppository containing
five grains of iodoform.
It has been noted that when the growths are
situated low down there is always more tenesmus than when in theupper half of the rectum. In some instances before inserting the tube,
I have found it necessary to give the patient an injection of morphine.
I have a case now where the surgeon intends to make an artificial
anus so that the irritation of the feces will be avoided. He feels sureTemporary results havethat then much better results can be obtained.
been marked that is, pain has been relieved and the mass has been
reduced. Two cases that improved, in which the distressing symptoms
disappeared and the mass became smaller and more freely movable,
were operated upon. One is in good condition and expects to continue
the treatment, the other case developed a rectal abscess and was unable
to return for treatment.""The results in inoperable and recurrent carcinoma of the uterus
have been gratifying, in that the local manifestation of the disease has
been benefited in a striking manner. Checking of hemorrhage and discharge and relief from pain and the healing of ulceration with a reductionin the size of the mass in a large percentage of cases have been observed.
In some patients the relief of these symptoms is only temporary, while
many authorities have shown, by using radium locally and X-ray externally, a certain percentage of apparent cures have been obtained.
I treated a case f9ur months ago where there was a recurrence afterUpon examination thee weeks ago no evidence of thehysterectomy.
The
expect to give more treatment.
disease could be found.
results which have been accomplished in deep seated malignant growths
have been the means of inducing a few surgeons to refer patients forradiation after hysterectomy."'Tn conclusion, it should be stated that there is some confusionin the minds of many in regard to the limitations of radium and RoentIt is generally conceded that certain lesions can be
gen therapy.
Many authorities
just as well treated with one agent as with the other.
conclude that the only places where radium is superior to the Roentgenrays is in its accessibility in cavities and in its greater penetrating power.
Most lesions are so situated that rays so penetrating as those of thehigh gamma rays are not neceseary for the best possible therapeutic
We know that the high X-rays give, in a majority of cases,
results.
results quite as good as those obtained from radium,";

We"The reason why the X-ray has maintained its place in the treatment of cancer is not merely on account of the difficulty of obtaining
sufficient

radium; butithas the advantage of being administered in

Radium

24

uniform depth, whereas, the radiation from radium is only
within comparatively short distances.
This, in carcinoma of
the mouth, esophagus, rectum, cervix, etc., radium should be preferred
for the treatment of the primary growth, although X-ray is necessary
in the treatment of the lymphatics draining the part.
In other words
it is impossible to treat large areas homogenously by radium.""If radio-therapy was employed only as a prophylactic routine
measure, many lives would be lengthened and many recurrences prevented. Rapidity of development of the growth is no contra-indicationafairlyc-ffective

to ray treatment, although the dissemination of the disease is more
rapid and even when the local growth disappears recurrence in distant
At the stage at which malignant growths areparts is more common.
referred for radio-therapy it is true that only a small proportion of thecases get well but no other method even offers any hope of relief.
Kxperience of a numlber of years has taught Roentgenologists to look
for temporary improvement in the treatment of malignancy as a matterof course. For instance, anything from one to three years' prolongationof life is the usual and is almost the rule in /hopeless and recurrent cases.
are accustomed to see recurrent growths disappear in a few weeks,with complete restoration of health. When such results are producedby radium they are looked upon as marvelous, chiefly because they are
now seen for the first time by physicians who had no previous belief
in the efficiency of ray therapy in any form, but now progress is coming
about by the co-operation of the surgeon and the professional radiotherapeutist, when the proper ray is selected for each case.""Finally, radium therapy is the method of choice in carcinoma of
the rectum, vagina, uterus, axilla, etc., but even where the X-ray forms
a useful adjunct so far as the adjacent parts are concerned. The raysfrom both radium and the X-ray affect certain cells more than others,
lymphoid tissue and the endothelium of the blood vessels being first
All cells that are undergoing rapid reproduction are more
affected.
Tumors richreadily affected han where the reproduction is normal.
in blood vessels and spreading by the lymphatics are checked in three
ways: first, by the action on the epithelial cells, second, the endotheliumof the blood vessels undergoes "proliferation until the lumen is almost
obliterated, and third, the channels or lymphatic glands are blocked,

We

preventing metastases."

Walter B. Chase, M.D., F.A.C.S., (Brooklyn, New York). Radium
Gynecological Practice. The American Journal of Obstetrics, July,
Read before the Seventh Pan-American Congress,
1915, pp. 90-97.
San Francisco, June 17-21, 1915. "Watching and participating in theunequal struggle for the mastery of malignant growths by excision, thewriter believes with many other operators, that surgical procedure hasapparently reached the limit of palliative and curative power, andwhile holding to the principle that large operable growths belong to
the domain of surgery; that surgery and radium are not incompatible,
but in their utility reciprocal and supplemental.""The efficacy of radium rests on its occult power to inhibit lawThe law of reaction
less cell proliferation and destroy cancer tissue.
is the governing factor in its use, and only by mastery of this art can
success be attained.
It is assumed a given amount of radium appliedat the same distance with the same screening will produce the same
results if the tissues, to which it is applied, normal or malignant,inRadium25

the same resistance.
When lack of uniformity in curative
found, the inference is unmistakable that the individual
resistance of the patient's tissues is a controlling factor in radium
therapy.
Knowledge of such resistance can only be determined byactual application.
This principle has been demonstrated to my satisfaction as being clinically and logically correct, and is apparently the
only natural and rational explanation, why one case is cured by small
dosage of radium, while another is irresponsive to several times thequantity.
The mastery of the art in the application of radium is only
acquired by observation and experience, and must be applied in every
case, before results can be tested or predicted.
In this paper I shallstate some of my experience and report a few of my own cases, together
vvith the experience of American and European authorities."

possess
resultsis"The treatment of uterine cancer, whether curative or palliative,a matter for clear and discriminating judgment, as its operability
hinges on the degree of parametric infiltration and the extension andlocation of lymphatic metastasis.
If inoperable, it belongs to the fieldof radiumization. This has its limitations. Too small quantities stimulate malignant growth.
Too large quantities may perforate hollow
organs, blood-vessels and irreparably injure nerve trunks causing
destruction of both malignant and normal areas of tissue, as wasproven in von Eiselberg's clinic in Vienna. The palliative function ofradium afifords dimunition or arrest of pain for days, weeks and sometimes months, and gives a new lease of hope to the unfortunate sufferer.
I note two cases of its analgesic power.""Case 1. Mrs'. K. A., aged thirty-two, of New Jersey. Advanced
inoperable carcinoma of entire uterus
suffering hemorrhage, cachexia
and great exhaustion taking opiates. Commencing September 14, 1914,
radium was used twice* a week. In less than a month pain was almost
absent, hemorrhage controlled, appetfte and strength much increased.
Prom this time on, until three weeks before her death in January, 1915,
she was almost without pain.""Case 2. Mrs. D., aged seventy, widow, mother of four children.
Came under my care February, 1911, with cervical carcinoma of thecauliflower variety.
She was weak, cachectic, with a prospect of living
six or eight months.
each
She had three thermocautery operations
followed by the use of radium after the second operation healing tookplace
recurrence followed and radium was used with partial healing.
She remained in comfortable health and without pain until January,
1915.
It is quite safe to affirm three years of comfort were added toher life.""For ten years it has been my practice in cervical cancer to do thehigh thermocautery operation and destroy the endometrium by doming
Experience confirms my belief that it
the body, followed by radium.
is the most efficient method of treatment except as hereafter menis

—

—

—

—

—

;

—

—

tioned.""Panhysterectomy

in allmalignant conditions of the uterus

is

the

remedy par excellence before metastasis renders it futile. The particular form of operation rests with the operator.""It will be noted that radium therapy is based on prophylactic
preoperative and postoperative application. To insure the highest degreeAlarge percentage of postof efficiency its early use is imperative.
operative radiation, is deferred weeks or months after metastasis has
The most favorable time for application is immediately
appeared.
subsequent to operation. Another requirement must be kept in view,

Radium26

namely, crossfire with radium, which greatly enchances its power, whenanatomically possible.
Not infrequently burying radium in malignant
structures or placing it in the vagina is of the highest importance.
Inuterine cancer I have so used it continuously for a period of ninetysix hours.""Cancer of the vagina, clitoris, and labia yield to radium rather
reluctantly, as is true of all mucous surfaces.
It is oftentimes wellto subject such growths to the intluence of heat by the thermocautery
and follow with radium. The bladder and rectum, so contiguous to
the uterus, with or without involvement of that organ or vagina, arewithin the domain of the gynecologist, as are the uterine adnexa.""Not alone in malignancy has radium a field of application in
gynecological practice.
Its power to control uterine hemorrhage isworthy of trial and consideration. Later it is my purpose to reportmy experience.""Without attempting a resume of the several features under discussion, particular emphasis should be given to prophylactic radiation.
Its analgesic influence in affording palliation and sometimes a controllinginfluence over pain with avoidance of perturbing opiates, is one of its
most precious properties', almost unknown and little appreciated. Insistance on the utility of crossfire frequently by burying the radium
in malignant growths has too long been neglected.""The writer is impressed with the belief that too little attention
paid to the general health and the hygienic surroundings of the patient.
Finally, as in surgery, so in radium, disappointments are and must be
encountered, and caution should be exercised in making promises as toisresults.

"Radium and X-Rays as Complements to Surgery in Lymphosarcoma.

—Two cases of lymphosarcoma of the neck,ablationinwhich incomplete

was followed by radium and X-ray treatment, are describedby Begouin (Arch, d'electr. med., June 25th, 1914), The observations
are of too recent a date to permit a definite judgment as to the ultimate
value of the treatment, but the result was so different from the usual
sequel to an incomplete operation as to justify reporting.
The first
case was that of a woman, aged 45 years, with a tumor slightly below
the midcarotid region, taking the size and form of an elongated orange.
A surgical intervention was made by means of a long incision on theborder of the sterno-mastoid, and the tumor proved to be a ragged encephaloid mass, which bled freely.
It had infiltrated the sternomastoid
muscle, and penetrated the environing interstices in such a manner that,the principal mass being removed, there remained on all sides aninextirpable neoplastic remainder.
The operation, therefore, wasnecessarily incomplete, the skin was sutured, and a drain was left inplace in the lower part of the wound.
In this drain, four days after
operation, a tube containing 18 eg. of pure radium bromide, with asilver filter 0.3 mm. in thickness, was left in place for twenty-eight
hours, and a further application similar in character was made foreight hours to a different part of the cavity a few days later.
Afterwards, the cicatrization of the wound being complete, the patient was
submitted to intensive X-ray treatment, strong doses (8-9 H.) of very
hard and heavily filtered rays being given. These irradiations wererepeated at various ports of entry at intervals of a few days, at first
directly on the site of the tumor, and then indirectly to traverse theneck.
The histological examination of the tumor had proved it toRadium27

be a lymphosarcoma, and, judging by other cases, if recourse had been
made to surgery only, the removal being incomplete, a relapse would
have been immediate. Eight months have passed since the intervention,and the operated region remains supple, with no tumefaction or traceof relapse, and the general health is perfect. The author brings forward
a similar case in a woman aged 60 years. The mass of the tumor wasagain removed in order to facilitate the action of the radium.
Thetumor had the same encephaloid aspect as in the preceding case, andwas pronounced a lymphosarcoma. Radium was applied, producing
neither reaction nor suppuration, and was followed by intensive radiotherapy.
Treatment in this case was undertaken only three months
before the publication of the report; up to that time, however, there
was no sign of relapse, nor any trace of generalization." Brit. Med.
Journ. May 8, 1915. p. 38.

*****

'

In a Symposium on Tumors of the Bladder With Special Reference
to the Technique and Post-Operative Results, the following remarks
concerning the use of radium were made:Papers presented at theannual meeting of the American Urological Association, Baltimore,
April 13-15, 1915.
Surgery, Gynecology and Obstetrics, August, 1915,
pp. 135-179.
Radium Versus
J. Bentley Squier, M.D., F.A.C.S., New York.
Surgery in the Treatment of Vesical Neoplasms, pp. 176-78. "Surprising it is, therefore, that even though ten years have elapsed since
the application of radium to the treatment of malignant tumors, certain
fundamiental information concerning its therapeutic capacity is stilllacking.
One explanation of this seems obvious namely, that ourknowledge of the real cure of cancer will depend upon our knowledgeof the real cause of. cancer, and the finality of one will absolutely depend
upon the accuracy of the other.""It is not at present known what quantity of radium must be
applied to kill a cell of a cancer within a given distance. It is perfectly
certain that in the benign epitheliomata of the face, including many
types of basal-cell epitheliomata, radium is capable of inducing a cure,since there are already a sufficient number of observations on humanbeings to enable us to make so positive a statement.
do knowthat radium will not cure a carcinoma or sarcoma at a distance of, say,This has been shown by the work
three or four inches from the tube.
of Kroenig and Gauss and Bumm in Germany, who have published aseries of cases of carcinoma of the uterus which have shown recurrence
at a considerable distance from the site of the radium application, eventhough the primary carcinoma in the uterus had been completely
destroyed. As far as one can judge it is useless to expect any efifectfrom the quantities of radium now available at a greater depth thanWithin this distance it is often
about two inches from the tube.
possible to influence tumor growth, but the quantity of radium required
By large quantities
is so large that but few have the necessary amount.
is meant four or five hundred milligrams, which at the present market
The application ofprice is worth sixty to seventy thousand dollars.
these large quantities, however the radium may be protected or screened,frequently results in serious burns of surrounding tissue which do not
Therefore extreme caution in application isheal for a long time.
necessary when applying radium to vesical tumors.""It is well known ^^-^^ many of the bladder papillomata are benign
or at least not extremely malignant. If such growths can !)e approached;We

RADIUM28

and the radium
placed in contact with the base in quantities of 200 mg. and for an
exposure of twenty-four to forty-eight hours, there is no question butthat a good deal of effect may be secured within a radius of two to
The danger of deep ulcerathree inches from the site of appHcation.
tion with the production of rectovesical fistulae or fibrosis, must, however,always be kept in mind and guarded against."
either from the urethra or through a suprapubic incision"In the malignant tumors of the prostate, involvement of the rectumor at least close approach to the rectal wall is not infrequently noted.
In such cases the greatest care must be taken not to radiate too long,and the tube should be buried in the body of the tumor so as to get the
Merely laying the tube infull effect of all the rays in all directions.
the bladder over the surface of the growth cannot be expected to domuch good. The final results of the application of radium to the bladderand prostate tumors cannot at present be estimated from the clinicalside, for the reason that the number of cases thus reported is small,and of these many have not been studied microscopically and therefore
must be excluded, and most of the reports have been made before asufficient time has elapsed to make it possible to judge whether the cureis permanent.
Certainly, with our knowledge of the slowness of thegrowth of certain prostatic tumors, some of which do not recur extensively in less than one or two years, it is the height of folly to reportmust rather wait patiently fora cure at the end of two months.
at least three years before even considering that the results may beWepermanent.""It is wiser then not to consider radium as the primary therapeutic
choice in the treatment of vesical tumors where operation is possible.
]f the operation has necessarily incomplete, it may be wiser to radiumize
the field thoroughly with large quantities of radium in order to destroy
cancer-cells which may have been distributed throughout the field ofoperation and those which have remained beyond it. When a tumor has
recurred after operation the use of large quantities of radium may checkthe course of the growth for a certain length of time, but the use ofsmall quantities is to be deprecated, for stimulation with increased
rapidity of the growth of the tumor may result from the application of
insufficient quantity.""My experience with the use of radium has been limited to a number of cases of extensive vesical carcinoma, and personal observationof the work of Dr. Francis Carter Wood, Director of the Crocker
Cancer Laboratories of Columbia University, in experimenting withradium in mice tumors.""The vesical carcinomata cases were those who had previously been
subjected to operation for the removal of the growth. In each instance,
the incompleteness of the surgical removal was recognized at the timeof operation and the patient at once given the benefit of the application
The technique was the same inof radium to the unremoved tumor.
each case
Eighty to 100 mg. of radium element with 1 mm. lead, 2 mm.
paper, and a thin sheet of rubber were applied to the tumor throug^ia large suprapubic tube. This was left in situ for varying periods oftime; the shortest period being six hours, the longest period being
thirty-six hours.
The number of applications was usually three. The
immediate results were similar in all cases; a checking of hemorrhage,an inhibition of bacteriouria with markedly diminished pus in the urine,
and, strange as it may seem, a feeling of well-being expressed by theindividual.
In all the patients, the suprapubic wounds healed quicklv.
:

T?ADIUM

29

Each patient died of an extension of the growth within six months ofthe operation. In no case was there a return of vesical haemattiria, theextension being into the pelvis or peritoneal cavity.
The number ofcases treated

was four.""Appreciating that these cases are not at all conclusive and thatthey add but little to the scientific data concerning the therapeutic valueof radium, it may be of interest to include in these remarks some ofthe data derived frorrt animal experimentation carried out by Dr.

Wood.""The experiments comprise quantitative studies of the lethal effectof radium on tumor-cells. They are undertaken because of the paucity
of information attainable from the writings of various experimenters,
working both with human and with animal tumors, on the quantities ofradium used, the screens employed, and the time of exposures. These
factors being the only ones which would furnish a scientific basis forcomputing the efficacy of radio-active substances, experiments werecarried out with the idea of solving some of the above-mentioned pro-blems.""Rat and mouse tumors of various types w^ere used. These were
Following an exposure of the beta andtreated in vitro and in vivo.
gamma rays in different amounts and for varying periods of time,
portions of the treated tumors and untreated controls were inoculated
The alpha rays were not employed, as
into animals of the same strain.
they are soft rays, causing superficial burns.""The beta rays, composed of soft, medium, and hard rays, were
The absorption limit of the soft rays
found to be screened as follows
was 0.4 mm. brass. The medium and hard rays would penetrate sucha screen for about 0.8 mm. To absorb the medium and hard beta rays:

mm. of brass was required.""The gamma rays are the most penetrating. They passed throughUpon striking the metal used to remove the beta rays,
1.2 mm. brass.
the gamma rays produce a soft secondary beta ray of very slight pene1.2

tration.

These are blocked by a screen of filter paper 5 mm., in thick-ness.""Filtering out the beta rays greatly increased the time recfuired to
After a long series of experiments it w^as
jiroduce a lethal effect.
found that exposures of seven hours to 100 mg. of radium were necessary to kill the tumor-cells with the beta rays filtered out.""From a series of inoculation experiments on a previously radiatedtumor, it was shown that from as large a quantity of radium as 83 mg.
of the element with an exposure of two hours the tissue was not affected
at a distance of 1 cm., the inoculated- radiated tumor growing as rapidly
as the unradiated controls.""Wood calls attention to the action being'

governed by th^ law of
inverse squares. 'If the distance of the tube from the proximal portionof the tumor is 2 mm., and from the distal portion 12 mm., then theHis experiments
effect is not as 1 to 6 but as 4 to 144 or as 1 to 36.'
seemed to prove that in radiated tumors the slowness of growth after
inoculation was probably due to injury of the mechanism of mitotic

Wood's conclusions are:division of the cells.
1.
"Three factors only are dominant in the action of radium on
tumors; i.e., the time of exposure, the amount of radium element, andthe distance between the tube and the tissue to be acted upon."
2.
"The removal by suitable filters of the greater part of the beta
rays diminishes proportionally the lethal effect of the radiumi, but that;

ItADIUlM

30
the gamma ray

efifect

follows the same law as that governing the beta

rays.""Sublethal lethal exposures slow the growth of tumor- cells for3.

some time, while a still shorter treatment seems to stimulate the cellular
growthactivities.""Therefore, in the light of our present knowledge, we believe thatcures in bladder tumors by the use of radium may be hoped for only
in benign papillomata; that it may be possible in certain instances torender the symptoms of vesical malignancy less distressing by intraurethral and rectal or cross-fire intra-urethral and rectal radiations
that Iby the time vesical carcinoma has been made clinically manifest
the growth has already extended too far to be readily influenced by theamounts of radium at present at our command; that the question of
the best management of a case of vesical carcinoma is no different thanthe management of carcinoma anywhere else in the body and such is,
if the growth is anatomically accessible, wide surgical extirpation followed by every means known of science to treat any unremoved growth—or recurrence.""We may find, however, as further experience develops more ingenious means to use radium intravesically, that radiating the tumor
before operation may lessen the danger of tumor transplants occuring
at the time of operation."
B. A. Thomas, A.M., M.D.. F.A.C.S., Philadelphia.
Techniqueof Operative Treatment of Bladder Tumors,loc. cit.
pp. 135-150.
"The treatment of bladder tumors may be considered under two chief

forms

:

non-incisional and incisional.""Non-incisional forms of treatment.
Under this heading may be
enumerated: (1) high-frequency electro-coagulation, (2) radium. (3)perurethral excision, snare strangulation and cauterization, and (4)irrigations with coagulable solutions.""Technique of the application of radium. Thus far the sphere of
the utility of radium in the treatment of bladder tumors has been largely
and should be restricted to inoperable malignant* growths, and as a postoperative prophylactic against recurrence.
There is no evidence towarrant its substitution for established and well-recognized methods oftreatment for operable benign or malignant neoplasmata. Paschkis andlittinger in 1910 treated successfully a case of sarcoma of the prostate,jiud the former, the following year, reported on a number of cases ofThe
carcinoma of the bladder and prostate, also one of papillioma.
results were poor, due probably to the employment of insufificient
radium.""Through the courtesy of Drs. Charles H. Frazier and Henry K.
Pancoast of the University Hospital, I have utilized radium in two
In each case, approximately
cases to supplement surgical procedures.
110 mg. of radium sulphate or 50.5 mg. of the element radium werePreferably, in extensive inoperable tumors it is best applied(employed.
through a suprapubic vesical opening, enbedding the capsule in theThetissue at various sites for the sake of cross-fire.
enclosed or not in a rubber tube or catheter, is allowed toTheremain in one position for two to twenty-four or more hours.
radiations may also be applied to bladder lesions through the urethra.
This may be effected with a cystoscope carrying the element as was doneby Paschkis, or especially in cases of involvement of the neck by the
careful manipulation of a carrier* after previous determination by])athologicalcapsule,Radium

31

cystoscopy of the exact location of the growth. Possibly in the future,with the employnient of enormous dosage, taking care to cut off all
but the gamma and deep-penetrating rays, the duration of treatment
may be shortened and its effectiveness greatly increased. It will be
remembered, however, that radium cannot supersede surgery."Louis E. Schmidt, M.D., F.A.C.S., Chicago. Surgery of the Urinary
loc. cit.
"In taking up the palliative operations,pp. 155-168.
how is it possible to select the cases correctly? I need not state thatit frequently becomes necessary to do so for other than surgical reasons.
This matter cannot be discussed.
If an individual shows signs ofcachexia or if metastatic conditions are present, or if loss of blood fromulceration of the bladder tumor, or again if pain is excessive as when
the internal orifice is involved, it is justifiable to perform the suprapubic
operation in the ordinary fashion and remove with curette and scissors
or otherwise, and cauterize with thermocautery, 'spark' with the highfrequency current, or 'bake' with diathermy, the parts involved. It isneedless to state that these cases demand the establishment of a permanent outlet for the flow of urine. This treatment may be carried out
from time to time as found necessary. It also demands the wearing of
Naturally the question of X-ray therapy and radiumi ora urinal.
mesothorium treatment is of special interest at this point. However,the question will arise, why use this mode of treatment in these advanced
cases only?
I believe that this can be readily answered at the present
time. Neither the modern X-ray treatment for deep-seated growths nor
the application of radium for growths involving the bladder, have as
yet been sufficiently tried out to prove them of sufficient value to replace
other surgical procedures. However, it must be understood that either
or both, if carried out according to the precepts already known, may
be used to advantage. I certainly do not believe it wise to rely entirely
on one or both, but I have knowledge of one case which has been, to all
I mustcystoscopic and other evidence, freed from malignant growth.
insist in the present stage of our knowledge, that it certainly is advisable,
I might even state correct, to treat all cases before and after operation,
and all cases not operated upon, with the X-ray. I do not feel quite
certain as to radium and mesothorium therapy. It remains to be proved
whether it is good practice in cases which have been operated upon andapparently not freed from the growth."
Bladder,

*

*

*

*

*

Papilloma of the Larynx. Discussing theradium treatment of this condition Dr. Smith said: "Radium has been
applied in a number of instances, and in some cases marvelous results

Harmon Smith. M. D.

have been obtained. Abl>e reports a case in which the application of
100 mg. of radium kept in position for one-half hour resulted in the
Similar experiences have been
rapid disappearance of the growth.
In my experience, however, there isrelated by Harris and Culbert.
one case presenting sufficient interest to warrant a detailed account, notyielding to radium.""Case 1. A. V., aged 15, had from birth a husky voice, leading to
the supposition that there were congential growths in the larynx. WhenIts
is a woven-shotted bougie and therefore flexible.
Surrounding
with a silver capsule, one millime'tter in thickness.
a lead cover, one and a half millimeters thick, provided with an oval
fenestrum permitting the passage of the effective radium rays. After cystoscopy,
by careful manipulation, it is possible to bring the diseased area in close opposition with the fenestrum and conduct cross-fire irradiations.

*The graduated shaft

tip

is

this isfitted^ADIUMI

32

about 5 years of age he was operated on by Dr. Culbert for multiple
laryngeal papilloma
associatedwiththe characteristic
symptoms.
Laryngo-fissure was performed at that time and the entire contents of
the larynx cleaned out and the mucosa was cauterized.
Within two
weeks there was noticeable improvement, which improvement lasted forabout six years. At the end of that time there began a recurrence of•the symptoms such as hoarseness, dyspnea and imperfect voice production.
As this continued to increase he came to my clinic at the
Manhattan Eye, Ear and Throat Hospital, Sept. 19, 1911, at whichtime there could be seen a number of warts on both sides of thelarynx, both anteriorly and posteriorly.
The voice was very imperfectand of a hoarse, whispering character. The evidence of the former
laryngofissure was observable and the movement of the larynx was
somewhat imperfect.
tracheotomy was performed and the tube
worn for the space of nearly a year. The growths were removed
under cocain anesthesia by the direct method, it being reasonable tosuppose that surgical removal at this stage, when the patient was approaching puberty, might result in a permanent eradication. They recurred with regular frequency. It was later determined, April 23,
1912, that fulguration should be tried without surgical interference.
The growths disappeared following the fulguration and the necessity
lor another seance did not occur for a period of three months, when
they were again removed in the same manner. They occured again at
the end of two months, when the third application was made.
Thistime they recurred at the end of a month.
After each fulguration,
however, a less number of growths returned and the right side of thelarynx cleared up almost entirely. The persistent fibrosis together with alarge sessile papilloma remained on the left vocal cord and ventrical band.
The obstruction to laryngeal respiration, however, was so slight thatthe trachetomy-tube was removed in October, 1912, since which time
local treatment and rest together with partial removal of the growth,
whenever it encroached on the larynx, has followed. This procedurev/as carried out in the belief that the 'boy was approaching thatphysiologic change incident to puberty, which would result in a permanent disappearance.""Radium Treatment. As this did not take place it was decided in
March to employ radium. Through the kindness of Dr. Wolf Freudenthal a tube of radium was placed in the larynx after cocainization,
March 19, 1914, and left in for about three-quarters of an hour. Thereappeared to be a disappearance of some of the thickening around theA—growth.""March 26, it was again applied for a period of about one-halfhour, following which there seemed to "be a marked reaction.
Thevoice has improved under the application of the radium, but the growthcontinues to recur.
There have been three additional applications ofradium, varying from fifteen minutes to three-quarters of an hour, but
so far as clinical observation goes there has been no dimunition in
the size of the growth. The boy is in good health, speaks with a hoarse
voice, and while the radium has apparently had little or no effect on
it, my belief still holds that physiologic change
will ultimately bringabout that which therapeutic measures have failed to accomplish."J. A. M. A., Dec. 19, 1914.

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